61-Year-Old Man With Chronic Diarrhea

Abstract

61-year-old man presented with an 18-month history of progressively worsening diarrhea with multiple nonbloody stools of varying volume per day. His medical history included atrial fibrillation with onset at age 40 years, hypothyroidism, hyperlipidemia, and bilateral surgical release for carpal tunnel syndrome. He reported a 14-kg weight loss since the onset of diarrhea, which included intermittent nocturnal stools and occasional urge fecal incontinence. He hadnoabdominaloranorectal pain,abdominal bloating, nausea, vomiting, fever, chills, or night sweats. Empirical trials of lactose- and gluten-free diets resulted in no symptom improvement. At the time of presentation, he reported no recent travel or medication changes over the symptomatic interval, including the use of antidiarrheal agents. The patient appeared well and was in no acute distress. His vital signs included the following: temperature, 36.2 � C; heart rate, 79 beats/min; respiratory rate, 12 breaths/ min; and blood pressure, 117/77 mm Hg. Physical examination revealed a soft, nontender, and nondistended abdomen with normoactive bowel sounds. A rectal examination revealed intact perianal sensation with 2 to 3 cm of perianal descent on simulated defecation. Resting and squeeze anal sphincter pressures were adequate. There was no excessive tenderness on digital rectal examination and appropriate relaxation of the puborectalis muscle and external anal sphincter. The remainder of the examination findings were unremarkable except for an irregularly irregular pulse consistent with known atrial fibrillation.