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Danialifar TF, Chumpitazi BP, Mehta DI, Di Lorenzo C. Genetic and acquired sucrase-isomaltase deficiency: A clinical review. J Pediatr Gastroenterol Nutr 2024; 78:774-782. [PMID: 38327254 DOI: 10.1002/jpn3.12151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 01/05/2024] [Accepted: 01/19/2024] [Indexed: 02/09/2024]
Abstract
Genetic sucrase-isomaltase deficiency (GSID) is an inherited deficiency in the ability to digest sucrose and potentially starch due to mutations in the sucrase-isomaltase (SI) gene. Congenital sucrase-isomaltase deficiency is historically considered to be a rare condition affecting infants with chronic diarrhea as exposure to dietary sucrose begins. Growing evidence suggests that individuals with SI variants may present later in life, with symptoms overlapping with those of irritable bowel syndrome. The presence of SI genetic variants may, either alone or in combination, affect enzyme activity and lead to symptoms of different severity. As such, a more appropriate term for this inherited condition is GSID, with a recognition of a spectrum of severity and onset of presentation. Currently, disaccharidase assay on duodenal mucosal tissue homogenates is the gold standard in diagnosing SI deficiency. A deficiency in the SI enzyme can be present at birth (genetic) or acquired later, often in association with damage to the enteric brush-border membrane. Other noninvasive diagnostic alternatives such as sucrose breath tests may be useful but require further validation. Management of GSID is based on sucrose and potentially starch restriction tailored to the individual patients' tolerance and symptoms. As this approach may be challenging, additional treatment with commercially available sacrosidase is available. However, some patients may require continued starch restriction. Further research is needed to clarify the true prevalence of SI deficiency, the pathobiology of single SI heterozygous mutations, and to define optimal diagnostic and treatment algorithms in the pediatric population.
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Affiliation(s)
- Tanaz Farzan Danialifar
- Children's Hospital Los Angeles, Los Angeles, California, USA
- Keck School of Medicine of USC, Los Angeles, California, USA
| | - Bruno P Chumpitazi
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Devendra I Mehta
- Center for Digestive Health and Nutrition, Arnold Palmer Hospital for Children, Orlando, Florida, USA
| | - Carlo Di Lorenzo
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
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Castellón Méndez AJ, Bodán Campbell A, Rosales Obregón V, Zahran M. Waldmann's disease: Primary intestinal lymphangiectasia diagnosed by 99mTc-labeled albumin macroaggregate scintigraphy-A case report in an adult patient. Clin Case Rep 2024; 12:e8772. [PMID: 38634090 PMCID: PMC11022294 DOI: 10.1002/ccr3.8772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 03/14/2024] [Accepted: 03/15/2024] [Indexed: 04/19/2024] Open
Abstract
Key Clinical Message Rare yet significant, this case sheds light on the uncommon presentation of Waldmann's disease in adults, showcasing the diagnostic challenges it poses. A multidisciplinary approach, integrating clinical, endoscopic, histological, and radiological evaluations, is crucial for accurate diagnosis and management. Further research is needed to deepen our understanding of this complex disorder. Abstract Waldmann's disease, or primary intestinal lymphangiectasia, is a rare disorder characterized by protein-losing enteropathy due to dilation and leakage of intestinal lymphatic vessels. Although typically diagnosed in early childhood, we present a case of a 55-year-old male with a complex medical history. The patient's history included intestinal obstruction, multidrug-resistant pulmonary tuberculosis, and primary antiphospholipid syndrome. He presented with a 2-year history of chronic diarrhea, weight loss, and lower limb edema. Endoscopic and histological examination revealed scattered white spots in the duodenum and terminal ileum, indicative of intestinal lymphangiectasia. Nuclear medicine studies confirmed abnormal protein loss. The rarity of Waldmann's disease in adulthood and its association with other significant medical conditions pose diagnostic challenges. The distinct endoscopic and histological findings, coupled with scintigraphy results, contribute to a comprehensive understanding of this complex case. Differential diagnoses and management considerations are discussed. This case highlights the atypical presentation of Waldmann's disease in adulthood, emphasizing the importance of a multidisciplinary approach for accurate diagnosis and management. Further research is warranted to enhance our understanding of this uncommon disorder and its potential implications for patients with complex medical histories.
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Affiliation(s)
| | | | | | - Mohammed Zahran
- Department of Internal MedicineManolo Morales Peralta HospitalManaguaNicaragua
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3
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Costa CA, Lopes T, Rodrigues AP, Lamas NJ, Cruz C. The skin as a window to the gut: A case of carcinoid syndrome. Clin Case Rep 2024; 12:e8641. [PMID: 38455854 PMCID: PMC10918735 DOI: 10.1002/ccr3.8641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 01/29/2024] [Accepted: 02/12/2024] [Indexed: 03/09/2024] Open
Abstract
Neuroendocrine tumors (NETs) are a group of uncommon neoplasms derived from enterochromaffin or Kulchitsky cells (that secrete serotonin or other molecules into the bloodstream), which can manifest with symptoms of hormonal overproduction, namely carcinoid syndrome (CS). This can be the presenting feature in patients with advanced disease. We report the case of a 66-year-old woman presenting with chronic diarrhea, facial venous telangiectasia and elevated urinary 5-hydrocyindoleacetic acid levels. A 68-Ga DOTATOC PET/CT scan revealed an ileal mass and lesions consistent with liver, ovary and bone metastasis. A liver biopsy confirmed the diagnosis of well-differentiated NET G1. Therapy with somatostatin analogs achieved symptom control, but the liver disease progressed and the patient passed away after 2 years of follow-up. The challenge of diagnosing CS resides in its heterogeneous manifestations, which may range from mild to life-threatening conditions. In this case, the cutaneous findings of venous telangiectasia strongly pointed to the correct diagnosis. Treatment can also be difficult due to refractory symptoms and inevitable progression of disease, highlighting the importance of early detection and thorough disease staging.
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Affiliation(s)
- Catarina Alves Costa
- Internal Medicine DepartmentCentro Hospitalar Universitário de Santo António (CHUdSA), Porto, Largo Professor Abel SalazarPortoPortugal
| | - Tânia Lopes
- Internal Medicine DepartmentCentro Hospitalar Universitário de Santo António (CHUdSA), Porto, Largo Professor Abel SalazarPortoPortugal
| | - Ana Patrícia Rodrigues
- Anatomic Pathology Service, Pathology DepartmentCentro Hospitalar Universitário de Santo António (CHUdSA), Porto, Largo Professor Abel SalazarPortoPortugal
| | - Nuno Jorge Lamas
- Anatomic Pathology Service, Pathology DepartmentCentro Hospitalar Universitário de Santo António (CHUdSA), Porto, Largo Professor Abel SalazarPortoPortugal
- Life and Health Sciences Research Institute (ICVS), School of MedicineUniversity of MinhoBragaPortugal
- ICVS/3B's, PT Government Associate LaboratoryUniversity of MinhoBragaPortugal
| | - Célia Cruz
- Internal Medicine DepartmentCentro Hospitalar Universitário de Santo António (CHUdSA), Porto, Largo Professor Abel SalazarPortoPortugal
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崔 艺, 王 德, 谢 东, 王 海, 徐 睿, 唐 潇, 张 印. [Efficacy of navel application of Jianpiwenyang Gel for chronic diarrhea of spleen and stomach weakness type: a randomized controlled trial and analysis of the mechanism]. Nan Fang Yi Ke Da Xue Xue Bao 2024; 44:217-225. [PMID: 38501406 PMCID: PMC10954536 DOI: 10.12122/j.issn.1673-4254.2024.02.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Indexed: 03/20/2024]
Abstract
OBJECTIVE To investigate the efficacy of Jianpiwenyang Gel (SSWYG) for treating chronic diarrhea and explore its therapeutic mechanism. METHODS Eighty patients with chronic diarrhea of spleen and stomach weakness type were randomized into two groups for interventions with lifestyle adjustment and treatment with bifid triple viable capsules (control group, n=40) or naval application with SSWYG (treatment group, n=40) for one week, after which symptoms of chronic diarrhea were evaluated. The Chinese medicine system pharmacology analysis platform (TCMSP), GeneCards, NCBI, OMIM database and GEO database (GSE14841) were used to obtain the active ingredients and target proteins of SSWYG and chronic diarrhea-related targets. The key targets were obtained by topological analysis for Gene Ontology (GO) and KEGG analyses. The affinity and binding characteristics of SSWYG for specific targets were verified by molecular docking using AutoDock software. RESULTS In both groups, gastrointestinal symptom rating scale (GSRS), Bristol Scale and TCM syndrome scores significantly improved after the treatments (P < 0.05), and better effects were observed in the treatment group (P < 0.05). Sixtyeight targets of SSWYG in treating chronic diarrhea were obtained, and 33 most probable ones were screened out by topological analysis. GO and KEGG analyses identified several chronic diarrhea-related pathways including the TNF and IL-17 pathways. Molecular docking study showed good affinity of the core components of SSWYG for the key targets CASP3, JNK, IL1B, IL6, and AKT1. JUN and CASP3 had the lowest binding energy and the highest stable binding energy with multiple major active ingredients of SSWYG. CONCLUSION SSWYG can significantly improve clinical symptoms of chronic diarrhea possibly by regulating the TNF and IL-17 as well as other pathways via CASP3 and JUN, suggesting a complex therapeutic mechanism of SSWYG involving multiple ingredients and targets and coordinated regulation of multiple pathways.
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Affiliation(s)
- 艺馨 崔
- 中国人民解放军总医院第六医学中心中医医学部,北京 100853Department of Traditional Chinese Medicine of the Sixth Clinical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - 德财 王
- 航天中心医院,北京 100049Second Outpatient Department, Aerospace Center Hospital, Beijing 100049, China
| | - 东晴 谢
- 中国人民解放军总医院第一医学中心超声科,北京 100853Department of Ultrasound of the First Clinical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - 海明 王
- 中国人民解放军总医院第六医学中心中医医学部,北京 100853Department of Traditional Chinese Medicine of the Sixth Clinical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - 睿鑫 徐
- 中国人民解放军总医院第六医学中心中医医学部,北京 100853Department of Traditional Chinese Medicine of the Sixth Clinical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - 潇然 唐
- 中国人民解放军总医院第六医学中心中医医学部,北京 100853Department of Traditional Chinese Medicine of the Sixth Clinical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - 印 张
- 中国人民解放军总医院第六医学中心中医医学部,北京 100853Department of Traditional Chinese Medicine of the Sixth Clinical Center, Chinese PLA General Hospital, Beijing 100853, China
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Costa C, Bartilotti Matos F, Carvalho Sá D, Neves Maia J. Tropical Sprue: A Rare Cause of Malabsorption Syndrome. Cureus 2024; 16:e53748. [PMID: 38465131 PMCID: PMC10921071 DOI: 10.7759/cureus.53748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2024] [Indexed: 03/12/2024] Open
Abstract
Chronic diarrhea is a common disorder in tropical regions, affecting residents, visitors, and even expatriates. It may stem from a myriad of infectious, inflammatory, and even malignant causes. In patients in whom no etiology has been found, tropical sprue (TS) is an important diagnosis to consider. We report the case of a 60-year-old man originally from Guatemala, presenting with chronic diarrhea and megaloblastic anemia due to severe vitamin B12 deficiency. Biopsies of the small bowel revealed partial villous atrophy and inflammatory infiltrate with the participation of eosinophils. The diagnosis of TS was established after exclusion of other causes of malabsorption syndrome. This is a disease of unknown etiology with complex and multifactorial pathophysiology, with an important component of intestinal dysbiosis. Antibiotics and vitamin supplementation are the pillars of therapy. Awareness of this disorder is essential in preventing delayed diagnosis and subsequent morbidity.
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Affiliation(s)
- Catarina Costa
- Department of Internal Medicine, Centro Hospitalar Universitário de Santo António, Porto, PRT
| | - Francisca Bartilotti Matos
- Department of Infectious Diseases, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, PRT
| | - Diogo Carvalho Sá
- Department of Pathology, Centro Hospitalar Universitário de Santo António, Porto, PRT
| | - João Neves Maia
- Department of Internal Medicine, Centro Hospitalar Universitário de Santo António, Porto, PRT
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Santos S, Costa RS, Ferreira S, Gomes Ferreira S, Maciel R. Olmesartan-Induced Enteropathy: When the Treatment of One Disease Causes Another. Cureus 2024; 16:e53556. [PMID: 38445141 PMCID: PMC10913834 DOI: 10.7759/cureus.53556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2024] [Indexed: 03/07/2024] Open
Abstract
Olmesartan is an angiotensin II receptor antagonist used for the management of hypertension. This drug can lead to an enteropathy that clinically and histologically resembles coeliac disease. Symptoms may appear months or years after the introduction of the drug and usually resolve after discontinuation. The authors present a case of an 86-year-old woman with hypertension who was treated with olmesartan for 10 years. She presented to the emergency department with diarrhoea after three months of development and weight loss. The aetiological study that was conducted excluded infectious, inflammatory, endocrinological, and neoplastic causes. The pathological anatomy of the duodenal biopsy was suggestive of coeliac disease, but the serology was not compatible. The patient presented complete remission of the condition with the suspension of the drug and subsequent recrudescence when, by self-initiation, she resumed olmesartan. This case study aims to alert readers of a rare cause of enteropathy with a clinical manifestation that mimics coeliac disease. Olmesartan-induced enteropathy seems to be a diagnosis of exclusion and should be considered in patients chronically medicated with olmesartan.
