Mild chronic diarrhea for almost 2 years; explosive smelly flatulence

[Don__0__0]

  I am a 46 year old male in good health.  (Although I need to exercise more.)  I take no medications except for Metamucil (on the recommendation of my GI).  I have been taking this for about 6 months.  It seems to help, but not eliminate the mild diarrhea which started Nov 4 1996, soon after which I was treated for parasites by my GP (Vermox) and then my GI (Flagyl and something else - the standard drugs).  The condition persisted.  The second GI did blood tests, tests on numerous stool samples (O&P and fat), a colonscopy with biopsy, and an upper endoscopy with biopsy.  I tested negative for HIV.  I have no fever, and no weight loss.  (If anything, I have gained weight!)  I have not changed my eating habits.  I consume a moderate amount of alcohol, and will often eliminate my intake for 10 days or more at a time with no change.  I travel to the Far East regularly, and do sample the local cuisine in Japan, Hong Kong, Shanghai and Singapore.  My stools are most often loose to soft, sometimes very watery, but occassionally formed.  In bed, before I go to sleep, and just after waking up, I regularly experience "rumblies in my tumblies" - the kind of feeling usually associated with diarrhea.  I would not go as far as to call them "cramps".  They are not painful, just mildly uncomfortable.  This is less evident once I am up and about.  I feel bloated most of the time.  I frequently and explosively pass large quantities of gas, which is exceptionally smelly.  My anus burns (probably from the gas).  I have had a mild haemeroids since the age of 24 which have never bothered me, or caused burning.  The GIs didn't seem too concerned about the haemeroids.  I don't seem to have any energy, am often tired, and easily fatigued.
  Any ideas what to consider next?
  Thanks so much  
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dear Don,
It seems as if you have already had an extensive workup to define the cause of your diarrhea including upper endoscopy with ? duodenal biopsy, colonscopy with biopsy, malabsorption and immunosuppression.  It is alsways possible to miss an infectious etiology, particularly if you may have drunk contaminated water during one of your trips to southeast Asia.  I would repeat stool cultures for parasites, acid fast bacilli and worms.  
It uis conceivable that you could have lactose intolerance or irritable bowel syndrome.  A trial of a lactose free diet or adding Lactaid to your milk products is a safe and effective approach.  I would increase the dosage of metamucil and consider adding another medication.  For symptomatic relief you could try Imodium (immodium) or Lomotil.  Recent work has suggested that some people have bile acid malabsorption as the cause of the chronic diarrhea.  You should discuss with your primary physician the possibility of treament with cholestyramine, a bile acid binding resin.
The pproach to the patient with documented chronic diarrhea can be directed in two distinct directions.  Some patients have diarrhea with eating and are relatively symptom free during a period of fasting.  These patients are evaluated for malabsoprtion or other causes for osmotic diarrhea.  In contrast, patients who have relatively constant diarrhea, independent of eating, are evaluated for a secretory cause of diarrhea.  Other factors that affect the tests ordered are the pattern of bowel movcements and the osmotic gap, information that your physician can easily obtain.
This information is presented for educational purposes only.  Always consult your personal physician for specific medical issues.
HFHSM.D.-rf
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