Name:
A 54-Year-Old with Diarrhea
Description:
A 54-Year-Old with Diarrhea
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T00H05M40S
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Upload Date:
2022-02-28T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
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CATHY: Hi. Welcome to Harrison's Podclass where we discuss important concepts in internal medicine. I'm Cathy Handy. And I'm Charlie Wiener, and we're coming to you from the Johns Hopkins School of Medicine.
CATHY: Welcome to Episode 19, A 54-year-old with Diarrhea.
CHARLIE: So, the question starts: A 54-year-old man is evaluated by a gastroenterologist for diarrhea that has been present for approximately one month. He reports that his stools float and are difficult to flush down the toilet. These stools can occur at any time of the day or the night, but seem worsened by fatty meals. Cathy, any thoughts so far?
CATHY: It sounds like he has chronic diarrhea, since it's been going on for about four weeks. Most causes of chronic diarrhea are non-infectious, but certainly not all. And when thinking about chronic diarrhea, I try to distinguish between the type. So, what I mean by that is that there are secretory causes of diarrhea. This includes laxative use or hormonal changes that can cause diarrhea. There are osmotic causes, like lactose intolerance being a classic example; steatorrheal causes with malabsorption, for example, celiac sprue and Whipple disease would be in here; pancreatic exocrine insufficiency, as well.
CATHY: There are inflammatory causes-- Crohn's and ulcerative colitis fall into that category. And then, lastly, I think about dysmotility issues, like hypothyroidism or sometimes even from medications.
CHARLIE: So, it really does require taking a more detailed history than just finding out someone telling you that they have diarrhea.
CATHY: Yeah, absolutely. And, so far, in this case, based on what we hear, I would say that it's probably in the category of steatorrhoeal cause of diarrhea, because we hear that his stools don't flush and they're worse after fatty meals. But are there any other symptoms to note here?
CHARLIE: So, the patient reports that he has pain in many joints, large and small, that has been lasting days to weeks and is not relieved by ibuprofen. This has been going on for at least as long as the diarrhea. His wife also notes that he's had difficulty with memory for the past few months. The patient has lost 30 pounds and reports intermittent low-grade fevers.
CATHY: Any medications or any significant past medical history?
CHARLIE: The patient takes no medications. He's tried ibuprofen for the joint pains, without much relief, and he's otherwise healthy prior to this presentation.
CATHY: So, to summarize, we have a 54-year-old man with chronic steatorrhea and who also has systemic symptoms that include fever, arthralgia, weight loss, and even some CNS dysfunction. The differential diagnosis here is really broad, and the next steps will depend on more of the medical history, social history, and family history for this patient.
CHARLIE: So, at his evaluation, the gastroenterologist recommends an upper endoscopy with a small bowel biopsy.
CATHY: Well, that recommendation, along with the clinical presentation, makes me think that they're suspicious that this patient has Whipple disease.
CHARLIE: Tell me more about that.
CATHY: Well, the cardinal manifestations are arthralgias, weight loss, diarrhea, abdominal pain and fever, which this patient has all of those. You can also get extreme fatigue and cardiac problems if there's involvement of the endocardium. It's caused by the gram-positive bacillus Tropheryma whipplei-- I think I'm pronouncing that right-- and it occurs most commonly in middle-aged white men. The presentation is usually insidious in onset, which we hear about in this case, and dementia is typically a way of finding, but a poor prognostic sign.
CHARLIE: And how is Whipple disease typically diagnosed?
CATHY: Well, it's actually rather difficult to diagnose, especially in patients with less prominent GI symptoms. So, for example, our patient, in this case, may have presented to his neurologist because of the memory loss before presenting to the gastroenterologist. The main thing is to suspect the disease as the first step, and, unfortunately, there's no single blood test that can diagnose it, but usually tissue is required. Often patients with suspected Whipple disease, even without the GI symptoms, may require an endoscopic GI biopsy.
CHARLIE: Okay, so as I mentioned, this patient undergoes upper endoscopy with small bowel biopsy. But now, the question asks: Which of the following is the most likely finding on small bowel biopsy? And the options are: a) dilated lymphatics; b) flat villi with crypt hyperplasia; c) mononuclear cell infiltrate in the lamina propria; d) a normal small bowel biopsy; option e) periodic acid shift, or PAS-positive macrophages containing small bacilli.
CATHY: The classic pathologic finding of Whipple disease is PAS-positive macrophages that contain the small bacilli, which are the causative organisms in this disease. So, therefore, the answer to this question is option e). There are other causes of PAS-positive macrophages, so that additional pathologic studies such as PCR directed at T. whipplei are useful to confirm the diagnosis.
CHARLIE: What about the other options?
CATHY: The dilated lymphatics you see in patients who have intestinal lymphangiectasia, mononuclear cell infiltration in the lamina propria you see when patients have tropical sprue, and the flat villi with crypt hyperplasia is the hallmark of celiac disease.
CHARLIE: Okay, so the teaching point, in this case, regards Whipple disease. We pointed out that malabsorption, migratory arthralgias, CNS or cardiac problems, can be indicative of this disease and can present at any time in the course of the disease. The diagnosis is typically made by tissue biopsy of the small intestine or other involved organs, demonstrating PAS-positive macrophages and consistent PCR results.
CATHY: And to read more about this, you can check out Harrison's chapter on Disorders of Absorption in the Gastrointestinal Symptom Disorder chapter. ♪ (music) ♪