A Case of Severe Diarrhea

No clear diagnosis was made after expensive work up

The patient's diabetic diet restricted calories. He was fond of diet drinks. With every meal he took a diet soda. The doctor told him to quit all diet drinks and food items and avoid lactose. He got better without any expensive medications. What happened?

Diet drinks have unabsorbable substances which cause changes in the bacteria and draw water into intestine leading to diarrhea. The changes in gut bacteria, insulin secretion, and insulin sensitivity make control of blood sugar more difficult. Lactose intolerance is one of the most common causes of diarrhea.

Once these two offenders were out, diarrhea went away and blood sugar got under control. Of course, he still needed to take his medicines for diabetes, but it became manageable with simple less expensive medications.

Return to the Real life cases

Real-life case scenarios

A case of constipation

A young patient had chronic constipation. He had no bleeding, weight loss or loss of appetite. PCP gave treatment including Amitiza (about $250/month cost) and Linzess ($500/month cost). 80% of cost covered by the insurance, and he did not have to pay for it all. But There was no relief for his problem.

He was referred to a gastroenterologist who performed a colonoscopy on him ($3,500+ cost) to evaluate his constipation. It was normal. He was sent back to his PCP. The GI specialist said that he cannot help him any more. The patient was not better.

The patient got a second opinion. Detailed history was taken. This led to the correct diagnosis. Recommendations were made specific to his situation. After following them, he was completely better.

Pearls:

1. This problem requires detailed evaluation by a specialist interested in helping patient.

2. A majority of patients can get better without the expense of colonoscopy and expensive medicines after such an evaluation.

Pitfalls:

1. Marketing affects many. PCPs and specialists are not spared. The expensive medicines Amitiza and Linzess should be prescribed only when necessary and only after above type of evaluation. Insurance may cover most of the cost, but ultimately will have to collect from people for the cost one or the other way - ? increased premium.

2. A colonoscopy is not indicated for evaluation of chronic constipation in the young with no alarm symptoms. This cost and colonoscopy associated risks were not justified.

Colon cancer screening by stool test

Out of available choices, Mr. John Smith chose to have a stool test. He had been hearing about it on the TV and on the radio. It sounded very easy, safe and much less expensive than a colonoscopy. His doctor was supportive of his decision and the test was done. It was positive. Now the doctor wanted him to have a colonoscopy and Mr. Smith followed the advice by having a colonoscopy at a hospital.

Later, he got the bill. He could not believe it. It was more than $6,000, not counting the doctor's fee of less than $500. Importantly, his insurance wanted him to pay deductible and copay. But he thought that the colonoscopy is fully covered as it is a screening test. What happened?

Pitfall: If a patient's stool test for colon cancer screening is positive, then the colonoscopy to investigate it by a colonoscopy is NOT a screening test. It is a diagnostic test. Copay and deductible are going to apply.

Pearl: Before choosing to have a stool test for colon cancer screening, give the above a thought.

A case of upper abdominal pain and H. pylori

A middle-aged patient had persistent upper abdominal pain. She was diagnosed with H. pylori infection. Antibiotics were given. He apparently cleared the infection, but did not get better. An upper endoscopy (EGD) was performed. Not much was found other than mild gastritis without any H. pylori. After some relief, the pain recurred. Another course was given as he tested positive for H. pylori. Multiple imaging tests did not give the diagnosis. He still had the problem. When a colonoscopy was done, he felt better for a few days and 80% of the pain went away. But the problem was back in a short while. He sought second opinion.

The second GI was a good clinician. He took careful history. It turns out that the patient had severe constipation with only a little bit of hard stool every four or five days. He pieced the picture together and explained to her how transverse colon runs across the upper abdomen and can get distended due to blockage by stool in the lower part of the colon. The colon is sensitive to distention. The pain was from that and was relieved with the colonoscopy prep cleaning the colon out.

He did not perform any tests. He advised bowel training and proper diet to improver her bowel habits. The patient improved so much that he said during a visit, 'You are the best doctor. No one else took time to listen to me, understand my problem and give me the right advice.'

Pitfall:

It is common to see that clinical history is skipped in treating patients. This is partly due to pressure to generate better billable note in the computer and pressure from employers of doctors. This can result in unnecessary expense and suffering.

Pearls:

Chronic H. pylori infection is found in many 'normal' people and finding it does not necessarily mean that the pain is due to the infection. Tests are helpful, but to use them appropriately, patients are better off with a good clinician.