Persisting diarrhoea and malabsorption

Persistent diarrhea in the returning traveler: think beyond persistent infection

The report describes a young female United Nations worker, stationed in East Timor for an extended duration, who presented with persistent travelers' diarrhea and who was convinced that she was harboring a persistent infestation. In fact, careful history, laboratory evaluation and endoscopy with duodenal biopsies found all the classical hallmarks of unmasked celiac sprue. The patient then had a dramatic response to a gluten-free diet, with complete resolution of symptoms. Persistent travelers' diarrhea is an entity which carries an interesting and extensive differential diagnosis beyond persistent enteric infections or infestations. Rather, many sufferers have long been cleared of the initial offending pathogen and are left with either a post-infectious disorder of absorption, digestion, motility or visceral sensation or carry a chronic gastrointestinal disorder which has been unmasked by an enteric infection, such as idiopathic inflammatory bowel disease, gastrointestinal malignancy or celiac sprue. Other key issues raised by the case include the vanishing incidence of tropical sprue, an entity to which most clinicians would have mistakenly attributed this malabsorptive syndrome arising in a traveler, and the under-recognition of the protean manifestations of celiac sprue, to which we would add persistent travelers' diarrhea.

Intestinal protein loss in acute and persistent diarrhea of early childhood

GOALS

To determine fecal protein loss in children with acute and persistent diarrhea.

BACKGROUND

In children with diarrhea, ongoing losses of endogenous proteins have been suggested as contributing to impairment of nutritional and immunologic status. However, there is a paucity of information and inconclusive data in the literature.

STUDY

Fecal protein loss was assessed prospectively in children (<3 years of age) with acute diarrhea (<7 days' duration) or persistent diarrhea (>14 days) and in controls using alpha-1-antitrypsin determination; fecal protein loss then was correlated with age, duration of diarrhea, nutritional status, plasma proteins, and stool pathogens.

RESULTS

Children with acute diarrhea (n = 43) and those with persistent diarrhea (n = 41) had significantly higher fecal alpha-1-antitrypsin levels compared with controls (n = 14) (2.26 +/- 1.71 and 2.25 +/- 1.51, respectively, vs. 1.02 +/- 0.73 mg/g stools; p = 0.002). However, there was no significant decrease of plasma albumin, globulin, or immunoglobulins. Fecal protein loss did not differ significantly among stool pathogens (bacterial, viral, and parasitic) and demonstrated no significant correlation with age, duration of diarrhea, or nutritional status (mild malnutrition).

CONCLUSIONS

Enhanced fecal protein loss was observed in more than 50% of children with acute and persistent diarrhea caused by various pathogens. This did not correlate with age, duration of diarrhea, or nutritional status and did not result in significant decrease of plasma proteins or immunoglobulins. This protein-losing enteropathy does not appear to have a causal role in perpetuation of diarrheal episodes in children with mild malnutrition.

Fecal alpha-1-antitrypsin excretion in children with diarrhea

BACKGROUND

The aim of this study was to compare the concentration and immunoelectrophoretic characterization of alpha-1-antitrypsin (AAT) excreted in random fecal samples in children with acute and chronic diarrhea and in control groups.

METHODS

Thirty-two children with diarrhea and 23 healthy children were evaluated. The concentration and characterization of AAT were determined by radial immunodiffusion and crossed immunoelectrophoresis, respectively.

RESULTS

The increase in the concentration of fecal AAT was more than the upper limit for the control group (1.25 mg/g of dry stool mass) in the patients with chronic infectious diarrhea and in 52% of those with chronic non-infectious diarrhea but not in those with acute diarrhea, infectious or non-infectious. Immunoelectrophoretic analysis showed two forms of fecal AAT in both sick and healthy children. The alterations in the concentration of fecal AAT did not correlate with the immunoelectrophoretic pattern of AAT.

CONCLUSION

Our results suggest that the determination of fecal AAT could give clinically useful information about the difference between infectious and non-infectious diarrhea and the activity of characterizing disease with diarrhea.

Tropical sprue and subclinical enteropathy: a vision for the nineties

Aside from infectious intestinal diseases with known etiology, there is a group of gastrointestinal disorders mainly affecting the small intestine of individuals predominantly living in and less often visiting or returning from the Third World, usually the tropics, and ranging from asymptomatic structural and/or functional abnormalities of the gastrointestinal mucosa (subclinical enteropathy, SE) to a fully symptomatic condition highlighted by malabsorption of nutrients with associated nutritional deficiencies responsive to folate and broad spectrum antibiotic treatment (tropical sprue, TS). Mounting evidence supports an infectious cause in many instances. The exact nature of the infection, whether initiated and/or perpetuated by enterotoxigenic coliform bacteria, virus(es) or a combination of these, is not clear. Further studies, including those using molecular techniques, are needed in order to clarify various aspects of these widely prevalent disorders.

Nutritional support in HIV infection and AIDS

Weight loss and wasting are common features of HIV infection and AIDS. Patterns of weight loss can be acute or chronic which appear to be related primarily to systemic infections and gastrointestinal pathology, respectively. However, weight loss is not inevitable. and periods of weight stability and weight gain have been documented. Reduced food intake appears to be a major cause of weight loss in HIV infection. Since time of death has been associated with degree of wasting, it seems reasonable to suggest that nutritional support may contribute to enhancing survival and quality of life. All patients should have early access to a qualified dietitian such that assessment of individual situations can be made and appropriate dietary advice given, within a multi-disciplinary approach. Choice of nutritional therapy should be made based on an assessment of the causes of weight loss and an assessment of gut function. Treating infections and alleviating symptoms is vital for ensuring effective nutritional support. Enhancing the energy and protein density of foods and use of oral supplements should be considered if a normal diet alone cannot meet nutritional requirements. Unnecessary dietary restrictions should be avoided. Enteral feeding is indicated for patients unable to meet their needs via the oral route, and in cases of inadequate gut function, parenteral nutrition may be necessary. There is currently insufficient clinical evidence to justify the need for special enteral formulae specifically for patients with HIV infection.

'The tropics in our bathroom': chronic diarrhoea after return from the tropics

Interest in imported tropical diseases has increased with the rising number of travellers to the tropics. This is especially true in the case of tropical gastroenterologic disorders. The causative organisms of chronic diarrhoea are different from those causing acute diarrhoea. Bacteria are relatively unusual; parasites, e.g. Entamoeba histolytica or Giardia lamblia or an opportunistic parasitic infestation associated with an HIV infection are more likely. Furthermore, non-infectious causes, such as postinfective tropical malabsorption, lactase deficiency or coeliac disease have to be considered. Today, elderly people often undertake a journey to the tropics; in these cases the diarrhoea may be associated not only with an increased susceptibility to tropical bowel infections but also with causes previously present, such as diverticulosis, carcinoma or inflammatory bowel disease. The classification of chronic diarrhoea following a visit to the tropics is essentially the same as that for acute diarrhoea: diarrhoea with and without fever and with and without blood. In addition, malabsorption is an important feature of chronic diarrhoea.