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Suggest treatment for gas, stomach cramps and greasy stools

Answered by
Dr.
Dr. Suresh Raghavaiah

Gastroenterologist, Surgical

Practicing since :2003

Answered : 164 Questions

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Posted on Mon, 8 Sep 2014 in Digestion and Bowels
Question: Hi, I am 30 year old male from XXXXXXX I have been suffering from various digestive problem and some other problems since 2004. I want give you a brief summary about my diagnosis, treatment and its effect in chronological order.
1. I started feeling a kind of discomfort and incomplete evacuation in XXXXXXX 2004 as I remember. After a month I had heavy diarrhea lasted in 4-5 days with coffee like color and mucus followed by severe constipation. Constipation continued in a way that I couldn't pass stool 3-4 days and it was so hard and brown in color. I reached to general physician. They prescribed me some medicine but couldn't help me a bit.
2. Then after 4-5 month I sought help of gastroenterologist. Blood profile, endoscopy and ultrasound done on Nov 2004. He said no serious prob, have gastritis, given medication but it hadn't helped me.This episode was used to end with heavy diarrhea in the in interval of 2-3 months. This sequence continued for over a year.
3. Over a time my constipation relieved , started having gas, bloating, undigested food in stool, bowel noise, stomach pain and discomfort, sudden pass of stool some time hard in form of nuts, some time greasy, some time loose with different color. Along with that I started having others problem like burning sensation through out my body, fatigue, watery skin rash, muscle twitching, tingling and anxiety. I continued to meet different doctors, but there was nobody to address my problem.
4. Finally I reached to Asian Institute of gastroenterology, XXXXXXX in Aug 2006. Majority of diagnosis ( endoscopy, biopsy, barium test, colonoscopy, many blood tests, urine and stool test) done. Doctor told me to have ulcer and inflammation. Given treatment for 3 months with PPI and some other medicine. It didn't solve my problem. Finally he told me don't be afraid. It will be cured slowly. And your symptoms will reduced over the time.
5. Than I wasted my 3 year to see the result. Oh my God what the hell these doctor knows. My symptoms were getting clustered. I started having Irritation, Insomnia, health deteoriation and loss in weight and appetite I could not sleep whole night because of stomach rumbling and pain. Immediately I reached to a gastroenterologist, He has done some tests and said you don't have ulcer now. It may because of Irritable bowel syndrome. Given some medication and said reduce stress and manage your diet. Sleep in time and eat in time. But it was not going help me because all these disruptions caused by some unknown cause.
6. Since I did not have any earlier reports of my diagnosis of before 2010. I tried to consolidate all the reports once again to reach some conclusive point and to get tested for IBS, IBD, celiac, SIBO etc. in different hospital.
I want to share with you some points of reports.
Asian Institute of Gastroenterology (Once again in 2013)
a) Endoscopy--Normal.
b) D2 Biopsy(Single bit measuring 0.2 cm )
Microscopic Descp: normal villous to crypt ratio, normal number of intraepithelial lymphocytes, areas of ulceration, denudation, lymphoplasmacytic infiltration of lamina propria.
Impression: No significant changes seen. Negative for MAS/ malignancy/ parasites.
c) Colonscopy: Normal
Impression: Sigmoid colon hyperemia with mucosal edema.
d) Ultrasound: Normal
e) Complete blood picture, thyroid profile, biochemistry etc.---will attach them.
They said nothing wrong, Then I asked "why these all problems are there. I am living in a hell. Can you assume a life of a person cannot eat well, cannot sleep well, cant work properly." He simply given nexpro rd, neurozac cap and cremadite. I asked him about further test for celiac and SIBO. He didn't listen to me and said have this medicine for 3 months and come after that. I took this medicine for 13 days it starting creating problem for me too much gas, cramping, lumpy and greasy stool, increased stomach pain. I thought medicine is not leading me in right direction. I started looking for breath test and celiac disease.
7.In Oct 2013 I went VGM hospital, XXXXXXX Because there is available, Lactose, hydrogen and urea breath test.
Find report detail from there
a) Urea breath test (H Pylori ---positive)
b) Glucose breath test-- Negative
c) Lactose breath test-- negative
d) TTG IGA, serum-- 1.8
I have been told you have h pylori infection, given one week antibiotic treatment followed by some other medicine for one month. And said u can come after 3-4 month for further evaluation. During course of antibiotic treatment I felt great relief, No gas, No bloating and good stool formation. After one week problems started again. I cut milk and wheat from my diet. It relieves my symptoms 20-30 %. But problems are always there. I am highly malnourished, did not gain weight for last 5 years. Its around 55 kg with height of 5.10".
My vitamin B12 is low it is 240 pg/ml. RBC is low 4.4, HG is fine it is 15.4 but have increased MCV and MCH i.e. 102 and 35. What does this indicate ?
8. I again went VGM hospital in May 2014 for further evaluation.
They performed test:
a) Lactose intolerance : No
b) Endomysial IGA Antibodies (IFA) Not detected < 1:10
C) Gastroscopy : Passed up to jejenum for Bx foe HPE -----------------will attach that'
shows H Pylory : Negative
Jejunal Biopsy: The jejunal mucosa shows patchy villous atrophy C : V ratio 1 : 2 to 1 : 3. There is an increase in the theliocyte number and lamina proprial congestion, edema with neutrophils and cells in the lamina propria ----suggestive of Nonspecific 'Infective' Jejunitis. There are no granulomata. There are no Gardia. There is no dysplasia or infiltrative malignancy.
They said you don't have celiac desease and lactose intolerance. Given some medicine and probiotics.
It does help me much. Problems are as much as before. But not taking wheat and milk product are helping me some how. Could you please suggest me something what is wrong with me. what test should I look for further clarification. I am fed up with doctors attitude towards me. They don't listen until u have serious life threating disease. I am helpless, hopeless and completely frustrated now.
Currently I am having stomach pain, cramping, rumbling, undigested food in stool. Different type of stool in shape and color. there is not fix time for passing a stool. Some time 3 motion a day sometime only one. Additionally fatigue, burning pain in whole body, muscles twitching and cramping. tingling and sleep problems.
doctor
Answered by Dr. Suresh Raghavaiah 20 hours later
Brief Answer:
H pylori with Vit B 12 defeciency

