Chronic laxative abuse associated with pancreatic islet cell hyperplasia.

Abstract

SUMMARY Marked pancreatic islet cell hyperplasia was found in a patient with laxative-induced diarrhoea. It is suggested that laxative abuse might be an important aetiological factor in patients with pancreatic islet cell hyperplasia and the watery diarrhoea syndrome but in whom no hormonal excess can be demonstrated.The abuse of laxatives is a well-recognised cause of watery diarrhoea and is most frequently seen in middle-aged women (Cummings et al., 1974). The diagnosis of this condition can frequently be difficult because such patients ingest laxatives only intermittently and vegetable laxatives cannot easily be detected in stool and urine. The watery diarrhoea syndrome is an important differential diagnosis and, in the absence of a tumour mass, this is frequently associated with pancreatic islet cell hyperplasia (Verner and Morrison, 1974). In this paper we describe a patient with watery diarrhoea caused by chronic laxative abuse in whom marked pancreatic islet cell hyperplasia was also found. Case historyA thirty-nine year old Caucasian male first presented in 1971 when he required five admissions to hospital for pilonidal sinus surgery. In 1972 he developed a discharging sinus in the right groin and after excision first developed diarrhoea with the passage of bloodstained mucus. Investigations, including barium meal, barium enema, and sigmoidoscopy, were normal. The diarrhoea continued and after losing 19 kg (3 stones) in weight he was admitted for investigation but no abnormality was found apart from a low serum folate. About this time he first complained of cramping lower abdominal pain. In 1973 he was admitted on three occasions for vasectomy, re-excision of a pilonidal sinus, and appendicectomy (appendix histology normal) but during this time the diarrhoea had subsided. In early 1974 he was admitted with chest pain and later that year he developed heartburn, vomiting, and weight loss of 16 kg (2j stones). Investigations were normal Received for publication 30 May 1977 but a laparotomy and cholecystectomy were performed. Neurological and psychiatric assessments at this time were normal.In August 1974 he had a lymph node biopsy and soon after this presented to Medical Outpatients with intractable diarrhoea with a stool volume of 3 1 per day, some lower abdominal pain, and weight loss. At this time laxative abuse was considered but this he denied and tests for phenolphthalein and magnesium in the stool were negative. The watery diarrhoea syndrome was also considered but serum gastrin, enteroglucagon, secretin, vasoactive intestinal polypeptide, and urinary 5 hydroxyindolactic acid concentrations were normal. He never became hypokalaemic. In May 1975 he was admitted for a further laparotomy because of continuing disabling symptoms but the intra-abdominal organs were completely normal. A distal pancreatectomy was performed and a 10 cm segment of the ileum was reversed in an attempt to slow down intestinal transit. Postoperatively there was an immediate cessation of symptoms and his weight returned to nor...

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“…6. Other medical complications which have been described include the development of steatorrhea and protein losing gastroenteropathy (Larusso and McGill, 1975), pancreatic dysfunction (Lesna, Hamlyn, Venables & Record, 1977), osteomalacia and pseudofractures (Cummings, 1974;Frier, 1977), hypocalcemia (Silva, 1978), and hypomagnesemia (Swift, 1979).…”

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“…Nesidioblastosis in children is a pathological condition, which is characterized by persistent hyperinsulinemic hypoglycemia and the occurrence of hypertrophic insulin cells, which may show a close association with pancreatic ductules [25]. However, the occurrence of ductulo-insular complexes is not restricted to children but is also found in adults and in the course of a variety of conditions, including the Zollinger-Ellison and watery-diarrhea syndromes and after sulfonylurea medication [4,6,7,8,9,16,18].…”

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“…Laxative abuse has been associated with chronic or nocturnal diarrhea, constipation, laxative dependence, bloody stool, bleeding, and abdominal tenderness, in addition to melanosis coli (darkening of the colon) and gastric melanosis (darkening of the stomach). In addition to colon problems, one case study documented hyperplasia (cell proliferation) in pancreatic islet cells . A larger study of treatment‐seeking patients suggested that laxatives may damage the pancreas, interfering with insulin secretion .…”

“…129 In addition to colon problems, one case study documented hyperplasia (cell proliferation) in pancreatic islet cells. 130 A larger study of treatment-seeking patients suggested that laxatives may damage the pancreas, interfering with insulin secretion. 131 Both laxative abuse and diuretic abuse are associated with finger clubbing (enlargement of soft tissue beneath finger nails).…”