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

2. Salient Features 2 yrs and 3/12 months PTA – Chronic Cough – Loss of appetite – Weight loss – Feverish sensation – Body malaise – Diagnosed with Pulmonary TB – Enrolled in DOTS and claims to have continuously undergone the program for 6 months – Claims to have been cleared by the doctorr – No record available

3. 8 months PTA – Colicky but tolerable abdominal pain (bloatedness) – Accompanied by abdominal distention that is relieved by passage of flatus or stool 4 weeks PTC – Vomiting of previously ingested food (1-2x/wk) – Progressed to intolerance of both solid and soft diet becoming almost daily – Abdominal distention more frequent and severe – Colicky pain localized in Right Lower Quadrant – Lost 20-30% of weight since last month

4. On Admission – Stable vital signs – Markedly hyposthenic – Evidence of fast muscle wasting – High risk of pulmonary complications – Nutrition is a compounding problem Nutrition – Decreased oral intake (short of starvation) due to vomiting – Only ate water,coffee and diluted bear brand. – Weak with poor hand grip – Underweight (BMI = 15.5)

5. Radiologic findings

6. ToolsPatientInterpretation Anthropometrics Mid-arm Circumference, Mid-arm mass Circumference, Triceps Skin Fold Height150cm Actual Body Weight35kg BMI15.6Underweight IBW (Height in cm) – 100) - Frame Assume: patient is medium frame = 5% Or 105 lbs/5 ft + 5 lbs/inch over 5 ft. 49.95 = 50 kgPatient is just 35 kg. 15 kg below the IBW % IBW (ABW/IBW) x 100% 70%Moderate malnutrition

7. Psychosocial Factors

8. Financial difficulties – Financial constraints for hospitalization and treatment Disruption of work or schooling – Adults won’t be able to work – Children may have to absent themselves

9. Unhealthy living conditions – Lack of ventilation – Substandard hygiene and sanitation – Population density Stigma – “Nakakahawa”

10. Primary Impression

11. Active Pulmonary TB and Gastrointestinal tuberculosis previous history of TB – No sputum AFB smear was done to see if the patient has really been cured – Possibility of relapse current symptoms and x-ray results – Fever, weight loss, etc. symptoms of obstruction: abdominal pain, anorexia, nausea and vomiting

12. Pathophysiology

13. Primary Infection Mycobacterium tuberculosis Inhalation of droplet Invasion of alveoli by bacteria, macrophages react Formation of Ghon (Primary) complex Granulomatous reaction to prevent spread of infection

14. Active Pulmonary TB Patient becomes immunocompromised Reactivation of primary infection Destruction and caseous necrosis of lung tissue Scarring and cavitation

15. From the lungs to the GI system… Ingestion of infected sputum Hematogenously: via lymph nodes (LN) Local spread of infection Inflammation and fibrosis of bowel walls and regional LN Necrosis of Peyer’s patches and lymph follicles Ulceration of mucosa Fibrosis and thickening of bowel wall OBSTRUCTION

16. Active Pulmonary TB and Gastrointestinal tuberculosis Mycobacterium tuberculosis Transmission: infected air droplets Primary infection: usually asymptomatic and latent. – bacteria reach the pulmonary alveoli and invade the macrophages – Formation of Ghon focus or complex – this granulomatous reaction serves to prevent the spread of the infection

17. Active Pulmonary TB and Gastrointestinal tuberculosis Patient becomes immunocompromised  reactivation Caseous necrosis – destruction and necrosis of the lung tissue – Scarring, cavitation

18. Active Pulmonary TB and Gastrointestinal tuberculosis Infection from the lungs  gastrointestinal tract – ingestion of infected sputum by patients with active TB – Hematogenously: lymph nodes – Local spread of infection

19. Active Pulmonary TB and Gastrointestinal tuberculosis In the GIT: – bowel walls and regional lymph nodes: inflammation and fibrosis. – necrosis of the Peyer’s patches and the lymph follicles  ulceration of mucosa  fibrosis  thickening of bowel wall  mass lesions – Symptoms of obstruction

