Gastrointestinal
Infections
Gimmi Chhetry
Tutor
PhD Scholar
Introduction
• Gastrointestinal infections may manifest as diarrhoeal
diseases or other gastrointestinal infective syndromes
• The human GIT contains a number of resident microbial
flora
• The microbial flora gradually increases towards the lower
part of GIT and is maximum in the distal ileum ( 10 11 to 1012
per gram )
• Anaerobic bacteria and aerobes both are present in lower
bowel but anaerobes are 1000 times more than aerobes
• This normal microbial flora provide several benefit such as
preventing colonisation of pathogens in
intestine,synthesizing various vitamins, etc
Normal Resident Microbial Flora
Gatrointestinal Infective Syndromes
Diarrheal Diseases
• Diarrhea
• Dysentry
• Traveler’s diarrhea
• Persistent ( chronic ) diarrhea
• Gastroenteritis
• Food poisoning
Other Gastrointestinal Infective Syndrome
• Acute vomiting
• Necrotizing enterocolitis
• Necrotizing enteritis
• Pseudomembranous enterocolitis
• Tropical sprue
• Peptic ulcer disease
• Infections of other GI structures such as appendicitis, diverticulitis and Typhlitis
Diarrhea
• It is define as passage of three or more loose or liquid
stools per day , in excess than the usual habit for that
person
• It may be caused by microbial infections or as a result
of other GIT diseases such as inflammatory bowel
diseases, coeliac disease, etc
• Acute diarrhea usually last for <14 days ,most often
caused by viral agents,followed by bacterial or parasitic
agents
Dysentry
• It is define as passage of blood and mucous with
motion, often associated with tenesmus ( sensation of
a desire to pass stools despite an empty colon )
Agents causing dysentry
Traveler’s diarrhea
• It is the most common travel related infectious illness
Persistent and chronic diarrhea
• Diarrhea that last for ≥ 14 days ( usually 2-4 weeks ) is
considered persistent
• Chronic diarrhea usually last for >4 weeks
Bacteria Parasites viruses fungi
• Aeromonas • Cryptosporidium • Ctomegalovirus • Microsporidia
• Campylobacter • cyclospora
• Clostridium • Entamoeba
difficile histolytica
• Plesiomonas • Giardia
Gastroenteritis
Gastroenteritis or infectious diarrhea may be define as
inflammation of the mucous membrane of the stomach and
intestine resulting in combination of diarrhea,vomiting and
pain abdomen with or without mucous or blood in stool,fever
or dehydration
• Bacterial agents - V.cholerae, E.coli
( ETEC,EIEC,EPEC,EHEC), Salmonella spp., Shigella
spp.,clostridium spp.,S.aureus , Campylobacter spp., Yersina
enterocolitica
• Virus - Rotavirus, Norwalk virus, Adenovirus, Calcivirus
• Fungi - Candida albicans
• Parasites- E.histolytica, G.lamblia,B.coli, Taenia
spp.,H.nana
Food poisoning
Food poisoning refers to an illness acquired through the
consumption of foods or drinks contaminated either with
microorganisms, or their toxins
Bacterial Agents include -
• Satphylococcus aureus
• Bacillus cereus
• Clostridium perfringens
• Clostridium botulinum
Pathogenesis
The infection occur by ingestion of contaminated water or food
Infective dose ( mininum dose require to start infection ) differ in
different causative agents like V.cholerae 105 to108 bacilli
A variety of pathogenic mechanisms are involved to overcome host
defences and resulting in diarrhoea which include -
Toxin production - ( Enterotoxin, Cytotoxins, Neurotoxins )
Invasion - Microorganisms invade the instestinal mucosal cells and
destroy them
Adhesion - adherence to intestinal mucosa helps these
organisms to compete with normal flora and thus to colonise
the intestinal mucosa . They destroy the ability of intestinal
mucosal cells to participate in normal function of secretion
and absorption
Multiplication within intestinaln cells
Host factors - Host defence mechanisms such as Acidity ,
normal flora, normal intestinal motility normally prevents the
disease but if there is alterations in these mechanisms,it may
lead to GIT infections
Laboratory Diagnosis
Specimen collection
• Stool
• Rectal swab
• Vomit
• Blood for serology : useful in viral causative agents
Collection
• A sterile screw-capped wide-mouthed, leak proof
container is used to collect feces for culture
• If collection of feces is not possible a rectal swab can be
submitted
• For an outbreak of food posioning, the food implicated
and the vomitus is collected along with the feces sample
in a sterile container
Transport
• Fresh feces are ideal , if delay of more than 2 hr the
specimen should be collected in a suitable transport
medium
• The following transport media can be used -
Cary-blair transport medium
Stuart’s transport medium
Amies transport medium
