BIOCHEMICAL ASPECTS OF DIARRHEA

Group 5

Althea Elinzano Anne Falcon Rafael Ferrer Benedick Fronda Mariane Gabaon Ramon Gallardo Kristine Gamponia Crisha Habaluyas Rhiza Hernandez 1-A Medicine 4 July 2012

TOPIC OUTLINE

I. INTRODUCTION A. Definition of Diarrhea B. Causes of Diarrhea C. Clinical manifestations

II. Metabolic changes observed in diarrhea III. Case I Discussion A. Evaluation of nutritional status and state of hydration of the patient. B. Cycle of malnutrition and diarrhea in relation to patients diet before and during diarrhea. C. Advantages of breastfeeding and oral rehydration solution. D. Biochemical significance of am with sugar in diarrheic patients.

IV. Biochemical basis of diarrhea caused by cholera A. Definition of cholera B. Mechanism involved in the causation of diarrhea

I. INTRODUCTION Diarrhea is defined as the frequent passing of loose or watery stools. Diarrhea is a common but potentially serious illness in early childhood. A child suffers, on an average, 10 to 15 episodes of diarrhea in the first five years of life. Of these, three to five occur in the first year of life. A child may lose almost as much water and electrolytes from the body during an episode of diarrhea as an adult, since the length and surface area of intestinal mucosa of a child, from where the diarrheal fluids are secreted, are fairly large. Loss of one liter of fluid from the body of a child weighing 7 Kg is much more hazardous compared with a similar depletion from an adult of 70 Kg weight. Significant dehydration disturbing the balance of electrolytes and acid- base status of the body occurs in about 2 to 3 per cent of all cases of diarrhea. Some of these cases may prove fatal, if fluids and electrolytes are not replaced to restore normal circulation and body functions which are impaired in the dehydrated state.

It is classified as: Acute diarrhea, which is a common cause of death in developing countries. This type is usually caused by infections and the duration is 14 days or less.

Chronic diarrhea. It may be caused by infection, allergy, or could be a sign of a serious disorder, such as IBD (inflammatory bowel disease), or Crohn's disease. The duration is more than 14days. According to the World Health Organization (WHO) approximately 3.5 million deaths each year are attributable to diarrhea. 80% of those deaths occur in children under the age of 5 years. Children are more susceptible to the complications of diarrhea because a smaller amount of fluid loss leads to dehydration, compared to adults. Types of Diarrhea Secretory diarrhea Either the gut is secreting more fluids than usual, or it cannot absorb fluids properly. In such cases structural damage is minimal. This is most commonly caused by a cholera toxin a protein secreted by the bacterium Vibrio cholera Osmotic diarrhea Too much water is drawn into the bowels. This may be the result of celiac disease, pancreatic disease, or laxatives. Too much magnesium, vitamin C, undigested lactose, or undigested fructose can also trigger osmotic diarrhea. CAUSES OF DIARRHEA INFECTIOUS AGENT- includes bacteria, toxins and viruses. This is acquired by fecaloral transmission.

MECHANISM OF ACTION OF ENTEROPATHOGENS Organisms which adhere to the mucosa and produce enterotoxins (secretory diarrhoea, no inflammation of the gut). Organisms which damage the brush border and its enzymes (cause carbohydrate malabsorption). Organisms that invade the mucosa and proliferate in the intestinal epithelium. Enterotoxigenic E. coli Vibrio cholerae

Enteropathogenic E. coli (some of these are enteroadherent) Rotavirus Shigella Enteroinvasive E. coli

Organisms which proliferate in the lamina propria and invade the mesenteric lymph anodes. Disordered small intestinal epithelial renewal.

Non-typhoid salmonella; Campylobacter jejuni; Yersinia enterocolitica Rotavirus

HORMONES- gastrinoma, medullary carcinoma and pancreatic cholera are few example illnesses that can be attributed to hormones. These illness are often accompanied by episodes of diarrhea as characterized by frequently having watery stool and dehydration. OSMOTIC LAXATIVE- may be induced by ingestion of laxatives which are commonly observed in people with eating disorders. CARBOHYDRATE MALABSORPTION- lactose intolerance where one is unable to digest sugars because there is deficiency of enzyme lactase. IMMUNODEFICIENCY- susceptibility to different viruses and bacteria may cause diarrhea.

HOW DOES DIARRHOEA CAUSE SIGNIFICANT PHYSIOLOGICAL DISTURBANCES IN THE BODY Water constitutes about 75 per cent of body weight at birth and approximately 60 per cent of child's body weight is present in two separate compartments-the extracellular (E.C.F.) and intracellular (I.C.F.) The extracellular compartment includes circulating blood, interstitial fluid and secretions. Diarrhoea losses come from ECF and replacement fluids should be of a similar composition: relatively rich in sodium with low potassium. Kidneys regulate the electrolyte content of the extracellular compartment by filtering, concentrating, diluting and reabsorbing fluids and metabolites from the circulation. Functional ability of the kidney of very young infants is not fully developed as compared with older children.

Large amounts of water and water-soluble nutritive substances such as electrolytes, metabolites and vitamins are lost from the body during diarrhoeal episodes. Loss of water from the body causes a reduction or shrinkage in the volume of extracellular compartment. In about half of these cases, the concentration of sodium in the plasma or extracellular compartment remains nearly normal (about 140 mEq/ L). Since excessive sodium may be lost in the stools in another 40 to 45 per cent of cases, there is a relative decline in the serum and ECF sodium level (hyponatremia). Sodium is a major osmotic determinant of ECF Therefore, the osmolality of ECF falls, causing movement of water from the extracellular to intracellular compartment. This causes further shrinkage of the already reduced extracellular compartment volume. Skin turgor or elasticity is normally maintained by the presence of water and fat in the tissues. Shrinkage of extracellular water in both hypo and isonatremic types of dehydration impairs the skin elasticity. The skin appears to be wrinkled like that of an old man. On pinching, it takes a few seconds for the skin folds to return to normal.

Symptoms of diarrhea can be broken down into uncomplicated (or non-serious) diarrhea and complicated diarrhea. Complicated diarrhea may be a sign of a more serious illness. Symptoms of uncomplicated diarrhea include: Abdominal bloating or cramps Thin or loose stools Watery stool Sense of urgency to have a bowel movement Nausea and vomiting In addition to the symptoms described above, the symptoms of complicated diarrhea include: Blood, mucus, or undigested food in the stool Weight loss Fever LABORATORY APPROACH TO DIAGNOSIS i. ii. iii. iv. v. Microscopic examination of stools for pus cells, red blood cells' and macrophages (cellular exudate) and presence of cysts or vegetative forms of Entamoeba histolytica or Giardia lamblia. Blood investigations such as pH, base excess, electrolytes such as N +, K+ haemoglobin level, urea and osmolality. Record of the pH or reaction of the stools by dipping a strip of pH indicator paper of blue litmus paper in the stools suspension. Culture of stools for enteropathogenic bacteria. Tests for the presence of toxins in the organisms cultured from stools e.g. distension of the isolated rabbit ileal. loop or GM1 ELISA etc.
6

vi.

Tests for the presence of rotavirus by electron microscopic examination or by ELISA test.

II. Metabolic Changes Observed in Diarrhea QUESTION 1: Describe the sequence of the various metabolic changes observed in diarrhea and correlates these to the clinical manifestations observed in the patient. a. Gastrointestinal function and motility INCREASE GI FUNCTION AND MOTILITY

When food moves too fast, the intestines cannot absorb water. Parasympathetic nervous system increases GI motility. When segments in the intestines become infected by bacteria, the pits in the small intestine called crypts of Liberkuhn secrete large amounts of choride and bicarbonate. Such activity increases the osmotic movement of water and thus propels the movement of stool out of the system.

LOOSE WATERY STOOL b. Alteration in fluid volume DEFICIENT FLUID VOLUME - Too much secretion of water by the crypts of Liberkuhn in the small intestine causes the fecal matter to travel faster to anus.

Dehydration c. Acid- base balance Metabolic acidosis, increase in bicarbonate and decreases in pH may be a precursor to diarrhea. Hypokalemia
7

