Approach to a Child with Chronic Diarrhea

Chronic diarrhea in children is challenging both with regards to etiological diagnosis and for management. Etiology and pathophysiological mechanisms vary widely from neonates to adolescents. Congenital or genetic causes are more frequent in neonates, while infections, allergy and immune-mediated mechanisms are more frequent in childhood. A thorough history and proper physical examination are required to decide for further diagnostic evaluation. The approach to a child with chronic diarrhea should be age specific and based predominantly on the pathophysiological mechanism involved. The nature of the stool like watery, bloody or fatty (steatorrhea) can suggest the probable etiology and organ system involved. After routine tests, evaluation with specific serological tests, imaging, endoscopy (gastroscopy/colonoscopy), histopathology of intestinal mucosa, breath tests or radionuclide imaging may be required to make a definitive diagnosis. Genetic evaluation is important in congenital diarrheas, monogenic inflammatory bowel disease (IBD) and immunodeficiency disorders. Management is aimed at stabilization, nutritional support and etiology specific treatment. Specific therapy can be as simple as exclusion of specific nutrient or as complicated as small bowel transplant. Evaluation and management require expertise and thus patients need to be referred in a timely fashion. This will minimise morbidity including nutritional consequences and improve outcome.

Cow's Milk Protein Allergy

Cow's milk allergy refers to an immunological reaction to milk protein. It is one of the commonest food protein allergies with an estimated prevalence of 0.5% to 3% at 1 y of life. The disease may be IgE or non-IgE mediated or mixed with a wide range of symptoms often involving multiple organ systems. Gastrointestinal manifestations are common in non-IgE disease and may consist of enteropathy, proctocolitis, colic, reflux-like symptoms, constipation, enterocolitis syndrome and eosinophilic esophagitis. The gold standard for diagnosis remains a double-blind placebo-controlled oral challenge. Specific IgE and skin prick tests may predict severe and persistent disease, and aid in deciding on reintroduction or oral immunotherapy; however, they do not contribute to a definitive diagnosis as they indicate only sensitization. In practice, an elimination diet followed by open challenge under medical supervision is often used for diagnosis except when symptoms are severe such as anaphylaxis. Management consists of the elimination of the allergen with resolution of symptoms between 1-4 wk later depending on the type of allergy. Extensively hydrolyzed and Amino acid formulas are used to substitute milk in infants. Soy-based formulas are often utilized in resource-limited settings. Tolerance to the protein develops over time and periodic reintroduction should be attempted every six months after the initial one year of elimination diet. Oral immunotherapy is a newer treatment technique for IgE-mediated disease. There is no firm evidence on prevention apart from recommending breast feeding in early life along with initiating complementary feeding between 4-6 mo age.

Congenital sucrase-isomaltase deficiency in Türkiye; a single center experience

BACKGROUND

Congenital sucrase-isomaltase deficiency (CSID) is a rare inherited carbohydrate malabsorption disorder caused by sucrase-isomaltase (SI) gene variants. In CSID, an autosomal recessively inherited disease, symptoms can also be seen in individuals with heterozygous mutations.

METHODS

The variant spectrum was evaluated retrospectively in individuals who presented with chronic diarrhea between 2014 and 2022 and had undergone genetic testing of the SI gene considering CSID due to diet-related complaints.

RESULTS

Ten patients with chronic diarrhea were genetically evaluated with SI gene sequencing. In patients diagnosed with CSID and whose symptoms improved with enzyme replacement therapy, the genetic mutation zygosity was found to be heterozygous at a rate of 90%. In 10% of the patients, the mutation was homozygous. Limiting consuming sucrose and isomaltose foods reduced the patients' complaints, but the symptoms did not disappear completely. With the initiation of sacrosidase enzyme replacement therapy, the patient's complaints completely disappeared.

CONCLUSION

In CSID, defined as an autosomal recessive disease, clinical symptoms can also be seen in heterozygous cases previously described as carriers, and these patients also benefit from sacrosidase enzyme replacement therapy. In light of these findings, the autosomal recessive definition of CSID does not fully characterize the disease.What is Known:CSID is a rare inherited carbohydrate malabsorption disorder caused by sucrase-isomaltase gene variants.In congenital sucrase-isomaltase deficiency, an autosomal recessively inherited disorder, symptoms can also be seen in individuals with heterozygous mutations.What is new:Severe disease symptoms can also be seen in heterozygous cases, which were thought to be carriers because the disease was previously described as autosomal recessive.Sacrosidase enzyme replacement therapy also eliminates the disease symptoms in patients with heterozygous CSID mutations.This is the second study on sucrase-isomaltase enzyme deficiency pediatric groups in Türkiye and Europe.

Sporadic gastrinoma with refractory benign esophageal stricture: A case report

BACKGROUND

Gastrinoma is characterized by an excessive release of gastrin, leading to hypersecretion of gastric acid, subsequently resulting in recurrent peptic ulcers, chronic diarrhea, and even esophageal strictures. This case report aims to improve awareness and facilitate early diagnosis and treatment of gastrinoma by presenting a rare case of gastrinoma with refractory benign esophageal stricture (RBES). Additionally, it highlights the persistent challenges that gastroenterologists encounter in managing RBES.

CASE SUMMARY

This case demonstrates a patient with gastrinoma who developed RBES and complete esophageal obstruction despite management with maximal acid suppressive therapy, multiple endoscopic bougie dilations and endoscopic incisional therapy (EIT).

CONCLUSION

It is essential to diagnose gastrinoma as early as possible, as inadequately controlled acid secretion over an extended period increases the risk of developing severe esophageal strictures. In patients with esophageal strictures causing complete luminal obstruction, blind reopening EIT presents challenges and carries a high risk of perforation.

Assessment of the triglyceride glucose index in adult patients with chronic diarrhea and constipation

BACKGROUND

Accumulating evidence suggests that the gut microbiome is involved in the pathogenesis of insulin resistance (IR). However, the link between two of the most prevalent bowel disorders, chronic diarrhea and constipation, and the triglyceride glucose (TyG) index, a marker of IR, has not yet been investigated.

AIM

To investigate the potential association between TyG and the incidence of chronic diarrhea and constipation.

METHODS

This cross-sectional study enrolled 2400 participants from the National Health and Nutrition Examination Survey database from 2009-2010. TyG was used as an exposure variable, with chronic diarrhea and constipation as determined by the Bristol Stool Form Scale used as the outcome variables. A demographic investigation based on TyG quartile subgroups was performed. The application of multivariate logistic regression models and weighted generalized additive models revealed potential correlations between TyG, chronic diarrhea, and constipation. Subgroup analyses were performed to examine the stability of any potential associations.

RESULTS

In the chosen sample, chronic diarrhea had a prevalence of 8.00%, while chronic constipation had a prevalence of 8.04%. In multiple logistic regression, a more prominent positive association was found between TyG and chronic diarrhea, particularly in model 1 (OR = 1.45; 95%CI: 1.17-1.79, P = 0.0007) and model 2 (OR = 1.40; 95%CI: 1.12-1.76, P = 0.0033). No definite association was observed between the TyG levels and chronic constipation. The weighted generalized additive model findings suggested a more substantial positive association with chronic diarrhea when TyG was less than 9.63 (OR = 1.89; 95%CI: 1.05-3.41, P = 0.0344), and another positive association with chronic constipation when it was greater than 8.2 (OR = 1.74; 95%CI: 1.02-2.95, P = 0.0415). The results of the subgroup analyses further strengthen the extrapolation of these results to a wide range of populations.

