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Persistent diarrhoea and occult vipomas in children

BMJ 2000; 320 doi: (Published 03 June 2000) Cite this as: BMJ 2000;320:1524
  1. M S Murphy, consultant paediatric gastroenterologist (,
  2. A Sibal, clinical fellowa,
  3. J R Mann, consultant paediatric oncologistb
  1. a Department of Gastroenterology and Nutrition, Birmingham Children's Hospital, Birmingham B4 6NH
  2. b Department of Oncology, Birmingham Children's Hospital
  1. Correspondence to: M S Murphy, Institute of Child Health, Clinical Research Block, Whittall Street, Birmingham B4 6NH
  • Accepted 1 November 1999

Failure to recognise secretory diarrhoea leads to inappropriate gastrointestinal investigations, delayed diagnosis of a vipoma, and avoidable morbidity

A wide range of gastrointestinal disorders may cause chronic diarrhoea in childhood. In a small proportion of cases the diarrhoea is due to active intestinal fluid secretion—secretory diarrhoea. It is essential to identify such cases because of important diagnostic implications. Patients with unexplained persistent watery diarrhoea should undergo a period of fasting; continuing diarrhoea indicates a secretory process. Secretory diarrhoea is confirmed by a raised stool sodium concentration. In the developed world the most likely explanation for persistent secretory diarrhoea may be an occult vipoma—a tumour that secretes vasoactive intestinal polypeptide.12 This is an uncommon tumour. The first two cases described here presented 25 and 15 years ago respectively, and the remaining four presented in the past 10 years. As these reports illustrate, however, vipomas are amenable to curative surgery. If the diagnosis is not considered, extensive gastrointestinal investigations may be undertaken, the diagnosis will be delayed, and avoidable morbidity will occur.

Case reports

Case 1

An 18 month old boy presented with an eight month history of diarrhoea, malnutrition, and abdominal distension. During eight weeks of inpatient investigation only a xylose absorption test proved abnormal. Coeliac disease was suspected, and he received a gluten free diet without intestinal biopsy. He was lost to follow up until 28 months of age, when he presented with a respiratory infection. A chest radiograph showed a tumour in the pulmonary right upper zone. The diarrhoea had persisted and he was severely malnourished.

Case 2

A 1 year old boy was referred with a two month history of watery diarrhoea, malnutrition, and abdominal distension. Investigations were normal, but a gluten free diet was started without intestinal biopsy. There was no improvement. Treatment with metronidazole for unproved giardiasis was ineffective. …

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