Tropical Sprue Workup

  • Author: Rohan C Clarke, MD; Chief Editor: Julian Katz, MD   more...
 
Updated: Mar 30, 2012
 

Laboratory Studies

  • Clinical presentation, including diarrhea, malabsorption of nutrients, and anemia workup, influences the extent of diagnostic tests. Findings of steatorrhea, mucosal malabsorption of 2 substances (eg, fat, D-xylose), and villous atrophy (demonstrated by means of biopsy) are adequate to make a diagnosis. Response to treatment is considered by some to be the conclusive evidence that confirms the diagnosis.
  • CBC count: This shows megaloblastic anemia associated with reduced folate and vitamin B-12 levels in as many as 60% of patients.
  • Blood chemistry test: This includes potassium, calcium, magnesium, phosphate, albumin, cholesterol, and iron studies.
  • Stool collection test
    • This measures fat content over 72 hours on a diet of 80-100 g of fat.
    • A result of more than 6 g in 24 hours is abnormal (positive for fat malabsorption). Fatty stools are usually observed when the stool fat content is 15 g or more.
  • D-Xylose absorption test
    • For this study, 25 g D-xylose is administered orally.
    • In well-hydrated patients with normal renal function, abnormal results (ie, positive for mucosal malabsorption) include a 5-hour urine collection of less than 4 g and a 1-hour serum collection of less than 20 mg/dL.
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Imaging Studies

  • A barium swallow and follow-through may reveal increased caliber and thickening of mucosal folds or flocculation and segmentation of barium, depending on the type of barium used.
  • Use of esophagoduodenoscopy may reveal subtle or dramatic mucosal changes,[5] as seen in the following images.Endoscopic views of unsuspected celiac disease. A:Endoscopic views of unsuspected celiac disease. A: Absent duodenal folds. B: Mucosal fissures and scalloped folds. C: Scalloped fold.
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Other Tests

Another possible tool to determine gut health may be a noninvasive marker. In a small Australian study, Ritchie et al reported a novel use of of13 C-sucrose breath test in 36 Aboriginal and non-Aboriginal children to measure enterocyte sucrase activity as a marker of small intestinal villus integrity and function.[6] The investigators simultaneously performed intestinal permeability measurements with the lactulose/rhamnose (L/R) ratio on a timed 90-minute blood test with the13 C-sucrose breath test.

Findings included a significantly decreased absorption capacity in Aboriginal children with acute diarrhea (mean 1.9%; cumulative percentage calculated of dose recovered at 90 min) relative to Aboriginal children without diarrhea (4.1%) or non-Aboriginal children (6.1%).[6] The mean L/R ratio in the Aboriginal children with diarrhea was 31.8, whereas the nondiarrheal Aboriginal children's was 11.4.

Ritchie et al noted a significant inverse correlation between the13 C-sucrose breath test and the L/R ratio and concluded the breath test discrimated "among Aboriginal children with diarrhea, asymptomatic Aboriginal children with an underlying environmental enteropathy, and healthy non-Aboriginal controls."[6] The investigators believe the13 C-sucrose breath test "provides a noninvasive, easy-to-use, integrated marker of the absorptive capacity and integrity of the small intestine and could be a valuable tool in evaluating the efficacy of interventions aimed at improving gut health."[6]

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Procedures

  • Jejunal biopsy
    • Mild villous atrophy
    • Increased villous crypts and mononuclear cellular infiltrates, enlarged epithelial cells, and large nuclei caused by folate and/or vitamin B-12 deficiency
  • Characteristic accumulation of lipid beneath the basement membrane
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Histologic Findings

The following images are supportive of histopathologic findings of tropical sprue.[7]

Subtotal villous atrophy (H&E, orig. mag. ×10). Subtotal villous atrophy (H&E, orig. mag. ×10). Tropical sprue (H&E, orig. mag. ×10). Tropical sprue (H&E, orig. mag. ×10).
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Contributor Information and Disclosures
Author

Rohan C Clarke, MD  Consulting Staff, Department of Gastroenterology, JPS Health Systems Hospital

Rohan C Clarke, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, and American Society of Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Coauthor(s)

Rachael M Ferraro, DO  Internal Medicine Hospitalist, Torrance Memorial Medical Center, Little Company of Mary Hospital

Rachael M Ferraro, DO is a member of the following medical societies: American College of Osteopathic Internists, American College of Physicians, and American Osteopathic Association

Disclosure: Nothing to disclose.

Lisa Ozick, MD  Former Chief, Division of Gastroenterology, Harlem Hospital Center

Lisa Ozick, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Sabo B Tanimu, MD  Fellow, Department of Medicine, Division of Gastroenterology, Harlem Hospital Center

Disclosure: Nothing to disclose.

