Guest Paula Posted February 23, 2014 Share Posted February 23, 2014 Oh, thanks. I will look at the pathology and notes from GI when I can get my hands on the chart. I'll ask for the chart tomorrow. Link to comment Share on other sites More sharing options...
Joelseff Posted February 23, 2014 Share Posted February 23, 2014 I am just a PAS-1, but as somebody mentioned IBS is likely. Very interesting, though! IBS is nebulous but usually constipation predominant and its also a "garbage diagnosis" rule out infxn, then rule out functional disorders. GI pathology is not yet in so I wouldnt jump to IBS right away. Sent by my Samsung S4 Active via Tapatalk Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted February 23, 2014 Share Posted February 23, 2014 Though IBS now has a diagnostic criteria consisting of catagories, and numbers met within each (I'm always leery of these types of made diagnoses), IBS remains a diagnosis of exclusion. Link to comment Share on other sites More sharing options...
Purrpa Posted February 24, 2014 Share Posted February 24, 2014 Just a thought, but have you considered Habba Syndrome (a form of gallbladder dysfunction, treated w cholestyramine [Questral ])? Not all ppl w chronic diarrhea are abusing laxatives. Sent from my iPad using Tapatalk Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted February 24, 2014 Share Posted February 24, 2014 I still want someone to confirm that she's actually having diarrhea with her hx. Link to comment Share on other sites More sharing options...
patachok Posted February 24, 2014 Share Posted February 24, 2014 IBS is nebulous but usually constipation predominant and its also a "garbage diagnosis" rule out infxn, then rule out functional disorders. GI pathology is not yet in so I wouldnt jump to IBS right away. Sent by my Samsung S4 Active via Tapatalk Excellent learning point. Thank you! Link to comment Share on other sites More sharing options...
CAdamsPAC Posted February 24, 2014 Share Posted February 24, 2014 I would look for phenolphthalein in her stool. I encountered an affluent 20 something woman sent to Yale from New Jersey" due to her complicated case". This pt was the most well groomed women I'd ever seen, body habitus ideal body weight, VS stable and PE very benign. Her mother and father were present and visibly concerned and hung onto every word. As part of FMHx it was elicited that her brother had been dx'ed with HIV a few weeks prior to onset of her "diarrhea". Bottom line is stool was (+) for phenolphthalein as only abnormal finding. In d/w her PCP he mentioned a phone call from a local pharmacist in the past reporting the pt had purchased a significant amount of laxatives. We all know kids always compete for the attention of their parents...... Link to comment Share on other sites More sharing options...
Guest Paula Posted February 24, 2014 Share Posted February 24, 2014 I reviewed the chart: Normal mucosa and vascular pattern of the colon. No references to a melanotic colon. Biopsies of colon no significant histologic abnormalities. gastral antral biopsy with mild chronic gastritis. No H. Pylori. No C.Diff. No O&P on stool studies. EGD and colonoscopy comment on post-procedure: Mild erosive esophagitis, mild duodenitis, large gastric pool, and normal colon and TI. One note said she was having 2-3 loose stools a day, with urgency in January. Weight fluctuates between 97 and 105 with current weight on 1/22/14 at 101.8 #. She is 62 1/4 " tall and BMI 18.4. On 1/09/2014 was 105#. Another note stated soft stools. So maybe NOT diarrhea but note after note from the doc records abdominal cramping with diarrhea. She is on omeprazole. Older notes from when she was a kid showed she has had chronic abdominal complaints and had a colonoscopy in 2002 at age 18 and was normal. The GI note from 2/3/14 commented on the following sx: Arthralgias, weight loss, heartburn, nausea, vomiting, dysphagia, anorexia and fatigue. CBC and CMP normal. Next step is the doc is waiting for endocrinologist to call him for a phone consult. Last TSH was .69 (.66-5.45) with FT4 1.5 ( .5-1.4). So borderline at best but maybe an underlying thyroid issue???? I'll suggest testing for stool osmol gap, phenothalian and stool magnesium. I've never heard of Habba syndrome. I will look it up. Link to comment Share on other sites More sharing options...
