Gastroenteritis
Bacterial gastroenteritis has many causes, can range
from mild to severe, and typically manifests with
symptoms of vomiting, diarrhea, and abdominal
discomfort. It is usually self-limited, but improper
management of an acute infection can lead to a
protracted course.
Signs and symptoms
An index of suspicion can be generated for a specific set
of potential causative pathogens by considering the
following stool characteristics:
 Appearance
 Volume
 Frequency
 Presence or absence of blood
 pH
 Presence or absence of reducing substances
 White blood cell (WBC) count
 Serum WBC count
Food-borne bacteria
Particular foods are associated with certain bacteria.
Ingestion of raw or contaminated food, particularly raw
milk and meat, is a common cause of bacterial
gastroenteritis. The following list outlines organisms that
cause food poisoning:
 Dairy - Campylobacter, Salmonella, Listeria,
and Staphylococcus species
 Eggs - Salmonella species
 Meats - C
perfringens and Salmonella, Aeromonas, Campylo
bacter, and Staphylococcusspecies
 Ground beef - Enterohemorrhagic E coli
 Poultry - Campylobacter species
 Pork - C perfringens and Y enterocolitica
 Seafood
- Aeromonas, Plesiomonas, Vibrio species, and
astrovirus
 Oysters - Plesiomonas and Vibrio species and
calicivirus
 Vegetables - Aeromonas species and C
perfringens
 Alfalfa sprouts - Enterohemorrhagic E
coli and Salmonella species
 Fried rice - Bacillus species
 Custards, mayonnaise - Staphylococcus species
A study by Calbo et al reported a foodborne nosocomial
outbreak due to extended-spectrum β-lactamase
(ESBL)–producing Klebsiella pneumoniae. [20] This may
be the first reported hospital outbreak that provides
evidence that food can be a transmission vector for
ESBL K pneumoniae.
Water-borne bacteria
Water is a major reservoir for many organisms that cause
diarrhea. Swimming pools have been associated with
outbreaks of Shigella organisms, and Aeromonas species
are associated with exposure to the marine environment.
Animal-borne bacteria
Animals can transmit particular bacteria. Exposure to
young dogs or cats is associated
with Campylobacter transmission. Exposure to turtles is
associated with Salmonella transmission.
Travel-associated infections
Travel history is an important and useful clue in
determining bacterial etiology. Enterotoxigenic E coli is
the leading cause of traveler's
diarrhea. Rotavirus, Shigella, Salmonella,
and Campylobacter species are prevalent worldwide and
need to be considered, regardless of specific travel
history.
The risk of contracting diarrhea while traveling is the
highest in Africa. Travel to Portugal, Spain, and Eastern
European countries is also associated with a relatively
high risk. Organisms associated with travel to particular
locations are as follows:
 Nonspecific - Enterotoxigenic E
coli and Aeromonas, Giardia, Plesiomonas,
Salmonella, andShigella species
 Developing tropics - C perfringens
 Africa - Entamoeba species and Vibrio cholerae
 Americas (South and Central)
- Entamoeba species and V cholerae
 Asia - V cholerae
 Australia, Canada, Europe - Yersinia species
 India - Entamoeba species and V cholerae
 Japan, North America (Atlantic coast [8] ) - V
parahaemolyticus
 Mexico - Aeromonas, Entamoeba,
Plesiomonas, and Yersinia species
 New Guinea - Clostridium species
Bacteria associated with preexisting conditions
Preexisting medical conditions can predispose patients to
infections with particular organisms. The following list
outlines such medical conditions and their associated
organisms:
 C difficile - Hospitalization with antibiotic
administration
 Plesiomonas species - Liver diseases or
malignancy
 Salmonella species - Intestinal dysmotility,
malnutrition, achlorhydria, hemolytic anemia
(especially sickle cell disease),
immunosuppression, and malaria
 Rotavirus - Hospitalization
 Giardia species - Agammaglobulinemia, chronic
pancreatitis, achlorhydria, and cystic fibrosis
 Cryptosporidia - Immunocompromise and
immunosuppression
Enteritis
 Enteritis is the inflammation of your small intestine.
