Professional Documents
Culture Documents
Group 13
GI Tract Block
Group 13 of GIT block
Leader : Vinawine Puteri T.
Writer : Cynthia Monica
Secretary : Felix Halim
Members : Cinintya Lestari Ling
Rasita Zahrina
Giovanni Anggasta
Maria Brigitta T.
Elfarini
Budi
Clarensia
Desintha C. N.
Efi Kardiana
Learning Objectives
1.Typhoid Fever
2.Gastroenteritis
3.Dehydration
LO 1
Typhoid Fever
Typhoid Fever
Definition
Is an acute infectious intestinal disease
A bacterial infection characterized by
diarrhea, systemic disease, rash, most
commonly caused by the bacteria
Salmonella typhii
Synonym: - enteric fever
- Typhus
Epidemiology
Fig. 1. The typhoid fever
surveillance study sites
http://www.who.int/bulletin/volumes/86/4/06-039818/en/
Classification
SALMONELLOSIS
Enteric
Nontyphoidal
(typhoid)
Salmonellosis
fever
S.Typhi S.Typhimurium
S.Paratyphi S.Enteriditis
8
Salmonella sp.
Structure and physiology
- Bacillus 0.5 0.8 x 1 3 - Stand in sodium
m deoxycholate, brilliant
green, sodium
- Gram negative tetrathionate
- No spore - sugar reactions:
- Fakultative anaerob fermentation of glucose
(+), mannosa (+)
- Flagel peritrich move not ferment lactose and
(+) sucrose
- Stand in the freezing - Oksidase test :
water in a long period negative, nitrate
positive, urease
negative
- TSIA : -/+, H2S (+),
without gas
STRUCTURE
1. Flagel : movement
2. DNA : contain genetic codes to
maintain the structure of the bacterium
3. Cell wall : keep shape
4. Capsule : to protect bacterium
5. Plasma membrane : use for a way
through nutrien & waste
6. Ribosom : to produce a cell protein
Salmonella sp.
Virulence Factors
Sign &
symptoms
The 2nd week
If you don't receive treatment for typhoid
fever, you may enter a second stage during
which you become very ill and experience
Sign &
symptoms
The 3rd week ( typhoid stage
)
Sign &
symptoms
The 4 week th
(Improvement )
If a person survives
until the fourth week,
their symptoms will
gradually improve
fever
blood
stool
urine
antibody
1 2 3 4 5 6 7
S.typhi in
8 week(s)
Typhoid Fever
Pathophysiology
Salmonella Typhi
Lab test
Blood culture
Positif (+) result typhoid fever +
Negative (-) result possibility of
typhoid fever, because of :
Early antibiotic treatmentinhibits
growth of bacteria.
Lackness of blood volume ( 5cc of
blood)
Vaccination history
Incubatio Wee Wee Wee Wee
n k1 k2 k3 k4
Bone marrow 90% (may decrease after 5 d of
aspirate (0.5-1 mL) antibiotics)
Blood (10-30 mL), 40%-80% ~20% Variable (20%-
stool, or duodenal 60%)
aspirate culture
Urine 25%-30%, timing unpredictable
Specific serologic tests
Assays that identify Salmonella antibodies or antigens
support the diagnosis of typhoid fever, but these
results should be confirmed with cultures or DNA
evidence.
The Widal test was the mainstay of typhoid fever
diagnosis for decades. It is used to measure
agglutinating antibodies against H and O antigens of S
typhi
Indirect hemagglutination, indirect fluorescent Vi
antibody, and indirect enzyme-linked immunosorbent
assay (ELISA) for immunoglobulin M (IgM) and IgG
antibodies to S typhi polysaccharide, as well as
monoclonal antibodies against S typhi flagellin,37 are
promising, but the success rates of these assays vary
greatly in the literature.
