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Key Features

  • Chronic or intermittent watery diarrhea with normal-appearing mucosa at endoscopy

  • Much more common in women, especially in the fifth to sixth decades

  • Cause is usually unknown

  • Several medications have been implicated as etiologic agents, including

    • NSAIDs

    • Proton pump inhibitors

    • Low-dose aspirin

    • Selective serotonin reuptake inhibitors

    • Angiotensin-converting enzyme inhibitors

    • β-Blockers

  • Diarrhea usually abates within 30 days of stopping the offending medication

Clinical Findings

  • Chronic or recurrent diarrhea

  • May remit spontaneously after many years

  • A more severe illness may develop in a subset of patients and is characterized by

    • Abdominal pain

    • Fatigue

    • Dehydration

    • Weight loss

Diagnosis

  • Serologic testing (IgA tissue transglutaminase antibody [or IgA tTG]) can exclude celiac disease, which may be present in up to 20% of patients

  • Sigmoidoscopy or colonoscopy with biopsy

  • Histologic evaluation of mucosal biopsies shows chronic inflammation in the lamina propria and increased intraepithelial lymphocytes

Treatment

  • Loperamide

    • First-line treatment

    • Provides symptom improvement in up to 70%

  • Delayed-release budesonide (Entocort EC)

    • 9 mg once daily orally for 6–8 weeks has demonstrated efficacy in controlled studies

    • However, clinical relapse is common after cessation of therapy

    • Remission is maintained in 75% of patients treated long term with low doses

    • In clinical practice, budesonide is tapered to the lowest effective dose for suppressing symptoms (3 mg every other day to 6 mg daily)

  • 5-Aminosalicylates (sulfasalazine, mesalamine) or bile-salt binding agents (cholestyramine, colestipol) may be effective for patients who do not respond to budesonide

  • Immunosuppressive agents (azathioprine or methotrexate) or anti-TNF agents (infliximab or adalimumab) may be given for refractory or severe symptoms (which occur in < 3% of patients)

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