ROLE OF GIARDIASIS IN CHRONIC RECURRENT ABDOMINAL PAIN IN SCHOOL CHILDREN IN DAKAHLIA GOVERNORATE

ROLE OF GIARDIASIS IN CHRONIC RECURRENT ABDOMINAL PAIN IN SCHOOL CHILDREN IN DAKAHLIA GOVERNORATE

By

Raed Hamed Mansour, Ahmed Abdel-Shafi Mohamed

and Magdy Zaki  El-Ghannam*

Departments of Tropical Medicine and Clinical Pathology*, AL-Azhar Faculty of Medicine

ABSTRACT

Background: Chronic and recurrent abdominal pain is a common symptom in children with prevalence ranging between 10% and 20%.  Community and school based studies reported that recurrent abdominal pain occurred in 7% to 25% of school-aged children and was severe enough to affect activities in 21 % of them. Chronic abdominal pain includes organic and nonorganic causes. Among organic causes is Giardia Lamblia which is the most important protozoan causing recurrent abdominal pain.

Objective: Detection ofthe frequency of giardiasis in school children in Dakahlia Governorate with chronic recurrent abdominal pain using routine stools analysis and stools ELISA test for giardia antigen .

Patients and methods: The present study was carried out on 200 school children ( primary, preparatory and secondary schools), aged 7-18 years, from Dakahlia Governorate during  the period from February 2016 to October 2016. School children chosen complained from chronic abdominal pain and one or more of the cumulative symptoms that support giardiasis like diarrhea, inefficient defecation ,vomiting, ,weight loss and generalized fatigue.

Each child enrolled in the study was submitted thorough clinical examination, blood sample for complete blood count , and stool sample for microscopic stool analysis, and ELISA test for detection of giardia antigen.

Anthropometric measurements (Height, weight and determination of nutritional status) were detected.

Results : Routine stool analysis showed giardia cysts  in 50%of the examined  stool samples . ELISA detected the giardia antigen in 90% of the examined stool samples.  Regarding validity of stool analysis in relation to Giardia antigen by ELISA ,the sensitivity and specificity was  55.5% and 100% respectively  . The stool analysis agreed with ELISA antigen detection for giardiasis by 60%.

Conclusion: Giardia Lamblia infection is a causative factor of the recurrent abdominal pain in children. Also, ELISA test for detection of Giardia Lamblia antigen in stool is more sensitive than ordinary stool microscopical examination for diagnosis of giardiasis.

INTRODUCTION

    Giardia lamblia (G. lamblia) is a cosmopolitan parasite with a worldwide distribution, and the most common protozoon isolated from gastrointestinal tract (Fort , 2009  and Freitas, 2012 ).

    Giardia alternates between two different forms: a hardy, dormant cyst that contaminates water or food, and an active disease causing form called trophozoite that emerges after the parasite is ingested (Langeland, 2014).

     It is a parasite of the small intestine occurring endemically in certain areas and one of the causes of waterborne outbreaks. The parasite is commonly found in children in developing countries and travelers to endemic regions. It causes infections varying from asymptomatic to protracted and severe illness (Hanevik & Dizar, 2009 and Hawrelak, 2013).

      The clinical aspects of giardiasis are largely nonspecific, the most common symptoms are diarrhea, abdominal pain, bloating, flatulence and weight loss resulting from malabsorption (Berger  2007 and Giacometti 2013). These symptoms may overlap those of patients with other gastrointestinal disorders (Caccio and Ryan, 2008). Irritable bowel syndrome (IBS) is a diagnosis of exclusion. The Rome criteria specify three months of abdominal discomfort, unrelated to a physiological or biological cause, which can be associated with bloating ,constipation, diarrhea or mucous. These symptoms also overlap with many other gastrointestinal illnesses, such as inflammatory bowel disease, lactose intolerance, gastrointestinal cancers and parasitic diseases including giardiasiswhich also can become chronic (Rogers, 2014).

       By definition, patients with IBS do not have a physiological cause for their illness, but some studies have shown that a significant number of patients who have been given the diagnosis of IBS proved to have infection with G. lamblia (Devanarayana, 2008). Further evidence for a possible relation between parasitic infections and IBS is that treatment with metronidazole which is an anti-parasitic medication has been shown to decrease symptoms of IBS (Gieteling, 2007 and Bankston, 2013 ).  Other authors have described a syndrome of post-infectious IBS (PI-IBS) due to either bacterial or parasitic etiologies (Graham 2014). Giardiasis is potentially successfully managed using nutritional interventions which should be considered the first-line approach due to the increased risk of drug side effects and the possible emergence of drug resistance (Taylor, 2014).

