Severe Chronic Diarrhea Research Articles

EFFECT OF CARBOHYDRATE(CHO) CONCENTRATION IN A “SEMI- ELEMENTAL” INFANT FORMULA ON TOLERANCE AND MACR0- NUTRIENT ABSORPTION IN INFANTS WITH CHRONIC DIARRHEA

To determine the effect of CHO concentration in infant formula on tolerance and macronutrient absorption, we studied 12 lactose-intolerant males (age x±SD 5.7±2 mo) with chronic diarrhea and malnutrition. In 2 successive metabolic balances infants received a semi-elemental formula that contained high CHO (HCHO) (9.1 g/dl) or low CHO (LCHO) (6.7 g/Dl). Formulas were isocaloric; the difference in CHO content was counterbalanced by the amount of fat. Breath was collected for H2. Fecal fat, osmolality, N, and energy were determined and energy-derived from fecal CHO was calculated. Mean daily caloric intake was not significantly different between the 2 periods (x±SD was 114±26 vs 117±28 kcal/kg/d; HCHO vs LCHO, respectively). No significant difference was seen between the 2 periods in: wt gain/g body wt during the 3 d of each balance, peak H2 levels, fecal N, and osmolality. LCHO formula was tolerated better than HCHO as shown by a significantly lower stool output (x±SD 387±230 g vs 764±443, respectively, [p<0.05]), higher fecal pH (p<0.05), and lower amount of fecal CHO determined at bedside (p<0.05), Macronutrient absorption was also better during the ingestion of LCHO formula as shown by significantly lower amounts of total fecal energy, lower CHO excretion (p<0.05), and a better coefficient of fat absorption (p<0.001). CHO content had an overriding effect on nutrient absorption and formula tolerance in infants with severe chronic diarrhea.

A Carbon‐13 Breath Test to Characterize Glucose Absorption and Utilization in Children

SummaryAfter the administration of a 59% glucose‐water solution that contained tracer amounts of the stable non‐radioactive isotope 13C, breath samples were collected from five children with congenital glucose‐galactose malabsorption and five with severe small bowel villous atrophy and chronic diarrhea. The 13CO2, breath test curves of the children with the congenital malabsorption and chronic diarrhea were compared with each other and with those from three healthy children and four infants with severe malnutrition but no diarrhea. The breath test curves from the children with glucose‐galactose malabsorption and from those with diarrhea were significantly different from those of the other two groups, a finding consistent with impairment of glucose absorption. The [13C]glucose breath test clearly identified the children with severe glucose malabsorption. Further studies are required to determine whether less severe cases of carbohydrate malabsorption also can be identified using the parameters described in our study.

A carbon-13 breath test to characterize glucose absorption and utilization in children.

After the administration of a 5% glucose-water solution that contained tracer amounts of the stable nonradioactive isotope 13C, breath samples were collected from five children with congenital glucose-galactose malabsorption and five with severe small bowel villous atrophy and chronic diarrhea. The 13CO2 breath test curves of the children with the congenital malabsorption and chronic diarrhea were compared with each other and with those from three healthy children and four infants with severe malnutrition but no diarrhea. The breath test curves from the children with glucose-galactose malabsorption and from those with diarrhea were significantly different from those of the other two groups, a finding consistent with impairment of glucose absorption. The [13C]glucose breath test clearly identified the children with severe glucose malabsorption. Further studies are required to determine whether less severe cases of carbohydrate malabsorption also can be identified using the parameters described in our study.

Acquired immunodeficiency syndrome (AIDS) in Africa. A review.

Acquired immunodeficiency syndrome (AIDS) has been reported in patients from Zaire Congo Rwanda Kenya Burundi Angola Mali Central African Republic Gabon Cameroon Chad Zambia and Uganda. Preliminary data suggest that AIDS occurs endemically in Central Africa. Most African AIDS patients do not belong to the major high risk groups identified in the US and the disease occurs with almost equal frequency in both sexes. African patients generally have multiple sexual partners have traveled frequently and often have a history of sexually transmitted diseases. The most striking clinical manifestations of AIDS in African patients are profound weight loss severe chronic diarrhea and fever of unknown origin. Generalized lymphadenopathy has been detected in 50% of Zairian AIDS patients and in 76% of Rwandan AIDS patients. Opportunistic infections and malignancies found in African AIDS patients have included thrush cryptococcosis cryptosporidiosis and Isospora belli infection herpes simplex infection cytomegalovirus infection aggressive Kaposis sarcoma Pneumocystis carinili pneumonia Strongyloidasis tuberculosis generalized atypical mycobacterial infection cerebral toxoplasmosis and cerebral lymphoma and parasitic infections. Immunologic abnormalities are similar to those found in US AIDS patients. Although the mode of transmission of AIDS in Africa remains unknown the possible role of scarifications unsterile injections and transfusions needs investigation. Preventive measures recommended include avoidance of sexual contact with multiple partners use of condoms when the sexual partner belongs to a risk group and use of properly sterilized syringes and needles.