CONCLUSION

Higher TyG levels were positively associated with abnormal bowel health.

Evaluation of chronic diarrhea in patients newly diagnosed with HIV infection through the FilmArray® gastrointestinal panel

INTRODUCTION

The treatment and diagnosis of chronic diarrhea in the immunocompromised patient depends on the ability to rapidly detect the etiologic agents.

AIMS

Our aim was to evaluate the results of the FilmArray® gastrointestinal panel in patients newly diagnosed with HIV infection that presented with chronic diarrhea.

MATERIAL AND METHODS

Utilizing nonprobability consecutive convenience sampling, 24 patients were included that underwent molecular testing for the simultaneous detection of 22 pathogens.

RESULTS

In 24 HIV-infected patients with chronic diarrhea, enteropathogen bacteria were detected in 69% of the cases, parasites in 18%, and viruses in 13%. Enteropathogenic Escherichia coli and enteroaggregative Escherichia coli were the main bacteria identified, Giardia lamblia was found in 25%, and norovirus was the most frequent viral agent. The median number of infectious agents per patient was three (range of 0 to 7). The biologic agents not identified through the FilmArray® method were tuberculosis and fungi.

CONCLUSIONS

Several infectious agents were simultaneously detected through the FilmArray® gastrointestinal panel in patients with HIV infection and chronic diarrhea.

Enterocolitis and other immunotherapy and targeted therapy-related gastrointestinal manifestations: A review for gastroenterologist

New oncologic treatments, particularly immunotherapy (IT), have revolutionized the treatment of advanced-stage malignant tumors. Immune checkpoint inhibitors are the main form of IT and act by increasing T cell activity and the organism's immune response against neoplastic cells. Targeted therapy is another form of IT that acts by inhibiting oncogenes or inflammation signaling and tumor angiogenesis pathways. However, these mechanisms of tumor destruction can interfere with the host's immune self-tolerance or with the mechanisms of epithelial tissue repair and predispose to immune system-mediated adverse events that can affect multiple organs, including the digestive tract. The gastrointestinal manifestations of damage caused by IT can range from low-grade mucositis to ulceration, and in some cases, necrosis and perforation. Any part of the gastrointestinal tract can be affected, but there is greater involvement of the small bowel and colon, with a pattern similar to that seen in inflammatory bowel disease. The most common clinical manifestation is chronic diarrhea. The differential diagnosis includes enteropathogenic infections, especially those caused by opportunistic microorganisms; adverse drug reactions; and other inflammatory and malabsorption disorders. Treatment is guided by damage severity. Mild cases can be treated with antidiarrheals and rehydration in the outpatient setting; moderate cases with hospitalization, systemic steroids, and temporary suspension of IT; and severe cases with immunosuppressants or biologic agents and definitive suspension of IT.

Getting the BS out of Irritable Bowel Syndrome with Diarrhea (IBS-D): Let's Make a Diagnosis

PURPOSE OF REVIEW

Irritable bowel syndrome with diarrhea (IBS-D) is diagnosed when chronic symptoms of abdominal pain accompany loose stools, and alarm features, such as fever, anemia, rectal bleeding, and weight loss are absent. This combination of symptoms makes structural disorders, such as inflammatory bowel disease or cancer, unlikely, but does not exclude other conditions that cause these symptoms. The question is whether making a "positive diagnosis" of IBS-D based on symptoms alone and instituting therapy based on that diagnosis still makes sense.

RECENT FINDINGS

Clinical observations suggest that at least two-thirds of cases of IBS-D can be explained by three mechanisms: a) food intolerances (~ 30-40%), b) bile acid diarrhea (~ 20-30%), and c) disturbed microbial flora (~ 15-20%). Other conditions that are less frequent but can cause IBS symptoms or be confused with IBS include: celiac disease, microscopic colitis, mastocytosis/mast cell activation, and drug side-effects. Many cases of IBS-D have a discoverable, underlying cause that can direct therapy more efficiently.

The incidence of chronic diarrhea decreases with increasing serum calcium levels: a cross-sectional study based on NHANES 2005-2010

BACKGROUND

Chronic diarrhea is difficult to prevent and treat due to its complex etiology and pathogenesis. It places a huge burden on patients and public healthcare. It is known that the regulation of body homeostasis relies heavily on calcium. However, in the general population, the relationship between calcium and chronic diarrhea remains uncertain.

METHODS

We assessed the association between serum calcium and diarrhea using data from the 2005-2010 National Health and Nutrition Examination Survey (NHANES). Serum calcium level was measured from collected blood samples. Diarrhea was assessed using the Bristol Stool Scale (BSFS) (types 1-7). The stability of the results was assessed using logistic regression and sensitivity analysis. The dose-response association between serum calcium and the risk of diarrhea was analyzed using a restricted cubic spline plot.

RESULTS

This study included 12,342 participants. In each of the five models, an increased calcium level was negatively associated with the incidence of diarrhea (OR[95%CI]:0.26 [0.13-0.53], 0.28 [0.14-0.58], 0.4 [0.19-0.82], 0.27 [0.11-0.64] and 0.24 [0.10-0.59], respectively). When serum calcium was analyzed as a categorical variable, a significant association between serum calcium and diarrhea prevalence was found. The restricted cubic spline plot showed a linear relationship between serum calcium and diarrhea. Sensitivity analysis confirmed that the results were stable.

CONCLUSION

The results of our cross-sectional study suggest that a higher level of serum calcium may reduce the incidence of diarrhea. In the future, this finding should be further validated in a randomized controlled trial.

Association between frailty and chronic constipation and chronic diarrhea among American older adults: National Health and Nutrition Examination Survey

BACKGROUND

This study was to explore the relationship between chronic constipation, chronic diarrhea, and frailty in older Americans.

METHODS

This cross-sectional study selected a total of 4241 community-dwelling individuals aged 60 years and older from the 2005-2010 National Health and Nutrition Examination Survey. Frailty was measured using a 49-item frailty index, and a frailty index > 0.21 was defined as a frail status. Chronic constipation and chronic diarrhea were defined as the "usual or most common type of stool" by the Bristol Stool Form Scale (BSFS) Types 1 and 2 and BSFS Types 6 and 7, respectively. Weighted logistic regression analysis was used to examine the relationship between gut health and frailty status. Restricted cubic spline (RCS) curves were built to assess the association between frailty index and stool frequency.

RESULTS

Frailty status was associated with higher odds of constipation in an unadjusted model; however, after further adjusting for confounding variables, the relationship between frailty status and constipation was not statistically significant. We discovered a positive correlation between the frailty status and diarrhea after adjustment for all variables. The frailty index showed a U-shaped relationship with stool frequency, and the frailty index was the smallest at a frequency of 10 stools/week.

CONCLUSION

Negative associations were observed between frailty status and chronic constipation and diarrhea among older adults. Older adults who have a bowel movement frequency of about 10 times per week are the least frail. Future studies are warranted to confirm the causal relationship in this association.