Detailed Answer:
Hello Mr XXXXXX,
Thanks for writing in to HCM. My name is Dr Suresh Raghavaiah and I am a liver transplant surgeon. I hope to answer your question today.
I am sorry that you are having all these symptoms and i am sorry that medications have not been able to help you. I can understand the frustrations you must be going through and I hope I will be able to help you.
First of all thank you very much for the detailed history and the excellent cataloging of the various reports. It makes my job that much easier. After looking over all your symptoms and all your blood reports, two things which jump out are; you do have a H Pylori infection and a blood picture suggestive of Vitamin B 12 deficiency. When the level of Vitamin B12 is low, the red blood cells become larger than normal (indicated by the raised MCV). Vitamin B12 deficiency can also affect the nerves and can causing tingling and numbness of the hands and feet, irritability, "pins and needle sensation" in the skin and other symptoms. It can also lead to difficulty in thinking in some people. It has also been linked to depression and mania and long standing deficiency can lead to permanent brain damage.
The next question to be addressed is the cause for Vitamin deficiency. The most common cause for any vitamin deficiency in XXXXXXX is poor dietary intake. You have yourself confessed of poor eating habits. Vitamin B12 is normally synthesised by bacteria in the gut and is found in large amounts in foods of animal origin (Meat, fish, eggs, fortified milk, etc). So people who are strict vegetarians usually suffer from Vitamin B12 deficiency.
The second commonest cause of Vitamin B12 deficiency is bacterial infection of the intestines. This is usually seen if there is a blockage of the intestine or in cases of misuse of antibiotics. The good bacteria which produce B12 will be suppressed by the infection or the overuse of antibiotics and so the amount of Vit B12 produced is decreased.
By looking at your detailed history, it is my personal opinion that most of your symptoms will disappear if your H.Pylori infection and Vitamin B12 deficiency are treated.
You did mention that you took one week of antibiotics for the H pylori infection. This usually cures the infection and it has to be followed up by two weeks of antacid therapy (pantoprazole, omeprazole or rabiprazole). If you do not get relief from this I would repeat the anti H.pylori treatment and take antibiotics for one more week.
Regarding your Vitamin B12 deficiency, I would start eating foods which are rich in Vitamin B12. If you are a vegetarian, then there are Vitamin B12 fortified foods available in the market (cereal, Milk, Cheese, Paneer, Tofu, etc) which can provide adequate Vitamin B12 to you. Or you could also visit a local practitioner and get a injection of Vitamin B12. In addition I would suggest you start taking a multivitamin tablet everyday to build up your stores.
Coming to the last aspect, your bowel movements can vary in the normal course of life ranging from 1-4 stools per day. You did state that your stools look greasy. So I would suggest a test for looking for the amount of fat in your stools (Fecal fat estimation test). In addition to this I would suggest a Liver function test, Peripheral smear, serum amylase and lipase levels and a stool routine examination.

