ACCREDITATION STATEMENT: University of California, San Diego School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The University of California, San Diego School of Medicine designates this educational activity for a maximum of one credit per hour AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity. 1 Didactic Series Didactic Series Managing Common Complaints: Diarrhea Daniel Lee, MD UCSD Medical Center – Owen Clinic October 10, 2013
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ACCREDITATION STATEMENT: University of California, San Diego School of Medicine is accredited by the Accreditation Council for Continuing Medical Education.
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ACCREDITATION STATEMENT: University of California, San Diego School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The University of California, San Diego School of Medicine designates this educational activity for a maximum of one credit per hour AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
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Didactic SeriesDidactic Series
Managing Common Complaints: Diarrhea
Daniel Lee, MDUCSD Medical Center – Owen Clinic
October 10, 2013
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Learning Objectives
1) To review the definition of diarrhea
2) To identify some common infectious causes of diarrhea in HIV
3) To discuss diagnosis and treatment options for various infectious causes of diarrhea in HIV
• Second leading cause of morbidity and mortality worldwide1
• In the United States:– 211-375 million diarrheal illnesses (>1 day)– 73 million physician consultations– 1.8 million hospitalizations– 3100 deaths– $23 billion spent– 10 to 15 million Americans suffer from chronic
diarrhea2
1. Guerrant R. IDSA Practice Guidelines. Clinical Infectious Diseases, 2001; 32: 331-50.2. AGA Technical Review on the Evaluation and Management of Chronic Diarrhea, Gastroenterology, 1999
Definition of Diarrhea
• “Diarrhea” – the alteration in the normal bowel movement characterized by an increase in the water content, volume, or frequency of stools
• “Infectious diarrhea” – diarrhea due to an infectious etiology, often accompanied by symptoms of nausea, vomiting, abdominal cramps
• “Acute diarrhea” – diarrhea of 14 days duration• “Persistent diarrhea” – diarrhea of >14 days duration• “Chronic diarrhea” – diarrhea of >30 days duration
Guerrant R. IDSA Practice Guidelines. Clinical Infectious Diseases, 2001; 32: 331-50.
Managing Diarrheal Illnesses:Basic Principles
Managing Diarrheal Illnesses:Basic Principles
• Adequate fluid and electrolyte replacement• Thorough clinical and epidemiological
evaluation• Selective approach to diagnosis and treatment• Avoid antimotility agents if concern about
infectious diarrhea• Advise bland diet and avoidance of fat, dairy,
and complex carbohydrates
• Adequate fluid and electrolyte replacement• Thorough clinical and epidemiological
evaluation• Selective approach to diagnosis and treatment• Avoid antimotility agents if concern about
infectious diarrhea• Advise bland diet and avoidance of fat, dairy,
and complex carbohydrates
Clinical EvaluationClinical Evaluation
• Clinical features– Onset
– Duration
– Stool characteristics
– Frequency
– Volume of stool
– Volume depletion
• Clinical features– Onset
– Duration
– Stool characteristics
– Frequency
– Volume of stool
– Volume depletion
Guerrant RL et al, Practice Guidelines for the Management of Infectious Diarrhea. Clinical Infectious Diseases, 2001; 32:331-51.
E. coli O157, C. Diff toxin– O&P examination + AFB (Cryptosporidia, Cyclospora,
Isospora), trichrome or other stain for Microsporidia and antigen detection (Giardia)
• If stool cultures are negative– Consider flexible sigmoidoscopy (or colonoscopy)
with biopsies– Consider upper endoscopy with duodenal biopsies for
electron and light microscopyGuerrant R. IDSA Practice Guidelines. Clinical Infectious Diseases. 2001; 32: 331-50.Cohen J, et al. Gastroenterology Clinics. 2001; 30(3):
pain, nausea, vomiting, anorexia, low-grade fever– may lead to severe dehydration, malabsorption,
electrolyte abnormalities, and wasting
Diagnosis and Treatment of Cryptosporidium parvum
• Diagnosis:– Cryptosporidium smear (modified acid-fast stain or Kinyoun
stain)– AFB smear– Direct fluorescent-antibody (DFA)– Enzyme immunoassay (EIA)– Not usually seen on O&P
• Treatment1:– Highly Active Antiretroviral Therapy (HAART)– Nitazoxanide 500-1000 mg PO BID– Paromomycin 1000 mg PO BID– Azithromycin 600 mg PO QD
1. Sande MA, et al. Sanford Guide to HIV/AIDS Therapy. 2003: 90.
Prevention ofCryptosporidium parvum
• Large-scale water purification systems for city water supplies (including filtration and chlorination) have not eliminated cryptosporidiosis
• Drink only bottled water that has undergone one of the following processes:– Reverse Osmosis– Filtered through an absolute pore size of 1 micron or smaller– Tested and certified by NSF Standard 53 for cyst removal or
reduction
• Consider boiling water that could be ingested, including water used for brushing teeth, making ice cubes, and washing fruits or vegetables
Ball S. AIDS Reader. 1998; 8(1): 4-6.
Giardia lamblia• Flagellated enteric protozoan• Up to 2.5 million cases of giardia annually in
• Presentation:– Profuse, watery diarrhea, cramps, bloating, flatulence– Chronic infection can lead to greasy or foul-smelling stools,
malaise, weight loss, abd pain, malabsorption
Giardia lamblia• Diagnosis: presence of cysts/trophozoites
– Ova & Parasites (O&P)• Detection rate from 1 stool = 67%1
• Detection rate from 3 stools on 3 separate days = 85%2-4
– Direct fluorescent-antibody (DFA)– Enzyme immunoassay (EIA)
• Detection rate from 1 stool = 80%1
• Detection rate from 2 stools = >90%1
• Treatment:– Metronidazole 500-750 mg PO TID x 5 days– Nitazoxanide 500 mg PO BID x 3 days– Tinidazole 2 gm PO x 1
1. Hansen KL and Cartwright CP. J Clin Microbiol. 2001; 39: 474-7.2. Turgeon DK, et al. Gastroenterol Clin North Am. 2001; 30: 693-707.3. Goka AKJ, et al. Trans R Soc Trop Med Hyg. 1990; 84: 66-7.4. Katz DE, et al. Gastroenterol Clin North Am. 2001; 30: 797-815.
Isospora belli
• Endemic in tropical and subtropical areas• Hardy oocysts, resist chlorination• Transmission via contaminated food or water1
• Presentation:– High volume watery diarrhea, crampy abdominal pain, steatorrhea,
low-grade fever, malabsorption, weight loss
– Only protozoa that causes eosinophilia
• Diagnosis: O+P, modified acid-fast stain (Kinyoun stain)• Treatment2: will need chronic suppression after acute Rx
– TMP/SMX 1 DS QID x 10 days, then 1 DS BID x 3 weeks