Submission to Rajiv Gandhi University of Health Sciences

SYNOPSIS

“STUDY OF GASTROINTESTIONAL MANIFESTATIONS IN

DENGUE FEVER”

Name of the candidate : Dr. Sumuk.M.S

Guide : Dr. Rajesh S

Course and Subject : M.D. General Medicine

Department of General Medicine,

A.J. INSTITUTE OF MEDICAL SCIENCES,

Kuntikana, Mangalore – 575004

1 2013

1. Name of the candidate

& address:

(in block letters)

2. Name of the Institute:

3. Course of study and Subject: M.D. GENERAL MEDICINE

4. Date of admission to course: 8 th JUNE 2013

5. Title of the Topic: “ STUDY OF GASTROINTESTIONAL

MANIFESTATIONS IN DENGUE FEVER”

2 BRIEF RESUME OF THE INTENDED WORK:

6.1 Need for the study:

Dengue infection is a major health problem in worldwide including our country. Globally the incidence of dengue has grown dramatically in the recent years. The WHO estimates that presently about two fifths of the world population is at risk for this virus infection.3 Dengue fever can cause several gastrointestitional manifestations which are hepatitis, pancreatitis, acaculous cholecystitis and peptic ulcer disease.4 Therefore this study is undertaken as gastrointestional manifestations play a role in outcome of dengue fever.

6.2 Review of literature:

A study was done on gastrointestinal manifestations in dengue showed that gastrointestional manifestations are very common in dengue patients. Presence of abdominal pain and tenderness, gastrointestinal bleed, jaundice, hepatomegaly and ascites can be used to triage patients requiring intensive care.1 Gastrointestinal symptoms of dengue was studied in mexico which showed that Abdominal and gastrointestinal symptoms were present in 67% of patients. The most frequent symptom was nausea (n=4453, 52%), followed by abdominal pain (n=3058, 36%), vomiting (n=2477, 29%), diarrhea (n=1471, 17%), hepatomegaly, (n=144, 2%), gastrointestinal bleeding (n=34, 0.3%) and ascites (n=8, 0.1%).2 Analysis of dengue fever patients in a study revealed that in addition to the classical features of fever, body ache, rash, thrombocytopenia and bleeding tendency, there were other features such as liver dysfunction including a preferential rise of SGOT, hepatosplenomegaly, ascitis,

3 pleural effusion and leucopoenia.3 A etiology based study of abdominal pain in dengue fever showed that The various causes of pain abdomen diagnosed in patients with DF were: acute hepatitis, acalculus cholecystitis, acute pancreatitis, appendicitis, spontaneous bacterial peritonitis, enteritis, peptic ulcer disease and gastric erosions in 20 (36.4%), 9 (16.4%), 8 (14.5%), 3 (5.45%), 2 (3.63%), 8 (14.54%), 2 (3.63%) and 3 (5.45%)of the patients respectively.4 A study done on ultrasound findings in dengue fever showed that The ultrasound findings in early milder form of DF include GB wall thickening, pericholecystic fluid, minimal ascites, pleural effusion, pericardial effusion and hepatosplenomegaly. Severe forms of the disease are characterized by fluid collection in the perirenal and pararenal region, hepatic and splenic subcapsular fluid, pericardial effusion, pancreatic enlargement and hepatosplenomegaly.5 A study done in brazil showed that the average values for the rise in aspartate aminotransferase and alanine aminotransferase were 93.3 U/L and 86.0 U/L. The greatest alterations were observed among females (p<0.001), cases of dengue hemorrhagic fever (p<0.001), and cases with sequential infections (p=0.001). Liver damage with elevation of aminotransferases and reactive hepatitis was a common complication of dengue virus infection in dengue fever patients.6

A study was done in jakarta which showed that The majority of patients with DHF and epigastric pain do not have an enlarged pancreas, different echogenicity of the pancreas compared with the liver, or a dilated pancreatic duct. Thus, pathologic changes of the pancreas cannot be the only cause of epigastric pain in DHF patients. Increased serum levels of amylase and lipase are commonly seen in patients with severe DHF and an enlarged pancreas.7

6.3 Objectives of the study:

 To study incidence of various gastrointestional symptoms in dengue fever.  To study incidence of various gastrointestional signs in dengue fever.  To correlate the signs and symptoms with various investigations in dengue fever.

