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

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Presentation on theme: "Approach to the Patient with Chronic Diarrhea and A Few Interesting IBS Cases Christina Surawicz, MD, MACG Professor of Medicine University of Washington."— Presentation transcript:

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 – up Chronic 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 OsteomalaciaD Night blindnessA Easy bruisabilityK VitaminE

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 Mucosal Luminal CELIAC SPRUE PANCREATIC INSUFFICIENCY CROHN’S Bile salt deficiency Ileitis/ Bacterial overgrowth Ileal resection 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 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 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 group68% Placebo40% 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 Enteroscopy or 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 B 12 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

51 Watery Diarrhea If work-up negative so far, Consider other stool tests Fecal Fat Laxative screen Osmotic gap Consider small bowel evaluation

52 Stool Osmotic Gap Normal 290 – 2 (Na+K) Secretory< 50 Osmotic> 125 Contamination> 375 Lab will not do test on solid stool, so can use to confirm diarrhea

53 Secretory Diarrhea Continues with fast ● Hormonal: ZE- Gastrin VIP- VIP Carcinoid- 5HIAA Medullary Ca - Calcitonin Thyroid ● Idiopathic secretory diarrhea

54 Idiopathic Secretory Diarrhea Often sudden onset Up to 20 pound weight loss, then stable Lasts 2 years 1. Epidemic Contaminated food or water “Brainerd” Minnesota 2. Sporadic Travel to local lakes or other No one else sick

55 Previously healthy, likely infectious Epidemic – Brainerd Sporadic – travel, lakes, no one else sick Abrupt onset, 20 lb wt loss then stable Resolves over 2 yrs Idiopathic Secretory Diarrhea

56 When I am stumped... I Take More History Diarrhea onset After Infectious gastroenteritis PI – IBS After GI tract surgery Post-cholecystectomy Post anti reflux surgery Sugarless chewing gum 10 packs/day

57 When I am stumped... I Take More History Family history Example: Celiac disease in 65 yo with sent for evaluation of recurrent C. difficile

58 When I am stumped... I May Order a Special Study A woman with protein losing enteropathy, Extensive evaluation negative except diffuse edema of small intestine ? Slight ↑ eosinophils in duodenal bx

59 When I am stumped... Empiric Trials Cholestyramine Pancreatic enzymes Antibiotics Antimotility agents

60 Dx of Obscure Diarrheas at Referral Center Fecal incontinence Functional, IBSHistory Iatrogenic – drugs, surgery, radiation Surreptious laxativesColon + bx Microscopic colitis Schiller, Sleisinger & Fordtran, GI & Liver Dis, 2002

61 Dx of Obscure Diarrheas at Referral Center – Cont’d SB bacterial overgrowth Panc insufficiency Hx + Therapeutic trial CHO malabsorption Peptide secreting tumors Assays + Scans Chr idiop secr diarrhea Schiller, Sleisinger & Fordtran, GI & Liver Dis, 2002

62 Empiric Trials Loperamide Adsorbents, bulk, Bismuth subsalicylate Bacterial overgrowth- Metronidazole or Quinolone Bile salt Malabsorption Cholestyramine

63 Therapeutic Trials Unexplained steatorrhea – pancreatic enzymes or conjugated bile acid Unexplained idiopathic Bile acid resins Opiates helpful in some Opium tincture 2 – 20 drops QID Others Octreotide Clonidine Probiotics

64 Chronic Diarrhea - Summary 1. History, + stool characteristics & initial labs will guide w/u 2. Reasonable w/u will diagnose most Check Diet/meds Exclude infection Endoscopy and Biopsy – upper & lower 3. If normal further w/u to include therapeutic trials 4. Uncommon causes are uncommon

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