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Sexually Transmitted Infections and the GI Tract

Sexually Transmitted Infections and the GI Tract. Dr Sarah Allstaff Consultant GUM Physician April 5 th 2013. Learning objectives. At the end of this lecture you will Have an understanding of how infections can be transmitted to the GI tract during sexual contact

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Sexually Transmitted Infections and the GI Tract

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  1. Sexually Transmitted Infectionsand the GI Tract Dr Sarah Allstaff Consultant GUM Physician April 5th 2013

  2. Learning objectives At the end of this lecture you will • Have an understanding of how infections can be transmitted to the GI tract during sexual contact • Be able to describe the common presentation of STIs in the GI tract • Not be able to describe the full natural history and management of all STIs

  3. How are infections transmitted during sex? What is “sex”? Collin’s Dictionary (sexual intercourse) Noun: the act carried out for procreation or for pleasure in which, typically, the insertion of the male's erect penis into the female's vagina is followed by rhythmic thrusting usually culminating in orgasm

  4. CDC sexual violence definitions A completed sex act is defined as contact between the penis and the vulva or the penis and the anus involving penetration, however slight; contact between the mouth and penis, vulva, or anus; or penetration of the anal or genital opening of another person by a hand, finger, or other object. http://www.cdc.gov/violenceprevention/sexualviolence/definitions.html

  5. How are infections transmitted during “sex”? Direct innoculation Trauma Sexual/genital secretions “Sex” IVDU Ingestion Fomites

  6. www.thelancet.com Vol 381, Jan 2013

  7. http://www.hpa.org.uk/NewsCentre/NationalPressReleases/2011PressReleases/111007ShigellaFlexneri/http://www.hpa.org.uk/NewsCentre/NationalPressReleases/2011PressReleases/111007ShigellaFlexneri/

  8. Case 1. A 38-year old man presents with a two day history of anal discharge and occasional bleeding. He also has a urethral discharge. He has a regular male partner of 2 years with whom he has regular condomless anal sex (receptive and insertive). He last had sex with another partner (shared with his partner) 1 week ago. This was a male friend and they had oral sex only.

  9. Case 1 Examination Well nourished and otherwise well Purulent urethral discharge Anus – discharge evident Proctoscopy Rectal mucosa inflamed Purulent discharge No ulcers or masses

  10. Case 1. Differential diagnosis Inflammatory bowel disease Sexually transmitted infection • Chlamydia • Gonorrhoea • Lymphogranuloma venereum x 3 x 3

  11. Gonorrhoea NAAT and culture positive Urine Rectum Pharynx Chlamydia positive (non LGV) Urine Rectum Syphilis, HIV, hepatitis B and C negative Management Ceftriaxone 500mg im stat Doxycycline 10mg bd 7/7 Test of cure 2-3/52 Public health interventions Case 1

  12. Public health interventions

  13. Rectal gonorrhoea Neisseria gonorrhoea Transmission: direct contact of mucosal surfaces For proctitis: anal sex, transmucosal spread, ?fomite Symptoms Short incubation period (5-10 days) Low abdo pain, diarrhoea, rectal bleeding, anal discharge, tenesmus May have associated symptoms (urethral discharge, dysuria) May be asymptomatic Proctoscopy Inflamed mucosae Purulent exudate

  14. Rectal gonorrhoea Emergence of antibiotic resistance High rate of chlamydia co-infection Management • Cephalosporin • Chlamydia treatment • Comprehensive STI screening • Test of cure • Public health interventions

  15. Rectal gonorrhoea Complications Absess formation • Increased susceptibility to HIV • Increased infectiousness of HIV

  16. Rectal chlamydia Chlamydia trachomatis (serovars D-K) Transmission: same as gonorrhoea In GU clinics Detected in 5% of women per rectum Detected in 10% MSM per rectum 50% of chlamydia in MSM is found solely in the rectum

