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PROBLEM 3
ALMIRA NABILA VALMAI
405130193
1.
LO
LO 1
HUBUNGAN SUHU
DENGAN HR
LO 2
DISTENSI DENGAN
PALPASI DALAM
LO 3
LO 4
COATED TONGUE
LO 5
ANATOMI, HISTOLOGI,
FISIOLOGI SALURAN
PENCERNAAN BAWAH
Small Intestine
90% of absorption occurs in the small
intestine
Small Intestine
The Jejunum
Is the middle segment of small intestine
2.5 meters (8.2 ft) long
Is the location of most
Chemical digestion
Nutrient absorption
Small Intestine
The Ileum
The final segment of small intestine
3.5 meters (11.48 ft) long
Ends at the ileocecal valve, a sphincter
that controls flow of material from the
ileum into the large intestine
Small Intestine
Intestinal Secretions
Watery intestinal juice
1.8 liters per day enter
intestinal lumen
Moisten chyme
Assist in buffering acids
Keep digestive enzymes
and products of
digestion in solution
Intestinal Movements
Chyme arrives in
duodenum
Weak peristaltic
contractions move it
slowly toward jejunum
Myenteric reflexes
Not under CNS control
Parasympathetic
stimulation accelerates
local peristalsis and
segmentation
Large Intestine
Is horseshoe shaped
Extends from end of ileum to anus
Lies inferior to stomach and liver
Frames the small intestine
Also called large bowel
Is about 1.5 meters (4.9 ft) long and 7.5
cm (3 in.) wide
Is an expanded pouch
Receives material
arriving from the ileum
Stores materials and
begins compaction
Appendix
Also called vermiform
appendix
Is a slender, hollow
appendage about 9 cm
(3.6 in.) long
Is dominated by lymphoid
nodules (a lymphoid
Parts of Colon
Ascending Colon
Begins at superior border of cecum
Ascends along right lateral and posterior wall of
peritoneal cavity to inferior surface of the liver and
bends at right colic flexure (hepatic flexure)
Transverse Colon
Crosses abdomen from right to left; turns at left
colic flexure (splenic flexure)
Is supported by transverse mesocolon
Is separated from anterior abdominal wall by
greater omentum
Parts of Colon
The Descending Colon
Proceeds inferiorly along left side to the iliac
fossa (inner surface of left ilium)
Is retroperitoneal, firmly attached to abdominal
wall
Parts of Colon
Anus
Stimulus is distension of
stomach and duodenum;
relayed over intestinal nerve
plexuses
LO 6
KELAINAN SALURAN
PENCERNAAN BAWAH
DIARRHEA
Definition
clinically, diarrhea defined as stools that are looser
and/or more frequent than normal; or 24 h stool weight
>200 g (physiological definition, less useful clinically)
Classification
acute vs. chronic
small volume (tablespoons of stool; typical of colonic
diseases) versus large volume (>1/2 cup stool; typical
of small bowel diseases)
watery (bowel disease) vs. steatorrhea
secretory (diarrhea persists with fasting) vs. osmotic
(diarrhea stops with fasting)
ACUTE DIARRHEA
Definition
passage offrequent unformed stools for <14 d
Etiology
most commonly due to infections
most infections are self-limiting and resolve within 7 d
Risk Factors
food (seafood, chicken, turkey, eggs, beef)
medications: antibiotics, laxatives
others: high risk sexual activity, infectious outbreaks, family history (IBD)
Classification
broadly divided and classified into inflammatory and non-inflammatory
diarrhea
mechanisms: stimulation of intestinal water secretion and inhibition of water
absorption (i.e. secretory problem)
in inflammatory diarrhea, organisms and cytotoxins invade mucosa, killing
mucosal cells, further perpetuating the diarrhea
Investigations
stool cultures/microscopy (C&S/O&P)
C&S only tests Campylobacter, Salmonella, Shigella,
E. Coli other organisms must be ordered separately
flexible sigmoidoscopy: useful if inflammatory
diarrhea suspected
biopsies are the most useful method of distinguishing
idiopathic IBD (Crohn's disease and ulcerative colitis)
from infectious colitis or acute self-limited colitis
C. difficile toxin: indicated when recent/remote
antibiotic use, hospitalization, nursing home or recent
chemotherapy
Treatment
Fluid and electrolyte replacement orally in most cases, intravenous if
severe extremes of age/coma
anti-diarrheals
antimotility agents: diphenoxylate, loperamide (Imodium);
contraindicated in mucosal inflammation
side effects: abdominal cramps, toxic megacolon
CHRONIC DIARRHEA
Definition
passage of frequent unformed stool for >14 d
differential is similar to that of acute diarrhea, except that the majority
of cases are non-infectious
Etiology I Classification
Investigations
Guided by history
stool analysis for: C. difficile toxin, C&S, O&P fecal fat, WBC
blood for: CBC, chemistry, CRP, TSH, celiac serology (anti-tTG, protein
