Antimotility Agents Research Articles

Chronic Diarrhea, Abdominal Pain, and Wasting: Cryptosporidiosis in the AIDS Patient

Introduction: Cryptosporidiosis is a diarrheal illness caused by the protozal pathogen Cryptosporidium. Clinical manifestations in the immunocompetant exist in three forms: asymptomatic carrier, acute, selflimited diarrhea or persistence of diarrhea for weeks. Watery-mucus rich diarrhea may last for months in the immunocompromised, especially those with acute immunodeficiency syndrome (AIDS). Rare since the advent of highly active antiretroviral therapy is a severe form of Cryptosporidiosis classified by cholera-like diarrhea, failure to thrive, and extra-intestinal disease. Case Report: A 59-year-old male with no past medical history presents with 6 months of watery, nonbloody diarrhea, 10-12 episodes per day, intermittent abdominal pain, and 40-pound unintentional weight loss. Physical exam: cachexia, temporal wasting and abdominal tenderness. Laboratory results: Potassium 2.5 meq/L; CBC, Chem 7, TSH, LFT, anti-tissue trans-glutaminase unremarkable. Colonoscopy: proctitis with diffuse ulceration; biopsies consistent with cytomegalovirus (CMV) colitis. HIV positive. Despite therapy with ganciclovir and initiation of HAART diarrhea persisted and patient developed worsening right upper quadrant abdominal pain. Upper endoscopy: increased nodularity of duodenal mucosa and loss of normal villous structure; biopsies notable for duodenitis, ulceration, villous atrophy and surface yeast forms consistent with cryptosporidium. Abdominal MRI: intra and extra-hepatic ductal dilation concerning for AIDS cholangiopathy. Despite HAART, patient's immune system did not reconstitute. Paramomycin, nitazoxanide, and anti-motility agents including tincture of opium were unsuccessful in slowing diarrhea frequency. Total parenteral nutrition (TPN) was initiated however patient ultimately elected for comfort care only and deceased. Discussion: AIDS cryptosporidiosis can be relentless and has significant morbidity and mortality. Sixty percent of cases result in a chronic diarrhea lasting months; however, minorities of patients have choleralike frequency of watery diarrhea. Small bowel villous atrophy potentiates malnourishment. Severe presentations are associated with CD4+ counts below 50 cells/mm3. Extra-intestinal cryptosporidiosis to the lungs or biliary tract is possible. Supportive care including rehydration and nutrition supplementation, as well as paramomycin and nitazoxanide may shorten disease course; however, immune reconstitution is the mainstay of therapy. Our patient represents a severe case of AIDS cryptosporidiosis, a now rare manifestation in the current HAART era. The importance of considering cryptosporidiosis in AIDS patients presenting with chronic diarrhea and wasting is highlighted by this case.

Index of Suspicion

A 5-year-old previously healthy boy presents to the emergency department (ED) with a 2-week history of intermittent left groin pain, usually occurring later in the day. Pain is not related to eating, movement, urination, or stooling. There is no report of trauma or precipitating event. He screams and refuses to stand up during pain episodes, which occur suddenly and last approximately 1 to 2 hours at a time. He otherwise has normal gait and activity when pain free. He does not wake up at night in pain. No recent illnesses or fevers are reported. Review of systems and his examination findings are unremarkable. Two days prior, he was evaluated in the ED for the same issue and had normal urinalysis, urine culture, and scrotal ultrasonogram results. The consulting urologist did not suspect a urologic process. He was discharged home with pain medication. Today, he returns to the ED because of the intense pain. The patient is admitted for further evaluation and pain management. Complete blood cell (CBC) count, C-reactive protein level, urinalysis results, and plain radiographs of the hips are unremarkable. Computed tomography of the abdomen and pelvis reveals a trace amount of nonspecific free fluid in the pelvis. His pain appears to be alleviated with ibuprofen and bed rest. The following day, he has another episode of intense groin pain after returning from the play room. Physical examination at this time demonstrates only point tenderness on palpation over his symphysis pubis area. No swelling, erythema, or increased warmth was noted in that area. An additional imaging study reveals the diagnosis. A 15-year-old girl presents to the clinic with an itchy rash, fever, headache, nausea, and dizziness. A few days earlier she was evaluated for rash on her back and low-grade fevers. She was prescribed amoxicillin clavulanate for suspected streptococcal …

