MINISTRY OF HEALTH OFTHE REPUBLIC OF UZBEKISTAN
CENTER OF DEVELOPMENT OF MEDICAL EDUCATION
TASHKENT MEDICAL ACADEMY
Department of infectious and pediatric infectious diseases
Subject: Infectious diseases
THEME:
Early and diffential diagnostics of infectious diseases
Occurring with diarrhea syndrome Educational metholodical course book for lecturers
and students Of Treatment Department
TASHKENT
MINISTRY OF HEALTH OFTHE REPUBLIC OF UZBEKISTAN
CENTER OF DEVELOPMENT OF MEDICAL EDUCATION
TASHKENT MEDICAL ACADEMY
"A F F I R M E D"
Pro-rector of educational work
Professor Teshaev O.R.
__________________________
«____»____________2012
Department of infectious and pediatric infectious diseases
Subject: Infectious diseases
THEME:
Early and diffential diagnostics of infectious diseases
Occurring with diarrhea syndrome Educational metholodical course book for lecturers
and students Of Treatment Department
"A F F I R M E D"
at a DNC meeting of Therapeutic Faculty
Protocol № ___from_________2012
Chairman of DNC, Professor
Karimov M.Sh.___________
TASHKENT
THEME: Early and differential diagnostics of infectious diseases occurring with diarrhea
syndrome
1. Place of the lessons, equipping
- The auditorium;
- Box department;
- Outpatients' clinic;
- Diagnostic department;
- Reception room;
- Labs (clinical, biochemical, bacteriological, immunological);
- Thematical patients with salmonellesis, cholera, dysentery, FTI, viral diarrheas, parasitical, amebic
diarrheas, lamblyosis, slide projector, TV-video.
2.The duration of the study subjects
– 6 hours
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3.The purpose of classes
Aim of lesson – to train integral approach to clinical diagnostics of infectious diseases with diarrhea
syndrome, rational use of laboratory methods of testing. Teaching of rational therapy on house, means
of individual prevention, prophylactic medical examination and rehab of diarrhea reconvalescents
To accquant students with basic symptoms of diarrhea
To teach an interest for the speciality, to stimulate the process of self-education and to develop
responsibility and compassion to patient
To develop scientific thinking, to stimulate creative approach for decision nonstandard clinical tasks and
ability of independent decisions. To develop logical thinking
Goals:
Student has to know:
Differential diagnosis of viral diarrheas and diarrheas from another infectious diseases
Diff diagnosis of diarrhea syndrome causen from infect and noninfect diseases
Early rational laboratory diagnostics of diarrhea syndrome
Principles of complex therapy and rehab
Student has to do:
To lead the professional anamnesis collection and patient examination
To form preliminary diagnosis
To administrate purposeful examination
To interpret laboratory and instrumental datas
To own clinical logic of decision-making
To diagnose emergency conditions and give first aid
To carry out the rehab
Skills of 1 order:
Patient examination, stomach palpation
To take a faeces on bacteriologic analysis
To take a blood on Vidal reaction
Skills of 2 order:
Interpretation of laboratory data
First aid
First aid on dehydration
4. Motivation
Wide spreading in Central Asia region diseases with diarrhea syndrome of infectious and non-infectious
genesis, the ability of fast forming heavy status of patient define the necessity of doctor’s knowledge in
differential symptoms of diarrhea syndrome and methods of fist aid providing.
5.Interdisciplinary communication
Teaching of this theme is based on students’ knowledge of basics of water-mineral exchange,
biochemistry of disbolism, microbiology, immunology, patanatomy, patphysiology, physiology of
gastrointestinal tract and urinal system, endocrine and nerve systems.
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-
6.The content of training
6.1.The theoretical part
Diarrhea is a frequent defecation, when the stools have liquid consistention; disorder of different degree
from simple inconvenience to acute disease which is dangerous to life. In present days diarrhea
syndrome means a complex of different symptoms connected with intestinal evacuation disturbance,
characterized by stools frequency elevation (more than 3 times a day) with discharging of big amount of
liquid fieces.
In diarrhea pathogenesis we mark out 4 mechanisms:
Intestinal hypersecretion
Elevation of osmotic pressure in intestine cavity
Abnormalities in intestine contest transit
Intestinal hyperexudation
Intestinal hypersecretion – the mostly common mechanism of diarrhea conditioned by intestinal
electrolyte transport abnormality which characterized by water and sodium content elevation in
intestinal cavity. These processes are regulating and starting up by neuroendocrinal mediators, bilious
acids, hormones, producing in organism or in intestine. Secretor diarrhea characterizing by equal
meanings of osmollarity of faeces and blood plasma and the starvation (till 72 hours) doesn’t stop it.
