ACUTE DIARRHOEA in Paediatrics 6 slidespptx

Acute watery diarrhea

1. ACUTE DIARRHOEA GROUP 5 PRESENTATION

2. outline Introduction Definitions Epidemiology Etiology Pathogenesis Clinical evaluation Treatment complications

3. introduction Diarrheal illness is the second leading cause of child mortality; among children younger than five years of age worldwide, it accounts for approximately 1.7billion cases and 525000 deaths per year.(WHO 2020) In resource-limited countries, infants experience a median of six episodes annually; children experience a median of three episodes annually.   Diarrheal illness may consist of acute watery diarrhea, invasive (bloody) diarrhea, or chronic diarrhea (persistent ≥14 days). This classification facilitates the approach to management of childhood diarrhea.

4. definitions Diarrhoea Stools that are more frequent or looser in consistency than an individual’s regular stools Is the passage of loose or watery stools at least three times in a 24 hour period.  Is excessive loss of fluid and electrolyte in the stool.

5. Definition… Acute diarrhea is defined as sudden onset of excessively loose stools of >10 mL/kg/day in infants and >200g/24 hour in older children, which lasts <14 days Acute diarrhea: 3 loose, watery stools within 24 hours Dysentery:bloody diarrhea, visible blood and mucus. Persistent diarrhoea:episodes of diarrhea lasting more than 14 days (MOH,UCG 2023)

6. classification

7. n Characteristic of the stool Invasive No invasive WATERY BLOODY Secretory Osmoti c

8. Epidemiology Diarrheal disease is a major public health problem worldwide. Globally, 525,000 children under-5 years die due to diarrhea every year, roughly 2195 every day. This represents 8% of all deaths and is the second leading cause of death among children under-5 years old. The majority of morbidity and mortality occurred in south Asia and sub-Saharan African countries, which 88% were attributable to unsafe water, inadequate sanitation, and insufficient hygiene

9. ...... In Uganda, diarrhoea is among the top 4 causes of morbidity in infants and young children . The prevalence of diarrhoea among children < 5 years in Uganda was 20.9% in 2016.The total deaths attributed to diarrheal disease was 6.4% making uganda 27th worldwide that year Rotavirus being responsible for about 40% of all diarrhoeal cases .

10. Etiology Most cases of acute diarrhea in resource-limited countries are caused by infectious gastroenteritis. Less commonly, acute diarrhea can be a symptom of a systemic infection or an intra-abdominal surgical emergency. Others causes of diarrhea may be non infectious; Possible causes of parenteral diarrhoea (Reflex gastro intestinal irritation ; toxic absorption)

11. . . INFECTIOUSE Otitis media; Urinary tract infections; Pneumonia Bacterial meningitis Other systemic infections Gastrointestinal Non-gastro-intestinal infections (Parenteral diarrhea) Viruses Bacteria Parasites NON-INFECTIOUSE Toxins Dietary disturbances Immunodeficiency Endocrinopathy Antibiotic, Iron salts; Medicinal teas or infusions Overfeeding; Food allergy ; Starvation stools Immunodeficiencies and other genetic disorders; HIV Hyperthyroidism; Hypoparathyroidism ; DM Diarrhea 4 3 2 1 1 4 3 2 1 2 2 1 CAUSES

12. risk factors Failure of exclusive breast feeding in the first 4-6 months Bottle feeding Malnutrition Immune suppression: HIV, measles Attendance of day care centers Unsanitary storing of foods Poor water quality Unsanitary food handling Unsanitary disposal of feces

13. Major etiologies of childhood diarrhea in resource-limited countries Syndrome Etiologic agents Features Acute watery diarrhea Watery stools; may contain mucous. Fever may be present. Rotavirus Leading cause of gastroenteritis in children younger than two years Enterotoxigenic   Escherichia coli  (ETEC) Leading cause of gastroenteritis in older children and adults. Vibrio cholerae  O1 and O139 associated with endemic and epidemic disease. Vomiting and voluminous "rice-water diarrhea" in severe cases. Cryptosporidium Common in infants (younger than one year) even in the absence of HIV; infrequently seen in older children Norovirus Abrupt onset of vomiting and diarrhea with low grade fever.

