Re: Diarrhea and weight loss; no dianosis

Posted By Antonio on July 09, 1999 at 09:09:29
I am a 48 year old male, who until recently has been in excellent health. About four months ago I began to experience a daily and (typically) single episode of watery and/or very loose diarrhea, usually immediately upon rising in the morning.  I do not wake up in the night with symptoms, but in the morning the need is often extremely urgent.  I also have had pronounced stomach cramps after eating almost anything, but not consistently, accompanied by gas and bloating.  Sometimes the cramps persist throughout the day.  I have tried eliminating dairy products, wheat, and sweets (no effect).  I have lost over fifteen pounds (I started out at about 150, now down to 134), despite attempts to eat regularly, and even to eat more than what I would consider normal for me.  I have been taking no medications (but see below), laxatives, herbs, etc., and typically eat a healthy diet (plenty of fruits and veggies; low fat; but now I have been told to avoid roughage, and to eat a bland diet--rice, chicken, etc.). I have had a whole battery of tests, some more than once, as follows (all have been essentially negative/normal):
-Parasites and ova; visual inspection for worms
-Clostridium, Cryptosporidium, Cyclospora, Microsporidium, Giardia antigen, Entamoeba antigen; Isospora; Campylobacter antigen; enterohemorragic E. coli toxin, all negative
-HIV (negative twice); hepatitis A,B,C, all negative
-sigmoidscopy; colonscopy; upper GI series with small bowel follow through--all normal; gastroscopy (minor gastritis detected); biopsies of gastric mucosa (normal), jejunum (normal)
-no H. pylori detected; cultures of aspirated stomach and intestinal contents negative for ova and parasites; no evidence of celiac disease.
-CLOTEST negative for urease
-hematology/blood work all normal (including electrolyte panel, total blood cells and diff, platelets, WBC, etc., etc; thyroid panel (T-uptake at 46%; T4, TSH, and FT4 index OK; transferrin, iron, etc.); coagulation panel OK; sed rate zero; "protein electrophoresis" (?) was normal.
-BUN and creatinine OK
-absorption (carotene and B12; folate) OK; but I take supplements (not mega-doses)
-albumin, AST, alk phos, all OK; ALT determined to be OK at 57; --billirubin normal
-stool WBC negative
-stool weight 218; 72 hr fecal fat 5.3 (I was told to eat "normally", but did not monitor fat intake)
-split fat normal (see below); no occult blood; urine chemistry normal; no mucus in stool
I have also been tested for reticulin Abs, endomysial Abs, and anti-gliadin IgG and IgM (all normal).
One of my stool lab tests showed total short chain fatty acids to be elevated (188 umoles/g); butyrate was high (?) at 47 umoles/g. B-glucuronidase and pH were normal.
Another stool test showed somewhat elevated levels of Proteus mirabilis and Candida albicans.
Total fecal secretory IgA was high (?) at 235 ug/g.  Chymotrypsin was also elevated at 61.5 IU/g (due to rapid transit time?).
Prior to all of this I had been treated with antibiotics (at different times floxin, levofloxacin, doxycycline, augmentin, azithromycin), diflucan, and nystatin on and off for a year or so, to treat non-specific prostatitis (no agent was detected).  I had stopped antibiotics in September, and my stools were a little loose. Diflucan was for possible yeast infection in prostate; nystatin to prevent yeast overgrowth after antibiotic treatment.  The cramps and diarrhea began the following March, after diflucan and nystatin treatment. My doctors don't think the prior medications are a factor.
I have seen two gastroenterologists.  My primary care physician recently (two-three weeks ago) tried putting me on Flagyl for 10 days, to see if it would help.  It seemed to help for a few days, then my symptoms returned during treatment, and now persist.  About once a week or so I may have a somewhat normal bowel movement, but the cramps remain, on and off.
Lately I have been experiencing what appears to be stomach pain after eating certain foods (e.g., applesauce).  I wonder if this is due to the gastritis, and acidic foods?  I am monitoring this.
I am now having more blood work done to test VIP and gastrin levels, and a 24-hr urinalysis for 5-HIAA.  Results are due next week.
Puzzlingly, I have also begun to experience joint pain (fingers, wrists, and knees) -- could this be related to Proteus overgrowth and a "leaky gut"? (I have read that the surface antigen of Proteus can trigger rheumatoid arthritis).  I have also been tested for Lyme disease, but the results were "inconclusive", (immunoblot--some but not all of the diagnostic bands positive).  My primary care doctor said he is not concerned about Lyme disease.  I am scheduled to see a rheumatologist in a week, but I strongly feel that all of my symptoms are related.  I have also noticed that my eyes seem somewhat redder than normal (but not as bad as conjunctivitis).  Before all this I was completely healthy!
I feel that GI doctor should order another fecal fat test, for which I would eat a prescribed amount of fats each day.  Also, he has not yet tested stool electrolytes (he said that we were "beyond that").  But he has proscribed Prilosec for the gastritis.  I have just started taking this; it may be helping with the "stomach" pain.
I have considered Irritable Bowel Syndrome, but all of my doctors are unanimous in thinking that IBS cannot account for my weight loss, as long as my appetite is healthy (and it is for the most part).
Can it be that the antibiotic treatment severely imbalanced my intestinal flora?  One of my stool tests showed that I completely lacked lactobacilli (Bifodobacteria and E. coli were normal).  I have tried taking probiotics (lactobacilli, etc. from several sources) with no discernible results.  I am also concerned about pancreatitis, possible liver damage due to my antibiotic/antifungal medications, or pancreatic cancer.  Any insight anyone could give to help (and to possibly explain my symptoms) would be very much appreciated.  The weight loss is the most troubling, although my weight may be stabilizing; I cannot gain weight, though.  Still, my symptoms are making daily life very tough.  Yesterday my morning diarrhea and cramps were about the worst yet.  Any diet that would help me gain weight without inducing diarrhea would really be helpful.  
Thanks.

[HFHSM.D.-rf]

Posted By HFHSM.D.-Gastro-RF on July 10, 1999 at 08:50:27
Dear Antonio,
Based on the description of the tests that have been ordered, your physicians have done a complete evaluation of the many common ( and some unusual) causes for chronic diarrhea.  Your history does not provide any clues as to possible next steps.  An important clinical feature that often directs evaluation is whether you have diarrhea when fasting.  Persistent diarrhea when not eating is a clue suggesting a secretory diarrhea.  If the diarrhea improves, your doctors would have to continue investigations for an osmotic diarrhea.  Similar information could be obtained by stool electrolytes which is a simple test and often worth doing.  There is an extensive list of possible causes for secretory diarrhea.  Based on the information that you provide, your physicians are beginning the investigations along that line.  More specific information can not be provided without a detailed review of your history, physicial examination and laboratory tests.
This information is presented for educational purposes only.  Ask specific questions to your personal physician.  If you wish a second opinion, you can arrange an appoinment with Dr. Fogel, one of our experts in diarrkeal illness. You can arrange an appoinment bt calling our Physician Referral Line at [phone].
HFHSM.D.-Gastro-RF
*keywords: diarrhea
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Diarrhea and weight loss; no dianosis Michele 7/13/1999
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Re: Diarrhea and weight loss; no dianosis Antonio 7/13/1999
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