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Bacteria are classified under a distinct kingdom because of its peculiar cellular and morphological characteristics that makes it different and distinct from all other kingdoms like fungi, animal and virus.
This article will discuss some major characteristics that are helpful in the determination of different types of bacteria. Streptococcus Pyogenes is the causative agent of mild sore throat and skin infections that may worsen in certain situations to lead to life threatening infections like toxic shock syndrome and septicemia (when bacteria gain access to the blood stream).
E- Coli is a gram negative bacillis as discussed previously and is considered as a causative agent of travelera€™s diarrhea; however some pathogenic strains can also lead to bloody diarrhea and circulatory shock. Vibrio cholerae is the causative agent of cholera and is associated with intake of improperly cooked food or poor sanitary conditions. The most common causative agent of food poisoning throughout the world is Enteritis salmonella and can lead to serious and life threatening food poisoning, diarrhea, circulatory shock and dehydration in children.
Lactobacillus acidophilus exists in different parts of human body like intestine, vagina and oral cavity. Due to its beneficial properties, it is used in a variety of dietary products like tempeh, yogurt, miso and probiotics supplements.
Bacillus subtilis occurs independently in the environment around us and was first used by Nazi army to manage diarrheal illness. Bifidobacterium animalis is found in the intestine of animals and humans as a normal commensal that aid in digestive process. Streptococcus thermophilus is classified under coccus and it has the ability to withstand a temperature of about 212 degrees Fahrenheit.
Lactobacillus reuteri is one of the probiotics agents that are present in maternal breast milk and becomes a permanent part of gut flora.
Since bacterial organisms are so minute, it is impossible to view the organisms without compound microscope.
Gram staining is a special method that involves dying the outer covering of the bacterial cell wall that prevents it from physical and environmental trauma.
There are a number of structural and functional variations in the bacteria of one group that helps in adapting these bacterial agents to survive in one environment where other bacteria cannot. Rickettsia is considered unique bacteria since it is incapable of surviving outside living organisms.
All bacteria are characterized by a cell wall outside cell-membrane; however, mycoplasma is unique as it lacks a cell wall that is also considered a protective mechanism that makes it easier for bacteria to evade antibiotic therapies.
Normal bowel frequency ranges from three times a day to three times a week in the normal population. Worldwide, acute diarrhea constitutes a major cause of morbidity and mortality, especially among the very young, very old, and infirm. Diarrhea is more prevalent among adults who are exposed to children and non-toilet-trained infants, particularly in a daycare setting. Approximately 8-9 L of fluid enters the intestines daily – 1-2 L represents food and liquid intake, and the rest is from endogenous sources such as salivary, gastric, pancreatic, biliary, and intestinal secretions. Acute watery diarrhea is most commonly seen with traveler's diarrhea caused by enterotoxigenic E. Exudative diarrhea results from extensive injury of the small bowel or colon mucosa as a result of inflammation or ulceration, leading to a loss of mucus, serum proteins, and blood into the bowel lumen. Noninfectious causes of diarrhea include: inflammatory bowel disease, irritable bowel syndrome, ischemic bowel disease, partial small bowel obstruction, pelvic abscess in the rectosigmoid area, fecal impaction, carcinoid syndrome, food allergies, the ingestion of poorly absorbable sugars such as lactulose, and acute alcohol ingestion. Patients ingesting toxins or those with toxigenic infection typically have nausea and vomiting as prominent symptoms, along with watery diarrhea but rarely have a high fever.
Infection with invasive bacteria such as Campylobacter, Salmonella, and Shigella spp., and organisms that produce cytotoxins, such as C. Hemolytic-uremic syndrome and thrombotic thrombocytopenic purpura can occur in infections with enterohemorrhagic E. Epidemiologic risk factors should be investigated for certain diarrheal diseases and their spread.