PTH-047 A Prospective Study on the Impact of a ‘Bowel Cleansing Care Bundle’ on Inpatient Colonoscopy Visualisation Scores: A London District Hospital Experience

IntroductionIt is recognised that a well prepared colon increases adenoma detection and removal rates1 and the discovery of other significant pathology at endoscopy. Several factors can lead to a suboptimal...

Chronic radiation enteritis and malnutrition

Radiation enteritis is defined as the loss of absorptive capacity of the intestine following irradiation, which is most commonly seen after radiotherapy for pelvic and abdominal malignancies. It is divided into acute and chronic forms and usually presents with diarrhea and malabsorption. Malnutrition is a common complication of chronic radiation enteritis (CRE). We reviewed the etiology, prevalence, symptoms, diagnosis and management of CRE and CRE with malnutrition in this article. Functional short bowel syndrome as a cause of malnutrition in CRE is also considered. The diagnostic work-up includes serum markers, endoscopy, cross-sectional imaging and the exclusion of alternative diagnoses such as recurrent malignancy. Management options of CRE include dietary manipulation, anti-motility agents, electrolyte correction, probiotics, parenteral nutrition, surgical resection and small bowel transplantation. Treatment may also be required for coexisting conditions including vitamin B12 deficiency, bile acid malabsorption and depression.

Evaluating the safety of anti-CTLA-4 therapy in the elderly with unresectable melanoma.

9063 Background: Anti-CTLA-4 monoclonal antibodies demonstrated an improvement in overall survival in patients with metastatic melanoma and ipilimumab (ipi) was FDA approved in 2011. We performed a retrospective analysis of 74 elderly (age ≥ 65) patients (pts) who were treated with anti-CTLA-4 therapy (tx) and evaluated their treatment related adverse events (AEs) as well as clinical response. Methods: 65 pts were treated with ipi 3 mg/kg x 4, among whom 8 pts were re-treated with ipi 3 mg/kg x 4; 3 pts were treated with ipi 10 mg/kg x 4 with 2 pts who went on to receive maintenance tx; 2 pts were treated with tremelimumab (treme) 15 mg/kg q 3 months; 4 pts are currently undergoing tx with ipi 3 mg/kg x 4. There were 17 treatment naïve pts, and 57 pts were previously treated with 1-4 prior therapies. Thirty-nine pts received all 4 doses of ipi. There were 46 males and 28 females. Ages ranged from 65 to 90, median age 74. Melanoma subtypes included: 55 cutaneous, 8 mucosal, 7 ocular, 3 acral, and 1 unknown primary. Ten pts had M1a, 18 M1b, and 45 M1c disease. One pt had unresectable stage IIIC disease. Results: The most common tx related AEs included rash (33 AEs ≤ grade 3), diarrhea/colitis (21 AEs ≤ grade 3, with 1 grade 4 AE), fatigue (17 AEs ≤ grade 2), and pain at tumor site (17 AEs ≤ grade 2). There were 3 hepatotoxicity-related AEs, including 1 grade 5 AE; and 3 endocrinopathy-related AEs, including 1 grade 4 hypopituitarism. Toxicities were managed with corticosteroids, anti-histamines, anti-motility agents, analgesics, thyroid and cortisol supplementation. Of the 69 pts evaluable for response, 16 pts (23%) had complete response (CR) or partial response (PR), and 9 pts (13%) had stable disease (SD) as measured radiographically using mWHO criteria at least 12 weeks post completion of treatment. When analyzed within melanoma subtypes, 17 cutaneous pts (31%) had tumor response (CR, PR, SD), 6 mucosal (75%), and 2 ocular (29%). Conclusions: Anti-CTLA-4 tx, including ipi and treme, was safe and well tolerated by the elderly population. Reported adverse events and response rates were consistent with published data in younger cohorts.

