CISAK 2013 C4/P/37

Porridge Feeding as Nutritional Management of

Typhoid Fever: Take it or Leave it?
Fia A. Mutiksa1, Mentari1, Trivanie S. Elona1 and M. Sadikin2
1

Faculty of Medicine, University of Indonesia

Salemba Raya Street Number 6, Jakarta, Indonesia
2

Department of Biochemistry and Molecular Biology, Faculty of Medicine, University of Indonesia

Salemba Raya Street Number 6, Jakarta, Indonesia
1

fiaafifahmutiksa@yahoo.com
2
msadikin@fk.ui.ac.id

Abstract. Typhoid fever is a systemic disease caused by a bacterium named Salmonella typhi and some presentations include fever,
malaise, abdominal pain, and diarrhea. This illness is a big problem in the developing countries. In Indonesia, the prevalence of
typhoid fever is 358-810/100,000 people in 2007. The flourished paradigm in Indonesian citizens is porridge feeding as nutritional
care for someone suffers from typhoid fever. This literature review has some purposes to reanalyze the paradigm from the point of
view of anatomy, histology, biochemistry, and immunology as well as giving some breakthrough for the management of typhoid fever
after analyzing. This paper is written as the review from previous studies by reading text books, medical journals, and official medical
websites. After assessing the anatomy and histology, long consumption of porridge may be the account of intestinal muscle disuse
atrophy, change of intestinal mucosal layer that are composed by the shortening of the intestinal villi and decreasing mucosal mass,
shortening of intestinal crypt, and cause luminal starvation. The changes of anatomy and histology will affect biochemical and
immunological function. The amount of Na+ in membrane will be decreasing due to the changing of mucosal layer. This case will be
dropping the carbohydrate and protein absorption. Infection and colonization of Salmonella will increase when the stomach is filled
more by fine food than coarse one. Based on those facts and arguments, we obtained some conclusion that the paradigm in Indonesian
citizens about feeding the typhoid fever patients with porridge as the nutritional care is not proper. Some problem solving we submit
is a modified management for typhoid fever by controlling the time of proper food intake.
Keywords: typhoid fever; porridge; nutrition; time modification.

A. INTRODUCTION

B.

Typhoid fever is one of diseases that have high prevalence in

the developing countries. The incidence of typhoid fever is 358810/100,000 populations in Indonesia. Around 64% of cases
attacked people with age 3-19 years old. Worldwide, the
prevalence of typhoid fever is 2.16 million cases in 2000, and
216,000 people are reported to be dead due to this illness [1].
The etiologic agent of typhoid fever is Salmonella typhi
infection. The transmission is through contaminated water or
food. Large epidemics are most often related to fecal
contamination of water supplies or street vended foods. Some of
presentations of typhoid fever include malaise, headache,
diarrhea, abdominal pain, red spots on the chest, spleen and liver
enlargement [2]-[9]. Nutrition intake must be concerned as the
management of typhoid fever to treat the injured intestine. The
flourished paradigm in Indonesian citizens is to treat typhoid
fever patients by porridge feeding. This paper is written to
reanalyze and assess the point of view of anatomy, histology,
biochemistry, and intestinal immunology in determining whether
porridge feeding is proper or not as a nutritional care.

1.

BODY
Structures of Intestine

Gastrointestinal tract has four basic layers; they are

mucosa, submucosa, muscularis externa, and serosa.
Mucosal layer consists of simple columnar brushhelium,
lamina propria as the loose connective tissue with lymphoid
follicles, and muscular mucosa which is a simple smooth
muscle functioning of mucosa movement. Second layer is
submucosa, a layer of aerolar connective tissue that consists
of blood vessels, lymph, lymphoid follicles, and nerve
fibers. Third one is muscularis externa with an inner
circular smooth muscle and an outer longitudinal smooth
muscle layer. Lastly, serosa layer consists of areolar
connective tissue covering by a single-layered squamous
cell named mesothelium [10].
Small intestine is the primary organ in digestive system
and divided by three sections. Section one is duodenum, a
25 centimeters long tube that surrounds the pancreas. Second
one is jejunum with 2.5 meters long, and the last is ileum
with 3.6 meters long. The small intestinal wall is covered
by numerous folds and divided by three structures; circular

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mucosa and submucosa as high as 1 cm, finger-shaped villi as

high as 1 mm, and microvilli which are the part of villi
forming the brush border [10].
Villus is a single-layered columnar cell that binds each other
with tight junction and rich in microvilli. Intestinal crypt is
located among villi and has a function to secrete mucus for
absorbing nutrients. Inner part of the crypt, there are Paneth cells
that produces antibacterial enzyme called lysozyme. Moreover,
stem cells can be found in the crypt and will be specialized into
certain cells in villi. Payers patches are found in lamina propria
of mucosa layer and have function to prevent the entrance of
bacteria into blood circulation [10].

