gastrointestinal disorders by akram.ppt - mmc.gov.bd file/gastrointestinal disorders.pdf ·...

Gastrointestinal DisordersGastrointestinal Disorders

Prof. Md. Akram Hossain

12/24/2013 1Prof. Muhammad Akram Hossain,

Gastointestinal disorders

Spectrum of GIT

Gastroenteritis- syndrome with GITsymptoms i.e.nausea, vomitting, diarrhoea, discomfort

Diarrhoea-frequent and or fluid stool (small intestine)

Dysentery - Stool with blood pus accompaniedbyDysentery - Stool with blood pus accompaniedbypain, fever, abdominal cramps (L.intestine),inflammatory disorder of large intestine

Enterocolitis - Inflammation of mucosa of bothintestine

Food poisonning- infection associated withconsumption of contaminated food- Food associatedinfection



Prevalence of Diarrheal disease

One of the Top six causes of death in the World.

1 billion (100 crores) children under 5 yrs suffers every year of which 33 lakh dies.suffers every year of which 33 lakh dies.



Etiology

Bacterial cause

Viral cause

Protozoal cause

Fungal causeFungal cause



Bacterial Etiology

Sl no. Agent Comment

1. Shigella spp. Invasive

2. Salmonella Invasive

3. Vibrio cholerae watery



Bacterial Etiology…


4. Campylobacter jejuni

Invasivejejuni

5. ETEC

EPEC

EIEC

EHEC

EAgEC

Invasive



Bacterial Etiology…


7. Yersinia Enterocolitica

Invasive

8. Staph aureus Food poisoning

9. Bacilus cereus Food poisoning

10. Clostridium perfringens

Food poisoning



Viral Etiology…


1. Rota virus Commonest,

Watery, among childrenchildren

2. Norwalk virus

3. Calici virus

4. Adenovirus

5. Astrovirus12/24/2013 8

Prof. Muhammad Akram Hossain, Gastointestinal disorders

Protozoal Etiology…


1. E. histolytica Invasive

2. Giardia lamblia Non invasive2. Giardia lamblia Non invasive

3. Cryptosporidium parvum

Immunosuppressed

4. Balantidium coli Immunosuppressed



Etiology in Bangladesh ( 1996 -2001)

Agent All ages

N= 14,000

< 5 yrs

N= 8,000

V. Cholerae O1 20.00 % 12.1%

V. Cholerae O139 2.9% 0.6%V. Cholerae O139 2.9% 0.6%

Shigella spp.

dysentery 1

dysentery 2-10

flexneri

boydii

sonni

6.0%

0.3%

0.5%

3.5%

1.1%

0.6%

5.6%

0.4%

0.3%

3.2%

0.9%

0.8%



Etiology in Bangladesh ( 1996 -2001)..

Agent All ages

N= 14,000

< 5 yrs

N= 8,000

Rotavirus 23.7 % 37.9%

E. coli 34.9% 43.6%E. coli 34.9% 43.6%

ETEC

EPEC

EAgEC

EAdEC

12.7%

8.1%

6.9%

7.2%

14.4%

11.5%

9.4%

8.3%

Campylobacter 9.5% 11.0%

Salmonella 2.0% 1.6%12/24/2013 11

Prof. Muhammad Akram Hossain, Gastointestinal disorders


Agent All ages

N= 14,000

< 5 yrs

N= 8,000

E. histolytica 1.2 % 0.3%

Giardia lamblia 1.6% 0.8%Giardia lamblia 1.6% 0.8%

Cryptosporidium 0.7% 1.1%

No Pathogen 19.6% 17.5%

Mixed Pathogen 31.6% 36.0%



Etiology in Bangladesh ( 1996 -2001)

Agent All ages

N= 14,000

< 5 yrs

N= 8,000

E. coli 34.9% 43.6%

Rotavirus 23.7 % 37.9%

V. Cholerae O1 22.9 % 12.7%

Campylobacter 9.5% 11.0%

Shigella spp. 6.0% 5.6%

Salmonella 2.0% 1.6%


Mixed pathogen 31.6% 36.0%




Agent All ages

N= 14,000

< 5 yrs

N= 8,000

ETEC

EPEC

EAgEC

12.7%

8.1%

6.9%

14.4%

11.5%

9.4%EAgEC

EAdEC

6.9%

7.2%

9.4%

8.3%




Agent All ages

N= 14,000

< 5 yrs

N= 8,000

E. histolytica 1.2 % 0.3%

Giardia lamblia 1.6% 0.8%Giardia lamblia 1.6% 0.8%

Cryptosporidium 0.7% 1.1%


Mixed Pathogen 31.6% 36.0%



Mechanisms inovlved

Invasion of GITSalmonella, Shigella, Campylobacter,Escherichia coli, and Entamoeba histolytica.