Salient feature of secretor diarrhea – polyfecalia, green color of faeces, steatorrhea (due to fatty acids
with long carbon backbone chain), big loses of sodium, potassium, chlorine, metabolic acidosis, high
pH.
Hyperosmollar diarrhea is due to the elevation of chyme osmotic pressure which causes water delay in
intestinal cavity; the reasons can be: carbohydrates digestion and suction disturbances (the lack of
lactose), increased flux of osmotic stuffs (saline laxatives, sorbitol, some antacids), broken resorption
syndrome. Characterized by polyfecalia, high chyme osmollarity, elevation of shortchain fatty acids and
lactic acid, trivial loss of electrolytes with stools, low pH.
Hypo- and hyperkinetic diarrhea – disturbance of intestinal content transit (increasing or decreasing of
intestine motion). Characterized by retrograde motor activity decreasing, stimulation of secretor
intestine processes, colicky abdominal pains (like intestinal colic) before stools and getting quietly after
it, awaking diarrhea.
Hyperexudative diarrhea – transudation in intestine lumen plasma, blood, mucus of intestinal cells.
Characterized by frequent blood discharges, sometimes mixed with mucus or pus, moderate volume or
like a spit.
Infectious diseases:
Acute (dysentery, cholera, salmonellesis, etc)
Chronic (tuberculosis, intestine syphilis)
Protozoa invasion (amebiasis, balantidiasis, lambliasis, trichomoniasis, etc)
Helminthiasis (ascaridiasis, enterobiasis, hymenolepiasis)
Nonspecific inflammatory processes (enteritis, enterocolitis, Crohn’s disease, diverticulitis)
Disbacteriosis (the complication of antibacterial therapy, mycosis)
Dystrophic changes of intestine wall (amyloidosis, intestinal lipodystrophy, celiacia-spru, collagenosis)
Toxic influences (uremia, poisoning of heavy metals salts, alcoholism, medicamental intoxications)
Dysentery. Causative agent is Sh. disenteria, sonnei, boydi, flexneri, incubation period 1-7 days, acute
onset, chill, fever till 38-40°С, asthenovegetative syndrome, single vomiting, colitis, constant dull pain,
tenesmus, false urges, 10-25 stools a day, decreasing in volume and has a potato smell, consist of mucus
and blood, last portion only mucus – “rectal spit”.
Salmonellisis. Causative agent is salmonella, incubation period is from 2-6 hours to 2-3 days, acute
onset, chill, fever, repeated vomiting, watery liquid diarrhea, diffuse stomachache around the navel,
headache, rumbling of sigma, 10-15 stools a day, abundant with mucus, like thin gruel, green color,
fetid.
Food toxic infection. Causative agent - St. aureus, proteus, incubation period 30 min – 7 hours, nausea,
vomiting, colicky stomachache, frequent watery stools, no fever and muscle pain, in heavy cases
tachycardia, hypovolemia, oliguria, dryness of skin and mucous.
Botulism. Caus agent - Cl. Botulinum, incubation period – from 2 hours till 7 days, common
indisposition, weakness, dryness in mouth, stomachache, liquid stools without impurities, sometimes
vomiting, lesions of cerebral nerves, paresis, dysarthria, vision disturbance, diplopia, dysphagia, soft
palate paresis, muscle weakness.
Cholera. Causative agent is Vibrio cholerae classica, Eltor, incubation period is to 5 days, typical flow –
acute onset, diarrhea without intoxication, fast turns to exicosis, painless stomach, watery stools, like a
rice water with fish smell, defecation is painless, after diarrhea the vomiting without nausea begins,
status cholericus, 10 l stools a day, colorless.
Amebiasis. Causative agent is Е. histolytica, incubation period is from 1 till 3 months, gradually begins,
weakness, headache, moderate stomachache, liquid stools with glassy mucus and blood, subfebril
temperature, in case of long flow asthenic syndrome, decrease of appetite develop.
Lambliasis. Causative agent is Lamblia intestinalis, incubation period is 1 to 3 weeks, during the acute
period the clinical manifestations are rare, watery stools without mucus or blood, fetid, impurities of fat
on the surface, pain in right subcostal area and around the navel, flatulence, decrease of appetite, nausea,
may be vomiting, insignificantly temperature increase.
Dysbacteriosis. Reasons are: fermentative insufficient, starving, avitaminosis, active hormonal therapy,
allergization, antibiotics and chemiopreparations use, immunologic reactivity decrease, helminthic
invasion, biliary tracts dyskinesis, chronic pancreatitis. In intestine the long running inflammatory
process develops, in case of absence the infection generalization nausea, vomiting, fever, frequent stools
with mucus, rarely with blood, abundant gases are registered. Because of abundant gases the sharp pains
are appear when the peristaltic getting stronger. The process is longer, develops gradually, the abnormal
stools can preserve for a long period of time even when the specific therapy is carried on.
