Prevalence and Characteristics of Duodenal Villous Atrophy in Renal Transplant Patients Presenting With Persistent Diarrhea in a Developing Country.

OBJECTIVES: Persistent diarrhea is a common complication after solid-organ transplant, including kidney transplant. Data on duodenal villous atrophy as a cause of persistent diarrhea in renal transplant recipients are scarce. MATERIALS AND METHODS: We conducted a prospective analysis of 207 patients who received renal transplants from 2009 to 2012 with persistent diarrhea and who underwent upper gastrointestinal endoscopy and duodenal biopsies. Duodenal biopsies were examined for duodenal villous atrophy. Age, sex, transplant duration, and drugs were compared between patients with and without duodenal villous atrophy. After exclusion of known causes of duodenal villous atrophy, a 3-month course of antibiotics was given and outcomes were analyzed. RESULTS: Of 207 renal transplant recipients, 104 patients (49.8%) displayed duodenal villous atrophy. Of these, 92 (88.5%) were male patients. The mean age of patients with duodenal villous atrophy was 34.9 ± 10.3 years. The mean onset of persistent diarrhea in DVA-positive patients posttransplant was 2.16 ± 0.8 years. Celiac disease serology was positive in 18 (17.3) patients. Giardiasis was demonstrated in 11 patients (10.7%), whereas immunoproliferative small intestinal disease was shown in 7 patients (6.8%). The remaining 68 patients (65.38%) received antibiotics, with 50 recipients (74.6%) showing complete response, although 13 of these patients (26%) relapsed. Among the remaining 18 patients (26.47%), 9 (50%) had other causes and 9 (50%) had no cause found. Isoniazid prophylaxis showed statistically significant negative association with duodenal villous atrophy. CONCLUSIONS: Duodenal villous atrophy is highly prevalent in renal transplant recipients irrespective of age, sex, and posttransplant duration. We found tropical sprue, giardiasis, immunoproliferative small intestinal disease, and celiac disease to be important causes of duodenal villous atrophy. Therefore, duodenal biopsy is recommended in renal transplant recipients with persistent diarrhea.

A presentation of latent tropical sprue in a Canadian hospital.

Tropical sprue (TS) is a chronic diarrheal disease of unknown etiology characterized by malabsorption and small bowel mucosal abnormalities. TS affects residents of, and visitors to, endemic tropical regions. Rarely the disease may remain latent for several years, and to date, few cases of latent TS have been reported in Europe or North America. However, in our increasingly multicultural communities and in a 'global village' where travel is common, clinicians must maintain a high index of suspicion for TS in patients presenting with diarrhea and malabsorption who have traveled to endemic regions. TS may mimic common diarrheal diseases that are seen in developed nations, including celiac disease, Crohn's disease, bacterial overgrowth, and other infectious etiologies. Accordingly, once these more common etiologies have been ruled out, TS must be considered in patients presenting with diarrhea after travel to endemic regions. We present a unique Canadian case of latent TS, with a brief review of the diagnostic approach and treatment.

Tropical sprue: two cases report and review of literature. Has anything changed in the past 40 years?

BACKGROUND: Tropical sprue is an acquired condition seldom reported in travelers from tropical countries including Thailand. Only one case report from Thailand was reported in 1969. CASE REPORT: The authors report two cases of American residents living in Thailand and Vietnam who had been suffering from chronic diarrhea, weight loss, being easily fatigued and nutritional deficiency and who dramatically responded after treatment for tropical sprue. However a relapsed episode was seen in one case and somewhat permanent damage was detected in another case. CONCLUSION: Tropical sprue is currently which a rare condition for which the diagnosis is obtained by clinical presentation, laboratory tests which show evidence of mal-absorption, endoscopic findings and clinical response to antimicrobial treatment.

Tropical malabsorption.

Malabsorption is an important clinical problem both in visitors to the tropics and in native residents of tropical countries. Infections of the small intestine are the most important cause of tropical malabsorption. Protozoal infections cause malabsorption in immunocompetent hosts, but do so more commonly in the setting of immune deficiency. Helminth infections occasionally cause malabsorption or protein-losing enteropathy. Intestinal tuberculosis, chronic pancreatitis and small-bowel bacterial overgrowth are important causes of tropical malabsorption. In recent years, inflammatory bowel disease and coeliac disease have become major causes of malabsorption in the tropics. Sporadic tropical sprue is still an important cause of malabsorption in adults and in children in South Asia. Investigations to exclude specific infective, immunological or inflammatory causes are important before considering tropical sprue as a diagnosis. This article briefly reviews the management of tropical sprue and presents an algorithm for its investigation and management.