Non invasiveNon invasiveToxin production

• Vibrio cholerae, ETEC

Decreased absorption• rotavirus, norwalk agent, giardia lamblia



Shigella endocytosed by M cells, escapes from M cell vacuole, spreadslaterally from cell to cell propelled by actin tails, replicates intra- andextracellularly, and invades adjacent cells from basolateral side.



After binding to cell receptorsbacteria taken in by endocytosisbut do not escape endosome..

Pathogenesis of Salmonella enteritidis



Salmonella Enetritidis



Mechanism of action of Cholera toxin

Cholera toxin

Binds with intestinal epithelial cells by B subunit

A subunitA subunit enters into cells & activatesenters into cells & activates adenyl cyclaseadenyl cyclase

Increases concentration ofIncreases concentration of cAMP cAMP within cellswithin cells

Hypersecretion of water & chloridesof water & chlorides and and inhibition of reabsorption inhibition of reabsorption of sodium.of sodium.

Intestinal lumen is distended with fluid & there is hypermotility Intestinal lumen is distended with fluid & there is hypermotility leading to profuse diarrhea.leading to profuse diarrhea.



Pathogenesis of rotavirus diarrhoea

Three mechanisms are involved� It infects the epithelial cells of the small intes tine and

multiplies in the tip of the villi resulting in de ath and desquamation. desquamation.

� There is reactive hyperplasia of the crypt cells. T hese two effect is responsible for decreased absorption of f luids and nutrients and increased secretion of fluids.

� A third mechanism is also involved – a viral protei n stimulates the nervous system of the intestine that causes

increased secretion. Regeneration of villi occurs in 1 week

time.12/24/2013 22

Prof. Muhammad Akram Hossain,


Pathogenesis of Protozoal diarrhoea

E. histolytica-

� By local invasion and inflammation

� Giardia lambliaGiardia lamblia

� By mechanical interference, cup like disc oftrophozoite adhere to the intestinal epithelial cells &thereby interfere with absorption



Principle: is based on demonstration of the CA by M/E and isolation &identification by standard bacteriological techniques and also byimmunological tests and some special tests.

•Steps:•Specimen : freshly passedStool or rectal swab

•M/E : Saline, Iodine, and Z-N preparation is helpful for Eh, Gl,Cryptosporidium& natureof diarrheaby PC,Mc, RBC.

Lab Dx of Diarrheal diseases

Cryptosporidium& natureof diarrheaby PC,Mc, RBC.•Isolation & identification (Culture): MA, SSA, TCBS,Campy BA depending on provisional diagnosis to be incubatedat370C aerobically for usual pathogens & at 420C microaerophilic forCampylobacter•Immunological test : Detection of rotaviral Ag, C.diffcile toxinfrom stool by LAT or other tests.•Special tests:for ETEC, EPEC, VTEC done in reference lab.



Enterotoxigenic E. Coli

Usually self-limited.

This is the most common cause of traveler’s diarrhea.

It is acquired from contaminated food source.It is acquired from contaminated food source.

It generally responds well to empiric self-treatment of rehydration, loperamide (Immodium), and amoxicillin, bactrim, or ciprofloxacin.



Salmonella

Gram negative bacteria.

Responsible for diseases such as acute enterocolitis, typhoid fever, paratyphoid fever, bacteremia, and focal infections such fever, bacteremia, and focal infections such as cholecystitis, miningitis, pneumonia, mycotic aortic aneurysms, and osteomyelitis.



Salmonella

Salmonella is acquired from contaminated food and water, but may also me transmitted by asymptomatic human carriers.carriers.

Foods commonly associated with infection include uncooked meats, poultry, eggs, and dairy products.



Salmonella

Unsanitary kitchen practicesare often the source of food contamination. One very common practice that leads to contamination is failure to adequately clean contamination is failure to adequately clean cutting boards, countertops and utensils.

Most strains of salmonella are resistant to freezing and some are resistant to heat.



Shigella

Usually spread by fecal-oral contamination associated with poor sanitation, inadequate water supply, contaminated food, crowed living conditions, and a fly-infested living conditions, and a fly-infested environment.

The incubation period is 36-72 hours.



Campylobacter

Short, comma-shaped, gram-negative rod.

May be more common than salmonella and shigella.

It is acquired from contaminated food and water and may be directly transmitted from a sick patient.



Campylobacter

Incubation is 2-4 days.

Symptoms include abdominal cramps, fever, and watery diarrhea. Occasionally the stools will contain blood and sometimes the stools will contain blood and sometimes it is due to colonic ulceration.



Campylobacter

Fetal infection may occur during the birthing process and is associated with systemic infection and severe complication.

Treatment includes hydration and Treatment includes hydration and antibiotics such as cipro, e-mycin, or doxycycline.



Yersinia Enterocolitica

Acquired by contaminated food, water, and person-to-person contact.

