STUDY GUIDES OS 214

DIGESTIVE
DIGESTIVE MODULE WEEK 1 BLOCK A
Exam 1

LECTURE #1: will be given complimented by Self-Instructional

EMBRYOLOGY AND DEVELOPMENTAL Modules.
ANOMALIES OF THE DIGESTIVE TRACT
VI. COURSE OUTCOMES AND CONTENT
I. DATE AND TIME: Monday, 12 February Objectives: At the end of the session, the
2007, 9-11am students are expected to:
I. Describe the normal physiology of the
II. FACILITATORS AND LECTURERS: gastrointestinal tract of neonates.
► Josefina Almonte, M.D. II. Describe the embryology, pathologic
Department of Surgery, anatomy, clinical features, diagnosis, and
Division of Pediatric Surgery principles of management of the different
► Ma. Corazon P. Estrella M.D. congenital and developmental anomalies of
Department of Pediatrics, the gastrointestinal tract including
Division of Neonatology necrotizing enterocolitis.

III. FORMS OF TEACHING Content

Lecture 1. Normal physiology of the gastrointestinal
Self-Instructional Module tract of neonates
2. Congenital and developmental problems of
IV. PREREQUISTIES the gastrointestinal tract
To obtain maximum benefit from this session the a. Esophageal atresia
students must review the following topics i. Embryology
1. embryology of the digestive tract ii. Types of esophageal atresia
iii. Clinical features
2. anatomy and physiology of the oropharynx, iv. Diagnosis
esophagus and gastrointestinal tract
v. Principles of management
3. principles of radiology
b. Pyloric stenosis
i. Etiology
V. OVERVIEW OF THE TOPIC
ii. Clinical features
The fully functional alimentary tract is a
iii. Diagnosis
complex organ system that develops from a
iv. Principles of management
simple digestive tube through a complicated
c. Duodenal atresia
series of events that span the period from very
early embryonic life to birth. A wide spectrum of i. Embryology
congenital as well as acquired anomalies may ii. Clinical features
affect the oral cavity, pharynx, esophagus, and iii. Diagnosis
the gastrointestinal tract. Because congenital iv. Principles of management
abnormalities are the result of abnormal d. Malrotation
embryogenesis, knowledge of the normal i. Embryology
development of the alimentary tract is helpful in ii. Classification
understanding anomalous development. iii. Clinical features
Congenital anomalies of the digestive tract may iv. Diagnosis
manifest during the neonatal period or later on v. Principles of management
in life, even in adulthood. With few exceptions, e. Intestinal atresia (jejunum, ileum,
congenital abnormalities involving the colon)
gastrointestinal tract are detected in neonates i. Embryology
only when they are the direct cause of ii. Classification
obstruction. Such abnormalities must be iii. Clinical features
rectified surgically if the patient is to survive. iv. Diagnosis
Acquired anomalies of the digestive tract in v. Principles of management
contrast to congenital anomalies usually f. Hirschsprung Disease
manifest during adulthood. Clinical signs and i. Etiology and embryology
symptoms including an oral mass, dysphagia, ii. Clinical features
vomiting, abdominal distension, and obstipation iii. Diagnosis
prompt the clinician to consult the radiologist iv. Principles of management
who must determine the presence, location, and g. Anorectal malformation
cause of an obstruction. The indications for each i. Embryology
imaging modality and the order in which ii. Classification
examinations are to be conducted should be iii. Diagnosis
considered carefully to avoid unnecessary • Clinical assessment
examinations. This session will tackle the normal • Radiologic assessment
physiology of the gastrointestinal tract of iv. Principles of management
neonates, the different congenital and h. Necrotizing enterocolitis
developmental anomalies of the gastrointestinal i. Etiology
tract and necrotizing enterocolitis including their ii. Pathophysiology
embryology, pathophysiology, clinical picture, iii. Diagnosis
diagnosis, and principles of treatment. Lectures iv. Principles of management

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 STUDY GUIDES OS 214
DIGESTIVE
DIGESTIVE MODULE WEEK 1 BLOCK A
Exam 1

VII. RESOURCES/REFERENCES The most powerful diagnostic maneuver

1. Self instructional modules
2. Behrman RE et. al. (eds). 2004. Nelson
Textbook of Pediatrics. Philadelphia: WB
Saunders. 17th ed.
3. Schwartz ' Principles of Surgery . 8th ed.
4. Any Pediatric Surgery Book
III. EVALUATION
Written examination (part of the first long exam
for the Digestive Module)
LECTURE 2:
VIDEO WITH GROUP DISCUSSION ON
HISTORY AND PHYSICAL EXAMINATION OF
PATIENTS WITH DIGESTIVE DISORDERS
I. DATE AND TIME: Monday, 12 February
2007, 1–3pm
II. FACILITATORS
► Ma. Lourdes G. Genuino, M.D. (Lead
Person)
Department of Pediatrics,
Section of Gastroenterology and Nutrition and
Department of Physiology
► Melflor Atienza, M.D.
Department of Internal Medicine,
Section of Gastroenterology
► Antonio Catangui, M.D.
Department of Surgery,
Division of Pediatric Surgery
► Junjun Kaw, M.D.
Department of Surgery
► Hermogenes Monroy, M.D.
Department of Surgery
► Eulenia R. Nolasco, M.D.
Department of Internal Medicine,
Section of Gastroenterology
► Aurora I. Labadia, M.D./Resti Ma.
Bautista, M.D.
Department of Pediatrics,
Section of Neonatology
► Celine A. Villegas, M.D.
Department of Surgery,
Division of Pediatric Surgery
III. FORMS OF TEACHING
► Lecturette after video presentation
► Actual patient exposure
► Group Discussion
IV. PREREQUISITES/ RECOMMENDED
PREPARATION
The student is expected to review and read the
following:
► Bates, Chapter 9
► De Gowin
► Abdominal anatomy: location of most
abdominal organs; which organs “move”
during pregnancy; which organs
retroperitoneal
V. OVERVIEW OF THE TOPIC
available for a clinician is clinical evaluation
based on a good history and physical
examination. Seventy percent (70%) of
diagnoses can be made based on history alone
while 90% of diagnoses can be made based on a
combination of history and physical
examination. Laboratory tests most often
confirm what is found during history taking and
physical examination.
The evaluation of patients with digestive
disorders relies most heavily on the benefits of a
good clinical evaluation. The physical
examination of the abdomen is distinct from that
of other regions in that it follows a different
sequence of the four basic methods, which are:
inspection, auscultation, percussion, and
palpation. There are techniques and peculiarities
especially in the younger age groups that must
be appreciated by the learner. This session will
reintroduce the art of history taking and physical
examination with emphasis on the differences
between the evaluation of digestive disorders of
an adult versus an infant or a child. The general
conduct of history and physical examination
which includes attitude and communication
skills may not be learned totally during this
session but this will be given equal importance.
Key historical points of the more common
digestive disorders along with the classic
presentations as well as their variations will be
presented. Emphasis will also be made on the
techniques and maneuvers to elicit important
pathologic signs.
VI. COURSE OUTCOMES/CONTENT
Objectives: At the end of the sessions, the
student should be able to:
1 Describe the techniques on how to obtain
rapport with patients or caregivers, in the
case of the pediatric age groups.
II. Elicit the key historical points in the
evaluation of patients with the following
complaints:
a. abdominal pain
b. bowel disorder
c. abdominal enlargement
d. jaundice
3. Describe the classic presentations of the
following most common digestive disorders:
a. Acute appendicitis and its variations
b. Acute cholecystitis
5. Recognize common physical examination
findings associated with digestive disorders.
Content
1. General Conduct of History taking and
Physical examination
a. Introduction and closure
b. Developmental dimensions in the
pediatric patient
c. Attitude and courtesy
are 2. Key historical points in abdominal pain
a. Time course
b. Location
c. Four Quadrants: right upper, right lower,
left upper, left lower

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 STUDY GUIDES OS 214
DIGESTIVE
DIGESTIVE MODULE WEEK 1 BLOCK A
Exam 1

d. Three central areas: epigastric, ►Tympany normal in supine position

periumbilical, suprapubic ►Unusual dullness
e. Radiation: perforated ulcer; biliary colic ► Liver span: hepatic dullness above
f. Associated symptoms: fever, weight loss, (lung) and below (bowel), In adults:
anorexia normal = 6-12 cm, right
g. Types of abdominal pain midclavicular line In pediatrics: 1
► Pain from a hollow viscera: week of age: normal = 4.5-5 cm
crampy/paroxysmal; often poorly 12 years of age: normal = 7-8 cm
localized; related to peristalsis; patient (males) 6-6.5 cm (females)
writhing on the examination table ► Splenic enlargement: Percuss the
► Pain from peritoneal irritation: lowest interspace in the left anterior
steady/constant; often localized; axillary line. Ask patient to take a
patient lies still with knees up deep breath and repeat. A change
3. Key historical points in bowel disorder from tympany to dullness suggest
a. Nausea enlargement.
b. Vomiting d. Palpation
c. Diarrhea ► Light palpation
d. Constipation Begin with light palpation. Remember
e. Frank blood that you are mostly looking for areas
f. “Coffee grounds” emesis of tenderness. The most sensitive
h. Black stool indicator of tenderness is the
4. Key historical points in abdominal patient’s facial expression. Voluntary
enlargement/distention and involuntary guarding may also
a. Ascites be present.
b. Discrete mass ► Deep palpation
c. Weight loss Proceed to deep palpation after surveying
d. Sexual activity and last menstrual period the abdomen lightly. Try to identify
in reproductive age women abdominal masses or areas of deep
6. Key historical points in jaundice tenderness.
a. Fever ► Palpation of the liver
b. Chronic alcohol ingestion To palpate the liver edge, place fingers
c. Breastfeeding just below the costal margin and press
d. Maternal history of infection and drug firmly. Ask the patient to take a deep
intake i.e. Vitamin K, oxytocin breath. The edge of the liver may be felt
e. Peripartal and postpartal events i.e. pressed against or would slide under your
cephalhematoma, delayed cord fingers. Normally, it is not tender; the
clamping, hypoxia, acidosis edge is sharp and the surface smooth.
7. Classic presentation: Acute appendicitis Check for tenderness, blunted edge, and
a. diffuse periumbilical pain and anorexia nodularities on the surface. An alternate
early method for palpating the liver (for the
b. pain localizes to RLQ as peritonitis obese patient) uses hands “hooked”
develops around the costal margin from above. The
c. low grade fever, nausea and vomiting patient should be instructed to breath
may not be present deeply to force liver down the examining
d. X-rays and other tests are often negative fingers.
► Palpation of the spleen
Variations of Appendicitis Press down just below the left coastal
a. Position of appendix is highly variable. margin with the right hand while asking
The associated pain varies with its patient to take a deep breath. Remember
anatomy. that the edge is normally palpable in 15%
b. It can be found against the abdominal of neonates, 10% of normal children, and
wall (anteriorly), below the pelvic brim 5% of adolescents. For adults, it is not
(pelvic), behind the cecum (retrocecal), normally palpable.
or behind the terminal ileum (retroileal). e. Special tests
8. Classic presentations - Acute cholecystitis • Rebound tenderness
a. Localized or diffuse RUQ pain
• Costovertebral angle tenderness
b. Radiation to right scapula
c. Vomiting and constipation • Shifting dullness
d. Low grade fever • Fluid wave
9. Physical examination of the abdomen • Acute Appendicitis
a. Inspection: contour, symmetry, scars, • Rovsing’s sign
rashes, other lesions • Psoas sign
b. Auscultation • Obturator sign
► Bowel sounds as present, increased, • Acute cholecystitis
decreased or absent • Murphy’s sign
► Bruits - aorta, renal and iliac arteries
c. Percussion Things to Remember