Some common bacteria that cause enteritis include:
 Salmonella
 Escherichia coli (E. coli)
 Staphylococcus aureus (S. aureus)
 Campylobacter jejuni (C. jejuni)
 Shigella
 Yersinia enterocolitica (Y. enterocolitica)
 Bacillus species
You can also get enteritis when you come into close
contact with other people or animals that are infected.
This is less common.
Symptoms of enteritis can start anywhere from a few
hours to a few days after infection. Symptoms may
include:
 diarrhea
 nausea and vomiting
 loss of appetite
 abdominal cramps and pain
 pain, bleeding, or mucus-like discharge from the
rectum
 fever
Dx
Clinical dx: berdasar gejala medis + keluhan pasien,
drpd diagnostic test
Lab dx: berdasar kpd hasil lab / tes drpd PF.
Radiology dx: berdasar kpd hasil imaging
Principal dx: 1 Dx yg paling relevan sama keluhan
utama pasien / kebutuhan Tx
Admitting dx: Dx yg diberikan sebagai alasan knp
pasien masuk RS, bisa beda sama masalah sebenernya
ato dari discharge Dx (Dx yg recorded saat pasien
discharged)
DDx: proses identifikasi semua kemungkinan Dx yg
nyambung sama SnS, lab, kemudian rule out” sampe
ketemu yg final.
Endemik Indo
Selain penyakit DBD, ada beberapa penyakit endemik
lainnya di Indonesia, di antaranya adalah sebagai
berikut:
 Malaria
Malaria adalah penyakit yang ditularkan melalui gigitan
nyamuk Anopheles betina yang
mengandung plasmodium, yaitu parasit penyebab
malaria.
Penyakit ini dapat menyerang semua kelompok umur,
termasuk laki-laki maupun perempuan. Gejala yang
dikeluhkan meliputi demam, menggigil, sakit kepala,
mual atau muntah. Penyakit malaria sebagian besar
terjadi di daerah pedesaan.
 Hepatitis
Merupakan penyakit endemik yang terjadi di beberapa
negara, disebabkan oleh infeksi virus hepatitis. Hepatitis
terbagi dalam 5 jenis, yaitu hepatitis A, B, C, D, dan E.
Indonesia merupakan negara dengan jumlah
penderita hepatitis B terbesar kedua di negara Asia
Tenggara setelah Myanmar.
 Kusta
Kusta atau dikenal juga sebagai lepra adalah penyakit
yang disebabkan oleh infeksi Mycobacterium
leprae. Kusta menyerang beberapa bagian tubuh, di
antaranya adalah saraf dan kulit. Gejala yang
ditimbulkan dari penyakit kusta antara lain kulit
mengalami bercak putih atau merah seperti panu, dan
kesemutan hingga mati rasa pada saraf tepi. Di
Indonesia, pria lebih banyak menjadi penderita kusta
dibandingkan wanita.
 Filariasis
Filariasis atau dikenal sebagai penyakit kaki
gajah adalah penyakit menular yang disebabkan infeksi
cacing filaria yang ditularkan melalui gigitan nyamuk
sebagai perantara penyakit ini, dan menyebar hampir di
semua wilayah di Indonesia. Filariasis dapat menyerang
semua golongan tanpa mengenal usia dan jenis kelamin.
Filariasis dapat menimbulkan kecacatan seumur hidup
dan rasa tidak nyaman akibat pembengkakan di berbagai
bagian tubuh. Edukasi yang kurang mengenai kondisi ini
pada lapisan masyarakat tertentu, menyebabkan
penderitanya kerap dikucilkan oleh lingkungan sekitar.
