Sandbox:Mydah: Difference between revisions

Latest revision as of 22:10, 26 August 2020

Associate Editor(s)-in-Chief: Mydah Sajid, MD [1]

Dysentery in adults resident survival guide

Overview

Dysentery is described as blood with stools. It occurs due to inflammatory reaction causing damage to the intestinal tract. The patient also has a fever, abdominal cramping, discomfort, increased bowel movements, fecal urgency, and tenesmus. The underlying cause is mostly an infection due to bacteria. The main aim of the physician is to assess the severity of gastrointestinal symptoms, dehydration, and hypovolemia. In patients with severe symptoms, prompt investigations, and treatment should be carried out to reduce morbidity. This section provides a short and straight to the point overview of the dysentery in adults.

Causes

Life-threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.

Does not include any known cause

Common Causes

Shigellosis^[1]
Shiga toxin-producing E. coli (STEC) (eg, E. coli O157:H7) infection
Amebic dysentery caused by Entamoeba histolytica^[1]
Salmonella infection
Campylobacter infection^[1]
Enteric viruses (eg, cytomegalovirus [CMV] or adenovirus)^[2]
Inflammatory bowel disease
Ischemic colitis

Evaluation

Shown below is an algorithm summarizing the diagnosis of dysentery according to the American College of Gastroenterology guidelines.^[2]^[1]^[3]^[4]

Treatment

Shown below is an algorithm summarizing the treatment of dysentery according to the Infectious Diseases Society of America clinical practice guidelines.^[1]^[5]^[6]

Characterize the symptoms:

Duration of diarrhea
Frequency and consistency of stools
Presence of mucus and blood in the stools

To evaluate cause ask the following questions:

Food history
Occupational exposure (e.g. daycare center, poultry farm)
Exposure to animals (pets, poultry, zoo, turtles)
Recent travel to endemic areas
Medication history (use of proton pump inhibitor increase susceptibility to infection with Shigella)

Does the patient have any of the following clinical signs or history?

Old age (more than 70 years)
Presence of co-morbidities (advance heart disease, severe immunocompromised state)
Fever (>101.3 degrees Fahrenheit)
Presence of severe symptoms
Need for hospitalization
Signs of dehydration (dry mucous membranes, sunken eyes, decreased skin turgor, orthostatic hypotension, oliguria, dark-colored urine, and drowsiness )

abdominal tenderness on palpation, rebound tenderness, abdominal distention, and abdominal rigidity.

Yes

No

Perform the following stool tests:

Bacterial culture for Salmonella, Shigella, and Campylobacter.
Test for Shigella toxin and E. coli O157: H7
Test for fecal leukocytes and lactoferrin.

Does the patient have any of the following:

Clinical signs suggestive of inflammatory bowel disease

Symptoms present for more than a week despite conservative management

The patient is a health care worker or food handler (which can be a potential health hazard)

Is the fecal leukocytes or lactoferrin test positive?

Yes

No

Yes

No

* Perform routine stool culture.

Specific tests should be performed depending upon the patient’s history.

No need to perform Stool culture and additional tests.

Test for Entamoeba histolytica

Amebic dysentery highly unlikely. Look for other causative agents.

Characterize the symptoms of the patient:

Presence of severe diarrhea along with systemic symptoms.
Two or more clinical signs for dehydration (i.e. Sunken eyes, dry mucous membrane, reduced skin turgor, increased thirst ).

Yes

No

Fluid replacement therapy.
Empirical antibiotics therapy.
The drug of choice is fluoroquinolones (500mg Levofloxacin (oral) once daily for 3 days). If the symptoms do not improve in a few days, the patient should be switched to either azithromycin (oral) or cephalosporin.
Bismuth sulphate and loperamide to relieve abdominal cramps and discomfort.

Oral fluid replacement therapy. Give ORS solution for every bowel movement. Approximately 2 liters of ORS solution is given to the patient.

Antimicrobial therapy should be initiated on the basis of stool culture results.

Bismuth sulphate and loperamide can be given to relieve abdominal symptoms.

Reassess hydration status after every 6 hours.

Assess patient for symptoms of hypovolemia (i.e. altered mental status with lethargy and unconsciousness, weak pulses , and inability to drink)

Yes

No

Patient has severe hypovolemia.

Give parenteral fluid replacement with 5 % dextrose or normal saline solution.
Give rapid infusion initially and then slow infusion.
The aim is to give 200 ml/kg in 24 hours with 100ml/kg in the first 4 hours of infusion.
Reassess hemodynamic and hydration status of the patient after 6 hours.

Patient has mild hypovolemia.

Give oral fluid replacement therapy.

2.2 to 4 liters of ORS is given in the first 4 hours.

Reassess hemodynamic and hydration status of the patient after 6 hours.

