GASTROENTRITIS
AND
DEHYDRATION
Prof. Dr. Khaled Zayed Unit
LECTURE definitions of diarrhea.
OBJECTIVES mechanisms and
pathophysiology of diarrhea.
Approach to a child with diarrhea.
Differential diagnosis of acute
diarrhea.
Complications of diarrhea.
management of diarrhea.
dehydration and how to manage.
DEFINITIONS:
DIARRHEA:
Excessive loss of fluid and electrolyte in the stool.
ACUTE WATERY DIARRHEA:
Passage of liquid (or watery stools) 3 or more times in 12 hours
Or: single soft or watery stool containing blood, mucus, or pus.
DESENTRY:
Small-Volume
Frequent Bloody Stools With Mucus
Tenesmus :(painful defecation with incomplete sense of evacuation)
Urgency
CAUSES: It is the predominant symptom of colitis.
PERSISTENT DIARRHEA:
Episodes that began acutely but last for at least 14 days.
CHRONIC DIARRHEA:
Prolonged course and started gradually (e.g. malabsorption
syndromes)
MECHANISMS OF
DIARRHEA:
01
SECRETORY DIARRHEA
02
OSMOTIC DIARRHEA
03
MOTILITY DISORDERS
Caused by secretagogue Caused by Ingestion of a poorly absorbed Causes:
Mechanism: THEY bind to a receptor solute. 1. Rapid or delayed transit
on the surface epithelium of the Mechanism: Poorly Absorbed Solute. May 2. associated with bacterial overgrowth
bowel then stimulate Be: in slow motility disorder
intracellular accumulation of cAMP 1. Normally not well absorbed E.g. Nature: They are not generally
or cGMP. Magnesium, phosphate, lactulose, or associated with large-volume diarrhea.
Example Such as cholera toxin. sorbitol
Nature: Watery and of large volume. 2. Not well absorbed because of a disorder
Effect of fasting: Persists even when of the small bowel e.g.
no feedings are given by mouth. Lactose with lactase deficiency
Glucose with rotavirus diarrhea).
Nature: Usually of lesser volume than a
secretory diarrhea
Effect of fasting: Stops with fasting.
NB. Disorders that interfere with absorption in the small bowel tend to produce voluminous diarrhea, and those interfere with clonic absorption produces lower volume diarrhea.
APPROACH TO
A CHILD WITH
DIARRHIA
HISTORY
PERSONAL HISTORY:
Age (Type of weaning food and social class).
HISTORY OF PRESENT ILLNESS:
1. Onset & Duration (Acute or persistent).
2. Frequency in 24 hours (To prove diarrhea, follow-up).
3. Consistency: (soft or watery).
4. Blood in the stools (Dysentery).
5. Associated manifestations: cough, fever, vomiting etc.
6. Dehydration (irritability, thirst, decreased urine output).
DIETETIC HISTORY:
Diet (breast-feeding, artificial feeding, weaning food).
PAST HISTORY:
1. Vaccinations (completed or not)
2. Drugs (may cause lethargy, ileus)
EXAMINATION:
PHYSICAL EXAMINATION:
1. Body weight.
2. Temperature.
3. Signs of dehydration.
4. Systemic examination.
STOOL EXAMINATION:
1. Volume
2. Color
3. Consistency
4. Odor
5. Content (blood or mucous)
DIFFERENTIAL DIAGNOSIS
INFANT
common causes Rare causes:
Systemic Infection. Primary Disaccharidase
Antibiotic Associated. deficiency.
Overfeeding. Hirschsprung toxic colitis.
CHILD
common causes Rare causes:
Food poisoning. Toxic ingestion.
Systemic infection.
Antibiotic associated
ADOLESCENT
common causes Rare causes:
Food poisoning. Hyper- thyroidism
Antibiotic associated.
INFECTIVE DIARRHEA
(GASTROENTRITIS)
DEFINITION THE COMMON PATHOGENS
he term gastroenteritis denotes infections of the 1- Rotavirus
gastrointestinal tract caused by bacterial, viral, or 2- Enterotoxigenic EC
parasitic pathogens. 3- Shigella
Many of these infections are foodborne illnesses. The 4- Campylobacter
most common manifestations are diarrhea and vomiting, 5- Cryptosporidium
which can also be associated with systemic features
such as abdominal pain and fever
COMPLICATIONS OF
DIARRHEA:
DEHYDRATION
shock, pre-renal failure, disseminated intravascular coagulopathy.
