Seyidov N.Z., Founder and Editor.
CASE REPORT 6 - 2014 — 53 years old male patient with over 10 years history of abdominal pain and diarrhea.
Seyidov N.Z., M.D., Ph.D.
Uptodate İn Medicine Jurnalı, 2014 October 15, 2014
Abstract.
Irritable bowel syndrome (IBS) is a chronic gastrointestinal disorder. IBS is characterized by chronic abdominal pain and altered bowel habits in the absence of any organic disorder. Treatment of IBS includes dietary modification, psychotherapies, and medications. Among medications, antidepressants and anti-motility agents has been frequently used and considered beneficial in IBS.
This is a report of a case of 53 years old man with over 10 years long history of gastrointestinal symptoms of diarrhea-predominant IBS and severe obsessional thinking as part of illness anxiety regarding the bowel habits which slowly improved with combination of low dose antidepressant and followed the improvement of gastrointestinal symptoms and repeat reassurances provided to patient by physician.
Keywords: irritable bowel syndrome, diarrhea, SSRI, TCA, somatisation disorder
ANAMNESİS MORBİ.
Mr. A.V., a 53-year-old man, presented to a general practice clinic in August 2014 complaining of frequent diarrhoea which is often unto 3-5 times a day and chronic abdominal pain that has been interfering with his daily activities and work. These symptoms, present for 10-11 years, had intensified during the previous month when due to severe abdominal cramps pain he was taken to the emergency room of local hospital. There were no abnormal findings on a physical examination or gastrointestinal endoscopy or CT of abdomen and pelvis. Upon discharge from hospital the next day, he was given a diagnosis of gastroenteritis of unspecified ethnology and recommended fluids, antibiotics and pain medications. Although the next few days his symptoms have improved, he however continued to complain of abdominal cramps pain mainly in the pelvis, urges to empty his bowels, overall relief and relief of abdominal pain after the defecation. He also continued to be in significant emotional distress over his illness lasting many years now and fear of repeat "exacerbation" of illness which may cause him to go to emergency room again.
He denies hematochezia, melena, or hematemesis. All diarrhoea episodes occur during awake hours. There is no association between the bowel pattern and diet that the patient can discern. Gastrointestinal problems in general date back to his childhood years and adolescence with some improvements and worsening during young adulthood. He denied any symptoms of dyspepsia and gastroesophageal reflux disorder (GERD). Also he denies regurgitation, nausea, or vomiting.
Early this year he was seen by gastroenterologist who also performed colonoscopy and found no evidence of organic disease and referred patient to the chronic pain management. He was prescribed narcotic pain medication that was helping with the abdominal cramping but only for brief period of time and was not improving his overall condition, including diarrhoea and anxiety and depression episodes associated with his symptoms.
ANAMNESIS VITAE.
Mr. V.A. has been seen by multiple physicians in his home country as well as other countries during the last 10-11 years. He remembers that the initial visit to the physician was related to the abdominal cramping and changes in the bowel habits, which included frequent daily loose or watery stools. He has had 4-5 colonoscopies during this period with no evidence of organise bowel disease. He also has had multiple CT and MRI imaging of abdomen and pelvis with negative results.
During this long period he has been at times seriously stressed out about his symptoms and their relation to possible organic cause, including mainly malignant disease or tumour.
He otherwise has remained healthy and maintained some level of regular exercise and fitness.
He admitted of having childhood problems with his bowels, but they were not as bothersome as they are in the last 10 years.
He admitted also of having internal haemorrhoids for which he had hemorrhoidectomy surgery year ago and since then no further symptoms, including bleeding and itching.
He has had several bouts of herpes (likely genital herpes) in his scrotal area for which he was treated with antiviral medications.
SOCIAL.
A.V. is employed full time at a trade firm and his work is associated with some degree of stress. He does exercise at home but does not run at all. He tries to eat 3-4 servings of fruits and vegetables daily. However, the main part of his daily meal is comprised of red meat and chicken, as well as rice and bread.
