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Having nausea and stomach pain. Episodes of watery diarrhea. Suffer abdominal pain and bloating. Cure?

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Practicing since : 1996
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Thank you for looking into my gastroenterology question.
I am a 31 year old female. I have seen my family physician and yesterday a gastroenterologist for a change in bowel habits that started 6 months ago.
The present complaints started acutely after having been out for dinner with my husband. I was woken up at night by nausea and stomach pain. I had an episode of watery diarrhea, no blood. A couple of days of acute diarrhea followed, with 2-4 bowel movements per day. Afterwards the symptoms improved but a few weeks later I realized that my bowel movements were not as they had been in the past: they continued to be loose.
In the couple of months that followed I realized that on top of the loose bowel movements I am also passing a lot of gas, this often being the first thing that happens when I sit on the toilet. There is bloating, some days more than on others. I also have some lower abdominal pain, again, of variable intensity. Sometimes there are also sharp pains, often accompanied by an urgency to go to the washroom. The pain is often either relieved or improved my having a bowel movement.
Currently, 6 months after the onset of these symptoms I continue to have looser stools, with variable abdominal pain, flatulence and bloating. The stools are sometimes well formed, but still not as thick as they used to be, and sometimes looser. On most days I have 1 or 2 bowel movements.
That would be the history.

I have seen my family doctor in July, after 3 months of symptoms.
He performed routine blood work as well as a Stool culture + Ova and Parasites. Everything came back negative, blood work normal.
We decided to book an appointment with a gastroenterologist, as I said I would feel best to have a colonoscopy done as well.

I saw the gastroenterologist yesterday, but it was a very short encounter. I think we spent about 7-8 minutes together.
I described the above history. She asked whether I have a family history of GI problems. My grandfather was diagnosed with Crohn's disease when he was in his 80s. There is some ambiguity about my grandmother. She had very advanced Alzheimer's disease when she had an episode of urinary retention, and it was seen on ultrasound that she has a lower abdominal tumor, but it was not established whether it was coming from the bladder or colon. Further tests were not done as she passed away a few days later.

The gastroenterologist just said that it is worth looking into the matter further and that we should book both an EGD and a colonoscopy.
I have 2 very important exams in November and I wasn't sure whether I shouldn't wait until after my exams to have further investigations done.
I have asked the doctor what she thinks about my condition.
She just said that it's hard to say.

I decided to proceed with the endoscopies as soon as possible then, and I am having both done in a little over a week.

I just wanted to ask another opinion until then though, as I see I can't concentrate well on my studies today, and if it's nothing that will keep me from going to my first exam in 5 weeks, 1 week of studying is extremely important.
I am the first person who wanted a colonoscopy done, because functional diseases are a diagnosis of exclusion, and one must rule out other more serious diseases. Still, I was hoping the gastroenterologist would share her thoughts a little, as to her primary diagnosis and the main differentials. I found it unsettling that it was so hard to say what the most likely diagnosis is.
I guess this is why I'm here.
I am perfectly aware there is no way of knowing for sure, and I guess she did not want to waste time hypothesizing what it could be, when she will have a look and know for sure soon.
Still, I would appreciate your thoughts. Sorry for the lengthy message.

Thank you, XXXXXXX
Posted Sun, 20 Oct 2013 in Digestion and Bowels
Answered by Dr. Ratnakar Kini 10 hours later
Brief Answer:
Detailed answer given below

Detailed Answer:
Thanks for posting your query.
I am Dr.Ratnakar Kini and I am pleased to assist you.

I went through your post.
It looks like you are having symptoms of post-infectious irritable bowel syndrome.
But before calling it as IBS, oraganic causes should be ruled out.

Routine blood work and stool tests have been already done.
Other tests that need to be done include blood glucose test, thyroid function test, test for celiac disease, an EGD with biopsy from duodenum and a colonoscopy.

Till all these tests are done, consider taking probiotic supplements.
Let me know if I can assist you further.
Dr.Ratnakar Kini
Above answer was peer-reviewed by
Follow-up: Having nausea and stomach pain. Episodes of watery diarrhea. Suffer abdominal pain and bloating. Cure? 15 hours later
Thank you for your reply, Dr XXXXXXX Kini

Functional diseases are always a diagnosis of exclusion, so I definitely want to have confirmation that it is nothing organic, hence the colonoscopy and EGD.

Blood glucose and TSH were done as well, and they are normal.
Celiac desease is unlikeley, there is no steathorrea and the bloodwork does not reflect any defficiencies that would result from malabsorption.
The biopsy from the duodenum would be to check for celiac disease, right?

How about Crohn's disease and Ulcerative Colitis? Is it enough if the colon looks fine macroscopically, or would some biopsies from the colon and maybe terminal ileum be taken as well?

Thank you, XXXXXXX
Answered by Dr. Ratnakar Kini 5 hours later
Brief Answer:
Detailed answer given below.

Detailed Answer:
You seem to be very knowledgeable!

Good to hear that blood glucose and TFT are normal.

You need not have steatorrhea to suspect celiac. Celiac can be atypical also. We always test for celiac also in patients whom we suspect functional diarrhea.
Biopsy from duodenum is for celiac and other malabsorption syndromes. Giardiasis also present with bloating, gas and loose stools. Stool test may miss it. But biopsy and duodenal aspirate may diagnose it.

For Inflammatory Bowel Disease, multiple biopsies would be helpful.
Let me know if I can assist you further.
Dr.Ratnakar Kini
Above answer was peer-reviewed by
Follow-up: Having nausea and stomach pain. Episodes of watery diarrhea. Suffer abdominal pain and bloating. Cure? 38 hours later
Thank you so much for your helpful, informative reply, Dr XXXXXXX Kini!

2 follow-up questions, as I have noticed the gastroenterologist I am seeing is very brief in her answers, and has a very non-reassuring manner:

For inflammatory bowel disease, would you take biopsies regardless of the macroscopic aspect of the colon? Can Crohn's or Ulcerative Colitis be present even though the colon looks fine?
I think even if everything looks fine with the naked eye, you would still want to collect some biopsies, to rule out microscopic colitis, for example.

How about cancerous or precancerous lesions? Can they be excluded in the absence of polyps, adenomas, or any other lesion that looks suspect, or can you actually never be sure (there may always be a carcinoma in situ in the colonic mucosa, that the endoscopist has no way of identifying).

Thank you for your time, XXXXXXX
Answered by Dr. Ratnakar Kini 1 hour later
Brief Answer:
Detailed answer given below.

Detailed Answer:
You really know a lot of things in gastroenterology.

Biopsy is usually taken when obvious lesions are present. The disease may however exist in a quiescent state without mucosal lesions. But in that case, you may not be having any bowel symptoms. Moreover Crohn's can involve any part from mouth to anus and colonoscopy and gastroscopy do not screen the entire GI tract and lesions in the small bowel may be missed and may require other tests like a capsule endoscopy or an enteroscopy or a barium meal follow through if Crohn's is suspected.
And also like you said, microscopic colitis is diagnosed only with biopsy and colonoscopy may look normal.

Cancerous lesions can be excluded if the mucosa is normal and if there are no polyps or DALM ( Dysplasia Associated Lesions/ Mass). But lesions may be missed if they are behind folds. Virtual colonoscopy is better in this aspect as they do not miss lesions behind the folds. But the negative points are biopsy cannot be done if there is a lesion and also it may show false positive lesions.

Let me know if I can assist you further.
Dr.Ratnakar Kini
Above answer was peer-reviewed by
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