Dysentery | Causes | Pathophysiology | Signs and Symptoms | Nursing Management

Dysentery is a well-known condition. It is characterized by the frequent passage of small, watery stools that often contain blood and mucus. This condition affects the large intestine and is accompanied by severe abdominal cramps. It can manifest as either an acute or chronic disease.

Causes of dysentery

Dysentery can be caused by various factors, including:

  1. Bacterial Infections: Pathogenic bacteria such as Shigella, Salmonella, Campylobacter, and Escherichia coli can cause dysentery through contamination of food or water sources.
  2. Parasitic Infections: Protozoa like Entamoeba histolytica can lead to dysentery when ingested through contaminated food or water.
  3. Viral Infections: Certain viruses, such as the norovirus, can cause dysentery-like symptoms, particularly in outbreaks or crowded environments.
  4. Poor Hygiene Practices: Inadequate sanitation, improper handwashing, and unsanitary living conditions can contribute to the spread of dysentery-causing pathogens.
  5. Contaminated Food and Water: Consumption of contaminated food or water, particularly in regions with inadequate sanitation, is a common cause of dysentery.
  6. Travel to Endemic Areas: Traveling to regions where dysentery is endemic increases the risk of exposure to the pathogens responsible for the condition.
  7. Weakened Immune System: Individuals with compromised immune systems, such as those with HIV/AIDS or undergoing immunosuppressive therapy, are more susceptible to developing dysentery.
  8. Poor Food Handling: Improper handling, storage, or preparation of food can lead to bacterial contamination and subsequent dysentery.

Types of dysentery

Dysentery is a term used to describe intestinal inflammation, particularly of the colon, resulting in severe diarrhea with blood and mucus in the feces. It is most commonly caused by bacterial or parasitic infections. There are two main types of dysentery:

  1. Bacterial Dysentery: This type of dysentery is caused by bacterial infections, most commonly by strains of bacteria such as:
    • Shigella: Shigellosis is caused by the Shigella bacteria and is a common cause of bacterial dysentery, especially in developing countries.
    • Campylobacter: Campylobacteriosis can also lead to dysentery-like symptoms, including bloody diarrhea.
    • Escherichia coli (E. coli): Certain strains of E. coli, such as E. coli O157:H7, can cause dysentery when ingested.
  2. Amoebic Dysentery: Amoebic dysentery is caused by the protozoan parasite Entamoeba histolytica. This type of dysentery is more common in tropical and subtropical regions and can lead to severe complications if left untreated.

Bacillary dysentery is a condition marked by acute inflammation and ulceration of the large intestine, manifesting as frequent small bowel movements containing blood and mucus in the stool. It is caused by non-motile gram-negative bacteria belonging to the genus Shigella. Shigella is classified into four strains:

  • Shigella flexneri,
  • Shigella boydii,
  • Shigella dysenteriae,
  • Shigella sonnei.

These types of dysentery share similar symptoms, including diarrhea, abdominal pain, fever, and sometimes dehydration. However, the treatment may vary depending on the specific cause, with bacterial dysentery often treated with antibiotics and amoebic dysentery treated with anti-parasitic medications. A proper diagnosis is essential for effective treatment.

Predisposing Factors

The predisposing factors contributing to the occurrence of dysentery can be summarized by the “6 F’s”: Formites, Food, Faeces, Fingers, Fluids, and Flies. Addressing these factors effectively can help mitigate the problem. These factors include:

i. Poor feeding practices: This encompasses the improper handling of feeding bottles for infants, which may become contaminated if not cleaned adequately. Additionally, consuming unboiled or improperly prepared foods increases the risk of dysentery transmission.

ii. Inadequate personal hygiene: This involves insufficient attention to hand hygiene, such as inadequate handwashing practices and neglecting to trim and maintain fingernails. Poor personal hygiene can facilitate the transmission of pathogens responsible for dysentery.

iii. Unsafe water sources and storage: The lack of access to safe drinking water, coupled with inadequate treatment and storage facilities, can expose individuals to waterborne pathogens, including those causing dysentery.

iv. Inadequate sanitation: This encompasses issues such as the presence of rubbish pits or dumping sites in close proximity to living areas, as well as poorly maintained sewerage lines. These conditions create environments conducive to the proliferation and spread of disease-causing organisms.

v. Overcrowding: Overcrowded living conditions facilitate the rapid spread of infectious diseases like dysentery. Close contact between individuals increases the likelihood of transmission, particularly in settings where sanitation and hygiene practices are suboptimal.

