GASTROINTESTINAL INFECTIONS DEEPA BABIN TMC KOLLAM
GASTROINTESTINAL INFECTIONS Deepa Babin TMC,Kollam
Leading cause of illness and death among children in developing countries. Estimated 1.3 thousand million episodes and 4 m...
Gastroenteritis <ul><li>Gastroenteritis is a nonspecific term for various pathologic states of the gastrointestinal tract....
Types of GIT Infections and Their Symptoms <ul><li>Gastroenteritis / Food Poisoning  – syndrome characterized by GIT sympt...
Types of GIT Infections and Their Symptoms <ul><li>Enteric fever   – fever, headache, lethargy, shock, splenomegaly </li><...
Definition <ul><li>Defined as- Inflammation of the mucous membrane of both the stomach and intestine, usually causing  nau...
Cause of Gastroenteritis <ul><li>Infectious agents usually cause acute gastroenteritis.  </li></ul><ul><li>These agents ca...
Condition <ul><li>Increase in frequency, size or loosening of bowel movements. </li></ul><ul><li>Increase in the frequency...
Diarrhea <ul><li>Diarrhea is both a symptom and a sign. </li></ul><ul><li>Symptom : Typically considered as an increased f...
DEFINITIOINS <ul><ul><ul><li>Acute Diarrhoea </li></ul></ul></ul><ul><ul><ul><ul><li>sudden onset and lasts less than two ...
Mechanism   <ul><li>1) Osmotic load within the intestine resulting in retention of water within the lumen </li></ul><ul><l...
EVALUATION OF DIARRHEA <ul><li>Acute diarrhea – lasts longer than 3-4 days </li></ul><ul><li>Chronic diarrhea – lasts long...
ETIOLOGY <ul><li>Viral : 70-80% of infectious diarrhea in developed countries </li></ul><ul><li>Bacterial : 10-20% of infe...
Infectious diarrhea <ul><li>Acquired by  </li></ul><ul><ul><li>fecal-oral route via direct personal contact </li></ul></ul...
Bacterial <ul><li>Watery </li></ul><ul><ul><li>Enterotoxigenic -  </li></ul></ul><ul><ul><ul><li>Vibrio cholera  </li></ul...
Bacterial <ul><li>Bloody </li></ul><ul><ul><li>Invasive </li></ul></ul><ul><ul><ul><li>Campylobacter jejuni </li></ul></ul...
Viral <ul><li>Rotavirus -Children less than 2 years </li></ul><ul><ul><li>Most common cause of diarrhea in children all ov...
Parasitic <ul><li>Protozoa </li></ul><ul><ul><li>Giardia lamblia </li></ul></ul><ul><ul><li>Entamoeba histolytica </li></u...
Opportunistic pathogens <ul><li>Clostridium difficile </li></ul><ul><ul><li>Nosocomial pathogens in healthcare and long te...
In Immunocomromised Hosts <ul><li>Besides the common pathogens </li></ul><ul><ul><li>Giardia </li></ul></ul><ul><ul><li>Le...
Others <ul><li>Tropical sprue </li></ul><ul><ul><li>In those who live or travel to the tropics </li></ul></ul><ul><ul><li>...
Causes of   Dysentery <ul><li>Shigella </li></ul><ul><li>Enteroinvasive E. coli </li></ul><ul><li>Campylobacter jejeuni </...
History <ul><li>Is it truly diarrhea? </li></ul><ul><li>Duration- </li></ul><ul><ul><li>acute <3 weeks </li></ul></ul><ul>...
High Risk Groups <ul><li>Travelers- “traveler's diarrhea” commonly due to enterotoxigenic  Escherichia coli ,  Campylobact...
High Risk Groups <ul><li>2. Consumers of certain foods- Salmonella  or  Campylobacter  from chicken; </li></ul><ul><li>Ent...
RISK GROUPS <ul><li>3 .  Immunodeficient person </li></ul><ul><li>4. Daycare participants - Infections with  Shigella ,  G...
