Case Report
Copyright ©The Author(s) 2018.
World J Gastroenterol. Jun 7, 2018; 24(21): 2320-2326
Published online Jun 7, 2018. doi: 10.3748/wjg.v24.i21.2320
Table 1 Potential causes of chronic diarrhea and their diagnostic investigations and results in a patient with severe bile acid diarrhea and intestinal failure
Potential cause of diarrheaInvestigationsResults
Excess bile acid production with deficient retentionSeHCAT scintigraphy0 retention, indicating an excess loss of bile acids
Active Crohn’s diseaseSmall bowel imaging; colonoscopy; fecal calprotectinNormal MRI of small bowel and capsule endoscopy; normal colonoscopy with biopsies; fecal calprotectin < 30 mg/kg
Small bowel disease (celiac disease, autoimmune enteropathy)Duodenal and jejunal biopsies; plasma tissue transglutaminase antibodyNormal biopsies; anti-transglutaminase negative
Clostridium difficile infectionClostridium difficile toxin testPositive before fecal transplant; negative repeated tests after fecal transplant
Pathogenic intestinal infectionSalmonella, Shigella, Campylobacter, and Yersinia fecal cultures; PCR for intestinal parasitesNegative
Systemic infectionHIV test; gamma-interferon test for tuberculosisNegative
Small intestinal bacterial overgrowth (SIBO)Hydrogen breath testNegative
Use of antidepressant and antiepileptic medicationsObservation during drug holiday; therapeutic drug monitoringTreatment dose optimized
Laxative useUrine laxative screen repeated with a patient-blinded sampling timeNegative × 2
Neuroendocrine tumorChromogranin A, gastrin, vasoactive intestinal polypeptide, renin, and aldosteroneAll within the reference range
Metabolic diseaseThyroid function test and synacthen testAll within the normal range
Table 2 Anti-diarrheal drug treatments, their mechanisms of action, and their treatment results in a patient with severe bile acid diarrhea and intestinal failure
DrugMechanism of actionTreatment effect
Colestyramine (Questran®)Bile salt sequestrantLimited effect
Colesevelam (Cholestagel®)Bile salt sequestrantLimited effect
PantoprazoleProton pump inhibitorNo effect
Loperamide (Imodium®)Decreases intestinal motilityNo effect
Codeine phosphateDecreases intestinal motilityNo effect; sedation
SpironolactoneIncreases renal potassium reabsorptionNo effect on potassium deficiency
OctreotideAntisecretoryNo effect; abdominal pain
Liraglutide (Victoza®)Increases glucagon-like peptide 1 (GLP-1)No effect; weight loss of 2 kg to 52 kg
Obeticholic acid (Ocaliva®)Stimulates ileal FGF19 production, thereby inhibiting hepatic bile acid productionMarked reduction of stool volume and fecal electrolyte loss