Gastro Week 2

Gilbert S. Octavius 2014

 Anatomy
• Small Intestine  Kerckring folds (Valvulae
conniventes)  slow down the progression of the
luminal contents & increase the SA
• Terminal ileum  bloodless fold of treves &
mesoappendix
• Ileocecal valves  labrum coli & labrum iliocecal
• Terminal ileum  peyer patches in lamina
propria; Jejunum  solitary nodule, ileum 
aggregrate
 Anatomy
• Colon  Haustra; Total length  120-150 cm
• AC  15-20 cm; TC  30-60cm; DC  20-25 cm
• 3 distinctive features:
1. Taeniae: taenia mesocolica, taenia omentalis
and taenia libera (the only one seen
anatomically  identify appendix)
2. Haustra
3. Appendices epiploicae
 Sigmoid Colon
• Omega shaped flexure arching over the pelvic
inlet toward the S1/S2
• Joins the rectum at an acute angle at S3
 Innervation
• Parasympathetic  CN X
• Sympa:
1. SI  T9-T10
2. AC & Appendix  T10-T12
3. TC  T12-L1
4. DC & rectum  L1&L2
 Motility of Small Intestine
Segmentation
• Oscillating, ring-like contraction of the circular smooth muscle along
the small intestine’s length
• Initiated by small intestine’s pacemaker cells which produce BER
• Duodenum primarily responses to local distension while ileum
responds to gastrin in stomach (gastroileal reflex)
• Extrinsic nerves can modify the strength  PNS enhances
segmentation while SNS do the opposite
• Segmentation serves to mix the chyme with digestive juices and
expose all the chyme to the absorptive surfaces
• Frequency of segmentation declines along the length of small
intestine; duodenum 12 per minute while terminal ileum 9 per
minute  more food is pushed forward than backward even
though it is shuffled back and forth to accomplish thorough mixing
and absorption
Migrating Motility Complex (MMC)
• “Stomach Growling”
• Regulated by motilin
1. Phase I = lasting 40-60 minutes with very few
contractions
2. Phase II = lasting 20-30 minutes with some
peristaltic contractions
3. Phase III = shortest phase where intense
peristaltic contractions begin in the upper stomach
and migrate through the end of small intestine.
Contractions repeat for 5-10 minutes the pyloric
sphincter relaxes and opens completely
 Ileocecal valve
• Distension in ileum  sphincter relax
(mediated by gastrin at the onset of a meal),
distension in cecal  contract
• This way it prevents the bacteria from
contaminating small intestine
 Digestion
• Exocrine gland cells secrete 1.5 L of succus entericus that contains a lot of water
for lubrication and enzymatic degradation of food but it contains NO ENZYMES!
• Pancreatic enzymes are responsible for digestion in small intestine with fat
digestion is enhanced by bile secretion
• Small intestine has special cells called microvilli that form brush border and
three categories of integral proteins can be found here:
1. Enterokinase
Activates pancreatic proteolytic enzyme trypsinogen

2. Disaccharidases (maltase, sucrose-isomaltase, and lactase)

α-limit dextrins can only be broken down by sucrose-isomaltase
The end digestion of the sucrose and lactose is completed y sucrose-isomaltase and
lactase respectively

