CASE POSTED BY DR JAMAL AT https://www.facebook.com/groups/ceeyemee/
One elderly man has come to my op to tell abt his wife...She has got severe diarrhea for past 18 yrs, tried a lot of medicines from many doctors of various hospitals, lot of scopies and all...no improvement. Presently she was on treatment under a physician..He also has given up her...Finally the husband came to me today to know whether anything can be done for her..If am ready to see her, he is willing to bring the wife to my op....When i asked the details, these are the information i could get..
18 yrs duration..!!!
So severe so that she had to take VRS from her profession!!!( I think no more explanation is needed to highlight the severity)
Pure watery, large volume stools
Frequent abdominal pain is there.
Short periods of constipation in between.
Occasional episodes in the middle of sleep also. Often cant hold the urge till she reach the toilet, spoils her dress frequently in the night
Large volume watery stools
I specifically asked whether she is emaciated or not..But he told that she is very obese..!!
Recent onset diabetes, well controlled, but diarrhea is there many years prior to diabetes
No blood in stools or steatorrhea.
These are the information i got from her husband...She will come to my op on day after tomorrow....Before that i have to make a plan to investigate and treat her
IBS came to my mind first when i heard the history..But there are some strong arguments against IBS which are:
1. Large volume stools
2. Nocturnal symptoms..
But most other points are favoring a functional GI cause like IBS
ie, long duration, no e/o malabsorption, alternate constipation and diarrhea...
One of the imp DD explained in harrison is celiac spru...but malabsoption and nutritional deficiency is the hallmark of celiac spru.. What are the DDs considered here..Pls actively participate so that let us try whether something can be done for her sufferings...
DISCUSSION BY DR PURUSHOTHAMAN
Lower abdominal problems....Frequency, tenesmus. abdominal pain. Loose stools (watery , bloody , malabsorption type,,,,,,,greenish.......) etc
Here older lady , i take it as 45). with loose stools. OF 18 Years without loss of weight /no other systemic problem ,
First thing i ll check is to verify the complaint .......i wont go by the history ,,,,,as ajith said , Most important part is to see the motion, and as reghu pointed out , keep the patient under your observation for 24 hours verify what she said is right.........( In this case i dont think it is functional or malingering because. 1. Noctural symptoms 2 . Abdominal pain is there. (but this can be part of malingering )
i ll start analysis by Macroscopic Appearance of stools and i ll classify the stool appearance ( which inidirectly help you to pin point the pathogenesis
1.Watery ........and more volume significant enough to cause dehydration
2.Watery ...........not much volume
3.Watery greenish
4.Blood , and mucus
5.Fat /other undigested particles /froths /floating /very foul smelling
i ll look at the peri anal area ...........before i proceed further
Now i try to relate this to pathogenesis.
Water in stools results by three mechanisms.....
1.Active secretion ............eg cyclic AMP mediated , cholera, toxigenic E Coli , other toxins etc
2.Osmotic .....................Here fluid is imbibed in to GI lumen ..lactose intolerance of osmotic food intake
3. No secretion /no osmosis , but there is no time for the colon to absorb the water , This can happen in hyper peristalsis and in some coloinc pathology ..
Prescence of greenish stools argue for hyper peristalsis.
Next mal absorption states, where evidence of fat/CHO/Protein........Here Look at the stool for froth ( fermented non absorbed CHO make stool frothy. ,,,,,,,,and the acidic stoosl make the anus angry .........also the clue for chrons you get by this examination
In this case all these years only watery stools ,,,,,,,No blood or mucus, and no malabsorption features......( Here dont go forward without verifying this by macrscopy ...jamal ) ,,,,,,,,,so mucosa is not invaded , and intestinal secretion contains all the enzymes for digestion in adequate quantities. ie even the brush border and tip of villus is intact ,,,,,,,in spite of long history............
So i ll put possibility as
1.Osmotic
2 Hyper peristalsis without any way altering the bowel anatomy or histology or function
2.secretary or some type of colonic pathology ( last and least important.
Take First one
Is it osmotic diarohea.........Most common ...of a short duration is intake of high osmotic diet. But in this case ........unlikely as the duration is 18 years. Next important is Lactose intolerance.......That again unlikely ( Primaly ll start early in life , and seconday will invariably lead to lot of problems after first few weeks.....
Third very importnat possibility ,,,,,,,,,,,,,,,some drugs and laxatives...........Highly likely in this case
2 Second , Is it due to hyper peristalsis........Intestinal motility increased by lot of known and unknown factors, eg emotional , hormones like thyrotoxicosis, , VIP oma, , Ganglioneuroma, neuroblastoma,,,,,and autonomic disturbances...