Case 18.1

Case Submitted by Kendall Beck, MD

A 44 year old female with a history of stricturing and inflammatory Crohn’s ileocolitis diagnosed in 1990 presents to your gastroenterology clinic for chronic diarrhea. She has had multiple small bowel resections for recurring small bowel obstruction and has 135 cm of small bowel remaining, including the distal ileum. Her ileostomy was taken down in 2011, therefore her terminal ileum is in continuity with her colon. She was recently started on total parenteral nutrition 7 days per week due to protein-calorie malnutrition and diarrhea. She currently reports 8-10 loose/watery, non-bloody bowel movements daily and is having trouble gaining weight. The patient has been on multiple agents for her Crohn’s disease and has most recently been on vedolizumab.

What work up would you initiate for her chronic diarrhea? Choose all that apply

Infectious stool studies

Viral, bacterial, and parasitic infections can present with unexplained diarrhea

Pancreatic Elastase

Pancreatic insufficiency is on the differential diagnosis for chronic diarrhea

Tissue Transglutaminase IgA and total serum IgA

Testing for celiac disease is reasonable

Colonoscopy

Colonoscopy with ileal intubation to assess for active ileocolonic Crohn's disease and to take random biopsies for microscopic colitis should be performed

Trial of bile-acid binding resin

Treatment with a bile acid binding resin like cholestyramine or chelestepol can be aneffective test and treatment for bile acid diarrhea which can be seen if the terminal ileum has been resected

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