Do's

Important clues regarding the etiology of dysentery can be narrowed down while taking history. If the patient has dysentery more than 16 hours after having an outdoor food consider Enterotoxigenic E.coli. There is an increased risk of acquiring the ''Salmonella'' infection in individuals exposed to turtles and poultry. People working in daycare have an increased risk of infection with enteric viruses and ''Shigella''.^[1]
Physicians can take a rectal swab in patients in whom stool samples cannot be obtained and immediate diagnosis is required.^[7] Though the rectal swab has less sensitivity than stool culture in identifying the causative agent.^[8]
If the clinician is suspecting a particular bacteria, it should be mentioned while ordering the test. Certain bacteria require special culture media to grow and methods to be visualized. ''Campylobacter jejuni'' grows on the specific ‘CAMP’ agar plates at a particular temperature and environmental conditions. If infection with ''Yersinia'' is suspected, it should be specified as it is commonly overlooked.^[9]
Physicians need to monitor the patients for the complications of the infection with certain bacteria. Bacteremia and reactive arthritis can occur with infection with non- typhoidal ''Salmonella'' and ''Shigella''.^[10] The hemolytic-uremic syndrome can occur due to E 0157:H7 or ''Shigella''. A neurological complication Guillain-Barré syndrome can occur with ''Campylobacter'' infection.

Don'ts

The empirical antimicrobial treatment for dysentery does not include treatment for E. histolytica. Metronidazole (500mg thrice daily for 7 to days) should be administered to patients only when trophozoites or cysts are visualized under a microscope in the stool sample.^[11]
A complete metabolic profile is not routinely performed in patients with dysentery. Serum electrolytes and glucose levels should only be measured in patients who present with complications (i.e. altered mental status, seizures, anuria, oliguria, and ileus ).

References

↑ ^1.0 ^1.1 ^1.2 ^1.3 ^1.4 ^1.5 Riddle MS, DuPont HL, Connor BA (2016). "ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults". Am J Gastroenterol. 111 (5): 602–22. doi:10.1038/ajg.2016.126. PMID 27068718.
↑ ^2.0 ^2.1 Shane AL, Mody RK, Crump JA, Tarr PI, Steiner TS, Kotloff K; et al. (2017). "2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea". Clin Infect Dis. 65 (12): e45–e80. doi:10.1093/cid/cix669. PMC 5850553. PMID 29053792.
↑ Thielman NM, Guerrant RL (2004). "Clinical practice. Acute infectious diarrhea". N Engl J Med. 350 (1): 38–47. doi:10.1056/NEJMcp031534. PMID 14702426.
↑ Kane SV, Sandborn WJ, Rufo PA, Zholudev A, Boone J, Lyerly D; et al. (2003). "Fecal lactoferrin is a sensitive and specific marker in identifying intestinal inflammation". Am J Gastroenterol. 98 (6): 1309–14. doi:10.1111/j.1572-0241.2003.07458.x. PMID 12818275.
↑ Victora CG, Bryce J, Fontaine O, Monasch R (2000). "Reducing deaths from diarrhoea through oral rehydration therapy". Bull World Health Organ. 78 (10): 1246–55. PMC 2560623. PMID 11100619.
↑ Christopher PR, David KV, John SM, Sankarapandian V (2010). "Antibiotic therapy for Shigella dysentery". Cochrane Database Syst Rev (8): CD006784. doi:10.1002/14651858.CD006784.pub4. PMC 6532574 Check |pmc= value (help). PMID 20687081.
↑ Jean S, Yarbrough ML, Anderson NW, Burnham CA (2019). "Culture of Rectal Swab Specimens for Enteric Bacterial Pathogens Decreases Time to Test Result While Preserving Assay Sensitivity Compared to Bulk Fecal Specimens". J Clin Microbiol. 57 (6). doi:10.1128/JCM.02077-18. PMC 6535583 Check |pmc= value (help). PMID 30944186.
↑ Kotar T, Pirš M, Steyer A, Cerar T, Šoba B, Skvarc M; et al. (2019). "Evaluation of rectal swab use for the determination of enteric pathogens: a prospective study of diarrhoea in adults". Clin Microbiol Infect. 25 (6): 733–738. doi:10.1016/j.cmi.2018.09.026. PMID 30315956.
↑ Guerrant RL, Shields DS, Thorson SM, Schorling JB, Gröschel DH (1985). "Evaluation and diagnosis of acute infectious diarrhea". Am J Med. 78 (6B): 91–8. doi:10.1016/0002-9343(85)90370-5. PMID 4014291.
↑ Rodríguez M, de Diego I, Martínez N, Rosario Rodicio M, Carmen Mendoza M (2006). "Nontyphoidal Salmonella causing focal infections in patients admitted at a Spanish general hospital during an 11-year period (1991-2001)". Int J Med Microbiol. 296 (4–5): 211–22. doi:10.1016/j.ijmm.2006.01.068. PMID 16621698.
↑ Misra NP, Gupta RC (1977). "A comparison of a short course of single daily dosage therapy of tinidazole with metronidazole in intestinal amoebiasis". J Int Med Res. 5 (6): 434–7. doi:10.1177/030006057300100209. PMID 590600.

