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  1. 1. Acute Gastroenteritis
  2. 2. Definition • characterized by changes in the character and frequency of stool. • defined as the passage of a greater number of stools of decreased form from the normal lasting less than 14 days. • Generally associated with other symptoms including nausea, vomiting, abdominal pain and cramps, increase in intestinal, fever, passage of bloody stools, tenesmus, and fecal urgency.
  3. 3. EPIDEMIOLOGY According to WHO and UNICEF • 2 billion cases of diarrheal disease worldwide every year • 1.9 million children <5 years old die from diarrhea each year • 78% of child deaths occur in the African and South –East Asian regions • Globally it is the 2nd leading cause of death
  4. 4. EPIDEMIOLOGY ORS, improved rates of breastfeeding, improved nutrition, better sanitation and hygiene have contributed to a decline in the mortality rates in the past three decades
  5. 5. ETIOLOGY  Bacterial agents • Escherichia coli – most common 1. ETEC – causes traveler’s diarrhea 2. EPEC – rarely causes disease in adults but is common in children <2 years old and persistent diarrhea 3. EIEC – causes bloody mucoid (dysentery) diarrhea, fever is common
  6. 6. Bacterial agents 4. EHEC –produces the Shiga toxin causes bloody diarrhea, severe hemorrhagic colitis, HUS (6-8%), cattles are the predominant reservoir, O157:H7 from undercooked hamburger 5. EAEC – causes watery diarrhea in young children and persistent diarrhea in children with HIV
  7. 7. Bacterial agents  Campylobacter – Asymptomatic infection is common – Associated with watery diarrhea sometimes dysentery – Develops Guillain-Barre syndrome in about 1 in 1000 patients with colitis – Poultry is a common source – Should ask abut recent picnic or banquets – Common among children <2 years
  8. 8. Bacterial agents  Shigella species – More common in toddlers and older children – S. sonnei is common in developed countries and causes mild illness and may cause institutional outbreaks – S. flexneri is endemic and causes dysentery and persisitent illness
  9. 9. Bacterial agents – S. dysenteriae type 1- only one that produces the Shiga toxin; is the epidemic serotype – Commonly acquired from eating chicken – Definitive dx: isolation of the organism from fecal material
  10. 10. Bacterial agents  Vibrio cholerae – >2000 serotypes and all are pathogenic for humans – Serogroups O1 & O139 only two types that causes severe cholera and outbreaks – Severe dehydartion can lead to hypovolemic shock and death can occur w/in 12-18h after onset
  11. 11. Bacterial agents – Stools are watery, colorless, eith mucus – “rice watery stools” – Vomiting is common, fever is typically absent – Potential for epidemic spread and should be reported promptly
  12. 12. Bacterial agents – Commonly from seafood, especially if raw – Laboratory isolation of the organism requires a special medium – taurocholate-tellurite gelatin agar or thiosulfate-citrate-bile salts-sucrose (TCBS)
  13. 13. Bacterial agents  Salmonella – Infants, children and the elderly who are immune- compromised are of greatest risk – Animals are major reservoir – Enteric fever – S. enterica serovar Typhi and Paratyphi A, B, C (typhoid fever) causes prolonged fever that lasts > 3 weeks; normal bowel habits, constipation or diarrhea
  14. 14. Bacterial agents – Nontyphoidal salmonellosis- acute onset of nausea, vomiting and diarrhea that may be watery or dyseteric – Fever develops in 70% of children – Bacteremia occurs in 1-5%, mostly in infants – Commonly acquired from mayonnais, creams or raw eggs