Joelseff Posted February 24, 2014 Share Posted February 24, 2014 Can also try switching omeprazole to another ppi or h2 blocker. Omeprazole can cause diarrhea. What other meds is she on. Sent from my SAMSUNG-SGH-I537 using Tapatalk Link to comment Share on other sites More sharing options...
Guest Paula Posted February 25, 2014 Share Posted February 25, 2014 Other meds: Klonipin, Advair, amitriptyline. Has been on bentyl and lomotil but quit them. Didn't help. Omeprazole was just prescribe after EGD/colonoscopy was done in January. Link to comment Share on other sites More sharing options...
Guest Paula Posted February 25, 2014 Share Posted February 25, 2014 P.S. I checked with pharmacist and the patient is not asking for ex-lax or milk of mag or other laxatives when she picks up her meds. She could be buying it elsewhere but why would she when she can get it free or at cost at the IHS pharmacy. Link to comment Share on other sites More sharing options...
taotaox1 Posted February 25, 2014 Share Posted February 25, 2014 Does she have a history of sexual abuse as a kid? If I am not mistaken abdominal pain is a common psychosomatic presentation of sexual trauma in children, and this may just be a continuance. The rest of her social history makes me feel like sexual trauma is a real likelihood in her past. That said, you gotta rule out all the possible physiologic causes first imo. Link to comment Share on other sites More sharing options...
Joelseff Posted February 25, 2014 Share Posted February 25, 2014 Now she's fitting that picture of IBS. Klonopin for sleep or anxiety? Does her anxiety declare itself that you can observe/have observed? It seems this might have a psychological component? Wonder of she has fibromyalgia type sx's as well... Have you checked for sprue? U can try double dose of Metamucil to stop her up. 4 tbsp q12h. Sent from my SAMSUNG-SGH-I537 using Tapatalk Link to comment Share on other sites More sharing options...
whoRyou Posted February 25, 2014 Share Posted February 25, 2014 Does she have a history of sexual abuse as a kid? If I am not mistaken abdominal pain is a common psychosomatic presentation of sexual trauma in children, and this may just be a continuance. The rest of her social history makes me feel like sexual trauma is a real likelihood in her past. That said, you gotta rule out all the possible physiologic causes first imo. Tao I think you might be onto something. I remember when I used to work with girls/women who were sexually abused many complained of abdominal pain. Causes Of Chronic Diarrhea IBS symptoms may worsen during times of emotional or physiologic stress. Those with especially severe symptoms and persistent lower abdominal pain may have been physically or sexually abused in the past. While a diagnosis of "non-disease" is often difficult to make, irritable bowel syndrome is thought to be a functional disorder (dysmotility) since no anatomic or organic intestinal problems are found to explain the symptoms. Link to comment Share on other sites More sharing options...
Guest Paula Posted February 25, 2014 Share Posted February 25, 2014 Does she have a history of sexual abuse as a kid? If I am not mistaken abdominal pain is a common psychosomatic presentation of sexual trauma in children, and this may just be a continuance. The rest of her social history makes me feel like sexual trauma is a real likelihood in her past. That said, you gotta rule out all the possible physiologic causes first imo. I don't know if she has had a history of sexual abuse. The tricky part is if she has, getting the information from a patient. There is a high rate of child abuse and neglect and sexual abuse on the rez. To my knowledge she lived off-rez but her mother also has a history of drug/alcohol issues supposedly in remission now too. I will ask the doc what he thinks as he has seen this patient when she was a teenager. Our patients come and go and are quite transient. We have a gap of about 11 years with this patient from age 18 to now. Perhaps this is IBS? I am assuming the GI docs would have tested for sprue and that should be noted on colonoscopy, right? I did not see any of the labs one might do for sprue. Link to comment Share on other sites More sharing options...