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Affiliation(s)
- Sara Santos
- Internal Medicine, Centro Hospitalar de Entre Douro e Vouga, Santa Maria da Feira, PRT
| | - Rita S Costa
- Internal Medicine, Centro Hospitalar de Entre Douro e Vouga, Santa Maria da Feira, PRT
| | - Sofia Ferreira
- Internal Medicine, Centro Hospitalar de Entre Douro e Vouga, Santa Maria da Feira, PRT
| | - Sérgio Gomes Ferreira
- Internal Medicine, Centro Hospitalar de Entre Douro e Vouga, Santa Maria da Feira, PRT
| | - Rita Maciel
- Internal Medicine, Centro Hospitalar de Entre Douro e Vouga, Santa Maria da Feira, PRT
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Ansari AG, Haider Mehdi HS, Nasar A. The Importance of Considering Common Variable Immunodeficiency in Patients With Chronic Diarrhea. Cureus 2023; 15:e50556. [PMID: 38222158 PMCID: PMC10787943 DOI: 10.7759/cureus.50556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2023] [Indexed: 01/16/2024] Open
Abstract
Chronic diarrhea poses a diagnostic challenge due to its diverse etiology, encompassing various gastrointestinal disorders. This case report emphasizes the clinical significance of considering common variable immunodeficiency (CVID) as a potential underlying cause in a patient presenting with chronic diarrhea. In this case study, we describe a 36-year-old female with a 9-year history of chronic diarrhea, recurrent sinopulmonary infections, and weight loss for 3 years, where previous evaluations failed to yield a diagnosis. This case underscores the diagnostic hurdles faced by healthcare professionals, often causing a delay in identifying fewer common conditions like immunodeficiency syndromes. Early recognition of CVID is crucial, enabling timely intervention with immunoglobulin replacement therapy, markedly enhancing patients' quality of life and averting complications. This report highlights the necessity for a comprehensive evaluation of non-responsive chronic diarrhea cases and raises awareness about CVID as an essential consideration, facilitating precise diagnoses and tailored treatments.
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Affiliation(s)
- Ahmad G Ansari
- Medicine, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, IND
| | | | - Ariba Nasar
- Department of Internal Medicine, Jawaharlal Nehru Medical College, Aligarh, IND
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Lupianez-Merly C, Dilmaghani S, Camilleri M. Recent developments in diagnosing bile acid diarrhea. Expert Rev Gastroenterol Hepatol 2023; 17:1185-1195. [PMID: 38086533 DOI: 10.1080/17474124.2023.2293814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 12/08/2023] [Indexed: 01/19/2024]
Abstract
INTRODUCTION Bile acid diarrhea (BAD) commonly causes chronic diarrhea. Symptoms may be mistaken for disorders of gut brain interaction. Due to the lack of widely available diagnostic tests and poor recognition of BAD, there is a delay in diagnosis leading to increased healthcare system burden and decreased patient quality of life. AREAS COVERED A thorough review of the literature was conducted using PubMed for articles on the biological functions of bile acids, pathophysiology and management of BAD, but focusing on diagnostic testing including 75SeHCAT retention, 7αC4, FGF-19, fecal bile acids, and single stool tests. This narrative review discusses available modalities focusing on noninvasive stool and serum testing that are more widely available and show good sensitivity and specificity for diagnosis of BAD. 75SeHCAT retention is not available in many countries. Alternative diagnostic tests include total and primary fecal bile acid (BA) excretion in 48-hour collection or a single stool sample, serum7αC4 >46 or 52.5 ng/mL, and combination of single stool and serum 7αC4 ±watery stools (Bristol Stool Form Scale 6-7). EXPERT OPINION Given the ease of serum and single stool sample acquisition and diagnostic advances, clinical practice should embrace positive diagnosis, rather than BAS therapeutic trial. BAD needs to be considered in diverse gastrointestinal diseases.
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Affiliation(s)
- Camille Lupianez-Merly
- Division of Gastroenterology and Hepatology, Mayo Clinic, Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Rochester, MN, USA
| | - Saam Dilmaghani
- Division of Gastroenterology and Hepatology, Mayo Clinic, Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Rochester, MN, USA
| | - Michael Camilleri
- Division of Gastroenterology and Hepatology, Mayo Clinic, Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Rochester, MN, USA
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Xue H, Mei C, Wang F, Tang X. Relationship among Chinese herb polysaccharide (CHP), gut microbiota, and chronic diarrhea and impact of CHP on chronic diarrhea. Food Sci Nutr 2023; 11:5837-5855. [PMID: 37823142 PMCID: PMC10563694 DOI: 10.1002/fsn3.3596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 07/13/2023] [Accepted: 07/22/2023] [Indexed: 10/13/2023] Open
Abstract
Chronic diarrhea, including diarrhea-predominant irritable bowel syndrome (IBS-D), osmotic diarrhea, bile acid diarrhea, and antibiotic-associated diarrhea, is a common problem which is highly associated with disorders of the gut microbiota composition such as small intestinal bacterial overgrowth (SIBO) and so on. A growing number of studies have supported the view that Chinese herbal formula alleviates the symptoms of diarrhea by modulating the fecal microbiota. Chinese herbal polysaccharides (CHPs) are natural polymers composed of monosaccharides that are widely found in Chinese herbs and function as important active ingredients. Commensal gut microbiota has an extensive capacity to utilize CHPs and play a vital role in degrading polysaccharides into short-chain fatty acids (SCFAs). Many CHPs, as prebiotics, have an antidiarrheal role to promote the growth of beneficial bacteria and inhibit the colonization of pathogenic bacteria. This review systematically summarizes the relationship among gut microbiota, chronic diarrhea, and CHPs as well as recent progress on the impacts of CHPs on the gut microbiota and recent advances on the possible role of CHPs in chronic diarrhea.
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Affiliation(s)
- Hong Xue
- Digestive Laboratory of Traditional Chinese Medicine Research Institute of Spleen and Stomach DiseasesXiyuan Hospital, China Academy of Chinese Medical SciencesBeijingChina
| | - Chun‐Feng Mei
- Digestive Laboratory of Traditional Chinese Medicine Research Institute of Spleen and Stomach DiseasesXiyuan Hospital, China Academy of Chinese Medical SciencesBeijingChina
| | - Feng‐Yun Wang
- Digestive Laboratory of Traditional Chinese Medicine Research Institute of Spleen and Stomach DiseasesXiyuan Hospital, China Academy of Chinese Medical SciencesBeijingChina
| | - Xu‐Dong Tang
- Digestive Laboratory of Traditional Chinese Medicine Research Institute of Spleen and Stomach DiseasesXiyuan Hospital, China Academy of Chinese Medical SciencesBeijingChina
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10
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Zhang Q, Zhang X, Wang Q, Chen S. Dioscoreae Rhizoma starch improves chronic diarrhea by regulating the gut microbiotas and fecal metabolome in rats. Food Sci Nutr 2023; 11:6271-6287. [PMID: 37823173 PMCID: PMC10563677 DOI: 10.1002/fsn3.3567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 06/11/2023] [Accepted: 07/05/2023] [Indexed: 10/13/2023] Open
Abstract
Chinese yam (Dioscorea opposite Thunb.) has been used as food and medicine to treat diarrhea for thousands of years. This article aimed to elucidate the potential mechanism of Dioscoreae Rhizoma starch in alleviating chronic diarrhea induced by rhubarb based on gut microbiotas and fecal metabolome. The administration of the Dioscoreae Rhizoma aqueous extracts, crude polysaccharides, and starch could improve diarrhea and alleviate intestinal injury in chronic diarrhea rats. The Dioscoreae Rhizoma starch displayed the most apparent effect on regulating intestinal microbiotas by increasing the abundance and diversity of microbiotas. At the genus level, there were 17 changed intestinal microbiotas in model rats, and the treatment with Dioscoreae Rhizoma starch regulated 11 microbiotas. Metabolomics analysis revealed that Dioscoreae Rhizoma starch could regulate abnormal fecal metabolites to alleviate diarrhea, and these metabolites are involved in phenylalanine, tyrosine, and tryptophan biosynthesis; tyrosine metabolism; vitamin B6 metabolism; and purine metabolism. This study will contribute to the further research and development of Dioscoreae Rhizoma starch.
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Affiliation(s)
- Qing Zhang
- School of PharmacyHenan University of Chinese MedicineZhengzhouChina
| | - Xu Zhang
- School of PharmacyHenan University of Chinese MedicineZhengzhouChina
| | - Qing Wang
- School of PharmacyHenan University of Chinese MedicineZhengzhouChina
| | - Suiqing Chen
- School of PharmacyHenan University of Chinese MedicineZhengzhouChina
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Deng F, Wang H, Wang X. Chronic Diarrhea with Villous Blunting of the Small Intestine Under Capsule Endoscopy in Common Variable Immunodeficiency and X-Linked Agammaglobulinemia: A Case Series. J Asthma Allergy 2023; 16:997-1006. [PMID: 37772267 PMCID: PMC10522781 DOI: 10.2147/jaa.s418996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 09/14/2023] [Indexed: 09/30/2023] Open
Abstract
Introduction Primary immunodeficiencies (PIDs) are a heterogeneous group of disorders, common variable immunodeficiency disorder (CVID) and X-linked agammaglobulinemia (XLA) are PIDs related to B-cell defect, characterized by reduced levels of immunoglobulins and immune dysregulation. Infections are the most common clinical manifestations, while underlying autoimmune and inflammatory conditions are present in some patients with CVID and XLA, leading to clinical misdiagnosis and diagnostic delay. Chronic diarrhea in patients with CVID and XLA, particularly complicated malabsorption and protein-energy malnutrition, is responsible for poor prognostic outcomes. Methods In this study, we described three PID adult patients (two with CVID and one with XLA) who presented with varying degrees of chronic diarrhea, weight loss, and protein-energy malnutrition. We suggest that villous blunting of the small intestine under capsule endoscopy may be an endoscopic feature of PID-related enteropathy, thus highlighting the application of capsule endoscopy in patients with CVID and XLA presenting with chronic diarrhea. Conclusion We also summarize regular Ig supplementation is the basic treatment for CVID and XLA patients, proper enteral nutrition and probiotic therapy can be explored to use to alter gut microbiota and modulate intestinal immune response. However, vedolizumab is not helpful to PID-related enteropathy therapy, as it exacerbates the inflammatory response in extra-intestinal organs and ultimately causes poor clinical outcomes.
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Affiliation(s)
- Feihong Deng
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, People’s Republic of China
- Research Center of Digestive Disease, Central South University, Changsha, Hunan, 410011, People’s Republic of China
| | - Hanyu Wang
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, People’s Republic of China
- Research Center of Digestive Disease, Central South University, Changsha, Hunan, 410011, People’s Republic of China
| | - Xuehong Wang
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, People’s Republic of China
- Research Center of Digestive Disease, Central South University, Changsha, Hunan, 410011, People’s Republic of China
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Solís-Sánchez P, Fernández-Martínez M, Rodrigo-Calabia E, de Alegría-Puig CR. Chronic Diarrhea Due to Aeromonas hydrophila in an Immunosuppressed Patient with a Pancreas-Kidney Transplant. Pathogens 2023; 12:1151. [PMID: 37764959 PMCID: PMC10536218 DOI: 10.3390/pathogens12091151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 09/06/2023] [Accepted: 09/08/2023] [Indexed: 09/29/2023] Open
Abstract
The genus Aeromonas belongs to the Aeromonadaceae family. A patient with a pancreas-kidney transplant had multiple episodes of abdominal sepsis after surgery. Aeromonas hydrophila was isolated in the ascitic and biliary fluid drains. After discharge, the patient had several diarrhea episodes, and A. hydrophila was isolated in four stool samples. We decided to test whether the one strain that we initially isolated in ascitic fluid was the same that appeared in the successive stool samples. Five isolates of A. hydrophila were found in the patient. Identification was performed using the MALDI-TOF system and confirmed via multiplex PCR. The analysis of the REP-PCR fingerprint patterns showed one cluster and confirmed that all isolates were related. We also demonstrated the virulent character of this species associated with genes encoding different toxins (act, alt, ast, hlyA, and aerA). The virulence of this species is associated with the expression of genes that encode different toxins, structural proteins, and metal-associated proteins. This case report highlights the severity of this disease, especially in immunocompromised patients, and its adequate treatment.