I am again sorry for all the symptoms you have been having. Hope this discussion helps you and Please do get back to me with all the reports I have asked for. Please do not hesitate to contact me for further details

Dr Suresh Raghavaiah

Above answer was peer-reviewed by : Dr. Prasad
doctor
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Follow up: Dr. Suresh Raghavaiah 8 hours later
Thank you Sir for your detailed response. I hope you might have seen my latest gastroscopy report which I had attached with my earlier post, which is showing that I don't have H Pylori infection now. I had already taken second round of antibiotic with pylokit for one week. And last year I had taken 8 days antibiotic refaximin for presuming SIBO.

Sir I want to know some points from your side.

1. As per TTG IGA and EMA I don't have celiac disease, and still supported by that I am not having diarrhea. But what why I get some relief when I exclude wheat from my diet. And same thing is true for milk product.

2. Can you please put some light on my jejunal biopsy report----what does that indicate like patchy villious astropy....increased theliosyte...lamina proprial congestion...edema...Nonspecific infective jejunitis...etc...

3. After taking antibiotic there is much gas formation and undigested particle in my stools. I think antibiotic created this. So I don't want go for it anymore. My stool has very unpleasant metallic or chemical odor. I don't know what is causing this. I have attached a pic of my stool that I generally have. I have greasy stools when I eat wheat product.

4. When I meet a gastroenterologist for my condition. They see all my reports normal they think I am exaggerating about my symptoms and say you have IBS nothing else stop going to meet deferent docs and wasting your money. Simply they prescribe some medicine like antispasm, SSRI, Cremadite..etc and ask me to go. I have been fed up with there attitude. If I will ask him about the test you have asked I don't know how will they react. Next week I am going meet a dietician for my diet plan. I will ask him to perform such test. I already have Liver function test, Kidney fn Test and stool test. They are normal. I had attached some of them. Please see in the attachment.

5. I hope you will guide me in such a way so that I can move forward positively. I will start taking multivitamin and manage my diet with the help of dietician so I can recover.

Note: My all the attached reports lies between Sep 2013 to May 2014. Please see the date if you have any confusion.
Once again thank you for positive feedback and Please help me so I can live a normal life.
doctor
Answered by Dr. Suresh Raghavaiah 1 hour later
Brief Answer:
Gluten sensitivity is not same as celiac disease

Detailed Answer:
Hello again Mr XXXXXX,
I am sorry that you have been running into difficulties with doctors, but I would advise you to stick to one specialist and let him run out of all options before consulting another specialist. Most doctors utilise a step-ladder approach to treating any condition - meaning they will give you the mildest of the drug first and then drugs of increasing potency. So if you do not follow up with your regular doctor, you might not be getting the full benefit of his expertise or the full benefit of the treatment. Now let us address your concerns.

