Fillers can transform people's lives

Editor—Not only can fillers be educational, as Singh points out,¹ but they have the power to transform people's lives.

In his filler, entitled “Thank you for ending 40 years of misery,” Lakhani described his memorable patient, an 85 year old woman whose life had been made “sheer hell” by diarrhoea up to six times a day since she had had a vagotomy and gastroenterostomy in 1957, which had proved resistant to treatment with a fat free diet, pancreatic supplements, antibiotics, and codeine.² Suspecting this might be diarrhoea after vagotomy, he treated her with the bile acid sequestrant cholestyramine, which promptly restored her bowel function to normal.

After describing this case in my weekly medical column in the Sunday Telegraph nine readers reported a similar dramatic response after the initiation of cholestyramine treatment. Two readers said that they had had 26 years of “wind and fluid” and 31 years of “severe diarrhoea” after vagotomy and two three years of “severe painful diarrhoea” and diarrhoea for “several years” after cholecystectomy. Two readers with irritable bowel syndrome reported having had “many years” of severe diarrhoea and having had diarrhoea “six times a day.” Three readers with diverticulitis said that they had had diarrhoea “every few days and without warning,” colicky pains and diarrhoea “as soon as I eat anything,” and “very bad diarrhoea.”

Cholestyramine is a well recognised (if probably underused) treatment for chronic diarrhoea due to bile acid malabsorption as may occur after abdominal surgery or in association with inflammatory bowel disease. Its value in chronic idiopathic diarrhoea—often attributed, as in this series, to irritable bowel syndrome or diverticulitis—is more contentious, with conflicting evidence as to the contributory role or bile acid malabsorption (or increased endogenous bile acid secretion) and responsiveness to bile acid sequestrants.³,⁴

It might be more useful, in the absence of a clear understanding of the pathophysiological mechanisms involved, to take an empirical view. Cholestyramine is prescribed as an antidiarrhoeal agent in several conditions, while 40% of those taking the drug in a primary prevention trial for coronary heart disease reported constipation as a side effect.⁵

Before patients with chronic diarrhoea are diagnosed as having diverticulitis or irritable bowel syndrome, they should first be given a therapeutic trial of cholestyramine. Those experiencing a marked symptomatic improvement could then be described as having cholestyramine responsive diarrhoea. This would have the merit, certainly for patients, of making doctors more aware of this remarkably effective, if poorly understood, remedy for a most debilitating condition.