Could small bowel resection cause consistent diarrhea?

Hi,

Welcome to icliniq.com.

I need to know a few things before knowing the cause of this diarrhea. Please say about the reason for having surgery and whether you have done a biopsy of the removed specimen. Please explain whether you had diarrhea before surgery and the quantity of stool present for twenty-four hours. Please say whether it is mushy or formed and do you had any bowel movement in the middle of the night. Please mention the length of the small bowel resected whether it is hundred centimeters less or more. Please mention whether you had a bag attached after the surgery. Please give me this information to establish the cause of your diarrhea and low appetite. So, I can guide you further. Imodium (Loperamide) is an anti-spasmodic medication that is not going to correct the underlying problem. Best regards.

Hi,

Welcome back to icliniq.com.

I can understand that it is painful when you are suffering so hard. I really feel sorry. I appreciate that you took time to elaborate on the essential information. I understand that you had surgery when you are a child because Intussusception caused an obstruction. This subsequent obstruction might be due to postoperative adhesion formation (fibrosis or scarring). Now since almost eighty centimeters of terminal ileum plus cecum has been removed and it may be the cause of this current diarrhea. Since terminal ileum is the portion of the small bowel that absorbs the bile acids required for digestion of the lipids. These bile acids instead of absorption, go in the large bowel and start irritating the large bowel, which causes diarrhea. The stool which is moreover a semi-formed stool, suggests the problem with large bowel absorption of the fluids.

I suggest you take Cholestyramine 4 mg powder twice daily two hours before major meals and see for the improvement from diarrhea. This medication is a bile acid chelator, which adheres to the bile acids present in the lumen of the gut, and hence decreases the amount of bile acids delivery to the large bowel and thus improves diarrhea. I suggest you take Vitamin A 3000 IU once daily and Vitamin E 400 mg once daily while taking cholestyramine. This vitamin can decline with the use of Cholestyramine, therefore I am giving replacement as per their daily requirement. The anemia present for the last three years is explainable by the ulcer present at the previous surgical site, and which tends to ooze some occult blood resulting in the anemia. If you are still anemic, then it is something of concern.

I admit that this is not a sole mechanism that bile induced diarrhea and there is some more mechanism that collectively causes diarrhea. The mechanism which partly explains his symptoms is rapid transit of the bowel, which can occur if you have developed SIBO (small intestinal bacterial overgrowth) a condition of excessive abnormal gas-producing bacteria that can occur in a patient who had prior surgeries and had some blink small bowel loops which potentiate bacterial growth.

The last mechanism which explains the rapid transit is a short gut syndrome, meaning that there is a shortened length of the small bowel overall due to resection, hence you could not tolerate the average meal load as a common person would do. For SIBO I can consider giving you an antibiotic course tablet Rifaximin 200 mg thrice daily for twenty-one days and for rapid transit secondary to the short gut, continue with tab Immodium two tablets after a loose bowel. Please upload the surgical notes and histopathological report and CT (computed tomography) scan that has been performed.

Hi,

Welcome back to icliniq.com.

I consider reassessing the diagnosis. It means to re-investigate the actual cause of diarrhea, and malnutrition before jumping to treat it. Since you have already been on various medications which we just discussed, then it is essential to explore is anything missing throughout all this course of illness.

To rule out the possible common causes of diarrhea in an individual without having previous surgery are celiac disease, food allergies, infections, and immunocompromised state leading to immunodeficiency diarrhea, and pancreatic diarrhea. These diseases need extensive blood and stool workup, including work up to show the impact of this disease on nutritional deficiencies like vitamin B12, Vit D deficiency, and others.

Small intestinal bacterial overgrowth (SIBO) and short gut syndrome due to extensive resection of the bowel particularly of the small bowel, and rapid transit has been evident on gastric emptying studies which you just shared, all seem to play a role. Considering these possible underlying mechanisms, the other option available is to consider giving some other novel therapies to resolve rapid transit, hence diarrhea, and malabsorption.

The options are Octreotide (Sandostatin) 50 mg subcutaneously thrice daily for one to two weeks. Based on the response, you can take it as a sustained-release Intramuscular injection of the Octreotide every four weeks interval. These medications decrease the gut secretions and hence decreases the amount of flow of stools. It prevents rapid transit, allows the gut to absorb nutrients from the gut, and prevent malabsorption.

You can take a low dose of Tricyclic Antidepressant (TCA) medications like tablet Amitriptyline 25 mg at night time. Based on the response you can increase or decrease the dose. These medications reduce rapid transit, reduce gut secretions, and help with diarrhea. However, as I told you, they are not recommended therapies but can be used in an exceptional scenario like this one.

TCA has been frequently used in functional diarrhea FD and Irritable bowel syndrome IBS. You might have lots of concerns regarding these medications, but as in my practice, I have seen people improving with these novel therapies. Let me know your thoughts. At any point, we can reconsider testing you extensively to establish the cause, in case if the above strategy fails.