My patient pooped after every meal, had diarrhoea and pain for 5 years: Why doctors could not diagnose a common gut health problem

Sometimes inflammatory bowel disease doesn’t show up in blood and stool tests, can happen without fever and fatigue

Crohn’s disease is most commonly characterised by diarrhoea, stomach cramps and abdominal pain. (Image/Pixabay)

This is an unusual case of one of the commonest gut issues that went undetected for five years. A 50-year old woman just couldn’t hold her food in, would rush to the loo immediately after having a meal, had bouts of bloating, diarrhoea and abdominal pain, even vomiting. But since she didn’t lose weight or have fever and fatigue, most of the doctors she consulted thought it was irritable bowel syndrome (IBS), a gastrointestinal disorder where the digestive tract appears normal but does not function correctly. She learnt to live with it and had regular gastric pills.

Her symptoms worsened in the five years of visiting doctors’ clinics but her tests showed no major red flags. There was no blood in her stool, no inflammatory markers in her blood tests. Then she came to see me one day with acute abdominal pain, which she said had been troubling her for the last few years. Since she had chronic abdominal pain and her tests weren’t showing anything significant, we did a CT scan. And that’s how we found that she had Crohn’s disease, a kind of inflammatory bowel disease.

The pain was because we found there were three strictures or blockages towards the lower part of her small intestine, the part nearer the colon. This had thickened her intestines, was cramping her gut and triggering her nausea. We also found nodules or clusters of live immune cells, which had worsened the inflammation. Since her condition had been undetected for a long time and her nodules were affecting her digestive functions, she needed surgery to remove them.

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What is inflammatory bowel disease or Crohn’s disease?

Crohn’s disease is a chronic autoimmune condition, where your body’s immune system mistakenly attacks its own healthy cells, tissues and organs, leading to inflammation and damage. In this case it inflames and irritates your digestive tract, mostly affecting the large and small intestines.

In a healthy gut, the immune system can distinguish between harmful and beneficial bacteria. In people with Crohn’s, it cannot and attacks all the good bugs. This triggers inflammation in the digestive tract. Inflammation in the lower small intestine and the lining of the large intestine is most common though it can affect the gastro-intestinal tract anywhere.

What are symptoms?

Crohn’s disease is most commonly characterised by diarrhoea, stomach cramps and abdominal pain. But about 30 per cent will have external symptoms too like perinanal diseases. These are caused by inflammation around the anus and can cause fistulas and abscesses. Some have arthritis and some like my patient have iron and vitamin B12 deficiencies, low haemoglobin and a loss of bone mass, all because the body isn’t able to absorb the nutrients from the little food that can be tolerated.

What about therapy?

Common treatments include anti-inflammatory drugs, immunosuppressants and biologics, often used in combination. Since biologics are administered via infusions under the skin and bypass the digestive system, they worked for my patient, who is now in remission. For complications like abscesses or fistulas, antibiotics may be prescribed. Other options include long term lifestyle changes of a gut-friendly diet, exercise and quitting smoking and alcohol.

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What are tests?

A fecal calprotectin test is a stool test that measures the level of calprotectin, a protein released by white blood cells, to detect inflammation in the intestines. If the reading is higher than 50, then you have inflammatory bowel disease. Endoscopy with biopsy may still be necessary to confirm a diagnosis of Crohn’s disease.

Does inflammation recur after surgery?

Yes, surgical removal of diseased sections does not cure the disease, and recurrence is common in the long term. That’s why it is important to detect it early and manage the condition with drugs and corrective lifestyles. This requires a highly individualised approach.

(Dr Tickoo is Director, Internal Medicine, Max Healthcare)