Factitious Diarrhea Induced by Stimulant Laxatives: Accuracy of Diagnosis by a Clinical Reference Laboratory Using Thin Layer Chromatography

Shelton, Joseph H.; Ana, Carol A. Santa; Thompson, D. R.; Emmett, Michael; Fordtran, John S.

doi:10.1373/clinchem.2006.077883

Cited by 26 publications

(7 citation statements)

References 27 publications

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“…Specimens that are submitted for laxative screening in the United States are directed to a single reference laboratory. In this regard, Shelton et al (33) submitted stool and urine samples that were taken from normal volunteers in which diarrhea was induced by ingestion of either bisacodyl or senna to verify the sensitivity and specificity of the assay used in this reference laboratory. Interestingly, the tests were reported as negative in all samples of urine and stool taken from the participants with senna-induced diarrhea.…”

Section: Discussion Of Case 3 (Question 3)mentioning

confidence: 99%

Nephrology Quiz and Questionnaire

Glassock

Bargman²,

Palmer³

et al. 2010

Clinical Journal of the American Society of Nephrology

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T he Nephrology Quiz and Questionnaire returns to the pages of CJASN after an absence of 3 years, but it still remains one of the most popular sessions at the annual meeting of the American Society of Nephrology. The meeting in 2009 in San Diego was no exception, with a full-house attendance, estimated at more than 800 eager nephrologists. Eight challenging and educational cases were presented and discussed by four able and skilled experts. The discussants were asked to prepare vignettes of puzzling cases, each illustrating some topical, challenging, or controversial aspect of diagnosis or management of ESRD and dialysis (Dr. Bargman), fluid and electrolytes (Dr. Palmer), kidney transplantation (Dr. Samaniego), and glomerular disease (Dr. Fervenza). One or two single best answers questions followed each case presentation, which were addressed by the audience in a live electronic response system. In addition, several weeks before the meeting, the cases and questions (without the answers) were sent to all of the US nephrology training program directors as a questionnaire. Their responses to the questions were tallied and presented after the audience response but before the answers to the quiz and the analyses of the cases were given by the discussants.Each discussant prepared a manuscript summarizing his or her discussion of the cases, an edited version of which serves as the main text of this article. We hope that this "distillate" from San Diego will serve the subscribers to CJASN well and provide some fresh insights into the complexity and vibrancy of clinical nephrology for those who were unable to attend (Richard J. Glassock, MD, Moderator).

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Section: Discussion Of Case 3 (Question 3)mentioning

confidence: 99%

Nephrology Quiz and Questionnaire

Glassock

Bargman²,

Palmer³

et al. 2010

Clinical Journal of the American Society of Nephrology

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“…Urine testing can be used to find absorbed stimulant laxatives, such as senna or bisacodyl. The performance of commercial stool assays for laxatives is not ideal . Dilution of a stool sample with water can be detected by measuring stool osmolality; because there is no mechanism to dilute luminal contents below isotonicity, measured stool osmolality below 290 mOsm/kg is due to addition of water or dilute urine to stool.…”

Section: Diagnosismentioning

confidence: 99%

“…The performance of commercial stool assays for laxatives is not ideal. 132 Dilution of a stool sample with water can be detected by measuring stool osmolality; because there is no mechanism to dilute luminal contents below isotonicity, measured stool osmolality below 290 mOsm/kg is due to addition of water or dilute urine to stool. Addition of urine to stool can be discovered by finding substantial amounts of creatinine in stool water.…”

Section: Peptide Hormonesmentioning

confidence: 99%

Gastro 2013 APDW/WCOG Shanghai Working Party Report: Chronic diarrhea: Definition, classification, diagnosis

