A sixty-two year-old woman was admitted to the hospital with
hypotension, metabolic acidosis and acute renal failure. She had been in her usual stable but poor
health until two days prior to her admission.
Because of Crohn’s Disease with colitis she had had a
proctocolectomy with an iliostomy seven years prior to admission. This was followed by persistently high
output from her iliostomy, a folate-deficiency anemia, hypocalcemia and
hypomagnesium. She had frequently required
outpatient saline infusions because of volume depletion, approximately once
weekly. She required oral
supplementation of calcium, magnesium and vitamins. She recently had had an upper endoscopy with duodenal
biopsies and both the gross and the microscopic examinations were interpreted
as normal.
For the two
days before admission she had had an abrupt increase in the volume of fluid in
her iliostomy bag that she described as profuse and watery. She also was nauseated, had abdominal
cramps that were then followed by leg cramps. She attar
ibuted this illness to having eaten “too many
peaches”.
At admission her blood pressure was 99/64 and the pulse
126. Her neck veins were not
detectable when she was supine, and she was thought to be volume depleted. The sodium was 136; potassium 3.6;
chloride 106; and the bicarbonate 16. The creatinine was 5.2 which four months earlier had been 2.3
mg/dl. The anion gap was
calculated to be 4. The serum
albumin was 3.1gm/dl. The venous
lactate was mildly elevated at 2.3 mol/L.
She was given large amounts of saline, calcium and magnesium
and her vital signs normalized as did her creatinine. The iliostomy effluent returned to her normal 3 bags per
day.
She wondered if the peaches had been tainted, but others in
her household who also ate the fruit disagreed and no one else had had diarrhea,
nor did the peaches have an abnormal odor, taste or consistency.
More likely, the peaches did cause her illness, and this was
most likely due to their high sorbitol content. The average peach contains 3 grams of sorbitol, and she ate four,
therefore, she ingested ~12 grams of sorbitol. As a laxative sorbitol is
usually given in a 70% solution or 70 grams in 100ml of water, and the usual
dose is 30 to 150ml or 21 to 105 grams.
The sorbitol packed into the four peaches that she ate cannot
alone explain her acute illness. It
seemed obvious that something else must be going on. I suspect that after her colectomy she has developed chronic
small intestinal bacterial overgrowth (SIBO).
People with SIBO have excess production of fermentation products,
gases such as hydrogen and methane, and are bothered by gut distention,
flatulence, belching and diarrhea.
There is some evidence that the distended small bowel releases cytokines
and other vasoactive molecules and that these cause extra intestinal symptoms
such as nausea, anorexia, and vague neurologic symptoms often referred to as
“brain fog”.
Avoiding easily fermentable carbohydrates ameliorates these
symptoms. These are referred to by
the acronym FODMAP for Fermentable Oligosaccharides, Disaccharides, Monosaccharide’s
and Polyols. Sorbitol is a potently
fermentable disaccharide and is found in among other foods the so-called stone
fruits such as peaches and these are forbidden for people with SIBO. I believe that this patient has
undiagnosed SIBO and that the four peaches abruptly in creased the level of
fermentation products in her small bowel.
As it turns out, Crohn’s Disease is regularly associated
small bowel bacterial overgrowth and should be considered and a breath test
obtained. * I can find no reliable
data about SIBO in patients who have had a colectomy.
*Jochen Klaus,Ulrike Spaniol, Guido Adler,
Richard A Mason, Max Reinshagen and Christian von Tirpitz:
Small intestinal bacterial overgrowth mimicking acute flare as a
pitfall in patients with Crohn's Disease
BMC
Gastroenterology 2009; 9:61
This
is a case from the notes that I keep from my Chief Service Rounds. For these last four years I had been
content with the catchy title “Near Death
from Peaches” and I did not look into the actual sorbitol content of
peaches. The patient has
disappeared from our clinics, and now I need to find her, and to see if my
hypothesis can be tested with a breath test looking for excess hydrogen and/or
methane after she drinks a solution of a standard dose of a fermentable
carbohydrate such as lactulose.
