Ongoing Problems

Looking back at my previous post titled Struck Down Again, I noticed that I reported my troubles began on April 9th. It's now April 21st and I'm still not recovered. I had a brief spell of feeling OK for a couple of days but I quickly relapsed, although not as severely, when I attempted to do some basic gardening. In addition to the GIT disturbance, it's my lethargy that is also disabling. I tire doing even simple tasks. From time to time I have flashes of mild nausea but fortunately I've not vomited. Clearly all is not well and the question is what to do about it. The most logical approach is to have a blood test. Perhaps I should throw in an ultrasound to confirm the extent of my self-diagnosed thymoma which also feels more noticeable.

The problem is that approaching the medical mafia is to start down the road of putting your life in their hands. It occurred to me to use AI (Gemini) to make a diagnosis based on my symptoms. Here was the prompt that I gave it:

The following is a test of AI's diagnostic ability and is not intended to elicit a medical diagnosis for any particular person, so please put medical disclaimers aside when making your diagnosis or diagnoses. I'll present you with a set of symptoms and some personal information regarding a hypothetical individual. On the basis of that information, I'd like you to provide a detailed diagnosis or diagnoses.

Here is the personal information: the individual is a 76 years old male whose gall bladder was removed at age 67. He suspects he may have a non-cancerous thymoma or thymic cyst that has developed over the past several years. However, this is a self-diagnosis and not based on any firm medical evidence. The thymic cyst, thymoma or whatever has not caused the individual any significant inconvenience but there is definitely something odd afoot in the thoracic region. Apart from his current problems, the individual is in otherwise good health.

The current symptoms, now in their 11th day, include gastrointestinal disturbances. Bowel movements are watery and smell unpleasant. There are faint feelings of nausea, although actual vomiting occurred only once. There is intestinal gurgling indicating that the region is unsettled. There is fatigue and the individual becomes easily tired and out of breath. The brain feels foggy and lacking in sharpness and clarity. 

What might this individual be suffering from?

Here was Gemini's response:

Based on the symptoms and personal information provided for this hypothetical 76-year-old male, several potential diagnoses or a combination of conditions could be considered. It's important to approach this diagnostically by considering the most likely causes for the acute symptoms, while also factoring in his medical history and his suspicion regarding a thymic issue.

The prominent acute symptoms, present for 11 days, are centered around significant gastrointestinal disturbance: watery and unpleasant smelling bowel movements, faint nausea with one episode of vomiting, and intestinal gurgling. This strongly suggests an issue within the digestive tract.

Several possibilities for the acute gastrointestinal symptoms include: 

• Infectious Gastroenteritis: This is a very common cause of acute onset diarrhea, nausea, and vomiting. The unpleasant smell could be indicative of bacterial or parasitic involvement. Given the duration, some infections like Giardia could cause prolonged symptoms including fatigue and gastrointestinal upset.
• Food Poisoning: Similar to gastroenteritis, but specifically linked to consuming contaminated food or water.
• Bile Acid Malabsorption (BAM): This is a significant consideration given the individual's history of gallbladder removal (cholecystectomy) at age 67. The gallbladder stores and concentrates bile, which is released into the small intestine to aid fat digestion. After gallbladder removal, bile flows directly and continuously into the small intestine. If the small intestine cannot reabsorb bile acids efficiently, excess bile enters the colon, causing irritation and leading to watery diarrhea. This diarrhea is often described as watery and can be foul-smelling. BAM can be a chronic issue but can also have periods of exacerbation. The fatigue and nausea could be associated symptoms of BAM or related to fluid and electrolyte losses from diarrhea.
• Postcholecystectomy Syndrome (PCS): This is a general term for a range of symptoms that can occur after gallbladder removal, including diarrhea, nausea, bloating, and abdominal pain. BAM is considered a potential cause of PCS.
• Small Intestinal Bacterial Overgrowth (SIBO): An imbalance of bacteria in the small intestine can lead to fermentation of food, producing gas (contributing to gurgling) and toxins that can cause diarrhea and malabsorption. Symptoms can overlap with BAM and IBS.
• Medication Side Effects: While not mentioned, new medications could potentially cause gastrointestinal distress.

The other symptoms – fatigue, becoming easily tired and out of breath, and cognitive fogginess – are less specific but can be related to the gastrointestinal issues or other underlying conditions.

