Tropical sprue differential diagnosis: Difference between revisions

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__NOTOC__
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{{Tropical sprue}}
[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Tropical_sprue]]
{{CMG}};{{AE}}{{AKI}}{{Akshun}}
{{CMG}};{{AE}}{{AKI}}{{Akshun}}


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{{familytree | | | | | | | D05 | | | | D02 | | | | | | | | | | | | | | | | | | D05 = Specific treatment per results and symptomatic treatment | D02= Suspect Tropical sprue and initiate antibiotic therapy and folate supplementation }}
{{familytree | | | | | | | D05 | | | | D02 | | | | | | | | | | | | | | | | | | D05 = Specific treatment per results and symptomatic treatment | D02= Suspect Tropical sprue and initiate antibiotic therapy and folate supplementation }}
{{familytree/end}}
{{familytree/end}}
Tropical sprue must be differentiated from other diseases that may cause [[chronic diarrhea]], [[weight loss]], and [[abdominal pain]] especially in [[Immunocompromised|immunocompromised patients]]. These conditions include chronic giardiasis, cryptosporidiosis, [[Cystoisospora belli|Cystoisosporiasis (isosporiasis)]]<ref name="pmid1889046" /><ref name="pmid11113253">{{cite journal |vauthors=Thompson RC |title=Giardiasis as a re-emerging infectious disease and its zoonotic potential |journal=Int. J. Parasitol. |volume=30 |issue=12-13 |pages=1259–67 |year=2000 |pmid=11113253 |doi= |url=}}</ref><ref name="pmid17172373" /><ref name="pmid1091526" />
{| style="border: 0px; font-size: 90%; margin: 3px; width:1000px;" align="center"
|+
! style="background: #4479BA; color:#FFF;  width: 150px;" | Disease
! style="background: #4479BA; color:#FFF;  width: 200px;" | Prominent clinical findings
! style="background: #4479BA; color:#FFF;  width: 200px;" | Laboratory or radiological findings
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" |  [[Giardiasis|Chronic giardiasis]]
| style="padding: 5px 5px; background: #F5F5F5;" |
* [[Giardiasis|Chronic giardiasis]] may develop after acute episode of giardiasis or without any acute events.
* Loose foul smelling stools
* [[Flatulence]]
* [[Fatigue]]
* [[Weight loss]]
* [[Steatorrhea]]
* Some patients develop acquired [[lactose intolerance]] (manifested by exacerbation of symptoms following ingestion of dairy products)
| style="padding: 5px 5px; background: #F5F5F5;" |
* Microscopic identification of the organism in the stool
* [[Hypoalbuminaemia]]
* [[Vitamin B12]] and [[Folate deficiency|folate deficiencies]] (as the organism inhabits the [[duodenum]])
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" |  [[Cryptosporidiosis]]<ref name="pmid17172373">{{cite journal |vauthors=Sánchez-Vega JT, Tay-Zavala J, Aguilar-Chiu A, Ruiz-Sánchez D, Malagón F, Rodríguez-Covarrubias JA, Ordóñez-Martínez J, Calderón-Romero L |title=Cryptosporidiosis and other intestinal protozoan infections in children less than one year of age in Mexico City |journal=Am. J. Trop. Med. Hyg. |volume=75 |issue=6 |pages=1095–8 |year=2006 |pmid=17172373 |doi= |url=}}</ref>
| style="padding: 5px 5px; background: #F5F5F5;" |
* [[Incubation period]] is 7-10 days.
* In [[immunocompetent]] patients:
:* Disease might be asymptomatic or cause [[gastroenteritis]] (but without any biliary involvement)
:* [[Gastroenteritis]] usually resolves spontaneously within 14 days.
* In [[immunocompromised]] patients:
:* Disease is usually more severe and prolonged (especially in severly [[Immunocompromised|immunocomprmised patients]] with [[CD4|CD4 count]] < 100 cells/microL).
:* [[Cryptosporidiosis]] may involve the [[biliary tract]] and the [[liver]].
:* [[Weight loss]]
:* [[RUQ|Abdominal RUQ]] [[tenderness]] might be present if [[biliary]] or [[hepatic]] involvement is present.
| style="padding: 5px 5px; background: #F5F5F5;" |
* Microscopic identification of the [[organism]] in the stool: The [[oocysts]] appear red on staining with modified acid fast staining
* [[PCR]]: Most specific and sensitive diagnostic tool. [[PCR]] is expensive and used in limited cases.
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" |  [[Cystoisospora belli|Cystoisosporiasis (isosporiasis)]]<ref name="pmid1889046">{{cite journal |vauthors=Current WL, Garcia LS |title=Cryptosporidiosis |journal=Clin. Microbiol. Rev. |volume=4 |issue=3 |pages=325–58 |year=1991 |pmid=1889046 |pmc=358202 |doi= |url=}}</ref>
| style="padding: 5px 5px; background: #F5F5F5;" |
* [[Cystoisospora belli|Cystoisosporiasis]] is usually seen in [[Immunocompromised|immunocompromised patients]].
* [[Incubation period]] can last up to 2 weeks
* [[Watery diarrhea]] that is profuse and foul smelling
* Constitutional symptoms ([[headache]], [[Low-grade fever|low grade fever]], [[myalgia]] and [[malaise]])
| style="padding: 5px 5px; background: #F5F5F5;" |
* [[Isospora]] ova or parasites can be visualized on stool microscopic examination.
* [[Endoscopy|Upper GI endoscopy]] may used for excluding other esophageal or gastric disease and obtaining specimens for histopathology.
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" | [[Tropical sprue]]<ref name="pmid1091526">{{cite journal |vauthors=Klipstein FA, Schenk EA |title=Enterotoxigenic intestinal bacteria in tropical sprue. II. Effect of the bacteria and their enterotoxins on intestinal structure |journal=Gastroenterology |volume=68 |issue=4 Pt 1 |pages=642–55 |year=1975 |pmid=1091526 |doi= |url=}}</ref>
| style="padding: 5px 5px; background: #F5F5F5;" |
* History of travel to a tropical region (for a period more than a month)
* [[Chronic diarrhea]]
* [[Steatorrhea]]
* Examination may show signs of [[vitamin deficiencies]] (eg [[glossitis]])
| style="padding: 5px 5px; background: #F5F5F5;" |
* [[Megaloblastic anemia]] that might progress into [[pancytopenia]]
* [[Hypoalbuminaemia]]
* [[Vitamin D Deficiency|Vitamin D defeciency]] and [[hypocalcemia]]
|}


