GastroenterologyTier 2Disease (DEADMAN)

Tropical sprue

Description

Tropical sprue - a chronic malabsorptive small bowel disorder occurring in residents of or travellers to specific tropical regions (particularly South Asia, Southeast Asia, and the Caribbean), causing villous atrophy and malabsorption without the gluten-dependence of coeliac disease

Geographically restricted to endemic tropical regions; incidence has declined over recent decades with improved sanitation, but it remains relevant in returning travellers and residents of endemic areas presenting with unexplained chronic diarrhoea/malabsorption

The precise cause remains incompletely understood but is thought to involve chronic small intestinal bacterial overgrowth/infection (following an initial acute enteric infection in many cases), causing persistent mucosal inflammation, villous atrophy, and secondary malabsorption - distinct from coeliac disease's autoimmune gluten-driven mechanism

Chronic diarrhoea, weight loss, and features of malabsorption (steatorrhoea, fat-soluble vitamin deficiency, folate and B12 deficiency are particularly prominent given the small bowel segments typically affected) in a patient with an appropriate travel/residence history
Small bowel biopsy shows villous atrophy (can resemble coeliac disease histologically) but does not improve with gluten withdrawal and coeliac serology is negative - these two features are key to distinguishing it from coeliac disease
Diagnosis is largely clinical (compatible presentation + geographic exposure + exclusion of coeliac disease and other causes), supported by the biopsy findings and response to treatment

Prolonged antibiotic therapy (e.g. tetracycline-class, for weeks to months) targeting the presumed bacterial overgrowth component, alongside folate supplementation (often produces rapid symptomatic improvement even before the antibiotic course is complete) and correction of other identified deficiencies (B12, fat-soluble vitamins)
Response to this treatment (clinical and biochemical improvement) further supports the diagnosis retrospectively

Folate deficiency, vitamin B12 deficiency, coeliac disease (the key differential diagnosis), small intestinal bacterial overgrowth

Response to antibiotics and folate is usually clear within weeks, and most patients recover fully with treatment, in contrast to coeliac disease, which requires lifelong dietary management rather than a defined treatment course - this difference in expected treatment duration is itself a useful distinguishing clinical feature

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