PBL 6: ALS – FOOD POISONING spread by faeces-contaminated water.

Infection is more common when there is a

1. Aetiophatology of diarrhoea shortage of adequate sanitation and hygiene
2. Types & classification of stool and safe water for drinking, cooking and
- Colour cleaning. Rotavirus and Escherichia coli, are
- Consistency the two most common etiological agents of
3. Histology of GIT moderate-to-severe diarrhoea in low-income
4. 9 abdominal region & 4 quadrant countries. Other pathogens such
5. Management & treatment as cryptosporidium and shigella species may
- ORS also be important. Location-specific etiologic
- IV fluid patterns also need to be considered.
- Antibiotic - Malnutrition : Children who die from
6. Communicable & non-communicable diarrhoea often suffer from underlying
disease malnutrition, which makes them more
7. Notifiable disease vulnerable to diarrhoea. Each diarrhoeal
8. Importance of hygiene food preparation & episode, in turn, makes their malnutrition
avoidance of eating overnight food even worse. Diarrhoea is a leading cause of
9. High risk food implicated in GIT malnutrition in children under five years old.
10. Common causes of acute food poisoning - Source : Water contaminated with human
faeces, for example, from sewage, septic tanks
and latrines, is of particular concern. Animal
1. AETIOPATHOLOGY OF DIARRHOEA faeces also contain microorganisms that can
cause diarrhoea.
What is diarrhoea? - Other causes : Diarrhoeal disease can also
• Diarrhoea is when your bowel spread from person-to-person, aggravated by
movements become loose or watery. The poor personal hygiene. Food is another major
definition of diarrhoea is passing loose or cause of diarrhoea when it is prepared or
watery bowel movements 3 or more stored in unhygienic conditions . Unsafe
times in a day (or more frequently than domestic water storage and handling is also
usual). an important risk factor. Fish and seafood
• Diarrhoea occurs when the lining of the from polluted water may also contribute to
intestine is unable to absorb fluid, or it the disease
actively secretes fluid. 2. TYPES & CLASSIFICATION OF STOOL
Causes
 infection (with a virus, bacteria or parasite)
 change in diet
 food intolerance (e.g. lactose)
 drinking excess alcohol
 inflammatory bowel disease (ulcerative colitis
or Crohn’s disease)
 coeliac disease
 malabsorption (e.g. due to problems with the
pancreas)
 surgery (e.g. when part of the bowel has been
removed)
 irritable bowel disease
 medicines (e.g. a side effect of antibiotics or
some diabetes medications)
Classification of causes of diarrhoea:
- Infection : Diarrhoea is a symptom of
infections caused by a host of bacterial, viral
and parasitic organisms, most of which are
 A loose connective tissue layer, with larger blood
vessels, lymphatics, nerves, and can contain
mucous secreting glands.

3) Muscularis propria (externa): smooth muscle

layer
There are usually two layers; the inner layer is
circular, and the outer layer is longitudinal. These
layers of smooth muscle are used for peristalsis
(rhythmic waves of contraction), to move food
down through the gut.

4) Adventitia layer (or serosa)

Outermost layer of loose connective tissue -
covered by the visceral peritoneum. Contains
blood vessels, lymphatics and nerves.

There are seven types of stools (faeces) according

to the Bristol Stool Chart. The Bristol Stool Chart or
4. 9 ABDOMINAL REG. & 4 QUADRANT
Bristol Stool Scale is a medical aid designed to
classify faeces into seven groups. OF ABDOMEN

Every person will have different bowel habits, but

the important thing is that your stools are soft and
easy to pass – like types 3 and 4 below.

- Type 1–2 indicate constipation

- Type 3–4 are ideal stools as they are easier to
pass
- Type 5–7 may indicate diarrhoea and urgency.
3. HISTOLOGY OF GIT
Layers of the Gastrointestinal Tract
The GI tract contains four layers. The structure of
these layers varies, in different regions of the
digestive system, depending on their function.

