gastro-enterologie op reis -...
TRANSCRIPT
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Prof. Dr. Fons Van Gompel
Dr.Jan Clerinx
Dept. of Clinical Sciences
Institute of Tropical Medicine
Antwerp
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Gastro-enterologie
op reis
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2
incapacity of work after return
any health problem: used medication or felt ill 100,000
10,000 consulted M.D. abroad or back home
felt subjectively ill
1,000
100
10
1
stayed in bed
died abroad
emergency
air evacuation
Monthly incidence rates of health problems
during stays in developing countries
Malignant
neoplasm
and other
Cardiovascular
Accidents Traffic
Drowning
1% Infection
50%
40%
9%
PRIORITY No. 1
“Steffen-tree”
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4
100%
10%
1%
0.01%
0.001%
malaria (no chemoprophylaxis West Africa)
typhoid (India, N, NW-Africa, Peru)
PPD conversion
cholera
influenza A or B
typhoid (other areas)
dengue infection (SE-Asia)
animal bite with rabies risk
hepatitis B (expatriates)
HIV-infection
legionella infection
meningococcal disease
0.1%
Incidence rate / month of health problems
during a stay in developing countries (R.Steffen et al, 2008)
traveler’s diarrhea
Incl. ETEC
0.0001%
20 - 60 %
hepatitis A
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Diarrhea is by far the most frequent condition associated with travel to the tropics and subtropics
Incidence of travel related health conditions
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500 million international travelers/year
50 million travel to tropical or developing areas
(North Americans 27m, Europeans 18m, Japanese 3m, Aussies & Kiwi’s 1m)
DIARRHEA IN THE RETURNED TRAVELER
Diarrheal disease
-One third of all travelers to tropical developing areas
-Vast majority either self-limited or promptly responsive to short-course antibiotic
effective against common enteropathogenic bacteria
Source: PERSISTENT DIARRHEA IN THE RETURNED TRAVELER
Nathan M. Thielman MD, MPH and Richard L. Guerrant MD
Infect Dis Clin North Am. 1998 Jun;12(2):489-501.
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•Low risk (<8%): North-America, Western Europe, Japan, Australia & NZ,
•Intermediate risk (8-15%): S- en E-Europe, Russia, China, Israel, S-Africa
•High risk (20-90%): …..all the rest…but some more risky than others…..
Very high risk
“Dehli belly”
Diarrhea risk
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……Food & Beverage catering in the tropics……
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Travelers Diarrhea
Clinical Syndromes
• Acute watery diarrhoea (80 - 90 %)
• Dysenteric disease (10 - 20 %)
• Protracted > 2 weeks (1 - 5%)
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Travelers Diarrhea
Outcome
+ 0 % will die
< 1 % hospitalized
20-30 % stay in bed for a few days
40 % change their itinerary
mean duration : 4 days (median : 2 days)
- 90 % < 1 week
- 3 % > 2 weeks
- 1 % > 1 month
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Travel origin Total Diarrhea > 30d Highest risk areas
N % (n)
Swiss travelers 7886 0.9 (73) West Africa, Far East
Peace Corps volunteers 4607 1.7 (78) Haiti, Central & West Africa, Nepal
Students 35 2.9 (1) Latin America
Persistant diarrhea in returning travelers
Prospective studies
Source: PERSISTENT DIARRHEA IN THE RETURNED TRAVELER
Nathan M. Thielman MD, MPH and Richard L. Guerrant MD
Infect Dis Clin North Am. 1998 Jun;12(2):489-501.
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Casus Thailand
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Casus: “un train peut cacher un autre”
• Man, 32 jaar
• 6 maanden in regio
• terug uit Thailand sedert 2
weken
• Diarrhee sedert 3 weken
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• Brijerige stoelgang
3x/dag
• Wat krampen
• Flatulentie
• Meteorisme
• Geen koorts
Casus: “un train peut cacher un autre”
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Beleid…
Faeces microscopie met verrijking
coprocultuur
Resultaat: geen staal ingeleverd….