===== Differentiating Tropical Sprue from Other causes of Fat Malabsorption =====
===== Differentiating Tropical Sprue from Other causes of Fat Malabsorption =====
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<span style="font-size:85%">'''Abbreviations:'''
<span style="font-size:85%">'''Abbreviations:'''
'''[[RUQ]]'''= Right upper quadrant of the abdomen, '''LUQ'''= Left upper quadrant, '''LLQ'''= Left lower quadrant, '''RLQ'''= Right lower quadrant, '''LFT'''= Liver function test, SIRS= [[Systemic inflammatory response syndrome]], '''[[ERCP]]'''= [[Endoscopic retrograde cholangiopancreatography]], '''IV'''= Intravenous, '''N'''= Normal, '''AMA'''= Anti mitochondrial antibodies, '''[[LDH]]'''= [[Lactate dehydrogenase]], '''GI'''= Gastrointestinal, '''CXR'''= Chest X ray, '''IgA'''= [[Immunoglobulin A]], '''IgG'''= [[Immunoglobulin G]], '''IgM'''= [[Immunoglobulin M]], '''CT'''= [[Computed tomography]], '''[[PMN]]'''= Polymorphonuclear cells, '''[[ESR]]'''= [[Erythrocyte sedimentation rate]], '''[[CRP]]'''= [[C-reactive protein]], TS= [[Transferrin saturation]], SF= Serum [[Ferritin]], SMA= [[Superior mesenteric artery]], SMV= [[Superior mesenteric vein]], ECG= [[Electrocardiogram]], US = [[Ultrasound]]</span>
'''[[RUQ]]'''= Right upper quadrant of the abdomen, '''LUQ'''= Left upper quadrant, '''LLQ'''= Left lower quadrant, '''RLQ'''= Right lower quadrant, '''LFT'''= Liver function test, SIRS= [[Systemic inflammatory response syndrome]], '''[[ERCP]]'''= [[Endoscopic retrograde cholangiopancreatography]], '''IV'''= Intravenous, '''N'''= Normal, '''AMA'''= Anti mitochondrial antibodies, '''[[LDH]]'''= [[Lactate dehydrogenase]], '''GI'''= Gastrointestinal, '''CXR'''= Chest X ray, '''IgA'''= [[Immunoglobulin A]], '''IgG'''= [[Immunoglobulin G]], '''IgM'''= [[Immunoglobulin M]], '''CT'''= [[Computed tomography]], '''[[PMN]]'''= Polymorphonuclear cells, '''[[ESR]]'''= [[Erythrocyte sedimentation rate]], '''[[CRP]]'''= [[C-reactive protein]], TS= [[Transferrin saturation]], SF= Serum [[Ferritin]], SMA= [[Superior mesenteric artery]], SMV= [[Superior mesenteric vein]], ECG= [[Electrocardiogram]], US = [[Ultrasound]]</span>
 
