DYSENTRY

MRS. MUYUNDA CHIBOCHI K

Definition
Dysentery is an intestinal disorder which
is caused by the Shigella species or
entamoeba histolytica, characterized by
inflammation, abdominal pains and
straining, and diarrhea often containing
blood and mucus
or Dysentery is an inflammatory disorder
of the intestine, especially of the colon
cause by Shigella species or entamoeba
histolytica that results in severe diarrhea
containing blood and mucus in the feces
with fever, abdominal pain, and rectal
tenesmus (painful continued evacuation of
bowels) caused by any kind of infection.
Causes
The main causative organisms of dysentery
are:
Shigella species (most common)
Internal invasive E. coli
External Hemorrhagic E. coli
Yersinia enterocolitica
Entamoeba histolytica (most common)
Types of dysentery

There are two main types of dysentery:

1. Bacillary dysentery or shigellosis
2. Amoebic dysentery or amoebiasis
Bacillary Dysentery /Shigellosis

Bacillary dysentery is an acute

inflammation and ulceration of large
intestines characterized by small frequent
bowel movements consisting of blood and
mucous in stool.
Bacillary dysentery is caused by non-
motile gram negative bacteria of the
genus Shigella.
CAUSES OF BACILLARY DYSENTRY

Shigella is in 4 strains:
1. Shigella flexneri
2. Shigella boydii
3. Shigella dysenteriae
4. Shigella sonnei
Predisposing factors

These are best summarized by the 6 F’s

which are Formites, Food, Faeces,
Fingers, Fluids and Flies.
If these are well taken care then the
problem is solved.
The predisposing factors include;
i. Poor feeding methods, example, use of
dirty feeding bottles for infants, eating
unboiled and improperly prepared foods.
ii. Poor personal hygiene especially hand
hygiene(hand washing, long unkempt finger
nails and so forth)
iii. Poor source, treatment and storage
facilities for water to drink
iv. Poor sanitation - Rubbish pits or
dumping sites; Sewerage lines.
v. Overcrowding
EPIDEMIOLOGY

It is most prevalent in unhygienic areas of

the tropics, but, because it is easily
spread, sporadic outbreaks are common in
all parts of the world.
Bacillary dysentery occurs among
confined populations, such as those in
nursing homes, large institutions subject
to overcrowding (Diseases, 1992).
Mode of transmission
The route of transmission of shigella is
fecal oral route.
 The bacilli are excreted in feces and
through poor sanitation and bad hygiene,
food and water can then become
contaminated.
Flies also frequently cause contamination
of food and are prevalent mode of spread
of dysentery
Incubation period

The incubation period of shigella is 1 - 7

days.
Pathophysiology

When the bacillus enters the GIT, it

invades the large intestine causing
activation of the white blood cells, action
of the WBCs on the intestinal mucosa
causes inflammation of the mucosa
leading to ulceration and bleeding of the
mucosa Stool would be blood stained and
mucoid.
In the later stage, pus forms due to
infection. Adjacent lymph nodes may be
affected and the inguinal lymph nodes
swells.
Presence of infection causes an increase
in the metabolic rate and this leads into
fever
Signs and symptoms

Sudden onset of signs and symptoms.

Fever which results from infection and
inflammatory reaction.
Signs and symptoms of dehydration such
as loss of skin turgor, as a result of
diarrhea. Dehydration may or may not be
present in this condition because patient
passes small amount of stool, but it’s the
frequency which is increased.
Abdominal discomfort: This may be due
to irritation of the mucosal lining of the
gastro-intestinal tract by the bacteria and
usually it is an early symptom of
dysentery.
Nausea and Vomiting: This may be due to
irritation of mucosal lining of the GIT
(stomach).
Colic abdominal pains: May be due to
inflammatory reaction in the mucosal
lining of the intestines.
Bloody diarrhea - This may be due to
damage of the mucosal lining of the large
intestines during inflammation. Damage
to the mucosal lining may also cause
damage to the capillaries.
The passage of bloody diarrhea is usually
accompanied by Urgency and tenesmus.
(Urgency is the urge to open bowels at
very frequent intervals even if small
amounts of stool are passed and tenesmus
is a painful ineffective straining to empty
the bowels.
Management

