Tropical sprue differential diagnosis: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Tropical_sprue]] | |||
{{CMG}}; {{AE}} {{AKI}} | {{CMG}};{{AE}}{{AKI}}{{Akshun}} | ||
==Overview== | ==Overview== | ||
[[Tropical sprue]] should be differentiated from diseases causing chronic [[diarrhea]] and [[malabsorption]] such as [[celiac disease]], osmotic diarrhea and secretory diarrhea. | [[Tropical sprue]] should be differentiated from diseases causing chronic [[diarrhea]] and [[malabsorption]] such as [[celiac disease]], [[Diarrhea|osmotic diarrhea]] and [[Diarrhea|secretory diarrhea]]. | ||
==Differentiating Tropical Sprue from other Diseases== | ==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: <ref name="pmid26628100">{{cite journal| author=Dosanjh G, Pardi DS| title=Chronic unexplained diarrhea: a logical and cost-effective approach to assessment. | journal=Curr Opin Gastroenterol | year= 2016 | volume= 32 | issue= 1 | pages= 55-60 | pmid=26628100 | doi=10.1097/MOG.0000000000000232 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26628100 }} </ref><ref name="pmid24889052">{{cite journal| author=Langenberg MC, Wismans PJ, van Genderen PJ| title=Distinguishing tropical sprue from celiac disease in returning travellers with chronic diarrhoea: a diagnostic challenge? | journal=Travel Med Infect Dis | year= 2014 | volume= 12 | issue= 4 | pages= 401-5 | pmid=24889052 | doi=10.1016/j.tmaid.2014.05.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24889052 }} </ref><ref name="pmid23073866">{{cite journal| author=Corinaldesi R, Stanghellini V, Barbara G, Tomassetti P, De Giorgio R| title=Clinical approach to diarrhea. | journal=Intern Emerg Med | year= 2012 | volume= 7 Suppl 3 | issue= | pages= S255-62 | pmid=23073866 | doi=10.1007/s11739-012-0827-4 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23073866 }} </ref><ref name="pmid22085666">{{cite journal| author=Juckett G, Trivedi R| title=Evaluation of chronic diarrhea. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 10 | pages= 1119-26 | pmid=22085666 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22085666 }} </ref> | [[Tropical sprue]] is a diagnosis of exclusion therefore it must be be differentiated from other diseases causing [[malabsorption]] such as: <ref name="pmid26628100">{{cite journal| author=Dosanjh G, Pardi DS| title=Chronic unexplained diarrhea: a logical and cost-effective approach to assessment. | journal=Curr Opin Gastroenterol | year= 2016 | volume= 32 | issue= 1 | pages= 55-60 | pmid=26628100 | doi=10.1097/MOG.0000000000000232 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26628100 }} </ref><ref name="pmid24889052">{{cite journal| author=Langenberg MC, Wismans PJ, van Genderen PJ| title=Distinguishing tropical sprue from celiac disease in returning travellers with chronic diarrhoea: a diagnostic challenge? | journal=Travel Med Infect Dis | year= 2014 | volume= 12 | issue= 4 | pages= 401-5 | pmid=24889052 | doi=10.1016/j.tmaid.2014.05.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24889052 }} </ref><ref name="pmid23073866">{{cite journal| author=Corinaldesi R, Stanghellini V, Barbara G, Tomassetti P, De Giorgio R| title=Clinical approach to diarrhea. | journal=Intern Emerg Med | year= 2012 | volume= 7 Suppl 3 | issue= | pages= S255-62 | pmid=23073866 | doi=10.1007/s11739-012-0827-4 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23073866 }} </ref><ref name="pmid22085666">{{cite journal| author=Juckett G, Trivedi R| title=Evaluation of chronic diarrhea. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 10 | pages= 1119-26 | pmid=22085666 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22085666 }} </ref> | ||
*Infectious causes | *[[Infectious]] causes | ||
*[[Celiac disease]] | *[[Celiac disease]] | ||
*[[Pancreatic insufficiency]] | *[[Pancreatic insufficiency]] | ||
*Osmotic diarrhea | *[[Diarrhea|Osmotic diarrhea]] | ||
*Secretory diarrhea | *[[Diarrhea|Secretory diarrhea]] | ||
===Approach to a Patient with Chronic Diarrhea=== | ===Approach to a Patient with Chronic Diarrhea=== | ||
The following is an algorithm describing the approch to a patient with [[Chronic diarrhea resident survival guide|chronic diarrhea]]: | The following is an algorithm describing the approch to a patient with [[Chronic diarrhea resident survival guide|chronic diarrhea]]: | ||
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{{familytree/end}} | {{familytree/end}} | ||
===== 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. | |||
<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" | ||
|- | |- | ||
| | | | ||
{| style="border: 0px; font-size: 90%; margin: 3px;" align="center" | {| style="border: 0px; font-size: 90%; margin: 3px;" align="center" | ||
! rowspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |Disease | ! rowspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |Disease | ||
| colspan=" | | colspan="12" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" |'''Clinical manifestations''' | ||
! colspan="2" rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Diagnosis | ! colspan="2" rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Diagnosis | ||
! rowspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |Comments | ! rowspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |Comments | ||
|- | |- | ||
| colspan=" | | colspan="8" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" |'''Symptoms''' | ||
