P4142 - The Villous Villain: A Rare Case of Insidious Onset Enteropathy in a Patient on Olmesartan

Bryant Pinto. Javier, DO, MHA, Uday Patel, DO, Aleena Sammar, MD, Rajiv Singh, MD, Stephanie Murphy, DO, Christopher Calcagno, DO
Parkview Medical Center, Pueblo, CO

Introduction: Iatrogenic causes of pathology should always be considered when evaluating a patient complaint. We present a case of insidious onset diarrhea in a 74-year-old female with a history of hypertension treated with Olmesartan.

Case Description/Methods: We present a 74-year-old female who endorsed worsening watery diarrhea over one year with up to 4 to 5 bowel movements daily. She denied fevers, abdominal pain, nausea, vomiting, and hematochezia but endorsed worsening diarrhea with oral intake. She had seen her primary care physician for medication reconciliation, which included: levothyroxine, duloxetine, atorvastatin, aspirin, famotidine, chlorthalidone, and olmesartan, all for which she had been taking greater than two years. Initial workup included CBC, stool ova and parasites, clostridium difficile toxin, pancreatic elastase, stool culture, fecal fat, TSH, ferritin, celiac disease panel, SARS-COV-2 test, giardia, cryptosporidium, all of which were negative. Gastroenterology was consulted, who performed EGD and colonoscopy with multiple random biopsies of the duodenum, gastric region, and colon. Her endoscopic studies were grossly normal, and biopsies demonstrated mild gastric inflammation without pathological abnormalities of villi. Due to her unremarkable workup, her medications were reviewed, and olmesartan was transitioned to amlodipine. At six-week follow-up, patient was found to have a complete resolution of her chronic diarrhea.

Discussion: Olmesartan is an angiotensin receptor blocker (ARB) commonly used as an antihypertensive medication that has been reported to be associated with enteropathy. Although a chronic medication, patient’s symptoms resolved six weeks after discontinuation. Time for resolution is variable, including anywhere from 1 to 8 weeks. The incidence of this rare side effect is not well known, although the physiology causing the above symptom appears to be due to villous blunting in the small bowel. This enteropathy seems to have a highly variable onset, and its cause may go unnoticed due to insidious worsening over months to years. Although biopsy results in the above case did not demonstrate villous changes, further diagnostic testing or additional biopsies may have demonstrated this pathology. Many olmesartan-associated diarrhea studies illustrate that the majority of biopsy samples return pathology consistent with villous changes. This case emphasizes that possible iatrogenic causes for medical concerns should never be overlooked.


Disclosures:


Bryant Pinto. Javier, DO, MHA, Uday Patel, DO, Aleena Sammar, MD, Rajiv Singh, MD, Stephanie Murphy, DO, Christopher Calcagno, DO. P4142 - The Villous Villain: A Rare Case of Insidious Onset Enteropathy in a Patient on Olmesartan, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.