Steven Desautels, Author at Granite Peaks Gastroenterology of Utah

Acute and Chronic Diarrhea: A Brief Review

Posted on November 12, 2019November 13, 2019 by Steven Desautels

Diarrheal diseases represent one of the five leading causes of death worldwide and are a particular concern for children younger than five years old in resource-limited settings.¹

Diarrhea may be defined as the passage of loose or watery stools, typically at least three times in a 24-hour period. Objectively, it is defined as stool weight exceeding greater than 200 grams per day. It reflects increased water content of the stool, whether due to impaired water absorption and/or active water secretion by the bowel.²Normally, the small intestine and colon absorb 99% of both oral intake and endogenous secretions from the salivary glands, stomach, liver, and pancreas. This constitutes a total fluid load of roughly 9 to 10  liters daily. Of the 10 liters of fluid that enters the jejunum (small intestine) daily (2 liters from food and drink and 8 liters from salivary, gastric, biliary, and pancreatic secretions), the majority is absorbed before entering the colon. Approximately one liter enters the colon with 80-100 ml excreted daily. Diarrhea results when a disruption of this normally fine-tuned mechanism. A reduction of water absorption by as little as 1% can result in diarrhea.³

The following definitions have been suggested according to the duration of symptoms:

Acute – 14 days or fewer in duration
Persistent diarrhea – more than 14 but fewer than 30 days in duration
Chronic – more than 30 days in duration

Globally, diarrhea kills 2,195 children every day, more than AIDS, malaria, and measles combined.

Diarrheal diseases account for 1 in 9 child deaths worldwide, making diarrhea the second leading cause

of death among children under the age of 5.²

ACUTE DIARRHEA

Approximately 179 million cases of acute diarrhea occur each year in the United States.⁴ Taken together, most cases of acute infectious diarrhea are likely viral. Among those with severe diarrhea, however, bacterial causes are responsible for most cases. Protozoa are less commonly identified as the etiologic agents of acute gastrointestinal illness. Noninfectious etiologies become more common as the course of the diarrhea persists and becomes chronic.

Infectious causes of acute diarrhea

Viral

Norovirus, Rotavirus, Astrovirus

Bacterial

Salmonella, Campylobacter, Shigella, C. diff, E. coli

Parasitic

Cryptosporidium, Giardia, Cyclospora, Entamoeba

Noninfectious causes of acute diarrhea

Medications

Antibiotics, antacids, antihypertensives, NSAIDS, antidepressants

Toxins

Organophosphate insecticides

Ischemic colitis

Fecal impaction

Most episodes of acute diarrhea are mild and self-limited, however, further evaluation should be pursued if any of the following apply:

Profuse diarrhea with dehydration
Bloody stool
Fever >38.5 (101.3)
Duration > 48 hours without improvement
Recent antibiotic use
Community outbreaks
Immunocompromised patients
Abdominal pain in patients >50
Elderly

CHRONIC DIARRHEA

Chronic diarrhea affects approximately 3 to 5% of the US population at any given time^..A much more extensive differential diagnosis exist for chronic vs acute diarrhea. The principal causes of chronic diarrhea vary based upon the socioeconomic status of the population. In resource-rich settings, irritable bowel syndrome, inflammatory bowel disease, and malabsorption syndromes (e.g., lactose intolerance and celiac disease). Whereas, in resource-limited settings, chronic bacterial, mycobacterial, and parasitic infections or more prominent. However, functional disorders, malabsorption, and inflammatory bowel disease are also prevalent. Characterizing the diarrhea as infectious, inflammatory, osmotic, or secretory is a useful way to guide evaluation and subsequently elucidating a diagnosis by focused testing. The distinction between types of diarrhea can often be made based upon the medical history but in other cases may require additional laboratory, radiographic and endoscopic evaluation.

