approach to the patient with chronic diarrhea and a few interesting ibs cases christina surawicz,...
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Approach to the Patient with Chronic Diarrhea and A Few Interesting IBS Cases
Christina Surawicz, MD, MACGProfessor of Medicine
University of Washington
McCall, IdahoJanuary 2014
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Alarm Symptoms
• Weight loss “Beware the diet that works”
• Blood in stool
• Nocturnal diarrhea
• Anemia
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Diagnostic Approach to Chronic Diarrhea
● BLOODY – gross or occult
● Fatty
● Watery
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Diarrhea with Blood → Colitis
InfectionIBDIschemiaSome drugs
NSAIDSIsotretinoin
SCAD – Segmental Colitis Associated with Diverticular Disease
RadiationDiversion colitis
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Work – upChronic Bloody Diarrhea
Stool culture for enteric pathogens, Yersinia, Aeromonas, Plesiomonas, C. difficile
Stool O + P – Ameba, Trichuris
Stool WBC, lactoferrin--nonspecific
Colonoscopy/biopsy= helpful to distinguish IBD vs. infection
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Colonoscopic AppearancesInfections – often patchy
Ulcerative Colitis – typical
Crohn’s - segmental
Ischemia – Rectal sparing Location, location, location
Can be multifocal
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Chronic Bloody Diarrhea
History + exam
Stool cultures, O + P, in some
Colonoscopy and colorectal biopsy - mainstay of diagnosis
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Colonoscopy in Any Diarrhea Work Up
Age > 50 years old
Family history colon cancer at an early age (<60)
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Infection Uncommon Stool Culture O + P• Salmonella • Ameba• Campylobacter • Trichuris• Yersinia • Aeromonas • Plesiomonas• C. difficile
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Chronic Bloody Diarrhea: Work – up
Colonoscopy/biopsy - mainstays of diagnosis
Helpful to distinguish IBD vs. infection
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Colonic Biopsy can Diagnose Specific Infections
PseudomembranesC. difficileSTEC
Viral InclusionsCMVHSV
ParasitesAmebaShistosomiasis
Tuberculosis
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Diagnostic Approach to Chronic Diarrhea
● Bloody – gross or occult
● FATTY
● Watery
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Steatorrhea – Clinical Clues
Dietary history – Intake compared to others
Weight lossStools – Not always diarrhea, may
be bulkyHard to flushOily droplets floating on
toilet water (unhydrolyzed TG)
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Steatorrhea – Vitamin Malabsorption
Fat soluble vitamins D A K E
Osteomalacia DNight blindness AEasy bruisability KVitamin E
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Fecal Fat Analysis
Qualitative – Can be subjective Variable lab personnel Nl is less than 20 drops/ hpf
Quantitative – 24 hr on 100 gm fat diet
Weight < 200 – 300 gm
Fat < 7 gm / 24 hr
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Stool Fat Tests – Caveats
1. High carbohydrate diet – increases stool weight to 300 – 400 gms
2. Voluminous stools will raise fat excretion (up to 14 g/24 hour)
3. Correct for fat intake - low fat diets
4. False positives; Olestra, Brazil nuts
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Steatorrhea
Mucosal Luminal
CELIAC SPRUE • PANCREATIC INSUFFICIENCY
CROHN’S • Bile salt deficiencyIleitis/ • Bacterial overgrowth Ileal resection • SIBOShort bowel syndrome
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Celiac Disease – Not Just Diarrhea
Weight Loss Infertility
Abdominal distension Recurrent fetal loss
Abnormal LFTs – enzymes Microscopic colitis
Iron deficiency
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Celiac Diagnosis Antibody tests - On gluten
* IgA tTG and Serum IgA (2-3 % of sprue patients are IgA deficient)
- EmA antibody – second line- Not antigliadin ab (unless deaminated)
Small bowel biopsy + response to therapy High suspicion – biopsy even if
serology negative Genotype-HLADQ2, DQ8
- Rules out if negativeRubio-Tapia et al. Guidelines, AM J Gastroentrol, Feb 2013
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You have a patient on a gluten free diet who is convinced she has celiac disease. She does not want a gluten challenge. Which of the following applies to her?
