Black -Slides Integration Session 1st sem

Blue Italics- Audio

Green additional notes from slides SLU SOM - Batch 2018 Integration Team

Outline:
- Patients profile
- To be discussed:
Anatomy
Physiology
Clinical manifestations
Clinic-pathological correlation
Etiology and laboratory tests
Pharmacology/ management
Epidemiologic investigation
Patients Profile
Patients profile
Male
GUIDE QUESTIONS
What structures are involved in fluid and electrolyte
1 absorption in the intestines? (describe both gross
and microscopic structures)
- Anatomical basis of absorption
Total quantity of fluid absorbed each day in the
intestines is 8-9 liters
The total quantity of fluid that must be absorbed
each day by the intestines is equal to the ingested
fluid plus that which is secreted in the various
gastrointestinal secretions
All but 1.5 liters are absorbed in the small intestine
leaving only 1.5 liters to pass through the ileocecal
valve into the colon each day.
3 - Year - old

Chief Complaints:

Fever Vomiting Diarrhea

Social and environmental history:

Several classmates in the

No adult members of the
same day care center were
household are ill SMALL INTESTINES
also sick
- the small intestine has an average length of 22 feet and is
divided into 3 parts : duodenum, jejunum and ileum
Past medical history: - The structures important for absorption of water and
electrolytes in the small intestines include Valvulae
No significant events conniventes, Villi, and microvilli

Physical examination:

Temperature 37.9C

Heart rate Tachycardic

Mucous membranes Dry

Appearance Sunken eyeballs

Non-tender with hyperactive

Abdomen
bowel sounds

Laboratory test:

Watery consistency
Stool Exam

No blood

No fecal leukocytes
- (picture) - absorptive surface of the small intestinal mucosa -
many gross folds called Valvulae conniventes (or folds of
Kerckring or Plicae circulares); they increase the surface area of
the absorptive mucosa by about threefold.
- These folds extend circularly most of the way around the
intestine; especially well developed in the duodenum and
jejunum - each fold is covered by minute structures called Villi
- Located on the epithelial surface of the small intestine up
to the ileocecal valve are millions of small villi.
LARGE INTESTINES
- Has a greater diameter than the small intestines
- Wall contains haustrations series of large sacs
- Intestinal glands and the intestinal lumen - lined by
goblet and absorptive cells, with a small number of
enteroendocrine cells
- Colonocytes Absorptive cells
- Goblet cells produce lubricating mucus
High power view of colonocytes and goblet cells.
Red box colonocytes with irregular microvilli
Yellow box - goblet cell which functions to produce mucus
in the intestines.
Orange box dilated intercellular spaces with
interdigitating leaflets of cell membrane indicating active
fluid absorption in the lumen of the large intestine. (TEM-
transmission electron microscope)
What mechanisms are involved in fluid and
2
electrolyte absorption in the intestines?
- Water and electrolytes may cross the intestinal
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epithelial cells by either transcellular or paracellular
routes
Water Osmosis via paracellular route
Electrolytes Transcellular or paracellular
- Active and passive transports
2
 There are 2 major mechanisms by which water and Potassium Small intestine:
electrolytes may cross the intestinal epithelial cells these are - Passive diffusion via paracellular route
either through transcellular or paracellular route. Large intestine:
- 90 95% of water absorption takes place in the small
- K+ secretion in the lumen via K+
intestine though osmosis via paracellular route. (which
channels is driven by basolateral Na-K-
means that water pass through the junctions to be absorbed)
o Absorption of water is entirely dependent on absorption ATPase pumps
of solutes, primarily Na
+ - Stimulated by aldosterone
- Transcellular Passage from the lumen, through the cell, to Calcium Passive from lumen into the cell
the blood. (paracellular routes)
- Electrolyte absorption makes use of either trancellular or Intracellularly:
paracellular routes with the aid of active and passive - Ca-binding proteins
transporters Cell to blood:
- Ca ATPase
- Na Ca exchange