1) Mucosa
A lining epithelium, including glandular tissue, an
underlying layer of loose connective tissue called
the lamina propria, which provides vascular
support for the epithelium, and often contains
mucosal glands. Products of digestion pass into
these capillaries. Lymphoid follicles, and plasma
cells are also often found here. Finally, a thin
double layer of smooth muscle is often present -
the muscularis mucosa for local movement of the
mucosa.

2) Submucosa
 Parasites or their eggs can be seen under a
microscope.
The doctor will ask about the symptoms and about
any current medications, past medical history, and
other medical conditions.
They will also ask:
• when the problem started
• how frequent the stools are
• whether blood is present in the stool
• whether there has been vomiting
• whether the stools are watery,
mucus- or pus-filled, and how much
stool there is
The doctor will also look for signs of dehydration.
Severe dehydration can be fatal if treatment with
rehydration therapy is not given urgently.
Tests for diarrhea
Most cases of diarrhea resolve without treatment,
and a doctor will often be able to diagnose the
problem without tests.
However, in more severe cases, a stool test may be
needed, especially if the patient is very young or
old.
Further tests may also be recommended if the
patient:
• has signs of fever or dehydration
• has stools with blood or pus
• has severe pain
• has low blood pressure
• has a weakened immune system
• has recently traveled to places
outside Western Europe, North
America, Australia, and New Zealand
• has recently received antibiotics or
been in hospital
• has diarrhea persisting for more than
1 week
• If a person has chronic or persistent
diarrhea, the doctor will order tests
according to the suspected
underlying cause.
• These may include the following
investigations:
• Full blood count: Anemia or a raised
platelet count will suggest
inflammation.
• Liver function tests: This will include
testing albumin levels.
• Tests for malabsorption: These will
check the absorption of calcium,
vitamin B-12, and folate. They will
also assess iron status and thyroid
function.
• Erythrocyte sedimentation rate (ESR)
5. MANAGEMENT & TREATMENT and C-reactive protein (CRP): Raised
Tests and diagnosis levels may indicate inflammatory
bowel disease (IBD).
 • Testing for antibodies: This may
detect celiac disease.
Treatment
Mild cases of acute diarrhea may resolve without
treatment. Persistent or chronic diarrhea will be
diagnosed and any underlying causes will be
treated in addition to the symptoms of diarrhea.
Dehydration
For all cases of diarrhea, rehydration is key:
Fluids can be replaced by simply drinking more
fluids, or they can be received intravenously in
severe cases. Children and older people are more
vulnerable to dehydration.
- Oral rehydration solution or salts
(ORS) refers to water that contains salt
and glucose. It is absorbed by the small
- This solution is an isotonic crystalloid that
intestine to replace the water and
electrolytes lost in the stool. In
developing countries, ORS costs just a few
cents. The World Health Organization
(WHO) says ORS can safely and effectively
treat over 90 percent of non-severe
diarrhea cases.
Oral rehydration products, such
as Oralyte and Rehydralyte, are available
commercially. Zinc supplementation may
reduce the severity and duration of
diarrhea in children. Various products are
available to purchase online.
- Is an isotonic carbohydrate (sugar)
- Intravenous fluid regulation is the
control of the amount of fluid you receive
intravenously, or through your
bloodstream. The fluid is given from a bag
connected to an intravenous line. This is a
thin tube, often called an IV, that’s
inserted into one of your veins.
Types of IV fluid:
1. 9% Normal Saline ( also known as
NS, 0.9NaCl, or NSS)
- This is a hypotonic crystalloid solution of
- Less commonly, this solution is referred
to as physiological saline or isotonic saline
- This is one of the most common IV fluids
because it works for most hydration
needs due to vomiting, diarrhea,
hemorrhage, or even shock. It’s the fluid
of choice for resuscitation efforts as well.
NS is also the only fluid used in
conjunction with blood product
administration. It is an isotonic crystalloid
that contains 0.9% sodium chloride (salt)
that is dissolved in sterile water. It is
sometimes used with caution or even
avoided in patients with cardiac or renal
compromise because of the sodium
causing fluid retention that may put extra