<small>
{| align="center"
{| align="center"
|-
|-
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* Stigmata of liver disease
* Stigmata of liver disease
* Cruveilhier- Baumgarten murmur
* Cruveilhier- Baumgarten murmur
|-
|Giardiasis
|Diffuse
| +
| -
| -
| +
| +
| -
| -
| -
|N
|
* [[Hypoalbuminaemia]]
* [[Vitamin B12]] and [[Folate deficiency|folate deficiencies]] (as the organism inhabits the [[duodenum]])
|EGD with small bowel tissue biopsy
* Reserved for patients with high suspicion of giardiasis and undiagnosed by other methods
|
* Microscopic identification of the organism in the stool
|-
|Cryptosporiadisis
|Diffuse
|<nowiki>+</nowiki>
|<nowiki>+</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>+</nowiki>
|<nowiki>+</nowiki>
|<nowiki>-</nowiki>
|<nowiki>+</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|N
|
* [[PCR]]: Most specific and sensitive diagnostic tool. [[PCR]] is expensive and used in limited cases.
|Normal
|
* Stool examination: [[Oocysts]] appear red on staining with modified acid fast staining
|-
|[[Cystoisospora belli|Cystoisosporiasis (isosporiasis)]]
|Diffuse
| +
| +
| -
| -
| +
| +
| -
| +
| -
| -
|N
|
* Peripheral eosinophilia
* Stool test is positive for immature oocyst that contains a spherical mass of [[protoplasm]]
|Upper GI series depicts minimal or irregular thickening of mucosal folds
|
* AIDS defining condition
|-
|-
|}
|}
|}
|}
 
