UnPar-Final Modul Gastro 2013

7/27/2019 UnPar-Final Modul Gastro 2013

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Dr. Agnes Kurniawan,

PhD, SpParK


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GI Module Feb 2013-AK-UniB/UnPar 2

1. To acquire knowledge on protozoa and

worms which often leads to gastrointestinal

disorders

2. To understand the life cycle, epidemiology,clinical symptoms, diagnosis, treatment and

prevention of the protozoa and worms

causing GI disorders


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Trichuris trichiura

Taenia saginata

E. histolytica

Cyclospora cayetanensis

3GI Module Feb 2013-AK-UniB/UnPar

WORM

PROTOZOA


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= Whipworm, a roundworm/nematode, STH

Commonly infect children

Epidemiology : warm, humid climates, crowded

Mode of infection : ingested of mature eggs

Risk factor : poor hygiene, sanitation, raw vegetables

Mature egg ingested hatch in the small intestine

larvaeadult worm in caecum/ascending colon

egg adult female = 60-70 days

egg infective stage:36 wks, soil

eggs produced: 3000-10.000/day



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Adult:

- female 5 cm, male 4 cm

- anterior portion whip like- live in colon ascendens and caecum

- no lung cycle: egg ingested hatch in thesmall intestine larvae adult worm in

caecum/ascending colon



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< 10 worms asymptomatic

Heavy infection

diarrhea, dysentery,anemia, rectal prolapse,growth retarded

Note : dysentry : frequent, painfulpassage of stool that contains amixture of mucus, water, and

blood.



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The anterior part of the worm dip into the

intestinal mucosa irritation trauma and

inflammation of the intestinal mucosa and

bleeding -- sucked by the worms

anemia

Parasitology Lab Diagnosis

Microscopy :Wet smear : T. trichiura eggs in the stool



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Treatment

- Mebendazol 2x100 mg for 3 days (>2 yo)

2x200 mg for 3 days (adult)

- Albendazol 400 mg, single dose



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1. BREAK THE WORM LIFE CYCLE- environmental sanitation : use of toilet

for defecation, not using stool forfertilizer

- good personal hygine : handwashingwith soap & water, wash well the fruitsand vegetables

- mass treatment when prevalence > 30%

2. HEALTH EDUCATION



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Definitive host: man

Adult worm: in the middle third small intestine

Intermediate host : cattle

larva (cyst) in muscles Mode of infection:

- 1. in cattle: grazing on moist pasture contaminatedwith eggs ofT. saginata from human stool

- 2. in man: consuming uncooked/rare cooked beefwith larvae (cysticercus bovis)



LIFE CYCLE



LIFE CYCLE & PREVENTION



Proglotid: crawling out of anus

GI complaints: nausea, diarrhea, abdominal

pain

Systemic symptoms: fatigue, hunger,

dizziness, moderate loss of weight

Rare symptoms: vomiting of segments,

obstruction of bile ducts, pancreatic ducts orappendix



eggs in stool

proglotid crawling out

of anusTreatment

praziquantel 10mg/kg, single dose

albendazole



EVALUATION OF TREATMENT- Relieve of symptoms- Parasitology lab examination :

1. 24 hours collected stool after th/:

scolex + proglottids

2. stool, 3 months after th/:

negative for eggs and

or segments


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E. histolytica: histo=tissue ; Lysis = dissolve,

destroyed

Aetiology of intestinal and extra intestinal

amebiasisHost : human

Habitat : colon

Distribution : cosmopolitan, in tropical and

subtropical countries



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2 stages: trophozoite and cyst

TROPHOZOITE :

- 2 forms : histolytica (pathogen) and minuta

(apathogen). Size : 10-60 um, entameba nucleus

Endoplasm: fine granules, contains bacteriaor food metabolites

If contains red blood cells erythrophago-cytosis typical for E. histolytica infection

Live 2 hours outside the host



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Size: 10-20 um

round/oval shape

Structure: cyst wall, endoplasm with 1,2 or 4

nuclei

Endoplasm : chromatoid body (cigar form) &

glycogen vacuol (food storage)

apathogenic Infective stage : mature cyst (cyst

with 4 nuclei)



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Ingestion of mature cyst

Excystation in the stomach with the help of

gastric juice trophozoite release colon

multiplication by binary fission

invadethe mucose ( cause symptoms ) or transform

into cyst stage (encystation )



