Nonspecific Diarrhea Research Articles

Evaluation of rational drug use in primary healthcare centres of Probolinggo District, Indonesia

Background: The Indonesian government has been working on optimising drug use in primary healthcare centres (puskesmas) of the Probolinggo District Health Office (dinkes). Objective: This study aimed to evaluate the rationality of drug use (RDU) using indicators set by the Indonesian Ministry of Health. Method: A retrospective descriptive study was conducted using data from 33 Puskesmas in Probolinggo Dinkes during the year 2022. Data on patients diagnosed with Acute Respiratory Infection (ARI) non-pneumonia (n = 36,378), non-specific diarrhoea (n = 4,291), and myalgia injection cases (n = 9,641) were collected. Result: The study's findings showed that the percentage of antibiotics for ARI was 17.11%, meeting the standard. Of the 33 Puskesmas, 67% met the standard, while 33% did not. Meanwhile, the antibiotic used for non-specific diarrhoea was 9.58%, exceeding the tolerance limit, with 55% of Puskesmas meeting the standard and 45% not. The percentage for injectable drugs in myalgia cases was 0.43%, in line with the standard, with 82% of Puskesmas meeting the standard and 18% not. Conclusion: The study found that antibiotic usage for ARI and injections for myalgia met the standards, but for non-specific diarrhoea cases did not.

QbD approach for developing Fast-dissolving Tablets containing Loperamide hydrochloride using Super Disintegrant Blends and Subliming Materials

Mouth dissolving pills, which dissolve or disintegrate quickly on the tongue or buccal cavity, have been developed in response to the growing demand for more patient-compliant dosage forms. It is utilized to improve bioavailability by reducing dose frequency in order to reduce adverse effects and make tablets with high first-pass metabolism more cost-effective. The most commonly used drug for diarrhoea is loperamide hydrochloride. It is an opioid receptor agonist that targets the mu opioid receptors in the large intestines of the myenteric plexus. It specifically works by lowering myenteric plexus activity, which lowers the motility of the circular and longitudinal smooth muscles of the intestinal wall. It is a synthetic anti-diarrheal that is used to treat the symptoms of inflammatory bowel disease-related chronic diarrhoea as well as acute, non-specific diarrhoea. Due to substantial hepatic first-pass metabolism, loperamide hydrochloride has a very limited systemic bioavailability. Therefore, the primary goal of the study was to develop Loperamide hydrochloride orally disintegrating tablets to obtain a better breakdown rate, enhance the drug's bioavailability, and provide very rapid relief from diarrhoea. The pre-compression parameters, such as bulk density, compressibility, angle of repose, etc., for orally disintegrating tablets manufactured by direct compression and using three super disintegrants, croscarmellose sodium (CCS), Microcrystalline cellulose (MCC), and sodium starch glycolate (SSG), were prepared and assessed. The manufactured batches of tablets passed tests for satisfactory results. The highest amount of medicine was released at all-time intervals in the optimised formulation, which also displayed a favourable release profile.

Bowel Necrosis in the Setting of COVID-19 Infection, Report of 2 Cases

Severe respiratory syndrome coronavirus 2 (SARS-CoV-2) is well known for causing respiratory and other extrapulmonary manifestations. Patients infected with coronavirus disease 2019 (COVID-19) may demonstrate atypical presentations with gastrointestinal symptoms. Clinicians managing these patients should reserve a high index of suspicion for the rare complication of acute mesenteric ischemia (AMI). It is a challenging diagnosis that is often missed when presenting symptoms are subtle and nonspecific like nausea, emesis, or diarrhea. Outcomes are typically catastrophic and fatal as bowel ischemia progresses to necrosis but may be averted with timely diagnostic and therapeutic methods to swiftly restore blood flow.

Antibiotic Use in Patients with Non-Specific Diarrhea at Tilongkabila Health Center, Bone Bolango Regency in 2023

Antibiotics that are not used wisely can trigger resistance problems. According to the World Health Organization (WHO), every year more than 1.27 million people worldwide die due to resistance to antimicrobials. The tolerance limit for prescribing antibiotics in patients with non-specific diarrhea according to WHO prescribing indicators is 8%. This study aims to determine the use of antibiotics in patients with non-specific diarrhea at the Tilongkabila Health Center. This research method uses a quantitative approach. Data was taken retrospectively with descriptive analysis. The results of the study showed that the use of antibiotics for patients with non-specific diarrhea was 10.6% with the dominant type of antibiotic used being amoxicillin at 63.2%. It was concluded that the use of antibiotics for patients with non-specific diarrhea at the Tilongkabila Health Center was not rational because it exceeded the prescription tolerance limits set by WHO.

