Chronic Intermittent Diarrhea Research Articles

Single large enterolith in a cat with chronic inflammatory enteropathy

AbstractA 3‐year‐old, male, neutered, domestic shorthair cat with a history of chronic intermittent vomiting, diarrhoea and constipation was referred for abdominal ultrasound of a mid‐abdominal mass identified on palpation. Findings included a densely shadowing structure within the distal ileum with severe local muscularis thickening, mild diffuse small intestinal muscularis thickening, and an enlarged right ileocolic lymph node. Abdominal radiographs showed the structure to be most consistent with an enterolith. Enterolithiasis is a rare condition in companion animals, but common in horses and selected populations of human patients. Enterectomy was performed, and histopathology results of intestinal biopsies were consistent with chronic inflammatory enteropathy. Chemical analysis of the enterolith revealed a predominantly calcium phosphate composition. At the 3‐month follow‐up, the cat had gained weight and showed marked improvement in gastrointestinal signs. Screening for underlying structural intestinal disease may be beneficial in cats diagnosed with enteroliths.

S1980 Cocaine-Induced Pseudomembranous Colitis With Negative Clostridium difficile Infection

Introduction: Pseudomembranous colitis (PMC) is most commonly caused by Clostridium difficle (C.Diff). The incidence of C.Diff related PMC is 3-8% and increasing. Other than Clostridium difficile, ischemia, infections, medications, and inflammatory conditions can cause PMC. We report a case of pseudomembranous colitis-tested negative PCR for C. difficile. Case Description/Methods: A 52-year-old female with a past medical history of hypothyroidism, asthma, and polysubstance abuse (history of chronic heroin, cocaine, benzodiazepine, alcohol, and cigarette use) with Hx of chronic intermittent diarrhea due to opioid withdrawal presented to the emergency department with bloody watery diarrhea of 3-4 times in a day for 5 days. On initial evaluation, the patient's vital signs are stable. The abdomen is diffusely tender on physical examination with increased tenderness in the left lower quadrant. Labs showed WBC count of 15,900/μL, 90.2% neutrophils, AST of 80 U/L, ALT of 41 U/L, ALP of 97 U/L, total bilirubin of 0.5 mg/dL, lactic acid of 0.9 mmol/L and c-reactive protein of 11.9 mg/dL. The urine drug screen was positive for benzodiazepine, cocaine, opiate, and methadone. CT scan of the abdomen showed mild diffuse concentric colonic wall thickening representing colitis. The patient was empirically treated with IV ceftriaxone, IV metronidazole, and PO vancomycin. Stool for C. difficile PCR was negative 3 times on 3 different days. Stool culture was negative for Salmonella, Shigella, Campylobacter, or E. coli O157:H7. Fecal lactoferrin quantification was 320.72 μg/mL. The patient underwent sigmoidoscopy, which showed discontinuous areas of ulcerated mucosa covered with yellowish punctate membrane with stigmata of recent bleeding in the entire examined colon. Biopsy of the colon showed focal active colitis with superficial crypt erosion and focal adherent mucopurulent material negative for crypt abscesses and granulomas, consistent with pseudomembranous colitis. The patient was continually treated with supportive care including IV fluids and bowel rest. Her diet was advanced, and her diarrhea improved (Figure). Discussion: Other than C. difficile, we propose keeping other differentials of pseudomembranous colitis is essential. Other infections from S. aureus, E. coli, Shigella and Strongyloides may also cause PMC. Non-infectious causes of PMC include chemical endoscope cleaning agents, intestinal ischemia, drug abuse from cocaine, inflammatory bowel disease, and microscopic colitis to avoid over-usage of antibiotics and focus on targeted therapy.Figure 1.: Discontinuous areas of ulcerated mucosa covered with yellowish punctate membrane with stigmata of recent bleeding in the entire examined colon.