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A. Order HLA DQ2,8 – if positive it will confirm she has celiac disease
B. Order HLA DQ2,8- if negative it will rule out celiac disease
C. Order serology as it will help even on a gluten free diet
D. Screen her siblings for celiac disease
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Answer BHLA DQ2,8- if negative it does rule
out celiac but does not everyone who is positive has celiac disease
The serology will be negative if on a true gluten free diet, and screening siblings is only helpful if you have a true case
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Gluten and IBS34 patients with IBS
NonceliacDouble blind RCT – 6 weeks
Gluten free muffins & bread vs. PlaceboResults
Symptoms better
Gluten free group 68%
Placebo 40%
Biesierkierski et al, Am J Gastroenterol 2011; 106:508-14
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Symptoms Worse within 1 Week
OverallBloatingPainFatigueSatisfaction with stool
consistency
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GFD in IBS-DNon celiac patients
RCT of GFD
Reduced stool frequency
(Vazquez-Roque et al, Gastroenterol. 2013)
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Bottom Line
Non-celiac glutenSensitivity probably exists
We need to know more
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Malabsorption - think about…
Post gastric surgery or anti-reflux surgery - history
Chronic mesenteric ischemia - history
Drugs, including HAART - history
Radiation - history
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Malabsorption - think about…
Parasites – stool tests Giardia
Cryptosporidia
Cyclospora
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Next Steps in Evaluation
• Radiologic imaging- cross sectionalCT Abdomen and pelvis and CT Enterography
• Capsule study
• Enteroscopy or DBE for biopsy
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Uncommon Small Intestinal Diseases• Collagenous sprue
• Whipple’s disease
• Eosinophilic enteritis
• Lymphoma
• Amyloid
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Luminal - Pancreatic Insufficiency
∙ Direct function test: secretin test, research tool
∙ Indirect tests ∙Serum amylase/lipase∙Serum trypsin∙Fecal chymotrypsin ∙Fecal elastase
ALL HAVE POOR SENSITIVITY/SPECIFICITY
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Fecal Elastase 1 6% of pancreatic enzymesAbnormal: < 200 μg/gram stoolBut abnormal in many other
conditionsCeliac diseaseIBDIBSHIV Diabetes
(Leeds et al, Nature Rev Gastro Hep 2011)
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Pancreatic Insufficiency
Empiric trial of enzymes – reasonable
• High dose – monitor wt gain or fecal fat
• If respond, image pancreas
Another option is to rule out mucosal disease first
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Bile Acid DiarrheaBile acids cause colonic salt and water
secretion and increased colon motility
Secondary bile acid malabsorptionIleal resection or disease (Crohn’s)< 100 cm – watery> 100 cm - malabsorption
Primary bile acid malabsorption? (misnomer)
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Luminal - Small Intestinal Bacterial Overgrowth (SIBO)• Structural causes • SI diverticulosis• Stricture• Surgical diversions
• Dysmotility• Scleroderma • Intestinal pseudo-obstruction
• Others ?• Diabetes• IBS • Acid suppression
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SIBO Diagnosis• Clue: high folate, low B12
Bacteria produce/consume
• SB aspirate
• Breath tests – not great
• Therapeutic trial – probably bestAntibiotics
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Watery DiarrheaIf Not Bloody and
Not fatty
It’s WATERY . . .
All the rest
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Watery Diarrhea –HistorySurgery – gall bladder, stomach, intestine
Family historyCeliacIBD
Sexual historyInfectionsHIV
Travel History – Traveler’s diarrheaHigh risk areas
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Watery Diarrhea – History • Medications - 7% of all drug side effects
especially “new” ones
• Antimicrobials• PPIs (lansoprazole)• NSAIDS, 5-ASAs• SSRIs• Psycholeptics• Allopurinol• Metformin• Angiotensin ARBs
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Watery Diarrhea - Diet
AlcoholDairyNutritional supplements, herbals,
OTC drugsHerbalsFructose and sorbitol – osmotic
diarrhea
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Watery Diarrhea -Diabetes
• Visceral autonomic neuropathy- Often nocturnal
• Bacterial overgrowth• Celiac disease • Pancreatic insufficiency• Unabsorbed CHO (Sugarless
sweets)
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Watery Diarrhea - Post Cholecystectomy Diarrhea
Incidence 20%
Can be delayed
Rarely severe
Rx – bile acid binders
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Watery Diarrhea – Initial Labs• CBC• Chemistries (total protein, albumin)• Thyroid tests• Celiac serology• ESR/CRP • Stool FOBT
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Watery Diarrhea - Infections
• Ameba• Giardia• Cryptosporidia • Cyclospora• Blastocystis hominis (?)• Candida (?)