Epidermiology

Bacillary dysentery is predominantly found in unhygienic tropical regions; however, due to its ease of transmission, sporadic outbreaks can occur worldwide. The disease is particularly prevalent among densely populated communities, including nursing homes and large institutions where overcrowding is common.

Mode of Transmission 

When examining this picture, one immediately thinks about the mode of transmission of dysentery. Shigella, the causative agent, spreads primarily through the fecal-oral route. The bacteria are expelled in feces, and inadequate sanitation and hygiene practices can lead to contamination of food and water sources. Flies further exacerbate the problem by frequently spreading the bacteria to food, making them a significant mode of transmission for dysentery. Figure 8 depicts the transmission pathway of dysentery, highlighting the importance of proper sanitation and hygiene measures in preventing its spread. The incubation period of Shigella is typically 1 to 7 days.

Pathophysiology

Dysentery, particularly bacillary dysentery caused by Shigella species, involves a complex series of events within the gastrointestinal tract. It begins with the ingestion of Shigella bacteria, often through contaminated food, water, or contact with infected individuals. Upon reaching the lower intestine, Shigella bacteria adhere to and invade the epithelial cells lining the intestinal mucosa. This invasion triggers a vigorous inflammatory response characterized by the release of pro-inflammatory cytokines and chemokines, recruiting immune cells such as neutrophils and macrophages to the site of infection.

As Shigella infiltrates the intestinal tissue, it causes damage to the epithelial cells, disrupting the mucosal barrier. This damage facilitates the release of toxins produced by Shigella species, including Shiga toxin, which further exacerbates tissue damage and inflammation. Consequently, mucosal ulceration occurs in the colon, resulting in the formation of erosions or ulcers in the intestinal lining. These ulcers contribute to the hallmark symptoms of dysentery, such as abdominal pain, cramping, frequent and urgent bowel movements, and the passage of bloody and mucoid stools.

In severe cases, dysentery can lead to complications such as dehydration due to fluid loss from diarrhea, electrolyte imbalances, systemic spread of infection leading to sepsis, and, rarely, the development of conditions like reactive arthritis or hemolytic uremic syndrome (HUS). Overall, understanding the pathophysiology of dysentery is crucial for the development of effective prevention strategies and treatments aimed at mitigating the impact of this infectious disease on affected individuals and communities.

Signs and Symptoms

  • Dysentery presents with a sudden onset of symptoms.
  • Fever is common due to infection and inflammation.
  • Dehydration signs, like loss of skin turgor, may occur due to diarrhea; however, dehydration may not always be present as stool frequency increases.
  • Abdominal discomfort is an early symptom, likely from irritation of the gastrointestinal tract’s mucosal lining by the bacteria.
  • Nausea and vomiting may result from irritation of the stomach’s mucosal lining.
  • Colicky abdominal pains are common, likely due to the inflammatory reaction in the intestinal mucosal lining.
  • Bloody diarrhea is characteristic, resulting from damage to the large intestine’s mucosal lining during inflammation, potentially damaging capillaries.
  • Bloody diarrhea often accompanies urgency and tenesmus, with urgency being the frequent urge to defecate even with small stool amounts passed, and tenesmus being the painful, ineffective straining to empty the bowels.

Management:

  1. Correct electrolyte and fluid imbalance.
  2. Eliminate the causative organism.
  3. Prevent and manage complications.

Investigations:

  • Microscopic examination of a fresh stool specimen and rectal swab for culture and sensitivity. Stool should be cultured promptly after collection. Detection of the organism in stool confirms diagnosis.
  • Immunofluorescent techniques can be used to detect the organism in stool.
  • Sigmoidoscopy can reveal a red, bleeding mucosa with patches of necrotic membrane, which may separate to leave ulcerated areas.

