Identify and describe the laboratory and x-ray investigations useful in the diagnosis of the entities listed in Objective 1. Construct a treatment plan for a patient with hyperactivity of the intestinal tract which includes both parmacologic and nonpharmacologic approaches. Construct a differential diagnosis and treatment plan for a patient with hyperactivity of the intestinal tract, given signs, symptoms, Fray and laboratory data. Acute disturbances of intestinal function are common and usually manifest themselves as diarrhea. The increase in water content of diarrheas stools can be due to impaired water absorption by the intestinal mucosa or increased secretion of water by the intestinal mucosa. Acute viral gastroenteritis is marked by relatively sudden onset of nausea and vomiting followed by explosive diarrhea with or without abdominal cramps. Gastrointestinal infections secondary to Salmonella are probably the most common bacterial gastroenteritides in the U.
The incidence of asymptomatic carriers of salmonella in the general population is about 0.2%, but the most important reservoir is domestic and wild animal species, varying from less than 1% to more than 40%.
The stools of a patient with salmonella gastroenteritis are usually loose, slimy, green and smell like rotten eggs. Shigellosis, frequently referred to as bacillary dysentery, is another cause of acute bacterial gastroenteritis.
The major clinical features of shigella gastroenteritis are diarrhea, abdominal pain and fever. Among the many parasites isolated from patients in this country, the two most important clinically in terms of gastroenteritis are Giardia lamblia and Entamoeba histolytica. Many infected patients are asymptomatic, but the most consistent clinical presentation in symptomatic patients is anorexia, nausea, a sensation of gastric fullness and watery diarrhea. Amebiasis is a disease of the large intestine caused by an invasion of Entamoeba histolytica into the submuco6a. Cases of amebic dysentery are usually sporadic, but epidemics (sometimes waterborne) do occur. Bacterial enterotoxemia, commonly referred to as food poisoning, is considered by some authorities to be a relative medical emergency, as the consequences can be lethal.
One of the most common forms of food poisoning is due to the enterotoxin produced by staphylococci. The foods that seem to be involved quite often in this disease are custards, mayonnaise, cream filled pastries, milk products and whipped cream.
Another relatively common cause of food poisoning is the enterotoxin produced by a bacterium known as Clostridium perfringens. The usual clinical picture is as follows: clostridium perfringens food poisoning begins 8 to 24 hours after ingestion of the contaminated food and consists of abdominal pain, abdominal cramps and profuse diarrhea. There are other types of food poisoning, of course, but the two mentioned in this minicourse are both relatively common. Allergies to food can cause hyperactivity of the gastrointestinal tract, but are often difficult to document because proper objective tests are lacking.
Gastrointestinal symptoms caused by food allergies include diarrhea, abdominal distention, abdominal pain, vomiting, and flatulence. Milk is the most common food allergen, but other common food allergens include wheat, apple, egg, tomato, foods in the pea family, corn, citrus fruit and chocolate. Because objective tests for the specific diagnosis of food allergens are lacking, one must rely on the patient's history and food diaries to identify offending foods. Ulcerative colitis is a diffuse acute and chronic inflammatory disease of unknown origin which involves a part or all of the colon.
The major clinical manifestations of ulcerative colitis include diarrhea, rectal bleeding, abdominal pain, fever and weight loss.
The course of the disease varies from very mild where the patient complains of slight blood-staining of the stool without any systemic symptoms to the severe fulminating variety which if not interrupted may be fatal. Regional enteritis is an inflammatory disease of the intestinal tract that is referred to in the literature by a variety of names such as regional ileitis, transmural colitis, granulomatous colitis and Crohn's disease. This disease is approximately one-third as common as ulcerative colitis and although it can affect any age group the peak incidence is between 15 and 35 years of age.
The most common clinical presentation of regional enteritis consists of diarrhea, colicky abdominal pain and weight loss.
In patients with the more chronic form of the disease there is evidence of perianal disease such as pertrectal or ischiorectal fistulae (a fistula is an abnormal passage between two organs or passage between internal organ to body surface), strictures of the bowel, and malnutrition. Ulcerative colitis and regional enteritis are the two most important nonspecific chronic GI inflammatory disorders - both can produce the prominent symptoms of diarrhea, abdominal cramps and fever. Rectal involvement occurs in nearly all patients with ulcerative colitis, but in only 20% of those with regional enteritis.
