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Pemicu 3
Pemicu 3
1st LO (1)
• Histology of large intestine
Large intestine
Appendix
-. Fewer glands
-. No taenia coli
-. Has no mesentery
-. Lies in the iliac fossa
inferior
-. If distended with feces or
gas palpable
-. Ileocolic artery
Appendix
-. Position: retrocecal
-. Has short triangular
mesentery mesoappendix
-. Appendicular artery
Rectum
• The pelvic part of the alimentary tract and is continuous
proximally with the sigmoid colon and distally with the anal canal
• The rectosigmoid junction lies anterior to the S3 vertebra
• The rectum follows the curve of the sacrum and coccyx, forming
the sacral flexure of the rectum
• Ends anteroinferior to the tip of the coccyx, immediately before a
sharp posteroinferior angle (the anorectal flexure of the anal
canal)
• The roughly 80° anorectal flexure fecal continence, being
maintained during the resting state by the tonus of the
puborectalis muscle and by its active contraction during
peristaltic contractions if defecation is not to occur
Arteries & veins
Lymph drainage
Innervation
1st LO (3)
• Physiology of intestine
Small intestine
• Divided into three segments—the duodenum,
the jejunum and the ileum
• Motility
▫ Segmentation Segmentation contractions mix
and slowly propel the chyme
▫ Migrating motor complex weak, repetitive
peristaltic waves that move a short distance down
the intestine before dying out
• The waves start at the stomach and migrate down the
intestine; that is, each new peristaltic wave is initiated
at a site a little farther down the small intestine.
• After the end of the small intestine is reached, the
cycle begins again and continues to repeat itself until
the next meal
• The migrating motility complex is regulated between
meals by the hormone motilin, which is secreted
during the unfed state by endocrine cells of the small-
intestine mucosa.
• Small-intestine secretions do not contain any digestive
enzymes
• The small intestine does synthesize digestive enzymes, but
they act within the brush-border membrane of the epithelial
cells that line the lumen instead of being secreted directly
into the lumen
• Digestion within the small-intestine lumen is accomplished
by the pancreatic enzymes, with fat digestion being
enhanced by bile secretion.
• Thus, fat digestion is completed within the small-intestine
lumen, but carbohydrate and protein digestion have not
been brought to completion
• Special hairlike projections on the luminal
surface of the small-intestine epithelial cells, the
microvilli, form the brush border. Contain
three categories of integral proteins that
function as enzyme :
▫ Enterokinase
▫ Dissacharidases (maltase, sucrase, and lactase)
▫ Aminopeptidase
• Biochemical balance among the stomach, pancreas,
and small intestine is normally maintained
• HCl + NaHCO3 NaCl + H2CO3
• The resultant H2CO3 decomposes into CO2 + H2O:
• H2CO3 + CO2 H2O
• The end products of these reactions—Na, Cl, CO2,
and
• H2O—are all absorbed by the intestinal epithelium
into the blood.
LO 2
• Capable to explain diarrhea
Diarrhea
• Passage of abnormally liquid or unformed stools at an
increased frequency
▫ Pseudodiarrhea ~ frequent passage of small volumes of
stool, is often associated with rectal urgency and
accompanies IBS or proctitis
▫ Fecal incontinence ~ involuntary discharge of rectal
contents and is most often caused by neuromuscular
disorders or structural anorectal problems
• Epidemiology
▫ From tropical & subtropical areas
▫ Transmitted by contaminated food or water; person-person oral-
anal contact
▫ AIDS persistent & chronic diarrhea
Life cycle
Pathogenesis & Immunology
• Infection on the intestinal epithelium
▫ Flattened mucosa
▫ Shortened villi
▫ Hypertrophic crypts
▫ malaobsorption of fat, protein, sugar, & vit B12
• Parasite developmental stages are found
predominantly within the epithelial, and rarely in
lamina propria or submucosa
• Inflamation in lamina propria
▫ MN, PMN, eosinophils
Clinical features
• A non spesific watery diarrheal illness, +
abdominal cramps, nausea, malaise, anorexia,
weight loss
• Severe illness dehydration (6 liters of stool)
• Strikingly protracted illness
• Malabsorption
• AIDS
▫ Disseminated infection
Laboratory diagnosis
• I. belii oocysts are acid-fast (Rhodamine-Auramine)
• Contains 2 sporoblasts
• Prevention
▫ Resistant to many disinfectans
▫ survive for months in the environment under moist,
cool condition
Cyclospora
• An acid-fast, autofluorescent large Cryptosporidium like
parasite in the stools of a patient with HIV infection
• Epidemiology
▫ Seasonal occurence of infections among expatriates in Nepal
▫ Association with drinking contaminated water & with foods
such as imported raspberries, mesclun lettuce and basil
▫ Require an obligatory phase of maturation in the
environment after they are excreted in the feces
▫ Unlikely to be transmitted directly from person to person
▫ Seasonality infection
Life cycle
Pathogenesis
• Oocysts excyst in the small bowel sporozoites
invade enterocytes
• Histopathologic change
▫ Villous blunting (widening & shortening of the
small intestinal villi due to diffuse edema)
▫ Crypt hiperplasia
▫ Inflammatory infiltration in the lamina propria
with reactive hyperemia