Other nonspecific laboratory studies
erythrocyte sedimentation rate (ESR),
thrombocytopenia, and relative
lymphopenia
elevated prothrombin time (PT) and
activated partial thromboplastin time
(aPTT) and decreased fibrinogen levels
Mild hyponatremia and hypokalemia are
common
Imaging Studies
Radiography: Radiography of the
kidneys, ureters, and bladder (KUB) is
useful if bowel perforation
(symptomatic or asymptomatic) is
suspected.
CT scanning and MRI: These
studies may be warranted to
investigate for abscesses in the liver
or bones, among other sites.
Hystologic Findings
Infiltration of tissues by macrophages (typhoid cells) that
contain bacteria, erythrocytes, and degenerated lymphocytes
In the mesenteric lymph nodes, the sinusoids are enlarged
and distended by large collections of macrophages and
reticuloendothelial cells
The spleen is enlarged, red, soft, and congested; its serosal
surface may have a fibrinous exudate. Microscopically, the red
pulp is congested and contains typhoid nodules
The gallbladder is hyperemic and may show evidence of
cholecystitis
Liver biopsy specimens from patients with typhoid fever often
show cloudy swelling, balloon degeneration with vacuolation
of hepatocytes, moderate fatty change, and focal typhoid
nodules
Treatment
Bedrest and treatment to prevent complication and speed healing
Diet and supportive therapy restore a sense of comfort and
optimal patient health
Medication (antimicrobial) stop and prevent the spread microbial.
Chloramfenicol
Tiamfenicol
Chotrimoxazol
Amphicilin and Amoxcillin
Sefalosporin 3rd generation
Fluorokuinolon group :
Norfloxacin
Cifrofloxacin
Ofloxacin
Pefloxacin
Fleroxacin
Corticosteroid
Antibiotic Recommendations by Origin and
Severity
Location Severity First-Line Second-Line
Antibiotics Antibiotics
South Asia, East Uncomplicated Cefixime PO Azithromycin PO
Asia45 Complicated Ceftriaxone IV or Aztreonam IV or
48,40
Cefotaxime IV Imipenem IV
Eastern Europe, Uncomplicated Ciprofloxacin PO or Cefixime PO or
Middle East, sub- Ofloxacin PO Amoxicillin PO or
Saharan Africa, TMP-SMZ PO
South America46,49 or Azithromycin PO
Complicated Ciprofloxacin IV or Ceftriaxone IV or
Ofloxacin IV Cefotaxime IV or
Ampicillin IV
or
TMP-SMZ IV
Unknown Uncomplicated Cefixime PO plus Azithromycin PO*
geographic origin or Ciprofloxacin PO or
Southeast Asia50,45 Ofloxacin PO
48,40,46,49
Complicated Ceftriaxone IV or Aztreonam IV or
Cefotaxime IV, plus Imipenem IV, plus
Ciprofloxacin IV or Ciprofloxacin IV
Ofloxacin IV or
Ofloxacin IV
Table 1: Typhoid Vaccines Available in the United States
Total Time
Number of Time Needed to Minimum Booster
Vaccine How
Doses Between Set Aside Age For Needed
Name Given For
Necessary Doses Vaccination Every...
Vaccination
Ty21a
(Vivotif
Berna, 1
Swiss capsule
4 2 days 2 weeks 6 years 5 years
Serum by
and mouth
Vaccine
Institute)
ViCPS
(Typhim
Injectio
Vi, 1 N/A 2 weeks 2 years 2 years
n
Pasteur
Merieux)
Pathological Changes in
Typhoid Fever
1. The changes in the Payer's
patches from hyperplasia &
ulceration to frank ulceration &
typhoid perforation.
2. The liver may be enlarged with
fatty changes.
3. The skin may show changes with
collections of bacilli, which cause
the classical rose spots
Pathological changes in
typhoid fever
4. Cholecystitis may lead to the formation of
infected gall
stones.
5. The spleen is enlarged and soft.
6. The mesenteric glands are enlarged.
7. The kidneys show result in albuminuria.
8. Bronchitis is a usual finding on clinical
auscultation of
lungs in typhoid fever.
