Pediatrics 5th year, 4th lecture (Dr. Adnan)


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The lecture has been given on Oct. 28th, 2010 by Dr. Adnan.

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Pediatrics 5th year, 4th lecture (Dr. Adnan)

  1. 1. Diarrhea Dr. Adnan Hamawandi Professor of Pediatrics
  2. 2. Dysentery  Is defined as diarrhea with visible blood in stools.  The most important and frequent cause of acute dysentery is Shigella. Other causes include Campylobacter jujeni, Salmonella, and enteroinvasive E. coli.  Entameba histolytica causes dysentery in older children but rarely in children under 5 years of age.
  3. 3. Dysentery Dysentery is specially sever in :- 1. Malnourished infants and children. 2.Those who develop clinically evident dehydration during their illness. 3. Those who are not breast fed. 4. Children with measles or had measles in the preceding month. 5. Those who present with convulsion or develop coma.
  4. 4. Dysentery Clinical features and diagnosis The clinical diagnosis of dysentery is based solely on the presence of visible blood in the diarrheal stool. The stool will also contain pus cells which are visible microscopically, and it may contain large amounts of mucus, the later features suggest infection with an invasive microorganism, but alone are not sufficient to diagnose dysentery.
  5. 5. Dysentery Clinical features and diagnosis  Patients frequently have fever, cramping abdominal pain and tenesmus.  The cause is identified by stool culture.  Stool microscopy may help in differentiating E.histolytica which can only be diagnosed with certainty when trophozoites containing RBCs are seen in fresh stools or in mucus from rectal ulcers obtained during colonoscopy.
  6. 6. Dysentery Complications  Intestinal perforation.  Toxic megacolon.  Rectal prolapse.  Convulsions.  Septicemia.  Hemolytic uremic syndrome.  Prolonged hyponatremia.
  7. 7. Dysentery Management  Children with dysentery should be presumed to have Shigellosis and treated accordingly. This is because Shigellae cause 60% of dysentery cases seen at health facilities and nearly all cases of sever life threatening disease.  1. Antimicrobial therapy: Trimethoprim sulfamethoxazole is the usual choice for five days.
  8. 8. Dysentery Management There should be substantial improvement after 2 days i.e. reduced fever, less pain and fecal blood, and fewer loose stools. If this does not occur the antimicrobial should be stopped and a different one used like Naladixic acid, Cefixime, or Ceftriaxone according to the local culture and sensitivity. 2. Fluid: Assess and correct any dehydration. 3. Feeding: Continue feeding.
  9. 9. Persistent diarrhea  Is a diarrheal episode that last for 14 days or longer. About 10% of acute diarrheal episodes become persistent.  Persistent diarrhea is largely a nutritional disease, it occur more frequently in children who are already malnourished and is itself an important cause of malnutrition. It is associated with increased mortality causing about 30% of all diarrhea associated death.
  10. 10. Persistent diarrhea There is no single microbial cause although Shigella, Salmonella, Enteroinvasive E.coli and Cryptosporidium play a greater role than other agents. Irrespective of the cause, persistent diarrhea is associated with extensive changes in the bowel mucosa, specially flattening of the villi and reduced production of disaccharidase enzymes; these cause reduced absorption of nutrients and
  11. 11. Persistent diarrhea perpetuate the illness after the original infectious cause has been eliminated.  Risk factors: 1. Malnutrition. 2. Young age. 3. Recent introduction of animal milk(formula 4. Immunological impairment. 5. Recent diarrhea.
  12. 12. Persistent diarrhea Management  Fluid and electrolyte replacement.  Nutritional therapy: the goals are 1. Reduce temporarily the amount of animal milk or lactose in the diet. 2. Provide a sufficient amount of energy, protein, vitamins and minerals. 3. Avoid foods or drinks that may aggravate diarrhea. 4. Ensure adequate food intake during convalescence to correct malnutrition.
  13. 13. Persistent diarrhea Management  Drug therapy: Antimicrobials and antiprotozoal agents should be given only when indicated and according to culture and sensitivity. However, blind use of these drugs is not effective and should not be given as they may make the illness worse. Likewise antidiarrheal drugs has no proven value and should not be given.
  14. 14. Extraintestinal causes of diarrhea  Parenteral diarrhea( otitis media, UTI,..  Congenital defects( malrotation, duplication..  Malabsorption( cystic fibrosis, celiac disease  Endocrinopathies( CAH, hyperthyroidism..  Neoplasms( neuroblastoma,  Inflammatory bowel diseases  Miscellaneous(acrodermatitis enteropathica, Hartnup disease..