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 STUDY GUIDES OS 214
DIGESTIVE
DIGESTIVE MODULE WEEK 1 BLOCK A
Exam 1

1. Consider inguinal/rectal examination in 2. Accuracy, specificity, sensitivity of laboratory

males. tests
2. Consider pelvic/rectal examination in 3. Correlation of results of analytes with the
females. patient’s illness
3. It is wise to examine the chest when a. Bilirubin
evaluating an abdominal complaint. b. Ammonia
4. The abdominal examination in the pediatric c. Albumin
age group requires that the child be on the d. Enzymes (AST, ALT, ALP, GGT, LDH,
examination table. Ask the parent to hold lipase, amylase)
the child’s hand and speak reassuringly. e. Tumor markers (CEA, a-fetoprotein, CA
19-9)
IV. RESOURCES/REFERENCES f. H. pylori
1. Behrman RE et. al. (eds). 2004. Nelson g. Examination of diarrheic/ steatorrheic/
Textbook of Pediatrics. Philadelphia: bloody stools
Saunders. 17th ed. 4. Preferred and/or currently used methods for
2. Harrison’s Principles of Internal Medicine. laboratory determination with reference
McGraw Hill. 16th ed. values for the tests
5. Pitfalls in the use of laboratory tests
VIII. EVALUATION
Written examination (part of the first long exam VI. REFERENCES
for the Digestive Module) 1. Costran RS, Kumar V, Collins T (eds). 1999.
Robbin’s Pathologic Basis of Disease.
2. Philadelphia: WB Saunders Co. 6th ed.
LECTURE #3: 3. Henry JB (ed). 2001. Clinical Diagnosis and
LABORATORY DIAGNOSIS IN GI AND Management. 20th ed.
HEPATOBILIARY DISEASES (PATHOLOGY) 4. Burtis CA, Ashwood ER, Bruns DE (eds).
2005. Tietz Textbook of Clinical Chemistry
I. DATE AND TIME: Monday, 12 February 2007; and
3-5 pm. 5. Molecular Diagnosis, 4th ed.

II. FACILITATORS/LECTURERS
Nelson T. Geraldino, M.D. LECTURE #4
Department of Pathology IMAGING IN GASTROINTESTINAL
RADIOLOGY
III. FORMS OF TEACHING
Lecture I. DATE AND TIME: Tuesday, 13 February 2007;
10–12 pm
IV. OVERVIEW OF THE TOPIC
The session will deal with the utility of II. FACILITATOR/LECTURER
laboratory examinations in the diagnosis and Vicente Francisco R. Hizon, M.D.
management of patients with Department of Radiology
gastrointestinal, hepatobiliary, and
pancreatic diseases. III. FORM OF TEACHING
Lecture
V. COURSE OUTCOMES AND CONTENT
Objectives : At the end of the session, the IV. PREREQUISITES
students are expected to: To obtain maximum benefit from this
1. Review the biochemical and molecular basis session, the student should have reviewed
for the use of common laboratory tests. the normal radiologic anatomy and have a
2. Describe the reported utility (accuracy, clinical knowledge of gastrointestinal
specificity, sensitivity) of these tests for diseases.
patient management.
3. Correlate the rise and fall of these specific V. OVERVIEW OF THE TOPIC
analytes with the course of the patient’s This lecture is based on the most frequent
illness. radiographic presentations of the more
4. Describe the currently used or preferred common gastrointestinal diseases
methods for the determination of these encountered in practice. The imaging
analytes. modalities to be discussed are plain x-ray
5. Delineate the reference ranges for these radiographs, contrast studies, ultrasound,
tests. computed tomography scanning (CT Scan),
6. Describe any reported pitfall in the use of magnetic resonance imaging (MRI),
these tests for patient management. angiography, and radioisotope imaging
(nuclear medicine).
VI. COURSE OUTCOMES AND CONTENT
Content Objectives: At the end of the session, the
1. Biochemical and molecular basis of common students are expected to:
laboratory tests

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 STUDY GUIDES OS 214
DIGESTIVE
DIGESTIVE MODULE WEEK 1 BLOCK A
Exam 1

1. Describe the most frequent imaging malignancies (annular, polypod,

procedures in diagnosing gastrointestinal infiltrating, and ulcerative)
diseases. f. Liver, gall bladder, and biliary tree
2. Correlate the pathologic and radiographic ► Imaging modalities: Plain abdominal
findings in selected gastrointestinal radiographs, ultrasound, CT scan, MRI,
diseases. radionuclide scanning, angiography
► Hepatobiliary tract/gall bladder
Content diseases discussed: Infections
1. Upper gastrointestinal tract (pharynx to the (hepatitis), stones, cirrhosis, tumors
small intestines) (malignancies)
a. Pharynx (nasopharynx, oropharynx, h. Pancreas
hypopharynx) ► Imaging modalities: Plain radiographs,
► Imaging modalities: Plain radiographs ultrasound, CT scan, MRI, radionuclide
(soft tissue lateral), double contrast scanning
pharyngography, CT scan, MRI ► Pancreatic diseases discussed:
► Pharyngeal diseases discussed: Infections (acute and chronic
Diverticuli (Zender ‘s or pancreatitis), malignancies
pharyngoesophageal diverticuli); i. Radiologic emergencies
functional disorders [neuromuscular ► Imaging modalities: Plain radiographs
dysfunction (CNS disease, muscle and contrast studies
disease, myasthenia gravis, ► Diseases discussed: Obstruction, ileus,
peripheral nerve disease) and pneumoperitoneum, volvulus,
abnormalities of the cricopharyngeal intussusception
sphincter]; achalasia; tumors
(malignant epithelial tumors) VII. RESOURCES/REFERENCES
b. Esophagus 1. Margulis and Burhenne. 1995. Practical
► Imaging modalities: Plain radiographs Alimentary Tract Radiology. Mosby Year Book.
(chest bucky radiographs), single or 2. Palmer. 1995. Diagnostic Ultrasound. Mosby.
double contrast esophagography, CT 3. Weissleder and Wittenburg. 1995. Primer of
scan, MRI Diagnostic Imaging. Mosby.
► Esophageal diseases discussed:
Motility disorders (acahlasia),
congenital disorders LECTURE #5
(tracheoesophageal fistula and INTERACTIVE GAME SHOW:
atresia), malignant tumors APPROACH TO A PATIENT WITH VOMITING
c. Stomach and duodenum
► Imaging modalities: Plain abdominal I. DATE AND TIME: Tuesday, 13 February 2007;
radiographs, double contrast 1-3pm
gastrointestinal series, ultrasound
(abdominal and endoscopic), CT scan, II. FACILITATORS
MRI ► Wilma A. Baltazar, M.D. (Lead Person)
► Gastric and duodenal diseases Department of Surgery, Division of Pediatric
discussed: Acid-related disorders, Surgery
chemical gastritis, tumors (Type I ► Antonio Comia, M.D.
polypoid, Type II superficial, Type III Department of Internal Medicine, Section of
excavated) Gastroenterology
d. Small intestines ► Ida Marie T. Lim, M.D.
► Imaging modalities: Plain abdominal Department of Surgery
radiographs, double contrast ► Elizabeth G. Martinez, M.D.
gastrointestinal series, ultrasound, CT Department of Pediatrics, Section of
scan, MRI Gastroenterology and
► Small intestinal diseases discussed: Nutrition
Inflammatory diseases (infectious ► Esther A. Saguil, M.D.
enteritis and Crohn’s disease), Department of Surgery, Division of Pediatric
neoplastic diseases, malabsorption Surgery
and immune diseases ► Peter Sy, M.D.
e. Colon, rectum, and anus Department of Internal Medicine, Section of
► Imaging modalities: Plain radiographs, Gastroenterology
single or double contrast barium
enema, ultrasound (rectal and
transabdominal), CT scan, MRI III. FORM OF TEACHING
► Colorectal diseases discussed: Interactive Game Show
Congenital diseases (Hirschsprung
disease), diverticula, inflammatory IV. PREREQUISITES/ RECOMMENDED
diseases (infectious colitis, ileocecal PREPARATION
tuberculosis, cecal abscess, ulcerative
colitis, and Crohn’s disease), polyps,

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 STUDY GUIDES OS 214
DIGESTIVE
DIGESTIVE MODULE WEEK 1 BLOCK A
Exam 1