• 3. Aminopeptidases
Hydrolyze most of the peptide segments
 Absorption
• Only the absorption of calcium and iron is
regulated
• Most absorption occurs in the duodenum and
jejunum (mostly)
• Small intestine has an abundant reserve
absorptive capacity but if the terminal ileum is
removed, vitamin B12 and bile salts are not
properly absorbed
 Mucosal Lining Turnover
• Shallow invagination in small intestine  crypts of Lieberkϋhn 
secrete water and salt and contributes to succus entericus
• Function also as nurseries  produce new stem cells that migrate
up the villi and push off the older cells at the tip of lumen into
lumen every 3 days (hence the tip of villus has the highest digestive
and absorptive activity)
• Crypt cells are very sensitive to radiation due to this high turnover
• Dead cells are digested and cell constituents are absorbed into the
blood and reclaimed for synthesis of new cells
• Paneth cells (for defense purposes):
• 1. Lysozyme  lyses bacteria’s cell wall
• 2. Defensins  small proteins with antimicrobial powers
 Physiology of Large Intestine
• Colon receives 500 mL of chyme each day
• Contents delivered to colon consist of indigestible
food residues (cellulose), unabsorbed biliary
components and the remaining fluid
• Colon extracts more water and salt  feces
• Main function: store feces before defecation
• Cellulose and other indigestible food residues
provide bulk and help maintain regular bowel
movements by contributing to the volume of the
colonic contents
 Motility
• Gastrocolic reflex  when food enters the
stomach, mass movements are triggered in the
colon (Mediated by gastrin and extrinsic
autonomic nerves). It triggers the defecation
reflex as it moves food further in preparation for
the next food.
• Most of the time  slow and non-propulsive (for
absorptive and storage function)
• Main motility  Haustral contractions initiated
by BER of colon (30 mins elapse before next
contraction)
 Defecation Reflex
• Internal anal sphincter (smooth muscle) relax and
rectum & sigmoid colon contract more vigorously
• External anal sphincter (skeletal muscle) also
relaxes  defecation occurs
• If defecation is delayed, the distended rectal wall
gradually relaxes and the urge to defecate
subsides until the next mass movement
• Assisted by voluntary straining movements 
contraction of abdominal muscles and a forcible
expiration against a closed glottis  increased
intra-abdominal pressure
 Secretion
• No enzymes
• Secretion consists of alkaline (NaHCO3) mucous
solution  protect mucosa from mechanical and
chemical injury
• Mucus provides lubrication to facilitate passage of
feces
• NaHCO3 neutralizes irritating acids produced by local
bacterial fermentation
• Secretion increases by mechanical and chemical
stiulation mediated by short reflexes and PNS
• Colonic bacteria digests some of the cellulose for their
use
 Absorption
• Absorbs salt and water; sodium is actively
absorbed, chloride follows passively down the
electrical gradient and water follows osmotically
• Feces  100g of water and 50g of solid
(cellulose, bilirubin, bacteria, and small amounts
of salt)
• Main waste product excreted in feces  bilirubin
• Bacteria  1/3 dry weight of feces
 Embryology of Small Intestine
• The cephalic limb of the loop develops into
the distal part of the duodenum, the jejunum,
and part of the ileum.
• The caudal limb becomes the lower portion of
the ileum, the cecum, the appendix, the
ascending colon, and the proximal two-thirds
of the transverse colon.
 Embryology of Small Intestine
• As a result of the rapid growth and expansion of
the liver, the abdominal cavity temporarily
becomes too small to contain all the intestinal
loops, and they enter the extraembryonic cavity
in the umbilical cord during the sixth week of
development (physiological umbilical herniation)
• Coincident with growth in length, the primary
intestinal loop rotates around an axis formed by
the superior mesenteric artery
 Embryology of Small Intestine
• Rotation of 270 degree counterclockwise occurs
• Rotation occurs during herniation (about 90°), as
well as during return of the intestinal loops into
the abdominal cavity (remaining 180°)
• During the 10th week, herniated intestinal loops
begin to return to the abdominal cavity.
• The proximal portion of the jejunum, the first
part to reenter the abdominal cavity, comes to lie
on the left side
 Gastroschisis
• Body wall closure fails in abdominal region
• Intestinal loops herniate into abd. cavity 
affected loops of bowel might be damaged by
amniotic fluid
• Usually lies to the right of umbilicus
• Occurs more commonly in mother <20 yrs
with elevated AFP
 Omphalocele
• Failure of physiological umbilical herniation
• Loops of bowel, other viscera and liver may
herniate
• Umbilical cord is covered by amnion  no
damage
• Associated with cardiac abnormalities and
neural tube defects
• Elevated AFP in mother
 Meckel’s Diverticulum
Rule of 2’s:
• 2% of population
• 2% are symptomatic
• Symptomatic before age of 2
• Found within 2 feet (40-60cm) of ileocecal valve
on antimesenteric border
• 2x more common in male
• Approximately 2 inches in length (5 cm)
• 2 common types of ectopic tissues: gastric &
pancreas
 Intestinal Atresia
• Hypertrophic pyloric stenosis (not part of
intestinal atresia) : Single-bubble sign
• Duodenal atresia : Double-bubble sign
• Jejunal atresia: Triple-bubble sign
 Definition of Diarrhea
• Diarrhea is defined as stool weight greater
than 200 g per day but this definition has
limited value in clinical practice.

