Chronic Loose Stools Research Articles

P1139 Lymphocytic Colitis: A large case series in the United Kingdom

Abstract Background Lymphocytic colitis, a type of microscopic colitis, was previously thought to be a rare condition. It is a histological diagnosis characterised by chronic loose stools and normal findings on endoscopy. It is now thought that it could be implicated in up to 10% of people with chronic diarrhoea, and has traditionally been associated with certain medications. We conducted a retrospective case analysis of patients diagnosed with the condition on histology between January 2018 till December 2022. Methods A list of patients who had undergone colonoscopy and biopsy for chronic diarrhoea, with no evidence of inflammatory bowel Disease (IBD), was generated. The patient’s electronic health records were then manually analysed, and data was collected using certain parameters including presence of autoimmune disease, faecal calprotectin levels/QFIT, smoking status, medication use (NSAIDS, PPI, Statins or SSRIs), colonoscopy findings, treatment choice and treatment outcomes. 121 patients were eligible based on histopathology consistent with a diagnosis of lymphocytic colitis. Results The median age was 63, with a 3:2 split of female to male patients. 63% reported painless, chronic diarrhoea lasting more than 6 weeks. 10.7% had painless and bloody diarrhoea, 23% had diarrhoea with abdominal pain. 25.4% had evidence of autoimmune disease. 43% were taking a PPI, 6.6% and NSAID, 41% a statin and 25.6% an SSRI. 27% were active smokers at the time of presentation. 62.8% of patients had a normal colonoscopy report, with the rest having ‘’abnormal reports” due to polyps. Faecal calprotectin levels ranged from 20-954. QFIT was positive in 35% of patients. 34% of patients were treated under a gastroenterologist. Of those who received budesonide only: 46% recovered with no relapse, 20% had relapsed in under 6 months, 16% relapsed after 6 months, 16% did not present again. Of the patients who received loperamide only, 66% reported resolution of symptoms. All histology demonstrated lymphocytosis in the lamina propria, 16% had expansion of the subepithelial collagen band, often termed ‘incomplete Microscopic colitis’. Conclusion Use of PPIs, statins and SSRIs are highly represented in the data, compared with general population usage. Treatment with either budesonide or loperamide generally lead to better symptom control, indicating patients should be referred to gastroenterology upon diagnosis. Clinicians should judiciously prescribe the above medications with clear indication and avoid prescribing indefinitely.

Is mastocytic colitis a specific clinical-pathological entity?

The number of intestinal mast cells (MC) is increased in several types of colitis, but the mucosa of patients with chronic non-bloody diarrhea has not been studied. The current study sought to determine the relationship between MC counts and degranulation and the severity of symptoms in patients with chronic loose stools. Following a negative laboratory workup for the most common causes of chronic diarrhea, patients with chronic non-bloody loose stools were included in the study. Patients with macroscopic evidence of inflammation or organic disease were excluded after endoscopy with biopsies. Biopsies from the 179 patients in the study were stained with hematoxylin and eosin and anti-CD117 c-kit antibodies. Immunohistochemistry was used to assess the degree of MC degranulation. Out of the 179 patients, 128 had normal histologic findings suggestive of irritable bowel syndrome and were used as controls. Twenty-four presented with abnormally high MC counts (≥40 MC x HPF), 23 with ≥20 intraepithelial lymphocytes x HPF suggesting lymphocytic colitis, and 4 had both (≥40 MC and ≥20 intraepithelial lymphocytes x HPF). In the patients with high MC counts, figures were significantly higher in the right colon versus the left colon (p=0.016), but degranulation did not differ in the right versus the left colon (p=0.125). No age or sex-related difference was observed (p=0.527 and p=0.859 respectively). The prevalence of abdominal pain and bloating did not differ in the three groups (p=0.959 and p=0.140, respectively). Patients with lymphocytic colitis (p=0.008) and those with high MC counts (p=0.025) had significantly higher evacuation rates compared to controls. There was no difference between these two groups (p=0.831). Mast cell degranulation was not associated with the number of evacuations, abdominal pain, or bloating (p=0.51; p=0.41; p=0.42, respectively). The finding that a significantly higher number of evacuations was linked to increased MC in the colonic mucosa of a subset of patients with otherwise normal laboratory and endoscopic findings suggests that "mastocytic colitis" may be a new clinical-pathological entity responsible for chronic non-bloody diarrhea. Prospective studies with a larger number of patients, as well as endoscopic and histological follow-up, are needed to confirm this hypothesis.

