DE LA SALE HEATH SCIENCES INSTITUTE COLLEGE OF MEDICINE Dasmarinas, Cavite

INTEGRATION ACTIVITY 3

Submitted by: Group 19 Group Members: Jualayba, Elkie Jurao, Adorissa Kalalo, Michael Kamantigue, Janine Lagamayo, Dian Lao, Charles Lapitan, Jaecel Licudan, Lester

11 Jan 2012, 1:30 5::00 PM, Villarosa Convention Hall

CASE: GG is a 30 year old medical representative who consulted for increased frequency in bowel movement. She traveled last week to Puerto Prinsesa, Palawan and stayed there in 4 days. She had been eating at various restaurants serving local delicacies and seafoods. She was drinking tap water, too. On arriving in Manila, 1 day PTC, she noticed abdominal bloating and abdominal cramps followed by loose bowel movements. The bowel movement started as voluminous sometimes explosive which later became scanty, mucoid and associated with tenesmus. She did not seek medical consultation, taking only over-thecounter medications (lomotil and Diatabs) for loose bowel movement. The condition persisted with associated body malaise, low grade fever, urgency and colicky abdominal pain which prompted the consultation Vital signs: BP 110/80 Pulse 64 Temperatre 38.0C She was in mild distress without associated orthostatic hypotension. GUIDE QUESTIONS: 1. List the pertinent findings in the patients history and from these preliminary data, what other additional historical data would you extract from the patient? What are the physical exam findings that you would look for? 2. What complications can possibly arise from this condition 3. Give the possible etiologic agents and describe the characteristics features of each. 4. Categorize the diarrheal state. List the laboratory examinations that can be done the patient and describe probable results relating it to the patients condition 5. What ancillary diagnostic procedures can be done to the patient? Describe the expected characteristics findings in each. 6. What is the most appropriate drug for this condition? 7. What adverse effects can the drug/s possibly have which you have to warn your patient about? 8. What supportive measures including medications can you give to alleviate your patients discomfort? DIAGNOSIS: AMOEBIASIS ANSWERS TO GUIDE QUESTIONS: 1. List the pertinent findings in the patients history and from these preliminary data, what other additional historical data would you extract from the patient? What are the physical exam findings that you would look for? PERTINENT FINDINGS FROM PATIENTS HISTORY : Chief Complaint: Increased frequency in bowel movement. - Onset: 1 day prior to confinement - Duration: 1-2 days - Progression: started as voluminous sometimes explosive, w/c later became scanty, mucoid and assoc. with tenesmus - Presence of blood, mucus: (+) mucus Risk factors: Last travel: Puerto Princesa, Palawan Offending Agents: Food source/ preparation: Various restaurants in Puerto Princesa, Palawan, serving local delicacies and seafood

Water source: Tap water - Intake of medications that can precipitate, and/or alleviate the symptoms: (+) over-the-counter medications (Lomotil and Diatabs) Accompanying manifestations: Abdominal pain: (+) abdominal cramps, (+) colicky abdominal pain Fever: (+) 38.0 OC Abdominal distention: (+) abdominal bloating (+) body malaise, low grade fever, urgency

ADDITIONAL HISTORICAL DATA TO EXTRACT FROM PATIENT: Additional Historical Data / Additional info - Character of the stools or the Diarrhea Consistency of the stool Amount per episode Reason Diarrhea is an excessive frequency in the passage of stools that are usually unformed or watery. Characteristic of determine if it is: the stool will help

a. Small bowel or proximal colon disorders -- which is often large diarrheal stools b. Left colon or rectal disorders which is small frequent stools with urgency of defecation 1 Acute diarrhea is usually caused by infection while chronic diarrhea is typically noninfectious in origin, as in Crohns disease and ulcerative colitis High volume, frequent watery stools usually are form the small intestine while; Small volume stools with tenesmus or diarrhea with mucus, pus or blood occur in rectal inflammatory conditions Associated illnesses/ conditions: Diabetes Thyroid disorder Stroke Pancreatic disease Previous abdominal surgery Accompanying manifestations Vomiting, nausea Flatulence Anal pain Other gastro intestinal symptoms associated with abdominal pain is constipation which occurs with diabetes, hypothyroidism, hypercalcemia, multiple sclerosis, parkinsons disease and systemiic sclerosis Relief after passing feces or gas suggests left colon or rectal disorders; tenesmus in rectal conditions near the anal sphincter

