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Unit 5 Persistent Diarrhoea PowerPoint PPT Presentation


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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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Unit 5 persistent diarrhoea l.jpg

Unit 5

Persistent Diarrhoea


Learning objectives l.jpg

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


Definition persistent diarrhoea l.jpg

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


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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


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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


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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


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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


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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


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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


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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


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Nutrition

  • Maintain intake of healthy balanced diet during episodes of diarrhoea

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


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Some Clinical Categories of Diarrhoea

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


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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


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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


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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


Non bloody diarrhoea without fever l.jpg

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


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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


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Empiric Therapy of Severe or Persistent Diarrhoea

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


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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


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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


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Parasites and Their Treatment

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


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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


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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


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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


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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


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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


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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


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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


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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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