Mistakes in... 2022 - 30

ueg education
Mistakes in... 2022
Watery
Stool appearance
Mushy
patients with IBS. Considering the non-approval
of rifaximin for IBS treatment by the European
Medical Agency (EMA), it is advisable to avoid its
widespread use for chronic diarrhoea.
Osmotic diarrhoea
* Magnesium supplements
* Sorbitol in drug-mixtures
* Lactose intolerance aggravation
Secretory diarrhoea
* Microscopic colitis
* Drug induced
Inflammatory diarrhoea
* Malignancy
* Radiation enteritis
* C.difficile colitis, recurrent
Fatty diarrhoea
* Enteropathies (drug induced, autoimmune)
* Mesenteric ischemia, chronic
* Post-surgical
* Chronic pancreatitis
* SIBO
Figure 2 | Aetiologies of chronic diarrhoea that can be considered more frequently at an older age.
Faecal incontinence becomes more prevalent
in older patients (> 65 years) and can be a
contributing or significant cause for symptoms
communicated as diarrhoea. A careful clinical
history and a digital rectal exam will be crucial in
diagnosing. If incontinence is frequent, especially
with low-volume stools, these patients should
primarily be evaluated for incontinence, not
diarrhoea.
Among the inflammatory aetiologies
explaining diarrhoea in the elderly, Clostridioides
difficile infection is highly considered and tested
for using glutamate dehydrogenase assay or
nucleic acid amplification test,24
where an
enzyme immunoassay confirms positive results
for C. difficile toxin A/B or toxigenic culture.
Confirmation should involve toxin testing or
toxigenic culture if considering a recurrent
infection. The bacteria and spores can be
excreted for an extended period (weeks) after
the infection has been successfully treated.
Mistake 6 Improper use of medical therapy
The most common medication to treat chronic
diarrhoea is the synthetic peripheral μ-opioid
receptor agonist loperamide. It effectively reduces
diarrhoea due to many aetiologies with a benign
side effect profile (constipation) and a wide dose
range of up to 16 mg/day. A mistake that needs to
be avoided is that some patients are reluctant to
use the doses needed due to a misconception of
the risk for drug-dependency, which healthcare
providers should firmly negate. Another problem is
related to patients with IBS-D that may experience
worsening in abdominal pain from loperamide.
Among treatments aimed at specific
aetiologies of chronic diarrhoea, bile acid
sequestrants can wrongfully be discarded as
ineffective before their appropriate evaluation.10
The most common treatment choice is
cholestyramine, but it is unclear if this
medication should be taken with a meal or not
to achieve optimal effect. The recommendation
18
regarding dosage with a meal is based on treating
hypercholesterolemia and not on studies of bile
acid diarrhoea. From a practical perspective,
starting with a trial of 4 g twice daily if taken
with a meal is recommended. If this approach is
ineffective, adding a dose late in the evening can
be considered. The dose range is also uncertain,
but if tolerated, 4-24 g/day is harmless based on
clinical experience and when doses are divided
appropriately. The risk of interfering with other
medications and reducing their absorption must
be also acknowledged. This can be avoided by
not administering bile acid sequestrants within
an hour after, or 4-6 hours before intake of other
medications. For those not responding to or
not tolerating cholestyramine, colestipol
and colesevelam are valid alternatives. It is
encouraged to perform an objective test (golden
standard selenium-75 homotaurocholic acid test
[75
Se]Se-HCAT) for bile acid malabsorption if this
has not been previously done i.e., in those
where the treatment trial period also had a
diagnostic purpose.
The 5-HT3
antagonists alosetron and
ramostron are effective for treating chronic
diarrhoea but they are only available through
prescription in parts of the world. Therefore, an
off-label alternative in non-responders to
loperamide is the 5-HT3
Mistake 7 Failing to use dietary therapy
properly
Many patients often highly appreciate dietary
advice that can help reduce diarrhoea. There are
no clear clinical or biological predictors for
symptomatic response to dietary adjustments,
but current knowledge gained from the IBS field
may be of some help.27
The best use of dietary
advice should ensure that no unnecessary
avoidance behaviour is promoted, and the general
recommendation on healthy eating should be
transferred to the patient. The first line of dietary
treatment for diarrhoea that is not due to a
readily identifiable cause, e.g., coeliac disease,
milk protein allergy or other less common
identifiable immune reactions to food items,
should focus on the general guidelines of healthy
eating. It includes not skipping meals, paying
attention to the speed and the environment of
where the patient eats, portions, and frequency of
meals. Few scientific evidence exists on the effects
of this advice on specific symptoms. However,
clinical experience supports the effectiveness of
this approach on some patients.
As a second step, exclusion diets can be
tested. A mistake that should be avoided is not
having the patient do this with the guidance of a
trained dietitian. Among the exclusion diets, the
scientific evidence is most robust for a diet low
in fermentable oligosaccharides, disaccharides,
monosaccharides, and polyols (FODMAP) that can
lead to symptom reduction in IBS, in particular
in IBS-D.28
The short-term risks with this type of
antagonist ondansetron,
used for chemotherapy-induced nausea and
vomiting. There is little evidence supporting its
use in patients with chronic diarrhoea. However,
a randomized placebo-controlled trial in IBS-D
supports the use of a wide dose range (4-24 mg/
day) as a second-line treatment for diarrhoea.25
Antibiotic treatment in SIBO is not
controversial if the clinical manifestation has
a sound evidence base regarding its link to
SIBO.20
Generally, data supports the beneficial
effect of a planned rotating treatment schedule
in SIBO.26
The use of rifaximin in patients with
non-constipated IBS is still debated. It would
be beneficial to identify a biomarker that better
defines its proper use in a smaller proportion of
restrictive diet are probably negligible. However,
long-term risks related to inadequate nutrition,
socially restricting dietary habits, and fear related
to eating must be prevented. Many patients, even
before seeking healthcare, often test other diets,
including gluten and a lactose-free diet. These
are less restrictive, and healthcare providers
should not contradict improvement symptoms
experienced by the patient. However, this
mechanism should be assessed further to
appropriately treat the correct diagnosis: coeliac
disease, non-coeliac gluten sensitivity, wheat
sensitivity, lactose intolerance, food intolerance
related to IBS, wheat allergy and others.
Mistake 8 Failing to use augmentation
therapy
One therapeutic option might not lead to
sufficient diarrhoea control for many patients.
A severe mistake in such circumstances is to miss
out on therapies that have had some effect,
perhaps restricted by side effects in adequate
doses, or have an overall good treatment

Mistakes in... 2022

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