Tropical sprue differential diagnosis: Difference between revisions

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__NOTOC__
__NOTOC__
{{Tropical sprue}}
[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Tropical_sprue]]
{{CMG}}
{{CMG}};{{AE}}{{AKI}}{{Akshun}}


==Overview==
==Overview==
Tropical sprue must be differentiated from [[celiac disease]], chronic [[diarrhea]], [[Clonorchiasis]], traveler's [[diarrhea]], and [[whipworm]].
[[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==
{| border="1"
[[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
'''Differentiating Tropical sprue from other causes of Tropical malabsorption'''
*[[Celiac disease]]
! colspan="2" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Causes}}
*[[Pancreatic insufficiency]]
!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Pathophysiology and Histology}}
*[[Diarrhea|Osmotic diarrhea]]
!Fever
*[[Diarrhea|Secretory diarrhea]]
!Vomiting
===Approach to a Patient with Chronic Diarrhea===
!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Acute diarrhea}}
The following is an algorithm describing the approch to a patient with [[Chronic diarrhea resident survival guide|chronic diarrhea]]:
!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Traveller's diarrhea}}
 
!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Chronic diarrhea}}
{{familytree/start}}
!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Malabsorption}}
{{familytree | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | |A01= '''Classify diarrhea by the results of the stool analysis'''}}
!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Steatorrhoea}}
{{familytree | | | |,|-|-|-|-|-|v|-|^|-|v|-|-|-|.| | | | | | | | | | }}
!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Diagnosis}}
{{familytree | | | E01 | | | | E02 | | E03 | | E04 | | | | | | | | | | | E01 = Stool osmotic gap >50 mOsm/kg | E02 = Stool osmotic gap <50 mOsm/kg | E03 = Fecal occult blood (+), WBC (+), [[lactoferrin]] (+), calprotectin(+) | E04 = Fecal fat (+)}}
!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Confirmatory tests}}
{{familytree | | | |!| | | | | |!| | | |!| | | |!| | | | | | | |}}
!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Associations}}
{{familytree | | | E01 | | | | E02 | | E03 | | E04 | | | | | | | | | | |E01= '''Osmotic diarrhea''' | E02= '''Secretory diarrhea'''|E03= '''Inflammatory diarrhea''' |E04= '''Fatty diarrhea''' }}
{{familytree | | | |!| | | | | |!| | | |!| | | |!| | | | | | | |}}
{{familytree | | | E05 | | | | |!| | | |!| | | |!| | | | | | | |E05= • Check the pH of the stool}}
{{familytree | |,|-|^|-|.| | | |!| | | |!| | | |!| | | | | | | | | | | | }}
{{familytree | F01 | | F02 | | F03 | | F04 | | F05 | | | | | | | | | | | |F01= '''Low pH'''<br> <div style="float: left; text-align: left">• Evaluate for [[malabsorption|carbohydrate malabsorption]]</div> | F02= '''High pH''' <br> <div style="float: left; text-align: left">• Evaluate for ingestion of magnesium or antacids <br> • Evaluate for laxative abuse </div>|F03= <div style="float: left; text-align: left">'''1. Exclude infection by any/combination of the following tests:'''
----
• [[Diarrhea laboratory findings#Fecal Cultures|Stool culture]] <br> • Microscopic evaluation for ova and [[parasite]]s <br> • Stool antigen test for [[Giardia]] <br> • [[Diarrhea laboratory findings#Upper Tract Endoscopy|Small bowel aspirate]] or [[Diarrhea laboratory findings#Tests for Bacterial Overgrowth|breath H2 test]] to rule out bacterial overgrowth </div>
|F04=<div style="float: left; text-align: left"> '''1. Exclude structural disease by any/combination of the following tests:'''
----
• [[Diarrhea laboratory findings#Radiography|Small bowel radiographs]] <br> • [[Diarrhea laboratory findings#Sigmoidoscopy and Colonoscopy|Sigmoidoscopy or colonoscopy with biopsy]] <br> • [[Diarrhea laboratory findings#Radiography|CT abdomen]] <br> • [[Diarrhea laboratory findings#Upper Tract Endoscopy|UGI scopy and small bowel biopsy]] <br>
</div>  |F05=<div style="float: left; text-align: left; line-height: 150% "> '''1. Exclude structural disease by any/combination of the following tests'''
----
• [[Diarrhea laboratory findings#Radiography|Small bowel radiographs]] <br> • [[Diarrhea laboratory findings#Radiography|CT abdomen]] <br> • [[Diarrhea laboratory findings#Upper Tract Endoscopy|Small bowel biopsy and aspirate for quantitative culture]] <br>
</div>  }}
{{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | | | | | | | | | | }}
{{familytree | G01 | | G06 | | G02 | | G03 | | G04 | | | | | | | | | | |G01= • Take a careful dietary history <br> •  Order [[lactose intolerance laboratory findings|breath H2 test (lactose), OR • Order lactase measurement in a mucosal biopsy]] | G06 = • Order stool alkanization test <br> • Order chromatographic and chemical tests | G02=<div style="float: left; text-align: left; line-height: 150% "> '''2. Exclude structural disease by any/combination of the following tests:'''
----
• [[Diarrhea laboratory findings#Radiography|Small bowel radiographs]] <br> • [[Diarrhea laboratory findings#Sigmoidoscopy and Colonoscopy|Sigmoidoscopy or colonoscopy with biopsy]] <br> • [[Diarrhea laboratory findings#Radiography|CT abdomen]] <br> • [[Diarrhea laboratory findings#Upper Tract Endoscopy|Biopsy of the proximal small bowel mucosa]] <br>
</div> |G03=<div style="float: left; text-align: left; line-height: 150% "> '''2. Exclude infection by any/combination of the following tests:'''
----
• [[Diarrhea laboratory findings#Fecal Cultures|Stool culture]]: Standard [[Aeromonas]], [[Plesiomonas]], [[Tuberculosis]] etc <br> • Stool for ova and [[parasite]]s <br> • [[Clostridium difficile laboratory findings|Clostridium toxin assay]] <br> • Other specific test (Serology, [[ELISA]], [[immunofluorescence]] to rule out virus and parasites) <br>
</div> |G04=<div style="float: left; text-align: left; line-height: 150% ">'''2. Exclude exocrine pancreatic insufficieny by any/combination of the following tests:'''