[pmid27068718-1] 1.0 ^1.1 ^1.2 ^1.3 ^1.4 ^1.5 Riddle MS, DuPont HL, Connor BA (2016). "ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults". Am J Gastroenterol. 111 (5): 602–22. doi:10.1038/ajg.2016.126. PMID 27068718.

[pmid29053792-2] 2.0 ^2.1 Shane AL, Mody RK, Crump JA, Tarr PI, Steiner TS, Kotloff K; et al. (2017). "2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea". Clin Infect Dis. 65 (12): e45–e80. doi:10.1093/cid/cix669. PMC 5850553. PMID 29053792.

[pmid14702426-3] Thielman NM, Guerrant RL (2004). "Clinical practice. Acute infectious diarrhea". N Engl J Med. 350 (1): 38–47. doi:10.1056/NEJMcp031534. PMID 14702426.

[pmid12818275-4] Kane SV, Sandborn WJ, Rufo PA, Zholudev A, Boone J, Lyerly D; et al. (2003). "Fecal lactoferrin is a sensitive and specific marker in identifying intestinal inflammation". Am J Gastroenterol. 98 (6): 1309–14. doi:10.1111/j.1572-0241.2003.07458.x. PMID 12818275.

[pmid11100619-5] Victora CG, Bryce J, Fontaine O, Monasch R (2000). "Reducing deaths from diarrhoea through oral rehydration therapy". Bull World Health Organ. 78 (10): 1246–55. PMC 2560623. PMID 11100619.

[pmid20687081-6] Christopher PR, David KV, John SM, Sankarapandian V (2010). "Antibiotic therapy for Shigella dysentery". Cochrane Database Syst Rev (8): CD006784. doi:10.1002/14651858.CD006784.pub4. PMC 6532574 Check |pmc= value (help). PMID 20687081.

[pmid30944186-7] Jean S, Yarbrough ML, Anderson NW, Burnham CA (2019). "Culture of Rectal Swab Specimens for Enteric Bacterial Pathogens Decreases Time to Test Result While Preserving Assay Sensitivity Compared to Bulk Fecal Specimens". J Clin Microbiol. 57 (6). doi:10.1128/JCM.02077-18. PMC 6535583 Check |pmc= value (help). PMID 30944186.

[pmid30315956-8] Kotar T, Pirš M, Steyer A, Cerar T, Šoba B, Skvarc M; et al. (2019). "Evaluation of rectal swab use for the determination of enteric pathogens: a prospective study of diarrhoea in adults". Clin Microbiol Infect. 25 (6): 733–738. doi:10.1016/j.cmi.2018.09.026. PMID 30315956.

[pmid4014291-9] Guerrant RL, Shields DS, Thorson SM, Schorling JB, Gröschel DH (1985). "Evaluation and diagnosis of acute infectious diarrhea". Am J Med. 78 (6B): 91–8. doi:10.1016/0002-9343(85)90370-5. PMID 4014291.

[pmid16621698-10] Rodríguez M, de Diego I, Martínez N, Rosario Rodicio M, Carmen Mendoza M (2006). "Nontyphoidal Salmonella causing focal infections in patients admitted at a Spanish general hospital during an 11-year period (1991-2001)". Int J Med Microbiol. 296 (4–5): 211–22. doi:10.1016/j.ijmm.2006.01.068. PMID 16621698.

[pmid590600-11] Misra NP, Gupta RC (1977). "A comparison of a short course of single daily dosage therapy of tinidazole with metronidazole in intestinal amoebiasis". J Int Med Res. 5 (6): 434–7. doi:10.1177/030006057300100209. PMID 590600.

[1]

[2]

[3]

[4]

[5]

[6]

[7]

[8]

[9]

[10]

[11]