     The aim of the present study was to detect the frequency of giardiasis in school children in Dakahlia Governorate with chronic recurrent abdominal pain using routine stools analysis and stools ELISA test for giardia antigen.

PATIENTS AND METHODS

    The present study was carried out on 200 school children of both sexes from primary, preparatory and secondary schools, aged 7-18 years, from Dakahlia Governorate during the period from February 2016 to October 2016.

Inclusion criteria :

1. Age: 7-18 years.

2. School children subjected to this study having chronic abdominal pain or discomfort and one or more of the cumulative symptoms that support  Giardiasis: diarrhea, inefficient defeca-tion, nausea, anorexia, vomiting, weight loss and generalized fatigue.

Exclusion criteria :

1. Age: < 7 or >18 years old.

2. Acute abdominal pain (medical or surgical).

3. Children with urinary symptoms as dysuria and frequency or urgency.

4. There was an exclusion of  the so-called 'alarm  indicators', signs suggesting that severe organic disease as progres-sive severe symptoms, persistent diarrhea, bleeding, persistent vomiting or significant weight loss (loss of >10% of weight through 3 months).

5. History of drug intake in the last 10 days especially non-steroidal anti-inflammatory drugs, antibiotics like ampicillin and its derivatives.

6. Children with any evident chronic disease known to be associated with abdominal pain, e.g. diabetes mellitus, sickle cell anemia, T.B., etc.

Each child enrolled in the study was submitted to the following:

1.Questionnaire after verbal consent (form appended).

2. Thorough clinical examination.

3. Blood sample for complete blood count.

4. Stool sample for:

- Microscopic stool analysis for consis-tency, color, odor, presence of food particles, blood, mucous, ova and parasit.

- ELISA test for detection of giardia antigen.

5. Anthropometric measurements: Height, weight and determination of nutritional status.

Statistical Analysis: Data were analyzed with statistical package SPSS version 16 (statistics Package for the Social Sciences).  Qualitative data were descri-bed using number and percent. Associa-tion between categorical variables was tested using Chi-square test. Data were considered significant when p<0.05.

RESULTS

    This study included 200 school children 99 males (49.5%) and 101 females (50.5%) complaining from chronic abdo-minal pain. Their ages ranged from 7 to18 years (mean 11.85±4.0). Their weight ranged from 20 to 61 kg (mean 47.56±12.02). Their height ranged from 110 to 167 cm mean) 143.08±17.15). Their BMI ranged from 17.44-24.78 (mean 22.24±2.78) (Table 1).

Table (1): General characteristics data of the studied group.

      The majority of the examined cases (80%) had abdominal pain less than 6 months in duration and the majority of them (65%) complained from abdominal distension (Table 2).

Table (2): Gastro-intestinal manifesta-tions among the studied group.

     Among the 200 school children the mean level of hemoglobin was (10.37± 1.03) Regarding routine stool examination we found that routine stool analysis detected giardia cysts in (50%) of the examined samples ( Table 3).

Table (3): Blood picture  and Stool analysis findings among the studied group.

    ELISA detected giardia antigen in (90%) of the examined stool samples (Table 4).

Table (4): Detection of Giardia antigen by ELISA among the studied group.

     As regard the validity of routine stool analysis in relation to Giardia antigen by ELISA we found that the sensitivity, specificity and agreement was (55.5%, 100% and 60%) respectively (Table 5).

Table (5) Validity of stool analysis in relation to Giardia antigen by ELISA.

     As regard Characteristics of abdominal pain among the studied group we found that the majority of ELIZA positive cases (94.4%) had periumblical pain and (44.4%) of them had severe abdominal pain (Table 6).

Table (6): Characteristics of abdominal pain among the studied group 

The majority of the ELISA positive cases (69.4%) had abdominal distension and only 25% of the ELISA negative cases had abdominal distension and the majority of the  ELISA positive children (72.2%) were with normal nutritional status, 16.7% were wasted, and 11.11% were stunted, while none of the ELISA negative patients were stunted or wasted (Table 7).