</small>
===== Differentiating Tropical Sprue from Other causes of Fat Malabsorption in Immunocompromised Patients =====
Tropical sprue must be differentiated from other diseases that may cause [[chronic diarrhea]], [[weight loss]], and [[abdominal pain]] especially in [[Immunocompromised|immunocompromised patients]]. These conditions include chronic giardiasis, cryptosporidiosis, [[Cystoisospora belli|Cystoisosporiasis (isosporiasis)]]<ref name="pmid1889046">{{cite journal |vauthors=Current WL, Garcia LS |title=Cryptosporidiosis |journal=Clin. Microbiol. Rev. |volume=4 |issue=3 |pages=325–58 |year=1991 |pmid=1889046 |pmc=358202 |doi= |url=}}</ref><ref name="pmid11113253">{{cite journal |vauthors=Thompson RC |title=Giardiasis as a re-emerging infectious disease and its zoonotic potential |journal=Int. J. Parasitol. |volume=30 |issue=12-13 |pages=1259–67 |year=2000 |pmid=11113253 |doi= |url=}}</ref><ref name="pmid17172373">{{cite journal |vauthors=Sánchez-Vega JT, Tay-Zavala J, Aguilar-Chiu A, Ruiz-Sánchez D, Malagón F, Rodríguez-Covarrubias JA, Ordóñez-Martínez J, Calderón-Romero L |title=Cryptosporidiosis and other intestinal protozoan infections in children less than one year of age in Mexico City |journal=Am. J. Trop. Med. Hyg. |volume=75 |issue=6 |pages=1095–8 |year=2006 |pmid=17172373 |doi= |url=}}</ref><ref name="pmid1091526">{{cite journal |vauthors=Klipstein FA, Schenk EA |title=Enterotoxigenic intestinal bacteria in tropical sprue. II. Effect of the bacteria and their enterotoxins on intestinal structure |journal=Gastroenterology |volume=68 |issue=4 Pt 1 |pages=642–55 |year=1975 |pmid=1091526 |doi= |url=}}</ref>
<small>
{| align="center"
{| align="center"
|-
|-
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! colspan="1" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" | Lab Findings
! colspan="1" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" | Lab Findings
! style="background:#4479BA; color: #FFFFFF;" align="center" |Imaging
! style="background:#4479BA; color: #FFFFFF;" align="center" |Imaging
|-
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Tropical sprue]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Diffuse
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |N
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Fat soluble vitamin deficiency
* [[Hypoalbuminemia]]
* Fecal stool test
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Barium studies:
* Dilation and edema of mucosal folds
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Steatorrhea]]- 10-40 g/day (Normal=5 g/day)
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |Giardiasis
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |Giardiasis
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Diffuse
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Diffuse
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |±
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |±
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |+
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |+
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |+
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |±
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |±
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |N
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |N
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
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| style="padding: 5px 5px; background: #F5F5F5;" align="left" |EGD with small bowel tissue biopsy
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |EGD with small bowel tissue biopsy
* Reserved for patients with high suspicion of giardiasis and undiagnosed by other methods
* Reserved for patients with high suspicion of giardiasis and undiagnosed by other methods
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Microscopic identification of the organism in the stool
* Microscopic identification of the organism in the stool
|-
|-
|style="padding: 5px 5px; background: #DCDCDC;" align="center" |Cryptosporiadisis
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |Cryptosporiadisis
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |Diffuse
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Diffuse
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki>
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki>
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>-</nowiki>
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>-</nowiki>
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki>
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki>
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>-</nowiki>
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki>
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>-</nowiki>
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>-</nowiki>
|style="padding: 5px 5px; background: #F5F5F5;" align="center" |N
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |N
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[PCR]]: Most specific and sensitive diagnostic tool. [[PCR]] is expensive and used in limited cases.
* [[PCR]]: Most specific and sensitive diagnostic tool. [[PCR]] is expensive and used in limited cases.
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Normal
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Normal
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Stool examination: [[Oocysts]] appear red on staining with modified acid fast staining
* Stool examination: [[Oocysts]] appear red on staining with modified acid fast staining
|-
|-
|[[Cystoisospora belli|Cystoisosporiasis (isosporiasis)]]
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Cystoisospora belli|Cystoisosporiasis (isosporiasis)]]
|Diffuse
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Diffuse
| +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
|N
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |N
|
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Peripheral eosinophilia
* Peripheral eosinophilia
* Stool test is positive for immature oocyst that contains a spherical mass of [[protoplasm]]
* Stool test is positive for immature oocyst that contains a spherical mass of [[protoplasm]]
|Upper GI series depicts minimal or irregular thickening of mucosal folds
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Upper GI series depicts minimal or irregular thickening of mucosal folds
|
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* AIDS defining condition
* AIDS defining condition
|-
|[[Tropical sprue]]
|Diffuse
| +
|−
|−
|−
| +
|<nowiki>+</nowiki>
|−
|−
|−
|−
|N
|
* Fat soluble vitamin deficiency
* [[Hypoalbuminemia]]
* Fecal stool test
|Barium studies:
* Dilation and edema of mucosal folds
|
* [[Steatorrhea]]- 10-40 g/day (Normal=5 g/day)
|}
|}
|}
|}
</small>
==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
[[Category:Emergency mdicine]]
 