S1777 Polyps and an Uninvited Host

Introduction: Blood fluke illness like Schistosomiasis is considered rare in the United States. Most cases are reported in patients that have migrated from endemic zones like Africa or Asia. Occasionally this infection is seen in individuals from non-endemic regions whereby travel history plays an important role in diagnosis. Zoonotic diseases can be life threatening, thus prompt treatment is crucial to avoid major complications. Herein, we present an European individual living in the United States who underwent routine colon cancer screening in which the polyps that were biopsied revealed calcified Schistosoma eggs. Case Description/Methods: A 67-years-old male with past medical history of hypertension, goiter, and hyperlipidemia presented to the outpatient gastroenterology clinic for routine screening. Coloscopy done showed multiple colonic polyps, the largest being 1 cm in diameter. Pathology reported tubular adenomatous polyps with calcified Schistosoma eggs. Patient was asymptomatic and the physical exam was benign. On social and travel history, he pointed out that he lived in Angola from 1971-1973. Treatment with Praziquantel 600 mg three times daily was started, and the patient was asked to be followed up in 3 months. Negative serology was reported after treatment. Colonoscopy done 3 years later showed complete resolution of the polyps. Discussion: Schistosoma is a blood fluke causing Bilharziasis, an infection caused by freshwater parasitic worms. The parasite itself can be found living in certain freshwater snails. About 5 Schistosoma species have been identified to infect the human body with S. Mansoni and S. Japinicum being the main culprit for intestinal disease. Schistosomiasis is more prevalent in Sub-Saharan Africa with approximately 200 million cases reported worldwide. Infection occurs once the cercariae released by the snail penetrates the skin and begins its life cycle. Most individuals are asymptomatic. Migrating eggs cause bowel inflammation by triggering granulomatous reactions resulting in ulcerations, blood loss, and scaring. The same is true for Host immune response. The most common symptoms for intestinal Schistosomiasis are chronic intermittent abdominal pain, poor appetite, and diarrhea. Chronic ulcerations can be seen in severe cases with strictures as late complications. A combination of Polypectomy plus Praziquantel is often use as treatment. Follow up Colonoscopy to assure resolution is recommended.Figure 1.: Endoscopic mucosal removal of a Cecal granular cell tumor.

Treating chronic diarrhea: A systematic review on Immunoproliferative Small Intestinal Disease (IPSID).

Immunoproliferative Small Intestinal Disease (IPSID) is a disease characterized by extra-nodal marginal zone B-cell lymphoma with villous atrophy in the small intestine, causing chronic intermittent non-bloody diarrhea. Although originally associated with the Mediterranean region, this disease is present in many countries worldwide and may have been underreported due to its complicated diagnosis and scarce scientific literature, especially in regards to treatment. This study aims to review IPSID clinical features, therapeutic options, and treatment outcomes to help physicians identify and treat IPSID. Using PRISMA guidelines, a systematic review of articles was conducted on PubMed database with search terms including IPSID, therapy, treatment, and outcomes. Inclusion and exclusion criteria were used to select 33 English language articles published from the year 2000–2020 that included relevant clinical information about IPSID treatment. Data were extracted independently by at least two authors to reduce the introduction of potential bias. There were 22 case reports, 7 reviews, 1 research article, 1 prospective study, 1 letter to the editor and 1 memoriam in which 76 patients were identified. Epidemiological analysis showed a mean patient age of 32 years old, 2.4:1 mal to female ratio and heterogeneous ethnicities, with 16 Europeans (43.2%) and 12 Asians (32.4%). Chief symptoms included chronic diarrhea (53/76, 69.7%), weight loss (49/76, 64.4%), malabsorption (38/76, 50%), abdominal pain (32/76, 42.1%), and finger clubbing (24/76, 31.6%). Patients stratified into the early disease stage (Galian A) were treated with tetracycline antibiotics, corticosteroids, and non-pharmacological supplements with mostly with complete or partial remission. Late stages (Galian B or C), were treated mostly with anthracycline-based chemotherapy, and occasionally surgery, radiotherapy, or rituximab. This work offers a targeted approach to diagnosing and treating IPSID to aid physicians and serve as a treatment guideline recommendation for future public policies and clinical studies.