Therapy:

Fluid and electrolyte replacement: Oral rehydration is typically necessary to address fluid and electrolyte imbalances. However, each patient should undergo assessment to determine the extent of dehydration and receive appropriate fluid replacement therapy.

Drugs: Antibiotics are prescribed to shorten the duration of illness and prevent relapse. Any of the following antibiotics can be given while awaiting the results of culture and sensitivity:

  • Nalidixic acid: 1g orally four times a day for 7 to 14 days.
  • Ciprofloxacin: 500mg orally twice daily for 5 days.
  • Trimethoprim-Sulfamethoxazole (Septrin, Co-trimoxazole): 960mg orally twice daily for 5 days.
  • Chloramphenicol: 50 to 100mg per kilogram of body weight orally four times a day for 5 days.
  • Ampicillin: 500mg orally four times a day for 5 days.

Amoebic dysentery

Amoebic dysentery, also known as amoebiasis, is the second type of dysentery caused by an infection with the pathogenic amoeba Entamoeba histolytica. This chronic enteric infection is brought about by a protozoan organism known as Entamoeba histolytica, which is a single-celled parasite.

  • Cause: Amoebic dysentery is caused by the protozoan parasite Entamoeba histolytica.
  • Predisposing Factors: Similar to bacillary dysentery, predisposing factors include poor sanitation, inadequate hygiene practices, contaminated food and water sources, overcrowding, and low socioeconomic conditions.
  • Epidemiology: Entamoeba histolytica has a global distribution and is endemic in regions with poor sanitation and low socioeconomic status. The use of night soil (human feces used as fertilizer) in agriculture facilitates the spread of the disease. The organism is acquired through the ingestion of cysts.
  • Mode of Transmission: Transmission occurs primarily through the fecal-oral route, where ingestion of contaminated food or water containing cysts leads to infection. Vectors such as flies, cockroaches, and rodents can carry cysts and contaminate food and drink, further spreading the disease.
  • Incubation Period: The incubation period for amoebic dysentery can vary widely, ranging from 2 weeks to years. Human beings serve as the principal reservoirs and carriers of the parasite, contributing to its transmission.

Pathophysiology:

When ingested, cysts of Entamoeba histolytica enter the alimentary tract via the mouth and proceed to the stomach, where they undergo excystation during digestion. Motile trophozoites are released, which then multiply. These trophozoites proceed to invade and ulcerate the intestinal mucosa of the large bowels, forming flask-like ulcers. Additionally, some of the amoebae may travel through the mesenteric artery, reaching the liver. In the liver, they cause total destruction, resulting in amoebic hepatocellular necrosis and the formation of liver abscesses.

Signs and Symptoms:

  • The onset of symptoms is gradual and typically involves abdominal discomfort.
  • Other signs and symptoms may include:
    • Mildly loose stools or frank diarrhea, sometimes with blood and mucus. Diarrhea may alternate with episodes of constipation.
    • Tenderness may develop over the caecum, transverse colon, or sigmoid.
    • Fever may be present.
    • Abdominal pains that may occur intermittently.
    • In cases of hepatic amoebiasis, symptoms may include body malaise, fluctuating temperature, sweating, and an enlarged, tender liver.
    • Foul-smelling stool.
    • Weight loss in chronic cases.

Investigations:

  • Stool microscopy, culture, and sensitivity testing (m/c/s) can help identify the presence of Entamoeba histolytica.
  • History of blood-stained stool is essential for diagnosis.
  • Physical examination may reveal signs of dehydration.
  • Rectal swab culture can aid in confirming the presence of the parasite.
  • Hemoglobin (Hb) levels in blood can indicate anemia, which may occur due to chronic infection.
  • Sigmoidoscopy can visualize ulcers in the intestinal mucosa.
  • Liver scan may be conducted to detect liver abscesses.

