Severe weight loss caused by chewing gum

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Abstract
Case reportsCase 1A 21 year old woman had experienced diarrhoea and diffuse abdominal pain for eight months. She had four to 12 bowel movements with watery stools daily. She was initially suspected to have infectious colitis. However, as clinical investigation suggested no clear diagnosis and diarrhoea persisted, she was transferred to our department for further evaluation. At that time she had lost 11 kg and weighed 40.8 kg (body mass index 16.6). Laboratory analysis showed hypoalbuminaemia (albumin 30.7, normal range 33-50 g/l; total protein 64.3, 66-87 g/l). Further laboratory investigations (including antigastrin antibodies, antigliadin antibodies, endomysial antibodies, stool pancreatic elastase, and stool cultures) were normal. The colon had a normal macroscopic appearance on colonoscopy; histology showed no specific changes (single lymphocytes and plasma cells, no granulocytes, normal mucosal architecture) and no evidence of microscopic colitis. Findings of gastroscopy with deep duodenal biopsy, abdominal ultrasound, and computed tomography were normal. Stool collection showed that the patient produced large amounts stool—up to 1900 g daily (normal <250 g). Stool electrolytes were 71 mmol/l of sodium and 34 mmol/l of potassium. Using the formula, osmotic gap = 290−2([Na]+[K]) (× 2 to account for anions), we found the osmotic gap to be 80 mmol/l (normal <50 mmol/l), raising the suspicion of an osmotic purgative. When we questioned the patient further, we found that she chewed large amounts of sugar-free gum, accounting for a total daily dose of 18-20 g sorbitol (one stick contains about 1.25 g sorbitol). After she started a sorbitol-free diet her diarrhoea subsided—with one formed bowel movement daily on discharge from hospital. One year later she still had normal bowel movements (one or two formed stools daily) and had gained 7 kg (body mass index 19.5).Case 2A 46 year old man was admitted to our hospital because of diarrhoea and a weight loss of 22 kg within the past year. Extensive diagnostic procedures had been performed previously: Blood and stool investigations (including albumin, protein, antigastrin antibodies, antigliadin antibodies, endomysial antibodies, stool pancreatic elastase, and stool cultures) and endoscopic and radiological examinations (gastroscopy with distal duodenal biopsy, colonoscopy, abdominal ultrasound, and computed tomography) were normal. Histology of colon biopsies showed an intact mucosal architecture with single lymphocytes, no infiltrating granulocytes, and no evidence of microscopic colitis. On admission he weighed 79.9 kg (body mass index 25.8) and reported abdominal gas, bloating, and seven to 10 watery stools daily. Apart from slight abdominal tenderness his physical examination was normal. Thorough evaluation of the patients’ history with detailed analysis of eating habits suggested that he might have sorbitol induced diarrhoea—he reported chewing 20 sticks of sugar-free gum and eating up to 200 g of sweets each day, which together contained around 30 g sorbitol. We therefore evaluated his stool electrolytes, which were 54 mmol/l for sodium and 33 mmol/l for potassium, resulting in a stool osmotic gap of 116 mmol/l. During a 24 h fast with intravenous fluid substitution diarrhoea stopped, also consistent with osmotic diarrhoea. The patient was then asked to resume his normal diet. Within one day he had four watery stools. After he started a sorbitol-free diet, diarrhoea completely subsided, with one bowel movement daily. Six months later he had gained 5 kg (body mass index 27.4) and had normal stool frequency (one formed stool daily).