ALIEN INVASION

1) Trichuriasis

world-wide distribution; 
it is the third most common worm of man

Causal Agent:
The nematode (roundworm) Trichuris trichiura, also called the human whipworm.

Transmission

Trichuriasis is common worldwide (in particular among countries with warm, humid climates as this kind of climate
favors the optimum where the larvae optimally grow within the egg) The worm infection begins with ingestion of
eggs from soil contaminated with feces, or, less commonly ingestion of contaminated vegetables (due to presumed
soil contamination, linked to the habit of fertilizing soil with human feces, common among third world countries).
The ingested eggs hatch, and the whipworm embeds in the wall of the large intestine (cecum, colon, rectum).

Risk factors

Whipworm infection is more likely when ingesting soil contaminated with feces. This can happen by eating foods
that have been contaminated with these organisms, or by introducing the organism into one's mouth with dirty
and contaminated hands. Some outbreaks have been traced to contaminated vegetables (due to presumed soil
contamination).

Children, due to a higher propensity to directly or indirectly consume soil, are more commonly and more heavily
infected. Also, it is widely believed that partial protective immunity develops with age and children are not
protected initially. Boys are more likely to be infected because they, generally, eat more dirt than girls.

Life Cycle:
 The unembryonated eggs are passed with the stool, at this stage it is not infective.  .  In the
soil(optimally under warm, moist and shady conditions where the rhabditiform larva develops in the egg),
the eggs develop into a 2-cell stage  , an advanced cleavage stage  , and then they embryonate  ;
eggs become infective in 15 to 30 days.  After ingestion (soil-contaminated hands or food), the eggs hatch
in the small intestine, and release larvae where they emerge through the pole of the egg   that mature
and establish themselves as adults in the colon  .  The adult worms (approximately 4 cm in length) live in
the cecum, appendix and ascending colon. The adult worms are fixed in that location, with the anterior
portions threaded into the mucosa, feeds on tissue secretions, not blood.  The thick posterior end
projecting out.  The females begin to oviposit 60 to 70 days after infection.  Female worms in the cecum
shed between 3,000 and 20,000 eggs per day.  The life span of the adults is about 1 year.

However, for the transmission of infection to other hosts and perpetuation of the species, the egg has to
undergo development then only it can infect another person. Humans are the only natural host for
T.trichiura.

Geographic Distribution:
The third most common round worm of humans.  Worldwide, with infections more frequent in areas with
tropical weather and poor sanitation practices, and among children.  It is estimated that 800 million
people are infected worldwide.  Trichuriasis occurs in the southern United States.

Clinical Features:

Disease may result either due to mechanical effects or allergic reaction.

 Light infestations are frequently asymptomatic (have no symptoms).
 Heavier infestations, especially in small children, can present gastrointestinal problems including
abdominal pain and distention, bloody or mucous-filled diarrhea, and tenesmus (feeling of incomplete
defecation, generally accompanied by involuntary straining). While damage may be done to the GI tissue and
appendicitis may be brought on (by damage and edema of the adjacent lumen) if there are large numbers of
worms or larvae present, it has been suggested that the embedding of the worms into the ileo-cecal region
may also make the host susceptible to bacterial infection. Severe infection may also present with rectal
prolapse, although this is typically seen only in heavy infections of small children. High numbers of embedded
worms in the rectum cause edema, which causes the rectal prolapse. The prolapsed, inflamed and edematous
rectal tissue may even show visible worms.
 Untreated severe infections can lead to clubbing of the fingers
 Growth retardation, weight loss, nutritional deficiencies, and anemia (due to long-standing blood
loss,seeping of blood after penetration of mucosa by the worms, though the worms are not blood-feeder, and
0.005ml loss per worm per day) are also characteristic of infection, and these symptoms are more prevalent
and severe in children. Does NOT commonly cause eosinophilia.
 Coinfection of Trichuris trichiura with other parasites is common and with larger worm burdens can cause
both exacerbation of dangerous trichuriasis symptoms such as massive gastrointestinal bleeding (shown to be
especially dramatic with coinfection with Salmonella typhi) and exacerbation of symptoms and pathogenesis
of the other parasitic infection (as is typical with coinfection with Schistosoma mansoni, in which higher worm
burden and liver egg burden is common). Parasitic coinfection with HIV/AIDS, tuberculosis, and malaria is also
common, especially in Sub-saharan Africa, and helminth codinfection adversely affects the natural history and
progression of HIV/AIDS, tuberculosis, and malaria and can increase clinical malaria severity. In a study
performed in Senegal, infections of soil-transmitted helminths like Trichuris trichiura (as well as schistosome
infections independently) showed enhanced risk and increased incidence of malaria.