In ulcerative colitis the inflammation generally is superficial, involving the mucosa and submucosa only. Cancer of the colon is relatively common in patients with ulcerative colitis and uncommon in granulomatous colitis.
Perianal fistulae and internal fistulae are uncommon in ulcerative colitis and quite common in granulomatous colitis. Strictures of the bowel are common in granulomatous colitis and rare in ulcerative colitis. Functional gastrointestinal disease encompasses a variety of complaints in which no gross organic lesions can be found and the clinical manifestations are probably the result of altered physiological mechanisms.
The functional lower abdominal disorders are classified and discussed in the literature on the basis of their more obvious clinical manifestations or their suspected but unproved etiologies. Other associated gastrointestinal symptoms are passage of excessive gas and mucus per rectum, abdominal rumbling and gurgling, belching, and vomiting (not common). Functional gastrointestinal abnormalities may be regarded as aberrations of the secretory activities or motor activities (or both) of a gastrointestinal segment. It is generally agreed that the symptoms of irritable bowel syndrome (IBS) can be attributed to colonic motility abnormalities. Functional gastrointestinal complaints are common, vague, varied in presentation, often perplexing in differential diagnosis and as yet have no explanation that can be proven. The microorganisms that cause acute infectious nonbacterial gastroenteritis are probably viruses that replicate within the human gastrointestinal tract. Thus, while a number of viruses possessing the ability to replicate in the intestinal tract have been identified, the microorganisms responsible for the endemic and epidemic (often seasonal) bouts of gastroenteritis have so far eluded identification.
The major diagnostic tool in the diagnosis of Salmonella gastroenteritis, after a complete history and physical are obtained, are stool cultures for the purpose of identifying the causative bacterial pathogen.
Agglutination tests with acute convalescent sera from patients with Salmonella are not very helpful in the diagnosis. The peripheral white blood count in patients with salmonella gastroenteritis is usually normal. The definitive diagnosis of gastrointestinal infections due to shigella depend on isolation of the organism from stool cultures or rectal swab.
Although not specific, demonstration of leukocytes in a smear of the patient's stool or of mucus obtained on rectal swab gives an indication of bacterial etiology to the gastroenteritis as opposed to viral gastroenteritis where leukocytes are generally not found in the stool. A rapid method of distinguishing the presence or absence of a bacterial etiology in patients with gastroenteritis involves the demonstration of leukocytes in a smear of a patient's stool or of mucus obtained from a rectal swab.
Stools from patients with shigellosis are characterized by large numbers of WBCs in the stool (greater than 50 per high power field), more than 80X of which are polymorphonuclear leukocytes (sometimes band forms are present).
This test is rapid and simple and merely requires one to place a small amount of mucus obtained from a rectal swab (or stool) on a glass slide and add methylene blue stain. The diagnosis of giardiasis is sometimes made by identifying the characteristic cysts or trophozoites in a stool specimen.
Several daily stool specimens should be obtained and this serial stool examination may increase the Jikelihood of finding the organism.
Intestinal amebiasis should be considered immediately when patients present with colonic complains, especially bloody diarrhea, so that appropriate specimens can be obtained before any procedures are performed or medications are given that might alter diagnosis. The diagnosis of gastroenteritis due to Entamoeba histolytica is best established by identification of the tropozates or cysts of the ameba in the patient's stool. Serologic tests are positive in a great majority of patients with acute amebic dysentery, but because significant antibody titers can persist for months or years after complete cure, this method is of more value in excluding the diagnosis of amebiasis than in confirming it.
The total white blood counts in patients with acute amebic dysentery may be normal or moderately elevated.
The diagnosis of food poisoning due to staphylococci generally depends on a careful history of food intake and epidemiologic investigation.
The exact etiology can only be established if samples of the ingested contaminated food can be shown to contain large numbers of enterotoxin producing staphylococci. The diagnosis of Clostridium perfringens food poisoning also depends on history of food intake and epidemiologic investigation. The most important tools in the diagnosis of ulcerative colitis, after a thorough history and physical examination, are sigmoidoscopy and barium enema.
The barium enema is a very important part of the diagnostic work-up of patients with ulcerative colitis. The most significant diagnostic features on barium enema are the continuous involvement, the symmetrical abnormal appearance of the bowel wall and the visualization of inflammatory polyps when they are present.
Barium x-ray studies are the major diagnostic tool in the diagnosis of granulomatous colitis (regional enteritis). Laboratory investigation of patients with regional enteritis will often reveal the extent of the disease. Functional bowel disease, such as the "irritable bowel syndrome" can be frustrating diagnostically.
It is important to remember that the examining clinician is usuallv dealing with ill-defined symptoms that could arise from any source.
Colorectal cancer is the formation of malignant tumor in the end part of the large intestine.
If passing of stools occurs less than 4 times in a week, it is medically known as constipation. A common but a very vague symptom of colorectal cancer is the occurrence of abdominal pain.
The presence of a lump, especially on the right hand side of the abdomen, is a symptom for bowel cancer. Most colorectal cancer patients have reported of symptoms such as unexplained tiredness and fatigue.
But sometimes, the mechanisms that regulate cell growth stop working and cells divide out of control. People who have a history of colon cancer in their family are at greater risk of getting the disease themselves. HNPCC (also called Lynch syndrome) is caused by mutations in one of several genes that fix damaged DNA.
People who inherit one bad copy of the APC gene are practically guaranteed to develop colon cancer by age 40.
Colonoscopy - Using a thin instrument called a colonoscope, the doctor looks inside the patient's colon.


During the procedure, the doctor removes pieces of tissue (called a biopsy) to test them for cancer.
Inherited cancers often provide clues about the genes mutated in noninherited (sporadic) cancers. For example, mutations in the APC gene are found not only in FAP tumors but in 85% of all sporadic colon tumors as well.
This is an extremely important class of diseases--one which is encountered frequently, requires a keen application of problem-solving ability and which is not likely to become rare in the foreseeable future.
The most common cause of diarrhea in this country is an acute infectious non-bacterial gastroenteritis that usually is self-limiting and usually is viral in etiology.
Under normal conditions the large intestine resorbs liquids and electrolytes added to the stream of intestinal contents along the gastrointestinal tract.
Enteric diarrhea is characterized by large stool volume containing undigested food and is caused by impairment of digestion.
Muscle aches and pains (myalgia), loss of appetite (anorexia) often accompany the vomiting and diarrhea.
If the infection is more severe, a disruption of the intestinal mucosa can occur with necrosis and ulceration.
The natural disease is limited to man and the asymptomatic carrier or convalescent shigella patient are the only recognized reservoirs. The first symptom is typically colicky abdominal pain followed shortly by diarrhea and high fever. Changes are most pronounced in the rectum and sigmoid and consist of diffuse swelling and petechial hemorrhages in mild cases. What is the great potential danger ensuing from acute gastroenteritis of the type described in Question 1? Describe the clinical features of acute salmonella gastroenteritis including a description of the stool. What is the distinction pathologically between salmonella gastroenteritis and Shigella gastroenteritis in terms of the intestinal area involved? How does the gross appearance of the diarrheal stools differ in patients with shigellosis from those with salmonellosis?
Giardiasis is acquired through the ingestion of cysts of the parasites which are passed in human feces and usually spread through the imbibing of contaminated water and only rarely in food. In a significant number of patients the diarrhea becomes chronic on an intermittent or continuous basis resulting in weight loss, abdominal distention, flatulence, pale bulky malodorous stools and malabsorption.
The infection may be entirely asymptomatic, or chronic, or presenting with mild abdominal discomfort and diarrhea alternating with constipation, or the presentation may be in the form of acute diarrhea. Outbreaks of this disease are usually not explosive as are those produced by pathogenic intestinal bacteria such as Shigella.
The symptoms are quite acute and begin approximately within 4-6 hours of the ingestion of food contaminated by the staphylococci.