• Yersinia• Salmonella• Aeromonas• Plesiomonas
• C. difficile (recurrent)
Stool exam low yield
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Watery Diarrhea - Mucosal Disease
Colonoscopy + biopsyCrohn’s Microscopic colitisColon cancerLarge rectal villous adenoma
Small bowel diseases - EGD + duodenal biopsy
Previously Mentioned
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Chronic Diarrhea – Yield of Biopsy at Colonoscopy
Series vary: 10—20%
Most commonly:IBDMicroscopic ColitisPseudomelanosis coliSpirochetosis
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Pseudomelanosis coli
Surreptitious laxatives
Factitious Diarrhea
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Microscopic Colitis—Collagenous and Lymphocytic
Typically: Chronic watery diarrheaColon bx diagnosticOther w/ u – negative
Histology: increased lamina propria lymphocytes, intraepithelial lymphocytes, increased collagen band in CC, not LC
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Collagenous Colitis
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Lymphocytic Colitis
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Watery Diarrhea
If work-up negative so far,
Consider other stool testsFecal FatLaxative screenOsmotic gap
Consider small bowel evaluation
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Stool Osmotic Gap
Normal 290 – 2 (Na+K)
Secretory < 50Osmotic > 125Contamination > 375
Lab will not do test on solid stool,
so can use to confirm diarrhea
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Secretory Diarrhea
Continues with fast● Hormonal: ZE - Gastrin VIP - VIP Carcinoid - 5HIAA Medullary Ca - Calcitonin
Thyroid
● Idiopathic secretory diarrhea
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Idiopathic Secretory Diarrhea
Often sudden onsetUp to 20 pound weight loss, then stableLasts 2 years
1. EpidemicContaminated food or water“Brainerd” Minnesota
2. SporadicTravel to local lakes or otherNo one else sick
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Previously healthy, likely infectiousEpidemic – BrainerdSporadic – travel, lakes, no one else
sickAbrupt onset, 20 lb wt loss then stableResolves over 2 yrs
Idiopathic Secretory Diarrhea
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When I am stumped . . . I Take More History
• Diarrhea onset After Infectious gastroenteritis
PI – IBSAfter GI tract surgery
Post-cholecystectomyPost anti reflux surgery
Sugarless chewing gum10 packs/day
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When I am stumped . . . I Take More History
• Family history
Example: Celiac disease in 65 yo with sent for evaluation of recurrent C. difficile
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When I am stumped . . . I MayOrder a Special Study
A woman with protein losing enteropathy,
Extensive evaluation negative except diffuse edema of small intestine
? Slight ↑ eosinophils in duodenal bx
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When I am stumped . . .Empiric Trials Cholestyramine
Pancreatic enzymes
Antibiotics
Antimotility agents
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Dx of Obscure Diarrheas at Referral Center
Fecal incontinenceFunctional, IBS HistoryIatrogenic – drugs,
surgery, radiation
Surreptious laxatives Colon + bxMicroscopic colitis
Schiller, Sleisinger & Fordtran, GI & Liver Dis, 2002
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Dx of Obscure Diarrheas at Referral Center – Cont’d
SB bacterial overgrowthPanc insufficiency Hx + Therapeutic
trialCHO malabsorption
Peptide secreting tumors Assays + Scans
Chr idiop secr diarrhea
Schiller, Sleisinger & Fordtran, GI & Liver Dis, 2002
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Empiric TrialsLoperamide Adsorbents, bulk, Bismuth
subsalicylate
Bacterial overgrowth - Metronidazole or Quinolone
Bile salt MalabsorptionCholestyramine
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Therapeutic TrialsUnexplained steatorrhea – pancreatic
enzymes or conjugated bile acidUnexplained idiopathic
Bile acid resinsOpiates helpful in some
Opium tincture 2 – 20 drops QIDOthers
OctreotideClonidineProbiotics
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Chronic Diarrhea - Summary
1. History, + stool characteristics & initial labs will guide w/u
2. Reasonable w/u will diagnose most
Check Diet/medsExclude infectionEndoscopy and Biopsy
– upper & lower3. If normal further w/u to include
therapeutic trials4. Uncommon causes are uncommon