14. , Syndrome Etiology agents Features Invasive diarrhea Gross blood in stool. Often associated with fever, vomiting, abdominal pain. Shigella spp. Leading cause of invasive diarrhea.  S. dysenteriae  serotype I produces Shiga-toxin and is associated with epidemics of severe disease. Complications include toxic megacolon, rectal prolapse, intestinal perforation, seizures, encephalopathy and sepsis. Nontyphoidal  Salmonella enterica Several serotypes cause gastroenteritis. Infants, elderly, and immunocompromised at increased risk for disseminated infection Campylobacter spp. Predominantly  C. jejuni  and  C. coli . May mimic appendicitis. Complications include Guillain-Barré syndrome Enteroinvasive  Escherichia coli  (EIEC) EIEC are closely related to Shigella and cause a syndrome essentially identical to shigellosis. Enterohemorrhagic  Escherichia coli  (EHEC) EHEC produce Shiga toxin identical to that produced by  S. dysenteriae  serotype I, associated with increased risk of hemolytic uremic syndrome. Entamoeba histolytica E. histolytica  is a protozoal organism which causes intestinal infection which may be indistinguishable from Shigella and other bacteria. Rare complications include extraintestinal infections, most commonly hepatic abscess. Adenovirus types 40/41 Also cause watery diarrhea.

15. Pathogenesis Normal fluid absorption and secretion  : The normal movement of fluid between the intestinal lumen and blood is driven by the active transport of ions (mainly Na + , Cl – , HCO 3 – , and K + ) and nutrients (mainly glucose). Fluid absorption is driven by the active transport of Na +  across the epithelium with parallel Cl –  or HCO 3 –  absorption. Fluid secretion is driven by transepithelial Cl –  secretion through basolateral and apical Cl –  channels and transporters.

16. It is caused by enterotoxins (as an example the non-structural glycoprotein (NSP4) from bacteria These (NSP4) agents act on the adenyl cyclase and convert ATP to cAMP releasing energy for Chloride pump. The chloride out in the intestine lumen also the sodium follow.

17. The excess fluid is accumulated in the light of small intestine and passes into the colon where maximum absorption of water, sodium and chloride is produced and a large amount of Potassium and bicarbonate is removed The ability of the colon to absorb water is overcome and a watery, abundant stool with high content of sodium bicarbonate and Potassium occur that often lead patients to dehydration and metabolic acidosis

18. Pathogenesis of osmotic diarrhoea Osmotic diarrhea typically results from one of two situations: Ingestion of a poorly absorbed substrate :  The offending molecule is usually a carbohydrate or divalent ion. Common examples include mannitol or sorbitol, epson salt (MgSO 4 ) and some antacids (MgOH 2 ). Malabsorption :  Inability to absorb certain carbohydrates is the most common deficit in this category of diarrhea.

19. . Lactose intolerance: there is an intestinal epithelium deficiency in lactase , and lactose cannot be effectively hydrolyzed into glucose and galactose for absorption. The osmotically-active lactose is retained in the intestinal lumen, where it "holds" water. To add insult to injury, the unabsorbed lactose passes into the large intestine where it is  fermented by colonic bacteria , resulting in production of excessive gas.

20. . The action of intestinal bacteria on undigested carbohydrates results in the production of lactic acid, which results in a decrease of the intestinal pH, resulting in acid deposition that translates clinically by the perianal erythema. A distinguishing feature of osmotic diarrhea is that it stops after the patient is fasted or stops consuming the poorly absorbed solute.

21. CLINICAL ASSESSMENT The assessment of the child with diarrhea can be divided into four components to guide clinical management: Classification of the type of diarrheal illness Assessment of hydration status Assessment of nutritional status Assessment of co-morbid conditions

22. Classification of diarrhea : The assessment of a child with diarrhea should include a history of the duration, frequency, and character of the diarrhea, as well as an assessment of the stool. Patients can be classified as having: Acute watery diarrhea : loose or watery stools at least three times in a 24 hour period. Invasive diarrhea : (synonymous with dysentery) gross blood (by history or inspection) in the stool of <14 days duration, typically accompanied by fever. Persistent diarrhea : loose, watery, or bloody stools of ≥14 days.