Eosinophilic Colitis, an Uncommon Cause of Diarrhea: Case Report and Literature Review

Eosinophilic colitis and hypereosinophilic syndrome with colic involvement are rare diagnosis that are characterized by wide-ranging gastrointestinal symptoms and idiopathic infiltration of eosinophils in the colon. The diagnostic workup is challenging since there are no standardized criteria. We report a case of a man admitted to the hospital with a history of nonbloody chronic diarrhea. The detailed workup demonstrated blood eosinophilia, and the colonic biopsies revealed extensive eosinophilic infiltration. He was treated with steroids with clinical and analytical improvement. Due to relapsing colitis after therapy withdrawal, he was chronically medicated with 10 mg of prednisolone with ultimate symptom control. This case report describes the diagnostic workup and highlights the most important features of this often underdiagnosed entity.

Fresh-Frozen Plasma as a Low-Cost Replacement of Intravenous Immunoglobulin for the Treatment of Symptomatic Hypogammaglobulinemia

Hypogammaglobulinemia commonly presents with chronic diarrhea. Unfortunately, these patients require intravenous immunoglobulin (IVIG) transfusions of 400-800 mg/kg every 3-4 weeks as a standard treatment for hypogammaglobulinemia. Repeated transfusion of IVIG is costly, and many patients may not be able to afford it. We report the case of a young male with chronic small intestinal diarrhea who was later diagnosed with hypogammaglobulinemia. We treated the patient with fresh-frozen plasma (FFP) and the patient responded favorably. FFP transfusion may be an affordable alternative to IVIG in the treatment of hypogammaglobulinemia.

Inflammatory Bowel Disease

Crohn disease and ulcerative colitis, the predominant forms of inflammatory bowel disease (IBD), occur in approximately 1% of the population and are typically characterized by chronic diarrhea (with or without bleeding), abdominal pain, and weight loss. The diagnosis is based on history, physical examination, laboratory studies, and endoscopic evaluation. Extraintestinal manifestations may coincide with or precede IBD diagnosis. Treatments have markedly advanced in the past decade, resulting in improved outcomes. IBD, itself, as well as immunosuppressive therapy can increase rates of certain conditions, making collaboration between primary care and gastroenterology imperative for ensuring comprehensive patient care.

Approach to Diarrhea

Diarrhea is a common complaint in primary care offices. It affects the patient's quality of life and increases health care resource utilization. Although most cases of diarrhea are acute and self-limiting, there are multiple causes that can lead to serious morbidity and mortality. Likewise, chronic diarrhea can be a sign of a more serious condition and requires thoughtful evaluation. Ultimately, primary care physicians must take an evidence-based and comprehensive approach to diarrhea to appropriately apply health care resources in the interest of patient care.

Functional Diarrhea in Children

Functional diarrhea in children is a disease that has been focused on by both general pediatricians as well as pediatric gastroenterologists across the world. Although it is seen across the pediatric age group from late infancy to adolescence, most still believe that functional diarrhea only occurs in younger children. Recent epidemiological studies have shown that functional diarrhea is prevalent in all subcontinents. The classic clinical features include chronic loose stools with undigested food particles without growth faltering. Although known for long years, pathophysiological mechanisms and therapeutic options are not well explored, and the existing literature is outdated. In this article, authors review the available literature on functional diarrhea, with a reminder that a fresh look is needed to broaden the horizons of understanding of this disease.

Primary Immunodeficiencies in Children Initially Admitted with Gastrointestinal/Liver Manifestations

Purpose

The gastrointestinal system is the most commonly affected organ, followed by the lungs, in patients with primary immunodeficiency disease (PID). Hence, it is common for children with PIDs to present with gastrointestinal symptoms. We aimed to analyze the clinical and histopathological findings of patients who were initially admitted to pediatric gastroenterology/hepatology clinics and subsequently diagnosed with PIDs to identify the clinical clues for PIDs.

Methods

The demographic, laboratory, and histopathological findings, treatment modality, and outcomes of patients initially admitted to the pediatric gastroenterology/hepatology unit and subsequently diagnosed with PIDs were recorded.

Results

The study included 24 patients (58.3% male; median age [range]: 29 [0.5-204] months). Common clinical presentations included chronic diarrhea (n=8), colitis (n=6), acute hepatitis (n=4), and acute liver failure (n=2). The association of autoimmune diseases, development of malignant diseases, and severe progression of viral diseases was observed in 20.8%, 8.3%, and 16.6% of the patients, respectively. Antibody deficiency was predominantly diagnosed in 29.2% of patients, combined immunodeficiency in 20.8%, immune dysregulation in 12.5%, defects in intrinsic and innate immunity in 4.2%, autoinflammatory disorders in 8.3%, and congenital defects of phagocytes in 4.2%. Five patients remained unclassified (20.8%).

Conclusion

Patients with PIDs may initially experience gastrointestinal or liver problems. It is recommended that the association of autoimmune or malignant diseases or severe progression of viral diseases provide pediatric gastroenterologists some suspicion of PIDs. After screening using basic laboratory tests, genetic analysis is mandatory for a definitive diagnosis.

A case of colonic perforation in collagenous colitis without diarrheal symptoms.: A case report

INTRODUCTION

Collagenous colitis is an inflammatory disease characterized by hyperplasia of the collagen band beneath the colonic mucous membrane. Chronic diarrhea is a characteristic clinical symptom. The disease is often diagnosed accidentally on colonoscopy for chronic diarrhea, and patients without chronic diarrhea have few chances to suspect the disease.

PRESENTATION OF CASE

The patient was a 75-year-old woman. The chief complaint was sudden upper abdominal pain and vomiting. There were no important findings regarding the consumed food or bowel habits (no diarrhea). Computed tomography revealed wall thickness and a small amount of free air around the descending colon. An emergency laparotomy was performed with the diagnosis of spontaneous colonic perforation. Intra-operative findings revealed a longitudinal ulcer and micro-perforation to the mesenterial side at the descending colon. Pathological findings revealed subepithelial collagenous band in the submucosal background of the ulcer, and which was diagnosed as collagenous colitis.

DISCUSSION

Intestinal perforation in collagenous colitis is extremely rare. It was considered that perforation was caused by a transient increase in intestinal pressure in the background of collagenous colitis. Further, to the best of our knowledge, this is the first report of a critical case which presented without the characteristic symptom of chronic diarrhea.

CONCLUSION

We report a rare case of colonic perforation of the collagenous colitis.

Fecal calprotectin level in microscopic colitis: a systematic review and meta-analysis

Background

There are no specific biomarkers for microscopic colitis (MC), and the diagnosis depends on histopathological tissue obtained during colonoscopy. Studies on the role of fecal calprotectin (FCP) in MC are limited. A literature search of PubMed, Embase, and Scopus was conducted from each database's inception through September 2022.

Methods

A DerSimonian-Liard random-effects meta-analysis was performed to examine the standardized mean difference (SMD) in FCP levels between patients with MC and control patients with chronic diarrhea.

Results

Six studies with 96 active MC patients and 200 controls were included in the meta-analysis. Random effects meta-analysis revealed that FCP was significantly and moderately elevated in patients with MC compared to the control group (SMD = 0.6 [95% CI 0.3, 1.0], P = 0.001). Imputing one effect size confirmed the observation that FCP is significantly higher in patients with MC than control subjects with chronic diarrhea (SMD = 0.5 [95% CI 0.2, 0.9], P = 0.004). Study heterogeneity between the SMDs was not significant (I2 = 41%, P = 0.1).