9. Severe case: heart may be enlarged &
affected by fatty
degeneration.
10.Finally thrombosis of the deep veins may
occur, lead to a
Complications
Intestinal bleeding or perforation may develop
in the third week of illness. Often marked by a sudden
drop in blood pressure and shock, followed by the
appearance of blood in your stool.
Other, less common complications
- myocarditis
- Pneumonia
- pancreatitis
- Kidney or bladder infections
- osteomyelitis
- meningitis
- delirium, hallucinations and paranoid psychosis
Complications
Gastroenteritis
Definition
Inflammation of the mucous membrane of
both stomach and intestine. (Source:
Stedman's Medical Spellchecker,
2006 Lippincott Williams & Wilkins)
Risk Factors
Overcrowding
Poverty
Poor sanitation
International travel
For Children :
Young age
Immune deficiency
Measles
Malnutrition
Lack of exclusive breast feeding
Risk Factors
1. Consumers of certain foods :
Dairy food-Campylobacter and Salmonella species
Eggs -Salmonella species
Meats -C perfringens and Aeromonas, Campylobacter,
and Salmonella species
Ground beef - Enterohemorrhagic E coli
Poultry -Campylobacter species
Pork-C perfringens, Y enterocolitica
Seafood - Astrovirus and Aeromonas, Plesiomonas, and
Vibrio species
Oysters - Calicivirus and Plesiomonas and Vibrio species
Vegetables -Aeromonas species and C perfringens
2. Immunodeficient persons
http://activity.ntsec.gov.tw/lifeworld/english/content/images/en_dis_c
Signs & Symptoms
Signs & Symptoms
Common symptoms
Low grade fever (99F)
Nausea with or without vomiting
Mild-to-moderate diarrhea: May range from 2-4 loose stools per day
for adolescents and adults to stools that run out of the diaper in
infants.
Crampy painful bloating
Vomiting
More serious symptoms
Blood in vomit or stool
Vomiting more than 48 hours
Fever higher than 101F
Swollen abdomen or abdominal pain coming from the right lower
side
Dehydration - Little to no urination, extreme thirst, lack of tears, and
dry mouth (dry diapers in infants)
Diarrhea
Rapid movement of fecal matter through
the intestines resulting in poor absorption
of water, nutritive elements, and
electrolytes and producing abnormally
frequent watery bowel
movements.(dorland)
Increased stooling, with stool consistency
less solid than normal, constitutes a
satisfactory, if somewhat imprecise
(clevelandclinic)
Types of diarrhea
Acute, persistent, &
chronic diarrhea
Acute diarrhea is defined as a greater
number of stools of decreased form
from the normal lasting for less than
14 days.
If the illness persists for more than 14
days, it is called persistent.
If the duration of symptoms is longer
than 1 month, it is considered chronic
diarrhea.
Osmotic diarrhea
osmotic force that acts in the lumen
to drive water into the gut (caused by
hyperosmotic drugs (MgSO4, Mg(OH)2),
malabsorption, defect in mucosal
absorption (disacharide deficiency,
glucose/galactose malabsorption)
Mechanism
Osmotic
Mechanism
Osmotic
Lactase Deficiency (Gastroenteritis)
ingested lactose remains osmotic load
Laxative
Aeromonas, Shigella, and Vibrio spp. (e.g., produce enterotoxins and also invade the
V. parahaemolyticus) intestinal mucosa.
O
G
Carbohydrate Disakarida (laktosa, maltosa, sukrosa)
Y Monosakarida ( glucosa, fructosa, galactosa)
Malabsorpsi Fat Especially Long Chain trigyceride
O
F Asam amino, B lactoglobulin
Protein
Dehydration
Dehydration
Dehydration is a condition that
occurs when the loss of body fluids,
mostly water, exceeds the amount
that is taken in
Symptoms
Dry or sticky mouth
Low or no urine output; concentrated
urine appears dark yellow
Not producing tears
Sunken eyes
Markedly sunken fontanelles (the soft
spot on the top of the head) in an
infant
Lethargic or comatose (with severe
dehydration)
Muscle cramps
Nausea and vomiting
Heart palpitations
Causes of dehydration
Diarrhea : Worldwide, more than four million children
die each year because of dehydration from diarrhea.
