Acute gastroenteritis/Diarrhea Clinical.ppt

Diarrhea

1. Acute Gastroenteritis
Prof. Dr. D.RAJKUMAR,
MD[PED]
Associate Prof. of Pediatrics

2. Definitions & Terminologies
about Diarrhea
What is Diarrhea?
The passage of three or more loose or watery stools in a
24-hour period
Classification depending upon duration:
Acute diarrhea 3 -7 days
Prolonged or Indeterminate 8 -14 days
Persistent diarrhea > 14 days
Chronic diarrhea > 14 days
Parenteral diarrhea Primary pathology
outside GIT

3. •Depending upon characteristics of stools:
Watery diarrhea ---Secretory & Osmotic
Blood & Mucus ---Dysentery

4. ORDER OF HISTORY TAKING
•Chief complaints
–Chronological order
•History of Presenting illness
Relevant History only from
•Past history
•Diet history
•Socio economic history

5. CHIEF COMPLAINTS
•Diarrhoea
•Vomiting
•Fever
•Convulsions

6. DIARRHOEA
•Duration
•Onset[ Preceding URI / Preceding Vomiting / High
fever ]
•Frequency of diarrhoea

7. –Consistency
–Smell [ Sour milk / Malodorous]
–Color [ Yellow / green / Black / Red]
–Blood & mucous
–Perianal excoriation

8. Vomiting
•Contents
•Color / Blood stained
•Projectile or non projectile

9. Fever
–Duration
–Onset
–High grade or low grade
–Chills and rigors
–Continuous or intermittent

10. Convulsions
•No of episodes, Duration, Febrile or afebrile, …
•Sensorium
•Common causes of Seizures during AGE:
•Febrile Hypoglycemia
•Dyselectrolemia Acute CNS infections
•Venous sinus thrombosis

11. PAST HISTORY
•Similar illness in past
•Any illness like measles, Asthma, jaundice ..
•Previous history of hospitalization
•H/o Medications

12. DIETARY HISTORY
•Breast fed or Bottle fed
•Early Weaning or Late weaning
•Diet adequate or not
•Hand Hygiene followed

13. •Icterus, Pallor, Clubbing, Pedal edema
•Signs of dehydration[ AF, Eyes, Tears,
Mucosa, Tongue, Acidotic breathing]
•Bowel sounds, Tenderness
•Abdominal organomegaly
Clinical Examination

14. Features of Dehydration
Mild Moderate Severe
Looking at the
condition
Well, alert Restless, IrritableLethargic or
unconscious; floppy
Eyes Normal Sunken Very sunken & Dry
Tears Present Absent Absent
Mouth & TongueMoist Dry Very dry
Thirst Drinks normally, no
Thirst
Thirst, drinks
eagerly
Drinks poorly or not
able to drink
Feel Skin pinchGoes back QuicklyGoes back slowlyGoes back very
slowly > 2 sec
Decide –Hydration
Status
No signs of
Dehydration
Has two or more
signs, there is Some
Dehydration
Has two or more
signs, there is
Severe
Dehydration

15. Signs of Dehydration

16. Clinical Picture in certain special situations
Conditions Physical Signs
Acidosis Breathing increased in depth and rate
Hypokalemia Abdominal distention, paralytic ileus,
hypotonia, hyporeflexia, mental apathy
ECG changes
Hypomagnesemia Tetany, Muscular twitching
Hypernatremic Doughy skin
Dehydration

17. Discussion

18. Failure to breast-feed exclusively for 4-6
months.
Failure to breast-feed until at least one year of
age.
Using infant feeding bottles.
Storing cooked food at room temperature for
long periods.
Drinking water contaminated with fecal bacteria.
Risk factors for acute diarrhea

19. Predisposing host factors
Under nutrition.
Recent measles (In previous four weeks).
Immunodeficiency
Age: First two years of life, maximum at 6-11 months
Why ?Weaning period
-Declining levels of maternal antibodies.
-Lack of active immunity in the infant.
-Infant starts to crawl.
Seasonal : Rotavirus throughout the year.
Bacterial in summer & rainy season.
Epidemics: Vibriocholerae, Shigella.

