Articulo Diarrea.

REVIEW

Review: Management of Postprandial Diarrhea Syndrome
Mary E. Money, MD,a,b Michael Camilleri, MDc
a c

Department of Medicine, University of Maryland School of Medicine, Baltimore; bMeritus Medical Center, Hagerstown, Md; Department of Medicine and Physiology, Mayo Clinic, Rochester, Minn.

ABSTRACT Unexpected, urgent, sometimes painful bowel movements after eating are commoncomplaints among adults. Without a clear etiology, if pain is present and resolves with the movements, this is usually labeled “irritable bowel syndrome-diarrhea” based solely on symptoms. If this symptom-based approach is applied exclusively, it may lead physicians not to consider treatable conditions: celiac disease, or maldigestion due to bile acid malabsorption, pancreatic exocrine insufficiency,or an a-glucosidase (sucrase, glucoamylase, maltase, or isomaltase) deficiency. These conditions can be misdiagnosed as irritable bowel syndromediarrhea (or functional diarrhea, if pain is not present). Limited testing is currently available to confirm these conditions (antibody screens for celiac disease; fecal fat as a surrogate marker for pancreatic function). Therefore, empirical treatment withalpha amylase, pancreatic enzymes, or a bile acid-binding agent may simultaneously treat these patients and serve as a surrogate diagnostic test. This review will summarize the current evidence for bile acid malabsorption, and deficiencies of pancreatic enzymes or a-glucosidases as potential causes for postprandial diarrhea, and provide an algorithm for treatment options. © 2012 Elsevier Inc. Allrights reserved. • The American Journal of Medicine (2012) 125, 538-544 KEYWORDS: Bile acid malabsorption; Disaccharidase deficiency; Functional diarrhea; Glucosidase deficiency; Glucosidase inhibition; Irritable bowel syndrome; Maldigestion; Pancreatic insufficiency; Postprandial diarrhea; Trigger foods

Currently, the diagnosis of irritable bowel syndrome is based predominantly upon symptoms listedin Table 1, recurrent abdominal pain coinciding with changes in stool frequency or consistency. The symptom-based diagnosis stems from validation studies that contrasted symptoms with “organic” diseases. For example, in the classical paper of Manning et al,1 there was a comparison of the symptoms of 32 irritable bowel syndrome patients and 33 with organic diseases: 13 duodenal ulcer; 5inflammatory bowel disease; 4 gastroesophageal reflux; 2 gastric ulcer, gallstones, and carcinoma of the colon respectively; and 5 miscellaneous gastrointestinal disorders. Primary care physicians have been advised to make a positive, symptom-based diagnosis of irritable bowel syndrome,2 although the diagnostic accuracy of the symptom-based criteria has not been validated in
Funding: None. Conflicts ofInterest: None. Authorship: Both authors participated fully in the writing of this review. Requests for reprints should be addressed to Mary E. Money, MD, Department of Medicine, Meritus Medical Center, 354 Mill Street, Hagerstown, MD 21740

large patient cohorts where all structural organic diseases, or more subtle digestive disorders, had been definitively excluded.3 Although 50% of patients classifiedas having irritable bowel syndrome complain of postprandial diarrhea, symptom criteria for irritable bowel syndrome do not include the meal association.4 In addition, there are physiological changes stimulated postprandially, such as intestinal secretion, and ileocolonic and proximal colonic transit that may contribute to symptoms including bloating, diarrhea, or urgency.5-7 The diagnostic work-upfor these patients typically focuses on identifying medical conditions with easily detectable abnormalities such as Crohn disease, celiac disease, occult neoplasm, or microscopic colitis. Once these are excluded, physicians may diagnose irritable bowel syndrome based on symptoms. Without further testing of such recommendations, patients also may receive centrally acting medications (such as...