Intest Res.  2016 Jan;14(1):75-82. 10.5217/ir.2016.14.1.75.

Spectrum of chronic small bowel diarrhea with malabsorption in Indian subcontinent: is the trend really changing?

• Pipaliya N
• Ingle M
• Rathi C
• Poddar P
• Pandav N
• Sawant P

• KMID: 2174513
• DOI: http://doi.org/10.5217/ir.2016.14.1.75

Abstract

BACKGROUND/AIMS
This study aimed to document the recent etiological spectrum of chronic diarrhea with malabsorption and also to compare features that differentiate tropical sprue from parasitic infections, the two most common etiologies of malabsorption in the tropics.
METHODS
We analyzed 203 consecutive patients with malabsorption. The etiological spectrum and factors that differentiated tropical sprue from parasitic infections were analyzed.
RESULTS
The most common etiology was tropical sprue (n=98, 48.3%) followed by parasitic infections (n=25, 12.3%) and tuberculosis (n=22, 10.8%). Other causes were immunodeficiency (n=15, 7.3%; 12 with human immunodeficiency virus and 3 with hypogammaglobulinemia), celiac disease (n=11, 5.4%), Crohn's disease (n=11, 5.4%), small intestinal bacterial overgrowth (n=11, 5.4%), hyperthyroidism (n=4, 1.9%), diabetic diarrhea (n=4, 1.9%), systemic lupus erythematosus (n=3, 1.4%), metastatic carcinoid (n=1, 0.5%) and Burkitt's lymphoma (n=1, 0.5%). On multivariate analysis, features that best differentiated tropical sprue from parasitic infections were larger stool volume (P=0.009), severe weight loss (P=0.02), knuckle hyperpigmentation (P=0.008), low serum B12 levels (P=0.05), high mean corpuscular volume (P=0.003), reduced height or scalloping of the duodenal folds on endoscopy (P=0.003) and villous atrophy on histology (P=0.04). Presence of upper gastrointestinal (GI) symptoms like bloating, nausea and vomiting predicted parasitic infections (P=0.01).
CONCLUSIONS
Tropical sprue and parasitic infections still dominate the spectrum of malabsorption in India. Severe symptoms and florid malabsorption indicate tropical sprue while the presence of upper GI symptoms indicates parasitic infections.

Keyword

Sprue, tropical; Parasitic infections; Malabsorption; Villous atrophy; B12 deficiency

MeSH Terms

Atrophy
Burkitt Lymphoma
Carcinoid Tumor
Celiac Disease
Crohn Disease
Diarrhea*
Endoscopy
Erythrocyte Indices
HIV
Humans
Hyperpigmentation
Hyperthyroidism
India
Lupus Erythematosus, Systemic
Multivariate Analysis
Nausea
Pectinidae
Sprue, Tropical
Tuberculosis
Vomiting
Weight Loss

Figure

• 

  Fig. 1 Graph showing the etiological spectrum of chronic small bowel diarrhea with malabsorption. Total 203 patients were included in the study. Note that one patient with cryptospora and one patient with microspora also had underlying human immunodeficiency virus, while one patient with microspora also had hypogammaglobulinemia. HIV, human immunodeficiency virus; SIBO, small intestinal bacterial overgrowth.

• 

  Fig. 2 Receiver operating characteristic curve of mean corpuscular volume (MCV) that differentiates tropical sprue from parasitic infections, (area under the curve, 0.869). An MCV more than 91 fL can best differentiate tropical sprue from parasitic infections with 85.7% sensitivity and 80% specificity.

• 

  Fig. 3 Receiver operating characteristic curve of degree of weight loss that differentiates tropical sprue from parasitic infections, (area under the curve, 0.774). Weight loss of more than 7.5 kg can differentiate tropical sprue from parasitic infections with 64.3% sensitivity and 80% specificity.

• 

  Fig. 4 Duodenal biopsy of a patient with tropical sprue. Partial villous atrophy (arrow) and lymphoplasmacytic infiltration in the lamina propria (asterisk) are visible. The crypt to villous ratio is almost 1:1 (H&E, ×20).

• 

  Fig. 5 Stool microscopic examination after wet mount showing multiple larvae of Strongyloides stercoralis (arrow).

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