Repurposing of Loperamide as a New Drug With Anticancer Activity for Human Osteosarcoma.

Osteosarcoma is an aggressive malignant bone tumor, with unfavorable outcomes in patients with metastatic and recurrent disease. To improve patient survival new treatment options are needed. By using the drug repurposing approach, which takes advantage of already approved drugs with non-oncology primary use, we investigated the activity of loperamide, a peripheral opiate receptor agonist, a drug widely used in clinical practice to treat acute non-specific and chronic diarrhea, on human osteosarcoma. Human osteosarcoma cell lines (143B, Saos-2, HOS and MG-63) and multidrug-resistant MG-63DXR30 cells were treated with loperamide. Proliferation and cell viability were determined by viable cell count and acid phosphatase assay. Loperamide activity on cell cycle and apoptosis induction were evaluated by flow cytometry and a luminescence assay testing caspase 3/7 activity, respectively. Loperamide significantly inhibited cell proliferation, through alteration of cell cycle profile at G0/G1 phase and apoptotic death in human osteosarcoma cells. Furthermore, loperamide significantly inhibited the growth of multidrug-resistant osteosarcoma cells. Our findings provide new perspectives for loperamide and its therapeutic repositioning for the treatment of osteosarcoma.

Evaluation of Rationality of Drug Use Based on National Rational Drug Use Indicators at Paal Lima Public Health Center Period January – March 2023

Background: World Health Organization (WHO) estimates that more than half of all drugs in the world are prescribed, dispensed and sold in an inappropriate manner and half of patients use drugs inappropriately, thus enabling irrational drug use. If the drug is used irrationally, it can have a negative impact. The purpose of this study was to evaluate the rationality of drug use at the Paal Lima Public Health Center for the period January - March 2023 based on the National Rational Drug Use (POR) indicator.
 Method: This study used an observational method with retrospective data collection, namely prescription data for non-pneumonic acute respiratory infections (ARI), non-specific diarrhea, and myalgia during the period January - March 2023. The data were analyzed descriptively by calculating the use of antibiotics, injections, and the average drug items which were then displayed in percentage form. There were 509 prescriptions for non-pneumonic acute respiratory infections (ARI) cases, 74 prescriptions for non-specific diarrhea cases, and 120 prescriptions for myalgia cases.
 Result: The results of the study showed that for the period January - March 2023 it was found that the use of antibiotics in cases of non-pneumonic acute respiratory infections (ARI) was 19.65%, the use of antibiotics in cases of non-specific diarrhea was 35.14%, the use of injections in cases of myalgia was 0%, and the average number of drug items per prescriptions of 3.68 items.
 Conclusion: Overall, the rationality of drug use at the Paal Lima Public Health Center has not met the requirements, so it needs to be improved.

An Unusual Case of Loperamide Toxicity in a Neonate - A Case Report

Introduction: Loperamide is an antidiarrheal agent approved by the Food and Drug Administration for the treatment of various forms of diarrhea in adults, including traveler’s diarrhea, irritable bowel syndrome associated with chronic diarrhea, and acute nonspecific diarrhea in patients 2 years of age and older, and reducing ileostomy output. The drug has, however, been shown to be toxic at therapeutic doses and causes serious cardiac adverse reactions, central nervous system (CNS) effects such as decreased level of consciousness, coordination abnormality, muscular hypertonia, miosis, respiratory depression, urinary retention, paralytic ileus, abdominal distension, and fecal impaction in infants and toddlers. Methods: We report an unusual case of suspected loperamide toxicity in a 22-day-old baby who presented with respiratory and CNS depression after consuming a single therapeutic dose of loperamide. Results: The neonate’s respiratory depression was attributed to ingestion of loperamide, prescribed by a local quack, as all other causes were ruled out. There was a significant improvement in the baby’s respiratory efforts after IV naloxone, an effective antidote. Conclusion: Special caution should be taken when administering loperamide to pediatric patients due to their greater variability in response. Loperamide is often given by local quacks as a nonprescription medicine for immediate relief, even to infants and toddlers, without complete knowledge about its potential side effects at therapeutic doses. To address this, it is imperative that strict measures should be taken.