  15. 15. Bacterial agents • Definitive dx: isolation of the organism from blood(40-80 %sensitive), BM or other sterile sites • 1st week – blood • 2nd week – urine • 3rd week - stool
  16. 16. Viral agents Predominant cause of acute diarrhea in both industrialized and developing countries Rotavirus – Leading cause of severe, dehydrating gastroenteritis among children – Neonatal infections are common but often asymptomatic – Peaks between 4-23 months of age
  17. 17. Viral agents  Norovirus – Belongs to the family Caliciviridae – Most common cause of outbreaks affecting in all age group  Sapovirus – Also from the family of Caliciviridae – Primarily affects children – 2nd most common viral agent after rotavirus
  18. 18. Parasitic agents  Cryptosporidium parvum, Giardia intestinalis, Entamoeba histolytica  Usually causes traveler’s diarrhea  Relatively small portion of cases
  19. 19. PATHOGENESIS  Pathogens have a variety of tactics to overcome host defenses  Mechanisms: 1. Inoculum size- varies  Shigella, EHEC, G. lamblia, Entamoeba as few as 10 -100 bacteria or cysts  Vibrio cholerae - 105 – 108 organisms  Salmonella – varies on the specie, host and food vehicle
  20. 20. PATHOGENESIS 2. Adherence  Adheres to the GI mucosa  Specific cell surface proteins involved in attachment of the bacteria to intestinal cells  Ex. V. cholerae adheres to the brush border of the SI enterocytes via specific surface adhesins  ETEC produces an adherence protein called colonization factor antigen
  21. 21. PATHOGENSIS  EPEC and EHEC produce virulence that allow these organisms to attach to and efface the brush border of the intestinal epithelium 3. Toxin production  Enterotoxin – ex. Cholera toxin, Heat labile enterotoxin, heat stable  Cytotoxins – ex. Shigella dysenteriae type 1  Neurotoxins – ex. Bacillus cereus toxins
  22. 22. PATHOGENESIS 4. Invasion 5. Host defenses – ability to combat pathogens  Normal flora  Gastric acidity  Intestinal motility  Immunity  Genetic determinants
  23. 23. CLASSIFICATION  Classified accordingly as:  Acute diarrhea - >3 loose watery stools in the previous 24 hours  Dysentery – presence of visible blood in stools  Persistent diarrhea – acutely starting episode of diarrhea lasting more than 14 days
  25. 25. CLINICAL MANIFESTATIONS Loose watery stools Fever Bloody stools Nausea and Vomiting Abdominal pain
  26. 26. Clinical evaluation • Assess the degree of dehydration, presence of acidosis and provide rapid rehydration • Obtain appropriate contact, travel or exposure history • Clinically determine the probable etiology for prompt antibiotic institution if indicated
  27. 27. HISTORY  Initial evaluation should include the ff: Onset, frequency, type, volume +/- blood Vomiting Medicines taken Comorbidities Epidemiologic clues 24h food recall
  28. 28. PHYSICAL EXAM Body weight Temperature PR and RR BP Complete PE and assess the level of dehydaration
  29. 29. DHAKA METHOD ASSESSMENT PLAN A PLAN B PLAN C 1. General condition N Irritable/ less active* Lethargic /comatose * 2. Eyes N Sunken Sunken 3. Mucosa N Dry Dru 4. Thirst N Thirsty Unable to drink* 5. Radial pulse N Low volume* Absent 6. Skin turgor N Reduced* Reduced Diagnosis No signs of dehydration Some dehydration At least 2 signs; including one key sign (*) are present Severe dehydration Some signs of dehydration plus at least one key sign present
  30. 30. LABORATORY EVALUATION • Stool examination • Stool cultures are indicated in cases of dysentery or where the diagnosis of AGE is unclear • CBC to look for anemia, hemoconcentration, or an abnormal white blood cell count.
