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Tropical Sprue Workup

  • Author: Rohan C Clarke, MD; Chief Editor: Julian Katz, MD  more...
 
Updated: Dec 15, 2014
 

Laboratory Studies

See the list below:

  • 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

See the list below:

  • 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, [7] 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.[8] 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%).[8] 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."[8] 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."[8]

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Procedures

See the list below:

  • 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.[9]

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 Director, 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, American Society for Gastrointestinal Endoscopy

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Cubist; <br/>Received reimbursement from Boston Scientific for learning observership for eus; Received honoraria from Optimer pharmaceutical for speaking and teaching.

Coauthor(s)

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

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

Disclosure: Nothing to disclose.

Lisa Anne Ozick, MD Attending Gastroenterologist, Leumit Health Clinic, Israel

Lisa Anne Ozick, MD is a member of the following medical societies: American College of Gastroenterology, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

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

Disclosure: Nothing to disclose.

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, American Osteopathic Association

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

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

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, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

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, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

References
  1. Gray, GM. Tropical Sprue. 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. Brown IS, Bettington A, Bettington M, et al. Tropical sprue: revisiting an underrecognized disease. Am J Surg Pathol. 2014 May. 38(5):666-72. [Medline].

  6. Ghoshal UC, Mehrotra M, Kumar S, et al. Spectrum of malabsorption syndrome among adults & factors differentiating celiac disease & tropical malabsorption. Indian J Med Res. 2012 Sep. 136(3):451-9. [Medline]. [Full Text].

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

  8. 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. 2009 Aug. 124(2):620-6. [Medline].

  9. 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. 2007 Aug. 66(2):377-82. [Medline]. [Full Text].

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

  11. 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. 2009 Mar 31. epub ahead of print. [Medline].

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

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

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

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

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

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

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

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

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

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

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

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

  24. Toskes P. Malabsorption. 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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