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Serotonin-Transporter Polymorphism Pharmacogenetics in Diarrhea-Predominant Irritable Bowel Syndrome. Gastroenterology. 123(2): 425-432. August 2002.

Irritable bowel syndrome (IBS) affects approximately 15 percent of adults, causes abdominal pain, discomfort, and altered bowel habits, and predominantly affects women. This article reports on a study of the use of serotonin (5HT) receptor antagonists in women with diarrhea- predominant IBS (DIBS). 5HT undergoes reuptake by a transporter protein (SERT). In the study, 30 patients (15 men, 15 women) with DIBS received 1 milligram twice a day of alosetron for 6 weeks; colonic transit was measured by scintigraphy at baseline and at the end of treatment. Results showed that SERT polymorphisms tended to be associated with colonic transit response; there was a greater response in those with long homozygous than heterozygous polymorphisms. Age, gender, and duration of IBS were not significantly different in the three groups (long, short, heterozygous). The authors conclude that genetic polymorphisms at the SERT promoter influence response to a 5HT antagonist in DIBS and may influence benefit to risk ratio with this class of compounds. 3 figures. 1 table. 57 references.

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Travel Risks: Update on Traveler's Diarrhea and Other Common Problems. Consultant. 42(14): 1778-1784. December 2002.

This article updates physicians on traveler's diarrhea and other common travel-related problems. The author notes that patients can greatly reduce the risk of traveler's diarrhea by drinking only bottled water and eating only hot foods prepared in sanitary conditions or peelable fruits and vegetables. Antibiotic prophylaxis for traveler's diarrhea is no longer routinely recommended; this approach should be reserved for patients who may have to consume food and beverages of questionable safety, those with reduced immunity, and those likely to experience serious consequences of illness. Adequate hydration is the first step in treating traveler's diarrhea. Drug therapy (loperamide or fluoroquinolones in adults and bismuth subsalicylate or azithromycin in children) can ameliorate symptoms and speed recovery. The article also discusses motion sickness, altitude sickness, travel medicine kits, and contraindications to air travel. 5 tables. 18 references.

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Tropical Malabsorption and Tropical Diarrhea. In: Feldman, M.; Friedman, L.S.; Sleisenger, M.H. Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology/Diagnosis/Management. 7th ed. [2-volume set]. St. Louis, MO: Saunders. 2002. p. 1842-1853.

Malabsorption of dietary nutrients by the small intestine has special relevance for people living in the tropics and subtropics. The causes of intestinal malabsorption differ from those commonly seen in the industrialized world, and the clinical impact is often substantially greater because many persons in the developing world, particularly infants and young children, often exist in a state of borderline undernutrition. Tropical malabsorption can be caused either by specific causes, such as infections of known etiology and inflammatory and neoplastic disorders, or nonspecific conditions, such as tropical enteropathy and tropical sprue, for which the etiology has not been determined. This chapter on tropical malabsorption and tropical diarrhea is from a comprehensive and authoritative textbook that covers disorders of the gastrointestinal tract, biliary tree, pancreas, and liver, as well as the related topics of nutrition and peritoneal disorders. Topics include specific causes of tropical malabsorption, including intestinal infection, celiac sprue, lymphoma, severe undernutrition, and primary hypolactasia; nonspecific tropical malabsorption; the definition, epidemiology, pathophysiology, and theories of pathogenesis of tropical enteropathy; and the definition, historical aspects, epidemiology, clinical features, pathology, pathophysiology, pathogenesis, diagnosis, treatment, and prevention of tropical sprue. The chapter includes a mini-outline with page citations, illustrations, and extensive references. 7 figures. 2 tables. 171 references.

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Chronic Diarrhea: Differential Diagnosis and Management. Consultant. 41(1): 53-57. January 2001.

Diarrhea that lasts longer than 4 weeks is considered chronic. This article reviews the differential diagnosis and management of patients with chronic diarrhea. Physicians are advised to first examine the patient for signs of fluid and nutritional depletion. Patients should be asked about exacerbating and alleviating factors, diet, drug use, recent travel, abdominal pain, weight loss, and stool characteristics. Blood in the diarrhea may implicate malignancy or chronic inflammatory bowel disease; food particles or oil in the stool may indicate maldigestion or malabsorption. Fecal leukocytes suggest inflammation, and eosinophilia is seen with neoplasms, allergy, collagen vascular diseases, parasitic infestation, and colitis. Stool analysis for fecal weight, osmotic gap, fat, occult blood, pH, and laxative abuse is often important in making the diagnosis. A 24 hour stool collection weighing less than 200 grams suggests incontinence, irritable bowel syndrome (IBS), or rectal disease, but not true diarrhea. Stool weight of more than 500 grams is rare with IBS; weight of less than 1,000 grams rules out pancreatic cholera syndrome. When the weight exceeds 2,000 grams per day, patients usually require intravenous fluids. Treatment options include bismuth subsalicylate, opiates, bulking agents, kaolin attapulgite, anticholinergics, and cholestyramine. 1 figure. 3 tables. 15 references.

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Clinical Practice Guideline: The Management of Acute Gastroenteritis in Young Children. In: American Academy of Pediatric. Pediatric Clinical Practice Guidelines and Policies: A Compendium of Evidence-based Research for Pediatric Practice. Elk Grove Village, IL: American Academy of Pediatrics. 2001. p. 182-194.

This practice parameter formulates recommendations for health care providers about the management of acute diarrhea in children ages 1 month to 5 years. It was developed through a comprehensive search and analysis of the medical literature. Three specific management issues were considered: methods of rehydration, refeeding after rehydration, and the use of antidiarrheal agents. Main outcomes considered were success or failure of rehydration, resolution of diarrhea, and adverse effects from various treatment options. Oral rehydration was found to be as effective as intravenous therapy in rehydrating children with mild to moderate dehydration and is the therapy of first choice in these patients. Refeeding was supported by enough comparable studies to permit valid analysis. Early refeeding with milk or food after rehydration does not prolong diarrhea; there is evidence that it may reduce the duration of diarrhea by approximately half a day and is recommended to restore nutritional balance as soon as possible. Data on antidiarrheal agents were not sufficient to demonstrate efficacy; therefore, the routine use of antidiarrheal agents is not recommended, because many of these agents have potentially serious adverse effects in infants and young children. 1 figure. 3 tables. 93 references.

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Clostridium Difficile Infection. Participate. 10(3): 6-7. Fall 2001.

Clostridium difficile (a gram positive anaerobic bacterium) is now recognized as the major causative agent of colitis (inflammation of the colon) and diarrhea that may occur following antibiotic intake. This brief article on Clostridium difficile infection is from a newsletter from the International Foundation for Functional Gastrointestinal Disorders. The author notes that this bacterium is primarily acquired in hospitals and chronic care facilities following antibiotic therapy covering a wide variety of bacteria (broad spectrum) and is the most frequent cause of outbreaks of diarrhea in hospitalized patients. The author describes the development of the C. difficile infection, transmission factors, clinical features (symptoms), C. difficile infection in patients with other intestinal diseases, laboratory diagnosis, and therapy, including therapy for relapsing C. difficile infection.

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Dealing with Irregularity: Constipation, Diarrhea, Excessive Gas and Foul-Smelling Gas. Digestive Health and Nutrition. 3(1): 16-20. January-February 2001.

This article offers strategies for dealing with problems of bowel irregularity, including constipation, diarrhea, excessive gas, and foul-smelling gas. The author notes that bowel habits vary greatly among individuals, so each person's perception of whether there even is a problem and how to deal with it best is different. The author stresses that too little fiber and liquid in the diet are by far the most common reasons for constipation among people living in western cultures. The fiber found in foods such as fruits, grains, and vegetables adds bulk to the stool, making it easier to move through the colon (large intestine). Liquids add both bulk and fluid to the stool. Exercise helps prevent constipation by maintaining energy levels and promoting intestinal activity. A number of pain medications; antidepressants; antacids that contain aluminum; diuretics; and antiinflammatory and antiseizure medications are some of the many medications that can contribute to constipation. Changes in routines can also cause irregularity. The author explores the role of aging as a cause of constipation. Laxatives are an effective remedy for constipation, but they should be used with caution. As with constipation, diarrhea means different things to different people. Bacterial and viral infections are the most common causes of acute diarrhea; food intolerance is another frequent cause of both diarrhea and gas. Regardless of the cause, diarrhea usually lasts only a few days and ends on its own without the need for medical attention. The author reviews the concerns regarding dehydration, which can be a consequence of diarrhea, particularly in children and in the elderly. Gas comes from two sources: swallowed air and the breakdown of certain undigested foods in the large intestine. Simple ways of reducing the gas from swallowed air include eating and drinking more slowly, not chewing gum, and having dentures properly fitted. For episodes of excessive or smelly intestinal gas, the use of a food diary may help identify the offending items. The author concludes by reiterating the importance of adequate fiber and fluid intake. The websites of four information resource organizations are listed.

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Diarrhea and Malabsorption in the Elderly. Gastroenterology Clinics of North America. 30(2): 427-444. June 2001.

Diarrhea from infectious organisms is common in the elderly and leads to frequent hospitalizations and a relatively high mortality (death) rate in this population. Diarrhea can be a disabling manifestation of several systemic disorders, including diabetes mellitus, and drug induced diarrhea is particularly common in advanced age. This article, from a special issue on gastrointestinal (GI) disorders in the elderly, addresses diarrhea and malabsorption in the elderly. Although the physiologic functions of intestinal digestion and absorption of macronutrients and most micronutrients are not decreased simply as a function of aging, malabsorptive diseases including chronic pancreatitis and celiac disease (gluten intolerance) are more common in the elderly than has been realized in the past. A particular potential cause of covert malabsorption of macro and micronutrients in older patients is bacterial overgrowth, which may occur in the absence of 'blind loops.' The impact of silent malabsorption on the nutritional health of older patients may be more severe than in the young. Physicians who care for elderly patients are cautioned to be alert to the possible presence of diarrhea and malabsorption. Older patients may not admit to having chronic diarrhea, particularly if they are also incontinent. When an intestinal infection and potential medication-induced gastrointestinal disturbances have been excluded, the differential diagnosis of diarrhea in the elderly is the same as in the young. In the elderly, micronutrient deficiency is a common presenting clinical picture; because the symptoms of malabsorption are covert, the diagnosis often is delayed and nutritional deficiencies are more common and more severe than in the young. 1 table. 102 references.

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Diarrhea Following Small Bowel Resection. In: Bayless, T.M. and Hanauer, S.B. Advanced Therapy of Inflammatory Bowel Disease. Hamilton, Ontario: B.C. Decker Inc. 2001. p. 471-474.

This chapter on diarrhea following small bowel resection (removal) for Crohn's disease is from the second edition of a book devoted to the details of medical, surgical, and supportive management of patients with Crohn's disease (CD) and ulcerative colitis (UC), together known as inflammatory bowel disease (IBD). In intestinal diseases, such as CD and colitis, the normal orderly process of absorption is disrupted, and malabsorption of fluid and electrolytes may cause diarrhea. These intestinal diseases also may result in nutrient malabsorption and the consequences of malnutrition. Intestinal resection permanently removes one or more segments of the intestine. The extent of the absorptive defect depends upon which segment has been removed, how extensive the resection has been, and the ability of other segments to compensate for the missing functions of that segment. Diarrhea can develop shortly after recovery from surgery and refeeding, or some time after recovery from surgery. The time of onset after surgery is an important clue to the possible cause of the diarrhea, thus, careful patient history is crucial for appropriate diagnosis. If a specific problem, such as bacterial overgrowth, is identified, specific treatment can be applied and may substantially improve the situation. Often a specific treatable entity cannot be diagnosed and nonspecific treatment must be applied. Nonspecific treatment can provide significant improvement in symptoms and allow for use of the absorptive surface of the intestine in a more efficient fashion. Nonspecific treatments include diet therapy (reduction in fat intake, frequent feedings, dietary supplements, reduced caffeine intake); antidiarrheal medications; stool modifying agents; adjunctive medications; and replacement therapy (oral rehydration solution, vitamins). 4 tables. 8 references.

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Gastrointestinal Complications in Stem Cell Transplantation. In: Bayless, T.M. and Hanauer, S.B. Advanced Therapy of Inflammatory Bowel Disease. Hamilton, Ontario: B.C. Decker Inc. 2001. p. 649-654.

Stem cell transplantation (SCT) is the standard of care for the treatment of many hematologic (blood) malignancies, pediatric solid tumors, inherited disorders, and aplastic anemia (a deficiency of all the formed elements of blood). SCT also is being used to treat many autoimmune disorders in experimental situations. This chapter on gastrointestinal complications in SCT is from the second edition of a book devoted to the details of medical, surgical, and supportive management of patients with Crohn's disease (CD) and UC, together known as inflammatory bowel disease (IBD). Several patients with CD and leukemia have remitted or remained in remission after bone marrow transplantation. Complications related to SCT are becoming more widely recognized. Gastrointestinal complications of SCT result from preparative regimen toxicity, infection, and acute and chronic graft-versus-host (GVH) disease, which may be difficult to diagnostically separate and are therefore addressed in this chapter. Diarrhea related to toxicity induced by the preoperative regimen may last until day 15 after SCT. Infectious causes of diarrhea must be considered and can include bacterial and viral pathogens. Once infectious causes are ruled out, antidiarrheal agents (such as loperamide) may be initiated. Nausea, vomiting, and anorexia occur commonly during the preparative regimen; if they are severe, total parenteral (outside the GI tract) nutrition (TPN) must be used. At its simplest level, GVH disease arises from the recipient's immune recognition of minor antigenic differences between donor and recipient. Patients with gut GVH disease present with abdominal pain, nausea, and vomiting or diarrhea. The physical examination and history may include a rash on the hands, feet, and ears. In addition, significant GI bleeding may occur post transplant and contribute to higher mortality associated with SCT. 4 figures. 10 references.

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