Treatment:

The disease is managed with the following interventions:

  • Flagyl (metronidazole) at doses of 200-400mg three times daily.
  • Septrin (trimethoprim-sulfamethoxazole) at a dose of 960mg twice daily for 5-7 days.
  • Furamide (diloxanide furoate) at a dose of 500mg three times daily for 10 days.
  • For hepatic amoebiasis, Flagyl (metronidazole) and Chloroquine are given at a dose of 600mg once daily for 2 days, followed by 300mg once daily for 21 days.
  • Panadol (acetaminophen) may be prescribed for fever and pain relief.
  • Intravenous fluids, such as Ringer’s lactate, may be administered to manage dehydration.

Nursing Care of Dysentery:

The goals of nursing care include:

  • Preventing further transmission of infection.
  • Replenishing lost fluids and electrolytes.
  • Preventing complications such as shock.

Environment:

  • Admit the patient to an isolation room separate from other patients to prevent the spread of infection. The room should be well-lit for easy observation and have good ventilation to promote air circulation. Position the patient near the toilet for convenience. Ensure essential equipment such as drip stands, intravenous sets, and observation trays are readily accessible within the patient’s environment.

Observation:

  • Monitor the patient’s general condition regularly. Frequently monitor vital signs such as temperature, pulse, respiration, and blood pressure. The frequency of observations depends on the patient’s condition. Assess the quality and quantity of stool passed by the patient. Monitor intake and output and record on fluid balance charts. Evaluate stool characteristics including amount, consistency, and color, and report any abnormalities. Watch for signs of dehydration such as loss of skin elasticity, sunken eyes, thirst, and dry mucous membranes of the mouth.

Infection Prevention:

  • Isolate the patient away from other patients to prevent the spread of infection. Individuals coming into contact with the patient should adhere to isolation protocols, including wearing gowns and masks when entering the room and washing hands before and after attending to the patient. Limit visitors to reduce the risk of infection transmission. Disinfect patient linens with a solution of JIK 1:6 and label them as “infectious” before sending them to the laundry. Avoid mixing this linen with other ward linens. Administer prescribed medication to treat the causative organism. Disinfect all utensils used by the patient to prevent contamination and further spread of infection.

Nutrition:

Provide the patient with plenty of fluids to ensure hydration, along with a gentle diet that is free from irritants. If the patient is unable to consume food or fluids orally due to their condition, initiate intravenous fluid therapy to maintain hydration and electrolyte balance. It’s essential to closely monitor both the intake and output of fluids. Keep detailed records of the amount and type of fluids administered intravenously, noting the start time of IV fluid therapy and the date it commenced. Additionally, record the patient’s oral intake and output to accurately assess their fluid balance and nutritional status.

Hygiene:

Depending on the patient’s condition, offer assistance with a bed bath to enhance comfort, preserve self-esteem, and eliminate dirt. Provide oral care assistance to prevent complications arising from poor oral hygiene, such as mouth infections. This also aids in promoting salivation, particularly crucial when the patient experiences dry mouth due to significant fluid loss. Promptly change soiled linens as needed, ensuring they are disinfected with a solution of Jik 1:6 before being sent to the laundry. This helps maintain cleanliness and reduce the risk of infection. Thoroughly clean the perineal area to uphold hygiene standards and minimize the risk of infections in this sensitive region.

Psychological Care:

Patients with dysentery may experience feelings of neglect, therefore, it’s essential for nurses to provide appropriate psychological support to alleviate anxiety. Educate the patient about the disease process, including its cause, mode of transmission, signs and symptoms, treatment, and potential complications. Explain the necessity of isolation to the patient, emphasizing its role in preventing the spread of infection. Similarly, inform significant others why visitation is restricted. Ensure that any procedures performed on the patient are thoroughly explained to gain their cooperation. Encourage patients to ask questions, and respond truthfully to address their concerns. This fosters trust and understanding between the patient and healthcare provider.

Medication Management:

Administer medications as prescribed by the healthcare provider, ensuring adherence to dosage and timing instructions. Monitor the patient closely for any adverse reactions or side effects that may occur as a result of medication administration. Additionally, administer fluids to the patient based on their individual condition and hydration status. Adjust fluid administration according to the patient’s fluid balance and response to treatment. Regularly assess the patient’s response to both medication and fluid therapy, and promptly report any concerning symptoms or changes in condition to the healthcare team. This proactive approach helps to ensure effective management of dysentery and promotes optimal patient outcomes.