EVALUATION OF QUALITY OF CLINICAL PHARMACEUTICAL SERVICES AT PATTALLASSANG HEALTH CENTER IN TAKALAR DISTRICT

One of the government's efforts to realize health development for the community is to create a Community Health Center (Puskesmas). The Puskesmas is responsible for providing comprehensive, integrated and sustainable first-level health service activities. Pharmaceutical care (pharmaceutical care) has undergone a paradigm shift from initially only focusing on drug management (drug oriented) to developing into services that also aim to improve the quality of life of patients (patient oriented). Standard clinical pharmacy is very important to note because it is directly related to patients so that it can have an impact on reducing the length of patient care and reducing therapy costs. 74 of 2016. This research is a quantitative descriptive study using observational data and retrospective data at the Pattallassang Health Center in Takalar District. Based on the results of the study, it was found that the percentage of conformity of the quality of clinical pharmacy services at the Pattallassang Health Center, Takalar Regency, based on Permenkes Number 74 of 2016, was 38.88% in the unfavorable category. This is because there are 11 assessment indicators (prescription review, labeling, delivery accompanied by information, polypharmacy, counseling, drug information service documentation, visit documentation, MESO documentation, PTO documentation, drug costs per prescription visit, and number of items per prescription) that do not meet standards and for those that meet there are 7 indicators (time to prescribe, generic preparations, use of antibiotics in non-specific diarrhea, ORS and zinc for diarrhea, antibiotics in ARI, injections and patient satisfaction) out of 18 research indicators.

Calf diseases at Jhenaidah district, Bangladesh: Epidemiological status with relation to age and season

In Bangladesh calves are affected by several types of diseases and most of them are parasitic, infectious, metabolic or nutritional, surgical affection etc. causing severe economic losses in every year. The study was conducted to investigate the epidemiological status of calves’ diseases with relation to age and seasonal variation at Jhenaidah district, Bangladesh. A total of 12525 clinical cases were registered in all 6 Upazila of Jhenaidah district for the clinical diagnosis and therapeutic purposes during a period of two years, which were analyzed to evaluate the prevalence of clinical diseases in calves. Each of the clinical case was diagnosed on the basis of history, general examination, physical examination and clinical findings. Among the recorded cases the highest prevalence of clinical cases in calves were found to be round worm infestation ( 14.80%), and followed in descending order by non-specific diarrhoea ( 9.20 %), liver fluke infestation ( 8.34%), anorexia ( 7.95%), lice infestation ( 6.66%), debility (6.42%), wounds (4.68 %), tick infestation (3.93 %), tape worm infestation (3.54%), non-specific fever & navel ill (3.42%), coccidiosis (3.35%), conjunctivitis (3.16%), FMD (2.83%), pneumonia (2.49%), allergy/skin disease (2.30%), coldness (2.06%), tympany/bloat (1.71%), calf-scour (1.61%) etc. Among the general clinical disorder, the highest prevalence of clinical cases was non-specific diarrhoea (9.20%), among parasitic disease the highest prevalence was round worm infestation (14.80%), among infectious disease the highest prevalence was coccidiosis (3.35%), among surgical affection the highest prevalence was wound (4.68%). The influence of age and season on the occurrence of these diseases was considered. Immuno prophylaxis and hygienic management should be introduced to curtail the prevalence of calf diseases and disorders. So more epidemiological and intensive laboratory study should be needed to confirm the etiology, prevention and control measures of the diseases and disorders in cattle at the study area. Res. Agric. Livest. Fish. Vol. 10, No. 2, August 2023: 189-197

