Diarrhea is defined as 3 or more loose stools per day. It is a major cause of morbidity and mortality in children in developing countries. There are different types of diarrhea including acute and chronic. Common causes of acute diarrhea include gastroenteritis, food poisoning, and antibiotics. Chronic diarrhea has causes such as lactose intolerance and inflammatory bowel disease. Assessment of diarrhea involves history, physical exam, and testing to identify dehydration and the underlying cause. Management depends on the degree of dehydration and may include oral rehydration, IV fluids, and antibiotics for severe cases.

1. DIARRHEABy: Syed Ariff Amir Syed Awaly

2. TOPICSDefinitionEpidemiologyTypes of diarrheaCausesAcute Diarrhea

3. DEFINITIONAccording to WHO- passage of 3 or more loose or liquid stools per day, or more frequently than is normal for the individual.

4. EPIDEMIOLOGY Diarrheal diseases continue to be a major cause of morbidity and mortality in children in developing nations.

5. In the year 2000, diarrheal diseases claimed an estimated 1.4 to 2.5 million lives; they are among the leading causes of death in children in developing countries

6. In developed nations , they are an important cause of hospital admission although mortality rates may be lower.

7. About 9% of all hospitalizations of children younger than 5 years were reported to be a result of diarrhea. TYPES OF DIARRHEA

8. CAUSES OF DIARRHEA IN INFANTACUTECommon causes:GastroenteritisSystemic infectionAntibiotic associatedRare causes:Primary disaccharidase deficiencyHirschsprung’s toxic colitisAdrenogenital syndromeCHRONICCommon causes:Post-infectious secondary lactase deficiencyCow’s milk/ soy protein intolerance Toddler’s diarrheaCoeliac diseaseCystic fibrosisAIDS enteropathyRare causes:Primary immune deficiencyFamilial villous atrophySecretory tumorShort bowel syndrome

9. CAUSES OF DIARRHEA IN CHILDRENACUTECommon causes:GastroenteritisFood poisoningSystemic infectionAntibiotics associatedRare cause:Toxic ingestionCHRONICCommon causes:Post-infectious secondary lactase deficiencyIrritable bowel syndromeCoeliac diseaseLactose intoleranceGiardiasisInflammatory bowel diseaseAIDS enteropathyRare causes:Acquired immune defectSecretory tumorPseudo-obstruction

10. ACUTE DIARRHEA

11. ETIOLOGY Protozoal

12. Giardiasis

13. Food poisoning

14. Drugs

15. NSAIDs

16. Antibiotics

17. Viral

18. Rotavirus

19. Norovirus

20. Bacterial

21. Vibrio cholera

22. E. coli

23. Salmonella*

24. Shigella*

25. Campylobacter*

26. Clostridium defficile** Associated with bloody diarrhoea

27. ASSESSMENT1). HistoryFoods ingested ???

28. Duration & frequency of diarrhea

29. Presence of blood or steatorrhoea

30. Abdominal pain

31. Tenesmus

32. Ask whether family @ community members have been affectedASSESSMENT2). Physical ExaminationAssess degree of dehydration by :- Skin tugor

33. Pulse and BP measurement

34. Monitoring of urine output and ongoing stool losesASSESSMENT3). InvestigationFBC

35. Serum electrolyte

36. Blood and urine culture

37. Stool inspection for blood and examination for ova, cysts and parasites

38. Chest X-rayDEHYDRATIONAsses based on :-1.General condition2. Sunken eyes3. Offer the child drink4. Skin turgorClassification: -1. Mild dehydration (<5%) 2. Moderate dehydration (5-10%)3. Severe dehydration (>10%)

39. MANAGEMENTFirst, assess the state of dehydration & then choose the treatment plan A, B or CPLAN A (mild diarrhea)Give extra fluidBreastfeed frequently

40. Give ORS and cooled boiled water

41. Plus food-based fluid (not exclusively breastfed)*10ml/kg of ORS after each loose stool

42. 2. Continue FeedingFeed as usual on demand

43. Avoid food high in simple sugar as osmotic load may worsen the diarrhea3. When to Return (to clinic/hospital)Not able to drink

44. Becomes sicker

45. Develops fever

46. Has blood in stoolPLAN B (moderate diarrhea)Give recommended amount of ORS 4- hourly* Approximat amount of ORSs required = weight (in kg) x 75After 4 hoursReassess the child