This type of bacterial enterotoxemia typically involves the ingestion of food that has been prepared and cooked 24 or more hours before consumption and allowed to cool slowly at room temperature and then served either cold or warm.
In both instances the disease is usually benign and self-limited, but can be extremely serious and even lethal in elderly patients or patients with cardiovascular disease, as the enterotoxemia can be severe enough to result in hypotension.
The symptoms may range from mild cases where nausea, diarrhea, and abdominal discomfort are present, to severe cases marked by forceful vomiting, severe abdominal colic, bloody and mucoid diarrhea and dehydration. Some patients can ingest a food allergen once a week or so and experience no symptoms, other patients can react to the ingestion of even a small amount of the offending allergen.
The disease may arise suddenly or insidiously and the patients involved may experience spontaneous remission or relapses. Other clinical features that may occur are tenesmus with small "squirts" of bloody mucus, nocturnal defecation and stool incontinence.
The average patient with ulcerative colitis experiences increasing diarrhea until 5-10 liquid stools are passed each day and there is an associated loss of appetite, loss of weight, abdominal cramps, weakness and anemia. Thus, the patient's history of these complaints cannot always help you to distinguish them.
In regional enteritis rectal bleeding occurs in a minority of the patients and is usually mild and intermittent. Grarulomatous colitis, on the other hand, commonly affects the right side of the colon, sometimes affecting one wall of the intestine, leaving the opposite intestinal wall normal and producing patchy lesions in such a way that diseased segments of the bowel alternate with normal segments (skip lesions).
These disorders comprise an estimated 3050% of all the gastrointestinal illnesses that a primary care physician is confronted with. The description of any of these abnormalities should prompt an aggressive evaluation for alternative explanations for the patient's complaint.
Thirty years of colonic motility research has failed to consistently back up this assumption. They may be aware of or more sensitive to contractions and fecal movement than non-IBS individuals.
It is a great problem of immense scope and is responsible for a good deal of the primary health care practitioner's time and energy. What part of the intestine is involved in giardiasis and how is the disease usually acquired? By what common name is bacterial enterotoxemia known and what are the two most common causes in this country? Contrast the pathophysiological difference between bacterial gastroenteritis and bacterial enterotoxemias.
What is the most common food allergen and what are some common symptoms produced by food allergens in terms of the gastrointestinal system? If a stool sample is not readily available, a rectal swab may be obtained and the contents cultured.
Bacteremia can occur with the disease and all patients suspected of having blood stream invasion by salmonella should have blood cultures. Shigella organisms survive for only a short time in the stool and, therefore, fresh stool specimens are required for culture. The presence of leukocytes on such a smear gives an indication of a bacterial etiology of the gastroenteritis. In patients with salmonellosis the total white blood count on stool examination is lower than in shigellosis and there is a greater proportion of mononuclear cells (approximately 25z). Wait two to three minutes and examine the slide under low power to note the presence of white blood cells and then under high power to do a differential white cell count. The diagnosis is based on such features as a short incubation period, short duration of symptoms, lack of fever and the epidemic nature of the syndrome. The disease is usually so benign and self-limiting that laboratory investigations are usually not performed.
Eosinophils in the stool mucus can be present but this is not diagnostic; blood eosinophilia can also be present. What is the value of obtaining a stool culture on a patient with acute nonbacterial gastroenteritis? Discuss the value of fecal leukocyte examination in the diagnosis of acute bacterial gastroenteritis.
What is the best practical method of diagnosing gastroenteritis due to Entamoeba histolytica? The sigmoidoscopy is probably the most important procedure in the diagnosis of this disease. This study can reveal straightening and shortening of the rectosigwoid and sigmoid area with a very symmetrical involvement of the bowel wall with small ulcerations, a loss of the normal haustral markings and a "lead pipe" appearance of the descending colon. It is common for patients with this disease to have an anemia which is due to a combination of iron deficiency and chronic inflammation. In this disease barium studies reveal "skip" areas rather than continuous involvement, fistulae, strictures of the bowel wall, coarse mucosal ulcerations and usually noninvolvement of the rectum. In young patients (under 40) , the major diagnostic consideration is inflammatory bowel disease. Discuss the two tools most useful in the diagnosis of ulcerative colitis (outside of the history and physical examination) and discuss the typical findings of each.
