Download to read offline
Uploaded byHasan Arafat
Gastroenteritis
The document provides a detailed overview of acute gastroenteritis in children, focusing on diagnosis and management according to the latest guidelines. It emphasizes the importance of early rehydration, the outdated nature of 'bowel rest', and discourages the use of antidiarrheal agents. It also highlights effective treatment options such as oral rehydration solutions, zinc supplementation, and probiotics, while stressing prevention through education and sanitation.
More Related Content
Gastroenteritis
- 1. Acute Gastroenteritis: Scopeon Diagnosis and Management Hasan Arafat, MD Rose Najeeb, MD, PBP, MRCP, DCH
- 2. Disclosure • All informationprovided inside related to the last published NASPHGAN/ESPHGAN guideline regarding gastroenteritis definition, diagnosis and management. • AAP: American Academy of pediatrics • Nelson Textbook is our main reference. • No conflict of interest.
- 3. Educational Gap • Inmanaging acute diarrhea in children, some clinicians might tend to approach their patient using “bowel rest” • This approach is outdated • Reinstitution of an appropriate diet has been associated with decreased stool volume & duration of diarrhea • Drug therapy is not indicated in managing diarrhea in children • However, zinc supplementation & probiotic show promise
- 4. Objectives • Recognize theelectrolyte changes associated with isotonic dehydration • Effectively manage a child who has isotonic dehydration • Effectively manage a child who has isotonic dehydration • Understand the importance of early feedings on the nutritional status of a child who has gastroenteritis • Fully understand that antidiarrheal agents are not indicated nor recommended in the treatment of acute gastroenteritis in children • Recognize the role of vomiting in the clinical presentation of acute gastroenteritis
- 5. Introduction Derived from Greekdia means “through” and rhien “to flow”
- 6. Introduction • Acute gastroenteritisis an extremely common illness in pediatrics • In developed countries, it account for a large chunk of outpatient visits, hospitalizations, & deaths • In developing countries, it’s a common cause of mortality, specially in young children • 1/3 of hospitalized cases of diarrhea younger than 3 years are due to rotavirus
- 7. Definition • Sudden onsetof increased fluid content of the stool above normal • Duration: • Acute: < 2 weeks • Volume: • Infants and toddlers >10 mL/kg/day • Older children > 200 mL/day • From Practical viewpoint: • Decrease in consistency (to loose or liquid) and increase in frequency of bowel movements to ≥ 3 per day
- 8. Epidemiology • WHO estimates:Diarrheal disease cause 17% of deaths in children < 5 yrs worldwide • In United States: • Annually 38 million cases. • 2 million to 3.7 million physician visits. • 320,000 hospitalizations • associated with up to 9% of all hospitalizations in children < 5yrs • 325 to 425 deaths • Seasonal peak in the winter
- 9. Epidemiology • Rotavirus isthe most frequent agent of AGE; however, norovirus is becoming the leading cause of medically attended AGE in countries with high rotavirus vaccine coverage. • The most common bacterial agent is either Campylobacter or Salmonella depending on country. • Intestinal infections are a major cause of nosocomial infection.
- 10. Pathophysiology • Four processesthat either individually or collectively contribute to diarrhea – Secretory – Cytotoxic – Osmotic – Inflammatory
- 11. Effect of bacterialenterotoxin on mucosal cells of the small intestine • Enterotoxin stimulates secretion of fluid and electrolytes from mucosal crypt cells – Mediated through prostaglandins – Affects cAMP, GMP and calcium ion flows – Blocks absorption of fluid and electrolye by the villi
- 12. Cytotoxic process • Destructionof small intestinal mucosal villi by infectious viral agent • Villi shorten after cell lysis • Decreased small bowel surface area decreases capability of small intestine to absorb fluid and electrolytes • Proportional increase in secretion with marked decrease in absorptive function of small bowel mucosa