! colspan="4" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" | Signs | ! colspan="4" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" | Signs | ||
|- | |- | ||
! style="background:#4479BA; color: #FFFFFF;" align="center" |Abdominal Pain | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Abdominal Pain | ||
! colspan="1" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" | Fever | ! colspan="1" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" | Fever | ||
! style="background:#4479BA; color: #FFFFFF;" align="center" |Nausea or vomiting | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Nausea or vomiting | ||
! style="background:#4479BA; color: #FFFFFF;" align="center" |Jaundice | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Jaundice | ||
Line 159: | Line 93: | ||
! 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="left" |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" |[[Whipple's disease]] | |||
| 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="left" |N | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | |||
* [[Thrombocytopenia]] | |||
* [[Hypoalbuminemia]] | |||
* [[Small intestinal]] [[biopsy]] for [[Tropheryma whipplei]] | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Whipple's disease other diagnostic studies|Endoscopy]] is used to confirm diagnosis. | |||
Images used to find complications | |||
*[[Whipple's disease x ray|Chest and joint x-ray]] | |||
*[[Whipple's disease CT|CT]] | |||
*[[Whipple's disease MRI|MRI]] | |||
*[[Whipple's disease ultrasound|Echocardiography]] | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Extra intestinal findings: | |||
* [[Uveitis]] | |||
* [[Endocarditis]] | |||
* [[Encephalitis]] | |||
* [[Dementia]] | |||
* [[Hepatosplenomegaly]] | |||
* [[Arthritis]] | |||
* [[Ascites]] | |||
|- | |||
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Celiac disease]] | |||
| 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="left" |Hyperactive | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | |||
* [[IgA]] endomysial antibody | |||
* [[IgA]] [[tissue transglutaminase]] antibody | |||
* [[Anti-gliadin antibodies|Anti-gliadin antibody]] | |||
* Small bowel biopsy | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |US: | |||
* Bull’s eye or target pattern | |||
* Pseudokidney sign | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | |||
* Gluten allergy | |||
|- | |||
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" | [[Acute pancreatitis]] | | colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" | [[Acute pancreatitis]] | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | [[Epigastric]] | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | [[Epigastric]] | ||
| 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" |<nowiki>+</nowiki> | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | ||
Line 183: | Line 191: | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* Pain radiation to back | * Pain radiation to back | ||
|- | |||
! style="background:#4479BA; color: #FFFFFF;" align="center" |Disease | |||
! style="background:#4479BA; color: #FFFFFF;" align="center" |Abdominal Pain | |||
! style="background:#4479BA; color: #FFFFFF;" align="center" |Fever | |||
! style="background:#4479BA; color: #FFFFFF;" align="center" |Nausea or vomiting | |||
! style="background:#4479BA; color: #FFFFFF;" align="center" |Jaundice | |||
! style="background:#4479BA; color: #FFFFFF;" align="center" |Constipation | |||
! style="background:#4479BA; color: #FFFFFF;" align="center" |Diarrhea | |||
! style="background:#4479BA; color: #FFFFFF;" align="center" |Weight loss | |||
! style="background:#4479BA; color: #FFFFFF;" align="center" |GI bleeding | |||
! style="background:#4479BA; color: #FFFFFF;" align="center" |Hypo- | |||
tension | |||
! style="background:#4479BA; color: #FFFFFF;" align="center" |Guarding | |||
! style="background:#4479BA; color: #FFFFFF;" align="center" |Rebound Tenderness | |||
! style="background:#4479BA; color: #FFFFFF;" align="center" |Bowel sounds | |||
! style="background:#4479BA; color: #FFFFFF;" align="center" |Lab Findings | |||
! style="background:#4479BA; color: #FFFFFF;" align="center" |Imaging | |||
! style="background:#4479BA; color: #FFFFFF;" align="center" |Comments | |||
|- | |- | ||
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Chronic pancreatitis]] | | colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Chronic pancreatitis]] | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[Epigastric]] | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[Epigastric]] | ||
| 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" | ± | ||
Line 211: | Line 236: | ||
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Pancreatic carcinoma]] | | style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Pancreatic carcinoma]] | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[Epigastric]] | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[Epigastric]] | ||
| 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" |<nowiki>+</nowiki> | ||
Line 238: | Line 262: | ||
* [[Panniculitis|Pancreatic panniculitis]] | * [[Panniculitis|Pancreatic panniculitis]] | ||
|- | |- | ||
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Dumping syndrome]] | | style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Dumping syndrome]] | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Lower and then diffuse | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |Lower and then 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" |<nowiki>+</nowiki> | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki> | ||
