Symposium on diarrhea. 3. Investigation of chronic diarrhea.

The practical approach to the investigation of diarrhea must be logical and based on anatomic considerations. The site of the underlying disorder may be determined by the clinical picture, and the logic of investigation will be influenced by the history. Important specific investigation in a case of colonic diarrhea include a careful rectal examination, stool inspection, sigmoidoscopy, rectal biopsy and barium enema study. Colonoscopy has been used, but its role has yet to be defined. In a case of small-bowel steatorrhea or diarrhea quantitative chemical estimation of the daily output of stool fat is useful, and to this investigation is added a small-bowel radiograph series and, if the radiographic findings are abnormal, small-bowel biopsy. Other investigations for small-bowel disease may include the breath test with carbon-14-labelled glycocholic acid, the lactose tolerance test, duodenal aspiration for giardiasis, analysis of serum immunoglobulins and, on occasion, isolation of vasoactive intestinal polypeptide hormone (which may aid the diagnosis of functioning tumours of the pancreas or small bowel). Investigations for pancreatic steatorrhea include abdominal radiography, performance of the secretin test and testing of the response to pancreatic replacement therapy. In some patients it may be useful to use endoscopic retrograde cholangiopancreatography to differentiate pancreatic carcinoma and chronic pancreatitis.     

Symposium on diarrhea. 1. Definition and mechanisms of diarrhea.

Diarrhea, an increase in frequency of evacuation and in water content of the stool, is the result of three categories of mechanism--solute malabsorption, secretion of fluid and motility disturbance. Before diarrhea is considered an abnormal condition, any alteration in stool frequency and content must be related to an individual person''s normal bowel habit and to norms for the population, but more than three bowel movements or the passage of liquid stools exceeding 300 g daily should, in general, be considered abnormal. A useful way of understanding the mechanism of diarrhea is to become familiar with the normal functions of the bowel in regard to water and electrolyte absorption and motility, and then to relate these functions to solute malabsorption, fluid secretion and motility disturbance.     

复方嗜酸乳杆菌片对感染性腹泻患者胃肠道症状的影响

目的应用复方嗜酸乳杆菌片治疗感染性腹泻,观察微生态制剂对患者胃肠道症状的影响。方法选择100例感染性腹泻患者,均来自青岛大学附属中心医院,采用随机数字表法随机分为A、B组。其中A组患者(80例)单用复方嗜酸乳杆菌片(1.0g/次,3次/d,口服)治疗;B组患者(20例)单用利福昔明片(0.2g/次,4次/d,口服)治疗。两组患者均采用配对设计方法,治疗前进行胃肠道症状分级评分,包括单个症状(腹痛、腹胀、腹泻频率、大便性状)的评分和上述症状的总评分。治疗3d后门诊随访或电话随访,再次进行胃肠道症状分级评分,比较治疗前后患者的胃肠道症状评分改善情况并判断疗效以及治疗中的不良反应。结果两组患者的总有效率分别为78.75%和85.00%,差异无统计学意义(P0.05)。两组患者治疗过程中均未见不良反应。复方嗜酸乳杆菌片治疗后患者腹胀、腹泻频率、大便性状的症状评分和症状总评分较治疗前显著降低,差异有统计学意义(P0.01)。腹痛症状评分治疗前后差异无统计学意义(P0.05)。结论复方嗜酸乳杆菌片治疗感染性腹泻能达到满意的疗效,可改善患者腹胀、腹泻频率、大便性状等胃肠道症状。     