TREATMENT OF GIARDIASIS IN DOMESTIC CATS

Giardiasis is a disease caused by Giardia sp. a protozoan which infects the small intestine causing non-specific diarrhea in humans and other mammals. This article aims to help readers find out the causes of giardiasis in cats, and how to treat cases of giardiasis in cats. A 1-year-old queen named Qaqa that weighs 2.15 kg had suffered diarrhea for a month. Previously, the cat had been given an antidiarrheal drug called Guanistrep which helped in reducing the frequency of diarrhea but after finishing the drug, the diarrhea recurred. Clinical examination showed the cat experience inflammation on the anus, slow capillary refill time (CRT), and increased body temperature but there was no indication that the cat was dehydrated. Examination of the feces found the presence of the protozoa Giardia sp. The Hematological examination of the cat indicates leukocytosis, monocytosis, and granulocytosis. The cat was diagnosed with Giardiasis. The therapy given is the administration of Metronidazole, Nutria Gel Plus, and Guanistrep which all were given orally. Two weeks after the administration of the medication, the frequency of the cat's defecation decreased and the feces had a solid consistency. To avoid Giardia sp. infection, owners need to be educated on how to properly care for their cat’s by providing drinking water with mineral water and limiting the interaction with wild animals, as well as maintaining the cleanliness of the cat's residence, especially where the cat eats and drinks.

Proposal for a new pharmaceutical form based on orodispersible tablets for therapeutic optimization and treatment of non-specific acute diarrhea in the operating area

Proposal for a new pharmaceutical form based on orodispersible tablets for therapeutic optimization and treatment of non-specific acute diarrhea in the operating area

Complicated appendicitis wrongly diagnosed as nonspecific diarrhea: ways to decrease this continuous threat

The diagnostic assessment of right lower quadrant pain in children and adolescents is still a challenge. The aim of this study was to analyze the cases of complicated appendicitis wrongly diagnosed as nonspecific diarrhea, and based on the information obtained suggest a clear and simple policy in order to decrease misdiagnosis in the future. Three groups of patients were analyzed: children who underwent appendectomy (group 1); those with gastroenteritis (group 2), and those who underwent appendectomy following hospitalization under the wrong diagnosis of gastroenteritis (group 3). Group 3 presented a more prolonged and complicated clinical course, higher fever, diffuse abdominal pain, repeat vomiting, higher C-reactive protein values, longer surgery duration and recovery. When the etiology of right lower quadrant abdominal pain is not immediately evident and associated with atypical diarrhea, high fever, repeat vomiting, and significantly increased CRP values, early surgical consultation is required. If the clinical findings are unclear, an abdominal US should be performed as soon as possible. A limited abdominal computed tomography scan CT should follow those cases not resolved by history, physical examination, blood tests, and abdominal ultrasound.

Effect of a Commercially Available Electrolyte Solution on Acute, Non-Specific Diarrhea in Dogs

Purpose: To determine if a commercially available electrolyte solution is safe and lessens the duration and severity of diarrhea in shelter dogs in stressful situations. Methods: In Experiment 1, six healthy beagles were administered the protocol-approved dose of the electrolyte solution to evaluate clinical, biochemical, or fecal microbiome changes. In Experiment 2, 22 dogs with small or large bowel diarrhea were randomized into one of three groups: the electrolyte solution and a prescription veterinary diet, a placebo and a prescription veterinary diet, or the electrolyte solution and a standard diet. A fecal score was assigned by trained, masked observers through Day 5 using the Purina 7-point fecal scoring system. All dogs were screened for enteric parasites by fecal flotation and the use of a fluorescence antibody assay for Giardia spp. cysts and Cryptosporidium spp. oocysts and all dogs that were parasitized were administered fenbendazole for five days. Results: In Experiment 1, all dogs tolerated the electrolyte solution with no vomiting or diarrhea noted and there was no evidence of negative effects on the gastrointestinal microbiome. In Experiment 2, 16 of the 22 dogs enrolled in the study had a normal stool the day after the first dose of the electrolyte solution, prescription diet, or placebo. All six dogs with the first day of normal stool detected after Day 1 were parasitized. When the days to normalcy were compared, the parasitized dogs had a significantly slower resolution (P = 0.018) than dogs with no parasites regardless of the other treatment group. Conclusions and Relevance: The results of the study suggest that this electrolyte solution is safe for use in dogs and that adding the electrolyte solution to a standard diet is equivalent to using a therapeutic diet alone or the electrolyte solution combined with a therapeutic diet.