Prolonged diarrhea may cause intestinal loss of potassium. When the plasma concentration falls below 3.0 meq/L, patients may experience muscle weakness, muscle cramps and cardiac arrhythmias. Diarrhoeal stools contain large amounts of potassium. Therefore, the serum potassium level invariably falls if diarrhoea persists for more than a few days. The affected children present with abdominal distension and hypotonia of muscles. Electrocardiogram shows ST depression and flat T waves. d. Composition Too much secretion of water also affects the composition of feces, thus producing semisolid or loose stool. III. Case I Discussion A mother brought her 10-months old, 8-kg daughter to a health center because of diarrhea of one day duration which occurred 4 times. There was no accompanying vomiting. She has been breastfed since birth. At 5 months old. Lugaw with fish and vegetables were started. At the onset of diarrhea, the mother stopped breastfeeding and giving of solid foods and instead shifted to giving am with sugar. The child is alert, with good skin turgor and adequate urine output. A. Evaluation of nutritional status and state of hydration of the patient. QUESTION 2: Evaluate the nutritional status and state of hydration of the patient (use growth chart and assessment of hydration table). Compute for the ideal weight for age of the patient. DATA: Sex: Female Age: 10 months old Weight: 8 kg Does the young infant have diarrhea? YES For how long? One day Frequency : Four times CLINICAL FEATURES OF DEHYDRATION Mild Irritable Moderate Irritable Weak pulse Severe Moribund, apathetic Peripheral circulatory failure (cold extremities, warm body, excessive blanching, weak pulse)
8

Some reduction in urine volume Fontanelle depressed Eyeballs sunken Facies dry and pinched Buccal mucosa dry Lips parched Loss of skin turgor (except in in hypernatremic variety) Thirsty Thirsty

Marked reduction in urine volume Fontanelle markedly depressed Eyeballs markedly sunken Facies markedly dry and pinched Buccal mucosa dry Lips parched Loss of skin turgor (except hypernatremic in which it may not be variety prominent) Thirsty

based on IMCI chart, danger signs diarrhea ASSES AND CLASSIFY SICK CHILD AGED 2 MONTHS UP TO 5 YEARS ASK: Does the child have diarrhea? If YES, ask: For how long? Is there blood in the stool?

Look and feel: Look at the childs general condition. Is the child: Abnormally sleepy or difficult to awaken? Restless and irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen.
9

Does it go back: Very slowly (longer than 2 seconds)? Slowly? Look and feel: Is the child: Abnormally sleepy or difficult to awaken? Restless and irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it goes back: Very slowly? (> 2 sec) Slowly? CLASSIFY DIARRHEA SEVERE ( Refer) MODERATE MILD SIGNS For DEHYDRATION Two of the following signs: - Abnormally sleepy or difficult to awaken - Sunken eyes - Not able to drink or drinking poorly - Skin pinch goes back slowly CLASSIFY AS TREATMENT If the child has no other severe classification: - give fluid for severe dehydration (Plan C). OR.. If the child has another severe classification: - Refer URGENTLY to hospital, with mother giving frequent sips of ORS on the way. - Advise mother to continue breastfeeding. If child is 2 years or older and there is cholera in your area, give antibiotic for cholera. Give fluid and food for some dehydration (Plan
10

SEVERE DEHYDRATION

Two of the following signs: - Restless, irritable

SOME DEHYDRATION

Sunken eyes Drinks eagerly, thirsty Skin pinch goes back very slowly

B). If child also has another severe classification: - Refer URGENTLY to hospital, with mother giving frequent sips of ORS on the way. - Advise mother to continue breastfeeding. Advise the mother when to return immediately. Follow up in 5 days if not improving. NO DEHYDRATION Give ORS, zinc supplements and food to treat diarrhea at home (Plan A). Advise mother when to return immediately. Follow up in 5 days when not improving.

Not enough signs to classify as some or severe dehydration.

..and if diarrhea for 14 days or more Dehydration present SEVERE PERSISTENT DIARRHEA Treat dehydration before referral unless the child has another severe classification. Give Vitamin A Refer to hospital. Advise the mother on feeding a child who has PERSISTENT DIARRHEA Give Vitamin A. Follow up in 5 days. Advise mother when to return immediately. Treat for 5 days with an oral antibiotic recommended for
11

No dehydration

PERSISTENT DIARRHEA

and if blood in stool Blood in the stool

DYSENTERY

Shigella in your area. Follow up in 2 days. Advise mother when to return immediately. Based on Integrated Management of childhood Illness the infant is considered NO DEHYDRATION status. Based on the assessment that the child is alert, with good skin turgor and adequate urine output. Computation: Formula: [ AGE (month) + 9] / 2 ( weight for kilograms) WHO Weight standards = 10 months + 9/ 2 = 9.5 kg The infant has poor nutritional status based on her low weight for age. B. Cycle of Malnutrition and Diarrhea

SOURCE:Understanding and Managing Acute Diarrhea in Infants and Young Childrenhttp://hetv.org/resources/acute-diarrhoea.htm#WHAT CAUSES DIARRHOEA