口服双歧杆菌活菌散剂治疗急慢性腹泻的随机对照双盲双模拟多中心临床研究

目的 评价口服双歧杆菌活菌散剂治疗肠道菌群失调所致的急慢性腹泻的疗效和安全性.方法 采用阳性药物平行对照、分层区组随机、双盲双模拟、多中心临床试验设计方法.其中急性腹泻136例,慢性腹泻125例;每次口服双歧杆菌活菌散剂1包(1.0 g,含双歧杆菌活菌1.0亿个)或丽珠肠乐胶囊2粒,每日2次;急性腹泻疗程3 d,慢性腹泻疗程14 d,观察治疗后临床症状和大便常规的恢复情况,慢性腹泻中39例进行肠道菌群分析.结果 疗程结束时急性腹泻总有效率:口服双歧杆菌活菌散剂组为89.6%,丽珠肠乐胶囊组为91.2%,2组疗效相似,差异无显著性(P＞0.05);慢性腹泻总有效率:口服双歧杆菌活菌散剂组为88.1%,丽珠肠乐胶囊组为79.0%,2组疗效相似,差异无显著性(P＞0.05);慢性腹泻组中39例治疗前后进行的肠道菌群分析表明,2组双歧杆菌、拟杆菌和真杆菌治疗后比治疗前均有显著增加(P=0.00～0.02),但治疗前后增加值2组间比较差异无显著性(P＞0.05).安全性研究未发现不良反应.结论 口服双歧杆菌活菌散剂能有效治疗急慢性腹泻,疗效和安全性与丽珠肠乐胶囊相当.     

320例腹泻患者病原菌分离及流行病学分析

目的了解广州市2009年至2010年肠道门诊就诊的细菌性腹泻患者病原谱的分布情况,为制定针对重点人群肠道传染病防治策略提供依据。方法收集2009年5月至2010年5月暨南大学附属第一医院腹泻患者的粪便标本,使用卡-布运送培养基,增菌培养后,采用生化反应和氧化酶试验进行菌株鉴定,并用梅里埃API生化板条进行验证,用病原菌诊断血清进行细菌分型。结果从320份粪便标本中分离到38株菌株,其中沙门菌15株,产毒大肠埃希菌12株,致病大肠埃希菌6株,志贺菌2株,出血性大肠埃希菌、霍乱弧菌、气单胞菌各1株。0—20岁年龄段高发,以1岁以内婴幼儿为主;7—10月为发病高峰期。结论来该院肠道门诊就诊的细菌性腹泻患者,其病原体以沙门菌为主,其次为产毒大肠埃希菌。因此．广州地区细菌件腹泻的预防．廊右针对件的面向雷占人群和重占病厢莴．     

Dynamic antibody specificities and virion concentrations in circulating immune complexes in acute to chronic HIV-1 infection

Understanding the interactions between human immunodeficiency virus type 1 (HIV-1) virions and antibodies (Ab) produced during acute HIV-1 infection (AHI) is critical for defining antibody antiviral capabilities. Antibodies that bind virions may prevent transmission by neutralization of virus or mechanically prevent HIV-1 migration through mucosal layers. In this study, we quantified circulating HIV-1 virion-immune complexes (ICs), present in approximately 90% of AHI subjects, and compared the levels and antibody specificity to those in chronic infection. Circulating HIV-1 virions coated with IgG (immune complexes) were in significantly lower levels relative to the viral load in acute infection than in chronic HIV-1 infection. The specificities of the antibodies in the immune complexes differed between acute and chronic infection (anti-gp41 Ab in acute infection and anti-gp120 in chronic infection), potentially suggesting different roles in immunopathogenesis for complexes arising at different stages of infection. We also determined the ability of circulating IgG from AHI to bind infectious versus noninfectious virions. Similar to a nonneutralizing anti-gp41 monoclonal antibody (MAb), purified plasma IgG from acute HIV-1 subjects bound both infectious and noninfectious virions. This was in contrast to the neutralizing antibody 2G12 MAb that bound predominantly infectious virions. Moreover, the initial antibody response captured acute HIV-1 virions without selection for different HIV-1 envelope sequences. In total, this study demonstrates that the composition of immune complexes are dynamic over the course of HIV-1 infection and are comprised initially of antibodies that nonselectively opsonize both infectious and noninfectious virions, likely contributing to the lack of efficacy of the antibody response during acute infection.     

Intestinal coccidia in Cuban pediatric patients with diarrhea

From May to August 1999, we evaluated 401 patients from a pediatric hospital of Havana City. One group was composed of 113 patients with diarrhea admitted to the Gastroenterology ward and a second consisted of 288 patients without diarrhea, admitted for other reasons, and hospitalized within the same time period. Three stool samples were collected from each child and were examined using three parasitological techniques. When we compared the frequency of parasite species between both groups, we found Cryptosporidium spp. and Cyclospora cayetanensis, only in the group of children with diarrhea (P < 0.01). However, no significant differences were found in the occurrence of the other intestinal parasites (P > 0.05). In addition, in those children infected with Cryptosporidium, the diarrhea had a more prolonged duration (P < 0.01), while those infected with Cyclospora, the abdominal cramps or pain, and acute diarrhea were more frequently detected (P < 0.01). Our results showed that emerging intestinal coccidia are pathogens strongly associated in this group of children with diarrhea.     