Line 261: | Line 283: | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* Postgastrectomy | * Postgastrectomy | ||
|- | |- | ||
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Diverticulitis|Acute diverticulitis]] | | colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Diverticulitis|Acute diverticulitis]] | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |LLQ | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |LLQ | ||
| 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" |<nowiki>+</nowiki> | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
Line 312: | Line 308: | ||
| 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" | ± | ||
Line 332: | Line 327: | ||
* [[Uveitis]] | * [[Uveitis]] | ||
* [[Arthritis]] | * [[Arthritis]] | ||
|- | |- | ||
! style="background:#4479BA; color: #FFFFFF;" align="center" |Disease | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Disease | ||
! style="background:#4479BA; color: #FFFFFF;" align="center" |Abdominal Pain | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Abdominal Pain | ||
! style="background:#4479BA; color: #FFFFFF;" align="center" |Fever | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Fever | ||
! style="background:#4479BA; color: #FFFFFF;" align="center" |Nausea or vomiting | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Nausea or vomiting | ||
! style="background:#4479BA; color: #FFFFFF;" align="center" |Jaundice | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Jaundice | ||
Line 407: | Line 346: | ||
! style="background:#4479BA; color: #FFFFFF;" align="center" |Comments | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Comments | ||
|- | |- | ||
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[ | | style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Irritable bowel syndrome]] | ||
| 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" | − | ||
Line 421: | Line 359: | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N | | style="padding: 5px 5px; background: #F5F5F5;" align="left" |N | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | | 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" |Symptomatic treatment | |||
* High [[dietary fiber]] | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | |||
* [[Osmotic]] [[laxatives]] | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | * [[Antispasmodic]] drugs | ||
* [[ | |||
* [[ | |||
* [[ | |||
|- | |- | ||
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Infective colitis]] | | style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Infective colitis]] | ||
| 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" | − | ||
Line 477: | Line 388: | ||
* Edema | * Edema | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
|- | |- | ||
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Colon carcinoma]] | | style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Colon carcinoma]] | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Diffuse/ RLQ/LLQ | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |Diffuse/ RLQ/LLQ | ||
| 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" | − | ||
Line 523: | Line 414: | ||
* PILLCAM 2: A colon capsule for CRC screening may be used in patients with an incomplete colonoscopy who lacks obstruction | * PILLCAM 2: A colon capsule for CRC screening may be used in patients with an incomplete colonoscopy who lacks obstruction | ||
|- | |- | ||
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Hepatitis|Viral hepatitis]] | | style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Hepatitis|Viral hepatitis]] | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[RUQ]] | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[RUQ]] | ||
| 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" |<nowiki>+</nowiki> | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
Line 549: | Line 438: | ||
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Liver abscess]] | | style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Liver abscess]] | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |RUQ | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |RUQ | ||
| 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" |<nowiki>+</nowiki> | ||
Line 569: | Line 457: | ||
* CT | * CT | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
|- | |- | ||
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Cirrhosis|Cirrhosis]] | | style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Cirrhosis|Cirrhosis]] | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[RUQ]] | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[RUQ]] | ||
| 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" | − | ||
Line 616: | Line 484: | ||
* Cruveilhier- Baumgarten murmur | * Cruveilhier- Baumgarten murmur | ||
|- | |- | ||
! style="background:#4479BA; color: #FFFFFF;" align="center" |Disease | |} | ||
|} | |||
</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" | |||
|- | |||
| | |||
{| style="border: 0px; font-size: 90%; margin: 3px;" align="center" | |||
! rowspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |Disease | |||
| colspan="12" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" |'''Clinical manifestations''' | |||
! colspan="2" rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Diagnosis | |||
! rowspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |Comments | |||