Use of octreotide for relief of gastro-intestinal (GI) symptoms in systemic mastocytosis

e present the case of an 82-year-old Caucasian female who was evaluated by hematology oncology for further work up and management of her chronic but progressive anemia. She reported weight loss, poor appetite, fatigue, nausea, several episodes of non-bloody diarrhea and increased abdominal girth over the past 3 months. On admission, her hemoglobin was 8.9 gm/dL, platelets were 43 k/mcl, WBC was 5.49 K/mcl with absolute neutrophil count of 3.73 k/mcl and 0% peripheral blasts. Her metabolic panel was abnormal for elevated LDH (245 U/L) and alkaline phosphatase (207 U/L). Her liver function tests were normal except for albumin of 2.5 g/dl. Computed tomography (CT) of the abdomen/pelvis showed splenomegaly, ascites, and retroperitoneal lymphadenopathy, a concern for a lymphoproliferative or metastatic disease. A bone marrow biopsy and aspirate performed to determine the cause of her progressive anemia and thrombocytopenia revealed hypercellularity (90%) and increased blasts (35% on the touch preparation). The blasts had scant cytoplasm and fine chromatin (blue arrows in Figure 1). In addition, there were paratrabecular infiltrates of round to spindled mast cells (red arrow in Figure 1), which by immunohistochemistry were strongly positive for tryptase (shown in Figure 2), CD117, CD68 and CD25. The blasts were weakly positive for CD117 and strongly positive for myeloperoxidase, CD56, Bcl-2, and CD43 (not shown). The aspirate was severely hemodiluted, likely due to the reticulin fibrosis observed in the biopsy. Flow cytometry specimen was also hemodiluted (9% blasts) with the following myeloid immunophenotype: CD33 positive CD13 positive CD56 positive CD117 partially positive CD34 negative HLA-DR negative. Based on these findings the patient was diagnosed with AML and SM, a subset of systemic mastocytosis with associated clonal hematologic non-mast cell lineage disease (SM-AHNMD). The patient’s diarrhea responded briefly to antimotility agent loperamide, but while awaiting definitive treatment plan, her symptoms worsened rapidly and required admission for severe, profuse non-bloody diarrhea, dehydration and abdominal distension. Splenomegaly and ascites were noted on clinical exam. Labs continued to show anemia and thrombocytopenia. Initial test was positive for clostridium difficile (C. diff). This was successfully treated with metronidazole and then with oral vancomycin. Subsequent tests for C. diff, other infectious agents and transglutaminase IgA antibody were negative. However, the patient continued to have multiple episodes of diarrhea with little relief from antimotility agents. Diarrhea was deemed secondary to SM. Extensive work up for portal hypertension was non-diagnostic. She could not undergo colonoscopy and liver biopsy due to thrombocytopenia. As a consideration for treatment with imatinib she was tested for BCR/ABL and PDGFRA fusion genes which were negative. KIT mutation analysis could not be performed due to lack of tissue sample. After a lengthy discussion with the patient regarding various options of treatment, she chose palliative care and hospice. However, severe diarrhea limited her transition to hospice; she was then started on a trial of octreotide every 8 h for her diarrhea. She had a rapid response with dra-

Gastroesophageal Reflux Disease Treatment: Side Effects and Complications of Fundoplication