20. Mechanisms Of Diarrhea
Osmotic diarrhea
Secretory diarrhea
Invasive/Inflammatory diarrhea

21. Osmotic Diarrhea
Small bowel mucosa is a porous epithelium; water and
salts move across it rapidly to maintain osmotic
balance
Diarrhea occurs when a poorly absorbed, osmotically
active substance is present in the gut .
If substance is isotonic, the water and solute will
simply pass through the gut unabsorbed, causing
diarrhea.
Eg ; lactose, magnesium sulfate

22. Markers of Osmotic Diarrhoea
•Children often stable
•Stools –Small or large volume, watery or loose
•Stool sodium < 50 mEq/L
•Stool Osmolality –Less than the ionic Constituents
•Stool Reaction –Acidic (pH < 5.5)
•Discontinuation of feed results in improvement.
•Perianal excoriation
•Abdominal distention before passing stool.
•Reducing substance positive E.g. Rota virus diarrhoea
& Disaccharide Malabsorption

23. SECRETORY DIARHOEA
ACTIVE SECRETION
Caused by the abnormal secretion (water and salt)
into the small bowel.
Occurs when
Sodium absorption by the villiis impaired.
Chloride secretion in crypts continues/increased.
Mediators : Cyclic A.M.P of Cholera
Cyclic G.M.P of E.T.E.C

24. Markers of Secretory Diarrhoea
•Dehydration
•Dyselectrolemia
•Large Volume Stool
•Stool Sodium > 70mEq/L
•Stool often Alkaline
•No effect with Discontinuation of feeding
•Reducing substance –Negative

25. Invasive/Inflammatory
diarrhea
A. Infective –Shigellosis, Amebiasis.
B. Non infective –Ulcerative colitis.
How to diagnose ?
Fever
Blood in stool, Increased fecal leucocytes
Abdominal pain, cramps, tenesmus.

26. •Dehydration
•Acute renal failure
•Venous Thrombosis -Cerebral, Renal
•HUS ( Hemolytic Uremic Syndrome)
•Malabsorption
•Food Intolerance
•Intussusceptions
•Disseminated Intravascular Coagulation
•Persistent Diarrhea
•Dyselectrolemia
Complications of Acute Diarrhoea

27. 1.Stool -Ova, Cysts, Trophozoites, Leucocytes
Hanging drop for V. cholerae
Culture practically not required
2.Blood tests -CBC, PBF for band cells
Serum Electrolytes
BUN and Creatinine
Culture and sensitivity
3.Urine -R/M, Culture may be required
Investigation in a child with acute severe
diarrhoea

28. Management
•Treatment of Dehydration
•Nutritional support
•Zinc therapy
•Antimicrobials
•Others

29. Dehydration Management

30. Features of Dehydration
Mild Moderate Severe
Looking at the
condition
Well, alert Restless, IrritableLethargic or
unconscious; floppy
Eyes Normal Sunken Very sunken & Dry
Tears Present Absent Absent
Mouth & TongueMoist Dry Very dry
Thirst Drinks normally, no
Thirst
Thirst, drinks
eagerly
Drinks poorly or not
able to drink
Feel Skin pinchGoes back QuicklyGoes back slowlyGoes back very
slowly > 2 sec
Decide –Hydration
Status
No signs of
Dehydration
Has two or more
signs, there is
Some
Dehydration
Has two or more
signs, there is
Severe
Dehydration

31. Acute Diarrhoea without Dehydration ( Plan -A )
Asses Risk of Dehydration
High Risk Low Risk
Age < 6 months Age ≥ 6 months
Vomiting > 4 times/day Vomiting ≤ 4 times/day
Liquid motions > 8 times/dayStool ≤ 8 times/day
Continue Breast feeding &
usual fluids-HAF
Encourage to take more
Discharge

32. Home Available Fluids
Recommended
•Salt sugar solution
•Lemon water
•Rice water / Kanjee
•Soups
•Dal water
•Lassi
•Coconut water
•Diluted Tea
Not recommended
•Simple sugar solution
•Glucose solution
•Carbonated soft drinks
•Fruit juices-tinned or
fresh

33. High Risk Admit for Observation (Plan -A
Contd…)
Maintenance fluid
On going loss -ORS 10 ml/kg/each stool/vomiting
Reassess every 4 hours
Good hydration Dehydration ensues
Stable on ORS treat as Some Dehydration
Discharge with ORS
Packets and advise