Esprue tropical / Tropical sprue

El esprue tropical es un desorden crónico, que se caracteriza por anormalidades estructurales y funcionales del intestino delgado, que progresivamente origina diarrea crónica y deficiencias nutricionales, las cuales mejorar o curan con ácido fólico o tetraciclina. El mejor conocimiento de la historia natural de la enfermedad, indica que el evento inicial es la infección intestinal por las enterobacterias contaminantes del fecalismo ambiental, en algunos sujetos se produce la colonización persistente del intestino delgado, que parece responder a fenómenos de adherencia bacteriana, alteración de la barrera ácida (gástrica), etc. El exceso de bacterias secuestra o modifica las cobalaminas, también daña las microvellosidades, disminuyendo la absorción de folatos. Esto trae como consecuencia anemia megaloblástica y atrofia de las vellosidades que se traducen en malabsorción, diarrea crónica y déficit nutricional. En la actualidad, el reconocimiento de la patogénesis de la enfermedad, nos indica que no es exclusiva del trópico, lo que implicaría inclusive la posibilidad del cambio de nombre.

Tropical sprue is a chronic disorder characterized by structural and functional small intestine abnormalities, that originate chronic diarrhea and nutritional deficiencies which improves or cure with folic acid or tetracycline. The better knowledge of its natural history indicates that the initial event is intestinal infection caused by contaminant enterobacterias of fecal environment, in some subjects produce persistent colonization of the small intestine, that seems to respond to bacterial adhesion, acid barrier (gastric) disturbance, etc. The excess of bacteria kidnap or modifies the cobalamin, also hurts the microvillous, decreasing the absorption of folate. This results in megaloblastic anemia and villous atrophy which traduce in malabsorption, chronic diarrhea and nutritional deficit. The understanding of the phatogenesis of this disease indicates us that it is not exclusive of the tropics, implicating that it could be renamed.

Jejunal and ileal glucose-stimulated water and sodium absorption in tropical enteropathy: implications for oral rehydration therapy.

Intestinal glucose and water absorption in response to glucose has been studied in tropical enteropathy with a view to determine the optimum glucose concentration in oral rehydration solutions for use in the tropics. Maximum jejunal water and sodium absorption occurred from an 80-mM glucose-sodium chloride solution (-285.7 +/- 46.0 ml/30 cm/h and -31.8 +/- 3.8 mM/30 cm/h, respectively) during in vivo steady-state jejunal perfusion. At perfusate glucose concentrations greater than 250 mM, however, jejunal water and sodium secretion occurred. In the ileum, maximum glucose-stimulated water absorption (-91.1 +/- 27.1 ml/30 cm/h) was significantly less than in the jejunum. Glucose absorption demonstrated saturation kinetics in both the jejunum and ileum. The half-saturation concentration was higher in the jejunum (167 mM) compared to the ileum (28 mM). This study suggests that the optimal glucose concentration for oral rehydration solutions used in the tropics should be 80 mM, as lower and higher concentrations result in diminished jejunal water absorption.

Tropical sprue in travelers and expatriates living abroad.

Changes in the world political situation, the rapidity of transportation, and the availability of effective therapy have altered the pattern of sprue in persons going to the tropics. Gone, for the most part, are the days when expatriates liver for years in tropical areas, progressed on the full-blown pattern of debilitating disease when they acquired sprue, and then were never totally cured either by return home or by the then-available forms of therapy. Today, visitors to the tropics usually return home by jet aircraft within weeks or months after acquiring the disease, and thus they present just with manifestations of small bowel disease in the absence of nutritional deficiencies. In this circumstance, the differential diagnosis usually lies between sprue and giardiasis. Both of these disorders are caused by chronic contamination of the small bowel by enteric pathogens, and both can be cured by specific therapy directed at eradicating these organisms. In contrast to the situation in travelers, sprue among the indigenous population of the tropics remains largely unchanged: a chronic debilitating disorder that represents a significant contributory factor to the pathogenesis of morbidity and malnutrition in some areas.