• World Health Organization  three or more

loose or watery stools per day or more
frequently than an individual’s baseline
 WHO Classification
• Acute watery diarrhoea (including cholera), which lasts several
hours or days: the main danger is dehydration; weight loss also
occurs if feeding is not continued;
• Acute bloody diarrhoea, which is also called dysentery: the main
dangers are damage of the intestinal mucosa, sepsis and
malnutrition; other complications, including dehydration, may also
occur;
• Persistent diarrhoea, which lasts 14 days or longer: the main danger
is malnutrition and serious non-intestinal infection; dehydration
may also occur;
• Diarrhoea with severe malnutrition (marasmus or kwashiorkor): the
main dangers are severe systemic infection, dehydration, heart
failure and vitamin and mineral deficiency.
 Classification Based on Duration
• Acute: less than or equal to 14 days in
duration
• Persistent: more than 14 days in duration
• Chronic: more than 30 days in duration
 Causes
• 80% infections; 20% drugs and/or chemicals
• Non-infectious causes: medications,
microbiota shifts, ischemic colitis, food allergy,
fecal impaction, malignancy, and early
manifestations of chronic diseases such as
inflammatory bowel disease and
thyrotoxicosis
Epidemiological Clues to Infectious
Diarrhea
Systemic Symptoms and Complications
of Enteric Infection
High-risk groups
 Infectious Diarrhea
• Most common: Viral
• Bacterial and protozoan less common
 Viral Gastroenteritis
• Most common in adult: Norovirus
• Common outbreak settings include: (1)
restaurants or events with catered meals, (2)
long-term care facilities, (3) schools, day-care
centers, and (4) vacation destinations
including cruise ships
 Viral Gastroenteritis
• Most common in infants & young children:
Rotavirus (However, Pediatrics In Review 2016
states that it is now norovirus that is the most
common cause; not rotavirus)  Just answer
rota for exam
• Typical symptom: vomiting, nonbloody
diarrhea, and fever
 Bacterial GE
• If bloody, think of these 4 causes: Shigella,
Campylobacter, Salmonella, and
enterohemorrhagic Escherichia coli (EHEC)
O157:H7.
• If non-bloody, think: enterotoxigenic E. coli
(ETEC), Clostridium difficile, Vibrio cholerae,
and Yersinia (psuedoappendicitis)
 Bacterial GE
• Shigella  person-to-person; a problem in day-
care centre
• Campylobacter  undercooked poultry (2nd most
common foodborne disease)
• Nontyphoidal salmonellosis  most common
foodborne illness
• Salmonella  poultry, eggs & milk
• EHEC  undercooked ground beef (hamburger
dz); complication  TTP & HUS
• C. Difficile  Antibiotic-related diarrhea
 Protozoa
• The common parasites are Cryptosporidium,
Giardia, Cylospora, and Entamoeba histolytica
• Most common: Cryptosporodium (transmitted
by infected person or animal, fecally
contaminated food or water source)
• Immunocompetent  severe dehydration but
self-limited
 Protozoa
• G. lamblia  2nd most common
• Cyclospora  diarrhea more than 3 weeks
with intense fatigue
• E. histolytica  intestinal amebiasis and in
developed countries is mainly seen in
migrants from and travelers to endemic
countries. Sexually active homosexuals are
also at an increased risk.
 Food Poisoning
• Causes of food poisoning include heavy
metals, monosodium glutamate, insecticides,
and toxins found in seafood and mushrooms.
• Puffer fish poisoning is caused by tetrodotoxin
contained only in that fish, and scombroid
poisoning results from the breakdown of flesh
in certain fish with the release of histamine
 Traveler’s Diarrhea
• Traveler’s diarrhea is the most common illness of
patients from developed countries traveling to
developing countries
• Benign & Self-Limited
• 90% caused by ETEC
• Other common causes: Shigella, Campylobacter and
Salmonella
• The main preventative tool is education but useful
medications include fluoroquinolones, rifaximin, and
bismuth subsalicylate.
• Treatment comprises fluid and electrolyte repletion
and antibiotics when necessary.
 Diagnostic Approach
• The American College of Gastroenterology published
guidelines regarding which patients should undergo
additional medical evaluation as defined by the severity of
illness.