Differential diagnosis of chronic diarrhea
Watery diarrhea
A. Osmotic:
Medications	Osmotic laxatives (Mg, SO4, PO4)
Unabsorbed sugars	Diet foods/drinks/gum (sorbitol); enzyme deficiencies (lactase/sucrase)
B.Secretory:
Medications	Stimulant laxatives, antibiotics, many others
Small intestinal bacterial overgrowth
Endocrine
Tumors	Carcinoid, gastronome, medullary thyroid cancer, VIPoma
Systemic	Adrenal insufficiency, hyperthyroidism
Bile salt malabsorption	Postcholecystectomy, Ileal resection
Non-invasive infections	Giardia, Cryptosporidium
Fatty diarrhea
A. Maldigestion	Decreased duodenal bile salt concentration (bile duct obstruction, ileal resection). Pancreatic dysfunction
B. Malabsorption	Mucosal disease (celiac sprue, giardiasis, Whipple’s disease)
Inflammatory diarrhea
A. Inflammatory bowel disease	Crohn’s, Ulcerative Colitis
B. Malignancy	Colon cancer, lymphoma
C. Radiation colitis/enteritis
D. Mastocytosis
E. Infections	C. difficle, CMV, Entamoeba
F. Ischemia

If you are suffering with ongoing diarrhea, please contact one of our specialists at Granite Peaks Gastroenterology in Sandy or Lehi.

Microscopic Colitis: Causes and Treatment

Posted on December 4, 2018April 18, 2019 by Steven Desautels

By Steven Desautels, MD

Microscopic colitis is a chronic inflammatory disease of the colon that is characterized by watery, non-bloody diarrhea. Microscopic colitis should be suspected in patients with chronic diarrhea without a clear cause. There is a female predominance and the median age at diagnosis is approximately 65 years. Colonoscopic investigation reveals an endoscopically normal-appearing colon; however, biopsy evaluation demonstrates either a collagenous or lymphocytic colitis.

Collagenous colitis is characterized by a sub epithelial collagen band > 10 mm in thickness with lymphocytic colitis demonstrating an intraepithelial lymphocytic infiltrate (>20 per high power field).

Microscopic Colitis Causes

The cause of microscopic colitis is unknown, but it is likely to be related to a multitude of factors, including mucosal immune responses to luminal factors and various medications (e.g. non-steroidal anti-inflammatory drugs, Proton pump inhibitors, Sertraline and Clozapine).

Treating Microscopic Colitis

Antidiarrheal medications may be used in patients with mild diarrhea, but for patients experiencing greater than three stools per day or greater than one water stool daily, budesonide is usually required. The dosing of budesonide is associated based on the clinical response, and usually only requires short-term treatment courses. Patients are advised to avoid non-steroidal anti-inflammatory medications, and, if possible, discontinue medications associated with microscopic colitis. In very rare, refractory cases, anti-tumor necrosis factor (TNF) agents may be necessary.

The gastroenterology specialists at Granite Peaks Gastroenterology can evaluate patients experiencing chronic diarrhea, determine the cause of the symptoms and treat appropriately based on test results.

Obesity and Your Gastrointestinal Health

Posted on June 12, 2018April 18, 2019 by Steven Desautels

By Steven G. Desautels

Obesity is a growing medical and public health problem worldwide. The health implications of obesity include a wide spectrum of benign digestive diseases such as gastroesophageal reflux disease (GERD), Barrett’s esophagus (BE), erosive esophagitis, nonalcoholic fatty liver disease (NAFLD), gallstones, and pancreatitis and digestive organ cancers such as cholangiocarcinoma, hepatocellular carcinoma (HCC), pancreatic cancer, colorectal cancer (CRC), and esophageal cancer.

Esophagus:

Obesity increases the prevalence of esophageal motility (i.e. movement) disorders. Esophageal transit time has been demonstrated to be prolonged in subjects with obesity. This is thought to be related to increased gastric and gastroesophageal junction resistance. Excess body weight produces higher intra-abdominal pressure and reduces lower esophageal sphincter pressure, predisposing obese individuals to GERD. Obesity is one of the known risk factors for developing erosive esophagitis. Barrett’s refers to the replacement of the normal squamous epithelium of the distal (lower) esophagus by specialized columnar epithelium. Barrett’s is usually a consequence of chronic GERD and predisposes one to adenocarcinoma of the esophagus. Several studies have shown an association between obesity, abdominal circumference and metabolic syndrome and Barrett’s esophagus. The incidence of esophageal adenocarcinoma is increasing. The molecular mechanisms linking obesity and esophageal adenocarcinoma have been investigated extensively and thought to be related to increased insulin and insulin like growth factors.