India
1. Malaria:
The risk of getting malaria extends to almost the entire
population in India (almost 95 percent). The following
states that have the highest number of malaria cases are
Madhya Pradesh, Maharashtra, Orissa, Karnataka,
Rajasthan, Assam, Gujarat and Andhra Pradesh.
2. Typhoid:
Indian Statistics Typhoid fever is endemic in India.
Health surveys conducted by the Central Ministry of
Health in the community development areas indicated a
morbidity rate varying from 102 to 2,219 per 1, 00,000
population in different parts of the country. A limited
study in an urban slum showed 1 percent of children up
to 17 years of age suffer from typhoid fever every year.
Carriers of Typhoid Fever Typhoid infection is mainly
acquired from persons who are carriers of the disease.
Carriers are the people who continue to excrete
salmonella through their urine and feces a year after an
attack of typhoid. A chronic carrier state develops in
about 2 to 5 percent of the cases. The organisms in such
cases make the gall bladder their habitat.
3. Hepatitis:
Hepatitis is the inflammation of liver. It can be caused
by viruses (five different viruses— termed A, B, C, D
and E cause viral Hepatitis), bacterial infections, or
continuous exposure to alcohol, drugs, or toxic
chemicals, such as those found in aerosol sprays and
paint thinners, or as a result, of an auto-immune
disorder.
Hepatitis A:
Hepatitis A is a self-limiting disease that is found all
across the world. It is usually transmitted through oral
ingestion of infected material (mainly water), but
sometimes transmitted parenterally; most cases resemble
the symptoms of a mild flu attack and jaundice is mild
too.
Hepatitis B:
Hepatitis B is an acute vital disease. It primarily spreads
parenterally, but sometimes orally as well. However, the
main mode of spread is intimate contact and from
mother to the new born. Fever, anorexia, nausea,
vomiting are the initial symptoms, and they soon lead to
severe jaundice, urticarial skin lesions, arthritis, etc.
Some patients become carriers or even remain
chronically ill, even though most patients recover in
about three to four months.
Hepatitis C:
Hepatitis C is a viral disease commonly occurring after
transfusion or parenteral drug abuse. It frequently
progresses to a chronic form that is usually asympto-
matic, but may involve liver cirrhosis.
Hepatitis D:
Hepatitis D or Delta Hepatitis is caused by the Hepatitis
D virus. It usually occurs simultaneously with or as a
super infection in case of Hepatitis B, thus increasing its
severity.
Hepatitis E:
Hepatitis E is transmitted by the oral fecal route; usually
by contaminated water. Chronic infection does not occur
but acute infection may be fatal in pregnant women.
4. Jaundice:
5. Leptospirosis:
Leptospirosis is a disease caused by a type of bacteria
and is associated with animals. It is more common in the
tropical countries. The disease is also known as
canefield fever; cani- cola fever, field-fever, mud fever,
seven day fever and swineherd disease. Leptospirosis is
caused by different strains of bacteria of the genus
Leptospira. Of all the varieties that cause disease,
Leptospira icterohaemorrhagiae is the most serious type.
6. Diarrhoeal Diseases:
The term gastroenteritis’ is most frequently used to
describe acute diarrhoea. Diarrhoea is defined as the
passage of loose, liquid or watery stools. These liquid
stools are usually passed more than three times a day.
The attack usually lasts for about 3 to 7 days, but may
also last up to 10 to 14 days.
Diarrhoea is a major public health problem in
developing countries. Diarrhoeal diseases cause a heavy
economic burden on health services. About 15 percent of
all pediatric beds in India are occupied by admissions
due to gastroenteritis. In India, diarrhoeal diseases are a
major public health problem among children under the
age of 5 years. In health institutions, up to a third of total
pediatric admissions are due to diarrhoeal diseases.
7. Amoebiasis:
Amoebiasis is an infection caused by a parasite
‘Entamoeba Histolytica. The intestinal disease varies
from mild abdominal discomfort and diarrhoea to acute
fulminating dysentery. Extra intestinal amoebiasis
includes involvement of the liver (liver abseess), lungs,
brain, spleen, skin, etc.