Duration Frequency Timing Aggravating factors Relieving factor

PHYSICAL EXAM FINDINGS TO LOOK FOR: Inspection: o Abdominal Contour to note if the abdomen is distended o Presence of Scars (note location, shape and length) to rule out one of the causes of loose bowel movement which is deranged motility due to surgical reduction of gut length that decreases intestinal transit time Auscultation: o Character and Frequency of Bowel Sounds o Bowel sounds may be altered in diarrhea, intestinal obstruction, paralytic ileus, and peritonitis.

2. What complications can possibly arise from this condition? The most common complication of diarrhea is dehydration. Mild diarrhea is characterized by thirst, dry mouth, decreased axillary sweat, decreased urine output, and slight weight loss. Moderate cases, on the other hand, are indicated by orthostatic hypotension, skin tenting, and sunken eyes. Even more severe forms are evidenced by hypotension, tachycardia, confusion and frank shock. The level of dehydration in a patient may be indicative of the severity of the illness and the need for rapid therapy. In some cases, intake of dyphenoxylate hydrochloride (Lomotil) and loperamide (Diatabs) may also lead to prolonged fever. This is due to the impairment of intestinal motility needed to clear the causative organisms from the intestines.2

3. Give the possible etiologic agents and describe the characteristics features of each. Infection causes (bacterial, viral, and parasitic) account for most cases of diarrhea and the following are the commonest etiologic agents of diarrhea for all ages in decreasing order of prevalence obtained from pooled data worldwide: Rotavirus, ETEC, Shigella, Campylobacter, Vibrio cholerae, and non-typhoidal salmonella. Similar organisms have been isolated from epidemiologic studies done in the Philippines. Other important viral agents of diarrhea are Norwalk and adenovirus; among parasites, cryptosporidium, Entamoeba histolytica, and Giardia intestinalis. A number of pathogens have also been associated with the presence of bloody stools and cases of persistent diarrhea.

The usual pathogenic mechanisms for infectious diarrhea are toxin production and tissue invasion (invasion of intestinal cells with consequent alteration of their function and reproduction). Noninfectious causes of diarrhea include drugs, surgical conditions, systemic infections and food intolerance. a Hospital- and community-based etiology studies done in the Philippines showed thepredominance of rotavirus and enterotoxigenic E. coli as causes of diarrhea. 3

PROBLEM

PROCESS Infection by viruses, preformed bacterial toxins (such as Staphylococcus aureus, Clostridium perfringens, toxigenic Escherichia coli, Vibrio cholerae), cryptosporidium, Giardia lamblia Colonization or invasion of intestinal mucosa (nontyphoid Salmonella, Shigella, Yersinia, Campylobacter, enteropathic E. coli, Entamoeba histolytica)

CHARACTERISTICS OF THE STOOL

TIMING

ASSOCIATED SYMPTOMS

SETTINGS, PERSONS AT RISK Often travel, a common food source, or an epidemic

Acute Diarrhea Secretory Infections

Watery, without blood, pus, or mucus

Duration of a few days, possibly longer. Lactase deficiency may lead to a longer course.

Nausea, vomiting, periumbilical cramping pain. Temperature normal or slightly elevated

Inflammatory Infections

Loose to watery, often with blood, pus, or mucus

An acute illness of varying duration

Lower abdominal cramping pain and often rectal urgency, tenesmus; fever

Travel, contaminated food or water. Men and women who have had frequent anal intercourse.