Complication

  Complications may include rectal prolapse (particularly in children), appendicitis, colitis and proctitis.
Dehydration and anemia from bloody diarrhea can occur.

Laboratory diagnosis:

FBC

-relative tissue invasion causes occasional peripheral eosinophilia.

Morphology
 a)Eggs( oval,barrel-shaped, thick-shelled and possess a pair of polar mucous“plugs” at each end). It is also
brown , bile-stained. It has triple shell,outermost is stained brown. The ratio of length (50 um):
width(25um) is 2:1.

b)Adult worms

i)Length:( male- 30-45mm, female 40mm-50mm)

ii)Colour:flesh- coloured

iii)Shape: resembles a whip, with the anterior 3/5 thin and thread-like, and the posterior 2/5 thick and
fleshy, appearing like the handle of a whip

iv)Parts:

- attenuated anterior portion which contains the capillary esophagus, is embedded in the mucosa(caecum,
appendix, ascending colon)

-posterior part contains intestine and reproductive organs

 In Male, ventrally coiled; female is straight, blunt, rounded…

Microscopic

Microscopic identification of characteristic whipworm eggs(oval-shaped, thick-shelled and possess a pair of polar
“plugs” at each end. ) in feces is evidence of infection.  The degree of infection can be assessed by egg counts. Less
than 10 eggs per smear in direct stool preparation is considered light infection and more than 40 as heavy
infection. Because eggs may be difficult to find in light infections, a concentration procedure is recommended and
the patient is asymptomatic at this stage. . Charcot-Leyden crystals are usually abundant in stools of this kind of
patients.( enzyme released by damaged eosinophils, suggests the presence of a parasite or an
inflammatory/allergic condition known as eosinophilic gastroenteritis.)

Macroscopic (Gross) Observations

Examination of the rectal mucosa by proctoscopy (or directly in case of prolapses) can occasionally demonstrate
adult worms as they are found on the rectal mucosa in whipworm diarrhrea and dysentery

Adult males of Trichuris trichiura are 30-45 millimeters long, with a coiled posterior end. Adult females are 35-50
millimeters with a straight posterior end. Both sexes have a long, whip-like anterior end.  Adults usually reside in
the large intestine, cecum and appendix of the host.
 Image showing the posterior end of an adult 

Microscopy

Trichuris trichiura eggs are 50-55 micrometers by 20-25 micrometers. They are football-shaped, thick-shelled and
possess a pair of polar “plugs” at each end.  Eggs are passed unembryonated in stool.

Treatment

Supportive
Medication

The drug of choice for trichuriasis is mebendazole. A single dose of 500 mg can results in a cure rate of 40-75%.
Albendazole is an alternative drug. However, its efficacy for trichuriasis is slightly lower than for mebendazole.

i)Mebendazole (Vermox)

Causes worm death by selectively and irreversibly blocking glucose uptake and other nutrients in the susceptible
adult intestine where helminths dwell.
Administer a second course if patient is not cured within 3-4 wk.

 Dosing
 Adult
 100 mg PO bid for 3 d for individual patients or a single dose of 500 mg in a community setting that
requires treatment of large numbers of infected patients
 Pediatric
 <2 years: Not established
>2 years: Administer as in adults

 Interactions

Carbamazepine and phenytoin may decrease effects; cimetidine may increase levels

 Contraindications
 Documented hypersensitivity

ii)Albendazole (Albenza)

Decreases whipworm ATP production, causing energy depletion, immobilization, and death.

