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After weeks of having to rush to the bathroom day and night, the 77-year-old had lost 25 pounds. What was wrong?
“My husband has been sick for a month and can barely walk and you’re going to send him home?” The woman, usually reserved, was now shouting at the doctor in the Texas Health Arlington Memorial Hospital emergency room in Arlington, Texas. Her husband, 77 years old and until recently quite healthy, sat and watched his wife in amazed gratitude. “Don’t you have a GI specialist you can talk to?” she added. The doctor was silent for a moment, then nodded. “I’ll be back,” he said before disappearing into the crowded emergency room.
One month earlier, the man developed terrible and unrelenting diarrhea. Pepto-Bismol didn’t help; neither did Imodium. He gave up all dairy products. He ate more fiber. When after two weeks he still found himself getting up two or three times a night and hurrying to the bathroom just as many times during the day, he went to see his primary-care doctor, Samrath Sokhey. The doctor gave him a stronger antidiarrheal medication, Lomotil, and sent him to the lab for tests.
When the tests were unrevealing, Sokhey saw him again. By then the patient looked sick; he was tall and had always been trim, but now he looked gaunt. The patient walked, cycled or lifted weights every day and had for years. But not these days, he reported. After weeks of this diarrhea, his only exercise was running to the bathroom. He had lost nearly 10 pounds. He always wanted a six-pack stomach, he joked, but he wasn’t sure it was worth this. Sokhey ordered tests to look for parasites and referred the patient to a GI specialist.
The patient saw the specialist, who ordered a slew of new tests. But before any of them were completed, Sokhey called him and told him to go to the E.R. He had been monitoring the man’s weight and his renal function, and the change in both worried him. The patient had never been to an E.R. before and wasn’t inclined to change that. Sokhey was sympathetic but unyielding. He wasn’t sure the man’s kidneys could take much more.
A Strange Cessation of Symptoms
The E.R. was packed when the patient arrived that afternoon; it was mid-September of 2021, and the Delta variant of Covid-19 was roaring through Texas. Even so, the man was taken into the treatment area almost immediately and started on intravenous fluids. The E.R. doctor looked tired, but he was kind and listened as the patient and his wife described his life-altering illness. At this point, the patient was so weak he could barely walk, much less exercise or tinker with his classic 1966 Ford Mustang, his current obsession. Before he left the tiny room, the couple recall, the doctor told them that he might not be able to admit him. These days you had to be pretty sick to get into the hospital, he cautioned.
He returned with the news that the patient was to go home, and that’s when the patient’s wife got angry. She was scared — and then relieved, hours later, when the decision was made to admit her husband. The patient spent three days in the hospital and was tested for everything the doctors could think of. There was no sign of a parasite; it wasn’t Clostridioides difficile, a bacterium that can cause life-threatening diarrhea; it wasn’t Crohn’s or ulcerative colitis. A colonoscopy showed that it wasn’t microscopic colitis, an inflammatory disorder found most frequently in those over 60. Although there was some inflammation in the small intestine suggestive of celiac disease, blood tests ruled that out. The CT scan showed no sign of a tumor. When he was discharged three days later, he had no diagnosis. But his diarrhea was better. No one was sure why, but the man was grateful.
The reprieve didn’t last long. Within days of arriving home, the diarrhea was back, as bad as ever. The GI specialist piled on medications he thought might help.
The only abnormality he could find was a low level of a digestive protein called elastase in the man’s stool. This enzyme is made in the pancreas and helps break down foods into digestible components. Inadequate amounts of elastase and other pancreatic enzymes allow fats and proteins to pass through the small intestine intact and unabsorbed. These undigested foods suck water into the GI tract, and a result is often a watery mess. Was there something wrong with the man’s pancreas? The doctor referred him to another GI specialist, but the first available new-patient appointment was in five months.
The wife called Sokhey. She didn’t think her husband could last that long; she was worried. So was Sokhey. He called the practice and explained the man’s story. An appointment was made for the following week.
Some Type of Cancer?
Dr. Tarek Sawas, a gastroenterologist at the University of Texas Southwestern in Dallas, introduced himself to the patient and his wife and sat down to listen. He had already reviewed the patient’s records, and given his age and the 25-pound weight loss, he suspected the man had some type of cancer. Still, there were other possibilities, and Sawas didn’t want to miss anything.
The man had only a couple of medical problems: high blood pressure, for which he took a combined medication, Amlodipine-Olmesartan; and osteoarthritis in his knees and shoulders. By that point, he also took a handful of meds for his GI tract. Maybe they helped, but he still had to hurry to the bathroom several times a day and most nights.
To Sawas, the fact that he had to get up at night was a red flag. Diarrhea is often an exaggeration of normal colonic function and frequently occurs within hours of eating. Irritable bowel syndrome (I.B.S.), one of the most common causes of chronic diarrhea, is considered a functional disorder — which means that no pathological cause has been found, yet the gut isn’t functioning normally. But I.B.S. rarely causes symptoms during sleep. And many of the pathologies that do cause nighttime symptoms had been ruled out. Sawas focused on the two abnormalities of the work-up — the inflammation of the small intestine and the low elastase. The latter could be caused simply by dilution. Having the normal amount of the enzyme but more than the normal number of bowel movements can reduce the concentration of elastase found in any single movement. But a tumor could produce the same finding.
Sawas had a far more likely culprit, however: one of the patient’s medications. When the patient mentioned that he took a medication containing Olmesartan for his high blood pressure, it suddenly all made sense. That medication is an effective antihypertensive and considered quite safe. But 10 years ago, doctors at the Mayo Clinic published a report of 22 patients who came to Mayo for chronic diarrhea that was ultimately linked to this medication.
The diagnosis was first suggested by a couple of patients when they came for help. They noticed that their diarrhea resolved when they were in the hospital. They were dehydrated, and their blood-pressure medication was put on hold during their hospital stay. The diarrhea restarted once they began taking the medication again. The Mayo doctors looked for a link between chronic diarrhea and this medication in other patients. They found about two dozen with the same issue. In most cases the medication was taken without a problem for months, often years. Yet stopping the medication completely eliminated the diarrhea and the celiac-like abnormalities seen in their GI tracts. In the years since, a link has been found between this class of medication, known as angiotensin receptor blockers, and this kind of diarrhea.
Sawas explained this to the patient and took him off the medication. His blood pressure was on the low side now, so he would probably be fine without it. If it went up, his primary-care doctor should start him on a different drug.
Why this class of antihypertensives can cause this reaction in some patients is not clear. It’s the kind of information physicians might call a “clinical pearl,” a bit of free-standing, clinically relevant information based on experience or observation. But to the patient, this was more than a jewel; it was a lifesaver. A few days after he stopped taking the medication, the diarrhea disappeared. A week later he felt well enough to go for walks and get on his bike. The only sad part was saying goodbye to his six-pack abs when he regained some of his lost weight, but it seemed a small price to pay.
Lisa Sanders, M.D., is a contributing writer for the magazine. Her latest book is “Diagnosis: Solving the Most Baffling Medical Mysteries.” If you have a solved case to share, write her at Lisa.Sandersmdnyt@gmail.com.