47. Select appropriate treatment

48. Begin feeding the childExplain the 3 rules of PLAN A

49. PLAN C (severe diarrhea)Start IV or IO fluid immediately. Give 100ml/kg Ringers Lactate @ normal saline devided as :- - 1st give 20ml/kg as fast as possible. Repeat boluses until perfusion has improved - Give the remaining fluid 5 hrs (age < 1 year) or 2 ½ hrs (age >1 year)Reassess the child after every bolus

50. Reassess the child every 1-2 hour during rehydration

51. Give ORS as soon as the child can drink.

52. Classify the degree of dehyration

53. Choose appropriate treatmentMaintenance Fluid TherapyVolume of fluid required< 6 months age : 150 ml/kg/day

54. 6 to 1 year : 120 ml/kg/day

55. >1 year : 1st 10 kg = 100 ml/kg 10- 20 kg = + 50 ml/kg for the subsequent kg > 20 kg = + 20 ml/kg for the subsequent kg

56. Antimicrobial TreatmentIndicators:-

57. Toxic looking

58. Severe dehydration

59. Blood in stool

60. Types of Antibiotics:-

61. Ampicilin

62. Trimethoprim (TMP)

63. SulfamethoxazoleVOMITING

64. Chief Complaint:“Sally has a fever and is vomiting.”History of Present IllnessA 4-year-old female is brought to the emergency dept. by her parents.She started complaining of abdominal pain 3 hrs ago and then had an onset of vomiting episodes x 4. No blood noted in the emesis or bile appearance.Temperature taken at home one half hour ago, temperature was 38.2 C.Mother has also commented on Sally’s increased level of thirst over the past week, and has attributed Sally’s new onset of night time bedwetting to her increased consumption of fluids.CASE SCENARIO

65. Vomiting is a coordinated, sequential series of events that leads to forceful oral emptying of gastric contents.DEFINITION

66. –Duration, frequency, bilious material, abdominal pain, diarrhea, hematemesis, hematochezia, melena, headache, fever, dysuria, weight loss, urine output –Sick contacts, cough, rhinorrhea, neck stiffnessFamily history: Genetic diseaseHx of vomiting

67. –Vital signs, weight, mucous membranes, nasal discharge, breath sounds, rashes–Abdominal pain/distension, hepatosplenomegaly, abdominal masses, Murphy/obturator/psoas sign –Skin turgor, capillary refill –Neuro exam including funduscopy for papilledemaPhysical exam

68. Bilateral vomition centers in the reticular formation of the medulla integrate signals triggers vomition.Thevomition centers receive afferent signals from four major sources: The chemoreceptor trigger zone -bilateral set of centers in the brainstem lying under the floor of the fourth ventricle. The chemoreceptor trigger zones function as emetic chemoreceptors for the vomition centers - chemical abnormalities in the body (e.g. emetic drugs, uremia, hypoxia and diabetic ketoacidosis) are sensed by these centers, which then send excitatory signs to the vomition centers. Visceral afferents from the gastrointestinal tract (vagus or sympathetic nerves)Visceral afferents from outside the gastrointestinal tract - this includes signals from bile ducts, peritoneum, heart and a variety of other organs. Afferents from extramedullary centers in the brain - certain psychic stimuli (odors, fear), vestibular disturbances (motion sickness) and cerebral traumaPhysiology of vomiting

70. Nausea - unpleasant psychic experience.Retching phase - abdominal muscles undergo a few rounds of coordinated contractions together with the diaphragm and the muscles used in respiratory inspiration.Expulsive phase - intense pressure is formed in the stomach brought by enormous shifts in both the diaphragm and the abdomen. The vigorous contractions of these muscles last much longer than a normal period of muscular contraction. The pressure is then suddenly released when the upper esophageal sphincter relaxes resulting in the expulsion of gastric contents. VOMITING PHASES

71. VOMITINGManifested by nausea, pallor and diaphoresis, followed by forceful gagging and retching. REGURGITATIONEffortless and not preceded by nausea. But , the unpleasant sensations of gastric contents in mouth during regurgitation, may trigger gagging and true vomiting.

