Gastroenteritis_(diarrhoea_&_vomiting)_1[1].ppt

GASTROENTERITIS (GE)

1. Gastroenteritis
(diarrhoea & vomiting)
(cholera, amoebic
dysentry, bacillary
dysentery)
PRESENTED BY E. KUNGWIMBA
TO: 2023 COHORT
DATE: 30
TH
AUGUST, 2024

2. Learning Objectives
1.Define gastroenteritis, diarrhea, vomiting,
cholera, amoebic dysentery, & bacillary
dysentery.
2.Describe the causes
3.Describe the predisposing factors
4.Review the pathophysiology

3. OBJECTIVES CTD
5. Describe the clinical manifestations
6. Explain the investigations
7. Explain the management of diarrhea,
vomiting, cholera, amoebic dysentery, &
bacillary dysentery.

4. Gastro enteritis
•Is a diarrheal disturbances that involves the
stomach and the intestines.
•Is infective
•Causes diarrhea and vomiting, massive fluid
and electrolyte loss, sepsis, and death

5. High risk groups
•Children in day care centers, pre
schools, and long term care facilities
•Children who are immunocompromised.

6. Aetiology
•Caused by viruses (rotavirus being common),
bacteria and parasites.
•Ingestion of contaminated food or water
•Person-to-person contamination.
•High risk groups:
•Under fivechildren attending day-care
centres
•pre-school children
•Long-term facilities
•Immunocompromised

7. Incidence
•Common infectious disease in children
•1.5 million childhood deaths/year
occurs worldwide
•2.5 billion episodes of diarrhoea occurs
in developing countries, WHO &
UNICEF, (Ashwill, 2013, pg 428)

8. Diarrhea
•An increase in the volume, frequency (4
or more stools in 24 hours), and fluid
consistency of stools.
•Types of diarrheal diseases:
1.Acute watery (including Cholera):
lasts several hours or days.
2.Acute bloody, (dysentery): dangers;
sepsis and malnutrition, damage to
the intestinal mucosa, dehydration.

9. Cont..
•3. Persistent diarrhea: lasts 14 days or
longer: main danger is malnutrition.
•4. Diarrhea with severe malnutrition
(marasmus or kwashiorkor): main
dangers: severe systemic infection,
heart failure and vitamin and mineral
deficiency.

10. Diarrhea
•Causative factors
•Infectious agents
•Malabsorption syndromes
•Fat malabsorption syndromes
•Inflammatory bowel disease
Electrolytes lost: potassium, sodium,
chloride, and Bicarbonate

11. Pathophysiology
•The causative organism enters through the
mouth and adheres to the mucosa of the
intestines.
•Epithelial invasion occurs, causing an
inflammatory response and epithelial cell
death.
•This leads to ulcerations,
pseudomembranes, bleeding and possibly
sepsis.

12. Pathophysiology ctd
•As the pathogens multiply, they may
produce toxins.
•The toxins cause fluid and electrolyte
shifts that result in increased secretion
into the intestines and simultaneous
decrease in absorption caused by
oedema.

13. Pathophysiology ctd
•The absorption capacity of the colon is
exceeded, and massive diarrhea and
dehydration result.
•Cytotoxins produce local oedema,
malabsorption, and dehydration.
•Some pathogens are also capable of
producing neurotoxins that act outside
the GIT.

14. Clinical manifestation
Loose or watery stools
Normal or elevated temperature
Vomiting, Tenesmus (feeling that you
need to pass stools, even though the
bowels are already empty)
Abdominal pain
Fretfulness (extremely irritable and
anxious)

15. Clinical manifestations ctd
Signs of dehydration
Drawn (looking strained from illness),
flaccid expression
Cry lack vigor, often whining and
higher pitched.
Seeks comfort and attention of parent
Purposeless movements
lethargic

16. Diagnostic Evaluation
•Blood culture
•Stool culture

17. ACUTE DIARRHOEA
•All children with diarrhoea must be
assessed for dehydration and should be
classified as severe dehydration, some
dehydration and no dehydration.
•After classification, appropriate
treatment must be given.
•Assess the general condition, look for
sunken eyes, make a skin pinch, offer
fluid to see if they are thirsty or drinks
poorly

18. Cholera
•Caused by VIBRIO cholerae, which
multiply in the intestines, and produce
toxins that cause profuse diarrhea and
vomiting, leading rapidly to severe
dehydration.
•Transmitted through contaminated
food and water
•Incubation period 2-3 Days.

19. •Pathology:
–enterotoxins causes increased
secretion of chloride and possibly
bicarbonate.
–Intestinal mucosa congested with
enlarged lymph follicles.
–Intact mucosal surface.

20. Cholera Cont..
•Manifestations: sudden onset of
profuse watery diarrhea without
clamping, tenesmus, or anal irritation.
•Stools are rice water like.
•Management:
–Rapid infusion of R/Lactate. Followed
by half strength Darrow’s dextrose.
ORS in mild cases.