23. Secretory Osmotic The consistency of the diarrhea is always liquid, it is not alternating like the osmotic. The diarrhea is abundant on quantity and frequent on number, more than 15 per day, lead quickly to dehydration and metabolic acidosis, can appear high grade fever, and the child sick looking. The diarrhea is watery and its consistency alternates sometimes liquid, other semiliquid and other semi-solid. The child often has a good general condition, rarely lead to dehydration and the more important sign on physical examination is the perianal erythema. The clearest example is viral diarrhea due to rotavirus.

24. Osmotic watery diarrhea

25. Bacteria acute bloody invasive diarrhea Parasitic acute bloody invasive diarrhea Th Osmotic watery diarrhea e motions has a lot of blood, there is high grade fever, and the child sick looking. Some patients can develop convulsions. On physical examination the patient could has dehydration signs together with signs of metabolic acidosis (fast breathing, cyanosis, abdominal pain, and irritability in younger children). The most common example is shigellosis. The principal symptom is loss of appetite, the child is afebrile and vomiting may be present. The diarrhea has a little amount of blood like stria or spot. The physical examination shows clinical features of intestinal infestation such as big abdomen, pallor, and mental apathy, the child is not sick looking. The commonest example is amebiasis.

26. Invasive bloody diarrhea

27. II. Hydration status : The degree of dehydration should be assessed at presentation based on physical signs and symptoms. WHO has issued recommendations for assessing dehydration based on four clinical signs. Following the initial assessment, ongoing fluid losses should be estimated based on the volume of emesis and stool. These assessments are essential for determining the volume, route, and pace of rehydration therapy needed.

28. WHO guidelines for assessment of dehydration Clinical feature Predicted degree of dehydration None (<5 percent) Some dehydration (5-10 percent) Severe dehydration (>10 percent) General appearance Well, alert Restless, irritable Lethargic or unconscious Eyes Normal Sunken Sunken Thirst Drinks normally, not thirsty Thirsty, drinks eagerly Drinks poorly or unable to drink Skin pinch Goes back quickly Goes back slowly Goes back very slowly Estimated fluid deficit <50 mL/kg 50-100 mL/kg >100 mL/kg

29. Caption

30. Caption

31. older children Caption

32. . III. Nutritional status :  Recurrent diarrhea in childhood is associated with malnutrition, which contributes to delays or irreversible deficits in physical and cognitive development. Children presenting with diarrhea in resource-limited countries should be assessed for malnutrition according to WHO standards. Children with acute diarrhea and malnutrition are at increased risk for developing fluid overload and heart failure during rehydration. The risk of serious bacterial infection is also increased. As a result, such children require an individualized approach to rehydration, nutritional care, and antibiotics

33. . IV. examination (assessment of co-morbidities)  Assessment of a child with acute diarrhea should include evaluation of the following: Temperature : Fever is common in the setting of diarrheal illness. The presence of fever or hypothermia in a patient with watery diarrhea should also raise clinical suspicion of a comorbid illness. Respiratory tract : Tachypnea can be a sign of pneumonia in the setting of cough or difficulty breathing. Abdomen : Abdominal pain out of proportion to typical gastroenteritis raises the possibility of a surgical emergency. (Intussusception, appendicitis, Intestinal obstruction)

34. . Central nervous system: Moderate dehydration can lead to irritability; severe dehydration can lead to lethargy and coma. Encephalopathy and/or seizures can occur in the setting of severe disease due to  Shigella. The differential diagnosis of seizures in a child with diarrhea includes hypoglycemia, hyponatremia, hypernatremia, encephalopathy, meningitis, and febrile seizures.  

35. Diagnostic studies Most children with acute diarrhea do not require laboratory testing, although in complex cases some laboratory studies may be useful. Patients with seizures or altered consciousness should have glucose and electrolyte assessment if possible. Children with suspected pneumonia, sepsis, meningitis, urinary tract infection, or HIV infection should have the relevant investigations. Imaging studies are warranted for patients with acute abdominal findings on physical examination.

