Diarrhea is exceedingly common and produces high economic burden. Understanding pathophysiologic mechanisms of chronic diarrhea facilitates a rational approach to diagnosis and management. Careful history taking and physical examination can characterize the mechanism of diarrhea and identify causes. In contrast to acute diarrhea, causes of chronic diarrhea are noninfectious, and most common causes in primary care are functional disorders. The first step is to differentiate functional from organic cause by asking about alarm symptoms and performing minimal screening tests. A therapeutic trial, for example, cholestyramine for bile acid malabsorption, is often appropriate, definitive, and highly cost effective without need for further evaluation. Treatment of chronic diarrhea depends on the specific etiology. For many chronic conditions, diarrhea can be controlled by suppression of the underlying mechanism. For functional diarrhea, empirical therapy may be beneficial.
Bile ; Cholestyramine Resin ; Diarrhea ; Mass Screening ; Physical Examination ; Primary Health Care ; Resin Cements

Leflunomide was licensed for the treatment of rheumatoid arthritis in 1998 and has been available in Korea since 2003. Allergic cutaneous reactions (rash, purpura) are common (<10%) side effects of leflunomide, but severe cases such as Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN) are rarely reported. There has not been a report of SJS or TEN induced by leflunomide in Korea. Here we report a case of leflunomide-induced TEN in a patient with rheumatoid arthritis. Leflunomide was discontinued, and the TEN was treated with methylprednisolone, cholestyramine and immunoglobulin. The skin lesion eventually resolved over four weeks with residual post-inflammatory hyperpigmentation.
Arthritis, Rheumatoid* ; Cholestyramine Resin ; Humans ; Hyperpigmentation ; Immunoglobulins ; Korea ; Methylprednisolone ; Skin ; Stevens-Johnson Syndrome*

Diarrhea is a common complication of antibiotics usage. The diarrhea ascribed to antibiotics usually consist of loose or watery stools, sometimes containing mucus but rarely grossly evident blood. Almost every antibiotics has been implicated, although cases related to the use of vancomycin or aminoglycosides are rare. Although the pathogenesis of antibiotics-associated diarrhea is not confirmed, recent studies have shown that a toxin of clostridium difficile is implicated as a cause of it. Diagnosis is made by detecting toxin in the stool or stool culture for C.difficile. Treatment is either directed at binding the toxin with anion exchange resins such as cholestyramine in mild case, or at eradicating the C.difficile organism with vancomycin, metronidazole or bacitracin for more severe cases. (continue...)
Aminoglycosides ; Anion Exchange Resins ; Anti-Bacterial Agents ; Bacitracin ; Cholestyramine Resin ; Clostridium difficile ; Clostridium* ; Diagnosis ; Diarrhea ; Enterocolitis, Pseudomembranous* ; Metronidazole ; Mucus ; Vancomycin

Leflunomide is a disease-modifying antirheumatic drug that has been available in Korea since 2003. Leflunomide induced interstitial pneumonitis has been reported as an adverse effect in other countries but not in Korea. A 57-year-old woman was treated with leflunomide since she had been resistant to methotrexate, hydroxychloroquine and sulfasalazine. She developed high fever, dyspnea, and non-productive cough 3 months after the administration of leflunomide. She was diagnosed leflunomide-induced interstitial pneumonitis based on history, physical, laboratory, radiologic and pathologic findings. The patient was treated by prednisolone 1 mg/kg/day with cholestyramine 24 g/day, resulting in dramatic improvement. Here we report a case of leflunomide induced pneumonitis treated successfully with high dose steroid.
Arthritis, Rheumatoid ; Cholestyramine Resin ; Cough ; Dyspnea ; Female ; Fever ; Humans ; Hydroxychloroquine ; Korea ; Lung Diseases, Interstitial* ; Methotrexate ; Middle Aged ; Pneumonia ; Prednisolone ; Sulfasalazine

