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Approach to Diarrhea in HIV Patients dr. Ronald Ariyanto Wiradirnata Dr. dr. Nu’man As Daud, Sp.PD-KGEH
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Introduction Diarrhea is defined as the passage of three or more loose or liquid stools per day Diarrhea is regarded as chronic when the diarrhea occurs more than 15 days. Other literature indicates such term when the diarrhea has been occurred more than 1 month Chronic diarrhea as one of common symptoms in patients with HIV infection has different etiology compared to immunocompetent patients it is necessary to have adequate approach, recognition and understanding in the management of chronic diarrhea, especially for HIV patients. Kurniawan J, Simadibrata M, Karyadi T. Diarrhea in HIV Infection. Indones J Gastroenterol Hepatol Dig Endosc. 2009;10(1):23-28.
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PATHOPHYSIOLOGY Venegas AAG. Approach to diarrhea in HIV patients. Enfoque la diarrea en pacientes infectados con VIH Rev Colomb Gastroenterol. 2018;33(2):150-160.
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ETIOLOGYINFECTIOUS CAUSES
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Bacterial Infections Venegas AAG. Approach to diarrhea in HIV patients. Enfoque la diarrea en pacientes infectados con VIH Rev Colomb Gastroenterol. 2018;33(2):150-160.
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Viral Infections Venegas AAG. Approach to diarrhea in HIV patients. Enfoque la diarrea en pacientes infectados con VIH Rev Colomb Gastroenterol. 2018;33(2):150-160.
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Parasitical Infections Venegas AAG. Approach to diarrhea in HIV patients. Enfoque la diarrea en pacientes infectados con VIH Rev Colomb Gastroenterol. 2018;33(2):150-160.
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Fungal Infections Venegas AAG. Approach to diarrhea in HIV patients. Enfoque la diarrea en pacientes infectados con VIH Rev Colomb Gastroenterol. 2018;33(2):150-160.
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NON-INFECTIOUS CAUSES Venegas AAG. Approach to diarrhea in HIV patients. Enfoque la diarrea en pacientes infectados con VIH Rev Colomb Gastroenterol. 2018;33(2):150-160.
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Clinical Manifestation Small bowel diarrhea Large bulky postprandial stools almost immediately after eating Postprandial paraumbilical abdominal pain Usually experience weight loss Large intestine diarrhea (termed “colitic diarrhoea”) Usually present with frequent, small-volume stools, and the stools may have visible blood and mucus. Usually experience lower-quadrant abdominal pain, and The sensation of rectal urgency. JH D. The gastrointestinal tract and HIV pathogenesis. S Afr J Clin Nutr. 2010;23(1):65-69.
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DIAGNOSTIC APPROACH
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First stage: evaluation of infections by germs Complete medical history that focuses on the evolution of the HIV infection, treatment received, adherence to treatment and risk factors for infections such as travel to endemic areas (amebae and giardia), anal sex ( C. trachomatis or herpes), and recent use of antibiotics (C. difficile). Whether diarrhea is acute or chronic must be defined, and it should be categorized into one of four grades. Grade 1. Mild: transient or intermittent diarrhea with less than 3 stools/day in the normal pattern. Grade 2. Moderate: persistent liquid diarrhea or 4 to 6 bowel movements. Grade 3. Severe: bloody diarrhea or more than 7 bowel movements/day that require handling with IV fluids. Grade 4. Potentially incompatible with life with shock or organ dysfunction. Venegas AAG. Approach to diarrhea in HIV patients. Enfoque la diarrea en pacientes infectados con VIH Rev Colomb Gastroenterol. 2018;33(2):150-160.
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First stage: evaluation of infections by germs Venegas AAG. Approach to diarrhea in HIV patients. Enfoque la diarrea en pacientes infectados con VIH Rev Colomb Gastroenterol. 2018;33(2):150-160.
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First stage: evaluation of infections by germs Determining the level of CD4 is essential for finding causes of diarrhea in patients with HIV Venegas AAG. Approach to diarrhea in HIV patients. Enfoque la diarrea en pacientes infectados con VIH Rev Colomb Gastroenterol. 2018;33(2):150-160.
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Second Stage: Gastrointestinal Tract Examination If a pathogen is not diagnosed in the first phase, and diarrhea persists and is severe, endoscopic or radiological studies should be performed Whenever endoscopic procedures are performed, regardless of the findings, biopsies of both the colon and small intestine should be taken CT scan and MRI if patient develops extra-digestive symptoms (respiratory, adenopathy, and others) Venegas AAG. Approach to diarrhea in HIV patients. Enfoque la diarrea en pacientes infectados con VIH Rev Colomb Gastroenterol. 2018;33(2):150-160.
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Third Stage: Evaluation of ART Diarrhea associated with ART has been described in 2% to 19% of patients. If it is considered that there is a relationship between ART medication and diarrhea, this third stage may precede the second. Venegas AAG. Approach to diarrhea in HIV patients. Enfoque la diarrea en pacientes infectados con VIH Rev Colomb Gastroenterol. 2018;33(2):150-160.
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THANK YOU