Conclusion

These results indicate that FCP levels in patients with chronic diarrhea can help identify patients with MC. More studies with serial measurements of FCP would provide a better understanding of its utility in MC.

Gastrointestinal Eosinophilic Granulomatosis with Polyangiitis following a Clostridium difficile Infection

Eosinophilic granulomatosis with polyangiitis (EGPA), historically named Churg-Strauss syndrome, is a rare vasculitis affecting small- and medium-sized blood vessels. The disease has a predilection for numerous organs including the lungs, sinuses, kidneys, heart, nerves, and gastrointestinal tract but is prominently associated with asthma, rhinosinusitis, and eosinophilia. Gastrointestinal involvement is common; however, a gastrointestinal manifestation as the cardinal symptom following an infection is atypical. Here, we present a case of a 61-year-old male who presented with persistent diarrhea following a toxigenic Clostridium difficile infection despite multiple antibiotic courses. Repeat testing confirmed eradication of the infection, and further evaluation with colon biopsy revealed small and medium-sized vasculitis with eosinophilic infiltration and granulomas. Treatment with prednisone and cyclophosphamide resulted in rapid improvement of his diarrhea. Gastrointestinal symptoms in EGPA are associated with worse prognosis, so prompt identification and treatment of the disease is crucial. EGPA is rarely documented in histopathological samples from the gastrointestinal tract as endoscopic biopsies are typically too superficial to sample the submucosal layer containing the affected vessels. Additionally, the link between EGPA and infections as a potential trigger has not been clearly established, but gastrointestinal EGPA manifesting after a colonic infection raises concerns that this may have been a triggering event. Ultimately, further study is needed to understand, diagnose, and treat gastrointestinal and postinfection EGPA.

Presence of antibodies against Mycobacterium avium subspecies paratuberculosis in Brazilian high-producing dairy herds

This study aimed to determine the presence of antibodies against Mycobacterium avium subspecies paratuberculosis (MAP) in high-producing dairy cows, the presence of the pathogen in the feces, and the risk factors associated with the disease. Blood and fecal samples were collected from 708 dairy cows over 2 years from 54 herds located in five municipalities of Paraná, Brazil. The serum samples were evaluated for the presence of antibodies against MAP using enzyme-linked immunosorbent assay (ELISA). Fecal samples from 100 cows (69 seropositive and 31 seronegative) were assessed using real-time PCR (qPCR) for IS900 of MAP. The herd prevalence of antibodies against MAP was 61.1% (33/54; 95% CI 46.88-74.08), ranging from 12.5 to 80% across the municipalities, and the prevalence in the animals was 9.8% (69/708; 95% CI 7.77-12.15); it ranged from 0 to 87.5% per herd. Only one of the 69 (1.45%) fecal samples from the seropositive cows was positive for the qPCR. The factors associated with the occurrence of paratuberculosis in herds were the use of compost barn system and the type of bed, whereas only the type of bed was associated with the infection of cows. The only risk factor (OR = 2.45; 95% CI 1.03-5.85) associated with the occurrence of paratuberculosis was the introduction of animals purchased from other dairy farms. The prevalence of active infection was low; however, our results demonstrate the presence of MAP in high-producing dairy herds in Paraná state, Brazil.

Microscopic Colitis with Escitalopram Use and New Onset Vitiligo

Microscopic colitis is a common cause of chronic diarrhea, particularly in patients with autoimmune disorders. Colonic mucosa appears normal and only shows inflammation on histological examination. There are two histological variations of microscopic colitis. It has been associated with several drug classes, and certain drugs are associated with one variation or another. In this case report, we discuss the case of a patient who is on a drug not previously associated with her variation of microscopic colitis and who has an autoimmune condition whose relationship to microscopic colitis is not well studied. We aim to outline the potential triggers for the disease and to call for further studies regarding how certain drugs and/or autoimmune disorders trigger it in order to further our understanding and improve management.

Investigating associations between urinary phthalate metabolite concentrations and chronic diarrhea: findings from the National Health and Nutrition Examination Survey, 2005-2010

This study aimed to explore the relationship between chronic diarrhea and urinary phthalate metabolite concentrations in US adults from the 2005-2010 NHANES study. After adjusting for potential confounding factors, logistic regression was used to explore the relationship between phthalates (PAEs) concentrations and chronic diarrhea, Bayesian kernel machine regression (BKMR), and quantile g calculation (quantile-based g calculation, qgcomp) which was used to study the combined and independent effects of PAEs on gastrointestinal infections. In the current study, 4260 adult participants over the age of 20 from the NHANES study were included, of whom 542 (12.72%) were assessed as having chronic diarrhea. In multivariate logistic regression analysis, after adjusting for all relevant covariates, the results showed that urinary phthalate metabolite concentrations were significantly associated with the risk of chronic diarrhea (P<0.001). Various PAEs were risk factors for chronic diarrhea, among which MiBP (OR=1.419, 95% CI: 1.416-1.423) and MCPP (OR=1.237, 95% CI: 1.235-1.239) were more significant. The BKME results showed a significant increase in the risk of chronic diarrhea with increasing total levels of the PAEs mixture. Mixed exposure to PAEs can promote the occurrence of chronic diarrhea, and the effect was more pronounced in obese people. Notably, most PAEs showed some degree of protection in overweight people. The risk effect of PAEs was more significant in the middle-aged and older population than in the younger population.

Obesity is associated with colitis in women but not necessarily causal relationship

The relationship between obesity and female risk of microscopic colitis remains to be discussed.

Microbiome function underpins the efficacy of a fiber-supplemented dietary intervention in dogs with chronic large bowel diarrhea

Background

Chronic large bowel diarrhea is a common occurrence in pet dogs. While nutritional intervention is considered the primary therapy, the metabolic and gut microfloral effects of fiber and polyphenol-enriched therapeutic foods are poorly understood.

Methods

This prospective clinical study enrolled 31 adult dogs from private veterinary practices with chronic, active large bowel diarrhea. Enrolled dogs received a complete and balanced dry therapeutic food containing a proprietary fiber bundle for 56 days. Metagenomic and metabolomic profiling were performed on fecal samples at Days 1, 2, 3, 14, 28, and 56; metabolomic analysis was conducted on serum samples taken at Days 1, 2, 3, 28, and 56.

Results

The dietary intervention improved clinical signs and had a clear effect on the gut microfloral metabolic output of canines with chronic diarrhea, shifting gut metabolism from a predominantly proteolytic to saccharolytic fermentative state. Microbial metabolism of tryptophan to beneficial indole postbiotics and the conversion of plant-derived phenolics into bioavailable postbiotics were observed. The intervention altered the endocannabinoid, polyunsaturated fatty acid, and sphingolipid profiles, suggesting a modulation in gastrointestinal inflammation. Changes in membrane phospholipid and collagen signatures were indicative of improved gut function and possible alleviation of the pathophysiology related to chronic diarrhea.