electrophoresis)
colonoscopy and ileoscopy with biopsy
Small bowel biopsy
upper GI endoscopy with duodenal biopsy
wireless small bowel endoscopy capsule (last resort - very costly)
rial of lactose free diet
may delay diagnosis of IBD and celiac disease
Maldigestion &
malabsorbtion
Definition
maldigestion: inability to break down
large molecules in the lumen of the
intestine into their component small
molecules
malabsorption: inability to transport
molecules across the intestinal mucosa
to the circulation
malassimilation: encompasses both
maldigestion and malabsorption
Etiology
Maldigestion
inadequate mixing of food with enzymes (e.g. post-gastrectomy)
pancreatic exocrine deficiency
primary diseases of the pancreas (e.g. cystic fibrosis, pancreatitis, cancer)
Bile salt deficiency
terminal ileal disease (impaired recycling), bacterial overgrowth (deconjugation ofbile salts),
rarely liver disease (cholestatic)
specific enzyme deficiencies (e.g. lactase)
Malabsorption
drug-induced
cholestyramine, ethanol, neomycin, tetracycline and other antibiotics
Endocrine
e.g. diabetes (complex pathogenesis)
Clinical Features
Symptoms usually vague unless disease
is severe
weight loss, diarrhea, steatorrhea,
weakness, fatigue
manifestations of
malabsorption/deficiency
Investigations
72 h stool collection (weight, fat content)
serum carotene, folate, Ca2+, Mg2+, vitamin B12,
albumin, ferritin, serum iron solution, INR/PTT
stool fat globules on fecal smear stained with
Sudan (rarely used)
other tests specific for etiology (e.g. CT scan/MRI
to visualize pancreas)
trial of therapy with pancreatic enzymes
Treatment
dependent on underlying etiology
Etiology
only autoimmune disease in which antigen (a.-gliadin) is recognized
associated with other autoimmune diseases, especially thyroid disease
gluten, a protein in cereal grains, broken down to gliadin, is toxic factor
HLA-DQ2 (chromosome 6) found in 80-90% of patients compared with 20% in general
population; also associated with HLA-DQ8
Epidemiology
more common in women
family history: 15% of first-degree relatives
may present any time from infancy (when cereals introduced) to elderly
peak presentation in infancy
Clinical Features
classically: diarrhea, weight loss, anemia, symptoms ofvitamin/mineral deficiency, failure to
thrive; now more commonly bloating, gas, iron deficiency
improves with gluten-free diet, deteriorates when gluten reintroduced
disease is usually most severe in proximal bowel
thus iron, calcium and folic acid deficiency more common than vitamin B deficiency
gluten enteropathy may be associated with dermatitis herpetiformis skin eruption, epilepsy,
myopathy, depression, paranoia, infertility, bone fractures/metabolic bone disease
12
Investigations
small bowel mucosal biopsy (usually duodenum) is usually
diagnostic:
villous atrophy and crypt hyperplasia
increased number of plasma cells and lymphocytes in lamina
propria
increased intraepitheliallymphocytes
similar pathology in: small bowel overgrowth, Crohn's,
lymphoma, Giardia, HIV
Treatment
Dietary counselling
gluten free diet: avoid barley, rye, wheat
oats allowed if not contaminated by other grains
incorrect diagnosis
non-adherence to gluten-free diet
unsuspected concurrent disease (e.g. microscopic colitis, pancreatic insufficiency)
development ofintestinal (enteropathy-associated T-cell) lymphoma (abdominal pain,
weight loss, palpable mass)
development ofdiffuse intestinal ulceration, characterized by aberrant intraepithelial Tcell population (precursor to lymphoma)
Prognosis
associated with increased risk oflymphoma, carcinoma (e.g. small bowel and
colon)
risk of malignancy may be lowered by dietary gluten restriction
Gastroenteritis
Definition
Etiology
Gastroenteritis is an
inflammation of the
lining of the intestines
caused by a virus,
bacteria or parasites.
Virus
Bacteria
Parasites
urce: https://www.nlm.nih.gov/medlineplus/gastroenteritis.html
Virus
The most common cause of gastroenteritis.
They infect enterocytes in the villous
epithelium of the small bowel.
The result is transudation of fluid and salts
into the intestinal lumen;
Sometimes, malabsorption of
carbohydrates worsens symptoms by
causing osmotic diarrhea.
Diarrhea is mostly watery.
Viruses
Four categories of viruses cause most gastroenteritis:
Rotavirus and norovirus cause the majority of viral
gastroenteritis, followed by astrovirus and enteric
adenovirus.
1. Rotavirus is the most common cause of sporadic,
severe, dehydrating diarrhea in young children (peak
incidence, 3 to 15 mo).