Amoebiasis is a common infection of the human
gastrointestinal tract. It has a worldwide distribution. It
is a major health problem in the whole of China south-
east and west Asia and Latin America, especially
Mexico. It is generally agreed that amoebiasis affects
about 15 percent of the Indian population. Amoebiasis
has been reported throughout India.
8. Cholera:
Cholera is an acute diarrhoeal disease caused by V.
Cholera (classical or El T). It is now commonly due to
the El T or biotype. The majority of infections are mild
or symptomatic. Epidemics of cholera are
characteristically abrupt and often create an acute public
health problem. They have a high potential to spread fast
and cause deaths. The epidemic reaches a peak and
subsides gradually as the ‘force of infection declines.
Often, when time control measures are instituted, the
epidemic has already reached its peak and is waning.
9. Brucellosis:
Brucellosis is one of the major bacterial zoonoses, and in
humans is also known as undulent fever, Malta fever or
Mediterranean fever. It is occasionally transmitted to
humans by direct or indirect contact with infected
animals.
It is endemic wherever cattle, pigs, goats and sheep are
raised in large numbers. The important endemic areas for
Brucellosis exist in Mediterranean zones, Europe,
Central Asia, Mexico and South America. Animal
Brucellosis has been reported from practically every
state in India. However, no statistical information is
available about the extent of infection in humans in
various parts of the country. The prevalence of human
Brucellosis is difficult to estimate. Many cases remain
undiagnosed either because they are not apparent, or
because physicians in many countries are unfamiliar
with the disease.
10. Hookworm Infection:
Hookworm infection is defined as: ‘any infection caused
by Ancylostoma or Necator’. They may occur as single
or mixed infections in the same person through various
factors, which have to be prevented. Hookworm
infection is widely prevalent in India.
Necator americanus is predominant in south India, and
Ancylostoms duodenal in north India. Recently, another
species, A. ceylanicum has been reported from a village
near Calcutta. The heavily infected areas are found in
Assam (tea gardens).
West Bengal, Bihar, Orissa, Andhra Pradesh, Tamil
Nadu, Kerala and Maharashtra. More than 200 million
people are estimated to be infected in India. It is believed
that 60 to 80 percent of the population of certain areas of
West Bengal, Uttar Pradesh, Bihar, Orissa, Punjab, and
the eastern coast of Tamil Nadu and Andhra Pradesh are
infected with hookworms.
11. Influenza:
Influenza is an acute respiratory tract infection caused by
influenza virus of which there are three types—A, B and
C. All known pandemics were caused by influenza A
strains, due to various factors. Influenza is found all over
the world.
In India alone, over six million people died during this
pandemic. This pandemic was caused by what is now
known as the swine influenza virus. Recent pandemics
occurred in 1957-58 owing to the influenza A (H2N2)
and in 1968 owing to the influenza A (H3N2). Outbreaks
of influenza B also occur annually with epidemics
occurring at intervals of407 years. Influenza brought on
by the type C virus occurs sporadically as small
outbreaks.
12. Filariasis:
It is caused by a parasite, which belongs to the nematode
family Filariasis. According to WHO reports, an
estimated 751 million people are at ‘risk’ for infection,
and 120 million have actually been infected. The public
health problem of lymphatic filariasis is greatest in
China, India and Indonesia. These three countries
account for about two-thirds of the estimated world total
of persons infected.
Filarial Problem in India:
Filariasis is a major public health problem in India.
There are an estimated six million attacks of acute
filarial disease per year, and at least 45 million persons
currently have one or more chronic filarial lesions.
Heavily infected areas are found in Uttar Pradesh, Bihar,
Andhra Pradesh, Orissa, Tamil Nadu, Kerala and
Gujarat.