 Dosing
Adult
400 mg/d PO in single dose; repeat in 3 wk if patient is not cured

Pediatric
<2 years: 200 mg/d PO in a single dose; repeat in 3 wk if infestation persists
>2 years: Administer as in adults

 Interactions

Carbamazepine may increase metabolism and decrease its efficacy; conversely, dexamethasone and praziquantel
may increase plasma levels when coadministered

 Contraindications
Documented hypersensitivity
 Prevention
-Prevent promiscuous defecation and proper disposal of feces would eliminate transmission of infection
-checking consumption of unwashed fruits and vegetables grown on polluted fields can minimise the risk

2) Types of abdominal pain

What is abdominal pain?

Abdominal pain is pain that is felt in the abdomen. The abdomen is an anatomical area that is bounded by the
lower margin of the ribs and diaphragm above, the pelvic bone (pubic ramus) below, and the flanks on each side.
Although abdominal pain can arise from the tissues of the abdominal wall that surround the abdominal cavity
(such as the skin and abdominal wall muscles), the term abdominal pain generally is used to describe pain
originating from organs within the abdominal cavity. Organs of the abdomen include the stomach, small intestine,
colon, liver, gallbladder, spleen, and pancreas

Characteristics of the pain

The following information, obtained by taking a patient's history, is important in helping doctors determine the
cause of pain:

 The way the pain begins. For example, abdominal pain that comes on suddenly suggests a sudden event,
for example, the interruption of the supply of blood to the colon (ischemia) or obstruction of the bile duct by a
gallstone (biliary colic).

 The location of the pain. 

o Appendicitis typically causes pain in the right lower abdomen, the usual location of the appendix.

o Diverticulitis typically causes pain in the left lower abdomen where most colonic diverticuli are
located. 

o Pain from the gallbladder (biliary colic or cholecystitis) typically is felt in the right upper abdomen
where the gallbladder is located.

 The pattern of the pain. 

o Obstruction of the intestine initially causes waves of crampy abdominal pain due to contractions
of the intestinal muscles and distention of the intestine. 

o True cramp-like pain suggests vigorous contractions of the intestines. 

o Obstruction of the bile ducts by gallstones typically causes steady (constant) upper abdominal
pain that lasts between 30 minutes and several hours. 

o Acute pancreatitis typically causes severe, unrelenting, steady pain in the upper abdomen and
upper back. The pain of acute appendicitis initially may start near the umbilicus, but as the inflammation
progresses, the pain moves to the right lower abdomen. The character of pain may change over time. For
example, obstruction of the bile ducts sometimes progresses to inflammation of the gallbladder with or
without infection (acute cholecystitis). When this happens, the characteristics of the pain change to those of
inflammatory pain. (See below.)

 The duration of the pain. 

 o The pain of IBS typically waxes and wanes over months or years and may last for decades. 

o Biliary colic lasts no more than several hours. 

o The pain of pancreatitis lasts one or more days. 

o The pain of acid-related diseases - gastroesophageal reflux disease (GERD) or duodenal ulcers -

typically show periodicity, that is, a period of weeks or months during which the pain is worse followed by
periods of weeks or months during which the pain is better. 

o Functional pain may show this same pattern of periodicity.

 What makes the pain worse. Pain due to inflammation (appendicitis, diverticulitis,

cholecystitis, pancreatitis) typically is aggravated by sneezing, coughing or any jarring motion. Patients with
inflammation as the cause of their pain prefer to lie still.

 What relieves the pain.

o The pain of IBS and constipation often is relieved temporarily by bowel movements and may be 
associated with changes in bowel habit. 

o Pain due to obstruction of the stomach or upper small intestine may be relieved temporarily
by vomiting which reduces the distention that is caused by the obstruction. 

o Eating or taking antacids may temporarily relieve the pain of ulcers of the stomach or duodenum
because both food and antacids neutralize (counter) the acid that is responsible for irritating the ulcers and
causing the pain. 

o Pain that awakens patients from sleep is more likely to be due to non-functional causes.

