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Approach to the Patient with Chronic Diarrhea and A Few Interesting IBS Cases

Approach to the Patient with Chronic Diarrhea and A Few Interesting IBS Cases. Christina Surawicz, MD, MACG Professor of Medicine University of Washington McCall, Idaho January 2014. Alarm Symptoms. Weight loss “Beware the diet that works” Blood in stool Nocturnal diarrhea Anemia.

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Approach to the Patient with Chronic Diarrhea and A Few Interesting IBS Cases

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  1. Approach to the Patient with Chronic Diarrhea and A Few Interesting IBS Cases Christina Surawicz, MD, MACG Professor of Medicine University of Washington McCall, Idaho January 2014

  2. Alarm Symptoms • Weight loss “Beware the diet that works” • Blood in stool • Nocturnal diarrhea • Anemia

  3. Diagnostic Approach to Chronic Diarrhea • Bloody – gross or occult • Fatty • Watery

  4. Diarrhea with Blood → Colitis • Infection • IBD • Ischemia • Some drugs • NSAIDS • Isotretinoin • SCAD – Segmental Colitis Associated with Diverticular Disease • Radiation • Diversion colitis

  5. 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

  6. Colonoscopic Appearances Infections – often patchy Ulcerative Colitis – typical Crohn’s - segmental Ischemia – Rectal sparing Location, location, location Can be multifocal

  7. Chronic Bloody Diarrhea • History + exam • Stool cultures, O + P, in some • Colonoscopy and colorectal biopsy - mainstay of diagnosis

  8. Colonoscopy in Any Diarrhea Work Up • Age > 50 years old • Family history colon cancer at an early age (<60)

  9. Infection Uncommon Stool CultureO + P • Salmonella• Ameba • Campylobacter • Trichuris • Yersinia • Aeromonas • Plesiomonas • C. difficile

  10. Chronic Bloody Diarrhea: Work – up • Colonoscopy/biopsy - mainstays of diagnosis • Helpful to distinguish IBD vs. infection

  11. Colonic Biopsy can Diagnose Specific Infections • Pseudomembranes C. difficile STEC • Viral Inclusions CMV HSV • Parasites Ameba Shistosomiasis • Tuberculosis

  12. Diagnostic Approach to Chronic Diarrhea • Bloody – gross or occult • Fatty • Watery

  13. Steatorrhea – Clinical Clues Dietary history – Intake compared to others Weight loss Stools – Not always diarrhea, may be bulky Hard to flush Oily droplets floating on toilet water (unhydrolyzed TG)

  14. Steatorrhea – Vitamin Malabsorption Fat soluble vitamins D A K E Osteomalacia D Night blindness A Easy bruisability K Vitamin E

  15. 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

  16. 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

  17. Steatorrhea MucosalLuminal Celiac sprue • Pancreatic Insufficiency Crohn’s• Bile salt deficiency Ileitis/ • Bacterial overgrowth Ilealresection • SIBO Short bowel syndrome

  18. Celiac Disease – Not Just Diarrhea  Weight Loss  Infertility  Abdominal distension  Recurrent fetal loss  Abnormal LFTs – enzymes  Microscopic colitis  Iron deficiency

  19. Celiac Diagnosis • Antibody tests - On gluten * IgA tTGand Serum IgA (2-3 % of sprue patients are IgA deficient) - EmA antibody – second line - Not antigliadinab (unless deaminated) • Small bowel biopsy + response to therapy • High suspicion – biopsy even if serology negative • Genotype-HLADQ2, DQ8 - Rules out if negative Rubio-Tapia et al. Guidelines, AM J Gastroentrol, Feb 2013

  20. 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?

