Case 8: Mr.

Miah’s watery stools

Body in Health

o Anatomy (innervation, blood supply, lymphatic drainage)/ histology/function of (what is

absorbed in) large intestine
o Anatomy: the large intestine can be spilt into four parts: ascending, transverse,
descending and sigmoid. These sections form an arch, which encircles the small
intestine. It averages around 150 cm in length.
 Ascending Colon: retroperitoneal structure that ascends superiorly from the
caecum, to the transverse colon at the right colic flexure (beneath the liver)
 Transverse colon: this extends from the right colic flexure to the meet the
descending colon at the left colic flexure, underneath the spleen. The
transverse colon is the least fixed part of the colon, and is variable in
position. It is intraperitoneal and is attached to the posterior abdominal wall
by the transverse mesocolon.
 Descending colon: after the left colic flexure (is much further back than the
right colic flexure), the colon moves inferiorly towards the pelvis. It is
retroperitoneal, passing anterolaterally to the left kidney.
 Sigmoid Colon: the colon turns medially and it becomes the sigmoid colon. It
extends from the left iliac fossa to the level of the S3 vertebra. The sigmoid
colon is attached to the posterior pelvic wall by a mesentery – sigmoid
mesocolon
 Blood Supply: superior mesenteric artery (ascending colon and proximal 2/3
of the transverse colon) and inferior mesenteric artery (distal 1/3 of the
transverse colon, descending and sigmoid colon)
 Innervation: The innervation to the colon is dependent on embryological
origin:

 Midgut-derived structures (ascending colon and proximal 2/3 of the

transverse colon) receive their sympathetic, parasympathetic and
sensory supply via nerves from the superior mesenteric plexus.
 Hindgut-derived structures (distal 1/3 of the transverse colon,
descending colon and sigmoid colon) receive their sympathetic,
parasympathetic and sensory
supply via nerves from the inferior
mesenteric plexus:
o Parasympathetic innervation via
the pelvic splanchnic nerves
o Sympathetic innervation via the
lumbar splanchnic nerves.
o Histology: large intestine lacks plicae circulares,
villi and microvilli. Instead it has dips called crypts
made of simple columnar epithelium and large
amounts of goblet cells. Within the submucosa are
aggregations of lymphoid tissue. Instead of the
 usual long continuous longitudinal muscle, there are inconsistencies as the
longitudinal muscle is split into three ribbons called tenae coli
o Function: The colon is part of the large intestine, the final part of the digestive
system. Its function is to reabsorb fluids and process waste products from the body
and prepare for its elimination. It stores waste, reclaims water, maintains water
balance, absorbs certain vitamins (like vitamin K), and provides for flora-aided
(mostly bacterial) fermentation
o How are water and ions reabsorbed in the large intestine?
o Water, as always, is absorbed in response to an osmotic gradient. Sodium ions are
transported from the lumen across the epithelium by virtue of the epithelial cells
due to the sodium/glucose pump. The colonic epithelium is actually more efficient at
absorbing water than the small intestine and sodium absorption in the colon is
enhanced by the hormone aldosterone.
o Chloride is absorbed by exchange by co-transportation with Na+ and K+.
o The resulting secretion of bicarbonate ions into the lumen aids in neutralization of
the acids generated by microbial fermentation in the large gut.
o In addition to water and electrolytes, the large intestine efficiently absorbs short-
chain or volatile fatty acids.
o Goblet cells are abundant in the colonic epithelium, and secrete mucus in response
to tactile stimuli from lumenal contents, as well as parasympathetic stimuli from
pelvic nerves. Mucus is an important lubricant that protects the epithelium, and also
serves to bind the dehydrated ingesta to form faeces
o What is the process of egestion?

o What is the normal appearance of faeces?

o Normal faeces are roughly 75% water and 25% solids. The bulk of faecal solids are
bacteria and undigested organic matter and fibre. The characteristic brown colour of
faeces is due to stercobilin and urobinin, both of which are produced by bacterial
degradation of bilirubin. Faecal odour results from gases produced by bacterial
metabolism, including skatole, mercaptans, and hydrogen sulfide.
o What are normal blood pressure/haemoglobin conc. / specific gravity (of urine and
plasma)?
o Normal blood pressure: below 120/80 – 140/90 mmHg> Blood pressure is the
measure of force that your heart uses to pump blood around the body
o Normal Haemoglobin Concentration:
 For Men: 13.5 – 17.7 grams per dL
 For Women: 12.0 – 15.5 grams per dL
o Normal Specific Gravity: this test compares the density of urine to the density of
water. Urine that’s too concentrated could mean the kidneys aren’t function
properly or not enough water is being consumed. Normal specific gravity is ideally
between 1.002 and 1.030

Body in Disease

o What is cholera and how is it spread?

o What is it: this is a water-borne infection that can cause severe diarrhoea
o Distribution: You can catch cholera from:
  Drinking unclean water
 Eating food (particularly shellfish) that’s been in unclean water
 Eating food that’s been handled by an infected person
o Bacterium: cholera is caused by infection of the intestine with the toxigenic
bacterium Vibrio cholera. It is a highly motile Gram-negative, comma-shaped rod
bacterium. They are facultative anaerobe with flagellum at one end as well as pili
o Symptoms:
 Dehydration
 Nausea and vomiting
 Diarrhoea: often appears pale and milky
o Risk Factors:

 Poor sanitary conditions. 

 Reduced or nonexistent stomach acid (hypochlorhydria or achlorhydria).

Cholera bacteria can't survive in an acidic environment, and ordinary
stomach acid often serves as a first line defense against infection. But
people with low levels of stomach acid — such as children, older adults, and
people who take antacids, H-2 blockers or proton pump inhibitors — lack
this protection, so they're at greater risk of cholera.

 Household exposure. 

 Type O blood. For reasons that aren't entirely clear, people with type O
blood are twice as likely to develop cholera compared with people with
other blood types.

 Raw or undercooked shellfish

o Complications:

 Low potassium levels (hypokalemia): this can interfere with heart and nerve
function

 Low blood sugar (hypoglycaemia): this can cause seizures, unconsciousness

and even death

 Kidney (renal) failure: When the kidneys lose their filtering ability, excess
amounts of fluids, some electrolytes and wastes build up in your body — a
potentially life-threatening condition. In people with cholera, kidney failure
often accompanies shock.

o What are the causes/symptoms/risk factors of dehydration?

o Rapid heart rate
o Loss of skin elasticity (lax skin)
o Dry mucous membranes (e.g. mouth, eyes, throat, etc.)
o Low Blood Pressure
o Thirst
o Muscle cramps
o What are the causes of diarrhoea and constipation?

Procedures, Treatments and Professional Concerns

o What are the immediate and long-term treatments for cholera (catheter/oral
rehydration)?
o Immediate:
 Rehydration: this is to replace lost fluids and electrolytes orally
 Intravenous fluids: severely dehydrated people may also need intravenous
fluids of electrolytes and fluids
 Antibiotics: this is to get rid of the bacteria causing the cholera, thus
reducing the duration of illness
o Long-term:
 Zinc-treatment: this has been shown to help improve cholera symptoms
(especially in children)
o What is tetracycline and what does it do/ structure/ uses/ spectrum?
o What is it: it is a family antibiotics used to treat a number of infections e.g. acne,
syphilis, malaria, etc. It works by blocking the ability
of bacteria to do protein synthesis
o Spectrum: it is a broad spectrum antibiotic.
Originally they exhibit activity against a wide
range of microorganisms, both anaerobic and
aerobic Gram-negative and Gram-positive bacteria.
Tetracycline resistance now occurs in an increasing number of pathogenic,
opportunistic, and commensal bacteria.
o What are the pros and cons of a rubber dam?
o Pros:
 Most effective method of isolation
 Provides aseptic operating field, isolating the tooth from saliva
contamination
 Enables the use of strong medicaments e.g. in tooth whitening and root
canal treatment
 Protects the patient from the inhalation or ingestion of small items
o Cons:
 Time consuming
 Patient may feel suffocated with rubber dam placed
o What are white filling materials and their pros and cons?
o Pros:
 Less healthy tooth tissue needs to be removed
 Direct adhesion to tooth tissue
 Better aesthetics
o Cons
 More technique sensitive
 Needs complete fluid isolation
 Has post-operative shrinkage
 Low strength compare to enamel
o What are the infection control procedures?
o What are the appropriate control procedures to prevent spread of disease? Namely cholera