|- | |||
| colspan="8" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" |'''Symptoms''' | |||
! colspan="4" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" | Signs | |||
|- | |||
! style="background:#4479BA; color: #FFFFFF;" align="center" |Abdominal Pain | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Abdominal Pain | ||
! | ! colspan="1" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" | Fever | ||
! style="background:#4479BA; color: #FFFFFF;" align="center" |Nausea or vomiting | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Nausea or vomiting | ||
! style="background:#4479BA; color: #FFFFFF;" align="center" |Jaundice | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Jaundice | ||
! style="background:#4479BA; color: #FFFFFF;" align="center" |Constipation | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Constipation | ||
! style="background:#4479BA; color: #FFFFFF;" align="center" |Diarrhea | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Diarrhea | ||
Line 628: | Line 512: | ||
! style="background:#4479BA; color: #FFFFFF;" align="center" |Hypo- | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Hypo- | ||
tension | tension | ||
! style="background:#4479BA; color: #FFFFFF;" align="center" |Guarding | ! colspan="1" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" | Guarding | ||
! style="background:#4479BA; color: #FFFFFF;" align="center" |Rebound Tenderness | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Rebound Tenderness | ||
! style="background:#4479BA; color: #FFFFFF;" align="center" |Bowel sounds | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Bowel sounds | ||
! 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" |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" |<nowiki>+</nowiki> | ||
| style="padding: 5px 5px; background: #F5F5F5;" align=" | | 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" | | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* [[ | * Fat soluble vitamin deficiency | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | * [[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" | | | 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: #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=" | | 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" | | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* [[ | * [[Hypoalbuminaemia]] | ||
* [[Vitamin B12]] and [[Folate deficiency|folate deficiencies]] (as the organism inhabits the [[duodenum]]) | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |EGD with small bowel tissue biopsy | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | * 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 | ||
|- | |- | ||
| style="padding: 5px 5px; background: #DCDCDC;" align="center" | | | 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" | + | | 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" | | | 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" |<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=" | | 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="left" | | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* [[ | * [[PCR]]: Most specific and sensitive diagnostic tool. [[PCR]] is expensive and used in limited cases. | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | | 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 | ||
|- | |- | ||
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Cystoisospora belli|Cystoisosporiasis (isosporiasis)]] | |||
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[ | | 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=" | | 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" | | ||
* | * Peripheral eosinophilia | ||
* [[ | * Stool test is positive for immature oocyst that contains a spherical mass of [[protoplasm]] | ||
| 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" | | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* | * AIDS defining condition | ||
|} | |} | ||
|} | |} | ||
</small> | |||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
[[Category:Emergency mdicine]] | |||
[[Category:Disease]] | [[Category:Disease]] | ||
[[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 • 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 | 1. Exclude structural disease by any/combination of the following tests
• Small bowel radiographs | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
• 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 | 2. Exclude infection by any/combination of the following tests:
• Stool culture: Standard Aeromonas, Plesiomonas, Tuberculosis etc | 2. Exclude exocrine pancreatic insufficieny by any/combination of the following tests:
• Secretin 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
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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]
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References
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Juckett G, Trivedi R (2011). "Evaluation of chronic diarrhea". Am Fam Physician. 84 (10): 1119–26. PMID 22085666.
- ↑ Current WL, Garcia LS (1991). "Cryptosporidiosis". Clin. Microbiol. Rev. 4 (3): 325–58. PMC 358202. PMID 1889046.
- ↑ Thompson RC (2000). "Giardiasis as a re-emerging infectious disease and its zoonotic potential". Int. J. Parasitol. 30 (12–13): 1259–67. PMID 11113253.
- ↑ 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.
- ↑ 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.