[[Category:Emergency mdicine]]
[[Category:Disease]]
[[Category:Disease]]
[[Category:Primary care]]
[[Category:Up-To-Date]]
[[Category:Up-To-Date]]
[[Category:Infectious disease]]
[[Category:Infectious disease]]
[[Category:Gastroenterology]]
[[Category:Gastroenterology]]

Latest revision as of 00:30, 30 July 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Aravind Kuchkuntla, M.B.B.S[2] Akshun Kalia M.B.B.S.[3]

Overview

Tropical sprue should be differentiated from diseases causing chronic diarrhea and malabsorption such as celiac disease, osmotic diarrhea and secretory diarrhea.

Differentiating Tropical Sprue from other Diseases

Tropical sprue is a diagnosis of exclusion therefore it must be be differentiated from other diseases causing malabsorption such as: [1][2][3][4]

Approach to a Patient with Chronic Diarrhea

The following is an algorithm describing the approch to a patient with chronic diarrhea:

 
 
 
 
 
 
 
 
 
 
Classify diarrhea by the results of the stool analysis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stool osmotic gap >50 mOsm/kg
 
 
 
Stool osmotic gap <50 mOsm/kg
 
Fecal occult blood (+), WBC (+), lactoferrin (+), calprotectin(+)
 
Fecal fat (+)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Osmotic diarrhea
 
 
 
Secretory diarrhea
 
Inflammatory diarrhea
 
Fatty diarrhea
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
• Check the pH of the stool
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Low pH
 
High pH
• Evaluate for ingestion of magnesium or antacids
• Evaluate for laxative abuse
 
1. Exclude infection by any/combination of the following tests:
Stool culture
• Microscopic evaluation for ova and parasites
• Stool antigen test for Giardia
Small bowel aspirate or breath H2 test to rule out bacterial overgrowth
 
1. Exclude structural disease by any/combination of the following tests:

Small bowel radiographs
Sigmoidoscopy or colonoscopy with biopsy
CT abdomen
UGI scopy and small bowel biopsy

 
1. Exclude structural disease by any/combination of the following tests

Small bowel radiographs
CT abdomen
Small bowel biopsy and aspirate for quantitative culture

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
• Take a careful dietary history
• Order breath H2 test (lactose), OR • Order lactase measurement in a mucosal biopsy
 
• Order stool alkanization test
• Order chromatographic and chemical tests
 
2. Exclude structural disease by any/combination of the following tests:

Small bowel radiographs
Sigmoidoscopy or colonoscopy with biopsy
CT abdomen
Biopsy of the proximal small bowel mucosa

 
2. Exclude infection by any/combination of the following tests:

Stool culture: Standard Aeromonas, Plesiomonas, Tuberculosis etc
• Stool for ova and parasites
Clostridium toxin assay
• Other specific test (Serology, ELISA, immunofluorescence to rule out virus and parasites)

 
2. Exclude exocrine pancreatic insufficieny by any/combination of the following tests:

Secretin test
• Stool chymotrypsin activity
Bentiromide test
• Others (D-xylose absorption tests / Schilling test)

