Tropical sprue differential diagnosis: Difference between revisions
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Tropical sprue is a diagnosis of exclusion therefore it must be be differentiated from other diseases causing malabsorption: | Tropical sprue is a diagnosis of exclusion therefore it must be be differentiated from other diseases causing malabsorption: | ||
*Celiac disease<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> | *Celiac disease<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> | ||
*Infectious causes | |||
*Pancreatic insufficiency | |||
*Osmotic diarrhea | |||
*Secretory diarrhea | |||
===Approach to a Patient with Chronic Diarrhea=== | |||
{{familytree/start}} | |||
{{familytree | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | |A01= •'''Classify diarrhea by the results of the stool analysis:'''}} | |||
{{familytree | | | |,|-|-|-|-|-|v|-|^|-|v|-|-|-|.| | | | | | | | | | }} | |||
{{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 (+)}} | |||
{{familytree | | | |!| | | | | |!| | | |!| | | |!| | | | | | | |}} | |||
{{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 | Suspect Tropical sprue and initiate antibiotic therapy and folate supplementation }} | |||
{{familytree/end}} | |||
==References== | ==References== |
Revision as of 19:17, 13 April 2017
Tropical sprue Microchapters |
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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
Differentiating Tropical Sprue from other Diseases
Tropical sprue is a diagnosis of exclusion therefore it must be be differentiated from other diseases causing malabsorption:
- Celiac disease[1]
- Infectious causes
- Pancreatic insufficiency
- Osmotic diarrhea
- Secretory diarrhea
Approach 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 | {{{ D02 }}} | {{{ Suspect Tropical sprue and initiate antibiotic therapy and folate supplementation }}} | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
References
- ↑ 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.