Differential Diagnosis Of Chronic Diarrhea Research Articles

Determination of the Frequency of Celiac Disease in Patients Presenting With Chronic Diarrhea.

Celiac disease (CD) is a chronic inflammatory disorder affecting mainly the digestive system and accounts for more than 50% of adult cases presenting to the gastrointestinal clinic with chronic diarrhea. Therefore, in our study, we aimed to determine the prevalence of CDin patients presenting with chronic diarrhea at the gastroenterology outpatient department of Jinnah Hospital, Lahore. This cross-sectional study was conducted from December 9, 2021, to June 8, 2022, and included 140 patients aged 18 to 50 years with chronic diarrhea. Exclusion criteria were lack of informed consent and history of abdominal trauma or surgery. Data collected included age, gender, family history of CD, and clinical symptoms. Diagnostic measures involved serum tissue transglutaminase antibody IgA and IgGlevels, endoscopy, and duodenal biopsy. Statistical analysis was performed using SPSS version 23 (IBM Corp, Armonk, NY), with a p-value of ≤0.05 considered significant. Among the 140 patients, 80 (57.14%) were males, with a mean age of 21 ± 4.35 years. Common symptoms included weight loss (73.5%), abdominal pain (20.7%), and stunted growth (5.7%). A family history of CD was reported in 14.29% of patients. Endoscopy findings included fissuring of the duodenal mucosa (77.9%), decreased height of duodenal folds (15.7%), and nodularity (6.4%). Histopathological examination revealed Marsh III b (65%), Marsh III c (21.4%), and Marsh III a (9.3%). CD was diagnosed in 23.57% of patients. Significant associations were found between CD and female gender, family history of CD, weight loss, stunted growth, and Marsh III c histopathology. CD was diagnosed in 23.57% of patients with chronic diarrhea. It was more prevalent in females and those with a family history of CD. These findings emphasize the need for considering CD in the differential diagnosis of chronic diarrhea to ensure early detection and management.

Long-standing iron deficiency anemia could be a presentation of non-classical celiac disease: A case report and literature review

Celiac disease (CeD) is a complex disorder characterized by gastrointestinal (GI) symptoms as well as extraintestinal manifestations, sometimes difficult to diagnose. Commonly referred to as a childhood disease, adult CeD is a well-known entity that should be included in the differential diagnosis of chronic diarrhea or malabsorption syndrome. The pathogenesis involves a genetically mediated autoimmune pathway. In individuals with genetic susceptibility, the mucosa of the small intestine is damaged in response to foods containing gluten. The clinical presentation is variable and ranges from typical GI symptoms to extra-intestinal and systemic manifestations. Clinical improvement and restoration of the intestinal mucosa occur simply by eliminating gluten from the diet. We reported a case of CeD in a young man after 6 years of iron deficiency anemia (IDA), without asserting a clear etiology during this time. In our country, the search for CeD in patients with IDA is usually forgotten and we hereby put it in the spotlight.

Olmesartan-associated Enteropathy

Olmesartan,an angiotensin Ⅱ receptor blocker,is a commonly used antihypertensive drug.Several case reports and cohort studies in recent years have described a severe gastrointestinal adverse event with chronic diarrhea,intestinal malabsorption,and weight loss after the administration of olmesartan.In such cases,the patients recovered after discontinuing olmesartan.This adverse effect is called olmesartan-associated enteropathy(OAE).This article reviews the potential pathogenesis and clinical characteristics of OAE,which broadens the disease spectrum for the differential diagnosis of chronic diarrhea and intestinal malabsorption.

Differential diagnosis of chronic diarrhea in patients with HIV infection

Today, when the whole world is overwhelmed by the coronavirus pandemic, few people remember that it was AIDS that was called the plague of the twentieth century. The manifestations of the acquired immunodeficiency syndrome are the terminal stage of infection of the body with the human immunodeficiency virus, which belongs to retroviruses and leads to the development of secondary immunodeficiency. The first case of HIV infection in adults was described in 1981 in America. A young homosexual came to one of the hospitals in the city of San Francisco with a persistent fungal infection. Some time after the treatment, the young man developed pneumonia, from the complications of which he soon died. The human immunodeficiency virus got its name only in 1982, and the disease caused by it began to be called the acquired immunodeficiency syndrome. At present, there are more than 40 million infected people in the world, 2/3 of whom live in Africa; in total, since the beginning of the epidemic, almost 100 million people have been infected with HIV, and the number of victims has doubled the number of people who died in the First World War. Despite the fact that this infection is not airborne or transmitted by contact, the growth rate of this disease continues to shock. Thus, about 5 thousand people get infected with HIV every day in the world; annually about 1 million die from complications of this disease. It should be noted that only 71% of those infected are aware of their status, all the rest continue to serve as a potential source of the spread of this terrible infection.