*Calcitriol-dependent expression
- Potassium is absorbed through the small intestine passively
and through the large intestine through secretion in the
lumen via K channels driven by basolateral Na-K atpase
pumps which is stimulated by aldosterone
- Calcium also is passively absorbed into the cell through
ELECTROLYTES paracellular route
Sodium Small intestine: - It can also be absorbed through trancellular route. With this
- Na+ - glucose cotransport it needs Ca- binding protein which is produced by Calcitriol.
- Na+ - amino acid cotransport This is the reason why absorption of Ca is said to be Vit. D
dependent
- Na+ - H+ exchange
- For calcium, vitamin D is needed for absorption. Vitamin D
Colon:
will produce a calcium binding protein which is calbindin.
- Passive diffusion via Na+ channels Intracellularly, calcium will bind with binding proteins where
- Stimulated by aldosterone it can either be for storage or excretion. For excretion, the
Chloride Small intestine: calcium are released and then it will bind with Calcium
- Passive diffusion via paracellular route ATPase or Sodium-calcium exchanger to be excreted in the
- Cl HCO3 antiporter blood.
- Na+ - Cl cotransport
Colon:
- Cl HCO3 antiporter

- When it comes to the absorption of electrolytes this would

involve absorption through the small intestine and in the
colon.
- Na Is pumped out of the cell against its electrochemical
gradient by the Na K pump into the basolateral membranes
- Chloride is absorbed in the small intestine through passive
diffusion via paracellular route and through these
transporters
- It is also absorbed in the colon through Cl-HCHO3 antiporter
What electrolyte abnormality is expected in this
3
patient? (explain)

Electrolyte abnormalities
1) Metabolic alkalosis
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2) Metabolic acidosis
3) Hypokalemia
4) Hyponatremia
5) Hypochloremia

3

Aldosterone affects the Principal cell
- Na reabsorption consequently leads to K secretion
- It also affects Alpha intercalated cell.
- Aldosterone stimulates H- adenosine triphosphatase
which facilitates the secretion of H
- Increase in the aldosterone will cause the reabsorption of
Na and water in return there will be a subsequent
secretion of K -> hypokalemia
Hypokalemia
What are the mechanisms underlying the clinical
4
manifestations of this patient?
Recall:
- To properly manage our patient it is important that we
investigate what brought about the manifestations. As we
recall, the patient had fever, vomiting, diarrhea, tachycardia,
dry mucous membranes and sunken eyeballs, which we can
cluster as signs and symptoms of Acute Gastroenteritis or A-G-
E.
Acute gastroenteritis
- AGE is the number one cause of consult in the
pediatric emergency room of the Philippine General
Hospital Pediatric Infectious Disease Society of the Philippines
Journal
Risk Factors
- AGE: 5 years old
- CROWD EXPOSURE: attends day care center
- Our patients age is a significant risk factor
- It is an established fact that children 5 years of age and
below, are more vulnerable to different diseases given their
less developed immunity.
- At this age group, ACUTE GASTROENTERITIS IS ALSO
COMMON.
- Secondly, the patient had crowd exposure where he could
have contracted the pathogen causing his condition.
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Suppoorted by a study published in the Journal of Pediatric
Infectious Diseases last 2011, Entitled Viral etiology and incidence
of acute gastroenteritis in young children attending day-care
centers.
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 -