- 13. Osmotic process • Commonlyseen in malabsorption syndromes • Lactose intolerance • Malabsorbed substance is osmotically active, leading to a net flux of water into the intestinal lumen – resulting in loose diarrheal stools • Large intestinal flora is inundated with increased CHO, which then is metabolized and produces gas, abdominal pain and decreased stool pH
- 14. Inflammatory process • Inflammationof mucosa and submucosa of terminal ileum and large bowel • Invasion by a bacterial agent causes edema along with mucosal bleeding and leukocytic infiltration • Inflammation causes increased colon motility and frequent stooling with tenesmus • Alteration in GI motility – often with secretory and cytotoxic processes • Luminal dilation, delayed gastric emptying (cause nausea and vomiting), rapid intestinal transit time with marked peristaltic rushes
- 15. Causes of AcuteDiarrhea: Infectious and inflammatory Secretory • E. coli • Vibrio cholerae • Clostridium difficle • Clostridium perfringes • Aeromonas hydrophila • Staphylococcus aureus • Vibrio parahemolyticus • Bacillus cereus • Shigella • Salmonella • Yersinia enterocolitics • Giardia lamblia Cytotoxic • Rotavirus • Norwalk agent • Cryptosporidium • Escherichia coli Dysenteric • Campylobacter fetus • Clostridium difficle • Salmonella • Shigella • Yersinia enterocolitica • Entamoeba histolytica
- 16. Causes of Acutediarrhea • Drug Induced – Antibiotic associated – Laxatives – Antacids that contain magnesium – Opiate withdrawl • Surgical conditions – Acute appendicitis – Intussusception • Heavy metals or toxins – Copper, tin, zinc – Chemotherapy or radiation induced enteritis 11 • Vitamin Deficiency – Niacin, Folate • Vitamin Toxicity – Vitamin B3, C, Niacin • Disorders of Malabsorption – Lactase deficiency – Sucrase-isomaltase deficiency • Food allergies or intolerance – Cow’s milk or soy protein allergy – Methylxanthines(caffeine , theobromine, theophylline)
- 17. Indications of Moderateto Severe disease • Age < 3 months • Weight <8 Kg • History of Premature birth, or chronic medical conditions or concurrent illnesses. • Fever ≥ 38° C for infants < 3months or > 39 °C for 3 to 36 months • Visible blood in stool • High output diarrhea • Persistent emesis • Signs of dehydration • Mental status changes • Inadequate response to or caregiver are unable to administer ORT
- 18. Physical examination ofthe child with diarrhea • Growth chart • Vital signs • Muscle mass • Subcutaneous fat • Pubertal stage • Psychomotor development • Skin (perianal) • ENT region - otitis media • Abdomen – Organomegaly – Tenderness Rectal exam • Stool sample • Color Consistency • ? Occult blood → Hemoccult • ? pH → Indicator • ? Fermentation → Clinitest
- 19. Clinical Approach, cont’d •Physical Examination: • Focus on identifying signs of dehydration:
- 20. Microbiology • Viruses areresponsible for the majority of cases • Characterized by low-grade fever, watery diarrhea, no blood • Bacteria infiltrates the mucosal lining of small & large intestines, leading to inflammation • High fever, blood in stool, white blood cells in stool
- 21. Management • Acute gastroenteritisis usually self-limiting • Initial critical step: early fluid replacement at home • Families should be instructed to begin feeding a commercially available ORS product as soon as diarrhea develops • ORS (oral rehydration solution): the preferred treatment of fluid & electrolyte losses caused by diarrhea in children with mild to moderate dehydration. WHO and the AAP.
- 22. Management, cont’d • Lowoverall treatment failure, no increased incidence of iatrogenic hypo/hypernatremia, lower cost, no need for IV access, involvement of parents at home • Common household beverages (fruit juice, sport drinks, tea & soft drinks) should be avoided
- 23. Management, cont’d • Twophases of therapy: rehydration and maintenance • Rehydration phase: fluid should be replaced rapidly in a 3- to 4-hour period • Maintenance phase: calories, in addition to fluids, are administered • Rapid re-alimentation should follow rapid rehydration • Continuous losses should be replaced continuously • Remember: “bowel rest” is outdated.
- 24.