Cholestyramine (CS) is an ion exchange resin, which binds to iodothyronines and would lower serum thyroid hormone level. The use of CS added to conventional antithyroid drugs to control thyrotoxicosis has been applied since 1980's, and several studies indicate that using CS in combination with methimazole (MZ) produces a more rapid decline in serum thyroid hormones than with only MZ treatment. Our recent retrospective review of five patients taking high dose MZ and CS, compared to age-, gender-, initial free thyroxine (T4) level-, and MZ dose-matched 12 patients with MZ use only, showed more rapid decline of both free T4 and triiodothyronine levels without more adverse events. CS could be safely applicable short-term adjunctive therapy when first-line antithyroid medications are not enough to adequately control severe thyrotoxicosis or side effects of antithyroid drug would be of great concern.
Antithyroid Agents ; Cholestyramine Resin* ; Graves Disease ; Humans ; Ion Exchange ; Methimazole ; Retrospective Studies ; Thyroid Gland ; Thyroid Hormones ; Thyrotoxicosis* ; Thyroxine ; Triiodothyronine

The three major forms of treatment for Graves thyrotoxicosis are antithyroid drugs, radioactive iodine therapy and thyroidectomy. Surgery is the definitive treatment for Graves thyrotoxicosis that is generally recommended when other treatments have failed or are contraindicated. Generally, thyrotoxic patients should be euthyroid before surgery to minimize potential complications which usually requires preoperative management with thionamides or inorganic iodine. But several cases of refractory Graves' disease have shown resistance to conventional treatment. Here we report a 40-year-old female patient with Graves' disease who complained of thyrotoxic symptoms for 7 months. Her thyroid function test and thyroid autoantibody profiles were consistent with Graves' disease. One kind of thionamides and beta-blocker were started to control her disease. However, she was resistant to nearly all conventional medical therapies, including beta-blockers, inorganic iodine, and two thionamides. She experienced hepatotoxicity from the thionamides. What was worse is her past history of serious allergic reaction to corticosteroids, which are often used to help control symptoms. A 2-week regimen of high-dose cholestyramine improved her uncontrolled thyrotoxicosis and subsequent thyroidectomy was successfully performed. In conclusion, cholestyramine could be administered as an effective and safe adjunctive agent for preoperative preparation in patients with severe hyperthyroid Graves's disease that is resistant to conventional therapies.
Adrenal Cortex Hormones ; Adult ; Antithyroid Agents ; Cholestyramine Resin* ; Drug Resistance ; Female ; Glycogen Storage Disease Type VI ; Graves Disease* ; Humans ; Hypersensitivity ; Iodine ; Thyroid Function Tests ; Thyroid Gland ; Thyroidectomy* ; Thyrotoxicosis

PURPOSE: Dioctahedral smectite is an alumina silicate of phyllitic structure and absorbs bile acid in the intestine, forming a non-absorbable complex preventing enterohepatic circulation. The purpose of this study is to clarify the value of dioctahedral smectite and the adequate dosage, in combination with phototherapy, as well as to confirm whether it shortens the duration of hospitalization and to compare dioctahedral smectite with cholestyramine. METHODS: Total 45 full-term neonate with a total bilirubin level greater than 12 mg/dl were studied. The neonate were randomly divided into three groups : 1) Only phototherapy group (A) 2) 3.0 g/day dioctahedral smectite with phototherapy group (B) 3) 1.0 g/kg/day cholestyramine with phototherapy group (C). RESULTS: The mean serum bilirubin level of group B and C decreased significantly compared to group A at 48, 72 and 96 hours after the beginning of the study. The duration of phototherapy and hospitalization significantly decreased in group B and C. CONCLUSION: The data revealed that oral administration of dioctahedral smectite not only increased the efficacy of phototherapy, but also shortened the duration of phototherapy and can substitute for cholestyramine.
Administration, Oral* ; Aluminum Oxide ; Bile ; Bilirubin ; Cholestyramine Resin* ; Enterohepatic Circulation ; Hospitalization ; Humans ; Hyperbilirubinemia, Neonatal* ; Infant, Newborn ; Intestines ; Jaundice, Neonatal ; Phototherapy* ; Silicates