Pathogenisis <ul><li>Infectious agents cause diarrhoea in 3 different ways as follows: </li></ul><ul><ul><li>Mucosal adher...
Mucosal adherence <ul><li>Bacteria adhere to specific receptors on the mucosa, e.g. adhesions at the tip of the pili or fi...
Mucosa Invasion <ul><li>The bacteria penetrate into the intestinal mucosa, destroying the epithelial cells and causing dys...
Toxin Production- Enterotoxins <ul><li>Toxin produced by bacteria adhere to the intestinal epithelium, induce excessive fl...
TOXIN PRODUCTION- Cytotoxins <ul><li>- damage the intestinal mucosa and sometimes vascular endothelium, leads to bloody di...
Clinical Features <ul><li>Stools </li></ul><ul><ul><li>Loose </li></ul></ul><ul><ul><li>Blood stained </li></ul></ul><ul><...
HISTORY <ul><li>Age  </li></ul><ul><li>Diarrhea pattern  </li></ul><ul><li>Differentiating small bowel from large bowel  <...
Lab Diagnosis of GIT Infections <ul><li>Specimens- stool,rectal swab,duodenal aspirate </li></ul><ul><li>Specimens must be...
Lab diagnosis <ul><li>Culture- BA  /  MAC  / XLD / SS / TCBS / Selenite F broth </li></ul><ul><li>Antigen detection test <...
Other diagnosis <ul><li>** For unresolved diarrhoea: sigmoidoscopy, rectal biopsy and radiological studies to rule out oth...
Treatment <ul><li>Rehydration – oral vs. IV </li></ul><ul><li>Antiemetics </li></ul><ul><li>Antidiarrheals </li></ul><ul><...
Management <ul><li>Fluid therapy </li></ul><ul><ul><ul><li>Persons with moderate to severe diarrhea lose large amounts of ...
Why not treat everyone with bacterial diarrhea ? <ul><li>Some have no effective specific treatment </li></ul><ul><li>Treat...
Drug-induced diarrhea <ul><li>Accounts for 7% of all adverse drug effects. </li></ul><ul><li>Over 700 drugs have been impl...
Good nutrition and hygiene can prevent most diarrhea . <ul><li>  Thank You! </li></ul>
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Diarrhea clinical diagnosis

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Diarrhea clinical diagnosis

  1. 1. GASTROINTESTINAL INFECTIONS DEEPA BABIN TMC KOLLAM
  2. 2. GASTROINTESTINAL INFECTIONS Deepa Babin TMC,Kollam
  3. 3. Leading cause of illness and death among children in developing countries. Estimated 1.3 thousand million episodes and 4 million deaths occur each year in under-fives. Main cause of death from acute diarrhoea is dehydration. Others dysentery and undernutrition. Epidemiology
  4. 4. Gastroenteritis <ul><li>Gastroenteritis is a nonspecific term for various pathologic states of the gastrointestinal tract. </li></ul><ul><li>The primary manifestation is diarrhea, but it may be accompanied by nausea,vomiting,dysentry and abdominal pain. </li></ul><ul><li>A universal definition of diarrhea does not exist, although patients seem to have no difficulty defining their own situation. </li></ul>
  5. 5. Types of GIT Infections and Their Symptoms <ul><li>Gastroenteritis / Food Poisoning – syndrome characterized by GIT symptoms like nausea, vomiting, diarrhoea & abdominal discomfort </li></ul><ul><li>Diarrhea – Excess fluid in the intestinal lumen results in frequent, loose, watery stools. </li></ul><ul><li>Inflammatory diarrhea or dysentery – inflammation of the intestine with passage of frequent stools containing blood and pus; abdominal cramps and fever </li></ul>
