Acute Gastroenteritis in Childhood

Diarrhoea in the 21st Century

Second most common cause of morbidity and mortality worldwide WHO estimation (2002), diarrhoeal disease results in:
2.5 million people die annually, mostly children 1.6 million children <5yrs old (in developing countries)

 In the U.S.
211-375 million episodes of diarrhoeal disease occur annually 73 million physicians consultations 1.8 million hospitalization Over 3000 death

What is Diarrhea?
Excessive loss of fluid and electrolyte in the stool frequency of bowel movements form of stool (greater looseness of stool) Voluminous vs lower volume diarrhea

Mechanisms of Diarrhea
Mechanism Secretory Defect
Decreased absorption, increased secretion, electrolyte transport

Stool Exami
Watery, normal osmolality; osmoles = 2 (Na+ + K+)

Examples
Cholera, ETEC; carcinoid, VIP, neuroblastoma, congenital chloride diarrhea, Clostridium difficile, cryptosporidiosis

Comment
Persists during fasting; bile salt malabsorption may also increase intestinal water secretion; no stool leukocytes

Osmotic

Maldigestion, transport defects ingestion of unabsorbable

Watery, acidic, and reducing substances; increased osmolality; osmoles >2 (Na+ + K+)
Loose to normalappearing stool, stimulated by gastrocolic reflex Loose to normal appearing stool

Lactase deficiency, glucose-galactose malabsorption, laxative abuse

Stops with fasting; increased breath hydrogen with carbohydrate malabsorption; no stool leukocytes
Infection may also contribute to increased motility Possible bacterial overgrowth

Inc motility

Decreased transit time

IBS, thyrotoxicosis, postvagotomy dumping syndrome Pseudoobstruction, blind loop

Dec motility

Defect in neuromuscular unit(s) Stasis (bacterial overgrowth)

Dec surface area

Decreased functional capacity

Watery

SBS celiac disease, rotavirus enteritis

May require elemental diet plus parenteral alimentation Dysentery evident in

Inflammation,

Blood and increased

Salmonella, Shigella,;

Chronic diarrhoea
Generally lasts > 2 weeks Common causes:
IBS AIDS bacterial outgrowth of small int. Colon cancer Crohns disease

Acute diarrhoea
lasts a few days or up to a week

IMPORTANT !!! distinguish between acute and chronic diarrhea >>>different diagnostic tests, different

Common Causes of Acute Diarrhoea

Infection highly contagious
Viral gastroenteritis (stomach flu) Usually explosive watery

Typically last 48-72hrs

Usually no blood and pus in stool Rotavirus

Bacterial enterocolitis
Sign of inflammation blood or pus in stool, fever

E. Coli bacteria
Contaminated food or water
Usually affect small kids

Bacterial enterocolitis
Sign of inflammation blood or pus in stool, fever

Salmonella enteritidis
In contaminated raw or undercooked chicken and eggs

Bacterial enterocolitis
Sign of inflammation blood or pus in stool, fever

Shigella bacteria

Campylobacter bacteria

Parasites

Cryptosporidium in contaminated water can survive chlorination

Giardia lamblia in contaminated water Usually not associated with inflammation

Common Causes of Acute Diarrhea

Food Poisoning
Brief illness cause by toxins from bacteria (+) abdominal pain, vomitting Cause SI secrete high amnt of water Some bacteria produce toxins Symptoms usually appear within hours

 Food Poisoning

Staphylococcus aureus Produces toxins before it is eaten Usually unrefrigerated food

 Food Poisoning

Clostridium perfringens Multiplies in food Produces toxins in SI after food is eaten

Common Causes of Acute Diarrhea

Travellers Diarrhea Drugs / medications

Etiology
Enteropathogens
Non-inflammatory vs. inflammatory diarrhea
Non-inflammatory
Enterotoxin production Destruction of villi Adherence to GI tract

Inflammatory
Intestinal invasion Cytotoxins

Etiology
Chronic diarrhea
Infectious causes
Giardia lamblia Cryptosporidium parvum Escherichia coli
Enteroaggregative enteropathogenic

Non-infectious causes
Anatomic Malabsorption Endocrinopathies neoplasia

Immunocompromised host

Etiology
Bacterial
Inflammatory diarrhea
Aeromonas Campylobacter jejuni Clostridium dificile E. coli: enteroinvasive, O157:H7 Plesiomonas shigelloides Salmonella Shigella Vibrio parahaemolyticus Yersinia enterocolitica