Conducting a careful interview can provide valuable clues that will aid in diagnosing and choosing the most appropriate and cost- effective investigation. The presence of blood is a useful clue, suggesting infection by invasive organisms, inflammation, ischemia, or neoplasm. A medical evaluation of acute diarrhea is not warranted in the previously healthy patient if symptoms are mild, moderate, spontaneously improve within 48 hours, and are not accompanied by fever, chills, severe abdominal pain, or blood in the stool. The physical examination in acute diarrhea is helpful in determining the severity of disease and hydration status. The history and physical examination can help lead to a diagnosis but, for treatment of some organisms, a specific diagnosis is required, which will lead to more specific therapy and prevention of unneeded interventions. Stool evaluation for fecal leukocytes (or lactoferrin, a byproduct of white blood cells) is a useful initial test because it may support a diagnosis of inflammatory diarrhea. Indications for stool culture are bloody diarrhea, a toxic-appearing patient (fever, severe abdominal pain), possible epidemic, history of traveler's diarrhea, immunosuppression, or persistent diarrhea. Stool testing for ova and parasites should be done if the patient is at risk for parasitic infection. When organisms are not identified on stool cultures for ova and parasites, a sigmoidoscopy should be performed and biopsies obtained.
The principal components of the treatment of acute diarrhea are fluid and electrolyte replacement, dietary modifications, and drug therapy. In most cases of acute diarrhea, fluid and electrolyte replacement are the most important forms of therapy. Bismuth subsalicylate, somewhat less effective than loperamide, is effective in relieving symptoms of diarrhea, nausea, and abdominal pain in patients with traveler's diarrhea.
Because most patients have mild, self-limited disease caused by viruses or noninvasive bacteria, routine empirical treatment is not warranted. Diarrhea is one of the most common illnesses in all age groups and is second only to the common cold as a cause of lost days of work or school.
Acute diarrhea is a common problem worldwide, with high morbidity and mortality in high-risk groups, such as the very young, older adults, and immunocompromised individuals. Infectious agents are responsible for most cases of acute diarrhea, and may act via numerous mechanisms. Prevention of dehydration is the most important therapeutic intervention for the management of individuals with acute diarrhea. The use of nonspecific antidiarrheals, especially loperamide, is safe for most cases of acute diarrhea. 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.


Bacteria are microscopic, unicellular (single celled) ancient organisms that are responsible for a number of lethal diseases. Vibrio Cholerae is linked to hundreds and thousands of deaths worldwide (mostly in under- developed countries) due to cholera outbreak. Infection can be controlled by timely intake of proper antibiotics and circulatory support.
It is associated with a high mortality rate after initial infection and characterized by blood diarrhea, vomiting, dehydration, fever and may lead to death if proper treatment is not instituted at the right time. Our body is loaded with hundreds and thousands of bacteria that serve to colonize our body in order to prevent overgrowth of pathogenic elements. It is responsible for slightly acidic pH of vagina that is helpful in preventing overgrowth of other microorganisms. In addition it can also be consumed in supplemental doses to improve the symptoms of constipation or irritable bowel syndrome. In order to visualize the cellular components and to differentiate bacteria from other microbial agents, staining techniques are used by scientists to categorize different bacteria.
On the basis of gram staining, bacteria are widely classified as gram positive (bacteria with the cell wall) and gram negative (bacteria without cell- wall). These occurs abundantely in the environment and also as normal commensal on the human body (in nostrils, skin, oral cavity and genitals). Most popular species are salmonella (the causative agent of typhoid) and E- Col (causative agent for hemorrhagic diarrhea).
Due to unstable morphological features, it is transmitted by different vector sources like ticks, fleas and mites to cause life threatening infectious diseases like Rocky mountain spotted fever and typhus.
It is causative agent for life threatening pulmonary infections and some strains may cause pelvic disease. Increased stooling, with stool consistency less solid than normal, constitutes a satisfactory, if somewhat imprecise, definition of diarrhea.
It is also more prevalent in travelers to tropical regions, homosexual males, persons with underlying immunosuppression, and those living in nonhygienic environments who are exposed to contaminated water or foods.
Most of the fluid, about 6-7 L, is absorbed in the small intestine, and only about 1-2 L is presented to the colon. Risk factors for this type of transmission include improper disposal of feces, lack of proper hand washing following defecation, and contact with feces before handling food. Increased fecal water and electrolyte excretion results from impaired water and electrolyte absorption by the inflamed intestine rather than from secretion of water and electrolytes into the exudates. Diarrhea is one of the most frequent adverse effects of prescription medications; it is important to note that drug-related diarrhea usually occurs after a new drug is initiated or the dosage increased. Diarrhea caused by small intestine disease is typically high volume, watery, and often associated with malabsorption. Important clinical features include: abrupt versus gradual onset of symptoms, symptom duration, including bowel movement frequency, stool quantities, dysentery with fever, tenesmus, hematochezia or pus in the stool, signs of volume depletion (including thirst, tachycardia,and orthostasis), decreased urine output, skin turgor, and lethargy or confusion. Vomiting that begins within 6 hours of ingesting a food should suggest food poisoning caused by preformed toxin from bacteria such as S. These risk factors include: recent travel to an underdeveloped area, daycare center exposure, consumption of raw meat, eggs, shellfish, and unpasteurized milk products, contact with reptiles or pets with diarrhea, a history of other ill people in a shared dormitory facility, recent antibiotic use, and a history of HIV or medically induced immunosuppression.