  6. 6. Types of GIT Infections and Their Symptoms <ul><li>Enteric fever – fever, headache, lethargy, shock, splenomegaly </li></ul><ul><li>Stomach ulcers – stomach pain </li></ul><ul><li>Worm infestations – blockage of GI tract; malnutrition </li></ul>
  7. 7. Definition <ul><li>Defined as- Inflammation of the mucous membrane of both the stomach and intestine, usually causing nausea, vomiting, and diarrhea . </li></ul><ul><li>Acute gastroenteritis usually causes profuse watery diarrhea, often nausea and vomiting, but without localized findings. </li></ul><ul><li>Between cramps, the abdomen is completely relaxed. </li></ul>
  8. 8. Cause of Gastroenteritis <ul><li>Infectious agents usually cause acute gastroenteritis. </li></ul><ul><li>These agents cause diarrhea by adherence, mucosal invasion, enterotoxin production, and/or cytotoxin production. </li></ul><ul><li>These mechanisms result in increased fluid secretion and/or decreased absorption. </li></ul><ul><li>This produces an increased luminal fluid content that cannot be adequately reabsorbed, leading to dehydration and the loss of electrolytes and nutrients. </li></ul>
  9. 9. Condition <ul><li>Increase in frequency, size or loosening of bowel movements. </li></ul><ul><li>Increase in the frequency and fluid volume of the bowel movement. </li></ul><ul><li>Daily weight of stool is 100-250 grams (g) </li></ul><ul><li>Most patients with diarrhea will produce in excess of 250 g of stool a day </li></ul>
  10. 10. Diarrhea <ul><li>Diarrhea is both a symptom and a sign. </li></ul><ul><li>Symptom : Typically considered as an increased frequency or volume of stool (i.e., 3 or more liquid or semisolid stools daily for at least 2-3 consecutive days). </li></ul><ul><li>Sign : Diarrhea is formally defined as stool weight >200 g/24h </li></ul>
  11. 11. DEFINITIOINS <ul><ul><ul><li>Acute Diarrhoea </li></ul></ul></ul><ul><ul><ul><ul><li>sudden onset and lasts less than two weeks </li></ul></ul></ul></ul><ul><ul><ul><ul><li>90% are infectious in etiology </li></ul></ul></ul></ul><ul><ul><ul><ul><li>10% are caused by medications, toxin ingestions, and ischemia </li></ul></ul></ul></ul><ul><ul><ul><li>Chronic Diarrhoea </li></ul></ul></ul><ul><ul><ul><ul><li>Diarrhoea which lasts for more than 4 weeks </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Most of the causes are non-infectious </li></ul></ul></ul></ul><ul><ul><ul><li>Persistent Diarrhoea </li></ul></ul></ul><ul><ul><ul><li>-Diarrhoea lasting between 2 to 4 weeks </li></ul></ul></ul>
  12. 12. Mechanism <ul><li>1) Osmotic load within the intestine resulting in retention of water within the lumen </li></ul><ul><li>2) Excessive secretion of electrolytes and water into the intestinal lumen </li></ul><ul><li>3) Exudation of fluid and protein from the intestinal mucosa </li></ul><ul><li>4) Altered intestinal motility resulting in rapid transit through the colon </li></ul>
  13. 13. EVALUATION OF DIARRHEA <ul><li>Acute diarrhea – lasts longer than 3-4 days </li></ul><ul><li>Chronic diarrhea – lasts longer than 2 weeks </li></ul><ul><li>The approach to patients with acute or chronic diarrhea is very much the same </li></ul><ul><li>It is not always possible to identify one particular mechanism to account for diarrhea in a given patient </li></ul>