• Those having one or more of the following should have
additional testing:
a) profuse watery diarrhea resulting in hypovolemia,
b) bloody stools, fever (temperature >38.5°C), more than six
stools in 24 h, duration of illness greater than 48 h,
c) Severe abdominal pain,
d) diarrhea in the elderly (>70 years), or in the
immunocompromised patient (AIDS, after transplantation,
patients receiving chemotherapy)
 Historical Clues
• Fever suggests invasive bacteria such as
Campylobacter, Shigella, or Salmonella, or other
cytotoxic organisms such as C. difficile and Entamoeba
histolytica
• Symptoms that begin within 6 h of food ingestion
suggest the presence of a preformed toxin of
Staphylococcus aureus or Bacillus cereus.
• Symptoms that begin within 8–16 h are consistent with
infection with Clostridium perfringens.
• Symptoms that begin after more than 16 h may be due
to viral or bacterial infection.
 Lab Testing
• Fecal leukocytes & stool culture: not helpful
• Ova & parasites: not indicated for all; patients
with persistent diarrhea, diarrhea in men who
have sex with men, or patients with AIDS, a
community water outbreak (associated with
Giardia and Cryptosporidium), and bloody
diarrhea with few or no leukocytes (associated
with intestinal amebiasis).
• Because parasitic excretion may be intermittent,
obtaining three specimens on consecutive days is
recommended.
 Treatment
• The mainstay of treatment for acute diarrhea is
hydration
• Bismuth subsalicylate is safe and efficacious in bacterial
diarrheas
• Loperamide can also be useful and safe in patients with
traveler’s diarrhea as long as it is not given to patients
with high fevers or blood in stool
• Antiemetics are safe and make symptoms more
tolerable.
• Probiotics can also be useful in treating traveler’s
diarrhea
 Complications
• Guillain-Barre syndrome: Campylobacter
jejuni
• TTP-HUS: EHEC
• PI-IBS
• Reactive Arthritis: Salmonella, Shigella,
Yersenia, Campylobacter an C. difficile
Chronic Diarrhea
Chronic Diarrhea
 Laboratory Testing
• Initial laboratory testing typically begins with a complete blood
count with differential, electrolytes including renal function testing,
liver function tests, and serum albumin with total protein levels.
• Although nonspecific, elevation of erythrocyte sedimentation rate
and C-reactive protein levels may be indicative of inflammatory
bowel disease, particularly in those patients where there is a high
clinical suspicion.
• Low serum albumin levels occur in patients with poor nutritional
status as well as those with chronic inflammatory conditions
through a decrease in protein synthesis
• Testing for vitamin and mineral deficiencies can provide clues to the
localization of disease
• Colonoscopy with terminal ileal and colonic biopsies is
recommended in patients without an established diagnosis after
initial testing, particularly those over the age of 50
 Difference between secretory and
osmotic
• Secretory: frequent, watery, voluminous, bowel
movements, night-time awakening, dehydration,
altered serum electrolytes, and lack of response
to fasting
• Osmotic: Classically, patients suffering from
osmotic diarrhea report having loose stools that
improve or resolve with fasting. Because of this,
nighttime symptoms are rare and patients may
even report food avoidance prior to long trips in
an effort to avoid diarrhea.
 Difference between secretory and
osmotic
• Osmotic gap of secretory is < 50 mOsm/kg
while osmotic is > 100 mOsm/kg
• Osmotic gap is calculated though the equation
290 − 2 × (stool Na + stool K)
Stool Examination
Bristol Stool Chart
 Special Tests for Stool
• Ova, parasites, bacterial or viral
• Fecal calprotectin: test for inflammation (e.g :
IBD)  Presence of this rules out IBS most of
the time
• FOBT: think of colon cancer if old age  + test
is an indication for a
colonoscopy/sigmoidscopy
 Prebiotic vs Probiotic
• Probiotics are live-microbial food supplements
that benefit the person by improving microbial
balance
• Prebiotic is a nondigestible food ingredient
that promotes the growth of beneficial
microorganisms in the intestines
 Lactose Intolerance
• Lactose intolerance occurs when there is a
deficiency of lactase in the brush border of the
small intestine.