20. Differentials

21. Lymphoma of the distal ileum Rule InRule Out bloating, abdominal pain, weight loss, vomiting, and occasional intestinal obstruction. It can also show symptoms of malabsorption Although partial small-bowel obstruction is the most common mode of presentation, 10% of patients with small-intestinal lymphoma present with bowel perforation. Contrast radiographs show stasis of the contrast can also present with blood loss in vomitus or while defecating Primary intestinal lymphoma accounts for ~20% of malignancies of the small bowel history of malabsorptive conditions (e.g., celiac sprue), regional enteritis, and depressed immune function due to congenital immunodeficiency syndromes, prior organ transplantation, autoimmune disorders, or AIDS Periumbilical pain made worse by eating patient’s radiographs do not show infiltration and thickening of the mucosal folds, mucosal nodules, or areas of irregular ulceration

22. Colon Cancer Rule InRule Out rate and severity of weight loss, as well as the evidence of muscle wasting are suggestive of malignancy rate at which the patient’s condition worsened may be too rapid to indicate a cancerous process Abdominal pain and intestinal obstruction are common clinical presentations Colorectal cancer usually develops in older patients aged around 65 patient does not present with rectal bleeding, changes in bowel habits, a palpable abdominal mass, hepatomegaly or ascites

23. Lipoma of the Distal Ileum Rule InRule Out common benign mesenchymal tumor, which frequently occurs in the distal ileum and at the ileocecal valve condition is usually asymptomatic, but may cause fecal bleeding, which is absent in the patient usually presents with generalized or colicky abdominal pain, vomiting, nausea and anorexia, which are all exhibited by the patient. intussusception is usually produced rather than a plain obstruction

24. Crohn’s Disease Rule InRule Out focal inflammation and fistula tract formation that eventually resolves by fibrosis and bowel stricturing  obstruction no reports of mucus, blood or pus in the patient’s stool; no fever or diarrhea presentation of Crohn’s Disease may mimic colonic tuberculosis and vice versa characteristic "cobblestone" appearance of CD was not exhibited on barium radiography patient is not dehydrated, but she shows signs of severe malnutrition: Malabsorption in Crohn’s more common in Europe, the United Kingdom, and North America. chronic history of recurrent episodes of abdominal pain patient does not fall within the usual age groups affected by the disease, which are those aged 15-30 and those aged 60-80, since the age of onset has a bimodal distribution Patient shows signs of obstruction

25. Diagnostics: Imaging Endoscopy – visualizing the intestinal tract – discovering the exact nature of the abnormality – obtain tissue sample for biopsy purposes – also has therapeutic benefits.

26. Diagnostics: Imaging Biopsy – Gold standard for GI-TB. – Tissue sample can be obtained through colonoscopy or ultrasound or CT-guided percutaneous fine needle aspiration cytology (FNAC). – also opt to do a laparoscopic biopsy. – Histological findings: epitheliod cell granulomas with a peripheral rim of lymphocytes and plasma cells Langhan’s giant cells and central casseating. Fibrosis and calcifications – in healing infections

27. Diagnostics: Imaging Abdominal CT scan – detect and clearly see any abnormalities in the patient’s abdominal area. – Features: irregular soft-tissue densities in the omentum low-attenuating masses surrounded by thick solid rims low-attenuating necrotic nodes disorganized appearance of soft-tissue densities multiloculated appearance after the intravenous administration of iodinated contrast material

28. Diagnostics: Lab Tests AFB Smear and Sputum Culture – Classic and standard – Grade A Recommendations (PSMID, 2006) – Identify the exact pathogen – Useful in suspected cases of MDR TB.

29. Diagnostics: Lab Tests Tissue culture and drug sensitivity test – important in cases of relapse or of suspected MDR-TB – TC: identification of the exact identity of the infectious pathogen – DST: enables the determination of the kind of drug the pathogen is sensitive to.

30. Diagnostics: Lab Tests Complete blood count – check for increased WBC titers which are indicative of an ongoing infection. – to detect any other blood abnormalities such as anemia, thrombocytosis or leucopenia.

31. Diagnostics: Lab Tests Electrolytes and Serum albumin – to determine if she needs to be infused with exogenous sources due to depleted levels. – The nature of the patient’s diet calls for an assessment of her nutritional status.