Acute diarrheas are usually infectious in origin and, for the most part, resolve with or without intervention before a diagnosis is made. Large-volume diarrhea suggests small bowel or proximal colonic disease, whereas small frequent stools associated with urgency suggest left colon or rectal disease. On the other hand, evaluation is indicated if symptoms are severe or prolonged, the patient appears toxic, there is evidence of colitis (occult or gross blood in the stools, severe abdominal pain or tenderness, and fever), or empirical therapy has failed. Fecal testing should be performed in patients with a history of diarrhea longer than 1 day who have the following symptoms: fever, bloody stools, systemic illness, recent or remote antibiotic treatment, hospital admission, or signs of dehydration as described earlier. If the test is negative, stool culture may not be necessary, but culture is indicated if the test is positive. Multiple stool samples should be collected at different times because shedding of parasites may be intermittent. Mucosal biopsy is helpful in differentiating infectious colitis from inflammatory bowel disease.
All recommendations agree with the guidelines on acute infectious diarrhea in adults published by the American College of Gastroenterology.
If patients are otherwise healthy and are not dehydrated, adequate oral intake can be achieved with soft drinks, fruit juice, broth, soup, and salted crackers.
The most effective agents are the opioid derivatives-loperamide, diphenoxylate-atropine, and tincture of opium. Bismuth subsalicylate is contraindicated in HIV-infected patients because it may cause bismuth encephalopathy. Empirical treatment is indicated for those patients with suspected invasive bacterial infection, traveler's diarrhea, or immunosuppression.
Diagnostic studies are warranted for patients with fever or bloody diarrhea, or if the affected individual is immunocompromised.
Caution in use of these agents is urged when there is fever, chills, or bloody diarrhea, or when Clostridium difficile is suspected (diarrhea occurring after antibiotic use). Antibiotics may also be used for early Campylobacter infection and for suspected or confirmed cases of C.
Hospitalizations involving gastroenteritis in the United States, 1985: the special burden of disease among the elderly. 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. There are different types of bacteria that shares classic morphological characteristics of the kingdom but are classified differently in 5 major groups on the basis of their habitat, laboratory characteristics, staining methods, requirement of certain nutrients for the generation of energy and presence of certain cytoplasmic extensions like flagella or cilia (that are helpful in the motility of bacteria). Gram negative as well as gram positive bacilli are well known causative agents for gastroenterological, pulmonary and cutaneous infections. Acute diarrhea is defined as three or more stools per day of decreased form from the normal, lasting for less than 14 days.
Other risk factors include improper food hygiene, inadequate food refrigeration, food exposure to flies, and consumption of contaminated water. Yersinia infection and other enteric bacterial infections may be accompanied by Reiter's syndrome (arthritis, urethritis, and conjunctivitis), thyroiditis, pericarditis, or glomerulonephritis. In cases of homosexual males, in addition to immunosuppression, there are two other disease transmission routes that lead to an increased susceptibility to infectious agents that cause diarrhea.
All current and recent medications should be reviewed, specifically new medications, antibiotics, antacids, and the possibility of alcohol abuse. Vital signs (including temperature and orthostatic evaluation of pulse and blood pressure) and signs of volume depletion (including dry mucous membranes, decreased skin turgor, and confusion) should be carefully evaluated.
However, clinicians should remember that inflammatory diarrhea with a noninfectious cause, such as inflammatory bowel disease, ischemic or radiation-induced colitis, and diverticulitis, can be positive for stool leukocytes.
Multiple stool cultures are usually not necessary because bacteria usually shed continuously. Imaging studies may be required in patients with severe disease in order to rule out intestinal perforation, ileus or evidence of colitis. In those with excessive fluid losses and dehydration, more aggressive measures such as IV fluids or oral rehydration therapy with isotonic electrolyte solutions containing glucose or starch should be instituted.


Patients should be encouraged to take frequent feedings of fruit drinks, tea, flat carbonated beverages, and soft, easily digested foods such as bananas, applesauce, rice, potatoes, noodles, crackers, toast, and soup.