The student is expected to be familiar with a. Pediatric patients

the embryology, anatomy, physiology and ► Neonate
pathology of the gastrointestinal tract. He/she ► Infant
is expected to read on acute abdominal pain ► Children
and intestinal obstruction. b. Adult
4. Associated signs and symptoms of various
V. OVERVIEW OF THE TOPIC diseases that present with vomiting
Vomiting is a very common symptom 6. Consequences of vomiting
encountered in clinical practice. In most cases, 7. Medical and surgical conditions presenting
this symptom abates spontaneously without any with vomiting
medical intervention. However, vomiting may 8. Principles in the management of patients
also be indicative of a disease that can lead to with vomiting
significant morbidities like dehydration and
electrolyte imbalance that need prompt VIII. RESOURCES/REFERENCES
attention and care. In children, vomiting in 1. Behrman RE et.al. (eds). 2004. Nelson
particular may be indicative of a life-threatening Textbook of Pediatrics. Philadelphia:
condition. Every clinician should therefore be Saunders.17th ed.
able to know how to evaluate this problem 2. Schwartz ' Principles of Surgery. 8th ed.
eliciting a good clinical history and physical 3. Harrison’s Principles of Internal Medicine.
examination and a judicious use of laboratory McGraw Hill. 16th ed.
and radiologic tests to decide on the appropriate 4. Yamada. Textbook of Gastroenterology. 4th
course of action. ed.
This session is an interactive session. 5. Brown J, Li B. Recurrent Vomiting in Children.
The class will be divided into 4 teams. Case Clinical Perspectives in Gastroenterology
scenarios will be flashed on the overhead 2002; 5: 35-39.
screen, after which questions will be asked. The 6. Fleishers DR. Functional Vomiting Disorders
different teams will attempt to provide the best in Infancy: Innocent Vomiting, Nervous
answer for each of the queries. The session will Vomiting and Infant Rumination Syndrome J
subsequently be capped by a synthesis to be Pediatr. 1994; 125: S84-94.
highlighted by members of the faculty. 7. Forbes D. Differential Diagnosis of Cyclic
Vomiting Syndrome. J Pediatr Gastroenterol
VI. COURSE OUTCOMES AND CONTENT Nutr. 1995; 21: S11-14.
Objectives: At the end of the session, the 8. Lee M. Vomiting. In: Sleisinger & Fordtran.
students are expected to: Gastrointestinal and Liver Disease. WB
1. Define nausea, vomiting, regurgitation, Saunders Co. 7th ed. 2002.
rumination and retching. 9. Li B, Sferra T. Vomiting. In: Wyllie R, Hyams J,
2. Discuss the pathophysiology of vomiting. eds. Pediatric Gastrointestinal Disease. WB.
3. Identify the different causes of vomiting Saunders Co. 2nd ed. 1999: 14-31.
according to age groups. 10. Murray K, Christie D. Vomiting. Pediatrics in
► List the causes of vomiting in neonates, Review. 1998; 19: 337-341.
infants, children and adolescents, adults. 11.Sondheimer JM. Vomiting. In: Walker WA,
► Summarize the causes of vomiting Durie PR, Hamilton HR, Walker-Smith LA,
according to its mechanisms. Watkins JB, eds. Pediatric Gastrointestinal
4. Identify points to be elicited in the history Disease. Pathophysiology, Diagnosis,
and physical examination to properly Management. BC Decker: 3rd ed. 2000: 97-
determine the cause of the vomiting. 102.
5. Given clinical scenarios on patients 12. Handouts on “An Introduction to the Problem
presenting with vomiting/nausea and of Vomiting in Adults” by Comia A, Lim, IM,
vomiting, and Sy, P.
determine the most likely diagnoses. 13. Handouts on “An Introduction to Vomiting in
6. Describe the different complications of Children” by Baltazar WA, Martinez EG, and
vomiting. Sanguil, EA.
7. Outline the principles in the management of
vomiting.

Content:
1. Definition of terms
a. Nausea
b. Vomiting
c. Regurgitation
d. Rumination LECTURE #7
e. Retching BACTERIAL AND VIRAL PATHOGENS IN
f. Cyclic vomiting GASTROINTESTINAL INFECTIONS
g. Bulimia (MICROBIOLOGY)
2. Neurophysiologic pathways of nausea and
vomiting I. DATE AND TIME:
3. Causes of nausea and vomiting

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 STUDY GUIDES OS 214
DIGESTIVE
DIGESTIVE MODULE WEEK 1 BLOCK A
Exam 1

♥ Lecture: Wednesday, 14 February 2007, 2. Discuss the common bacterial, viral and
8–11 AM fungal agents that cause gastrointestinal
♥ Laboratory: Tuesday, 20 February 2007, infection based on:
1-3 PM ♥ Morphology and structure
♥ Pathogenesis
II. FACILITATORS/LECTURERS − Mode of transmission
(Department of Microbiology, College of − ii. Virulence factors
Public Health) ♥ Laboratory characteristics
Prof. Marohren T. Altura − Culture
Nina G. Barzaga, M.D.
− Biochemical test
Alice C. Bungay, M.D.
Prof. Lolit L. Cavinta − Serologic test
Prof. Teresita S. De Guzman 3. Discuss and perform the different laboratory
Maria Margarita M. Lota, M.D. (Department methods used in the isolation and
Coordinator) identification of microorganisms from clinical
Adelwisa R. Ortega, M.D. specimen.
Lilen C. Sarol, M.D.
Content
III. FORMS OF TEACHING 1. Normal Flora of the Gastrointestinal Tract
Lecture 2. Bacteria Involved in Gastrointestinal Tract
Preceptorials Infections
Laboratory work Must knows
♥ E. coli
IV. PREREQUISITES ♥ Salmonella
The student is required to know the basic ♥ Shigella
principles in medical microbiology and infectious ♥ Campylobacter jejuni
diseases. He/she should have basic concepts on ♥ Cholera
the morphology, pathogenesis, and diagnosis of ♥ Staphylococcus aureus
bacteria, viruses, and fungi. Skills on the routine ♥ Bacillus cereus
laboratory procedures must have been acquired ♥ Clostridium difficile
in previous courses. ♥ Helicobacter pylori
Nice to knows
V. OVERVIEW OF THE TOPIC ♥ Listeria
The study of the gastrointestinal ♥ Yersinia
infections is intended to provide an ♥ Plesiomonas
understanding of the microbial agents in the ♥ Aeromonas
pathogenesis of diseases found in the digestive 3. Viruses involved in Gastrointestinal Tract
tract. The sessions will concentrate primarily on Must knows
the major bacterial and viral Pathogens. ♥ Rotavirus
Laboratory activities are designed to focus on ♥ Enteric Adenovirus
the identification of common enteric pathogens
♥ Norwalk virus
to reinforce the lectures.
Nice to knows
Basic laboratory diagnostic tests will be
♥ Norovirus
performed, particularly biochemical tests and
♥ Calicivirus
culture to aid in the identification of enteric
bacteria. ♥ Coronavirus
The Medical Microbiology session is ♥ Astrovirus
presented in the form of lectures and laboratory 4. Fungal Agents involved in the
exercises. There will be two hours of lecture on Gastrointestinal Tract Infections
the different microbial gastrointestinal infections Nice to knows
and six hours of preceptorials and laboratory ♥ Mycotoxin producing agents
exercises. The class will be divided into seven − Claviceps purpurea
groups consisting of three subgroups. Each − Aspergillus flavas.
subgroup will have 3 to 4 students. The ♥ Opportunistic fungi
subgroup will be assigned a clinical vignette − Candida ablicans
accompanied by a pure culture. The subgroups
will identify the pure culture using a battery of VIII. RESOURCES/REFERENCES
tests. A written report will be submitted 1. Bailey and Scott. 2002. Diagnostic
correlating the students’ findings with the cases Microbiology. 11th ed.
given. 2. Brooks et al. 2000. Jawetz, Melnick and
Adelberg’s Medical Microbiology. 22nd ed.
VI. COURSE OUTCOMES AND CONTENT 3. Strohl. 2001. Microbiology Illustrated Review.
Objectives: At the end of the session, the Lippincott.
students are expected to: 4. Tortora. 2000. Microbiology: An Introduction.
1. Identify the normal flora of the 6th ed,
gastrointestinal tract.

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 STUDY GUIDES OS 214
DIGESTIVE
DIGESTIVE MODULE WEEK 1 BLOCK A
Exam 1

5. Other Medical Microbiology and Diagnostic 3. Cite the burden of disease in the country in
Microbiology books can also be used as general and by age group.
references. 4. Summarize the causes of diarrhea according
to the underlying mechanism and clinical
IX. EVALUATION presentation.
1. Written examination (part of the first long 5. Given a case presenting with diarrhea,
exam for the Digestive Module) determine the most likely etiology.
2. Group’s written report 6. Detect complications of diarrhea requiring
immediate medical or surgical attention.
7. Assess the degree of dehydration of patients
LECTURE #8 with diarrhea.
DIARRHEA 8. Contrast the assessment of dehydration in a
well nourished child from that of a severely
I. DATE AND TIME: Wednesday, 14 February malnourished child.
2007; 1–3 p.m. 9. Discuss the management of a patient with
diarrhea, considering the factor of nutritional
II. FACILITATORS status and duration of diarrhea.
► Juliet Sio Aguilar, M.D., M.Sc. 10. Discuss the various strategies in the control
Department of Pediatrics, Section of of diarrheal disease.
Gastroenterology and
Nutrition Content
► Melfor Atienza, M.D. 1. Definition of diarrhea, acute vs.
Department of Internal Medicine, Section of chronic/persistent diarrhea
Gastroenterology 2. Epidemiology of diarrhea in the Philippines
3. Pathophysiologic mechanisms of diarrhea
III. FORM OF TEACHING 4. Causes of diarrhea
Lecture 5. Clinical presentation of diarrhea according to
etiologies
IV. PREREQUISITES 6. Complications of diarrhea
To optimize learning in this session, the student 7. Degrees of dehydration
is expected to review the following topics: ♥ No dehydration
1. Anatomy and physiology of the ♥ Some (mild, moderate) dehydration
gastrointestinal tract ♥ Severe dehydration
2. Biochemical basis of digestion 8. Assessment of dehydration in severely
3. Normal anthropometric measurements in malnourished children
children 9. Management of diarrhea in the well-
nourished and severely malnourished
V. OVERVIEW OF THE TOPIC children
Over the years, diarrhea has remained ♥ Fluid therapy
among the leading causes of morbidity in the ♥ Nutritional therapy
country. It is particularly more common and ♥ Rational drug use
serious in children under five years of age, 11. Strategies in diarrheal disease control
exacting the lives of 4- 6 million children ♥ Breastfeeding
annually particularly in the developing countries. ♥ Improved weaning practices
In the majority of cases, diarrhea is self-limiting ♥ Immunizations vs. measles, rotavirus and
and no medications are necessary. Critical in the cholera
care of patients with diarrhea is the appropriate ♥ Improved water supply and sanitation
replacement of fluid and electrolyte losses. facilities
Failure to address this issue may lead to life- ♥ Promotion of personal and domestic
threatening diarrheal dehydration. Every hygiene
physician should therefore know how to evaluate
patients with this condition, and decide on the VII. REFERENCES
appropriate action to take. This session on 1. Harrison’s Principles of Internal Medicine.
diarrhea will consist of two lectures. Attention McGraw Hill. 16th ed.
will be given to presenting the clinical condition 2. Pickering LK and Snyder JD. Gastroenteritis.
in both the pediatric and the adult populations. In: Nelson Textbook of Pediatrics. Behrman
When appropriate, a differentiation of clinical RE
presentation in the two groups will be 3. et. al. (eds). 2004. Philadelphia: Saunders.
underscored. 17th ed. Pp. 1272-1276.
4. World Health Organization. The Treatment of
VI. COURSE OUTCOMES AND CONTENT Diarrhoea: A Manual for Physicians and
Objectives: At the end of the session, the 5. Other Senior Health Workers. 2005.
students are expected to: WHO/CDD/SER/80.2 (Handout)
1. Define diarrhea. 6. National Epidemiology Center. Field Health
2. Differentiate acute from chronic/persistent Service Information System Annual Reports.
diarrhea. 7. Department of Health. Philippines (Handout)

