Salient Features 42 y/o female CC: colicky but bearable abdominal pain

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