Considering the changes of intestinal structures, nutrition

intake which is recommended is the one without irritating
the ulcerated intestinal surface, containing chemical
products that might worsen the intestinal condition with
the result that the digestive process is well-maintained.
Porridge is the food that has already been decayed before
entering the intestine with the purpose that the food become
the primary nutrition care for the typhoid fever patients.

3.

Impact of Porridge Feeding: Anatomically

Analyzed

a.

Fig.1. Structures of intestine

2.

Porridge Feeding

Generally, oral nutritional care for patients with typhoid

fever is fine food and easily digested. Thus, distention of
abdomen or ileum will not occur. Porridge is an example of finestructured and semi-solid food. Porridge feeding for typhoid
fever patients is based on some of the intestinal changes due to
Salmonella typhi, they are degeneration of the intestinal brush
border, and hypertrophy of Payers patches. Certainly, the
purposes of intestinal are agitated, and may not digest and
absorb nutrition optimally. If typhoid fever occurs for the long
time, it will decrease the quality and quantity of digestive
secretion, weaken the circulation, accumulate the waste
products, and impair normal metabolism of the body.
Intestinal ulceration in typhoid fever will affect the Peyers
patches in the ileum, the jejunum or even the colon. The
intestine may be slender until the muscularis layer and appear
perforation to the serosa layer. Due to the ulceration, the
intestine does not function so well that react to the process of
digestion and absorption [14].

Muscularis Layer
Food enters the body through the mouth. Then, it will
flow through the esophagus, and reach the gaster. The kinds
of food that you have will influence the process of gastric
emptying. High carbohydrate food causes the process of
gastric emptying more rapid than the one contains protein and
lipid. After having the digestive process in the gaster, the
food will go to the duodenum. The presence of food will be
sensed by duodenal osmoreceptors that affects the gastric
emptying [11], [14], [15]
The porridge is the food with high carbohydrate, and
low protein and lipid. Furthermore, the fine structure of
porridge will lead the duodenal content becoming more
hypoosmolar than the coarse foods influence to the duodenal
content. This case may trigger to increase the gastric
emptying [15]
Duodenum senses the food, and triggers the changes of
calcium ion in the cytosol then induce ATP phosphorylation
in order to form the cross bridges by actins and myosins so
that the segmentation movement will occur. If the gastric
emptying happens more rapid, the duodenum will receive
the food more rapid also. This condition will lead to the
fast segmentation movement. The rapid movement causes the
food reach the colon earlier with the result that the intestine
becomes empty. Porridge feeding for a long time will
increase the risk of abridging the segmentation movement
period that minimizes the smooth muscle contraction. If this
condition occurs continuously, it will lead to muscle disuse
atrophy [15], [16].
b. Mucosal Layer
The innermost layer of the small intestine has villi for
the absorption process. These villi have columnar cells to
secrete the digestive protein (glycoprotein, disaccharidase,
enterokinase, phosphatase). There are brush border for
absorption on the apical surface of the villi. Moreover, the
villi have goblet cells to produce mucus for inducing food
clearance and becoming the primary defense against
microbes in the food. The microbes will be accumulated in
the mucus layer and killed via the peristaltic movement [17][19].
According to the research by Hedemann et al, it states
that food consumption with particle size less than 2 mm could