Diarrhea has been shown to have significant impact on nutrition. Most field studies identify diarrhea as the major determining factor leading to malnutrition in the developing
12

countries. It IS the child with multiple episodes of diarrhea and particularly chronic diarrhea, who suffers most severely from protein-energy malnutrition. But even a brief episode of diarrhea leads to the loss of I to 2 per cent of body weight per day. Infants and young children in developing countries are sick for about 10 per cent of the time (or nearly 30 days per year) with diarrheal illness. Thus over the time even the creeping deficit associated with mild illness can accumulate to become a major nutritional deficiency. If diarrhea becomes unusually prolonged or is recurrent, the child becomes severely malnourished, since he/she also loses nutrients through stools. The appetite is impaired and food is often withheld from the child by the mother due to an erroneous belief that starvation rests the bowel and promotes early recovery from diarrhea. QUESTION 3: Determine the adequacy of the patients diet before and during diarrhea relate this to the cycle of malnutrition and diarrhea. Before the occurrence of diarrhea the diet was inadequate. During her 10 month of age she was supposed to eat variety of foods such as rice and meat products to sustain her nutritional requirement to boost her immune system thus preventing malnutrition. Thereby, in her case she was vulnerable of having diarrhea because her immune system was poor. Patients diet during diarrhea is adequate but the mother supposed to continue breast feeding her daughter because during her daughters condition she needs further replacement of fluids. Her mother gave her am or rice water which is an alternative for starch requirement upon her cessation of giving solid food and for supplementary source of fluid and electrolytes requirement to prevent dehydration. According to WHO rice water has the nutritional advantage of providing more calories during rehydration than does ORS and the osmolar advantage that its carbohydrates are released gradually in the intestine. C. Advantages of breastfeeding and oral rehydration solution. QUESTION 4: What advice should be given to the patients mother regarding breastfeeding, use of home fluids/oral rehydration solutions and other nutritional support for the patient. A. Breastfeeding/Colostrums The infant should continue to be breastfed during an attack of diarrhea. Breast feeding should be allowed as often as the infant desires it. ADVANTAGES Has right amount of fat, sugar, water, and protein that is needed for a baby's growth and development

-Greater Immune Health: IgA antibodies against infections on the childs intestinal Breast-fed children are less prone to flora. diarrhoea. Since the human milk has low buffering capacity, stools of breast-fed Side Note: The quality of a mother's breast babies are acidic. Their E. coli count is milk may be compromised by alcoholic
13

low, but that of Lactobacillus bitidus is beverages, caffeinated drinks, marijuana, high. Breast milk contains viable methamphetamine, heroin, and methadone. phagocytes and other protective substances, such as secretory IgA and specific IgM which protect against most enteropathogens but possibly not against rotavirus infection. Breast-fed children have better growth performance. C. Oral Rehydration Solutions (ORS) -Replenishes lost essential fluids that maintain body homeostasis. A fairly satisfactory solution for oral -patient treated with Ors do not require an rehydration can be prepared at home by intravenous access, a potentially painful and mixing eight level teaspoonfuls of cane difficult procedure in young children. sugar (40 grams of sucrose), one level ..but teaspoonful of table salt (five grams of Although effective in rehydration, it do not NaCl) with or without a lemon squeezed in decreases stool volume because of the one litre of potable water. Since 2 g of sugar relatively high osmolality of glucose they releases I g of glucose, 40 g of sucrose is ontain. used. Alternatively a 3 finger pinch (upto the first crease) of table salt and closed fistful of cane sugar are mixed in half a litre of water. C. Nutritional Support Zinc Potassium Greatly reduces the severity and duration of diarrhea Influences osmotic balance between cells and interstitial fluid (Na-K-ATPase Pump)

QUESTION 5: What biochemical significance if any, can be given to the use of am with sugar in diarrheic patients? RICE WATER CONTENTS: Rice wateror am is the suspension of starch obtained by draining boiled rice or by boiling rice until it completely dissolves into the water. It is widely used in rural areas as a treatment for diarrhea. Normally, rice contains: 28.59% carbohydrates, 0.3% fat, 0.21% proteins, and 68.61% water.The contents of rice are diluted in water making rice water composed mostly of water with minute amounts of starch that becomes glucose when digested.