• The clinical picture varies with the amount of
lactose ingested and malabsorbed and the degree
of the lactase deficiency
• Treatment: removing all lactose-containing foods
or lactase substitutes
• DD: Carbo malabsoprtion  usually there is
redness around anus
 Celiac Disease
• Gluten enteropathy, or celiac disease, is a
malabsorption syndrome that results from
gluten-sensitive damage to the intestinal
microvilli and villi, producing an abnormal
villous architecture and resulting in
malabsorption
• Genetic studies show that a person must have
alleles that encode for HLA-DQ2 or HLA-DQ8
proteins.
 Whipple Disease
• Whipple disease is a systemic, infectious
disease that primarily affects the small
intestine and its lymphatic drainage, although
it also has many extraintestinal manifestations
• Tropheryma whippelii  causative organism
• Treatment: Pencillin G + Streptomycin
 SIBO
• The small intestinal bacterial overgrowth
(SIBO) syndrome may be caused by a
disturbance in gastrointestinal (GI) motility, by
an alteration in the anatomy of the intestine,
or less likely, by a loss of gastric acid secretion
• More than 10^5 CFU/ml
 SBS
• Short bowel syndrome (SBS) usually occurs when
less than 200 cm of small intestine remains after
intestinal surgery.
• Normally, the bowel measures 450 to 500 cm (18-
20 feet).
• Features of SBS may include
• hypovolemia, dehydration, metabolic acidosis,
hypoalbuminemia, and deficiencies of potassium,
calcium, zinc, magnesium, copper, body acids, fat-
soluble vitamins, folic acid, and B12
 Intussusception
• Intussusception is the invagination of a portion of
the intestine into the contiguous distal segment
of the enteric tube
• It usually occurs in infants at 4 to 10 months of
age and is associated with acute enteritis, allergic
reactions, and conditions that cause
hypermotility.
• sudden development of abdominal pain and
cramplike sensations occurring every 10 to 20
minutes. Children may appear to be in shock.
 Intussusception
• In children, the most common causes of
intussusception are associated infections, and
in adults, the most common causes are
neoplasms
• The most common is the ileocolic
intussusception
• Red-currant jelly stool
• X-ray: Crescent sign, sausage-shape sign &
coiled-spring sign
 Volvulus & Perforation
• Most common site for volvulus: sigmoid colon
• Most common site for perforation: Cecum
 Small & Large Bowel Obstruction
• Small – bowel obstruction: Air-fluid level on
xray, stepladder pattern, herring bone sign,
coil-spring sign and string-bead sign
• Large bowel obstruction  Colon dilation
 Hirchsprung’s Disease
• Aganglionosis in the rectum area
• Baby fails to pass stool in the first day
• On DRE, the stool “burst forth”
 Milk Allergy
• Most common in a baby that just switched to
formula milk
• Can occur up to 30 days from switching
• Need to be differentiated with lactose
intolerance
 Constipation
• Constipation can generally be defined as fewer than
three bowel movements per week. However, if it is
included as a “functional disorder” in accordance with
the Rome II criteria, the definition would state that the
diagnosis of constipation requires at least 12 weeks of
symptoms during the preceding 12 months, and that
two of the following criteria should be present:
• straining, lumpy or hard stool, sensation of incomplete
evacuation,
• sensation of anorectal obstruction, and
• fewer than three bowel movements per week
 Antidiarrheal Drugs
Principle of use :
1.May be used safely in patient w/ mild to
moderate acute diarrhea
2.Should not be used in bloody diarrhea, high fever,
systemic toxicity
3.Should be discontinued when diarrhea is
worsening despite therapy
4.Also used to control chronic diarrhea cause by IBS
(irritable bowel syndrome) or inflamatory bowel
disease (IBD)
 Opioid Antagonists
Opioid Agonists :
• decrease mass colonic movements & gastrocolic reflex
• Increased fecal water absorption
• Decrease fluid secretion
1.Loperamide  does not cross the blood-brain barrier,
no analgesic properties or potential addiction.
2.Diphenoxylate  no analgesic properties in standard
doses; however, higher doses have CNS effects &
prolonged use can lead to opioid dependence.
 Adrenergic Receptor Agonists