INTEGRATION SESSION 1ST SEM

5
 What etiologic agent is most likely responsible for - Rotavirus is a virus that infects the bowels, causing a
5 gastroenteritis (inflammation of the stomach and bowels).
the patients condition?
Rotavirus is the most common cause of severe diarrhea among
Acute Diarrhea: Watery, without blood, pus, or mucus infants and pre-school children throughout the world. Infection
is caused by person-to-person contact, such as touching
This means that the etiologic agent is minimally invasive. The
contaminated hands or feces.
most common causes of minimally invasive diarrhea are ff:
(arranged from the most common to the least common)
What diagnostic test will you request to confirm your
diagnosis and to rule out other differential diagnoses?
For letter B, they are responsible for watery diarrhea which
The 2 most common tests that we can rationally request from
maybe caused by preformed toxins rather than bacteria that
the emergency room if the patient will present with acute
is why it is less invasive.
diarrhea are CBC and fecalysis.
A. B. C.
Virus Preformed Toxins: Parasites
1. Complete Blood Count
Bacteria
Rotavirus Staphylococcus aureus Cryptosporidium
Etiologic agent Possible Results
Astrovirus Bacillus cereus Giardia lamblia
Viral Decrease in neutrophils
Calicivirus Clostridium perfringens
Increased lymphocytes
Clostridium difficile
Bacterial Increased neutrophils
Vibrio cholerae
Decreased lymphocytes
Eschericia coli
Parasitic Increased eosinophil
How can we rule out the different etiologic agents for this
- Blood panel which measures the quantity of all the different
case?
types of cells namely Red Blood cells, White Blood cells and
Pre-formed toxins: Bacterial Platelets
Ettiologic agent Rule out - Routine Screen test which aids in the diagnosis of different
Staphylococcus aureus Projectile vomiting, diseases such as acute and chronic infection of different
infrequent diarrhea etiologies, dehydration, fluid loss, etc.
Duration: <1 day - White Blood Cell Count (WBC) is the total number of white
Bacillus cereus Duration: <1 day blood cells. A high WBC usually means that the body is
Clostridium perfringens Fever is uncommon fighting an infection. Five types of white blood cells:
neutrophils, lymphocytes, monocytes, eosinophils and
Duration: <1 day
basophils. These are reported as a percentage of the WBC.
Clostridium difficile Associated with anti-biotic
use
2. Fecalysis
Vibrio cholerae Rice watery stool
Escherichia coli No vomiting or fever Etiologic agent Possible Result
Viral Watery, without blood, pus, or
Parasitic infection: mucus
Etiologic agent Rule out Bacterial Non-bloody or bloody mucoid
Giardia lamblia Diarrhea, stomach cramps, stool. Presence of leukocytes, red
gas blood cells, and pus cells
Duration: days to weeks Parasitic Non-bloody or bloody stool.
Cryptosporidium Mucosa inflammed, with Presence of eggs, trophozoites, or
infiltration of neutrophils, adult worms
macrophages and
lymphocytes
Should anti-diarrheal or antibiotics be given to this
6
patient? How should you manage this patient?
This leads us to the conclusion that the etiologic agent in this
case is a virus. Among pediatric patients, the most implicated Should anti-diarrheal or antibiotic be given to this
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virus that causes diarrhea is the rotavirus. patient?

Rotavirus - NO
o Anti-diarrheal
o Antibiotic medications
Anti-diarrheals are not given because it has been shown in
studies that these drugs will not have beneficial effects in
acute viral gastroenteritis and may pose side effects such
drowsiness and nausea.