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
3. Order selective testing:
• Cholestyramine test for bile acid diarrhea
• Plasma peptides (Gastrin, calcitonin, vasoactive intestinal polypeptide or somatostatin)
• Urine (5-hydroxyindole acetic acid, metanephrine or histamine)
• Others (TSH, ACTH stimulation test, serum protein electrophoresis or serum immunoglobulins)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Confirmatory diagnosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Specific treatment per results and symptomatic treatment
 
 
 
Suspect Tropical sprue and initiate antibiotic therapy and folate supplementation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Differentiating Tropical Sprue from Other causes of Fat Malabsorption

Tropical sprue must also be differentiated from other causes of fat malabsorption such as Whipple's disease, celiac disease, pancreatic disorders and other less common conditions.

Abbreviations: RUQ= Right upper quadrant of the abdomen, LUQ= Left upper quadrant, LLQ= Left lower quadrant, RLQ= Right lower quadrant, LFT= Liver function test, SIRS= Systemic inflammatory response syndrome, ERCP= Endoscopic retrograde cholangiopancreatography, IV= Intravenous, N= Normal, AMA= Anti mitochondrial antibodies, LDH= Lactate dehydrogenase, GI= Gastrointestinal, CXR= Chest X ray, IgA= Immunoglobulin A, IgG= Immunoglobulin G, IgM= Immunoglobulin M, CT= Computed tomography, PMN= Polymorphonuclear cells, ESR= Erythrocyte sedimentation rate, CRP= C-reactive protein, TS= Transferrin saturation, SF= Serum Ferritin, SMA= Superior mesenteric artery, SMV= Superior mesenteric vein, ECG= Electrocardiogram, US = Ultrasound

Disease Clinical manifestations Diagnosis Comments
Symptoms Signs
Abdominal Pain Fever Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging
Tropical sprue Diffuse + + + N Barium studies:
  • Dilation and edema of mucosal folds
Whipple's disease Diffuse ± ± + + ± N Endoscopy is used to confirm diagnosis.

Images used to find complications

Extra intestinal findings:
Celiac disease Diffuse + + Hyperactive US:
  • Bull’s eye or target pattern
  • Pseudokidney sign
  • Gluten allergy
Acute pancreatitis Epigastric + + ± + ± N
  • Ultrasound shows evidence of inflammation
  • CT scan shows severity of pancreatitis
  • Pain radiation to back
Disease Abdominal Pain Fever Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
Chronic pancreatitis Epigastric ± ± + + N
  • Increased amylase / lipase
  • Increased stool fat content
  • Pancreatic function test
CT scan
  • Calcification
  • Pseudocyst
  • Dilation of main pancreatic duct
  • Predisposes to pancreatic cancer
Pancreatic carcinoma Epigastric + + + + N

Skin manifestations may include:

Dumping syndrome Lower and then diffuse + + + + Hyperactive
  • Postgastrectomy
Acute diverticulitis LLQ + + + ± + Positive in perforated diverticulitis + + Hypoactive
  • CT scan
  • Ultrasound
Inflammatory bowel disease Diffuse ± ± + + + Normal or hyperactive

Extra intestinal findings:

Disease Abdominal Pain Fever Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
Irritable bowel syndrome Diffuse ± ± - N Normal Normal Symptomatic treatment
Infective colitis Diffuse + ± + + Positive in fulminant colitis ± ± Hyperactive CT scan
  • Bowel wall thickening
  • Edema
Colon carcinoma Diffuse/ RLQ/LLQ ± ± + + ±
  • Normal or hyperactive if obstruction present
  • CBC
  • Carcinoembryonic antigen (CEA)
  • Colonoscopy
  • Flexible sigmoidoscopy
  • Barium enema
  • CT colonography 
  • PILLCAM 2: A colon capsule for CRC screening may be used in patients with an incomplete colonoscopy who lacks obstruction
Viral hepatitis RUQ + + + Positive in Hep A and E + Positive in fulminant hepatitis Positive in acute + N
  • Abnormal LFTs
  • Viral serology
  • US
  • Hep A and E have fecal-oral route of transmission
  • Hep B and C transmits via blood transfusion and sexual contact.
Liver abscess RUQ + + + ± + + + ± Normal or hypoactive
  • US
  • CT
Cirrhosis RUQ + + + + N US
  • Stigmata of liver disease
  • Cruveilhier- Baumgarten murmur