Adrenergic Receptor Agonists

• Clonidine  interact w/ specific receptors on
enteric neurons & enterocytes  stimulating
absorption and inhibiting secretion of fluid and
electrolytes
• Have a special role in diabetics with chronic
diarrhea, in whom autonomic neuropathy can
lead to loss of noradrenergic innervations
• Side effects : hypotension, depression, and
perceived fatigue may be dose limiting in
susceptible patients
 Anticholinergics

Anticholinergics
• Decrease intestinal muscle tone and peristalsis of
GI tract  Slowing the movement of fecal matter.
• Inhibit secretion of fluids into GI tract.
Examples :
• –Belladonna alkaloids
• –Atropine
• –Hyoscyamine
 Side effects of Anticholinergics
• Urinary retention & hesitancy, impotence
• Headache, dizziness, confusion, anxiety,
drowsiness
• Dry skin, rash, flushing
• Blurred vision, photophobia, increased
intraocular pressure
• Hypotension, hypertension, bradycardia,
tachycardia
 Colloidal Bismuth Compound

Colloidal Bismuth Compound

• Have antisecretory (GI tract walls coating),
antiinflammatory & antimicrobial effects
• Bind to the causative bacteria or toxin (adsorbents)
• Also relieve nausea and abdominal cramps
• Used extensively for prevent & treatment traveler's
diarrhea
• Also is effective in other forms of episodic diarrhea and
in acute gastroenteritis
• Use for the alternative treatment of Helicobacter pylori
• Side effects: Dark stool & tongue
 Kaolin & Pectin

Kaolin & Pectin

• Kaolin is a naturally (mineral clay) occurring
hydrated magnesium aluminum silicate
(attapulgite)
• Pectin is an indigestible carbohydrate from apples
• Act as absorbents of bacteria, toxins, and fluid,
thereby decreasing stool liquidity and number
• May be useful in acute but are seldom used on a
chronic
• A common preparation is Kaopectate.
 Salt–Binding Resins (Cholestyramine)

Salt–Binding Resins (Cholestyramine)