Conclusions

In dogs with chronic diarrhea, feeding specific dietary fibers increased gut saccharolysis and bioavailable phenolic and indole-related compounds, while suppressing putrefaction. These changes were associated with improved markers of gut inflammation and stool quality.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12917-022-03315-3.

[A Case of Congenital Tufting Enteropathy with EpCAM Gene Complex Heterozygous Mutation (c.491+1G>A; c.352_353ins CACC)]

The patient, a one-month-old male infant, was admitted for "recurrent diarrhea for 20 + days and vomiting for 4 days". On the 8th day after birth, the patient began to develop recurrent refractory diarrhea, accompanied by abdominal distension, vomiting, dehydration, acidosis, and malnutrition. There were many cases of malignant tumors of the digestive system in the patient's family. Genetic testing identified compound heterozygous mutations (c.491+1G>A; c.352_353ins CACC) in epithelial cell adhesion molecule (EpCAM) gene and the patient was hence diagnosed with congenital tufting enteropathy. The patient was given partial parenteral nutrition support. The patient's diarrheal symptom was improved, but it was difficult to increase the amount of formula because any increase in the amount of formula for the patient would inevitably result in abdominal distention and vomiting. The patient experienced repeated fever in the later period of hospitalization and was eventually discharged from the hospital with the family's signed consent. He still had diarrhea and vomiting after leaving the hospital. Four weeks after discharge, the patient lost about 1 kg of weight and eventually died.

The gut microbiome and antibiotic resistome of chronic diarrhea rhesus macaques (Macaca mulatta) and its similarity to the human gut microbiome

BACKGROUND

Chronic diarrhea is a common disease causing morbidity and mortality of captive rhesus macaques (RMs, Macaca mulatta). Chronic diarrhea in RMs is typically characterized by long-term diarrhea and a weak response to antibiotic treatment. Diarrhea is also a common disease in humans and can cause death. However, the etiology of about half of diarrheal cases of humans is still unclear. Therefore, we performed shotgun metagenomic sequencing to characterize the differences in the gut microbiome and resistome of chronic diarrhea RMs and asymptomatic individuals.

RESULTS

Our results showed Lactobacillus spp. (mainly L. johnsonii, L. reuteri and L. amylovorus) were significantly depleted in chronic diarrhea RM guts compared to asymptomatic individuals (5.2 vs 42.4%). Functional annotation of genes suggested these Lactobacillus spp. carried genes involved in the adhesion of intestinal epithelial cells and production of bacteriocin. Chronic diarrhea RM guts also had a significantly greater abundance of many other gut bacteria, including mucin-degrading bacteria and opportunistic pathogens. The metabolic pathways of chronic diarrhea RM gut microbiome were enriched in aerobactin biosynthesis, while the metabolic pathways of asymptomatic RM gut microbiome were enriched in the production of short-chain fatty acids (SCFAs). Chronic diarrhea RM guts had a significantly greater abundance of antibiotic resistance genes (ARGs), such as ermF, aph(3')-IIIa, ermB, and floR. The strains isolated from feces and tissue fluid of chronic diarrhea RMs had higher resistance rates to the majority of tested antibiotics, but not cephamycin and carbapenem antibiotics. Gut microbial composition comparisons showed that several captive nonhuman primate (NHP) guts were more similar to the guts of humans with a non-westernized diet than humans with a westernized diet. Chronic diarrhea RM gut microbiome was strikingly similar to rural-living humans with diarrhea and humans with a non-westernized diet than asymptomatic RMs.

CONCLUSIONS

Our results suggested chronic diarrhea significantly altered the composition and metabolic pathways of the RM gut microbiome. The frequent use of antibiotics caused antibiotic resistance in chronic diarrhea RM gut microbiome with serious consequences for individual treatment and survival. The findings of this study will help us to improve the effective prevention and treatment of diarrhea in RMs. Video Abstract.

The first report of clinical case of intestinal trichomoniasis caused by Tritrichomonas foetus in a cat with chronic diarrhea in Iran

Background

Tritrichomonas foetus is recently found to be one of the causes of chronic diarrhea in domestic cats but there is no report of feline intestinal trichomoniasis in Iran.

Case description

A 9 months female domestic short-haired cat was referred to our hospital with a history of chronic diarrhea over the past two months, and with an unsuccessful previous antibiotic therapy in another clinic.

Findings/treatment and outcome

Clinical examination revealed 39.8°C rectal temperature. Complete blood count (CBC) showed moderate inflammatory leukogram. By the wet-mount faecal assessment, moving organisms were observed. Rectal scarping dry-mount cytology revealed many inflammatory cells along with huge numbers of trophozoites with typical morphologic characteristics including central axostyle, undulating membrane, flagella, and one laterally located nucleus. Polymerase chain reaction (PCR) was performed and confirmed the diagnosis of T. foetus. After treatment with metronidazole and probiotics, the cat was completely recovered.

Conclusion

This study represents the first case of intestinal trichomoniasis in a cat with chronic diarrhea in Iran.

Diagnostic yield of esophagogastroduodenoscopy, colonoscopy, and small bowel endoscopy in Thai adults with chronic diarrhea

Background

Gastrointestinal endoscopy is frequently recommended for chronic diarrhea assessment in Western countries, but its benefit in the Southeast Asia region is not well established.

Methods

Medical records of consecutive patients undergoing esophagogastroduodenoscopy (EGD), colonoscopy, and small bowel endoscopy for chronic diarrhea from 2008 to 2018 were reviewed. Small bowel endoscopy included push enteroscopy, balloon-assisted enteroscopy (BAE), and video capsule endoscopy (VCE). The diagnostic yield of each endoscopic modality and predictors for positive small bowel endoscopy were analyzed.

Results

A total of 550 patients were included. The mean age was 54 years, and 266 (46.3%) patients were male. The mean hemoglobin and albumin levels were 11.6 g/dL and 3.6 g/dL, respectively. EGD and colonoscopy were performed in 302 and 547 patients, respectively, and the diagnostic yield was 24/302 (7.9%) for EGD and 219/547 (40.0%) for colonoscopy. EGD did not reveal positive findings in any patients with normal colonoscopy. Fifty-one patients with normal EGD and colonoscopy underwent small bowel endoscopy. Push enteroscopy, BAE, and VCE were performed in 28, 21, and 19 patients with a diagnostic yield of 5/28 (17.9%), 14/21 (66.7%), and 8/19 (42.1%), respectively. Significant weight loss, edema, and hypoalbuminemia were independent predictors for the positive yield of small bowel endoscopy.

Conclusion

Colonoscopy was an essential diagnostic tool in identifying the cause of chronic diarrhea in Thai patients, whereas EGD provided some benefits. Small bowel endoscopy should be performed when colonoscopy and EGD were negative, particularly in patients with significant weight loss, edema, and hypoalbuminemia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-021-01998-w.