stress on the heart or kidneys.
2. Lactated Ringers (also known as LR,
Ringers Lactate, or RL)
contains sodium chloride, potassium
chloride, calcium chloride, and sodium
lactate in sterile water. It is the most
similar to the body’s plasma and serum
concentration, and is especially great for
burn victims or those with hypovolemia
due to fluid shifts. It is avoided in patients
with liver disease because the liver may
not be able to efficiently process the
lactate.
3. 5% Dextrose in Water (also known
as D5 or D5W)
solution that contains glucose (sugar) as
the solute. When this is absorbed, the
glucose is usually quickly grabbed up by
cells and utilized for energy, leaving only
water which is then a hypotonic solution.
One interesting fact is that this solution
provides 170 calories per liter, and is
often used for diabetic patients who are
nothing by mouth for various reasons. It is
avoided in patients with renal failure,
cardiac compromise, or those who are at
risk for increased intercranial pressure.
This is because it can sometimes lead to
fluid overload in cardiac and renal
patients, and cerebral edema those with
intercranial pressure issues.
4. 45% Normal Saline (also known as
Half Normal Saline, 0.45NaCl)
sodium chloride dissolved in sterile water
(unlike 0.9% Normal Saline which is
isotonic, as mentioned above). This fluid
is designed to treat cellular dehydration,
caused by such conditions as
hypernatremia or diabetic ketoacidosis. It
is always avoided in patients with burns,
 trauma, or liver disease because of its
tendency to deplete intravascular fluid
levels. Infusing half normal saline, causes
water to shift from the extracellular fluid
compartment to the ICF compartment.
- Antibiotics might help treat diarrhea
caused by bacteria or parasites. If a virus
is causing your diarrhea, antibiotics won't
help.
6. COMMUNICABLE &
NON-COMMUNICABLE DISEASE
What is a communicable disease?
- A communicable disease is one that is
spread from one person to another
through a variety of ways that include:
contact with blood and bodily fluids;
breathing in an airborne virus; or by being
bitten by an insect.
- Some examples of the reportable
communicable diseases include Hepatitis
A, B & C, influenza, measles, and
salmonella and other food borne (carried
or transported by the thing specified)
illnesses.
How do these communicable diseases
spread?
Depends on the specific disease or infectious
agent. Some ways in which communicable diseases
spread are by:
- Physical contact with an infected person,
such as through touch (staphylococcus),
sexual intercourse (gonorrhea, HIV),
fecal/oral transmission (hepatitis A), or
droplets (influenza, TB)
- Contact with a contaminated surface or
object (Norwalk virus), food (salmonella,
E. coli), blood (HIV, hepatitis B), or water
(cholera)
- Bites from insects or animals capable of
transmitting the disease (mosquito:
malaria and yellow fever; flea: plague)
- Travel through the air, such as
tuberculosis or measles.
What is non communicable disease?
- Non-communicable diseases, also known
as NCDs are non-infectious medical
diseases or conditions
- They usually last a long time and progress
slowly. Many are chronic diseases.
However, some chronic diseases are not
non-communicable because they are
infectious, such as HIV/AIDS
- Examples of non-communicable diseases
include diabetes,
Alzheimer's, cancer, osteoporosis, chronic
lung disease, stroke, and heart disease.
- Almost four-fifths of all deaths from non-
communicable diseases occur in
developing countries.
7. NOTIFIABLE DISEASE
What are notifiable diseases?
- Notifiable diseases are any diseases that are
required by law to be reported to government
authorities. Armed with this information,
health authorities can then monitor disease,
and provide early warning of possible
outbreaks, pandemics or epidemics, and
ensure the right medications or vaccinations
are stockpiled and appropriate procedures for
treatment are in place.
- There is a list of about 65 notifiable diseases in
Australia, which is reviewed regularly, and
may also vary from state to state. Some
examples of notifiable diseases are HIV,
hepatitis B and C, typhoid, cholera, Ross River
and dengue fevers, malaria, sexually
transmitted diseases such as chlamydia and
syphilis, as well as conditions which may have
been caused by food poisoning like salmonella
and listeriosis.
- Communicable diseases for which there are
vaccinations – for example, chicken
pox, measles, rubella, whopping
cough and mumps – are also notifiable