21. Cont..
•Follow guide on management of
dehydration
•Reassess (mental alertness, capillary
refill, pulse strength & urine output).
•Isolate pts.
•Erythromycin p.o. 12.5 mg/kg 6hrly
for 3 days, or Ciproflaxin 15mg/kg 12
hourly for 5 days, or Cotrimoxazole

22. •Guardian; health education & DCN
300mg stat orally.
•Wash hands with soap and water.
•Disinfect floors, beds, pots, and
clothing.
•Inform environmental health staff, who
will trace contacts, identify source and
carry out preventive measures.

23. Amoebic dysentery
Caused by Entamoeba histolytica, a mobile
protozoon that produces resistant cysts.
Cause diarrhea with blood and mucus.
May also invade to cause an abscess of the
large bowel wall, liver abscess.

24. MANAGEMENT
›metronidazole 10mg/kg/dose p.o., 8 hrly
x 10/7
›h/education on fecal disposal, hand
washing and food hygiene

25. Bacillary dysentery
(shigellosis)
•Caused by gram-negative bacilli called shigellae.
•Typically is acute with fever, abdominal pain, and
blood and mucus in the stools.
•Illness is brief and self-limiting, occasionally is
severe and prolonged.
•If persistent ( > 5/7) or if general health is poor,
give Nalidixic acid 50 mg/kg daily in 2-4 divided
doses.

26. Shigellosis Cont..
•Ciprofloxacin 20mg/kg od x 3/7.
•h/education as on above
•Complication acute renal failure.

27. Assessment of patient with diarrhea:
history
Presence of blood in the stool
Duration of diarrhea
Number of watery stools per day
Number of episodes of vomiting
Presence of fever, cough, or other
important problems

28. Assessment ctd
Pre-illness feeding practices
Type and amount of fluids (including
breast milk) and food taken during the
illness
Drug or other remedies taken
Immunization history

29. •Frequency of stools
•Duration of diarrhoea
•Blood in stools
•Report of cholera outbreak in the area

30. Physical examination
•Check for signs and symptoms of
dehydration:
•restlessness, or irritability
•Lethargy or reduced level of
consciousness
• Vital signs

31. Physical exam ctd
•Eyes, Fontanel
•Offer water or ORS to drink: drinks
eagerly, poorly, not able to drink
•Skin turgor
•Look for blood in stools
•Malnutrition assessment
•Abdominal distension, mass, stools

32. Classification of severity of
dehydration
Severe dehydration
•Child has 2 or more of the following signs:
•Lethargy or unconsciousness
•Sunken eyes
•Unable to drink or drinks poorly
•Skin pinch goes back very slowly > 2 seconds
•Management: give fluids for severe
dehydration (treatment plan C)

33. Classification ctd
Some dehydration
•Child has 2 or more of the following
signs:
•Restlessness, irritability
•Sunken eyes
•Thirsty and drinks eagerly
•Skin pinch goes back slowly
•Management: treatment plan B

34. Classification ctd
No dehydration
•Not enough signs to classify as some or
severe dehydration
•Management : treatment plan A

35. Management of G.E.
•Priority: replace water and correct acid-base
or fluid and electrolyte disturbance
•Assess and treat dehydration
•Breastfeeding
•Continue other feeding
•ORS, and additional water in between to
prevent hypertonic dehydration.
•Severe dehydration; Intravenous rehydration-
•If diarrhea is chronic-give vit. A

36. Fluid Balance
•Most childhood diseases including
gastroenteritis causes fluid imbalance.
•Children and infants have a high water and
electrolyte turnover and therefore
abnormalities occurs rapidly.
•Children become easily dehydrated and over
hydrated leading to brain edema and heart
failure. Fluids can be given orally, or by
nasogastric tube, or intravenously, or
intraosseous drips.

37. Severe dehydration: treatment
plan C
•Start Iv fluids immediately. If the child can drink,
give ORS by mouth while the drip is being set up.
•Give Ringers lactate 100ml/kg
Age First give 30ml/kg
in:
Then give 70
ml/kg in:
Infants (below 12
months)
1 hour 5 hours
Older children30 minutes 2 hours & 30
minutes

38. •Reassess the child every 15-30 minutes
until a strong pulse is present.
•If hydration is not improving, give the iv
fluid more rapidly and watch for signs of
overhydration.
• give ORS after (3-4 hours for infants)
and (1-2 hours for children) if they are
able to drink

39. Reassess infant after 6 hours and child
after 3 hours and classify dehydration,
and treat accordingly.
Areas of assessment: Skin pinch,
Level of consciousness, and ability to
drink.
Sunken eyes takes time to recover hence
not reliable for assessing improvement

40. Some dehydration: treatment
plan B
•Give children with some dehydration ORS
for the first 4 hours at the health facility.
•Monitor the child for improvement and
teach the mother how to prepare and give
ORS solution
•Give a teaspoon full every 1-2 minutes if
<2 years, and frequent sips from a cup for
older children.

41. •Check regularly to see whether there
are problems.
•If the child wants to vomit, wait for 10
minutes, then resume ORS solution
more slowly.

42. •If the eyelids become puffy, stop ORS
solution, reduce fluid intake and
continue with breastfeeding, weigh the
child and monitor urine output
•Check blood glucose and electrolytes in
a child who is restless or irritable and
convulsing

43. Age Less than
4 months
4-11
months
12-23
months
24-59
months
Weight Less than
5kg
5-7.9kg8-10.9kg11-15.9kg
In ml 200-400400-600600-800800-1200
Approximate amount of ORS Solution to give in the
first 4 hours for children with Some Dehydration

44. No dehydration: treatment
plan A
•Treat child as an outpatient.
•Counsel mother on the 4 rules of home
treatment:
1. Give child more fluids than usual, to
prevent dehydration
2.Give the child supplemental Zinc (10-
20mg) o.d for 10/7

45. 3. Continue to feed the child, to prevent
malnutrition
4. Take the child to a health worker if
there are signs of dehydration or other
problems.

46. Give extra fluids:
•Breastfeeding: frequent with longer
periods, plus ORS or clean water if on
exclusive breastfeeding.
•If not give: ORS, soup, rice water, clean
water, etc.
•Give fluids 50-100mls after each loose
stool if <2 years, 100-200mls if >2 years.

47. Four rules of plan A treatment
1.Give child more fluids than usual, to
prevent dehydration
2.Give the child supplemental Zinc (10-
20mg) o.d for 10/7
3.Continue to feed the child, to prevent
malnutrition
4.Take the child to a health worker if there
are signs of dehydration or other
problems.

48. Management of diarrhea
Drugs:
›Zinc: children up to 6 months-10mg/day x 10-
14 days.
6 months or more-20mg/day x 10-14 days.
Vaccine: Rota vaccine (Rotarix oral suspension)
›Live attenuated
›Dose: 1 dose 1.5mls, orally.
›Indication; infants age 6 weeks; second dose
after 4 weeks.

49. Zinc
•Plays critical roles in metallo-enzymes,
polyribosomes, the cell membrane, and
cellular function, and cellular growth
and in function of the immune system.

50. MANAGEMENT CONT..
•LOW OSMOLARITY ORS
•a mixture of glucose and several salts
(ORS) dissolved in water.
•Is absorbed in the small intestine even
during copious diarrhea, thus replacing
the water and electrolytes lost in the
stools.
•Also reduces the incidence of vomiting
by 30% and stools by 20%.

51. Management of Diarrhoea with Severe
Malnutrition
•Assessment:
•eagerness to drink
•Lethargy; cool and moist extremities; weak or
absent radial pulse; and reduced or absent urine
flow.
•Moderate dehydration:
•Assessment
•Stop feeds
•Give 5ml/kg of ReSoMal every 30 minutes for the
first 2 hours.

52. Cont.
•If improved but still dehydrated and persisting
waterly diarrhoea increase ReSoMal to 10ml/kg for
the next hour.
•If child refusing insert NGT
•Evaluate every 30 minutes.
•Continue breastfeeding
•If rehydration still continues after 6 hours start
feeds, using F75 3 hourly alternating with ReSoMal
•Evaluate every 30 minutes

53. Severe Dehydration with Severe Malnutrition
•Recent sunken eyes; sudden/recent
weight loss; no hypothermia; severe
oliguria.
•Treatment: 15ml/kg R/Lactate with 5%
dextrose or half strength saline with 5%
dextrose or half strength Darrow’s in 1
hour and reassess the child.

54. •Improvement, repeat the above RX over
the next hour and stop infusion.
•Then change to oral/NG rehydration
10ml/kg/hour of ReSoMal.
•Reassess the child every 30 minutes

55. Cont.
•Commence F75 after 4 hours of starting
oral/NG rehydration, every 3 hours
alternating with ReSoMal. Stop all
rehydration when the child regains the
normal weight.
•No improvement after 1 hour, this
might be septic shock then treat it
according to protocol.

56. Nursing Care
•Avoid fruit juices, cola, soft drinks, tea
•Continue feeding the child
•Avoid high fat and sugar diet
•Patient teaching

57. References
•James S.R., Nelson K.A., Ashwill J.W. (2013). Nursing
Care of Children: Principles & Practice. 4th edition,
St. Louis Missouri, Saunders.
•Ministry of Health. Management of Diarrhoea in
underfive children using Low Osmolarity ORS and
Zink
•Phillips, J.A, Kazembe P.N, Nelson E.A.S.,Fisher, J.A.F
&Grabosch E. (2015). A Paedatric Hand Book for
Malaŵi(3
rd
ed.). Limbe: Montifort Press.

58. •QUESTIONS?