TARLAC STATE UNIVERSITY COLLEGE OF NURSING Lucinda Campus,Brgy. Ungot, Tarlac City Philippines 2300 Tel No.

: (045) 982-6062 Fax: (045) 982-0110 website: www.tsu.edu.ph

A Case Study on Amoebiasis

In Partial Fulfillment of the Requirements of the Subject Nursing Care Management 103 RLE

Presented to the Faculty Of the Tarlac State University College of Nursing Presented by: BSN III - C Group C4 Querido, Richen T. Raiz, Jayscent F. Rodriguez II, Rolando D. Sabat, Aprillyn A. Santos, Marivic C. Santos, Willa Milafrosa M. Sotelo, Jeffrey R. Suarez, Christine Karen A. Sumang, Jerico B. Sumaoang, Maria Luisa S. Date Submitted: June 13, 2010

INTRODUCTION Amoebiasis is a protozoal infection of bowel in the human beings. It initially involves the colon, characterized by diarrhea, but may spread to soft tissues, most commonly to the liver or lungs, by contiguity or hematogenous or lymphatic dissemination. It is caused by the amoeba Entamoeba histolytica that is prevalent in unsanitary areas, common in warm climate, and acquired by swallowing. It is an intestinal infection that may or may not be symptomatic and can be present in an infected person for several years. When symptoms are present it is generally known as invasive amoebiasis and occurs in two major forms. Invasion of the intestinal lining causes "amoebic dysentery" or "amoebic colitis". If the parasite reaches the bloodstream it can spread through the body, most frequently ending up in the liver where it causes "amoebic liver abscesses". When no symptoms are present, the infected individual is still a carrier, able to spread the parasite to others through poor hygienic practices. While symptoms at onset can be similar to bacillary dysentery, amoebiasis is not bacteriological in origin and treatments differ, although both infections can be prevented by good sanitary practices. Amoebiasis is characterized by abdominal pain with an urge to go to the bathroom frequently and fever and diarrhea which frequently accompanied with blood and/or mucous discharge. But sometimes diarrhea alternates with bouts of constipation, with one occurring for several days, followed by the other. It is estimated n that amoebiasis, accounts annually for 40,000 to 110,000 deaths in the world per year. Prevalence rates vary from as low as 2 per cent to 60 per cent or more in areas devoid of sanitation .Symptoms, when present, can range from mild diarrhea to dysentery with blood and mucus in the stool. The disease can be passed from one person to another through fecal-oral transmission but it can also be transmitted through direct contact, through sexual contact by orogenital, oroanal, and proctogenital sexual activity. And through indirect contact, the disease can infect humans by ingestion of food especially uncooked leafy vegetables or foods contaminated with fecal materials containing E. histolytica cysts.

Objectives General: The objective of our case study is to develop and acquire understanding, skills, and knowledge about the disease, and health promotion to prevent further complication on the condition of the patient. Specific: Nurse Centered To assess the patients overall health status . To impart necessary health teachings to the patients significant others. To perform appropriate nursing care in conjunction with the condition of the patient To be more familiarized with the nurses roles in caring the patient and to educate patients significant others regarding the pts condition. To widen and enhance the student nurses knowledge and skills through additional research about the nature of the disease, its signs and symptoms, its pathophysiology, its diagnosis and treatment. Patient Centered To know when to seek help from the health care providers whenever the signs and symptoms may appear. To understand the occurrence of Amoebiasis. To know what other complications may arise, if left untreated. To gather information about the therapeutic regimen

Reasons in choosing the Case Study Our group chose this case study to gain more additional knowledge about the disease. The group wants to know more about the disease, its treatment, and the proper nursing management for patients with this kind of disease. The case will help the group in dealing with patient with this condition. Promotion of health, prevention of diseases and illnesses, rehabilitation and restoration of good health are important in doing the case. In the accomplishment of case study, the group will be able to know and develop more fully our skills in assessment, planning, nursing care plans, implementation/interventions and evaluation for this particular chosen condition. Importance of the Study
The case study is primarily important because it enhances the students skills, knowledge and attitude on the practice of the nursing process. It provides broader comprehension about the condition chosen through research and actual observation as it serves as a training ground and practice in developing learned skills in the assessment and management of Amoebiasis.

Through this case study, a holistic approach in assessing patients health will be delivered, where it can be immediately attended to and given proper interventions. It serves as a way to familiarize the students with the different medical approaches toward the ongoing curative phase. This study serves as a tool for future upcoming nursing students of the school. To share to other student nursing colleagues to understand the dynamics of Amoebiasis as to the book based management and actual clinical interventions. Furthermore, this study may be used as a spring board for a more advanced and in-depth study that is in accordance to changing and developing society.

ASSESSMENT I.PERSONAL DATA A.Demographic Data Name of the patient: Age: Sex: Civil status : Occupation: Religious Affiliation: Role position in the Family: Address: Date of Birth: Place of birth: Nationality: Health Care Financing: Chief Complaint: Admitting diagnosis: Revised diagnosis: Pt. AO 2 y/o Female Single None Roman Carholic Daughter 965 Luzon St. Tondo Manila October 01,2008 Tondo Manila Filipino Philhealth Vomiting AcuteGastroenteritis with some Dehydration Amoebiasis with some signs of Dehydraiton

B. Lifestyle According to the mother the client sleeps at around 11 oclock in the evening and wakes up up to 12 oclock in the morning. She spends most of his time watching television and playing with her peer neighbor with her toys with Bahay bahayan. Her favorite foods are meat and fish.During snack time she eats biscuits.

C. Environment Their house is made up of wood and located near the road. It has 2 rooms with a small sala and kitchen. It is a congested place.Their sources of water for washing , taking a bath, laundry and drinking water from NAWASA. The toilet is located near the barangay hall wherein everybody can use it.Their source of transportation from city to their house are jeeps , tricycle and pedicabs. The family source of income is that the father is a pedicab driver. Their house is near a canal called estero .It is a squatters area.

HISTORY OF PAST HEALTH ILLNESS According to the mother the patient never been hospitalized. Her immunization were completed. During fever and colds they buy over the counter medicines at their barangay botika because it is cheaper. HISTORY OF PRESENT ILLNESS Three days prior to admission the patien only drunk her milk and she suffer stonmache after that. The next day she has already diarrhea (+)vomiting (+)fever of 39C and 20 times bowel movement.Weak looking and pale. She has already (+) sunken eyes and dry lips. Prior to admission as described as 20 times bowel movement as mucoid, watery,non-foul smelling and vomiting was also noted approximately 15 times and there was also loss of appetite she brought to San Lazaru Hospital for proper and appropriate management and she confine.

