HealthCareMagic is now Ask A Doctor - 24x7 | https://www.askadoctor24x7.com

Have Fatty Liver, Loose Bowels And Diagnosed With IBS. Have Had Complete Blood Test. Findings?

Posted on Wed, 28 Aug 2013

Question: Hello Doctor
my Symptoms :
For many years i have fatty liver. My age is 23.
Loose bowel for last 3 months. Bowels are not formed properly. It is generally semi solid, but very few times it has been watery. Urgency is low to moderate. In the morning i have to go 3 times, and another 2 times in the rest of the day. I do not have any abdominal pain. I have reduced 2.5 kg in last 2 months due to exercise and diet. My weight is 69kg with height of 5 feet 5 inch. I do not have fatigue.

Doctor diagnogised me with IBS, but medicine gave me no relief.
I did the following test : lipid profile, TSH, Platelet, Sugar, HBSAg, Anti HCV, Liver function test, Ultrasonography of upper abdomen.

I have attached the reports.
PLATELETS - 0000/CU.MM
SERUM TSH - 2.49 uIU/ML
SERUM HBSAg - non reactive
Accept for slight liver problem all test were normal.
So doctor asked me to do endoscopy and colonoscopy.
Here the problem lies.
i had erosive antral gastritis and duodenitis.
I also had multiple erosion in terminal ileum and IC valve.
biopsy from ileum said :
Gross : multiple tiny bits of greyish white tissue. All the bits embedded.
Microscopical examination : Section shows multiple bits of ileal mucosa showing focal erosion of the lining surface epithelium. The glands in one of the bits shows mucin depletion. The lamina propria is infiltrated by inflammatory cells composed of lymphocytes, plasma cells admixed with eosinophils. Lymphoid follicles are present. No cryptitis or crypt abcess seen. No granuloma found. There is no evidence of malignancy in this biopsy.
Impression : Non specific ileitis.

I am afraid of crohns. Do my biopsy completely eliminate crohns ? I dont think my symptoms matches of crohns. my doctor asked me to take Vegaz OD 1.2 (mesalamine) for one month. Please help me. Can this non specific ileitis in future become crohns ? Is it 100% curable ? From the microscopic examination, what do you think this non specific ileitis is ? Is it a common problem ?

Answered by Dr. Amit Jain (43 minutes later)

Hello! Thanks for putting your query in XXXXXXX I am a Gastroenterologist (DM).

Diagnosis of crohn's disease can not be completely eliminated from these reports although the typical granuloma is absent however it is found in 15-30% patients only.

First of all I will like to advise few more tests like: Anti tissue transglutaminase levels for celiac disease, p XXXXXXX and ASCA antibodies, CRP and ESR levels

Now there are two ways of taclinkg the problem
1.To further confirm the diagnosis you may get above mentioned tests and MR or CT Enetrography. And after confirming the diagnosis start taking treatment accordingly.
2.Start with Tablet pentasa instead of vegas-od for a month and watch for improvement in stool consistency and weight and general well being. Actually crohn's disease mainly affects small bowel, vegas od is mainly released in colon, and as per your report of colonoscopy colon is normal but terminal ileum and IC valve is involved. But pentasa is release 1/2 in small intestine and another 1/2 in colon. So it will be more effective

Answers to your other queries:

.Your biopsy report did not completely eliminate Crohn's disease
.Symptoms of chrons may range from asymptomatic to florid presentations
. No specific ileitis is commonly found but what I do in similar patients like you I will give empirically Tab pentasa and watch for improvement in symptoms may be 4-6 weeks,if it shows improvement I continue wit pentasa. If no improvement then I will stop pentasa.

I hope I have answered your query and this will help you. Remain in touch and get-well soon.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Amit Jain (2 hours later)

If its simple No specific Ileitis, will after taking pentasa will it heal itself ? I do not have any family history of crohns neither is my bowel movement so bad. what should i do ? should i go for the folllowing test or should i first take some medicine.

as for the test u said,
what do you mean by Asca antibodies test ?
Is it ASCA IGA or ASCA IGG test ?

with the above following three test, which u prescribed, do I also need to do CT Entroclysis ?
or will CT entroclysis alone will do ...