Proefbehandeling:
Tinidazole 2g
Resultaat na 7 dagen:
Diarrhee is duidelijk minder uitgesproken,
maar niet geheel verdwenen
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Vervolg...
Drie weken later opnieuw diarrhee,
ditmaal met kleine hoeveelheden slijm
met wat donker bloedbijmenging…
“(Entero)colitis”
Bacteriëel?
Parasitair?
Niet-infectieuze colitis?
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17 © Mandell 2010 – chapter 97
Tropenpathologie!
SOA
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The Usual Suspects...
Bacteriëel?
Shigellose (S.dysenteriae, S.flexneri…)
Campylobacter jejuni
(Salmonella, EPEC, P.shigelloides…)
Parasitair?
Entamoeba histolytica
(Balantidium coli, Schistosoma mansoni…..)
Niet-infectieuze colitis
Colitis ulcerohemorrhagica, (Crohn…)
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Diagnose?
Klassiek Coprocultuur (Shigella, Salmonella, Campylobacter)
negatief
Feces microscopie rechtstreeks en met verrijking
WBC++, RBC++, Blastocystis hominis
Wat nu?
Anorectoscopie:
Directe microscopie
op vers uitstrijkje
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Diagnose?
Entamoeba histolytica colitis
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Diagnose?
Wat indien……
Aanvullend coprologisch onderzoek
Kysten E.histolytica
vs E.dispar
vs andere nietpathogene
amoeben
=> PCR E.histolytica op feces
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Entamoeba
histolytica
trophozoiet
Cyclus
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Amoebiasis
Hoe behandelen?
• Nitro-imidazolen: heel efficiënt voor
weefselamoebiasis
• Contact-amoebicide (paromomycine)
Opvolging?
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Casus India
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Casus: “diarrhée simple”
• Jongeman, 26 jaar
• 3 maanden in Zuid India
• terug uit India sedert 2
weken
• Diarrhee sedert 6 weken
• Behandeld in India 3
weken geleden met
medicatie gedurende 5
dagen…
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• Brijerige & kleverige stoelgang 1 tot 5x/dag
• Flatulentie
• Meteorisme
• Nausea, anorexie
• Geen koorts
• - 5 kg op 4 weken
Casus: “diarrhée simple”
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Faeces microscopie met verrijking
geen parasieten gevonden….
coprocultuur
geen enteropathogene bacteriën
Proefbehandeling??
Tinidazole 2g
Resultaat na 7 dagen:
Diarrhee is duidelijk minder uitgesproken,
maar niet geheel verdwenen
Beleid…
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Vervolg...
Drie weken later opnieuw brijerige
diarrhee, flatulentie, meteorisme….
Bacteriëel?
Parasitair?
Niet-infectieus?
Wat nu?
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The Usual Suspects...
Bacteriëel?
(Salmonella???)
Parasitair?
Giardia lamblia
Cyclospora sp.
Isospora sp.
Worms???
Niet-infectieuze diarrhee
lactose intolerantie, glutenenteropathie…..
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Diagnose?
Klassiek Coprocultuur (Shigella, Salmonella,
Campylobacter)
negatief
Feces microscopie rechtstreeks
en met verrijking
negatief
Nieuw Giardia lamblia antigeen in feces: pos.
Wat nu?
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Méd Trop Parasitol
Trop Med Parasitol
WP & GP
Giardiasis
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Giardiasis: behandeling?
Klassiek Tinidazole 2g éénmalig
Metronidazole 1.5g x 5d
“Resistente giardiasis”
Tinidazole 2g/d x 3d
Mepacrine 100mg tid x 5d
(Albendazole 400mg bid x 5d
Nitazoxanide 500mg bid x 5d)
Wat nu?