The most common cause of acute gastroenteritis in this country is an acute nonbacterial gastroenteritis, usually viral. The increase in water content of diarrheal stools can be due to impaired water absorption by the intestinal mucosa or increased secretion of water by the intestinal mucosa. Acute nonbacterial gastroenteritis is characterized by sudden onset of nausea and vomiting followed by explosive diarrhea with or without abdominal cramps. Salmonella gastrointestinal infections are usually transmitted from animals to man and occasionally from man to man.
A typical attack of acute salmonella gastroenteritis is mild, brief, self-limiting and consists of sudden onset of colicky abdominal pain and loose watery stools that can be slimy, green and smell like rotten eggs. Salmonella gastrointestinal infections primarily involve the small intestine, producing edema and Inflammation of the mucosa. The stools of patients with shigellosis are watery, relatively odorless, contain mucus, are yellow-green and commonly contain blood, whereas the stools of patients with salmonellosis are loose, slimy, smell like rotten eggs and green in color, but do not commonly contain blood. Giardia lamblia and Entamoeba histolytica are the two most important parasites in terms of gastroenteritis in the U.
Giardiasis is a disease of the small intestine and is acquired through ingestion of cysts of the parasites which are passed in human feces and spread through the ingestion of contaminated water. The clinical features of staphylococcal food poisoning are sudden intense nausea followed by explosive vomiting and intense abdominal cramps. The blood may appear maroon, bright red or blackish in color and in many cases it might not be visible to the naked eye (occult sample).
If you notice that your stool is thin, almost ribbon or pencil like, understand that this maybe an indication that something (perhaps a cancerous growth) is obstructing the colon or anal passage. Now, constipation is a very common gastro-intestinal problem and does not directly indicate cancer. Pain in the abdomen may occur when the colon is obstructed by a tumorous outgrowth which in turn traps the gas leading to bloating and pain. In many cases the lump cannot be easily detected owing to problems such as fat accumulation. If you have not been dieting yet you notice a drastic loss in your weight you should seek medical advice. If the small intestine is performing its function normally, the fecal matter arriving at the large intestine is liquid.
Salmonella gastrointestinal infections, in the vast majority of cases, are transmitted from animals to man and occasionally from man to man.
The spread occurs from man to man primarily when organisms from infected feces (deposited on hand or inanimate objects) are ingested. A fibrinous exudate often develops and necrosis of the mucosa can occur which leads to shallow ulcers which bleed readily, thus accounting for the blood in the stool often seen in this disease. The disease can also be transmitted by hand to mouth transfer of cysts from the feces of an infected individual. The acute form, referred to as acute amebic dysentery, is characterized by diarrhea with profuse blood and mucus and small amounts of pus.


S., often occur after social events, such as picnics, where food is prepared in advance in an effort to serve a substantial number of people.
The clinical features consist of sudden intense nausea followed by explosive vomiting and intense abdominal cramping. Clostridial enterotoxins are most commonly found in meat products, usually from beef or turkey products. The bloody mucus "squirts" are distinctive for this disease, although this condition also occurs during acute amebic dysentery.
Examination of the stools reveals the presence of mucus, pus, and blood with little fecal matter. Although this disease occurs most commonly in the terminal ileum, it occurs often in the colon and can produce identical lesions from the stomach to the anus. The patients commonly have urban backgrounds, are better educated and have a slightly higher economic status than the average person. The absence of gross blood in the stool in a patient with chronic diarrhea should suggest a diagnosis other than ulcerative colitis. There is at present a rather sharp Limitation in the knowledge of the exact pathophysiology of functional gastrointestinal complaints. These clinical manifestations such as anorexia, nausea, and sense of fullness are vague as defined by the patient when a history is elicited. The physician extender must take interest in this common problem and not treat these patients as "malingerers," "crocks," "turkeys," etc. This illness has been transmitted experimentally in man by bacteria-free stool filtrates obtained from patients infected with acute gastroenteritis.