@@ Line 1: / Line 1: @@
 __NOTOC__
 {{AE}} {{MSJ}}
-==Collateral circulation==
+==Dysentery in adults resident survival guide==
 ===Overview===
-Collateral circulation is a network of blood vessels that provide a bypass or alternate conduit of blood flow in tissue. These specialized blood vessels are naturally present in tissue and undergo adaptive growth and development in response to ischemia. The main function of collateral vessels is to provide an alternate pathway for nutrient and oxygen supply in the case of stenosis or obstruction of the main artery.
+[[Dysentery]] is described as [[blood]] with [[Human feces|stools]]. It occurs due to inflammatory reaction causing damage to the [[Gastrointestinal tract|intestinal tract]]. The patient also has a [[fever]], abdominal cramping, discomfort, increased [[Intestine|bowel]] movements, fecal urgency, and [[tenesmus]]. The underlying cause is mostly an infection due to [[bacteria]]. The main aim of the [[physician]] is to assess the severity of gastrointestinal symptoms, [[dehydration]], and [[hypovolemia]]. In [[patient|patients]] with severe symptoms, prompt investigations, and treatment should be carried out to reduce morbidity. This section provides a short and straight to the point overview of the [[dysentery]] in adults.
-===Classification===
-Rentrop devised a grading system to assess the filling of collateral arteries. <ref name="pmid3156171">{{cite journal| author=Rentrop KP, Cohen M, Blanke H, Phillips RA| title=Changes in collateral channel filling immediately after controlled coronary artery occlusion by an angioplasty balloon in human subjects. | journal=J Am Coll Cardiol | year= 1985 | volume= 5 | issue= 3 | pages= 587-92 | pmid=3156171 | doi=10.1016/s0735-1097(85)80380-6 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3156171  }} </ref>
+===Causes===
-*Grade 0: no visible filling of any collateral channels
+====Life-threatening Causes====
-*Grade I: collateral filling of branches of the vessel to be dilated without any dye reaching the epicardial segment of that vessel
+Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.
-*Grade 2: partial collateral filling of the epicardial segment of the vessel being dilated
-*Grade 3: complete collateral filling of the vessel being dilated.
+*Does not include any known cause
-Collateral circulation can be classified on the basis of size. <ref name="pmid12665484">{{cite journal| author=Werner GS, Ferrari M, Heinke S, Kuethe F, Surber R, Richartz BM | display-authors=etal| title=Angiographic assessment of collateral connections in comparison with invasively determined collateral function in chronic coronary occlusions. | journal=Circulation | year= 2003 | volume= 107 | issue= 15 | pages= 1972-7 | pmid=12665484 | doi=10.1161/01.CIR.0000061953.72662.3A | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12665484  }} </ref>
-*CC0: no continuous connection between donor and recipient artery.
+====Common Causes====
-*CC1: continuous, threadlike connection. The diameters of collaterals are ≤0.3 mm.
+*[[Shigellosis]]<ref name="pmid27068718">{{cite journal| author=Riddle MS, DuPont HL, Connor BA| title=ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults. | journal=Am J Gastroenterol | year= 2016 | volume= 111 | issue= 5 | pages= 602-22 | pmid=27068718 | doi=10.1038/ajg.2016.126 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27068718  }} </ref>
-*CC2: continuous, small side branch-like size throughout its course. The estimated diameter of CC2 ≥0.4 mm.
+*[[Escherichia coli enteritis|Shiga toxin-producing E. coli]] (STEC) (eg, E. coli O157:H7) infection
-===Pathophysiology===
+*[[Amoebiasis|Amebic dysentery]] caused by [[Entamoeba histolytica]]<ref name="pmid27068718">{{cite journal| author=Riddle MS, DuPont HL, Connor BA| title=ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults. | journal=Am J Gastroenterol | year= 2016 | volume= 111 | issue= 5 | pages= 602-22 | pmid=27068718 | doi=10.1038/ajg.2016.126 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27068718  }} </ref>
-There are four stages in the development of mature collateral blood vessels from collateral microvasculature.
+*[[Salmonella]] infection
-*Phase 1 lasts for approximately two days following stenosis or obstruction of the main artery by an embolus. The stenosis of the main artery results in diversion and increase blood flow through small collateral blood vessels. This increases the circumferential diameter of small collateral vessels and augments sheer stress on its walls. The increased stress on the vessel wall causes activation of the Nf-kb gene. <ref name="pmid23091063">{{cite journal| author=Tirziu D, Jaba IM, Yu P, Larrivée B, Coon BG, Cristofaro B | display-authors=etal| title=Endothelial nuclear factor-κB-dependent regulation of arteriogenesis and branching. | journal=Circulation | year= 2012 | volume= 126 | issue= 22 | pages= 2589-600 | pmid=23091063 | doi=10.1161/CIRCULATIONAHA.112.119321 | pmc=3514045 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23091063  }} </ref> There is an increased expression of adhesion molecules on endothelial cells which attracts monocytes at the site of the blocked blood vessels. The monocytes from the bone marrow start accumulating at the extracellular site of collateral vessel formation. The main distinguishing features of this phase is an increase in the permeability of the blood vessel and the transformation of smooth muscle and endothelial cells in the proliferative phase.