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Reizigersdiarrhee
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Incl >90% E.dispar
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Aanslepende (reizigers)diarrhee
Protozoaire parasieten
Pathogeen Apathogeen
• Giardia lamblia
• Cryptosporidium parvum
• Cyclospora cayetanensis
• Isospora belli
• (Microsporidium sp.)
• Entamoeba histolytica*
• (Balantidium coli)*
• Iodamoeba butschlii
• Entamoeba coli
• Endolimax nana
• Entamoeba hartmanni
• Trichomonas intestinalis
• Chilomastix mesnili
• Entamoeba dispar
• Sarcocystis sp.
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Blastocystis hominis ?? Dientamoeba fragilis ??
* Dysenterie
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Coccidiosen van de darm
Cryptosporidium Sarcocystis
Cyclospora
Isospora
“Ookystes”
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Aanslepende reizigersdiarrhee
Pathogeen Behandeling Respons
Giardia lamblia
Entamoeba histolytica*
Cryptosporidium parvum*
Cyclospora cayetanensis
Isospora belli
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* intraluminaal amoebicide, zekere activiteit op C.parvum
** C.jejuni
Tinidazole > 80%
& Paromomycine* > 95%
? Paromomycine ?*
Cotrimoxazole > 90%
Shigella sp.
Campylobacter jejuni
Fluoroquinolones 40** à 90%
Azithromycine > 90%
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Casus Mexico
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Casus: “diarrhée sans fin”
Man, 53 jaar
• 3 weken in Mexico
(Yucatan) in februari 2014
• Waterige diarrhee sedert 4
maanden
• Behandeld in Mexico met
cotrimoxazole met (tijdelijk)
succes
• Nu aanslepende waterige
diarrhee, 2 à 5x per dag…
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• Waterige tot halfvaste stoelgang tot 4/dag
• Borborygmi
• Geen koorts
• Geen krampen
• Niet vermagerd
Casus: “diarrhée sans fin”
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Laboratorium
Faeces microscopie met verrijking
geen parasieten gevonden….
coprocultuur
geen enteropathogene bacteriën
Proefbehandeling
Tinidazole 2g, en ofloxacine 400mg/d x 10d
Resultaat na 7 dagen:
Tijdelijk beter tijdens de inname van ofloxacine
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Vervolg...
Na stoppen behandeling:
diarrhee….
Bacteriëel?
Parasitair?
Niet-infectieus?
Wat nu?
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The Usual Suspects...
Bacteriëel?
(???)
Parasitair?
Giardia lamblia
Cyclospora sp.
Isospora sp.
Worms….
Niet-infectieuze diarrhee
lactose intolerantie, glutenenteropathie…..
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Diagnose?
Coloscopie met colonbiopten
geen afwijkingen
Gastroscopie met duodenumbiopten
geen afwijkingen
Labtesten
Serum IgA: normaal
anti-transglutaminase IgA ab: afwezig
Wat nu?
Wat nu?
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Glutenenteropathie
• Duodenumbiopsie
– Stompe darmvilli, hypertrofische crypten
– Lamina propria infiltratie met lymfocyten en plasmacellen
• Auto-antistoffen
– Anti-endomysium IgA Ab
– Anti-transglutamase IgA Ab
– Antigliadine IgG & IgA Ab
– IgA deficientie in 10% (geeft vals negatief resultaat)
– IgA antistoffen verdwijnen tijdens glutenvrij dieet
Melissa P. Upton (2008) “Give Us This Day Our Daily Bread”—Evolving Concepts in Celiac Sprue. Archives of Pathology & Laboratory Medicine: October 2008, Vol. 132, No. 10, pp. 1594-1599.
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Vervolg…
R/ Lactosevrij dieet: geen resultaat
R/ Cholestyramine (Questran) 12g/dag x 2 weken
=> Geen diarrhee meer!
=> onmiddellijk resultaat!
Galzuurdiarrhee door bacteriële overgroei in
dundarm: niet te vergeten!
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47
Chapter 55 –
Persistent Travelers'
Diarrhea
Bradley A. Connor
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EPILOOG