My mother is 77 and recently (Feb 26) suffered a mild heart attack, accompanied by congestive heart failure. There are other complications; she has (I think it's called) atrial fibrillation as well. Triple coronary bypass and aortic valve replacement surgery had been scheduled.
She was originally very resistant to having the surgery, feeling that she was too old. (We think she's been feeling so bad she couldn't imagine feeling good enough to want to live.) She changed her mind after a visit from a wonderful older woman who'd had the surgery.
But what has become apparent in the hospital was that she's been suffering chronic diarrhea, even worse than we or her doctor had known. (It's been getting progressively worse since she had her carotid artery done about five years ago.) Now they're running GI tests which are making her feel REALLY miserable; she's lost four pounds just this week and is having trouble keeping the electrolyte solutions down.
My question is -- what are the probable causes of this diarrhea, barring a tumor? I've read up on sprue. My queries on the Internet have uncovered lots on diarrhea in infants and even plenty on diarrhea in horses and cows, but precious little on diarrhea in the elderly.
REPLY: ------------
Although it is tempting to try to link your mother's known cardiac problems and her age to the newly recognized problem of her worsening chronic diarrhea I would approach the problem in a more open fashion.
Diarrhea is only a symptom and the causes are too numerous to list here. The most important aspect of her evaluation will be to listen to her description of her symptoms. Diarrhea can be of a high volume, low volume, nocturnal, never nocturnal, associated or unassociated with blood, mucus, cramps, etc. Too often there is a knee jerk response to "diarrhea" and patients get "the diarrhea workup" which can sometimes be streamlined with the taking of a good medical history (provided the patient can accurately answer one's questions). Physical exam provides some additional information. Lab tests of blood and of the stool are very helpful. Often these will suggest the cause of the diarrhea. Stool should be checked for hidden blood, routine infectious agents, parasites, the toxin for Clostridium difficile, white blood cells, etc.
Often a look into the colon will demonstrate the problem be it some form of colitis (often overlooked in the elderly), a cancer (often curable with surgery alone), or some other problem.
Diarrhea may present as a side-effect to one of the many medications your mother may be taking and this possibility may need to be explored with a trial of drug elimination. Ironically this cause is often overlooked and only considered when the patient has had an exhaustive workup.
Similarly, common things such as lactose intolerance need to be considered and eliminated by trials of dietary elimination or specific diagnostic tests.
Sprue would be an unlikely diagnosis but it is important to consider the small intestine in the evaluation of chronic diarrhea since malabsorption and inflammatory diseases are often overlooked in the differential diagnosis.
Finally if no serious cause can be found for her diarrhea and common and uncommon diseases (such as collagenous colitis) have been excluded I would not forget to offer her treatment with appropriate drugs but only once we can be sure we have looked into the specifically treatable entities. It is always better to search for a condition and treat it specifically (hopefully permanently) than treat it symptomatically and this is especially true with diarrhea.
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Bruce Sckolnick, M.D.
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