Table (7): The prevalence of distension  and nutritional status among the studied group

     Out of the 200  school children exami-ned we found that the majority of ELISA positive patients (55.5%) were from 7 to 12 years, while 44.5% were from 13-18 years. All of the ELISA negative patients were from 13-18 years , Female sex was more common among ELISA positive patients (52.2%). 

     Hemoglobin level among the examined cases showed that the majority of the ELISA positive patients (71.1%) had HB level less than 10g\dl.(Table 8).

Table (8) Age groups, gender distribution  and  HB level among the studied cases

DISCUSSION

     Chronic and recurrent abdominal pain are common symptoms in children with prevalence ranging between 10% and 20%. It accounted for 7% to 25% among school aged children, and sometimes it was severe enough to affect activity in 21 % of them. It constitutes a serious diagnostic and therapeutic problem in childhood (Wyllie, 2008). Chronic or recurrent abdominal pain (RAP) are due to organic and nonorganic (functional) causes. Among the organic causes, protozoal infections mainly giardia lamblia are being reported as the most common cause accounted for about 33% (Memon et aI., 2009).

    There are many methods for diagnosis of giardiasis. Among these are microscopic stool examination, microscopic examination of duodenal or jejunal fluid aspirate, small bowel biopsy, and detection of giardia antigen in stool by ELISA or PCR (Nash,  2014)  . ELISA is a new immunologic test which is capable of detecting small quantities of fecal parasitic antigens, even in mild infections. This antigen is present in the cysts and trophozoites of Giardia lamblia and is very specific to this parasite. ELISA is a simple, sensitive and specific test that can be applied in epidemiological studies for detection of Giardia lamblia coproantigen (Strand et al., 2008 ).

     The sensitivity of ELISA for detection of giardia antigen varies from 85 to 98 % and its specificity ranges from90 to 100 % (Mayer, 2013).The female sex were more frequent among the ELISA positive cases (52.2%), and this was not uncommon as girls are probably affected by recurrent abdominal pain more often than boys (Murray, 2013).

     The majority of ELISA positive cases (55.5%) were from 7 to 12 years. This may be due to that this age is the age of school entry and acquiring infection is so easy due to overcrowdness, sharing a common bathrooms, and may eat or drink contaminated water or foods with bad hygiene that will predispose to transmission of infection (Ford  2007).

     72.2% of the ELISA positive cases were with normal nutritional status,16.7% were wasted, and 11.11% were stunted , while no one was wasted or stunted among ELISA negative cases . This is likely because of the relation between giardia lamblia infection and anthropometric indicators of malnutrition among school children , significantly associated with low height for age (stunting) and low weight for height (wasting) (Nematian et al., 2008) .

     The majority of ELISA positive cases showed that71.1% have Hb level less than 10 g/dl which may be due to parasitic infestation especially giardia lamblia, may interfere with iron absorption among the infected cases(Marz, 2012). Routine stool analysis detected giardia cysts in 50% of the examined samples while ELISA test detected giardia lamblia antigen in 90% of the examined samples.This was expected because the recurrent abdominal pain is caused by protozoal infections mainly giardia lamblia (Posserud,  2011).

     As regard the sensitivity and specificity of  routine stool analysis for giardia in relation to stool ELISA for giardia antigen among cases, we found that; the routine stool analysis sensitivity was (55.5%) and specificity was (100%) . (Memon et aI., 2009). From these results, single stool analysis was not reliable for detection of giardia infection because it has false negative results. This was due to  erratic excretion of the parasite in the stool (Prins, 2012). On the other hand, stool analysis agreed with ELISA antigen detection for giardiasis by60%. This was because ELISA test was capable of detecting small quantities of fecal parasite antigens even in mild infection (Smith, 2013).

CONCLUSIONS

1. Recurrent abdominal pain appeared to be a common problem among school aged children.

2. Giardia Lamblia infection was a causa-tive factor of the recurrent abdominal pain in children.

3. ELISA test for detection of Giardia Lamblia antigen in stool was more sensitive than ordinary stool microsco-pical examination for diagnosis of giardiasis.

4. Single stool analysis has a large negative results and can not exclude giardiasis.

RECOMMENDATIONS

1. In every child complaining of recurrent abdominal pain, parasitic infections and mainly the Giardia Lamblia should be put on the top of differential diagnosis.