conditions so governments can be aware of
the impact immunisation, or the lack of, is
having on the population.
8. IMPORTANCE OF HYGIENIC FOOD
PREPARATION & AVOIDANCE OF
EATING OVERNIGHT FOOD
- Proper food hygiene is very important when it
comes to food preparation.
Without washing hands and kitchen
tools, diseases may easily spread. In some
places though, this crucial matter is not always
known and is unfortunately taken lightly.
Since cross-contamination is a major cause of
food poisoning and can transfer bacteria from
one food item to other foods, it is crucial to be
aware of how it spreads so you will know how
to prevent it.
- Food poisoning spreads when one food,
mainly raw food, comes in contact with other
types of food. Bacteria can also be transferred
indirectly, for example from hands, tools,
surfaces, knives, and clothes. One thing you
can do for preventing cross-contamination is,
keep separate chopping boards for raw and
cooked foods.
- Refrigerators must also be checked regularly
to guarantee that they are running at the
proper temperature and they should also be
cleaned, both inside and out.
- Another essential tool to keep your kitchen
clean is to install the right kitchen extractor
and ventilation systems. Over-the-
cooker canopies and the ductwork leading
from them are fitted with filters and should be
regularly replaced.
6 Health Effects of Eating at Night
- Altered hormone function. Eating at night
alters levels of insulin, glucagon, and leptin.
- When people eat more in the evening, they
have higher markers of inflammation. In one
study, for each 10 percent increase in the
proportion of total calories consumed
between 5 pm and midnight, there was a 3
percent increase in C-Reactive protein, a
major marker of inflammation in the body.
- Impairments in blood sugar regulation. Our
body’s ability to use insulin to control blood
sugar changes throughout the day, and it is
least efficient at night. Glucose levels after
meals are highest when meals are consumed
late in the day. Shift workers show
decreased blood sugar control when eating
food at night. Researchers suggest avoiding
meals with a high-glycemic index in the
evening to avoid the negative effects and
increased disease risk associated with high
blood sugar.
- Weight gain. Human studies have shown that
when we eat a significant portion of our total
food intake in the evening, we are more likely
to be obese. One reason for this may be that
there are regulatory elements for the
circadian clock in our fat tissues, and
disrupting those elements can lead to
impaired fat storage.Eating at night can also
increase the total amount of food you eat
each day, leading to more weight gain.
- Elevated triglycerides and cholesterol. Eating
out of sync with our circadian rhythm can
impact the way the body metabolizes lipids.
This can lead to increased levels of both
triglycerides and cholesterol. Read more
about the link between nighttime eating and
elevated lipid levels here.
- Impaired memory. Recent research suggests
that our memory can be affected by eating at
night. Researchers found that mice who were
fed meals during the time they should have
been sleeping experienced deficits in learning
and memory.
9. HIGH RISK FOOD IMPLICATED IN GIT
10 High Risk Foods More Likely to Cause
Food Poisoning
1. Poultry
- Raw and undercooked poultry has a high-risk
of causing food poisoning if it's not handled
properly. Campylobacter bacteria and
salmonella are the two most common
contaminants of poultry and even small
amounts can make people seriously sick.
These bacteria often contaminate the raw
meat when it’s first processed and can survive
up until cooking kills them.
- Although these bacteria can live on raw
poultry, there are ways to lower the risk.
Always make sure that poultry is completely
cooked through before you eat it because this
will kill harmful bacteria. Also, don’t wash raw
chicken before cooking it because this will just
spread the bacteria around your kitchen,
making it easier to contaminate something
else. When handling raw chicken and other
poultry it’s really important to thoroughly
wash and sanitise anything that the raw meat
touches - including utensils, clothes, chopping
boards and especially your hands.
2. Eggs
- Eggs are a versatile, convenient and nutritious
protein and are part of countless meals all
around the world. However, they’re
considered high-risk when it comes to food
poisoning, specifically when raw or
undercooked
- Salmonella in eggs is responsible for many of