ANATOMY AND PHYSIOLOGY An overview of the Digestive System

Digestion is the breaking down of food in the body, into a form that can be absorbed. It is also the process by which the body breaks down food into smaller components that can be absorbed by the blood stream. In mammals, preparation for digestion begins with the cephalic phase in which saliva is produced in the mouth and digestive enzymes are produced in the stomach. Mechanical and chemical digestion begins in the mouth where food is chewed, and mixed with saliva to break down starches. The stomach continues to break food down mechanically and chemically through the churning of the stomach and mixing with enzymes. Absorption occurs in the stomach and gastrointestinal tract, and the process finishes with excretion. Digestion is usually divided into mechanical processing to reduce the size of food particles and chemical action to further reduce the size of particles and prepare them for absorption. In most vertebrates, digestion is a multi-stage process in the digestive system, following ingestion of the raw materials, most often other organisms. The process of ingestion usually involves some type of mechanical and chemical processing. Digestion is separated into four separate processes: 1. Ingestion: The first activity of the digestive system is to take in food through the mouth. This process has to take place before anything else can happen. 2. Mechanical Digestion: The large pieces of food that are ingested have to be broken into smaller particles that can be acted upon by various enzymes. This is

3.

4.

5. 6.

mechanical digestion, which begins in the mouth with chewing or mastication and continues with churning and mixing actions in the stomach. Chemical Digestion: The complex molecules of carbohydrates, proteins, and fats are transformed by chemical digestion into smaller molecules that can be absorbed and utilized by the cells. Chemical digestion, through a process called hydrolysis, uses water and digestive enzymes to break down the complex molecules. Digestive enzymes speed up the hydrolysis process, which is otherwise very slow. Movements: After ingestion and mastication, the food particles move from the mouth into the pharynx, then into the esophagus. This movement is deglutition, or swallowing. Mixing movements occur in the stomach as a result of smooth muscle contraction. These repetitive contractions usually occur in small segments of the digestive tract and mix the food particles with enzymes and other fluids. The movements that propel the food particles through the digestive tract are called peristalsis. These are rhythmic waves of contractions that move the food particles through the various regions in which mechanical and chemical digestion takes place. Absorption: movement of nutrients from the digestive system to the circulatory and lymphatic capillaries through osmosis, active transport, and diffusion Elimination: The food molecules that cannot be digested or absorbed need to be eliminated from the body. The removal of indigestible wastes through the anus, in the form of feces, is defecation or elimination

Underlying the process is muscle movement throughout the system, swallowing and peristalsis.

Human digestion process Phases of Gastric Secretion

Cephalic phase - This phase occurs before food enters the stomach and involves preparation of the body for eating and digestion. Sight and thought stimulate the cerebral cortex. Taste and smell stimulus is sent to the hypothalamus and medulla oblongata. After this it is routed through the vagus nerve and release of acetylcholine. Gastric secretion at this phase rises to 40% of maximum rate. Acidity in the stomach is not buffered by food at this point and thus acts to inhibit parietal (secretes acid) and G cell (secretes gastrin) activity via D cell secretion of somatostatin. Gastric phase - This phase takes 3 to 4 hours. It is stimulated by distention of the stomach, presence of food in stomach and increase in pH. Distention activates long and myentric reflexes. This activates the release of acetylcholine which stimulates the release of more gastric juices. As protein enters the stomach, it binds to hydrogen ions, which raises the pH of the stomach to around pH 6. Inhibition of gastrin and HCl secretion is lifted. This triggers G cells to release

gastrin, which in turn stimulates parietal cells to secrete HCl. HCl release is also triggered by acetylcholine and histamine. Intestinal phase - This phase has 2 parts, the excitatory and the inhibitory. Partially-digested food fills the duodenum. This triggers intestinal gastrin to be released. Enterogastric reflex inhibits vagal nuclei, activating sympathetic fibers causing the pyloric sphincter to tighten to prevent more food from entering, and inhibits local reflexes.

The digestive system includes the digestive tract and its accessory organs, which process food into molecules that can be absorbed and utilized by the cells of the body. Food is broken down, bit by bit, until the molecules are small enough to be absorbed and the waste products are eliminated. The digestive tract, also called the alimentary canal or gastrointestinal (GI) tract, consists of a long continuous tube that extends from the mouth to the anus. It includes the mouth, pharynx, esophagus, stomach, small intestine, and large intestine. The tongue and teeth are accessory structures located in the mouth. The salivary glands, liver, gallbladder, and pancreas are major accessory organs that have a role in digestion. These organs secrete fluids into the digestive tract Digestion begins in the oral cavity where food is chewed. Saliva is secreted in large amounts (1-1.5 litre/day) by three pairs of exocrine salivary glands (parotid, submandibular, and sublingual) in the oral cavity, and is mixed with the chewed food by the tongue. There are two types of saliva. One is a thin, watery secretion, and its purpose is to wet the food. The other is a thick, mucous secretion, and it acts as a lubricant and causes food particles to stick together and form a bolus. The saliva serves to clean the oral cavity and moisten the food, and contains digestive enzymes such as salivary amylase, which aids in the chemical breakdown of polysaccharides such as starch into disaccharides such as maltose. It also contains mucin, a glycoprotein which helps soften the food into a bolus. the tongue which tastes and manipulates the food Swallowing transports the chewed food into the esophagus, passing through the oropharynx and hypopharynx. The mechanism for swallowing is coordinated by the swallowing center in the medulla oblongata and pons. The reflex is initiated by touch receptors in the pharynx as the bolus of food is pushed to the back of the mouth. Pharynx, leads to both the trachea and the esophagus. The Esophagus, a narrow, muscular tube about 25 centimeters (11 inches) long, starts at the pharynx, passes through the larynx and diaphragm, and ends at the cardiac orifice of the stomach. The wall of the Esophagus is made up of two layers of smooth muscles, which form a continuous layer from the Esophagus to the oten and contract slowly, over long periods of time. The inner layer of muscles is arranged circularly in a series of descending rings, while the outer layer is arranged longitudinally. At the top of the Esophagus, is a flap of tissue called the epiglottis that closes during swallowing to prevent food from entering the trachea (windpipe) while. The uvula blocks off the nose. The chewed food is pushed down the Esophagus to the stomach through peristaltic contraction of these muscles. It takes only seconds for food to pass through the Esophagus, and little digestion actually takes place.

