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Unit 5 Persistent Diarrhoea

Unit 5 Persistent Diarrhoea. Learning Objectives. Participants will be able to: Provide empirical treatment for persistent diarrhoea Use and interpret stool exams in patients who do not respond to empirical therapy Provide appropriate treatment for identified infections.

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Unit 5 Persistent Diarrhoea

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  1. Unit 5 Persistent Diarrhoea

  2. Learning Objectives Participants will be able to: • Provide empirical treatment for persistent diarrhoea • Use and interpret stool exams in patients who do not respond to empirical therapy • Provide appropriate treatment for identified infections Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  3. Definition: Persistent Diarrhoea • Liquid stools • 3 or more times per day • Continuous or intermittent • At least 2 weeks duration • HIV positive Defined in the MoHSS Guidelines for the Clinical Management of HIV and AIDS, 2001. Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  4. Case History - Nangura • Nangura is a 28 year old woman with HIV who presents with diarrhoea and nausea. She has had 4 liquid stools per day most days for about 2 weeks. She otherwise feels well and is urinating normally. She thinks the symptoms may be improving over the past 2 or 3 days. Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  5. Case History (2) • Nangura was diagnosed with HIV 6 months ago. Her most recent CD4 count 4 months ago was 46. • Her opportunistic infection history includes tuberculosis treated last year, and oral candidiasis 6 months ago that resolved with nystatin suspension. • She developed hepatitis when she started nevirapine and HAART was discontinued until she recovered. Three weeks ago, she began stavudine (d4T) + lamivudine (3TC) + Lopinavir/ritonavir. She has taken cotrimoxazole daily for 6 months. Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  6. Case Exam • On exam, Nangura is afebrile. She appears agitated, but she relates this to her long wait to see you. BP 110/60. Pulse 94. RR 16. Weight 50 kg. Her mouth appears mildly dry with some chapping of the lips. Her skin retracts promptly on pinching. Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  7. Additional History - Nangura • She reports no fevers. • She reports no visible blood in the stools. • She has no recent sick contacts. • She reports no recent antibiotic use besides cotrimoxazole. Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  8. First Assess for Dehydration Table 3 - MoHSS, Guidelines for the Clinical Management of HIV and AIDS, 2001. Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  9. Rehydration in Primary Care Setting • Mild or moderate dehydration – Oral rehydration • Oral Rehydration Solution (ORS) packets preferred • ‘Home’ recipe • ½ tsp salt with • 8 tsp sugar in • 1 liter boiled water • Severe dehydration – initial IV rehydration preferred • If unable to correct, refer to level 2 Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  10. Potassium Replacement • Oral rehydration solution (ORS) • Fruits – like bananas, oranges, etc. • Vegetables including potatoes and leafy greens like spinach Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  11. Nutrition • Maintain intake of healthy balanced diet during episodes of diarrhoea Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  12. Some Clinical Categories of Diarrhoea Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  13. Any CD4 count Bacillary dysentery Shigella* Salmonella* Campylobacter* Invasive E. coli* Clostridium difficile colitis* Schistosoma mansoni Ulcerative colitis* CD4 < 200 CMV** Bloody Diarrhoea with Fever *Specific treatment available ** May respond to HAART Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  14. Any CD4 count Amebic dysentery* Entameba histolytica Bacillary dysentery* Strongyloides stercoralis* Ulcerative colitis* CD4 < 200 CMV** Bloody Diarrhoea without Fever *Specific treatment available ** May respond to HAART Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  15. Any CD4 count Bacillary dysentery* Crohn’s* Disease C. difficile* CD4 < 200 CMV** MTB* or MOTT** KS*** and Lymphoma* HIV enteropathy** Non-Bloody Diarrhoea with Fever *Specific treatment available ** May respond to HAART Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  16. Any CD4 count Protozoa Giardia* Helminths