The infection is acquired from a person who has
filariasis. The maximum infectivity is when the
organisms are circulating the blood. The largest number
appears in the blood at night time, and retreats from the
blood stream during the day. Their usual habitat is in the
lymph nodes.
Climate is an important factor in the epidemiology of
filariasis. Regions which are damp and moist and have
stagnant water all year round afford a good breeding
ground for mosquitoes. It influences the breeding of
mosquitoes, their longevity and also determines the
development of parasite in the insect vector.
13. Tuberculosis:
Tuberculosis remains a worldwide public health
problem, particularly in the Third World countries.
Tuberculosis is India’s biggest public health problem.
An estimated that 5, 00,000 deaths annually are reported
due to this disease, while a similar number of persons
get cured.
Widal
Pemeriksaan serologi ini ditujukan untuk mendeteksi
adanya antibodi (didalam darah) terhadap antigen
kuman Samonella typhi / paratyphi (reagen). Uji ini
merupakan test kuno yang masih amat popular dan
paling sering diminta terutama di negara dimana
penyakit ini endemis seperti di Indonesia. Sebagai uji
cepat (rapid test) hasilnya dapat segera diketahui. Hasil
positif dinyatakan dengan adanya aglutinasi. Karena itu
antibodi jenis ini dikenal sebagai Febrile
agglutinin.Hasil uji ini dipengaruhi oleh banyak faktor
sehingga dapat memberikan hasil positif palsu atau
negatif palsu. Hasil positif palsu dapat disebabkan oleh
faktor-faktor, antara lain pernah mendapatkan vaksinasi,
reaksi silang dengan spesies lain (Enterobacteriaceae
sp), reaksi anamnestik (pernah sakit), dan adanya faktor
rheumatoid (RF). Hasil negatif palsu dapat disebabkan
oleh karena antara lain penderita sudah mendapatkan
terapi antibiotika, waktu pengambilan darah kurang dari
1 minggu sakit, keadaan umum pasien yang buruk, dan
adanya penyakit imunologik lain.
Diagnosis Demam Tifoid / Paratifoid dinyatakan bila
a/titer O = 1/160 , bahkan mungkin sekali nilai batas
tersebut harus lebih tinggi mengingat penyakit demam
tifoid ini endemis di Indonesia. Titer O meningkat
setelah akhir minggu.
Melihat hal-hal di atas maka permintaan tes widal ini
pada penderita yang baru menderita demam beberapa
hari kurang tepat. Bila hasil reaktif (positif) maka
kemungkinan besar bukan disebabkan oleh penyakit saat
itu tetapi dari kontrak sebelumnya.
PENILAIAN TES WIDAL
Titer widal biasanya angka kelipatan : 1/32 , 1/64 , 1/160
, 1/320 , 1/640.
– Peningkatan titer uji Widal 4 x (selama 2-3 minggu) :
dinyatakan (+).
– Titer 1/160 : masih dilihat dulu dalam 1 minggu
kedepan, apakah ada kenaikan titer. Jika
ada, maka dinyatakan (+).
– Jika 1 x pemeriksaan langsung 1/320 atau 1/640,
langsung dinyatakan (+) pada pasien dengan gejala
klinis khas.
Uji Widal didasarkan pada :
– Antigen O ( somatic / badan )
– Antigen H ( flagel/semacam ekor sebagai alat gerak )
Jika masuk ke dalam tubuh kita, maka timbul reaksi
antigen-antibodi. ANTIBODI terhadap :
Antigen O : setelah 6 sampai 8 hari dari awal penyakit.
Antigen H : 10-12 hari dari awal penyakit.
Uji ini memiliki tingkat sensitivitas dan spesifitas sedang
(moderate).
Pada kultur yang terbukti positif, uji Widal yang
menunjukkan nilai negatif bisa mencapai 30 persen.