Guest Paula Posted February 25, 2014 Share Posted February 25, 2014 Now she's fitting that picture of IBS. Klonopin for sleep or anxiety? Does her anxiety declare itself that you can observe/have observed? It seems this might have a psychological component? Wonder of she has fibromyalgia type sx's as well... Have you checked for sprue? U can try double dose of Metamucil to stop her up. 4 tbsp q12h. Sent from my SAMSUNG-SGH-I537 using Tapatalk Klonopin for both sleep and anxiety. I wish she wasn't on it due to her PMH of drug use and opioid dependence. In December she was drinking 5 beers a day to relieve the lower abdominal pain according to the GI note. I see trouble brewing for this young woman. No pun intended or maybe it is. Link to comment Share on other sites More sharing options...
Joelseff Posted February 25, 2014 Share Posted February 25, 2014 Klonopin for both sleep and anxiety. I wish she wasn't on it due to her PMH of drug use and opioid dependence. In December she was drinking 5 beers a day to relieve the lower abdominal pain according to the GI note. I see trouble brewing for this young woman. No pun intended or maybe it is. Sprue affects the small bowel so c scope would not find it. You can order the IgA for celiac sprue. Sent from my SAMSUNG-SGH-I537 using Tapatalk Link to comment Share on other sites More sharing options...
Guest Paula Posted February 25, 2014 Share Posted February 25, 2014 Ok, I asked the doc if that was done by GI and he wasn't sure. We discussed the case this morning. He agrees the thyroid labs are unimpressive. We discussed sprue, anorexia, psychological issues. He has not been able to determine if she has a history of sexual abuse but she has had several partners who have beat the crap out of her. Plus I commented that she seems to have a dependent personality and he agrees. I think she is coming here often because she looks at the doc as her "father" figure and one who is nice to her and affirms her value and worth. He actually agreed with me. Also, he mentioned that every drug he has tried her on for IBS she cannot tolerate because she develops all the side-effects of them that are listed on the pharmacy info sheets. She reads them and looks them up on the internet. Psych case in my opinion. She refuses to be seen by mental health. Link to comment Share on other sites More sharing options...
Moderator ventana Posted February 25, 2014 Moderator Share Posted February 25, 2014 what about klonopin withdrawals? does diarrhea always happen before a refill?? Link to comment Share on other sites More sharing options...
Guest Paula Posted February 25, 2014 Share Posted February 25, 2014 ^^^^^^^^ interesting thought. But she has had a long standing history of abdominal pain and the klonopin was started after the diarrhea complaints. I prescribed her an SSRI many months ago for her anxiety. She only took it 2-3 days and then had an adverse reaction to it..... it made her feel "not quite right and gave her diarrhea and made her sleepy." Klonopin doesn't have any side-effects and works for her! Why is that????? Rhetorical question. Link to comment Share on other sites More sharing options...
db_pavnp Posted February 25, 2014 Share Posted February 25, 2014 I'm reaching, but could her history of opioid abuse have altered her gut homeostasis in such a way that diarrhea is her new norm? Link to comment Share on other sites More sharing options...
Joelseff Posted February 26, 2014 Share Posted February 26, 2014 Next Stop: Psych Eval .... Sent from my SAMSUNG-SGH-I537 using Tapatalk Link to comment Share on other sites More sharing options...
Guest Paula Posted February 26, 2014 Share Posted February 26, 2014 Thanks for all the input. I am now out of the office for the next 2-3 weeks and will post here if there is any resolution to this case when I return. Link to comment Share on other sites More sharing options...
Joelseff Posted February 26, 2014 Share Posted February 26, 2014 Thanks for all the input. I am now out of the office for the next 2-3 weeks and will post here if there is any resolution to this case when I return. Have a good vacation! Sent from my SAMSUNG-SGH-I537 using Tapatalk Link to comment Share on other sites More sharing options...
whoRyou Posted March 16, 2014 Share Posted March 16, 2014 Any updates Paula? Link to comment Share on other sites More sharing options...
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