• Conjugated bile salts normally absorbed in
terminal ileum.
• Disease of the terminal ileum (eg, Crohn's
disease) or surgical resection leads to
malabsorption of bile salts may cause colonic
secretory diarrhea
• Decrease diarrhea caused by excess fecal bile
acids
• Adverse effects include bloating, flatulence,
constipation, and fecal impaction
 Octreotide
• Octreotide is a synthetic Somatostatin with
actions similar to somatostatin.
Clinical Uses
• Inhibition of Endocrine Tumor Effects
(acromegaly)
• Two gastrointestinal neuroendocrine tumors
(carcinoid, VIPoma) cause secretory diarrhea.
• For patients with advanced symptomatic tumors
that can’t be completely removed by surgery,
octreotide decreases secretory diarrhea and may
slow tumor progression.
 WHO Diarrhea
5 Pilar WHO:
1. Oralit
2. Zinc  6 bulan (1/2 tablet; 10 mg per hari); 6 bulan ke
atas (1 tablet; 20 mg per hari) selama 10
3. ASI dan makanan tetap untuk mencegah kehilangan
berat badan serta pengganti nutrisi yang hilang.
4. Antibiotik jangan diberikan kecuali dengan indikasi
misalnya diare berdarah, kolera.
5. Nasihat pada ibu atau pengasuh: kembali segera jika
demam, tinja berdarah, muntah berulang, makan atau
minum sedikit, sangat haus, diare makin sering, atau
belum membaik dalam 3 hari.
 Pearl(s)
Oedematous (puffy) eyelids are a sign of over-
hydration. If this occurs, stop giving ORS
solution, but give breastmilk or plain water, and
food. Do not give a diuretic. When the oedema
has gone, resume giving ORS solution or home
fluids according to Treatment Plan A.
 Pearl(s)
Vomiting often occurs during the first hour or
two of treatment, especially when children drink
the solution too quickly, but this rarely prevents
successful oral rehydration since most of the
fluid is absorbed. After this time vomiting
usually stops. If the child vomits, wait 5-10
minutes and then start giving ORS solution
again, but more slowly (e.g. a spoonful every 2-3
minutes).
 Pearl(s)
If ORT must be interrupted, provide enough
supplies to the mother and show her how to
feed the baby. The supplies should be enough
for 2 days and after that she should come back
 Pearl(s)
Causes of ORT failures:
1) continuing rapid stool loss (more than 15-20
ml/kg/hour), as occurs in some children with
cholera;
2) insufficient intake of ORS solution owing to
fatigue or lethargy;
3) frequent, severe vomiting.
 Pearl(s)
Contraindications for ORT:
• Abdominal distension with paralytic ileus,
which may be caused by opiate drugs (e.g.
codeine, loperamide) and hypokalaemia;
• Glucose malabsorption, indicated by a marked
increase in stool output when ORS solution is
given, failure of the signs of dehydration to
improve and a large amount of glucose in the
stool when ORS solution is given.
 Vibrio Cholera
• Gram (-), non-invasive
• Requires high infective dose (sensitive to gastric
acid)  100 million
• Agar  TCBS
• Serogroup O1 & O139
• Virulence strain: H antigen & O-LPS
• Rice water stool (usually endemic in places that
suffered from natural disaster)
• NO FEVER
• Increase cAMP
 Salmonella
• Gram (-) bacilli
• Hektoen agar
• K (Vi) antigen
• Agglutination with O, H & Vi antigen
• Widal test; leukopenia
• There might be some ‘rose spots’
• Carrier  gallbladder of females
• Cause hypertrophy of peyer patches (terminal
ileum)
 Shigellosis
• Facultative anaerobic; gram (-) rods
• Severe dysentry  Shigella dysenteriae; Mild
dysentry  S. sonnei
• Shiga toxin!!!
• Most common cause of dysentry
 Campylobacter
• Gram (-), spiral curve
• Poultry  chicken, cows etc