36. . Microscopy can be used for presumptive diagnosis of two important causes of gastroenteritis: Cholera may be diagnosed using dark field microscopy to detect motile Vibrios, which appear as "shooting stars". In the setting of acute bloody diarrhea, direct microscopic evidence of Entamoeba trophozoites containing red blood cells is a sufficient diagnostic finding warranting treatment for amoebic dysentery Microbiology laboratory evaluation, when available, is warranted for patients with invasive diarrhea who do not respond to empiric antibiotic therapy

37. laboratory exams Stool Exams Blood Exams Other Serial stool CBC Urinalysis Neutrophilus in fecal mucus Blood culture Urine culture PH in feces. Duodenal aspirated Stool cultures Rotavirus in feces

38. treatment Acute watery diarrhea I. Fluid and electrolytes Oral and Enteral Rehydration. Oral rehydration and replacement of ongoing fluid losses with ORS Results in reduced stool output, reduced vomiting, and reduced need for supplemental IV therapy. The oral route is preferred, but when this is not feasible, enteral instillation via nasogastric (NG) tube is a secondary option

39. Parenteral Rehydration The use of IV rehydration should be limited to select circumstances, including: Shock Dehydration with altered level of consciousness or severe acidosis Worsening of dehydration or lack of improvement despite oral or enteral rehydration therapy Persistent vomiting that compromises oral or NG tube hydration Severe abdominal distention and ileus

40. Children presenting with shock due to acute gastroenteritis need rapid IV infusion of crystalloid solution as a 20-mL/kg bolus, followed by repeated boluses as needed, based on clinical response.

41. Plan A (No dehydration and for prevention) Counsel the mother on the 4 rules of home treatment: extra fluids (ORS), continue feeding, zinc supplementation, when to return Give extra fluids: as much as the child will take. If child exclusively breastfed, give ORS or safe clean water in addition to breast milk If child not exclusively breastfed, give one or more of: ORS, soup, rice-water, yoghurt, clean water

42. Treatment… In addition to the usual fluid intake, give ORS after each loose stool or episode of vomiting Child <2 years: 50-100 ml Child 2-5 years: 100-200 ml If child vomits, wait 10 minutes, then give more slowly If diarrhoea, give Zinc supplementation Child <6 months: 10 mg once a day for 10 days Child >6 months: 20 mg once a day for 10 days

43. Plan B (Some dehydration) Give ORS in the following approximate amounts during the first 4 hours ORS to give a child in the first 4 hours as weight (kg) x 75 ml Give frequent small sips from a cup If the child wants more than is shown in the table, give more as required If the child vomits, wait 10 minutes, then continue more slowly

44. Treatment plan B… If the child vomits, wait 10 minutes, then continue more slowly For infants <6 months who are not breastfed, also give 100-200 ml of clean water during the first 4 hours Reassess patient frequently (every 30-60 minutes) for classification of dehydration and selection of Treatment Plan After 4 hours

45. Plan C (Severe dehydration) If you are unable to give IV fluids and this therapy but a nasogastric tube (NGT) is available: Start rehydration with ORS by NGT or by mouth: Give 20 ml/kg/hour for 6 hours (total = 120 ml/ kg) Reassess the child every 1-2 hours If there is repeated vomiting or increasing abdominal distension, give more slowly.

46. Plan C (Severe dehydration) If hydration status is not improving within 3 hours, the child urgently needs IV therapy After 6 hours, reassess the child and reclassify

47. Plan C (Severe dehydration) Give 100 ml/kg of Ringer’s Lactate Or half-strength Darrow’s solution Divide the IV fluid as follows: AGE FIRST GIVE:30 ML/KG IN: THEN GIVE:70 ML/KG IN: Infants <1 years 1 hour 5 hours Child 1-5 years 30 minutes 2. 5 hours Repeat once if radial pulse still very weak/ undetectable

48. As soon as patient can drink, usually after 3-4 hours in infants or 1-2 hours in children. Also give ORS 5 ml/kg/hour

49. . II. Nutrition  : The goal of nutritional management for patients without malnutrition is to encourage sufficient feeding both during and after the diarrheal illness episode to prevent development of malnutrition and chronic enteropathy. Infants with diarrhea should be encouraged to breastfeed as much as possible. Infants that are not breastfed should be encouraged to continue to take undiluted formula at least every three hours, in addition to ORS Children with diarrhea should be encouraged to take solid foods immediately after initial dehydration is corrected; delaying the initiation of a nutrient rich diet may increase the risk of malnutrition

50. . III. Vitamins and minerals : Zinc  : T he WHO recommends zinc for children under 5 years of age with diarrhea: 10 mg/day for children under 6 months 20 mg/day for children 6 months to 5 years, each for 10 days). Folic acid at 5 mg on day 1; then 1 mg daily Multivitamin syrup 5 ml Copper at 0.3 mg/kg/day

51. . Vitamin A ONLY if child has signs of vitamin a deficiency like corneal ulceration or history of measles. Give it on day 1, and repeat on days 2 and 14. < 6 months 50000 IU daily one dose >6 months to 1 year 100ooo IU daily one dose >1 year 200000 IU daily one dose Note: If a first dose was given in the referring center, treat on days 1 and 14 only.