----
• [[Zollinger-Ellison syndrome laboratory tests|Secretin test]] <br> • Stool chymotrypsin activity <br> • [[Bentiromide|Bentiromide test]] <br> • Others ([[Diarrhea laboratory findings#Tests for Bacterial Overgrowth|D-xylose absorption tests / Schilling test]]) <br>
</div> }}
{{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | | | | | | | | | | }}
{{familytree | |!| | | |!| | | H01 | | |!| | | |!| | | | | | | | | |H01=<div style="float: left; text-align: left; line-height: 150% "> '''3. Order selective testing:'''
----
• Cholestyramine test for bile acid diarrhea <br> • Plasma peptides ([[Gastrin]], [[calcitonin]], [[vasoactive intestinal polypeptide]] or [[somatostatin]]) <br> • Urine (5-hydroxyindole acetic acid, [[metanephrine]] or [[histamine]]) <br> • Others ([[TSH]], [[ACTH stimulation test]], serum protein electrophoresis or serum [[immunoglobulins]]) <br> </div> }}
{{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | | | | | | | | }}
{{familytree | |`|-|-|-|^|-|-|-|+|-|-|-|^|-|-|-|'| | | | | | | | | | }}
{{familytree | | | | | | | | | G05 | | | | | | | | | | | | | | | | | | | | | | G05 = Confirmatory diagnosis}}
{{familytree | | | | | | | |,|-|^|-|-|-|.| | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | D01 | | | | |!| | | | | | | | | | | | | | | | D01= Yes | D02= No }}
{{familytree | | | | | | | |!| | | | | |!| | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | D05 | | | | D02 | | | | | | | | | | | | | | | | | | D05 = Specific treatment per results and symptomatic treatment | D02= Suspect Tropical sprue and initiate antibiotic therapy and folate supplementation }}
{{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:'''
'''[[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"
|-
|-
! colspan="2" |Tropical sprue
!
!
!
!
|
|
|
|
|
|
|
|
{| 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
! 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" |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
! 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" |Bowel sounds
! colspan="1" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" | Lab Findings
! 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]]
| 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" |<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="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" |
* Increased [[amylase]] / [[lipase]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Ultrasound shows evidence of [[inflammation]]
* CT scan shows severity of pancreatitis
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* 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]]
| 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" |−
| 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" |
* Increased [[amylase]] / [[lipase]]
* Increased stool fat content
* Pancreatic function test
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |CT scan
* Calcification
* Pseudocyst
* Dilation of main pancreatic duct
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Predisposes to pancreatic cancer
|-
| 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" | −
| 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" |<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="center" |N
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* ↑ [[Alkaline phosphatase]]
* ↑ [[Bilirubin|serum bilirubin]]
* ↑ [[gamma-glutamyl transpeptidase]]
* ↑ [[CA 19-9]] 
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Computed tomography|MDCT]] with   [[Positron emission tomography|PET]]/[[Computed tomography|CT]]
* MRI
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
[[Skin]] manifestations may include:
* [[Bullous pemphigoid]]
* [[Mucous membrane pemphigoid|Cicatricial pemphigoid]]
* [[Thrombophlebitis|Migratory superficial thrombophlebitis]] (classic [[Trousseau's syndrome]])
* [[Panniculitis|Pancreatic panniculitis]]
|-
| 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" | −
| 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" |<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" |
* Glucose challenge test
* [[Hydrogen Breath Test|Hydrogen breath test]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Upper gastrointestinal series|Upper GI series]]
* Gastric emptying study
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Postgastrectomy
|-
| 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" | +
| 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" |−
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Positive in perforated diverticulitis
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hypoactive
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Leukocytosis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* CT scan 
* Ultrasound
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* History of [[constipation]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Inflammatory bowel 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" |Normal or hyperactive
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Anti-neutrophil cytoplasmic antibody]] ([[P-ANCA]]) in [[Ulcerative colitis]]
* [[Anti saccharomyces cerevisiae antibodies]] (ASCA) in [[Crohn's disease]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[String sign]] on [[abdominal x-ray]] in [[Crohn's disease]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
Extra intestinal findings:
* [[Uveitis]]
* [[Arthritis]]
|-
|-
! colspan="2" |Tropical Enteropathy
! style="background:#4479BA; color: #FFFFFF;" align="center" |Disease
!Increased mucosal permeability, shorter villi, elongated crypts and increased lymphocytes in the lamina propria
! 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
!Subclinical
! 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
|-
|-
! rowspan="4" | '''Infectious'''
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Irritable bowel syndrome]]
!Protozoal
| 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="left" |N
| 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]]


