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Diarrhea vi



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  • 1. SeminarOn“APPROACH TO DIARRHEOA INCHILDREN”Presented byVijay kr. SinghDNB PGT (Pediatrics)Under guidance ofDr T K MAITYMD(PEDIATRICS)Consultant pediatrician M R Bangur HospitalDate 18 june 2013VenueDNB Seminar hall M R Bangur hospital Kolkata-33
  • 2. DIARRHEOADiarrhea is best defined asexcessive stool loss of fluid andelectrolyte more than threewithin 24hrs period. Recentchange of consistency is moreimportant than frequency
  • 3. Types of diarrheaAcute watery diarrhoea-start suddenlyand last for hours or days.Dysentery- it is similar to acutediarrhea but associated blood loss instool.Persistent diarrhea- if diarrhea persistmore than 14days
  • 4. WHO and UNICEF estimate thatalmost 2.5billion episode ofdiarrhea in children less than 5years of age in developingcountries. More than 80%occringin Africa and south Asia. Globallymortality dicrease significantly butincidence remain unchanged.
  • 5. Epidemiology of diarrheaDiarrhoeal disorder in childhoodaccount for a large proportion 18%of childhood death about 1.5 milliondeaths per year globally and makingsecond most common cause ofchildhood mortality
  • 6. Diarrhea can cause undernutritionand worsen the milder form ofmalnutrition becauseImpaired intestinal absorption of macroand micronutrient.Urinary loss of specific nutrient Vit A.Increase catabolism due to infection.A child with diarrhea is often not hungry.Mother often make the mistake of not tofeed during diarrhea.
  • 7. Etiology of diarrheaOrganism causes noninflammatory(enterotoxin or adherence /superficial invasion) Location- Proximal small intestine Causes watery diarrheaThese are E.coli(ETEC,LT,ST) Clostiridum perfringens Bacillus cereus Staph. Aureus, giadia lambia, Rota virus, Norwaklikevirus,Crytosporidium,Microsporidia,
  • 8. Enteropathogens elicit noninflamatorydiarrheoa through entrotoxineproduction by some bacteria,destruction of villous surface byviruses, adherence by parasite andadherence and translocation bybacteria. Bacterial enterotoxin canselectively activate enterocyteintracellular signal transduction andcause alteration in the water andelectrolyte fluxes across enterocyte.
  • 9.  Location- colon DysenteryOrganisms Shigella E.coli(EIEC,EHEC) Salmonella enteridis Vibrio parahemolyticus Clostiridum difficilue, campylobacter jejuni,Entaemaeba hitolytica. Inflammatory diarrhea is usually caused by bacteria anddirectly invade the intestine or produce cytotoxin withconsequent fluid, protein, and cells. That inter theintestineInflammtory(invasive, cytotoxin)
  • 10. PenetratingLocation- Distal small intestineSalmonella typhiYersinia enteropathicaCampylobacter fetus
  • 11. Risk factors of gastroenteritisEnvinmental contamination andincreased exposure to pathogensMalnutritionLack of exclusive breast feeding orprolong and predominantbreastfeedingMeaslesImmunodeficiency
  • 12. Clinical evaluation of diarrheaChild dehydration can be classifiedaccording to WHO criteriaNo dehydration Treatment planASome dehydration Treatment Plan BSevere dehydration Treatment Plan C
  • 13. Signs of dehydration: Decreased urination (fewer than 4 wet diapers in24 h), Increased thirst, No tears, Dry skin, mouth and tongue, Faster heart beat, Sunken eyes, Grayish skin, Sunken soft spot (Anteriar fontanelle) on baby’shead
  • 14. Treatment PLAN A•Age less than 24 months•50-100ml per each loose stool•Age between 2yrs to 10yrs•100 to 200 ml after each stool•Age more than 10 yrs•As much as wants
  • 15. Treatment Plan BThe fluid therapy has three component.Correction of the existing water andelectrolyte deficient.Replacement of ongoing loss due tocontinuing diarrhea Deficient replacement
  • 16. 75 ml/ kg of ORS In first 4 yrsMaintenance therapy This begins when dehydration corrected over4hrs ORS 10-20 ml/kg after each stool . Offer plan water in between
  • 17.  High stool purge- 5ml/ kg/hr Persistent vomiting > 3episode per hr Incorrect preparation Abdominal distention Glucose malabsorptionWhen ORT therapy is ineffective
  • 18. Treatment Plan CStart IV fluid immdiatelyAge <12months30ml/kg in 60 minutesThen 70ml/ kg in 5hrsAge between 12months to 5 years30ml/kg in 30 minutesThen 70 ml/kg in2.5 hrs
  • 19. MonitoringReassess the child every 15-30 minutesuntil a strong radial pulse is present.Repeat IV fluid is severe dehydrationstill present.If child is improving but still showssign of dehydration.Discontinue IV fluid and give ORS for4hrs
  • 20. Secretory diarrhea Secretory diarrhea is often caused by asecretagogue, such as cholera toxin, bindingto a receptor on the surface epithelium ofthe bowel and thereby stimulatingintracellular accumulation of cyclicadenosine monophosphate or cyclicguanosine monophosphate. Someintraluminal fatty acids and bile salts causethe colonic mucosa to secrete through thismechanism.
  • 21. Secretory diarrhoea occurs afteringestion of a poorly absorbed solute. The solutemay be one that is normally not well absorbed(magnesium, phosphate, lactulose, or sorbitol) orone that is not well absorbed because of adisorder of the small bowel (lactose with lactasedeficiency or glucose with rotavirus diarrhea).Malabsorbed carbohydrate is fermented in thecolon, and short-chain fatty acids (SCFAs) areproduced.
  • 22. ROLE OF DRUGS IN DIARRHOEA ORS Antibiotics Zinc supplement Antimotility drugs Probiotics Enkephaline inhibitor
  • 23. ORSAn oral rehydration solution (ORS)lowosmolility is an exact mixture ofwater, salts and sugar. These solutions canbe absorbed even when your child isvomiting. The key is to give small amountsof ORS often (for example, 1 teaspoonevery 5 minutes), gradually increasing theamount until your child can drinknormally.
  • 24. AntibioticsAntibiotics have very minorroll in diarrhoea.It is only in bacterial infectivediarrhoea and dysentry.
  • 25. ZincIt increase recovery rateDecrese stool out putMaintain mucusal layerIncrese immunityDose 20mg/ day in case of age lessthan 6month 10mg once a day
  • 26. Antimotility agentsIt is contra indicated indysentry.No role in management ofacute watery diarrhoea.
  • 27. ProbioticsIt restore the beneficial bacterialintestinal flora and enhance hostprotective immunity such as downregulation of pro- inflammatorycytokines and up- regulate anti –inflammatory cytokines.
  • 28. ENKEPHALINSE INHIBITORIt consistently has beenshown to reduce stool output.But experience with this drugis limited.
  • 29. Foods to avoidDo not give your child sugary drinkssuch as: fruit juice or sweetened fruitdrinks, carbonated drinks (pop/soda),sweetened tea, broth or rice water.These have the wrong amounts ofwater, salts and sugar and can makeyour child’s diarrhea worse.
  • 30. Preventive measure fordiarrhoeal diseaseImprove domestic & food hygiene.Improve water supply.Improve excreta disposalMaintain good nutrition. Health education.Immunization