Elimination Management:

Monitor and record the patient’s intake and output meticulously to track fluid balance and hydration status accurately. Observe stool characteristics, including volume, consistency, contents, and odor, to assess gastrointestinal function and identify any abnormalities. Initially, provide a bedpan for elimination, ensuring patient comfort and dignity. As the patient’s condition improves, encourage and assist them to use the toilet independently. This gradual transition promotes patient mobility and autonomy while maintaining hygiene and minimizing discomfort.

Prevention and Control of Dysentery:

Based on our discussion regarding the mode of transmission and predisposing factors of dysentery, several measures can be implemented to prevent its occurrence:

  1. Improved Environmental Sanitation: This includes:
  • Providing safe and sufficient water supply to communities.
  • Ensuring the safe and proper disposal of human waste through the use of pit latrines or toilets.
  • Implementing measures to safeguard food against fecal contamination.
  • Offering information, education, and communication campaigns about dysentery to raise awareness and promote preventive measures.
  • Discouraging the use of untreated human waste as fertilizer or manure, which can contribute to the spread of the disease.

Early Diagnosis and Treatment of Cases and Carriers:

  • Ensure prompt detection and provide appropriate and adequate treatment for both cases and carriers of dysentery.
  • Conduct regular screening of food handlers to identify and prevent potential sources of infection.

Improved Personal and Communal Hygiene:

  • Encourage adequate handwashing with soap and running water after using the toilet and before handling or consuming food.
  • Promote the use of pit latrines or toilets for defecation to prevent fecal contamination of the environment.
  • Prohibit children from defecating on the ground; instead, use toilet training pots and disinfect them after each use. Dispose of children’s stools in the toilet or pit latrine.
  • Boil water for drinking and washing vegetables and fruits to eliminate potential sources of contamination.
  • Avoid consuming vegetable and fruit salads, which may pose a risk of transmitting infection if not properly washed or cooked.

Complications of Dysentery:

  1. Perforation of the colon due to ulceration: Ulcers formed in the colon may lead to perforation, allowing the contents of the colon to spill into the abdominal cavity.
  2. Peritonitis due to perforation: If the colon perforates, the resulting spillage of intestinal contents can cause peritonitis, leading to severe abdominal inflammation and infection.
  3. Rectal prolapse due to tenesmus: Persistent straining during bowel movements (tenesmus) can lead to rectal prolapse, where the rectum protrudes through the anus.
  4. Hematogenous dissemination of the Shigella bacteria (rare): In some cases, Shigella bacteria may spread through the bloodstream, causing abscesses in various organs and potentially leading to meningitis.
  5. Acute, nonsuppurative arthritis: Large weight-bearing joints may become inflamed during the recovery phase, resulting in acute arthritis.
  6. Conjunctivitis, iritis, and peripheral neuropathy (rare): Rare complications may include inflammation of the eyes (conjunctivitis and iritis) and damage to peripheral nerves.
  7. Hemolytic uremic syndrome (7-10 days after onset): A severe complication characterized by acute kidney failure, low platelet count, and red blood cell breakdown.
  8. Toxic megacolon: The colon may become massively dilated due to inflammation, leading to life-threatening complications.
  9. Hemiplegia: In rare cases, dysentery may lead to paralysis affecting one side of the body (hemiplegia).
  10. Encephalopathy: Severe dysentery can cause brain dysfunction, leading to encephalopathy and neurological symptoms.
  11. Septicemia: The presence of pathogens in the bloodstream can lead to systemic infection and septicemia.
  12. Hyponatremia: Imbalances in electrolytes, such as low sodium levels, may occur due to excessive dehydration from diarrhea.
  13. Reiter’s syndrome: A reactive arthritis that can develop following an infection, characterized by joint pain, eye inflammation, and urinary tract symptoms.
  14. Liver abscess: Shigella infection may lead to the formation of abscesses in the liver, causing abdominal pain and other symptoms.
  15. Renal failure: Severe dehydration resulting from dysentery can lead to kidney failure due to reduced blood flow and electrolyte imbalances.

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