*  
* [[Osmotic]] [[laxatives]]
|
* [[Antispasmodic]] drugs
|
|-
|
| 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" | +
|
| 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" | Positive in fulminant colitis
| 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" |
* [[Stool culture]] and studies
* Shiga toxin in bloody diarrhea
* [[PCR]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |CT scan
* Bowel wall thickening
* Edema
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
|-
| 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" | −
| 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" |
* Normal or hyperactive if obstruction present
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* CBC
* Carcinoembryonic antigen (CEA)
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Colonoscopy
* Flexible sigmoidoscopy
* Barium enema
* CT colonography 
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* 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: #F5F5F5;" align="center" |[[RUQ]]
| 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" | Positive in Hep A and E
| 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" | Positive in fulminant hepatitis
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Positive in acute
| 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" |
* Abnormal LFTs
* Viral serology
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* US
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Hep A and E have fecal-oral route of transmission
* Hep B and C transmits via blood transfusion and sexual contact.
|-
|-
!Helminths
| 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" | +
!
| 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" |<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" |Normal or hypoactive
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* CBC
* Blood cultures
* Abnormal [[Liver function test|liver function tests]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* US
* CT
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
|-
|-
!Bacterial
| 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" | −
!
| 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" |
* [[Hypoalbuminemia]]
* Prolonged PT
* Abnormal LFTs
* [[Hyponatremia]]
* [[Thrombocytopenia]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |US
* Nodular, shrunken liver
* [[Ascites]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Stigmata of liver disease
* Cruveilhier- Baumgarten murmur
|-
|-
!Viral
|}
!
|}
!
</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"
|
|
|
|
|
|-
|-
! rowspan="3" |Inflammatory and Immune mediated
!Crohn's disease
!Decreased small intestinal absorptive surface area
!
!
!
|
|
|
|
|
|
|
|
{| 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
|-
|-
!Ulcerative colitis
| colspan="8" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" |'''Symptoms'''
!
! colspan="4" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" | Signs
!
!
!
|
|
|
|
|
|
|
|-
|-
!Coeliac sprue<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>
! style="background:#4479BA; color: #FFFFFF;" align="center" |Abdominal Pain
!Complete villous atrophy of the jejunal mucosa
! 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" |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-
|Antiendomysial and tissue transglutaminase  antibodies
tension
|Clinical and histological response to gluten withdrawal.
! 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" |Bowel sounds
! colspan="1" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" | Lab Findings
! style="background:#4479BA; color: #FFFFFF;" align="center" |Imaging
|-
|-
!Malignant
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Tropical sprue]]
!Intestinal Lymphoma
| 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="center" |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)
|-
|-
! colspan="2" |Pancreatic disease
| 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" |N
| 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
* Reserved for patients with high suspicion of giardiasis and undiagnosed by other methods
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Microscopic identification of the organism in the stool
|-
|-
! colspan="2" |Post Infective-Irritable bowel syndrome.<ref name="GhoshalRanjan2011">{{cite journal|last1=Ghoshal|first1=Uday C|last2=Ranjan|first2=Prabhat|title=Post-infectious irritable bowel syndrome: The past, the present and the future|journal=Journal of Gastroenterology and Hepatology|volume=26|year=2011|pages=94–101|issn=08159319|doi=10.1111/j.1440-1746.2011.06643.x}}</ref>
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |Cryptosporiadisis
 