The stomach is a pear shaped pouch and it is also described as a thick walled elastic bag. The food enters the stomach after passing through the cardiac orifice. In the stomach, food is further broken apart, and thoroughly mixed with gastric acid and digestive enzymes that break down proteins. The acid itself does not break down food molecules; rather, the acid provides an optimum pH for the reaction of the enzyme pepsin. The parietal cells of the stomach also secrete a glycoprotein called intrinsic factor which enables the absorption of vitamin B-12. Other small molecules such as alcohol are absorbed in the stomach as well by passing through the membrane of the stomach and entering the circulatory system directly. The form of the food in the stomach is in semiliquid form. The transverse section of the alimentary canal reveals four distinct and well developed layers called serosa, muscular coat, submucosa and mucosa. Serosa: It is the outermost thin layer of single cells called mesothelial cells. Muscular coat: It is very well developed for churning of food. It has outer longitudinal, middle smooth and inner oblique muscles. Submucosa: It has connective tissue containing lymph vessels, blood vessels and nerves. Mucosa: It contains large folds filled with connective tissue. The gastric glands have a packing of lamina propria. Gastric glands may be simple or branched tubular secreting mucus, hydrochloric acid, pepsinogen and renin. The cardiac sphincter which closes off the top end of the stomach and the pyloric sphincter, which closes off the bottom. Small intestine which has a length of about 6 m. The surface of the small intestine is wrinkled and convoluted to produce a greater surface area for absorption. the sections of the small intestine include the duodenum, jejunum, ileum. After being processed in the stomach, food is passed to the small intestine via the Pyloric sphincter. The majority of digestion and absorption occurs here as chyme enters the duodenum. Here it is further mixed with three different liquids: 1. bile, which emulsifies fats to allow absorption, neutralizes the chyme, and is used to excrete waste products such as bilin and bile acids (which has other uses as well). It is not an enzyme, however. The bile juice is stored in a small organ called the gall bladder. 2. pancreatic juice made by the pancreas. 3. intestinal enzymes of the alkaline mucosal membranes. The enzymes include: maltase, lactase and sucrase, to process sugars; trypsin and chymotrypsin are also added in the small intestine. Most nutrient absorption takes place in the small intestine. As the acid level changes in the small intestines, more enzymes are activated to split apart the molecular structure of the various nutrients so they may be absorbed into the circulatory or lymphatic systems. Nutrients pass through the small intestine's wall, which contains small, fingerlike structures called villi, each of which is covered with even smaller hair-like structures called microvilli. The blood, which has absorbed nutrients, is carried away from the small intestine via the hepatic portal vein and goes to the liver for filtering, removal of toxins, and nutrient processing.

The small intestine and remainder of the digestive tract undergoes peristalsis to transport food from the stomach to the rectum and allow food to be mixed with the digestive juices and absorbed. The circular muscles and longitudinal muscles are antagonistic muscles, with one contracting as the other relaxes. When the circular muscles contract, the lumen becomes narrower and longer and the food is squeezed and pushed forward. When the longitudinal muscles contract, the circular muscles relax and the gut dilates to become wider and shorter to allow food to enter. In the stomach there is another phase that is called Mucus which promotes easy movement of food by wetting the food. It also nullifies the effect of HCl on the stomach by wetting the walls of the stomach as HCl has the capacity to digest the stomach. If the form of food in the stomach is semi-liquid form, the form of food in the small intestine is liquid form. It is in the small intestine where the digestion of food is completed. After the food has been passed through the small intestine, the food enters the large intestine. The large intestine is roughly 1.5 meters long, with three parts: the cecum at the junction with the small intestine, the colon, and the rectum. The colon it has four parts: the ascending colon, the transverse colon, the descending colon, and the sigmoid colon. The large intestine absorbs water from the bolus and stores feces until it can be egested. Food products that cannot go through the villi, such as cellulose (dietary fiber), are mixed with other waste products from the body and become hard and concentrated feces. The feces is stored in the rectum for a certain period and then the stored feces is egested due to the contraction and relaxation through the anus. The exit of this waste material is regulated by the anal sphincter. The large intestine functions to re-absorb (resorb) water and in the further absorption of nutrients. The bacterial flora of the large intestine includes such things as Escherichia coli, acidophilus spp., and other bacteria, as well as Candida yeast (a fungus). These bacteria produce methane (CH4), hydrogen sulfide (H2S), and other gases as they ferment their food. Occasionally, some of this gas is released as flatus. As these bacteria digest/ferment left-over food, they secrete beneficial chemicals such as vitamin K, biotin (a B vitamin), and some amino acids, and are our main source of some of these nutrients. The rectum is the terminal portion of the large intestine and functions for storage of the feces, the wastes of the digestive tract, until these are eliminated. The external opening at the end of the rectum is called the anus. The anus has two sphincters, one voluntary and one involuntary. The pressure of the feces on the involuntary sphincter causes the urge to defecate and the voluntary sphincter controls whether a person defecates or not. Carbohydrate digestion Carbohydrates are formed in growing plants and are found in grains, leafy vegetables, and other edible plant foods. The molecular structure of these plants is complex, or a polysaccharide; poly is a prefix meaning many. Plants form carbohydrate chains during growth by trapping carbon from the atmosphere, initially carbon dioxide (CO2). Carbon is stored within the plant along with water (H2O) to form a complex starch containing a combination of carbon-hydrogen-oxygen in a fixed ratio of 1:2:1

respectively. Plants with a high sugar content and table sugar represent a less complex structure and are called disaccharides, or two sugar molecules bonded. Once digestion of either of these forms of carbohydrates is complete, the result is a single sugar structure, a monosaccharide. These monosaccharide can be absorbed into the blood and used by individual cells to produce the energy compound adenosine triphosphate (ATP). The digestive system starts the process of breaking down polysaccharides in the mouth through the introduction of amylase, a digestive enzyme in saliva. The high acid content of the stomach inhibits the enzyme activity, so carbohydrate digestion is suspended in the stomach. Upon emptying into the small intestines, potential hydrogen (pH) changes dramatically from a strong acid to an alkaline content. The pancreas secretes bicarbonate to neutralize the acid from the stomach, and the mucus secreted in the tissue lining the intestines is alkaline which promotes digestive enzyme activity. Amylase is secreted by the pancreas into the small intestines and works with other enzymes to complete the breakdown of carbohydrate into a monosaccharide which is absorbed into the surrounding capillaries of the villi. Nutrients in the blood are transported to the liver via the hepatic portal circuit, or loop, where final carbohydrate digestion is accomplished in the liver. The liver accomplishes carbohydrate digestion in response to the hormones insulin and glucagon. As blood glucose levels increase following digestion of a meal, the pancreas secretes insulin causing the liver to transform glucose to glycogen, which is stored in the liver, adipose tissue, and in muscle cells, preventing hyperglycemia. A few hours following a meal, blood glucose will drop due to muscle activity, and the pancreas will now secrete glucagon which causes glycogen to be converted into glucose to prevent hypoglycemia. Note: In the discussion of digestion of carbohydrates; nouns ending in the suffix -ose usually indicate a sugar, such as lactose. Nouns ending in the suffix -ase indicates the enzyme that will break down the sugar, such as lactase. Enzymes usually begin with the substrate (substance) they are breaking down. For example: maltose, a disaccharide, is broken down by the enzyme maltase (by the process of hydrolysis), resulting in a two glucose molecules, a monosaccharide. Fat digestion The presence of fat in the small intestine produces hormones which stimulate the release of lipase from the pancreas and bile from the gallbladder. The lipase (activated by acid) breaks down the fat into monoglycerides and fatty acids. The bile emulsifies the fatty acids so they may be easily absorbed. Short- and medium chain fatty acids are absorbed directly into the blood via intestine capillaries and travel through the portal vein just as other absorbed nutrients do. However, long chain fatty acids are too large to be directly released into the tiny intestinal capillaries. Instead they are absorbed into the fatty walls of the intestine villi and reassembled again into triglycerides. The triglycerides are coated with cholesterol and protein (protein coat) into a compound called a chylomicron.