Acute and chronic diarrhea: a roadmap to differential diagnosis and therapy

Diarrhea is among the most frequently reported symptoms in clinical practice. Acute diarrhea is usually caused by infectious agents with a self-limited disease course. In contrast, differential diagnosis of chronic diarrhea may be challenging. The aim of this review is to provide the reader with an overview on the causes, pathomechanisms, differential diagnosis and clinical management of acute and chronic diarrhea in adults.

Pellagra: A forgotten ailment in current clinical practice

We rarely come across deficiency of niacin in the current clinical practice. Deficiency of niacin (Vitamin B3) leads to pellagra with constellation of symptoms affecting gut, skin, and nervous system. We present a case of nutritional deficiency of niacin presenting as pellagra in a 45-year-old female. The patient was treated successfully with Vitamin B3 supplementation. Pellagra shall be considered in differential diagnosis of chronic diarrhea when associated with skin lesions affecting sun-exposed areas.

Review article: bile acid diarrhoea - pathogenesis, diagnosis and management.

Bile acid diarrhoea results from imbalances in the homoeostasis of bile acids in the enterohepatic circulation. It can be a consequence of ileal disease/dysfunction, associated with other GI pathology or can be idiopathic. To summarise the different types of bile acid diarrhoea and discuss the currently available diagnostic methods and treatments. Bile acid diarrhoea is found in up to 40% of patients diagnosed as having functional diarrhoea/IBS-D, and in up to 80% of patients who have undergone ileal resection. It is likely under-diagnosed and under-treated. In idiopathic disease, errors in regulation feedback of fibroblast growth factor 19 contribute to the development of the condition. Clinical therapeutic trials for bile acid diarrhoea have been used to diagnose it, but the 75 SeHCAT test is the primary current method. It is sensitive, specific and widely available, though not in the USA. Other diagnostic methods (such as serum measurement of the bile acid intermediate 7α-hydroxy-4-cholesten-3-one, or C4) have less widespread availability and documentation, and some (such as faecal measurement of bile acids) are significantly more complex and costly. First-line treatment of bile acid diarrhoea is with the bile acid sequestrant cholestyramine, which can be difficult to administer and dose due to gastrointestinal side effects. These side effects are less prominent in newer agents such as colesevelam, which may provide higher efficacy, tolerability and compliance. Bile acid diarrhoea is common, and likely under-diagnosed. Bile acid diarrhoea should be considered relatively early in the differential diagnosis of chronic diarrhoea.

How to Manage Chronic Diarrhoea

The differential diagnosis of chronic diarrhoea is broad and the evaluation of these patients represents a diagnostic challenge. This review provides a practical approach to reduce unnecessary testing while minimising the oversight of an important disease. Initial investigations include a detailed history, physical examination, and basic laboratory tests. Most younger patients (<50) with normal initial screen have functional diarrhoea. In patients above age 50, colonoscopy is recommended complementary for initial evaluation. In the absence of an identifiable cause, categorizing patients by having inflammatory or non-inflammatory chronic diarrhoea is helpful in directing further evaluation.

Gastro 2013 APDW/WCOG Shanghai Working Party Report: Chronic diarrhea: Definition, classification, diagnosis

Diarrhea is best defined as passage of loose stools often with more frequent bowel movements. For clinical purposes, the Bristol Stool Form Scale works well to distinguish stool form and to identify loose stools. Laboratory testing of stool consistency has lagged behind. Acute diarrhea is likely to be due to infection and to be self-limited. As diarrhea becomes chronic, it is less likely to be due to infection; duration of 1 month seems to work well as a cut-off for chronic diarrhea, but detailed scientific knowledge is missing about the utility of this definition. In addition to duration of diarrhea, classifications by presenting scenario, by pathophysiology, and by stool characteristics (e.g. watery, fatty, or inflammatory) may help the canny clinician refine the differential diagnosis of chronic diarrhea. In this regard, a careful history remains the essential part of the evaluation of a patient with diarrhea. Imaging the intestine with endoscopy and radiographic techniques is useful, and biopsy of the small intestine and colon for histological assessment provides key diagnostic information. Endomicroscopy and molecular pathology are only now being explored for the diagnosis of chronic diarrhea. Interest in the microbiome of the gut is increasing; aside from a handful of well-described infections because of pathogens, little is known about alterations in the microbiome in chronic diarrhea. Serological tests have well-defined roles in the diagnosis of celiac disease but have less clearly defined application in autoimmune enteropathies and inflammatory bowel disease. Measurement of peptide hormones is of value in the diagnosis and management of endocrine tumors causing diarrhea, but these are so rare that these tests are of little value in screening because there will be many more false-positives than true-positive results. Chemical analysis of stools is of use in classifying chronic diarrhea and may limit the differential diagnosis that must be considered, but interpretation of the results is still evolving. Breath tests for assessment of carbohydrate malabsorption, small bowel bacterial overgrowth, and intestinal transit are fraught with technical limitations that decrease sensitivity and specificity. Likewise, tests of bile acid malabsorption have had limited utility beyond empirical trials of bile acid sequestrants.