562: A RARE CASE OF LISTERIA MONOCYTOGENES PRESENTING AS SEPTIC SHOCK

Introduction: Listeria Monocytogenes (L. Monocytogenes) is a gram-positive intracellular bacterium that enters the host by ingestion of contaminated foods. Listeriosis is challenging to diagnose, however diagnosis is crucial given the mortality rate in severe disease. We describe a case of a 26-year-old pregnant female who presented to the hospital in shock secondary to L. Monocytogenes bacteremia. Description: 26-year-old Hispanic female, 18 weeks pregnant, presented with fevers, right flank pain, nausea, and vomiting. Vitals on admission were: temperature 104.7 °F, BP 86/49 mmHg, HR 140s, and RR 40s. She was started on Vancomycin, Cefepime, and Metronidazole. Despite 4 Liters of IV fluids, she remained hemodynamically unstable, requiring admission to the medical ICU for inotropic support. Labs were notable for hyponatremia (130), transaminitis (AST 80, ALT 93), normal WBC (10.9) with significant bandemia (26%). Urine analysis was negative. Ultrasound abdomen showed renal fullness. Azithromycin, Ampicillin, and Acyclovir were added empirically. After 24 hours, blood cultures became positive for gram-positive bacilli, and ultimately L. Monocytogenes was identified in multiple specimens. Ampicillin was continued and patients hemodynamics improved. Discussion: L. Monocytogenes is an intracellular pathogen that initially encounters the gut mucosa and invades the blood and lymphatic system, traveling directly between cells, thus avoiding T-cell immunity, complement, and antibodies. Listeriosis has an annual incidence of 2.4 per 1 million in the US, most commonly affecting the elderly, pregnant women, neonates, and immunocompromised individuals. Pregnant women have a 16-18-fold increased risk of infection, and pregnant Hispanic women are at 24 times increased risk. Noninvasive listeriosis is often self-limiting, and may be associated with nonspecific symptoms like diarrhea, fever, myalgias, and headaches. Invasive listeriosis, on the other hand, has a mortality rate of 20-30% and can cause septicemia, meningitis, and in pregnancy, miscarriage, or stillbirth. L. Monocytogenes, although rare, has severe implications for both mother and fetus. In addition to the obstetrics population, critical care providers must have a high index of suspicion to prevent, diagnose, and treat patients for L. Monocytogenes.

Lactobacillus acidophilus Supplementation Restores Gut Epithelial Integrities and Barrier Functions in Non-specific Diarrhea

Objectives: The study was aimed to evaluate the roles of Lactobacillus acidophilus supplementation in maintaining intestinal epithelial integrities, tight junction proteins, and adhesion molecules in non-specific diarrhea.
 Methods: In this study, we used the pre-weaned BL/6 pups (3 weeks of age, same litters) as a model animal. We supplied the non-sterilized and poor-quality water to experimental pups (n=7) to develop non-specific diarrheic symptoms. Then diarrheic pups were supplemented with Lactobacillus acidophilus (LA) for three consecutive weeks. The control group (n=5) was supplied with sterilized water and no LA. The sampling and analysis were performed on day 0, day 7, day 14, and day 21. The expressions of pro-inflammatory cytokines (IL-6, TNF-a) and tight junction proteins (TJPs) of gut mucosa were determined using qRT-PCR. And the serum cytokines level was screened through sandwich ELISA.
 Results: The intestinal cytoskeletal integrity becomes disrupted and characterized by lower ZO-1, Occludin, Claudin-1, Claudin-5, and JAM mRNA expressions upon real-time qRT-PCR. However, Claudin-4 was found to be not affected and illustrated with a higher expression like control pups. Interestingly, supplementing Lactobacillus acidophilus was found to maintain gut integrity and effectively reduce diarrheic symptoms. Like the control pups, the Lactobacillus acidophilus supplemented pups exhibited a higher expression of gut epithelial TJPs and adhesion molecules. Moreover, the diseased pups produced significantly increased IL-6, and TNF-α production in blood serum, compared to control BL/6 pups. 
 Conclusion: We concluded that L. acidophilus supplementation might orchestrate the equilibrium of gut health and immunity against non-specific diarrhea.