  14. 14. ETIOLOGY <ul><li>Viral : 70-80% of infectious diarrhea in developed countries </li></ul><ul><li>Bacterial : 10-20% of infectious diarrhea but responsible for most cases of severe diarrhea </li></ul><ul><li>Protozoan : less than 10% </li></ul>
  15. 15. Infectious diarrhea <ul><li>Acquired by </li></ul><ul><ul><li>fecal-oral route via direct personal contact </li></ul></ul><ul><ul><li>ingestion of food or water contaminated with pathogens from human or animal feces </li></ul></ul><ul><li>Mostly feco-oral route </li></ul><ul><li>Bacterial </li></ul><ul><li>Viral </li></ul><ul><li>Parasitic </li></ul>
  16. 16. Bacterial <ul><li>Watery </li></ul><ul><ul><li>Enterotoxigenic - </li></ul></ul><ul><ul><ul><li>Vibrio cholera </li></ul></ul></ul><ul><ul><ul><li>Enterotoxigenic E.coli </li></ul></ul></ul><ul><ul><li>Food borne toxins- </li></ul></ul><ul><ul><ul><li>Bacillus cereus </li></ul></ul></ul><ul><ul><ul><li>Clostridium perfringens </li></ul></ul></ul>
  17. 17. Bacterial <ul><li>Bloody </li></ul><ul><ul><li>Invasive </li></ul></ul><ul><ul><ul><li>Campylobacter jejuni </li></ul></ul></ul><ul><ul><li>Destructive </li></ul></ul><ul><ul><ul><li>Shigella </li></ul></ul></ul><ul><ul><ul><li>Enteropathogenic E.coli </li></ul></ul></ul><ul><ul><ul><li>Clostridium difficile </li></ul></ul></ul>
  18. 18. Viral <ul><li>Rotavirus -Children less than 2 years </li></ul><ul><ul><li>Most common cause of diarrhea in children all over the world (*Infantile diarrhea) </li></ul></ul><ul><li>Pentavalent rotavirus vaccine It combines (DPT), hepatitis B and (HIB). </li></ul><ul><li>Norwalk- Older children and adults </li></ul><ul><ul><ul><li>These viruses injure the small intestinal mucosa .Watery diarrhea </li></ul></ul></ul><ul><li>Adenovirus </li></ul><ul><li>Astrovirus </li></ul><ul><li>CMV -Immunocompromised </li></ul><ul><li>Hepatitis A </li></ul><ul><ul><li>Calicivirus </li></ul></ul>
  19. 19. Parasitic <ul><li>Protozoa </li></ul><ul><ul><li>Giardia lamblia </li></ul></ul><ul><ul><li>Entamoeba histolytica </li></ul></ul><ul><ul><li>Cryptosporidium </li></ul></ul><ul><ul><li>Cyclospora </li></ul></ul><ul><ul><li>Balantidium coli </li></ul></ul><ul><li>Helminths </li></ul><ul><ul><li>Ascaris lumbricoides </li></ul></ul><ul><ul><li>Ancylostoma </li></ul></ul><ul><ul><li>Strongyloides stercoralis </li></ul></ul><ul><ul><li>Trichinella spiralis </li></ul></ul><ul><ul><li>Capillaria philippensis </li></ul></ul><ul><ul><li>Schictosomiasis </li></ul></ul><ul><ul><li>Taenia </li></ul></ul>
  20. 20. Opportunistic pathogens <ul><li>Clostridium difficile </li></ul><ul><ul><li>Nosocomial pathogens in healthcare and long term care facility </li></ul></ul><ul><ul><li>Poor handwashing </li></ul></ul><ul><ul><li>Clindamycin, Cephalosporins, Ampicillin </li></ul></ul><ul><ul><li>Exotoxin mediated </li></ul></ul>
  21. 21. In Immunocomromised Hosts <ul><li>Besides the common pathogens </li></ul><ul><ul><li>Giardia </li></ul></ul><ul><ul><li>Legionella </li></ul></ul><ul><ul><li>Candida albicans </li></ul></ul><ul><ul><li>Cryptosporidium species </li></ul></ul><ul><ul><li>Mycobacterium avium-intralcellulare </li></ul></ul><ul><ul><li>CMV </li></ul></ul>
  22. 22. Others <ul><li>Tropical sprue </li></ul><ul><ul><li>In those who live or travel to the tropics </li></ul></ul><ul><ul><li>Overgrowth of predominantly coliform bacteria in the small intestine </li></ul></ul><ul><li>Whipple’s Disease </li></ul><ul><ul><li>Infection by Tropheryma whippelii </li></ul></ul><ul><ul><li>HLA B27 </li></ul></ul>