Within the villi, the chylomicron enters a lymphatic capillary called a lacteal, which merges into larger lymphatic vessels. It is transported via the lymphatic system and the thoracic duct up to a location near the heart (where the arteries and veins are larger). The thoracic duct empties the chylomicrons into the bloodstream via the left subclavian vein. At this point the chylomicrons can transport the triglycerides to where they are needed. Digestive hormones There are at least four hormones that aid and regulate the digestive system:

Gastrin - is in the stomach and stimulates the gastric glands to secrete pepsinogen(an inactive form of the enzyme pepsin) and hydrochloric acid. Secretion of gastrin is stimulated by food arriving in stomach. The secretion is inhibited by low pH . Secretin - is in the duodenum and signals the secretion of sodium bicarbonate in the pancreas and it stimulates the bile secretion in the liver. This hormone responds to the acidity of the chyme. Cholecystokinin (CCK) - is in the duodenum and stimulates the release of digestive enzymes in the pancreas and stimulates the emptying of bile in the gall bladder. This hormone is secreted in response to fat in chyme. Gastric inhibitory peptide (GIP) - is in the duodenum and decreases the stomach churning in turn slowing the emptying in the stomach. Another function is to induce insulin secretion.

Significance of pH in digestion Digestion is a complex process which is controlled by several factors. pH plays a crucial role in a normally functioning digestive tract. In the mouth, pharynx, and esophagus, pH is typically about 6.8, very weakly acidic. Saliva controls pH in this region of the digestive tract. Salivary amylase is contained in saliva and starts the breakdown of carbohydrates into monosaccharides. Most digestive enzymes are sensitive to pH and will not function in a low-pH environment like the stomach. Low pH (below 5) indicates a strong acid, while a high pH (above 8) indicates a strong base; the concentration of the acid or base, however, does also play a role. pH in the stomach is very acidic and inhibits the breakdown of carbohydrates while there. The strong acid content of the stomach provides two benefits, both serving to denature proteins for further digestion in the small intestines, as well as providing non-specific immunity, retarding or eliminating various pathogens. In the small intestines, the duodenum provides critical pH balancing to activate digestive enzymes. The liver secretes bile into the duodenum to neutralise the acidic conditions from the stomach. Also the pancreatic duct empties into the duodenum, adding bicarbonate to neutralize the acidic chyme, thus creating a neutral environment. The

mucosal tissue of the small intestines is alkaline, creating a pH of about 8.5, thus enabling absorption in a mild alkaline in the environment. COLON (LARGE INTESTINE) The colon is approximately 4.5 feet long, 2.5 inches wide, and is a muscular tube composed of lymphatic tissue, blood vessels, connective tissue, and specialized muscles for carrying out the tasks of water absorption and waste removal. The tough outer covering of the colon protects the inner layer of the colon with circular muscles for propelling waste out of the body in an action called peristalsis. Under the outer muscular layer is a sub-mucous coat containing the lymphatic tissue, blood vessels, and connective tissue. The innermost lining is highly moist and sensitive, and contains the villi- or tiny structures providing blood to the colon. The location of the parts of the colon is either in the abdominal cavity or behind it in the retroperitoneum. The colon in those areas is fixed in location. The colon is actually just another name for the large intestine. The shorter of the two intestinal groups, the large intestine, consists of parts with various responsibilities. The names of these parts are: the transverse colon, ascending colon, appendix, descending colon, sigmoid colon, and the rectum and anus. PARTS OF THE COLON

Several parts make up the continuous tube of the colon. Each part contributes to the movement of materials and the formation of stools. The parts include:

Illeocecal Valve: The illeocecal valve is a fold of mucus membrane at the entry way to the colon. It is located where the small intestine meets the colon. Materials from the small intestine pass into the colon through this valve. Vermiform Appendix: The appendix is attached to the bottom of the cecum. This is a twisted coiled tube that is about 3 inches long. The function of the appendix is not known. Cecum: It is located below the illeocecal valve at the base of the colon. The upper part of the cecum is open to the colon. The muscles of the cecum and the colon advance feces upward out of the cecum. Ascending Colon: The ascending colon is located on the right side of the abdomen above the cecum. Here, most of the water is absorbed from the feces as it moves upward through the ascending colon. The ascending colon ends at the hepatic flexure where the colon bends to the left and connects to the transverse colon. Transverse Colon: The transverse colon runs laterally across the abdomen below the belly button. As feces move across the transverse colon, stools begin to take form. The transverse colon ends at the splenic flexure where the colon bends again and connects to the descending colon which heads down the left side. Descending Colon: The descending colon runs down the left side of the abdomen. Stools move down the descending colon. Stools are now more solid in form. Here, stools may be stored for a time. The descending colon ends where it continues into the sigmoid colon. Sigmoid Colon: The sigmoid colon angles to the right, curving down and inward to about the midline, then it curves slightly upward where it connects to the top of rectum. Stools continue their descent as they move through sigmoid colon. Stools may also be stored here for a time before they are moved into the rectum. Rectum and Rectal Sac: The rectum is a passageway about 8 inches long that leads to the anus. The rectum is usually empty until mass peristalsis drives the stools into the rectum. When stools fill the rectum, the elastic qualities of the walls permit the rectum to expand, creating a sac to accommodate stools just prior to elimination. Anal Canal and Anus: The last inch of the rectum is called the anal canal. The mucus membrane of the canal has folds called anal columns that contain arteries and veins. The opening of the