By the time the viral agent is identified in an individual patient, the patient is usually over the illness.
Stool cultures usually become negative for the Salmonella organism within one week to a month, but on occasion some patients, even though asymptomatic, can excrete the organism for months - so called asymptomatic carriers.
Blood cultures are usually normal when the salmonella only involves the gastrointestinal tract.
Agglutinating antibodies can be detected in a majority of the patients with this disease, but serologic tests are generally of little or no value in the diagnosis of shigellosis. Gastrointestinal infections due to presumed viral etiologies are not associated with inflammatory cells in the stool. Serial samples of stool should be analyzed to increase the likelihood of finding the organism.
In the latter disease, there is actually a proliferation of viable staphylococci in the intestine.
However, exact etiologic diagnosis depends on the identification of the enterotoxin in samples of the contaminated food.
Extracts of food can be used for skin testing, but it is preferable to diagnose food allergies by history and by elimination diets. One of the characteristic x-ray findings is known as the "cobblestone" appearance; this is due to the fact that in granulomatous colitis the mucosa between intersecting linear and transverse ulcers resembles cobblestones when visualized on x-ray.
The diagnosis should probably be made on the clinical presentation, but to arrive at an accurate and final diagnosis on initial encounter is not realistic. Keep the lines of communication open with the patient and be Prepared to improvise additional diagnostic maneuvers as needed. Shigella infections, on the other hand, produce mucosal changes mainly in the rectum and sigmoid area consisting of diffuse mucosal swelling and petechial hemorrhages in mild cases; severe cases have a fibrinous exudate with necrosis of the mucosa and the development of shallow ulcers. The two most common causes in this country are the enterotoxins produced bv staphylococci and those produced by Clostridium perfringens. You need to understand that there is nothing like a sure shot symptom of bowel cancer; learn to identify the common symptoms and go in for an immediate medical check-up. In case the blood is not visible to the eye a pathological test called FOBT (Fecal occult blood test) needs to be conducted to investigate the presence of blood traces in the stool. However, occurrence of blood in stool can have varied causes like piles, hemorrhoids and cancer but if you notice blood or blood clots always seek medical advice to know the exact reason behind it. However, if the constipation problems persists for more than a week or two and refuses to go away after medication, you should undergo a checkup. In many cases, colorectal cancer patients may notice a drastic change in their normal bowel habits and in some cases they experience the feeling of incomplete emptying after a bowel movement such that one may frequently try to empty the bowel without any success. If you experience a chronic pain or an intermittent pain that remains for over 2-3 days, consult a doctor for advice. If stools contain 80% or more of water after passage through the large colon, they are liquid in form.
By the time fecal matter reaches the colon the process of digestion has already been completed and the stools are smaller, do not possess undigested food components but can have evidence of inflammation, such as blood and inflammatory cells. The high incidence of salmonella infections in those domestic animals used as a source of food for man (e.g.
Patients usually have some abdominal tenderness on palpation and fever of 38-39 degrees C is common. Man passes cysts in his stools and transmission occurs by the ingestion of food or water contaminated by human fecal matter. Nausea is an occasional symptom but vomiting is not common, unlike staphylococcal food poisoning.
Ulcerative colitis is primarily an inflammatory disease of the mucosa of the colon and affects the rectum and left side of the colon most severely.
Careful data collection of such patients will often reveal some abdominal discomfort, some loose stools, tenesmus, mild anorexia and a complaint of abdominal discomfort which increases after eating. Although the patient expresses many complaints, he nevertheless presents a healthy appearance and has expressed the same complaints or similar complaints for many years.
This syndrome is characterized by diarrhea, constipation or both alternatively, and feelings of "abdominal distress" which can occur in such varied presentations as postprandial fullness, dull nondescript discomfort in the left lower quadrant of the abdomen or severe cramping abdominal pain.
Physical examination of patients with lower abdominal disease of a functional nature can reveal tenderness over such areas as the sigmoid colon, or distention of the caecum, but usually the physical examination is otherwise within normal limits.