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Diffuse
!Following acute gastroenteritis, genetic susceptibility, change in gut flora, altered small intestinal permeability and sensory motor function
| 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>
|Positive stool culture
| 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" |
* [[PCR]]: Most specific and sensitive diagnostic tool. [[PCR]] is expensive and used in limited cases.
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Normal
| 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: #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" |N
| 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" |
* AIDS defining condition
|}
|}
 
|}
===Chronic diarrhea===
</small>
* Tropical sprue
* Ulcerative Colitis,
* Crohn's disease
* Diarrhea, chronic responsive to antiparasitic drugs
* Diarrhea, chronic unknown
* Inflammatory bowel disease, new onset post-travel (Crohn or ulcerative colitis)
* Irritable bowel syndrome
* Irritable bowel syndrome, post infectious
* Lactose intolerance, post infectious
* Malabsorption
 
===Acute diarrhea===
* E. coli
* Clostridium difficile-associated disease
* Campylobacter
* Cholera (toxigenic Vibrio cholerae)
* Cryptosporidium
* Cyclospora
* Diarrhea, acute bacterial
* Diarrhea, acute parasitic
* Diarrhea, acute unspecified
* Diarrhea, acute viral
* Dysentery, acute unspecified
* Entamoeba histolytica, ameba
* E. histolytica, diarrhea
* E. histolytica, dysentery
* Food poisoning
* Gastroenteritis
* Giardia
* Isospora
* Noncholera Vibrio
* Salmonella, other
* Shiga toxin-producing Escherichia coli
* Shigella, S. boydii
* Shigella, S. dysenteriae
* Shigella, S. flexneri
 
The following diseases have a similar presentation to tropical sprue.
* [[Celiac Disease]]
* Chronic [[diarrhea]]
* [[Clonorchiasis]]
* Traveler's [[diarrhea]]
* [[Whipworm]]


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}


[[Category:Emergency mdicine]]
[[Category:Disease]]
[[Category:Up-To-Date]]
[[Category:Infectious disease]]
[[Category:Gastroenterology]]
[[Category:Gastroenterology]]
{{WS}}
{{WH}}

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
 
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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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

Disease Clinical manifestations Diagnosis Comments
Symptoms Signs
Abdominal Pain Fever Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging
Tropical sprue Diffuse + + + N Barium studies:
  • Dilation and edema of mucosal folds
Whipple's disease Diffuse ± ± + + ± N Endoscopy is used to confirm diagnosis.