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Affiliation(s)
- Pablo Solís-Sánchez
- Internal Medicine Service, University Hospital Marqués de Valdecilla-IDIVAL, 39008 Santander, Spain
| | | | - Emilio Rodrigo-Calabia
- Nephrology Service, University Hospital Marqués de Valdecilla-IDIVAL, 39008 Santander, Spain
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Gowda VK, Srinivasan VM, Jetha K, Sugumar K, Bhat M, Shivappa SK, Bhat M, Christopher R. Case Series of Ethylmalonic Encephalopathy from Southern India. J Pediatr Genet 2023; 12:213-218. [PMID: 37575639 PMCID: PMC10421674 DOI: 10.1055/s-0041-1740370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 10/22/2021] [Indexed: 10/19/2022]
Abstract
Ethylmalonic encephalopathy is a rare neurometabolic disorder with central nervous system involvement and vasculopathy. It is presented in infancy with developmental delay, acrocyanosis, petechiae, chronic diarrhea, and early death. This was a retrospective study of confirmed cases of ethylmalonic aciduria from a tertiary care hospital over a period of 5 years from January 2015 to December 2020. Case details including analysis of clinical history, investigations, and outcomes are presented. Of six cases, male-to-female ratio was 4:2. Mean age of presentation was 35.5 months (range: 14-83 months). Consanguinity, global developmental delay, failure to thrive, skin rashes, microcephaly, hypotonia, and exaggerated deep tendon reflexes were observed in all cases. Chronic diarrhea was presented in five cases. The serum levels of C4 carnitine and urinary levels of ethylmalonic acid were increased in all cases. Magnetic resonance imaging (MRI) of the brain showed heterogenous bilateral symmetrical changes in the basal ganglia in five cases, and in one case, MRI could not be done. Genetic testing in two cases showed a homozygous variant in ETHE1 gene. Four children died, while the other two cases showed a decreased in recurrent encephalopathies and diarrhea after starting metronidazole. All children had global developmental delay, failure to thrive, skin rashes, central hypotonia, increased C4 carnitine levels in the serum, and increased ethylmalonic acid in the urine. Chronic diarrhea, acrocyanosis, and basal ganglia change in the MRI of the brain also give important clues for diagnosis. Metronidazole is useful in preventing recurrent episodes of encephalopathy.
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Affiliation(s)
- Vykuntaraju K. Gowda
- Department of Pediatric Neurology, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
| | - Varunvenkat M. Srinivasan
- Department of Pediatric Neurology, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
| | - Kapil Jetha
- Department of Pediatric Neurology, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
| | - Kiruthiga Sugumar
- Department of Pediatric Neurology, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
| | - Meenakshi Bhat
- Department of Genetics, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
| | - Sanjay K. Shivappa
- Department of Pediatric Medicine, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
| | - Maya Bhat
- Department of Neuroradiology, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
| | - Rita Christopher
- Department of Neurochemistry, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
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14
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Wakankar R. A Case of Pancreatic Neuroendocrine Tumor With Extensive Skeletal Metastases Detected on 68Ga-DOTANOC PET-CT. Cureus 2023; 15:e43130. [PMID: 37692584 PMCID: PMC10483888 DOI: 10.7759/cureus.43130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2023] [Indexed: 09/12/2023] Open
Abstract
Neuroendocrine tumors (NETs) are a rather uncommon cause of chronic non-bloody diarrhea and are therefore often left undiagnosed for prolonged periods of time. In this case, a 46-year-old man was inappropriately treated with antibiotics for months by various doctors, and by the time the diagnosis of NET was made, the tumor had already metastasized to the entire skeleton. The patient refused surgery and was started on octreotide, which resolved his diarrhea.
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Affiliation(s)
- Ritwik Wakankar
- Nuclear Medicine, Max Super Speciality Hospital, New Delhi, IND
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15
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Songtanin B, Chen JN, Nugent K. Microscopic Colitis: Pathogenesis and Diagnosis. J Clin Med 2023; 12:4442. [PMID: 37445477 DOI: 10.3390/jcm12134442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/26/2023] [Accepted: 06/29/2023] [Indexed: 07/15/2023] Open
Abstract
Microscopic colitis is a type of inflammatory bowel disease and is classified as either collagenous colitis or lymphocytic colitis. The typical presentation is chronic watery diarrhea. The disease occurs more frequently in women aged 60-65 years and is increasing in incidence. The pathophysiology of microscopic colitis remains poorly understood and has not been well-described with possible several pathogeneses. To date, the diagnosis of microscopic colitis depends on histological tissue obtained during colonoscopy. Other non-invasive biomarkers, such as inflammatory markers and fecal biomarkers, have been studied in microscopic colitis, but the results remains inconclusive. The approach to chronic diarrhea is important and being able to differentiate chronic diarrhea in patients with microscopic colitis from other diseases, such as inflammatory bowel disease, functional diarrhea, and malignancy, by using non-invasive biomarkers would facilitate patient management. The management of microscopic colitis should be based on each individual's underlying pathogenesis and involves budesonide, bile acid sequestrants, or immunosuppressive drugs in refractory cases. Cigarette smoking and certain medications, especially proton pump inhibitors, should be eliminated, when possible, after the diagnosis is made.
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Affiliation(s)
- Busara Songtanin
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
| | - Jason N Chen
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
| | - Kenneth Nugent
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
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16
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Raza D, Prajapati P, Bhavsar V, Raza SM, Papayannis I. Gastrointestinal (GI) Amyloidosis Presenting As Chronic Diarrhea: A Diagnostic Dilemma. Cureus 2023; 15:e41291. [PMID: 37539395 PMCID: PMC10393591 DOI: 10.7759/cureus.41291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2023] [Indexed: 08/05/2023] Open
Abstract
This case report describes a 63-year-old male patient with a four-year history of chronic diarrhea. Extensive diagnostic investigations failed to reveal a cause. Subsequent upper and lower gastrointestinal (GI) endoscopic procedures revealed the presence of amyloidosis in the GI tract. The patient was referred for further evaluation, but unfortunately, he presented with hypotension and shock, and ultimately succumbed to systemic amyloidosis involving multiple organs. GI amyloidosis, although rare, should be considered in patients presenting with chronic diarrhea, unexplained weight loss, or GI bleeding. Early recognition and appropriate management are crucial for optimizing patient outcomes. Healthcare providers should maintain a high index of suspicion for GI amyloidosis to ensure timely intervention and improve patient care.
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Affiliation(s)
- Daniyal Raza
- Internal Medicine, Louisiana State University Health Shreveport, Shreveport, USA
| | | | - Vatsa Bhavsar
- Internal Medicine, B.J. Medical College, Ahmedabad, IND
| | - Syed Musa Raza
- Gastroenterology, Louisiana State University Health Shreveport, Shreveport, USA
| | - Ioannis Papayannis
- Gastroenterology, Louisiana State University Health Shreveport, Shreveport, USA
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17
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Reddy A, Nwankwo N, Sekar A, Kumar A. An unusual cause of chronic diarrhea in a Middle-Aged adult: A diagnostic challenge. Clin Case Rep 2023; 11:e7357. [PMID: 37220509 PMCID: PMC10199814 DOI: 10.1002/ccr3.7357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 04/18/2023] [Accepted: 05/03/2023] [Indexed: 05/25/2023] Open
Abstract
Diarrhea is a common symptom in medical practice that often gets overlooked. This article is intended to increase the awareness of physicians and other providers on a subtle but important cause of chronic diarrhea.
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Affiliation(s)
- Aswanth Reddy
- Department of Hematology and OncologyMercy ClinicFort SmithArkansasUSA
| | - Nkolika Nwankwo
- Department of Internal MedicineMercy ClinicFort SmithArkansasUSA
| | - Arjun Sekar
- Department of Nephrology, Rochester Regional HealthRGH Center for Kidney Disease and HypertensionRochesterNew YorkUSA
| | - Aswini Kumar
- Department of CardiologyMercy ClinicFort SmithArkansasUSA
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18
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Marsilio S, Freiche V, Johnson E, Leo C, Langerak AW, Peters I, Ackermann MR. ACVIM consensus statement guidelines on diagnosing and distinguishing low-grade neoplastic from inflammatory lymphocytic chronic enteropathies in cats. J Vet Intern Med 2023; 37:794-816. [PMID: 37130034 PMCID: PMC10229359 DOI: 10.1111/jvim.16690] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 03/10/2023] [Indexed: 05/03/2023] Open
Abstract
BACKGROUND Lymphoplasmacytic enteritis (LPE) and low-grade intestinal T cell lymphoma (LGITL) are common diseases in older cats, but their diagnosis and differentiation remain challenging. OBJECTIVES To summarize the current literature on etiopathogenesis and diagnosis of LPE and LGITL in cats and provide guidance on the differentiation between LPE and LGITL in cats. To provide statements established using evidence-based approaches or where such evidence is lacking, statements based on consensus of experts in the field. ANIMALS None. METHODS A panel of 6 experts in the field (2 internists, 1 radiologist, 1 anatomic pathologist, 1 clonality expert, 1 oncologist) with the support of a human medical immunologist, was formed to assess and summarize evidence in the peer-reviewed literature and complement it with consensus recommendations. RESULTS Despite increasing interest on the topic for clinicians and pathologists, few prospective studies were available, and interpretation of the pertinent literature often was challenging because of the heterogeneity of the cases. Most recommendations by the panel were supported by a moderate or low level of evidence. Several understudied areas were identified, including cellular markers using immunohistochemistry, genomics, and transcriptomic studies. CONCLUSIONS AND CLINICAL IMPORTANCE To date, no single diagnostic criterion or known biomarker reliably differentiates inflammatory lesions from neoplastic lymphoproliferations in the intestinal tract of cats and a diagnosis currently is established by integrating all available clinical and diagnostic data. Histopathology remains the mainstay to better differentiate LPE from LGITL in cats with chronic enteropathy.
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Affiliation(s)
- Sina Marsilio
- Department of Veterinary Medicine and EpidemiologyUC Davis School of Veterinary MedicineDavisCaliforniaUSA
| | - Valerie Freiche
- Ecole Nationale Vétérinaire d'AlfortCHUVA, Unité de Médecine InterneMaisons‐AlfortFrance
| | - Eric Johnson
- Department of Surgical & Radiological SciencesUC Davis School of Veterinary MedicineDavisCaliforniaUSA
| | - Chiara Leo
- Anicura Istituto Veterinario NovaraNovaraItaly
| | | | | | - Mark R. Ackermann
- Oregon Veterinary Diagnostic Laboratory, Oregon State UniversityCorvallisOregonUSA
- Present address:
US Department of AgricultureNational Animal Disease CenterAmesIowaUSA
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19
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Toresson L, Suchodolski JS, Spillmann T, Lopes BC, Shih J, Steiner JM, Pilla R. The Intestinal Microbiome in Dogs with Chronic Enteropathies and Cobalamin Deficiency or Normocobalaminemia-A Comparative Study. Animals (Basel) 2023; 13:ani13081378. [PMID: 37106941 PMCID: PMC10135184 DOI: 10.3390/ani13081378] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 03/22/2023] [Accepted: 04/11/2023] [Indexed: 04/29/2023] Open
Abstract
Cobalamin deficiency is a common sequela of chronic enteropathies (CE) in dogs. Studies comparing the intestinal microbiome of CE dogs with cobalamin deficiency to those that are normocobalaminemic are lacking. Therefore, our aim was to describe the fecal microbiome in a prospective, comparative study evaluating 29 dogs with CE and cobalamin deficiency, 18 dogs with CE and normocobalaminemia, and 10 healthy control dogs. Dogs with cobalamin deficiency were also analyzed after oral or parenteral cobalamin supplementation. Overall microbiome composition (beta diversity) at baseline was significantly different in CE dogs with cobalamin deficiency when compared to those with normocobalaminemia (p = 0.001, R = 0.257) and to healthy controls (p = 0.001, R = 0.363). Abundances of Firmicutes and Actinobacteria were significantly increased (q = 0.010 and 0.049), while those of Bacteroidetes and Fusobacteria were significantly decreased (q = 0.002 and 0.014) in CE dogs with cobalamin deficiency when compared to healthy controls. Overall microbiome composition in follow-up samples remained significantly different after 3 months in both dogs receiving parenteral (R = 0.420, p = 0.013) or oral cobalamin supplementation (R = 0.251, p = 0.007). Because cobalamin supplementation, in combination with appropriate therapy, failed to restore the microbiome composition in the dogs in our study, cobalamin is unlikely to be the cause of those microbiome changes but rather an indicator of differences in underlying pathophysiology that do not influence clinical severity but result in a significant aggravation of dysbiosis.