Effects of COVID-19 on poultry and livestock health in Bangladesh

Background: Poultry and livestock are a leading sub-sector of agriculture, playing an important role to fulfill the protein requirements of the human diet and contributing to the national economy in Bangladesh. This sub-sector is often vulnerable due to frequent outbreaks of diseases in animals and unrest situations worldwide that hamper earning a profit up to the expected mark. Due to pandemic COVID-19, the Bangladesh government was bound to announce a countrywide lockdown and periodical restriction of movement in March 2020 to minimize the spread of the infection. This study aimed to evaluate the impact of COVID-19 on poultry and livestock health. Methods: This study was conducted at Keshabpur, Jashore before 3 months of lockdown, during lockdown and periodical restriction of movement in Bangladesh. Data on livestock and poultry were collected from the upazila livestock office register book. The impact of Covid-19 was calculated by comparing the number of animals brought to the veterinary hospital for treatment before, during, and after lockdown. Results: The effect of COVID-19 was most severe in the poultry and livestock sub-sector from April to May 2020, as animals were not being advised or treated at the upazila livestock office and veterinary hospital. In poultry, Newcastle disease, parasitic infestation, duck plague, and pigeon pox were mostly recorded, whereas deficiency diseases, non-specific diarrhea, non-specific fever, and endoparasitism were frequently recorded in livestock. We do not know exactly how many poultry and livestock died due to failure of management and treatment during the period of lockdown, but certainly, COVID-19 hampered the health of animals and farmers were affected due to the outbreak of the pandemic COVID-19. Conclusion: It might be concluded that the pandemic situation significantly hampered poultry and livestock health in Bangladesh.

The Clinicopathological Differences of Colon Cancer in Young Adults Versus Older Adults.

Purpose: Colon cancer is the third-most common and fatal cancer, with a mean age of onset >65 years. In recent years, there has been an increase in the number of cases of colon cancer in young (CCY) patients. This study investigates the biological behavior and epidemiological features of CCY and older adults in our area. Methods: Eighty-one patients (19 young adults <40 years old and 62 older adults ≥40 years old) were admitted to the General Surgery Clinic of the Constanta Emergency Hospital for colon cancer between January and December 2018. The biological behavior and epidemiological characteristics of the two groups were compared. Results: The group of young patients was characterized by finding the diagnosis on an average of 6-9 months after the onset of the first symptom, in a more advanced stage of the disease (73.69%); the onset of symptoms being nonspecific (diarrhea 26.32%, weight loss 21.05%, constipation 21.05%, and bloating 21.05%) and initially treated in a benign context, without the recommendation of additional specific explorations. The time between the onset of symptoms and the diagnosis established in the category of patients ≥40 years of age was on an average of 3-6 months, with most patients being diagnosed in the early stages of the disease (62.9%). Conclusions: Improving health education through colon cancer information programs should be implemented with information on alert symptoms and indications on the steps that a symptomatic patient should follow and no longer ignore his or her symptoms, because health is not necessarily the prerogative of youth.

Evaluasi Pengelolaan Obat dan Bahan Medis Habis Pakai di Puskesmas Kota Kupang serta Strategi Pengembangannya

The management of drugs and disposable medical supplies in healthcare units greatly affects the quality of healthcare services. However, the management is still not carried out optimally because it is not up to the standard. The Hanlon method is a basic priority rating system (Brief Priority Rating Scale, BPRS) which is used to compare health problems with relative and objective to identify factors that must be considered in determining a priority. This study aimed to describe and measure the efficiency of drugs and disposable medical supplies management in Healthcare Centers in Kupang City by using efficiency indicators and to develop the strategy using the Hanlon method. The design of this research is a descriptive quantitative-qualitative combination using retrospective and concurrent data. The sampling technique used was a total sampling of 11 Healthcare Centers in Kupang City, while the object of the study was the management of drugs and disposable medical supplies which were assessed using efficiency indicators. The results of research on the management of medicines and consumable medical materials at 11 Healthcare Centers in Kupang City have not been carried out efficiently because not all indicator values reached the standard, namely the suitability of drug items with DOEN and FORNAS, conformity of items received, the accuracy of planning, items expired or damaged, items that were not prescribed for 3 months, the level of availability of the drug, the percentage of drugs with generic names, use of antibiotics in patients with non-specific diarrhea and the average item per prescription sheet. Therefore it can be concluded that the management of drugs and disposable medical supplies in 11 Healthcare Centers in Kupang City using indicators at the selection, procurement, distribution, and use stages are not yet according to standards and the proposed improvements are proposed as a management development strategy, namely optimizing planning according to the needs of the health center, monitoring stock. and expiration date and conduct regular learning and growth of all human resources.