Tes Widal negative palsu dapat terjadi pada:
1. Carrier tifoid
2. Jumlah bakteri hanya sedikit sehingga tidak
cukup memicu produksi antibody pada host.
3. Pasien sudah mendapatkan terapi antibiotika
sebelumnya. Pemberian antibiotika yang
dilakukan sebelumnya (demam –> kasih
antibiotika –> tidak sembuh dalam 5 hari –> tes
Widal) sehingga dapat menghalangi respon
antibodi. Padahal sebenarnya bisa positif jika
dilakukan kultur darah
Tes Widal positif palsu dapat terjadi pada:
1. Imunisasi dengan antigen Salmonella
2. Reaksi silang dengan Salmonella non tifoid.
Beberapa jenis serotipe Salmonella lainnya
(misalnya S. paratyphi A, B, C) memiliki
antigen O dan H juga, sehingga menimbulkan
reaksi silang dengan jenis bakteri lainnya, dan
bisa menimbulkan hasil positif palsu. Padahal
mungkin yang positif yaitu kuman non S. typhi
(bukan tifoid).
3. Infeksi malaria, dengue atau infeksi
enterobacteriaceae lain, tetanus, sirosis, dan
lainnya.
The upper digestive tract has several innate defences to
protect you from your own secretions and from
microbial invaders. These defences include mucus and
gastric acid, enterosalivary nitrate circulation, peristalsis
and lymphoid tissue in the form of Peyer’s patches.
Mucus, a bicarbonate-rich slimy substance secreted by
superficial epithelial cells throughout your stomach,
protects you from foreign microbes, and protects you
from your gastric acid. In general, bacteria and other
microbes that you ingest are destroyed by their exposure
to gastric (stomach) acid (Shaffer, 1997; Holzapfel et al.,
1998; Dunne et al., 2001; Guarner & Malagelada, 2003).
For this reason, the stomach is viewed as the main
barrier against entry of foreign microbes into the
gastrointestinal tract. However, it is important to note
that, even with its acidic environment, the stomach is not
sterile.
Not chewing your food properly leads to reduced
peristalsis and reduced production of gastric acid and
saliva (O’May et al., 2005a, b). Inorganic nitrate
ingested as part of the diet is absorbed in the stomach
and ~25 % is concentrated in the salivary glands and re-
secreted into the mouth (Deri et al., 2005). Around 30 %
(~0.3 mM) of this nitrate is reduced to nitrite by the oral
microbiota on the tongue (O’May et al.,
2005a, b; Deri et al., 2005). Acidification of the nitrite in
the stomach generates nitric oxide: at the gastric level,
this molecule has antibacterial properties, and increases
gastric motility, mucus production and mucosal blood
flow (Deri et al., 2005).
Breakdown of the aforementioned defence mechanisms
leads to bacterial overgrowth in the upper
gastrointestinal tract (stomach and duodenum)
(O’May et al., 2005a, b), with the degree of overgrowth
dependent upon the elevation of the gastric pH
(Kerckhoffs et al., 2006).
In addition to the numerous defence mechanisms
associated with the stomach, protection of the rest of the
digestive tract from foreign microbes comes in the form
of hepatic and pancreatic secretions and secretions from
the small intestine. Bile acids are synthesized (500–700
ml per day) by the liver from cholesterol and secreted
from the liver or gallbladder into the duodenum in the
conjugated form (Dunne et al., 2001). These bile acids
are chemically modified (i.e. deconjugated,
dehydroxylated, dehydrogenated or deglucuronidated)
by gut bacteria. Both conjugated and deconjugated forms
of bile acids have been shown to have antibacterial
properties, with the deconjugated forms being more
inhibitory and Gram-positive bacteria more sensitive
than Gram-negative bacteria (Dunne et al., 2001). The
difference in sensitivity between Gram-positive and
Gram-negative bacteria is largely due to differences in
the composition of their cell walls. An intact ileocaecal
valve is also an important barrier to backflow of colonic
bacteria into the ileum