72. Gastric secretions are highly acidic.Recent foodMalodorous.Blood “coffee ground vomiting"(as the iron in the blood is oxidized) BileFecal vomiting-consequence of intestinal obstruction or a gastrocolic fistulanon-productive emesis or dry heaves-vomiting reflex continues for an extended period with no appreciable vomitusContents

73. Bright red-bleeding from the oesophagusDark red vomit with liver-like clots- profuse bleeding in the stomach (e.g.; perforated ulcer)Coffee ground-like vomit-less severe bleeding in the stomach-gastric acid has had time to change the composition of the bloodYellow vomit-bile indicates that the pyloric valve is open and bile is flowing into the stomach from the duodenum. Color

74. FBCU & ECreatinineStool serologyAbdominal X-RaySurgical opinion if obstructionExclude systemic disease INVESTIGATIONS

75. Aspiration of vomitUnder normal circumstances the gag reflex and coughing will prevent this from occurring. The individual may choke and asphyxiate or suffer an aspiration pneumonia.Dehydration and electrolyte imbalanceTears in GITIf these tears are limited to the inner lining of esophagus, they are called Mallory-Weiss tears-Passing of bright red or dark blood in the vomitus.Tears through the entire wall of the esophagus resulting in perforation and the escape of stomach contents outside the gut- “Boerhaave’s syndromePainful bruises or tears in the abdominal wall muscles.DentistryRecurrent vomiting may lead to destruction of the tooth enamel due to the acidity of the vomit and also can degrade tissue of the gum.If prolonged, weight loss or malnutrition may occur. Complications

76. Stabilize patient and fluid resuscitation as initial therapy with electrolyte correction Surgical consultation if obstruction suspected Oral rehydration with small amounts of liquids if tolerated Treat infections if indicated Remove toxins and allergens Surgical interventions for volvulus, Hirschprung, intracranial masses, pyloric stenosis, other anatomic causes Correct metabolic derangements Lifelong gluten-free diet for celiac disease Rare use of antiemetics/promotility agents for chemotherapy, motion sickness, postsurgery, gastroesophageal reflux diseaseTreatment

77. ABDOMINAL PAINAcute and recurrent

78. ABDOMINAL PAINDEFINITIONPain– feeling of distress, suffering, caused by stimulation of specialized nerve endings.Abdomen – the part of body lying between the thorax and pelvis, containing the abdominal cavity & visceraCATEGORIESReferred painPainful sensation in a body region distant from true source of pain

79. Caused by activation of spinal cord somatic sensory cell bodies by intense signaling from visceral afferent nerves located at the same level.Somatic painoverlying body structures are injured

80. Described as MSK pain

81. Pain is sharp, intense, discrete & localizedVisceral painnerves within gut detect injury,affecting soft organ n&body tissue

82. ‘’discomfort’’ and poorly localizedAcute Abdominal PainCan signal presence of dangerous intra-abdominal process-Eg: appendicitis, bowel obstructionOr originate from extraintestinal sources-Eg: lower lobe pneumonia or urinary tract stone

83. Diagnostic Approachhistoryonset- sudden or gradual, episodes, association w meals, history of injuryNature – sharp vs dull, colicky or constant, burningLocation – epigastric, periumbilical,generalized, R or L lower quardrant, change in location over timeFever – presence suggests appendicitis or other infection Extraintestinal symptoms – cough, dyspnea, dysuria, urinary frequency, flank painCourse of symptoms – worsening or improving, changes in nature or location of pain

84. PHYSICAL EXAMINATIONGeneral – growth & nutrition, general appearance, hydrational status, degree of discomfort, body position

85. Abdominal – tenderness, distention, bowel sounds, rigidity, guarding, mass

86. Genitalia – testicular torsion, hernia, PID, ectopic pregnancy

87. Surrounding structures – breath sounds, rales(crepitation), wheezing, flank tenderness, tenderness of abd. wall structures, ribs, costochondral joints

88. Rectal examination – perianal lesions, stricture, tenderness, fecal impaction, blood LABORATORYCBC, C-Reactive protein, ESR – evidence of infection/ inflammation

89. AST, ALT, GGT, Bilirubin – biliary or liver dss

90. Amylase, lipase - pancreatitis

91. Urinalysis – UTI, bleeding d/t stone, trauma or obstruction

92. Pregnancy test (older females) – ectopic pregnancyRADIOLOGYPlain flat & upright abdominal films – bowel obstruction, appendiceal fecalith, free intraperitoneal, kidney stones

93. CT scans – rule out abscess, appendicitis, Crohn dss, pancreatitis, gallstones, kidney stones

94. Barium enema - Intussusception, malrotation

95. Ultrasound – gallstones, appendicitis, intussusception, pancreatitis, kidney stones.ENDOSCOPYUpper endoscopy – suspected PU/ esophagitisDIFFERENTIAL DIAGNOSIS

97. DISTINGUISHING C.FEATURES

99. APPENDICITIS

100. APPENDICITISClinical FeaturesLower abdominal pain- right iliac fossa,Nausea and vomiting,loss of appetite,Diarrhoea,DysuriaPhysical Findingsquiet ,dehydrated.Tenderness on palpation or percussion ,discomfort, Guarding signifies peritonitis, Rectal examination is only required if other diagnosis are suspected e.g. ovarian or adnexal pathology.

103. INTUSSUSCEPTIONinvagination of one portion of intestine into another with involving the ileocaecal junction

104. peak age group being 2 months to 2 yearsClinical Features Pain - Sudden onset ,severe intermittent cramping pain lasting seconds to minutes

105. vomiting –undigested food ,Stools- dark red and mucoid (redcurrant jelly)Physical Findingswell- looking/ drowsy/ dehydrated

106. abdominal mass may be difficult to palpate in a distended abdomen Abdominal distension is a late signMANAGEMENTAPPENDICITISLaparoscopic surgeryINTUSSUSCEPTIONBarium enema in early intussusceptionSurgery

108. RECURRENT ABD. PAINDEFINITIONCRITERIAAt least 3 bouts of significant abd. pain over 3 months

109. Severe phase lasting at least 3 mins

110. Usually in children above 3 yr old.Occurrence of multiple episodes of abdominal pain over at least 3 months that are severe enough to cause some limitation of activity

111. DIAGNOSTIC APPROACHWhen taking history, pediatrician should ask about the warning signs for underlying diseases

112. If any warning signs are presents, further investigation is necessary.

113. Even if they are absent, some laboratory evaluation is warranted. VomitingfeverBilious emesisAbnormal screening lab. studyGrowth failureWeight lossPain awakening child from sleepLocation away from periumbilical regionBlood in stools or emesisDelayed pubertyWARNING SIGNS!

114. INVESTIGATIONSFOLLOW UP CBC

115. ESR

116. Amylase, lipase

117. Urinalysis

118. Abdominal ultrasound

119. Trial of 3- day lactose-free diet

120. CT scan

121. Celiac disease serology

122. Barium upper GI

123. Endoscopy

124. ColonoscopyDIFF. DIAGNOSIS OF RAPFunctional abdominal pain* -

125. IBS*

126. Chronic pancreatitis

127. Gallstones

128. Peptic disease - duodenal ulcer, gastric ulcer, esophagitis

129. Lactose intolerance*

130. Fructose malabsorption

131. Inflammatory bowel disease* - crohn’s disease, ulcerative colitis

132. Constipation*

133. Obstructive uropathy

134. Congenital intestinal malformation – stricture or web, malrotation, duplication cyst

135. Celiac disease*FUNCTIONAL A.P. Pain that characteristically occurs daily or nearly every day

136. Not assoc. with or relieved by eating/ defecation

137. Assoc. with sig. loss of ability to function normally.

138. These kids have personality traits that include tendency towards anxiety & perfectionism – results in stress

139. Parents noted that child enjoys going to school, but the pain often worst at the start of school day & before returning to school after vacations.Irrittable Bowel Syndromecramping, abdominal pain, bloating, constipation, and diarrhea.

140. Pain begin with a change in stool frequency /consistency.

141. A stool pattern fluctuating between diarrhea and constipation.

142. Relief of pain with defecation

143. Symptom are link to gut motility

144. Modulated by psychosocial factor such as stress and anxiety.MANAGEMENT Treat underlying conditions

145. Allows children to resume with daily activities

146. Reassures that the although pain is there, will not harm the children physically (in case of FAP)

147. IBS-can control symptoms with diet, stress management, and prescribed medications.