+*[[Campylobacter]] infection<ref name="pmid27068718">{{cite journal| author=Riddle MS, DuPont HL, Connor BA| title=ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults. | journal=Am J Gastroenterol | year= 2016 | volume= 111 | issue= 5 | pages= 602-22 | pmid=27068718 | doi=10.1038/ajg.2016.126 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27068718  }} </ref>
-*In the second phase, there is an infiltration of monocytes followed by the release of various cytokines including matrix metallopeptidases, tumor necrosis factor-alpha, platelet-derived growth factors, and vascular endothelial growth factors. There is controlled digestion of extracellular matrix and internal elastic lamina. The cytokines also promote increased proliferation of vascular smooth muscles and endothelial cells.
+*Enteric viruses (eg, [[cytomegalovirus]] [CMV] or [[adenovirus]])<ref name="pmid29053792">{{cite journal| author=Shane AL, Mody RK, Crump JA, Tarr PI, Steiner TS, Kotloff K | display-authors=etal| title=2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea. | journal=Clin Infect Dis | year= 2017 | volume= 65 | issue= 12 | pages= e45-e80 | pmid=29053792 | doi=10.1093/cid/cix669 | pmc=5850553 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29053792  }} </ref>
-*In phase three there is a maturation of smooth muscle cells in uniform circular layer with increase synthesis of elastin and collagen and formation of the cell to cell contacts. This results in the formation of a large-caliber blood vessel.
+*[[Inflammatory bowel disease]]
-*In phase four there is dissolution and reduction of small collateral vessels in which there is less blood flow. The collateral vessels which have more flow of blood enlarges and forms mature blood vessels while smaller collateral vessels regress due to decreased flow of blood. <ref name="pmid10782885">{{cite journal| author=Scholz D, Ito W, Fleming I, Deindl E, Sauer A, Wiesnet M | display-authors=etal| title=Ultrastructure and molecular histology of rabbit hind-limb collateral artery growth (arteriogenesis). | journal=Virchows Arch | year= 2000 | volume= 436 | issue= 3 | pages= 257-70 | pmid=10782885 | doi=10.1007/s004280050039 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10782885  }} </ref>
+*[[Ischemic colitis]]
+===Evaluation===
+Shown below is an algorithm summarizing the diagnosis of [[dysentery]] according to the American College of Gastroenterology guidelines.<ref name="pmid29053792">{{cite journal| author=Shane AL, Mody RK, Crump JA, Tarr PI, Steiner TS, Kotloff K | display-authors=etal| title=2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea. | journal=Clin Infect Dis | year= 2017 | volume= 65 | issue= 12 | pages= e45-e80 | pmid=29053792 | doi=10.1093/cid/cix669 | pmc=5850553 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29053792  }} </ref><ref name="pmid27068718">{{cite journal| author=Riddle MS, DuPont HL, Connor BA| title=ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults. | journal=Am J Gastroenterol | year= 2016 | volume= 111 | issue= 5 | pages= 602-22 | pmid=27068718 | doi=10.1038/ajg.2016.126 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27068718  }} </ref><ref name="pmid14702426">{{cite journal| author=Thielman NM, Guerrant RL| title=Clinical practice. Acute infectious diarrhea. | journal=N Engl J Med | year= 2004 | volume= 350 | issue= 1 | pages= 38-47 | pmid=14702426 | doi=10.1056/NEJMcp031534 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14702426  }} </ref><ref name="pmid12818275">{{cite journal| author=Kane SV, Sandborn WJ, Rufo PA, Zholudev A, Boone J, Lyerly D | display-authors=etal| title=Fecal lactoferrin is a sensitive and specific marker in identifying intestinal inflammation. | journal=Am J Gastroenterol | year= 2003 | volume= 98 | issue= 6 | pages= 1309-14 | pmid=12818275 | doi=10.1111/j.1572-0241.2003.07458.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12818275  }} </ref>
+{{Family tree/start}}
+{{Family tree | | | | A01 | | | |A01= <div style="float: center; text-align: left;">Characterize the symptoms:
+* Duration of [[diarrhea]]
+* Frequency and consistency of [[Human feces|stools]]
+* Presence of [[mucus]] and [[blood]] in the [[Human feces|stools]] }}
+{{Family tree | | | | |!| | | | | }}
+{{Family tree | | | | B01 | | | |B01= <div style="float: center; text-align: left;">To evaluate cause ask the following questions:
+* Food history
+* Occupational exposure (e.g. daycare center, poultry farm)
+* Exposure to animals (pets, poultry, zoo, turtles)
+* Recent travel to endemic areas
+* Medication history (use of [[proton pump inhibitor]] increase susceptibility to [[infection]] with [[Shigella]]) }}
+{{Family tree | | | | |!| | | | | }}
+{{Family tree | | | | C01 | | | |C01= <div style="float: center; text-align: left;">Does the patient have any of the following clinical signs or history?
+* Old age (more than 70 years)
+* Presence of co-morbidities (advance [[heart disease]], severe immunocompromised state)
+* [[Fever]] (>101.3 degrees Fahrenheit)
+* Presence of severe symptoms
+* Need for hospitalization
+* Signs of [[dehydration]] (dry mucous membranes, sunken [[Eye|eyes]], decreased [[skin]] turgor, [[orthostatic hypotension]], [[oliguria]], dark-colored [[urine]], and [[Somnolence|drowsiness]] )
+abdominal tenderness on [[palpation]], [[rebound tenderness]], [[abdominal distention]], and abdominal rigidity. }}
+{{Family tree | |,|-|-|^|-|-|-|-|.| | }}
+{{Family tree | D01 | | | | | | D02 |D01= Yes |D02= No}}
+{{Family tree | |!| | | | | | | |!| | }}
+{{Family tree | E01 | | | | | | E02 |E01= <div style="float: center; text-align: left;">Perform the following [[Human feces|stool]] tests:
+* Bacterial culture for [[Salmonella]], [[Shigella]], and [[Campylobacter]].
+* Test for [[Shigella]] toxin and [[Escherichia coli|E. coli]] O157: H7
+* Test for fecal [[leukocytes]] and [[lactoferrin]]. |E02= <div style="float: center; text-align: left;">Does the patient have any of the following:
+* Clinical signs suggestive of [[inflammatory bowel disease]]
+* Symptoms present for more than a week despite conservative management
+* The patient is a health care worker or food handler (which can be a potential health hazard) }}
+{{Family tree | |!| | | | | |,|-|^|-|.| }}
+{{Family tree | F01 | | | | |F02| |F03| |F01= Is the fecal [[leukocytes]] or [[lactoferrin]] test positive? |F02= Yes |F03= No }}
+{{Family tree |,|-|^|-|.| | | |!| | | |!| }}
+{{Family tree |G01| |G02| |G03| |G04| G01=Yes |G02= No |G03=
+* Perform routine [[Human feces|stool]] culture.
+* Specific tests should be performed depending upon the patient’s history. |G04= No need to perform [[Human feces|Stool]] culture and additional tests. }}
+{{Family tree |!| | | |!| | | }}
+{{Family tree |F01| |F02| |F01= Test for [[Entamoeba histolytica]] |F02= [[Amoebiasis|Amebic dysentery]] highly unlikely. Look for other causative agents. }}
+===Treatment===
+Shown below is an algorithm summarizing the treatment of [[dysentery]] according to the Infectious Diseases Society of America clinical practice guidelines.<ref name="pmid27068718">{{cite journal| author=Riddle MS, DuPont HL, Connor BA| title=ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults. | journal=Am J Gastroenterol | year= 2016 | volume= 111 | issue= 5 | pages= 602-22 | pmid=27068718 | doi=10.1038/ajg.2016.126 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27068718  }} </ref><ref name="pmid11100619">{{cite journal| author=Victora CG, Bryce J, Fontaine O, Monasch R| title=Reducing deaths from diarrhoea through oral rehydration therapy. | journal=Bull World Health Organ | year= 2000 | volume= 78 | issue= 10 | pages= 1246-55 | pmid=11100619 | doi= | pmc=2560623 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11100619  }} </ref><ref name="pmid20687081">{{cite journal| author=Christopher PR, David KV, John SM, Sankarapandian V| title=Antibiotic therapy for Shigella dysentery. | journal=Cochrane Database Syst Rev | year= 2010 | volume=  | issue= 8 | pages= CD006784 | pmid=20687081 | doi=10.1002/14651858.CD006784.pub4 | pmc=6532574 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20687081  }} </ref>
+{{familytree/start }}
+{{familytree | | | | | | | | A01 |A01= <div style="float: center; text-align: left;">Characterize the symptoms of the [[patient]]:
+* Presence of severe [[diarrhea]] along with systemic symptoms.
+* Two or more clinical signs for [[dehydration]] (i.e. Sunken [[Eye|eyes]], dry [[mucous membrane]], reduced [[skin]] turgor, increased [[thirst]] ). }}
+{{familytree | | | | |,|-|-|-|^|-|-|-|-|.| | | }}
+{{familytree | | | B01 | | | | | | | | B02 | | |B01= Yes |B02= No }}
+{{familytree | | | |!| | | | | | | | | |!| | | }}
+{{familytree | | | C01 | | | | | | | | C02 | | |C01= <div style="float: left; text-align: left;">
+* [[Fluid replacement]] therapy.
+* Empirical [[Antibiotic|antibiotics]] therapy.
+* The drug of choice is [[Quinolone|fluoroquinolones]] (500mg [[Levofloxacin (oral)]] once daily for 3 days).  If the symptoms do not improve in a few days, the patient should be switched to either [[azithromycin (oral)]] or [[cephalosporin]].
+* Bismuth sulphate and [[loperamide]] to relieve abdominal cramps and discomfort. |C02= <div style="float: left; text-align: left;">
