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A 25-year-old man comes to your office because he
has diarrhea. Four months ago, he had an
exploratory laparotomy for a small bowel obstruc-
tion. He was found to have 30 cm of distal ileal
Crohn's disease, which was resected with ileocolonic
continuity re-created. He received therapy with
antibiotics during an uneventful perioperutive period.
Shortly after beginning a normal diet and despite
feeling well otherwise, he began to have 6 to 8 watery
bowel movements daily that have not resolved. Most
bowel movements occur after breakfast. He has had
no fever, bloating, hematochezia, nocturnal diarrhea,
foreign travel, or weight loss. Physical examination of
the abdomen is normal except for a well-healed, mid-
line scar. Results of complete blood count, biochemi-
cal profile, and examination of the stool for
leukocytes are negative. What would be the best initial
therapeutic intervention?
A. Corticosteroids
B. Metronidazole
C. Cholestyrornine
D. Sulfasalazine
E. Codeine sulfate

E. Codeine sulfate

thought it was bb ..ABT ass. colitis
but i was wrong lol

swer: C. This patient has Crohn's disease of the
terminal ileum and had an ileal resection. He has the
common and challenging problem of recurrent diar-
rhea after the initial operation. Possible causes include
recurrent Crohn's disease, partial obstruction caused
by adhesions with or without bacterial overgrowth,
anitbiotipc-associated diarrhea, and either bile-salt
diarrhea or malabsorption secondary to the ileal
resection.
It would be unusual, but not impossible, for Crohn's
disease to recur within 1 month of a resection. Signs
of inflammation (e.g., leukocytosis, blood or leukocytes
in the stool, fever) or obstruction (e.g., bloa-
ting, distention, postprandial pain, weight loss) are
absent. Thus empiric therapy with either corticosteroids
or sulfasalazine is incorrect. The persistence of diarrhea
for 4 months without systemic symptoms or fever
and the absence of leukocytes in the stool make antibi-
otic-associated colitis extremely unlikely. Its treatment,
metronidazole, should not be selected.
Operations for cancer, inflammatory bowel disease,
and intestinal infarction can lead to resection of vary-
ing lengths of ileum. The pathophysiologic conse-
quences of the resection depend on the length of the
ileum resected. Normally, more than 95% of bile acids
secreted into the intestine are reabsorbed and recircu-
lated to the liver. Resection of a short segment of the
ileum leads to malabsorption of conjugated bile acids,
resulting in secretory diarrhea. Typically, bile-salt diar-
rhea is watery, may not start until a normal diet is
resumed after surgery, is precipitated by a meal (most
commonly breakfast when a large quantity of bile is
stored in the gallbladder), and does not lead to weight
loss. It is in a patient such as this that an empiric trial
of a bile acid binder, like cholestyrarnine, can dramati-
cally reduce troublesome watery diarrhea.
With ileal resections of about 100 cm or more, the
liver synthesis of bile acids cannot keep up with
the colonic losses; the concentration of bile acids in the
duodenum falls, and steatorrhea develops. It should be
expected, however, that such a patient with steatorrhea
would lose weight and not gain weight as in this case.
Although narcotics such as codeine sulfate can effec-
tively reduce the number of bowel movements, their
potential for psychologic and physical dependency
make them a poor choice when other alternatives are
available. (CH28)

hmmm.....nice explanation...tx!