Five Arab children with glucose-galactose malabsorption

Five children with glucose-galactose malabsorption (GGM) are presented. Two infants from Saudi Arabia were first-degree relatives, the third infant was unrelated and the other two were of Yemeni and Syrian origin, respectively. All the infants had chronic diarrhoea and four had failed to thrive since early infancy. All had stools positive for reducing substances, and sugar chromatography showed glucose and galactose malabsorption. Small bowel biopsies were normal in all. One infant developed gangrene of both legs as a complication of hypernatraemia and dehydration, necessitating bilateral amputation. Two infants had nephrolithiasis. All the infants responded well to fructose-based formulae. GGM should be considered in the differential diagnosis of chronic diarrhoea in infants breastfed or artificially fed from early life.

Toward an objective definition of diarrhea for differential diagnosis of chronic diarrhea in infants and toddlers

Among infants and toddlers with chronic frequent loose stool, normal frequent and loose stool (NFLS) is more common than diarrheal illness with dehydration and nutritional deficiency (DIDN). To identify more objective factors for differentiating between NFLS and DIDN is important. The frequency, mucus content, and microbiological findings of stools, as well as diaper dermatitis are not important factors to significantly differentiate the groups. Instead, a failure to gain weight, fever, colic/abdominal pain, gross blood in stool (except allergic proctocolitis), nocturnal stool, and the score of the stool quantity are important factors to significantly differentiate the groups. A failure to gain weight is also observed even in NFLS, which may come from iatrogenic diet manipulation with nutritionally deficient food. The most objective differential factors are nocturnal stool and the score of stool amount (≥7 points/day). The use of these objective factors could lessen parental anxiety and distress, iatrogenic undernutrition of patients, and socioeconomic loss due to improper medical investigations or inappropriate management of NFLS.

Gaps between Infant Diarrheal Disease and Frequent Loose Stool

Chronic diarrhea in children has a long differential diagnosis, but the clinician can usually distinguish disease from functional diarrhea. A careful history will provide information on medical and dietary problem, growth disturbance, associated symptoms and signs. The extent of laboratory evaluation should be guided by common sense. In the absence of the worrisome historical items noted, or abnormal findings on examination or growth history, reassurance may be all that is required. This article reviewed the diagnostic approach and differential diagnosis of chronic diarrhea, and summarized common non pathologic conditions of chronic diarrhea such as chronic nonspecific diarrhea (toddler’s diarrhea) and secondary lactase deficiency. [Korean J Pediatr Gastroenterol Nutr 2010; 13(Suppl 1): 44∼50]

Fistel zwischen rektosigmoidalem Übergang und Ileum als Komplikation eines AIDS-assoziierten hochmalignen Lymphoms

A 29-year-old man, a known heroin addict until 1984 in whom HIV antibodies had been first demonstrated in 1985, was hospitalized because of fever, nocturnal sweating, weight loss and treatment-resistant diarrhoea. An opportunistic infection of the gastrointestinal tract was excluded microbiologically and serologically. Coloscopy and biopsy revealed a highly malignant gastrointestinal B-cell lymphoma, which had caused a spontaneous rectosigmoid-ileum fistula. Lymphoma infiltrations were also found in the duodenum, jejunum, left lung and brain. Because the underlying disease was far progressed (CD4/CD8 ratio: 0.04) and the patient was in a poor general condition neither surgery nor chemotherapy was undertaken. He died of cerebral lymphoma involvement. Gastrointestinal lymphoma should be included in the differential diagnosis of chronic diarrhoea in HIV-positive patients.

A unique case of collagenous colitis presenting as protein-losing enteropathy successfully treated with prednisolone

A 76-year-old woman with a 5-mo history of recurrent diarrhea and generalized edema was admitted to our hospital. Colonoscopy revealed edematous mucosa, and histopathological examination was compatible with collagenous colitis. Protein leakage from the colon, particularly in the ascending portion, was identified on 99mTc-human serum albumin scintigraphy. Collagenous colitis associated with protein-losing enteropathy (PLE) without small bowel disease was diagnosed. Prednisolone treatment ameliorated diarrhea and hypoproteinemia. Collagenous colitis should be included in the differential diagnosis of chronic diarrhea with hypoproteinemia for appropriate management.