1. Celiac disease is a condition where antibodies formed to certain wheat products damage the lining of the intestine and leads to diarrhoea, bloating and mal-absorption. The most common antibodies encountered are TTA and EMA (tissue transglutaminase and endomysial antibodies). I do understand that your antibodies are negative and your small intestinal biopsy is not suggestive of celiac disease. But the most important thing which every one forgets is celiac disease is NOT the ONLY disease due to gluten sensitivity. There are many more antibodies other than TTA and EMA which can be formed and lead to the same clinical symptoms (nausea, bloating distention, flatulence and diarrhoea). So just because your TTA and EMA are negative does not mean you do not have gluten sensitivity. Testing for all these antibodies would not be very beneficial and the easiest thing to do is to avoid wheat and dairy products...especially since it is working for you and makes you feel better.

2. I would not concentrate on your jejunal biopsy report as it is negative for celiac disease. As the report rightly says it is non-specific inflammation which means it will go away by itself.

3. Antibiotics are appropriate when required. Over use of antibiotics not only causes development of resistant strains of pathologic bacteria, but also kills of the beneficial bacteria in the intestine which helps us digest a lot of food products and also helps in the absorption of nutrients. This could very well explain why you feel bloated and pass undigested food material in your stools. I would recommend you to take a over the counter probiotic to help the beneficial bacteria grow back in your intestine.

4. I understand that the gastroenterologists may not be ready to prescribe you the tests. But you could go to any private laboratory and ask them to do the test. And I am happy that you are working with a dietician to formulate a diet plan.

Please do not feel disheartened by your symptoms. I am sure you will start to feel better soon. And please do not hesitate to contact me for any further clarifications

Dr Suresh Raghavaiah
Above answer was peer-reviewed by : Dr. Shanthi.E
doctor
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Follow up: Dr. Suresh Raghavaiah 48 hours later
Thank you Sir for making me aware of "Non Celiac Gluten Sensitivity. I Don't know what is wrong with me Whether it is IBS, SIBO or Food Sensitivity (like gluten sensitivity). May be Gluten sensitivity or bacterial overgrowth have caused malabsorption. That's why I am so malnourished and underweight. So I think I should get tested for vitamin profile and some other deficiencies.
Yesterday I went to meet a gastroenterologist Whom I already had 3 appointment earlier last year. I just explained my all symptoms and asked him that my health is deteriorating and muscle wasting appearing in my shoulder and thigh. He asked me how much weight loss happened. 'It was 2 kg in last 4 month' I said. And I explained that it is fluctuating b/w 54-57 kg. I never went down less than 54 and more than 57 kg in last three years. He remembered me and seen all my reports. And He told me when will you stop. You went AIG Hyd, VGM Hospital XXXXXXX in last one year. If anything would be wrong they could not miss it. Stop wasting money. Your reports are normal. You must stop now. I said " I won't stop till I have a hope. And as far as money is concern it is never important than life. You shouldn't bother about my money. I am doing job. I am salaried employed. I am not asking money from anyone for my treatment. I am living in a hell and I am ready to pay any cost to come out from this hell".Then he asked what can I do now. I ask him to perform the test which you have asked me. He said you already peripheral smear included in hematology report and stool routine is normal. Then he was ready for the other tests. And referred me to dietician in same hospital (i.e. XXXXXXX Birla hospital pune). And he prescribed me medicine surbext XT, and XXXXXXX CR 2.5. which was his duty professionally.

Then I went to private lab pathology ( thyrocare ). Along with serum amylase and lipase levels I asked him to perform some other test like vitamin profile, renal profile, folic acid, Iron deficiency, complete hemogram and liver profile. These tests will be ready by tomorrow evening. There was no test for fecal fat estimation there. I will go in some different pathology for this test. Is it same "sudan stain for stool fat'? Because when I called him he was explaining this one instead of fecal fat estimation. And Please do let me know that I need any special instruction before this test, like what to eat and what not to eat and what should I ask before testing etc.

