Pemicu 3 GIT

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Gastroenteritis
Gastroenteritis is a condition that causes
irritation and inflammation of the stomach
and intestines (the gastrointestinal tract )
Gastroentritis Symptoms
Common gastroenteritis symptoms
Low grade fever to 100 F (37.7 C)
Nausea with or without vomiting
Mild-to-moderate diarrhea
Crampy painful abdominal bloating (The
cramps may come in cycles, increasing in
severity until a loose bowel movement occurs
and the pain resolves somewhat.)

Blood in vomit or stool (blood in vomit or stool is
never normal and the affected individual should
call or a visit a health care professional.)
Vomiting more than 48 hours
Fever higher than 101 F (40 C)
Swollen abdomen or abdominal pain
Dehydration - weakness, lightheadedness,
decreased urination, dry skin, dry mouth and lack
of sweat and tears are characteristic signs and
symptoms.

Norovirus
consuming contaminated food and liquids,
touching objects contaminated with norovirus and
then placing the hands or fingers in the mouth,
direct contact with an infected individual (for
example, exposure to norovirus when caring for or
sharing foods, drinks, eating utensils with an
affected individual, and
exposure to infected individuals and objects in
daycare centers and nursing homes
Rotavirus
Parvoviruses
Astroviruses - Astrovirus infection is the third
most frequent cause of gastroenteritis in
infants.

Escherichia coli
E. coli O157:H7(one type of the bacteria) can
cause complications in approximately 10% of
affected individuals (for example, kidney
failure in children [hemolytic-uremic
syndrome or HUS), bloody diarrhea, and
thrombotic thrombocytopenic purpura (TTP)
in the elderly.

Salmonella
contracted by ingesting the bacteria in
contaminated food or water, and by handling
poultry or reptiles such as turtles that carry
the germs
Campylobacter
occurs by the consumption of raw or
undercooked poultry meat and cross-
contamination with other foods. Infants may
acquire the infection by contact with poultry
packages in shopping carts. Campylobacter is also
associated with unpasteurized milk or
contaminated water. The infection can be spread
to humans by contact with infected stool of an ill
pet (for example, cats or dogs). It is
generally not passed from human to human.

Shigella
spreads from an infected person to another
person.Shigella are present in diarrheal stools of
infected individuals while they are ill, and for up
to one to two weeks after contracting the
infection. Shigellainfection also may be
contracted by eating contaminated food, drinking
contaminated water, or swimming or playing in
contaminated water (for example, wading pools,
shallow play fountains). Shigella can also spread
among men who have sex with men.

Clostridium difficile
(C difficile) bacteria may overgrow in the large
intestine after a person has been
on antibiotics for an infection.

The most common antibiotics that pose a
potential risk for C difficile include:
clindamycin (for example, Cleocin),
fluoroquinolones (for
example, levofloxacin [Levaquin], ciprofloxacin [Ci
pro, Cirpo XR, Proquin XR]),
penicillins, and
cephalosporins.

Giardia
most frequent cause of waterborne diarrhea,
causing giardiasis. Often, people become
infected after swallowing water that has been
contaminated by animal feces (poop). This
may occur by drinking infected water from
river or lakes but giardia may also be found in
swimming pools, wells and cisterns.

Cryptosporidium
parasite that lives in the intestine of affected
individuals or animals. The infected individual
or animal sheds theCryptosporidium parasite
in the stool.

Crypto may also be found in food, water, soil,
or contaminated surfaces (swallowing
contaminated water, beverages, uncooked
food, unwashed fruits and vegetables,
touching contaminated surfaces such as
bathroom fixtures, toys, diaper pails, changing
tables, changing diapers, caring for an infected
individual or handling an infected cow or calf).
Those at risk for serious disease are
individuals with weakened immune systems.
Diagnosis
Gastroenteritis is often self-limiting, and the
care is supportive designed to control
symptoms and prevent dehydration. Tests may
not be needed.
If the symptoms persist for a prolonged period
of time, the health care professional may
consider blood and stool tests to determine
the cause of the vomiting and diarrhea.

Diagnosis
History
Travel history:
E. coli bacterial infection or a parasite infection acquired from
something the patient ate or drank.
Norovirus
Exposure to poisons or other irritants:
Swimming in contaminated water or drinking from suspicious fresh
water
Diet change, food preparation habits, and storage:
undercooked or improperly stored or prepared food, food
poisoning
Medications:
antibiotics
Physical examination
Abdomen examination
Rectal examination
Laboratory
complete blood count (CBC),
electrolytes,
kidney function tests.
Stool samples may be collected and tested for
blood or different types of infection.
Prevention
Always wash your hands.
Eat properly prepared and stored food.
Bleach soiled laundry.
Vaccinations for Vibrio cholerae, and
rotavirus have been developed. Rotavirus
vaccination is recommended for infants in the
U.S. Vaccines for V. cholerae may be
administered to individuals traveling to at-risk
areas.