HIV-infection. Liquid stools to 15 times a day, significant dehydration sometimes, due to
criptosporidosis development. The reasons of intestinal dysfunction are diff microorganisms, that’s why
we need bacteriological scrutiny of feces.
In case of zinc and copper poisoning the strong thirst, metallic taste in the mouth, the burning
sensation behind the breastbone, elevated fatigability are registered. Diuresis is decreasing, urine
become black, in biological liquids of organism the poison is registered.
Noninfectious diarrhea. Poisoning of diff pesticides, diff surgical diseases, poisoning with mushrooms,
poisoning with sea products, somatic diseases (heart attack).
Poisoning with arsenic and mercury. Incubation period depends on dose, hours-days. Gastroenteritis
or enterocolitis in all cases, fever sometimes, garlic smell from the mouth, on mercury poisoning
strengthen sialorrhea, ulcerous stomatitis, gingivitis, rash, damage of kidneys are registered.
Acute appendicitis. Liquid stools with mucus, sometimes with blood 5-6 times a day, stomachache can
be primary and constant, diarrhea begins later. Appetite doesn’t disturbed. There is no intoxication in the
beginning. Schotkin-Blumberg, Sitkovsky symptoms are typical. Important diagnostic role plays digital
investigation of rectum. Local pain.
Acute intestine invagination. Clinical picture is looks like dysentery. Invagination frequently occurs
till 2 years. Suddenly in a state of total health strong colicky stomachache occurs, 1-2 min long, then
repeat after 20 min and hour. In the initial period the temperature and stools are normal, then it becomes
mucus-purulent. Stomach is soft, flatulence, compact painful sausage-look invaginate is palpated in the
ileocaecal region. Dance’s symptom is positive. In digital investigation the rectal ampoule is empty.
Intestinal diverticulum. Clinical picture is looks like acute dysentery. Frequently occurs on elderly
people, long flow, pain is left iliac region or in stomach downstairs, flatulence, compaction in affected
area, leukocytosis, elevated ESR.
Intesinal tumours. In the cases of rectum and sigmoid intestines cancer the haemocolitis phenomenon
is registered. Causeless diarrhea during 2-3 weeks with a blood impure frequently when the diet is
broken. Ribbon-look shape of stools, stools is consist of a pure blood or meat slops. The flow is long
and uninterrupted like a chronic dysentery. Stomachache occurs on later period. Untypical gigantic cells
and insignificant amount of neutrofiles in coprology.
Алгоритм диф. диагностики у больных
с кровянистым стулом
Кал с кровью
НЯК
Да
Да
Возможно
дивертикулит
Лихорадка
Длительное
течение
кишечных язв
НЕТ
Длительное течение,
не имеется
воспалительные
изменения
Новообразование
кишечнмка
Боль в животе,
геморрагический
синдром
Связан с
менструацией
Эндометриоз
толстого
кишечника
Кишечное
кровотечение
у лиц выше
50 лет
Тропический
регион, признаки
гиповитаминоза
Да
Да
Да
Пеллагра
Да
Болезнь
Шенлейна-Геноха
Кал с кровью
Лихорадка
Субфебрилитет
Да
Эозинофилия
Да
ДА
Затяжное
течение
кишечных
язв
Анкилостомидоз
или
Шистосомоз
Да
Да
Дизентерия
Амебиаз
Высокая температура
Тенезмы,
ложные
позывы
Да
Водянистый стул,
обезвоживание
Боль в
животе,
артрит,
эритема
Да
Да
Болезнь Крона
Кампилобактериоз
New pedagogical technology.
“The opinion review by rotation method”
In lectionary room is hanging on some numerated tasks. Each little group (2-3 people) in 10
min discussing and writing its variant of question
8. The recommended literature
1. Majidov V.M. Infectional diseases. Т., 1992.
2. Maxmudov O.S. Children inflectional diseases, Т., 1995.
3. Uchaykin V.R. Manual by children inflectional diseases, М.,2005.
4. Shuvalova E.P. Infectional diseases, М.,1999.
5. Musabaev I.K. «the Management on intestinal infections», Т, 1999.
7. Pokrovsk Century И, Pak Of this year, etc. «Infectious diseases and epidemiology». - М, 2003
8. Jushchuk N.D., Vengerov J.J. «Lectures on infectious diseases». - М, 1999.
9. Uchajkin V. F «the Management on infectious diseases at children», - М, 1998.
10. Internet resources (www <http://www.medlinks.ru/> medlinks
<http://www.medlinks.ru/><http://www.medlinks.ru/>ru <http://www.medlinks.ru/>, www.cdc.gov
<http://www.cdc.gov/>).