Download Lecture 3. Acute intestinal infections

Acute Intestinal Infections.
Lecturer: ass.prof. Gorishna I.L.
Plan of the lecture
1. Definition of Acute intestinal diseases
2. Reasons of Acute Intestinal Diseases
3. Clinical, Epidemiological Peculiarities, Differential
Diagnosis, Treatment of Escherichiosis
4. Clinical, Epidemiological Peculiarities, Differential
Diagnosis, Treatment of Shigellosis
5. Clinical, Epidemiological Peculiarities, Differential
Diagnosis, Treatment of Salmonellosis
6. Toxicosis And Exicosis. Pathogenesis, Clinical
Features,
7. Toxicosis And Exicosis. Treatment
Definitions
• Acute intestinal diseases – the
group of disorders with diarrhea
syndrome which can accompanied
with toxicosis and dehydration
Actuality
• Diarrheal diseases cause one billion
episodes of illness and 3-5 million
deaths annually.
• They range from 1.3 to 2.3 episodes of
diarrhea per year in children under
five years of age.
• Infectious gastroenterocolitis account
for about 10-15% of the diarrheal
illnesses of children presenting to the
emergency department.
common causes of diarrhea
•
•
•
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Functional digestive disorders
Inborn errors of metabolism
Some surgical disorders
Acute intestinal diseases
Etiology of Acute Intestinal Diseases
• bacterial agents
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Escherichia coli
Shigella,
Salmonella,
Campylobacter jejuni
Yersinia enterocolitica.
Clostridium difficile
Vibrio cholerae
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–
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Rotavirus
Coxsackie viruses
ECHO (Enteric Cytopathogenic Human Orphan) viruses
Astrovirus
Parvovirus
• enteroviruses (infectio enteroviralis)
- Parasites
• Giardia lamblia
• Cryptosporidium
Escherichia Coli Infection
• is an acute infectious disease mainly of
early age children, caused by different
pathogenic strains of Escherichia coli
(Enterotoxigenic, Enteropathogenic, Enteroinvasive,
Enterohemorrhagic, Enteroaggregative)
Etiology
• Escherichia coli, a facultatively anaerobic
gram-negative bacillus, is a major
component of the normal intestinal flora
and ubiquitous in the human environment.
Transmission
The way of transmission
• Contact
• Alimentary (by water, milk,
•
food)
Source of infection
• Contagious patient
• Bacillus carrier
Pathogenesis
•
Enteropathogenic E.coli strains destroy the microvilli,
lover the disaccharidases, and cause inflammation of
the small bowel and malabsorption.
•
Enterotoxigenic strains results in derangement of
electrolytes and water absorption, similar to that of
V.cholerae.
•
Enteroinvasive strains colonize the colon and distal
part of the small intestine and cause damage to the
epithelium.
•
Enterohemorrhagic E.coli O157H7 has been shown
to produce diarrhea and hemorrhagic colitis
•
Enteroaggregative E coli is not good studied
Localisation of the process
– in small intestinum
Incubation period
• Short (from a few hours to 8 days)
Enteropathogenic E.coli
infection
• Gradual growth of symptoms up to 5-7
days.
• Subfebril temperature.
• Vomits, regurgitation from the disease
beginning.
• The watery massive yellow-orange feces
with the two-bit of mucus, green color
admixtures, up to 10-15 times per day.
• Toxicosis with dehydration of 2-3 degree
Enteropathogenic E coli
metheorism (abdominal
distension)
Enteropathogenic E coli
infection, typical color of feces
Enteroinvasive E.coli infection
• Acute beginning with the severe toxic
syndrome, fever (1-3 days), rarer vomits.
• Diarrhea in the 1st day of the disease: feces
with the admixtures of mucus and green,
blood 3-5 times per day.
• Abdomen is tender by the colon way,
infiltrated sigmoid colon, tenesms are absent.
• Rapid recovery, normalization of feces in 3-5
days.
Enterotoxigenic E.coli infection
• Acute beginning from the repeated
vomiting, watery diarrhea.
• Intoxication is absent; body
temperature is normal or subfebrile.
• grumbling along thin intestine during
palpation.
• Feces 15-20 time per days, watery
without pathological admixtures, of
rice-water character.