Treatment of chronic secretory diarrhea of unknown origin by lithium carbonate

A 49-yr-old patient developed severe chronic secretory diarrhea associated with hypokalemia and gastric hypochlorhydria. Small bowel perfusion study revealed active proximal intestinal secretion. Despite thorough investigation, the cause of her secretory diarrhea was not elucidated. Her diarrhea was refractory to indomethacin, prednisone, and trifluoperazine therapy. The life-threatening profuse watery diarrhea responded, however, to oral lithium carbonate, an agent reported to inhibit cyclic adenosine monophosphate synthesis. Diarrhea stopped within 4 days of initiation of lithium chloride therapy. Discontinuation of lithium 2 wk later resulted in return of watery diarrhea. Lithium therapy was reinstituted and her diarrheal symptoms resolved completely. Three months later, lithium carbonate was discontinued. The patient continued to be well and remained asymptomatic 15 mo after discontinuation of therapy. Therefore, in patients with chronic secretory diarrhea in whom exhaustive tests fail to reveal an etiology, a trial of oral lithium therapy may be beneficial in ameliorating the disabling symptoms and could be life-saving.

Chronic diarrhea of unknown origin

We studied 27 patients with severe chronic diarrhea for which extensive investigations carried out at other institutions had failed to reveal a diagnosis. They were studied by standard diagnostic methods as well as by careful fecal analysis and intestinal perfusion. If they were incontinent of feces, anal sphincter function tests were performed. Although many were suspected of having pancreatic cholera syndrome, this diagnosis could not be established in a single patient. The most common diagnosis that could be established was surreptitious ingestion of drugs (laxatives in 7 patients and diuretics in 2). Other specific diagnoses included ulcerative colitis in 2 patients, allergy to beef in 1, and bacterial over-growth of the small intestine in 1. Thus, we were able to establish a specific diagnosis in 13 patients. Of the remaining 14 patients, 8 had findings suggestive of irritable bowel syndrome, and 2 others had anal sphincter dysfunction as the major cause of their disability. The other 4 undiagnosed patients had severe secretory (3 patients) or osmotic (1 patient) diarrhea. Follow-up interviews at 6 mo-6 yr failed to reveal evidence of a cause for diarrhea that had been overlooked during our studies. The diagnostic approach to patients with unexplained diarrhea is discussed. The importance of a search for surreptitious drug ingestion and accurate measurement of bowel movement frequency and stool weight is emphasized.

471 ISOLATED INTESTINAL BILE ACID (BA) MALABSORPTION, A CAUSE OF CHRONIC DIARRHEA

We studied a 5 year old girl from early infancy with severe chronic diarrhea, steatorrhea and growth failure. Intestinal structure, pancreatic function, liver function and structure and a laparotomy all were normal. During the first 2 years of life BA levels in duodenal juice were consistently below the critical micellar concentration. In recent studies fecal BA were 7 times normal, serum BA by radioimmunassay failed to rise significantly after meals or after oral taurocholate and in duodenal juice, dihydroxy predominated over trihydroxy BA. Pool sizes of cholate and chenodeoxycholate, by isotope dilution were reduced to 6 and 23%, serum cholate T½ was 12% and chenodeoxycholate 7% of normal. Vitamin B12 absorption (Schilling test) at age 4 years was normal. These data lead us to conclude that our patient, who now thrives, suffers from a specific congenital defect of ileal transport of bile acids causing a depleted BA pool and steatorrhea. This defect has not been reported previously.

Intractable diarrhea

Small-intestinal perfusion studies with a triple-lumen tube were performed in the jejunum and ileum of 11 patients with a presumptive diagnosis of pancreatic cholera syndrome (PCS). Ultimately PCS was proven to be present in only 3 patients, whereas 6 were discovered to be taking either laxatives or diuretics surreptitiously. In 2 of the 11 patients the cause of the diarrhea could not be determined. In PCS the major abnormality which we observed was that the jejunal mucosa secreted rather than absorbed when perfused with a plasma-like solution. By contrast, the ileum of the PCS patients absorbed a plasma-like solution in a normal fashion; however, one patient failed to absorb sodium and chloride when a solution with low (50 mM) sodium chloride concentration was perfused in the ileum. The volume of endogenous fluid was high in both the jejunum and ileum, presumably because of proximal small-intestinal secretion. Glucose stimulated sodium movement in an absorptive direction in each patient. Studies were repeated in one PCS patient after tumor removal, and his intestinal absorption of water and electrolytes was normal. Patients with diarrhea due to surreptitious ingestion of laxatives and diuretics showed normal absorption in the jejunum and ileum. This study shows that proximal small-bowel secretion was the major cause for diarrhea in our 3 patients with PCS. This cannot be a consequence of diarrhea per se since it was not found in patients with long-standing diarrhea due to surrepitious drug ingestion. Small-intestinal perfusion studies may be helpful in the diagnosis and management of selected cases of severe chronic diarrhea. On the other hand, measurement of plasma VIP concentration, especially by methods currently used in the United States, is of little use and may be misleading.