Subject(s)
Giardiasis/diagnosis , Ileum/parasitology , Adult , Biopsy , Child , Duodenum/parasitology , Feces/parasitology , Giardiasis/parasitology , Humans , Jejunum/parasitologyABSTRACT
We report a 60-year-old man with intermittent diarrhea for 15 years which was worsened by cholecystectomy. The results of routine laboratory tests, x-ray studies of the gut, and endoscopy were normal. Fecal fat excretion was normal, but total bile acid excretion was increased in the alkaline feces. The retention of 75SeHCAT was low. Jejunal mucosal biopsy showed normal mucosa. Ileal biopsy was performed at ileoscopy some 10 to 15 cm proximal to the ileocecal valve. Scanning-electron and light microscopy showed a transitional zone between villous atrophy in the distal and normal mucosa in the proximal part of the biopsy specimen. The response of diarrhea to cholestyramine treatment was unequivocal, suggesting bile acid malabsorption. The increased enterohepatic cycling of bile acids after cholecystectomy may be responsible for a decrease in their ileal uptake. Very often, as in our patient, the diarrhea precedes cholecystectomy and is considerably increased by it. Cholecystectomy may unmask a previously unrecognized bile acid transport defect. In our patient, this defect might have been caused by the villous atrophy of the terminal ileum.
Subject(s)
Bile Acids and Salts/metabolism , Cholecystectomy/adverse effects , Diarrhea/etiology , Ileal Diseases/metabolism , Malabsorption Syndromes/complications , Cholestyramine Resin/therapeutic use , Chronic Disease , Diarrhea/drug therapy , Feces/chemistry , Humans , Ileal Diseases/complications , Ileal Diseases/diagnosis , Intestinal Mucosa/pathology , Malabsorption Syndromes/diagnosis , Malabsorption Syndromes/drug therapy , Male , Middle Aged , Selenium Radioisotopes , Taurocholic Acid/analogs & derivativesABSTRACT
Three patients are presented with a history of chronic watery diarrhea due to bile acid malabsorption, proved by the tauro-23[75Se]selena-25 homocholic acid test and an unequivocal response to cholestyramine therapy. Fecal fat tests, Schilling tests, and barium studies of the small intestine and colon were all normal. Jejunal biopsies were normal but multiple biopsies of the terminal ileum, performed by retrograde ileoscopy, showed uniform crypt hyperplastic villous atrophy and features of colonic metaplasia with increased mononuclear infiltration of the lamina propria. All 3 patients demonstrated evidence of abnormal immune function, including the presence of serum autoantibodies, circulating immune complexes, and hypocomplementemia. One patient had Sjögren's syndrome. This disorder, which might be immunologically mediated, should be called primary bile acid malabsorption and should be distinguished from other ileal disorders.