  21. 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

  22. Answer B • HLA 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

  23. Gluten and IBS • 34 patients with IBS Nonceliac • Double blind RCT – 6 weeks Gluten free muffins & bread vs. Placebo • Results Symptoms better Gluten free group 68% Placebo 40% Biesierkierski et al, Am J Gastroenterol 2011; 106:508-14

  24. Symptoms Worse within 1 Week • Overall • Bloating • Pain • Fatigue • Satisfaction with stool consistency

  25. GFD in IBS-D Non celiac patients RCT of GFD Reduced stool frequency (Vazquez-Roque et al, Gastroenterol. 2013)

  26. Bottom Line • Non-celiac gluten Sensitivity probably exists • We need to know more

  27. Malabsorption - think about… • Post gastric surgery or anti-reflux surgery - history • Chronic mesenteric ischemia - history • Drugs, including HAART - history • Radiation - history

  28. Malabsorption - think about… • Parasites – stool tests • Giardia • Cryptosporidia • Cyclospora

  29. Next Steps in Evaluation • Radiologic imaging- cross sectional CT Abdomen and pelvis and CT Enterography • Capsule study • Enteroscopyor DBE for biopsy

  30. Uncommon Small Intestinal Diseases • Collagenous sprue • Whipple’s disease • Eosinophilic enteritis • Lymphoma • Amyloid

  31. 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

  32. Fecal Elastase 1 • 6% of pancreatic enzymes • Abnormal: < 200 μg/gram stool • But abnormal in many other conditions • Celiac disease • IBD • IBS • HIV • Diabetes (Leeds et al, Nature Rev Gastro Hep 2011)

  33. 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

  34. Bile Acid Diarrhea • Bile acids cause colonic salt and water secretion and increased colon motility • Secondary bile acid malabsorption Ileal resection or disease (Crohn’s) < 100 cm – watery > 100 cm - malabsorption • Primary bile acid malabsorption? (misnomer)

  35. Luminal - Small Intestinal Bacterial Overgrowth (SIBO) • Structural causes • SI diverticulosis • Stricture • Surgical diversions • Dysmotility • Scleroderma • Intestinal pseudo-obstruction • Others ? • Diabetes • IBS • Acid suppression

  36. SIBO Diagnosis • Clue: high folate, low B12 Bacteria produce/consume • SB aspirate • Breath tests – not great • Therapeutic trial – probably best Antibiotics

  37. Watery Diarrhea • If Not Bloody and • Not fatty • It’s Watery . . . All the rest

  38. Watery Diarrhea –History • Surgery – gall bladder, stomach, intestine • Family history • Celiac • IBD • Sexual history • Infections • HIV • Travel History – Traveler’s diarrhea • High risk areas

  39. 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

  40. Watery Diarrhea - Diet • Alcohol • Dairy • Nutritional supplements, herbals, OTC drugs • Herbals • Fructose and sorbitol – osmotic diarrhea

  41. Watery Diarrhea -Diabetes • Visceral autonomic neuropathy - Often nocturnal • Bacterial overgrowth • Celiac disease • Pancreatic insufficiency • Unabsorbed CHO (Sugarless sweets)

  42. Watery Diarrhea - Post Cholecystectomy Diarrhea • Incidence 20% • Can be delayed • Rarely severe • Rx – bile acid binders

  43. Watery Diarrhea – Initial Labs • CBC • Chemistries (total protein, albumin) • Thyroid tests • Celiac serology • ESR/CRP • Stool FOBT

  44. Watery Diarrhea - Infections • Ameba • Giardia • Cryptosporidia • Cyclospora • Blastocystis hominis (?) • Candida (?) • Yersinia • Salmonella • Aeromonas • Plesiomonas • C. difficile (recurrent) Stool exam low yield

  45. Watery Diarrhea - Mucosal Disease • Colonoscopy + biopsy • Crohn’s • Microscopic colitis • Colon cancer • Large rectal villous adenoma • Small bowel diseases - EGD + duodenal biopsy • Previously Mentioned

  46. Chronic Diarrhea – Yield of Biopsy at Colonoscopy Series vary: 10—20% Most commonly: IBD Microscopic Colitis Pseudomelanosis coli Spirochetosis

  47. Pseudomelanosis coli • Surreptitious laxatives • Factitious Diarrhea

  48. Microscopic Colitis—Collagenous and Lymphocytic Typically: Chronic watery diarrhea Colon bx diagnostic Other w/ u – negative Histology: increased lamina propria lymphocytes, intraepithelial lymphocytes, increased collagen band in CC, not LC

  49. Collagenous Colitis

  50. Lymphocytic Colitis

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