Answered by Dr. Amit Jain (2 hours later)

Hello! Thanks for feedback.

As I said earlier that from your symptoms and reports of investigation diagnosis of Crohn's is neither eliminated nor confirmed.

I discuss two ways for that. I usually prefer to start empirically Tab Pentasa in such situation which I found useful in my patients. However you may discuss regarding this with your treating doctor
ASCA antibodies are Antisaachromyces Cervisae antibodies, and is found more frequently in patients of Crohn's disease. May support diagnosis when other investigations are not able to give us confirm diagnosis.

It is both IgA and IgG

Actually diagnosis of disease like Crohn's sometimes is not clear cut or absolute, so we have to take all the things together like symptoms, signs, lab tests and imaging to support the diagnosis. CT enteroclysis is good modality which will give us detail of lining mucosa of the intestine, within wall of intestine and along with outside the lumen.

I think I answered your query. Remain in touch and Get well soon

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Amit Jain (2 hours later)

Respected doctor,
I just did my CRP and ESR test as per your suggestion, and the results are back
my ESR level is 6
my CRP is 2.6

well in the morning i just took a single tablet of Pentasa, first tablet of Pentasa in this life, so I am sure the single tablet did not alter the result much. I never took vegas od either.

I will soon do the ASCA test, as it is bit expensive, will do it in few days.
I have a question regarding this test. Since i will do it after few days of taking Pentasa, will the result make a difference to the test result. If someone has a positive test for ASCA, does it confirm Crohns, celiac, bechet, colitis. I mean cant ASCA test be positive due to NON SPECIFIC ILEITIS.

please answer my question as I am very worried. My doctor dont even give me a minute. He dont answer my question. I am very thankful to you for your patience.

Answered by Dr. Amit Jain (57 minutes later)

Thanks for feedback.

Ans1. It is generally found that patients who use mesalamine (Pentasa) the titre of ASCA may be lower than those who are not using it.

Ans2. ASCA levels are higher in patients with crohns disease. However in celiac, bechet level of ASCA may be increased if there is colitis that is inflammation in colon. ASCA test is not cofirmative for any specific disease it only supports the diagnosis. Also it is not specific for Crohns disease however titre of it is high in patients with crohns disease than any other disease.

Bechet's disease is characterised by recurrent oral ulcer, which is most commonly present in patients with this disease, recurrent genital ulcers, eye involvement, and joint pain which is not present in you.

Also sometimes the erosions in terminal ileum and IC valve may be completely non specific, and may heal on itself. So need not worry. Just continue with Tab pentasa at least for 4 weeks, see the improvement in symptoms as I described earlier.

Please don't worry and get well soon. Keep in touch

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Amit Jain (14 hours later)

my final question ... what do you think what is triggering this loose stool ? what problem i have ? Sometimes my stools are formed (very rarely) ? In the early morning i have high amount of urination which disturbs my sleep. I am taking Normaxin rt for IBS.

do i have IBS-D ? or these problem because of non specific ileitis ?

what do u think ?
Dear doctor,
since there is no cryptitis or crypt abcess, and also no granuloma, no abdominal pain, no acute diarrhea, normal ESR and CRP level
dont all these things eliminate crohns ?

Please do answer my question. Its a request from bottom of my heart.

