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A Curious Case of Chronic Bowel Symptoms


Seth, Nikhil MD1; Jovin, Franziska MD2; McGee, James MD2

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American Journal of Gastroenterology: October 2015 - Volume 110 - Issue - p S186
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Question: A 67 year-old Caucasian male with coronary artery disease, diabetes mellitus type II and morbid obesity presented to the General Internal Medicine Clinic with a chief complaint of diarrhea. The patient was in his usual state of health until 5 weeks prior to presentation, when he started to experience four to five bowel movements a day. The bowel movements were liquid in consistency with no reported gross blood or mucus, and not foul smelling. Most episodes were preceded by abdominal discomfort and bloating one hour prior to a bowel movement, and he did not experience any nocturnal episodes. There was no association with particular foods or recent consumption of undercooked foods or seafood. He denied any recent travel or other sick contacts in his household. Of note, the patient was on chronic doxycycline 100mg PO BID since his knee surgery two years prior due to an associated MRSA infection, but no new medications recently. He experienced a 25 pound weight loss over this time. The patient's most recent colonoscopy was in 2008, at which time a tubular adenoma was identified. He denies a family history of inflammatory bowel disease, irritable bowel syndrome or gastrointestinal malignancy. The patient was admitted from clinic for dehydration and further work up.

Physical examination revealed mild distension and normo-active bowel sounds. There was no hepatosplenomegaly. No rebound or guarding. Blood work revealed a potassium of 3.2 and a lipase of 211. Creatinine, other electrolytes, complete blood count, MCV and liver enzymes were within normal limits. Fecal occult blood testing was negative. An infectious work up consisting of a stool culture; stool leukocytes, ova and parasites exam, C. difficile nucleic acid, Giardia antigens and a Cryptosporidium smear were negative. Further studies including anti-gliadin IgA and IgG, anti-tissue transglutaminase IgA, fecal fat, pancreatic elastase, and TSH were also unrevealing. Stool electrolyte studies showed sodium 51, potassium 116, chloride 55, and osmolality 597. What is the cause of his diarrhea?

The biopsy results of both sites demonstrated increased intra-epithelial lymphocytes, surface epithelial injury and an expansion of the lamina propria by lymphocytes and plasma cells as well as a focal increase in the sub-epithelial collagen layer. The increased intra-epithelial lymphocytes and sub-epithelial collagen suggests microscopic colitis but did not explain the visible findings on colonoscopy. Given the patient's clinical course, the appearance of his colon on endoscopy, and otherwise negative testing, his presentation was felt to be most consistent with an atypical case of resolving infectious colitis superimposed on microscopic colitis.

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