32. Treatment and Management

33. Stabilize the Patient Airway Breathing Circulation

34. Initial Relief Insert nasogastric tube – Decompress the stomach and keep it free from air and liquid – Relief of distension and vomiting Replace fluid and electrolyte loss and address the malnutrition

35. TOTAL ENERGY ALLOWANCE (Inpatient) Actual body weight x caloric factor Elective surgery caloric needs= 28-30 kcal/kg/day 35kg x 30kcal/kg= 1050 kcal/day

36. FLUID NEEDS Patient’s Weight: 35 kg 100cc/kg for the first 10kg100cc/kg x 10kg= 1000cc 50cc/kg for the second 10kg50cc/kg x 10kg= 500cc 20cc/kg for each additional kg20cc/kg x 15kg= 300cc 1000 cc + 500 cc + 300 cc = 1800 cc 1800 cc/day

37. PROTEIN NEEDS Protein Requirement: 2.5 kg/due to protein losses Weight x 2.5 g/kg/day 35kg x 2.5g/kg= 87.5 g Protein/day Using 10% amino acid solution (100g protein/L) 87.7/X ml= 100g/1000mL X= 875ml Give 875 cc of 10% amino acid solution per day

38. PROTEIN NEEDS Protein Requirement: 2.5 kg/due to protein losses Weight x 2.5 g/kg/day 35kg x 2.5g/kg= 87.5 g Protein/day Using 10% amino acid solution (100g protein/L) 87.7/X ml= 100g/1000mL X= 875ml Give 875 cc of 10% amino acid solution per day

39. FAT NEEDS Essential Fatty Acids Requirement: 2-4% Caloric Fat Needs: 1050 kcal/day x 0.04 = 42kcal Fat needed (in grams) 35kg x 2.5g fat/kg = 87.5g fat 588 kcal/week / 286 kcal fat = 2.06 bottles of 10% fat emulsion = 1000cc of 10% fat emulsion Give 1000 cc of 10% fat emulsion

40. CARBOHYDRATE NEEDS Carbohydrate Requirements: (INSERT COMPUTATION FOR CALORIES) CHO given as dextrose monohydrate (3.4kcal/g) 956kcal/ 3.4kcal/g = 281g dextrose Using D50W as starting solution: 281g/ X ml= 500g/ 1000mlL X = 562cc Give 562 cc of D50W per day as starting solution

41. TOTAL ENERGY ALLOWANCE (Outpatient) Actual body weight x caloric factor Caloric factor= 30 kcal/kg/day 35kg x 30kcal/kg= 1050 kcal/day

42. PROTEIN NEEDS Protein Requirement: 1.0 g/kg/day (Weight x 1.0 g/kg/day) = 35 g Protein in grams x 4 calories = 140 Calories 35 g Protein 140 Calories

43. CARBOHYDRATE NEEDS Carbohydrate Requirement: (60% to 70% of non-protein calories) (1050 – 140 Cal) x 0.7 =637 calories 637 calories/4 = 159.25 or 239 g CHO 239g Carbohydrates 637 Calories

44. FAT NEEDS Fat Requirement: (30% to 40% of non-protein calories) (1050 – 140 Cal) x 0.3 = 273 calories 273 calories/9 = 30.3 g Fats 30.3 g Fats 273 Calories

45. PARENTERAL NUTRITIONDAILY NEEDS TOTAL CALORIC REQUIREMENT: 1050 CAL 1800cc fluid 10% amino acid solution of 875cc D50W dextrose562cc 10% intralipid 750cc Add 70-150cc of fluid electrolytes, vitamins, and additives Total volume 2300cc TOTAL CALORIC REQUIREMENT: 1050 CAL Protein: 140 Cal 25 g Carbohydrate: 239 g 637 Cal Fats: 30.3g 273 Cal

46. Medical The patient is diagnosed to have active TB – Consider the possibility that patient now has drug resistant strain Patient was already treated with TB before which was allegedly resolved through chest xray – However, chest xray sometimes show clear findings even with infection – Enroll the patient in DOTS program again