• Development of severe dehydration
• Duration of the disease 5-10 days.
Enterohemorrhagic
E.coli infection
•
•
•
•
•
severe abdominal cramps,
low – grade fever,
grossly bloody stools,
nausea and vomiting.
hemolytic uremic syndrome (HUS)
Mild form
• Consists or acute onset of diarrhea
• Stool is watery, yellow or golden in
colour.
• The temperature is normal
• Loss of appetites
• Duration of the disease is up to 1
week
Moderate form
• Acute onset of diarrhea
• Stool is watery, yellow or golden in
colour with mucous and blood.
• The temperature is 38-39°C
• Anorexia
• Symptoms of toxicosis
Severe form
•
•
•
•
•
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•
•
Acute onset of diarrhea
Symptoms of toxicosis
Dehydration 2nd-3rd degree
Stool is watery, yellow or golden in colour
with mucous and blood.
Defecation up to 20 times per day
Intractable vomiting
The temperature is 39-40°C
Anorexia
Diagnosis example
• E.coli infection (caused by
Enterotoxigenic strain), typical form,
severe degree.
Complication: hypertonic dehydration,
2nd degree.
DIFFERENTIALS
• should be performed among acute non
infectious diarrheas, salmonellosis,
shigellosis, staphylococcal diarrhea,
viral diarrhea, and cholera.
Lab Studies:
• Routine stool cultures
• Rapid enzyme immunoassays for E
coli 0157:H7
• Stool test (koprogram): inflammatory
changes, intestinal enzymopathy
• Electrolyte changes in blood
• Full blood count
stool
cultures
Shigellosis (dysentery)
• An acute human infectious diseases
with enteral infection that is
characterized by colitic syndrome
and symptoms of general
intoxication, quite often with
development of primary
neurotoxicosis.
Etiology of Shigella Infection
•
•
•
•
Shigella dysenteriae
Shigella sonnei
Shigella flexneri
Shigella boydii
Transmission
Shigella is spread through fecal-oral
mechanism of transmission.
The way of transmission
• Contact
• Alimentary
• Watery
Source of infection
• Contagious patient
• Bacillus carrier
• Susceptibility: 60-70%
especially infants and preschoolers.
• Seasonality:
is summer-autumn.
Pathogenesis:
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•
•
•
•
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Entering Shigella to gastrointestinal tract.
Destruction of them by the enzymes.
Toxemia.
Toxic changes in organs and systems
(especially in CNS).
Local inflammatory process (due to
colonizing of distal part of the colon).
Diarrhea.
Incubation period
• Short (from a few hours to 7 days)
Localisation of the
process
Classification of Shigella
Infection
I. Clinical Form
•
With dominance of toxicosis
•
with dominance of local inflammation
II. Severity (mild, moderate and severe)
III. Course
•
•
•
acute (up to 1.5 mo)
subacute (up to 3 mo)
chronic (about 3 mo)
– recurrent
– constantly recurring
IV. Complicated or uncomplicated
V. Bacterium carrying
With dominance of toxicosis
Toxicosis is the first sing may be
neurotoxicosis (headache, vomiting,
hallucinations, seizures, febrile
temperature 39-40 C).
Distal Colitis is secondary (abdominal pain,
tenesmus, false urge to defecate, sigmoid
colon is tender, anus is gaping in severe
cases. Feces in the form of a rectal spit.
Dehydration isn’t developed (except infants).
Toxicosis, marble skin
With dominance of local inflammation
•
•
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Sudden onset of high-grade fever
abdominal cramping
abdominal pain,
tenesmus,
and large-volume watery diarrhea →
fecal incontinence, and small-volume
mucoid diarrhea with frank blood
Peculiarities of shigellosis in
infants:
• Acute beginning with slow development of signs and
symptoms (for 3-5 days).
• Distal colitis is less common
• Enterocolitis is more often with enterocolitic feces,
hemocolitis is rare.
• Hepato- and splenomegaly
• Crying, anxiety, red face during defecation is equivalent to
tenesmus.