Even skilled surgeons will have complications after antireflux surgery. Fortunately, the mortality is low (<1%) with laparoscopic surgery, immediate postoperative morbidity is uncommon (5%-20%), and conversion to an open operation is <2.5%. Common late postoperative complications include gas-bloat syndrome (up to 85%), dysphagia (10%-50%), diarrhea (18%-33%), and recurrent heartburn (10%-62%). Most of these complications improve during the 3-6 months after surgery. Dietary modifications, pharmacologic therapies, and esophageal dilation may be helpful. Failures after antireflux surgery usually occur within the first 2 years after the initial operation. They fall into 5 patterns: herniation of the fundoplication into the chest, slipped fundoplication, tight fundoplication, paraesophageal hernia, and malposition of the fundoplication. Reoperation rates range from 0%-15% and should be performed by experienced foregut surgeons.

Travellers’ diarrhoea: causes, prevention and treatment

This article describes the prevention and treatment of travellers' diarrhoea, the leading cause of illness in people travelling abroad. The most common cause of travellers' diarrhoea worldwide is bacterial pathogens, which account for up to 80% of cases. Exercising caution over dietary selection and personal hygiene is the most common method used for reducing the risk of acquiring travellers' diarrhoea. Antibiotics, probiotics, prebiotics and bismuth subsalicylate have all been indicated for the prevention of this distressing condition. Treatments include antimotility agents, oral rehydration salts and antibiotics.

Antimotility effects of extracts and fractions of Eastern Nigeria mistletoe (Loranthus micranthus Linn)

ObjectiveTo evaluate the antimotility activity of Eastern Nigerian mistletoe[Loranthus micranthus (L. micranthus) Linn] parasitic on six different host trees viz. Baphia nitida, Persia americana, Kola accuminata, Irvingia gabonensis, Citrus simensis and Pentacletra macrophylla (P. mycrophylla). MethodsThe antimotility of the methanol extracts and solvent fractions were evaluated in castor oil induced diarrheoa in rats. ResultsThe methanol extracts (200 mg/kg, i.p.) inhibited defeacation significantly (P < 0.05) 4 h after administration (75.73% to 93.33%) more than that of atropine sulphate (2 mg/kg, i.p.) which inhibited defeacation by 80.0%. The methanol extract (200 mg/kg, i.p.) of L. micranthus parasitic on P. mycrophylla exhibited significant (P<0.05) inhibition in gastrointestinal transit (67.6%) more than that of atropine sulphate (2 mg/kg, i.p.) which inhibited gastrointestinal transit by 26.4%. The solvent fractions of L. micranthus parasitic on P. mycrophylla at dose levels of 150 mg/kg inhibited significantly the gastrointestinal transit of mice. Fraction F5 exhibited inhibitory activity which was comparable to loperamide (73.3%). ConclusionThe methanol extract of L. micranthus parasitic on P. macrophylla exhibits higher antimotility activity that other extracts. The solvent fractions could serve as source of novel antimotility agents.

Translational Approaches for Pharmacotherapy Development for Acute Diarrhea

Areport is presented of a National Institute of Diabetes and Digestive and Kidney Diseases–sponsored single topic conference designed to determine scientific advances needed to encourage development of pharmacotherapy for diarrheal diseases. Acute diarrheal diseases are a global public health problem in developing and developed countries. They are a leading cause of mortality and morbidity for children under the age of 5 worldwide and have a major economic impact in developed countries. Although oral rehydration solution (ORS) along with oral zinc therapy has reduced mortality owing to acute diarrheal diseases, there are essentially no other approved, safe, and effective drugs to decrease stool volume and prevent fluid loss. On September 25–27, 2011, the National Institute of Diabetes and Digestive and Kidney Diseases convened a workshop on Translational Approaches for Pharmacotherapy Development for Acute Diarrhea to assess current treatments for acute diarrhea, to identify common host pathways targeted by infectious agents associated with acute diarrhea, to evaluate which pathophysiologic mechanisms are most clinically relevant as potential targets, and to identify promising areas for translational research.