Clinically this theory is substantiated by the observation that the symptoms often occur during times of stress or anxiety and are often relieved by only reassurance from a single compassionate health provider. In individual cases of gastroenteritis isolation of a specific virus on stool culture does not necessarily mean that the agent has caused the illness since a considerable percentage of asymptomatic individuals will grow out the same virus from their stools. Enterotoxemias (food poisoning) such as those due to Staphylococcus aureus or Clostridium perfringens are not characterized by inflammation of the bowel and, therefore, white blood cells are not found in the stool.
A trophozoite is the motile stage of the parasite which feeds, multiplies and maintains the parasitic colony in the host. If stool samples are negative for ameba and the diagnosis is still suspected, one can resort to sigmoidoscopy which permits direct aspiration of the material from areas of inflammation or ulceration. CBCs, stool cultures and x-rays are of no help in the diagnosis of staphylococcal food poisoning.
Skin testing for food hypersensitivity is generally of little or no value as these tests are not very accurate. The typical sigmoidoscope findings are loss of the normal mucosal vascular pattern, edema and ulceration of the mucosa, friability of the mucosa upon swabbing, a purulent mucosal exudate which, when swabbed, reveals a bare, bleeding mucosa and strictures inside or above the anal canal. If granulomatous tissue is obtained on biopsy, it allows the unequivocal diagnosis of granulomatous colitis.
Shigella actually involves the entire colon but the maJor changes are in the rectum and sigwoid. Man passes cysts in his stools and transmission occurs by ingestion of food or water contaminated by human fecal matter.
For reasons that are not yet clear, professional food handlers as a group have a fairly large percentage of carriers of this bacteria.
As with salmonella gastroenteritis there is a significant group of patients who have mild diarrhea or are asymptomatic. The disease is more common in the better educated groups and there is a positive family history in 5-10% of the patients. Other patients with this disease present more acutely with sudden development of right lower quadrant pain and tenderness and fever plus either diarrhea or constipation. The cramping abdominal pain may be generalized in both lower quadrants or on occasion be localized in the right or left upper or lower quadrants giving rise to difficulties for the examiner in terms of differential diagnosis of other more potentially serious diseases. Such diarrhea can persist for months or years and yet is rarely associated with weight loss.
The results of recent studies comparing IBS patients and normal individuals in their reaction to stress and these same two groups response to psychotherapy vs. Invasive bacterial infections of the bowel such as salmonellosis and shigellosis are associated with leukocytes in the stool. Probably one of the most reliabJe methods involves examination of fluid aspirated from the duodenum.
Rectal swabs using cotton strands should not be used because the strands in the specimen can obscure the amebae.
Patients can have a positive skin test to a food that causes them no difficulty and vice versa. This is important so as to allow for expression of social and other aspects of the patient's Wife which may be causing stress or anxiety to adversely affect their gut.
Every variety of animal has the potential for infection, including pet baby chicks and pet turtles. The stools are watery, relatively odorless, contain mucus shreds, are green in color, and in 20-30% of patients contain varying amounts of gross blood. The diagnosis can be based on the short duration of symptoms, the lack of fever and the epidemic involvement of the disease. In children functional abdominal complaints are the overwhelming major cause of chronic and recurrent abdominal pain and are usually referable to the periumbilical area due to the embryologic development of the nerve supply to the intestines. The most reliable method of diagnosis in giardiasis involves examination of a smear of the biopsied duodenal mucosa stained by Giemsa solution.
In the presence of anemia, hemocult positive stools, or signs and symptoms of systemic disease, then a more aggressive evaluation is appropriate. Relief of pain with stooling is not universally observed, but when present, is fairly characteristic. Psychological factors are not the root cause of gut dysmotility, but rather modify behavior of the organ.
This latter method should only be utilized if simpler methods fail to yield the organism and the diagnosis is still suspected. In the case of a malfunctioning intestine, emotional or psychological events will often exaggerate the underlying malfunction. A fo]low-up procedure is reouired if a significant abnormality exists or if there is a strong familv history of colonic career.
Repeat examination is also needed if the patient's symptoms chance significantlv regardless of the normalev of the initial examination. Also, Just as with the vounger patient, the presence of abnormal lab tests dictate the need for more in-depth evaluation.



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