S3457 Unusual Gastrointestinal Manifestation of Fabry Disease

INTRODUCTION: Fabry’s disease (FD) is a rare lysosomal storage disease caused by an X-linked deficiency of α-galactosidase A, resulting in intracellular accumulation of glycolipids, globotriaosylceramide (Gb3) in various tissues. Primarily affecting the skin (angiokeratomas), kidney (proteinuria and renal failure), heart (cardiomyopathy and arrhythmias), nervous system (acroparaesthesia, and autonomic neuropathy). Gastrointestinal (GI) manifestations are common and include diarrhea, nausea, abdominal pain, early satiety, and diverticular disease typically attributed to enteric neuropathy and myopathy caused by the accumulation of (Gb3). CASE DESCRIPTION/METHODS: A 69-year-old male with a past medical history of FD on agalsidase-β bi-weekly infusion, chronic intermittent diarrhea, autonomic neuropathy, chronic kidney disease, and atrial fibrillation on Coumadin, presented with hematochezia, four hours from his presentation, associated with blood clots, lightheadedness, diaphoresis, and near syncope. At presentation, vitals were stable, the abdomen was soft and non-tender, digital rectal exam was remarkable for scant bright red blood, and guaiac positive stool. Routine laboratory testing was significant for 8.7 g/dl decreased from baseline 13 gm/dL, BUN 61 mg/dL, Creatinine 2.57 mg/dL, lactic acid 3.9 mg/dL, INR 3.8. Therapy initiated with oral vitamin K and fresh frozen plasma for reversal of Coumadin effect. With further bloody bowel movements, hemoglobin dropped to 6.8 gm/dL requiring blood transfusion. Tagged RBC scan was negative for active bleeding, esophagogastroduodenoscopy (EGD) showed mild non-bleeding erythematous antral gastropathy, colonoscopy revealed normal mucosa without a source of bleeding. In a few days hematochezia resolved, the patient tolerated oral intake, Coumadin was resumed, and the patient was discharged home with plans for virtual capsule endoscopy as an outpatient. DISCUSSION: Gastrointestinal bleeding is a rare manifestation of FD. Cutaneous angiokeratomas are vascular lesions caused by upper dermal vessels ectasia, affect 70% of FD patients. The absence of a clear source of GI bleeding in this case on EGD, increase the likelihood of mucosal angiokeratomas bleeding in the small intestine. Mucosal angiokeratomas have been reported as a cause of life-threatening GI bleeding, which can be found anywhere in the GI tract mucosa. Given the high likelihood of arrhythmias requiring anticoagulation in FD, physicians should be more vigilant of the possibility of severe GI bleeding.

CT findings in five dogs with surgically confirmed colonic torsion.

Colonic torsion is a life-threatening condition that results in colonic ischemia, necrosis, perforation, sepsis, and eventual death. The aim of this multicenter, retrospective case series study was to describe the CT findings in dogs with surgically confirmed colonic torsion. Medical records were searched for dogs with surgically confirmed colonic torsion following abdominal CT. Five dogs met the inclusion criteria. Three had a history of chronic intermittent diarrhea prior to presentation. Two dogs presented with acute vomiting, diarrhea, and abdominal pain and one dog presented with acute vomiting and lethargy. Computed tomographic findings in all dogs with surgically confirmed colonic torsion include: "whirl sign," displacement and distension of the cecum and colon, focal narrowing of the colon, and distension of the mesenteric vasculature in all dogs (5/5); streaky peritoneal fat and peritoneal effusion (4/5), pneumatosis coli (2/5), small intestinal distension (2/5), portal vein thrombosis (1/5), and reduced colonic wall contrast enhancement (1/5). In all dogs (5/5), the torsion site was the descending colon and demonstrated an anticlockwise rotation. At surgery, three of the five dogs had a partial colonic torsion with hyperemia at the site of obstruction and two of the five dogs had a complete torsion with marked necrosis of the colonic wall. Displacement of the colon and cecum, segmental distension and focal narrowing of the colon, the presence of a "whirl sign" and distension of the mesenteric vasculature are CT findings highly suggestive of colonic torsion.

