Lawrence R. Schiller M.D.

Schiller, L. R. (2020). “Maldigestion Versus Malabsorption in the Elderly.” Curr Gastroenterol Rep 22(7): 33.

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PURPOSE OF REVIEW: To evaluate recently published information about the frequency of maldigestion and malabsorption in older individuals, likely diagnoses causing these problems, and the diagnostic scheme when these diagnoses are being considered. RECENT FINDINGS: Although the prevalence of malnourishment and frank malnutrition may be increasing among older adults admitted to the hospital, this appears to be due to reduced food intake rather than maldigestion or malabsorption. The mechanisms of food digestion and absorption seem to be resilient, even in old age, but concurrent illness may produce malabsorption in older individuals. Illnesses that may be more common among the elderly include small intestinal bacterial overgrowth, exocrine pancreatic insufficiency, enteropathies, vascular disease, diabetes, and certain infections, such as Whipple’s disease. In addition, older adults may have had previous surgeries or exposure to medicines which may induce malabsorption. The presentation of maldigestion and malabsorption in the elderly may be different than in younger individuals, and this may contribute to delayed recognition, diagnosis, and treatment. Diagnostic testing for maldigestion and malabsorption generally is similar to that used in younger patients. Maldigestion and malabsorption occur in older individuals and require a high level of suspicion, especially when weight loss, sarcopenia, or nutrient deficiencies are present.

Schiller, L. R. (2020). “Good News about BAD.” Clin Gastroenterol Hepatol 18(1): 45-47.

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In this issue the Canadian Association of Gastroenterology (CAG) presents its official guidelines for the management of bile acid diarrhea (BAD). The American Gastroenterological Association (AGA) recently published its clinical guidelines for the laboratory diagnosis of chronic diarrhea, and the British Society of Gastroenterology (BSG) published its guidelines for investigation of chronic diarrhea in 2018. All 3 guidelines and the reviews that present the underlying evidence highlight the importance of bile acid malabsorption (BAM) as a potential mechanism for chronic diarrhea. The concept that bile acid entering the colon might cause secretory diarrhea goes back more than 50 years. In 1967 Alan F. Hofmann, then at the Mayo Clinic, synthesized what was known about the physiology of bile acids with several clinical reports of diarrhea occurring in patients who had evidence of BAM into the concept of “cholegenic diarrhea” or “cholerheic enteropathy.” These patients had several features in common, including ileal disease or resection, diarrhea, steatorrhea, and evidence of accelerated bile acid turnover. Bile acids were known to be cathartic, and Hofmann postulated that the excess bile acid in the colon inhibited water transport and caused diarrhea through that mechanism . . . [R]esearch during the last 50 years has established that BAD is a real mechanism for chronic diarrhea, not just with ileal disease or resection but in patients with functional diarrhea or IBS-D. It is incumbent on physicians now to consider this diagnosis in patients with chronic diarrhea. Whether one tests and then treats or just empirically treats, we will do a great service for many of our patients with chronic diarrhea by addressing this mechanism of disease. (Excerpts from text, p. 45-46, summarizing Sadowski D.C. et al: Canadian Association of Gastroenterology clinical practice guideline on the management of bile acid diarrhea; no abstract available.)

Schiller, L. R. (2019). “Chronic constipation: new insights, better outcomes?” Lancet: Gastroenterology and Hepatology 4(11): 873-882.

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Constipation is a symptom that affects around 11-20% of the adult population yearly. Most physicians consider infrequency of defecation as a hallmark of constipation. However, most patients view excessive straining as the biggest component of constipation and only a minority of patients with constipation have infrequent bowel movements. Constipation might be due to many different medical conditions or occur as a side-effect of drug therapy. When these medical conditions or drug therapies are not present, a diagnosis of functional constipation, chronic idiopathic constipation, or irritable bowel syndrome with constipation is often made. In all patients with constipation, rectal outlet dysfunction should be excluded by physical examination because this condition occurs in approximately 25% of patients diagnosed with idiopathic constipation and can be improved with different therapeutic approaches than administration of laxatives. Because of the availability of over-the-counter laxatives, most patients consider themselves able to self-manage constipation, and patients have often tried many different treatments before seeking professional help. The physician must carefully assess these previous efforts of self-treatment, optimise them, and strategically use the increasing list of prescription medications for management.

Schiller, L. R. (2019). “Network meta-analysis in chronic constipation: what have we learned?” Lancet: Gastroenterology and Hepatology 4(11): 812-813.

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Constipation is a common complaint among patients with gastrointestinal disorders, and many pharmacological therapies have been introduced in the last 20 years to treat them. Commonly, a new drug is tested against placebo in a randomised controlled trial to be approved by regulatory authorities; a trial needs to show that the drug is more efficacious than placebo and has minimal or manageable side-effects.

Schiller, L. R. (2019). “Good News about BAD.” Clin Gastroenterol Hepatol Oct 29. [Epub ahead of print].

Full text of this article.

The good news about bile acid diarrhea (BAD) is that research over the last 50 years has established that it is a real mechanism for chronic diarrhea, not just with ileal disease or resection, but in patients with functional diarrhea or IBS-D. It is incumbent upon physicians now to consider this diagnosis in patients with chronic diarrhea. Whether one tests, then treats or just empirically treats, we will do a great service for many of our patients with chronic diarrhea by addressing this mechanism of disease. (Excerpt from this article-in-press.)