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 STUDY GUIDES OS 214
DIGESTIVE
DIGESTIVE MODULE WEEK 1 BLOCK A
Exam 1

8. Sio-Aguilar, J. Management of Diarrheal At the end of this module, the student

Diseases in Children. (Handout)
VIII. EVALUATION
1. Written examination (part of the first long
exam for the Digestive Module)
2. Short quiz
should be able to describe the life cycles of all
nine parasites listed in this study guide (those
lectured as well as those for self-study). By
studying the life cycle, the student shall know
the following:

LECTURE #9
PROTOZOAN AND HELMINTHIC GI
INFECTIONS

I. DATE AND TIME

► Lecture: Wednesday, 14 February 2007; 3:00
p.m.–5:00 PM
► Laboratory Work:
o Thursday, 15 February 2007; 3–5 PM
o Monday, 19 February 2007; 3–5 PM
II. FACILITATORS/LECTURERS
(Department of Parasitology, College of
Public Health)
Pilarita T. Rivera, M.D.
Vicente Y. Belizario, Jr. , M.D.
Lydia R. Leonardo, M.D.
Juan A. Solon, M.D. (department
coordinator)
Prof. Winifreda de Leon
Ms. Ellen Villacorte
III. FORMS OF TEACHING
Lectures
Preceptorials
Laboratory work
IV. PREREQUISITES
The student is expected to have done the
following:
1. Read Chapter 1, Introduction to Medical
Parasitology, of the Textbook of Parasitology,
which introduces concepts in parasitology
that emphasize biological relationships such
as incubation periods, latent periods, and
the different types of hosts.
2. Passed HS202, Parasitology Module and
reviewed the different types of life cycles,
morphology for helminths, and diagnostic
methods.
V. OVERVIEW OF THE TOPIC
Some of the disorders affecting the
digestive tract are due to parasitic infections. In
the parasitology module, the student will learn
about the biology of the most common parasitic
infections affecting the digestive tract and how
these affect individuals and communities.
Although the sessions will not be sufficient to
provide a discussion of all parasites affecting the
digestive tract, the module however can serve
as a template upon which the student can
individually study the other parasitic infections.
The key lies in understanding the life cycle and
applying the information obtained in the life
cycle.
The student is also expected to discuss how the
host response (i.e. the immune response) to the
parasite results in pathology, and in some cases,
aids in diagnosis. There will be two hours
allotted for didactics and four hours for a
combination of preceptorial sessions and
laboratory sessions.
SCHEDULE OF SESSIONS
14 February 2007; 3:00 p.m.–5:00 PM
Introduction to Module on Parasitology Module
(JA Solon)
10 minutes
Water-borne Protozoan Infections (PT Rivera)
Review of Entamoeba Histolytica – lectured in OS2
Giardia lamblia
Cryptosporidium parvum
25 minutes
Food-borne Helminthic Infections (VY Belizario)
Capillaria philippinensis
Heterophyid flukes
25 minutes
10 minute break
Vector-borne Helminthic Infections (LR Leonardo)
Schistosoma japonicum
25 minutes
Soil-transmitted Helminthic Infections (JA Solon)
Review of Soil-transmitted Helminths:
Ascaris, hookworms, Trichuris (review)
Strongyloides stercoralis in immunocompromised
hosts
Summary
15 minutes
15 February 2007; 3–5 PM
Preceptorial session
The first 20 minutes of the session will be used to
discuss any issues regarding past lectures, lab
session or self-study materials. The rest of the time
will be devoted to the laboratory work.
Laboratory session 1:
1. Examination of prepared slides of eggs (to be
provided by the module)
2. Practice with Stool Unknown (vials to be
provided individually)
3. Laboratory demonstration of adult worms, eggs,
cysts, and diagnostic kits used (30 minutes)
19 February 2007; 3–5 PM

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 STUDY GUIDES OS 214
DIGESTIVE
DIGESTIVE MODULE WEEK 1 BLOCK A
Exam 1

Preceptorial session the different parasites. Submission of the

The first 20 minutes of the session will be used to answers to these exercises is not required.
discuss any issues regarding past lectures, lab
session or self-study materials. The rest of the time Mechanics of the Stool Unknown
will be devoted to the laboratory work. The student will be given a vial
Laboratory session 2: containing a mixture of helminth eggs. The vial
Practice with Stool Unknown (1 hour) will have the eggs listed in 4a–g above. The
Stool Unknown Practical (40 minutes) student will also be given a half-sheet of paper
on which to write his/her answers. The goal is to
The parasites that were chosen for discussion identify as many helminth eggs as one can
are the most important digestive tract parasites within 45 minutes. Once an egg has been
in the Philippine setting based on the impact in identified, the student writes down his/her
the community. Complications from these answer and raises his/her hand. A preceptor will
infections are also more severe than the other come and check to check the diagnosis.
parasites assigned for self-study (Enterobius The following points will be given for the
vermicularis, Echinostoma ilocanum, and Taenia student’s answers: one (1) point for each
spp). Moroever, these arasites represent correctly identified species, with no repeats in
different modes of transmission. Some can be egg identification. A perfect score of seven (7)
found all over the country, while others are will be given if all eggs were correctly identified.
limited by geographic conditions. Yet, others will A demerit of Minus 0.25 (-0.25) will be imposed
be defined even further by particular eating on each incorrectly identified species.
habits.
VI. COURSE OUTCOMES AND CONTENT
For the Laboratory Sessions OBJECTIVES CONTENT EVALUATION
1. The student will be evaluated based on To identify the Written Exam
his/her participation in the laboratory infective stage
of each Written Exam
(attendance) and the stool unknown. parasite
2. The students will be divided into six groups; Stool Unknown
To identify
each group will be assigned a preceptor. clinical
Details will be posted in the department. manifestations
associated with
Giardia,
3. The student is advised to use the first part of Cryptosporidium,
the session to clarify concepts and issues each parasitic
infection. Entamoeba
from the lectures and readings with the histolytica,
assigned preceptors. The rest of the time will To discuss the Capillaria
be devoted to microscopy and viewing clinical philippinensis,
demonstration. manifestations Heterophyid
4. Each group will be provided with slides associated with flukes,
each parasitic Schistosoma
containing eggs and proglottids of the
infection. japonicum
following parasites which the student must To identify the Ascaris,
identify with the light microscope: diagnostic hookworms, Written Exam
a. Ascaris lumbricoides egg stages of Trichuris,
b. Trichuris trichuira egg each parasite. Strongyloides,
c. Hookworm egg To discuss Self-study:
prevention and Taenia,
d. Capillaria egg control
e. Heterophyid eggs Enterobius,
measures for
f. Schistosoma japonicum eggs Echniostoma
each parasitic
g. Taenia eggs infection.
h. Enterobius egg To discuss
i. Taenia spp proglottids specific factors
that favor
j. Giardia lamblia cysts transmission of
5. Each group will also be provided with several the parasite.
vials containing a mixture of parasite eggs.
From the references provided, the student VII. RESOURCES/REFERENCES
should read on steps to make a direct fecal 1. Belizario VY, de Leon WU. 2005. Philippine
smear. By making a wet smear of this Textbook of Medical Parasitology. Manila:
mixture, the student will be able to test University of the Philippines Manila.
his/her skill in identifying parasitic eggs. The 2. Laboratory Manual. 2005. Department of
grade in the laboratory will depend on the Parasitology. Manila: University of the
student’s performance in the identification of Philippines Manila.
stool unknown.
6. The student may refer to the laboratory The Philippine Textbook of Medical Parasitology
manual of the Department of Parasitology, is an excellent resource for knowing the basic
as it directs the students to the important biology of each parasite and its clinical
diagnostic features of the parasites as well manifestations and management. The
as provides questions that could serve as a Laboratory Manual of the Department of
review for the examination. He/she can refer Parasitology, aside from directing the students
to the activities in the laboratory manual for to the important diagnostic features of the

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 STUDY GUIDES OS 214
DIGESTIVE
DIGESTIVE MODULE WEEK 1 BLOCK A
Exam 1

parasites, also provides questions that could factors and comprises a complex sensation with
serve as a review. Laboratory activities that are different manifestations in different individuals
deemed useful for medical students have been of different age groups. Therefore, it is the
identified. The enclosed table on the life cycles responsibility of the clinician to interpret the
of parasites is a condensed view of the more patient's complaint of pain with a complete
important parasites grouped by classes. understanding of factors modifying its sensation
and manifestations.
The Web is a rich resource of materials. The evaluation of acute abdominal pain
Particularly, the CDC website (www.cdc.gov) and is a profound clinical challenge especially in the
the WHO website (www.who.int) contain younger age groups, where pain may be a
information on tropical infections that the nonspecific symptom and where manifestations,
students may find useful. To augment student etiologies, severity, duration, and accompanying
learning, images of parasites abound and a signs and symptoms are variable. The most
Google search will undoubtedly be fruitful. significant issue to be resolved in the
assessment of acute abdominal pain is whether
the patient requires an operative procedure for
LECTURE #10 the underlying cause which may be life-
ABDOMINAL PAIN threatening. This module will serve to introduce
the students to the principles of diagnosis and
I. DATE AND TIME: Thursday, 15 February management of patients with acute abdominal
2007, 8-11 p.m. pain.
This session consists of 4 clinical case-
II. FACILITATORS/LECTURERS based lectures to be given by faculty-facilitators
► Alvin B. Caballes, M.D. with an overview provided by the faculty
Department of Surgery, coordinator of the topic. The lectures will be
Division of Pediatric Surgery interactive in nature and a discussion of the
► Nathaniel J. Labio, M.D. essential elements will revolve around the
Department of Surgery, featured clinical case. The pathophysiology,
Division of General Surgery pertinent differential diagnosis, and basic
► Jossie M. Rogacion, M.D. principles in the management will also be
Department of Pediatrics, tackled. The time allotted for each lecture is 45
Section of Gastroenterology and Nutrition minutes. There will be a 5 minute break between
► Felix M. Zano, M.D. lectures. The session will be capped by a panel
Department of Internal Medicine, discussion during which the members of the
Section of Gastroenterology faculty group will address any lingering issues of
the students.
III. FORMS OF TEACHING
Case-based Lecture VI. COURSE OUTCOMES AND CONTENT
Panel Discussion Objectives
At the end of the session, the students are
IV. PREREQUISITES expected to:
For an optimum learning outcome, the student is 1. Discuss the pathophysiology of acute
expected to read and review the following past abdominal pain in adults and children.
learning issues: 2. Describe the etiology, pathogenesis and
1. Neurologic basis for abdominal pain clinical presentation of
[Knowledge obtained from OS 202 (Human ► Somatic pain
Body and Mind 2/Integration and Control ► Visceral pain
Systems) Lecture on Pain]: Concepts of ► Referred pain
somatic, visceral, and referred pain 3. Differentiate between intra-abdominal pain
2. Basic human gastrointestinal embryology on and extra-abdominal pain in terms of
the derivatives of the foregut, midgut, and etiology and clinical characteristics.
hindgut 4. Discuss the significant components in the
3. Anatomy and physiology of the history and physical examination necessary
gastrointestinal tract, abdominal cavity, in the diagnosis of acute abdominal pain.
mesentery, and peritoneum 5. Enumerate appropriate diagnostic
4. Basic principles of body fluid physiology examinations and other imaging modalities
5. Basic principles of inflammation and its necessary in the diagnosis of acute
consequences abdominal pain.
6. Prescribed references for the diagnosis and 6. Discuss the principles of management of
management of abdominal pain in adult and common cases of acute abdominal pain.
pediatric age groups 7. Discuss the most common causes of acute
abdominal pain, their clinical features,
V. OVERVIEW OF THE TOPIC diagnosis and principles of management.
Abdominal pain is an unpleasant 8. Recognize the clinical features of patients
experience commonly associated with tissue who require urgent operative intervention
injury. The sensation of pain represents an (surgical abdomen).
interplay of pathophysiologic and psychosocial