Defective absorption of fat, including fatsoluble vitamins, with Voluminous steatorrhea Diarrheas (excessive _ excretion of Malabsorption fat) as in syndromes pancreatic insufficiency, bile salt deficiency, bacterial overgrowth

Typically bulky, soft, light yellow to gray, mushy, greasy or oily, and sometimes frothy; particularly foulsmelling; usually floats in the toilet

Onset of illness typically insidious

Anorexia, weight loss, fatigue, abdominal distention, often crampy lower abdominal pain. Symptoms of nutritional deficiencies such as bleeding (vitamin K), bone pain and fractures (vitamin D), glossitis (vitamin B), and edema (protein)

Variable, depending on cause

Biological and Epidemiologic Characteristics of Viruses that Cause Diarrhea SPECIAL FEATURES PATHOGENIC Site of infection EPIDEMIOLOGIC Ages primarily affected Incubation period (days) ROTAVIRUS Duodenum, jejunum Infants, children <2 y old 13 CALICIVIRUS Jejunum Older children and adults 0.52 ASTROVIRUS Small intestine ADENOVIRUS Small intestine

Infants, children ?12

Infants, children 810

Enterobacteriaceae Diarrhea is the universal finding with E. coli strains that are able to cause intestinal disease. The nature of the diarrhea varies depending on the pathogenic mechanism. y Enterotoxigenic and enteropathogenic strains produce a watery diarrhea y Enterohemorrhagic strains produce a bloody diarrhea y Enteroinvasive strains may cause dysentery with blood and pus in the stool.

The diarrhea is usually self-limiting after only 1 to 3 days. The enterohemorrhagic E. coli are an exception, with life-threatening manifestations outside the gastrointestinal tract due to Shiga toxin production Infections caused by all of the E. coli virulence types usually begin with a mild watery diarrhea starting 2 to 4 days after ingestion of an infectious dose. In most instances, the duration of diarrhea is limited to a few days, with the exception of EAEC diarrhea, which can last for weeks Shigella Shigella, unlike Vibrio cholerae and most Salmonella species, is acid-resistant and survives passage through the stomach to reach the intestine. Once there, the fundamental pathogenic event is invasion of the human colonic mucosa. This triggers an intense acute inflammatory response with mucosal ulceration and abscess formation. Shigella organisms cause an acute inflammatory colitis and bloody diarrhea, which in the most characteristic state presents as a dysentery syndromea clinical triad consisting of cramps, painful straining to pass stools (tenesmus), and a frequent, small-volume, bloody, mucoid discharge Signs and Symptoms includes watery diarrhea and is followed by fever, bloody mucoid stools, and cramping and the diarrhea may turn bloody with or without the other classical signs of dysentery.

The disease usually begins with fever and systemic manifestations of malaise, anorexia, and sometimes myalgia. Salmonella The clinical patterns of salmonellosis can be divided into gastroenteritis, bacteremia with and without focal extraintestinal infection, enteric fever, and the asymptomatic carrier state. Any Salmonella serotype can probably cause any of these clinical manifestations under appropriate conditions, but in practice the S. enterica serotypes are associated primarily with gastroenteritis. Typhi and a few related serotypes (Paratyphi) cause enteric fever. Signs and Symptoms: Diarrhea, vomiting, and cramps are common Gastroenteritis Typically, the episode begins 24 to 48 hours after ingestion, with nausea and vomiting followed by, or concomitant with, abdominal cramps and diarrhea. Diarrhea persists as the predominant symptom for 3 to 4 days and usually resolves spontaneously within 7 days. Fever (39C) is present in about 50% of the patients. The spectrum of disease ranges from a few loose stools to a severe dysentery-like syndrome. Entamoeba Entamoeba histolytica is a protozoan parasite responsible for a disease called amoebiasis. It occurs usually in the large intestine and causes internal inflammation as its name suggests (histo = tissue, lytic = destroying). Minor infections(luminal amoebiasis) can cause symptoms that include:
y y y y y

gas (flatulence) intermittent constipation loose stools stomach ache stomach cramping.

