ACP InternistMKSAP Quiz: 5-month History of Bloating, Diarrhea

Unraveling the Diagnostic Maze: Prolonged Diarrhea and Weight Loss in an Elderly Patient

Exploring the potential causes of chronic diarrhea in elderly patients can often be a complex task. This patient’s symptoms, combined with key findings such as multiple jejunal diverticula, add intriguing layers to this diagnostic puzzle.

Key Data:

• A 70-year-old male presents with a 5-month history of bloating and nonbloody diarrhea occurring three times daily, weight loss of 2.3 kg, and stool with oil droplets requiring multiple flushes.
• Physical examination reveals normal vital signs and diffuse abdominal tenderness without guarding.
• Laboratory tests show normal hematocrit, normal tissue transglutaminase IgA level, and a negative Giardia enzyme immunoassay.
• Colonoscopy with biopsy and abdominal CT are normal, except for multiple diverticula in the jejunum.

Question for Evaluation:

• Based on the above data, what is the most appropriate management?
  • Eluxadoline. A κ- and μ-opioid receptor agonist and δ-opioid receptor antagonist, which decreases bowel contraction frequency, used for diarrhea-predominant irritable bowel syndrome.
  • Glucose breath test. A diagnostic test for small intestinal bacterial overgrowth (SIBO), where exhaled hydrogen and methane levels are measured post glucose administration. It has approximately 80% sensitivity and 40% specificity for diagnosing SIBO.
  • Stool testing for Clostridioides difficile toxin. A test typically employed in patients with suspected C. difficile colitis, usually associated with previous antibiotic use.
  • Upper endoscopy with duodenal biopsy. Typically indicated in chronic diarrhea when serologic results suggest celiac disease.

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Did You Know?
The prevalence of small intestinal bacterial overgrowth (SIBO) can reach up to 15% in the general population and significantly increases with age, with rates of up to 40% in the elderly population. This makes it a critical diagnostic consideration in older patients presenting with nonspecific gastrointestinal symptoms like bloating and diarrhea.