ELECTROLYTE & PH DISTURBANCE
hypo or hyperkalemia, hypo or hypernatremia, acidosis and
hypocalcaemia.
PERSISTENT DIARRHEA
leads to protein energy malnutrition (PEM)
CONVULSIONS
febrile, hypo or hypernatremia, CNS hemorrhage, associated CNS
infection as meningitis.
MANAGEMENT OF
DIARRHEA:
A. TREATMENT OF ACUTE DIARRHEA
1- Rehydration Therapy (either oral on intravenous).
2- enteral feeding and diet selection.
3- zinc supplementation.
4- drugs (antibiotic in GE).
B. PREVENTION OF DIARRHEA
1- Promotion of exclusive breast-feeding
2- Improved complementary feeding practices
3- Rotavirus immunization
4- Improved water and sanitary facilities and
promotion of personal and domestic hygiene
ORAL REHYDRATION
THERAPY
COMPOSITION
Sodium chloride 3.5 g/L
Potassium chloride 1.5 g/L
Trisodium citrate 2.9 g/L
Glucose 20 g/L
FUNCTION OF EACH COMPONENT
Na+
Correct Na+ loss.
Facilitates secondary water absorption.
K+
correct K+ loss.
Prevent hypokalemia.
Trisodium citrate
Correct acidosis.
Glucose (2%)
facilitate Na+ absorption by Glucose NA co-transport.
TYPES OF ORS:
STANDARD GLUCOSE BASED ORS
As rehydran (90 mmol
Na)
Composition: as above
LOW OSMOLAR GLUCOSE BASED ORS
As lohydran , hydrosafe (75 mmol Na)
Composition: NaCl : 2,69\L , glucose : 13,5 g\L
↓↓ Na and glucose to Guard against osmotic
diarrhea and hypernatremia.
ZINC ORS
as low osmolar with add of zinc.
RICE ORS
rice replace glucose ( cholera).
DRUGS USED IN
TREATMENT OF GE:
ANTIMICROBIALS
Include
Trimethoprim-Sulfamethoxazole: (10 - 50mg/kg) for 5 days
Metronidazole:
1. For Giardiasis: 15 mg/kg,
2. For amoebiasis: 30 mg/kg for 10 days.
Indications
1. Bloody diarrhea.
2. Cholera.
3. Associated bacterial infections.
NITAZOXANIDE
broad spectrum antimicrobial including anti-rota virus.
ANTIDIARRHEAL
Constipating drugs and antimotility drugs
Hazards:
Not effective
Parasympatholytic action.
Prolongation of diarrhea.
INTRAVENOUS
FLUIDS
INDICATIONS
1- Severe dehydration
2- Paralytic ileus
3- Glucose intolerance
4- Protracted vomiting
5- Rapid loses, not corrected by ORS.
TYPES
Ringer lactate or normal saline in shock
therapy
D5 half normal saline is the most commonly
used as a deficit and maintenance therapies.
CAUSES OF CHRONIC
DIARRHEA
INFANT
Post- infectious.
Secondary lactase deficiency.
Cow's milk /soy pt. intolerance.
Chronic nonspecific diarrhea of infancy.
Excessive fruit juice (sorbitol) ingestion.
Celiac disease.
AIDS enteropathy.
Cystic fibrosis.
CHILD ADOLESCENT
Irritable bowel Syndrome. Irritable bowel Syndrome.
Celiac disease. Inflammatory bowel disease.
Lactose intolerance. Lactose intolerance.
Giardiasis. Giardiasis.
Inflammatorybowel disease. Laxative abuse (anorexia nervosa)
Excessive fruit juice (sorbitol) ingestion. Constipation with encopresis
AIDS enteropathy.
VOMITING WITH
DIARRHEA
CAUSES
Associated gastritis.
Acidosis.
Hypokalemia.
Hypovolemia.
HOW TO DEAL?
Antiemetics are not effective as it act
peripherally
Vomiting may be stopped either
1. Spontaneously
2. After correction of dehydration by ORS
If persistent give ORS by Nasogastric tube or IV
fluids
PRESISENT DIARRHEA
RISK FACTORS
1- Young age less than 18 months.
2- Artificial feeding.
3- Malnutrition.
4- Lowered immunity.
5- Withholding of food during the acute attack.
6- Abuse of drugs : (Antibiotics, constipating drugs).
HOW WOULD YOU MANAGE ??