anal canal to the exterior is called the anus. The anus is guarded by internal and external sphincters (muscles) that keep the anus closed except during elimination of a stool. The colon has no villi (multiple, minute projections of the intestinal mucous layer which serve to absorb fluids and nutrients) as compared to the small intestine and produces no digestive enzymes. It is like a tube of circular muscle lined with a layer of moist mucous cells that lubricate the contents. The smooth folds of the colon are speckled with glands that resemble skin pores. These glands extract the fluids and electrolytes from the passing food residue. Between 1/3 -1 liter of water (which is recycled and eventually filtered and excreted by the kidneys as urine), electrolytes, and some vitamins, are absorbed daily through the colon. If colon bacteria are normal, vitamins B-1, B-2, B-12 and K are produced by them, and all with the possible exception of B-12 are absorbed and used by the body traveling first to the liver via the portal circulation. Absorption and storing fecal material are the colon's two main functions. The colon does secrete mucus to help the digested food along and hold the fecal material together. It also plays a role in protecting the walls of the colon from bacterial activity and neutralizes some of the fecal acids. After processed matter from the small intestine enters the colon much absorption occurs in the cecum and ascending colon. Mixing movements called haustrations occur every few minutes and last about one minute apiece. They roll and mix the matter to expose most of it to the colons surface for absorption. Over 80% of the material reaching the colon is reabsorbed. There are no peristaltic waves in the colon but a few times daily (usually after meals) a segment of the colon usually eight inches long will constrict (usually in the transverse or descending colon) to force the fecal material along. Our Feces are usually 75% water, 7-8% dead bacteria, 2-7% fat, .5-10% protein, 5-10% roughage, byproducts, digestive juices, etc. Once the stool moves out of the sigmoid colon into the rectum, a parasympathetic reflex is set up and the brain gets the signal that nature is calling, and so we go. The external sphincter is under voluntary control and we can mentally overcome this reflex and prevent defecation if we desire to. Of all the vital organs in the body, the one that suffers the most abuse from modern dietary habits is the colon.

Large Intestine Microscopic Cross Section

Mucosal layer on the surface is made up simple columnar cells and a mucosal muscularis on the deep side . Submucosa contains fibrous connective tissue and blood vessels. The muscularis externa is made up of a circular and a longitudinal muscle layer with a myenteric plexus in between the layers. A very thin layer of Serosa is also present .

PROCESSING AND ACTIVITY OF THE COLON Aided by enzymes and muscular action, the mouth, stomach and small intestine perform their individuated jobs of breaking down and absorbing nutrients. The liquid that these organs generate is called chyme. However, when it passes to the colon, the liquid that is leftover is mostly waste matter. This liquid waste matter is called feces. It is passed to the colon for further processing and elimination. In the colon, instead of the enzymatic action that occurs in other organs of the G.I. tract, further breakdown of fecal matter and the production of substances occur by way of bacterial fermentation. Cellular exchanges, bacteria, and muscular actions all play a part in processing the feces as it passes through the colon: Fluid Absorption: The colon lining contains epithelial cells that absorb fluids and other substances such as vitamins and electrolytes. It is the absorption of fluids and bacterial processing that transforms the soupy fecal matter into a stool. Secretion of Mucus: The colon lining contains epithelial cells that secrete mucus. This mucus moisturizes and lubricates the colon lining. This lining protects the colon wall and nerve tissues.

Bacterial Growth: Bacteria live and grow along the colon lining. Using the fluids and foods you intake, bacteria actually manufacture the nutrients that sustain their environment and their food supply. Manufacture of Some Vitamins & Electrolytes: Bacteria change proteins into amino acids and break these amino acids down further into indole and skatole (which gives stools their odor), hydrogen sulfide, and fatty acids. Bacterial action also synthesizes some vitamins (K and some B), electrolytes, and breaks down bilirubin into a pigment that gives stools their brown color. Production of Lubrication: Bacteria ferment soluble fiber into a lubricating gel that is incorporated into the stool mass as it is formed. This gel helps to make stools soft and flexible. Some of this gel also coats the exterior of the stools and is used by the colon to moisturize the colon lining. This lubrication helps to ease stool passage through the colon. Defense against Infection: Healthy intestinal bacteria help to groom the colon and keep it clean so that infections do not develop. They also help to fight the growth of infectious bacteria. Stool Formation: To form stools, muscles in the colon churn the soupy liquid fecal matter as fluids are extracted until the particles have the consistency to form a stool.

CEPHALOCAUDAL ASSESSMENT (June 08, 2010) DATE 06-08-2010 AREA/REGION Head METHOD USED Inspection, palpation FINDINGS The patient has black, thin, shiny hair without infestation. Symmetrical and there is no signs of tenderness and lesions. No lesions and no signs of tenderness and symmetrical in shape There is no edema present. The skin is warm to touch and the capillary refill is 4 seconds and returns to original state slowly. NORMAL FINDINGS Black, thin, shiny hair without any infestations, lesions, and tenderness present. It should be symmetrical in shape, and no presence of masses. INTERPRETATION /ANALYSIS Normal.

Scalp

Inspection, palpation

There should be no signs of lesions, and tenderness in the area, and is symmetrical. No edema, redness and the skin is warm to touch. Capillary refill is less than 3 seconds and returns to its original state immediately.

Normal

Skin

Inspection, palpation

Abnormal. The capillary refill is 4 seconds and returns to original state slowly due to some signs of dehydration. Normal.

Eyes

Inspection, palpation

With clear sclera, The sclera should be clear eyes are in appearance, and the eyes symmetrical. The must be symmetrical.

patients conjunctiva Conjunctival sac should be is pink in color. No pink in color. There is no discharges noted. discharge present. Nose Inspection At the midline of the The nose should be at the face, and midline of the face, symmetrical. symmetrical, with patent airways. Normal

Mouth

Inspection

Dry lips, and The mouth should be Abnormal. The patient mucous membranes moist, has no lesions, and has dry lips and no infection, and no mucous membrane due swelling. to some signs of dehydration. Reacts when called, Reacts to noises being can hear whispered heard, should hear clearly words clearly. the words being said. The patient has no difficulty of breathing. Respiratory rate is 26 cpm, and the pulse rate is 120 bpm. Breath sounds are resonant, thorax is rounded, normal respiratory rate for children 20-30 cpm, normal pulse rate in children 90-120 bpm, no use of accessory muscles in breathing. Normal

Ears

Inspection

Chest, thorax and Inspection, lungs auscultation, palpation

Normal

Abdomen

Inspection,

Guarding behavior at No abdominal distention.