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 STUDY GUIDES
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9. Discuss the principles of the preoperative
management of the patient (adult and child)
with acute abdominal pain.
Content
1. Principles of evaluation of the patient with
abdominal pain
2. Neurologic basis for abdominal pain
3. Anatomy and physiology of the
gastrointestinal tract, abdominal cavity,
mesentery, and peritoneum
4. Acute pancreatitis
5. Peptic ulcer disease
6. Acute cholecystitis
7. Gastroesophageal reflux disease
8. Acute appendicitis
9. Urolithiasis
10. Ectopic pregnancy
11. Pelvic inflammatory disease
12. Intussusception
VII. CASES FOR CASE-BASED
LECTURE/DISCUSSION
Case A (Dr. Felix M. Zano)
The first session focuses on the
pathophysiology, clinical presentation, and
differential diagnosis of acute pancreatitis. The
basic principles of management for this featured
clinical case are discussed. This session
concentrates on learning objectives nos. 1-5 and
will touch on the causes of referred pain and
extra-abdominal causes of abdominal pain.
A case of a 54-year old male, admitted
for severe epigastric pain, burning in character,
with radiation to the back, associated with
vomiting for several episodes. A day prior to
admission, he had a drinking spree with his
friends to the point of intoxication. The patient
had a history of Diclofenac and Colchicine intake
for his gouty arthritis for several years now. He
is nonhypertensive, non-asthmatic and non-
diabetic. On review of systems, he had a history
of on and off epigastric pain, precipitated by
hunger and occasionally by fatty food intake.
On physical examination:
Conscious, coherent, cooperative
BP:130/80; PR:115/min; RR:20/min; T: 38.1o C
Skin: Dry, fair turgor
HEENT: Anicteric sclerae, slightly pale palpebral
conjunctivae, dry lips and tongue. No neck
masses. No lymphadenopathies
Chest /Lungs: Clear Breath Sounds, no rales, no
wheeze
CVS: Tachycardic, no murmurs appreciated
Abdomen: Globular, hypoactive bowel sounds,
direct tenderness over epigastric and RUQ area.
No organomegaly; (-) Kidney Punch sign,
bilateral
Extremities: No gross deformities, no edema, fair
pulses
DRE: Tight sphincter tone, no masses palpated,
no tenderness, empty rectal vault
Guide Questions
1. What is your clinical impression?
WEEK 1 Shelly |
OS 214
DIGESTIVE
BLOCK A
Exam 1
2. What is the pathophysiologic mechanism of
abdominal pain in this patient? Is there more
than one mechanism at work in this patient?
Explain.
3. What are your differential diagnoses?
4. What are the components in the history and
physical examination that support your
clinical diagnosis?
5. Does this patient have an acute abdomen?
Explain.
6. What diagnostic tests will be necessary to:
a. Verify your impression or exclude
other possibilities
b. Help guide you in the resuscitation
and therapy of this patient?
7. Explain the principles of management for
this patient’s problem. Should analgesics be
administered? If so, when?
Case B (Dr. Nathaniel J. Labio)
The second session focuses on the
clinical presentation, differential diagnosis, and
pathophysiology of acute appendicitis. Clinical
recognition and features of the surgical
abdomen are elucidated and the principles in
the management tackled. The basic concepts in
pre-operative preparation are discussed. This
session focuses on learning objectives nos. 6-9.
The most important elements of the
evaluation of a patient with acute abdominal
pain are the history and physical examination. A
thorough description of the chronology, location,
intensity and character of the pain as well as
aggravating and alleviating factors, associated
symptoms and past medical history usually
allows an early, efficient, and accurate
diagnosis.
A previously healthy 24-year-old female
consulted at the emergency room for abdominal
pain. She relates that she developed vague,
periumbilical discomfort a day prior to consult.
This was associated with nausea and anorexia.
Twelve hours later, a steady right lower quadrant
supervened. She reports normal and regular
menses.
On physical examination:
Well developed and well nourished female lying
down still, with her right knee flexed.
BP: 120/70; HR: 88/min; RR: 12/min; T: 38.1oC
Abdomen: Normoactive bowel sounds, (-)
organomegaly, (+) direct and rebound
tenderness over the right lower quadrant, (-)
guarding
The rest of the physical examination is
unremarkable.
Guide Questions
1. What is your clinical impression?
2. What is the pathophysiologic mechanism of
abdominal pain in this patient? Is there more
than one mechanism at work in this patient?
Explain the noted shift in pain from the
periumbilical area to the right lower
quadrant.
3. What are the components in the history and
physical examination that support your
clinical diagnosis?
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 STUDY GUIDES
DIGESTIVE MODULE WEEK 1
4. What are your differential diagnoses?
5. What diagnostic tests would you request to
support your clinical impression and to
exclude other possibilities?
6. Explain the principles of management for
this patient’s problem.
Case C (Dr. Alvin B. Caballes)
This session focuses on the clinical
presentation, differential diagnosis, and
pathophysiology of intussusception. The basic
principles in the management for this condition
are discussed as well as the challenges facing
the clinician dealing with acute abdominal pain
in this age group. Likewise, the principles in the
recognition of the surgical abdomen and pre-
operative preparation of patients in this age
group are highlighted. This session focuses on
learning objectives nos. 6-9 with the pediatric
patient in mind.
An otherwise healthy 6-month-old male
infant was observed by the mother to be fidgety
and irritable. Soon, the baby would have crying
spells, unlike anything that the baby had done
before. During such spells, the baby could not be
comforted. After about 30 minutes, the baby
vomited previously ingested milk. Feedings were
attempted 30 minutes later, and this was
tolerated. However, the baby started to pass
stools admixed with blood and mucus. The infant
was thus brought to the emergency room.
On physical examination:
Well developed and well nourished male infant,
crying and irritable
HR: 150/min; RR: 30/min; T: 37oC; Body Weight:
6.5 kg
HEENT: Pink conjunctivae, (-) alar flaring
Chest: Clear breath sounds; distinct heart
sounds, (-) murmurs
Abdomen: Distended; tense (patient crying);
hyperactive bowel sounds
Rectal: Blood and mucus
Extremities: Fair pulses; capillary refill 10
seconds
Guide Questions
1. Does this patient have an acute abdomen?
Why?
2. What is your clinical impression?
3. What are the components in the history and
physical examination that support your
clinical diagnosis?
4. What are your differential diagnoses?
5. What is the pathophysiologic mechanism of
abdominal pain in this patient? Is there more
than one mechanism at work in this patient?
Explain.
6. What diagnostic tests will be necessary to
verify your impression or exclude likely
possibilities and help guide you in the
resuscitation/therapy of this patient?
7. Explain the principles of therapy for this
patient’s problem. Should analgesics be
administered? If so, when?
Case D (Dr. Jossie M. Rogacion)
WEEK 1 Shelly |
OS 214
DIGESTIVE
BLOCK A
Exam 1
This session focuses on the clinical
presentation, differential diagnosis, and
pathophysiology of common, non-surgical
causes of acute abdominal pain in the pediatric
age group. The unique features in clinical
presentation and management are highlighted
as well as the challenges faced by the clinician
treating this challenging group of patients. This
session focuses on learning objectives nos. 1-5
with the pediatric patient in mind.
A 7-year-old boy was seen at the
Pediatric Emergency Room because of severe
abdominal pain which was noted one week prior
to admission. A day before the onset, the
mother claimed that he just ate shrimps. Pain
was sudden in onset, colicky, associated with
episodes of non-bilious vomiting which accorded
relief of the pain. Pain would appear during or
immediately after eating, epigastric and
periumbilical in location, and would awaken him
at night. There was no previous episode of
abdominal pain. He was just taking his daily
multivitamins. He would usually skip breakfast
because of his early school schedule. Review of
systems showed no diarrhea, fever, cough/colds;
presence of anorexia; no jaundice, no joint
pains/rashes; no dysuria, hematuria; regular
bowel movements, no melena, and
hematochezia.
On physical examination:
Conscious, coherent, crying, restless and
complaining of abdominal pain
HR: 100/min; RR: 30/min; T:36.8oC; Body
Weight: 22 kg
HEENT: Pink conjunctivae, anicteric sclerae,
sunken eyeballs, dry lips; no tonsillopharyngeal
congestion, no cervical lymphadenopathy
Chest and Lungs: Clear breath sounds, no rales
or wheezes
Heart: distinct heart sounds, regular rhythm, no
murmurs
Abdomen: Flat, soft, hyperactive bowel sounds,
(+) epigastric and periumbilical tenderness,
(-) mases, (-) organomegaly
Extremities: Pink nailbeds, (-) edema, good
peripheral pulses
Guide Questions
1. What is your clinical impression?
2. What is the pathophysiologic mechanism of
pain in this patient? Is there more than one
mechanism involved in this patient? Explain.
3. Are there points in the history and physical
examination that you think are lacking?
4. What is your differential diagnosis?
5. What laboratory tests will you order and
why?
6. Explain the principles of management for
this patient.
VIII. RESOURCES/REFERENCES
1. McFadden DW and Zinner MJ. Manifestations
of Gastrointestinal Disease. In: Schwartz SI
(ed). Principles of Surgery. New York:
McGraw-Hill. 6th ed. 1994: 1025-20; 1307-
1318.
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 STUDY GUIDES
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2. Silen WT. Abdominal Pain. In: Braunwald ER
et al. (eds). Harrison’s Principles of Internal
Medicine, 15th ed. New York: McGraw-Hill.
2001: 67-70; 1705-1707.
3. Walker WA. Abdominal Pain. In: Walker WA,
Hamilton JR et. al. (eds). 2000. Pediatric
Gastrointestinal Disease. Pathophysiology,
Diagnosis and Management. Ontario: BC
Decker Inc. 3rd ed.
4. Almonte JR. 1998. Acute Abdominal Pain in
Children (Self Instructional Module). Manila:
Learning Resources Unit, NTTC-HP.
LECTURE #12
GASTROINTESTINAL BLEEDING IN ADULTS:
MEDICAL AND SURGICAL ISSUES
I. DATE AND TIME: Thursday, 15 February
2007; 1–3 p.m.
II. FACILITATORS/LECTURERS
► Virgilio Bañez, M.D.
Department of Internal Medicine,
Section of Gastroenterology
► Francisco Roxas, M.D.
Department of Surgery,
Division of Colorectal Surgery
III. FORMS OF TEACHING
Case-based Lecture
IV. OVERVIEW OF THE TOPIC
The extensive spectrum of
gastrointestinal bleeding may encompass many
different clinical scenarios. The reason for its
diversity is that bleeding can occur from multiple
different lesions and sites in the gastrointestinal
tract. Despite a number of recent advances in
the management of patients with
gastrointestinal bleeding, several fundamental
clinical principles remain constant, the most
important of which is immediate assessment
and stabilization of the patient’s hemodynamic
status.
This session aims to tackle the important
points in approaching a patient with GI bleeding.
Guide questions are given to the group to
facilitate the discussion of the case. At the end
of the group discussion, one group member will
discuss the approach to handling GI bleeding in
a plenary session.
V. COURSE OUTCOMES AND CONTENT
Objectives: At the end of the session, the
students are expected to:
1. Define melena, hematemesis, heamtochezia,
obscure, and occult bleeding.
2. Enumerate the different disease entities that
cause gastrointestinal bleeding.
3. Differentiate upper from lower
gastrointestinal bleeding in terms of clinical
features and diagnostic modalities.
4. Evaluate clinical features of the case
presented and determine the most likely
clinical impression.
WEEK 1 Shelly |
OS 214
DIGESTIVE
BLOCK A
Exam 1
Content
1. Definition of terms: melena, hematemesis,
hematochezia, obscure and occult bleeding
2. Causes of gastrointestinal bleeding
3. Differentiation between upper and lower
gastrointestinal bleeding
► Clinical features
► Diagnostic modalities
VI. CASE FOR DISCUSSION
A 62-year-old male came in for a two-
week onset of melena and body malaise. This
was preceded by two weeks of burning, localized
epigastric pain. He was diagnosed to have
Ischemic Heart Disease since 1998 and was
maintained on aspirin 80mg 1 tab OD. He is also
a chronic user of non-steroidal anti-inflammatory
drugs for steoarthritis for the past five years. On
admission, he was conscious, coherent, not in
respiratory distress with the following vital signs:
BP=120/60 (upright), 100/60 (supine);
HR=102/min; RR=20/min. His skin was dry, with
senile loss of turgor. He had distinct heart
sounds with no murmurs. His abdomen was soft
with normoactive bowel sounds. Direct
tenderness was elicited over the epigastric area.
No organomegaly was noted. On digital rectal
examination, he had tight sphincteric tone, no
tenderness, no mass palpated at pararectal
walls. There was black tarry stool on withdrawal
of the examining finger.
Guide Questions
1. Define melena, hematemesis, hematochezia,
occult bleeding and obscure bleeding.
2. What are the common causes of acute upper
gastrointestinal bleeding, small intestinal,
and colonic bleeding?
3. What are the relevant data in the history and
physical examination of the case presented
that give a clue to the diagnosis of
gastrointestinal Bleeding?
4. How do you approach a patient with
gastrointestinal bleeding?
5. How do you differentiate upper from lower
gastrointestinal Bleeding?
6. What are the different diagnostic modalities
in gastrointestinal bleeding?
7. In the above-described case, what could be
the probable cause of gastrointestinal
bleeding? Explain the pathophysiology.
8. How will you manage the case presented?
What are the indications for surgical
intervention?
VIII. RESOURCES/REFERENCES
1. Harrison’s Principles of Internal Medicine.
McGraw Hill. 16th ed.
2. Sleisenger and Fordtran. Gastrointestinal and
Liver Disease. 7th ed. Chapter 13.
SESSION 12 SIM
GASTROINTESTINAL BLEEDING IN
CHILDREN
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DIGESTIVE
DIGESTIVE MODULE WEEK 1 BLOCK A
Exam 1

