Tropical sprue differential diagnosis: Difference between revisions
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==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]], osmotic diarrhea and 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: <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 | *Osmotic diarrhea | ||
*Secretory 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: | The following is an algorithm describing the approch to a patient with [[Chronic diarrhea resident survival guide|chronic diarrhea]]: | ||
{{familytree/start}} | {{familytree/start}} |
Revision as of 20:43, 13 April 2017
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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 such as: [1][2][3][4]
- Infectious causes
- Celiac disease
- 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 | 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 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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.