Research Letters

We conducted this study to determine the prescribing practices of doctors in management of acute diarrhea in children in the age group of 6 month -5 year. Antimotility agents and low/zero lactose formula was prescibed in 9.8% and 24.7% cases, respectively by general practitioners. In about 66.6% and 5.7% cases pre/probiotics were prescribed and oral rehydration salt (ORS) were not prescribed by the pediatricians.

Syndrome hémolytique et urémique post-diarrhéique : Quand y penser ? Quel suivi ?

Haemolytic uremic syndrome (HUS) is characterized by thrombotic microangiopathy with acute renal failure, haemolytic anaemia with schizocytes and thrombocytopenia. Typical forms (D + HUS) are caused by gastrointestinal infection with Escherichia coli species producing verotoxines (or Shiga toxins, STEC). It is estimated that 5–8 % of infected individuals will develop HUS following STEC infection. E. coli O157:H7 is the most commonly involved serotype and can lead to D + HUS in 15 % of young infected children. Vehicles of STEC transmission are contaminated food (ground beef, unpasteurised dairy products, unwashed and uncooked fruit and vegetables), person-to-person transmission and contact with farm animals with STEC. After an average incubation period of 3 to 8 days, patients develop painful bloody diarrhoea followed by systemic toxinemia. This may lead to thrombotic microangiopathy with endothelial damage and activation of local thrombosis. Since 1996, the Institut de Veille Sanitaire (InVS) centralises all notified French cases of D + HUS in children less than 15 years of age and investigates cases regrouped by time and place for the presence of STEC risk factors. The average annual incidence ranges between 0.6 and one for 100 000 children younger than 15 years and with a peak at 1 year of age. Fifty-one percent of HUS occur between June and September. Patients with a suspicion of STEC infection or bloody diarrhoea should not receive antibiotics, antimotility agents, narcotics and non-steroidal anti-inflammatory drugs. Maintenance optimal hydration provides nephroprotection. The management of HUS remains supportive. Dialysis was required for 46 % of HUS cases in 2009. For similar indication, peritoneal dialysis has to be a first choice treatment. Neurological injury is the most frequent non-renal complication and the first cause of death. Early initiation of plasmapheresis might improve the prognosis. Overall mortality rate ranges between 1 and 5 %. One third of patients suffer from long-term renal morbidity such as proteinuria, arterial hypertension and decrease of glomerular filtration rate. The longer the duration of anuria, the greater the risk of sequellae. Any patient with a history of HUS needs a long-term renal follow-up.

Antimicrobial and Antimotility Agent Use in Persons with Shiga Toxin-Producing Escherichia coli O157 Infection in FoodNet Sites

Antimicrobial and antimotility agents are not recommended for the treatment of Shiga toxin-producing Escherichia coli O157 infection. In our study, many persons with Shiga toxin-producing E. coli O157 infection took antimicrobial (62%) and antimotility agents (32%); 43 (29%) of 146 reported commencing antimicrobial treatment after laboratory confirmation. Efforts are needed to promote practice guidelines.

Octreotide for Symptomatic Treatment of Diarrhea due to Cytomegalovirus Colitis

To report the improvement of diarrhea in a patient with cytomegalovirus (CMV) colitis who was treated with octreotide after failure of loperamide. An 84-year-old male presented with chronic diarrhea and CMV colitis; he had been experiencing protracted diarrhea since 2006. In October 2009 he failed a 21-day course of valgancyclovir 900 mg orally twice daily. Several months later, due to continuing diarrhea and progressive malnutrition, a colonoscopy and subsequent biopsy again showed CMV. In March 2010 he was started on a 28-day course of intravenous ganciclovir 130 mg daily. Three weeks into treatment he continued with copious amounts of diarrhea, with no relief from loperamide, which was titrated from 2 mg/day to 2 mg every 6 hours. On day 20 of ganciclovir treatment he was started on octreotide 50 μg subcutaneously every 8 hours; within a few days, the patient began to experience decreased stool frequency and consistency. He completed the full 28-day course of ganciclovir, with octreotide continuing unchanged, with much improvement in his diarrheal symptoms and improvement in appetite, nutritional status, and quality of life. Studies regarding the treatment of CMV colitis-associated diarrhea are scarce, and are typically limited to treating the underlying cause with antiviral medications and with the addition of antimotility agents. Three cases have been reported in the literature in which octreotide was used for the symptomatic treatment of diarrhea, none of which was refractory to loperamide. This is the first known case of a patient with chronic diarrhea due to CMV colitis that was unresponsive to loperamide, required protracted antiviral treatment (valgancyclovir and gancyclovir), and subsequently experienced relief by the use of octreotide 50 μg subcutaneously every 8 hours.