2. Use of ELISA detection of Giardia antigen in stool for diagnosis of Giardiasis because it is safe, easy, sensitive, reliable, accurate, and non invasive.

3. Single stool analysis should not be used for diagnosis of giardiasis except in epidemiological situations.

REFERENCES

1. Bankston, L.F (2013): Diagnosing the patient with abdominal pain and altered bowel habits: is it irritable bowel syndrome? Am. Fam. Physician., 67(10): 2157–2162.

2. Caccio SM and Ryan U (2008): Molecular epidemiology of giardiasis. Mol Biochem. Parasitol, 160(2):75-80

3. Devanarayana NM, Harendra DJ and Janaka H (2008): Recurrent abdominal pain syndrome in a cohort of Sri LanKan Children and Adolescent. Journal of Tropical Pediatrics, 54(3):178-183.

4. Ford B (2007): Antony Van Leeuwenhoek microscope and the discovery of Giardia in: Microscopy and Analysis; 21(4)5-7.

5. Fort, G.G and Mikolich DJ (2009): Giardiasis. In: Ferri, F. F. Clinical Advisor. 3^rded. Philadelphia, P.A: Mosby, An. Imprint. of Elsevier, 3(2):355-358.

6. Freitas,(2012): In vitro effects of propolis on Giardia duodenalis trophozoites. Phytomedi-cine., 2)13(:170-175.

7. Giacometti A.C. (2013): Irritable bowel syndrome in patients with Blastocystis hominis infection. Eur. J. Clin. Microbiol. Infect. Dis, 18 (6): 436–439.

8. Graham, D. Y. (2014): Evolution of concepts regarding Helicobacter pylori: From a cause of gastritis to a public health problem. Am. J. Gastroenterol., 89(4): 469-472.

9. Hawrelak, J.L (2013): Giardiasis: pathophysiology and management. Altern. Med. Rev, 8(2):129-142.

10. Hanevik, K and Dizdar, V (2009): Development of functional gastrointestinal disorders after Giardia lamblia infection B.M.C. Gastroenterol., 9: 27-30.

11. Langeland N.K. (2014): Development of functional gastrointestinal disorders after Giardia lamblia infection B.M.C. Gastro-enterol, 9(2):22- 27.

12. Marz, R. B. (2012): Medical Nutrition from Marz. Portland, OR: J.Med, 2(3):9-13.

13. Mayer, E. A. (2013): Clinical practice. Irritable bowel syndrome. N. Engl. J. Med., 358 (16): 1692–1699.

14. Memon LA, LAL MN, Murtaza G, Jamal A (2009): Recurrent Abdominal Pain in Children, 25(1):111-114.

15. Murray, M. (2013): Encyclopedia of nutritional supplements. Rocklin, CA: Prima Publishing, 2(4)320-323.

16. Nash, T. E. (2014): Mechanisms of Giardia lamblia differentiation into cysts. Microbiol. Mol. Biol. 1(5): 294–304.

17. Nematian J, Gholamrezanezhad A and  Nematian E (2008): Giardiasis and other intestinal parasitic infections in relation to anthropometric indicators of malnutrition: a large, population-based survey of school children in Tehran. Ann Trop Med Parasitol., 102(3) :209-14.

18. Posserud, L.P. (2011): Small intestinal bacterial overgrowth in patients with irritable bowel syndrome. Gut, 56 (6): 802–808.

19. Prins J.W. (2012): Chronic fatigue syndrome. Lancet, 2(9):346-355.

20. Rogers D.N. (2014): How Giardia swim and divide. Inject. Immun., 6(3):7866-7872.

21. Smith, H. (2013): Giardia and Cryptospori-dium join the neglected diseases initiative. Trends Parasitol, (2) 3: 203–208.

22. Taylor, D. N. (2014): Parasitic infections of the gastrointestinal tract. Gastroenterol .Clin. North, 3(2): 797-815.

23. Wyllie R (2008): Recurrent abdominal pain of childhood. In: Kliegman RM,Behrman BE, Jenson HB, Stanton BF. Nelson Textbook of Pediatrics.18^th ed. Philadelphia, PA: Saunders, An imprint of Elsevier INC.; vol. 4, chapter 339,5(2):1627-1628.