4 7. Material and methods:

7.1 Source of data.

It will be a prospective hospital based study. All enumerated dengue fever patients in the age group of 18 – 50 will be considered for the study.

7.2 Method of collection of data (including sampling procedure, if any)

This study will be conducted as a prospective Clinical study, wherein written informed consent will be taken prior to the investigation after detailed information given to the participants regarding the study. Dengue fever patients will be screened for gastrointestional manifestations through history, detailed examination and correlated through lab investigations.

Sample and sampling technique:  Study design: prospective clinical study.  Set-up: The AJ Institute of Medical Sciences.  Study Period: 2 year study.  Age group: 18 to 50 years.  All enumerated dengue patients during the study period will be considered for the study.

5 Study type: two year prospective study.

Inclusion criteria:

 All adult patients with diagnosis of dengue fever by dengue spot test being admitted in A J Institute of Medical Sciences .

Exclusion criteria:  Patients having mixed infections.  Patients having alcohol intake for 10 years or more.  Patients having underlying systemic illness  Patients who are having chronic history of drug intake.

Plan for data analysis: The various measures of central tendencies and graphical representations will be used to

analyze the data. Data collected will be analyzed by frequency, percentage, mean, standard deviation (S.D), paired 'f' test, chi-square tests.

6 7.3 Does the study require any investigations or interventions to be conducted on patients or other humans or animals? If so, please describe briefly.

This study requires the following investigations: • Blood investigations • Routine investigations like complete haemogram, platelet count, dengue spot, urine routine, RBS, serum electrolytes, MPFT, liver function tests, renal function tests, USG abdomen and pelvis, serology[hiv / hbsag / hcv],and serum amylase. • Tests done when required like leptospiral test, widal test.

7.4 Has ethical clearance been obtained from your institution in case of 7.3?

7 8. References:

1. Ooi ET, Ganesananthan S, Anil R, Kwok FY, Sinniah M. Gastrointestinal manifestations of dengue infection in adults. Medical Journal of Malaysia. 2008 Dec;63(5):401-5. 2. Ramos-De La Medina A, Remes-Troche JM, González-Medina MF, Anitúa- Valdovinos Mdel M, Cerón T, Zamudio C, et al. Abdominal and gastrointestinal symptoms of Dengue fever.[ Analysis of a cohort of 8559 patients]. Journal of Gastroenterology and Hepatology. 2011 Apr;34(4):243-7. 3. Vaibhav Shukla Ashok Chandra. A Study of Hepatic Dysfunction in Dengue. Journal of association of physicians of india. July 2013. Vol.61. 4. S. Khanna, J.C. Vij, A. Kumar, D. Singal and R. Tandon. Etiology of Abdominal Pain in Dengue Fever. Dengue Bulletin. 2005 Dec ;29:85-89. 5. P M Venkata Sai, B Dev, and R Krishnan. Role of ultrasound in dengue fever. British Journal of Radiology. May , 2005 Vol 78, 416-418. 6. Souza LJ, Alves JG, Nogueira RM, Gicovate Neto C, Bastos DA, Siqueira EW, et al. Aminotransferase changes and acute hepatitis in patients with dengue fever: analysis of 1,585 cases. Brazilian journal of infectious diseases. 2004 Apr;8(2):156-63. 7. Setiawan MW, Samsi TK, Wulur H, Sugianto D, Pool TN. Epigastric pain and sonographic assessment of the pancreas in dengue hemorrhagic fever. Journal of clinical ultrasound. 1998 Jun;26(5):257-9.

9. Signature of the candidate:

10. Remarks of the guide

8 11. Name and Designation of (in block letters):-

11.1 Guide:

11.2 Signature:

11.3 Head of Department:

11.4 Signature:

12. Remarks of the Chairman and Principal:

12.2 Signature: