So now let's move on
to our next case.
We have a 43-year-old woman, seen in
clinic for a 6-month history of diarrhea.
She has a history of Crohn's disease for which
she underwent small bowel resection a year ago.
Her diarrhea is non-bloody and occurs
anywhere from 3 to 5 times a day.
She notes it often happens
immediately after meals.
She has also lost 8
kilograms in the last year.
Vitals are notable for heart rate of 95
and her physical exam is notable
for mild diffuse muscle wasting.
So what is the most
So she has a history of both Crohn's disease and small
bowel resection which may cause chronic diarrhea.
She does have non-bloody
diarrhea that is worsened by eating
and weight loss which is
concerning for malabsorption.
Her physical exam also confirms that
she has some signs of malabsorption
with her tachycardia and her muscle wasting.
So at this point, I'll refer you back to
the approach to the patient with diarrhea
for more in-depth look at conditions of
the small bowel that can cause diarrhea.
But we'll talk specifically about her case.
As a quick review, malabsorption can occur
by several different mechanisms listed here.
You may have impaired
absorption at the mucosa,
a brush border enzyme deficiency,
you may have issues of pancreatic enzymes,
bile acid malabsorption
or bacterial overgrowth.
However in her case, it might be
a slightly different mechanism.
There is another way by which malabsorption
can occur in the small bowel.
If you recall that the small bowel is where
we absorb the majority of our nutrients,
then you can also know that malabsorption can
occur when there is not enough small bowel
or not enough surface area
to absorb those nutrients.
So now let's talk about a particular type of
malabsorption called short bowel syndrome.
This is when malabsorption occurs due to
either resected or diseased small bowel.
So over here on the right, you can see
a depiction of normal small bowel.
Normally, we have about 6
meters of healthy, small bowel.
On the right on the other hand,
you may have short bowel syndrome
which is when only less
than 200 centimeters remain.
So it can be caused by many
causes including Crohn's disease,
bowel ischemia, a history of
radiation or resection of the bowel.
Patients may present
with voluminous diarrhea.
They may have weight loss
because of this, and malnutrition.
The diagnosis is done by clinical symptoms.
There is no particular testing we
can do to make this diagnosis.
But you may check fecal
fats or electrolyte testing
to see if the patient truly is wasting
fat and electrolytes in their stool.
The treatment is mostly by supportive care.
So you may replace any electrolytes that
they are deficient in and give fluids.
In terms of maintenance therapy, you want to
counsel your patients on lifestyle modification.
So encouraging small and frequent meals
so that they don't have dumping syndrome
or rapid transit of food contents through
what small bowel they have left.
So now that brings us back to our case.
We had a 43-year-old woman with both Crohn's
disease and a history of small bowel resection
leading to her chronic diarrhea.
She has many signs of malabsorption.
So the most likely diagnosis in
this case is short bowel syndrome.
Thank you very much
for your attention.