+* Oral [[fluid replacement]] therapy. Give [[Oral rehydration therapy|ORS]] solution for every [[Intestine|bowel]] movement. Approximately 2 liters of [[Oral rehydration therapy|ORS]] solution is given to the [[patient]].
+* Antimicrobial therapy should be initiated on the basis of [[Human feces|stool]] culture results.
+* Bismuth sulphate and [[loperamide]] can be given to relieve abdominal symptoms.
+* Reassess hydration status after every 6 hours. }}
+{{familytree | | | |!| | | | | | | | }}
+{{familytree | | | D01 | | | | | | |D01= Assess [[patient]] for symptoms of [[hypovolemia]] (i.e. [[altered mental status]] with [[lethargy]] and [[unconsciousness]], weak [[Pulse|pulses]] , and inability to drink) }}
+{{familytree | |,|-|^|.| | | | }}
+{{familytree | D01 | | D02 | |D01= Yes |D02= No }}
+{{familytree | |!| | | |!| | | }}
+{{familytree | E01 | | E02 | |E01= <div style="float: left; text-align: left;">Patient has severe [[hypovolemia]].
+* Give [[Intravenous therapy|parenteral]] [[fluid replacement]] with 5 % dextrose or [[Saline (medicine)|normal saline]] solution.
+* Give rapid infusion initially and then slow infusion.
+* The aim is to give 200 ml/kg in 24 hours with 100ml/kg in the first 4 hours of infusion.
+* Reassess [[Hemodynamics|hemodynamic]] and hydration status of the [[patient]] after 6 hours. |E02= <div style="float: left; text-align: left;"> [[Patient]] has mild [[hypovolemia]].
+* Give oral [[fluid replacement]] therapy.
+* 2.2 to 4 liters of [[Oral rehydration therapy|ORS]] is given in the first 4 hours.
+* Reassess [[Hemodynamics|hemodynamic]] and hydration status of the [[patient]] after 6 hours. }}
+{{familytree/end}}
+===Do's===
+* Important clues regarding the etiology of dysentery can be narrowed down while taking history. If the patient has dysentery more than 16 hours after having an outdoor food consider [[Enterotoxigenic Escherichia coli|Enterotoxigenic ''E.coli'']]. There is an increased risk of acquiring the [[''Salmonella'']] infection in individuals exposed to turtles and poultry. People working in daycare have an increased risk of infection with enteric [[Virus|viruses]] and [[''Shigella'']].<ref name="pmid27068718">{{cite journal| author=Riddle MS, DuPont HL, Connor BA| title=ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults. | journal=Am J Gastroenterol | year= 2016 | volume= 111 | issue= 5 | pages= 602-22 | pmid=27068718 | doi=10.1038/ajg.2016.126 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27068718  }} </ref>
+* Physicians can take a rectal swab in patients in whom stool samples cannot be obtained and immediate diagnosis is required.<ref name="pmid30944186">{{cite journal| author=Jean S, Yarbrough ML, Anderson NW, Burnham CA| title=Culture of Rectal Swab Specimens for Enteric Bacterial Pathogens Decreases Time to Test Result While Preserving Assay Sensitivity Compared to Bulk Fecal Specimens. | journal=J Clin Microbiol | year= 2019 | volume= 57 | issue= 6 | pages=  | pmid=30944186 | doi=10.1128/JCM.02077-18 | pmc=6535583 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30944186  }} </ref> Though the rectal swab has less sensitivity than [[Human feces|stool]] culture in identifying the causative agent.<ref name="pmid30315956">{{cite journal| author=Kotar T, Pirš M, Steyer A, Cerar T, Šoba B, Skvarc M | display-authors=etal| title=Evaluation of rectal swab use for the determination of enteric pathogens: a prospective study of diarrhoea in adults. | journal=Clin Microbiol Infect | year= 2019 | volume= 25 | issue= 6 | pages= 733-738 | pmid=30315956 | doi=10.1016/j.cmi.2018.09.026 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30315956  }} </ref>
+* If the clinician is suspecting a particular [[bacteria]], it should be mentioned while ordering the test. Certain [[bacteria]] require special culture media to grow and methods to be visualized. [[''Campylobacter jejuni'']] grows on the specific ‘CAMP’ agar plates at a particular temperature and environmental conditions. If infection with [[''Yersinia'']] is suspected, it should be specified as it is commonly overlooked.<ref name="pmid4014291">{{cite journal| author=Guerrant RL, Shields DS, Thorson SM, Schorling JB, Gröschel DH| title=Evaluation and diagnosis of acute infectious diarrhea. | journal=Am J Med | year= 1985 | volume= 78 | issue= 6B | pages= 91-8 | pmid=4014291 | doi=10.1016/0002-9343(85)90370-5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4014291  }} </ref>
+* Physicians need to monitor the patients for the complications of the infection with certain [[bacteria]].  [[Bacteremia]] and [[reactive arthritis]] can occur with infection with non- typhoidal [[''Salmonella'']] and [[''Shigella'']].<ref name="pmid16621698">{{cite journal| author=Rodríguez M, de Diego I, Martínez N, Rosario Rodicio M, Carmen Mendoza M| title=Nontyphoidal Salmonella causing focal infections in patients admitted at a Spanish general hospital during an 11-year period (1991-2001). | journal=Int J Med Microbiol | year= 2006 | volume= 296 | issue= 4-5 | pages= 211-22 | pmid=16621698 | doi=10.1016/j.ijmm.2006.01.068 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16621698  }} </ref> The [[hemolytic-uremic syndrome]] can occur due to E 0157:H7 or [[''Shigella'']]. A neurological complication [[Guillain-Barré syndrome]] can occur with [[''Campylobacter'']] infection.