Aims
1. To correct electrolyte and fluid
imbalance
2. To eliminate the causative organism
3. To prevent and manage complications
Investigations
Microscopic examination of a fresh stool
specimen and a rectal swab for culture
and sensitivity. Stool should be cultured
within a few hours of collection.
Detection of the organism in stool
confirms diagnosis.
History taking will reveal living
conditions as well as signs and symptoms
Immunofluorescent techniques to detect
organism in stool.
Sigmoidoscopy reveals a red, bleeding
mucosa with patches of necrotic
membrane which may separate to leave
ulcerated areas.
Treatment
Fluid Therapy
Fluid and electrolyte replacement: oral
rehydration is usually required to restore
fluid and electrolyte imbalances.
However, each patient should be assessed
for the degree of dehydration and the
appropriate fluid replacement therapy
given.
Drugs: antibiotics are administered to
shorten the duration of illness and prevent
relapse. Any of the following are given
while waiting for result of culture and
sensitivity:
Nalidixic acid 1g PO qid for 7 to 14 days
MOA: inhibits cleaving of bacteria and it
also inhibits genetic transfer
S/E: nausea, vomiting, abdominal pain,
confusion, depression
Ciprofloxacin 500mg PO BD for 5 days
Trimethoprime-Sulfamethoxazole
(Septrin, Co-otrimoxazole) 960mg PO BD
for 5 days
Chloramphenicol 50 to 100mg/kg body
weight qid for 5 days
Ampicillin 500mg qid for 5 days
AMOEBIC DYSENTERY/AMOEBIASIS

Amoebic dysentery or Amoebiasis is an

infection caused by a pathogenic amoeba
Entamoeba histolytica.
This is a chronic enteric infection caused
by protozoa known as Entamoeba
hystolytica (Billings and stokes, 1982).
Amoebiasis is an infection of the large
intestines caused by Entamoeba hystolytica,
a single celled parasite (Berkow et al,
1997).
Cause of amoebiasis

The cause of amoebic dysentery is

entamoeba histolytica
Predisposing factors

Refer to bacillary dysentery

Epidemiology
 Entamoeba histolytica has a worldwide
distribution and is endemic in most
countries with poor sanitation and low
socioeconomic conditions.
 Use of night soil for agricultural
purposes favors the spread of the disease.
 The organism is acquired when cysts are
ingested.
Mode of Transmission

Faecal-oral route; vectors such as flies,

cockroaches and rodents are capable of
carrying cysts and contaminate food and
water
Incubation Period

Itmay take 2 to 4 weeks or years.

Human beings are the principal
reservoirs/carriers.
Pathophysiology

Ingested cysts enter the alimentary tract

through the mouth to the stomach where
they excyst during digestion.
Motile trophozoites are released which
multiply, invade and ulcerate the intestinal
mucosa of the large bowels, forming flask
like ulcers.
Some of the amoeba goes through the
mesenteric artery and reach the liver
causing total destruction of the liver
resulting in amoebic hepatocellular
necrosis and then liver abscess.
Signs and symptoms

On set is gradual and associated with

abdominal discomfort.
Mildly loose stools or frank diarrhoea
with or without blood and mucus.
Diarrhea may alternate with constipation.
Tenderness may develop over the caecum,
transverse colon or sigmoid
Fever may be present
Abdominal pains that may be on and off.
If there is hepatic amoebiasis, there would
be body malaise, swinging temperature,
sweating, and enlarged tender liver.
Foul-smelly stool.
Weight loss in chronic cases.
Investigations

Stool for m/c/s

History of blood stained stool.
Physical inspection will reveal
dehydration.
Rectal swab culture.
Blood for Hb.
Sigmoidoscopy will review ulcers.
Liver scan will review Liver abscess.
Treatment

Flagyl 200-400mg tids

Septrin 960mg bd x 5-7 days
Furamide[diloxanide furoate] 500mg tds
for 10 days
For Hepatic Amoebiasis give Flagyl and
Chloroquine 600mg od for 2 days and
then 300mg od for 21 days.
Panadol 1 gram tds x3/7
Intravenous fluids [Ringers Lactate)
NURSING CARE OF DYSENTERY

Aims
1. To prevent further spread of infection
2. To replace lost fluids and electrolytes
3. To prevent complications such as
shock
4. To identify any contacts
Environment

Admit patient in an isolation room away

from other patients to prevent spread of
infection to other people.
The room should be well lit for easy
observation
The room should be well ventilated
environment to promote air circulation.
Patient should be nursed near the toilet
for convenience.
Equipment such as drip stands,
intravenous set and observations tray
should be within patient’s environment.
Observation

Observe general condition of patient.