Stomach:

Gastric physiology and its neurohormonal regulation are altered in obesity. Higher BMI has been associated with greater fasting gastric volume and accelerated gastric emptying of solids and liquids. Obesity has been found to be a risk factor for erosive gastritis and gastric and duodenal ulcers. Obesity is considered a pro inflammatory and pro carcinogenic and is recognized as an important risk factor for cancer, including gastric cancer.

Small intestine:

The prevalence of diarrhea in obese individuals is higher compared with normal weight controls. This is thought to be related to several mechanisms including bile acid diarrhea, accelerated colonic transit, increased mucosal permeability or intestinal inflammation. Medications used by obese individuals such as Metformin for diabetes or polycystic ovary syndrome also may cause diarrhea.

Colon and rectum:

Obesity is associated with a higher risk of developing diverticulosis. Several studies have documented an increased prevalence of adenomatous polyps with elevated BMI. Similarly, obesity is associated with an increased risk of adenoma recurrence.

Liver:

Nonalcoholic Fatty Liver Disease has become the most prevalent chronic liver disease in the United States and the most frequent cause of increased transaminase levels (liver enzymes). Patients with NAFLD are at risk of progressive fibrosis and eventual cirrhosis. NAFLD confers increased risk of cardiovascular mortality and hepatocellular carcinoma.

Gallbladder:

Obesity has been well recognized for its strong association with gallstone disease, including cholelithiasis, cholecystitis, and cholesterolosis. Cholesterolosis is characterized by the accumulation of lipids in the mucosa of the gallbladder wall. It is a benign condition that is usually diagnosed incidentally during cholecystectomy or on ultrasonography.

Pancreas:

Obesity and fat infiltration of the pancreas play a significant role in the endocrine pancreatic dysfunction that leads to the development of type 2 diabetes mellitus. Obesity is associated with more severe acute pancreatitis. Meta-analyses have reported an association between BMI and adenocarcinoma of the pancreas.

Understanding and Treating Dysphagia

Posted on December 12, 2017April 18, 2019 by Steven Desautels

By Dr. Steven G. Desautels

Dysphagia refers to difficulty swallowing. Dysphagia can be subdivided into: oropharyngeal dysphagia and esophageal dysphagia.

Oropharyngeal dysphagia is characterized by difficulty initiating a swallow, transferring the food bolus or liquid into the esophagus, and/or the association of coughing and choking during attempted meal consumption.

Many disorders cause oropharyngeal dysphagia (see below from UpToDate 2017). Generally, these include neuromuscular diseases, systemic diseases, and mechanical obstruction. Common symptoms in oropharyngeal swallowing disorders include recurrent bouts of aspiration pneumonia from inadequate airway protection, hoarseness, and nasal regurgitation.

The primary treatment of oropharyngeal dysphagia is swallowing rehabilitation by a swallowing professional, a speech pathologist. Patients who have oropharyngeal dysphagia due to an anatomical abnormality, such as a Zenker diverticulum usually require endoscopic or surgical intervention.

Esophageal dysphagia is characterized by the onset of symptoms after the initiation of a swallow. The normal function of the esophagus is to transfer food and liquid. Esophageal dysphagia can be caused by several diseases (see below from UpToDate 2017) but is most often related to a mechanical obstruction. Esophageal dysphagia caused by a motility disorder is commonly characterized by dysphagia with both solids and liquids. Dysphagia associated with only solid foods is more likely due to a mechanical obstruction, although a mechanical obstruction may progress to the extent that dysphagia is associated with both solids and liquids.

Esophageal dysphagia is an alarm symptom and warrants consultation with a Gastroenterologist and subsequent investigation with an upper gastrointestinal endoscopy and possible esophageal manometry (motility test). The goal of testing is to identify structural or mucosal abnormalities that require intervention, to detect underlying systemic disease, and to define functional disorders. The association of liquid dysphagia merits manometry evaluation.

Broadly speaking, esophageal motility disorders are classified into achalasia and related disorders (eg, diffuse esophageal spasm) and nonspecific disorders (eg, jackhammer esophagus). Achalasia is the loss of peristalsis of the esophageal body and failure of relaxation of the lower esophageal sphincter. Achalasia is the best established of the motility disorders, with defined and effective treatments. Most other esophageal motility disorders have questionable associations with clinical symptoms and few effective treatment options.

If you experience frequent choking or have difficulty swallowing, contact our office for evaluation of your symptoms by any of our board-certified gastroenterologists.