Immuungemedieerde hemolytische anemie geassocieerd met chronisch fibroserende mediastinitis bij een Arabo-Fries paard

In deze casuïstiek wordt een tienjarige ruin beschreven met immuungemedieerde hemolytische anemie geassocieerd met chronische fibroserende mediastinitis van onbekende oorsprong. De patiënt leed aan chronisch gewichtsverlies en intermitterende diarree en werd aangeboden in de kliniek met uitgesproken anemie, anorexie en koorts die reeds 24 uur aanwezig was. Een directe Coombs’ test was sterk positief voor IgG-autoagglutinatie. Bij het klinisch onderzoek werd geen onderliggend patho-logisch proces van de immuungemedieerde hemolytische anemie gevonden. Post-mortemonderzoek toonde groene vloeistof met voedselpartikels in het craniale mediastinum aan. Histologisch onderzoek suggereerde chronische fibroserende mediastinitis. Hoewel slokdarmperforatie hiervoor een mogelijke oorzaak is, werden bij macroscopisch onderzoek geen tekenen van ruptuur waargenomen. In deze casereport wordt aangetoond dat bij niet-responsieve, immuungemedieerde hemolytische anemie, een niet-gedetecteerde onderliggende pathologie, zoals chronische mediastinitis, aanwezig kan zijn.

2649 A Case of Primary Intestinal Lymphangiectasia in an African American Adult Male With Intermittent Abdominal Pain and Diarrhea

INTRODUCTION: Primary intestinal lymphangiectasia is a rare type of protein losing enteropathy in which there is a localized or diffuse ectasia of the enteric lymphatic causing leakage of protein into the intestinal lumen. Here, we describe a case of Primary Intestinal Lymphangeictasia in a patient presenting with chronic intermittent abdominal pain and diarrhea. CASE DESCRIPTION/METHODS: Patient is a 56-year-old African-American male with history of COPD, DM, morbid obesity, GERD who presented to our office as a referral after hospitalization for for evaluation of abdominal pain and diarrhea. Patient was hospitalized for 3 day duration of epigastric pain and watery diarrhea. There, he was noted to have hypocalcemia, hypoalbuminemia, and trace urine proteinuria. Lactate was normal. CT abdomen pelvis showed nonspecific Jujenitis. He was treated empirically with Intravenous antibiotics and discharged home. During follow up visits, initial comprehensive workup for inflammatory bowel disease, celiac disease, stool pathogens, thyroid panel, lipid panel, Alpha-1-Antitrypsin stool clearance, and HIV were all unremarkable. Patient subsequently underwent colonoscopy and EGD. Colonoscopy revealed sigmoid diverticulosis and internal hemorrhoids. EGD revealed nonspecific jejunitis. He had yet another hospitalization for worsening similar acute abdominal pain. During his second hospitalization, labs showed mild leukocytosis, CT abdomen and pelvis revealed jejunal edema. He was taken for diagnostic laparoscopy which only showed mild ascites and thickening of the jejunum. Surgical pathology unfortunately was inconclusive. Patient followed up again as an outpatient and underwent small capsule endoscopy which revealed lymphangiectasia at the jejunum. Patient was referred to a dietitian where he was placed on high protein and Medium chain triglycerides diet. DISCUSSION: Primary Intestinal Lymphangeictasia is a rare cause of protein losing enteropathy that can manifest as non-specific abdominal pain and diarrhea. In this case, the patient had chronic intermittent abdominal pain and diarrhea which required capsule endoscopy in order to diagnose and was missed on surgical pathology. Much like an Inflammatory Bowel disease which can take several studies and biopsies in order to diagnose, albeit different pathophysiology, Primary intestinal lymphaniectasia is a rare cause of abdominal pain that should be on the differential when evaluating chronic intermittent severe abdominal pain and diarrhea of unknown etiology.

