Pediatric Digestive Disorders

1. DIGESTIVE DISORDERS
Chapter-2

2. Diarrheal diseases
• Diarrhea is one of the most common diseases
of children, especially of those living in
developing countries.
• It is defined as passage of three or more loose
or watery stools per 24 hours; or
• It is an increase in stool frequency or liquidity
that is considered abnormal by the mother.

3. Types
There are three clinical types of diarrhea
• Acute diarrhea- A diarrheal episode that
begins acutely and lasts for less than 14 days
with passage of watery stools without blood.
• Persistent diarrhea- This is a diarrheal
episode that starts acutely and lasts for 14 days
or longer
• Dysentery- diarrhea with visible blood in it.

4. Epidemiology
• An estimated 500 million children in the developing
world suffer from diarrhea three or four times a year
• Diarrheal disease cause about 30% of infant deaths in
developing countries and contribute a lot to the high
prevalence of malnutrition in such countries.

5. • Acute watery diarrheal episodes are the
commonest accounting for 80-82% of the
cases.
• Children of 6-11 months of age are the most
commonly affected
• This coincides with onset of initiation of
complementary feeding.
Epidemiology cont…

6. Risk factors for diarrhea
1. Behavioral risk factors
Sub-optimal breast-feeding practice-
• Early initiation of complementary feeding increases
the incidence of diarrheal diseases, hence increasing
child mortality and morbidity.
Using feeding bottles
• Feeding bottles are difficult to clean, easily
contaminated, and are fertile media for microbial
growth.

7. Behavioral risk factors cont…
Eating uncooked food
• If the food item is improperly handled, and given to
the child unheated.
Drinking contaminated water
• contaminated water is the main source of pathogens
causing diarrheal diseases.
Not washing dirty hands
Not disposing of feces safely

8. 2. Host factors affect incidence or severity of diarrhea
 Malnutrition- malnourished children have frequent
episodes of diarrhea and each episode is more severe
and long lasting.
 Measles- recent measles attack predisposes to
diarrhea.
 Immunosuppression- like HIV/ AIDS, DM patients
have more frequent and more severe diarrhea and the
offending organisms could be opportunistic
organisms.

9. Etiologic agents
• The commonest cause of acute watery
diarrhea is rota virus and
– others are Escherichia coli, vibrio cholerae, giardia
lamblia, etc.
• The commonest cause of dysentry is shigella
and
– others are campylobacter jejuni, entero invasive
E.coli, entamoeba histolytica, etc.
• The transmission is usually through the fecal-
oral route-by ingestion of fecally contaminated
water or food.

10. Pathophysiology of Diarrhea
• Microbial agents cause diarrhea by any one of
the following mechanisms:
– Villous damage and epithelial cell destruction e.g.,
rota virus
– Mucosal adhesion e.g., giardia lamblia
– Mucosal invasion e.g., shigella, entamoeba
histolytica
– Release of toxins e.g., vibrio cholerae

11. Complications of diarrhea
The commonest complications that are expected in
patients with acute watery diarrhea are:
• Dehydration and hypovolemic shock
• Electrolyte imbalance such as;
 hypokalemia due to loss of K+ in diarrheic stools,
 hyponatremia due to loss of Na+ in diarrheic stools
• Base deficit acidosis; due to loss of bicarbonate in
diarrheic stools:
• Malnutrition; due to reduced intake and absorption,
and increased requirement associated with diarrhea

12. Dehydration
• Dehydration is the main cause of death from
acute diarrhea.
• It is associated with loss of body fluid and
electrolytes mainly sodium through the diarrheal
stools

13. Assessment and classification of dehydration
• Based on the degree of dehydration
1. Severe Dehydration: two of the following signs:
• Lethargy or unconsciousness
• Sunken eyes
• Not able to drink or drinking poorly
• Skin pinch goes back very slowly (takes >2 sec)

15. Assessment and classification of dehydration
2. Some Dehydration: Two of the following signs:
• Restless, Irritable
• Sunken eyes
• Drinks eagerly & thirsty
• Skin pinch goes back slowly (takes <2 sec)
3. No dehydration
• No enough signs to classify as some or Severe
dehydration

16. Clinical manifestation
1. Acute watery
• This is defined as a diarrheal episode that begins
acutely and lasts for less than 14 days with passage
of frequent loose or watery stools without blood.
• It is commonly accompanied by dehydration.
• Vomiting and fever may be the manifestation.
• The common etiologies are Rotavirus, E. Coli
(entero toxigenic), and V. Cholerae.

17. 2. Bloody diarrhea
• This is diarrhea with visible blood either
macroscopically or microscopically.
• Most episodes are due to Shigella.
• Others like salmonella, entero invasive E
Coli, and E. Hystolytica are also incriminated.
Clinical manifestation cont…

18. 3. Persistent diarrhea
• It begins acutely, but it is unusually prolonged
duration, at least 14 days.
• It may begin as either watery diarrhea or as
dysentery.
Clinical manifestation cont…

19. Principles of Management of acute diarrhea
A. Antibacterial or anti parasitic therapy
• Anti microbial agents should not be used routinely
Dysentery- this should be treated with antimicrobials
effective for shigella.
• Oral antibiotics for 5 days should be given.
• The first line drugs are cotrimoxazole.
• If these are not effective, use the second line drugs
like nalidixic acid or ciprofloxacin.

20. Principles of Management of acute diarrhea cont…
If cholera is suspected;
• Cotrimoxazole or erythromycin are the first
line drug in younger children.
• Tetracycline is the drug of choice for children
older than 8 years.
If trophozoites or cyst of giardia or E.
histolytica are seen in stool microscopy;
• Anti-protozoal (Metronidazole or Tinidazole)
are considered.

21. B. Rehydration therapy
Level of dehydration Treatment
Severe dehydration Plan-C (rehydrate urgently
with IV fluids)
Some dehydration Plan B (rehydrate at the health
center with ORS)
No dehydration Plan-A (treat at home to
prevent dehydration)
Principles of Management of acute diarrhea cont…

22. Treatment plan A for No Dehydration
GIVE EXTRA FLUID (as much as the child will
take)
• Tell the mother to breastfeed frequently and for
longer at each feed.
• If the child is exclusively breastfed,;
– give ORS or clean water in addition to breast milk.
• If the child is not exclusively breastfed, give
one or more of the following:
– ORS solution, food-based fluids (such as soup,
rice water, and yoghurt drinks), or clean water.

23. • ORS amount guide for use
Less than 2 years = 50-100ml after each loose
stool
2-10 years = 100-200ml after each loose stool
More than 10 years = as much as wanted.
Treatment plan A cont…

24. • Advice the mother:
– how to prepare ORS solution (one packet in one liter of
pure water), and
– To give the fluids with teaspoon, not bottle.
• If vomiting occurs, the mother should stop giving the
fluid for about 10 minutes and start again, but give it
more slowly.
• Finally it is good to advise mothers to take the child to
health worker:
– if the child doesn’t get better in 3 days or develops many
watery stools, repeated vomiting, poorly eating, fever, or
blood in the stool.
Treatment plan A cont…

25. Treatment plan B in some dehydration
I. ORS
• When there is some dehydration, the deficit of water is
between 50 and 100 ml for each Kg of body weight.
– The ORS needed for rehydration can be estimated, using
75ml/Kg as the approximate deficit to be given over four
hours.
– If puffy eyelids (sign of over-hydration), stop ORS and give
water or breast milk and treat as plan A.

26. II. Intravenous therapy
• This is the last option:
– When oral treatment is not feasible (in case of
severe vomiting, severe diarrhea)
– Loss of greater than 15ml/Kg of body water per hour
– Glucose malabsorption.
• The dose is 70ml/Kg over 3-4 hours.
Treatment plan B cont…

27. • At the end of either IV or oral therapy, it is
recommended to reassess the child after four
hours of initiation of therapy.
– If still, patient has some dehydration, repeat the
same volume.
– If no dehydration, treat as plan A.
– If severe, treat as plan C.
Treatment plan B cont…

28. Treatment Plan C for Sever Dehydration
Intravenous therapy
• The most preferred Intra venous fluid is
Ringer’s Lactate.
• The initial 30ml/Kg is designed to expand
ECF volume rapidly and improves
circulatory and renal function.
• Subsequent therapy (70ml/Kg) is aimed at
replacing deficits while providing for
maintenance water.

29. IV Ringer’s lactate
Age 30ml/kg 70ml/kg
<12months Over 1 hour 5 hours
>12 months Over 30 minutes 2.5 hours

30. • Re-asses every 15-30 minutes until you get full
radial pulse.
If radial pulse is still undetectable, repeat the same
dose (30ml/Kg) once more.
Give ORS (5ml/kg/hr) as soon as child is able to
drink.
Re-asses child after 3 or 6 hours depending on the
age.
Then treat accordingly as plan A, B, or C.
Treatment Plan C cont….

31. Oral therapy or Nasogastric tube therapy
• This is done if IV therapy is not possible.
• The oral replacement is used if the child is able to
drink, if not the nasogastric replacement is used.
– ORS is given at a rate of 20 ml/kg/hr (the maximum
rate of infusion) over 6 hours.

32. Oral therapy or Nasogastric tube therapy cont…
• Reasses after one to two hours.
• If no improvement in 3 hours, treat with
intravenous fluids.
• This approach is not as satisfactory as IV infusion
because the fluid cannot be given as rapidly and
additional time is required for it to be absorbed
from the intestine.
• The oral replacement cannot be used for patients
who are very lethargic or unconscious.

33. C. Feeding of the child
• Breastfeeding should be frequent than usual and
should continue without interruption.
• Formula or cow’s milk should be given as usually
prepared.
• Those who are on complementary diet should continue
the feeding both during and after the diarrhea.
• During diarrhea, give as much food as the child
wanted.
– Small, frequent feedings are tolerated better than large
feedings given less frequently.

34. D. Follow up
• Advise the mother to return immediately to the
clinic:
– if the child become more sick, or unable to drink,
or breastfeed, or drinks poorly, or develops fever,
or shows blood in stool.
• If the child shows none of these signs but is
still not improving, advice the mother to return
for follow up at 5 days.

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