• Always occurs gaping anus, sphincteritis
• Dehydration is more often
• Prolonged duration of the disease
Sunken abdomen,
dehydration
Shigella
Infection
false
urge to
defecate
Stools with greenish and
mucous
Rectal spit
Rectal
prolapse
Mild form
• Consistent or acute onset of diarrhea
• Stools are 5-8 times per day with
mucous and blood
• Not permanent pain in abdominal
region.
• The temperature is normal
• Loss of appetites
• May be vomiting
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Moderate form
Acute onset of diarrhea
Symptoms of toxicosis
The temperature is 38-39°C
Anorexia
Crampy abdominal pain
Stools are 10-15 times per day
Pain during palpation in left inguinal
region
hepatomegaly
Severe form
• Multiple vomiting not only after meal, but
also independent, can be with bile,
sometimes - as coffee lees,
• slools - more 15 times per day, sometimes
- with each diaper, with much mucus, there
is blood, sometimes - an intestinal bleeding
• General condition is sharply worsened,
• quite often - sopor, loss of the
consciousness, cramps,
• changes in all organs and systems,
• severe toxicosis, may be dehydration (in
infants),
• significant weight loss
Lab Studies:
• The white blood cell count is often within
reference range, with a high percentage of
bands. Occasionally, leukopenia or leukemoid
reactions may be detected.
• If HUS, anemia and thrombocytopenia
occur.
• Stool examination
• Increasing of red blood sells and leukocytes
• Stool culture
• Specimens should be plated lightly onto
MacConkey, xylose-lysine-deoxycholate, or
eosin-methylene blue agars.
•
Serological test in dynamics with
fourfold title increasing in 10-14 days
Shigella
colonies
DIFFERENTIALS
• should be performed with:
salmonellosis, escherichiosis, acute
appendicitis, bowel invagination,
Krohn’s disease, nonspecific
necrotizing colitis.
Diagnosis example
• Shigellosis (Sh. sonnei), typical form (with
dominance of toxicosis), severe degree,
acute duration.
• Shigellosis (Sh. flexneri), typical form
(with dominance of local inflammation),
moderate degree, constantly recurring
duration, complicated by the rectum
prolapse
Salmonellosis
• an acute infectious disease of human
and animals, that is caused by the
numerous strains of Salmonella and
more frequent courses as gastrointestinal, rare – as typhoid or septic
form
Etiology of Salmonella Infection
•
•
•
•
S. typhimurium
S. enteritidis
S. java
S. anatum
Transmission
The way of transmission
• Contact
• Alimentary (by water, food)
• Droplet
Source of infection
• Domestic animals, birds
• Contagious patient
• Bacillus carrier
Pathogenesis
•
•
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•
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•
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Entering the salmonella into gastrointestinal tract.
Bacteria destruction of in the upper
parts of gastro-intestinal tract.
Toxemia.
Bacteria which remain, enter bowel,
colonize epitheliocytes.
Local inflammatory process 
diarrhea,  dehydration.
Bacteriemia in newborns 
Septic focci of salmonellosis.
Incubation period
• Short (from a few hours to 3 days)
Classification
1.
Local form


2.
Gastrointestinal form
Bacterium carrying
General form


Like typhoid fever
Sepsis
3. Asymptomatic form
II. Severity (mild, moderate and severe)
III. Course
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acute (up to 1.5 mo)
subacute (up to 3 mo)
chronic (about 3 mo)
IV. Complicated or uncomplicated
Salmonella Infection
(gastrointestinal form)
acute beginning from:
• intoxication (nausea, vomiting, high
body temperature, headache);
• abdominal pain;
• diarrhea, usually appears secondary,
stools are “muddy”, may be with
blood and mucus,
• abdomen is tender;
•
dehydration is moderate.
Salmonella Infection typical
color of feces, hemocolitis
Salmonella Infection,
severe hemocolitis
Typhoid form
• acute beginning from high temperature
(39-40˚ C) lasting for 1-2 weeks,
• vomiting, hallucinations;
• “Typhoid” tongue;
• hepato-, splenomegaly from the 5-6th day
of disease;
• skin rash (roseols) on the trunk;
• diarrhea;
• tenderness in the right inguinal region.
Salmonella Infection Typhoid form
Septic form
• Etiology - antibiotic resistant, nosocomeal strains
of Salmonella;
• contact transmittion.
• Incubation period is long (5-10 days).