I will delete all previously uploaded attachments and will attach new reports once they are ready. I hope you will review all my these new report and will provide proper guidance. what deficiencies, and problem are there. So I could take nutrition with the help of you and my dietician.

Thank you.

doctor
Answered by Dr. Suresh Raghavaiah 14 hours later
Brief Answer:
Good to work with Dietician

Detailed Answer:
Hello Mr XXXXX,
I apologize for the delay in getting back to you.
I understand your apprehensions again. But I don t think getting your vitamin levels checked is going to help us anyway in coming to a diagnosis. I am sure the results will be borderline normal or on the lower side given your malabsorption. I think treating your vitamin deficiency empirically makes more sense I understand you are already taking multi-vitamin supplements.
Regarding the fecal fat estimation test, Sudan red staining for fat will suffice as I am not sure if any Lab in XXXXXXX does a quantitative estimation.

I would continue to encourage you to follow a gluten free diet. There are thousands of people around the world leading normal lives with gluten sensitivity. I would advise you to do the same and not let the disease control your life.

Please do get back to me with the reports and we will discuss this further.
And as always do not hesitate to get back to me for any further clarifications

Dr Suresh Raghavaiah
Above answer was peer-reviewed by : Dr. Bhagyalaxmi Nalaparaju
doctor
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Follow up: Dr. Suresh Raghavaiah 10 hours later
Hi Sir,
My all reports has come except "Sudan stain Fat test". I want to share some of them. Because I have my appointment with dietitian on Thursday 10 AM. Before that I want to know some finding suggestions from you.

Please find the following point on the reports. Possibly I will attach the specific reports which you need.

1. In my HBA Hemogram all values are falling in reference range. If you need some of them to correlate with other finding, I will share those.

2. These are the specific tests with values, I want to share. Amylase 60 U/l, LIPASE 34 U/l, FOLIC ACID 7.2 ng/ml, IRON 87.56 microg/dl, TIBC 303, %transferrin saturation 28.87 %.

3. Only I have found abnormality in my vitamin profile.
where 25-OH VITAMIN D ( TOTAL ) is 10.95 ng/ml. and VITAMIN B12 is 235 pg/ml.

My assumption:
I think because of vitamin D deficiency I am having burning needle like sensation, muscle spasm and twitching and Vitamin B12 deficiency is causing mood related disparity like poor memory, depression, mania etc that's what I am going through. I also think my small intestine is not absorbing enough nutrients that's why I am seeing lots of undigested food in stool having gas and distension may be caused by bacterial fermentation. One thing want to highlight here that I am not having any problem with my upper abdomen like nausea, belching, acidity and vomiting etc. I never had these problems. Instead of that I have been given acid suppressor like antacid, PPI many times by gastro physicians.

My vitamin profile included only these two vitamins.

Can you suggest me what test to be performed for calcium, magnesium, Vitamin K etc and other test related to my symptoms. so I can ask my dietician for those test.

My stool test for fat will come in 2-3 days. That will determine if there is any degree of malabsorption.

Sir I am expecting comment on this from your side. And also want to know how to move further from here.

Thanks and regards


doctor
Answered by Dr. Suresh Raghavaiah 12 hours later
Brief Answer:
No other tests required

Detailed Answer:
Hello Mr XXXXX,
I hope things went well with your dietician. After looking over your reports, i am happy that almost all values are in the normal range. Your vitmain D levels are definitely low, but that is very easy to treat. Spend some time in the sun (Take a walk in the early morning sun). Your skin will synthesise adequate levels of Vitmain D. In addition, as we discussed earlier, it will be beneficial to take a multi-vitamin supplement everyday.

Please do let me know how the meeting with your dietician goes.

And as always, do not hesitate to contact me for any further clarifications

Dr Suresh Raghavaiah
Above answer was peer-reviewed by : Dr. Shanthi.E
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