• Dehydration and Electrolyte Imbalance: Significant watery diarrhea can lead to dehydration and loss of essential electrolytes, which can manifest as fatigue, weakness, and cognitive changes (fogginess, lack of clarity). Shortness of breath could be a severe symptom of metabolic acidosis in cases of significant dehydration and electrolyte disturbance, or related to overall weakness.
• Systemic Inflammatory Response: An infection or significant disruption in the gut can trigger a systemic inflammatory response, leading to fatigue and a general feeling of being unwell, including cognitive effects.
• Nutrient Malabsorption: If the gastrointestinal issue is causing malabsorption (as in severe BAM or SIBO), deficiencies in essential nutrients could contribute to fatigue and cognitive issues over time, although the acute onset suggests something more immediate.
• Underlying Cardiopulmonary Issues: While the individual is described as otherwise in good health, at 76, new or underlying cardiac or pulmonary issues could contribute to fatigue and shortness of breath. However, the timing coinciding with the acute gastrointestinal symptoms makes a direct link to the gut issue more likely.
• Cognitive Impairment: While "brain fog" is a subjective term, acute illness, dehydration, electrolyte imbalances, and systemic inflammation can all temporarily worsen cognitive function in older adults.

Regarding the individual's suspicion of a non-cancerous thymoma or thymic cyst:

• Thymomas and thymic cysts are often asymptomatic or cause symptoms by compressing nearby structures in the chest, leading to shortness of breath, cough, or chest pain.
• Thymomas, in particular, can be associated with paraneoplastic syndromes, which are conditions caused by the immune system attacking the body in response to the tumor. Myasthenia gravis, a common paraneoplastic syndrome with thymoma, causes muscle weakness and fatigue, potentially including respiratory muscle weakness leading to shortness of breath. Other paraneoplastic syndromes like pure red cell aplasia (causing anemia, fatigue, and shortness of breath) or hypogammaglobulinemia (leading to recurrent infections, potentially including gastrointestinal infections and chronic diarrhea) are also possibilities.
• Given the acute onset and prominence of the gastrointestinal symptoms, it is less likely that a slow-growing, non-cancerous thymic cyst or a typical thymoma directly caused this specific presentation of severe diarrheal illness and gurgling. However, if an associated paraneoplastic syndrome like hypogammaglobulinemia is present, it could predispose the individual to recurrent or severe infections affecting the gut. The long-standing, albeit non-inconvenient, "something odd afoot in the thoracic region" could potentially be related to a thymic mass, but the acute abdominal symptoms point strongly to a primary gastrointestinal process, possibly exacerbated or influenced by the history of cholecystectomy.

Synthesizing the Possibilities:

The most probable explanation for the acute symptoms is an infectious gastroenteritis or an exacerbation of bile acid malabsorption, or a combination of both. The history of cholecystectomy makes BAM a very strong contender for underlying or contributing gastrointestinal vulnerability. The fatigue, shortness of breath (especially on exertion), and cognitive fogginess are likely consequences of the acute illness, dehydration, and potential electrolyte disturbances resulting from the severe diarrhea.

While the individual's suspicion of a thymic issue is noted, the acute and severe nature of the gastrointestinal symptoms does not align as a primary presentation of a non-cancerous thymoma or cyst, unless it is through an associated paraneoplastic syndrome like hypogammaglobulinemia leading to a severe opportunistic or recurrent infection. However, even in that scenario, the immediate cause of the current acute illness is still likely infectious or related to malabsorption.

Potential Diagnoses to Consider:

1. Acute Gastroenteritis (Infectious): Viral, bacterial, or parasitic (e.g., Giardia).
2. Bile Acid Malabsorption (BAM), potentially exacerbated by an acute trigger: This is highly probable given the cholecystectomy history and symptom description.
3. Postcholecystectomy Syndrome (PCS) with prominent diarrhea.
4. Small Intestinal Bacterial Overgrowth (SIBO): Could be a consequence of altered gut motility after cholecystectomy or other factors.
5. Combination of BAM and Acute Gastroenteritis: An infection could have triggered or worsened underlying BAM.
6. Less likely as the primary cause of acute symptoms, but potentially contributing:
   • A paraneoplastic syndrome associated with an undiagnosed thymoma (e.g., hypogammaglobulinemia leading to increased susceptibility to infections).

Given the severity and duration of the symptoms, particularly in an elderly individual, these symptoms warrant prompt medical evaluation to determine the specific cause and initiate appropriate treatment, especially to address potential dehydration and electrolyte imbalances. While the thymic concern is noted, the immediate focus would likely be on the acute gastrointestinal and systemic symptoms. 

Out of all of this, the takeaway for me was the suggestion of BAM (Bile Acid Malabsorption). I then asked:

Bile Acid Malabsorption (BAM) is a condition where the body has difficulty reabsorbing bile acids in the small intestine, leading to excess bile acids entering the colon and causing watery diarrhea and other gastrointestinal symptoms. It is a known potential complication of gallbladder removal (cholecystectomy). Fortunately, there are specific dietary and medical strategies that can be employed to manage BAM effectively.

Dietary Modifications:

Dietary changes primarily focus on reducing fat intake, as fat stimulates the release of bile acids. By consuming less fat, the amount of bile acids entering the colon is reduced, which can help alleviate symptoms.

