4Diarrhoea due to small bowel diseases
Introduction
This chapter will cover the clinical features of small intestinal diseases that can result in chronic diarrhoea (Table 1). A major focus will be on coeliac disease and other disorders that can mimic the clinical features, pathologic changes, and occasionally overlap with coeliac disease. We will address small intestinal overgrowth, tropical sprue, Whipple's disease and briefly discuss common variable immunodeficiency and other miscellaneous disorders.
Section snippets
Clinical clues for small bowel origin of diarrhoea
The small intestine is both a secretory and absorptive organ. Disorders of the small intestine can be primarily malabsorptive or secretory in nature but most disorders on the small intestine mucosa result in both excess secretion and failure of absorption. Diarrhoea of small bowel origin is more often non-inflammatory and high output. Improvement of diarrhoea after fasting suggests an osmotic component of the symptoms. Postprandial diarrhoea, bloating, malodorous flatus, and pale stools which
Coeliac disease
The most common inflammatory disorder of the small intestine in the Western world is coeliac disease. This is a chronic inflammation due to an immune reaction to dietary gluten which is present in wheat, barley, and rye.
Non-responsive coeliac disease
Approximately 10–20% of patients with coeliac disease will continue to have frequent symptoms or will have a relapse of symptoms despite an initial response to a gluten-free diet. The most common persistent symptoms are diarrhoea, and the most common explanation is continued contamination of the diet with gluten, either advertent or inadvertent [15]. A systematic approach to these patients is most valuable and will often reveal causes (Fig. 3). A systematic evaluation by an expert dietician is
Refractory coeliac disease
Refractory coeliac disease probably affects no more than 1–2% of patients. It is defined as severe malabsorptive symptoms that have persisted or recurred despite verified strict adherence to a gluten-free diet for at least 6 months in whom other causes of non-response (see above) have been either ruled out or adequately treated and who do not have overt lymphoma [16]. Much of what is known about refractory sprue comes from case series in national and international referral centres. The disorder
Small intestine bacterial overgrowth
Small intestine bacterial overgrowth occurs when symptoms are related to increased numbers of small bowel bacteria – by definition, >105 bacteria/mm3 in small bowel fluid culture [22]. These bacteria are usually but not exclusively anaerobic.
Whipple's disease
Whipple's disease is a rare disorder, primarily affecting the intestine but also affecting extraintestinal locations including the joints, lungs, central nervous system, heart and the eyes [30]. It is a chronic infection by Tropheryma whipplei, a fastidious intracellular organism. The modes of infection, transmissibility and predisposition to infection are poorly understood.
Tropical sprue
While coeliac disease is the most common chronic enteropathy in the developed world, tropical sprue is one of the most common disorders in certain parts of the developing world. The cause has never been identified [36] but is assumed to result from exposure to enteric bacteria.
Adult autoimmune enteropathy
Autoimmune enteropathy was first described in young children, often neonates who have a syndrome characterized by 1) severe diarrhoea with malabsorption, 2) total villous atrophy, and 3) anti-enterocyte antibodies. By definition, this condition does not respond to any form of food exclusion diet, and the patients lack obvious immunodeficiency [40]. The disorder also occurs in adults. It is thought that the immune system targets the components of the enterocyte via activation of the innate and
Conclusion
In summary, coeliac disease and these other disorders with malabsorptive symptoms can overlap or can be confused with each other. In particular, coeliac disease can be associated with small intestine bacterial overgrowth and in the context of IgA deficiency coeliac disease also with giardiasis. Small intestinal bacterial overgrowth itself can be seen in patients with immune deficiencies. Tropical sprue must always be considered in residents in or who travel to tropical sprue areas and travel
Conflict of interest
Grant support: Alba Therapeutics (>$50,000).
Advisory Board: Alvine Pharmaceuticals, Inc. (<$10,000).
Consultant: Ironwood, Inc. (<$10,000), Flamentera (<$10,000).
Actogenix (<$10,000), Bayer Healthcare Pharmaceuticals (<$10,000), Vysera Biomedical (<$10,000), 2G Pharma, Inc. (<$10,000), ImmunosanT, Inc (<$10,000), Shire US Inc (<$10,000).
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