Vomiting
Sweat
Diabetes:In people withdiabetes, elevated blood
sugar levels cause sugar to spill into the urine and
water then follows,frequent urinationand excessive
thirst are among the early symptoms of diabetes.
Burns:The skin acts as a protective barrier for the
body and is also responsible for regulating fluid loss.
Inability to drink fluids
Dehydration Rate
a.Mild dehydration
Fluid lost 2-5% of body weight with clinical
picture is less elastic skin turgor,
hoarseness, the client has not fallen on the
state of shock.
b.Moderate dehydration
Fluid lost 5-8% of body weight with poor
clinical skin turgor, hoarseness, rapid pulse
and in presyok.
c.Severe dehydration
Loss of fluid 80-10% of body weight with
such clinical signs of dehydration is
coupled with decreased consciousness,
apathy to coma, stiff muscles until
cyanosis.
Level of dehydration Estimated fluid loss Signs
and Symptoms in Children
Level of Estimate
dehydrat d fluid Signs and symptoms
ion loss
<3% of
Minimal body none
weight
Fussy, tired, irritable child. Dry
mucous membranes (mouth,
Mild to <10% of
tongue), increased heart rate,
moderat body
increased breathing rate,
e weight
decreased urine output,
increased thirst
Listless, lethargic, unconscious.
Too weak to cry. Sunken eyes,
sunken fontanelle (soft spot of
10% of
skull). Increased heart rate,
body
Severe weak pulses, and rapid shallow
weight or
breathing. Cool, mottled skin.
more
No urine output (dry diapers).
Too weak to suckle or drink
Based on tonicity of fluid
Isotonis Dehydration
Loss water and Na within same
proportion.
Caused by diarrhea
Signvery rapid, thirsty ,cold extremity
and sweaty, consciousness goes down
and appears hypovolemik shock
Hypertonis Dehydration
Loss water and Na ,but the proportion
of lossing water is more than lossing
Na (Na >150 mmol/L)
Sign very thirsty,irritable
Hypotonis dehydration
Loss water and Na ,but the proportion
of lossing Na is more than lossing
water (Na >130 mmol/L)
sign letargi, spasm
Physical exam
Low blood pressure
Blood pressure that drops when
you go from lying down to standing
Rapid heart rate
Poor skin turgor-- the skin may lack
its normal elasticity and sag back
into position slowly when pinched
up into a fold by the doctor;
normally, skin springs right back
into position
Delayed capillary refill
Shock
Scoring System
Degree of dehydration
Score 0 1 2
General condition Healthy Irritability, Delirium, coma
sleepy, or shock
apathy Very
Skin elasticity Normal
Decreased decreased
Eye Normal
Sunken(ckun Very sunken
Fontanel (ubun2) Normal
g) Very sunken
Mouth Normal
Sunken Dry & cyanotic
Pulse Normal
Dry > 140
120-140
Amount of score: 0- 2 Mild dehydration
3- 6 Moderate dehydration
7-12 Severe dehydration
Plan A
(to prevent dehydration)
1. Give patients more liquid than usual, such as:
Oralite,dll
Keep breastfeeding and give formula milk
2. Continue give meals
Porridge with meats or fish.
Bananas/ juices to additional Kalium.
Give foods every 3-4 hours (6x a day).
Plan A
(to prevent dehydration)
3. Bring patient to medical centre if:
Often defecation
Very thristy
Sunken eyes
Fever
Anorexia
Bloody stools
4. Give oralite
<2 years : 50-100 ml (1/4 -1/2 cup)
2-5 years : 100-200 ml (1/2-1 cup)
Plan B
(for mild/ moderate dehydration)