Astrovirus MLB1 is not associated with diarrhea in a cohort of Indian children

Astroviruses are a known cause of human diarrhea. Recently the highly divergent astrovirus MLB1 (MLB1) was identified in a stool sample from a patient with diarrhea. It has subsequently been detected in stool from individuals with and without diarrhea. To determine whether MLB1 is associated with diarrhea, we conducted a case control study of MLB1. In parallel, the prevalence of the classic human astroviruses (HAstVs) was also determined in the same case control cohort. 400 cases and 400 paired controls from a longitudinal birth cohort in Vellore, India were analyzed by RT-PCR. While HAstVs were associated with diarrhea (p = 0.029) in this cohort, MLB1 was not; 14 of the controls and 4 cases were positive for MLB1. Furthermore, MLB1 viral load did not differ significantly between the cases and controls. The role of MLB1 in human health still remains unknown and future studies are needed.     

Prevalence of moderate and severe depression among Croatian patients infected with human immunodeficiency virus

The aim of the study was to assess the prevalence of depression among Croatian patients infected with human immunodeficiency virus (HIV) and to make a comparison with patients with other acute and chronic infectious diseases. We assessed the depressive disorder using the Beck Depression Inventory questionnaire (BDI), without clinical confirmation. The BDI scores were examined in 80 HIV-infected persons and compared to 80 persons with chronic viral hepatitis and 78 with acute infectious diarrhea. All examinees were treated as outpatients at the University Hospital for Infectious Diseases in Zagreb in March and April of 2003. Prevalence of moderate and severe depression among HIV-infected was 16/80 (20%) with a 95% confidence interval 11% to 29%. Male patients with HIV or chronic viral hepatitis had a significantly higher BDI scores than males with acute infectious diarrhea (p = 0.017, Kruskall-Wallis, d.f. 2). Female patients with HIV infection tended to have a lower BDI score than females with chronic viral hepatitis or acute infectious diarrhea (p = 0.087, Kruskall-Wallis, d.f. 2). Prevalence of moderate and severe depression among Croatian HIV-positive patients is higher than the upper estimate for general population. Croatian males with chronic infectious disease have higher rate of depression than those with acute infectious disease.     

Metagenomic analysis of human diarrhea: viral detection and discovery

Worldwide, approximately 1.8 million children die from diarrhea annually, and millions more suffer multiple episodes of nonfatal diarrhea. On average, in up to 40% of cases, no etiologic agent can be identified. The advent of metagenomic sequencing has enabled systematic and unbiased characterization of microbial populations; thus, metagenomic approaches have the potential to define the spectrum of viruses, including novel viruses, present in stool during episodes of acute diarrhea. The detection of novel or unexpected viruses would then enable investigations to assess whether these agents play a causal role in human diarrhea. In this study, we characterized the eukaryotic viral communities present in diarrhea specimens from 12 children by employing a strategy of "micro-mass sequencing" that entails minimal starting sample quantity (<100 mg stool), minimal sample purification, and limited sequencing (384 reads per sample). Using this methodology we detected known enteric viruses as well as multiple sequences from putatively novel viruses with only limited sequence similarity to viruses in GenBank.     

Symposium on diarrhea. 5. Postoperative diarrhea.

Under normal circumstances many physiologic mechanisms prevent diarrhea. The most important are the normal processes of gastric emptying, digestion and absorption, the functioning of the ileocecal valve and elimination of bacteria from the small bowel. A surgical procedure may disrupt any of these mechanisms or may unmask a previously asymptomatic disorder that now requires appropriate treatment. Treatment of diarrhea related to surgery may be directed toward the diarrhea itself with such agents as tranquilizers and opiates but if these are not soon effective any disrupted functions must be analysed and specific measures taken to correct or compensate for these disruptions. The most useful measures in appropriate cases are the prevention of the dumping syndrome and the administration of pancreatic enzymes, cholestyramine, hydrophilic stool thickeners and broad-spectrum antibiotics. These measures may be ineffective or inadequate and surgical revision may be necessary.     