34. ACUTE DIARRHOEA WITH SOME DEHYDRATION
(Plan -B)
ADMIT
ORS 75 ml./kg.
in 4 hours
Reasses after 4 hours
Dehydration No Dehydration
Persists (Treat as Plan -A)
Consider NGT .
For rehydration with ORS
Dehydration Continues No Dehydration
(Treat as Plan -A)
Contd……

35. PLAN -B Contd..
Dehydration Continues Review every 2 hours
Commence IV. Fluid Dehydration continues
Calculate for Dehydration NGT/IV Fluids.
Maintenance, Ongoing losses
Invest -Urea creatinine No Dehydration
And electrolytes (Treat as Plan -A)
No signs of dehydration
(Treat as Plan -A)
Maintenance fluid -100 ml/kg ORS for 1
st
10 kg. then 50 ml./kg. for
next 10 kg.

36. Indications of IV fluids
•1. Severe dehydration
•2. Some Dehydration-
–Persistent vomiting
–Paralytic ileus
–Altered sensorium
–High Purge rate

37. ACUTE DIARRHOEA WITH SEVERE
DEHYDRATION (Plan -C)
Rapid bolus of Ringer lactate/Normal
saline, 20 ml./kg.
Circulation Circulation
Restored not restored
Further bolus of NS
max. 40 ml./kg.
Improve Not Improved
ADMIT to Intensive
care unit
With Circulatory Compromise
Admit
Age
30 ml per kg70 ml perkg
Less than
1 year
1 hour 5 hours
More than
1 year
30 minutes2 and half
hours

38. Composition of Fluids for Intravenous &
Oral Rehydration
Oral
Osmolarity
mOsm/L
Glucose
mmol/L
Sodium
mmol/L
Chloride
mmol/L
Potassium
mmol/L
Base (Citrate)
mmol/L
WHO
ORS
311 111 90 80 20 10
WHO Low
Osmolar
ORS
245 75 75 65 20 10
IAP
Recomnd.
ORS
224 84 60 50 20 10
INTRA VENOUS FLUID
Ringer’s
lactate
280 130 110 04 25 (Bicarb)
Normal
Saline
308 154 154

39. Composition of WHO High & Low
Osmolality ORS
------------------------------------------------------------------------------------------------------------------------------------
Ingredients / L High Osmolality Low Osmolality Components / Lit
Sodium Chloride 3.5 2.6 Na 9075
Sodium Citrate 2.9 2.9 Citrate 1010
or
Sodium Carbonate 2.5 2.5 H CO3 3030
Potassium Chloride1.5 1.5 K 2020
Glucose 20 13.5 Glucose 11175
Osmolality 311 245
-----------------------------------------------------------------------------------------------------------------

41. Oral Rehydration Therapy (ORT)
•Oral Rehydration Solution (ORS)
+
•Other Fluids & Liquid Diets

42. Limitations of WHO High Osm-ORS
Does not lower volume, frequency and duration of
diarrhea
Induces vomiting due to taste, acceptability poor
Enhances volume, purge rate & duration of
diarrhea due to high osmolality
More chances of dehydration –Dehydrating fluid
So more oftenly IV fluids required
Hypernatremia
Good to correct deficit fluids but not good for
maintenance therapy

43. Advantages of Low Osm-ORS
•Does lower volume, frequency & duration
•Equally effective in cholera, toxin related & RV
diarrhea : Deficit & maintenance therapy
•No need of IV fluids
•Good for all ages infancy to adulthood
•Asymptomatic hyponatremia.

44. Super ORS
Rice powder when digested releases twice the
amount of glucose than in ORS. This is enough to
support the absorption of water & electrolytes in
ORS
Protein in rice adds to this effect by release &
absorption of amino acids.
Osmotic activity of rice-ORS ( 220 mOsm/l) is
lower than that of blood or other tissues (290
mOsm/l).
Calories in rice may help prevent malnutrition
Trials show lower rate of stool volume in cholera.

