Post on 13-Jan-2016
Salient Features
42 y/o femaleCC: colicky but bearable abdominal pain
Salient Features• 2 yrs and 3/12 months PTA
– Chronic Cough– Loss of appetite– Weight loss– Feverish sensation– Body malaise– Diagnosed with Pulmonary TB– Enrolled in DOTS and claims to have continuously
undergone the program for 6 months– Claims to have been cleared by the doctorr– No record available
• 8 months PTA– Colicky but tolerable abdominal pain (bloatedness)– Accompanied by abdominal distention that is
relieved by passage of flatus or stool
• 4 weeks PTC– Vomiting of previously ingested food (1-2x/wk)– Progressed to intolerance of both solid and soft
diet becoming almost daily– Abdominal distention more frequent and severe– Colicky pain localized in Right Lower Quadrant– Lost 20-30% of weight since last month
• On Admission– Stable vital signs– Markedly hyposthenic– Evidence of fast muscle wasting – High risk of pulmonary complications– Nutrition is a compounding problem
• Nutrition– Decreased oral intake (short of starvation) due to
vomiting– Only ate water,coffee and diluted bear brand.– Weak with poor hand grip– Underweight (BMI = 15.5)
Radiologic findings
Tools Patient Interpretation
Anthropometrics Mid-arm Circumference, Mid-arm mass Circumference, Triceps Skin Fold
Height 150cm
Actual Body Weight 35kg
BMI 15.6 Underweight
IBW(Height in cm) – 100) - FrameAssume: patient is medium frame = 5%Or105 lbs/5 ft + 5 lbs/inch over 5 ft.
49.95 = 50 kg Patient is just 35 kg. 15 kg below the IBW
% IBW(ABW/IBW) x 100%
70% Moderate malnutrition
Psychosocial Factors
Psychosocial Factors
• Financial difficulties– Financial constraints for hospitalization and
treatment
• Disruption of work or schooling– Adults won’t be able to work– Children may have to absent themselves
• Unhealthy living conditions– Lack of ventilation – Substandard hygiene and sanitation– Population density
• Stigma– “Nakakahawa”
Primary Impression
Active Pulmonary TB and Gastrointestinal tuberculosis
• previous history of TB– No sputum AFB smear was done to see if the
patient has really been cured – Possibility of relapse
• current symptoms and x-ray results – Fever, weight loss, etc.
• symptoms of obstruction: abdominal pain, anorexia, nausea and vomiting
Pathophysiology
Primary Infection
Mycobacterium tuberculosis
Mycobacterium tuberculosis
Inhalation of droplet Invasion of alveoli by
bacteria, macrophages react
Invasion of alveoli by bacteria, macrophages
react
Formation of Ghon (Primary) complexFormation of Ghon (Primary) complex
Granulomatous reaction to prevent spread of infection
Active Pulmonary TB
Patient becomes immunocompromised
Patient becomes immunocompromised
Reactivation of primary infection
Reactivation of primary infection
Destruction and caseous necrosis of lung tissue
Destruction and caseous necrosis of lung tissueScarring and cavitationScarring and cavitation
From the lungs to the GI system…Ingestion of
infected sputumIngestion of
infected sputum
Hematogenously: via lymph nodes (LN)
Hematogenously: via lymph nodes (LN)
Local spread of infection
Local spread of infection
Inflammation and fibrosis of
bowel walls and regional LN
Inflammation and fibrosis of
bowel walls and regional LN
Necrosis of Peyer’s patches
and lymph follicles
Necrosis of Peyer’s patches
and lymph follicles
Ulceration of mucosa
Ulceration of mucosa
Fibrosis and thickening of
bowel wall
Fibrosis and thickening of
bowel wall
OBSTRUCTIONOBSTRUCTION
Active Pulmonary TB and Gastrointestinal tuberculosis
• Mycobacterium tuberculosis • Transmission: infected air droplets• Primary infection: usually asymptomatic and
latent. – bacteria reach the pulmonary alveoli and invade
the macrophages – Formation of Ghon focus or complex – this granulomatous reaction serves to prevent the
spread of the infection
Active Pulmonary TB and Gastrointestinal tuberculosis
• Patient becomes immunocompromised reactivation
• Caseous necrosis– destruction and necrosis of the lung tissue – Scarring, cavitation
Active Pulmonary TB and Gastrointestinal tuberculosis
• Infection from the lungs gastrointestinal tract – ingestion of infected sputum by patients with
active TB– Hematogenously: lymph nodes– Local spread of infection
Active Pulmonary TB and Gastrointestinal tuberculosis
• In the GIT:– bowel walls and regional lymph nodes:
inflammation and fibrosis. – necrosis of the Peyer’s patches and the lymph
follicles ulceration of mucosa fibrosis thickening of bowel wall mass lesions
– Symptoms of obstruction
Differentials
Lymphoma of the distal ileumRule In Rule Out
bloating, abdominal pain, weight loss, vomiting, and occasional intestinal obstruction. It can also show symptoms of malabsorption
Although partial small-bowel obstruction is the most common mode of presentation, 10% of patients with small-intestinal lymphoma present with bowel perforation.