  17. www.hps.scot.nhs.uk

  18. Rectal chlamydia Symptoms • 70% asymptomatic • Milder than gonorrhoea • Anal discomfort/itch, discharge • Associated symptoms Proctoscopy • Less severe Gram stain rectal swab CT PCR (all sites)

  19. Rectal chlamydia Azithromycin (stat dose) Doxycycline (7/7 course) Better clearance at rectal site 20% treatment failure Test of cure 6/52 Comprehensive STI testing Public health interventions

  20. Case 2 49-year old man 1/12 history of pain on defaecation Blood mixed in stools Crampy abdominal pains Colonoscopy • Patchy mild congestion at rectum Rectal biopsy Biopsy Cryptitis Crypt abscesses ?Crohn’s disease • Asacol

  21. Case 2 2/12 later developed a rash on trunk Dermatologist Biopsy 1/12 later developed lymphadenopathy ENT Fine needle aspiration CXR normal Fine needle aspiration of lymph node Lymphoid hyperplasia

  22. Case 2 1/12 later developed painful right eye • Reduced visual acuity • Acute anterior uveitis • Occlusive vasculitis Syphilis test positive

  23. Case 2 Regular male partner (HIV+) – last sex 4/12 before symptoms started Oral sex with 2 other male partners 3/12 before symptoms started • Comprehensive STI screening • Benzathene penicillin 2.4MU stat • Public health interventions • Follow-up serology

  24. Syphilis “Know syphilis in all its manifestations and relations, and all other things clinical will be added unto you” Sir William Osler, MD

  25. Syphilis Primary syphilis Solitary painless ulcer Secondary syphilis Mucosal patches and ulcers Mouth, anogenital, rectal Condylomata lata Systemic inflammation Hepatitis

  26. Herpes simplex virus Transmission: ano-genital or oro-anal Usually HSV 2 Usually peri-anal mucosa but may extend into rectum Symptoms: pain, ulcers, painful defaecation, bleeding, mucus, viraemic symptoms (in primary infection)

  27. Human papillomavirus Transmission: ano-genital, oro-anal HPV 6, 11, 16, 18 Usually causes anal warts Can extend to rectum Increasing prevalence of AIN and anal cancers (MSM and HIV+ people)

  28. Case 3 23-year old HIV+ man presents with 8/52 bloody diarrhoea, severe anorectal pain and low grade fever. Also arthralgia and myalgia. Condomless receptive anal sex 4/12 ago Examination: Absesses perianally Fexi-sigmoidoscopy Friable rectal mucosa, large ulcers, contact bleeding

  29. Case 3 Full STI screen Chlamydia positive in rectum (LGV serovar) Dx – Lymphogranuloma venereum • Doxycycline 100mg bd for 21/7 • Public health interventions

  30. Lymphogranuloma venereum Epidemiology MSM Often HIV+ Associated with Group sex Drug use Syphilis Hepatitis C Clinical features Primary (3-30 days) Ulcer Secondary (3-6/12) Inguinal sydrome Ano-rectal syndrome Tertiary Strictures Fistulae Genital elephantiasis

  31. HIV and the GI tract Gut-associated lymphoid tissue is the largest immune compartment in the body Mucosal lymphocytes: Rectum, foreskin, cervico-vagina Higher proportion of CD4+ T helper cells express CCR5 GI tract in constant state of “physiological inflammation” Dense clustering of lymphocytes (cell-cell transmission) • High susceptibility to HIV infection

  32. HIV and the GI tract Depletion of intestinal GALT regardless of site of infection Acute and chronic infection Up to 60% loss at day 14 (SIV) Clinical result of GALT loss • Unknown • HIV enteropathies • Opportunistic infection • Persisten immune activation – microbial translocation • Accelerated immunosenescence

  33. Summary: STIs and the GI tract STIs can present with  Peri-anal pathology  Proctitis  Proctocolitis  Hepato-biliary problems Sexual histories should be taken where an STI forms part of the differential diagnosis STIs often co-exist and comprehensive testing should be performed at all sexual sites (including HIV testing) Public health interventions important  Prevent re-infection  Maintain good sexual health for future

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