Abnormal. The pt. has

palpation

times noted. There is no presence of distention in the abdominal area.

been doing guarding behavior at times due to stomach ache.

Musculoskeletal Inspection and neurological statu

The pt. is alert, and No restriction in activities, Abnormal. The pt. is irritable at times. any weakness and alert. irritable at times due to uncomfortable environment.

Genitourinary

Inspection

The patient felt no pain when voiding. Urine output: 1 Soak Diaper during the shift (4pm-8pm). Bowel movement: 3x during the shift (4pm-8pm), with loose watery stool, yellowish in color in moderate amount. There is no presence of protein in the urine.

There should no pain felt when voiding. Protein is not evident in the urine. Normal urine output is 500-1,000cc/day based Book. on Potts or and equivalent to 20-25cc/hr Mandleco Pediatric Nsg.

Normal.

Lower Extremeties

Inspection, palpation

No presence of There should no edema, edema, and

Normal

tenderness on the tenderness, or swelling pts extremities. The present on the extremities. pts legs are symmetrical. The legs should be symmetrical.

ASSESSMENT SUBJECTIVE:

SCIENTIFIC EXPLANATION Infectious process

PLANNING Within 1hour of appropriate nursing interventions, the pt. will be able to replace fluid losses with the help of her significant others.

INTERVENTIO N INDEPENDENT: Monitor for the existence of factors causing deficient fluid volume (diarrhea).

RATIONALE

EXPECTED OUTCOME After 1hour of appropriate nursing interventions, the pt. was able to replace fluid losses with the help of her significant others as evidenced by: a. Increase oral fluid intake in a tolerable level. b. Eating foods to give sufficient nutrients in the body.

OBJECTIVE: Invades the lining of the intestines Bowel movement: Stimulation of the 3x with SNS/PNS and decrease loose watery water reabsorption stool, yellowish in Increase gastrocolic reflex color in Diarrhea results moderate ( Active fluid volume amount.>dry loss) lips & mucus membrane Fluid Volume Deficiency noted. delayed capillary refill noted (4 seconds) weak in appearance

Early identification of risk factors can decrease the occurrence and severity of complications of fluid volume Encourage the pts deficit. mother to increase the oral fluid To replace the intake of her child fluid loss in the as tolerated. pts body. Instruct the parents to give her child foods with complex carbohydrates such as potatoes, rice, bread, cereal, yogurt, fruits, and vegetables, especially the BRAT diet. To provide sufficient nutrients needed by her child.

To moisten the mucous membrane Provide and prevent injury

pale looking Decrease in urine output ( 1 soak diaper)

meticulous oral from dryness care (toothbrush and mouthwash). To check for an increase or Check voiding and decrease fluid record amount losses Promote a quiet To decrease environment and oxygen demand bed rest thereby resulting from weakness Regularly assess client for changes in conditions (e.g. mental status, fatigability, restlessness etc.) To assess for signs of dehydration and monitor progress of client.

Nursing Diagnosis: Fluid Volume Deficit related to active fluid volume loss ( diarrhea) secondary to infectious process

DEPENDENT >Administer IV For replacement of fluids as fluids and prescribed by the electrolytes physician.

ASSESSMENT SUBJECTIVE:

SCIENTIFIC EXPLANATION

PLANNING

INTERVENTION

RATIONALE

EXPECTED OUTCOME After 1hour of appropriate nursing interventions, the pt. was able to replace fluids and electrolyte losses through hydration and electrolyte supplement with the help of her significant others as evidenced by: a. increased in oral fluid intake and maintained electrolyte balance.

Release of enterotoxins by Within 1hour of invading microorganism appropriate OBJECTIVE: nursing Increase secretion of interventions, the water and electrolytes pt. will be able to Bowel replace fluids and moveme Inhibits the sodium electrolyte losses nt: 3x reabsorption through hydration with and electrolyte loose Large amount of CHON supplement with watery rich fluids the help of her stool, significant others. yellowis Diarrhea h in color in moderate amount. Hyperactive bowel sounds Abdominal cramps Nursing Diagnosis: Diarrhea related to invasion of the lining of the colon secondary to

INDEPENDENT: - Observe and To note for degree record amount, of fluid losses. characteristics and frequency of bowel movement. -To replace fluid - Increase oral losses due to fluid intake frequent bowel movement - Monitor intake - To assess for and output decrease in fluid volume resulting to dehydration - Assess for signs of dehydration. -To determine clients hydration status and determine DEPENDENT: dehydration. -Administer IV fluids as prescribed by the physician. -To replenish and establish hydration and maintain

infectious processes

-Administer electrolyte balance antiprotozoal medication as -Inhibits nucleic prescribed by the acid of the bacteria physician. there by eliminating spread of infection.

ASSESSMENT SUBJECTIVE: sumasakit po paminsan minsan ung tiyan ko PS of 6/10 OBJECTIVE: Recurrent abdominal pain Guarding behavior at times Slight facial grimace Weak and pale in appearance Irritable at times hyperactive bowel sounds Nursing Diagnosis: Acute pain r/t inflammatory responses.

SCIENTIFIC EXPLANATION Damage to the intestinal tissue Increase vascular permeability Vasodilation Swelling Edema Compression of nerve endings Pain Perception

PLANNING Within 30 minutes of appropriate nursing intervention the patients significant others will be able to report a decrease in pain perception of the patient through providing methods to alleviate pains.

INTERVENTION

RATIONALE

EXPECTED OUTCOME

After 30 minutes Establish rapport to To gain the trust of of appropriate nursing the patient. the patient intervention, the Place patient to a To provide patient was able to comfortable comfort for the report a decrease in pain perception position patient through providing to Encourage patient To promote methods alleviate pains as to have adequate relaxation as to evidence by period of rest. prevent fatigue decrease in pain scale from 6/10 to 5-10 Provide comfort To decrease pain measures (e.g. back through rub, proper stimulation of positioning etc.) release of endorphins

To assist in muscle Encourage deep and generalized breathing exercise relaxation

ASSESSMENT SUBJECTIVE: OBJECTIVE: Weight of 9kg Appears thin Weal and pale in appearance Decreased energy level Irritable at times

SCIENTIFIC EXPLANATION Chronic damaged of intestinal tissue Inflammatory response Compression of nerve endings Pain perception Narrowed focus Preoccupation to pain perceived Loss of appetite ( Anorexia) Imbalanced Nutrition less than body requirements

PLANNING After 1 hour of appropriate nursing intervention, the patient and significant others will be able to understand the need to eat a well balanced diet both in quality and quantity as to improved nutritional status through health teaching and demonstration.

INTERVENTION

RATIONALE

EXPECTED OUTCOME

Establish rapport to the patient and S.O.

Assess clients condition such as energy levels and feeling of body weakness

After 1 hour of To gain the trust of appropriate nursing intervention, the the patient patient and significant others was able to To determine understand the clients need to eat a well balanced diet both physiologic in quality and response to food quantity as to intake as with improved regards to quality nutritional status and quantity. through health teaching and demonstration.

Nursing Diagnosis: Imbalance nutrition less than body requirements related to loss of appetite due illness

Encourage to eat a well balanced meal and proper hydration by citing some health benefits that could build strong line of defense.

Balanced diet and adequate hydration are known to contribute to a good nutrition.

Encourage bed rest during acute phase of illness

Decrease metabolic needs aids in preventing caloric depletion and conserves energy Decrease metabolic needs aids in preventing caloric depletion and conserves energy To determine health knowledge of client that needs to be modified or to enhance regarding food management

Provide foods that are high in calories, proteins and carbohydrates

Give a health teaching on the importance of a balanced diet and adequate hydration that it helps in building strong immune system.

Administer To build strong vitamins and immune system supplements as per

doctors order

and body resistance to diseases

DRUGS

Name of Drugs

Date administered

Route of administration, dosage and frequency of administration

Genera action / Mechanism of Action

Indication / purpose

Clients response to Medication

Zinc Sulfate Syrup

June 5, 2010 2.5 ml, once a day

Bactericidal for a -is used to treat and variety of gram- to prevent zinc positive and gram- deficiency. negative organisms. It interferes with bacterial cell wall synthesis by inhibition of the regeneration of phospholipid receptors involved in peptidoglycan synthesis. Zinc is important for growth and for the development and health of body tissues.

The patients significant others understood the importance of medications needed by the patient.

Nursing Responsibility: - Check the doctors order Prepare the medication Identify the client Explain what medication to be give. Assist patient during drug administration After giving medication, assess patient for the adverse reaction of drugs Route of administration, dosage and frequency of administration 125mg/5ml 5ml ,three times a day

Name of Drugs

Date administered

Genera action / Mechanism of Action BactericidalInhibits synthesis in specific (obligate) anaerobes causing cell death; antiprotozoal trichomanicidal, amebicidal. Biochemical action not known.

Indication / purpose

Clients response to Medication

Metronidazole

June 5, 2010

Acute infection with susceptible bacteria. Acute instestinal amoebiasis Amebic liver abcess

The patients significant others understood the importance of medications needed by the patient.

Nursing Responsibility: -Monitor liver function test results carefully in elderly patients - Give oral forms with meals -Observe patient for edema, especially if taking corticosteroids; Flagyl IV may cause Sodium retention -Record number and character of stool Route of administration, dosage and frequency of administration 250mg/5ml 2ml q4 for temp of > 37.8 C

Name of Drugs

Date administered

Genera action / Mechanism of Action Decrease fever by a hypothalamic effect leading to sweating and vasodilation. Also inhibits the effect of pyrogens or the hypothalamic heat-regulating center. May causes analgesia by

Indication / purpose

Clients response to Medication

Paracetamol

June 5, 2010

For fever

The patients significant others understood the importance of medications needed by the patient.

inhibiting CNS prostaglandin synthesis, however due to minimal effects on peripheral prostaglandin synthesis acetaminophen has no inflammatory or uricosuric effect Nursing Responsibility: -Assess patients fever or pain: type of pain, location, intensity, duration, temperature. -Assess allergicreactions: rash,urticaria; if theseoccur, drug may have to bediscontinued -Assess for chronic poisoning: rapid, weak pulse, dyspnea: cold, clammy extremities.

Diagnostic and Laboratory Procedure Diagnostic/ Laboratory Procedures Fecalysis Date Ordered and Date results 06-05-2010 Indications and purposes Fecalysis is used to determined whether there is a presence of blood and parasites in the stool Result/s Normal Values (Units used in the hospital) Yellow-Brown formed Analysis and Interpretation of results The stool in color must be in yellow-brown and the pt. stool has presence of parasites.

Color-green Consistency- watery With parasites of Entamoeba histolitica cyst 0-2 tropozites 1-3 present

Nursing Responsibility: Before: Collect the specimen for the client and assist the client when assistance is needed. During: Specimen must be free from any contamination. After: Make sure that the specimen is labeled & the laboratory requisition carry the correct information & attached them securely to the specimen.

Diagnostic/ Laboratory Procedures Urinalysis

Date Ordered and Date results 06-05-2010

Indications and purposes Urinalysis is used to determined the color, transparency and if there is a presence of blood

Result/s Color-Yellow Transparency-hazy

Normal Values (Units used in the hospital) Yellow-amber Clear

Analysis and Interpretation of results The urine color must be in yellow amber the pt. urine is yellow and hazy

Nursing Responsibility: Before: Collect the specimen for the client and assist the client when assistance is needed. During: Specimen must be free from any contamination. After: Make sure that the specimen is labeled & the laboratory requisition carry the correct information & attached them securely to the specimen.

SUBJECTIVE

OBJECTIVE >Bowel movement: 3x with loose watery stool, yellowish in color in moderate amount.>dry lips & mucus membrane noted. >delayed capillary refill noted (4 seconds) >weak in appearance >pale looking >Decrease in urine output ( 1 soak diaper)

ANALYSIS Fluid Volume Deficit related to active fluid volume loss ( diarrhea) secondary to infectious process

PLANNING Within 1hour of appropriate nursing interventions, the pt. will be able to replace fluid losses with the help of her significant others.

INTERVENTION INDEPENDENT: Monitored for the existence of factors causing deficient fluid volume (diarrhea).

EVALUATION After 1hour of appropriate nursing interventions, the pt. was able to replace fluid losses with the help of her significant others as evidenced by: a. Increased oral fluid intake in a tolerable level. b. Eating foods to give sufficient nutrients in the body

Encouraged the pts mother to increase the oral fluid intake of her child as tolerated. Instructed the parents to give her child foods with complex carbohydrates such as potatoes, rice, bread, cereal, yogurt, fruits, and

vegetables, especially BRAT diet.

the

Provided meticulous oral care (toothbrush and mouthwash). Checked voiding and record amount Promoted a quiet environment and bed rest Regularly assessed client for changes in conditions (e.g. mental status, fatigability, restlessness etc.) DEPENDENT >Administered IV fluids as prescribed by the physician.

SUBJECTIVE

OBJECTIVE >Bowel movement: 3x with loose watery stool, yellowish in color in moderate amount. >Hyperactive bowel sounds >Abdominal cramps

ANALYSIS Diarrhea related to invasion of the lining of the colon secondary to infectious processes

PLANNING Within 1hour of appropriate nursing interventions, the pt. will be able to replace fluids and electrolyte losses through hydration and electrolyte supplement with the help of her significant others.

INTERVENTION INDEPENDENT: - Observed and recorded amount, characteristics and frequency of bowel movement. - Increased oral fluid intake of the patient as tolerated. - Monitored intake and output - Assessed for signs of dehydration.

EVALUATION After 1hour of appropriate nursing interventions, the pt. was able to replace fluids and electrolyte losses through hydration and electrolyte supplement with the help of her significant others as evidenced by: a. Increased in oral fluid intake and maintained electrolyte balance.

DEPENDENT:

-Administered IV fluids as prescribed by the physician. -Administered antiprotozoal medication as prescribed by the physician.

SUBJECTIVE

OBJECTIVE >Weight of 9kg >Appears thin >Weal and pale in appearance >Decreased energy level >Irritable at times

ANALYSIS Imbalance nutrition less than body requirements related to loss of appetite due illness

PLANNING Within 1 hour of appropriate nursing intervention, the patient and significant others will be able to understand the need to eat a well balanced diet both in quality and quantity as to improved nutritional status through health teaching and demonstration.

INTERVENTION

EVALUATION

Establish rapport to After 1 hour of the patient and S.O. appropriate nursing intervention, the Assess clients patient and condition such as significant others energy levels and was able to feeling of body understand the need weakness to eat a well balanced diet both quality and Encourage to eat a in as to well balanced meal quantity and proper improved status hydration by citing nutritional health some health through and benefits that could teaching build strong line of demonstration. defense. Encourage bed rest during acute phase

of illness Provide foods that are high in calories, proteins and carbohydrates Give a health teaching on the importance of a balanced diet and adequate hydration that it helps in building strong immune system. Administer vitamins and supplements as per doctors order

SUBJECTIVE sumasakit po paminsan minsan yung tiyan ko PS of 6/10

OBJECTIVE

ANALYSIS

PLANNING Within 30 minutes of appropriate nursing intervention the patients significant others will be able to report a decrease in pain perception of the patient through providing methods to alleviate pains.

INTERVENTION

EVALUATION

>Recurrent abdominal Acute pain r/t pain inflammatory responses. >Guarding behavior at times >Slight facial grimace >Weak and pale in appearance >Irritable at times >hyperactive sounds bowel

Establish rapport to After 30 minutes of appropriate nursing the patient. intervention, the patient was able to report a decrease in Place patient to a pain perception through providing comfortable methods to alleviate position pains as evidence by decrease in pain scale from 6/10 to Encourage patient 5-10 to have adequate period of rest.

Provide comfort measures (e.g. back rub, proper positioning etc.)

Encourage deep breathing exercise

III. Conclusion As a student nurses, it is important that we are equipped with enough information and knowledge on how to prevent further complication that may arise. We found out ways on how we can acquire and prevent having this kind of a disease. Through this case study, our knowledge in this particular disease becomes broader. We are confident that the next time we are going to handle a patient with a Amoebiasis with some signs of Dehydration in order to interventions. Proper dissemination of information is needed to be able to increase the awareness of people especially in children because early detection is very important in order to prevent further complication of the disease. provide better nursing

IV. Recommendations: When we assessed the patient we advise the mother to let her daughter continue her Continue medications as prescribed Prescribed medication must be taken on time Strenuous exercise should be avoided Encouraged to take enough rest to regain strength Take home medications as doctors order Report unusual signs and symptoms Advised the client to have enough bed rest Upon discharge patient education should emphasize the importance of close follow up care Encourage to practice personal hygiene properly like washing of foods thoroughly before cooking and if raw, wash their hands also before and after using the rest room and before eating. or handling any objects , wash kitchen utensils before using them Follow her diet, increase fluid intake Eat foods which are rich in calcium like the BRAT Diet.

Pathopysiology-book-base Ingestion of bacteria entamoeba histolytica

Multiplication in mucosa

Endotoxin production affecting the lining of the small intestines colon and capillary

Necrosis of the mucosal layer ulceration gangren e toxemia

Acute amoebic dysentery Chronic amoebic dysentery Extraintestinal forms 1. hepatic

pathopysiology patient base

Ingestion of bacteria entamoeba histolytica

Multiplication in mucosa

Endotoxin production affecting the lining of the small intestines colon and capillary

Necrosis of the mucosal layer

ulceration gangrene

toxemia

watery and foul smelling stool often containing blood streaked mucus, colic and gaseous distention of the lower abdomen, nausea, flatulence, anorexia, weight loss and weakness

PATHOPHYSIOLOGY OF AMOEBEASIS Normally human intestinal flora protects the bowel from colonization of pathogens; however, the intestinal flora can be disrupted by harmful bacteria and viruses that cause tissue damage and inflammation or depressed by antibiotic c therapy. Amoeba cause tissue damage and inflammation by releasing toxins (enterotoxins) that stimulates the mucosal lining of the intestine, resulting greater secretion of water and electrolytes into the intestinal lumen. The active secretion of chloride and bicarbonate ions in the small bowel leads to inhibition of sodium reabsorption. To balance the excess sodium, large amounts of protein rich fluids are secreted in the bowel, leading to diarrhea The metacystic trophozoites or their progenies reach the cecum and those that cone contact with cecal mucosa penetrate or invade the epithelium by the lytic digestion if condition is favorable. The trophozoites burrow deeper with tendency to spread laterally by flask shape ulcers. There may several points of penetration. From the primary site of invasion, secondary lesions may be produced at the lower levels of the large intestines. Progenies of the initial colonies are squeezed out of the neck of the ulcer and carried to the lower portion of the bowel, thus have opportunity to invade and produce additional ulcers. Eventually the whole colon may be involved. When the integrity of the GIT impaired its ability to carry out digestive and absorptive functions can be affected as well as the sympathetic and parasympathetic afferent nerve will be stimulated thru the vagus, glossopharyngeal, vestibular and splanhnic nerves, which is located at the proximal duodenum, thus stimulates emetic center resulting to vomiting. As inflammation occurred, inflammatory response happened, chemical mediators are released in he injured tissue causing blood dilation of the blood vessels which is beneficial because it increases the speed with which blood cells and other important for r fighting infections and repairing the injury and brought to the injury site.It also increase permeability of the blood vessels and fluid leaves the capillaries, producing swilling of the tissue. WBC and RBC leave the dilated and move to the site of infection, where they begin to phagocytize foreign microorganisms and other debris.