Dehydration

Clinical Findings
Estimated fluid deficit

Common cause
Common causes
Gastroenteritis: This is the most common cause of
dehydration
Stomatitis: Pain may severely limit oral intake.
Diabetic ketoacidosis (DKA): Dehydration is caused by
osmotic diuresis. Weight loss is caused by both excessive
fluid losses and tissue catabolism. Rapid rehydration,
especially rapid initial volume resuscitation, may be
associated with a poor neurologic outcome. DKA requires
very specific and controlled treatment
Febrile illness: Fever causes increased insensible fluid
losses and may affect appetite.
Pharyngitis: This may decrease oral intake.

Treatment
Oral Rehydration Solution
Traditional clear fluid
Typhoid fever

Definition
Typhoid fever, also known as enteric fever, is a
systemic bacterial disease contracted by
consuming food or water that has been
contaminated with the bacterium
Salmonella typhi.
EPIDEMIOLOGY
Typhoid fever occurs worldwide, primarily in
developing nations whose sanitary conditions are poor
Typhoid fever is endemic in Asia, Africa, Latin America,
the Caribbean, and Oceania, but 80% of cases come
from Bangladesh, China, India, Indonesia, Laos, Nepal,
Pakistan, or Vietnam

Within those countries, typhoid fever is most common
in underdeveloped areas
Typhoid fever infects roughly 21.6 million people
(incidence of 3.6 per 1,000 population) and kills an
estimated 200,000 people every year



Sources of Infection
Water
Contamination with feces often results in explosive epidemics.

Milk and Other Dairy Products (Ice Cream, Cheese, Custard)
Contamination with feces and inadequate pasteurization or improper handling. Some outbreaks are
traceable to the source of supply.

Shellfish
From contaminated water.

Dried or Frozen Eggs
From infected fowl or contaminated during processing.

Meats and Meat Products
From infected animals (poultry) or contamination with feces by rodents or humans.

"Recreational" Drugs
Marijuana and other drugs.

Animal Dyes
Dyes (e.g, carmine) used in drugs, foods, and cosmetics.

Household Pets
Turtles, dogs, cats, etc.

Salmonellosis
Salmonella infection in man is caused by the
enteric fever group which includes:
- Salmonella typhi Typhoid fever
- Salmonella paratyphi A paratyphoid fever
- Salmonella paratyphi B paratyphoid fever
- Salmonella paratyphi C has different
symptomatology.
Bacteriology
The enteric bacili have 3 common
antigens:
- H antigen on the flagellae
- O antigen (body or somatic)
- Vi antigen (virulence antigen)
The bacteria may also have different
phage types which number over 70,
and are only recognize by the use of
different bacteriophages.


Bacteriology
The H antigens differ from one another.
The O antigens are group specific.
The Vi antigen is used in detection of carriers.
Enterobactericeae
Table. Clinical Diseases Induced by Salmonellae.

Enteric Fevers Septicemias Enterocolitis
Incubation period 720 days Variable 848 hours
Onset Insidious Abrupt Abrupt
Fever Gradual, then high
plateau, with
"typhoidal" state
Rapid rise, then
spiking "septic"
temperature
Usually low
Duration of disease Several weeks Variable 25 days
Gastrointestinal
symptoms
Often early
constipation; later,
bloody diarrhea
Often none Nausea, vomiting,
diarrhea at onset
Blood cultures Positive in first to
second weeks of
disease
Positive during high
fever
Negative
Stool cultures Positive from 2nd
week on; negative
earlier in disease
Infrequently positive Positive soon after
onset
Risk Factors
Worldwide, children are at greatest risk of getting the disease,
although they generally have milder symptoms than adults do.
If you live in a country where typhoid fever is rare, you're at
increased risk if you:
- Work in or travel to areas where typhoid fever is endemic
- Work as a clinical microbiologist handling Salmonella typhi bacteria
- Have close contact with someone who is infected or has recently
been infected with typhoid fever
- Have an immune system weakened by medications such as
corticosteroids or diseases such as HIV/AIDS
- Drink water contaminated by sewage that contains S. typhi

CLINICAL MANIFESTATIONS
After incubation period (3 21 days) fever is the most
prominent symptom.
Additional nonspecific symptoms include:
Chills, headache, sweating, cough, malaise, and arthralgia
GI symptoms are variable and can include:
Anorexia, nausea, vomiting, diarrhea, constipation (less
often)
Abdominal pain (30 40 %)
Physical findings include:
Rash (rose spots), hepatosplenomegaly, epistaxis,
bradycardia

SYMPTOMS BY WEEK
First week of illness
Once signs and symptoms do appear,
you're likely to experience:
Fever,
Headache and dizziness
Weakness and fatigue
Sore throat
Abdominal pain
Diarrhea (children) or
constipation (adult)
Rash:
a rash of small, flat, rose-colored
spots on your lower chest or upper
abdomen.
The rash is temporary, usually
disappearing in two to five days.