大肠杆菌O121侵袭性菌株的发现与研究

本文报告从一急性腹泻患儿的脓血便中分离的具有侵袭性的大肠杆菌。该菌株发酵葡萄糖,产酸产气,不发酵乳糖,β-半乳糖苷酶试验阳性,在醋酸钠培养基上生长,赖氨酸脱羧酶阴性,无动力,能引起豚鼠角膜结膜炎,侵入上皮细胞,具有140Md的质粒带,经血清学试验证实其血清型为O121:H-,是国内外首次报道的新的侵袭性大肠杆菌血清型。     

Cytotoxicity and antimicrobial susceptibility of Clostridium difficile isolated from hospitalized children with acute diarrhea

Clostridium difficile is an important pathogen associated with outbreaks of pseudomembranous colitis and other intestinal disorders such as diarrhea. In this study, 181 stool samples from children with and without acute diarrhea were analysed. Eighteen children with acute diarrhea were positive to C. ramosum, C. difficile, C. limosum, C. clostridioforme, C. septicum, C. butyricum, C. innocuum and Clostridium sp. Nineteen children without diarrhea harbored C. ramosum, C. septicum, C. barattii, C. butyricum, C. innocuum, C. sphenoides, C. bifermentans, C. clostridioforme and C. paraputrificum. No patient with diarrhea harbored C. barattii, C. bifermentans, C. paraputrificum and C. sphenoides. In addition, ten C. difficile strains were detected in 5 (5.5%) of the children with diarrhea. Also, no children from control group harbored C. difficile, C. limosum and Clostridium sp. Most of the tested strains were resistant to all the used antimicrobial. Nine C. difficile were toxigenic on VERO cells and by multiplex PCR, six strains showed both toxin A and B genes and three strains showed only toxin B gene. In this study, the presence of C. difficile was not significant, and it is suggested the need of more studies to evaluate the role of clostridia or C. difficile play in the childhood diarrhea and these organisms must be looked for routinely and a periodic evaluation of antimicrobial susceptibility should be performed.     

Symposium on diarrhea. 6. Infectious diarrhea.

Diarrhea may be primarily infectious in origin. Causes can be conveniently classified according to the etiologic agent, which may be viral, chlamydial, bacterial, protozoal, helminthic or fungal. The most common type of infectious diarrhea in Canada is viral. Bacterial infection, particularly staphylococcal and salmonellal, also is relatively common.     

成人急性感染性腹泻治疗新进展

成人急性感染性腹泻与儿童感染性腹泻在发病率、严重程度、预后等方面有所不同,其治疗以补液、止泻为主,必要时使用抗微生物药物。近年来,成人急性感染性腹泻在补液治疗和益生菌、新止泻药物应用等方面更新了一些新的循证医学证据,在进一步确保现有药物安全性的同时促进了腹泻治疗思路与手段的发展。     

Skin maculae,chronic diarrhea,cachexia, and splenomegaly—Late presentation of the first autochthonous case of visceral leishmaniasis in Tanzania

A 20-year-old man from Simanjiro district in northern Tanzania presented with a 3-year history of splenomegaly, fatigue, cachexia, skin maculae, and recent onset of watery diarrhea at Kilimanjaro Christian Medical Centre (KCMC) in Northern Tanzania. Due to laboratory findings of pancytopenia, diagnostic workup included bone marrow aspiration cytology and biopsy. Although the rapid test (IT LEISH, rK39 RDT) was negative, blood smear showed amastigote forms of leishmaniasis in macrophages. Repeat bone marrow aspiration and PCR eventually confirmed visceral leishmaniasis (VL). The patient denied travel to known endemic areas of VL. Treatment was initiated with Amphotericin B, but the patient died on the fourth day of treatment from respiratory insufficiency. An autopsy revealed massive organ manifestations of VL. This is the first reported autochthonous case of VL in Tanzania. Clark and colleagues detected the vector Phlebotomus martini in Northern Tanzania in 2013, in a region bordering the district of our patient. The negative rapid test draws attention to the fact that sensitivity and specificity were found to be low in East African VL patients as displayed earlier by a Kenyan study. Therefore, tissue samples (spleen or bone marrow) remain necessary for diagnosis. The variety of symptoms in this presented case was remarkable, including the occurrence of post-kala-azar dermal leishmaniasis (PKDL) and VL at the same time. This has been described in East African VL cases before as well as the occurrence of chronic diarrhea. An elongated undiagnosed period likely led to a mixed clinical picture that included hepato-splenomegaly, PKDL, cachexia, and diarrhea.     