Associations Between Iron Intake and Serum Iron with Inflammatory Bowel Disease and Chronic Diarrheal Symptoms in Adults: the National Health and Nutrition Examination Survey, 2007-2010

Iron may be involved in the etiology of inflammatory bowel disease (IBD) and chronic diarrhea by modulating gut microbiota and immune responses, but data from epidemiological studies in adults examining this relationship are limited. Thus, the aim of this study was to evaluate the association between iron intake and serum iron levels with IBD and chronic diarrhea in adults. Data from the National Health and Nutritional Examination Surveys (NHANES) between 2007 and 2010 for adults ≥ 20 years were obtained. Chronic diarrheal symptoms were determined by using the 2007-2010 NHANES questionnaire which included questions pertaining to bowel health. The presence of IBD was analyzed from the NHANES data, directly querying the presence or absence of ulcerative colitis (UC) and Crohn's disease (CD). A total of 9605 participants were initially included in this study. Multivariable logistic regression analysis was used and stratified by gender. Compared with quartile 1 (the lowest quartile), the multivariate-adjusted ORs (95% CI) for risk of having chronic diarrheal symptoms were 1.01 (0.86-1.18), 1.29 (1.07-1.56) and 1.25 (1.02-1.54) across quartiles 2 to 4 of iron intake. This significant association remained among men, but not among women in subgroup analyses. No significant association between either iron intake or serum iron level and the risk of IBD was observed. Generally, there was a positive association between iron intake and chronic diarrheal symptoms in adults that was modified by sex.

Chronic diarrhea and parasitic infections: Diagnostic challenges

BACKGROUND

Diarrhea is among the top ten global causes of death. Chronic diarrhea may have destructive impact on physical and mental health of patients and is also associated with high risk of mortality in children. Parasitic intestinal infections remain an important cause of chronic diarrhea especially in the developing part of the world.

OBJECTIVE

To study the parasitic causes of chronic diarrhea and highlight the challenges faced in the diagnosis of chronic diarrhea caused due to parasitic infections.

CONTENT

Due to non-specific symptoms, insensitive available diagnostic techniques, asymptomatic carriage and transmission, recurrent infections in endemic areas, pose a challenge for diagnosis of the parasitic infections and thus delay the treatment. Conventional techniques like microscopy, though cheaper are not very sensitive. Advanced techniques like molecular methods are more sensitive but expensive and are not readily available in resource limited settings. Newer cost-effective diagnostic techniques with higher sensitivity and specificity are required to detect the infectious agent and for appropriate management.

Association Between Selenium Intake with Chronic Constipation and Chronic Diarrhea in Adults: Findings from the National Health and Nutrition Examination Survey

The effects of dietary selenium intake on specific bowel habits (i.e., constipation or diarrhea) in the general population are not well understood. This study aims to evaluate the associations of selenium intake with the risk of chronic constipation and chronic diarrhea in adults aged ≥ 20 years using data from the 2007-2008 and 2009-2010 continuous National Health and Nutritional Examination Surveys (NHANES) (N = 9585). Chronic constipation and chronic diarrhea were defined by Bristol Stool Form Scale (BSFS) types 1 and 2 and BSFS types 6 and 7 as the "usual or most common stool type," respectively, and frequent laxative users were also defined as having chronic constipation. Dietary selenium intake was obtained from 24-h dietary recall. Multivariable logistic regression models were performed controlling for confounding factors (dietary, lifestyle, psychological, and health conditions). No significant associations between selenium intake and chronic diarrhea were found. However, selenium intake was inversely associated with the risk of chronic constipation. Compared with quartile 1, the multivariate-adjusted ORs (95% CI) of chronic constipation across quartiles 2 to 4 of selenium intake were 0.81 (0.64-1.03), 0.74 (0.58-0.95), and 0.54 (0.33-0.89), respectively. This association was significant among men, but not significant among women in subgroup analyses. Generally, there was an inverse association between selenium intake and chronic constipation in adults that modified by sex.

Approach to the adult patient with chronic diarrhea: A literature review

Chronic diarrhea is defined by symptoms lasting longer than 4 weeks. It is a common problem that affects up to 5% of the adult population. Different pathophysiologic mechanisms involve numerous causes, including drug side effects, postoperative anatomic and physiologic alterations, intestinal and colonic wall abnormalities, inflammatory or malabsorption causes, pancreatobiliary diseases, and functional or gut-brain axis disorders associated with dysbiosis or gastrointestinal motility alterations. Due to such a broad differential diagnosis, it is important to categorize chronic diarrhea into five main groups: drug side effect, postoperative, postinfectious, malabsorptive, inflammatory, and functional. The present review is a narrative analysis of the diagnostic approach, emphasizing key aspects of the clinical history, the utility of biomarkers (in breath, stool, urine, and serology) and malabsorption and motility tests, the role of radiologic and endoscopic studies, and the most common histologic findings. A diagnostic algorithm aimed at determining etiology and personalizing therapy is also proposed.

Potential protein–phenotype correlation in three lipopolysaccharide-responsive beige-like anchor protein-deficient patients

BACKGROUND

Patients with lipopolysaccharide (LPS)-responsive beige-like anchor protein (LRBA) deficiency have a variety of clinical symptoms, but there is no apparent genotype–phenotype correlation, and patients carrying the same mutations may have different phenotypes. Therefore, it is not easy for doctors to make a decision regarding hematopoietic stem cell transplantation (HSCT) for LRBA-deficient patients. We hypothesized that there may be a protein–phenotype correlation to indicate HSCT for LRBA-deficient patients.

AIM

To report on three Chinese LRBA-deficient patients and determine the correlation between residual protein expression and disease phenotypes.

METHODS

Clinical data of three Chinese LRBA-deficient patients were collected, and protein levels were detected by Western blot analysis. In addition, LRBA mutation information of another 83 previously reported patients was summarized.

RESULTS

All the major clinical findings indicated enteropathy, but patients 1 and 3 presented with more severe symptoms than patient 2. Endoscopy and histology indicated nonspecific colitis for patients 1 and 3 but Crohn's disease-like colitis for patient 2. Compound heterozygous mutations in LRBA were found in patient 1, and homozygous mutations in LRBA were found in patient 2 and patient 3. Only patient 2 responded well to traditional immunosuppressive treatment. Residual expression of the LRBA protein in patients 1 and 3 was very low, but in patient 2, a more than 0.5-fold in expression of the LRBA protein was found compared to that in the control. After HSCT, patient 1 had increased LRBA protein expression. We summarized the genetic information of 86 patients, and the mutations in patients 1 and 3 were novel mutations.

CONCLUSION

We described three Chinese LRBA-deficient patients, two of whom carried novel mutations. These patients had no genotype-phenotype correlations, but their residual LRBA protein expression might be associated with disease outcome and could be an indicator for HSCT.

Prevalence of primary eosinophilic colitis in patients with chronic diarrhea and diarrhea-predominant irritable bowel syndrome

INTRODUCTION

Primary eosinophilic colitis (PEC) is an inflammatory disease caused by the infiltration of eosinophils into the mucosa of the colon, determined after having ruled out other possible causes. It is characterized by abdominal pain and diarrhea and its prevalence is unknown.

AIMS

To know the prevalence of PEC in patients with chronic diarrhea and in those with clinical criteria for diarrhea-predominant irritable bowel syndrome (IBS-D).

PATIENTS AND METHODS

All patients with chronic noninflammatory diarrhea that were consecutively seen over a decade were studied through colonoscopy, with systematic biopsy. Patients with a known or decompensated organic disease, alarm features, abnormal minimal laboratory test results, and factors associated with eosinophilia were excluded. Patients with the clinical criteria for IBS-D (Rome III) were selected from the general group. Eosinophilic colitis was defined as the presence of > 35 eosinophils/100 epithelial cells per field in any of the segments.