 Associated signs and symptoms. 

o The presence of fever suggests inflammation.

o Diarrhea or rectal bleeding suggests an intestinal cause of the pain.

o The presence of fever and diarrhea suggest inflammation of the intestines that may be infectious
or non-infectious (ulcerative colitis or Crohn's disease).

Appendicitis
 Appendicitis is a common cause of abdominal pain and can strike without warning. Appendicitis occurs when the
appendix becomes inflamed and infected with bacteria. The appendix may become blocked by feces or other
foreign objects. If you have appendicitis, you may have slight pain around your umbilical area. It is common for the
pain to radiate down your abdomen and towards your right hip. This type of pain is excruciating and worsens with
movement or walking.

Menstrual Cramps
 Menstrual cramps are caused by the normal contractions of the uterus that become stronger when
menstruation begins. Menstrual cramps can feel sharp, achy, or dull and originate in the lower pelvic region. This
abdominal pain often travels to the lower back and legs. Menstrual pain can occur 2 to 4 weeks before or after
menstruation begins. Some women are hardly bothered by this type of abdominal pain. Others are tortured every
month by severe abdominal cramping and frequently miss days of work because their menstrual cramps are
debilitating. Taking regular doses of Ibuprofen can help lessen the severity of menstrual cramps.

Constipation
 Constipation is often an underlying symptom of another digestive problem. Constipation occurs when the colon
absorbs too much fluid from your stools. Stools become hard, dry, and small and are difficult to pass. Common
symptoms of constipation include abdominal pressure, bloating, and achy abdominal pain. Constipation is caused
by a lack of fiber in the diet, excess consumption of fats, cheese, or dairy products, and lack of exercise. This
condition can usually be treated effectively with home remedies.

Irritable Bowel Syndrome

 Irritable Bowel Syndrome (IBS) affects the normal motility of your gastrointestinal tract. The colon spasms and is
unable to function normally. This condition can be uncomfortable because it causes lower abdominal pain that is
achy and dull. Some patients have severe abdominal pain that is disabling. IBS causes alternating episodes of
constipation and diarrhea. Abdominal pain is often triggered by eating certain foods such as dairy, caffeine, and
barley. Treatment for IBS differs for each patient but can include following a proper diet, exercise, and avoiding
stress.

Gallbladder Stones
 Most gallstones are made of crystals from cholesterol, salts, and calcium. These gallstones can collect in
the bile ducts or in the gallbladder. Abdominal pain is felt when the gallstones travel and block the bile
ducts. Some people that have gallstones think that they are having a heart attack because of the intensity
of this type of abdominal pain. Gallbladder pain can last for several hours. It originates from the upper
right part of your abdomen and travels all the way to your right shoulder blade. Gallbladder removal is
advised if you are having recurring episodes of gallbladder attacks.

3)PE of GIT(abdomen)
Refer CSL….

4)Pattern of dysentery caused by different organisms

5) how to assess dehydration in adults?

Symptom/Sign Mild Dehydration Moderate Dehydration Severe Dehydration

level of consciousness Alert Lethargic Obtunded(drowsy, cold, sweaty)

Capillary refill* 2s 2-4 s >4 s, cool limbs

Mucous membranes Normal Dry Parched, cracked

Tears Normal Decreased Absent

Heart rate Slightly increased Increased Very increased

Respiratory rate/pattern* Normal Increased Increased and hyperpnea

Blood pressure Normal Normal, but Decreased

orthostasis
Pulse Normal Thready Faint or impalpable

Skin turgor* Normal Slow Tenting

Eyes Normal Sunken Very sunken

Urine output Decreased Oliguria Oliguria/anuria

* Best indicators of hydration

status1 

6)Clinical Assessment of Anemia

Signs and symptoms of anemia vary with the rapidity of onset with underlying disease of the cardiovascular
system. Thus, rapid blood loss, especially if plasma volume decreases rapidly, or brisk hemolysis may result in
cardiovascular reaction, including tachycardia, postural hypotension, vasoconstriction in skin and extremities,
dyspnea on exertion, and faintness. Slow developing anemias, such as those resulting from nutritional deficiency,
permit gradual expansion of the plasma volume so that increase cardiac output gradually compensates. So the
subject may remain asymptomatic for long time or noting only slight exertional dyspnea, pallor of skin and mucous
membranes, jaundice, cheilosis, beffy red, smooth tongue and koilonychia are signs that accompany more
advanced anemias of different types.

