ASGE Annual GI Advanced Practice Provider Course (Virtual) (Day Two) | March 2026-Clinical Vignettes: Approach to Acute and Chronic Diarrhea Including Celiac Sprue and SIBO

Video Transcription

Video Summary

The speaker reviews a practical, stepwise approach to patients presenting with bloating, chronic diarrhea, possible celiac disease, and small-bowel disorders such as SIBO. Celiac disease diagnosis is often delayed about five years after symptom onset. For chronic diarrhea, key alarm features include onset after age 50, rectal bleeding/melena, unexplained weight loss, and iron-deficiency anemia (all of the above).<br /><br />Bloating has a broad differential (dietary intolerances/high-FODMAP foods, constipation/pelvic floor dysfunction, celiac disease, SIBO, gastroparesis, obstruction, pancreatic insufficiency, hypothyroidism, ascites, prior surgeries, malignancy, aerophagia). The speaker emphasizes careful history-taking and avoiding premature SIBO testing/treatment, as breath tests and rifaximin can be costly and dietary triggers may be the real cause.<br /><br />Celiac disease can present with classic GI symptoms or non-classic manifestations (iron deficiency, osteoporosis, elevated liver enzymes, rash, headaches, psychiatric symptoms). Testing should include tTG-IgA plus total IgA (use IgG-based tests if IgA-deficient) and must be done while eating gluten; biopsy via upper endoscopy is recommended. Management requires lifelong gluten-free diet, dietitian support, monitoring serologies and micronutrients, and repeat endoscopy if symptoms persist.<br /><br />Chronic diarrhea (>30 days) is categorized (malabsorptive, secretory, osmotic, inflammatory, motility-related). Workup includes stool studies, labs, and often colonoscopy with random biopsies to diagnose conditions like microscopic colitis (associated with PPIs/SSRIs/NSAIDs). SIBO is diagnosed by breath testing and treated based on gas pattern (hydrogen vs methane), often triggered by prior surgery or altered anatomy.

Asset Subtitle

Jill Olmstead, DNP, ANP-BC, FAANP

Keywords

bloating differential diagnosis

chronic diarrhea alarm features

celiac disease testing tTG-IgA total IgA

gluten-free diet management

small intestinal bacterial overgrowth (SIBO) breath test

microscopic colitis random colon biopsy

rifaximin hydrogen vs methane treatment