RESULTS

From the 683 patients seen, a total of 545 patients (361 women) were included in the study. Twenty-two cases of PEC were detected, resulting in a prevalence of 4.0%. A total of 343 patients had IBS-D criteria (223 women), with 16 cases of PEC detected, for a prevalence of 4.7%. Colonoscopy was normal, or almost normal, in all the PEC cases detected.

CONCLUSIONS

The prevalence of PEC was 4.0% in the patients with chronic diarrhea and 4.7% in the patients with IBS-D. Peripheral eosinophilia appeared to be the main distinctive clinical characteristic, but systematic biopsy was essential for making the diagnosis.

70-year-old woman with chronic diarrhea

We present the clinical case of a seventy-year-old female patient with hypertension in treatment with olmesartan since one year ago and no other past medical history of interest. She was hospitalized in the internal medicine department in order to study constitutional symptoms which consisted of confirmed weight loss of 13 kg, chronic diarrhea, loss of appetite, asthenia, and intermittent colic-like abdominal pain. After an initial screening for neoplastic disease, other possible options were considered.

Approach to the adult patient with chronic diarrhea: a literature review

Chronic diarrhea is defined by symptoms lasting longer than 4 weeks. It is a common problem that affects up to 5% of the adult population. Different pathophysiologic mechanisms involve numerous causes, including drug side effects, postoperative anatomic and physiologic alterations, intestinal and colonic wall abnormalities, inflammatory or malabsorption causes, pancreatobiliary diseases, and functional or gut-brain axis disorders associated with dysbiosis or gastrointestinal motility alterations. Due to such a broad differential diagnosis, it is important to categorize chronic diarrhea into five main groups: drug side effect, postoperative, postinfectious, malabsorptive, inflammatory, and functional. The present review is a narrative analysis of the diagnostic approach, emphasizing key aspects of the clinical history, the utility of biomarkers (in breath, stool, urine, and serology) and malabsorption and motility tests, the role of radiologic and endoscopic studies, and the most common histologic findings. A diagnostic algorithm aimed at determining etiology and personalizing therapy is also proposed.

Diarrhea as a Clinical Challenge: General Practitioner Approach

BACKGROUND

Diarrhea is defined as the passage of loose stools and increase in stool frequency, weight, or volume. Diarrhea is an important health issue since it accounts for 2.5 million deaths in the world each year.

SUMMARY

Diarrhea can be acute, persistent, or chronic. Acute diarrhea (AD) is usually infectious, caused by viruses, less frequently by bacteria and parasites. The majority of cases of AD are self-limiting and do not require diagnostic workup. The use of diagnostic tests in AD should be limited to patients with signs of severe dehydration, bloody stools, persistent fever and those suffering from immunodeficiencies using immunosuppressive therapy or to cases of suspected nosocomial infection. These patients should be referred to gastroenterologists or infectious disease specialists. Therapy in AD consists of early oral refeeding, antidiarrheal medications, antibiotics, and probiotics. Chronic diarrhea (CD) has diverse etiology. The majority of patients have self-limiting symptoms or functional gastrointestinal disorders. Patients with blood in stool, weight loss, clinical and laboratory signs of anemia, and palpable mass in the abdomen (red flag symptoms) need urgent gastroenterology referral. Therapy in CD is possible when the underlying cause of symptoms is identified.

KEY MESSAGES

The general practitioner should identify high-risk patients with AD and/or red flag symptoms for urgent gastroenterology referral.

Pancreatic VIPoma as a Differential Diagnosis in Chronic Pediatric Diarrhea: A Case Report and Review of the Literature

Chronic diarrhea is a common chief complaint in the pediatric population with a wide range of diagnostic differentials; as such, whilst suspecting common causes, less prevalent conditions tend to be overlooked, such as neuroendocrine tumor pathologies. VIPomas are characterized by hypersecretion of the vasoactive intestinal peptide (VIP), causing watery diarrhea, hypokalemia, and achlorhydria. Nonetheless, its low incidence rate in children makes it an easily unnoticed pathology. Herein, we report a case of a 14-year-old female patient and a review of relevant literature. The patient complained of 7-month history of watery diarrhea, multiple emetic episodes, and relevant past medical history of multiple hospitalizations. Chronic diarrheal disease work-up studies, including a high VIP scintigram, showed a lesion suggestive of a VIPoma-type neuroendocrine pancreatic tumor. A distal pancreatectomy was performed with a complete resolution of the symptoms. When faced with a pediatric patient presenting with chronic secretory diarrhea and whose work-up studies rule out the most common pathologies, the possible presence of a neuroendocrine tumor as VIPoma should be considered.

The Role of Purported Mucoprotectants in Dealing with Irritable Bowel Syndrome, Functional Diarrhea, and Other Chronic Diarrheal Disorders in Adults

Chronic diarrhea is a frequent presenting symptom, both in primary care medicine and in specialized gastroenterology units. It is estimated that more than 5% of the global population suffers from chronic diarrhea. and that about 40% of these subjects are older than 60 years. The clinician is frequently faced with the need to decide which is the best therapeutic approach for these patients. While the origin of chronic diarrhea is diverse, impairment of intestinal barrier function, dysbiosis. and mucosal micro-inflammation are being increasingly recognized as underlying phenomena characterizing a variety of chronic diarrheal diseases. In addition to current pharmacological therapies, there is growing interest in alternative products such as mucoprotectants, which form a mucoadhesive film over the epithelium to reduce and protect against the development of altered intestinal permeability, dysbiosis, and mucosal micro-inflammation. This manuscript focuses on chronic diarrhea in adults, and we will review recent evidence on the ability of these natural compounds to improve symptoms associated with chronic diarrhea and to exert protective effects for the intestinal barrier.

Whipple's disease diagnosed in a patient with suspected sarcoidosis

This paper presents a case of a 51-year-old patient with chronic diarrhea, weight loss, polyarthralgia, and diffuse lymphadenopathy. Laboratory work-up showed anemia, leukocytosis and thrombocytosis, and increased C-reactive protein (CRP). Due to an inconspicuous differential leukocyte count and lymph node biopsy findings showing granulomatous lymphadenopathy, sarcoidosis was initially suspected. Colonoscopy found no abnormalities and duodenal biopsies showed negative Periodic acid-Schiff stains. However, PCR testing on these biopsies revealed Tropheryma whipplei DNA. Further PCR testing of urine and cerebrospinal fluid also revealed T. whipplei DNA. The patient was treated with ceftriaxone for 2 weeks followed by trimethoprim for a year. A rapid improvement of his symptoms was seen.

Prevalence of primary eosinophilic colitis in patients with chronic diarrhea and diarrhea-predominant irritable bowel syndrome

INTRODUCTION

Primary eosinophilic colitis (PEC) is an inflammatory disease caused by the infiltration of eosinophils into the mucosa of the colon, determined after having ruled out other possible causes. It is characterized by abdominal pain and diarrhea and its prevalence is unknown.

AIMS

To know the prevalence of PEC in patients with chronic diarrhea and in those with clinical criteria for diarrhea-predominant irritable bowel syndrome (IBS-D).