Chronic loose stools following right-sided hemicolectomy for colon cancer and the association with bile acid malabsorption and small intestinal bacterial overgrowth.

Patients treated with right-sided hemicolectomy for colon cancer may suffer from long-term bowel dysfunction, including loose stools, urgency and faecal incontinence. The underlying causes are poorly understood. The aim of this case-control study was to investigate the aetiology of chronic loose stools among patients with right-sided hemicolectomy curatively operated for cancer. Cases with chronic loose stools (Bristol stool type 6-7) after right-sided hemicolectomy were compared with a control group of patients with right-sided hemicolectomy without loose stools. All patients underwent a selenium-75 homocholic acid taurine (SeHCAT) scan to diagnose bile acid malabsorption (BAM) and a glucose breath test to diagnose small intestinal bacterial overgrowth (SIBO). Gastrointestinal transit time (GITT) was assessed with radiopaque markers. In a subgroup of patients, fibroblast growth factor 19 (FGF19) was measured in fasting blood. SIBO was treated with antibiotics and BAM was treated with bile acid sequestrants. We included 45 cases and 19 controls. In the case group, 82% (n=36) had BAM compared with 37% (n=7) in the control group, p < 0.001. SIBO was diagnosed in 73% (n=33) of cases with chronic loose stools and in 74% (n=14) of controls, p=0.977. No association between BAM and SIBO was observed. GITT was similar in cases and controls. No difference in median FGF19 was observed between cases and controls (p=0.894), and no correlation was seen between FGF19 and SeHCAT retention (rs 0.20, p=0.294). Bowel symptoms among cases were reduced after treatment. BAM and SIBO are common in patients having undergone right-sided hemicolectomy for cancer. Chronic loose stools were associated with BAM but not with SIBO.

1871 Rare Case of Endoscopic Erosive Ulcerations in Celiac Disease

INTRODUCTION: Celiac disease is a common disorder of the small intestine caused by an autoimmune reaction to dietary gluten in the setting of genetic predisposition. Patients can present with a variety of symptoms ranging from diarrhea and unintentional weight loss to extraintestinal signs such as iron deficiency anemia and dermatitis. The diagnosis is confirmed with serologies and duodenal biopsies while a patient is on a gluten-containing diet. Histopathology of the small bowel demonstrates characteristic villous atrophy, mucosal inflammation, or crypt hyperplasia with increased intraepithelial lymphocytes. Gross endoscopic findings are typically normal with occasional endoscopies can show gastritis or atrophy. This is the first case of celiac disease with gross endoscopic findings consistent with non-bleeding erosive gastropathy. CASE DESCRIPTION/METHODS: A 68-year-old Veteran male presents for evaluation of weight loss, left lower quadrant discomfort and chronic loose stools. He denied any dietary changes, changes in appetite, nausea, vomiting, skin lesions, joint pain or recent travel. Endoscopy was performed demonstrating petechial gastropathy in the proximal stomach, mild duodenal bulb erosions with marked transverse-oriented erosions from the second part of the duodenum to proximal jejunum. Jejunal and duodenal biopsies were consistent with Celiac disease without H pylori, intestinal dysplasia or metaplasia. Serum TSH was 0.876, IgA was 276 (normal 58-484 mg/dL), Tissue transglutaminase IgA &gt;100 U/mL and gastrin &lt;15 pg/mL. DISCUSSION: The chronic lymphocytic infiltration triggered by the ingestion of gluten causes the classic histopathological findings. However, endoscopically, celiac disease has not been shown to have significant features outside of scalloped duodenal folds, fissures and grooves. This is the first documented case that presents an endoscopic pattern of erosive ulcerations consistent both histologically and serologically with celiac disease. While biopsy remains the standard of care, further exploration into diagnosing this disease through gross pathology is warranted.