2598 Jejunal Lymphocytic Enteritis: An Unusual Location for a Rare Condition

INTRODUCTION: Lymphocytic enteritis (LE), a subclassification of microscopic enteritis (ME), is defined as abnormal infiltration of intraepithelial lymphocytes (IELs) in the gastrointestinal mucosa. Causes include gluten exposure, H. pylori (Hp) infection, small intestinal bacterial overgrowth, autoimmune conditions, irritable bowel syndrome, or medications such as proton pump inhibitor (PPI), NSAIDs, and selective serotonin reuptake inhibitors. A majority of cases are found in the colon or duodenum; we report a rare case of jejunal LE. CASE DESCRIPTION/METHODS: A 51-year-old man with untreated Hp and diabetic gastroparesis, on chronic pantoprazole, presented with chronic intermittent watery diarrhea, diffuse abdominal pain, nausea, vomiting, and generalized malaise. A CT showed jejunal mucosal thickening. The jejunal mucosa appeared normal by deep enteroscopy; a subsequent colonoscopy was also normal. Jejunal pathology demonstrated IELs with normal villous architecture consistent with LE; colon biopsies were negative for IEL. Laboratory tests were remarkable for iron deficiency anemia, but otherwise negative for other nutritional deficiencies, transglutaminase antibodies, or IgA deficiency. The patient received 10 days of solumedrol and concomitant Hp therapy; the PPI was then stopped. His diarrhea improved and repeat enteroscopy demonstrated resolution of jejunal LE. DISCUSSION: LE is a rarely diagnosed subclass of ME, but growing epidemiologic trend confirms that it will become a common condition in clinical practice. Multiple potential causes have been identified and treatment includes steroids, and/or addressing the underlying cause. Our patient had at least two potential causes: Hp and PPI use. Due to the unusual location of his LE and his severe illness, we treated multiple possible causes at the same time, with notable clinical and histologic improvement. This case demonstrates the success of standard treatment modalities for a unique anatomical location of a rare condition. With increasing disease prevalence, LE represents a novel entity that warrants further investigation. Subsequent care will be dictated by his clinical course, and repeat biopsies if necessary.

3041 Eosinophilic Colitis: A Rare Entity

INTRODUCTION: Eosinophilic colitis (EC) is a rare entity characterized by abnormal infiltration of colon mucosa by eosinophils without evidence of any secondary causes. Presentation may include asymptomatic state, chronic diarrhea, abdominal pain, rectal bleed, bowel obstruction or ascites. We present two cases of EC with very different presentations requiring minimal or no therapy. CASE DESCRIPTION/METHODS: CASE 1: 57 year old Filipino male presented with abdominal pain and new onset ascites. Paracentesis revealed elevated SAAG suggestive of portal hypertension. Imaging studies were negative for cirrhosis. Negative liver workup for chronic liver disease. Lab studies revealed microcytic anemia and peripheral eosinophilia of 10%. No eosinophilia noted in ascitic fluid. EGD showed LA Grade C esophagitis. Colonoscopy showed multiple polyps which were removed. Pathology from polyps showed markedly increased eosinophil infiltrate in mucosa and submucosa. There was no evidence of inflammatory bowel disease, Stool studies were negative for infectious etiology. No incriminating medications were found which could lead to above finding. The patient was treated with omeprazole and diuretics with complete resolution of symptoms. CASE 2: 27 year old female presented with chronic intermittent abdominal pain, nausea and diarrhea for 2 years. Her only medications were birth control pills. She had normal blood counts, electrolytes, liver, and renal function. Stool studies were negative for any infectious etiology. She had normal fecal fat and electrolytes. EGD and colonoscopy were unremarkable. Biopsies were negative for celiac disease, Helicobacter and eosinophilic esophagitis. Random colon biopsies showed benign colon mucosa with focal infiltration of colonic mucosa with eosinophils suggestive of eosinophilic colitis. There was no peripheral eosinophilia. Patient was started on probiotics with prompt resolution of symptoms. DISCUSSION: EC is a rare condition, included in the group of eosinophilic gastrointestinal disorders, characterized by eosinophil infiltration of colonic mucosa in the absence of any food allergies, parasitic/helminthic infections, drugs, IBD, celiac and autoimmune diseases. The treatment options include dietary modifications, steroids, mesalamine, immunomodulatory agents, fecal microbiota transplant and surgery. The evidence for most of treatment options is limited to case reports. One of our patients required no specific therapy while other one was treated successfully with probiotics.