Second week of illness
If you don't receive treatment for
typhoid fever, you may enter a
second stage during which you
become very ill and experience:
Continuing high fever
Relative bradycardia
Coated tongue
Either diarrhea that has the color
and consistency of pea soup, or
severe constipation
Considerable weight loss
Extremely distended abdomen
SYMPTOMS BY WEEK
Third week of illness
Become delirious
Lie motionless and
exhausted with your eyes
half-closed in what's
known as the typhoid
state
Life-threatening
complications often
develop at this time.

Fourth week of illness
Improvement may come
slowly
Your fever is likely to
decrease gradually until
your temperature returns
to normal in another
week to 10 days.
But signs and symptoms
can return up to two
weeks after your fever
has subsided

The 1st week
Fever, which will gradually rise and then
settle at around 3940C
Abdominal pain -Constipation or Diarrhoea-
Vomiting,
Dry cough
Dull headache -Delirium
Skin rash
Sign & symptoms
The 2
nd
week
Continuing high fever
Either diarrhea or severe constipation
Considerable weight loss
Extremely distended abdomen
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 3
rd
week ( typhoid stage )
Become Delirious
Lie motionless and exhausted
with eyes half-closed in what's
known as the typhoid state
Life-threatening complications
often develop at this time.
Sign & symptoms
The 4
th
week (Improvement )

If a person survives until the
fourth week, their symptoms
will gradually improve

Though weight loss and
physical exhaustion can
continue for several months.

Sign & symptoms
Other symptoms :
Young children, individuals with AIDS, and one
third of immunocompetent adults who develop
typhoid fever develop diarrhea rather than
constipation.
In addition, in some localities, typhoid fever is
generally more apt to cause diarrhea than
constipation.
PATHOGENESIS
Salmonella cause infection when 10
3
-10
6
organisms are
ingested.
Conditions that reduce gastric acidity or decrease
intestinal integrity increase susceptibility to infection.
Organisms penetrate the small intestinal mucosa and
traverse the intestinal layer through cells within Peyers
patches.
S. typhi and S. paratyphi survive within macrophages,
then disseminate throughout the body via lymphatics,
and ultimately colonize reticuloendothelial tissues.



Pathogenesis
Food and
Beverage
Salmonella Typhi
Mouth Small intestine
lymphatic
vessels
Bloodstream
(Transient bacteremia)
Organs
(Liver, spleen)
Bloodstream
(Secondary bacteremia)
Lymphoid Gland
small intestine
Peyers patches
Perforation
Gallblader Chronic Carrier
Endotoxins
Fever
Hemorrage
Peritonitis
Pathogenesis
Entry in GIT localisation in Gut associated
lymphoid tissue Lymphatic channel
thoracic duct circulation primary silent
bacteremia localisation in macrophages of
RES in spleen, liver, bone marrow (incubation
period 8-14 days) secondary bacteremia.
rabiezahran@gawab.com
Life cycle of
Salmonella
typhi.
Pathological changes in typhoid fever.
1) The changes in the Payer's patches of the
ileum vary from hyperplasia and ulceration to
frank ulceration and 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 in the gall bladder.
These may be asymptomatic & may be a
potent source of infection in the typhoid
carrier, sometimes many years after the initial
infection.
5) The spleen is enlarged and soft.
6)The mesenteric glands are enlarged.

Pathological changes in typhoid fever
7)The kidneys show cloudy swelling and as a result
this may result in albuminuria.
8)Bronchitis is common in typhoid fever, and diffuse
rales and rhonchi are a usual finding on clinical
auscultation of the lungs in typhoid fever.
9)In a severe case of typhoid fever the heart may be
enlarged and affected by fatty degeneration.
10)Finally thrombosis of the deep veins may occur,
particularly in the lower limb, and lead to a fatal
pulmonary embolus.

Laboratory Examination
1. Routine examination
Complete Perifer Blood test
mostly leucopenia (possibly normal leukocytes or
leukocytosis)
Mild anemia and trombositopenia
Leukocytes count : aneosinofilia and limfopenia
LED : increased
SGOT,SGPT : increased
2. Widal test used to determine the existency of
aglutinin in the patients serum
- Aglutinin O (from bacterias body)
- Aglutinin H ( bacterias flagela )
- Aglutinin Vi (simpai kuman )

Factors that affect Widal test:
- Premature treatment of antibiotic
- Disability of develop antibodies and corticosteroid
treatment
- Time of blood taking
- History of vaccination
- Anamnestic reaction ( caused by past typhoid infection)
- Examination tecnic of the laboratorium

To diagnose
3. 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

Identification of Salmonella
Sub cultures are done after overnight
incubation at 37
0
c,and subcultures are done
on Mac Conkey's agar
Subcultures are repeated upto 10 days after
futher incubation.

