Acute Intestinal Infections. Acute Intestinal Infections. Acute Intestinal Infections. Acute Intestinal Infections.

Lecturer: ass.prof. Gorishna I.L.Lecturer: ass.prof. Gorishna I.L.

Plan of the lecture1. Definition of Acute intestinal diseases 2. Reasons of Acute Intestinal Diseases3. Clinical, Epidemiological Peculiarities, Differential

Diagnosis, Treatment of Escherichiosis4. Clinical, Epidemiological Peculiarities, Differential

Diagnosis, Treatment of Shigellosis5. Clinical, Epidemiological Peculiarities, Differential

Diagnosis, Treatment of Salmonellosis6. 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

• Functional digestive disorders• Inborn errors of metabolism• Some surgical disorders • Acute intestinal diseases

Etiology of Acute Intestinal Diseases

• bacterial agents– Escherichia coli – Shigella,– Salmonella, – Campylobacter jejuni – Yersinia enterocolitica. – Clostridium difficile – Vibrio cholerae

• enteroviruses (infectio enteroviralis)– Rotavirus – Coxsackie viruses– ECHO (Enteric Cytopathogenic Human Orphan)

viruses– Astrovirus

Parvovirus

- 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.

TransmissionThe 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 coliinfection, 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• 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 culture

s

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

TransmissionShigella 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:• 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 uncomplicatedV. 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

• 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 Infectio

n

false urge to defecat

e

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

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 gastro-intestinal, rare – as typhoid or septic form

Etiology of Salmonella Infection

• S. typhimurium• S. enteritidis• S. java• S. anatum

TransmissionThe way of transmission • Contact• Alimentary (by water, food) • Droplet

Source of infection• Domestic animals, birds• Contagious patient• Bacillus carrier

Pathogenesis• Entering the salmonella into gastro-

intestinal 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

Gastrointestinal form Bacterium carrying

2. General form Like typhoid fever Sepsis

3. Asymptomatic formII. Severity (mild, moderate and severe)III. Course 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.

Dehydration

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 dullness

Adynamia

Concentration of the sodium in blood

Increased Normal Decreased

Loss of body weight

5-10 % Less than 5 % More than 10 %

General principals of intestinal infections

treatment Dietary treatmentSpecific 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 8-10 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

Lactose-free or dairy

formulas

Rice and oat flakes

Specific treatment• BacteriophageColiphage, Salmonella phage, Shigella

phage – Infant younger 6 mo

10 ml twice a day per os20 ml a day per enema

- Infant from 6 mo up to 12 mo 20 ml twice a day per os40 ml a day per enema

- Children older then 12 mo 30 ml twice a day per os60 ml a day per enema

•

Etiotrope therapy for 5-7 days

• is used: • in all severe cases, • in case of hemocolitis, • in moderate cases:

» children before 1 year, » immune deficiency » shigellosis, amebiasis» secondary bacterial complications

• in mild cases in case of:» 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 glucose-

saline 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 100-200 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 treatmentantipyreticsantidiarrhealEnzymes 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 moContact children Stool culture

Thanks for attention!