Chronic pancreatitis is associated with a high prevalence of giardiasis

JJ LOPEZ, JA WRlGHT, RA HAMMER, A ERTAN. Chronic pancreatitis is associated with a high prevalence of giardiasis. Can J Gastroenterol 1992;6(2):73-76. ln a previous study, a significantly higher prevalence of giardiasis was found in patients with cystic fibrosis compared with. a control population (28.0 versus 6.3%, P<0.0006). In th.is study, the prevalence of giardiasis in an adult population with chronic pancreatitis was investigated. The test population consisted of 15 patients with alcoholic pancreatitis and 50 vol.unteers with hypertension or o rthopedic problems who were surveyed for Giardia lamblia by countcrimmunoclectrophoresis (ClE) in fecal samples. CIE results were positive in four of 15 patients (27%) with chronic pancreacitis and negative in all contro l subjects (P<0.001). It was concluded that patients with chronic pancreatitis, similar to patients with cystic fibrosis, h ave a previously unrecognized increased prevalence of giardiasis compared with a control population. It is important to investigate for G lamblia in any patient with pancreatic insufficiency whose diarrhea is difficult to control by dietary measures or pancreatic enzyme supplementation.

G IARDrA LAMBL/A LS A FLAGEL- lated cnceric protozoan which has been contracted in every part of the world and is an important cause of endem ic a nd epidemic diarrhea.The prevalence of G /.amblia ranges from 1 to 20% and va ries with socioeconomic level and age ( L ).In t he Un ited States, approximately 4% of the population harbour the o rganism, mak ing it the most prevalen t entcric parasite and the leading infectious agent identified in water-borne outbreaks of diarrhea.Between l 965 and 1984, 90 separate outbreaks affecting over 23,000 people were reported (2,3).
Patien ts wi th symptoma tic giardiasis often complai n of acute or chronic diarrhea, weight los~ and diffuse or cpigastric abdominal pain ( which often is exacerbated by caring and varyi ng degrees of malabsorprion symptoms) ( 4 ).T hese symptoms a rc simi lar to chose frequently encounte red in pati ents with ch ron ic pancreatitis (S); although an assoc iation between these two di~cases has been Sl1spccted (6), th ere has been no syscemar ic in vestigation of a potential association.In a recent study, an increased prevalence (>f giardias is was fo und in a group of patients with cystic fibrosis, all of whom had pancreatic exocri ne insufficiency (7).Subsequently, the authors proceeded to in vestigate the preva-atteints de pancrcacite c h ronique (27%), ct ncgatifs chez tous \cs sujets temoins (P<0,00 I ).On conclut quc !'augmentation de la prevalence de giardiasc par rapport au groupe tcmoin n'etaitjusque-la pas reconnuc chez lcs patients atteints de pancreatite chronique, comme chez !es patients porteurs de fibrose kystique.
11 est important de reche rch e r G lamblia c h cz tout insuffisanr pancreat iquc done \es d iarrhees restent rebellcs a Jes mesures <l'hygiene alimentaire ou a un apport complcmentairc d'enzymes pancrcatiques.lence of giardiasis in an adult population with chronic panc rcntitis and assess the effect of treatmem on their sympwms.

PATIENTS AND METHODS
Fifteen patients ( 13 male, two female) aged 33 to 7  All of the patients with chronic panc reatitis had steatorrhea and were receiving pancreatic enzyme supplementation.Nine of rhese patients had evidence of weight loss, diarrhea and postprandial abdominal pain for at least six months, anJ had failed to respond to conventional med1rnl management for chronic pancreatitis.In these raticnts, the degree of weight loss ranged from 4.5 to l I kg ( mean net lnss 7.4) and their diarrhea consisted of four to six bowel movements per day with production of fo ul-smelling stools.S udan Ill stain demonstrated fa t globules.
The control population consisted of 50 volunteers ( 42 male, eight female) aged 29 to 76 years (mean 48.9) from the same hospiLa l population as the study group.They were hcmg treated for uncomplicated hypcnem1on or orthopedic problems and had no evidence of alcoh olism, pancreatic disease or other medical illness discern1hlc by history and medical c ha rt review.All participants in the study were residents of Louisiana a nd had not traveled out -side the state during the past six months.They did nnt have any condit inns knmvn to predispose them to giardinsis, including hnmosexual11y, cystit: fihmsb or immunoglohulin deficiency S)ndwmes (7)(8)(9).Statistical analysis of the results was made using the Fisher-exact tc~t.P<0.05 was considered stat1st1cally signifk:int.

RESULTS
(] lamhlia wa~ detected 111 four of I 5 patients (27%) with well-documented chronic pancrcatit1s (Table I).None o f the control ,ubjccts had evidence of giardiasis by C IE.The higher rate of giardiasis 111 the panenb with chron1L pancreatitis was statist1call y s1gn 1ficant (P<0.00 1).The four pauents who tested posn I vc were among those who h,1d evidence nf weight loss, steatorrhea and pnstprand1al ahdom111al p,1111 (Table I); these four hnd wor,ening symptoms which cuuld not he cuntrollcd with 111crens111g pancreatic enzyme supplemenratinn, b1carhonate or hisrnm inc-2 receptor .intagonish.The patients with pos1uve results recel\•ed a one-week cour,e nf ant ihiotiL therapy for giardi,lSls (oral metronida:nlc 250 mg t hree times a day for seven day,) without change in any o cher med1ca-tirn1.Folhiwing treatment, they reported complete resolution 1lf their d ia rrhea and ,1hdom111al pain, ,md CIE retesting of their swob revealed dearmg of G lamhlw.

DISCUSSION
In the currl•nt stud), the pre\'alencc of giardiasis 111 ,in adult popuh1t11m wnh alcohol-induced chronic pancrl•atitiwas 27%.Although thl• stud) group sl:t• was small, the pre\'alence rate is similar w the 28% for giardia,is found in larger groups of patients wnh LYM IC hhros1s, all of whom had p,mLreatic exocrine insufficiency (7).Cnmhined consideration of the resu I ts from these two studies supports the hypmhcs1s that pancreatic exoc rine insufficiency may be a prcdispos111g condition tn 111cestinal colonization with G km1hlra and suggests pancreatic exocrine seL retion may have a role in host defense again,t G lamblia.The poss1h le mechanisms h) which pancreatic exoui nc insufficiency may predispose pmients to giardmsi, include deficiency of pancrc,111c enzymes, decreased pancreatic hicarhonare secret1nn and ahsencc of nonimmunological fauors wnh anrnnicrohial activi ty normally present in pancreatil juice.
G lamhlia, like some banena and other protozoa, has lcct in activity associated with its surface membrane which has a high spec1fic1ty for nglycosy l a nd 11-manno~yl residues ( I I, 12).This surface membrane lectin ac-ti\'1ty mediates giardi.1 1 ropho:01te adherence en intestinal epithelial cells with preference to those in the small intest111e.Trypsm rc1rnwe~ paras1re surface leccin and poss1h ly other surface Jeterminants 111volved with paras Ile attachment to entenKytes, and may abo mediate parnsire rclern,l.'from the guc 3 years ( mean 50.4)