Differentiating Tropical Sprue from Other causes of Fat Malabsorption in Immunocompromised Patients

Tropical sprue must be differentiated from other diseases that may cause chronic diarrhea, weight loss, and abdominal pain especially in immunocompromised patients. These conditions include chronic giardiasis, cryptosporidiosis, Cystoisosporiasis (isosporiasis)[5][6][7][8]

Disease Clinical manifestations Diagnosis Comments
Symptoms Signs
Abdominal Pain Fever Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging
Tropical sprue Diffuse + + + N Barium studies:
  • Dilation and edema of mucosal folds
Giardiasis Diffuse ± + - - + + - ± - - N EGD with small bowel tissue biopsy
  • Reserved for patients with high suspicion of giardiasis and undiagnosed by other methods
  • Microscopic identification of the organism in the stool
Cryptosporiadisis Diffuse + + - - + + - + - - N
  • PCR: Most specific and sensitive diagnostic tool. PCR is expensive and used in limited cases.
Normal
  • Stool examination: Oocysts appear red on staining with modified acid fast staining
Cystoisosporiasis (isosporiasis) Diffuse + + - - + + - + - - N
  • Peripheral eosinophilia
  • Stool test is positive for immature oocyst that contains a spherical mass of protoplasm
Upper GI series depicts minimal or irregular thickening of mucosal folds
  • AIDS defining condition

References

  1. Dosanjh G, Pardi DS (2016). "Chronic unexplained diarrhea: a logical and cost-effective approach to assessment". Curr Opin Gastroenterol. 32 (1): 55–60. doi:10.1097/MOG.0000000000000232. PMID 26628100.
  2. Langenberg MC, Wismans PJ, van Genderen PJ (2014). "Distinguishing tropical sprue from celiac disease in returning travellers with chronic diarrhoea: a diagnostic challenge?". Travel Med Infect Dis. 12 (4): 401–5. doi:10.1016/j.tmaid.2014.05.001. PMID 24889052.
  3. Corinaldesi R, Stanghellini V, Barbara G, Tomassetti P, De Giorgio R (2012). "Clinical approach to diarrhea". Intern Emerg Med. 7 Suppl 3: S255–62. doi:10.1007/s11739-012-0827-4. PMID 23073866.
  4. Juckett G, Trivedi R (2011). "Evaluation of chronic diarrhea". Am Fam Physician. 84 (10): 1119–26. PMID 22085666.
  5. Current WL, Garcia LS (1991). "Cryptosporidiosis". Clin. Microbiol. Rev. 4 (3): 325–58. PMC 358202. PMID 1889046.
  6. Thompson RC (2000). "Giardiasis as a re-emerging infectious disease and its zoonotic potential". Int. J. Parasitol. 30 (12–13): 1259–67. PMID 11113253.
  7. Sánchez-Vega JT, Tay-Zavala J, Aguilar-Chiu A, Ruiz-Sánchez D, Malagón F, Rodríguez-Covarrubias JA, Ordóñez-Martínez J, Calderón-Romero L (2006). "Cryptosporidiosis and other intestinal protozoan infections in children less than one year of age in Mexico City". Am. J. Trop. Med. Hyg. 75 (6): 1095–8. PMID 17172373.
  8. Klipstein FA, Schenk EA (1975). "Enterotoxigenic intestinal bacteria in tropical sprue. II. Effect of the bacteria and their enterotoxins on intestinal structure". Gastroenterology. 68 (4 Pt 1): 642–55. PMID 1091526.