  31. 31. LABORATORY EVALUATION • Serum electrolyte concentrations are used to determine the extent of fluid and electrolyte depletion • Blood culture for some etiologies like Salmonella
  32. 32. TREATMENT
  33. 33. TREATMENT PLAN A PLAN B PLAN C TREATMENT Prevent dehydration Reassess periodically Rehydrate with ORS solution Reassess frequently Rehydrate with I.V. fluids and ORS Reassess more frequently
  34. 34. TREATMENT  PLAN A -Home therapy to prevent de hydration and malnutrition Rule 1: give more fluids than usual • <2 y.o : 50-100 ml after each loose stool • 2-10 : 100-200ml • Older children and adults : as much as the want
  35. 35. PLAN A Rule 2: give Zinc (10-20mg) daily for 10-14 days Rule 3: Continue to feed the child to prevent malnutrition Rule 4: take the child to a health worker when signs f dehydration develop
  36. 36. PLAN B  Oral rehydration therapy  Give also supplemental Zinc  Monitoring of the patient’s conditon  If at any time the patient develops signs of severe dehydration, shift to plan C
  37. 37. PLAN C • Intravenous rehydration - Give 100ml/kg PLR: • Reassess patient every 1-2 hours • After 3 or 6 hrs evaluate patient then choose appropriated treatment plan Age First give 30ml/kg in: Then give 70ml/kg in: Infants <12 months 1 hour 5 hours Older 30 minutes 2.5 hours
  38. 38. Oral Rehydration Therapy Oral rehydration therapy (ORT) is the administration of appropriate solutions by mouth to prevent or correct diarrheal dehydration. ORT is a cost-effective method of managing acute gastroenteritis and it reduces hospitalization requirements in both
  39. 39. Oral Rehydration Therapy The new lower-osmolarity ORS recommended by (WHO and UNICEF) has reduced concentrations of sodium and glucose and is associated with less vomiting, less stool output, lesser chance of hypernatremia, and a reduced need for intravenous infusions in comparison with standard ORS.
  40. 40. Oral Rehydration Therapy This formulation is recommended irrespective of age and the type of diarrhea including cholera. According to the 2012 WGO guidelines ORT is contraindicated as initial therapy in cases of severe dehydration, children with paralytic ileus, frequent and persisitent vomiting.
  41. 41. Oral Rehydration Therapy However, nasogastric administration of ORS solution is potentially lifesaving when intravenous rehydration is not possible. Rice-based ORS is superior to standard ORS for adults and children with cholera, and can be used to treat such patients wherever its preparation is convenient.
  42. 42. Oral Rehydration Therapy Constituents of the new oral rehydration solution (ORS) Sodium 75 mmol/L Chloride 65 mmol/L Anhydrous glucose 75 mmol/L Potassium 20 mmol/L Trisodium citrate 10 mmol/L Total osmolarity 245 mmol/L
  43. 43. In comparison
  44. 44. Oral Rehydration Therapy Home-made oral fluid recipe  Preparing 1 L of oral fluid using salt, sugar and water at home. The ingredients to be mixed are:  One level teaspoon of salt.  Eight level teaspoons of sugar.  One liter (five cupfuls) of clean drinking water, or water that has been boiled and then cooled.