Rotavirus is highly contagious; most infections occur
by the fecal-oral route.
Adults may be infected after close contact with an
infected infant. The illness in adults is generally mild.
Incubation is 1 to 3 days.
Viruses
2. Norovirus most commonly infects older children and adults.
Infections occur year-round. Norovirus is the principal cause of
sporadic viral gastroenteritis in adults and of epidemic viral
gastroenteritis in all age groups; large waterborne and foodborne outbreaks occur. Person-to-person transmission also
occurs because the virus is highly contagious. Incubation is 24
to 48 h.
3. Astrovirus can infect people of all ages but usually infects
infants and young children. Infection is most common in
winter. Transmission is by the fecal-oral route. Incubation is 3
to 4 days.
4. Adenoviruses are the 4th most common cause of childhood
viral gastroenteritis. Infections occur year-round, with a slight
increase in summer. Children<2 yr are primarily affected.
Transmission is by the fecal-oral route. Incubation is 3 to 10
days.
Bacteria
Escherichia
this is a common
coli
problem for
travelers to
countries with poor
sanitation.
Infection is caused
by drinking
contaminated
water or eating
contaminated raw
fruits and
vegetables.
Campylobacter
the bacteria are found in animal
feces. Infection is caused by, for
example, consuming
contaminated food or water,
eating undercooked meat
(especially chicken), and not
washing your hands after
handling infected animals.
Azithromycin (500 mg orally one
time a day for 3 days) should be
first line Rx therapy for
symptoms lasting >7days,
otherwise self-limited
symptomatic therapy
recommended.
Salmonella
Bacteria are found in animal feces.
Infection is caused by consuming
food that is contaminated with
animal feces
8-48 hours incubation
Fever with chills
Nausea and vomiting
Cramping and abdominal pain
Diarrhea often grossly bloody 3-5
days
Tx if not self-limited:
Trimethoprim-sulfamethoxazole,
ampicillin, ciprofloxin
Shigella
Cholera
Clostridium difficile
Clostridium difficile
20% chance after completing
broad spectrum antibiotic
The A and B toxins produced by
C. difficile can cause severe
diarrhea, pseudomembranous
colitis, or toxic megacolon.
High risk pts: nursing home
residents and employees,
hospitalized pts and employees
metronidazole (250 mg orally
four times a day or 500 mg
orally three times a day for 10
days)
Tetracycline, ampicillin,
azithromycin, trimethoprimsulfamethoxazole, fluoroquinolones
Parasites
Cryptosporidium
infection
Cryptosporidium
parvumcauses watery
diarrhea sometimes
accompanied by
abdominal cramps,
nausea, and vomiting.
Entamoeba
Entamoeba
histolytica(amebiasis)
is a common cause of
subacute bloody
diarrhea in the
developing world
Giardia
Giardia infection can be transmitted through water,
food, and person-to-person contact.
Watery yellow, sometimes foul-smelling diarrhea that
may alternate with soft, greasy stools, fatigue,
abdominal cramps and bloating, nausea, weight loss
Infections usually clear up within six weeks. But you
may have recurrent episodes or have intestinal
problems long after the parasites are gone.
Several drugs are generally effective against giardia
parasites, but not everyone responds to them.
Tinidazole 2 g orally as a single dose
Metronidazole (Flagyl) 250mg po tid x 5d
Diagnose
Based on symptoms
Physical exam
The presence of
similar cases in your
Source:
community
http://www.mayoclinic.org/disea
A rapid stool test
ses-conditions/viralSource:
http://www.ece.ncsu.edu/imagi
ng/MedImg/SIMS/GE2_1.html
gastroenteritis/basics/testsdiagnosis/con-20019350
Complication
Dehydration: the condition that
results from excessive loss of body
water (Dorland)
Source: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm
Source: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm
Prevention
rce: http://www.cdc.gov/healthywater/pdf/global/programs/Globaldiarrhea508c.p
Source: http://www.health.nt.gov.au/library/scripts/objectifyMedia.aspx?
file=pdf/76/18.pdf&siteID=1&str_title=Typhoid%20and%20paratyphoid
Diagnose
Source: https://www.nlm.nih.gov/medlineplus/ency/article/001332.htm
Prognosis
Symptoms usually
improve in 2 to 4 weeks
with treatment. The
outcome is likely to be
good with early treatment,
but becomes poor if
complications develop.
Symptoms may return if
the treatment has not
completely cured the
infection.
Complications
Intestinal hemorrhage
(severeGI bleeding)
Intestinal perforation
Kidney failure
Peritonitis
Source: https://www.nlm.nih.gov/medlineplus/ency/article/001332.htm
Treatment
Prevention
Source: https://www.nlm.nih.gov/medlineplus/ency/article/001332.htm