  23. 23. Causes of Dysentery <ul><li>Shigella </li></ul><ul><li>Enteroinvasive E. coli </li></ul><ul><li>Campylobacter jejeuni </li></ul><ul><li>Salmonella enterica </li></ul><ul><li>Vibrio parahemolyticus </li></ul><ul><li>Entamoeba histolytica </li></ul>
  24. 24. History <ul><li>Is it truly diarrhea? </li></ul><ul><li>Duration- </li></ul><ul><ul><li>acute <3 weeks </li></ul></ul><ul><ul><li>Chronic >4 weeks </li></ul></ul><ul><li>Texture </li></ul><ul><li>Frequency </li></ul><ul><li>Blood? </li></ul>
  25. 25. High Risk Groups <ul><li>Travelers- “traveler's diarrhea” commonly due to enterotoxigenic Escherichia coli , Campylobacter , Shigella , and Salmonella, Giardia, Cyclospora. </li></ul>
  26. 26. High Risk Groups <ul><li>2. Consumers of certain foods- Salmonella or Campylobacter from chicken; </li></ul><ul><li>Enterohemorrhagic Escherichia coli (O157:H7) from undercooked hamburger </li></ul><ul><li>Bacillus cereus from fried rice </li></ul><ul><li>S. aureus from mayonnaise or creams </li></ul><ul><li>Salmonella from eggs </li></ul><ul><li>Vibro species, acute hepatitis A or B from (raw) seafood </li></ul>
  27. 27. RISK GROUPS <ul><li>3 . Immunodeficient person </li></ul><ul><li>4. Daycare participants - Infections with Shigella , Giardia , Cryptosporidium , Rotavirus </li></ul><ul><li>5. Institutionalized person- Clostridium difficile . </li></ul>
  28. 28. Pathogenisis <ul><li>Infectious agents cause diarrhoea in 3 different ways as follows: </li></ul><ul><ul><li>Mucosal adherence </li></ul></ul><ul><ul><li>Mucosa Invasion </li></ul></ul><ul><ul><li>Toxin Production </li></ul></ul>
  29. 29. Mucosal adherence <ul><li>Bacteria adhere to specific receptors on the mucosa, e.g. adhesions at the tip of the pili or fimbriae </li></ul><ul><li>Mode of action: effacement of intestinal mucosa causing lesions, produce secretory diarrhoea as a result of adherence </li></ul><ul><li>Causing moderate watery diarrhoea </li></ul><ul><li>e.g. Enteropathogenic E.coli </li></ul>
  30. 30. Mucosa Invasion <ul><li>The bacteria penetrate into the intestinal mucosa, destroying the epithelial cells and causing dysentery </li></ul><ul><li>e.g. Shigella spp. </li></ul><ul><li>Enteroinvasive E.coli </li></ul><ul><li>Campylobacter spp </li></ul>
  31. 31. Toxin Production- Enterotoxins <ul><li>Toxin produced by bacteria adhere to the intestinal epithelium, induce excessive fluid secretion into the bowel lumen, results in watery diarrhoea without physically damaging the mucosa. </li></ul><ul><li>Some enterotoxin preformed in the food can cause vomiting </li></ul><ul><li>e.g Staph.aureus (enterotoxin B) </li></ul><ul><li>Bacillus cereus </li></ul><ul><li>Vibrio cholerae </li></ul>
  32. 32. TOXIN PRODUCTION- Cytotoxins <ul><li>- damage the intestinal mucosa and sometimes vascular endothelium, leads to bloody diarrhoea with inflammatory cells, decreased absorptive ability. </li></ul><ul><li>e.g. Salmonella spp. </li></ul><ul><li> Campylobacter spp. </li></ul><ul><li>Enterohaemorrhagic E.coli 0157 </li></ul>