3071 A Rare Case of Colonic Mucosal Schwann Cell Hammartoma That Mimics a Regular Polyp

INTRODUCTION: Mucosal Schwann cell hammartomas are considered benign and were rarely reported as an incidental finding during colonoscopies. There is a lack of data on outcomes and surveillance guidelines due to the rarity of these unusual polyps. Here we report a case of colonic mucosal Schwann cell hammartoma incidentally found in a patient with intermittent diarrhea to enhance recognition of this rare lesion. CASE DESCRIPTION/METHODS: A 70-year-old-male with history of venous thromboembolism in setting of Factor V Leiden mutation on rivaroxaban had presented to our gastroenterology clinic complaining of chronic intermittent diarrhea without pain, hematochezia, melena, upper GI symptoms, or weight loss. To further evaluate ongoing diarrhea, the patient had a colonoscopy that showed patchy erythematous mucosa of the sigmoid colon with a single polyp measuring 4 mm at the descending colon, which was removed with a cold snare. The polyp showed focal expansion of the lamina propria by a bland spindle cell proliferation (Schwann cells) with no evidence of atypia or mitotic figures. No ganglion cells were noted and by immunostaining the spindle cells were strongly immunoreactive for S100 (Figure 1). Neuron-specific enolase (NSE) and synaptophysin were negative supporting the absence of ganglion cells. The immunoprofile and morphology was consistent with a diagnosis of mucosal Schwann cell hamartoma. Random colon biopsies ruled out microscopic colitis. Follow up visits were suggestive that food intolerances were the likely cause of his intermittent diarrhea. DISCUSSION: Benign nerve sheath tumors are mostly seen in the stomach and are rare in the rest of the gastrointestinal tract. The differential diagnosis is wide including neurofibromas, perineuromas, ganglioneuromas, granular cell tumors, gastrointestinal stromal tumors, carcinoid, and leiomyoma. Although there are common histological features of neural tumors, the immunostaining pattern is necessary to differentiate them from one another. Due to its rare occurrence, the exact incidence and prevalence of mucosal Schwann cell hammartoma is unknown. This distinction is important as this lesion has no association with any inherited polyposis syndrome and has a benign clinical course.

3227 Can a Gluten-Free Diet Be an Option in Treating Collagenous Colitis in the Absence of Celiac Disease?

INTRODUCTION: Collagenous colitis (CC), a subtype of Microscopic Colitis, is known to cause chronic diarrhea in the elderly. Steroid medication, particularly budesonide, has been rigorously studied and shown to be effective, leading to remission. Few studies have revealed the role diet has on decreasing these symptoms. CASE DESCRIPTION/METHODS: 69 y/o male with past medical history of chronic intermittent diarrhea for the past thirteen years. He initially presented with recurrence of non-bloody watery diarrhea, alternating with constipation and fecal incontinence for 2 weeks. Previous colonoscopy performed thirteen years ago revealed normal mucosa with diverticulosis. Further workup revealed a negative tTG- IgA, polypharmacy, or an infectious etiology. Labs were unremarkable. He underwent repeat colonoscopy, which demonstrated a fractured and nodular appearance of the cecum and ascending colon with small tears. Biopsies showed a focal increase in intraepithelial lymphocytes with a positive trichrome stain consistent with the diagnosis of CC. He was started on a GFD trial and had complete remission of his symptoms for three years. DISCUSSION: Chronic diarrhea affects approximately 5% of the population and at times can be challenging for gastroenterologists. When working up chronic diarrhea, microscopic colitis and celiac disease often play a large role. In this case, the patient was diagnosed with CC, however symptoms resolved on a GFD alone despite having multiple negative TTG levels. We believe that the multiple negative TTG levels were indicative of negative celiac disease. However, there is evidence showing that gluten can induce microscopic colitis. However, in women dietary gluten intake may not be a risk factor for the development of microscopic colitis in the absence of celiac disease. Nevertheless, the effects of gluten may be different in male veterans. CC is usually treated with a steroid based regimen, budesonide, to obtain remission. There are limited studies that have evaluated the impact that a GFD has upon the symptoms and histological findings in CC. Use of these medications can be associated with hyperglycemia, hypertension and metabolic bone disease which may be detrimental to the patient's health and prognosis. In conclusion, in patients diagnosed with CC consider starting a trial of GFD. Further studies are needed to evaluate the response of how a GFD affects the spectrum of severity in symptoms and histologic findings in patients diagnosed with CC, specifically in male veterans.