An Uncommon Occurrence of Intestinal Spirochetosis in an Immunocompetent Host

Introduction: Intestinal spirochetosis (IS) is a condition defined morphologically by the presence of spirochetal microorganisms attached to the apical cell membrane of the colonic and rectal epithelium. It is a rare disease and difficult to diagnose, as its symptoms resemble those seen in many other common diseases. It has an increased prevalence in immunocompromised hosts particulary homosexual men and HIV-infected individuals but few symptomatic cases in immunocompetent hosts have been described. Clinical significance in individual cases has remained unclear. There is still controversy as to treatment with antibiotics (metronidazole or Penicillin G) and eradicating organisms will result in symptomatic improvement. Case Report: We report a case of a 54 year old African American male with a 10 year history of intermittent watery diarrhea. He reported upto 4 bowel movements per day with no associated abdominal pain or cramping. He also reported intermittent hematochezia. Patient's only other medical problem included hypertension. Our patient is a painter and also involed in maintainence work on old roofs and claimed to have frequent contact with excreta from birds and rodents including mice. Physical examination of the patient was unrevealing. An initial laboratory workup that included complete blood count, basic metabolic panel, and liver function tests was normal. Stool cultures were negative; however, the presence of bright red blood and diarrhea prompted a colonoscopy which showed a normal appearing colonic mucosa throughout and moderate sized internal haemorrhoids. Random colon biopsies were obtained to evaluate for microscopic colitis which revealed the presence of spirochetes on the surface of colonic epithelium which were confirmed by positive staining with Dieterle stain. The patient was treated with metronidazole 500 mg 3 times per day for 14 days, and showed improvement. Intestinal spirochetosis should be included in the differential diagnosis of chronic diarrhea not only in immunocompromised but also in immunocompetent patients. A colonoscopy with biopsy will aid in the diagnosis of this disorder. Treatment with metronidazole or penicillin G should be considered in symptomatic patients with intestinal spirochetosis.

Chronic diarrhoea-all in the bowel?

Chronic diarrhoea is a common presenting symptom of patients attending gastroenterology clinics. When routine tests fail to reveal a cause for the diarrhoea, rarer causes need to be excluded. We report such a case where a diagnosis of medullary thyroid carcinoma (MTC) was eventually made. The patient underwent radical surgery with amelioration of her symptom. Diarrhoea is rarely the presenting symptom of MTC but it should be considered in the differential diagnosis of chronic diarrhoea. Measurement of serum calcitonin should be included in the investigation of difficult chronic diarrhoea.

Chronic diarrhoea-all in the bowel?

Chronic diarrhoea is a common presenting symptom of patients attending gastroenterology clinics. When routine tests fail to reveal a cause for the diarrhoea, rarer causes need to be excluded. We report such a case where a diagnosis of medullary thyroid carcinoma (MTC) was eventually made. The patient underwent radical surgery with amelioration of her symptom. Diarrhoea is rarely the presenting symptom of MTC but it should be considered in the differential diagnosis of chronic diarrhoea. Measurement of serum calcitonin should be included in the investigation of difficult chronic diarrhoea.

Massive Trichuris trichiura Infection as a Cause of Chronic Bloody Diarrhea in a Child

The differential diagnosis of chronic diarrhea is extensive and requires the investigation of several diseases, such as celiac disease, inflammatory bowel disease and irritable bowel syndrome. A few patients infected by Trichuris trichiura may present a chronic dysentery-like syndrome in the context of a massive infestation of the colon leading to anemia and growth retardation, but the rarity of that finding demands a high level of suspicion. Herein we report the case of an 8-year-old boy from the rural zone who had suffered diarrhea without blood or mucus for 4 years and was taken to our Service because his mother had noticed the presence of blood on the feces on the 3 previous months. The diagnosis of a massive Trichuris trichiura infestation as the cause of the process was only reached by colonoscopy. We stress that Trichuris trichiura infection can mimic other forms of inflammatory bowel disease and lead to physical growth retardation and that prolonged regimens of albendazole may be required to the effective treatment of massive infestations.

Chronic diarrhea

Chronic diarrhea

Diarrhea

Diarrhea is not a single disease, but only a symptom of different diseases. Diarrhea is characterized by an increase in bowel movements (more than three per day) and an increased liquidity of stools. Acute diarrheas are defined as those that last less than four weeks, whereas chronic diarrheas persist for more than four weeks. The pathophysiological basis of diarrhea is a disturbed enteral water- and electrolyte balance, which can be caused by an increased secretion of osmotically active electrolytes (secretory diarrhea) or the increased ingestion of osmotically active substances (osmotic diarrhea). The stool characteristics allows to distinguish watery, bloody and fatty diarrhea. Acute diarrheas are mostly caused by an infectious agent (viruses, bacteria and parasites), whereas the differential diagnosis of chronic diarrhea is considerably larger and therefore the diagnostic work-up is more complex.