Leflunomide, a disease-modifying antirheumatic drug (DMARD) for the treatment of rheumatoid arthritis has been available in Korea since 2003. Leflunomide-associated interstitial pneumonitis has been appearing recently. A 25-year-old woman with a 12-month history of seronegative rheumatoid arthritis (RA) presented with acute respiratory insufficiency. She developed fever, dyspnea, and non-productive cough. Her medication history included methotrexate (15 mg/week. commencing 1 year prior) and leflunomide (20 mg/day, no loading dose, commencing 4 months prior). She was diagnosed with leflunomide-associated interstitial pneumonitis based on history, physical examination, laboratory and radiologic findings. She recovered quickly after leflunomide was withdrawn and steroids and cholestyramine were initiated quickly. We report a case of leflunomide-associated interstitial pneumonitis treated successfully with intravenous high-dose steroid and cholestyramine.
Adult ; Arthritis, Rheumatoid ; Cholestyramine Resin ; Cough ; Dyspnea ; Female ; Fever ; Humans ; Isoxazoles ; Korea ; Lung Diseases, Interstitial ; Methotrexate ; Physical Examination ; Respiratory Insufficiency ; Steroids

A 22-year-old woman with severe Graves' disease was referred from a local clinic because of her refractory hyperthyroidism. She presented with exophthalmos, diffuse goiter, and tachycardia. She was treated with a maximal dose of methimazole and a beta-blocker for 2 months. However, her thyroid function test (TFT) did not improve. TFT showed a free T4 level of 74.7 ng/dL and a thyroid stimulating hormone (TSH) level of 0.007 µIU/mL. She was then administered cholestyramine (4 g thrice daily), hydrocortisone (300 mg/day) and methimazole (100 mg/day) which prepared the patient for surgery by reducing the free T4 level (4.7 ng/dL). The patient underwent a total thyroidectomy without experiencing thyrotoxic crisis. This case describes the use of cholestyramine for the first time in Korea in treating Graves' disease and provides limited evidence that cholestyramine can be an effective option.
Cholestyramine Resin* ; Exophthalmos ; Female ; Goiter ; Graves Disease* ; Humans ; Hydrocortisone ; Hyperthyroidism ; Korea ; Methimazole ; Tachycardia ; Thyroid Crisis ; Thyroid Function Tests ; Thyroidectomy ; Thyrotoxicosis ; Thyrotropin ; Young Adult

A 22-year-old woman with severe Graves' disease was referred from a local clinic because of her refractory hyperthyroidism. She presented with exophthalmos, diffuse goiter, and tachycardia. She was treated with a maximal dose of methimazole and a beta-blocker for 2 months. However, her thyroid function test (TFT) did not improve. TFT showed a free T4 level of 74.7 ng/dL and a thyroid stimulating hormone (TSH) level of 0.007 µIU/mL. She was then administered cholestyramine (4 g thrice daily), hydrocortisone (300 mg/day) and methimazole (100 mg/day) which prepared the patient for surgery by reducing the free T4 level (4.7 ng/dL). The patient underwent a total thyroidectomy without experiencing thyrotoxic crisis. This case describes the use of cholestyramine for the first time in Korea in treating Graves' disease and provides limited evidence that cholestyramine can be an effective option.
Cholestyramine Resin* ; Exophthalmos ; Female ; Goiter ; Graves Disease* ; Humans ; Hydrocortisone ; Hyperthyroidism ; Korea ; Methimazole ; Tachycardia ; Thyroid Crisis ; Thyroid Function Tests ; Thyroidectomy ; Thyrotoxicosis ; Thyrotropin ; Young Adult