the foodborne illness cases in Australia.
Bacteria can contaminate either the yolk, the
white or the eggshell. Often a contaminated
egg will not look, smell or taste any different,
making it almost impossible to detect.
- Many popular meals contain lightly cooked or
even raw eggs, so have a high risk of causing
foodborne illness. It’s recommended that you
thoroughly cook all foods that contain eggs,
and avoid foods that purposely contain
undercooked eggs, like mayonnaise and salad
dressings. It’s also important not to taste
 anything that contains raw eggs when you’re
cooking - cake batter for example.
- To enjoy eggs safely, it’s recommended that
you buy clean, uncracked eggs. You should
keep them cool, preferably under 5°C. Also,
make sure when cracking the egg, the egg yolk
or white doesn’t touch the outside of the shell
before going in the dish.
- These recommendations are especially
important for vulnerable people - including
children, the elderly, pregnant women and
anyone suffering from an illness that weakens
the immune system.
3. Leafy Greens and Vegetables
- Because leafy greens and vegetable are often
eaten raw, any harmful contaminants
affecting them won’t be killed in the cooking
process. Bacteria like E. coli can live in the soil
that the greens are grown in and can easily
leave traces on them. Contaminated water
and animals can also transfer harmful
substances to the food at any time during the
supply-chain.
- Washing lettuce and vegetables not only
reduces the risk of harmful bacteria being
present but also any chemical pesticides that
might still be on the food. Always make sure
that before you eat them, lettuce, vegetables
and salad greens are thoroughly washed.
4. Raw Milk
- Raw milk is milk that is unpasteurised, which
means that it hasn’t been heated to kill any
harmful bacteria. The risk of consuming raw
milk is that there’s a higher chance of the milk
containing bacteria, for example, E. coli,
salmonella or listeria. If consumed, these
bacteria can cause a range of food poisoning
illnesses, which vary from mild to life-
threatening.
5. Cheese
- Cheese is another food that’s considered to be
at high-risk of contamination. Pregnant
women are usually told to avoid eating all soft
cheeses, for example, feta and ricotta,
because of the risk of becoming sick.
Tragically, in some cases, eating contaminated
cheese can cause serious complications in
pregnancy - including miscarriage.
- Staphylococcus aureus is another common
bacteria that can be found in cheese. It’s often
transferred to the cheese from an infected
person that comes into contact with it. The
bacteria have a high tolerance for salt, so
cheese and meat are an ideal breeding
ground. Like some other causes of food
poisoning, Staphylococcus aureus is heat
resistant so cooking doesn’t kill it.
- The best ways to stop cheese becoming
contaminated are to make sure it’s stored at
or under 5°C; thoroughly wash your hands
before handling the cheese and if possible,
wear single-use disposable gloves; and make
sure all surfaces, utensils and equipment that
the cheese touches have been thoroughly
cleaned and sanitised. Also, avoid eating
unpasteurised products.
6. Sprouts
- Sprouts grow in a warm and wet environment,
which are the perfect conditions for rapid
bacteria growth. This means they’re really
difficult to keep clean. Because sprouts are
often eaten raw, they carry a high-risk of
causing foodborne illness, in particular from
salmonella and E. coli
- If contaminated, it’s likely that the seeds of
the sprouts are the home of any harmful
bacteria. Although there are different ways to
reduce the risk of contamination, no
treatment is guaranteed to kill all of the
bacteria.
- Often people who might be more vulnerable
to the effects of the potential bacteria -
pregnant women, the elderly, children and
people with a weakened immune system - are
directed to stay away from sprouts. If you’re
going to eat them, you’re advised to cook all
raw sprouts to lower the risk of potential
contamination.
7. Seafood
- Fish must be properly stored throughout the
entire supply chain. This begins when the fish
 is first caught and ends when it’s prepared
and eaten. When it comes to food poisoning
from seafood, there are many different
illnesses. It all depends on the type of
seafood, whether it’s contaminated with a
toxin, bacteria or another harmful substance,
and the conditions the fish has been kept in.
- Fish which is not stored at the correct
temperature has a high-risk of being