  45. 45. SUPPORTIVE TREATMENT  Zinc supplement Recommendation : 20mg OD for 10 days  Multivitamins and minerals  Diet normal feeding should be continued for those with no signs of dehydration food should be started immediately after correction of some and severe dehydration
  46. 46. SUPPORTIVE TREATMENT Breastfed infants and children should continue receiving food However, for non-breastfed, dehydrated children and adults, rehydration is the first priority. Avoid fruit juices Probiotics are said to be beneficial
  47. 47. Nonspecific antidiarrheal agents
  48. 48. Antimicrobial agents
  49. 49. ORGANISM DOC DOSAGE Shig e lla Ciprofloxacin, ampicillin, ceftriaxone, azithromycin, or TMP-SMX Most strains are resistant now to several antibiotics •Ceftriaxone 50-100 mg/kg/day IV or IM, qd or bid for 7 days •Ciprofloxacin 20-30 mg/kg/day PO bid for 7-10 days •Ampicillin PO,IV 50-100 mg/kg/day qid for 7 days EPEC, ETEC, EIEC TMP-SMX or ciprofloxacin •TMP 10 mg/kg/day and SMX 50 mg/kg/day bid for 5 days •Ciprofloxacin PO 20-30 mg/kg/day qid for 5-10 days Sa lm o ne lla No antibiotics for uncomplicated gastroenteritis in normal hosts caused by nontyphoidal species Treatment is indicated in infants <3 mo, and patients with malignancy, chronic GI disease,severe colitis hemoglobinopathies, or HIV infection, and other immunocompromised patients Most strains have become resistant to multiple antibiotics See treatment of Shig e lla
  50. 50. ORGANISM DOC DOSAGE Cam pylo bacte r je juni Erythromycin or azithromycin •Erythromycin PO 50 mg/kg/day divided tid for 5days •Azithromycin PO 5-10 mg/kg/day qid for 5 days Entam o e ba histo lytica Metronidazole followed by iodoquinol or paromomycin •Metronidazole PO 30-40 mg/kg/day tid for 7-10 days •Iodoquinol PO 30- 40 mg/kg/day tid for 20 days •Paromomycin PO 25-35 mg/kg/day tid for 7 days Giardia lam blia Furazolidone or metronidazole or albendazole or quinacrine •Furazolidone PO 25 mg/kg/day qid for 5-7 days •Metronidazole PO 30-40 mg/kg/day tid for 7 days •Albendazole PO 200 mg bid for 10 days
  51. 51. Antimicrobial agents
  52. 52. Antimicrobial agents
  53. 53. Approach in adults with acute diarrhea1. Perform initial assessment. 2. Manage dehydration. 3. Prevent dehydration in patients with no signs of dehydration, using home-based fluids or ORSsolution. • Rehydration of patients with some dehydration using ORS – Correct dehydration of a severely dehydrating patient with an appropriate intravenous fluid. • Maintain hydration using ORS solution.
  54. 54. Approach in adults with acute diarrhea – Treat symptoms if necessary 4. Stratify subsequent management: • Epidemiological clues: food, antibiotics, sexual activity, travel, day-care attendance, other illness, outbreaks, season. • Clinical clues: bloody diarrhea, abdominal pain, dysentery, wasting, fecal inflammation. 5. Obtain a fecal specimen for analysis 6. Consider antimicrobial therapy for specific pathogens.
  55. 55. Indications for medical consultation or in-patient care are:  Caregiver’s report of signs consistent with dehydration  Changing mental status  History of premature birth, chronic medical conditions, or concurrent illness  Young age (< 6 months or < 8 kg weight)  Fever 38 °C for infants < 3 months old or 39 °C for children aged 3– 36 months
  56. 56. Indications for medical consultation or in-patient care are:  Visible blood in stool  High-output diarrhea, including frequent and substantial volumes  Persistent vomiting, severe dehydration, persistent fever  Suboptimal response to ORT  No improvement within 48 hours—symptoms exacerbate and overall condition gets worse  No urine in the previous 12 hours
  57. 57. WHEN to discharge?
  58. 58. When to discharge? Stable Vital signs Normal urine output Maintains a sufficient fluid intake Able to eat meals adequately Able to take medications (if still indicated)
  59. 59. Prevention • Promotion of exclusive breast feeding Promotes passive immunity • Improved complementary feeding practices  Start giving complementary food at 6 mo. And continue BF up to 1 year or longer • Rotavirus immunization • Improved case management of diarrhea • Patient education
  60. 60. Patient Education • Risk factors – Environmental contamination – Young age, immunodeficiency state, measles, lack of exclusive breast-feeding – Malnutrition • Vitamin A deficiency • Zinc deficiency
  61. 61. Patient Education • Proper personal hygiene and safe food preparation. • Hand-washing with soap is an effective step in preventing spread of illness • Human feces must always be considered potentially hazardous, whether or not diarrhea or potential pathogens have been identified. • Select populations may require additional education about food safety, and health care providers can play an important role in providing this information.
  62. 62. Thank you!