Schiller

Pardi

Spiller

et al. 2013

J of Gastro and Hepatol

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Diarrhea is best defined as passage of loose stools often with more frequent bowel movements. For clinical purposes, the Bristol Stool Form Scale works well to distinguish stool form and to identify loose stools. Laboratory testing of stool consistency has lagged behind. Acute diarrhea is likely to be due to infection and to be self-limited. As diarrhea becomes chronic, it is less likely to be due to infection; duration of 1 month seems to work well as a cut-off for chronic diarrhea, but detailed scientific knowledge is missing about the utility of this definition. In addition to duration of diarrhea, classifications by presenting scenario, by pathophysiology, and by stool characteristics (e.g. watery, fatty, or inflammatory) may help the canny clinician refine the differential diagnosis of chronic diarrhea. In this regard, a careful history remains the essential part of the evaluation of a patient with diarrhea. Imaging the intestine with endoscopy and radiographic techniques is useful, and biopsy of the small intestine and colon for histological assessment provides key diagnostic information. Endomicroscopy and molecular pathology are only now being explored for the diagnosis of chronic diarrhea. Interest in the microbiome of the gut is increasing; aside from a handful of well-described infections because of pathogens, little is known about alterations in the microbiome in chronic diarrhea. Serological tests have well-defined roles in the diagnosis of celiac disease but have less clearly defined application in autoimmune enteropathies and inflammatory bowel disease. Measurement of peptide hormones is of value in the diagnosis and management of endocrine tumors causing diarrhea, but these are so rare that these tests are of little value in screening because there will be many more false-positives than true-positive results. Chemical analysis of stools is of use in classifying chronic diarrhea and may limit the differential diagnosis that must be considered, but interpretation of the results is still evolving. Breath tests for assessment of carbohydrate malabsorption, small bowel bacterial overgrowth, and intestinal transit are fraught with technical limitations that decrease sensitivity and specificity. Likewise, tests of bile acid malabsorption have had limited utility beyond empirical trials of bile acid sequestrants.

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“…11 Thinlayer chromatography methods must be avoided as they have a high false-negative rate for senna based products and a high false-positive rate for bisacodyl. 42 Repeat screening may be necessary to identify intermittent intake. 11 In addition, broad screening is recommended for all laxative testing, even if a previous positive result for a particular agent has been obtained.…”

Section: Factitious Chronic Diarrhoeamentioning

confidence: 99%

Munchausen syndrome and factitious disorder: the role of the laboratory in its detection and diagnosis

2013

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The term Munchausen syndrome is used to describe the patient who chronically fabricates or induces illness with the sole intention of assuming the patient role. Such persons often have a close association with the medical profession and thus use their knowledge to falsify symptoms and laboratory specimens to mimic disease. Cases of factitious disease have appeared in the literature originating from all medical specialties, and include such rare disorders as phaeochromocytoma and Bartter's syndrome. The laboratory can play a key role in the detection and diagnosis of factitious disorders. Indeed discrepant biochemistry results may provide the first clue to the diagnosis. Laboratory staff should be particularly aware of highly variable test results and extreme abnormalities that are not consistent with the wider biochemical profile, suggesting sample tampering. Factitious disorder should also be included in the clinician's differential diagnosis when disease presentation is unusual or an underlying cause cannot be found. Investigation to exclude or confirm factitious disorder at an early stage can prevent unnecessary testing in the search for increasingly rare diseases. Appropriate analyses may include screening tests for the detection of surreptitious drug administration or replication of a fabricated sample to confirm the method used. In all cases close communication between the clinician and laboratory is essential. This will ensure that appropriate tests are conducted particularly with regard to time critical and repeat tests.

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Factitious Diarrhea Induced by Stimulant Laxatives: Accuracy of Diagnosis by a Clinical Reference Laboratory Using Thin Layer Chromatography

Cited by 26 publications

References 27 publications

Nephrology Quiz and Questionnaire

Nephrology Quiz and Questionnaire

Gastro 2013 APDW/WCOG Shanghai Working Party Report: Chronic diarrhea: Definition, classification, diagnosis

Munchausen syndrome and factitious disorder: the role of the laboratory in its detection and diagnosis

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