Contrast radiographs show stasis of the contrast
can also present with blood loss in vomitus or while defecating
Primary intestinal lymphoma accounts for ~20% of malignancies of the small bowel
history of malabsorptive conditions (e.g., celiac sprue), regional enteritis, and depressed immune function due to congenital immunodeficiency syndromes, prior organ transplantation, autoimmune disorders, or AIDS
Periumbilical pain made worse by eating
patient’s radiographs do not show infiltration and thickening of the mucosal folds, mucosal nodules, or areas of irregular ulceration
Colon CancerRule In Rule Out
rate and severity of weight loss, as well as the evidence of muscle wasting are suggestive of malignancy
rate at which the patient’s condition worsened may be too rapid to indicate a cancerous process
Abdominal pain and intestinal obstruction are common clinical presentations
Colorectal cancer usually develops in older patients aged around 65
patient does not present with rectal bleeding, changes in bowel habits, a palpable abdominal mass, hepatomegaly or ascites
Lipoma of the Distal IleumRule In Rule Out
common benign mesenchymal tumor, which frequently occurs in the distal ileum and at the ileocecal valve
condition is usually asymptomatic, but may cause fecal bleeding, which is absent in the patient
usually presents with generalized or colicky abdominal pain, vomiting, nausea and anorexia, which are all exhibited by the patient.
intussusception is usually produced rather than a plain obstruction
Crohn’s DiseaseRule In Rule Out
focal inflammation and fistula tract formation that eventually resolves by fibrosis and bowel stricturing obstruction
no reports of mucus, blood or pus in the patient’s stool; no fever or diarrhea
presentation of Crohn’s Disease may mimic colonic tuberculosis and vice versa
characteristic "cobblestone" appearance of CD was not exhibited on barium radiography
patient is not dehydrated, but she shows signs of severe malnutrition: Malabsorption in Crohn’s
more common in Europe, the United Kingdom, and North America.
chronic history of recurrent episodes of abdominal pain
patient does not fall within the usual age groups affected by the disease, which are those aged 15-30 and those aged 60-80, since the age of onset has a bimodal distribution
Patient shows signs of obstruction
Diagnostics: Imaging
• Endoscopy– visualizing the intestinal tract– discovering the exact nature of the abnormality– obtain tissue sample for biopsy purposes– also has therapeutic benefits.
Diagnostics: Imaging• Biopsy
– Gold standard for GI-TB. – Tissue sample can be obtained through colonoscopy
or ultrasound or CT-guided percutaneous fine needle aspiration cytology (FNAC).
– also opt to do a laparoscopic biopsy. – Histological findings:
• epitheliod cell granulomas with a peripheral rim of lymphocytes and plasma cells
• Langhan’s giant cells and central casseating. • Fibrosis and calcifications – in healing infections
Diagnostics: Imaging
• Abdominal CT scan– detect and clearly see any abnormalities in the
patient’s abdominal area. – Features:
• irregular soft-tissue densities in the omentum• low-attenuating masses surrounded by thick solid rims • low-attenuating necrotic nodes• disorganized appearance of soft-tissue densities• multiloculated appearance after the intravenous
administration of iodinated contrast material
Diagnostics: Lab Tests
• AFB Smear and Sputum Culture– Classic and standard– Grade A Recommendations (PSMID, 2006)– Identify the exact pathogen– Useful in suspected cases of MDR TB.
Diagnostics: Lab Tests
• Tissue culture and drug sensitivity test– important in cases of relapse or of suspected
MDR-TB– TC: identification of the exact identity of the
infectious pathogen – DST: enables the determination of the kind of
drug the pathogen is sensitive to.