  33. 33. Clinical Features <ul><li>Stools </li></ul><ul><ul><li>Loose </li></ul></ul><ul><ul><li>Blood stained </li></ul></ul><ul><ul><li>Offensive smell </li></ul></ul><ul><ul><li>Steatorrhea (floating, oily, difficult to flush) </li></ul></ul><ul><li>Sudden onset of bowel frequency </li></ul><ul><li>Crampy abdominal pain </li></ul><ul><li>Urgency </li></ul><ul><li>Fever </li></ul><ul><li>Loss of appetite </li></ul><ul><li>Loss of weight </li></ul>
  34. 34. HISTORY <ul><li>Age </li></ul><ul><li>Diarrhea pattern </li></ul><ul><li>Differentiating small bowel from large bowel </li></ul><ul><li>Stool characteristics </li></ul><ul><li>Diurnal variation </li></ul><ul><li>Weight Loss </li></ul><ul><li>Medication and dietary intakes </li></ul><ul><li>Recent travel to undeveloped areas </li></ul>
  35. 35. Lab Diagnosis of GIT Infections <ul><li>Specimens- stool,rectal swab,duodenal aspirate </li></ul><ul><li>Specimens must be delivered to lab within 1 hr </li></ul><ul><li>Delay of > 2 hr anticipated use transport medium (Cary-Blair TM) </li></ul><ul><li>Rectal swab in Stuart’s transport or viral TM stored in refrigerated if delay > 2 hrs </li></ul><ul><li>Direct wet mount -Ova & parasites, Fecal leukocytes </li></ul><ul><li>Gram stain –Campylobacter, Vibrio </li></ul><ul><li>Modified Acid fast –Cryptosporidium, Isospora </li></ul><ul><li>Trichrome stain-Parasites </li></ul>
  36. 36. Lab diagnosis <ul><li>Culture- BA / MAC / XLD / SS / TCBS / Selenite F broth </li></ul><ul><li>Antigen detection test </li></ul><ul><li>Fluorescent antibody stain </li></ul><ul><li>ELISA </li></ul><ul><li>Isolation of pathogens in stool samples must be notified to public health authority </li></ul>
  37. 37. Other diagnosis <ul><li>** For unresolved diarrhoea: sigmoidoscopy, rectal biopsy and radiological studies to rule out other organic causes </li></ul>
  38. 38. Treatment <ul><li>Rehydration – oral vs. IV </li></ul><ul><li>Antiemetics </li></ul><ul><li>Antidiarrheals </li></ul><ul><ul><li>Decrease intestinal motility </li></ul></ul><ul><ul><li>Diphenoxylate, loperamide, codeine </li></ul></ul><ul><li>+/- Antibiotics ? </li></ul><ul><ul><li>Shigella, Yersinia, campylobacter, cholera, C.difficile, giardia </li></ul></ul>
  39. 39. Management <ul><li>Fluid therapy </li></ul><ul><ul><ul><li>Persons with moderate to severe diarrhea lose large amounts of Na, CL, K, HCO3 & H20 </li></ul></ul></ul><ul><ul><li>ORS </li></ul></ul><ul><ul><li>IV Fluids </li></ul></ul>
  40. 40. Why not treat everyone with bacterial diarrhea ? <ul><li>Some have no effective specific treatment </li></ul><ul><li>Treatment may not change disease duration or severity </li></ul><ul><li>Treatment may predispose to carrier state </li></ul><ul><li>Treatment may produce complications (HUS, antibiotic resistance, C. difficle, toxic megacolon) </li></ul>
  41. 41. Drug-induced diarrhea <ul><li>Accounts for 7% of all adverse drug effects. </li></ul><ul><li>Over 700 drugs have been implicated. </li></ul><ul><li>Unexplained onset of diarrhea that occurs with the administration of any antibiotic eg: Clindamycin (Pseudomembrane colitis) </li></ul><ul><li>Due to disruption of normal intestinal flora, which leads to either proliferation of pathogenic microorganisms or impairment of the metabolic functions of the microflora </li></ul>
  42. 42. Good nutrition and hygiene can prevent most diarrhea . <ul><li> Thank You! </li></ul>

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