Monitor vital signs such as temperature,
pulse, respirations and blood pressure
frequently.
 The frequency of vital sign observations
depends on patient’s condition.
Observe the quality and amount of stool
passed by patient.
Monitor the intake and output and record
on the fluid balance charts.
Monitor stool for amount, consistency
and color and report.
Observe for any signs of dehydration
such as loss of skin elasticity, sunken
eyes, and thirsty and dry mucus
membranes of the mouth.
Infection prevention

Isolate patient away from other patients to

prevent spread of infection.
People who come in contact with this
patient should observe isolation techniques
such, putting on gowns and masks
whenever they enter the room, washing
hands before and after attending to the
patient.
Restrict visitors because they can also get
the infection.
The linen which is used by the patient should
be disinfected with JIK 1:6 and should be
labeled “infectious” before sending it to the
laundry.
It should not be mixed with other linen from
the wards.
Administer prescribed medication to treat
the causative organism.
All utensils used by patient should be
disinfected.
Nutrition

Give some copious drinks and a light diet

free from irritants.
If patient is unable to take food and fluids
orally commence him/her on intravenous
fluids.
Maintain strict intake and output.
Record intake and output, time
commenced IVF, type of fluid and date
started.
Hygiene

Assisted /bed bath can be given

depending on the condition of the patient
to promote comfort, self esteem and to
remove dirty.
Assist the patient with oral care to prevent
complications of a dirty mouth such as
mouth infections and also promote
salivation as the patient’s mouth can be
dry due to excessive loss of fluids.
Change linen whenever soiled and
disinfect the linen with Jik 1:6 before
sending to the laundry. Ensure perineal
area is cleaned.
Psychological care

Patientswith dysentery may feel as if

they have been neglected.
The nurse needs to give proper
psychological care to allay anxiety.
Explain the disease process to patient
which should include the cause, mode of
transmission, signs and symptoms,
treatment and complications.
Explain to the patient the reason for isolation
which is prevention of spread of infection.
Explain also to the significant others on why
they are not allowed to visit the patient.
Any procedure which is done to patient
should be explained to gain his/her
cooperation.
Allow patients to ask questions and answer
them truthfully.
Medication

Administer prescribed drugs as prescribed

and observe for side effects.
Administer fluids according to patient’s
condition.
Elimination

Observe intake and output and record.

Observe stool for amount, contents and
odor.
Provide bed pan in the initial stage but as
condition improves, encourage patient to
go to the toilet.
PREVENTION AND CONTROL OF DYSENTERY

Dysentery can be prevented by doing the

following measures:
Improved Environmental Sanitation:
measures include:
Provision of safe and adequate water
supply.
Safe and adequate disposal of human
excreta through use of pit latrines or
toilets
Food safety against faecal contamination
Provision of information, education and
communication about dysentery.
Discourage use of untreated human
excreta for manure.
Early Diagnosis and Treatment of Cases and
Carriers
Prompt detection and appropriate and
adequate treatment of both cases and carriers
Regular screening of food handlers

Improved Personal and Communal Hygiene

Adequate hand washing with soap under
running water after using the toilet and
before handling and eating food.
Use of pit latrines or toilets for defaecation.
Children should not be allowed to defaecate
on the ground. Toilet training pots should be
used and disinfected after use. Children’s
stools should be disposed off in the toilet or
pit latrine
Boil water for drinking and for washing
vegetables and fruits.
Avoid eating vegetable and fruit salads.
Complications of Dysentery

1. Perforation of the colon

2. Peritonitis
3. Rectal prolapse
4. Haematogenous dissemination of the
shigellas (rare) causing abscesses and
meningitis
5. Acute, non suppurative arthritis
involving large weight-bearing joints may
occur during convalescence
6. Conjuctivitis, iritis and peripheral
neuropathy (rare).
7. Haemolytic uraemic syndrome (7-10
days after the onset of disease).
8. Toxic megacolon
9. Hemiplegia
10. Encephalopathy
11. Septicaemia
12. Hyponatraemia
13. Reiter’s syndrome
14. Liver abscess