Differentials
Parasitic infections: Strongyloides, Isosporiasis, Giardia lambia, Entamoeba histolytica, Cyclosporiasis
SIGNS / SYMPTOMS
Parasitic infections often present with the same signs and symptoms as TS.
Malabsorption in TS is generally more profound and typically involves micronutrients such as folate.
INVESTIGATIONS
Stool microscopy may reveal ova and parasites.
Stool and/or serum antigen testing for specific parasites may be positive.
Giardiasis may feature some degree of villous blunting in the proximal small bowel as seen in TS; other infections do not.
Bacterial infections: Shigella, Salmonella, Escherichia coli
SIGNS / SYMPTOMS
Bacterial infections typically lead to an acute presentation.
Gastrointestinal and constitutional symptoms such as diarrhea, abdominal pain, and fever are more severe.
Diarrhea may be bloody, which is not seen in TS.
INVESTIGATIONS
Stool should be cultured for the presence of these microorganisms.
HIV enteropathy
SIGNS / SYMPTOMS
Chronic diarrhea, weight loss, abdominal cramps, anal pain, fevers.
Diffuse abdominal tenderness, hepatosplenomegaly, lymphadenopathy.
INVESTIGATIONS
HIV test is positive.
Can mimic the histologic small-bowel findings that are seen in TS.
Tuberculosis
SIGNS / SYMPTOMS
Can closely mimic the clinical signs and symptoms of TS.
Features of systemic disease may be present.
INVESTIGATIONS
Staining for mycobacterium of bowel tissue positive.
Blood, biopsy, or sputum samples may show mycobacterial infection.
Can mimic the histological small bowel findings that are seen in TS.
Whipple disease
SIGNS / SYMPTOMS
Can closely mimic the clinical signs and symptoms of TS.
Arthralgia/adenopathy may be present.
INVESTIGATIONS
Small-bowel biopsy may demonstrate periodic acid-Schiff-positive macrophage inclusions.
Small-bowel lymphoma
SIGNS / SYMPTOMS
In immunoproliferative small intestinal disease, gastrointestinal/constitutional symptoms such as abdominal pain, fever, and chills predominate over features of malabsorption.
INVESTIGATIONS
Small-bowel biopsy may be histologically distinguishable.
Crohn disease
SIGNS / SYMPTOMS
Profound malabsorption not commonly seen. Bloody diarrhea is common.
Crohn disease course waxes and wanes. TS more commonly features an indolent progression.
INVESTIGATIONS
Colonoscopy with intubation of the terminal ileum may reveal macroscopic features (gross mucosal erythema and ulceration) not seen in TS.
Abdominopelvic CT and/or upper gastrointestinal series with small bowel follow may reveal strictures and fistulae.
Celiac disease
SIGNS / SYMPTOMS
More commonly affects white people of European descent.
No acute period of diarrhea with celiac disease.
INVESTIGATIONS
IgA antibodies positive in celiac disease.
Antiendomysial antibodies should also be positive.
Biopsies can be indistinguishable.
Therapeutic trial of folic acid: TS responds.
Gluten-free diet: celiac disease responds.
Scleroderma
SIGNS / SYMPTOMS
Upper gastrointestinal symptoms such as heartburn and dysphagia more common.
Features of malabsorption unlikely unless concomitant small-intestinal bacterial overgrowth present.
Likely to manifest classic skin changes; evidence of interstitial lung disease, and renal involvement common.
INVESTIGATIONS
Antinuclear antibodies are present in about 95% of patients.
Topoisomerase I antibodies and anticentromere antibodies often present in limited disease.
Small-intestinal bacterial overgrowth
SIGNS / SYMPTOMS
Can complicate altered intestinal anatomy (e.g., blind loops following surgery), scleroderma, or disordered intestinal motility, as well as patients with no underlying disorders.
Features of malabsorption, particularly folic acid deficiency, not as common as in TS.
INVESTIGATIONS
No villous atrophy on small-bowel biopsy as is seen in TS.
No evidence of multiple micro- and macronutrient deficiencies as seen in TS.
Pancreatic insufficiency
SIGNS / SYMPTOMS
Often manifests signs/symptoms of malabsorption including diarrhea, steatorrhea, and fat-soluble hypovitaminosis, but signs/symptoms of protein, carbohydrate, folic acid, and vitamin B deficiencies not present.
INVESTIGATIONS
No evidence of megaloblastic anemia, abnormal D-xylose testing, or hypoproteinemia.
Tropical enteropathy
SIGNS / SYMPTOMS
Closely resembles TS; often viewed as a subclinical form of the disease.
Tropical enteropathy (TE) is found in the same endemic areas.
Associated with the malabsorption of multiple micro- and macronutrients.
Rarely causes the symptoms that typify TS.
TE does not respond as predictably to treatment with folic acid and antibiotics.
Malabsorption seen in TE resolves after 6 to 12 months spent in temperate climate.
INVESTIGATIONS
No differentiating tests.
Drug-induced enteropathy
SIGNS / SYMPTOMS
Signs and symptoms can closely resemble those of TS, though the malabsorption from drug-induced enteropathy is typically not as severe.
Associated primarily with angiotensin-II receptor antagonists and ACE inhibitors. Risk is most notable with olmesartan, an angiotensin-II receptor antagonist.[34] Symptoms and histologic changes resolve after offending drug is discontinued.
INVESTIGATIONS
No differentiating tests.
Careful history and medication review.
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