Oluyinka S Adediji, MD  Consulting Staff, Department of Adult and General Medicine, Health Services Incorporated, Montgomery, Alabama

Oluyinka S Adediji, MD is a member of the following medical societies: American College of Physicians and American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Manoop S Bhutani, MD  Professor, Co-Director, Center for Endoscopic Research, Training and Innovation (CERTAIN), Director, Center for Endoscopic Ultrasound, Department of Medicine, Division of Gastroenterology, University of Texas Medical Branch; Director, Endoscopic Research and Development, The University of Texas MD Anderson Cancer Center

Manoop S Bhutani, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Institute of Ultrasound in Medicine, and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Noel Williams, MD  Professor Emeritus, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Professor, Department of Internal Medicine, Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada

Noel Williams, MD is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Alex J Mechaber, MD, FACP  Senior Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine

Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine

Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD  Clinical Professor of Medicine, Drexel University College of Medicine

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

References

  1. Gray, GM. Tropical Sprue. In: Blaser,MJ, Smith, PD, Ravdin, JI. Infections of the Gastrointestinal Tract. New York: Raven Press; 1995:333.

  2. Klipstein, FA. Tropical Sprue. Gastroenterology. 1968;54:275.

  3. Gorbach, SL, Banwell, JG, Jacobs, B, et al. Tropical Sprue and Malnutrition in West Bengal. I. Intestinal microflora and absorption. American Journal of Clinical Nutrition. 1970;23:1545.

  4. Klipstein, FA, Holdeman, LV, Corcino, JJ, et al. Enterotoxigenic intestinal bacteria in tropical sprue. Annals of Internal Medicine. 1973;79:632.

  5. Green PH, Shane E, Rotterdam H, Forde KA, Grossbard L. Significance of unsuspected celiac disease detected at endoscopy. Gastrointest Endosc. Jan 2000;51(1):60-5. [Medline].

  6. Ritchie BK, Brewster DR, Davidson GP, Tran CD, et al. 13C-sucrose breath test: novel use of a noninvasive biomarker of environmental gut health. Pediatrics. Aug 2009;124(2):620-6. [Medline].

  7. Lo A, Guelrud M, Essenfeld H, Bonis P. Classification of villous atrophy with enhanced magnification endoscopy in patients with celiac disease and tropical sprue. Gastrointest Endosc. Aug 2007;66(2):377-82. [Medline]. [Full Text].

  8. Cook GC. Aetiology and pathogenesis of postinfective tropical malabsorption (tropical sprue). Lancet. Mar 31 1984;1(8379):721-3. [Medline].

  9. Dutta AK, Chacko A, Avinash B. Suboptimal performance of IgG anti-tissue transglutaminase in the diagnosis of celiac disease in a tropical country. Dig Dis Sci. Mar 31 2009;epub ahead of print. [Medline].

  10. Evans KE, Leeds JS, Sanders DS. Be vigilant for patients with coeliac disease. Practitioner. Oct 2009;253(1722):19-22, 2. [Medline].

  11. Farthing MJ. Tropical malabsorption and tropical diarrhea. In: Feldman M, ed. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 6th ed. Philadelphia, Pa: WB Saunders Co; 1998:1574-84.

  12. Floch MH, Ozick L. Tropical sprue. In: Hurst JW, ed. Medicine for the Practicing Physician. 3rd ed. Boston, Mass: Butterworth;1992:1547-1549.

  13. French AB. Tropical sprue--specific disease or extreme of a spectrum?. Ann Intern Med. Jun 1968;68(6):1362-5. [Medline].

  14. Gilman AG, ed. The Pharmacological Basis of Therapeutics. 8th ed. New York, NY:. Pergamon Press Inc;1990.

  15. Greeberger NJ, Isselbacher KJ. Disorders of absorption. In: Fauci AS, ed. Harrison's Principle of Internal Medicine. 14th ed. New York, NY: McGraw-Hill; 1998:1626.

  16. Klipstein FA. Tropical sprue in travelers and expatriates living abroad. Gastroenterology. Mar 1981;80(3):590-600. [Medline].

  17. Klipstein FA. Tropical sprue--an iceberg disease?. Ann Intern Med. Mar 1967;66(3):622-3. [Medline].

  18. Klipstein FA, Baker SJ. Regarding the definition of tropical sprue. Gastroenterology. May 1970;58(5):717-21. [Medline].

  19. Kuhlmann FM, Weil GJ. Infectious risks for travelers to the tropics. Mo Med. Jul-Aug 2009;106(4):263-8. [Medline].

  20. Nath SK. Tropical sprue. Curr Gastroenterol Rep. Oct 2005;7(5):343-9. [Medline].

  21. Thielman NM, Guerrant RL. Persistent diarrhea in the returned traveler. Infect Dis Clin North Am. Jun 1998;12(2):489-501. [Medline].

  22. Toskes P. Malabsorption. In: Bennet JC, Plum F, eds. Cecil's Textbook of Medicine. 20th ed. Philadelphia, Pa: WB Saunders Co; 1996:705-6.

 
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Subtotal villous atrophy (H&E, orig. mag. ×10).
Tropical sprue (H&E, orig. mag. ×10).
Endoscopic views of unsuspected celiac disease. A: Absent duodenal folds. B: Mucosal fissures and scalloped folds. C: Scalloped fold.
 
 
 
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