35
Diarrhea
Sita Chokhavatia and Arvind J. Trindade
Questions and Answers
1. Seventy-six-year-old woman is evaluated for weakness and
fatigue. She has a history of diabetes mellitus and hypothyroidism. She does not report melena or weight loss, and
despite a good appetite, has recently noted some weight
loss. She is noted to be anemic, hemoglobin 10.5 g/dL, has
a low ferritin level, and HgbA1c is 8.5.
Further investigation should include:
A.Chromogranin A
B.5 Hydroxy indole acetic acid assay
C.Thyroid-stimulating hormone assay (TSH)
D.Tissue transglutaminase antibodies
Answer: D
Prevalence of celiac disease is higher than suspected in
the elderly and presenting symptoms may be subtle.
Celiac disease can present with steatorrhea or anemia or
failure to thrive. Autoimmune diseases such as diabetes
and hypothyroidism are associated with celiac disease.
The diagnosis is made by serum IgA antibodies to tissue
transglutaminase. Chromogranin A and 5 HIAA tests for
neuroendocrine tumors may be indicated in patients presenting with profuse watery diarrhea. A high TSH indicates hypothyroidism; here patients may present with
constipation, whereas a low TSH may suggest hyperthyroidism in an older patient presenting with diarrhea or
relief of constipation.
2. Factors that predispose a 92-year-old man to complications of diarrhea, such as dehydration or volume depletion, include all except:
A.Decreased mobility
B.Impaired cognition
C.Polypharmacy
D.Increased thirst sensation
Answer: D
Age-related factors increasing the older patients’ risk for
diarrhea complications include decreased thirst sensation
and decreased response to thirst and inability to access
fluids due to immobility, dementia, or dysphagia, as along
the inability to communicate needs. This is further compounded by decreased total body water, impaired renal
diluting and concentrating ability, and decreased total body
water with aging. Comorbidity and use of medications such
as diuretics and laxatives exacerbate fluid losses.
3. Eighty-five-year-old woman was evaluated for a 1 year
history of watery diarrhea that occurred 4–5 times during
the day and 2–3 times at night. Nocturnal symptoms had
often caused fecal incontinence due to inability to maintain control of the liquid stools. On enquiry, she recalled
avoiding eating bread when living at home (recent move
to assisted living facility) as she was told she had wheat
allergy. No other recent change in diet or medications.
Medications to treat diarrhea include all except:
A.Loperamide
B.5 ASA
C.Budesonide
D.Rifaximin
Answer: D
Microscopic colitis is a common cause of chronic watery
diarrhea especially in the older women. Nocturnal symptoms occur frequently. Fecal incontinence occurs due to
the inability to maintain continence of the loose stools and
the decreased mobility leads to nocturnal soiling of mattress and clothes. Nonspecific antidiarrheal agents relieve
symptoms and clinical response has been reported to both
5 aminosalicylic acid and budesonide therapies. Rifaximin
is a nonabsorbable antibiotic approved for traveler’s diarrhea and has been used for treatment of small intestinal
bacterial overgrowth and IBS with variable results.
C.S. Pitchumoni and T.S. Dharmarajan (eds.), Geriatric Gastroenterology,
DOI 10.1007/978-1-4419-1623-5_35, © Springer Science+Business Media, LLC 2012
377