Hyperammonemia in a Child Presenting with Growth Delay, Short Stature, and Diarrhea

A 5-year-old male child was referred to the metabolism clinic with a history of failure to thrive, chronic intermittent emesis, diarrhea, seizures, hypotonia, and growth hormone deficiency. He was also noted to experience frequent falling episodes. Routine biochemistry testing revealed increased plasma ammonia concentration at 184 μmol/L (reference interval, 16–47) and lactate dehydrogenase concentration at 445 U/L (reference interval, 110–295). Plasma free and total carnitine concentrations were decreased at 5 μmol/L (reference interval, 26–60) and 17.1 μmol/L (reference interval, 32–84), respectively. Orotic acid excretion in urine was also markedly increased at >80 mmol/mol creatinine (reference interval, 0.2–1.5). Plasma insulin-like growth factor-I (IGF-I)4 concentration was also decreased at <25 ng/mL (reference interval, 50–286). Paired plasma and urine specimens were collected for amino acid analysis using ultraperformance liquid chromatography. The results are shown in Table 1. View this table: Table 1. Amino acid analysis of paired plasma and urine. This patient has lysinuric protein intolerance (LPI), an autosomal recessive disorder of amino acid transport, caused by mutations in the solute carrier family 7, member 7 ( SLC7A7 ) gene (1, 2, 3). Although the worldwide incidence is not known, LPI is estimated to occur in approximately 1 in 60000 newborns in Finland and Japan (2). The SLC7A7 gene product is the …

Salmonella enterica subsp. diarizonae serotype 61:k:1,5,(7) associated with chronic proliferative rhinitis and high nasal colonization rates in a flock of Texel sheep in Switzerland

Salmonella (S.) enterica subspecies diarizonae (IIIb) serovar 61:(k):1,5,(7) (S. IIIb 61:(k):1,5,(7)) is considered to be host adapted to sheep and is found regularly in feces of healthy carriers and of sheep with salmonellosis.A few cases of chronic proliferative rhinitis (CPR) in sheep have been described as a new disease in association with S. IIIb 61:k:1,5,(7) in the USA, in Spain and now for the first time in Switzerland. Three animals of a flock of Texel sheep suffering from chronic nasal discharge and dyspnea with subsequent death were necropsied. The pathological lesions are consistent with a severe proliferation of the nasal mucosae of the turbinates in association with severe chronic inflammation. S. IIIb 61:(k):1,5,(7) was isolated from the lesions by direct bacteriological culture and the presence of Salmonella spp. was confirmed by immunohistochemistry. The affected flock was systematically tested after the first occurrence of the disease. Clinical examination of the flock revealed approx. 20% of the adult sheep to show nasal discharge, approx. 5% having severe dyspnea and approx. 5% having chronic intermittent diarrhea. Lambs (n=28) showed no clinical signs at all. High positivity of nasal mucosa (46%), but low prevalence in feces (6%) for S. IIIb 61:k:1,5,(7) was found. The results lead to the assumption of a direct animal to animal transmission by nasal discharge followed by a chronic disease leading to death after several months to years. Animals tested positive for S. IIIb 61:k:1,5,(7) were all >1year old. CPR represents a chronic disease in adult sheep posing a risk for spreading S. IIIb 61:k:1,5,(7) between flocks and with a zoonotic potential.

Behçet's disease with multiple splenic abscesses in a child.

We report the case of a 5-year-old male patient with multiple aseptic splenic abscesses associated with Behçet's disease. The patient visited Gachon University Gil Hospital with fever, abdominal pain, and acute watery and bloody diarrhea, and reported a 2-year history of chronic abdominal pain and intermittent watery diarrhea. He was treated with antibiotics at a local clinic for fever and cervical lymph node swelling. Additionally, he had recurrent stomatitis. A colonoscopy showed multiple well-demarcated ulcerations throughout the colon, and abdominal computed tomography showed multiple splenic abscesses. Pathergy and HLA-B51 tests were positive. Investigations did not reveal any infectious organisms in the aspirate obtained via ultrasound-guided fine needle aspiration. After steroid treatment, all symptoms and multiple aseptic splenic abscesses resolved. However, oral ulcers, genital ulcers, and abdominal pain recurred after tapering the steroids. Infliximab treatment improved the patient's symptoms. However, 5 months after the treatment, the symptoms recurred. The treatment was changed to include adalimumab. Subsequently, the patient's symptoms resolved and colonoscopic findings improved. No recurrence was noted after 3 months of follow-up.