1292 Combined Postcholecystectomy Bile Leak and Benign Biliary Stricture—Should a Temporary Placement of Fully Covered Self-Expanding Metal Stent Be the First Choice?

INTRODUCTION: Bile leaks are common complications seen after cholecystectomy. Endoscopic Retrograde Cholangiopancreatography (ERCP) with the establishment of an enhanced transpapillary flow – through biliary stent placement and/or sphincterotomy – is considered the standard of care and usually has high success rates. Failure of initial endoscopic therapy (complex bile leak) can be managed with the placement of a fully covered self-expanding metal stent (FCSEMS) or surgery. We present a patient in which large postcholecystectomy biloma developed despite the presence of biliary plastic stent in place. CASE DESCRIPTION/METHODS: 48-year-old female with history of chronic pancreatitis and benign distal biliary stricture was admitted with worsening abdominal pain for the last 2 days. One month prior to this episode, the patient was admitted with the diagnosis of acute on chronic pancreatitis. She underwent ERCP with balloon dilatation and placement of plastic biliary (10 Fr × 10 cm) and pancreatic duct (5 Fr × 7 cm) stents. She had cholecystectomy prior to her discharge. Her abdominal pain on readmission was associated with nausea, vomiting, loss of appetite. She has chronic loose stools, which remained unchanged. She denied fevers, chills, or hematemesis. Her vital signs were within normal range. Abdominal exam revealed sluggish bowel sounds and right upper quadrant abdominal tenderness. She had elevated white cell count at 13,900/µL. The rest of the labs including kidney and liver function tests were unremarkable. CT scan of the abdomen showed moderate to large subcapsular and intraperitoneal fluid. There was mild dilatation of the common bile duct with the biliary and pancreatic duct stents in place. Findings were consistent with post-cholecystectomy biliary leak. A right upper quadrant pigtail drain was placed followed by ERCP. Cystic duct stump bile leak was diagnosed and treated with placement of FCSEMS. The patient tolerated the procedure well with improvement of symptoms. Bile leak resolved and FCSEMS was removed after three months. DISCUSSION: Patients with postcholecystectomy bile leak superimposed on a benign biliary stricture are probably appropriate candidates for endoscopic therapy with FCSEMS. Despite their higher costs, initial temporary placement of FCSEMS may obviate additional ERCP sessions in cases of failure of plastic stents. FCSEMS improve drainage since they have larger lumens. They should be considered especially in the presence of biliary prestenotic duct dilatation and high-grade leaks.

Chitin supplementation in the diets of captive giant anteaters (Myrmecophaga tridactyla) for improved gastrointestinal function.

Clinical issues associated with keeping giant anteaters (Myrmecophaga tridactyla) in captivity may be linked with colon health and digestive function. Chronic loose stools are one such problem often suspected to be related to dietary intake. The objective of this study was to determine the acceptability, digestibility and faecal composition in a population of captive giant anteaters on four different experimental diets, including a baseline diet (B) comprising high fibre primate biscuit and dry feline diet, ground and mixed together then blended with water, or a commercial dry insectivore diet (INS), also ground and mixed with water. Other treatments included addition of 5 or 10% of dry matter (DM) as ground chitin added to B. No difference in faecal DM or faecal organic matter content was observed across all experimental diets; faecal ash was increased on B5 compared to B10 or INS treatments, indicating a possible impact on mineral nutrition. Similarly, no differences were observed in DM digestibility, or neutral detergent fibre (NDF) or acid detergent fibre (ADF) fermentation across all diets. The majority of the dietary components of the four different diets are highly digestible and/or fermentable (> 90% for all except fibre fractions). Crude fat and ADIN digestibility, and calcium and magnesium absorption were significantly higher in the diet that was formulated containing 5% chitin. Apparent digestion of NDF (82-91%) or ADF (74-88%), as measures of chitin, did not differ statistically among the diets in this study; ranges of disappearance of these components are high compared to other mammals, but within the ranges reported for other species.

A study of the prevalence of serum vitamin B12 and folic Acid deficiency in Western maharashtra.