An Introduction to Hepatitis

Posted on May 9, 2017March 4, 2021 by Steven Desautels

by Dr. Steven Desautels

This blog is intended to be an introduction to hepatitis with an emphasis on some of the more common causes. Hepatitis is a disease characterized by inflammation of the liver. It can broadly be differentiated into acute (<6 months) or chronic.

1. ACUTE HEPATITIS
Acute hepatitis may be accompanied by fatigue, abdominal pain, and jaundice. Viral infections are important causes of acute and chronic liver disease worldwide. The five primary hepatitis viruses that have been identified are A, B, C, D, and E. Epstein-Barr virus, Cytomegalovirus, and Herpes Simplex virus also can result in hepatitis. In addition, toxins, medications, autoimmune hepatitis, and Wilson disease may cause acute or chronic hepatitis.

Common causes of acute hepatitis include:

• Viruses
–Hepatitis A
–Hepatitis B
• Drug induced
• Toxins
• Alcoholic hepatitis
• Ischemic hepatitis
• Uncommon causes
–Cytomegalovirus
–Epstein-Barr virus
–Herpes simplex virus
–Hepatitis E
–Severe cardiovascular disease
–Autoimmune hepatitis
–Wilson’s disease

Hepatitis A
Common routes of transmission of hepatitis A (HAV) include ingestion of contaminated food or water and contact with an infected person. Hepatitis A is almost always self-limited. Treatment is supportive. Post exposure prophylaxis with hepatitis A vaccine or immune serum globulin (or both) is advised. Hepatitis A vaccine is recommended for all children at 12 months of age and should be considered in travelers to areas with high prevalence of hepatitis A, to men who have sex with men, to intravenous drug users, and to patients with chronic liver disease.

For more information on Hepatitis A from Uptodate.com refer to:
https://www.uptodate.com/contents/hepatitis-a-beyond-the-basics

Hepatitis B
Hepatitis B virus (HBV) leads to approximately 30% of the cases of acute viral hepatitis and 15% of the cases of chronic viral hepatitis in the United States. Risk factors for contracted HBV in the United States are sexual contact with an infected person and intravenous drug use. Patients with chronic hepatitis B and cirrhosis are at high risk for the development of hepatocellular carcinoma, Hepatitis B immunoglobulin should be given to nonimmune household and sexual contacts of patients who have acute hepatitis B. All infants should receive hepatitis B vaccine.

For more information on HBV refer to:
https://www.uptodate.com/contents/hepatitis-b-beyond-the-basics

Toxins
The use of certain complementary and alternative medicines (CAM) may potentially lead to acute hepatitis and sometimes fulminant hepatic failure. LiverTox- https://livertox.nih.gov/ is an online resource developed as a collaborative effort between the liver disease branch of the NIDDK and the National Library of Medicine.

2. CHRONIC HEPATITIS
Diseases that produce sustained (>6 months) increases in aminotransferase levels (liver enzymes) are included in the category of chronic hepatitis.

The most important disorders that cause chronic hepatitis include:

• Viruses
—Hepatitis C
–Hepatitis B
• Nonalcoholic fatty liver disease
• Alcoholic liver disease
• Autoimmune hepatitis
• Primary biliary cirrhosis
• Primary sclerosing cholangitis

Hepatitis C
HCV is the cause of the most common chronic blood-borne infection in the United States, where an estimated 3 to 4 million persons are infected. HCV is a factor in 40% of all cases of chronic liver disease and is a leading indication for liver transplant. Newer medications are having a major impact in the treatment success and eradication of HCV in individuals.

Nonalcoholic fatty liver disease
The obesity epidemic has increased the prevalence of nonalcoholic fatty liver disease (NAFLD). It currently is the most common cause of chronic liver disease in Western nations. NAFLD can be associated with cardiovascular disease, obstructive sleep apnea, type 2 diabetes mellitus, and other manifestations of the metabolic syndrome.

Click here for more information on NAFLD from Uptodate.com.

Alcohol-induced liver disease
Alcoholic liver disease is a major cause of morbidity and mortality worldwide. Globally, approximately 2 billion people consume alcohol, and alcohol use disorders are diagnosed in more than 75 million people.

If you have any questions about hepatitis, please contact your physician at Granite Peaks Gastroenterology. Call 801-619-9000 or click here to request an appointment.