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Antibiotic medications has no indications in the patients case. o Did the students eat something similar at one time
prior to the onset of the S/S?
Symptoms of viral infections usually go away - In order to make a hypothesis, first know the possible sources
How should you manage this patient? of infection, mode of onset (is it explosive{single exposure or
o Primary goal: multiple exposure} or gradual{spread follows the route of travel
or movement of people}), pattern of spread (is it common
Reduce symptoms
source patters, propagated, or mixed)
Prevent complications
o Replace fluids and electrolytes as estimated by the
4) Hypothesis testing
degree of dehydration
- Determine the attack rate and the vehicle of infection
o Oral rehydration therapy for ongoing loses in ions or
- Attack rate amount of pupils who have been infected
electrolytes.
with the disease compared to the pupils who were not
Homemade Oresol therapy
affected by the disease but have undertaken the same
1 liter safe drinking water
activity.
8 teaspoons sugar - Determine the attack rate to measure the frequency of disease
1 teaspoon - salt - In here we should know what the students ate, drank and
Identify the number who got ill and who were not ill
What steps will you undertake in order to further - It is used primarily in observational case control approach to
7 investigate the report that other pupils from the day food borne-outbreak to identify the vehicle to infection
care center are suffering from watery stools?
5) Conclusion and practical application
1. Define the problem - Evaluation of the results of the
2. Appraisal of the existing information investigation
3. Hypotheses formulation - Initiate control measures:
4. Hypotheses testing (general control measures and
5. Conclusion and practical application measures for sick person)
o General control measures
1) Define the problem Wash hands regularly
- Verify the case diagnosis of the with soap and water
pupils who suffered from watery Maintain a clean living environment
stools Facilities should be adequate to allow
- Determine if the disease is common residents to bathe at least twice weekly
in this area Laundry facilities should be available to allow
- Determine if the outbreak is appropriate laundering of clothes and bed
epidemic or due to new awareness lines
of endemic disease Maintaining good personal hygiene including
the following
2) Appraisal of the existing information Follow good hygienic practices
- Time: to determine the time of Do not share eating utensils or drinking
exposure, the incubation period, and containers
the route of spread. This is important Do not share personal toilet articles
to know if the disease is an epidemic
or not. o Measures for sick person
- Place: is it only in the day care Provide information about gastroenteritis and
center? If not, provide a spot map to its symptoms (including whether they have fever
observe distribution of cases or bloody diarrhea) to determine if medical care is
- Person: the pupils are the ones necessary.
who were affected. Did the pupils eat Separate sick person from other residents
or drink something or was there another factor in play all until 24 hours after nausea and vomiting and
diarrhea stop
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together?
3) Hypotheses formulation
- Formulate a hypothesis based on the source, type, mode
of onset, and route of spread
o What caused it?
It is a hypothesis on the source, type and route of
spread. Is there a person (index case) that brought
the infection into the day care center? Is it the
parents/guardians of the pupils, or teachers?
Sick children should be accompanied by only
one responsible adult. The same adult should
stay with the child until 24 hours after
symptoms stop. If possible, put them in a
separate room or, alternatively, place sick
people in a separate section of the evacuation
center away from evacuation center residents
who are not sick. Designated areas should
have full time staff supervision to ensure that
the area is properly cleaned and appropriately
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 supplied.
Provide residents with plastic bags to contain
vomit and to dispose of diapers
Provide residents with supplies to clean up spills
especially vomit and stool
Eg. Small bathroom trash can liners
Dr. Clavio
- Tignan ninyo, the department of family and community
medicine subjects are actually very important and you
can now see the linkage between the basic sciences, and
also the department of family and community medicine

- Initiate specific follow-up surveillance All of the Instructors said

Congratulations and Very Good!!!!!

References:
2018 Integration Team
Powerpoint presentation
& Audio of Reporting.

Comments from Instructors:

Dr. Cinio
- My only suggestion would be off course, uhh regarding
the digestive system diba? it is a very complicated
system and you were given guide questions specifically to
know the absorption regarding the small intestine and
the colon okay, so what do you think, which of the two is
more for the function of absorption?
o Small? Large? See now so these questions will
now guide us of course to be more specific and
detailed to able to correlate the first question to
the next regarding the function, diba?

Dr. Jimmy //TEAMSURGERY2018

- I think it is important that she had identified the risk
factors for this patient which is the age
- Im always emphasizing the role of the age in
determining the specific etiologic agent
- It is more believable because the journals taken are in the
Philippine setting
- And to add to the CPC, a reason why we do not treat
viral infections because there is such a thing as internal
repair for the enterocytes
o The enterocytes that are mature are the ones
destroyed by the organism and then the young/
immature enterocytes which are secretory will
replace them, okay? So the repair there is
important because it will have a bearing on the
treatment.
- For the CBC, it is very good that the reporter identified
that in viral infections, your WBC, specially your
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lymphocytes will increase but your neutrophils will

decrease, but in actual practice later on, you will know
that during a state of dehydration, still your neutrophils
will be increased so be careful with interpreting your CBC
especially in cases of dehydration.
- I am very glad they/the presentor did not over-request
laboratory tests because we all know that there are
specific tests for viral identification but for this case it is
not indicated actually