Context:This study summarizes the prevalence of vitamin B12 and folic acid deficiency in the population coming to tertiary care center in Western Maharashtra along with the main presenting symptom routinely misinterpreted in daily practice.Aims and Objectives:1. To study the prevalence of vitamin B12 and folic acid deficiency in the population of western Maharashtra. 2. To correlate the symptoms with serum vitamin B12 and folic acid levels.Materials and Methods:The present study is a cross-sectional observation study carried out on patients from western Maharashtra seeking medical attention on outpatient and inpatient basis in the medicine department of a teaching institute in Karad. One-hundred patients were selected on basis of below mentioned symptoms viz. tingling and numbness in extremities, dizziness, unsteady gait, early tiredness, forgetfulness, proximal weakness, distal weakness, chronic headache, less interest in work, chronic loose stools, strict vegetarians, alcoholics, intake of medications like anti-tubercular treatment, surgery involving terminal ileum. Serum vitamin B12 and folic acid levels of these patients were observed. Deficiency of vitamin B12 and folic acid was studied in 4 groups: (a) Absolute vitamin B12 deficiency; (b) Absolute folic acid deficiency; (c) Borderline vitamin B12 deficiency; (d) Combined vitamin B12 and folic acid deficiency.Results:Of the 100 cases, 33% patients were vegetarian. Folic acid deficiency formed the major chunk of deficiency group. Six percent patients had neuropsychiatric manifestations. Depressive illness in 1% patients, dementia in 0% patients, forgetfulness in 1% patients, mania/hallucination in 0% patients each, and chronic headache in 1% patients. Neuropathy in form of loss of reflexes, decreased touch sensation was present in 9% patients. Posterior column involvement viz. Loss of joint position, vibration, positive Romberg's sign were present in 34% patients of vitamin B12 and folic acid deficiency.Conclusion:In a small study, it was found that megaloblastic anemia may have symptoms and signs referable to several systems including hematology, dermatology, gastrointestinal, neurology, and neuropsychiatry.

Clinical Protests Food Allergy in Children

The best recognized intestinal manifestation of food allergy is food allergic (food-sensitive) enteropathy. The feature of enteropathy may include lymphocyte and plasma cell infiltration, epithelial abnormality, or crypt hyperplastic villous atrophy, and impairing absorption, enterophaty continues while the food remains in the diet, remitting on an exclusion diet, and usually recurring on food challenge. Diagnosis is now usually based on histological features at initial biopsy and clinical response to antigen exclusion and challenge. Clinical findings in food allergic enteropathy include abdominal distension, loose stools, micronutrient deficiency, and rarely protein-losing enteropathy. There may be other features of allergic disease, most commonly eczema unlike coeliac disease, food allergic enteropathies are usually transient in early life, and later challenge is usually tolerated. Cow’s milk-sensitive enteropathy (CMSE) was the first recognized food allergic enteropathy and remains the most common cause. The best-characterized syndrome is CMSE, classically presenting with chronic loose stools and failure to thrive, often beginning after an episode of gastroenteritis in a formula-fed infant. Other clinical features include abdominal distension, perianal erythema or napkin rash (due to malabsorbed dietary carbohydrates), and deratographia. Associated clinical features may include colic, gastroesophageal reflux, rectal bleeding, or eczema. There may be evidence of micronutrient deficiency, notably for iron and zinc. Up to 40% of infants with classic CMSE also sensitize to soy, often after an initial period when it is tolerated. The great majority however settle on extensively hydrolyzed formulate. Classic CMSE is usually self-limiting, with most children tolerating reintroduction at the age of 2 to 3 years. By contrast, some children may have persistent low-grade symptoms for a prolonged period. A proportion of children manifest additional immediate reactions to food antigens, such as rash, urticaria, angioedema, or anaphylaxis. However, many children suffer enteropathy without immediate reactions, and it is important to recognize that food allergic entropathy often occurs in the absence of systemic signs of food allergy. Thus, skin prick tests may be negative and specific IgE undetectable. Review of growth records in classic CMSE often shows a period of good weight gain prior to the onset of symptoms, followed by downward drift against the centiles until antigen exclusion is adequate. This presentation probably represents the loss of initially established oral tolerance.