Mr. A.V. consumes alcohol moderately, but does not smoke or do illicit drugs.
He is married and lives with his wife and children.
MEDICATIONS. Current medications include bisoprolol 5 mg qday and cymbalta 30 mq qday.
ALLERGIES. No known drug allergies.
FAMILY HISTORY: No family history of bowel disease, no colorectal malignancy or symptoms of inflammatory bowel disease. No endocrine diseases noted in the family as well.
REVIEW OF SYSTEMS.
- GI: abdominal bloating, intermittent diffusely present abdominal pain - cramps, abdominal distension and discomfort; frequent loose and watery stools not related to meals or fluid intake;
- Neurology/Psychiatry: stressed out secondary to his abdominal symptoms; concerned about possible effect his disease may have on sexual functions; intermittently anxious and depressed.
- Cardio-vascular: intermittently have episodes of heart palpitations for which takes bisoprolol; no difficulty breathing;
- Respiratory: no complaints.
- Musculoskeletal: no pain with walking; normal tolerance of physical activities.
- Skin: no rash, no itching.
PHYSICAL EXAMINATION.
- GENERAL: Mr.A.V. is a well developed, well-nourished middle age man in no acute distress. His weight and other vital signs are within normal limits: height 175 cm, weight 85 kg, blood pressure 118/74 mm Hg, pulse 70 beats per minute, and respiratory rate 12 breaths per minute. Overall, his physical examination is notable for mild tenderness to palpation in the left lower quadrant, but there is no rebound tenderness, guarding, or other peritoneal signs. The remainder of the physical examination is unremarkable.
- HEENT: no throat erythema, no oral ulceration; no palpable thyroid nodules; hearing is within normal limits with whispering; no scleral icterus; pupils equal, round and reactive to light;
- CARDIO-VASCULAR: S1S2, regular rate and rhythm; no murmurs, gallop or rubs;
- PULMONARY: breathing sounds are heard throughout all lung fields, no rhonchi or crackles;
- GASTRO-INTESTINAL: abdominal round, mildly distended, bowel tones are hyperactive; no peritoneal signs; tenderness on deep palpation of abdomen; on rectal exam there is normal sphincter tone, no rectal masses, no prostate abnormality noted; no perianal inflammation; no external haemorrhoids noted.
- SKIN: no visible scars on abdomen; no rash or other skin abnormalities noted; skin turgor is within normal limits.
LABORATORY TESTS.
Laboratory tests reviewed included CBC, Chem7, liver functional panel, thyroid panel, hepatitis panel and were negative. The review of his previous and recent blood work and urine tests also showed no signs of anaemia, thyroid disease, vitamin D deficiency and no signs of urinary tract infections. His most recent stool analysis however showed signs of dysbacteriosis, but no ova or parasites.
He has never been tested for celiac diseases, autoimmune disorders, VIPomas and carcinoid tumours before.
DIAGNOSTIC IMAGING.
All his diagnostic imaging, including ECHO, abdominal and pelvic and lumbar spine MRI and CT were done year ago and all were negative.
The reports of his four recent colonoscopies were reviewed and revealed no pathologies. He however has never had biopsies during colonoscopies.
TREATMENT COURSE.
Based on his long history of typical symptoms and lack of alarm features, Mr.A.V. was diagnosed with irritable bowel syndrome (IBS) as primary diagnosis. His clinical presentation allowed for further categorisation of his disease into IBS-D (with predominant diarrhoea) with bloating. Mr. A.V.'s subjective findings were measured through completion of the Quality-of-Life with Irritable Bowel Syndrome (IBS-QOL) questionnaire. His diagnosis was made based on negative imaging and laboratory tests and per Rome III criteria which included abdominal pain or discomfort which is clearly linked to bowel function (in his case relieved by defecation (suggesting a colonic origin)) or associated with change in stool frequency or consistency (suggesting a link to changes in intestinal transit, which might reflect changes in either motor patterns or secretion). He was also given a diagnosis of illness anxiety disorder per DSM-V.