Evaluation of the anemic patient is best served by a systemic evaluation of the clinical and laboratory findings
together. First, is the patient truly anemic? Second, is the anemia acquired or inherited? Third is there evidence for
blood loss? Fourth is there evidence for nutritional deficiency or malabsorption? Fifth, is there evidence for
hemolysis? Sixth is there evidence for toxic exposure or drug ingestion that could cause bone marrow depression
and anemia? Finally, dose the patient have chronic inflammatory disease, renal insufficiency, or cancer, each of
which is associated with secondary mild anemias, the "anemia of chronic disease"

History

1. Family History of Anemia, Splenomegaly, Jundice, and Splenoctomy.

2. Been rejected as blood donor.
3. Exercise intolerance, syncope, easy fatigue.
4. Pallor and jaundice
5. Blood loss or bleeding tendency,br> 6. Chronic disease
7. Malnutrition, malabsorption and alcoholism
8. Transfusion or iron Therapy
9. Multiple pregnancy menorrhagia

Physical Examination

1. Skin and mucous membranes: Pallor, Jaundice, smooth or beefy tongue, Cheilosis, Koilonychia, Telangiectasia
2. Adenopathy
3. Hepatomegaly
4. Tachycardia, Cardiomegaly, Murmurs
5. Bone Tenderness
6. Neuropathy

Anemia of The chronic Diseases:

The mild to moderate anemia that often observed in patients with infectious, inflammatory, or neoplastic diseases
that persist for more than 1 or 2 months is called anemia of chronic disease. The characteristics feature of this
syndrome is the occurrence of hypoferremia in the presence of ample reticuloendothelial iron stores. The anemia
of chronic disorders is define by the presence of this unique combination of findings.

The anemia of chronic disorders is extremely common, and overall is probably more common than any anemia
syndrome other than blood loss with consequent iron deficiency. In a study by cash and Sears, 1986, 52% of
anemic patients met laboratory criteria for anemia of chronic disorders. The syndrome is also observed in 27% of
outpatients with rheumatoid arthritis and in 58% of new admissions to hospital rheumatology units. In general
anemia of chronic disease has the following characteristic:

 Accompanies chronic inflammatory, infectious, or neoplastic disorders

 One of the most frequent animas
 Due to underproduction of red cells
 Low reticulocyte production
 Most often Normochromic, normocytic anemia
 30% - 50% Hypochromic microcytic
 Low serum iron despite Adequate iron stores
 Low Total iron-binding capacity
 Low transferrin saturation

Nonmegalobalstic Macrocytic Anemias Due to Bone Marrow Failure

 Diamond-Blackfan Syndrome; an autosomal recessive, Pure red cell aplasia of unknown etiology. It's
associated with short stature, Web neck, shield chest, cleft lip & triphalangeal thumb.
 Idiopathic Aplastic Anemia; acquired failure of the hematopoietic stem cells results in pancytopenia
 Fanconi's anemia; Autosomal recessive disorder that results in pancytopenia and is commonly associated
with pigmentary, skeletal, renal and developmental abnormality
 Other causes; Drugs, Chronic liver disease and hypothyroidism

9) Pros and cons

Colonoscopy

Pros- allows visual inspection of the entire large bowel from the distal rectum to the cecum. The procedure is a
safe and effective means of evaluating the large bowel. It is useful in detecting small lesions such as adenomas;
however, the main advantage of colonoscopy is that it allows for intervention, because biopsies can be taken and
polyps removed.

Cons- Colonoscopy also has some disadvantages. The procedure can result in gastrointestinal bleeding severe
enough to lead to hospitalization. It can also result in perforation of the colon. In addition, colonoscopy requires
extensive preparation and anesthesia, a major deterrent for many patients. The patients may have adverse
reaction to the sedatives, and bowel infection