PATIENTS AND METHODS

All patients with chronic noninflammatory diarrhea that were consecutively seen over a decade were studied through colonoscopy, with systematic biopsy. Patients with a known or decompensated organic disease, alarm features, abnormal minimal laboratory test results, and factors associated with eosinophilia were excluded. Patients with the clinical criteria for IBS-D (Rome III) were selected from the general group. Eosinophilic colitis was defined as the presence of>35eosinophils/100 epithelial cells per field in any of the segments.

RESULTS

From the 683 patients seen, a total of 545 patients (361 women) were included in the study. Twenty-two cases of PEC were detected, resulting in a prevalence of 4.0%. A total of 343 patients had IBS-D criteria (223 women), with 16 cases of PEC detected, for a prevalence of 4.7%. Colonoscopy was normal, or almost normal, in all the PEC cases detected.

CONCLUSIONS

The prevalence of PEC was 4.0% in the patients with chronic diarrhea and 4.7% in the patients with IBS-D. Peripheral eosinophilia appeared to be the main distinctive clinical characteristic, but systematic biopsy was essential for making the diagnosis.

Distribution of histopathological features along the colon in microscopic colitis

PURPOSE

The diagnosis microscopic colitis (MC) consisting of collagenous colitis (CC) and lymphocytic colitis (LC) relies on histological assessment of mucosal biopsies from the colon. The optimal biopsy strategy for reliable diagnosis of MC is controversial. The aim of this study was to evaluate the distribution of histopathological features of MC throughout the colon.

METHODS

Mucosal biopsies from multiple colonic segments of patients with MC who participated in one of the three prospective European multicenter trials were analyzed. Histological slides were stained with hematoxylin-and-eosin, a connective tissue stain, and CD3 in selected cases.

RESULTS

In total, 255 patients were included, 199 and 56 patients with CC and LC, respectively. Both groups exhibited a gradient with more pronounced inflammation in the lamina propria in the proximal colon compared with the distal colon. Similarly, the thickness of the subepithelial collagenous band in CC showed a gradient with higher values in the proximal colon. The mean number of intraepithelial lymphocytes was > 20 in all colonic segments in patients within both subgroups. Biopsies from 86 to 94% of individual segments were diagnostic, rectum excluded. Biopsies from non-diagnostic segments often showed features of another subgroup of MC.

CONCLUSION

Conclusively, although the severity of the histological changes in MC differed in the colonic mucosa, the minimum criteria required for the diagnosis were present in the random biopsies from the majority of segments. Thus, our findings show MC to be a pancolitis, rectum excluded, questioning previously proclaimed patchiness throughout the colon.

Recommendations for the adjuvant use of the poly-antibiotic-resistant probiotic Bacillus clausii (O/C, SIN, N/R, T) in acute, chronic, and antibiotic-associated diarrhea in children: consensus from Asian experts

This paper proposes recommendations for probiotics in pediatric gastrointestinal diseases in the Asia-Pacific region. Evidence-based recommendations and randomized controlled trials in the region are included. Cultural aspects, health management issues and economic factors were also considered. Final recommendations were approved by utilizing a modified Delphi process and applying the Likert scale in an electronic voting process. Bacillus clausii was recommended as an adjunct treatment with oral rehydration solution for acute viral diarrhea. B. clausii may also be considered for prevention of antibiotic-associated diarrhea, Clostridium difficile-induced diarrhea, and as adjunct treatment of Helicobacter pylori. There is insufficient evidence for recommendations in other conditions. Despite a diversity of epidemiological, socioeconomical and health system conditions, similar recommendations currently apply to most Asia-Pacific countries. Ideally, these need to be validated with local randomized-controlled trials.

Diarrhea as an Initial Presentation in Patients with Medullary Thyroid Cancer: Delaying the Diagnosis

Tumoral secretion of various molecular factors, such as calcitonin (Ct), can cause diarrhea in patients with medullary thyroid cancer (MTC). We report 3 patients (age 26-38 years, serum Ct levels ranging from 2,890 to 52,894 ng/L) with chronic diarrhea, and the diagnosis of MTC was delayed. Diarrheal symptoms improved after thyroid surgery. Two patients with elevated Ct had no diarrhea. The link between tumor humoral secretion and diarrhea is not well established in patients with MTC. Diarrhea is more common in patients with metastatic disease and improves after resection of the tumor. Diarrhea may result from elevated circulating levels of Ct or other substances, such as prostaglandins or serotonin. Other proposed mechanisms include decreased absorption in the colon secondary to gastrointestinal motor disturbances. In conclusion, MTC should be considered when evaluating chronic diarrhea.

[Autoimmune enteropathy in adults : A rare and difficult but relevant differential diagnosis of chronic diarrhea]

Autoimmune enteropathy (AIE) was originally believed to be a pediatric disease until there were increasing numbers of adult cases reported over the last 20 years. AIE is an autoimmune disease that manifests as severe chronic diarrhea.The histological hallmark is villous atrophy. Histology alone is not sufficiently sensitive and consistent. Four different histological patterns are known. There are many differential diagnoses to be considered relating to both histology and symptoms.We present the case of a young woman with fatal AIE and homozygous germline-mutation of the CLEC7A gene. The course of disease is documented in multiple intestinal biopsies, which show a morphological change over time.Histology and symptoms often resemble celiac disease. In order to recognize this rare disease early in its course there is a need for a special awareness among attending physicians and pathologists.

Primary eosinophilic gastroenteritis: A case series from western India

Primary eosinophilic gastroenteritis is a rare inflammatory disorder of gastrointestinal tract characterized by symptoms like abdominal pain, diarrhea, vomiting, weight loss, and eosinophilic infiltration of the intestinal wall with or without peripheral eosinophilia. We found four cases with different causes of eosinophilic enteritis with varying manifestations ranging from chronic diarrhea with malabsorption, dysphagia, and gastric outlet obstruction due to mass-like lesions.

Utility of narrow band imaging in predicting histology in celiac disease

BACKGROUND

Narrow band imaging (NBI) with magnification better visualizes the duodenal microsurface and mucosal vascularity. NBI delineates villous atrophy better than conventional white light endoscopy.

AIMS

This study was conducted to evaluate the diagnostic accuracy of narrow band imaging with magnification (NBI-ME) in celiac disease (CD).

METHODS

In this prospective study, consecutive patients of suspected CD and controls were subjected to tissue transglutaminase antibody test and endoscopic evaluation initially with white light followed by NBI-ME, and biopsies were taken from duodenum. Duodenal villous patterns on NBI were interpreted as normal, blunted distorted, and absent. Severity of villous atrophy was reported according to the modified Marsh criteria.

RESULTS

One hundred and twenty-two patients (mean age of 27.53 ± 13.37 years and a male to female ratio of 1:1.26) and 40 controls were studied. The sensitivity and specificity of NBI-ME in predicting villous atrophy were found to be 95.54% and 90%, respectively. The specificity and negative predictive value of NBI-ME in predicting villous atrophy amongst controls was 100% and 97.5%, respectively. Abnormal findings (blunted and absent villous patterns) combined with elevated transglutaminase antibody (> 5-fold) were found to have high accuracy in predicting villous atrophy.

CONCLUSION

NBI with magnification has high sensitivity and specificity in predicting villous atrophy in patients with celiac disease.