Giardiasis Giardiasis is an infection of the small intestine caused by Giardia lamblia (also known as G. intestinalis), a flagellate protozoan. Travelers are the largest risk group for giardiasis infection, especially those who travel to the developing world. Most people contract the disease by ingesting contaminated water or food, or by not washing their hands after touching something contaminated withGiardia cysts. The most common symptoms of Giardia infection include diarrhea for a duration of more than 10 days, abdominal pain, flatulence, bloating, vomiting, and weight loss. Giardiasis has been associated with several gastrointestinal disorders, including irritable bowel syndrome, inflammatory bowel disease and biliary tract dysfunction. 4. Categorize the diarrheal state. List the laboratory examinations that can be done the patient and describe probable results relating it to the patients condition Acute diarrhea is a categorized as acute if its duration is less than 2 weeks. Infectious causes dominate and include viral, bacterial, and parasitic agents. Bacteria may cause diarrhea by producing a toxin in contaminated food or after ingestion or by invading the bowel mucosa. Some parasites invade the bowel wall, whereas others cling to it and alter the absorptive surface. < 2 weeks > 90% of infectious origin Associated with abdominal pain, vomiting, fever Persistent 2-4 weeks Chronic diarrhea normally last more than 4 weeks or a pattern of recurrent diarrhea requires an etiologic assessment > 4 weeks non-infectious Physical Examination Vital signs must be checked. Postural signs of significant volume depletion are an indication for prompt intravenous repletion. Any elevation in temperature or loss of weight also needs to be noted. Should the patient appears dehydrated or toxic, hospital admission should be taken into account. Skin should be examined for manifestations of sepsis, the macular rose spot rash on the trunk is an important clue for typhoid. The lymph nodes are checked for enlargement and the abdomen for tenderness, guarding, rebound, abnormal bowel sounds, organomegaly, and masses. A rectal examination and fecal occult blood test complete the physical evaluation. Laboratory Studies: Initial Evaluation Laboratory workup should be individualized. Patient who is ill with fever, nausea, abdominal cramps, or other systemic symptoms requires more extensive evaluation.

The following are the laboratory test that can be done: y Grams Stain of the stool Will provide etiologic information in selected instances, such as for Campylobacter infection Stool Cultures Though not necessary for acute diarrhea since it is self-limited but if the patient appears to be ill with significant fever, blood in the stool or immunocompromised then bacterial cultures should be obtained. Sigmoidoscopy

Should the Diarrhea persist for more than 2 weeks, a secondary evaluation is indicated. Stools should once again be examined for blood, sent for bacterial culture, and examined for ova and parasites. If the following diseases are in consideration, do the following; y Giardiasis -- at least three stool samples are necessary because the excretion of the organism is intermittent. y E. histolytica trophozites should be seen in the stool examination 5. What ancillary diagnostic procedures can be done to the patient? Describe the expected characteristics findings in each. Diagnostic tests Test stool antigen detection PCR or qPCR of stool or liver abscess pus for E histolytica DNA serum antibody test stool microscopy colonoscopy liver ultrasound CT liver/chest/head

Result positive for parasite antigen amplification of amoebic positive for antiamoebic antibodies identification of Entamoeba in stool granular, friable, and diffusely ulcerated mucosa homogenous hypoechoic round or oval lesion rounded, well-defined, low-attenuation lesion; wall commonly enhances with contrast; pleural effusion right hemidiaphragm elevation or rightsided pleural effusion space-occupying lesion(s)

CXR MRI brain

6.

What is the most appropriate drug for this condition? Metronidazole + Iodoquinol or Metronidazoe + Paromomycin.

7.

What adverse effects can the drug/s can possibly have which you have to warn your patient about? Metronidazole (flagyl) It may cause dark urine in some patients however this is only temporary and will go away when you stop taking this medicine. When taken in high doses or long-term administration of it can cause

peripheral neuropathy with sensory disturbances like numbness, tingling, pain, or weakness in hands or feet. Neuropathy is often only slowly reversible or not reversible at all. Neutropenia can also develop. Effect s in the GIT: y diarrhea y loss of appetite y change in taste sensation y dryness of mouth y unpleasant or sharp metallic taste y nausea or vomiting Effects in the CNS y dizziness or lightheadedness y headache y vertigo y insomnia y convulsion (rare) Less common y any vaginal irritation, discharge, or dryness not present before use of this medicine y clumsiness or unsteadiness y mood or other mental changes y skin rash, hives, redness, or itching y fever y stomach and back pain (severe) Iodoquinol In moderate or severe cases of intestinal amebiasis or extraintestinal amebiasis, iodoquinol should follow therapy with metronidazole. Less serious adverse effects: y nausea, vomiting, or abdominal cramps; y diarrhea y headache y dizziness y fever or chills y itching y enlargement of the thyroid gland. Uncommon but serious side effects: y an allergic reaction (difficulty breathing, closing of the throat, swelling of the lips, tongue, or face, or hives) y vision problems y numbness or tingling y skin rash Use caution when driving or performing other hazardous activities until you know how this medication affects you as it may cause dizziness or visual disturbances. If you must have thyroid function tests, make sure the doctor knows that you are taking iodoquinol or have taken it within the past 6 months as it may cause enlargement of thyroid gland. Paromomycin Paromomycin is usually given after Metronidazole. It is given as it is an effective drug for intestinal infection.