14

EFFECTS OF RICE WATER: It is said that rice based electrolyte solutions such as rice waterare effective treatment for diarrhea, because rice starch is rapidly converted to glucose by pancreatic amylase and brush border hydrolases.Rice powder, being mostly starch, releases more than twice the amount of glucose when digested than is present in standard ORS solution. The glucose from the digestion of starch aids in providing energy and also draws water that helps to replenish the water that are lost in the stool. COMPARISON BETWEEN RICE WATER AND ORS: Typical ORS contains water, sugar and salt while rice water is composed mainly of water and few amounts of starch. Although rice water has higher glucose content as compared to ORS, it has less sodium content than in the ORS. Since sodium is needed for the absorption of glucose by enterocytes, ORS is more effective than plain rice water. But plain rice water when added with sodium can surpass the efficacy of the ORS. WHAT BIOCHEMICAL SIGNIFICANCE IF ANY, CAN BE GIVEN TO THE USE OF AM WITH SUGAR IN DIARRHEIC PATIENTS? Rice water or am has little biochemical importance in treating patients with diarrhea since it is composed mainly of water and a few amount of starch. When added with sugar, its effect is increased since glucose is a source of energy. The water will help replenish what has been lost in the stools while the glucose will provide energy for cell processes.However, water and glucose alone will have a difficult time to be absorbed by enterocytes in the small intestine since it needs sodium to be transported inside the enterocytes with ease. V. BIOCHEMICAL BASIS OF DIARRHEA CAUSED BY CHOLERA A. Definition of cholera Cholera, a life-threatening disease marked by severe diarrhea, is caused by the bacterium Vibrio cholerae. The disease is typically transmitted by the ingestion of food or water contaminated with human feces. In the intestinal tract, cholera vibrios adhere to the surface of cells.

15

B. Mechanism Involved in the Causation of Diarrhea Vibrio cholera secretes cholera toxin, which has two types of subunits: five copies of a B subunit, which functions in binding to host cell receptors, and one copy of an A subunit, which exhibits the toxic activity. Cholera toxin is structurally similar to many other bacterial toxins that are generally termed AP toxins. Because it specifically affects the intestines, cholera toxin is also called an enterotoxin. Each of the five B subunits binds to a glycolipid, called ganglioside GM1, on the intestinal cell membranes. In this way, cholera toxin binds tightly to intestinal epithelial cells. The A subunit consists of two domains: the A1 domain, which contains the toxins activity, and the A2 domain, which tethers the A subunit to the B ring. A protease clips A subunit into two polypeptides, which remain together by virtue of a disulfide bond. The binding of cholera toxin to GM1 triggers endocytosis. The resulting toxin-containing vesicle is transported to the endoplasmic reticulum. The A1 peptide is then released from A2 and the rest of the complex by a reduction reaction at the disulfide bond. From the lumen of the endoplasmic reticulum, the toxin is then transported into the cytoplasm. The mission of the A1 peptide is to modify a membrane-associated protein called a G protein that binds to the enzyme adenylatecyclase and controls its activity. A G protein normally functions in the following way. An inactive G protein resides in a complex made up of , and subunits. The inactive subunit carries a GDP molecule. When a hormone activates an appropriate receptor, the activated receptor can activate the G protein, allowing it to release GDP and take up GTP. The subunit separates from the and subunits. The activated subunit can bind to and activate adenylatecyclase. Activated adenylatecyclase converts ATP to cAMP. The G protein subunit has a GTPase activity and soon cleaves GTP to form GDP, thereby inactivating itself and adenylatecyclase. The G protein complex reforms, and only a small amount of cAMPhas been made.
16

The A1 peptide of cholera toxin is an enzyme that uses a molecule of NAD +which is made up of a nicotinamide group, a ribose sugar, and an ADP moleculeand adds the ADP-ribose to the G protein subunit. This is an ADP ribosylation reaction, and it prevents the G protein from cleaving GTP into GDP and P i. Adenylatecyclase remains activated for a long period, increasing the levels of cAMP tremendously. Elevated levels of cAMP stimulate a host enzyme called protein kinase A. The catalytic subunits of the enzyme activate various ion transport channels, including one called CFTR (cystic fibrosis Transmembrane conductance regulator). CFTR exports chloride ions. As chloride and other ions leave the cell, water leave as well in an attempt to equilibrate the osmolarity. Ultimately, the bloodstream provides the water, chloride, and other ions that enter the intestinal lumen. The influx of fluid results in diarrhea. Although devastating to the human, diarrhea benefits the bacterium, in large part by helping in disseminate the species in the environment.

End

17