Hospitalization if
Younger than 6 months
Any degree of dehydration
Associated other severe infections e.g. viremia
Failure of home management
Presence of PEM
Lines of treatment
Diet: Breast-feeding
Low or lactose free formula
Drugs: According to the condition
Vitamins and minerals (Folate, vitamin A, Zinc, Mg+, copper and iron)
DEHYDRATION
DEFINITION
Loss of body fluids and electrolytes through:
Stoolsl Vomitus, Urine or Lack of food and
fluid intake
DEGREES AND TYPES
OF DEHYDRATION
DEGREE OF DEHYDRATION:
A. Minimal or no dehydration:
< 5 % in an infant
< 3 % in an older child or adult
B. Mild to moderate dehydration:
5-10 % in an infant
3-6 % in an older child or adult
C. Severe dehydration:
>10 % in an infant
> 6 % in an older child or adult
TYPES OF DEHYDRATION
The serum Na concentration determines the type of
dehydration:
a) Isotonatremic (serum Na+ 130 - 150 mEq/L)
b) Hypotonatremic (serum Na+ D 130 mEq/L)
c) Hypernatremic (serum Na+ 0 150 mEq/L)
SYMPTOMS ASSOCIATED WITH
MINIMAL OR NO DEHYDRATION
MENTAL STATUS THIRST HEART RATE
well Drinks normally Normal
Alert might refuse liquids.
QUALITY OF PULSES BREATHING EYES
Normal Normal Normal
TEARS MOUTH & TONGUE SKIN FOLD
present Moist Instant recoil
CAPILLARY REFILL EXTREMITIES
Normal Warm
SYMPTOMS ASSOCIATED WITH MILD
TO MODERATE DEHYDRATION
MENTAL STATUS THIRST HEART RATE
Normal, fatigued Thirsty Normal to
Restless, irritable Eager to drink increased
QUALITY OF PULSES BREATHING EYES
Normal to Normal; fast Slightly sunken
decreased
TEARS MOUTH & TONGUE SKIN FOLD
Decreased Dry Recoil in <2 sec
CAPILLARY REFILL EXTREMITIES
Prolonged Cool
SYMPTOMS ASSOCIATED WITH
SEVERE DEHYDRATION
MENTAL STATUS THIRST HEART RATE
Apathetic, lethargic Drinks poorly Tachycardia
Unconscious Unable to drink
QUALITY OF PULSES BREATHING EYES
Weak, thready, or Deep Deeply sunken
impalpable
TEARS MOUTH & TONGUE SKIN FOLD
Absent Parched Recoil in >2 sec
CAPILLARY REFILL EXTREMITIES
Prolonged, minimal Cold; mottled;
cyanotic
MANAGEMENT OF MINIMAL OR
NO DEHYDRATION (PLAN A)
PLACE
at home
TYPE
ORS
AMOUNT
for baby < 2 yrs.: 1/4 -1/2 cup
for child > 2 yrs.: 1/2 - 1 cup
METHOD
Oral cup and spoon
RATE
(After each watery stool)
OTHERS
Breast continues
Frequent formula as such, easily digested food
OBSERVE
Diarrhea not getting better in 3 days
Fever persists > 2 days or appears
generally more sicker
Vomiting persists or appears
Dehydration reappears
•Food and Drink refusal
MANAGEMENT OF MODERATE
DEHYDRATION (PLAN B)
PLACE
Under observation at hospital
TYPE
ORS
AMOUNT
50 - 100 ml/motion
or (75 ml / Kg)
METHOD
Oral cup and spoon, frequent sips
RATE
one spoon (5 ml) every 1-2 minutes
OBSERVE
Vomiting: Wait 10 min.
Resume by slower rate.
Refusal: If persistent, NGT
starts (Nasogastric tube feeding).
If signs of dehydration or stools output increased, start
IV fluids.
MANAGEMENT OF SEVER
DEHYDRATION (PLAN C)
PLACE
Admission to hospital
TYPE
Polyelectrolyte solution or Ringer lactate
If not available give saline.
AMOUNT
100 ml/kg "total amount"
METHOD
Intravenous
RATE
Shock therapy: 30 ml/kg (IV volume restoration)
• if age > 1 yrs. through 30 minutes
• If age < 1 yrs. through 60 minutes.
Deficit: 70 ml/kg
• if age > 1 yrs. through 2 .5 hours
if age < 1 yrs. through 5 hours
OBSERVE
Pulse for signs of shock (weak & rapid)
Consciousness (improved or still cloudy)
Other signs (Weight, eyes, skin, urine)