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Affiliation(s)
- Linda Toresson
- Evidensia Specialist Animal Hospital Helsingborg, 254 66 Helsingborg, Sweden
- Department of Equine and Small Animal Medicine, Faculty of Veterinary Medicine, University of Helsinki, 00014 Helsinki, Finland
| | - Jan S Suchodolski
- Gastrointestinal Laboratory, Department of Small Animal Clinical Sciences, Texas A&M University, 4474 TAMU, College Station, TX 77843-4474, USA
| | - Thomas Spillmann
- Department of Equine and Small Animal Medicine, Faculty of Veterinary Medicine, University of Helsinki, 00014 Helsinki, Finland
| | - Bruna C Lopes
- Gastrointestinal Laboratory, Department of Small Animal Clinical Sciences, Texas A&M University, 4474 TAMU, College Station, TX 77843-4474, USA
| | - Johnathan Shih
- Gastrointestinal Laboratory, Department of Small Animal Clinical Sciences, Texas A&M University, 4474 TAMU, College Station, TX 77843-4474, USA
| | - Jörg M Steiner
- Gastrointestinal Laboratory, Department of Small Animal Clinical Sciences, Texas A&M University, 4474 TAMU, College Station, TX 77843-4474, USA
| | - Rachel Pilla
- Gastrointestinal Laboratory, Department of Small Animal Clinical Sciences, Texas A&M University, 4474 TAMU, College Station, TX 77843-4474, USA
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20
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Hu L, Franco L, Parikh J, Zayat V. Mastocytic Enterocolitis: An Overlooked Diagnosis for Unexplained Chronic Diarrhea in a Patient With Colon Polyps and a Family History of Colon Cancer. Cureus 2023; 15:e37219. [PMID: 37168163 PMCID: PMC10166299 DOI: 10.7759/cureus.37219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 04/06/2023] [Indexed: 05/13/2023] Open
Abstract
Chronic intractable diarrhea is a common presenting complaint that is often clinically worked up for a wide variety of diseases including inflammatory bowel disease, celiac disease, and hyperthyroidism. When lab results come back normal, patients are often diagnosed with irritable bowel disease-diarrheal subtype, overlooking the potential diagnosis of mastocytic enterocolitis. Mastocytic enterocolitis is an uncommon diagnosis where patients can benefit from mast cell stabilizers that directly target the underlying pathology. Given the broad differential diagnosis of nonspecific diarrhea presentation, a histopathological examination is warranted for definitive diagnosis. We hope to raise awareness of this potentially treatable disease that can be effectively managed with antihistamines. We describe the case of a 63-year-old male patient with a family history significant for colon cancer who presented with intractable diarrhea and was ultimately diagnosed with mastocytic enterocolitis by histopathology. His symptoms were relieved by antihistamine treatment.
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Affiliation(s)
- Leeann Hu
- Medical School, University of Central Florida College of Medicine, Orlando, USA
| | - Liliana Franco
- Internal Medicine, University of Central Florida/HCA Healthcare Graduate Medical Education (GME), Orlando, USA
| | - Jignesh Parikh
- Pathology, Orlando Veterans Affairs Medical Center, Orlando, USA
| | - Vania Zayat
- Pathology, Orlando Veterans Affairs Medical Center, Orlando, USA
- Pathology, University of Central Florida College of Medicine, Orlando, USA
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21
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Carvalho AC, Pinho J, Cancela E, Silva A. Autoimmune Enteropathy: A Rare Cause of Chronic Diarrhea in an Adult Patient. ACG Case Rep J 2023; 10:e01009. [PMID: 36923989 DOI: 10.14309/crj.0000000000001009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 02/07/2023] [Indexed: 03/16/2023] Open
Abstract
Autoimmune enteropathy is a rare cause of malabsorption usually associated with circulating autoantibodies and predisposition to autoimmune disorders. The diagnosis is based on the following criteria: chronic diarrhea (>6 months), malabsorption, specific histological findings, anti-enterocyte and anti-goblet cell antibodies, and exclusion of similar disorders. We report a case of a 73-year-old woman presenting with severe chronic diarrhea, weight loss, and electrolyte abnormalities. Endoscopy revealed duodenal villous atrophy extending to proximal jejunum, and duodenal biopsies revealed villous blunting, cryptitis with apoptosis, and scattered intraepithelial lymphocytes. Therapeutic management included immunosuppressive treatment with corticosteroids, achieving clinical remission.
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22
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Trivedi A, Bathobakae L, Shenasan P, Yuridullah R, Akmal A, El-Sedfy A. Rectal Tropism: An Extremely Rare Case of Prostate Cancer Recurrence With Metastasis to the Rectum Postradical Prostatectomy. J Investig Med High Impact Case Rep 2023; 11:23247096231211053. [PMID: 37942542 PMCID: PMC10637143 DOI: 10.1177/23247096231211053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 10/15/2023] [Indexed: 11/10/2023] Open
Abstract
Prostate cancer is the most common noncutaneous cancer affecting men in the United States. It is a slow-growing tumor that can be missed during the nascent phase. Prostate cancer commonly metastasizes to the bones and nearby lymph nodes. However, cases of metastatic prostate cancer to the rectum are exceptionally rare. Such metastases may cause obstructive or malabsorption symptoms similar to those observed in primary rectal carcinoma. We present a very rare case of prostate cancer recurrence with rectal metastasis in an elderly male with a history of castration-resistant prostate carcinoma status postradical prostatectomy.
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Affiliation(s)
- Aakash Trivedi
- St. Joseph’s University Medical Center, Paterson, NJ, USA
| | | | - Pasha Shenasan
- St. Joseph’s University Medical Center, Paterson, NJ, USA
| | | | - Amer Akmal
- St. Joseph’s University Medical Center, Paterson, NJ, USA
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23
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Wang D, Li Y, Shi Y, Hu Z. U-shaped association between sleep duration with chronic constipation and diarrhea: A population-based study. Chronobiol Int 2022; 39:1656-1664. [PMID: 36322395 DOI: 10.1080/07420528.2022.2139713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
To examine the association between sleep duration with chronic constipation and diarrhea, we collected demographic and questionnaire data of participants from The National Health and Nutrition Examination Survey in the period 2005 to 2010. A restricted cubic spline curve function was used to determine the association between sleep duration and chronic constipation or diarrhea. Multivariate logistic regression models were used to estimate the association between sleep duration groups and chronic constipation or diarrhea. 14,054 eligible participants were included in this study. Among all sleep durations, 7 hours sleep per day had the highest percentage of normal stool forms (86.3%, P < .001), while people with ≤4 hours sleep had a higher number of bowel movements per week (P < .001). RCS models demonstrated a significant nonlinear association between sleep duration and risk of chronic constipation (P < .001). The inflection points of the U-shaped association curve corresponded to 7 hours of sleep per day. Multivariate logistic regression indicated that compared to participants with 7 hours daily sleep duration, participants with ≤4 hours and ≥10 hours sleep duration had a 54% (95%CI: (1.16-2.04), P = .002) and 90% (95%CI: (1.33-2.72), P < .001) higher risk of constipation, respectively. There is a non-linear association between sleep duration and the risk of chronic constipation. Our findings indicate that both shorter and longer sleep duration are associated with an increased risk of constipation.
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Affiliation(s)
- Dongyan Wang
- Department of Gastroenterology, Shanghai Pudong New Area Gongli Hospital, Shanghai, China
| | - Yan Li
- Department of Gastroenterology, Shanghai Tenth People's Hospital, Affiliated to Tongji University School of Medicine, Shanghai, China
| | - Yihai Shi
- Department of Gastroenterology, Shanghai Pudong New Area Gongli Hospital, Shanghai, China
| | - Zhengyu Hu
- Department of General Surgery, Shanghai Tenth People's Hospital, Affiliated to Tongji University School of Medicine, Shanghai, China
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24
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Muacevic A, Adler JR, Loureiro L, Gonçalves A. Celiac Patient With New Episodes of Diarrhea: A Case Report. Cureus 2022; 14:e32092. [PMID: 36601211 PMCID: PMC9803998 DOI: 10.7759/cureus.32092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2022] [Indexed: 12/03/2022] Open
Abstract
Celiac disease is a relatively common autoimmune disease that affects the gut's ability to process gluten. It is frequently associated with other autoimmune diseases. In this article, the authors present a clinical case of a 65-year-old female patient with a history of celiac disease and autoimmune hypothyroidism. This patient was admitted to the emergency room with generalized edema and chronic diarrhea with mucus as well as reports of unusual weight loss. A requested fecal analysis tested positive for fecal calprotectin. An endoscopic study further displayed flattening of the intestinal villi. A subsequent biopsy expressed overlapping evidence for both celiac disease and lymphocytic colitis. This case illustrates how a diagnosis of microscopic colitis should be explored when celiac patients with a history of a stable gluten-free diet display a sudden onset of chronic diarrhea. As the symptoms associated with this disease can often become debilitating, an early diagnosis and treatment are crucial.
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25
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Vernia F, Tatti T, Necozione S, Capannolo A, Cesaro N, Magistroni M, Valvano M, Pompili S, Sferra R, Vetuschi A, Latella G. Is mastocytic colitis a specific clinical-pathological entity? Eur J Histochem 2022; 66:3499. [PMID: 36440694 PMCID: PMC9761410 DOI: 10.4081/ejh.2022.3499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 11/10/2022] [Indexed: 12/23/2022] Open
Abstract
The number of intestinal mast cells (MC) is increased in several types of colitis, but the mucosa of patients with chronic non-bloody diarrhea has not been studied. The current study sought to determine the relationship between MC counts and degranulation and the severity of symptoms in patients with chronic loose stools. Following a negative laboratory workup for the most common causes of chronic diarrhea, patients with chronic non-bloody loose stools were included in the study. Patients with macroscopic evidence of inflammation or organic disease were excluded after endoscopy with biopsies. Biopsies from the 179 patients in the study were stained with hematoxylin and eosin and anti-CD117 c-kit antibodies. Immunohistochemistry was used to assess the degree of MC degranulation. Out of the 179 patients, 128 had normal histologic findings suggestive of irritable bowel syndrome and were used as controls. Twenty-four presented with abnormally high MC counts (≥40 MC x HPF), 23 with ≥20 intraepithelial lymphocytes x HPF suggesting lymphocytic colitis, and 4 had both (≥40 MC and ≥20 intraepithelial lymphocytes x HPF). In the patients with high MC counts, figures were significantly higher in the right colon versus the left colon (p=0.016), but degranulation did not differ in the right versus the left colon (p=0.125). No age or sex-related difference was observed (p=0.527 and p=0.859 respectively). The prevalence of abdominal pain and bloating did not differ in the three groups (p=0.959 and p=0.140, respectively). Patients with lymphocytic colitis (p=0.008) and those with high MC counts (p=0.025) had significantly higher evacuation rates compared to controls. There was no difference between these two groups (p=0.831). Mast cell degranulation was not associated with the number of evacuations, abdominal pain, or bloating (p=0.51; p=0.41; p=0.42, respectively). The finding that a significantly higher number of evacuations was linked to increased MC in the colonic mucosa of a subset of patients with otherwise normal laboratory and endoscopic findings suggests that "mastocytic colitis" may be a new clinical-pathological entity responsible for chronic non-bloody diarrhea. Prospective studies with a larger number of patients, as well as endoscopic and histological follow-up, are needed to confirm this hypothesis.
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Affiliation(s)
- Filippo Vernia
- Gastroenterology Unit, Department of Life, Health and Environmental Sciences, University of L’Aquila,*These authors contributed equally to this work
| | - Tiziana Tatti
- Pathology Unit, S. Salvatore Academic Hospital, L'Aquila,*These authors contributed equally to this work
| | - Stefano Necozione
- Epidemiology Unit, Department of Life, Health and Environmental Sciences, University of L'Aquila
| | - Annalisa Capannolo
- Diagnostic and Surgical Endoscopy Unit, San Salvatore Academic Hospital, L'Aquila
| | - Nicola Cesaro
- Gastroenterology Unit, Department of Life, Health and Environmental Sciences, University of L’Aquila
| | - Marco Magistroni
- Gastroenterology Unit, Department of Life, Health and Environmental Sciences, University of L’Aquila
| | - Marco Valvano
- Gastroenterology Unit, Department of Life, Health and Environmental Sciences, University of L’Aquila
| | - Simona Pompili
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Italy
| | - Roberta Sferra
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Italy
| | - Antonella Vetuschi
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Italy
| | - Giovanni Latella
- Gastroenterology Unit, Department of Life, Health and Environmental Sciences, University of L’Aquila,*These authors contributed equally to this work
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26
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Tian P, Gao J, Liang L, Cui B, Hu Q, Zhou W, Li B, Liu Y, Chen T, Rao J, Wei H. Fecal Microbiota Transplantation Could Improve Chronic Diarrhea in Cynomolgus Monkey by Alleviating Inflammation and Modulating Gut Microbiota. Biomedicines 2022; 10. [PMID: 36551772 DOI: 10.3390/biomedicines10123016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/04/2022] [Accepted: 11/11/2022] [Indexed: 11/24/2022] Open
Abstract
Chronic diarrhea is associated with enteric dysbiosis and provokes the overuse of antibiotics. Fecal microbiota transplantation (FMT) is a promising therapy, but it shows discrepant clinical efficacy. Bacterial colonization in recipients has been studied, although little is known about the role of gut fungi and Archaea after FMT. In this study, we evaluated the efficacy of human-derived FMT on spontaneous chronic diarrhea cynomolgus monkeys and revealed the effector mechanisms. We demonstrated that FMT can mitigate the appearance of diarrheal symptoms and inhibit the increase in interleukin-6, interleukin-8, interleukin-1β, and interferon-γ and the decrease in interleukin-10 in serum. We confirmed that FMT restored the disturbance of gut bacteria by reducing the relative abundances of potential pathogens, including Cloacibacillus porcorum, Desulfovibrio desulfuricans, Erysipelotrichaceae bacterium 5_2_54FAA, and Erysipelotrichaceae bacterium 21_3, and increasing the levels of Lactobacillus fermentum and Lactobacillus ruminis CAG_367 in diarrheal monkeys. The metabolic pathways of healthy and FMT monkeys' gut bacteria were enriched in amino acid metabolism, carbohydrate metabolism, and lipid metabolism, while the metabolic pathways of pre-FMT monkeys' gut bacteria were enriched in antibiotic production. Moreover, a higher Ascomycota/Basidiomycota ratio, higher Aspergillus levels, and lower Trichosporon asahii abundance were present in intestinal fungi after FMT. Although the abundance of the Archaea Methanosphaera stastmanae did not change significantly, it was inversely correlated with the anti-inflammatory factor IL-4 after FMT. These results support the further development and application of FMT for chronic diarrhea.