Diagnostics: Lab Tests
• Complete blood count– check for increased WBC titers which are
indicative of an ongoing infection. – to detect any other blood abnormalities such as
anemia, thrombocytosis or leucopenia.
Diagnostics: Lab Tests
• Electrolytes and Serum albumin– to determine if she needs to be infused with
exogenous sources due to depleted levels. – The nature of the patient’s diet calls for an
assessment of her nutritional status.
Treatment and Management
Stabilize the Patient
• Airway• Breathing• Circulation
Initial Relief
• Insert nasogastric tube– Decompress the stomach and keep it free from air
and liquid– Relief of distension and vomiting
• Replace fluid and electrolyte loss and address the malnutrition
TOTAL ENERGY ALLOWANCE(Inpatient)
Actual body weight x caloric factor
Elective surgery caloric needs= 28-30 kcal/kg/day
35kg x 30kcal/kg= 1050 kcal/day
FLUID NEEDSPatient’s Weight: 35 kg
100cc/kg for the first 10kg 100cc/kg x 10kg= 1000cc
50cc/kg for the second 10kg 50cc/kg x 10kg= 500cc
20cc/kg for each additional kg 20cc/kg x 15kg= 300cc
1000 cc + 500 cc + 300 cc = 1800 cc
1800 cc/day
PROTEIN NEEDS
Protein Requirement: 2.5 kg/due to protein losses
Weight x 2.5 g/kg/day
35kg x 2.5g/kg= 87.5 g Protein/day
Using 10% amino acid solution (100g protein/L)87.7/X ml= 100g/1000mL
X= 875ml
Give 875 cc of 10% amino acid solution per day
PROTEIN NEEDS
Protein Requirement: 2.5 kg/due to protein losses
Weight x 2.5 g/kg/day
35kg x 2.5g/kg= 87.5 g Protein/day
Using 10% amino acid solution (100g protein/L)87.7/X ml= 100g/1000mL
X= 875ml
Give 875 cc of 10% amino acid solution per day
FAT NEEDS
Essential Fatty Acids Requirement: 2-4%
Caloric Fat Needs:1050 kcal/day x 0.04 = 42kcal
Fat needed (in grams) 35kg x 2.5g fat/kg = 87.5g fat
588 kcal/week / 286 kcal fat = 2.06 bottles of 10% fat emulsion = 1000cc of 10% fat emulsion
Give 1000 cc of 10% fat emulsion
CARBOHYDRATE NEEDS
Carbohydrate Requirements:
(INSERT COMPUTATION FOR CALORIES)
CHO given as dextrose monohydrate (3.4kcal/g)
956kcal/ 3.4kcal/g = 281g dextrose
Using D50W as starting solution:281g/ X ml= 500g/ 1000mlL
X = 562cc
Give 562 cc of D50W per day as starting solution
TOTAL ENERGY ALLOWANCE(Outpatient)
Actual body weight x caloric factor
Caloric factor= 30 kcal/kg/day
35kg x 30kcal/kg= 1050 kcal/day
PROTEIN NEEDS
Protein Requirement: 1.0 g/kg/day
(Weight x 1.0 g/kg/day) = 35 g
Protein in grams x 4 calories = 140 Calories
35 g Protein140 Calories
CARBOHYDRATE NEEDS
Carbohydrate Requirement: (60% to 70% of non-protein calories)
(1050 – 140 Cal) x 0.7 =637 calories
637 calories/4 = 159.25 or 239 g CHO
239g Carbohydrates637 Calories
FAT NEEDS
Fat Requirement: (30% to 40% of non-protein calories)
(1050 – 140 Cal) x 0.3 = 273 calories
273 calories/9 = 30.3 g Fats
30.3 g Fats273 Calories
PARENTERAL NUTRITION DAILY NEEDS
TOTAL CALORIC REQUIREMENT:1050 CAL
1800cc fluid10% amino acid solution of 875cc
D50W dextrose562cc10% intralipid 750cc
Add 70-150cc of fluid electrolytes, vitamins, and additives
Total volume 2300cc
TOTAL CALORIC REQUIREMENT:
1050 CAL
Protein:140 Cal
25 gCarbohydrate:
239 g637 Cal
Fats:30.3g
273 Cal
Medical
• The patient is diagnosed to have active TB– Consider the possibility that patient now has drug
resistant strain• Patient was already treated with TB before which was
allegedly resolved through chest xray– However, chest xray sometimes show clear findings even with
infection
– Enroll the patient in DOTS program again
MedicalEmpiric treatment while awaiting laboratory results
Duration Drugs Dosage56 days Isoniazid 175 mg OD
Rifampicin 350 mg ODPyrazinamide 875 mg ODEthambutol 700 mg ODStreptomycin 525 mg OD
28 days Isoniazid 175 mg ODRifampicin 350 mg ODPyrazinamide 875 mg ODEthambutol 700 mg OD
140 days Isoniazid 175 mg ODRifampicin 350 mg ODEthambutol 700 mg OD
* Give Pyridoxine 875mg OD at night for patients with peripheral neuropathies
Medical• If considering TB infection as relapse
– Definition: previously treated with one full course of therapy under DOTS and has been declared cured but became smear positive again
Duration Drugs
