What Cause of Persistent Diarrhea and Weight Loss?

A 28-year-old woman presents with a 4-month history of diarrhea and a 15-lb weight loss. She was in her usual state of health until these symptoms started. She reports that she has always been “a little overweight” and has been trying to lose weight again.

The patient denies constitutional symptoms, such as fevers, chills, fatigue, and lethargy. She reports that diarrhea occurs 2 or 3 times daily and is not temporally related to eating. There is no mucus or blood in the stool. She experiences some mild cramps, but no significant abdominal pain. There is no family history of GI disease, and no one with whom she is associated has similar symptoms. She has not traveled recently, drinks only bottled or city tap water, and has not been camping.

The patient denies any rashes, joint pains, mouth ulcers, shortness of breath, and changes in her menses. She is 5 ft 3 in tall and weighs 145 lb. Her vital signs are normal.

She takes oral contraceptives, does not smoke or take illicit drugs, and does not drink to excess. She is married and has 1 child.

A stool sample is negative for occult blood. Screening laboratory findings: hemoglobin, 13.5 g/dL; WBC, 7400/µL, with a normal differential; platelet count, 215,000/µL; ESR, 12 mm/h; CRP, 1.5 mg/mL. All other chemistries are normal. Tests for laxative abuse (phenolphthalein) and a culture for Clostridium difficile are negative.

So far, there are not many facts on which to build a diagnosis-crampy abdominal pain, weight loss, and chronic diarrhea with no remarkable laboratory results.

Which of the following would best help you evaluate the patient at this point?

A. Upper GI with small-bowel series

B. Duodenal biopsy and tissue transglutaminase antibodies to evaluate for gluten deficiency

C. Stool for ova and parasites

D. 24-hour fecal fat

E. None of the above

You chose A. Upper GI and small-bowel series. Not recommended.

A suspicion of Crohn disease would warrant this series. This form of inflammatory bowel disease often presents in this age group and its symptoms include abdominal pain, diarrhea, and weight loss, all of which our patient has. This systemic disease is often associated with extraintestinal manifestations, such as rashes, mouth or genital ulcers, arthritis, fever, anorexia, and fatigue.

Because Crohn disease is inflammatory, one almost always sees an increased platelet count, ESR, and CRP level; a decreased hemoglobin level; and often decreased albumin level-none of which were found in this patient. Therefore, while she has some symptoms of Crohn disease, there are many more that she does not have, so while it is a possible diagnosis, it would be very unlikely.

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You chose B. Workup for gluten deficiency (sprue). Not recommended at this point.

This disease also presents with diarrhea and weight loss and is associated with eating products that contain wheat. Sprue is often overlooked because of a paucity of other findings. Patients may have a rash (dermatitis herpetiformis), family history, and often a mild iron deficiency anemia. The latter is caused by a problem in absorbing iron, which occurs in the duodenum-the site of this intestinal disorder. There are also other autoimmune disorders occasionally seen with gluten deficiency.

The absence of either a rash or anemia would speak against this disorder. Before ordering invasive studies, more history trying to relate symptoms with wheat intake or a trial of a gluten-free diet might be indicated.

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You chose C. Stool for ova and parasites. Not recommended at this time.

These studies are frequently ordered for any patient with diarrhea. While they are relatively inexpensive and noninvasive, there is nothing to suggest that this is the cause in our patient. She has not been camping and drinks bottled water or city water, both of which would make Giardia unlikely. She has no eosinophilia, which would speak against some but certainly not all parasites.

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You chose D. 24-hour fecal fat. Not the best choice at this time.

This test would suggest malabsorption. When this disorder is present, patients often complain of oily stools that float (increased fat in the stool) as well as worse than normal odor from their stools. There may be no physical findings but there can be abnormalities on simple laboratory tests. Often calcium levels are decreased in affected patients because vitamin D is a fat-soluble vitamin and is needed for calcium absorption.

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You chose E. None of the above. This is the correct answer at this point.

Since none of the above choices seem right, it is often time to step back and reexamine. Our patient weighs 145 lb AFTER losing 15 lb with her “illness.” She told us in the history that she was trying to lose weight. The key is MORE HISTORY as to how she was trying to lose weight.

Many “sugar-free” foods are sweetened with sorbitol, malitol, or other “alcohol” sweeteners. These are poorly absorbed and cause a watery diarrhea. There are many cases similar to this one, implicating sugar-free gum or mints. These substances are also found in sugar-free cookies, no-sugar-added ice creams (despite an aspartame label on the carton), and other foods. It is important for the health care provider to be aware of this syndrome, to take a complete dietary history in an otherwise healthy patient with chronic diarrhea and no other symptoms, and to counsel patients in this area before they start to diet.

Teaching points:

• Weight loss and diarrhea may have many different causes, ranging from very serious to benign.

• Look for red flags in the history, physical, and/or laboratory testing to guide you toward the appropriate differential diagnosis.

• In the absence of red flags, consider other etiologies. An extensive history will often help with the diagnosis.

References:

1. Gryboski JD. Diarrhea from dietetic candies. N Engl J Med. 1966;275:718

2. Badiga MS, Jain NK, Casanova C, Pitchumoni CS. Diarrhea in diabetes. The role of sorbitol. J Am Coll Nutr. 1990;9:578-582.

3. Yamada T, ed. Textbook of Gastroenterology. Vol 1. Philadelphia: Lippincott, Williams and Wilkins; 2003:863.

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