▫ Vascular dilatation & capillary congestion
Clinical features
• Substantial symptoms of
▫ Diarrhea
▫ Striking fatigue
▫ Weight loss
▫ Abdominal cramps
Laboratory diagnosis & Treatment
• Direct acid-fast stain / microwave-heated safranin
staining of fecal specimen
• PCR
• Treatment
▫ Cotrimoxazole b.i.d
▫ Tinidazole, diloxanide, quinacrine, azithromycin
Ineffective
▫ Trimethoprim patient who allergic to sulfametoxazole
▫ Ciprofloxacin
Prevention & control
• Detection of infection
• Viable oocysts in food and water supplies
• Avian or mammalian fecal contamination of
fresh fruits & vegetables that are eaten raw
remain paramount in preventing transmission
• Oocysts resistant to chlorine / water disinfection
Amebiasis
• Ex: Entamoeba histolytica
• Invasive & causes disease such as colitis & liver abcess
• Ameba in the stool of a young farmer with dysentery
(Fedor Losch, 1873)
• Morphology round, pear-shaped / irregular form,
almost continuous motion
• Infective form cyst form
• Epidemiology
▫ Children or farmworkers exposed to human wastewater
used to irrigate crops
Morpholgy of trophozoite & cyst
Life cycle
• Infective cyst & invasive trophozoite form
• Hypogammaglobulinemia
▫ prolonged diarrhea, malabsorption, severe histologic
change of intestine (nodular lymphoid hyperplasia)
• HIV & AIDS
Life cycle
Pathogenesis & Immunology
• Associated with intestinal mucosa but do not invade
adherence is necessary to establish infection &
cause disease
▫ affect brush border & its enzyme
▫ stimulate inflammatory cytokine response
secretion of fluid & electrolytes or damage to enterocytes
• Prevention
▫ Education to maintain personal & community hygiene
standards
▫ Improvement in community sanitary engineering
prevent faecal contamination & ingestion
Nematoda related diarrhea
• Strongyloidiasis
• Ascariasis
• Hookworms
• Trichuriasis
Strongyloides Stercoralis
• This roundworm,2.5 mm in length, is endemic in
southern U.S. and common in tropicsand Asia.
• Clinical manifestation:
▫ Skin becomes red and pruritic after penetration by larvae, which
usually occurs on feet.
▫ Diarrhea,
▫ Vomiting
▫ Abdominal pain
▫ Cough and pneumonia after migration of larvae through lung
scan
▫ Peripheral eosinophilia may occur.
• Identification of larvae in stooldiagnostic.
Ascaris Lumbricoides
• Clinical manifestations:
Can be asymptomatic
Mild diarrhea
Intermittent epigastric pain
Anorexia
Vomiting
• Diagnosed: by identifying whitish-brown Ascaris
worm,20–40 cm in length, or finding Ascaris
eggs on microscopic exam of stool is diagnostic.
Hookworm Infection
• Adult hookworms (N. americanus and A. duodenale)
• Clinical manifestations:
▫ Red, pruritic lesions on feetor between toes where larvae
penetrate.
▫ Diarrhea
▫ Vomiting
▫ Abdominal pain
▫ Anemia from GI blood loss
▫ Peripheral eosinophilia.
• Detecting hookworm eggs on stool smear is diagnostic.
Trichuris Trichiura
• T. trichiura,4-cm long whipworm, occurs most commonly
in tropical areas but is also found in subtropical areas (e.g.,
southern U.S.).
• Clinical manifestations:
▫ Most individuals are asymptomatic
▫ Diarrhea
▫ Tenesmus
▫ Weight loss
▫ Anemia
▫ Peripheral eosinophilia
• Diagnosed: by seeing eggs on microscopic stool examis
diagnostic.
Typhoid Fever
• Typhoid fever is an acute systemic infection caused
by Salmonella enterica serotype typhi or paratyphi
which is also known as Salmonella typhi
• Cause: Salmonella enterica serovar typhi(Salmonella
typhi)(Eberth’s bacillus), a Gram-negative bacillus.
• Synonim: Typhus abdominalis
• Clinical manifestation: Fever 1-2 weeks, abdominal
symptoms(pain, bloating,vomitus etc.), constipation,
diarrhea.
Salmonella sp.
Structure and physiology
- Bacillus 0.5 – 0.8 x 1 – 3
μm
- Gram negative - Stand in sodium deoxycholate,
- No spore brilliant green, sodium
- Fakultative anaerob tetrathionate
- sugar reactions:
- Flagel peritrich move (+)
fermentation of glucose (+),
- Stand in the freezing water mannosa (+)
in a long period not ferment lactose and
sucrose
- Oksidase test : negative,
nitrate positive, urease
negative
- TSIA : -/+, H2S (+), without
gas
Epidemiology
The typhoid fever surveillance study
sites
http://www.who.int/bulletin/volumes/86/4/06-039818/en/
Antigen Structure
Contaminated food of drinks Gastric acid
Pathogenesis
Bowel
1st systemic bacteriemia
lumen
Regional Colonizatio
Lymphadenitis n
Invation to Peyer
Adhesion to mucose
Patch
Infection of RE system ,Liver, 2nd
Pathogenesis
Spleen Bacteriemia
Feces
Systemic
Reinfection in bowel mucose
manifestation
Bleeding,
Hyperplasia Peyer Patch Inflammation,
perforatio
erosion
n
Pathogenesis
A schematic diagram of a single Salmonella typhi cell showing
the locations of the H (flagellar), 0 (somatic), and Vi (K
envelope) antigens.
Typhoid Fever – Antigen
• Salmonella typhi has 3 kind of antigen:
▫ Flagella antigen (H): survive up to 60⁰C, to
alcohol and acid. IgG is the antibody against this
antigen
▫ Somatic antigen (O): located in outer membrane,
survive up to 100⁰C, to alcohol and acid. IgM is
the antibody against this antigen
▫ Vi antigen: located on O antigen, prevent
phagocytosis, survive up to 60⁰C, not resistant to
alcohol and acid
Pathophysiology Salmonella Typhi
Dry cough
Skin rash
Become Delirious
Life-threatening complications
often develop at this time.