P-BN05 Solitary jejunal diverticulum: a rare unexpected cause of chronic pneumoperitoneum

Abstract Background Jejunal diverticula are rare acquired herniation of the mucosa and submucosa through the muscularis propria. They are asymptomatic in the majority of cases, however, they can present with non-specific abdominal symptoms and rarely complicate leading to acute abdomen. Perforation usually results in symptoms and signs of acute peritonitis and it is not an identifiable aetiology of chronic pneumoperitoneum. Computed tomography scan may identify intestinal wall oedema, air bubbles travelling through the mesentery, free intra-abdominal air and/or fluid . Radiological diagnosis requires high index of suspicion of such pathology. We report a case of an isolated jejunal diverticulum as a cause for aseptic chronic pneumoperitoneum . Methods A 77-year-old female was referred to the ambulatory emergency surgical unit (AESU) with a 4-month history of nonspecific abdominal pain, considerable weight loss, diarrhea, nausea and a few episodes of vomiting.Physical examination revealed no constitutional signs of sepsis and her abdomen was mildly distended but soft and nontender to palpation. Laboratory investigations were unremarkable. CT scan of her abdomen and pelvis on her first visit showed pneumoperitoneum with associated low volume ascites, which raised the possibility of sealed gastrointestinal perforation. In the absence of any clear signs of sepsis, a strategy of ambulatory, conservative management and follow up was chosen. Four months after her initial presentation our patient presented with ongoing vague abdominal symptoms with weight loss and failure to thrive. A CT colonogram described pneumoperitoneum and larger volume of ascites is in comparison to the previous CT scan. There was an unusual pattern of mural gas in some loops of small bowel in the left side of the abdomen that suggested pneumatosis. MDT decided to proceed with diagnostic laparoscopy. Results Laparoscopy exploration revealed odorless pneumoperitoneum, moderate amount of non-turbid bile stained serous ascites and thin fibrinous covering. We identified a jejunal diverticulum associated with mesenteric air bubbles and moderately enlarged reactive feeling lymph nodes in the diverticular segment . A small bowel resection with a primary side-to-side anastomosis, washout of the abdomen and cholecystectomy were done through a Kocher’s subcostal incision. She made an uneventful post-operative recovery and was discharged home well on day 4. Histopathological examination of the resected specimens confirmed the presence of a ruptured isolated jejunal diverticulum with a breach in muscularis propria and chronic cholecystitis in the gallbladder. Conclusions In summary, our case report highlights the importance of being aware of the possibility of perforated jejunal diverticula as a possible source of chronic pneumoperitoneum causing chronic nonspecific abdominal pain, diarrhea and unexplained weight loss. The surgical option of segmental resection and primary anastomosis was beneficial in this patient. However, calculating the risk benefit ratio remains the mainstay of the management plan, which, as ever, should be tailored to each patient’s general condition and fitness with appropriate counselling and consent.

PENGARUH RASIONALITAS PENGGUNAAN ANTIBIOTIK TERHADAP PROGRAM PENGGUNAAN OBAT RASIONAL (POR) DI PUSKESMAS SAMBI REJO KABUPATEN LANGKAT TAHUN 2020

Background: Rational drug selection is the key to quality health services. Improper use of antibiotics is one of the irrational uses of drugs and causes various health problems such as bacterial resistance and economic and social impacts. This study aimed to determine the pattern of antibiotic use against indicators of rational drug use in Sambi Rejo Public Health Center, Langkat Regency. Methods: The research method was carried out descriptively by retrospective data collection. Data on the use of antibiotics for the indicator of rational drug use is obtainable from the Rational Drug Use report data for the period January - December 2020, while data on pharmaceutical services was obtained in January - February 2021. The results of the study: The results showed that the use of antibiotics for indicators of rational drug use was Respiratory Tract Infection. The number of non-pneumonia was 28.33%, non-specific diarrhea was 46, 17 and the mean of drug items per prescription was 3.75 drug items. The results of research with in-depth interviews, participant observation and documentation study show that pharmaceutical services at the Sambi Rejo Health Center have been running quite well. The study concluded that pharmaceutical services at the Sambi Rejo Health Center have been running quite well, while the implementation of the rational drug use program at the Sambi Rejo Health Center has not been going well with the high use of antibiotics against indicators of rational drug use set by WHO.