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Patel M, Middleton JP, Goodkin HP, Barnes B, McGowan E, Eid R. Persistent Diarrhea and Eosinophilic Esophagitis Resulting From Chronic Cannabidiol Usage for Refractory Epilepsy. JPGN Rep 2022; 3:e253. [PMID: 37168471 PMCID: PMC10158314 DOI: 10.1097/pg9.0000000000000253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 05/25/2022] [Indexed: 05/13/2023]
Abstract
Cannabidiol is used in the care of treatment-resistant epilepsy. It has been associated with varying side effects, ranging from somnolence to diarrhea and weight loss. We present a patient on chronic cannabidiol therapy who had persistent diarrhea, abdominal pain, weight loss, and esophageal eosinophilia that improved with cannabidiol dose adjustment.
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Affiliation(s)
- Maitri Patel
- From the School of Medicine, University of Virginia, Charlottesville, VA
| | | | - Howard P. Goodkin
- Department of Neurology and Pediatrics, University of Virginia, Charlottesville, VA
| | - Barrett Barnes
- Division of Pediatric Gastroenterology, University of Virginia School of Medicine, Charlottesville, VA
| | - Emily McGowan
- Division of Allergy and Immunology, University of Virginia School of Medicine, Charlottesville, VA
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ryan Eid
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, MD
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28
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Takedomi H, Sakata Y, Tomonaga M, Naruse N, Yukimoto T, Akutagawa T, Tsuruoka N, Shimoda R, Kido S, Esaki M. Collagenous Colitis Possibly Associated with Dipeptidyl Peptidase-4 Inhibitor. Intern Med 2022; 61:2731-2734. [PMID: 35135927 PMCID: PMC9556224 DOI: 10.2169/internalmedicine.9040-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
A 60-year-old man with type 2 diabetes mellitus treated with a dipeptidyl peptidase-4 (DPP-4) inhibitor was referred to our hospital because of his refractory watery diarrhea. Ileocolonoscopy revealed increased capillary growth, fine granular mucosa, and longitudinal mucosal tears mainly in the left side of the colon. A bioptic examination revealed thickened subepithelial collagen bands, thus confirming the diagnosis of collagenous colitis. Systemic steroid therapy was initiated, but his symptoms recurred when tapering the steroid. However, withdrawal of the DPP-4 inhibitor was successful even after the cessation of steroid therapy. We therefore considered his collagenous colitis to have been caused by the DPP-4 inhibitor.
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Affiliation(s)
- Hironobu Takedomi
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Saga University, Japan
| | - Yasuhisa Sakata
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Saga University, Japan
| | - Michito Tomonaga
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Saga University, Japan
| | - Naomi Naruse
- Department of Endoscopic Diagnostics and Therapeutics, Saga University Hospital, Japan
| | - Takahiro Yukimoto
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Saga University, Japan
| | - Takashi Akutagawa
- Department of Endoscopic Diagnostics and Therapeutics, Saga University Hospital, Japan
| | - Nanae Tsuruoka
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Saga University, Japan
| | - Ryo Shimoda
- Department of Endoscopic Diagnostics and Therapeutics, Saga University Hospital, Japan
| | - Shinichi Kido
- Department of Pathology and Microbiology, Faculty of Medicine, Saga University, Japan
| | - Motohiro Esaki
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Saga University, Japan
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29
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Cerquetella M, Marchegiani A, Rossi G, Trabalza-Marinucci M, Passamonti F, Isidori M, Rueca F. Case Report: Oral Fecal Microbiota Transplantation in a Dog Suffering From Relapsing Chronic Diarrhea-Clinical Outcome and Follow-Up. Front Vet Sci 2022; 9:893342. [PMID: 35859811 PMCID: PMC9289623 DOI: 10.3389/fvets.2022.893342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 06/06/2022] [Indexed: 12/01/2022] Open
Abstract
The present case report describes the effects of orally administered fecal microbiota transplantation (FMT) (frozen capsules) in a dog suffering from relapsing chronic diarrhea, needing a continuous low prednisolone dose to maintain the condition under acceptable control. Through FMT, we aimed at evaluating the possibility of improving the clinical score and/or reducing/suspending steroid administration. During a first period of strict monitoring (21 days), the canine inflammatory bowel disease activity index (CIBDAI) score passed from mild to clinically insignificant disease. Furthermore, two additional gastrointestinal signs that had been reported, bloating and episodes of painful defecation, rapidly improved (bloating) or even resolved (painful defecation). The patient was then followed for 18 months (to the authors' knowledge, the longest follow-up time ever reported in a dog), during which no serious relapses occurred and no increase in prednisolone dose was necessary. No adverse clinical effects were ever reported during monitoring. The present description provides a further experience increasing those already present in the veterinary literature, in which an agreement on how to use FMT has not yet been achieved although strongly needed and recommended.
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Affiliation(s)
- Matteo Cerquetella
- School of Biosciences and Veterinary Medicine, University of Camerino, Camerino, Italy
| | - Andrea Marchegiani
- School of Biosciences and Veterinary Medicine, University of Camerino, Camerino, Italy
| | - Giacomo Rossi
- School of Biosciences and Veterinary Medicine, University of Camerino, Camerino, Italy
| | | | | | - Marco Isidori
- Department of Veterinary Medicine, University of Perugia, Perugia, Italy
| | - Fabrizio Rueca
- Department of Veterinary Medicine, University of Perugia, Perugia, Italy
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30
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Bottero E, Ferriani R, Benvenuti E, Ruggiero P, Astorina S, Giraldi M, Bertoldi L, Benvenuto G, Sattin E, Gianella P, Suchodolski JS. Clinical evaluation and microbiota analysis in 9 dogs with antibiotic-responsive enteropathy: A prospective comparison study. J Vet Intern Med 2022; 36:1220-1228. [PMID: 35621056 PMCID: PMC9308422 DOI: 10.1111/jvim.16443] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 04/27/2022] [Indexed: 12/28/2022] Open
Abstract
Background Antibiotic‐responsive enteropathy (ARE) is diagnosed by excluding other causes of diarrhea and when there is a short‐term response to administration of antibiotics. Objectives To characterize the gut microbiota and clinical trend of dogs with suspected ARE and to evaluate the variation in microbiota before (T0), after 30 days (T30) of tylosin treatment, and 30 days after discontinuation of treatment (T60). A further objective was to evaluate whether changes in gut microbiota are related to relapses of diarrhea when the therapy is tapered. Animals Study sample (group A) was composed of 15 dogs with chronic diarrhea, group B was composed of 15 healthy dogs. Group A was given tylosin for 30 days. Methods A multicentric prospective study. Clinical Indexes, fecal score, and samples for microbiota analysis were collected at T0, T30, and T60 in group A and T0 and T30 in group B. The gut microbiota was analyzed via 16S ribosomal RNA gene. Qiime2 version 2020.2 was used to perform bioinformatic analyses, and Alpha‐ and Beta‐diversity were computed. Results Diarrhea recurred after T30 in 9 of 14 dogs, which were classified as affected by ARE. At T0, a difference was noted in the beta‐diversity between groups (Bray Curtis metric P = .006). A T0‐T30 difference in alpha‐diversity was noted in group A (Shannon index P = .001, Faith PD P = .007). Conclusions and Clinical Importance Although tylosin influences the microbiota of dogs with ARE, we failed to find any specific characteristic in the microbiota of dogs with ARE.
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Affiliation(s)
- Enrico Bottero
- Endovet Group, Rome, Italy.,Ospedale Veterinario San Francesco, Milan, Italy
| | - Riccardo Ferriani
- Endovet Group, Rome, Italy.,Ospedale Veterinario San Francesco, Milan, Italy
| | | | | | - Simona Astorina
- Endovet Group, Rome, Italy.,Clinica Veterinaria Città di Catania, Catania, Italy
| | | | | | | | | | - Paola Gianella
- Department of Veterinary Science, University of Turin, Grugliasco, Italy
| | - Jan S Suchodolski
- Gastrointestinal Laboratory, Department of Small Animal Clinical Science, Texas A&M University, College Station, Texas, USA
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31
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Josyabhatla R, Tatevian N, Tchakarov AS, Cox CS, Van Arsdall MR. Chronic Diarrhea in an Infant With Malrotation: A Diagnostic Dilemma. JPGN Rep 2022; 3:e177. [PMID: 37168912 PMCID: PMC10158313 DOI: 10.1097/pg9.0000000000000177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 01/10/2022] [Indexed: 05/13/2023]
Abstract
In children, diarrhea has a global incidence of 2.7 episodes per child-year and contributes to significant disease burden and mortality in children under 5 years of age. Chronic diarrhea, defined as diarrhea lasting for more than 2 weeks, may be particularly challenging to evaluate and manage in children under 2 years of age. While most have infectious enteritis or cow milk protein intolerance, others have conditions such as malnutrition, anatomic abnormalities, or congenital enteropathies that can be challenging to diagnose and treat. We present here a complex case of chronic diarrhea in an infant and highlight such diagnostic and therapeutic challenges.
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Affiliation(s)
- Rohit Josyabhatla
- From the Department of Pediatrics, Division of Pediatric Gastroenterology, UTHealth McGovern Medical School, Houston, TX
| | - Nina Tatevian
- Department of Pathology and Laboratory Medicine, UTHealth McGovern Medical School, Houston, TX; and
| | - Amanda S. Tchakarov
- Department of Pathology and Laboratory Medicine, UTHealth McGovern Medical School, Houston, TX; and
| | - Charles S. Cox
- Department of Pediatric Surgery, UTHealth McGovern Medical School, Houston, TX
| | - Melissa R. Van Arsdall
- From the Department of Pediatrics, Division of Pediatric Gastroenterology, UTHealth McGovern Medical School, Houston, TX
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Matsumoto Y, Nadatani Y, Otani K, Higashimori A, Ominami M, Fukunaga S, Hosomi S, Kamata N, Kimura T, Fukumoto S, Tanaka F, Taira K, Nagami Y, Watanabe T, Fujiwara Y. Prevalence and risk factor for chronic diarrhea in participants of a Japanese medical checkup. JGH Open 2022; 6:69-75. [PMID: 35071791 PMCID: PMC8762620 DOI: 10.1002/jgh3.12704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 12/08/2021] [Accepted: 12/12/2021] [Indexed: 12/02/2022]
Abstract
BACKGROUND AND AIM Although chronic diarrhea is a major digestive disorder, it has not been well studied. The aims of this study were to investigate the prevalence and risk factors of chronic diarrhea in the Japanese population and to assess the relationship between stool type and frequency and symptoms related to chronic diarrhea. METHOD A total of 13 668 adults who underwent a medical checkup at MedCity21 were enrolled, and 9540 who met the inclusion criteria participated in the study. Participants with chronic diarrhea were defined as those who typically had a Bristol Stool Form Scale of type 6 or 7. RESULTS The prevalence of chronic diarrhea was 3.0%. The risk factors for chronic diarrhea were younger age (odds ratio [OR] 0.984, 95% confidence interval [CI] 0.972-0.996), male sex (OR = 2.270, CI = 1.730-2.960), alcohol intake on ≥5 days per week (OR = 2.390, CI = 1.860-3.060), not getting adequate sleep (OR = 0.712, CI = 0.559-0.907), skipping breakfast ≥3 times a week (OR = 1.490, CI = 1.120-1.980), and absence of diabetes mellitus (OR = 0.384, CI = 0.179-0.824). Only 23.5% of the participants in the diarrhea group had ≥3 bowel movements per day. Chronic diarrhea was significantly associated with heartburn, nausea, stomach ache, abdominal bloating and distension, and feeling of stress. CONCLUSIONS Our study shows that chronic diarrhea is common in Japan with a prevalence of 3.0%; unique risk factors related to gender, age, and irregular lifestyle were identified. An understanding of bowel habit in the healthy population is helpful for the assessment of change in bowel habit associated with gastrointestinal disorders.
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Affiliation(s)
- Yuji Matsumoto
- Department of GastroenterologyOsaka City University Graduate School of MedicineOsakaJapan
| | - Yuji Nadatani
- Premier Preventive MedicineOsaka City University Graduate School of MedicineOsakaJapan
| | - Koji Otani
- Department of GastroenterologyOsaka City University Graduate School of MedicineOsakaJapan
| | - Akira Higashimori
- Department of GastroenterologyOsaka City University Graduate School of MedicineOsakaJapan
| | - Masaki Ominami
- Department of GastroenterologyOsaka City University Graduate School of MedicineOsakaJapan
| | - Shusei Fukunaga
- Department of GastroenterologyOsaka City University Graduate School of MedicineOsakaJapan
| | - Shuhei Hosomi
- Department of GastroenterologyOsaka City University Graduate School of MedicineOsakaJapan
| | - Noriko Kamata
- Department of GastroenterologyOsaka City University Graduate School of MedicineOsakaJapan
| | - Tatsuo Kimura
- Premier Preventive MedicineOsaka City University Graduate School of MedicineOsakaJapan
| | - Shinya Fukumoto
- Premier Preventive MedicineOsaka City University Graduate School of MedicineOsakaJapan
| | - Fumio Tanaka
- Department of GastroenterologyOsaka City University Graduate School of MedicineOsakaJapan
| | - Koichi Taira
- Department of GastroenterologyOsaka City University Graduate School of MedicineOsakaJapan
| | - Yasuaki Nagami
- Department of GastroenterologyOsaka City University Graduate School of MedicineOsakaJapan
| | - Toshio Watanabe
- Premier Preventive MedicineOsaka City University Graduate School of MedicineOsakaJapan
| | - Yasuhiro Fujiwara
- Department of GastroenterologyOsaka City University Graduate School of MedicineOsakaJapan
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33
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Zou L, Wang Q, Li Y, Yang AM. [Olmesartan-associated Enteropathy]. Zhongguo Yi Xue Ke Xue Yuan Xue Bao 2021; 43:986-990. [PMID: 34980342 DOI: 10.3881/j.issn.1000-503x.13268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
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.