47. Medical Empiric treatment while awaiting laboratory results DurationDrugsDosage 56 daysIsoniazid175 mg OD Rifampicin350 mg OD Pyrazinamide875 mg OD Ethambutol700 mg OD Streptomycin525 mg OD 28 daysIsoniazid175 mg OD Rifampicin350 mg OD Pyrazinamide875 mg OD Ethambutol700 mg OD 140 daysIsoniazid175 mg OD Rifampicin350 mg OD Ethambutol700 mg OD * Give Pyridoxine 875mg OD at night for patients with peripheral neuropathies

48. Medical If considering TB infection as relapse – Definition: previously treated with one full course of therapy under DOTS and has been declared cured but became smear positive again DurationDrugs 2 monthsIsoniazid, Rifampicin, Pyrazinamide, Ethambutol, and Steptomycin 1 monthHRZE 5 monthsHRE or (2HRES/1HRZE/5HRE) * Give Pyridoxine 875mg OD at night for patients with peripheral neuropathies

49. Medical Pre – treatment before surgery Refer to TB DOTS plus if MDR-TB

50. Surgical Laparotomy – Surgical resection of the affected segments (possibly the ileocecal segment)

51. Monitoring and Follow-up

52. Monitoring and follow-up The patient’s nutritional status should be constantly monitored The patient should be monitored whether reintroduction of oral feeding could already be tolerated Function of the resected segment of the intestine should be assessed Patient’s intake of TB medications should be monitored

53. Prevention

54. As an extension of the DOTS strategy, contract tracing should be done – Detect other cases and prevent further spread of TB infection – Targeted contact tracing among family members and close contacts of the patient

55. Prognosis

56. If patient is not treated with surgery and TB medications – Prognosis is poor – Possible drug resistant TB of the lungs which spread to the gastrointestinal tract to cause obstructive symptoms If patient is treated with surgery and TB medications – Prognosis may improve if surgery is done to relieve the obstruction and the patient can tolerate food again allowing improvement in the nutritional status – Drug resistant TB could still be resolved with the DOTS program for drug resistant strains.

57. Public Health

58. TB-DOTS program Government commitment Case detection by DSSM among symptomatic patients self-reporting to health services Standard short-course chemotherapy; complete drug taking through DOT supervised by DOTS facility workers during the whole course of treatment for all smear positive cases;

59. TB-DOTS program A regular, uninterrupted supply of all essential anti-tuberculosis drugs and other materials; and A standard recording and reporting system that allows assessment of case finding and treatment

60. Access to drugs In far flung areas, barangay health workers (BHWs) should be mobilized Make the BHWs as their treatment partners and they can go to the patients’ home

61. Strengthen Patient and Healthcare Workers Relationship patients perceive health care workers’ attitudes as harsh develop good rapport as they deal with patients, learn to befriend them and take the time to explain to them the importance of taking their medications regularly

62. Inform patients that improvement of their symptoms does not necessarily mean that they are totally free from infection explain that they must take the whole set of drugs and get a negative reading in the sputum smear exam before they are considered completely free of the disease

63. Partnership with Private Practitioners use of anti-TB drugs has also contributed to the development of MDR and XDR-TB all practitioners must refer all suspected and diagnosed TB patients to the DOTS program as recommended in the guidelines

64. Partnership with Private Practitioners create a referral system, which would assure that the physician who referred the patient to the nearest DOTS center would still remain the patient’s primary attending physician Private practitioners must also be trained

65. Restricting the availability of drugs problem of low quality drugs and the over availability of drugs has also resulted in the development of MDR-TB Leads to self medication Restrict over the counter selling

66. Improve quality of DOTS Personnel working in the DOTS centers need to be trained further Lack of workers in the centers causes other employees to burn out and tire easily give more incentives or more health benefits build partnerships with other organizations Research and volunteers

67. Improve compliance If family members are also not educated about the disease, then they would not be able to assist in reinforcing positive behavior like treatment compliance and lifestyle modifications. Widespread non-compliance to treatment and lack of education about tuberculosis could be major factors leading to low cure rates of the DOTS program.

68. Improve compliance providing transportation proper education of the patients and their families widespread, comprehensive, proper education program involving the whole country

69. Diagnosis and Proper Treatment Misdiagnosis of the condition or misclassification of the specific type of TB receiving inappropriate treatment lead to greater drug resistance.