Less serious adverse effects y nausea or vomiting y diarrhea y itching Serious adverse effects y an allergic reaction (difficulty breathing, closing of the throat, swelling of the lips, tongue, or face, or hives) y decreased hearing or ringing in the ears y little or no urine production y dizziness 8. What supportive measures including medications can you give to alleviate your patients discomfort? Management of Diarrhea

Figure 1 Algorithm developed for the management of adult diarrhea. 1Stool examination and culture methods depend on availability, affordability, and local practice of each community or country. 2Strongly recommended for severly ill patients (select antibiotics according to sensitivity of local antibiogram). PE, Physical examination; DFM*, dark field microscopy (if not available, look for shooting bacteria under light microscopy); ATB, antibiotics; ORT, oral rehydration therapy; IVF, intravenous fluid.

Symptomatic and supportive treatment is usually sufficient. If the patient can drink, oral rehydration therapy is highly encouraged. If vomiting is severe and dehydration is significant, intravenous therapy may be necessary. Antiemetics, such as metocloparmide, are not effective if given orally, but intramuscular injection may be efficient. Abdominal cramping pain may respond to antispasmodics, for example hyoscine, hyoscyamine and dicyclomine. c

References:
1. 2. 3. Bickley, L.. S., & Szilagyi, P. G., 2009. Bates : Guide to Physical Examination and History Taking. 10th edition. Lippincott Williams & Wilkins. Pages 424-461. Kasper, D. L., et al. 2005. Harrisons Principles of Internal Medicine. 16th ed. The McGraw-Hill Companies, Inc. USA. Vol 1 pp 756-757 Saniel MC, Sta. Maria A, Sanvictores E, et al. Prospective study of diarrhea in infants and young children in a periurban community; morbidity pattern and etiologies. In: Tzipori S, ed. Infectious Diarrhea in the Young: Strategies for Control in Humans and Animals. The Netherlands; Elsevier,1985. pp. 113-116. Saniel MC, MoriIes RR, Monzon OT, et al. The relative importance of various enteropathogens in the etiology of acute diarrhea: a hospital-based study in urban Philippines. In: SEAMIC Proceedings of the 14th SEAMIC workshop: Gastrointestinalinfections in Southeast Asia (V). SEAMIC. Southeast Asian Medical Information Center/International Medical Foundation of Japan, 1988. pp. 91-96. Ryan, K. J., & Ray, C. G. SHERRIS MEDICAL MICROBIOLOGY AN INTRODUCTION TO INFECTIOUS DISEASES. 4th Ed. MCGRAW-HILL MEDICAL PUBLISHING DIVISION New York Chicago San Francisco Lisbon London Madrid Mexico City

4.

5.

6. Onine: a. http://psmid.org.ph/vol19/vol19num2topic3.pdf b. http://books.google.com.ph/books?id=bIZvJPcSEXMC&pg=PA506&lpg=PA506&dq=how+to+categorize+diarrhea l+state&source=bl&ots=asySizk0ih&sig=I9RuH__H31MzUxop_asoXQqh1N8&hl=en&sa=X&ei=ZX0JT6WjKsms 2gX3_Oi2Aw&ved=0CDwQ6AEwBQ#v=onepage&q&f=true c. http://faculty.ksu.edu.sa/hisham/Documents/Stud_Research/j.1440-1746.17.s1.11.x.pdf d. metronidazole http://www.infomed.ch/100drugs/menzadre.html http://ibdcrohns.about.com/cs/prescriptiondrugs/p/medflagyl.htm http://www.drugs.com/dosage/iodoquinol.html iodoquinol http://www.drugs.com/mtm/iodoquinol.html http://www.drugs.com/cons/iodoquinol.html paromomycin http://demo.healthwise.org/xhtml/content/multum/d01104a1.html