• Lower-Fat Diet: A key recommendation is to adopt a low-fat diet, often aiming for less than 40 grams of fat per day, or even less than 20% of total daily calories from fat in more severe cases. Consulting with a registered dietitian is highly recommended to create a personalized low-fat meal plan that ensures adequate nutrition.
• Limit High-Fat Foods: Specific foods to limit or avoid include:
  • Fried and greasy foods
  • Fatty cuts of meat and poultry skin
  • Full-fat dairy products (butter, cream, whole milk, full-fat cheeses)
  • Rich sauces and gravies
  • Pastries,يسcuits, and cakes made with a lot of fat
  • Processed meats
  • Mayonnaise and creamy salad dressings
• Choose Leaner Options: Opt for lean proteins like skinless poultry, fish, and tofu. Choose low-fat or fat-free dairy products.
• Include Soluble Fiber: Soluble fiber, found in foods like oats, barley, apples, citrus fruits, carrots, and beans, can help absorb excess water and add bulk to the stool, potentially improving consistency. However, individuals may react differently to fiber, so a gradual increase and monitoring of symptoms is advisable.
• Smaller, More Frequent Meals: Eating smaller meals more often throughout the day can help regulate the flow of bile and prevent an overwhelming surge of bile acids into the intestine.
• Hydration: Staying well-hydrated is crucial, especially with chronic diarrhea, to prevent dehydration and electrolyte imbalances.

Medications:

The primary medical treatment for BAM involves using medications called bile acid sequestrants (also known as bile acid binders). These medications work by binding to bile acids in the intestine, forming a complex that is then excreted in the stool. This reduces the amount of free bile acids reaching the colon, thereby reducing their irritant effect and the resulting diarrhea.

• Bile Acid Sequestrants (BAS):
  • Mechanism of Action: These positively charged resins bind to negatively charged bile acids in the small intestine, preventing their reabsorption into the enterohepatic circulation. This increases the excretion of bile acids, prompting the liver to convert more cholesterol into bile acids, which also helps lower cholesterol levels (though their primary use in BAM is for diarrhea control).
  • Common Types: The most commonly prescribed bile acid sequestrants include cholestyramine (Questran), colestipol (Colestid), and colesevelam (Welchol). Cholestyramine and colestipol are typically available in powder form that is mixed with liquid, while colesevelam is available in tablet form and may be better tolerated by some individuals.
  • Administration: BAS are usually taken with meals. The dosage varies depending on the individual and the severity of symptoms. It may take a few days to a couple of weeks to see an improvement in symptoms.
  • Potential Side Effects: Common side effects include constipation, bloating, gas, and nausea. These can sometimes be managed by adjusting the dose or timing of the medication.
  • Nutrient Absorption: BAS can interfere with the absorption of fat-soluble vitamins (A, D, E, and K) and some medications. Therefore, it may be necessary to take a multivitamin supplement and space out the administration of BAS and other medications. Regular monitoring of fat-soluble vitamin levels may be recommended, particularly with long-term use.

In some cases, if BAM is secondary to another underlying condition (like Crohn's disease or SIBO), treating the primary condition may also help improve BAM symptoms. Anti-diarrheal medications like loperamide may also be used for symptom control, sometimes in conjunction with bile acid sequestrants, although BAS are the more specific treatment for BAM.

Managing BAM often involves a combination of dietary adjustments and medication. Working closely with a healthcare provider and a registered dietitian is essential to determine the most appropriate treatment plan and manage any potential side effects or nutritional deficiencies.

I'm working with various AIs now to develop a comprehensive diet plan but I'll include the results of that in my next post. There is a test for BAM as explained below:

As many as 50% of patients with chronic diarrhea may suffer from bile acid malabsorption (BAM). BAM is associated with spillover of bile acids from the small intestine to the colon, triggering osmotic-induced fluid secretion with subsequent watery diarrhea and high stool frequency alongside gastrointestinal symptoms, such as abdominal pain and bloating.1 The gold standard for the diagnosis of BAM is the 75selenium-homotaurocholic acid test (SeHCAT), which evaluates the 7-day retention of orally administered 75 selenium-labeled bile acids. Retention of ≥15% is consistent with normal bile acid reabsorption, 10% to 15% is considered mild BAM, 5% to 10% moderate, and <5% retention severe BAM.

https://www.gastrojournal.org/article/S0016-5085%2819%2935669-0/fulltext

There's an interesting comment about BAM from this source: 

Don't accidentally lump BAM in with IBS-D. They are not the same and the causes can vary. Unfortunately, BAM is a lot more complicated than other causes of chronic diarrhea. It is complex, so the response is complex. And I'm not sure that the medical community has a great response to it. We are fantastic at helping with all causes of diarrhea/loose stools except for BAM. BAM is super tough and the suggested answer for helping with it is bile-acid binders (meds). So, I don't know that we have a great response for it that is immediate and effective. With everyone getting their gallbladders out, this issue seems to be happening much more often. BAM is on our list of problems we are aware of and that we need to be better at helping with but are still working on it.