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Going from A to Z

ARTICLE: Going from A to Z

AUTHORS: Deepak Atri, David Furfaro, Gurpreet Dhaliwal, Kenneth R. Feingold and Reza Manesh

JOURNAL: N Engl J Med. 2018 Jan 4;378(1):73-79.

In this Journal feature, information about a real patient is presented in stages (boldface type) to an expert clinician, who responds to the information, sharing his or her reasoning with the reader (regular type). The authors’ commentary follows.

A 70-year-old man presented to the emergency department with a 3-month history of diarrhea. The diarrhea varied between semiformed and liquid, but it never contained blood or mucus. On most days, he had hourly bowel movements over a period of 12 to 18 hours, but he was able to sleep through the night without bowel movements. The diarrhea was associated with nausea, nonbloody emesis, and a weight loss of 5.9 kg (13 lb). He reported no fevers or diaphoresis. Three weeks before the onset of diarrhea, intermittent episodes of severe nonradiating epigastric pain had developed that lasted for hours.

Chronic diarrhea, which is defined as persistently loose stools for more than 4 weeks, may be caused by infection, noninfectious inflammation, malabsorption, or functional disorders. The stool consistency can suggest the mechanism and cause of diarrhea. Inflammatory bowel disease frequently manifests with bloody stools and systemic symptoms such as fever. Malabsorptive syndromes such as celiac disease may cause steatorrhea. Watery diarrhea can result from osmotic (e.g., undigested disaccharides) or secretory (e.g., microscopic colitis) mechanisms. The intermittent epigastric pain could reflect peptic ulcer disease, gastritis, gastroesophageal reflux disease (GERD), or functional dyspepsia, although none of these conditions cause diarrhea. The duration of abdominal pain in this case makes acute, life-threatening processes such as perforation, obstruction, or ischemia unlikely.

The patient’s abdominal pain and diarrhea began during a trip to Sri Lanka and continued on his return to the United States. His diarrhea was not ameliorated by changes in diet, which included fasting and the avoidance of lactose.

Bacteria such as enterotoxigenic Escherichia coli, salmonella species, and Campylobacter jejuniaccount for most cases of travelers’ diarrhea. However, the long duration of the illness in this patient makes parasitic infections such as giardiasis, cryptosporidiosis, strongyloidiasis, and amebiasis more likely. An extended stay in Sri Lanka raises the possibility of tropical sprue, which is characterized by chronic diarrhea and resembles celiac disease clinically and histologically but is associated with seronegative findings and is thought to be infectious in origin. Human immunodeficiency virus (HIV) infection could confer a predisposition to diarrhea caused by opportunistic infections or cancers such as gastrointestinal lymphoma. The lack of improvement with fasting favors a secretory cause of chronic diarrhea.

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Kelsey Bennett