Images used to find complications

Extra intestinal findings:
Celiac disease Diffuse + + Hyperactive US:
  • Bull’s eye or target pattern
  • Pseudokidney sign
  • Gluten allergy
Acute pancreatitis Epigastric + + ± + ± N
  • Ultrasound shows evidence of inflammation
  • CT scan shows severity of pancreatitis
  • Pain radiation to back
Disease Abdominal Pain Fever Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
Chronic pancreatitis Epigastric ± ± + + N
  • Increased amylase / lipase
  • Increased stool fat content
  • Pancreatic function test
CT scan
  • Calcification
  • Pseudocyst
  • Dilation of main pancreatic duct
  • Predisposes to pancreatic cancer
Pancreatic carcinoma Epigastric + + + + N

Skin manifestations may include:

Dumping syndrome Lower and then diffuse + + + + Hyperactive
  • Postgastrectomy
Acute diverticulitis LLQ + + + ± + Positive in perforated diverticulitis + + Hypoactive
  • CT scan
  • Ultrasound
Inflammatory bowel disease Diffuse ± ± + + + Normal or hyperactive

Extra intestinal findings:

Disease Abdominal Pain Fever Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
Irritable bowel syndrome Diffuse ± ± - N Normal Normal Symptomatic treatment
Infective colitis Diffuse + ± + + Positive in fulminant colitis ± ± Hyperactive CT scan
  • Bowel wall thickening
  • Edema
Colon carcinoma Diffuse/ RLQ/LLQ ± ± + + ±
  • Normal or hyperactive if obstruction present
  • CBC
  • Carcinoembryonic antigen (CEA)
  • Colonoscopy
  • Flexible sigmoidoscopy
  • Barium enema
  • CT colonography 
  • PILLCAM 2: A colon capsule for CRC screening may be used in patients with an incomplete colonoscopy who lacks obstruction
Viral hepatitis RUQ + + + Positive in Hep A and E + Positive in fulminant hepatitis Positive in acute + N
  • Abnormal LFTs
  • Viral serology
  • US
  • Hep A and E have fecal-oral route of transmission
  • Hep B and C transmits via blood transfusion and sexual contact.
Liver abscess RUQ + + + ± + + + ± Normal or hypoactive
  • US
  • CT
Cirrhosis RUQ + + + + N US
  • Stigmata of liver disease
  • Cruveilhier- Baumgarten murmur

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]

Disease Clinical manifestations Diagnosis Comments
Symptoms Signs
Abdominal Pain Fever Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging
Tropical sprue Diffuse + + + N Barium studies:
  • Dilation and edema of mucosal folds
Giardiasis Diffuse ± + - - + + - ± - - N EGD with small bowel tissue biopsy
  • Reserved for patients with high suspicion of giardiasis and undiagnosed by other methods
  • Microscopic identification of the organism in the stool
Cryptosporiadisis Diffuse + + - - + + - + - - N
  • PCR: Most specific and sensitive diagnostic tool. PCR is expensive and used in limited cases.
Normal
  • Stool examination: Oocysts appear red on staining with modified acid fast staining
Cystoisosporiasis (isosporiasis) Diffuse + + - - + + - + - - N
  • Peripheral eosinophilia
  • Stool test is positive for immature oocyst that contains a spherical mass of protoplasm
Upper GI series depicts minimal or irregular thickening of mucosal folds
  • AIDS defining condition

References

  1. 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.
  2. 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.
  3. 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.
  4. Juckett G, Trivedi R (2011). "Evaluation of chronic diarrhea". Am Fam Physician. 84 (10): 1119–26. PMID 22085666.
  5. Current WL, Garcia LS (1991). "Cryptosporidiosis". Clin. Microbiol. Rev. 4 (3): 325–58. PMC 358202. PMID 1889046.
  6. Thompson RC (2000). "Giardiasis as a re-emerging infectious disease and its zoonotic potential". Int. J. Parasitol. 30 (12–13): 1259–67. PMID 11113253.
  7. 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.
  8. 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.