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Acute Diarrhea & Gastroenteritis

Acute Diarrhea & Gastroenteritis . Acute diarrhea. Normal bowel phenomena Definition Mechanisms of diarrhea Acute diarrhea Gastroenteritis General approach to children with acute diarrhea. Normal phenomena . The number ,color & consistency of stools varies with age & diet : Meconium

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Acute Diarrhea & Gastroenteritis

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  1. Acute Diarrhea & Gastroenteritis

  2. Acute diarrhea • Normal bowel phenomena • Definition • Mechanisms of diarrhea • Acute diarrhea • Gastroenteritis • General approach to children with acute diarrhea

  3. Normal phenomena • The number ,color & consistency of stools varies with age & diet : • Meconium • Transitional stools • Milk stools • Color of stools • Presence of solid particles

  4. Diarrhea …cont • Toddler`s diarrhea • 1-3 years • Healthy child • Excessive ingestion of beverages with high carbohydrate content. • Typically during the day • Limit sugar containing beverages, increase fat in the diet

  5. Definitions • Diarrhea : excessive loss of fluids & electrolytes in stool • More than 5g /kg /day • Increase in liquidity & frequency • Pseudodiarrhea & hyperdefecation • Encopresis • Dysentery : small volume , frequent,bloody, tenesmus , urgency

  6. Diarrhea • 9 liters of fluid enter the GI tract • 4-5l absorbed in jejunum , 3-4 ileum, 800 ml in colon. • Water transport follows Na & nutrient active & passive transport . • The basis for ORS treatment

  7. Mechanisms of diarrhea • Disturbed intestinal solute transport, water movement across intestinal wall. • Secratory • Osmotic • Dysmotility • Inflammatory

  8. Secratoy Diarrhea • Agent that binds to surface receptors , increasing cAMP,increased secretion. • Watery , large volume , normal osmolality( 2* Na+K ) • Persists during fasting,no stool leukocytes. • Examples; cholera, toxigenic E.coli,carcinoid ,VIP, congenital chloride diarrhea,Clostridium difficile,cryptosporidium.

  9. Osmotic Diarrhea • Occurs after ingesting a poorly absorbed solute . • Stools are of less volume, acidic, reducing substances, high osmolality > 2* Na + K. • Stops with fasting , increased breath hydrogen with malabsorption,no stool leukocytes. • Examples : lactase deficiency , glucose-galactose malabsorption,lactulose, laxative abuse.

  10. Motility Diarrhea • Increased motility : • decreased transit time. • Stimulated by gastro-colic reflex • Irritable bowel syndrome • Thyrotoxicosis • Post vagotomy • Infections • Decreased motility: • Stasis : bacterial overgrowth. • Pseudo-obstruction, blind loop

  11. Inflammatory • Inflammation . • decreased mucosal surface area &/Or colonic reabsorption. • Blood & increased WBC`s in stool. • Infectious gastroenteritis • dysentery

  12. Common Infant: Gastroenteritis Systemic infection Antibiotic use Child: Gastroenteritis Food poisoning Systemic infection Adolescent: Gastroenteritis Food poisoning antibiotic Rare Infant: Primary disaccharidase deficiency Adrenogenital s. Hirchsprung colitis Child: Toxic ingestion Adolescent: thyrotoxicosis Acute diarrhea

  13. Gastroenteritis • Most common cause of acute diarrhea in all age groups. • Clinical manifestations depend on the organism & the host response to infection. • A presumptive diagnosis can be made from epidemiological clues, good history & physical examination,laboratory investigations ( not required always )

  14. Etiology • Non- inflammatory : • enterotoxin production • Villus destruction • Adherence to surface • Inflammatory: • Direct invasion • cytotoxins

  15. Bacterial enteropathogens • Inflammatory: • Aeromonas, campylobacter jejuni,clostridium deficile,enteroinvasive E. coli,shiga toxin producing E. coli, salmonella, shigella, yersinia enterocolitica. • Non- inflammatory: • Enteropathogenic E.coli, • Vibrio cholera

  16. Viral enteropathogens • Rotavirus • Enteric adenoviruses • Astrovirus • Norwalk agent-like virus • Calicivirus

  17. Parasitic enteropathogens • G. lamblia • Entamoeba histolytica • Strongyloides stercoralis • Cryptosporedium • Cyclospora & isospora

  18. Epidemiology • Major cause of mortality & morbidity in children world wide. • Transmission: • person-to-person • feco-oral route • Water & food borne

  19. High risk groups • Young age groups • Immune deficient individuals • Measles • Malnutrition • Travel to endemic areas • Lack of breast feeding • Exposure to unsanitary conditions • Attendance to child care centers • Poor maternal education

  20. General approach • Clinical assessment:Historical points : • Diarrhea : • duration & severity • Stool consistency • Mucous & blood • Associated symptoms : • GI • Fever • Neurological Symptoms • Others • Risk factors • Social & family History

  21. Clinical assessment • Physical examination: • General appearance • Hydration Status • Mild • Moderate • severe • Systemic Examination • Extraintestinal manifestations

  22. Extraintestinal manifestations • Reactive arthritis :Salmonella ,shigella , Yersinia, campylobacter C.difficile • Guillain-Barre Syndrome: campylobacter • Glomerulonephritis:Shigella , campylobacter ,Yersinia • IgA nephropathy :campylobacter • Erythema nodosum: Yersinia ,campylobacter, salmonella • Hemolytic anemia : Yersinia ,campylobacter • HUS: shigella , E. coli

  23. Diagnostic Methods • Stool samples : • fresh collected • Mucous,bld,white cells • Ova & parasites: • Recent travel to endemic area,-ve stool cultures,diarrhea > 1wk • Part of an outbreak • Immunocompromised • Stool cultures: • As early as possible • Suspected HUS • Bloody diarrhea • outbreaks

  24. Diagnostic Methods • Stool cultures : • Routine : Salmonella, shigella,yersinia,campylobacter. • Toxin assays: C. difficle,E.coli • Special stains:Aeromonas, cryptosporidium & vibrio sp. • Duodenal aspirate & Biopsy: Giardia, Isospora,cryptosporidium. • ELISA • E.M. • Colonoscopy & sigmoidoscopy.

  25. Even with the application of all available laboratory studies , 20-40 % of all acute infectious diarrhea remain undiagnosed.

  26. Management • Fluids & electrolytes & refeeding: • Treating dehydration is the corner stone in managing diarrhea. • Infants are more susceptible to dehydration • Oral rehydration therapy • Home remedies • feeding

  27. Specific therapy • Anti-microbial therapy : • Indications are organism-dependant. • Salmonella : Infants< 3months, typhoid fever, bacteremia , disseminated disease with local suppuration. • Shigella : all cases • Vibrio cholera : all cases • Aeromonas: dysentery like, prolonged diarrhea. • C. difficile: moderate to severe disease. • E.coli. • Anti diarrheal agents

  28. Prevention • Precautions during hospitalization • Education • Child care attendance • Health authority notification. • Vaccines ??

  29. Thank you !

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