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Affiliation(s)
- Long Zou
- Department of Gastroenterology,PUMC Hospital,CAMS and PUMC,Beijing 100730,China
| | - Qiang Wang
- Department of Gastroenterology,PUMC Hospital,CAMS and PUMC,Beijing 100730,China
| | - Yue Li
- Department of Gastroenterology,PUMC Hospital,CAMS and PUMC,Beijing 100730,China
| | - Ai-Ming Yang
- Department of Gastroenterology,PUMC Hospital,CAMS and PUMC,Beijing 100730,China
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34
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Panezai MS, Ullah A, Ballur K, Gilstrap L, Khan J, Tareen B, Kakar M, Khan J, Rasheed A, Waheed A, Ghleilib I, White J, Cason FD. Frequency of Celiac Disease in Patients With Chronic Diarrhea. Cureus 2021; 13:e20495. [PMID: 35047307 PMCID: PMC8760010 DOI: 10.7759/cureus.20495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2021] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION Celiac disease (CD) is an immune-mediated disease caused by ingesting gluten-containing foods and is characterized mainly by malabsorptive diarrhea. Furthermore, distinguishing between mild disease and asymptomatic individuals is critical and necessitates a high level of clinical suspicion. Short stature, delayed puberty, bone abnormalities, neurological problems, and intestinal cancer can all be consequences of a delayed diagnosis. This study aimed to determine the prevalence of celiac disease among our community's recurrent diarrhea patients. METHODS This was a cross-sectional study aimed at determining the frequency of celiac disease in patients with chronic diarrhea. One hundred eighty-eight patients between the ages of 18 and 60 years who had chronic diarrhea lasting greater than three months were enrolled in this study. Stratification was utilized to control for modifiers. A p-value of ≤ 0.05 was considered significant. RESULTS A total of 74.5% of patients (n=140) were male, while 25.5% (n=48) were female with a mean age of 38.48±10.85 years. The average duration of celiac disease symptoms was 8.17± 3.75 months. Celiac disease was found in 12.2% (n=23) of the individuals. Also, 21% of individuals with a positive family history of CD devolved CD, compared to those without prior CD family history (p=0.01). CONCLUSIONS In individuals with chronic diarrhea for more than three months, the prevalence of celiac disease was determined to be 12.2% (n=23). There was a statistically significant difference between those with a positive family history of CD and those who did not have the condition.
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Affiliation(s)
| | - Asad Ullah
- Pathology, Medical College of Georgia, Augusta University, Augusta, USA
| | - Kalyani Ballur
- Clinical Oncology, Medical College of Georgia, Augusta University, Augusta, USA
| | - Lauren Gilstrap
- Pathology, Medical College of Georgia, Augusta University, Augusta, USA
| | - Jaffar Khan
- Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, USA
| | - Bisma Tareen
- Internal Medicine, Bolan Medical College, Quetta, PAK
| | - Mirwais Kakar
- Gastroenterology, Bolan Medical College, Quetta, PAK
| | - Javeria Khan
- Gastroenterology, Holy Family Hospital, Rawalpindi, PAK
| | - Amna Rasheed
- Internal Medicine, Touro University California, Vallejo, USA
| | - Abdul Waheed
- Surgery, San Joaquin General Hospital, French Camp, USA
| | - Intisar Ghleilib
- Pathology and Laboratory Medicine, Medical College of Georgia, Augusta University, Augusta, USA
| | - Joseph White
- Pathology, Medical College of Georgia, Augusta University, Augusta, USA
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35
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Vobugari N, Kim J, Gandhi KD, Lee ZE, Smith HP. Iron-Storage Disorder Presenting as Chronic Diarrhea. Cureus 2021; 13:e18864. [PMID: 34804717 PMCID: PMC8598083 DOI: 10.7759/cureus.18864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2021] [Indexed: 11/15/2022] Open
Abstract
The involvement of the endocrine pancreas leading to bronze diabetes is well studied. However, little is known about the pathophysiology of iron dysregulation involving the exocrine pancreas. We present a unique association between the exocrine pancreas and iron dysregulation. A 45-year-old female presented with chronic diarrhea and low fecal elastase indicative of pancreatic exocrine dysfunction. MRI of the abdomen/pelvis showed iron deposition in the pancreas, suggesting an associated iron-storage disorder without features suggesting chronic pancreatitis. Association of an iron-storage disorder with pancreatic exocrine dysfunction has been reported only in one other case report. Pancreatic exocrine dysfunction can be directly associated with an iron-storage disorder that involves the pancreas. This should be included in the differential and diagnostic work-up of chronic diarrhea of unclear etiology. Based on the literature, we have highlighted the potential pathophysiology relevant to the case.
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Affiliation(s)
- Nikitha Vobugari
- Internal medicine, MedStar Washington Hospital Center, Washington, D.C., USA
| | - Jeffrey Kim
- Gastroenterology and Hepatology, MedStar Georgetown University Hospital, Washington, D.C., USA
| | - Kejal D Gandhi
- Internal Medicine, MedStar Washington Hospital Center, Washington, D.C., USA
| | - Zone-En Lee
- Gastroenterology and Hepatology, MedStar Georgetown University Hospital, Washington, D.C., USA
| | - Hedy P Smith
- Hematology and Medical Oncology, MedStar Washington Hospital Center, Washington, D.C., USA
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Yang B, Yue Y, Chen Y, Ding M, Li B, Wang L, Wang Q, Stanton C, Ross RP, Zhao J, Zhang H, Chen W. Lactobacillus plantarum CCFM1143 Alleviates Chronic Diarrhea via Inflammation Regulation and Gut Microbiota Modulation: A Double-Blind, Randomized, Placebo-Controlled Study. Front Immunol 2021; 12:746585. [PMID: 34721416 PMCID: PMC8555466 DOI: 10.3389/fimmu.2021.746585] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 09/10/2021] [Indexed: 12/12/2022] Open
Abstract
Irritable bowel syndrome with diarrhea and functional diarrhea are both functional bowel disorders that cause chronic diarrhea. Chronic diarrhea is closely related to daily life and the psychological condition of diarrhea in patients, and probiotics can play a significant role in alleviating chronic diarrhea in some research. Lactobaccilus plantarum CCFM1143 can relieve diarrhea in mice caused by enterotoxigenic Escherichia coli (ETEC); however, its clinical effects remain unclear. This study aimed to assess the effects of CCFM1143 as a therapy for chronic diarrhea patients. Fifty-five patients with chronic diarrhea were randomly assigned into the probiotic group (n = 28) and the placebo group (n = 27), receiving the routine regimen with or without probiotics for 4 weeks, respectively. CCFM1143 can mitigate the apparent clinical symptoms and improve the health status and quality of life of patients. In addition, it could inhibit the increase in interleukin 6 (IL-6) and the decrease in motilin; modulate the short-chain fatty acids, especially acetic and propionic acids; and regulate the gut microbiota, particularly reducing the abundance of Bacteroides and Eggerthella and enriching the abundance of Akkermansia, Anaerostipes, and Terrisporobacter. In addition, treatment with probiotics showed clinical effectiveness in managing chronic diarrhea when compared with the placebo group. The findings could help to develop and further the application of probiotics for chronic diarrhea.
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Affiliation(s)
- Bo Yang
- State Key Laboratory of Food Science and Technology, Jiangnan University, Wuxi, China.,School of Food Science and Technology, Jiangnan University, Wuxi, China.,International Joint Research Laboratory for Pharmabiotics & Antibiotic Resistance, Jiangnan University, Wuxi, China
| | - Yue Yue
- State Key Laboratory of Food Science and Technology, Jiangnan University, Wuxi, China.,School of Food Science and Technology, Jiangnan University, Wuxi, China
| | - Yang Chen
- State Key Laboratory of Food Science and Technology, Jiangnan University, Wuxi, China.,School of Food Science and Technology, Jiangnan University, Wuxi, China
| | - Mengfan Ding
- State Key Laboratory of Food Science and Technology, Jiangnan University, Wuxi, China.,School of Food Science and Technology, Jiangnan University, Wuxi, China
| | - Bowen Li
- State Key Laboratory of Food Science and Technology, Jiangnan University, Wuxi, China.,School of Food Science and Technology, Jiangnan University, Wuxi, China
| | - Linlin Wang
- State Key Laboratory of Food Science and Technology, Jiangnan University, Wuxi, China.,School of Food Science and Technology, Jiangnan University, Wuxi, China
| | - Qun Wang
- Yancheng Tinghu District People's Hospital, Yancheng, Jiangsu, China
| | - Catherine Stanton
- International Joint Research Laboratory for Pharmabiotics & Antibiotic Resistance, Jiangnan University, Wuxi, China.,APC Microbiome Ireland, University College Cork, Cork, Ireland.,Teagasc Food Research Centre, Moorepark, Fermoy, Ireland
| | - R Paul Ross
- International Joint Research Laboratory for Pharmabiotics & Antibiotic Resistance, Jiangnan University, Wuxi, China.,APC Microbiome Ireland, University College Cork, Cork, Ireland
| | - Jianxin Zhao
- State Key Laboratory of Food Science and Technology, Jiangnan University, Wuxi, China.,School of Food Science and Technology, Jiangnan University, Wuxi, China
| | - Hao Zhang
- State Key Laboratory of Food Science and Technology, Jiangnan University, Wuxi, China.,School of Food Science and Technology, Jiangnan University, Wuxi, China.,National Engineering Research Center for Functional Food, Jiangnan University, Wuxi, China.,Wuxi Translational Medicine Research Center, Jiangsu Translational Medicine Research Institute Wuxi Branch, Wuxi, China
| | - Wei Chen
- State Key Laboratory of Food Science and Technology, Jiangnan University, Wuxi, China.,School of Food Science and Technology, Jiangnan University, Wuxi, China.,National Engineering Research Center for Functional Food, Jiangnan University, Wuxi, China
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Alshammari M, Aljohani MA, Hashash JM, Alsaedi HA, Alobaidi WY, Alhuzali NK, Alnumani MS, Alrashidi AH, Al-Battniji SA, Alotaibi NA, Alhumaidi NK, Alajaimi AN, Alqurashi RS, Albishri AT, Alshammari KH. Shwachman-Diamond Syndrome in a Child Presenting With Chronic Diarrhea: A Rare Case in Family Medicine Practice. Cureus 2021; 13:e19391. [PMID: 34925993 PMCID: PMC8654133 DOI: 10.7759/cureus.19391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2021] [Indexed: 11/18/2022] Open
Abstract
Diarrhea remains an important cause of morbidity and mortality worldwide. Chronic diarrhea often represents a diagnostic challenge for family medicine and pediatric physicians because of its broad spectrum of possible etiologies. The differential diagnoses can be narrowed by taking a detailed history and performing an appropriate physical examination. In general, chronic diarrhea can be due to osmotic, secretory, inflammatory, or dysmotility-related pathologies. We present the case of a 30-month-old male who was brought to the family medicine clinic with a complaint of abdominal bloating and persistent diarrhea after every feeding for four months. His stools were foul-smelling and occurred more than four times a day. The patient was below the second standard deviations for weight and height. He appeared pale, and there was no scleral icterus. The patient underwent upper endoscopy, which showed no abnormal gross findings. A dedicated abdominal computed tomography scan was performed to evaluate the pancreas for any structural abnormalities. The scan demonstrated complete replacement of the pancreatic parenchyma by fatty tissue. The diagnosis of Shwachman-Diamond syndrome was established as the analysis revealed a mutation in the SBDS gene. The patient was treated with pancreatic enzyme replacement therapy. After two months of follow-up, the parents reported that the patient had significant improvement in diarrhea. Shwachman-Diamond syndrome is a very rare inherited disorder characterized by bone marrow failure, exocrine pancreatic dysfunction, and skeletal abnormalities. Despite its rarity, clinicians should keep a high index for this condition when they encounter a child with unexplained chronic diarrhea.