52. . IV. Antibiotics  : Antibiotics are not indicated for most children with acute watery diarrhea; suspected cholera is an important exception in which antibiotic therapy is useful (bloody diarrhea, cholera, E. histolytica  etc.) Invasive diarrhea : Treatment consists of invasive diarrhea requires correction of fluid and electrolyte losses, appropriate nutritional care, and treatment of the underlying cause of illness Empiric antibiotic therapy for acute bloody diarrhea should be targeted against  Shigella  species.

53. ANTIBIOTIC Secretory (Cholera)26 Invasive (bacterian) First line of treatment: Azithromycin /20mg kg od one dose no more than 1G Erythromycin/ 12.5mgkg every / 6h(3days) Second line of treatment: Trimethoprim Sulfamethoxazole ( Cotrimoxazole ) 20mgkg od one dose Doxycycline/2-4mgkg od one dose (above 10 years of age ) Oral Ciprofloxacin 30mg/kg/day bd 3 days (the first day 15mg/kg initial dose) Oral Azithromycin 10mg/kg/day daily 5 days Ceftriaxone 50-100mg/kg/day (divide IM/IV every/6hrs 5 days)

54. Treatment of the cause If the cause is parasitic infestation give anti-parasites drug ( see the lecture about Intestinal parasitism) If the cause is any parenteral bacterial infection choose the antibiotic according to Uganda protocol If the cause if any viral infection supportive treatment If the cause is any enteral bacterial infection use the following antibiotics

55. others Breastfeeding should not be interrupted during episodes of Acute Gastro-Enteritis. Antimotility agents, such as loperamide, are usually contraindicated in the treatment of childhood. Probiotics are live microorganisms that are believed to work by stimulating the host immune system and competing for binding sites on intestinal epithelial cells. The use of probiotics in children with acute and persistent diarrhea is associated with reduced severity and duration of illness.

56. prevention Exclusive breastfeeding until age six months, and continued breastfeeding with complementary foods until two years of age The consumption of safe food and water. Hand washing after defecating, disposing of a child's stool, and before preparing meals. The use of latrines; these should be located more than 10 meters and downhill from drinking water sources Vaccination for Rota virus at 6 and 10 weeks

57. complications Electrolyte disturbance Gastrointestinal Respiratory Dehydration Metabolic acidosis Hypocalcemia Hypokalemia Hypernatremia Intestinal cystic pneumatosis Peritonitis with or without intestinal perforation , Appendicitis Transient deficit disaccharidase Mesenteric thrombosis Protein losing enteropathy Bronchopneumonia

58. Kidney Neurological Cardiovascular Urinary Tract infection Portal vein thrombosis Bilateral cortical necrosis Necrotizing papillitis Hemolytic uremic syndrome Toxic meningoencephalitis, Purulent meningoencephalitis Venous sinus thrombosis, Brain Abscess Myocarditis Shock

59. Hematologic Endocrine Iatrogenic Septicemia Acute adrenal insufficiency Super infection Dysbacteriosis Water intoxication H ypernatremia Trocar infection Inadequate fluid intake Prolonged IV fluid Cross-infection by poor handling of the patient

60. references Robert M. Kliegman , MD, 2020, Nelson Textbook Of Pediatrics , 21 th Edition, Elsevier Gary R Fleisher, Approach to diarrhea in children in resource-rich countries, In. UpToDate, Post TW (Ed)Waltham, MA ) Cajacob, N. J., & Cohen , M. B. (2021). Update on Diarrhea . Peds in Review , 37 (8), 313–322 . Sir Stanley Davidson , Davidsons principle and practices of medicine ,23 rd edition, pages 228-230 UNICEF Data on diarrhea (2023 january publication) MOH, Uganda Clinical Guideline , 2023 edition pages 401-403