Metabolic support of the enterocutaneous fistula patient.

Enterocutaneous fistula (ECF) is a challenging clinical problem with many etiologies; however, the most common cause is iatrogenic, complicating abdominal surgery. Advances in the overall care of the ECF patient have resulted in dramatic reductions in morbidity and mortality over the last five decades. A structured approach to the management of ECF has been shown to result in improved outcomes. Initial physiologic stabilization of the postoperative patient, focused on hemodynamic and fluid support as well as aggressive sepsis control are the critical initial maneuvers. Subsequent optimization of nutrition and wound care allows the patient to regain a positive nitrogen balance, and allow for healing. Judicious use of antimotility agents as well as advanced wound care techniques helps to maximize healing as well as quality of life, and prepare patients for subsequent definitive surgery.

Effects of Berberine Against Radiation-Induced Intestinal Injury in Mice

Radiation-induced intestinal injury is a significant clinical problem in patients undergoing abdominal radiotherapy (RT). Berberine has been used as an antimicrobial, anti-inflammatory, and antimotility agent. The present study investigated the protective effect of berberine against radiation-induced intestinal injury. The mice were administrated berberine or distilled water. A total of 144 mice underwent 0, 3, 6, 12, or 16 Gy single session whole-abdominal RT and 16 mice underwent 3 Gy/fraction/d for four fractions of fractionated abdominal RT. Tumor necrosis factor-alpha, interleukin-10, diamine oxidase, intestinal fatty acid-binding protein, malonaldehyde, and apoptosis were assayed in the mice after RT. The body weight and food intake of the mice receiving fractionated RT were recorded. Another 72 mice who had undergone 12, 16, or 20 Gy abdominal RT were monitored for mortality every 12 h. The body weight and food intake of the mice administered with distilled water decreased significantly compared with before RT. After the same dose of abdominal RT, tumor necrosis factor-alpha, diamine oxidase, intestinal fatty acid-binding protein in plasma and malonaldehyde and apoptosis of the intestine were significantly greater in the control group than in the mice administered berberine (p < .05-.01). In contrast, interleukin-10 in the mice with berberine treatment was significantly greater than in the control group (p < .01). A similar result was found in the fractionated RT experiment and at different points after 16 Gy abdominal RT (p < .05-.01). Berberine treatment significantly delayed the point of death after 20 Gy, but not 16 Gy, abdominal RT (p < .01). Treatment with berberine can delay mortality and attenuated intestinal injury in mice undergoing whole abdominal RT. These findings could provide a useful therapeutic strategy for radiation-induced intestinal injury.

Prescribing for acute diarrhoea

This article provides an overview of the main drugs used in the treatment of acute diarrhoea. There is reference to some of the prescribing issues associated with oral rehydration therapy and the use of antimotility agents. Other prescribing issues associated with acute diarrhoea are also discussed. The reader has the opportunity to self-check his/her own knowledge with a pre-reading self-assessment.