I. DATE AND TIME: Thursday, 15 February 3. Age-specific causes of GI bleeding

2007; 1–3 p.m. a. Neonates: Swallowed maternal blood,
gastritis/stress ulcers, foreign protein
II. FACILITATORS/LECTURERS sensitivity, necrotizing enterocolitis
► Ma. Lourdes G. Genuino, M.D. b. Infants: Peptic disease, GI infections,
Department of Pediatrics, dietary protein intolerance, anal fissures,
Section of Gastroenterology and intussception, Meckel’s diverticulum,
Nutrition and Department of Physiology bleeding varices
► Celine A. Villegas, M.D. c. Children: Peptic disease, GI infections,
Department of Surgery, anal fissures, intussuception, Meckel’s
Division of Pediatric Surgery diverticulum, bleeding varices, polyps,
Mallory-Weiss tears
III. FORMS OF TEACHING d. Adolescents: Peptic disease, bleeding
Self-Instructional Module varices, colitis, anal fissures, polyps,
Mallory- Weiss tears
IV. PREREQUISITES 4. Initial assessement and resuscitation of a
To optimize learning from this session, the child with GI bleeding
student should review the following topics: 5. Diagnostic modalities for GI bleeding
3. Anatomy and physiology of the a. Laboratory examinations
gastrointestinal tract b. Imaging studies
4. Principles of radiology c. Endoscopic procedures
6. Principles in management
V. OVERVIEW OF THE TOPIC a. Fluid and electrolyte resuscitation
Gastrointestinal bleeding (GI) in infants b. Specific care
and children is one of the more alarming
conditions encountered in pediatrics. Although VII. TAKE HOME ASSIGNMENT
not as frequent as in the adult population, it is Case A
nonetheless an anxiety-provoking complaint. JA, a 13-year-old male, was brought to the
Most etiologies are self-limited and benign, but outpatient department for epigastric pain and
some are potentially serious. The challenge in coffee-ground vomitus a few hours prior to
the assessment of a pediatric patient with consultation. He was very well until three days
gastrointestinal bleeding is in determining which ago when he had a left ankle sprain after
patients are seriously ill and would require jumping off from his skateboard. His pediatrician
immediate investigations. Depending on the advised him to take Ibuprofen 400 mg capsule
severity of the bleed, it may present as a twice a day for pain. He is on a tapering dose of
diagnostic and therapeutic dilemma. prednisone for his asthma taken at 5 mg thrice a
This session is a self-instructional day. Physical examination revealed a well-
module. The student is expected to study the nourished adolescent able to walk with the help
accompanying self-instructional material on the of crutches. He was not in any apparent
topic. Two cases will be provided as take home cardiorespiratory distress. Vital signs were as
assignment which will be graded as a short quiz. follows: BP=110/70 HR= 80/min RR= 24/min
The facilitators will meet the class briefly for afebrile with a weight of 35 kg. He had pink
instructions. conjunctiva, anicteric sclerae; chest and heart
findings were unremarkable. The abdomen was
VI. COURSE OUTCOMES AND CONTENT flat, with normoactive bowel sounds, no
Objectives: At the end of this module, the organomegaly but with epigastric tenderness on
student should be able to: palpation. His left ankle was swollen;
1. Define hematemesis, hematochezia, nailbeds were pink and pulses full. Rectal
melena, and occult bleeding. examination revealed good sphincter tone, no
2. Differentiate upper gastrointestinal from tenderness, masses, and brownish fecal material
lower gastrointestinal bleeding. upon withdrawal of examining finger.
3. Identify the common age-specific causes of
GI bleeding in children. Questions for Discussion
4. List the steps in the initial assessment and 1. Identify the most probable source of
resuscitation of a child with GI bleeding. bleeding in this adolescent.
5. Select the appropriate diagnostic 2. What is the most probable etiology of
modalities in the evaluation of bleeding in this case?
gastrointestinal bleeding and list their 3. Discuss very briefly the pathogenesis of
appropriate indications. bleeding in this case.
6. Describe the principles in the management 4. Are there other signs that should be checked
of gastrointestinal bleeding. to make sure this patient has not bled
significantly?
Content 5. Provide an algorithmic approach to the
1. Definition of terms: hematemesis, treatment of this patient.
hematochezia, melena, and occult bleeding
2. Differentiation between upper and lower GI Case B
bleeding

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DIGESTIVE
DIGESTIVE MODULE WEEK 1 BLOCK A
Exam 1