Ascaris* (Hookworm*) Strongyloides * Schistosomiasis (Bilharzia)* Non-invasive bacteria* Intestinal viruses Drug toxicity Other causes CD4 < 200 Opportunistic protozoa Isospora* Cryptosporidia** Microsporidia** Opportunistic viruses CMV** Adenovirus** HIV enteropathy** KS** Non-Bloody Diarrhoea without Fever *Specific treatment available ** May respond to HAART Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  17. Non-Bloody Diarrhoea without Fever (2) • Lactose intolerance and fat malabsorption • Can cause diarrhoea or occur following diarrhoea from another cause • Irritable bowel syndrome • Colonic malignancy Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  18. Empiric Therapy of Severe or Persistent Diarrhoea Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  19. Stool Examinations • Can be done at same time as empiric therapy where available • Can be done if empiric therapy at primary care level is not successful • Can be done for chronic diarrhoea Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  20. Stool Examinations (2) • Gram Stain (1 sample) • For WBC • Bacterial Culture (1 sample) • Salmonella, Shigella, Campylobacter, Clostridium • Wet Mount (3 samples) • Motile protozoa • Helminth eggs • Acid Fast Stain (3 samples) • MTB, MOTT, Isospora, Cryptosporidium • C. difficile toxin (sent to South Africa only) Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  21. Parasites and Their Treatment Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  22. Bacteria and Their Treatment MoHSS, Guidelines for the Clinical Management of HIV and AIDS, 2001. Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  23. Persistent Diarrhoea: No Organism Identified • Consider empiric C. difficile treatment if: • Patient is toxic • History of recent antibiotic use • Stool sent for culture • ELISA for C. difficile toxin available in South Africa • Consider cotrimoxazole for isospora • Consider albendazole 400 mg bd for 2-3 weeks for one type of microsporidia Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  24. Persistent Diarrhoea: No Organism Identified (2) • If not on HAART consider starting: • Immune restoration can help improve diarrhoea from Cryptosporidia, Microsporidia, and HIV enteropathy • Unexplained chronic diarrhoea for < 1 month is a WHO Clinical Stage 3 condition • If on HAART or other medications, consider drug toxicity Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  25. Persistent Diarrhoea: No Organism Identified (3) • Consider colonoscopy with biopsy if available: • Cytomegalovirus (CMV) • Kaposi’s Sarcoma (KS) • Lymphoma • Other malignancy • Inflammatory bowel disease • Consider anti-motility medication (e.g. loperamide) IF: • No organism identified after careful search • Diarrhoea is non-bloody • Patient not elderly or a child Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  26. Persistent Diarrhoea: Nutrition • Continue fluid replacement as needed • Emphasize nutrition to overcome maldigestion or malabsorbtion • Trial of lactose free diet • Trial of reduced fats • But use fats to maximize calories if fat restriction does not reduce diarrhoea • Maximize calories • Every food and drink item should include useful calories • Balanced diet and/or vitamin supplements Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  27. HIV Wasting Syndrome • Unexplained involuntary weight loss (>10% body weight) with obvious wasting or BMI<18.5 PLUS • Unexplained chronic diarrhoea for > 1 month OR • Reports of fever or night sweats for > 1 month (T>37.5°C) without known cause and lack of response to antibiotics or antimalarials • WHO Clinical Stage 4 Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  28. Case Follow-up • Nangura was advised to take more liquids and given nutritional counselling to maintain food intake while minimizing dairy products. • Stool studies were negative for bacteria and parasites. • The diarrhoea was attributed to the recently started lopinavir/ritonavir • She has been given anti-diarrhoeal agents as needed. Despite intermittent diarrhoea and gas pains, she has gained weight and strength. Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  29. Key Points • First correct any dehydration • Consider empiric therapy of persistent diarrhoea • If unsuccessful, use stool laboratory studies to identify a cause and guide treatment Training on Clinical Care of HIV, AIDS and Opportunistic Infections

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