• Usually occurs in newborns
• fever becomes hectic
• Septic focci: meningitis, pneumonia, osteomyelitis,
pyelonephritis, enterocolitis);
• hepatosplenomegaly;
• thrombocytopenia;
• development of toxic-dystrophic syndrome;
• relapses, bacterial carrying
• high mortality;
Salmonella Infection
septic form
Lab Studies:
• Complete blood count with differential
• Cultures: fecal, blood, urine, or bone
marrow.
• Stools examination: hemoccult positive
and positive for fecal polymorphonuclear
cells.
• Chemistry: Electrolyte tests may reveal
abnormalities consistent with
dehydration.
• Serologic tests in dynamics with fourfold
title increasing in 10-14 days
Diagnosis example
• Salmonellosis (S. enteritidis), typical
local gastrointestinal form (enterocolitis),
moderate degree, acute duration.
Complication: isotonic dehydration, 1st
degree.
• Salmonellosis (S. typhimurium), typical
generalized septic form (enterocolitis,
meningitis, bilateral pneumonia, left
humeral bone osteomyelitis), severe
degree, subacute duration.
• Complication: malnutrition, 2nd degree.
Differentials
• should be performed with: functional
diarrhea, shigellosis, escherichiosis,
klebsiellosis, typhoid fever, and
sepsis of different etiology.
Dehydra
tion
Dehydration
Symptom, sign Hypertonic
dehydration
Isotonic
dehydration
Hypotonic
dehydration
Body
temperature
Highly
increased
Normal,
subfebril
subnormal
Thirst
Severe
Moderate
Refusal of water
CNS reaction
Exiting
Some exiting or Adynamia
dullness
Concentration of Increased
the sodium in
blood
Normal
Decreased
Loss of body
weight
Less than 5 %
More than 10 %
5-10 %
General principals of intestinal
infections treatment
 Dietary treatment
 Specific treatment
 Antibacterial treatment
 Rehydration
 Enterosorption
 Symptomatic treatment
Hygienic regimen
Diet 4
• In the acute period it is recommended to
decrease daily food volume on 1/3 – 1/4.
• In infants and in case of urges to vomit
numbers of food intake may increase up to 810 per day.
• It is necessary to eliminate all dairy foods
(including cheese), fish, hard sausage,
chocolate, fried, greasy and spicy foods. Limit
intake of meat, fats and foods containing
gluten (barley, rye).
Diet 4
• Hypochloric diet; milk and foods rich with
fiber must be excluded. Stimulators of bile
secretion are not recommended.
• Diet with low carbohydrate and fat content is
administered.
• prepared in puree form and warm are
acceptable. Food taking is 5-6 times a day.
Nonacidic fresh or cooked vegetables are
recommended as well as plenty of liquids.
Breast feeding
• In infants breast feeding must continue,
those, who are bottle feeding – receive
adopted milk formulas, better with low
lactose content
Lactosefree or
dairy
formulas
Rice and oat flakes
Specific treatment
• Bacteriophage
Coliphage, Salmonella phage, Shigella
phage
– Infant younger 6 mo
10 ml twice a day per os
20 ml a day per enema
- Infant from 6 mo up to 12 mo
20 ml twice a day per os
40 ml a day per enema
- Children older then 12 mo
30 ml twice a day per os
60 ml a day per enema
•
Etiotrope therapy for 5-7
days
• is used:
• in all severe cases,
• in case of hemocolitis,
• in moderate cases:
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children before 1 year,
immune deficiency
shigellosis, amebiasis
secondary bacterial complications
• in mild cases in case of:
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immune deficiency
hemolytic anemia
shigellosis, amebiasis
secondary bacterial complications
Antibacterial treatment
• Mild or moderate form
– furazolidone 10 mg/kg day in 4 doses, or
ercefuril (niphuroxazide);
– Nalidixic acid (NegGram) - Pediatric Dose
55 mg/kg/d PO in 4 divided doses for 5 d.
• in severe cases –
– amoxiclav 25-50 mg/kg,
– or netylmycin 6-8 mg/kg, amikacin 10-15
mg/kg
– or cefotaxim 100-150 mg/kg,
– or ceftriaxon 100 mg/kg,
– or ciprophloxacin 10-20 mg/kg per day in 2
equal doses.