Alkaline peptone water ( if clinically cholera is suspected )
For viral diarrhoea - refrigerated at 2-8 ℃for viral Ag
detection.if dealay more then 24 hr then store ta - 20 ℃
Macroscopic Examination
The feces specimen is examined by
naked eye fir the following:
• Colour
• Consistency : formed,semisolid,or
liquid, e.g, watery stool in cholera
• Blood : suggestive of dysentry
• Mucus : suggestive of inflammatory
diarrhoea
• Presence of parasite,e.g Ascaris
lumbricoides or Taenia segments
Direct Microscopy
1) Wet Mount Preparation
Saline and Iodine wet mount - for
detection of pus cells , RBC, and
parasite (trophozoites,cysts,ova,
larva)
2) Hanging Drop Preparation
• It is done to demonstrate the
darting motility of V.cholerae
• which is confirmed by inhibition
of motility by adding vibrio
antisera
3) Gram Staining
• It is not done routinely due to the presence of normal flora
in faeces, however it is done in the following conditions -
Suspected cholerae case - Presence of comma shaped Vibrio
cholerae
Suspected fungal cause - Presence of Gram positive budding
yeast cells - Candida albicans
4) Modified ZN staining
It is done for detection of acid fast oocysts of
Cryptosporidium parvum , Cyclospora species, Cryptoisopora
belli
5) Electron Microscopy
• It is done for the viruses
6) Culture -
• Bacterial Culture
Solid Media include -
MacConkey agar
Deoxycholate citrate agar (DCA)
Xylose lysine deoxycholate agar (XLD)
Thiosulphate citrate bile salt sucrose agar(TCBS)
MacConkey Agar
Liquid Media
Enrichment broth - Selenite F broth
Alkaline peptone water
Liquid culture media are incubated at 37 ℃ for 6 hours and
then subculture onto solid culture media ( selenite F broth to
DCA/XLD and APW to TCBS /BSA) and then finally
incuabted at 37℃ for 18 -24 hrs
Identification - Colony morphology
Gram staining of colony
Hanging drop for motility
Biochemical tests
Automated Methods - VITEK
AST - by Disc Diffusion method
Anaerobic Bacterial Culture
• Media used - Cooked meat broth (CMB)
Viral Culture
• Tiisue cell lines
• Hela and HEp 2 cell lines - can also used for identification
of ETEC
• EHEC can produce cytotoxic change on vero cell line
7) Antigen Detection
• ELISA
• Direct Immunofluoresence test
• Immunochromatography test
8) Molecular Methods
• PCR
• BioFire Film Array - automated multiplex PCR
9) Toxin Demonstration
ELISA - demonstration of Cholera toxin and E.coli toxin
(LT,ST)
PCR for detection of genes coding for different enterotoxins
Other Gastrointestinal Infective
Syndrome
Necrotising Enterocolitis
• It is a fulminent diseases which affect the premature infants
• Characteristic features include - necrosis of bowel wall with
mucosa sloughing
• Common site is terminal ileum
• Microorganisms involved
Pseudomonas spp.
Klebsiella spp.
Salmonella spp.
Clostridium perfringens
EPEC serotype 0111:B4
Necrotising Enteritis
• It is a gas gangrene of the
bowel
• It is caused by
C.perfringens type C
strains
• It cause ischaemic
necrosis of jejunum and
presence of gas in the
tissue
Pseudomembranous Enterocolitis
• It is characterised by
formation of pseudomembrane
on colonic mucosa
• These are whitish - yellow
plaque spread over colonic
mucosa
• It is caused by Clostridium
difficile
Esophagitis
• It is the infection in the
mucosa of oesophagus
• It cause painful or difficulty
in swallowing
• Causative agents include-
Candida albicans
Herpes simplex virus
Cytomegalovirus
Gastritis
• Inflammation of
gastric mucosa
• Helicobacter pylori is
associated with
majority of cases and
also cause peptic ulcer
disease ( formation of
ulcer in stomach and
duodenum )
Appendicitis
• It is the acute
inflammation of the
vermiform appendix
• It may lead to
complications such as
intestinal obstruction ,
perforation , intraabdominal
abscesses
• The infection is generally
polymicrobial consisting of
aerobic and anaerobic
Gram negative bacilli
Proctitis
• It is the inflammation of the
rectum
• Characterized by itching and
mucous discharge per rectum,
which progresses to ulcer and
abscesses in the rectum
• Majority due to Sexually
transmitted by anal intercourse
• Etiological agents - Chlamydia
trachimatis,Treponema pallidium,
Herpes simplex virus, Niesseria
gonorrhoea
Whipple’s Disease
• It is caused by Gram positive actinomycetes named
Tropheryma whipplei
• Rare disease affecting small intestine and other systems
such as CNS and CVS ( endocardium )
• In GIT it involve impaired breakdown of foods ( such as
fats and carbohydrates and decrease absortion of nutrients
• Common symptoms include fever, diarrhoea, abdominal
pain
Lab Diagnosis - Tissue biopsy - ( PAS staining ) reveal
prominent macrophage infiltration , containing bacilli
PCR