Answered by Dr. Amit Jain (11 hours later)

Hello! Thanks for feedback and sorry for delay as it was a hectic day today for me. It would have been IBS-d if there was no alarming symptoms like weight loss of 2.5 kg in last 2 months, although it was along with diet restriction and exercise. It depends what kind of diet and exercise you were doing. If you think that this may cause loss of weight of 2.5kg in 2 months I mean to say diet and exercise then it may be ok. But finding of erosions in terminal ileum and IC valve should not be ignored and moreover presence of chronic inflammatory cells like lymphocyte and plasma cells suggest there is chronic inflammation. However presence of cryptitis and crypt abscess or granuloma may be pathognomic of crohn's disease is present in only up to 40% of the patients only. You may be right over there that in the sense like loss of weight is due to diet restriction and exercise, absence of granuloma and crypt abscess and cryptitis and normal ESR and CRP levels, that it may be simply IBS-d only. That's why I ask you initially that there are two ways to tackle this problem either you go for all the tests I have mentioned or you take treatment empirically.

Hope I have solved your queries. Get well soon

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Amit Jain (10 days later)

Hello doctor
how are you ?

I am recently on following medicine :
Rab-d and rab 20
Bifilac 2 times a day
Rcifax-200 3 times a day
Normaxin - daily night

I stopped taking Pentasa, after one week.

I have started having proper formed stools. Though frequency is still 5 times a day but with no urgency.

A doctor suggested me for vitamin b12 and vitamin d3 test.
Both were low.
Vitamin b12 = 186 pg/ml
Vitamin d3 = 12 nmol/l

now taking injection and medicines for it.

Is it normal for vegetarian diet ? My parents were also tested low on these parameters. I hardly go out in sun. Never consumed eggs even in cakes. Stopped taking milk for last 2 months. I havent noticed reduced weight.

what do u think the problem is ?
my doctor stopped Pentasa, because he felt i dont have IBD, he will repeat a colonoscopy after 3 months and then decide on it.

Answered by Dr. Amit Jain (5 hours later)

Hello! You sound to be better now. I am fine.

In pure vegetarian levels of Vitb12 may be low. As it is present only in foods from animal. Vit D3 may also be low in pure vegetarian who is not exposed to sun.

Your doctor has done right and advised good, he has started treatment of IBS-D and still wants to do repeat colonoscopy after 3 months. It is a good approach.

I will also advise here to take high protein diet. Since you are pure vegetarian you may take pulses, soyabean and cheese. If milk do not worsen your symptoms you may also take milk regularly. Hope you will get better soon. Keep in touch

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Amit Jain (40 hours later)

also my doctor said it could be SIBO, not IBS

what do you think ?

does SIBO causes loose stools instead of watery stools ?
can SIBO cause erosion (mild inflammation) in terminal ileum and IC valve ?
as u are so experienced and knowledgable, do u see in practical approach SIBO causing all these ?

Answered by Dr. Amit Jain (6 hours later)

Hello! Sorry for delay as it was a very hectic day for me.

SIBO is small intestinal bacterial overgrowth. Actually some useful bacteria are present in whole of the gastrointestinal tract. SIBO refers to abnormal increase in amount of useless or harmful bacteria in small intestinal. It occurs in patient with predisposing condition like decreased motility of gastrointestinal tract (GIT), some obstruction of GIT. SIBO is also present in some patient with IBS as there is motility defect in some patients of IBS. However is is not universal.

SIBO can cause symptoms like loose stools but it do not cause erosions in terminal ileum and IC valve

Diagnosis of SIBO is made by some breathe tests only or by small intestinal aspirate in which number of bacteria are counted.

However in patients with IBS sometimes empirically treatment of SIBO is given as the incidence of SIBO is around 40% in patients with IBS. It is usually treated with some antibiotics which is given in cyclical period for a longer period of time.

I hope I have made the things clear to you regarding your query. Hope you will get well soon

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Amit Jain (15 minutes later)

what could be the causes of the erosion in terminal ileum and ic valve ?

could these erosion self heal ? my doctor said ignore it.

i am going mad, please help... my stools are getting regularized, but still there lots of fear.

Answered by Dr. Amit Jain (5 minutes later)

Hello!
Many of the times these erosions are non-specific and may heal on itself.

I think what your doctor is doing is right .Moreover as your symptoms are also improving. Get repeat colonoscopy after 3 months and see the status of those erosions.

Note: For further follow up on digestive issues share your reports here and Click here.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar