Gastro 2013 APDW/WCOG Shanghai working party report: chronic diarrhea: definition, classification, diagnosis

Evaluation of In Vivo Antidiarrheal Activities of 80% Methanol Extract and Solvent Fractions of Peels of Colocasia esculenta (Araceae)

Background

Diarrhea is the common gastrointestinal disorder accounting for 2.5 billion episodes and 1.5 million deaths annually. Limitations and inaccessibility of currently available medications are the main problem associated with treatment of diarrhea. Hence, medicinal plants are usually preferred to manage diarrhea because they may contain constituents with high activity and fewer side effects. Even though the dose, safety, and efficacy of Colocasia esculenta (L.) Schott are not substantiated scientifically, several societies use it for the treatment of diarrhea.

Objective

This study was targeted at exploring the in vivo antidiarrheal activities of 80% methanol extract and solvent fractions of peels of Colocasia esculenta (L.) Schott in Swiss albino mice.

Methods

The plant was collected and extracted with 80% methanol, followed by fractionation with distilled water, chloroform, and diethyl ether. Castor oil-induced diarrhea, enteropooling, and motility tests were used to evaluate antidiarrheal activity. The test groups received graded doses of 100 mg/kg, 200 mg/kg, and 400 mg/kg. Negative controls received 10 ml/kg of 2% Tween 80 while positive controls received loperamide (3 mg/kg) or atropine (5 mg/kg).

Results

The crude and solvent fractions of the plant extract have induced significant effects in reduction of the number and weight of wet stools at all tested doses. However, delay in onset of diarrhea was observed only at 400 mg/kg (P < 0.001) for both crude extract and solvent fractions. In antienteropooling test, 80% methanol extract and solvent fractions have significantly reduced the weight and volume of intestinal contents, especially at 200 mg/kg and 400 mg/kg. Regarding the antimotility test, the crude extract reduced motility at all tested doses, whereas the solvent fractions reduced intestinal motility mainly at 400 mg/kg (P < 0.001).

Conclusion

The study has revealed that the 80% methanol extract and solvent fractions of the plant possess antidiarrheal activities supporting the traditional antidiarrheal claims of the plant.

Anti-diarrheal effect of piperine possibly through the interaction with inflammation inducing enzymes: In vivo and in silico studies

Piperine is a natural alkaloid that possesses a variety of therapeutic properties, including anti-inflammatory, antioxidant, antibacterial, and anticarcinogenic activities. The present study aims to assess the medicinal benefits of piperine as an anti-diarrheal agent in a chick model by utilizing in vivo and in silico techniques. For this, castor oil was administered orally to 2-day-old chicks to cause diarrhea. Bismuth subsalicylate (10 mg/kg), loperamide (3 mg/kg), and nifedipine (2.5 mg/kg) were used as positive controls, while the vehicle was utilized as a negative control. Two different doses (25 and 50 mg/kg b.w.) of the test sample (piperine) were administered orally, and the highest dose was tested with standards to investigate the synergistic activity of the test sample. In our findings, piperine prolonged the latent period while reducing the number of diarrheal feces in the experimental chicks during the monitoring period (4 h). At higher doses, piperine appears to reduce diarrheal secretion while increasing latency in chicks. Throughout the combined pharmacotherapy, piperine outperformed bismuth subsalicylate and nifedipine in terms of anti-diarrheal effects with loperamide. In molecular docking, piperine exhibited higher binding affinities towards different inflammatory enzymes such as cyclooxygenase 1 (-7.9 kcal/mol), cyclooxygenase 2 (-8.4 kcal/mol), nitric oxide synthases (-8.9 kcal/mol), and L-type calcium channel (-8.8 kcal/mol), indicating better interaction of PP with these proteins. In conclusion, piperine showed a potent anti-diarrheal effect in castor oil-induced diarrheal chicks by suppressing the inflammation and calcium ion influx induced by castor oil.

The effectiveness of walking exercise on the bowel preparation before colonoscopy: a single blind randomized clinical trial study

BACKGROUND AND AIM

Bowel preparation is a crucial factor affecting the diagnostic accuracy of colonoscopy, and few randomized control trials evaluated enhancement in bowel preparation. In this study, we aimed to evaluate the effectiveness of walking exercises on bowel preparation before a colonoscopy procedure.

METHODS

The present study is a single-blind randomized controlled trial involving 262 patients scheduled for colonoscopy procedures. These patients were randomly assigned to two groups: an intervention group (n = 131) and a control group (n = 131). In the intervention group, participants followed a predetermined plan that included the consumption of specific liquids and foods, bisacodyl pills, polyethylene glycol powder, and a regimen of walking exercises in preparation for their colonoscopy. Conversely, individuals in the control group followed the same regimen but were not instructed to engage in walking exercises. On the day of the colonoscopy, both groups were assessed for their level of physical activity using a foot counter. Additionally, an experienced gastroenterologist evaluated and compared the bowel preparation between the two groups using the Boston Bowel Preparation Scale (BBPS).

RESULTS

The number of footsteps recorded in the two groups exhibited a significant difference (P < 0.001). Although there was no statistically significant difference between the intervention and control groups in terms of mean BBPS scores (6.26 ± 1.9 vs. 6.29 ± 1.9, P = 0.416), individuals who took more than 6900 steps had significantly higher BBPS scores compared to those with fewer than 6900 footsteps (6.62 ± 1.8 vs. 5.92 ± 1.9, P = 0.003).In the univariate analysis, BBPS was found to be significantly associated with individuals under the age of 50 (OR: 2.45, 95% CI: 1.30-4.61, P = 0.006) and smoking status (OR: 0.41, 95% CI: 0.17-0.94, P = 0.043). In the multivariate analysis, the relationship between BBPS and age below 50 and smoking remained significant (OR: 2.50, 95% CI: 1.30-4.70, P = 0.005, and OR: 0.38, 95% CI: 0.16-0.93, P = 0.034, respectively).

CONCLUSION

A higher number of footsteps taken especially more than 6900 can significantly enhance bowel preparation; however, walking exercise as an intervention before colonoscopy is not significantly associated with BBPS. Also, older people and smokers seem to have fewer benefits from walking exercises for bowel preparation.

TRIAL REGISTRATION

ISRCTN32724024 (Registration date:22/08/2018).

Celiac Disease in Uzbek Children: Insights into Disease Prevalence and Clinical Characteristics in Symptomatic Pediatric Patients

BACKGROUND

A few studies on pediatric Celiac Disease (CD) are available from Central Asia. Recent immunogenetic research has highlighted that the HLA-DQ2/8 genetic predisposition to CD as well as the dietary intake of gluten in this geographical area, are comparable to other regions of the world where CD prevalence is known to be 1% or higher.

METHODS

This is a prospective and cross-sectional study investigating the prevalence and clinical characteristics of CD in symptomatic children referred to the pediatric gastroenterology department of a tertiary hospital in Uzbekistan from 1 September 2021, until 31 July 2022. In addition to collecting the relevant information related to clinical manifestations and laboratory analyses from the clinical files, a specific survey was also administered to patients' guardians. Serological, histopathological, and immunogenetic parameters specific to CD, fecal zonulin, and pancreatic elastases were assessed in CD patients.

RESULTS

The study population consisted of 206 children. Overall, almost all of them (n = 192; 93.2%) were referred because of gastrointestinal manifestations, which were associated with extra-gastrointestinal manifestations in most cases (n = 153; 74.3%); a minority (n = 14; 6.8%) was mainly referred due short stature and/or growth failure only. Among all of these study participants, CD was diagnosed in 11 children (5.3%). Notably, although diarrhea was similarly reported in CD and non-CD patients, watery diarrhea (type 7 according to the Bristol stool scale) was much more frequently and significantly observed in the former group. All of these CD patients showed anti-tTG IgA 10 times higher than the upper normal limit, except one child with lower serum levels of total IgA; however, all of them received a diagnostic confirmation by histopathological analysis due to the lack of EMA testing in the country. Notably, most CD children (82%) showed a Marsh III histological grading. Around half patients (54.5%) showed zonulin values above the reference range, whereas none showed insufficient levels of pancreatic elastase. However, no correlation or association between zonulin and clinical, laboratory, histopathological, and immunogenetic parameters was found.

CONCLUSIONS

This study may further suggest a relevant prevalence of CD in Uzbek children, based on this partial picture emerging from symptomatic patients only. Additionally, we highlighted the prevalence of typical CD forms with watery diarrhea, which should strongly support a full diagnostic work-up for CD in the local clinical setting. The high levels of anti-tTG IgA and high Marsh grade might also lead us to speculate a significant diagnostic delay despite the classical clinical expression of CD.

Common gastrointestinal drug-drug interactions in geriatrics and the importance of careful planning

INTRODUCTION

Polypharmacy, which uses multiple medications to treat chronic illnesses, is common among elderly patients. However, it can lead to drug interactions, especially with gastrointestinal (GI) medicines that are extensively used. These drug interactions can have severe consequences and pose a significant challenge to healthcare providers. Therefore, it is crucial to identify the underlying mechanisms of these interactions and develop strategies to minimize medication errors.

AREAS COVERED

We analyzed databases on GI illnesses common in older adults, including GERD, peptic ulcer disease, IBS, IBD, constipation, and diarrhea. Our research identified noteworthy drug interactions and utilized major electronic databases such as USFDA, PubMed, Scopus, and Google Scholar until 15 May 202315 May 2023, along with a review of reference lists.

EXPERT OPINION

Aging can affect how the body processes drugs, leading to an increased risk of drug interactions. Therefore, healthcare professionals must carefully evaluate a patient's medical history and health condition to design personalized treatment plans.

Diarrhea in the critically ill: definitions, epidemiology, risk factors and outcomes

PURPOSE OF REVIEW

In this paper, we review the current evidence with respect to definitions, risk factors, and outcomes of diarrhea in the critically ill and highlight research gaps in the literature.

RECENT FINDINGS

Definitions of diarrhea in the intensive care unit (ICU) include the World Health Organization quantified as >3 liquid bowel movements per day and the Bristol Stool Chart score of 7. Diarrhea incidence is 37.7-73.8% and varies based on definition applied. Clostridioides difficile associated diarrhea (CDAD) is uncommon with an incidence of 2.2%. Risk factors for diarrhea include total number of antibiotics, enteral nutrition, and suppository use. The composition of enteral nutrition including high osmolarity and high fiber feeds contributed to diarrhea occurrence. Opiates decrease diarrhea incidence whereas probiotics have no effect on the incidence or duration of diarrhea. Outcomes of diarrhea include increased length of stay in the ICU and hospital, however its impact on mortality is unclear.

SUMMARY

Diarrhea remains a common problem in clinical practice and attention must be paid to modifiable risk factors. Further research is needed on interventions to decrease its burden.

Diarrhea during critical illness: a multicenter cohort study

PURPOSE

To study the incidence, predictors, and outcomes of diarrhea during the stay in the intensive care unit (ICU).

METHODS

Prospective cohort of consecutive adults in the ICU for > 24 h during a 10-week period across 12 intensive care units (ICUs) internationally. The explored outcomes were: (1) incidence of diarrhea, (2) Clostridioides difficile-associated diarrhea (CDAD); (3) ICU and hospital length of stay (LOS) and mortality in patients with diarrhea. We fit generalized linear models to evaluate the predictors, management, morbidity and mortality associated with diarrhea.

RESULTS

Among 1109 patients aged 61.4 (17.5) [mean (standard deviation)] years, 981(88.5%) were medical and 645 (58.2%) were mechanically ventilated. The incidence was 73.8% (818 patients, 73.8%, 95% confidence interval [CI] 71.1-76.6) using the definition of the World Health Organisation (WHO). Incidence varied across definitions (Bristol 53.5%, 95% CI 50.4-56.7; Bliss 37.7%, 95% CI 34.9-40.4). Of 99 patients with diarrhea undergoing CDAD testing, 23 tested positive (2.2% incidence, 95% CI 1.5-3.4). Independent predictors included enteral nutrition (RR 1.23, 95% CI 1.16-1.31, p < 0.001), antibiotic days (RR 1.02, 95% CI 1.02-1.03, p < 0.001), and suppositories (RR 1.14 95% CI 1.06-1.22, p < 0.001). Opiates decreased diarrhea risk (RR 0.76, 95% CI 0.68-0.86, p < 0.001). Diarrhea prompted management modifications (altered enteral nutrition or medications: RR 10.25, 95% CI 5.14-20.45, p < 0.001) or other consequences (fecal management device or CDAD testing: RR 6.16, 95% CI 3.4-11.17, p < 0.001). Diarrhea was associated with a longer time to discharge for ICU or hospital stay, but was not associated with hospital mortality.

CONCLUSION

Diarrhea is common, has several predictors, and prompts changes in patient care, is associated with longer time to discharge but not mortality.

Symptoms and PCR testing interval for bacterial pathogens in patients with diarrhoea

Introduction . Acute diarrhoea can be caused by Salmonella species, Shigella species, Yersinia enterocolitica, Campylobacter species and Plesiomonas shigelloides (SSYCP). In clinical practice, however, polymerase chain reaction (PCR) for SSYCP is frequently performed as part of the diagnostic work-up for patients with chronic diarrhoea and gastrointestinal complaints.Hypothesis. This study postulates that PCR for SSYCP is of limited clinical use in patients with chronic diarrhoea and gastrointestinal complaints.Aim. The primary aim of this study is to evaluate whether testing for SSYCP remains sensible in patients with chronic diarrhoea and gastrointestinal symptoms and if earlier testing leads to more positive PCR results.Methodology. Between January 2017 and December 2018, data on PCR results, culture results, symptoms, symptom to testing interval (STI) and immune status were retrospectively collected from the medical records of patients with gastrointestinal symptoms for whom PCR results for SSYCP were available. The STIs of PCR-positive patients and PCR-negative patients were compared.Results. In total, 146 PCR-positive and 149 PCR-negative patients were included. STIs of <7 days occurred in 55 % of all PCR-positive patients compared to 38 % in PCR-negative patients. PCR-positive patients were more often tested within 7 days after onset of gastrointestinal symptoms or diarrhoea. A third of PCR-positive patients had an STI of >7 days. Immunocompromised patients had a shorter STI. Admitted patients had a shorter STI. Eighty-six PCR-positive patients had a positive culture (58 %). Antibiotic use 3 months prior to PCR testing was correlated with negative PCR results.Conclusions . This study shows that early testing correlates with more positive PCR results and underlines that PCR for SSYCP is of lesser importance in the diagnostic workup of chronic diarrhoea and/or gastrointestinal symptoms. The shorter STI found in immunocompromised patients is possibly due to a lower threshold for testing in this population. It is also important to take recent antibiotic use into consideration when interpreting PCR results, given the correlation between negative PCR results and antibiotic use. Careful and precise documentation of symptoms in medical records is essential for clinical practice and research.

Chronic diarrhea and parasitic infections: Diagnostic challenges

BACKGROUND

Diarrhea is among the top ten global causes of death. Chronic diarrhea may have destructive impact on physical and mental health of patients and is also associated with high risk of mortality in children. Parasitic intestinal infections remain an important cause of chronic diarrhea especially in the developing part of the world.

OBJECTIVE

To study the parasitic causes of chronic diarrhea and highlight the challenges faced in the diagnosis of chronic diarrhea caused due to parasitic infections.

CONTENT

Due to non-specific symptoms, insensitive available diagnostic techniques, asymptomatic carriage and transmission, recurrent infections in endemic areas, pose a challenge for diagnosis of the parasitic infections and thus delay the treatment. Conventional techniques like microscopy, though cheaper are not very sensitive. Advanced techniques like molecular methods are more sensitive but expensive and are not readily available in resource limited settings. Newer cost-effective diagnostic techniques with higher sensitivity and specificity are required to detect the infectious agent and for appropriate management.

Development of a Score to Predict Positive Colonic Histology in Chronic Diarrhea Assessed in Open-access Colonoscopy

GOALS

To evaluate the diagnostic yield of colonoscopy and esophagogastroduodenoscopy with biopsies and to identify predictors of positive colonic histology in patients with chronic diarrhea.

BACKGROUND

Colonoscopy with biopsies is performed in chronic diarrhea with negative initial work-up.

STUDY

We reviewed electronic medical records of 1022 consecutive patients with chronic diarrhea referred for a first colonoscopy (including 25% open-access referrals). Predictors of positive colonic histology were investigated using logistic regression.

RESULTS

Four hundred thirteen patients with macroscopically normal colon were divided into derivation (n=275) and validation (n=138) cohorts. All patients underwent colonoscopy; 369 had ileoscopy (biopsies in 43%), and 289 underwent esophagogastroduodenoscopy (duodenal biopsies in 93%). In patients with endoscopically normal colon, histology was positive in 13.3%: 10.6% microscopic colitis; 1.5% other colitides. Among 358 patients with negative histology, the recorded diagnoses were: 48% unexplained, 25% irritable bowel syndrome, 5.6% small intestinal bacterial overgrowth, and 4.7% bile acid diarrhea. The rates of diagnoses based on positive histologies were 4% for ileal and 5% for duodenal biopsies. Older age [odds ratio (OR)=1.05] was a positive predictor, whereas body mass index (OR=0.93) and duration of diarrhea (OR=0.98) were negative predictors of positive histology. A clinical diagnostic scoring system could correctly predict 41% to 54% of patients with normal colonic histology, with a false-negative rate of 0.8% to 2.6% and a negative predictive value of 95% to 98%.

CONCLUSIONS

Positive colonic biopsies were detected in <15% of patients with chronic diarrhea with normal colonoscopy; a clinical score correctly predicts likelihood of normal histology in about half the patients.

The Role of Purported Mucoprotectants in Dealing with Irritable Bowel Syndrome, Functional Diarrhea, and Other Chronic Diarrheal Disorders in Adults

Chronic diarrhea is a frequent presenting symptom, both in primary care medicine and in specialized gastroenterology units. It is estimated that more than 5% of the global population suffers from chronic diarrhea. and that about 40% of these subjects are older than 60 years. The clinician is frequently faced with the need to decide which is the best therapeutic approach for these patients. While the origin of chronic diarrhea is diverse, impairment of intestinal barrier function, dysbiosis. and mucosal micro-inflammation are being increasingly recognized as underlying phenomena characterizing a variety of chronic diarrheal diseases. In addition to current pharmacological therapies, there is growing interest in alternative products such as mucoprotectants, which form a mucoadhesive film over the epithelium to reduce and protect against the development of altered intestinal permeability, dysbiosis, and mucosal micro-inflammation. This manuscript focuses on chronic diarrhea in adults, and we will review recent evidence on the ability of these natural compounds to improve symptoms associated with chronic diarrhea and to exert protective effects for the intestinal barrier.

McKittrick-Wheelock Syndrome: A Rare Cause of Chronic Diarrhea

Diarrhea is the principal cause of the majority of healthcare utilization. When diarrhea lasts longer than four weeks, it is considered chronic diarrhea. There are several causes of chronic diarrhea, but here we focus on one of the rare causes, known as McKittrick-Wheelock syndrome (MWS). We here present the case of a patient in his seventies with chronic diarrhea, found to have tubulovillous adenoma and diagnosed with McKittrick-Wheelock syndrome. We also discuss the clinical presentation, pathophysiology, and management of MWS.

Beyond gait and balance: urinary and bowel dysfunction in X-linked adrenoleukodystrophy

Objective

To characterize the prevalence, onset, and burden of urinary and bowel dysfunction in adult patients with adrenoleukodystrophy (ALD) and to evaluate any sex differences in symptom presentation.

Methods

In this retrospective and prospective study, we performed medical record review (n = 103), analyzed the results of clinically indicated urodynamic testing (n = 11), and developed and distributed a symptom and quality of life (QOL) survey (n = 59).

Results

Urinary and bowel symptoms are highly prevalent in both males (75.0%) and females (78.8%) in this population, most commonly urinary urgency, often leading to incontinence. Time to onset of first urinary or bowel symptom occurs approximately a decade earlier in males. Seventy-two percent of symptomatic patients report a limitation to QOL. Urodynamic evaluation provides evidence of three distinct mechanisms underlying lower urinary tract dysfunction: involuntary detrusor contractions (indicating uncontrolled neuronal stimulation with or without leakage), motor underactivity of the bladder, and asynergy between detrusor contraction and sphincter relaxation.

Conclusions

Beyond gait and balance difficulties, urinary and bowel symptoms are common in adults with ALD and impair QOL. Males are affected at a younger age but both sexes experience a higher symptom burden with age. As this population also experiences gait and balance impairment, patients with ALD are more vulnerable to urinary urgency leading to incontinence. Urodynamic evaluation may help better elucidate the pathophysiologic mechanisms underlying neurogenic lower urinary tract dysfunction, which can allow more targeted treatment.

Chronic Diarrhea in a Drinker: A Breakthrough Case of Pellagra in the US South

The triad of diarrhea, dementia, and dermatitis constitutes the clinical diagnosis of pellagra. However, most reported cases of pellagra have occurred without all components of the triad. Pellagra was declared eradicated in the United States after an outbreak in the 1920s, and is now considered to be an exceedingly rare diagnosis in developed countries. In this article, we present a case of a 56-year-old man who presented with a significant history of alcohol use and chronic diarrhea. Pellagra was clinically diagnosed based on the triad of diarrhea, cognitive dysfunction, and dermatitis in this malnourished, alcoholic patient. The patient was treated and clinically improved with resolution of his diarrhea and cognitive dysfunction.

Evaluation of in-vivo antidiarrhoeal and in-vitro antibacterial activities of the root extract of Brucea antidysenterica J. F. Mill (Simaroubaceae)

BACKGROUND

Diarrhoea has been the major cause of death especially in children of developing countries. Brucea antidysenterica is one of the several medicinal plants used traditionally for the treatment of diarrhoea in Ethiopia. Hence, the present study was undertaken to investigate the antidiarrhoeal and antibacterial activities of the root extract of B. antidysenterica.

METHODS

Plant material was extracted by maceration technique using 80% methanol. The antidiarrhoeal activity was tested using castor oil-induced diarrhoea, castor oil-induced charcoal meal test, and castor oil-induced enteropooling models in mice. Whilst, the antibacterial activity of the crude extract was evaluated using agar well diffusion and broth microdilution methods.

RESULTS

The 80% methanolic crude extract significantly delayed the diarrhoeal onset at the two higher doses (p < 0.001) and it has also inhibited the number and weight of faecal output at all tested doses as compared with the negative control. Moreover, it showed a significant anti-motility effect (p < 0.001) at all tested doses. Whereas it displayed a significant reduction in the weight and volume of intestinal contents at the doses of 200 and 400 mg/kg (p < 0.01). The highest concentration (800 mg/mL) of test extract showed maximum zone of inhibition in all tested standard strains of bacteria (18.3 mm-22 mm). While MIC and MBC values (0.39 mg/mL and 1.56 mg/mL) showed that S. flexneri was the most susceptible pathogen for test extract.

CONCLUSION

The study revealed that the root extract of B. antidysenterica has antidiarrhoeal and antibacterial activities.

Transcriptomic Study of Porcine Small Intestine Epithelial Cells Reveals Important Genes and Pathways Associated With Susceptibility to Escherichia coli F4ac Diarrhea

BACKGROUND

Diarrhea represents one of the most frequent major problems during piglets' neonatal and post-weaning periods leading to tremendous economic losses in the swine industry. Enterotoxigenic Escherichia coli (ETEC) F4 is regarded as the most important cause of diarrhea in piglets. However, some pigs are naturally resistant to those diarrheas caused by ETEC-F4, because they have no F4 receptors (F4R) on their small intestine epithelial cells that allow F4 fimbriae attachment. Thus, our study characterized a complete transcriptome of small intestine epithelial cells of Large White piglets using RNA-Seq. The aim of the study was to identify DEGs with regard to differences in the F4R phenotypes and SNP (C/T) genotypes at ITGB5 and important pathways associated with ETEC-F4ac susceptibility in small intestine epithelial cells of Large White piglets and derive molecular markers as a result of loss of F4acR in swine.

METHODS

A total of eight samples of small intestine epithelial cells obtained from Large White piglets (35 days old) used in this study were selected on the basis of two criteria. One was the adhesion phenotype to ETEC-F4ac fimbriae, and the other was the comparison of ITGB5 SNP (C > T) genotype sequences across all the samples. The samples were then divided into two groups, non-adhesive with CC genotype (n = 4), and adhesive with TT genotype (n = 4).

RESULTS

More down-regulated DEGs (p < 0.05, |log2FC| > 2) were detected in the comparison of non-adhesive vs. adhesive small intestine epithelial cells in the present study. Six genes, of which two (CNGA4, SLC25A31) exclusively expressed and four (HCN4, MYLK, KCNMA1, and KCNMB1) DEGs with up-regulation pattern in adhesive (F4R positive) pigs were involved in two pathways associated with diarrhea. The DEGs with up-regulation pattern in non-adhesive (F4R negative) pigs were mostly engaged in multiple immune response-related pathways.

CONCLUSION

The results provide insights on the biology of the phenotypes of F4R positive and negative pigs. One gene (MYLK) located on SSC13 locus for F4acR strongly support that it might have played a role in the adhesion phenotype which was obviously detected by adhesion assay in adhesive (F4R positive) group.

Chronic diarrhoea due to bile salt malabsorption: nurse-led assessment, medical treatment and dietary management

Bile salt malabsorption (BSM) occurs when bile salts, which are secreted in the small bowel to aid digestion of fats and vitamins, are not sufficiently re-absorbed in the terminal ileum. Consequently, an excess of bile salts enters the colon, causing chronic explosive diarrhoea, associated with abdominal cramps, flatulence and urgent, frequent and unpredictable bowel habits. BSM affects around 1% of the population, often occuring in ileal Crohn's disease or after ileal resection. Diagnosis begins with a nurse-led assessment, including blood and stool tests, to exclude other potential organic causes of chronic diarrhoea. BSM can then be confirmed and classified with a75Se-homocholic acid taurine (SeHCAT) scan. BSM can be treated medically with bile salt sequestrants, including colestyramine sachets, which are approved but have an unpleasant taste, and colesevelam tablets, which are more tolerable but more expensive and not yet approved. However, long-term sequestrant use can impact absorption of vitamins and other medications. BSM can also be managed with a low-fat diet, which is cost-effective and can reduce the amount of bile secreted. Nurses should provide patient education to ensure adherence and safe use.