- 25. Composition of oralrehydration solution
- 26. Early refeeding • Earlyrefeeding is recommended in managing acute gastroenteritis • Luminal contents are known growth factors for enterocytes and help facilitate mucosal repair after injury • Almost all infants with acute gastroenteritis can tolerate breastfeeding • Diluted formula does not provide any benefit over full-strength formula • Infants with the most severe diarrhea may require lactose-free formula until mucosal recovery is complete at around 2 weeks • Older children can consume a regular age-appropriate diet • BRAT diet not recommended
- 27. Other treatment options •Antibiotics • Zinc • Immunoglobulin • Drugs • Probiotics
- 28. Limitations of ORSTherapy • Hemodynamic instability • Abdominal ileus • Suspicion of intussusception • Stool output >10 mL/kg • Persistent emesis
- 29. Pharmacologic Therapy: Antibiotics: • May prolong illness, increase carrier state & increased morbidity • Antibiotic use always indicated • V. cholera, Shigella and Giardia lamblia • Antimicrobial therapy in selected circumstances • Enetropathogenic E. Coli when running a prolonged course • Enteroinvasive E. Coli based on serologic, genetic and pathogenic similarities with shigella • Yersinia infection in subjects with sickle cell disease • Salmonella infection in very young infants, if febrile or with positive blood culture
- 30. Pharmacologic Therapy • AntidiarrhealAgents • Routine use: not recommended • Loperamide: opiate-induced ileus, drowsiness, and nausea • Bismuth subsalicylate: limited efficacy
- 31. Pharmacologic Agents • AntiemeticAgents • Ondansetron: selective serotonergic 5-HT3 receptor antagonist, effective, lowers rate of admission, few side effects • Promethazine: older generation, less effective, approved for children >2 years, adverse effects: sedation, extrapyramidal symptoms • Metoclopramide: dopamine receptor antagonist, high rate of extrapyramidal symptoms • None of these drugs addresses the causes of diarrhea, thus they may distract the physician away from the mainstay therapy
- 32. Pharmacologic Therapy • SupplementalZinc Therapy • Micronutrient deficiency in malnourished children with diarrhea • Zinc supplementation in acute diarrhea (WHO/UNICEF in 2004) • Infants > 6 months of age – 10mg/day • Children with 20mg/day • Duration 10- 14 days • Any of zinc salts ie, sulphate, gluconate or acetate may be used • Benefits – can shorten course and severity
- 33. Pharmacologic Therapy • FunctionalFoods • Probiotics: live microorganism in fermented foods that have the potential to benefit the host • Lactobacillus rhamnosus GG, Bifidobacterium lactis, and Streptococcus thermophiles • L rhamnosus GG: decreases the duration of diarrhea by 1 day, more potent against rotavirus gastroenteritis, decreases duration by 2 days • The earlier, the better • Prebiotics: oligosaccharides that stimulate the growth of intestinal flora • No evidence of benifit
- 34. Oral immunoglobulin • Oralor enteral immunoglobulin in treatment of rotavirus diarrhea (immunocompromised or immunocompetent) • Current evidence does not support the use of oral immunoglobulin preparations to prevent rotavirus infection in low birth weight infants
- 35. Prevention • Education • Sanitation •Hygiene • Simple hand washing has decreased incidence by >50% • Breast feeding • Food safety • Food safety has also been effective in decreasing the incidence by >50% • Appropriate use of oral rehydration therapy • Probiotics • Development of vaccinations • Rota virus vaccine – RotaTeq and Rotarix
- 36. Summary • Acute gastroenteritisis self-limited • Labs should be minimized • History and physical exam are key • ORS is the preferred method for treatment • Rapid re-institution of unrestricted age-appropriate diet is part of the maintenance treatment • Pharmacologic therapy is not indicated, drugs may complicate the natural course of the disease
Editor's Notes
- #8 Definition: or simply, more frequent passage of stool than normal Because stool patterns vary, it’s important to note that diarrhea should represent a change from norm, rather than having a rigid definition
- #20 Infant dehydration: 5% (50 mL/kg), 10% (100 mL/kg), 15% (150 mL/kg) Older children: 3% (30 mL/kg), 6% (60 mL/kg), 9% (90 mL/kg) Dehydration is the main concern in pediatric gastroenteritis In 2003, CDC combined mild & moderate dehydration into a single category. The authors of studies have evaluated the correlation of clinical signs of dehydration with posttreatment weight gain and have demonstrated that the first signs of dehydration might not be evident until 3% to 4% dehydration. Furthermore, more obvious clinical signs of dehydration become apparent at 5% dehydration, and indications of severe dehydration become evident when the fluid loss reaches 9% to 10%. As a result, the CDC revised its recommendations in 2003 and combined the mild and moderate dehydration categories, acknowledging that the signs of dehydration might be apparent over a relatively wide range of fluid loss (Table 2). The ultimate goal of this assessment is to identify which patients can be sent home safely, which should remain under observation, and which are candidates for immediate, aggressive therapy. (1)
- #23 High osmolality due to their high sugar content and little Na and K, they worsen the patient condition by increasing the stool output and increasing the risk for hyponatremia
- #24 Rapid re-alimentation is retungin the patient quickly to an age-appropriate, unresitricted diet. Breastfeeding should be continued, diet should be advanced as tolerated to compensate for lost caloric intake during acute illness. Lactose-free formula should be made only if the stool output increases significantly on a milk-based diet
- #29 Contraindication, because altered mental status and shock can increase the risk of aspiration because of the loss of airway protective reflexes Contraindication, bowel sounds should be present Proper radiologic studies may be warranted before considering ORS Failure rate is high, but should be administered anyways Parents should be instructed to offer small amounts of ORS (5 mL with a spoon or syringe every 5 minuts), with a gradual increase as toelrated
- #30 As most cases of acute gastroenteritis are viral, Abx are not indicated and might actually cause harm
- #31 In children <3 years
- #32 These symptoms interfere with the rehydration process
- #33 It protects cells from oxidative injury
- #34 They promote balance in the intestinal flora