2010年夏季急性细菌感染性腹泻患儿沙门菌感染分析

本文旨在了解急性细菌感染性腹泻患儿中沙门菌的感染现状及其耐药性.采集2010年7月1日~2010年9月30日复旦大学附属儿科医院门诊及住院急性细菌感染性腹泻患儿的粪便标本,进行沙门菌分离、培养及鉴定,采用Kirby-Bauer法进行药敏试验.共收集急性细菌感染性腹泻患儿粪便标本 1 045份,检出沙门菌 160株,阳性...     

Virus detection in monkeys with diarrhea: the association of adenoviruses with diarrhea and the possible role of rotaviruses.

To explore the role of viruses in the etiology of diarrhea in colony-reared monkeys, direct electron microscopy, the fluorescent virus precipitin test and cell culture inoculation were used to examine the stools of monkeys with and without diarrhea. The animals were predominantly rhesus with a few macaques of other species, and included infants, juveniles and adults. Adenoviruses were isolated from a higher proportion of specimens from rhesus monkeys with diarrhea (73% of specimens from infants and 78% of specimens from juveniles and adults) than from control monkeys without diarrhea (22% of specimens from infants and 26% of specimens from juveniles and adults). SV 20 was the most frequently isolated simian adenovirus type; SV 17 and SV 32 also were recovered. Noncultivable adenoviruses detectable only by electron microscopy were not seen. Although adenovirus excretion was associated with diarrhea, the causal role of adenoviruses was difficult to assess. When serial specimens from animals with chronic or intermittent episodes of diarrhea were examined, sequential infections with different viruses were found to be common. Rotaviruses were detected by electron microscopy and isolated in cell cultures from two infant rhesus monkeys with diarrhea. However, the low detection rate, together with negative serologic data on 40% of infant monkeys with diarrhea, suggested that rotaviruses were not the major cause of gastroenteritis in the monkeys under study.     

Isolation of Escherichia coli bacteriophages from the stool of pediatric diarrhea patients in Bangladesh

A 3-week coliphage survey was conducted in stool samples from 140 Bangladeshi children hospitalized with severe diarrhea. On the Escherichia coli indicator strain K803, all but one phage isolate had 170-kb genomes and the morphology of T4 phage. In spot tests, the individual T4-like phages infected up to 27 out of 40 diarrhea-associated E. coli, representing 22 O serotypes and various virulence factors; only five of them were not infected by any of these new phages. A combination of diagnostic PCR based on g32 (DNA binding) and g23 (major capsid protein) and Southern hybridization revealed that half were T-even phages sensu strictu, while the other half were pseudo-T-even or even more distantly related T4-like phages that failed to cross-hybridize with T4 or between each other. Nineteen percent of the acute stool samples yielded T4-like phages, and the prevalence was lower in convalescent stool samples. T4-like phages were also isolated from environmental and sewage water, but with low frequency and low titers. On the enteropathogenic E. coli strain O127:K63, 14% of the patients yielded phage, all of which were members of the phage family Siphoviridae with 50-kb genomes, showing the morphology of Jersey- and beta-4 like phages and narrow lytic patterns on E. coli O serotypes. Three siphovirus types could be differentiated by lack of cross-hybridization. Only a few stool samples were positive on both indicator strains. Phages with closely related restriction patterns and, in the case of T4-like phages, identical g23 gene sequences were isolated from different patients, suggesting epidemiological links between the patients.     

Factitious diarrhea

The causes of diarrhea are legion. In any diagnostic problem a factitious etiology must be carefully considered. Three cases are presented, in two of which daily ingestion of prunes and prune juice was found to be the cause of chronic diarrhea. In the third case an edible oil product, Coffee Rich, was determined by dietary manipulation to be the cause, carrageenan possibly being the laxative principle.