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Gastroenterology (Expert Forum)
IBS?
Answered by
Kevin Pho, MD - Internal Medicine
Kevin Pho, MD
Boston - MA
This forum is for questions regarding Gastroenterology issues such as Acid Reflux (GERD), Barretts Esophagus, Colitis, Colon/Bowel Disorders, Crohn's Disease, Diverticulitis/ Diverticulosis, Digestive Disorders, IBS, Stomach Pain.
IBS?
by hudy, Mar 12, 2004 12:00AM
I am Canadian woman,hypothyyroid, w/fibromyalgia. Age 58. 4 years ago, after taking Cipro for bladder infection, developed lower abd. pain, tenesmus,small amounts of blood with painful frequent bm's. This culminated in fever and hospital admission for 3 days, on IV antibiotics and fluids.
Colonosc. performed 2 weeks later. Internist in my community hospital unable to get very far in because colon "inflamed and tortuous." DX: "non-specific colitis," maybe due to diverticula, 2 of which were found.
Then referred to a gastroent, who did 1 colonosc. and 1 sigmoidosc. over next 2 years. Said colon normal, despite ongoing symptoms.
He died and new gastro. performed another colonosc. Colon looked normal. Biopsies sent to 2 places. One opinion: "mild chronic inflammation in lamina propria. No evidence cryptitis, crypt abscesses or granuloma, dysplasia, neoplasia or malignancy." 2nd opinion: "..melanosis coli. No evidence microscopic or collagenous colitis, or IBD..Hyperplastic polyp may be an incidental finding situated on prominent mucusal fold." ("Melanosis coli" had me puzzled since I've never taken laxatives other than Metamucil.) Also tested neg. for celiac, which my mother had. Gastro. concluded post-infectious IBS.
2 years ago I began having epigastric pain, no heartburn, first when leaning slightly forward, later spreading to right and left uper abdomen. Barium swallow: "mild distal esophag. spasm..motility otherwise normal..small sliding hiatus hernia with moderate free gastroesophageal reflux to level of pharynx in recumbancy." Put on pantolac for 16 months, which helped but problem kept returning. Gastroent. did upper endosc. which was normal and dilated esophagus, which helped for 6 months, but things got bad and next dilation did nothing. Next barium swallow:"dysmot. for solids with holdup of bread mid-esophagus..small hiatus hernia, no reflux when recumbent." PH study normal; motility study:"LES shows tone at lower end of normal range with complete, but uncoordinated relaxation noted. Peristaltic waves throughout esoph body; however 80% wet swallows induced low-very low amplitude contractions from mid-distal esophag.Ineffective motility, esp. with patient dilated 3 weeks ago."
Gastro. said "scleroderma esophagus", explaining it did not mean sclerod.- advised pureed and liquid diet. Prescribed nitro which did not work. Saw rheumatologist, who did blood tests and said no sclerod.
6 weeks ago I had week of diarrh & pain, little blood, tenesmus,fever. Now whole GI painful. Lost 33 lbs in 7 months.Eating painful.I have hard time believing digestive problems, esoph & bowel, not related, or that it's IBS, because bowel attacks preceded by anal or vaginal ulcers, biopsied:"focal ulceration squamous epithelium & adherent acute inflamm. exudates. Subepith. stroma inflamed." Also new case of psoriasis. And rt. hip arthritis. I should also say: I do not have depression. I think my drs. have washed their hands of me. What should I do?
Colonosc. performed 2 weeks later. Internist in my community hospital unable to get very far in because colon "inflamed and tortuous." DX: "non-specific colitis," maybe due to diverticula, 2 of which were found.
Then referred to a gastroent, who did 1 colonosc. and 1 sigmoidosc. over next 2 years. Said colon normal, despite ongoing symptoms.
He died and new gastro. performed another colonosc. Colon looked normal. Biopsies sent to 2 places. One opinion: "mild chronic inflammation in lamina propria. No evidence cryptitis, crypt abscesses or granuloma, dysplasia, neoplasia or malignancy." 2nd opinion: "..melanosis coli. No evidence microscopic or collagenous colitis, or IBD..Hyperplastic polyp may be an incidental finding situated on prominent mucusal fold." ("Melanosis coli" had me puzzled since I've never taken laxatives other than Metamucil.) Also tested neg. for celiac, which my mother had. Gastro. concluded post-infectious IBS.