45. Dietary therapy

46. Advantages of Dietary Therapy
•Maintains nutrition, helps in absorption
•Faster recovery
•Take care of infection and avoids
malnutrition
•Prevents prolongation of diarrhea
•Corrects malnutrition in mal-nourished
children.
•Extra diet in convalescence / on recovery

47. What are the Diets to be
Continued or Given ?
•Age appropriate diets
•Breast feeding : Aseptic paint.
•Artificially fed –milk
•Whatever child taking earlier
•Rice, khichri, pulses/ curd/yogurt
•Small frequent aliquots –Spoon & Katori

48. Breast Fed :Continue Breast feeding
throughout rehydration and
Maintenance phases.
Formula fed : Restart feed at full strength
as soon as rehydration is complete
(ideally after 4 hours)
Weaned Children: Child’s normal fluids and solids
following rehydration. Avoid fatty
foods or foods high in simple sugar.
Management of feeding during Acute
Diarrhoea

49. Diet in Indeterminate and Persistent
&Chronic Diarrhea
•Breast feeds continue
•Diet A : Low lactose diet
•Diet B : Lactose free diet, if no response to Diet A.
•Diet C : Monosaccharide based diet if no response
to Diet B.

50. Foods to be Avoided
•Fat rich
•Fruits and fruit juices
•Junk foods
•Spicy foods
•Carbonated fluids
•Sugar & glucose rich foods

51. •Indicated in
–Dysentery
–Cholera
–Infants under 6 months of age.
–Immunocompromised infants.
–Clinical suspicion of bacteremia.
Indication of Chemotherapy /
Antibiotics

52. Other Special Indications of Antibiotics
Severity of symptoms Host related risk factors
* Severely sick child * Neonatal age
* Septicemia * Malnutrition
* Neurological involvement* HIV Infection
* Septic shock State* Other immune deficiency
* Invasive diarrhea
Socio-environmental indications
* Cholera
* Nosocomial infection
* At risk contacts.
* Epidemics

53. Chemotherapy For Bacterial &
Protozoal Diarrhoea
Etiologic agent Chemotherapy
Shigella Nalidixic acid, Cotrimoxazole, Ampicillin
Enteroinvasive E:coliNalidixic acid, Cotrimoxazole, Ampicillin,
Inj Gentamicin (in case of septicemia)
Salmonella Ampicillin, Chloramphenicol
Campylobacter jejuniErythromycin, Furazolidin, Chloramphenicol, Gentamicin
Vibrio cholerae Furazolidin, Cotrimoxazole, Tetracycline, Erythromycin,
Ent. histolytica Metronidazole, Tinidazole, Secnidazole, Paromomycin
Giardia Metronidazole, Tinidazole, Secnidazole, Ornidazole,
Furazolidine

54. Role of Zinc in Acute
Diarrhea
Acute as well as persistent diarrhea
Tremendous loss in stools.
Absorption of Zinc intact
Deficiency during diarrhea results into lowering of
Cell division & maturation.
Tissue growth & repair.
Maturation of enterocytes.
Brush border enzymes.
Water & electrolyte absorption.
Immune functions.

55. Zinc Supplementation
!Responsible for > 200 enzymes in body.
!Improves the immune function & absorption.
!Supplementation in AD and PD helpful in 20-30% reduction in
diarrhea.
!42% lower rate of treatment failure or death.
Dosages
oInfants10mgdailyx2weeks.
oOlder children 20mg daily x 2 weeks.
o Persistent diarrhea x 4 week

56. PROBIOTICS
•Duration of acute diarrhea decreases by one day
in meta-analysis
•Saccharomyces boulardii : Strong benefit
•Lactobacillus sps. , Bifidobacterium sps. ,
Bacillus Coagulans, Streptococcus Fecalis….

57. RACECADOTRIL
Anti-secretory agent.
* Effective in treatment of acute diarrhea.
* Reduction in hyper secretion of water and electrolytes.
* Reduces diarrhea duration & number of stools
significantly.

58. Prevention
•Improvement of Nutritional status.
•Safe drinking Water Supply in community.
•Exclusive Breast feeding till 6 Months.
•Easy availability of ORS sachets.
•Hand washing before handling food.
•Vaccines :
–Rotavirus vaccine
–Cholera Vaccine
–Typhoid Vaccine
–ETEC Vaccine

59. Traditional Practices to be Avoided
•Antimotility & antispasmodic drugs
•Stool binding agents
•Enzyme preparations & steroids
•Antimicrobial agents in combination
•Bottle feeding
•IV fluids to every case
•Starvation-Nothing like bowel rest
•These will hamper natural clearance, lower immunity,
promote growth of unusual organisms & PEM

60. PRACTICES TO BE ADOPTED
•Breast feeding: Aseptic paint for GIT
•Cereal supplementation
•Spoon & katori/ directly from pot
•Judicious use of antimicrobials
•Proper hygiene & sanitation
•Rotavirus vaccine

61. Thank you