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Trophozoites express gal/gal nac lectins

antigen on its surface stick to colonic

epithelial cells present amoebapores and

excrete cysteine proteinases (amebapain dan

hystolisine) lyse extracellular protein matrix

epithelial cell lysis tissue necrosis,

further invasion to submucose flask shape

ulcer



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Form : bottle shape, small opener at the top, wide

at the bottom, irregular rim, slightly elevated

Inflammation, with blood and secondary infectionwith bacteria

Progression to submucose area along the lateral

axis of colon

Excretion of trophozoite into the lumen invadeother healthy area of colon or excreted with stool

dysentric stool (mucous and blood )



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1. Carrier state:

- intestinal amebiasis

- parasite multiplies in the body

- stools : cysts ++

- clinical signs /symptoms : none

- cause : low virulent strain, low number of

infection, adequate immune status



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2. Intestinal amebiasis

- dysentery, colitis, appendicitis, toxic

megacolon, amebomas

- Abdominal pain- Diarhoea with mucous and bloody stool ,

frequency up to 10 x/day

- Fever, loss of appetite, decrease body weight



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The most common extraintestinal complication

of amebiasis (8.5% of cases).

Hepatic infection occurs because colonic

trophozoites ascend via the portal vein

invade the parenchyma

Cause : toxin release & hepatocyte damage

Usually develop within days - months after dysentri


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Symptoms : fever (>90% acute cases), dullpleuritic right upper quadrant pain radiating to

the right shoulder, hepatomegali and pleural

effusions.

Acute form: often very high fever, continuous orintermittent + chills

Chronic forms : fever is low, develops gradually,

without chills or sweating

Right / left lobe



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Occasionally spread into the overlying

abdominal wall or form portal venous amebic

thrombi.

Hematogenous dissemination to the brain israre

Diarrhea (2%), with 4 - 5 x/ day,watery stool,

with mucus and blood, tenesmus, abdominal

cramping and distension due to potassium loss

Jaundice is an unusual feature(5%)



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the abscess extends upward the diaphragm,

pleura empyema .

Invasion of the lung parenchyma by E.

histolytica development of interstitialpneumonitis, liquefaction & formation lung

abscess



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1. Microscopic Faeces : trophozoite (invasive stage) and /

cysts (non invasive stage)

The 2 stages represent two separatespecies : E. histolytica & E. dispar which

are morphologically indistinguishable

unless E. histolytica is observed with

ingested red blood cellsCysts: found in formed stool

Trophozoites: found in diarrheal stool



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Body fluid: trophozoite

Stool examination is best performed 3X in a

week to exclude false negative

2. Serology test ( Antibody detection)

IHA, ELISA

To diagnose extraintestinal amebiasis

Performed together with the microscopic

examination of the abscess fluid and radio

diagnostic



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3. Antigen Detection

ELISA

Specimens: stool, serum, abscess fluid, saliva

Specific for E. histolytica ( cannot for E.dispar)

4. Polymerase chain reaction (PCR)

to differentiate E. Histolytica from E. dispar



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TREATMENTDrugs:

- metronidazole (trophozoite & cyst form)

- chloroquine (trophozoite form)

- paromomycin (trophozoite form)

Intestinal Amebiasis: paromomycin 25-35

mg/kgbb/hari, 3x/day, 7 days

Extraintestinal Amebiasis : metronidazol 3x750mg/hari 7-10 days + abscess drain



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Improving sanitation and hygine individuals

Health education on mode of transmission

Water treatment : chlorination and filtration



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Coccidia

Host: man

Epidemiology : developing countries



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Oocyst: 8-10 um

Immature (unsporulated) oocyst excreted instools sporulation 1 several weeks inwarm and humid climate

Mature Oocyst : 2 sporocysts @ foursporozoites

Infection : ingestion of mature oocysts

Source of infection : contaminated food /

vegetables, water such as raspberry

Parasite lives intracytoplasmic develop inthe jejunal enterocytes



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Diareanorexia, flatulance, epigastric pain,

nausea, vomitus, low grade fever Immune competent : acute, light diarrheaAIDS : chronic diarrhea, severe



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1. Microscopic :

- oocyst in the stool, duodenal aspirates,duodenal/jejunal biopsy

- 3 stools every 2-3 days- safranin / acid fast stainings

2. UV fluorecense microscope

3. PCR



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Treatment : trimetoprim + sulfametoksazol,

metronidazol, siprofloksasin

Prevention : Improving sanitation and hygine

individuals, health education, watertreatment, proper washing of raw vegetables

and fruits



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THANK YOU

UnPar-Final Modul Gastro 2013

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