70. MDR-TB resistant to both rifampicin and isoniazid Failure of completion of treatment leads to an increased incidence of MDR-TB or could even lead to the development of even more resistant strains of the bacteria, which would lead to higher rates of treatment failure.

71. Poor Case Reporting lead to inaccurate and incomplete data and statistics = lack of preparedness Strategy: increase the health seeking behavior of people Proper education

72. Management

73. McKinsey 7s and GAP Analysis

74. GOAL Control the TB burden in the Philippines

75. Strategy pursuing high-quality DOTS expansion and enhancement address TB-HIV, MDR-TB and the needs of poor and vulnerable populations contribute to health system strengthening based on primary health care engage all health care providers empower TB with and communities through partnership enable and promote research

76. Strategy STANDARDIZED TREATMENT – Yet with an individual touch Flexible and adaptable Patient treatment cards

77. Strategy NOW: People unaware of TB DOTS No good health seeking behavior Self medication and obtain treatment not from DOTS

78. Strategy PLAN: Mobilize media to educate and inform people: – facts about TB and its treatment – diagnosis and treatment is free Policies to address the factors associated w/ TB – poverty – lack of education – poor living conditions

79. Strategy NOW: Noncompliant private health providers PLAN: Continuous education and retraining of the private sector Better reimbursement from Philhealth Expansion of existing programs

80. Strategy NOW: No research and development PLAN: Research and development committee/ team

81. Structures DOHLGU DOTS Clinic LGU DOTS Clinic

82. Structure DOH – Provide standardized training – Central control – Where everyone reports to LGUs – Reports to DOH – Inspects DOTS clinics

83. Structure DOTS Clinic – Provides treatment and follow-up – TBDC (TB Diagnostic Committee) – Quarterly reports The centralization of the DOTS program is essential to their success – Explicit lines of communication

84. Structures NOW: Different management styles therefore different performance among DOTS clinics PLAN: Better communication and sharing of management techniques

85. Style Overall leadership: DOH – Trains everyone – Everyone reports to them Difference in management in individual DOTS clinics Dedication and teamwork

86. Style No Gaps Good leadership by the DOH

87. Shared values Dedication Team-work

88. Shared Values NOW: No written core values PLAN: Explicitly state core values of the program

89. Systems Main: DOH – Supplies drugs and equipment – Provides training – Implements rules

90. Systems NOW: Needs and issues of employees PLAN: Stronger human resource system be developed

91. Systems NOW: Poor documentation (slow) and communication PLAN: Use of technology for reporting and evaluation

92. Systems NOW: Insufficient networking between physicians and their DOTS referred patients PLAN: A program where physicians may be able to network, follow up their referrals in DOTS clinics

93. Skills Technical skills – DOH training Procedural competency

94. Skills NOW: Limitation of employee knowledge Poor patient relationship skills PLAN: Retraining and continuing medical education among the employees Invest on human resources Evaluation of staff by patients (external customer satisfaction survey)

95. Staff Nurse and med tech Trained by the DOH Dedication Teamwork Underpaid

96. Staff NOW: Poor attitude of staff towards patients PLAN: Invest on human resource through better pay and benefits Evaluation by patients

97. Financial Analysis More cost efficient to treat people early DALYs = lose P 8B per year

98. Pulmonary TB Treatment Generic DrugPrice per tabletTotal (8 months) Myrin P forte Dosage: (Ethambutol(275mg), Rifampicin (150mg), Isoniazid (75mg), Pyrazinamide (400mg)) P11.24P8,304 MyrinP-P15 (Rimstar) Dosage: (Ethambutol 275mg, Rifampicin 150mg, Isoniazid 75mg, Pyrazinamide 400mg) P11.75P5,640

99. Gastrointestinal TB Treatment Surgical – Open Surgery (Excision) – P120,000-P150,000 – Laparoscopic – P220,000 Medical – Pre-operation treatment (3 mos) - P2,115 – Post-operation treatment (12 mos) - P8,460

100. Please refer to the paper for the balanced scorecard for now