Giardiasis and Cryptosporidiosis

1. Sabah Kalyoussef, DO 2. David Goldman, MD 1. Albert Einstein College of Medicine Bronx, NY 1. 1. American Academy of Pediatrics 1. Pickering LK, 2. Baker CJ, 3. Long SS, 4. McMillan JA Giardiasis. American Academy of Pediatrics. In: Pickering LK, Baker CJ, Long SS, McMillan JA eds. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th ed.Elk Grove Village, Ill: American Academy of Pediatrics; 2009:303–305 2. 1. Yoder JS, 2. Beach MJ Giardiasis Surveillance-United States, 2003–2005. Yoder JS, Beach MJ. MMWR Morbid Mortal Wkly Rep. 2007;56:11–18 [OpenUrl][1] 3. 1. Chandy E, 2. McCarthy J Evidence Behind the WHO Guidelines: Hospital Care for Children: What is the Most Appropriate Treatment for Giardiasis?Chandy E, McCarthy J. J Trop Pediatr. 2008;55:5–6 [OpenUrl][2][CrossRef][3][PubMed][4] 4. 1. Escobedo AA, 2. Almirall P, 3. Alfonso M, 4. et al Treatment of Intestinal Protozoan Infection in Children. Escobedo AA, Almirall P, Alfonso M, et al. Arch Dis Child. 2009;94:478–482 [OpenUrl][5][Abstract/FREE Full Text][6] 5. 1. Huang DB, 2. White AC An Updated Review on Cryptosporidium and Giardia. Huang DB, White AC. Gastroenterol Clin North Am. 2006;35:291–314 [OpenUrl][7][CrossRef][8][PubMed][9][Web of Science][10] 6. 1. Centers for Disease Control Giardiasis. Centers for Disease Control. DPDx Laboratory Identification of Parasites of Public Health Concern. http://www.dpd.cdc.gov/dpdx/HTML/PDF_Files/MedLetter/Giardiasis.pdf 7. 1. Rossignol JF Cryptosporidium and Giardia: Treatment Options and Prospects for New Drugs. Rossignol JF. Exp Parasitol. 2009724. Epub ahead of print. DOI:10.1016/j.exppara.2009.07.005 Giardiasis is an infection of the small intestine caused by the flagellated protozoan Giardia intestinalis . Worldwide, giardiasis is the most common form of protozoan diarrhea. In the United States, the Centers for Disease Control and Prevention reported 20,075 cases in 2005. Giardiasis typically affects travelers and hikers who drink untreated water that has been contaminated with stool from infected animals such as beavers, muskrats, and sheep. Widespread outbreaks also may occur from sewage contamination of water supplies. Unprotected anal sex also is a source of transmission. Among children, giardiasis is an important cause of outbreaks of diarrhea in child care centers from fecal-oral transmission. Less commonly, food-associated outbreaks may occur. The infectious form of G intestinalis is the cyst, which can survive for prolonged periods within the environment. Once ingested, excystation occurs in the small intestine, releasing trophozoites that attach to the epithelium through a ventral sucker. Encystation occurs during transit to the colon. Both trophozoites and cysts can be identified in the stool. Diarrhea occurs because of damage to epithelial cells. The clinical manifestations of giardiasis … [1]: {openurl}?query=rft.jtitle%253DMMWR%2BMorbid%2BMortal%2BWkly%2BRep%26rft.volume%253D56%26rft.spage%253D11%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: {openurl}?query=rft.jtitle%253DJ%2BTrop%2BPediatr%26rft.volume%253D55%26rft.spage%253D5%26rft_id%253Dinfo%253Adoi%252F10.1093%252Ftropej%252Ffmn073%26rft_id%253Dinfo%253Apmid%252F18786986%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [3]: /lookup/external-ref?access_num=10.1093/tropej/fmn073&link_type=DOI [4]: /lookup/external-ref?access_num=18786986&link_type=MED&atom=%2Fpedsinreview%2F31%2F2%2F81.atom [5]: {openurl}?query=rft.jtitle%253DArch%2BDis%2BChild%26rft_id%253Dinfo%253Adoi%252F10.1136%252Fadc.2008.151852%26rft_id%253Dinfo%253Apmid%252F19329448%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [6]: /lookup/ijlink?linkType=ABST&journalCode=archdischild&resid=94/6/478&atom=%2Fpedsinreview%2F31%2F2%2F81.atom [7]: {openurl}?query=rft.jtitle%253DGastroenterology%2Bclinics%2Bof%2BNorth%2BAmerica%26rft.stitle%253DGastroenterol%2BClin%2BNorth%2BAm%26rft.aulast%253DHuang%26rft.auinit1%253DD.%2BB.%26rft.volume%253D35%26rft.issue%253D2%26rft.spage%253D291%26rft.epage%253D%2Bviii%26rft.atitle%253DAn%2Bupdated%2Breview%2Bon%2BCryptosporidium%2Band%2BGiardia.%26rft_id%253Dinfo%253Adoi%252F10.1016%252Fj.gtc.2006.03.006%26rft_id%253Dinfo%253Apmid%252F16880067%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [8]: /lookup/external-ref?access_num=10.1016/j.gtc.2006.03.006&link_type=DOI [9]: /lookup/external-ref?access_num=16880067&link_type=MED&atom=%2Fpedsinreview%2F31%2F2%2F81.atom [10]: /lookup/external-ref?access_num=000239969800005&link_type=ISI