Probiotics
• during acute
period and for
3-4 weeks in
the recovery
period
Home treatment of
dehydration
• The best fluid replacement for children younger
than 2 years is Rehydron,Elektrolyt, Gastrolyte,
• ORS-200, Pedialyte, Rehydralyte, Pedialyte, or
any similar product designed to replace fluids,
sugar, and electrolytes.
• You can make your own oral rehydration fluid by
following this recipe:
•
•
•
•
one-half teaspoon table salt
one-half teaspoon potassium chloride (lite salt)
one-half teaspoon baking soda
4 tablespoons sugar
• dissolved in 1 liter of water
• Give a few sips every few minutes.
Oral rehydration is effective in case of 1st 2nd degre. of dehydration in 80-95%.
• It is performed in 2 steps by glucosesaline fluids:
• first — water-electrolyte deficiency
liquidation for the first 4-6 hours after
hospitalization (50-100 ml/kg).
• second — maintenance therapy of the
fluid loss (80-100 ml/kg for 18-20 hours).
• Oral intakes should be small –– 1-2 tea
spoon every 5-10 minutes. water and saline
fluids correlation is 1:1, in neonates –– 2:1.
Adequate rehydration
criteria:
• Improvement of the clinical status;
• Progressive decreasing of
dehydration symptoms;
• Peroral rehydration should be
stopped when it is ineffective, and
edema and oliguria is developing.
Parenteral rehydration should
be performed in case of:
• Severe dehydration with hypovolemic
shock;
• Toxic shock syndrome;
• Combination of dehydration with severe
intoxication;
• Oliguria, anuria;
• Nonstop vomiting;
• Ineffective peroral rehydration during 4-6
hours.
Accounting of the fluids for rehydration
(in ml) per 1 kg of the body weight
stage
Fluid deficit, % Before
1 yr old
1-5 years
6-10 years
І
5%
130-150
100-125
75-100
ІІ
5-10 %
170-200
130-170
100-125
ІІІ
> 10%
200-230
170-200
125-150
Correlation of IV fluids (water to
saline):
• In case of isotonic dehydration ––
1:1;
• In case of hypertonic dehydration ––
2:1 or 3:1;
• In case of hypotonic dehydration ––
1:2.
Start fluids:
• In case of hypertonic dehydration –– 5
% glucose;
• In case of hypotonic dehydration ––
0,9 % NaCl;
• In case of isotonic dehydration –– 10 %
glucose.
Correction of the
electrolytes:
• Na, Cl deficit – by 0,9 % NaCl not
more 100 ml/kg,
• К deficit – 4 % KCl 2-5 ml/kg, or 1-2
ml/kg 7,5 % KCl (1 ml of which is
adequate to 1 mmol/l К)
• Mg deficit – 25 % MgSO4 0,75-1,0
ml/kg.
Correction of the toxicosis:
• in case of neurotoxicosis Lytic suspension
0,1 ml/kg, seduxen 0,3 mg/kg, prednisone
2-3 mg/kg, dehydration – lasix 1-2 mg/kg
• hormones IV 5-20 mg/kg per day in 2-4
takes (by prednisone),
• toxic shock syndrome albumin 5-15 ml/kg,
rheopolyglucin 10-20 ml/kg, trental 0,1-0,2
ml/kg, contrical 1000 U/ kg, heparin 100200 U/ kg;
•
•
hemodyalis (in case of HUS).
Parenteral
infusion in
toddler
Parenteral infusion in
the newborn
Enterosorption
• For 5-7 days, in case of stools
normalization or constipation
development enterosorption should be
discontinued.
– Smecta
– Enterosgel
– Polysorb
Other treatment
antipyretics
antidiarrheal
Enzymes in the recovery period in case
of enzymopathy no more than 2-3 weeks
Primary Prophylaxis
• Sanitary disposal of human feces
• Protection, purification and boiling of
water
• Correct preparing and saving of
foodstuffs
• Person hygiene
Secondary Prophylaxis
Ill Person
• Isolation period –until the stool
culture taken 3 days after stopping
treatment is negative
• Current and terminal disinfection
• Medical supervision for 1-3 mo
Contact children
Stool culture
Thanks for attention!