A complete blood count, thyroid studies, liver functional panel, celiac sprue and urine and stool tests, including for dysbacteriosis and ova and parasites were ordered. Based upon his age, lack of risk factors and alarm features, and previously negative four colonoscopies, there was a discussion with the patient who declined repeat colonoscopy at this time. However, given the concern for microscopic colitis, the patient was informed about possible need for colonoscopy with biopsy to exclude microscopic colitis.
Patient was initially started on probiotics PO 2 capsules a day (Bifidum bacteria, Lactobacillus, Streptococcus feacum), lomotil (diphenoxylate-atropin) 5 mg PO twice a day and grandaxin 50 mg PO twice a day. He was also given regular weekly appointments to review his symptoms and assist with alleviation of his anxiety. During next two weeks he reported significant improvement in bowel function, including decrease in stool consistency and frequency. He also reported improvement in bloating and distention which by end of second week have almost completely resolved, his bowel habits became more predictable. The next two weeks he continued to have one bowel movement a day and had more solid stool. He however did not report significant improvement in abdominal cramping or anxiety. He also reported occasional cramping and abdominal discomfort that signals the need to defecate, but this has been minimal and short lived. As the abdominal pain did not improve much, grandaxine was stopped and patient was started on amitriptiline 10 mg PO qday for 3 weeks. However, given the continuous significant anxiety and obsessive thinking about the symptoms of the illness (often requiring patient to call the doctor everyday and discuss all symptoms), the patient was recommended to start fluoxetine 20 mg PO qday, which patient initially declined given the side effects of this medication with particular concern for sexual side effects. But after some reassurance, the patient agreed to consider taking fluoxetine if amitriptiline is not effective to control his symptoms. Amitriptiline was thus increased to 19 mg PO qday. In next two weeks this combination of lomotil (5 mg PO TID) and amitriptilin (19 mg PO qday) as well as Linex forte (1 capsule TID) resulted in significant improvement of abdominal and pelvic pain as well as overall abdominal discomfort. Patient did not report any problems in sexual sphere and agreed to continue amitriptiline at 19 mg PO qday dose. His anxiety has also improved which was also confirmed with less phone calls to and rare appointments with the physician.
DISCUSSION.
Irritable Bowel Syndrome (IBS) is defined as a functional gastrointestinal (GI) disorder that includes a combination of chronic or recurrent GI symptoms that cannot be explained by structural or biochemical abnormalities. The main symptom criterion is abdominal pain that is relieved by defecation or that is associated with changes in frequency or consistency of stools. Disturbed defecation, such as changed stool frequency or stool consistency, with or without passage of mucus may also be present in IBS. For the diagnosis of IBS, physicians use the Rome criteria, which are highly sensitive and specific tool.
TABLE. Rome III diagnostic criteria* for irritable bowel syndrome
Recurrent abdominal pain or discomfort** at least 3 days a month in the past 3 months, associated with two or more of the following:
• Improvement with defecation
• Onset associated with a change in frequency of stool
• Onset associated with a change in form (appearance) of stool
* Criteria fulfilled for the past 3 months with symptom onset at least 6 months before diagnosis.
** ‘‘Discomfort’’ means an uncomfortable sensation not described as pain.
First reports of IBS are dated back to 19th and 20th centuries. Currently, IBS affects 11% of world population. The incidence is higher in western countries, including 67 IBS incidence per 1.000 patient-years in the US. The prevalence of IBS is for example higher in South America (21%) and lowest in South Asia (7%).
Most patients report experiencing first IBS symptoms before the age of 35 years old. Studies have shown that less IBS cases are diagnosed after the age of 50 years old. Studies have also suggested genetic linkages of the IBS. Interestingly, the relative risk of having IBS is a twice as high in individuals with biological relative with IBS.