Symptoms are abdominal cramping, fever, diarrhea which may be bloody and lasts diarrhea which may be bloody and lasts from 1 to 3 weeks.



Yersinia Enterocolitica

This infection often mimics appendicitis as the pain will often localized in the right lower quadrant of the abdomen where it invades the mesenteric lymph nodes.mesenteric lymph nodes.

Postinfectious complications may occur and consist of arthritis, erythema nodosum, Reiter’s syndrome and ankylosing spondylitis.

Treatment consists of hydration and appropriate antibiotics.



Vibrio

Gram-negative rod.

Vibrio cholerae is found in fresh and salt-water and is responsible for the disease known as cholera. It is transmitted by known as cholera. It is transmitted by ingestion of contaminated water and the consumption of shellfish.



Vibrio

Vivrio parahaemolyticus is a common cause of acute gastroenteritis in countries where raw, undercooked, or improperly stored seafood is frequently consumed.stored seafood is frequently consumed.Vibrio vulnificus is particularly associated with the consumption of raw oysters.



VibrioSymptoms of vibrio infection consists of watery diarrhea, abdominal cramps, nausea, and vomiting.In the case of vibrio cholerae, the diarrhea is often profound with large volume loss up to one liter profound with large volume loss up to one liter and hour. This is commonly referred to as “rice water”.The cornerstone of therapy is rapid fluid and electrolyte replacement. Antibiotics such as doxycycline or Cipro may be effective.



Rotavirus and Norwalk Agent

Most common cause of acute gastroenteritis in pediatric patients.

It may also occur in adults during epidemics.epidemics.



Rotavirus and Norwalk Agent

It is acquired from contaminated food, water, and person-to-person.

Clinical features include abdominal cramps, watery diarrhea, and vomiting. Fever is watery diarrhea, and vomiting. Fever is rarely present.The disease lasts only a few days and hydration is the only therapy.



WHO Rehydaration Solution

Commercially available packets.

Consists of 3.5 gm sodium chloride, 1.5 gm potassium chloride, 2.5 gm of sodium bicarbonate, and 20mg of glucose which is bicarbonate, and 20mg of glucose which is mixed in 1 liter of purified water.



Alternative Oral RehydrationGather together a bottle, bowl, spoon, salt, sugar, and a lemon or an orange.Boil water and fill the bottle.In a bowl, pour in the bottle of water, 2 pinches of In a bowl, pour in the bottle of water, 2 pinches of salt, and handful of sugar, and juice from the orange. Stir well and then put in the bottle.Taste the solution and if it tastes too salty then throw it out and start over. It should taste like a teardrop.



Shigella

Symptoms include fever, abdominal cramps, and watery diarrhea but may progress to blood, mucus, and pus in the stools and associated with left-lower stools and associated with left-lower abdominal pain.Symptoms will usually resolve in one week.Treatment consists of rehydration and five days of either cipro, bactrim, or ampicillin.



Hernia

A hernia is an opening or tear in the muscles of the abdomen through which bowel protrudes.

Common locations include the navel Common locations include the navel (particularly in children), the inguinal area (more common in men), and femoral area (more common in women).



Hernia

Simple measures can be implement to treat the hernia. One can make a truss to wear over the hernia and proper lifting techniques will help prevent hernia.will help prevent hernia.

If a hernia becomes very painful and cannot be reduced by pushing in or if bowel function ceases and vomiting ensues, then seek immediate surgical help.



Hemorrhoids

Hemorrhoids, frequently called pyles, dilated veins in the rectal plexus that may be located internally within the rectal vault or externally protruding through the anus.or externally protruding through the anus.



Hemorrhoids

While most are associated with diet in the tropical regions where there is a lot of fiber consumed, this frequently is a problem due to heavy lifting and childbirth.to heavy lifting and childbirth.

Hemorrhoids are treated with steroid creams, hot sitz baths, increase fiber, stool softner, and sometimes surgery.



Heartburn

May be described as stomach pain, chest pain, “internal heat”, stomach acid, or belching.

Diet may play a role in acid production. Diet may play a role in acid production. Consumption of greasy food, heavily spiced food, coffee, tea, and alcohol.



Heartburn

Prolonged heartburn may be warning of an ulceration in the stomach or small bowel.

Treatment consists of minimizing consumption of foods and beverages that promote acid. Also, one foods and beverages that promote acid. Also, one should try to eat smaller meals more frequently as opposed to large meals.

Elevation of the head of the bed is beneficial but not doing it with pillows.



HeartburnMilk is not helpful as it was once believed.Drink lots of water with meals and between.If available, take antacids, but if not available find and aloe plant and chop up the leaves into small and aloe plant and chop up the leaves into small bits soaking them overnight. The next day, drink the bitter concoction.Don’t smoke.If dark tarry stools occur or there is blood in vomit, seek medical attention.



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