Tropical sprue differential diagnosis

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

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:

• Celiac disease
• Infectious causes
• Pancreatic insufficiency
• Osmotic diarrhea
• Secretory diarrhea

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 • Evaluate for carbohydrate malabsorption

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

References

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