2 months Isoniazid, Rifampicin, Pyrazinamide, Ethambutol, and Steptomycin
1 month HRZE
5 months HRE or (2HRES/1HRZE/5HRE)
* Give Pyridoxine 875mg OD at night for patients with peripheral neuropathies
Medical
• Pre – treatment before surgery• Refer to TB DOTS plus if MDR-TB
Surgical
• Laparotomy– Surgical resection of the affected segments
(possibly the ileocecal segment)
Monitoring andFollow-up
Monitoring and follow-up
• The patient’s nutritional status should be constantly monitored
• The patient should be monitored whether reintroduction of oral feeding could already be tolerated
• Function of the resected segment of the intestine should be assessed
• Patient’s intake of TB medications should be monitored
Prevention
Prevention
• As an extension of the DOTS strategy, contract tracing should be done– Detect other cases and prevent further spread of
TB infection– Targeted contact tracing among family members
and close contacts of the patient
Prognosis
Prognosis
• If patient is not treated with surgery and TB medications– Prognosis is poor – Possible drug resistant TB of the lungs which spread to the
gastrointestinal tract to cause obstructive symptoms• If patient is treated with surgery and TB medications
– Prognosis may improve if surgery is done to relieve the obstruction and the patient can tolerate food again allowing improvement in the nutritional status
– Drug resistant TB could still be resolved with the DOTS program for drug resistant strains.
Public Health
TB-DOTS program
• Government commitment• Case detection by DSSM among symptomatic
patients self-reporting to health services• Standard short-course chemotherapy;
complete drug taking through DOT supervised by DOTS facility workers during the whole course of treatment for all smear positive cases;
TB-DOTS program
• A regular, uninterrupted supply of all essential anti-tuberculosis drugs and other materials; and
• A standard recording and reporting system that allows assessment of case finding and treatment
Access to drugs
• In far flung areas, barangay health workers (BHWs) should be mobilized
• Make the BHWs as their treatment partners and they can go to the patients’ home
Strengthen Patient and Healthcare Workers Relationship
• patients perceive health care workers’ attitudes as harsh
• develop good rapport as they deal with patients, learn to befriend them and take the time to explain to them the importance of taking their medications regularly
• Inform patients that improvement of their symptoms does not necessarily mean that they are totally free from infection
• explain that they must take the whole set of drugs and get a negative reading in the sputum smear exam before they are considered completely free of the disease
Partnership with Private Practitioners
• use of anti-TB drugs has also contributed to the development of MDR and XDR-TB
• all practitioners must refer all suspected and diagnosed TB patients to the DOTS program as recommended in the guidelines
Partnership with Private Practitioners
• create a referral system, which would assure that the physician who referred the patient to the nearest DOTS center would still remain the patient’s primary attending physician
• Private practitioners must also be trained
Restricting the availability of drugs
• problem of low quality drugs and the over availability of drugs has also resulted in the development of MDR-TB
• Leads to self medication• Restrict over the counter selling
Improve quality of DOTS
• Personnel working in the DOTS centers need to be trained further
• Lack of workers in the centers causes other employees to burn out and tire easily
• give more incentives or more health benefits• build partnerships with other organizations• Research and volunteers
Improve compliance
• If family members are also not educated about the disease, then they would not be able to assist in reinforcing positive behavior like treatment compliance and lifestyle modifications.
• Widespread non-compliance to treatment and lack of education about tuberculosis could be major factors leading to low cure rates of the DOTS program.