GM, two-month-old baby girl, was brought to the
emergency room because of diarrhea of a week
associated with blood streaking two days prior to
consultation. There was no accompanying fever
and mother claims that the baby has good suck
and activity. She was never breastfed and is
presently on Bonna at 1:2 dilution. Her mother is
diagnosed to have bronchial asthma. Physical
examination revealed an active baby who is not
in any apparent respiratory distress. Her vital
signs were as follows: HR=100/min RR= 32/min
afebrile
ABW=4.2 kg. She had pink conjunctiva, anicteric
sclerae, no tonsillopharyngeal congestion. There
was papulovesicular rash on the face with areas
of excoriation. Her lips and oral mucosa were
moist. Chest and heart findings were
unremarkable. Her abdomen: was globular, with
normoactive bowel sounds, with the liver edge
palpable 2 cms below the right coastal margin,
no splenomegaly, no masses. She had pink
nailbeds, and full pulses. Rectal examination
revealed good sphincter tone, faint streaks of
fresh blood on examining finger but no
hemorrhoids/fissures.
Questions for Discussion
1. What is your primary clinical impression?
2. List three other differential diagnoses for this
case and give a component in history and PE
that would exclude or include it. For
example: Meckel’s diverticulum: Age of
patient
3. Based on your impression, provide an
algorithmic approach to the management of
this patient to include laboratory work-ups
and appropriate treatment.
Case C
A six-month-old female was brought for medical
consultation because of passage of
bloodstreaked stool one day prior to the visit.
She was previously well and had normal bowel
movements until four days prior to consultation
when she started passing hard stools associated
with crying and straining. She continues to be
playful and has good appetite and only appears
distressed when having a bowel movement.
Physical examination revealed the following:
pink conjunctivae, afebrile, heart rate of
110/min. Breath sounds were clear, the
abdomen was full and soft without tenderness
and no palpable masses. Rectal exam revealed a
normal sphincter tone with very hard stool
within the rectal vault. She weighed
6.6 kg.
Questions for Discussion
1. What is the cause of the patient's blood-
streaked stool?
2. How will you treat this patient? Please write
down the specific steps you will take to
relieve the patient of her symptoms. For
medications, please state the medication to
be given and actual dosage.
Case D
A five-month old boy was brought in for bloody
mucous per rectum. He has been unwell for the
past 48 hours and was noted to have
postprandial vomiting and abdominal colic. He
was pale and lethargic. There was a vague
impression of a mass on the right side of the
abdomen. Heart rate was 150/min and
respiratory rate 28/min. He weighed 6 kg.
Questions for Discussion
1. What is the likely diagnosis?
2. Which of the following should be done for
this patient in the emergency room? (Please
place a check mark)
___ nasogastric tube insertion
___ intravenous hydration
___ complete blood count
___ blood typing
___ serum amylase
___ serum sodium, potassium and chloride
___ urinalysis
___ fecalysis
___ oral antibiotics
3. How can the diagnosis be confirmed?
4. Once treated, is it likely to happen again? If
yes, what is the recurrence rate?
VIII. RESOURCES/REFERENCES
1. Behrman RE et. al. (eds). 2004. Nelson
Textbook of Pediatrics. Philadelphia:
Saunders. 17th ed. P. 1203.
2. Schwartz ' Principles of Surgery. 8th ed.
3. Squires RH. Gastrointestinal Beeding. In:
Clinical Pediatric Gastroenterology. Altschuler
SM and Liacouras CA (eds). 1998.
Philadelphia: Churchill Livingstone. Pp. 31-
42.
4. SIM on Gastrointestinal Bleeding in Children
(Hand-outs)
LECTURE #13
COME ON DIARRHEAS IN CHILDREN:
TREATMENT AND PREVENTION
I. DATE AND TIME: Friday, 16 February 2007,
8-12 p.m.
II. FACILITATORS/LECTURERS
► Juliet Sio Aguilar, M.D., M.Sc.(Birm)
Department of Pediatrics,
Section of Gastroenterology and Nutrition
► Ma. Lourdes G. Genuino, M.D.
Department of Pediatrics,
Section of Gastroenterology and Nutrition and
Department of Physiology
III. FORMS OF TEACHING
Case-based Discussion
Role playing
IV. PREREQUISITES
To obtain maximum benefit from this session,
the student should review the following topics:
1. Normal membrane transport mechanisms
underlying the normal absorption of fluids
and electrolytes in the small bowel, OS 201