Diarrheal Diseases in Low- and Middle-Income Countries: Incidence, Prevention and Management

Diarrheal diseases due to infection constitute a major burden of disease. Dehydration resulting from diarrhea can be fatal. It is the cause of approximately 1.8 million deaths every year. The vast majority of these deaths are of children under five years of age living in low- and middle- income countries. Interventions to prevent diarrhea include provision of safe water, hand washing, the use of sanitation facilities, exclusive breastfeeding of infants and rotavirus vaccination. Diagnosis is guided by symptoms into one of three categories: acute watery diarrhea, dysentery or bloody diarrhea, or persistent diarrhea of longer than 2 weeks in duration. Treatment of diarrhea in children includes oral rehydration with a pre-formulated solution or with fluids that can be prepared and administered in the home. Zinc supplementation is recommended. Only in certain circumstances are antibiotics advised and anti-motility agents are discouraged. The lives of many children could be saved with proper case management of diarrhea. With immediate and sustained actions to decrease both the incidence and mortality attributed to diarrhea, the burden of this prominent public health threat could be dramatically reduced.

Pretreatment with Drotaverine Hydrochloride before endoscopic retrograde cholangiopancreatography ： a prospective multicenter randomized controlled trial

Objective To evaluate the effects of drotaverine hydrochloride versus scopolamine in reducing duodenal motility and in facilitating cannulation during endoscopic retrograde cholangiopancreatography （ERCP）. Methods Randomized controlled trial of 650 participants from 4 endoscopic centers assigned to receive scopolamine 20 mg or drotaverine hydrochloride 40 mg intravenously 15 minutes before ERCP. Parameters including duodenal motility grades, success rates of deep cannulation, ERCP-related complications and adverse effects were recorded. Results The data of 638 patients （319 in each group） were valid. There were no significant differences in duodenal motility grades （1.17 ± 0. 82 vs. 1.15 ±0. 89, P = 0. 705）, success rate of deep cannulation （90. 9% vs. 91.8% , P =0. 672） and incidence of ERCP-related complications （11.3% vs. 11.0% , P = 0. 900） between 2 groups. However, the incidence of tachycardia （heart rate 〉 120 bpm） during ERCP was lower in drotaverine group than in scopolamine group （2. 2% vs. 6. 9%, P = 0. 004）. There was no significant difference in other adverse effects （nausea, vomiting） between 2 groups. Conclusion Drotaverine hydrochloride may provide a reasonable alternative as antimotility agent before ERCP. Key words: Cholangiopancreatography, endoscopic retrograde ; Scopolamine ; Drotaverine