Improve compliance
• providing transportation• proper education of the patients and their
families• widespread, comprehensive, proper
education program involving the whole country
Diagnosis and Proper Treatment
• Misdiagnosis of the condition or • misclassification of the specific type of TB• receiving inappropriate treatment lead to
greater drug resistance.
MDR-TB
• resistant to both rifampicin and isoniazid• Failure of completion of treatment leads to an
increased incidence of MDR-TB or could even lead to the development of even more resistant strains of the bacteria, which would lead to higher rates of treatment failure.
Poor Case Reporting
• lead to inaccurate and incomplete data and statistics = lack of preparedness
• Strategy: increase the health seeking behavior of people
• Proper education
Management
McKinsey 7s and GAP Analysis
GOAL
• Control the TB burden in the Philippines
Strategy
• pursuing high-quality DOTS expansion and enhancement
• address TB-HIV, MDR-TB and the needs of poor and vulnerable populations
• contribute to health system strengthening based on primary health care
• engage all health care providers• empower TB with and communities through
partnership • enable and promote research
Strategy
• STANDARDIZED TREATMENT– Yet with an individual touch
• Flexible and adaptable• Patient treatment cards
Strategy
NOW:• People unaware of TB DOTS• No good health seeking behavior• Self medication and obtain treatment not
from DOTS
Strategy
PLAN:• Mobilize media to educate and inform people:
– facts about TB and its treatment– diagnosis and treatment is free
• Policies to address the factors associated w/ TB– poverty– lack of education– poor living conditions
Strategy
NOW:• Noncompliant private health providers
PLAN:• Continuous education and retraining of the
private sector• Better reimbursement from Philhealth• Expansion of existing programs
Strategy
NOW: • No research and development
PLAN:• Research and development committee/ team
Structures
Structure• DOH
– Provide standardized training– Central control– Where everyone reports to
• LGUs– Reports to DOH– Inspects DOTS clinics
Structure
• DOTS Clinic– Provides treatment and follow-up– TBDC (TB Diagnostic Committee)– Quarterly reports
• The centralization of the DOTS program is essential to their success– Explicit lines of communication
Structures
NOW:• Different management styles therefore
different performance among DOTS clinics
PLAN:• Better communication and sharing of
management techniques
Style
• Overall leadership: DOH– Trains everyone– Everyone reports to them
• Difference in management in individual DOTS clinics
• Dedication and teamwork
Style
No Gaps• Good leadership by the DOH
Shared values
• Dedication• Team-work
Shared Values
NOW:• No written core values
PLAN:• Explicitly state core values of the program
Systems
• Main: DOH– Supplies drugs and equipment– Provides training – Implements rules
Systems
NOW:• Needs and issues of employees
PLAN:• Stronger human resource system be
developed
Systems
NOW:• Poor documentation (slow) and
communication
PLAN:• Use of technology for reporting and
evaluation
Systems
NOW:• Insufficient networking between physicians
and their DOTS referred patients
PLAN:• A program where physicians may be able to
network, follow up their referrals in DOTS clinics
Skills
• Technical skills – DOH training• Procedural competency
Skills
NOW:• Limitation of employee knowledge• Poor patient relationship skills
PLAN:• Retraining and continuing medical education
among the employees• Invest on human resources• Evaluation of staff by patients (external customer
satisfaction survey)
Staff
• Nurse and med tech• Trained by the DOH• Dedication• Teamwork• Underpaid
Staff
NOW:• Poor attitude of staff towards patients
PLAN:• Invest on human resource through better pay
and benefits• Evaluation by patients
Financial Analysis
• More cost efficient to treat people early• DALYs = lose P 8B per year
Pulmonary TB TreatmentGeneric Drug Price per tablet Total (8 months)
Myrin P forteDosage: (Ethambutol(275mg), Rifampicin (150mg), Isoniazid (75mg), Pyrazinamide (400mg))
P11.24 P8,304
MyrinP-P15 (Rimstar)Dosage:(Ethambutol 275mg, Rifampicin 150mg, Isoniazid 75mg, Pyrazinamide 400mg)
P11.75 P5,640
Gastrointestinal TB Treatment
• Surgical– Open Surgery (Excision) – P120,000-P150,000– Laparoscopic – P220,000
• Medical– Pre-operation treatment (3 mos) - P2,115– Post-operation treatment (12 mos) - P8,460
Please refer to the paper for the balanced scorecard for now