Functional diarrhea - pathophysiology, investigation and treatment

The most important reason for functional diarrhea in clinical practice is diarrhea-predominant irritable bowel syndrome (IBS) which is characterized by chronic intermittent diarrhea and abdominal pain. The pathophysiology underlying IBS is complex and includes visceral hypersensitivity, abnormal gut motility and autonomous nervous system dysfunction as well as genetic and psychosocial factors. Treatment should be tailored to the individual's symptoms and involves general measures, pharmacological treatments, dietary interventions, psychotherapy and complementary and alternative approaches. The following manuscript will give an overview over pathophysiology, reasonable investigations and treatment of IBS.

Unexpected Crohn’s Disease after a Free Gastrointestinal Perforation

A 46-year-old male with history of chronic intermittent diarrhea and chronic lower-back pain was presented to our clinic with sudden diffuse abdominal pain irradiated to both shoulders. He had been on nonsteroidal antiinflammatory drugs (NSAIDs) and prednisone (5–20 mg POq24h) for three years with partial back pain relief. Physical examination revealed diffuse tenderness and rigid abdomen with no bowel sounds. X-ray of chest showed a pneumoperitoneum (Figure 1). A diagnosis of a possible peptic ulcer perforation was made. He was immediately managed with intravenous volume, nasogastric tube, intravenous proton-pump inhibitor (PPI), broadspectrum antibiotics, and urgent laparotomy. During surgery a 3–4 mm perforation 50 cm before the ileocecal valve was found along with multiple focal mucosal ulcerations (Figure 2). Partial bowel resection with an ileostomy was made. Erythrocyte sedimentation rate and C-reactive protein were elevated and a macrocytic anemia with low levels of serum B12 was documented. The ileum biopsy revealed focal ulcerations across the ileum wall with acute/chronic inflammation and no sign

Mycobacterium genavense and Chronic Intermittent Diarrhea in a Kidney and Pancreas Transplant Recipient

Mycobacterium genavense and Chronic Intermittent Diarrhea in a Kidney and Pancreas Transplant Recipient

Gastric Somatostatinoma: An Extremely Rare Cause of Upper Gastrointestinal Bleeding

A 49-year-old woman presented with chronic abdominal discomfort, significant weight loss, and chronic intermittent diarrhea. She suddenly developed massive upper gastrointestinal bleeding and was referred for further treatment. Endoscopy indicated a large mass in the upper gastric body with antral and duodenal bulb involvement. Endosonography showed a large well-defined isoechoic gastric subepithelial mass with multiple intra-abdominal and peripancreatic lymphadenopathy, suspected to be malignant on the basis of fine needle aspiration cytology. The tumor was surgically removed, and histopathology showed typical characteristics of a neuroendocrine tumor. On the basis of immunohistochemical staining, somatostatinoma, a rare neuroendocrine tumor, was diagnosed. Gastrointestinal bleeding is a rare presentation and the stomach is an uncommon tumor location.

57-Year-Old Man With Fever, Rash, Chronic Watery Diarrhea, Cough, and Sweats

57-year-old previously healthy man from Minnesota presented for evaluation of chronic intermittent diarrhea, cough, and sweats of 6 months’ duration. The symptoms started while he was in Fiji (to which he travels to annually) with an urticarial, nontender, nonvesicular rash sparing mucosal surfaces that resolved after 2 days. One week after the rash resolved, he experienced intermittent productive cough, dyspnea, malaise, and diarrhea. Chest radiography in Fiji revealed a left pulmonary infiltrate. He received antibiotics without improvement. He also continued to have watery, nonbloody diarrhea, about 10 bowel movements per day. Because of his illness, he returned to the United States. His condition transiently improved for about 10 days after his return, but the symptoms, including cough, fever, chills, and diarrhea, recurred. He therefore presented to our clinic for further evaluation.