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Affiliation(s)
- Malak Alshammari
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | | | - Joud M Hashash
- College of Medicine, Batterjee Medical College, Jeddah, SAU
| | | | | | | | - Mohammed S Alnumani
- College of Medicine, King Saud bin Abdulaziz University For Health Sciences, Riyadh, SAU
| | - Asrar H Alrashidi
- College of Medicine, King Saud bin Abdulaziz University For Health Sciences, Riyadh, SAU
| | | | | | | | | | - Rawabi S Alqurashi
- College of Medicine, Princess Nourah Bint Abdul Rahman University, Riyadh, SAU
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Phrommas J, Tanpowpong P, Getsuwan S, Lertudomphonwanit C, Chantarogh S, Anurathapan U, Treepongkaruna S. Diarrhea in pediatric recipients of solid organ or bone marrow transplants. Medicine (Baltimore) 2021; 100:e27625. [PMID: 34713851 PMCID: PMC8556011 DOI: 10.1097/md.0000000000027625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 10/14/2021] [Indexed: 01/05/2023] Open
Abstract
Diarrhea is common in adults after solid organ transplantation (SOT) and bone marrow transplantation (BMT), but data in children are limited. Therefore, we aimed to determine the incidence and etiology of pediatric early-onset diarrhea in post SOT and BMT.We reviewed children aged 6 months to 18 years who underwent liver transplantation, kidney transplantation or BMT between January 2015 and December 2019 with duration of diarrhea > 72 hours within the first 6 months after transplantation. Clinical data and diarrheal course were collected. Regression analyses were performed to define factors associated with the interested outcomes.Among 252 transplanted patients, 168 patients (66.6%) had 289 documented episodes of diarrhea. A diagnosis of 68.2% of post-transplant diarrhea remained 'indefinite'. Enteric infection in SOT and gastrointestinal acute graft-versus-host disease (GI-aGVHD) in BMT were the commonly identified etiologies. Among 182 episodes among BMT children, skin rash was more pronounced when compared the ones with diarrhea > 7 days vs ≤ 7 days (odds ratio [OR] 13.9; 95% CI 1.8, 107.6). Males were more likely to develop GI-aGVHD as compared to females (OR 8.9). We found that GI-aGVHD was more common in the ones with skin rash and the presence of white blood cells in stool examination (OR 8.4 and 3.1, respectively). Deaths occurred in 7.7%.Two-thirds of post-transplant children experienced at least one episode of early-onset diarrhea, of which the etiology mainly remains undefined. Various clinical factors of prolonged/chronic diarrhea and GI-aGVHD may help clinicians when managing these children.
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Rossi G, Gavazza A, Vincenzetti S, Mangiaterra S, Galosi L, Marchegiani A, Pengo G, Sagratini G, Ricciutelli M, Cerquetella M. Clinicopathological and Fecal Proteome Evaluations in 16 Dogs Presenting Chronic Diarrhea Associated with Lymphangiectasia. Vet Sci 2021; 8:242. [PMID: 34679072 PMCID: PMC8537460 DOI: 10.3390/vetsci8100242] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 09/10/2021] [Accepted: 10/14/2021] [Indexed: 12/21/2022] Open
Abstract
Canine intestinal lymphangiectasia (IL) is a condition characterized by variably severe gastrointestinal signs, frequently associated with laboratory abnormalities; the research for markers allowing a better understanding of the severity degree and/or obtaining an early diagnosis and/or monitoring is continuously progressing. In the present study, we investigated possible new diagnostic/follow-up markers in IL dogs, namely, serum C-reactive protein, serum bacterial lipopolysaccharide, serum cleaved cytokeratin 18, serum citrulline, and zonulin (in both serum and feces). A fecal proteomic study looking for possible confirmation and/or new marker candidates was also performed. All markers in both substrates, with the exception of serum citrulline, significantly differed between diseased and control dogs. Fecal proteomics allowed the retrieval of three proteins in IL dogs (Fc fragment of IgG-binding protein; transthyretin; proproteinase E) that were not previously found in clinically healthy subjects. Although further studies are needed, C-reactive protein, bacterial lipopolysaccharide, cleaved cytokeratin 18, and zonulin (in both serum and feces) resulted as promising markers for canine IL; similarly, fecal proteomics represents a road worthy of being pursued in the search for candidate biomarkers.
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Affiliation(s)
- Giacomo Rossi
- School of Biosciences and Veterinary Medicine, University of Camerino, Via Circonvallazione 93/95, 62024 Matelica, Italy; (G.R.); (A.G.); (S.V.); (L.G.); (A.M.); (M.C.)
| | - Alessandra Gavazza
- School of Biosciences and Veterinary Medicine, University of Camerino, Via Circonvallazione 93/95, 62024 Matelica, Italy; (G.R.); (A.G.); (S.V.); (L.G.); (A.M.); (M.C.)
| | - Silvia Vincenzetti
- School of Biosciences and Veterinary Medicine, University of Camerino, Via Circonvallazione 93/95, 62024 Matelica, Italy; (G.R.); (A.G.); (S.V.); (L.G.); (A.M.); (M.C.)
| | - Sara Mangiaterra
- School of Biosciences and Veterinary Medicine, University of Camerino, Via Circonvallazione 93/95, 62024 Matelica, Italy; (G.R.); (A.G.); (S.V.); (L.G.); (A.M.); (M.C.)
| | - Livio Galosi
- School of Biosciences and Veterinary Medicine, University of Camerino, Via Circonvallazione 93/95, 62024 Matelica, Italy; (G.R.); (A.G.); (S.V.); (L.G.); (A.M.); (M.C.)
| | - Andrea Marchegiani
- School of Biosciences and Veterinary Medicine, University of Camerino, Via Circonvallazione 93/95, 62024 Matelica, Italy; (G.R.); (A.G.); (S.V.); (L.G.); (A.M.); (M.C.)
| | - Graziano Pengo
- St. Antonio Veterinary Clinic, S.S. 415 Paullese 6, 26020 Madignano, Italy;
| | - Gianni Sagratini
- School of Pharmacy, University of Camerino, Via Sant’Agostino 1, 62032 Camerino, Italy; (G.S.); (M.R.)
| | - Massimo Ricciutelli
- School of Pharmacy, University of Camerino, Via Sant’Agostino 1, 62032 Camerino, Italy; (G.S.); (M.R.)
| | - Matteo Cerquetella
- School of Biosciences and Veterinary Medicine, University of Camerino, Via Circonvallazione 93/95, 62024 Matelica, Italy; (G.R.); (A.G.); (S.V.); (L.G.); (A.M.); (M.C.)
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Sotiropoulos C, Sakka E, Diamantopoulou G, Theocharis GJ, Thomopoulos KC. Olmesartan-Induced Enteropathy: A Report of an Unusual Cause of Chronic Diarrhea. Cureus 2021; 13:e17004. [PMID: 34540405 PMCID: PMC8423377 DOI: 10.7759/cureus.17004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2021] [Indexed: 01/09/2023] Open
Abstract
Olmesartan, an angiotensin II receptor blocker indicated in the treatment of hypertension, has been associated with a seronegative sprue-like enteropathy that should be considered in the differential diagnosis of patients with unexplained chronic diarrhoea. It typically presents with severe chronic diarrhoea, considerable weight loss, and villous atrophy on biopsy and may be difficult to recognize because of its clinical and histological similarities to other clinical entities. Practically, discontinuation of the drug leads to dramatic recovery of the symptoms. We report a 76-year-old Caucasian female who was admitted to our hospital with complaints of chronic diarrhea and significant weight loss. Medical history was notable for hypertension being treated with olmesartan. Initially, investigation for all potential infectious causes and celiac disease was negative. Both upper and lower endoscopy was performed with duodenal biopsies revealing total villous atrophy and colonic biopsies showing lymphocytic colitis. In the presence of negative serology for celiac disease and after a thorough review of the patient’s medications, olmesartan induced-enteropathy was the most possible diagnosis. Olmesartan was discontinued and the symptoms rapidly resolved. A follow-up done a few months later showed no recurrence of the symptoms. In olmesartan-associated enteropathy, discontinuation of olmesartan results in immediate clinical recovery. Although rare, it is considered an emerging and underdiagnosed enteropathy. This case report illustrates the need for a thorough medication history evaluation and regular review during workup. We aim to increase the awareness of olmesartan-induced enteropathy among clinicians and gastroenterologists. We hope it will add to the current literature and help to understand this rare phenomenon in order to avoid unnecessary testing.
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Affiliation(s)
| | - Eftichia Sakka
- Internal Medicine Department, General University Hospital of Patras, Patras, GRC
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Steck A, Nebiker C, Capraro J, Yurtsever H, Toutonji AA, Struja T. [VIPoma of the Pancreas]. Praxis (Bern 1994) 2021; 110:637-642. [PMID: 34465193 DOI: 10.1024/1661-8157/a003714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
VIPoma of the Pancreas Abstract. A 50-year old man was admitted for evaluation of progressive, chronic diarrhea with loss of weight and recurrent hypokalemia. Eventually, a neuroendocrine tumor of the pancreas secreting VIP (VIPoma) could be diagnosed. The patient was cured by a pancreaticoduodenectomy (Whipple procedure). With this case, we want to highlight the importance of a structured work-up in chronic diarrhea including thorough history and clinical assessment, laboratory tests and imaging studies.
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Affiliation(s)
- Andreas Steck
- Abteilung für Allgemeine Innere Medizin, Spital Zofingen, Zofingen
| | - Christian Nebiker
- Abteilung für Viszeralchirurgie, Klinik für Chirurgie, Kantonsspital Aarau, Aarau
| | - Joël Capraro
- Abteilung für Allgemeine Innere Medizin, Spital Zofingen, Zofingen
- bteilung für Endokrinologie, Diabetologie und Metabolismus, Medizinische Universitätsklinik, Kantonsspital Aarau, Aarau
| | | | - Ali Al Toutonji
- Abteilung für Allgemeine Innere Medizin, Spital Zofingen, Zofingen
| | - Tristan Struja
- Abteilung für Allgemeine Innere Medizin, Spital Zofingen, Zofingen
- bteilung für Endokrinologie, Diabetologie und Metabolismus, Medizinische Universitätsklinik, Kantonsspital Aarau, Aarau
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Pilla R, Guard BC, Blake AB, Ackermann M, Webb C, Hill S, Lidbury JA, Steiner JM, Jergens AE, Suchodolski JS. Long-Term Recovery of the Fecal Microbiome and Metabolome of Dogs with Steroid-Responsive Enteropathy. Animals (Basel) 2021; 11:2498. [PMID: 34573464 DOI: 10.3390/ani11092498] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 08/02/2021] [Accepted: 08/17/2021] [Indexed: 01/02/2023] Open
Abstract
The long-term impact of treatment of dogs with steroid-responsive enteropathy (SRE) on the fecal microbiome and metabolome has not been investigated. Therefore, this study aimed to evaluate the fecal microbiome and metabolome of dogs with SRE before, during, and following treatment with standard immunosuppressive therapy and an elimination diet. We retrospectively selected samples from 9 dogs with SRE enrolled in a previous clinical trial, which received treatment for 8 weeks, and had achieved remission as indicated by the post-treatment clinical scores. Long-term (1 year) samples were obtained from a subset (5/9) of dogs. Samples from 13 healthy dogs were included as controls (HC). We evaluated the microbiome using 16S rRNA sequencing and qPCR. To evaluate the recovery of gut function, we measured fecal metabolites using an untargeted approach. While improvement was observed for some bacterial taxa after 8 weeks of treatment, several bacterial taxa remained significantly different from HC. Seventy-five metabolites were altered in dogs with SRE, including increased fecal amino acids and vitamins, suggesting malabsorption as a component of SRE. One year after treatment, however, all bacterial species were evaluated by qPCR and 16S rRNA gene sequencing, and all but thirteen metabolites were no longer different from healthy controls.
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Essien F, Wassem J, Tate J, Roberts J. Cutaneous ulcers in association with sprue-like enteropathy secondary to Losartan. Clin Case Rep 2021; 9:e04645. [PMID: 34430010 PMCID: PMC8365551 DOI: 10.1002/ccr3.4645] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 06/28/2021] [Accepted: 07/08/2021] [Indexed: 01/14/2023] Open
Abstract
Losartan is an angiotensin II receptor blocker (ARB) which may cause severe sprue-like enteropathy (SLE) with skin manifestation. Clinicians should be informed of this side effect and its reversibility after cessation of the drug.
