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  • 1. Acute Gastroenteritis
  • 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Parasitic agents  Cryptosporidium parvum, Giardia intestinalis, Entamoeba histolytica  Usually causes traveler’s diarrhea  Relatively small portion of cases
  • 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. 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. 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. PATHOGENESIS 4. Invasion 5. Host defenses – ability to combat pathogens  Normal flora  Gastric acidity  Intestinal motility  Immunity  Genetic determinants
  • 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
  • 24. CLINICAL MANIFESTATIONS
  • 25. CLINICAL MANIFESTATIONS Loose watery stools Fever Bloody stools Nausea and Vomiting Abdominal pain
  • 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. HISTORY  Initial evaluation should include the ff: Onset, frequency, type, volume +/- blood Vomiting Medicines taken Comorbidities Epidemiologic clues 24h food recall
  • 28. PHYSICAL EXAM Body weight Temperature PR and RR BP Complete PE and assess the level of dehydaration
  • 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. 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. LABORATORY EVALUATION • Serum electrolyte concentrations are used to determine the extent of fluid and electrolyte depletion • Blood culture for some etiologies like Salmonella
  • 32. TREATMENT
  • 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. In comparison
  • 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. 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. 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. Nonspecific antidiarrheal agents
  • 48. Antimicrobial agents
  • 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. 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. Antimicrobial agents
  • 52. Antimicrobial agents
  • 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. 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. 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. 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. WHEN to discharge?
  • 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. 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. Patient Education • Risk factors – Environmental contamination – Young age, immunodeficiency state, measles, lack of exclusive breast-feeding – Malnutrition • Vitamin A deficiency • Zinc deficiency
  • 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. Thank you!

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