Diarrhoea: interventions, consequences and epidemiology in the intensive care unit (DICE-ICU): a protocol for a prospective multicentre cohort study

INTRODUCTION

Diarrhoea is a frequent concern in the intensive care unit (ICU) and is associated with prolonged mechanical ventilation, increased length of ICU stay, skin breakdown and renal dysfunction. However, its prevalence, aetiology and prognosis in the critically ill have been poorly studied. The primary objectives of this study are to determine the incidence, risk factors and consequences of diarrhoea in critically ill adults. The secondary objectives are to estimate the incidence of Clostridium difficile-associated diarrhoea (CDAD) in ICU patients and to validate the Bristol Stool Chart and Bliss Stool Classification System characterising bowel movements in the ICU. Our primary outcome is the incidence of diarrhoea . Our secondary outcomes include: CDAD, ICU and hospital mortality and ICU and hospital length of stay.

METHODS AND ANALYSIS

This international prospective cohort study will enrol patients over 10 weeks in 12 ICUs in Canada, the USA, Poland and Saudi Arabia. We will include all patients 18 years of age and older who are admitted to the ICU for at least 24 hours and follow them daily until ICU discharge. Our primary outcome is the incidence of diarrhoea based on the WHO definition, during the ICU stay. Our secondary outcomes include: CDAD, ICU and hospital mortality and ICU and hospital length of stay. We will use logistic regression to identify factors associated with diarrhoea (as defined using WHO criteria) and the kappa statistic to measure agreement on diarrhoea rates between the WHO definition and the Bristol Stool Chart and Bliss Stool Classification System.

ETHICS AND DISSEMINATION

The protocol has been approved by the research ethics board of all participating centres. The diarrhoea interventions, consequences and epidemiology in the intensive care unit (DICE-ICU) study will generate evidence about diarrhoea and its frequency, predisposing factors and consequences, to inform critical care practice and future research.

LAY SUMMARY

Diarrhoea is a frequent clinical problem for hospitalised patients including those who are critically ill in the ICU. Diarrhoea can cause complications such as skin damage, dehydration and kidney problems. It is not clear how common diarrhoea is in the ICU, the factors that cause it or the best way for clinicians to assess it. The DICE-ICU study is an international prospective observational study to examine the frequency, risk factors and outcomes of diarrhoea during critical illness.

Chronic diarrhoea in adults: what not to miss

PURPOSE OF REVIEW

Chronic diarrhoea remains a diagnostic challenge, with numerous causes and few effective symptomatic treatments. This review focuses on new methods for diagnosis of common disorders and alerts readers to rarer causes through a systematic approach to the underlying mechanisms.

RECENT FINDINGS

New strategies are emerging to stratify the need for endoscopic investigation. Faecal immunochemical testing, combined with standard blood tests, shows promise in excluding colorectal cancers, adenoma and inflammatory bowel disease, challenging the current use of faecal calprotectin. Serum analysis for markers of bile acid synthesis has been refined, potentially streamlining diagnostic pathways of bile acid malabsorption for those who are unable to access nuclear medicine scans, but the positive predictive value of faecal elastase in low prevalence populations has been questioned. Novel markers such as volatile organic compounds and stool DNA analyses continue to develop.

SUMMARY

A systematic approach to investigation of chronic diarrhoea will ensure all relevant causes are considered and minimize the chance of a missed diagnosis. Combination of clinical features with noninvasive testing supports a judicious approach to endoscopic investigations but further innovation will be needed to resolve the diagnostic challenge that diarrhoea poses.

Efficacy of gelatin tannate for acute diarrhea in children: a systematic review and meta-analysis

AIM

To investigate by meta-analysis the efficacy of gelatin tannate (GT), a mucosal barrier protector, in children with acute gastroenteritis.

METHODS

A comprehensive literature search was conducted. Studies were selected according to PICO: Participants: children aged 0-12 years with acute diarrhea; Intervention: GT; Comparison: oral rehydration solution and/or placebo; Outcomes: diarrhea-related outcomes.

RESULTS

Three published randomized controlled trials were identified of pediatric diarrhea treated with GT (n = 203) or control (n = 204). GT significantly (p < 0.01) reduced stool frequency at 12 h in two randomized controlled trials. A significant treatment effect (risk ratio = 0.74; p < 0.01) in favor of GT was found for the exploratory composite outcome of 'diarrhea or liquid stools at 24 h' in three studies. Risk ratios in a single study which reported the percentage of patients with liquid stools at 12, 24 and 48 h favored GT at all time points. No significant differences were found between GT and control for patients with diarrhea at 12 or 24 h or for duration of diarrhea.

CONCLUSION

GT improved stool frequency and stool consistency in children with acute diarrhea, although further well-controlled studies would be useful to confirm a beneficial treatment effect.

Guidelines for the investigation of chronic diarrhoea in adults: British Society of Gastroenterology, 3rd edition

Chronic diarrhoea is a common problem, hence clear guidance on investigations is required. This is an updated guideline from 2003 for the investigations of chronic diarrhoea commissioned by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG). This document has undergone significant revision in content through input by 13 members of the Guideline Development Group (GDG) representing various institutions. The GRADE system was used to appraise the quality of evidence and grading of recommendations.

First cases and risk factors of super yeast Candida auris infection or colonization from Shenyang, China

For the first time, we identified 15 cases of Candida auris in Shenyang, China, and then performed a risk factor assessment for these patients compared with 30 control subjects who were hospitalized in the same ward during the same period of time as the infected patients. We found that diarrhea, gastrointestinal decompression, infection, or colonization with other Candida isolates (especially Candida albicans) and tetracycline antibiotics were all risk factors for C. auris infection or colonization. Diarrhea and tetracycline antibiotics were independent risk factors. We suggest clinicians pay special attention to the emergence of multidrug-resistant C. auris infections or colonization.

Evaluation of chronic diarrhea and irritable bowel syndrome with diarrhea in adults in the era of precision medicine

Chronic diarrhea is a common clinical problem, affecting roughly 5% of the population in any given year. Evaluation and management of these patients can be difficult due to the extensive differential diagnosis of this symptom. Many patients with chronic diarrhea have structural problems, such as inflammatory bowel disease or celiac disease, that can be readily identified. Others do not, and often are given a diagnosis of irritable bowel syndrome with diarrhea (IBS-D). When based on generally accepted clinical criteria, a diagnosis of IBS-D identifies a group of patients who are unlikely to have disorders producing anatomical changes in the gut. It is less clear that a diagnosis of IBS-D identifies a specific pathophysiology or leads to better management of symptoms. Disorders such as small intestinal bacterial overgrowth, bile acid malabsorption, food intolerance, and motility disorders may account for symptoms in patients with IBS-D. More effective tests are being developed to identify the clinical problems underlying IBS-D and may lead to more specific diagnoses that may improve the results of therapy. Application of the principles of precision medicine (identifying a specific mechanism for disease and applying treatments that work on that mechanism) should lead to more expeditious diagnosis and treatment for patients with chronic diarrhea including IBS-D, but currently is limited by the availability of sufficiently sensitive and specific tests for underlying mechanisms that can predict response to treatment.

Severe enteropathy with villous atrophy in prolonged mefenamic acid users - a currently under-recognized in previously well-recognized complication: Case report and review of literature

RATIONALE

Mefenamic acid-induced enteropathy may be an under-recognized condition because few reported cases and no review of literature to comprehensively describe all reported cases exist. From inception until February 2017, a systematic literature search identified twenty original reports of cases of mefenamic acid-induced enteropathy. Additional five cases were identified at our hospital. All cases were included in the analyses.

PATIENT CONCERNS

Most patients had been regularly taking therapeutic dosages of mefenamic acid for at least three months before symptoms developed. All patients presented with chronic diarrhea with significant weight loss. Approximately one-third of the cases had some degree of anemia and hypoalbuminemia.

DIAGNOSES

Endoscopic findings could range from very mild abnormalities, such as mild atrophic mucosa, to marked abnormalities, such as blunted villi with scalloping appearance in the small intestine and inflamed mucosa with a few superficial ulcers in the ileum and colon. Pathological findings included flattened small intestinal villi and mixed inflammatory infiltrates including eosinophils in lamina propria.

INTERVENTION

After identifying history of prolong mefenamic acid exposure, all patients were prescribed to stop this medication. Nutritional support and substitutional treatment for mefenamic acid were provided as well.

OUTCOMES

All symptoms responded dramatically to drug withdrawal. Some patients could change to use other nonsteroidal anti-inflammatory drugs (NSAIDs) without symptoms reoccurring.

LESSONS

Unlike other traditional NSAIDs, mefenamic acid could induce intestinal villous atrophy. An adequate drug history is crucial to identifying the condition. Protracted diarrhea occurring during treatment should be the indication to cease the medicine promptly.

Antidiarrheal Drug Therapy

INTRODUCTION

Acute diarrhea often runs a self-limited course and little by way of treatment is needed except for oral rehydration therapy. Chronic diarrhea poses a longer-term problem. If not treatable with specific therapy aimed at the underlying pathophysiology, chronic diarrhea often needs long-term symptomatic therapy.

PURPOSE OF REVIEW

This paper aims to examine the options for symptomatic, nonspecific treatment of diarrhea.

RECENT FINDINGS

The most frequently used therapies are opiate antidiarrheal drugs. These drugs are effective for a wide variety of diarrheal conditions and generally can be used safely if monitored closely. They work by slowing motility and allowing more time for absorption. They vary in potency and in addictive liability. In recent years, a variety of other drugs have been developed, which provide more targeted therapy that can mitigate diarrhea in specific situations. These drugs work on other regulatory pathways in the gut or on mucosal absorptive mechanisms. There is evidence for efficacy for both traditional and newer agents used for the symptomatic management of diarrhea. Opiates are used most often for this indication. Other agents may benefit individuals, but further research is needed to establish indications and best practices.

Effectiveness of three commonly used transition phase diets in the inpatient management of children with severe acute malnutrition: a pilot randomized controlled trial in Malawi

Background

The case fatality rate of severely malnourished children during inpatient treatment is high and mortality is often associated with diarrhea. As intestinal carbohydrate absorption is impaired in severe acute malnutrition (SAM), differences in dietary formulations during nutritional rehabilitation could lead to the development of osmotic diarrhea and subsequently hypovolemia and death. We compared three dietary strategies commonly used during the transition of severely malnourished children to higher caloric feeds, i.e., F100 milk (F100), Ready-to-Use Therapeutic Food (RUTF) and RUTF supplemented with F75 milk (RUTF + F75).

Methods

In this open-label pilot randomized controlled trial, 74 Malawian children with SAM aged 6–60 months, were assigned to either F100, RUTF or RUTF + F75. Our primary endpoint was the presence of low fecal pH (pH ≤ 5.5) measured in stool collected 3 days after the transition phase diets were introduced. Secondary outcomes were duration of hospital stay, diarrhea and other clinical outcomes. Chi-square test, two-way analysis of variance and logistic regression were conducted and, when appropriate, age, sex and initial weight for height Z-scores were included as covariates.

Results

The proportion of children with acidic stool (pH ≤5.5) did not significantly differ between groups before discharge with 30, 33 and 23% for F100, RUTF and RUTF + F75, respectively. Mean duration of stay after transitioning was 7.0 days (SD 3.4) with no differences between the three feeding strategies. Diarrhea was present upon admission in 33% of patients and was significantly higher (48%) during the transition phase (p < 0.05). There was no significant difference in mortality (n = 6) between diets during the transition phase nor were there any differences in other secondary outcomes.

Conclusions

This pilot trial does not demonstrate that a particular transition phase diet is significantly better or worse since biochemical and clinical outcomes in children with SAM did not differ. However, larger and more tightly controlled efficacy studies are needed to confirm these findings.

Trial registration

ISRCTN13916953 Registered: 14 January 2013.

Chronic Diarrhea: Diagnosis and Management

Chronic diarrhea is a common problem affecting up to 5% of the population at a given time. Patients vary in their definition of diarrhea, citing loose stool consistency, increased frequency, urgency of bowel movements, or incontinence as key symptoms. Physicians have used increased frequency of defecation or increased stool weight as major criteria and distinguish acute diarrhea, often due to self-limited, acute infections, from chronic diarrhea, which has a broader differential diagnosis, by duration of symptoms; 4 weeks is a frequently used cutoff. Symptom clusters and settings can be used to assess the likelihood of particular causes of diarrhea. Irritable bowel syndrome can be distinguished from some other causes of chronic diarrhea by the presence of pain that peaks before defecation, is relieved by defecation, and is associated with changes in stool form or frequency (Rome criteria). Patients with chronic diarrhea usually need some evaluation, but history and physical examination may be sufficient to direct therapy in some. For example, diet, medications, and surgery or radiation therapy can be important causes of chronic diarrhea that can be suspected on the basis of history alone. Testing is indicated when alarm features are present, when there is no obvious cause evident, or the differential diagnosis needs further delineation. Testing of blood and stool, endoscopy, imaging studies, histology, and physiological testing all have roles to play but are not all needed in every patient. Categorizing patients after limited testing may allow more directed testing and more rapid diagnosis. Empiric antidiarrheal therapy can be used to mitigate symptoms in most patients for whom a specific treatment is not available.

