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20-Year History of Diarrhea with Intermittent Constipation


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Am Fam Physician. 2014 May 1;89(9):739-740.

A 79-year-old man presented with a 20-year history of diarrhea that was diagnosed as irritable bowel syndrome. He had regular cycles of liquid stools (about 4 cups per day) for several days, followed by constipation with small, pellet-like stools for the next two days. He did not have hematochezia, nocturnal stooling, weight loss, ill contacts, or recent travels, and he did not own pets. Colonoscopy findings two years earlier were negative, other than poor bowel preparation. He used loperamide (Imodium) on days he had diarrhea.

Physical examination revealed a palpable mass in the right lower quadrant that was firm but nontender. The mass was present while examining the patient in multiple positions. Rectal examination was significant for the presence of hard stool. Initial laboratory tests were notable only for a hemoglobin level of 11.9 g per dL (119 g per L). Because of the concern for possible malignancy, computed tomography enterography was performed (see accompanying figure).


Figure.

Question

Based on the patient's history, physical examination, and imaging findings, which one of the following is the most likely diagnosis?

A. Carcinoid syndrome.

B. Celiac disease.

C. Colorectal cancer.

D. Fecal impaction with overflow diarrhea.

E. Irritable bowel syndrome.

Discussion

The

Author disclosure: No relevant financial affiliations.

Address correspondence to Gururaj J. Kolar, MD, at kolar.gururaj@mayo.edu. Reprints are not available from the authors.

REFERENCES

1. Arora G, Mannalithara A, Mithal A, Triadafilopoulos G, Singh G. Concurrent conditions in patients with chronic constipation: a population-based study. PLoS One. 2012;7(10):e42910.

2. Wrenn K. Fecal impaction. N Engl J Med. 1989;321(10):658–662.

3. Geboes K, Bossaert H. Gastrointestinal disorders in old age. Age Ageing. 1977;6(4):197–200.

4. Read NW, Celik AF, Katsinelos P. Constipation and incontinence in the elderly. J Clin Gastroenterol. 1995;20(1):61–70.

5. De Lillo AR, Rose S. Functional bowel disorders in the geriatric patient: constipation, fecal impaction, and fecal incontinence. Am J Gastroenterol. 2000;95(4):901–905.

6. Halawi HM, Maasri KA, Mourad FH, Barada KA. Faecal impaction: in-hospital complications and their predictors in a retrospective study on 130 patients. Colorectal Dis. 2012;14(2):231–236.

7. Read NW, Abouzekry L. Why do patients with faecal impaction have faecal incontinence. Gut. 1986;27(3):283–287.

Contributing editor for Photo Quiz is John E. Delzell, Jr., MD, MSPH.

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