Number of various factors have been implicated in the etiology or exacerbation of IBS, including inadequate dietary fiber, gastroenteritis, bacterial overgrowth, antibiotic use, surgery, emotional stress, food intolerance or food allergy, and genetic predisposition. Treatment approaches are varied and initially often include bulking agents, adsorbents, laxatives, antidiarrheal agents, antispasmodics, analgesics, antidepressants, anxiolytics, seratonin antagonists, stress management, psychotherapy, and exclusion diets.
TABLE. Differential diagnosis of diarrhoea predominant irritable bowel syndrome
- Microscopic colitis: Although there was a concern for microscopic colitis given the patient symptoms and he was recommended to have a biopsy of colon to rule out microscopic colitis, patient however declined the colonoscopy given recent multiple negative colonoscopies.
- Coeliac disease: According to the patient, he was tested for celiac disease with Tissue anti-transglutaminase antibodies and anti-gliadin antibodies which were negative. As no results were available, patient was advised to do a repeat testing for celiac disease and in the meantime adhere to gluten-free diet. The patient however declined the testing at this time. He also did decline the upper GI endoscopy with biopsy of small intestine to rule out the diagnosis.
- Giardiasis: Azerbaijan where patient has resided for most of his life is considered an endemic area for Giardia Lamblia or Duodenalis. However, the analysis of stool was negative for parasites. And laboratory analysis were negative for fourfold increase in IgA or IgG as well as for elevated levels of IgM against lamblia. These tests helped to rule out Giardiasis in this patient.
- Lactose malabsorption
- Tropical sprue: Tropical spur is seen in residents of and visitors to tropical countries/areas. The disease usually begins with an acute episode of diarrhoea, fever and malaise before setting into a more chronic clinical presentation which includes steatorrhea, malabsorbtion, nutrient deficiency, anorexia, malaise and weight loss. Patients also tend to have folate deficiency. This patient however did not have signs or symptoms as well as laboratory signs of tropical sprue. He has also never visited tropical areas.
- Small bowel bacterial overgrowth: patient had confirmed mild degree dysbacteriosis with low level of lactobacilli in the intestine, he was initiated on high dose probiotics with Bifidum bacteria, Streptococcus feacum and Lactobacillus for 1 month period with questionable efficacy to help his symptoms.
- Bile salt malabsorption: In normal healthy people, 97% of bile acids released into the intestines is reabsorbed and only 3% are excreted with faeces. The patients with bile acid malabsorbtion (this can be idiopathic or post-cholecystectomy/peptic ulcer surgery/chronic pancreatitis/celiac disease or after ileal resection) have increased amount of bile acids in their intestines and tend to have large volumes of loose or watery stools (often 200 g/day) or 3-4 times of watery or loose stools a day. The primary cause of diarrhoea in bile acid malabsorbtion is an excess amount of bile acids in the colon which drives water and electrolytes into the colon lumen and leads to frequent watery/loose stools. The diagnosis of bile acid malabsorbtion is made by SeHCAT (tauroselcholic (75 selenium) acid) scan, which is radiopharmaceutical used to detect bile acid pool.
- Colorectal cancer: multiple negative colonoscopy and MRI and CT imaging as well as normal ESR, CEA and AFP ruled out the colon malignancy.
REFERENCES.
- Jailwala J, Imperiale TF, Kroenke K. Pharmacologic treatment of the irritable bowel syndrome: a systematic review of randomized, controlled trials. Ann Intern Med. 2000;133:136–147.
- Mertz HR. Irritable bowel syndrome. N Engl J Med. 2003;349:2136–2146.
- Kirsch MA, Louie AK. Paroxetine and irritable bowel syndrome. Am J Psychiatry.2000;157:1523–1524.
- Masand PS, Gupta S, and Schwartz TL. et al. Paroxetine in patients with irritable bowel syndrome: a pilot open-label study. Prim Care Companion J Clin Psychiatry. 2002. 4:12–16.
- Tabas G, Beaves M, and Wang J. et al. Paroxetine to treat irritable bowel syndrome not responding to high-fiber diet: a double-blind, placebo-controlled trial. Am J Gastroenterol. 2004. 99:914–920.