Farmacology
Kloramfenikol= Obat pilihan untuk demam tifoid
Tiamfenikol= komplikasi hematologi seperti anemia
aplastik < kloramfenikol
Kotrikmoksazol
Ampisillin dan amoksisilin(kemampuan menurunkan
demam lebih< dari kloramfenikol)= boleh untuk ibu hamil
Sefalosporin generasi 3(seftriakson)= boleh untuk ibu
hamil
Golongan Florokuinolon
Azitromisin
Kortikosteroid= hanya untuk demam tifoid yg mengalami
syok septik
Therapy
Indication Agent Dosage Duration,
days
Empirical Treatment ceftriaxone 1-2 g/d (IV) 7-14
Azithromycin 1 g/d (PO) 5
Fully susceptible Ciprofloxacin 500 mg bid (PO) or
400 mg q12h (IV)
5-7
Amoxicillin 1 g tid (PO) or 2 g q6h (IV) 14
Chloramphenicol 25 mg/kg tid (PO/IV) 14-21
Trimethopim-
sulfamethoxazole
160/800 mg bid 14
Multidrug-Resistant Ciprofloxacin 500 mg bid (PO) 5-7
Ceftriaxone 2-3 g/d (IV) 7-14
Azithromycin 1 g/d (PO) 5
Nalidixic Acid
Resistant
Ceftriaxone 1-2 g/d (IV) 7-14
Azithromycin 1 g/d (PO) 5
High dose
ciprofloxacin
750 mg bid (PO) or 400
mg q8h
10-14
Antibiotic Recommendations by Origin and Severity
Location Severity First-Line
Antibiotics
Second-Line
Antibiotics
South Asia, East Asia

Uncomplicated Cefixime PO Azithromycin PO
Complicated Ceftriaxone IVor
Cefotaxime IV
Aztreonam IV or
Imipenem IV
Eastern Europe,
Middle East, sub-
Saharan Africa, South
America
Uncomplicated Ciprofloxacin
PO or
Ofloxacin PO
Cefixime PO or
Amoxicillin PO or
TMP-SMZ PO
or Azithromycin PO
Complicated Ciprofloxacin IVor
Ofloxacin IV
Ceftriaxone IV or
Cefotaxime IV or
Ampicillin IV
or
TMP-SMZ IV
Unknown geographic
origin or Southeast
Asia


Uncomplicated Cefixime POplus
Ciprofloxacin
PO or
Ofloxacin PO
Azithromycin PO*
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.

Supportive therapy
- Drinking fluids. This helps prevent the dehydration
that results from a prolonged fever and diarrhea. If
you're severely dehydrated, you may need to receive
fluids through a vein in your arm (intravenously).
- Eating a healthy diet. Nonbulky, high-calorie meals
can help replace the nutrients you lose when you're
sick.

Complications
Intestinal bleeding or perforation may develop in the third week
of illness. Intestinal bleeding is often marked by a sudden drop in
blood pressure and shock, followed by the appearance of blood in
your stool.
Other, less common complications
- Inflammation of the heart muscle (myocarditis)
- Pneumonia
- Inflammation of the pancreas (pancreatitis)
- Kidney or bladder infections
- Infections of the spine (osteomyelitis)
- Infection and inflammation of the membranes and fluid
surrounding your brain and spinal cord (meningitis)
- Psychiatric problems such as delirium, hallucinations and paranoid
psychosis

Preventions
Vaccines are recommended for travelers.
Drink boiled or bottled water and eat well
cooked food.
Adequate water treatment, waste disposal,
and protection of food supply from
contamination are important public health
measures.
Personal hygiene.

VACCINES
Routine typhoid vaccination is indicated for:
travelers to endemic areas,
persons with intimate exposure to a documented
S typhi carrier (e.g, household contact),
and microbiology laboratory personnel who
frequently work with S typhi

Vaccines are not approved for use children
younger than 2 years.

VACCINES
Centers for Disease Control and Preventions

DIFFERENTIAL DIAGNOSIS
Paratyphoids A, B & C The laboratory is usually
required as the final authority. The paratyphoids tend
to run a milder course with profuse rose spots.
Salmonella infection and gastroenteritis
Salmonellae, the dysentery group, and staphylococci
may occasionally cause an invasive illness resembling
typhoid fever with bacteremia. Usually, however, the
gastrointestinal symptoms are more acute than the
general manifestations, and the pyrexia much lower
and of shorter duration.