• Low infective dose  < 1000 bacteria
• C. jejuni  complication can cause GBS
 Clostridium Difficile
• Gram (-)
• ANTIBIOTIC ASSOCIATED DIARRHEA
• Formation of yellowish pseudomembrane 
sigmoidoscopy
• Treatment  Discontinue the antibiotic; use
vancomycin and metronidazole
• Most common etiology  Clindamycin
 Escherichia Coli
• Gram (-) rods, peritrichous flagella
• MacConkey (pink), EMB (green) agar
• Facultative anaerobic
• Catalase (+), oxidative (+), VP (-)
• 6 types:
a) EIEC (Enteroinvasive)
b) EPEC (Enteropathogenic)
c) ETEC (Enterotoxigenic)
d) EHEC (Enterohemorrhagic)
e) EAEC (Enteroadherent)
f) DAEC (Diffusely Adhering)
 EIEC
• No LT (heat-labile) or ST (heat-stabile) toxin;
no shiga toxin
• Shigella-like dysentry w/ fever
 ETEC
• Most common cause of traveller’s diarrhea
• Produce ST & LT toxin
 EPEC
• Infantile GE, watery darrhea
 EAEC
• Moderately invasive; there is an inflammatory
response
• Produce enterotoxins
 EHEC
• Bloody diarrhea w/ no fever
• O157:H7
• Shiga toxin / Verotoxin
• Infective dose : <100 bacteria
• Cause TTP & HUS
 Ascariasis
• Loeffler syndrome:
a) Fever
b) Cough
c) Eosinophilia
d) CXR: infiltrate
• Treatment: Albendazole & Mebendazole
• Auscultation: Metallic sound
 Trichuriasis
• Trichuris Trichura
• Heavy infection: Prolapsus of rectum / anii
• Eggs: barrel-shapped/lemon-shaped/plug at
both ends
• Treat: Alben & Meben
 Amebiasis
• E. Histolytica
• Transmission  Ingestion of cysts (fecal-oral
route in food & water) or Anal-oral route
• Clinical finding  Dysentry amoeba
• Extraintestinal  Liver (most common), lung and
brain
• Diagnosis  Trophozoites in diarrhea stool or
cysts in formed stool
• Treatment  Metronidazole & Paromomycin
 Giardiasis
• G. Lamblia
• Water supplies, homosexuals
• Ingestion of cysts in contaminated water (RARELY
FOOD); person to person
• NO FEVER
• Steatorrhea WITHOUT BLOOD
• Diagnosis: Examination of stools for trophozoites
• Treatment: Metronidazole & Mepacrine
 Cryptosporodiasis
• Cryptosporodium
• Children & HIV patients
• Ingestion of cryptosporodium oocytes; fecal to oral,
person to person, zoonotics, water & foodborne
(resistant to chlorination)
• C. Parvum (outside) & C. hominis (Indo)
• CD4+ <50  can lead to death
• Extraintestinal manifestations: Biliary involvement
• Diagnosis: Kinyoun stain
• Treatment: Paromomycin, Nitazoxamide
 Balantidiasis
• Balantidium Coli
• Domestic animals; esp pigs (main reservoir)
• Ingestion of cysts in food or water contaminated
with animal or human feces
• Extraintestinal manifestations: Peritonitis &
Uretritis
• Diagnosis: Large ciliated trophozoites or large
cysts in stool
• Treatment: Tetracycline & Metro
 Fasciolopsis
• Intestinal fluke
• Fasciolopsis buskii; consumption of WATER
PLANTS (METACERCARIA)
• Sei Papuyu (South Kalimantan)
• Treatment: Praziquantel
 Fascioliasis
• Fasciola gigantica (Indo) & Fasciola hepatica
(Cone head  cow; Sheep liver fluke)
• Transmission: Watercress (aquatic plant);
metacercariae
• Treatment: Praziquantel, bithionol
 Clonorchiasis
• C. sinensis (Asian liver fluke)
• Transmission: Eating raw or undercooked fish
containing the encysted larvae (metacercaria)
• Def.host: human; intermediate host: snails
and fish
• Treatment: Praziquantel
 Schistosomiasis
• S. hematobium  Urinary bilharziasis
(hematuria + cystitis; Vesico schistosomiasis
 Veins of urinary bladder & rectum
• S. japonicum  Oriental schistosomiasis,
KATAYAMA fever  SMV, liver (cirrhosis or
portal hypertension)
• S. mansoni  Intestinal bilharziasis  IMV
• Treatment: Praziquantel