CISAK 2013 C4/P/37

trigger the shortening villi. Proven with clinical trial on pigs

that showed the different result of the given food with particle
size > 5 mm and < 2 mm. The pigs that consumed food with
the particle size > 5 mm had villi with 527 m long; whereas
food consumption with the particle size < 2 mm would
shorten the villi and the pigs villi were 442 m long. Coarse
food that you usually consume, have the particle size more
than 5 mm and porridges one is less than 2 mm. Thus, the
porridge consumption for a long time will induce the
shortening process of the villi [20].
The shortening villi cause the lessening columnar and goblet
cells that the absorption and defense process against microbes
will diminish. The reduced absorption process will lead to the
accumulated nutrients in the lumen. Therefore, the accumulation
of microbes will occur because of the lessening goblet cells that
produce mucus [20].
c. Crypt
In the intestine, there is a structure named crypt. The
epithelial cells of crypt serve as secretory cells which secrete the
intestinal juice. It is a watery mixture that contains mucus and
serves as carrier fluid for absorbing nutrients from the chyme.
As on the villi, mucus has function as the defense against
microbes [10].
Research by Hademann et al and Brunsgaard also shows that
coarse food (the particle size is > 5 mm) would cause the
increasing crypt depth (449 12 m in pigs). Let us compare to
the consumption of fine food that would decrease the crypth
depth (420 12 m in pigs). This increasing crypt depth
indicates the activity of the epithelial cell proliferation. Growth
of epithelial cells is stimulated by short-chain fatty acids which
are degradation products of unabsorbed starch and fibers
(Scheppach, 1994). Butyric acid is one the colon cells
substrates. A research by Mikkelsen et al states that the pigs
been given the coarse food had the colon with high
concentration of butyric acid [20].
Porridge that has fine structure certainly will not increase the
crypt depth so that the absorption and defense mechanism will
weaken [20].

membrane [10].
Brush border (microvilli) produces an enzyme called
disaccharidase that functions to break down the disaccharide
for becoming monosaccharide. For example, lactose will be
broken down by disaccharidase for becoming two units of
glucose. There is a transporter for hexose facilitated diffuse
named sodium-dependent glucose transporter or SGLT in the
brush border [15], [20], [22].
As the previous explanation, fine food will cause the
changes of anatomy structure i.e. the shortening villi. This
condition will also affect the structural changes of brush
border and the disruption of disaccharidase secretion and
hexose transport. One of the examples is the disruption that
occurs in breaking down the lactose. The unabsorbed lactose
will go to the colon and be fermented by bacteria (hydrogen,
carbon dioxide, and methane). Moreover, lactose will
increase the osmotic pressure in the colonic lumen. This
condition will upgrade the water secretion into the lumen
that cause diarrhea. The diarrhea indeed will worsen the
symptoms that are experienced by the typhoid fever patients
[15], [20], [22].
Jorgensen et al in 2002 performed the experiment on the
pigs and obtained a result that the prevalence of Salmonella
would decline when the pigs were given the coarse food.
The next research which is done by Mikkelsen et al in 2004
found that the pigs which are given the coarse food, the gaster
would act as the barrier to reduce the bacterial pathogen.

d. Luminal Starvation
Porridge consumption for a long time causes luminal
starvation in the small intestine. The consequences of this
condition are atrophy of intestinal mucosa, flat villi, reduction of
absorption level, and immunology interference. The immunology
interference will increase the translocation of bacteria.
Absolutely, it will worsen the condition of the patients with
typhoid fever [20].

4. Impact of Porridge Feeding: Biochemistrically and

Immunologically Analyzed
Biochemically, the point which is focused is the absorption.
The absorption process is a process of absorbing the food
nutrients and this process takes place from the intestinal lumen
to the blood vessels through the structure named brush border.
The brush border is the part of the intestinal villi apical

Fig 2. Effects of porridge feeding on typhoid fever patients

anatomically, hitologically, biochemistrically, and immunologically
analyze

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This research may be applied in humans. The moment

that the patients of typhoid fever are consuming the
porridge, the gastric function as the barrier will be not
happening well so that the probability of infection and
colonization by Salmonella increases [20], [22].

5. Solution
Based on our analysis, porridge feeding is not a proper
nutritional management for typhoid fever. We suggest a new
solution for nutritional care of typhoid fever patients named time
modification of food intake. It is a regulation of food intake
based on intestinal working time.
Intestine absorps food approximately in 3 to 5 hours. People
suffers from typhoid fever should eat something every 5 hour
because of the absorption time consideration. Coarse food
should be fed to the patients and absolutely, the given food is the
coarse food that usually healthy people consumes. Within 5
hours, typhoid fever patients must avoid consuming the coarse
food. This aims to improve the food metabolism and intestinal
clearence.
If the patients feel hungry within 5 hours, they can eat fine
food or liquid food. This kind of food will not produce residues
in the intestine. This way helps relieving the intestinal working
so the damage may decrease [23]-[28].

C. CONCLUSION
Porridge feeding as the nutritional management of typhoid
fever is not proper. If we analyze anatomically, histologically,
biochemistrically, and immunologically, porridge feeding can
interfere the physiologic function of the gastrointestinal tract of
the patient. A breakthrough for nutritional management of
typhoid fever is time modification of food intake. Patients
should eat coarse food every 5 hours. If the patients feel hungry
within 5 hours, they are allowed to be given fine food or liquid
food. This modification of food intake can improve patients
health.

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[20]

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