From the Guidelines
For a 25-year-old female with BMI 16 and intermittent abdominal pain with diarrhea, a comprehensive work-up focusing on both gastrointestinal disorders and potential eating disorders is essential to prevent further nutritional deterioration and complications. The initial evaluation should include a complete blood count, comprehensive metabolic panel, thyroid function tests, C-reactive protein, erythrocyte sedimentation rate, and albumin levels to assess nutritional status and inflammation 1. Stool studies, such as culture, ova and parasites, Clostridioides difficile toxin, fecal calprotectin, and fecal occult blood testing, are crucial to identify potential infectious or inflammatory causes 1.
Given the patient's low BMI, it is also important to consider the possibility of eating disorders, such as anorexia nervosa, which can present with gastrointestinal symptoms 1. Therefore, a psychological assessment for eating disorders should be performed. Screening for anxiety and depression should also be included, as these can exacerbate gastrointestinal symptoms.
The British Society of Gastroenterology guidelines recommend that patients with chronic diarrhea should undergo initial investigations, including blood and stool tests, in primary care 1. If alarm features, such as unexplained change in bowel habit, persistent blood in the stool, and unintentional weight loss, are detected, referral for further investigations, including endoscopic evaluation and abdominal imaging, should be initiated 1.
Key components of the work-up include:
- Complete blood count and comprehensive metabolic panel to assess for anemia, electrolyte imbalances, and kidney function
- Thyroid function tests to evaluate for hyperthyroidism
- Stool studies to identify infectious or inflammatory causes
- Celiac disease screening with tissue transglutaminase antibodies and total IgA
- Psychological assessment for eating disorders
- Screening for anxiety and depression
- Endoscopic evaluation with upper endoscopy and colonoscopy with biopsies, if necessary, to evaluate for inflammatory bowel disease, microscopic colitis, or celiac disease
- Abdominal imaging with ultrasound or CT scan to identify structural abnormalities.
By prioritizing a comprehensive work-up, clinicians can ensure that the underlying cause of the patient's symptoms is identified and addressed, ultimately improving morbidity, mortality, and quality of life outcomes 1.
From the Research
Initial Assessment
- The patient is a 25-year-old female with a BMI of 16, indicating severe malnutrition, and is experiencing intermittent abdominal pain with diarrhea 2.
- The patient's symptoms suggest a potential gastrointestinal disorder, which can have a significant impact on nutritional status.
Potential Causes and Complications
- Chronic diarrhea can lead to malabsorption, resulting in nutritional deficits and further exacerbating the patient's malnutrition 2.
- The patient's severe malnutrition may be contributing to impaired immune function and poor mucosal recovery, potentially perpetuating the cycle of diarrhea and malnutrition 2.
- Food intolerance or an inappropriate diet may also be contributing to the patient's symptoms, and self-imposed dietary restrictions could worsen malnutrition 2.
Treatment Options
- Disease-specific treatment, combined with appropriate nutritional counseling and intervention, is recommended to prevent and treat malnutrition in patients with chronic diarrhea 2.
- Loperamide may be an effective therapy for managing diarrhea, particularly in patients with painless diarrhea or diarrhea-predominant irritable bowel syndrome 3.
- Enteral or parenteral nutrition may be necessary to treat severe caloric and micronutrient deficiencies, particularly in patients with intestinal failure or those unable to maintain oral or enteral nutrition alone 4, 5, 6.
Nutritional Support
- Parenteral nutrition can improve clinical outcomes in patients with malnutrition and intestinal tract dysfunction, but it is not without risks of serious complications 4, 5.
- Enteral nutrition may be a safer and more effective option for patients with intestinal failure, and can be used in conjunction with intestinal rehabilitation techniques to enhance absorptive capacity of the remnant bowel 6.