These agents inhibit intestinal peristalsis, facilitating intestinal absorption, and have antisecretory properties. 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. Although many organisms simply impair the normal absorptive processes in the small intestine and colon, others organisms, such as Vibrio cholerae, secrete a toxin that causes the small intestinal cells to secrete, rather than absorb, fluid and electrolytes. Multiple host factors that determine the level of illness once exposure to infectious agents has occurred include: age, personal hygiene, gastric acidity and other barriers, intestinal motility, enteric microflora, immunity, and intestinal receptors. Diarrhea caused by colonic involvement is more often associated with frequent small-volume stools, the presence of blood, and a sensation of urgency.
Yersinia organisms often infect the terminal ileum and cecum and manifest with right lower quadrant pain and tenderness suggesting acute appendicitis. Enteric fever, caused by Salmonella typhi or Salmonella paratyphi, is a severe systemic illness manifested initially by prolonged high fevers, prostration, confusion, and respiratory symptoms, followed by abdominal tenderness, diarrhea, and rash. These include an increased rate of fecal-oral transmission of all infectious agents spread by this route, including Shigella, Salmonella, Campylobacter, and intestinal protozoa and anal intercourse.
Nutritional supplements should also be reviewed, including the intake of sugar-free foods (containing nonabsorbable carbohydrates), fat substitutes, milk products, shellfish, and heavy intake of fruits, fruit juices, or caffeine. A careful abdominal examination, to evaluate for tenderness and distention, and a stool examination to evaluate for grossly bloody stools are warranted. Further investigations will depend on the results of sigmoidoscopy, severity of diarrhea, immune status of the host, and presence of systemic toxicity. Oral rehydration therapy is less expensive, often just as effective, and more practical than intravenous fluids.
Dairy products should be avoided, because transient lactase deficiency can be caused by enteric, viral, and bacterial infections. Loperamide may reduce the duration of diarrhea in those with traveler's diarrhea and bacillary dysentery. Empirical antibiotic treatment is also appropriate specifically for early Campylobacter infections and C. 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.
Food and waterborne outbreaks involving a relatively small subset of population and recurrent bouts of illness in others comprise most cases. Bacillus cereus, Clostridium perfringens, Staphylococcus aureus, Salmonella spp., and others cause food poisoning. Anal intercourse can lead to a direct rectal inoculation, resulting in proctitis associated with rectal pain, tenesmus, and passage of small-volume, bloody, mucous stools.
A general algorithm for the evaluation and management of acute diarrhea is shown in Figure 11.
A number of oral rehydration solutions are available, including Pedialyte, Rehydralyte, Ricelyte (Infalyte), Resol, the World Health Organization formula, and the newer reduced osmolarity formula for children.
Caffeinated beverages and alcohol, which can enhance intestinal motility and secretions, should be avoided. These agents should be avoided in patients with fever, bloody diarrhea, and possible inflammatory diarrhea because they may be associated with prolonged fever in patients with shigellosis, toxic megacolon in patients with C.
Most patients with acute diarrhea have a mild and self-limited illness; most treat their illness at home and usually get better without medical intervention. 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. The history should include place of residence, drinking water (treated city water or well water), rural conditions, consumption of raw milk, consumption of raw meat or fish, and exposure to farm animals that may spread Salmonella or Brucella organisms. Empirical treatment for Giardia can be prescribed for those with a 2-week or longer history of diarrhea. 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.
Patients therefore often present with watery diarrhea, followed within hours or days by bloody diarrhea. When the incubation period is longer than 14 hours and vomiting is also a significant symptom, accompanied by diarrhea, viral agents should be considered. Sexual history is important, because specific organisms can cause diarrhea in homosexual men and HIV-infected patients. Diarrhea and related complications can cause severe illness, especially in high-risk groups, such as patients with severe comorbid conditions, underlying immunosuppression, and advanced age. 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. Bacteria that produce inflammation from cytotoxins include Clostridium difficile and hemorrhagic E. Parasites that do not invade the intestinal mucosa, such as Giardia lamblia and Cryptosporidium, usually cause only mild abdominal discomfort.
Hand washing is important for prevention; soap and water is more effective than alcohol-based hand sanitizers because alcohol-based sanitizers may not kill viruses. In patients with bloody diarrhea or hemolytic-uremic syndrome, the stool should be evaluated for E.
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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