Diarrhea

1
Diarrhea

• Alex Ulitsky, MD
• Walter Hogan, MD
• 9/10/07

2
HPI

• 25 y/o male with no previous hx presented with
  c/o diarrhea
• Sxs began suddenly 4 weeks prior with a
  flu-like feeling, low-grade fevers, sore throat
  and diarrhea
• Having up to 15 large-volume, foul-smelling,
  semi-liguid stools daily
• No blood, occasional specs of mucus
• Given 2 wk course of Ceftin by PCP, sore throat,
  fevers resolved, diarrhea continued
• Lost 16 lbs in 3 wks, had to come to clinic for
  IVF twice, 2 L each time

3
PMH/PSH

• No medical problems, no surgeries
• Denies travel, camping, laxative use
• No family Hx of IBD, Celiac disease or thyroid
  disease
• No tobacco or ETOH, no drugs, no STDs,
  heterosexual

4
Medications

• Immodium prn, without relief

5
Physical Exam

• Gen NAD, well-appearing
• HEENT No icterus, eyes not sunken
• Pulm Lungs clear
• CV Normal, no orthostasis
• Abd soft, n/t, no masses, no HSM
• Ext no edema
• Skin no rashes, good turgor

6
Labs from PCP

• WBC 15.9 86N 7L Hg 15.9 MCV 87 Plt
• 234
• Monospot negative
• Stool culture negative, no PMNs
• Rotavirus negative
• C.diff negative x2

7
Differential Dx

• Broad, included infectious, inflammatory,
  autoimmune, endocrine and pancreatic disorders

8
Studies from GI Clinic

• BMP potassium 2.7 LFTs, albumin normal
• ESR, CRP normal
• Celiac panel normal, IgA normal
• TSH normal
• Quantitative 48 hr stool fat Total stool
• weight1378g, Fat32.0g (2-7g/24hr)
• SBFT normal

9
Stool OP
10
Patient Course

• Started on Flagyl 250 tid for a 10 day course
• Felt better after 2 days of tx, after 5 days had
  1-2 formed stools/day
• SB bx at EGD 6 days after tx start no evidence
  of Giardia, normal villi
• At 8 day clinic f/u feels well, 1 stool/day,
  gained 6 lbs.

11
Final Diagnosis

• GIARDIASIS

12
Discussion
13
Discussion

• Incubation period 7-14 days
• Sxs include diarrhea, foul smelling, greasy
  stools, malaise, anorexia and weight loss
• Majority of patients will have self-limited sxs
  for 7-14 days
• Persons with immunoglobulin deficiency may be
  predisposed to more severe forms of the infection
• Steatorrhea of more than 8g/day reported in 27
  in one case series, associated with bacterial
  overgrowth in about 50 of the patients
• Mechanisms for steatorrhea postulated as bile
  acid deconjugation by bacteria or Giardia itself
  or transient pancreatic dysfunction.

14
Discussion

• Lactase deficiency in 20-40 of cases, persists
  for weeks after tx
• Diagnosis traditionally made by microscopic stool
  exam (50 sensitive) or duodenal aspirate/biopsy
• Newer, more sensitive/specific tests are DFA and
  ELISA
• Metronidazole for 5-7 days or tinidazole as
  single 2g dose have gt90 cure rate

15
References

• Huang, DB, et al. An Updated review of
  Cryptosporidium and Giardia Gastroenterology
  Clinics of North America, 2006 (35) 291-314
• Tandon,BN, et.al. Mechanisms of malasbsorption in
  Giardiasis a study of bacterial flora and bile
  salt deconjugation in the upper jejunum. Gut 1977
  (18)176-181
• Carroccio, A, et al. Secondary impairment of
  pancreatic function as a cause of severe
  malabsorption in intestinal giardiasis a case
  report. American Journal of Tropical Medicine and
  Hygiene 1997 June 56(6)599-602
• Sleisenger and Fortdrans Textbook of
  Gastrointestinal and Liver Disease, 7th Edition