contaminated with histamine. This is a toxin
that can cause Scombroid poisoning and
unlike many other dangerous contaminants,
isn’t destroyed by normal cooking
temperatures.
- Another common foodborne illness which can
develop after eating contaminated fish is
Ciguatera poisoning, which occurs because of
ciguatoxin. Unfortunately as ciguatoxin is also
heat stable, cooking the fish before eating will
not rid the fish of the harmful toxin.
- Shellfish also carries the risk of food poisoning
because the algae that the shellfish live in,
produces many toxins that can build up to
dangerous levels. The more well-known
foodborne illnesses that these toxins can
cause are neurotoxic shellfish poisoning,
amnestic shellfish poisoning and paralytic
shellfish poisoning.
- Like the previous two toxins, cooking the
shellfish will not reduce the toxic risk to safe
levels. To safeguard against these heat stable
toxins, you’re often advised to avoid eating
seafood in developing countries and if you’re
not sure whether it’s safe to eat - don’t.
8. Rice
- Rice is one of the most eaten foods on the
planet and is also considered a high-risk food
when it comes to food poisoning. It can
become contaminated with Bacillus cereus,
which can initially infect and live in uncooked
rice as spores. Rather than eliminating the
spores, cooking actually activates them and
moist cooked rice is the perfect breeding
ground for harmful bacteria. Not storing
cooked rice properly is one of the biggest
culprits of foodborne illnesses in the world.
- All cooked rice should be stored in the
refrigerator at the correct temperature, under
5 degrees Celsius, to avoid the further growth
of bacteria. Rice that has high-risk proteins in
it, for example, pork or egg, carries an even
higher risk of contamination.
9. Deli Meats
- Deli meats and other cold-cut meats are often
highly processed and include ham, hot dogs,
salami and bacon. The storage of deli meats is
especially important because they’re often not
cooked before being eaten.
- Listeria and other harmful bacteria can find its
way into the processing factory and
contaminate meats after they’ve been cooked
but before they’ve been packaged. This is why
it’s very important to cook hot dogs and bacon
to at least 75 degrees Celsius for at least 3
minutes before eating. Also, cold meats
should always be stored under 5 degrees
Celsius to reduce the risk of further bacterial
growth.
- All meats carry a high-risk of causing
foodborne illness if they’re not prepared and
stored properly. Although many people prefer
their red meat not to be cooked completely
through, this can mean that the amount of
bacteria remaining on the meat is not brought
down to a safe level. Those people who are
more susceptible to illness are advised to
make sure that all meats are thoroughly
cooked – this included pregnant women,
children, the elderly and anyone who suffers
from a weakened immune system.
10. Fruits
- Perhaps surprisingly, lots of raw fruits and
berries have a high-risk of causing food
poisoning. Listeria, in particular, can grow on
the skins of fruits and vegetables and can
cause food poisoning if eaten. Salmonella has
been found responsible for more and more
cases of food poisoning, which have been
traced back to berries, hot peppers and
tomatoes.
- Melons also have a high-risk of causing food
poisoning because they’re not often washed
before being eaten. Harmful substances can
easily be transferred to the flesh of the fruit
anytime throughout the supply chain process.
- The growing environment of these foods is a
major factor in their high-risk status. They’re
 often grown in warm, humid conditions, which
is the perfect breeding grounds for bacteria.
Thoroughly washing fruits and vegetables and
storing them at the proper temperature
before consumption is essential to minimise
the risk.

10. COMMON CAUSES OF ACUTE FOOD

POISONING
- Contamination of food can happen at any
point of production: growing, harvesting,
processing, storing, shipping or preparing.
Cross-contamination — the transfer of
harmful organisms from one surface to
another — is often the cause. This is
especially troublesome for raw, ready-to-
eat foods, such as salads or other
produce. Because these foods aren't
cooked, harmful organisms aren't
destroyed before eating and can cause
food poisoning.
- Many bacterial, viral or parasitic agents
cause food poisoning. The following table
shows some of the possible
contaminants, when you might start to
feel symptoms and common ways the
organism is spread.