Pathophysiology, Evaluation, and Management of Chronic Watery Diarrhea

Chronic watery diarrhea poses a diagnostic and therapeutic challenge and is often a disabling condition for patients. Although acute diarrhea is likely to be caused by infection, the causes of chronic diarrhea (>4 weeks in duration) are more elusive. We review the pathophysiology, diagnosis, and treatment of chronic diarrhea. Drawing on recent insights into the molecular mechanisms of intestinal epithelial transport and barrier function, we discuss how diarrhea can result from a decrease in luminal solute absorption, an increase in secretion, or both, as well as derangements in barrier properties. We also describe the various extraepithelial factors that activate diarrheal mechanisms. Finally, clinical evaluation and tests used in the assessment of patients presenting with chronic diarrhea are reviewed, and an algorithm guiding therapeutic decisions and pharmacotherapy is presented.

Acupuncture for chronic diarrhea in adults: Protocol for a systematic review

BACKGROUND

As 2 major common types of chronic diarrhea, functional diarrhea (FD) and diarrhea-predominant irritable bowel syndrome (IBS-D) affect 1.54% to 1.72% of people in China. Acupuncture is commonly used in clinical practice for patients with chronic diarrhea. Here, we present a protocol of systematic review aimed at systematically review all the clinical evidence on the effectiveness of acupuncture for treating FD and IBS-D in adults.

METHODS

The review will be performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement. We will search the following databases from their inception to January 2017: Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, China Biology Medicine disc, Wan-Fang Data, China National Knowledge Infrastructure, Citation Information by National Institute of Informatics, Oriental Medicine Advanced Searching Integrated System by Korea Institute of Oriental Medicine, and Japan Science and Technology Information Aggregator (J-stage). Clinical trial registrations will also be searched. Primary outcome measures are the change of bowel movements. The secondary outcomes include stool consistency, quality of life scales, other standardized rating scales, patient satisfaction, and acupuncture-related adverse effects assessment.

ETHICS AND DISSEMINATION

This review does not require ethical approval and will be disseminated electronically or in print.

PROSPERO REGISTRATION NUMBER

CRD42015017574.

Antibiotic Treatment of Hospitalized Patients with Pneumonia Complicated by Clostridium Difficile Infection

Clostridium difficile infection (CDI) is one of the most common gastrointestinal complication after antimicrobial treatment. It is estimated that CDI after pneumonia treatment is connected with a higher mortality than other causes of hospitalization. The aim of the study was to assess the relationship between the kind of antibiotic used for pneumonia treatment and mortality from post-pneumonia CDI. We addressed the issue by examining retrospectively the records of 217 patients who met the diagnostic criteria of CDI. Ninety four of those patients (43.3 %) came down with CDI infection after pneumonia treatment. Fifty of the 94 patients went through severe or severe and complicated CDI. The distribution of antecedent antibiotic treatment of pneumonia in these 50 patients was as follows: ceftriaxone in 14 (28 %) cases, amoxicillin with clavulanate in 9 (18 %), ciprofloxacin in 8 (16.0 %), clarithromycin in 7 (14 %), and cefuroxime and imipenem in 6 (12 %) each. The findings revealed a borderline enhancement in the proportion of deaths due to CDI in the ceftriaxone group compared with the ciprofloxacin, cefuroxime, and imipenem groups. The corollary is that ceftriaxone should be shunned in pneumonia treatment. The study demonstrates an association between the use of a specific antibiotic for pneumonia treatment and post-pneumonia mortality in patients who developed CDI.

Testing for Chronic Diarrhea

Chronic diarrhea is a frequently encountered symptom in clinical practice. The etiologies for chronic diarrhea are diverse and broad with varying clinical implications. A useful method of categorizing chronic diarrhea to guide a diagnostic work-up is a pathophysiology-based framework. Chronic diarrhea may be categorized as malabsorptive, secretory, osmotic, and inflammatory or motility related. Frequently, overlap between categories may exist for any given diarrhea etiology and diagnostic testing must occur with an understanding of the differential diagnosis. Investigations to achieve a diagnosis for chronic diarrhea range from screening blood and stool tests to more directed testing such as diagnostic imaging, and endoscopic and histological evaluation. The pathophysiology-based framework proposed in this chapter will allow the clinician to select screening tests followed by targeted tests to minimize cost and complications to the patient, while providing a highly effective method to achieve an accurate diagnosis.

Development and Initial Validation of a Questionnaire to Measure Health-Related Quality of Life of Adults with Common Variable Immune Deficiency: The CVID_QoL Questionnaire

BACKGROUND

Generic health status quality of life (QoL) instruments have been used in patients with common variable immune deficiency (CVID). However, by their nature, these tools may over- or underestimate the impact of diseases on an individual's QoL.

OBJECTIVE

The objective of this study was to develop and validate a questionnaire to measure specific-health-related QoL for adults with CVID (CVID_QoL).

METHODS

The 32-item content of the CVID_QoL questionnaire was developed using focus groups and individual patient interviews. Validation studies included 118 adults with CVID who completed Short Form-36, Saint George Respiratory Questionnaire, General Health Questionnaire-12, and EuroQol-5D questionnaire in a single session. Principal component and factor analysis solutions identified 3 scores to be similar in number and content for each solution. Validation of 3 factor scores was performed by construct validity. Reproducibility, reliability, convergent validity, and discriminant validity were evaluated. Matrices consisting of correlations between the 32 items in the CVID_QOL were calculated.

RESULTS

Factor analysis identified 3 dimensions: emotional functioning (EF), relational functioning (RF), and gastrointestinal and skin symptoms (GSS). The instrument had good internal consistency (Cronbach's alpha, min. 0.74 for GSS, max. 0.84 for RF, n = 118) and high reproducibility (intraclass correlation coefficient, min. 0.79 for RF, max 0.90 for EF, n = 27). EF and RF scores showed good convergent validity correlating with conceptually similar dimensions of other study scales. Acute and relapsing infections had a significant impact on EF and RF.

CONCLUSIONS

This study provides evidence of the reliability and construct validity of the CVID_QoL to identify QoL issues in patients with CVID that may not be addressed by generic instruments.

Electroacupuncture for patients with diarrhea-predominant irritable bowel syndrome or functional diarrhea: A randomized controlled trial

Diarrhea-predominant irritable bowel syndrome (IBS-D) and functional diarrhea (FD) are highly prevalent, and the effectiveness of acupuncture for managing IBS-D and FD is still unknown.The aim of this study was to compare the effectiveness of electroacupuncture with loperamide.It was a prospective, randomized, parallel group controlled trial.A total of 448 participants were randomly assigned to He electroacupuncture group (n = 113), Shu-Mu electroacupuncture group (n = 111), He-Shu-Mu electroacupuncture group (n = 112), or loperamide group (n = 112). Participants in the 3 acupuncture groups received 16 sessions of electroacupuncture during a 4-week treatment phase, whereas participants in the loperamide group received oral loperamide 2 mg thrice daily. The primary outcome was the change from baseline in stool frequency at the end of the 4-weeks treatment. The secondary outcomes were the Bristol scale, the MOS 36-item short form health survey (SF-36), the weekly average number of days with normal defecations and the proportion of adverse events.Stool frequency was significantly reduced at the end of the 4-week treatment in the 4 groups (mean change from baseline, 5.35 times/week). No significant difference was found between the 3 electroacupuncture groups and the loperamide group in the primary outcome (He vs. loperamide group [mean difference 0.6, 95% CI, -1.2 to 2.4]; Shu-Mu vs. loperamide group [0.4, 95% CI, -1.4 to 2.3]; He-Shu-Mu vs. loperamide group [0.0, 95% CI, -1.8 to 1.8]). Both electroacupuncture and loperamide significantly improved the mean score of Bristol scale and increased the weekly average number of days with normal defecations and the mean scores of SF-36; they were equivalent in these outcomes. However, the participants in electroacupuncture groups did not report fewer adverse events than those in the loperamide group. Similar results were found in a subgroup analysis of separating patients with IBS-D and FD patients.Electroacupuncture is equivalent to loperamide for reducing stool frequency in IBS-D and FD patients. Further studies on cost effectiveness of acupuncture are warranted.

Prevalence, symptom patterns and management of episodic diarrhoea in the community: a population-based survey in 11 countries

BACKGROUND

The extent of episodic diarrhoea in the community is relatively unknown.

AIM

To ascertain the prevalence, symptoms and management behaviours associated with self-reported diarrhoea across 11 countries.

METHODS

Community screening surveys were conducted using quota sampling of respondents to identify a nationally representative sample of individuals suffering from 'episodic' diarrhoea (occurring once a month or more often). Second-phase in-depth surveys provided data on epidemiology, symptoms, attributed causes and management of episodic diarrhoea.

RESULTS

A total of 11 508 phase 1 and 6613 phase 2 surveys were completed. The prevalence of self-reported episodic diarrhoea ranged from 16% to 23% across the 11 countries. The majority of episodic diarrhoea sufferers were female (57%) and were not diagnosed with pre-existing irritable bowel syndrome (IBS); IBS diagnosis ranged from 9% in Mexico to 44% in Italy. Diarrhoea was frequently attributed to anxiety/stress, food-related causes, gastrointestinal 'sensitivity' and menstruation. Accompanying symptoms included 'stomach pain/cramping' (35-62%), 'stomach grumbling' (29-68%) and 'wind' (18-74%). The proportion of episodic sufferers who reported treating their symptoms with remedies or medications ranged between 46% in Belgium and Canada and 90% in Mexico.

CONCLUSIONS

A substantial proportion of the population in middle- to high-income countries report episodic diarrhoea in the absence of a pre-existing diagnosis. These symptoms are likely to be associated with substantial social and economic costs, and have implications on how best to configure and guide self-led, pharmacist-led and primary care management.

Antibiotic Treatment of Hospitalized Patients with Pneumonia Complicated by Clostridium Difficile Infection

Clostridium difficile infection (CDI) is one of the most common gastrointestinal complication after antimicrobial treatment. It is estimated that CDI after pneumonia treatment is connected with a higher mortality than other causes of hospitalization. The aim of the study was to assess the relationship between the kind of antibiotic used for pneumonia treatment and mortality from post-pneumonia CDI. We addressed the issue by examining retrospectively the records of 217 patients who met the diagnostic criteria of CDI. Ninety four of those patients (43.3 %) came down with CDI infection after pneumonia treatment. Fifty of the 94 patients went through severe or severe and complicated CDI. The distribution of antecedent antibiotic treatment of pneumonia in these 50 patients was as follows: ceftriaxone in 14 (28 %) cases, amoxicillin with clavulanate in 9 (18 %), ciprofloxacin in 8 (16.0 %), clarithromycin in 7 (14 %), and cefuroxime and imipenem in 6 (12 %) each. The findings revealed a borderline enhancement in the proportion of deaths due to CDI in the ceftriaxone group compared with the ciprofloxacin, cefuroxime, and imipenem groups. The corollary is that ceftriaxone should be shunned in pneumonia treatment. The study demonstrates an association between the use of a specific antibiotic for pneumonia treatment and post-pneumonia mortality in patients who developed CDI.

Gastrointestinal complications in renal transplant recipients detected by endoscopic biopsies in a developing country

BACKGROUND

Renal transplantation is the treatment of choice for patients with end-stage renal disease. The renal transplant recipients are susceptible to a variety of gastrointestinal (GI) complications such as infections, ulcer disease, and malignancies.

OBJECTIVES

We aimed to determine the frequency of pathological lesions in GI endoscopic biopsies in recipients of live related renal transplantation in our setting.

METHODS

This retrospective survey was carried out at Histopathology Department of Sindh Institute of Urology and Transplantation, Karachi, from December 2010 to January 2011. All consecutive renal transplant patients of all ages and both genders on regular follow up, presenting with GI complaints and in whom GI endoscopic biopsies were performed, were included. The demographic, clinical, and laboratory data were retrieved from case files and the pathological diagnoses from the original biopsy reports.

RESULTS

A total of 200 consecutive renal transplant patients were enrolled. The biopsies comprised of 19 (9.5 %) esophageal biopsies, 119 (59.5 %) gastric biopsies, 148 (74 %) duodenal biopsies, and 66 (33 %) colorectal biopsies. The main pathological lesions included cytomegalovirus infection in 22 (11 %) of all patients, Helicobacter pylori in 11 (9.2 %) of gastric biopsies, cryptosporidium in 4 (1.6 %), giardiasis in 30 (15 %), immunoproliferative small intestinal disease in 5 (3.4 %), tropical sprue in 33 (15 %), tuberculosis in 3 (2 %) of the small intestinal biopsies, and gastric adenocarcinoma in 1 (1.7 %) gastric biopsy.

CONCLUSION

A wide spectrum of pathological lesions including opportunistic infections was seen in GI endoscopic biopsies in renal transplant patients. Endoscopic biopsies play an important role in the diagnosis and management of GI disease in renal transplant patients.