Persisting symptoms and duodenal inflammation related to Giardia duodenalis infection.

OBJECTIVES: After a large waterborne outbreak of Giardia infection in Bergen, some patients experienced persisting abdominal symptoms despite metronidazole treatment. This study aimed at investigating possible causes for their symptoms.

METHODS: Over a 15 month period, 124 referred patients were evaluated in a prospective cohort analysis with a standardised investigation including duodenal biopsies and aspirate, blood tests and faecal parasite and calprotectin tests. Recovered subjects were recruited for symptom analysis.

RESULTS: Persisting Giardia duodenalis infection was found in 40 patients (32.3%). Duodenal biopsies showed signs of inflammation in 57 patients (47.1%). Microscopic duodenal inflammation was present in 34 (87.2%) of the Giardia positive and 23 (28.0%) of the Giardia negative patients. There were significant associations between persistent Giardia positivity, microscopic duodenal inflammation and a positive calprotectin test. Duodenal aspirate and duodenal biopsies performed poorly in diagnosis of persistent giardiasis.

CONCLUSIONS: In patients with persisting symptoms after metronidazole treated Giardia infection we commonly found chronic Giardia infection and microscopic duodenal inflammation, especially in illness duration less than 7 months. Both these findings subsided over time. Increasingly, investigations could not determine a definite cause for the persistent symptoms. The very long-term post-giardiasis diarrhoea, bloating, nausea and abdominal pain documented here need further study.