Tropical sprue differential diagnosis: Difference between revisions
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| 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" | + | |||
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| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki> | |||
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| 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) | |||
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! rowspan="20" |Abdominal causes | |||
! rowspan="17" |Inflammatory causes | |||
! rowspan="3" |Pancreato-biliary disorders | ! rowspan="3" |Pancreato-biliary disorders | ||
| 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]] | ||
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* Postgastrectomy | * Postgastrectomy | ||
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! rowspan=" | ! rowspan="10" |Intestinal causes | ||
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Acute appendicitis]] | | colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Acute appendicitis]] | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Starts in [[epigastrium]], migrates to RLQ | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |Starts in [[epigastrium]], migrates to RLQ | ||
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! style="background:#4479BA; color: #FFFFFF;" align="center" |Imaging | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Imaging | ||
! style="background:#4479BA; color: #FFFFFF;" align="center" |Comments | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Comments | ||
|- | |- | ||
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Celiac disease]] | | style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Celiac disease]] | ||
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* 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 | ||
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! rowspan=" | ! rowspan="3" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Hepatic causes | ||
| 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]] | ||
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* 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]] | ||
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* Cruveilhier- Baumgarten murmur | * Cruveilhier- Baumgarten murmur | ||
|- | |- | ||
! colspan="2" |Hollow Viscous Obstruction | |||
! 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 | ||
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! style="background:#4479BA; color: #FFFFFF;" align="center" |Comments | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Comments | ||
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! | ! rowspan="2" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Vascular Disorders | ||
! rowspan="2" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Ischemic causes | ! rowspan="2" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Ischemic causes | ||
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Mesenteric ischemia]] | | style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Mesenteric ischemia]] | ||
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* May lead to shock | * May lead to shock | ||
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Revision as of 19:04, 20 December 2017
Tropical sprue Microchapters |
Diagnosis |
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Treatment |
Case Studies |
Tropical sprue differential diagnosis On the Web |
American Roentgen Ray Society Images of Tropical sprue differential diagnosis |
Risk calculators and risk factors for Tropical sprue differential diagnosis |
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 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Tropical sprue must be differentiated from other diseases that may cause chronic diarrhea, weight loss, and abdominal pain especially in immunocompromised patients.
Disease | Prominent clinical findings | Laboratory or radiological findings |
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Chronic giardiasis[5] |
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Cryptosporidiosis[6] |
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Cystoisosporiasis (isosporiasis)[7] |
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Tropical sprue[8] |
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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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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.
- ↑ 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.
- ↑ Current WL, Garcia LS (1991). "Cryptosporidiosis". Clin. Microbiol. Rev. 4 (3): 325–58. PMC 358202. PMID 1889046.
- ↑ 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.