2 years ago I began having epigastric pain, no heartburn, first when leaning slightly forward, later spreading to right and left uper abdomen. Barium swallow: "mild distal esophag. spasm..motility otherwise normal..small sliding hiatus hernia with moderate free gastroesophageal reflux to level of pharynx in recumbancy." Put on pantolac for 16 months, which helped but problem kept returning. Gastroent. did upper endosc. which was normal and dilated esophagus, which helped for 6 months, but things got bad and next dilation did nothing. Next barium swallow:"dysmot. for solids with holdup of bread mid-esophagus..small hiatus hernia, no reflux when recumbent." PH study normal; motility study:"LES shows tone at lower end of normal range with complete, but uncoordinated relaxation noted. Peristaltic waves throughout esoph body; however 80% wet swallows induced low-very low amplitude contractions from mid-distal esophag.Ineffective motility, esp. with patient dilated 3 weeks ago."
Gastro. said "scleroderma esophagus", explaining it did not mean sclerod.- advised pureed and liquid diet. Prescribed nitro which did not work. Saw rheumatologist, who did blood tests and said no sclerod.
6 weeks ago I had week of diarrh & pain, little blood, tenesmus,fever. Now whole GI painful. Lost 33 lbs in 7 months.Eating painful.I have hard time believing digestive problems, esoph & bowel, not related, or that it's IBS, because bowel attacks preceded by anal or vaginal ulcers, biopsied:"focal ulceration squamous epithelium & adherent acute inflamm. exudates. Subepith. stroma inflamed." Also new case of psoriasis. And rt. hip arthritis. I should also say: I do not have depression. I think my drs. have washed their hands of me. What should I do?
Doctor's Answer
by Kevin Pho, MD, Mar 13, 2004 12:00AM
, Mar 13, 2004 12:00AM
Difficult case. You have already been evaluated by multiple gastroenterologists as well as a rheumatologist. Here are some thoughts you may want to discuss.
The first would be inflammatory bowel disease. With the association with rheumatological symptoms as well as symptoms in the whole digestive tract this is a remote possibility. The presence of anal/vaginal ulcers can also present in this disease (esp. Crohn's disease).
In addition to the endoscopies you have already had, you can consider a small bowel follow-through to evaluate for Crohn's disease. There are also a variety of antibody tests to consider.
Two of the most commonly used antibody tests are antineutrophil cytoplasmic antibodies (P-ANCA) and anti-Saccharomyces cerevisiae antibodies (ASCA), the combination of which have been proposed as a means for diagnosing IBD and distinguishing Crohn's disease from ulcerative colitis.
Regarding the esophageal motility study, if it is truly scleroderma esophagus, there are other various options to consider if nitro does not work. This can include motility agents such as Reglan or Erythromycin.
All of these considerations (esp. the possibility of Crohn's disease) should be discussed with your personal physician.
Followup with your personal physician is essential.
This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.
Thanks,
Kevin, M.D.
The first would be inflammatory bowel disease. With the association with rheumatological symptoms as well as symptoms in the whole digestive tract this is a remote possibility. The presence of anal/vaginal ulcers can also present in this disease (esp. Crohn's disease).
In addition to the endoscopies you have already had, you can consider a small bowel follow-through to evaluate for Crohn's disease. There are also a variety of antibody tests to consider.
Two of the most commonly used antibody tests are antineutrophil cytoplasmic antibodies (P-ANCA) and anti-Saccharomyces cerevisiae antibodies (ASCA), the combination of which have been proposed as a means for diagnosing IBD and distinguishing Crohn's disease from ulcerative colitis.
Regarding the esophageal motility study, if it is truly scleroderma esophagus, there are other various options to consider if nitro does not work. This can include motility agents such as Reglan or Erythromycin.
All of these considerations (esp. the possibility of Crohn's disease) should be discussed with your personal physician.
Followup with your personal physician is essential.
This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.
Thanks,
Kevin, M.D.
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