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Affiliation(s)
- Francis Essien
- Department of Internal MedicineKeesler Medical CenterKeesler Air Force BaseKeesler AFBMSUSA
| | - Juakiem Wassem
- Department of Internal MedicineKeesler Medical CenterKeesler Air Force BaseKeesler AFBMSUSA
- Department of GastroenterologyKeesler Medical CenterKeesler Air Force BaseKeesler AFBMSUSA
| | - Joshua Tate
- Department of Internal MedicineKeesler Medical CenterKeesler Air Force BaseKeesler AFBMSUSA
- Department of EndocrinologyKeesler Medical CenterKeesler Air Force BaseKeesler AFBMSUSA
| | - Jared Roberts
- Department of Internal MedicineKeesler Medical CenterKeesler Air Force BaseKeesler AFBMSUSA
- Department of DermatologyKeesler Medical CenterKeesler Air Force BaseKeesler AFBMSUSA
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Kim JY, Lim MH. Psychological factors to predict chronic diarrhea and constipation in Korean high school students. Medicine (Baltimore) 2021; 100:e26442. [PMID: 34232176 PMCID: PMC8270581 DOI: 10.1097/md.0000000000026442] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 05/19/2021] [Accepted: 06/05/2021] [Indexed: 01/04/2023] Open
Abstract
ABSTRACT Chronic diarrhea and constipation are common in adolescents and are associated with depression and anxiety. However, the association was not reported in adolescents adjusted for other psychological factors (resilience, personality traits, perceived stress, and suicidal ideation). Therefore, we investigated the significant psychological factors predicting chronic diarrhea and constipation in adjusted individuals for co-variables.A total of 819 Korean high school students who completed bowel health and psychological questionnaires were enrolled in this study. Depression and anxiety were assessed using validated questionnaires. We used multivariate analyses, controlling for demographic, dietary, lifestyle, and psychological variables to predict chronic diarrhea and constipation.Chronic diarrhea and constipation were more common in individuals with depression (22.3% and 18.6%, respectively) than in individuals with no depression (7.0% and 10.9%, respectively). In addition, they were more prevalent in individuals with anxiety (24.5% and 18.6%, respectively) than in individuals with no anxiety (9.1% and 12.7%, respectively). Multivariate analyses showed that resilience (adjusted risk ratio [aRR] = 0.98, adjusted 95% confidence interval [CI] = 0.97-0.99), moderate (aRR = 6.77, adjusted 95% CI = 3.55-12.91), and severe depression (aRR = 7.42, adjusted 95% CI = 3.61-15.27) were associated with chronic diarrhea. Only mild depression was associated with chronic constipation (aRR = 2.14, adjusted 95% CI = 1.36-3.38). However, anxiety was not significantly associated with chronic diarrhea or constipation.Among the psychological factors predicting disordered bowel habits, resilience and moderate and severe depression were significant predictors of chronic diarrhea, but not anxiety. Furthermore, only mild depression was an independent predictor of chronic constipation.
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Affiliation(s)
- Ji Young Kim
- Department of Psychology, Graduate School of Dankook University
| | - Myung Ho Lim
- Department of Psychology and Psychotherapy, College of Health Science
- Environmental Health Center, Dankook Medical Hospital, Dankook University, Cheonan, Korea
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Vlaemynck K, De Man M, De Man K, Hoorens A, Geboes K. Neuroendocrine tumor with diarrhea: not always the usual suspects - a case report of metastatic calcitoninoma with literature review. Acta Clin Belg 2021; 76:239-243. [PMID: 31900071 DOI: 10.1080/17843286.2020.1711668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
We describe a case of a 59-year-old man without relevant past medical history, presenting with chronic diarrhea and weight loss. Extensive laboratory analysis, stool cultures and gastro- and ileocolonoscopy could not identify a diagnosis. Abdominal imaging revealed a mass in the uncinate process of the pancreas with mesenteric adenopathies and liver metastases. Fine needle aspiration was compatible with a pancreatic neuroendocrine tumor with low proliferative capacity (Ki-67 <1%). Immunohistochemical staining was positive for calcitonin and serum calcitonin levels were clearly elevated. Surprisingly, 18FDG PET-CT scan was positive, but no tracer uptake was seen on 68Gallium-DOTATOC PET-CT scan. Treatment with somatostatin analogues was not successful, but long-term tumor control could be obtained with Everolimus. However, no significant effect was seen on stool frequency despite additional treatment with multiple symptomatic therapies, liver-directed therapy with radio- and chemoembolization and additional external radiotherapy to the primary pancreatic tumor. Ondansetron, eventually, seems to be the only therapy, until now, causing a decrease in stool frequency.Functioning pancreatic calcitoninomas are considered to be a rare disease entity with few literature on optimal (nuclear) imaging and treatment. We discuss molecular insights regarding these aspects that can be of great interest to nuclear medicine physicians, pathologists, endocrinologists and gastroenterologists.
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Affiliation(s)
- Kenny Vlaemynck
- Department of Gastroenterology, Ghent University Hospital, Ghent, Belgium
| | - Marc De Man
- Department of Gastroenterology, Ghent University Hospital, Ghent, Belgium
| | - Kathia De Man
- Department of Nuclear Medicine, Ghent University Hospital, Ghent, Belgium
| | - Anne Hoorens
- Department of Pathology, Ghent University Hospital, Ghent, Belgium
| | - Karen Geboes
- Department of Gastroenterology, Ghent University Hospital, Ghent, Belgium
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Kondapi DS, Ramani S, Estes MK, Atmar RL, Okhuysen PC. Norovirus in Cancer Patients: A Review. Open Forum Infect Dis 2021; 8:ofab126. [PMID: 34189156 PMCID: PMC8232388 DOI: 10.1093/ofid/ofab126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/10/2021] [Indexed: 12/15/2022] Open
Abstract
Norovirus (NoV) is the leading cause of viral-related diarrhea in cancer patients, in whom it can be chronic, contributing to decreased quality of life, interruption of cancer care, malnutrition, and altered mucosal barrier function. Immunosuppressed cancer patients shed NoV for longer periods of time than immunocompetent hosts, favoring quasispecies development and emergence of novel NoV variants. While nucleic acid amplification tests (NAATs) for NoV diagnosis have revolutionized our understanding of NoV burden of disease, not all NAATs provide information on viral load or infecting genotype. There is currently no effective antiviral or vaccine for chronic NoV infections. Screening for inhibitors of NoV replication in intestinal organoid culture models and creation of NoV-specific adoptive T cells are promising new strategies to develop treatments for chronic NoV in immunosuppressed patients. Herein we summarize data on the epidemiology, clinical manifestations, diagnostic challenges, and treatment of NoV infection in patients with cancer.
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Affiliation(s)
- Divya Samantha Kondapi
- Department of Infectious Diseases, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA
| | - Sasirekha Ramani
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas, USA
| | - Mary K Estes
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas, USA
| | - Robert L Atmar
- Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA
| | - Pablo C Okhuysen
- Infection Control and Employee Health, Division of Internal Medicine, Department of Infectious Diseases, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Otagiri S, Nakajima S, Katsurada T, Sakurai K, Yamanashi K, Ara T, Takakuwa E, Mitsuhashi T, Sakamoto N. Chronic Diarrhea as the Presenting Feature of Amyloidosis with Multiple Myeloma: A Case Report Diagnosed by a Myocardial Biopsy. Intern Med 2021; 60:1197-1203. [PMID: 33191327 PMCID: PMC8112986 DOI: 10.2169/internalmedicine.6038-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
A 73-year-old woman with a history of diarrhea for one year and other various symptoms was admitted to our hospital. Gastrointestinal endoscopy that included enteroscopy with multiple biopsies was performed. However, no significant findings were observed. Electrocardiography showed low voltage in all limb leads, and an echocardiogram showed thickened cardiac walls with granular sparkling pattern. A myocardial biopsy revealed amyloidosis, and a bone marrow biopsy showed multiple myeloma. This case suggests that we should suspect the possibility of amyloidosis in a patient with diarrhea and various symptoms involving multiple organ systems. Additionally, electrocardiograms and echocardiograms should be performed even when gastrointestinal biopsies reveal negative results.
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Affiliation(s)
- Shinsuke Otagiri
- Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Japan
| | - Sae Nakajima
- Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Japan
| | - Takehiko Katsurada
- Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Japan
| | - Kensuke Sakurai
- Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Japan
| | - Kana Yamanashi
- Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Japan
| | - Takahide Ara
- Department of Hematology, Hokkaido University Hospital, Japan
| | - Emi Takakuwa
- Department of Surgical Pathology, Hokkaido University Hospital, Japan
| | - Tomoko Mitsuhashi
- Department of Surgical Pathology, Hokkaido University Hospital, Japan
| | - Naoya Sakamoto
- Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Japan
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Oyenuga M, Shaikh S, Harris B, Sinha J, Lacasse A. Recurrent neutropenia and chronic diarrhea following thymectomy: the good, the bad, and the ugly. J Community Hosp Intern Med Perspect 2021; 11:263-265. [PMID: 33889334 PMCID: PMC8043559 DOI: 10.1080/20009666.2021.1877400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Good syndrome (GS) is a rare paraneoplastic syndrome seen before or after diagnosis of thymoma, and its treatment, and is characterized by hypogammaglobulinemia. Rarely, pure white cell aplasia (PWCA) can also be seen which can present as recurrent neutropenia. We describe a 64-year-old man with recurrent sinus infections and previous thymectomy for stage 1 type B2 thymoma presenting with chronic diarrhea and recurrent neutropenia necessitating serial hospitalizations despite repeated antimicrobial treatment. Immunoglobulin levels, including IgM, IgA, IgD, and IgE were undetectable. Flow cytometry also showed absent B cells. Patient was initiated on immunoglobulin replacement therapy with consequent significant clinical improvement. Despite thymectomy, patients can develop thymoma-associated paraneoplastic syndromes, including GS.
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Affiliation(s)
- Mosunmoluwa Oyenuga
- Department of Internal Medicine, SSM St. Mary's Hospital, St. Louis, MO, USA
| | - Safia Shaikh
- Department of Internal Medicine, SSM St. Mary's Hospital, St. Louis, MO, USA
| | - Benjamin Harris
- Department of Internal Medicine, SSM St. Mary's Hospital, St. Louis, MO, USA
| | - Jyotsana Sinha
- Department of Hematology/Oncology, SSM St. Mary's Hospital, St. Louis, MO, USA
| | - Alexandre Lacasse
- Department of Internal Medicine, SSM St. Mary's Hospital, St. Louis, MO, USA
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Abstract
Diarrhea is the principal cause of the majority of healthcare utilization. When diarrhea lasts longer than four weeks, it is considered chronic diarrhea. There are several causes of chronic diarrhea, but here we focus on one of the rare causes, known as McKittrick-Wheelock syndrome (MWS). We here present the case of a patient in his seventies with chronic diarrhea, found to have tubulovillous adenoma and diagnosed with McKittrick-Wheelock syndrome. We also discuss the clinical presentation, pathophysiology, and management of MWS.
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Affiliation(s)
| | | | - Niel Shah
- Internal Medicine, Bronx-Lebanon Hospital Center, Bronx, USA
| | | | - Harish Patel
- Internal Medicine, Bronx-Lebanon Hospital Center, Bronx, USA
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Costa S, Gattoni S, Nicolardi ML, Costetti M, Maimaris S, Schiepatti A, Biagi F. Prevalence and clinical features of bile acid diarrhea in patients with chronic diarrhea. J Dig Dis 2021; 22:108-112. [PMID: 33438795 DOI: 10.1111/1751-2980.12969] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 01/04/2021] [Accepted: 01/10/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Bile acid diarrhea is a form of chronic diarrhea caused by excessive bile reaching the colon. Conditions involving the terminal ileum and cholecystectomy are predisposing factors but an idiopathic form of bile acid diarrhea has also been described. In this study we aimed to evaluate the prevalence of bile acid diarrhea in patients consecutively evaluated for chronic diarrhea in an Outpatient Gastroenterology Clinic. METHODS Medical records of all patients admitted for chronic diarrhea (>4 weeks) between June 2018 and April 2019 were retrospectively reviewed. Bile acid diarrhea was suspected in patients with ileal disease, cholecystectomy or post-prandial diarrhea. Patients' age at diagnosis, sex, presenting symptoms, results of main test and examinations, final diagnoses and date of last follow-up visit were also collected. Exclusion of chronic diarrhea of other causes and a 6-month clinical improvement with cholestyramine treatment confirmed the diagnosis of bile acid diarrhea. RESULTS In total, 139 patients aged 46 ± 20 years (76 women and 63 men) were included. Diarrhea due to an organic cause was diagnosed in 16 patients. A clinical response to cholestyramine persisting for more than 6 months led to a diagnosis of bile acid diarrhea in 39 (aged 52 ± 19 years) out of the remaining 123 patients with functional forms of diarrhea. Therefore, the prevalence of bile acid diarrhea was 28.1% (95% confidence interval 19.9%-38.4%) in patients with chronic diarrhea. CONCLUSIONS Bile acid diarrhea is a very common, yet under-recognized cause of chronic functional diarrhea. A therapeutic trial of cholestyramine is a valid diagnostic strategy.
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Affiliation(s)
- Stefania Costa
- Gastroenterology Unit of Pavia Institute, Istituti Clinici Scientifici Maugeri, University of Pavia, Pavia, Italy
| | - Serena Gattoni
- Gastroenterology Unit of Pavia Institute, Istituti Clinici Scientifici Maugeri, University of Pavia, Pavia, Italy
| | - Maria Luisa Nicolardi
- Gastroenterology Unit of Pavia Institute, Istituti Clinici Scientifici Maugeri, University of Pavia, Pavia, Italy
| | - Martina Costetti
- Gastroenterology Unit of Pavia Institute, Istituti Clinici Scientifici Maugeri, University of Pavia, Pavia, Italy
| | - Stiliano Maimaris
- Gastroenterology Unit of Pavia Institute, Istituti Clinici Scientifici Maugeri, University of Pavia, Pavia, Italy
| | - Annalisa Schiepatti
- Gastroenterology Unit of Pavia Institute, Istituti Clinici Scientifici Maugeri, University of Pavia, Pavia, Italy
| | - Federico Biagi
- Gastroenterology Unit of Pavia Institute, Istituti Clinici Scientifici Maugeri, University of Pavia, Pavia, Italy
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