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2. Definition of diarrhea
3. Clinical types of diarrhea
4. WHO Assessment Chart on Diarrheal
Dehydration
5. Treatment of Diarrhea, A Manual for
physicians and health workers, WHO
V. OVERVIEW OF THE TOPIC
Diarrheal diseases are a leading cause of
childhood morbidity and mortality in developing
countries. Many of the deaths are caused by
dehydration. In a developing country such as the
Philippines, an important morbidity is
malnutrition and not uncommonly, worsening of
preexisting malnutrition.
The past two decades of experience has
shown that dehydration from acute diarrhea of
any etiology and at any age , except when
severe, can be safely and effectively treated by
a simple method of giving oral dehydration. Oral
rehydration salts (ORS) combined with the
giving of nutrient-rich food prevents weight loss
and a decline of nutritional status during a
diarrheal episode. The session will be a practical
session emphasizing on these two essential
elements in the management of all children with
diarrhea. There will be drills on the assessment
of dehydration, fluid management of
dehydration as well as feeding in diarrhea both
for the wellnourished and the undernourished
using the WHO guidelines.
The second half of the session will be
devoted to the following activities: a practicum
on the preparation of ORS, counseling of
caretakers regarding ORS and appropriate fluids
and feeding through role playing; and taste
testing of the different commercially available
ORS and zinc preparations.
VI. COURSE OUTCOMES AND CONTENT
Objectives
At the end of the session, the students are
expected to:
1. Assess the hydration status of a child with a
history of acute diarrhea.
2. Enumerate the essential elements in the
management of children with no signs and
some signs of dehydration.
3. Enumerate the differences in the
management of malnourished children with
diarrhea.
4. Demonstrate the preparation of ORS and
counseling of caretakers regarding ORS and
appropriate fluids.
5. Taste the different preparation of oral
rehydration solutions and zinc preparations.
VII. CASES FOR DISCUSSION
SET I
1. A mother brought her 4-month-old son Tom
to the clinic because of diarrhea of several
days. Tom was not getting better. The doctor
looked and felt for signs of dehydration and
noted the following: alert, well child with
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BLOCK A
Exam 1
sunken eyeballs, tears and moist tongue. He
drinks eagerly and his skin pinch goes back
quickly.
► What is Tom’s state of hydration? What
treatment plan should be used?
► If Tom did not have sunken eyes, what
treatment plan would be used?
2. A 2-year-old child is brought to your clinic.
He seems well and alert. His eyes appear
sunken and he has very dry mouth and
tongue. He drinks eagerly when offered a
cup of water. A skin pinch goes back quickly.
► What treatment plan should be used?
3. A child has a dry mouth and sunken eyes but
is alert and active when your assistant in the
clinic assesses her. She cries tears, and a
skin pinch goes back quickly. When offered a
drink, she takes a sip but does not seem
thirsty.
► What treatment plan should your
assistant use while the patient is waiting
for you?
4. A child appears alert and well, and her eyes
were not sunken. Her tongue is dry, but she
pushes away a drink when it is offered. Even
when she cries loudly, there are no tears. A
skin pinch goes back quickly.
► What treatment plan should be used?
5. A mother brings her 18-month-old daughter
Sylvia to the health center. She is concerned
because Sylvia has had diarrhea for 3 days.
There is no blood in her stool. You see that
Sylvia’s eyes are somewhat sunken and her
mouth and tongue are very dry. When you
pinch the skin, it goes back slowly. Her
temperature is 39oC. Sylvia is fussy and
irritable and cries during the examination.
There are tears when she cries. You notice
that she is wellnourished. You offer Sylvia
some water and she drinks eagerly.
► What is the degree of dehydration shown
by Sylvia?
► What treatment plan would you select for
her?
► Does Sylvia show signs of any problems
other than dehydration? If so, what
sign(s)?
6. Zeny is 15 months old. She has had diarrhea
for 4 days. The health worker notices that
she is alert. When offered a drink, Zeny
takes it eagerly. A skin pinch goes back
quickly.
► Is enough information given to determine
what treatment plan Zeny needs? Why or
why not?
7. An 8-month-old girl named Jossie has had
diarrhea for 2 days. There is no blood in her
stools. Jossie has continued to breast feed
exclusively; her mother has not yet started
feeding her other foods. She appears to be
severely malnourished; she looks like “skin
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and bones.” She is alert and has no fever.
Her eyes appear slightly sunken. Her mouth
and tongue are moist. She has tears and
drinks normally. A pinch of the skin goes
back slowly (in about a second).
► Is Jossie dehydrated?
► How does Jossie’s severe malnutrition
affect your ability to assess her for
dehydration?
8. A mother brought her 3-year-old daughter
Paz to a clinic because she has diarrhea. The
clinic worker looked and felt for signs of
dehydration. She was restless and irritable
with normal eyes, tears and moist lips. She
drinks normally and a pinch of her skin goes
back quickly.
► Which treatment plan should be used?
► List five questions or observations that
should be made to assess Paz for
problems other than dehydration.
► To determine whether Paz has persistent
diarrhea, what information would you
need from her mother?
9. JM is a two-year-old boy from Cavite was
brought to the emergency room with the
chief complaint of loose watery stools.
History started a few hours prior to
admission, when he had six episodes of non-
bloody, non-mucoid, watery stools
amounting to about half a cup per bowel
movement. This was accompanied by three
episodes of postprandial vomiting, which
was non-projectile, non-bilious amounting to
one tablespoon per bout. There are no other
accompanying symptoms such as fever,
cough, or colds. The mother gave him
Relestal®, an antispasmodic, with no
improvement.
On physical examination, JM appeared restless.
His vital signs were as follows:
BP: 100/70 CR: 110/minute RR: 24/ minute
Temp: 37.8oC. He has sunken eyeballs and
avidly drank a bottle of Gatorade®. His
abdomen was tympanitic with hyperactive bowel
sounds.
► What is acute diarrhea?
► What is the most common cause of acute
diarrhea among Filipino children less than
5 years old?
► Explain the pathophysiologic mechanism
that leads to the production of watery
stools.
► What is JM’s hydration status?
► What are the essential components in the
treatment of JM? Comment on the use of
Relestal® and Gatorade®.
10. LG, an 18-month-old female infant was
brought to the ER by her mother for loose
watery stools. She has been having diarrhea
for the past three days, an average of four to
five times per day, half a cup per episode.
She also has a runny nose that does not go
away. Her mother described the stools as
WEEK 1 Shelly |
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BLOCK A
Exam 1
non-bloody and non-mucoid. A neighbor
advised her to give “am” for every loose,
watery stools. She was taking this aside from
Lucky Me® soup for the past three days. Her
mother claims that sLG breast fed only for a
month and she always had problems with
her poor appetite. On examination, her
temperature is 38.0oC. She appears
malnourished and has thin extremities, a
narrow face, prominent ribs, and wasted
buttocks. She has a prominent diaper rash,
unwashed skin, uncut fingernails, dirty
clothing and a skin rash that resembles the
skin infection of impetigo contagiosum. Her
weight is below the third percentile for her
age.
► How do you assess a child with
malnutrition?
► What are the elements in the history when
assessing a malnourished child with
diarrhea?
► How would you assess the hydration
status of this child?
► What are the essential elements in the
management of this child?
► What is peculiar in the electrolyte balance
of severely malnourished children?
SET II
1. Vicky, a 5-month-old girl, breast fed,
weighing 6 kg, was brought to you for
diarrhea. This started last night and she has
had several watery stools. Her mother said
there was no blood in the stools. Vicky also
vomited. Her mother breastfeeds her. As you
examine her, you find that she seems alert,
the skin pinch goes back slowly, and her
eyes are a little sunken. Vicky cries tears,
but her mouth and tongue are very dry. She
drinks eagerly.
► Does Vicky have signs of dehydration? If
yes, describe them.
► How much ORS solution should be given to
Vicky?
► When should Vicky be reassessed?
► When you reassess her, you find that she
is still quite thirsty. Her skin pinch goes
back quickly, her mouth moist, but her
eyes are still a little sunken. Vicky has
passed several watery diarrhea while
being treated. What should you do now?
► Vicky then starts to vomit at this time.
What should be done first?
► She continues to vomit frequently, and her
signs of dehydration are worsening,
though she is not yet severely dehydrated.
You are not able to give nasogastric
treatment and the nearest hospital is one
hour away. What should you do now?
► At the hospital after intravenous treatment
of 4 hours, Vicky looks much better. Her
eyes have filled out, the skin pinch goes
back quickly, and she has lost interest in
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drinking the ORS solution. What should
you do?
2. Ed has watery diarrhea and some
dehydration. His mother has been treating
him with an antidiarrheal containing codeine.
He is sleepy; his eyes are sunken; tears are
absent; his mouth is dry; and a skin pinch
goes back slowly. He is willing but not eager
to drink ORS solution. Therapy was given
according to Plan B. Although his mother is
giving the ORS solution slowly, his abdomen
has become very distended.
► What is the probable cause of the
abdominal distention?
► How should Ed be treated now?
3. Ricky is 8 months old. His mother brought
him to a health center because of worsening
diarrhea of one week. There has been no
blood in the stools. Ricky has received less
food than normal since the diarrhea started,
but he does not seem severely
malnourished. He is lethargic and floppy;
however, he is able to open his eyes to look
at the health worker. He takes a sip of ORS
when coaxed, but is too tired to drink well.
Ricky has very sunken and dry eyes and a
very dry mouth. A skin pinch goes back
slowly, and when he cries there are no tears.
The health worker takes Ricky’s temperature
and finds that it is 38 oC.
► What signs of dehydration does Ricky
have?
► The health worker is not able to provide IV
treatment, so she decides to send Ricky
with his mother to the hospital, which is 20
minutes away. What should she do for
Ricky before he is sent to the hospital?
► Ricky and his mother arrived at the
hospital. The nurse weighs Ricky and finds
his weight is 6 kg. How much and what
fluid should Ricky receive in the first hour?
How much over the next 5 hours?
► After about 3 hours, Ricky is more alert
and can drink well. What should be done
now?
► After 6 hours of therapy, Ricky looks much
better. His skin pinch goes back quickly.
His eyes are no longer sunken and he has
tears. His mouth is moist and he is
drinking ORS eagerly. What treatment plan
should be followed?
4. Gabby is a 9-kg child who lives in an area
where cholera has been recently diagnosed.
Her diarrhea started yesterday and she has
had 6 larger watery stools and started
vomiting this morning. Gabby is very sleepy,
has very sunken and dry eyes, and a very
dry tongue. A pinch of her skin goes back
very slowly. There is no IV equipment and
the nearest hospital is 2 hours away. The
health worker knows how to use a
nasogastric tube.
► How much ORS solution should be given in
the first hour?
WEEK 1 Shelly |
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DIGESTIVE
BLOCK A
Exam 1
► If the health worker does not know how to
use a nasogastric tube, what should she
do?
► How much ORS should be given each
hour?
► If Josie is no better after 3 hours, what
should be done?
► What other treatment should the health
worker give?
5. Jean is 11 months old and weighs 8 kg. She
has had bloody diarrhea for 4 days. She has
some dehydration and a fever of 38oC. She
appears adequately nourished and is breast
fed. There is no malaria in the area.
► How much fluid should she receive?
► What other treatment should she be
given?
► When should Jean return to the health
center?
► If blood is still present in the stool, or Jean
is not getting better, what should be done
next?
► If after 2 days Jean still has blood in her
stools, what should be considered?
6. Joe is 8 months old and weighs 6.5 kg. He
has had diarrhea for 2 1/2 weeks. His mother
has given him an antidiarrheal for 3 days.
Joe’s diet includes cow’s milk, cooked cereal
and some mashed vegetables. He is not
dehydrated.
► Should Joe be referred to the hospital?
► What special advice on feeding should be
given to Joe’s mother?
► After 5 days, Joe’s diarrhea is less but has
not stopped. What should you tell his
mother?
7. Agnes, aged 14 months, is brought in for
diarrhea. Her illness began 7 days ago when
she had a rash and fever which looked like
measles. Her rash disappeared but her
diarrhea began 3 days ago with blood in the
stools. She is febrile at 39.5oC, thin but not
severely malnourished; her weight is 8 kg.
She is irritable with no other signs of
dehydration. There is no malaria where
Agnes lives. Tick the items below which are
appropriate parts of Agnes’ treatment:
► Give paracetamol for her fever.
► Give vitamin A 200,000 units by mouth.
► Give cotrimoxazole for 5 days.
► Give an antimalarial.
► Have Agnes return in 2 days if her stool is
still bloody.
► Eliminate cow’s milk from Agnes’ diet for 5
days.
► Advise the mother to give Agnes 6 meals a
day of thick cereal with added vegetable
oil, vegetables, pulses and meat or fish.
8. Willie, age 8 months, has had watery
diarrhea for 3 days. There is no blood in his
stool. When examined you find he has signs
of some dehydration and his temperature is
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39oC. You also note that Willie is breathing
rapidly at a rate of 54/min. He coughs
several times, but there is no chest
indrawing. There is no malaria in the area.
► What treatment plan should be given for his
diarrhea and dehydration?
► What other treatment should Willie receive?
Why?
9. Celia has had diarrhea for 8 days. Although
she is 10 months old, she takes no other
food than milk. Her mother breast feeds her
3 times a day and gives supplemental cow’s
milk. Celia appears thin, but is not severely
malnourished. You suspect that she has
cow’s milk intolerance because diarrhea
occurs shortly after Celia takes milk and her
stool pH is 5.0. You want to advise Celia’s
mother about how she should be fed. Tick
the items below that are appropriate:
► Stop breast feeding Celia until the diarrhea
stops.
► Continue to breast feed Celia as often and
as long as possible.
► Reduce the amount of cow’s milk given
each day by half.
► Stop giving cow’s milk. Replace it with soy
milk formula.
► Start to give Celia solid foods, such as
cereal with added vegetable, well-cooked
and mashed vegetables.
► Mix Celia’s milk or formula with her solid
foods.
► . Give Celia extra fluids, such as soft drinks
or fruit drinks.
► . Bring Celia back in 2 days to check her
progress and decide next treatment.
11. Fely, a 5-month-old girl, breast fed, weighing
6 kg, was brought to you for diarrhea. This
started last night and she has had several
watery stools. Her mother said there was no
blood in the stools. Fely also vomited. Her
mother breast feeds her. As you examine
her, you find that she seems alert, the skin
pinch goes back slowly, and her eyes are a
little sunken. Fely cries tears, but her mouth
and tongue are very dry. She drinks eagerly.
► Does Fely have signs of dehydration? If
yes, describe them.
► How much ORS solution should be given to
Fely?
► When should Fely be reassessed?
► When you reassess her, you find that she
is still quite thirsty. Her skin pinch goes
back quickly, her mouth moist, but her
eyes are still a little sunken. Fely has
passed several watery diarrhea while
being treated. What should you do now?
► Fely then starts to vomit at this time. What
should be done first?
► She continues to vomit frequently, and her
signs of dehydration are worsening,
though she is not yet severely dehydrated.
You are not able to give nasogastric
WEEK 1 Shelly |
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BLOCK A
Exam 1
treatment and the nearest hospital is one
hour away. What should you do now?
► At the hospital after intravenous treatment
of 4 hours, Fely looks much better. Her
eyes have filled out, the skin pinch goes
back quickly, and she has lost interest in
drinking the ORS solution. What should
you do?
VIII. PREPARATION OF ORS AND
COUNSELLING
DEMONSTRATION AND RETURN
DEMONSTRATION AND COUNSELING
Counsel the mother on the three rules of
home treatment:
1. GIVE EXTRA FLUID (AS MUCH AS THE
CHILD WILL TAKE).
► Tell the mother:
− Breast feed frequently and for longer
at each feed.
− If the child is exclusively breastfed,
give ORS or clean water in addition
to breastmilk.
− If the child is not exclusively
breastfed, give one or more of the
following: ORS solution, food based
fluids (such as soup, rice water, and
yoghurt drinks) or clean water
► It is especially important to give ORS
at home when:
− The child has been treated with Plan
B or Plan C during this visit.
− The child cannot return to a clinic if
the diarrhea gets worse.
− Teach the mother how to mix and
give ORS. Give the mother 2 packets
of ORS to use at home.
► Show the mother how much fluid to
give in addition to the usual fluid
intake.
− Up to 2 years: 50-100 ml after each
loose stool
− 2 years or more: 100-200 ml after
each loose stool
Tell the mother to:
− Give frequent small sips from a cup.
− If a child vomits, wait 10 minutes
then continue more slowly.
− Continue giving extra fluid until
diarrhea stops.
► For patients with some dehydration
(treatment Plan B), reassess the child
after four hours and classify the child
for dehydration.
2. CONTINUE FEEDING.
► Breast fed children should continue to
breastfeed throughout the episode of
diarrhea.
► After four hours if the child still has some
dehydration and ORS continues to be
given, give food every 3-4 hours.
► All children over six months should be
given some food before being sent home.
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 STUDY GUIDES OS 214
DIGESTIVE
DIGESTIVE MODULE WEEK 1 BLOCK A
Exam 1

This helps to emphasize to caretakers the

importance of continued feeding during
diarrhea.
► If the child is six months or older or
already taking solid foods, give freshly
prepared foods that are cooked, mashed,
or ground. The following are
recommended:
− Cereals or other starchy food mixed
with pulses, vegetables and meat or
fish, if possible with 1-2 tsps of
vegetable oil added to each serving.
− Complementary foods recommended
by Integrated Management of
Childhood Illnesses (IMCI) in the area.
− Fresh fruit juice or mashed banana to
provide potassium.

3. WHEN TO RETURN
► Immediately if the child becomes more
sick or is unable to drink or breastfeed or
drinks poorly or develops fever or shows
blood in the stool.
► If none of the above occurs but the child is
still not improving, advise the mother to
return for follow up at five days.

IX. RESOURCES/REFERENCES
1. Behrman RE et. al. (eds). 2004. Nelson
Textbook of Pediatrics. Philadelphia: WB
Saunders. 17th ed.
2. World Health Organization. Diarrhoea
Treatment Guidelines for Clinic-based
Healthcare Workers. 2005 (Handout)
3. Sio-Aguilar, J. Management of Diarrheal
Diseases in Children. (Handout)
4. Sio-Aguilar, J. Diarrheal Diseases in Children
(Supplemental Handout)

IX. EVALUATION
1. Written examination (part of the first long
exam for the Digestive Module)
2. Short quiz

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