Updated: 03/13/08 12:05 PM
HOME HEAL EDUCATE RESEARCH DIRECTORY OUTREACH


Authors: D.R. Saunders, C.E. Rubin, and J.D. Ostrow
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X. Case Histories

Case I

A patient had four operations for Crohn’s disease of the small and large intestines. After the last operation, he was left without a colon, and with an ostomy of his proximal ileum. He was told to drink “lots of water” because he had lost his colon.

On a follow-up visit, he complained of profound weakness, and tiredness. He felt dizzy when he stood up from sitting. On a free-choice diet, his ileostomy delivered 3100 g in 24 hours, of which 102 g were fat. A 24-hour urine contained less than 2 meq of Na+ (normal >60 meq).

He was instructed to fast for 8 hours; at the end of his fast, no ileostomy excretion occurred in the following hour. He then drank 1000 ml of water over 30 minutes; in the next 3.5 hours, 264 ml of ileostomy fluid was collected which contained 35 meq of Na+.

  1. Was the ileostomy fluid isotonic with plasma?

  2. What would you advise him to drink?
Product Carbohydrate
gm/L		 Sodium
meq/L		 Osmolality
mosmol/L
Gatorade 58 (fructose, glucose, sucrose) 20 350
Ceralyte 70 40 (soluble rice starch) 70 235
Apple juice Fructose, glucose, sucrose, pectin 3 680


Case II

A 23 year old gentleman is referred for a three year history of diarrhea which is interfering with his occupation as a roofer. He says that his diarrhea began shortly after a laparotomy for abdominal pain, at which time a Meckel's diverticulum and a small ileal carcinoid were found. This required resection of 75 cm of the distal ileum.

His general physical exam was unremarkable. Stool obtained on rectal exam was soft, brown and negative for occult blood.

Normal results have been obtained on several past occasions for CBC, serum K+ and albumin, and urinary 5-HIAA (a metabolite that reflects hypersecretion of serotinin by a carcinoid). Also, he had normal upper and lower bowel X-rays, and a normal colonoscopy.

A 24-hour collection of stool, while he was eating his regular diet, weighed 313 grams and contained 4.3 grams of fat.

  1. What do you make of the analysis of his stool specimen?

  2. What would a good initial hypothesis be? Would his diarhhea resolve when he fasted?

He was admitted to the hospital for intravenous hydration while he fasted. He submitted a freshly passed stool specimen, which was watery. The laboratory reported that the stool [Na+] was 80 mOsms/L and the stool [K+] was 60 mOsms/L. Normal stool osmolar gap is less than 50 mOsms/L.

  1. What do you make of the analysis of his fasting stool specimen and the cause of his diarrhea?
Case III

A 35-year old single mother of three small children presented with two to three soft to liquid stools per day. Her intestinal troubles began at a Bible Camp on the Olympic Peninsula where she drank water from a well. She said that her diarrhea was worsened by eating, especially fatty foods. She lost 5 pounds in weight over a month’s time. Diarrhea did not awaken her at night. She denied ever having abdominal pain or abusing ethanol. Her stool weighed 700 grams in 24 hours, and it contained 12 grams of fat.

  1. What are your diagnostic suspicions?

  2. How would you proceed?

  3. What is the mechanism for her steatorrhea?

  4. If she remained untreated, why might she develop easy bruising, anemia, or demineralized bones?
Case IV

A 47-year-old professional man presented to the medical profession in the Summer of 1990 after having had two to three loose stools a day for the past three months. His entire family had diarrhea for one week after a daughter brought home a diarrheal illness from a Day Care Center. Although Giardia antigen was not found in the stool, he was treated with two courses of metronidazole, without improvement. Flexible sigmoidoscopy revealed normal rectual mucosa.

He decided against further work-up until the Spring of 1991. He felt well, although he had lost three to four pounds in weight despite eating heartily. He said that his diarrhea improved on a diet of rice, bananas, and applesauce. A 24-hour stool specimen weighed 1000 grams. It contained excess sudanophilic droplets.
  1. What would be your provisional diagnosis at this point?

  2. How would you proceed?
A small bowel biopsy was normal. An upper GI series with barium demonstrated a deeply penetrating gastric ulcer along the lesser curve of his stomach.
  1. What is the diagnosis?

  2. What is the pathogenesis of his steatorrhea?
Case V

Four years ago, this 28-year old computer programmer had to have 100 cm of terminal ileum resected because of extensive Crohn’s disease. A portion of his right colon was also removed and an anastomosis was created between the lower small intestine and the ascending colon. After this operation, he had trouble maintaining his weight. He had up to seven bowel movements a day, most of which were watery.
  1. How would you explain this diarrhea and weight loss?

  2. Why might he become anemic?

  3. How would you account for a low serum albumin and calcium?
Question

Consider a patient who had a gastric resection with Billroth II anastomosis (refer to Figure 11 in the stomach chapter). What difficulties are to be expected in the absorption of triglycerides, protein, carbohydrate, vitamins, and minerals?




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