+===Don'ts===
+* The empirical antimicrobial [[treatment]] for [[dysentery]] does not include [[treatment]] for [[Entamoeba histolytica|''E. histolytica'']].  [[Metronidazole]] (500mg thrice daily for 7 to days) should be administered to [[patient|patients]] only when trophozoites or cysts are visualized under a [[microscope]] in the [[Human feces|stool]] sample.<ref name="pmid590600">{{cite journal| author=Misra NP, Gupta RC| title=A comparison of a short course of single daily dosage therapy of tinidazole with metronidazole in intestinal amoebiasis. | journal=J Int Med Res | year= 1977 | volume= 5 | issue= 6 | pages= 434-7 | pmid=590600 | doi=10.1177/030006057300100209 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=590600  }} </ref>
+* A complete metabolic profile is not routinely performed in [[patient|patients]] with [[dysentery]]. [[Serum]] electrolytes and [[glucose]] levels should only be measured in [[patient|patients]] who present with complications (i.e. [[altered mental status]], [[Seizure|seizures]], [[anuria]], [[oliguria]], and [[ileus]] ).
-===Blood flow in Collaterals===
+==References==
-Collateral blood vessels are communicating vessels that bridge two main arteries. There is bidirectional blood flow in it with the minimal flow in the midpoint of the vessel. This results in low resistance blood flow with reduced incidence for thrombosis. <ref name="pmid25012127">{{cite journal| author=Faber JE, Chilian WM, Deindl E, van Royen N, Simons M| title=A brief etymology of the collateral circulation. | journal=Arterioscler Thromb Vasc Biol | year= 2014 | volume= 34 | issue= 9 | pages= 1854-9 | pmid=25012127 | doi=10.1161/ATVBAHA.114.303929 | pmc=4140974 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25012127  }} </ref>
+{{Reflist}}
-===Benefits of Collateral Circulation===
-Circle of Willis is a primary collateral vessel in the brain. Anterior and posterior communicating artery serves as a connection between the internal carotid and posterior cerebral artery. It provides blood flow if there is obstruction at any site at the circle of Willis. Collateral circulation is a protective adaptive response to restore blood flow in the hypoxic region due to stenosed blood vessels. A slowly developing plaque gives sufficient time for the development and maturation of collateral blood vessels. A study showed an increase in angiographic collaterals from 66% to 75% three to six hours after the onset of symptoms. There was also a reduced incidence of cardiogenic shock in patients with collateral vessels which further proved the protective role of collateral circulation. <ref name="pmid12001540">{{cite journal| author=Waldecker B, Waas W, Haberbosch W, Voss R, Wiecha J, Tillmanns H| title=[Prevalence and significance of coronary collateral circulation in patients with acute myocardial infarct]. | journal=Z Kardiol | year= 2002 | volume= 91 | issue= 3 | pages= 243-8 | pmid=12001540 | doi=10.1007/s003920200018 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12001540  }} </ref>
-===Drawbacks of Collateral Circulation===
-====Coronary steal syndrome====
-In situations of increased blood flow to heart i.e. administration of vasodilators like nitrates or exercise, the resistance to blood flow to collaterals is less compared to the obstructed artery. This results in enhanced blood flow through collateral vessels and further compromises blood flow through the stenosed artery. The supply of oxygen and nutrients to the hypoxic area of the heart is worsened exacerbating angina clinical symptoms. <ref name="pmid9416891">{{cite journal| author=Seiler C, Fleisch M, Meier B| title=Direct intracoronary evidence of collateral steal in humans. | journal=Circulation | year= 1997 | volume= 96 | issue= 12 | pages= 4261-7 | pmid=9416891 | doi=10.1161/01.cir.96.12.4261 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9416891  }} </ref>
-====Re-stenosis of the main artery====
-In a percutaneous intervention at the site of a coronary stent, there is a competition of anterograde blood flow through the main coronary artery and retrograde flow via a stenosed artery. This results in resistance to blood flow, with a slow velocity of blood flow. It causes a cascade of reactions including platelet aggregation, endothelial proliferation, and thrombus formation which results in restenosis of the vessel. <ref name="pmidhttps://doi.org/10.1186/1741-7015-10-62">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=https://doi.org/10.1186/1741-7015-10-62 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10  }} </ref>
-===References===