Etiology
Bacterial
Non-inflammatory
E. coli
Enteropathogenic enterotoxigenic

Viral
Rotavirus Enteric adenovirus Astroviruus Calcivirus Norwalk CMV HSV

Vibrio cholerae

Etiology
Parasites
Giardia lamblida Entamoeba histolytica Strongyloides stercoralis Balantidium coli Cryptosporidium parvum Cyclospora cayetanensis Isospora belli

Diagnosis
History Stool examination
Mucus Blood Leukocytes Stool culture

Diagnosis
Examination for ova and parasites
Recent travel to an endemic area Stool cultures negative for other enteropathogens Diarrhea persists >1 week Part of an outbreak Immunocompromised May require examination of more than one specimen

Complications of Diarrhea
Dehydration
Excessive loss of fluids and minerals (electrolytes) Common in infants and young children with viral gastroenteritis or bacterial infection Kidney failure, eg in infection by E.coli

Electrolyte deficiency Irritation to anus due to frequent passage of watery stool containing irritating substances

When Treatment is Needed?

Severe or prolonged episode of diarrhea Fever Repeated vomiting refusal to drink fluids Severe abdominal pain Diarrhea with blood or mucus

When Treatment is Needed?

Sign of dehydration
Dry, sticky mouth Few or no tears when crying Sunken eyes Lack urine or wet diaper Dry, cool skin Fatigue or dizziness

Dehydration: Mild
Symptoms of include:
Increased thirst. Dry mouth and sticky saliva. Reduced urine output with dark yellow urine.

Moderate dehydration
Symptoms of include:
Extreme thirst. Dry appearance inside the mouth No tears

Decreased urination Urine is dark amber or brown. Lightheadedness that is relieved by lying down. Irritability or restlessness. Arms or legs that feel cool to the touch. Rapid heartbeat. Muscle cramps.

severe dehydration
Symptoms:
Altered behavior
severe anxiety Confusion not being able to stay awake.

lightheadedness that continues after standing for 2 minutes. Inability to stand or walk. Rapid breathing. Weak, rapid pulse. Cold, clammy skin or hot, dry skin. Little or no urination for 12 hours or longer. Loss of consciousness.

Tests for Acute Diarrhoea

Measurement of BP in upright and supine post
demonstrate orthostatic hypotension

Moderate severe diarrhea do blood electrolytes Stool sxamination

Treatment
Antibiotics or antiviral medications are not always prescribed for cases of diarrhea Antibiotics may be given to very young children or children with weak immune system parasitic infection antiparasitic medicine

 Salmonella
Cefotaxime, ceftriaxone, ampicillin, TMP/SMZ Infants < 3 months Typhoid fever Bacteremia Dissemination with localized suppuration

Shigella
Ampicillin, ciprofloxacin, ofloxacin, ceftriaxone

Vibrio cholerae
Doxycycline, tetracycline

 Aeromonas
TMP/SMZ Dysentery-like illness, prolonged diarrhea

Campylobacter
Erythromycin, azithromycin

Clostridium dificile
Metronidazole, vancomycin

E. coli
TMP/SMZ

Treatment cont.
Oral rehydration solutions (ORS)
Contain carbohydrate (glucose or rice syrup) and electrolytes (Na, K, Cl, citrate, HCO3-) Infants and children
Infants with mild dehydration ORS at home (with doctor recommendation) Infants with moderate severe dehydration, IV fluids at hospital Avoid caffeine and lactose containing product

ORS
In 2003, WHO/UNICEF reduced osmolarity decreased stool output less vomiting

Treatment
Zinc supplementationdecreases duration and severity of diarrhea prevent chronic diarrhea promote absorption in GUT restore epithelial proliferation stimulate immune response WHO guideline: 10-14days < 6mos old- 10mg/day > 6mos old 20mg/day

Treatment
PROBIOTIC: CRITERIA 1. Human source 2. Non pathogenic 3. Safe 4. Prod. Antimicrobial substance 5. Favorable immunomodulation properties 6. Influence metabolic activities 7. Resist gastric bile & pancreatic digestion 8. Adhere to and colonize GI tract

Treatment
PROBIOTIC
Restore beneficial intestinal flora Enhance hopst protective immunity proinflammatory cytokine anti-inflammatory cytokine E.g.
lactobacillus bifidobacterium/ rhamnosus Saccharomyces boulardii

PREBIOTIC Enhance proliferation & devt probiotic microorganism Harmlessly pass GI tract Act as substrate to probiotic E.g.
Fructose Galactooligosaccharide Inulin Barley psyllium

Prevention
Proper hand wshing
before and after eating or when preparing the meals.

Proper preparation and storage of food

Thank you!!!