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Outline
1. Epidemiology
2. Etiology
3. Pathogenesis
4. Pathophysiology
5. Clinical Features
6. Prevention
7. Investigations
8. Diagnosis
9. Classification
10. Differential Diagnosis
11. Principle of Management
12. Complication
13. Prognosis
• In developing countries, acute gastroenteritis (AGE) is a
major cause of child mortality and morbidity due to
dehydration.
• AGE is one of frequent causes of hospitalization in children
under age of five in the hospital setting, both in Malaysia
and throughout the world, especially in developing
countries.
• It is estimated that approximately 440,000 annual deaths in
children <5 years of age worldwide due to diarrhoea related
illness, with rotavirus as the main cause.
• In Malaysia, recent study by Lee et al, the financial burden
of providing inpatient care for rotavirus GE range (US0.6
million to 7.5 million) annualy.
Based on Malaysian Journal of Medicine and
Health Sciences Vol. 7 (2) June 2011 :
BACTERIA (10-20%)
Campylobacter jejuni
Non-typhoid Salmonella spp
Enteropathogenic Escherichia coli
Shigella spp
Yersinia enterocolitica
Shiga toxin producing E coli
Salmonella typhi and S paratyphi
Vibro cholerae
PROTOZOA (<10%)
Crptosporidium
Giardia Lamlia
Entamoeba histolytica
HELMINTS
Strongtloides stercoralis
Research study : Best Approaches to Acute Gastroenteritis
(February, 2016)
Research study : Best Approaches to Acute Gastroenteritis
(February, 2016)
Ingestion of pathogenic organism will
cause : Adherence, mucosal invasion,
enterotoxin/cytotoxin production
• Increase in WBC • Specific gravity as •Done if: •To check if IV fluid is •To rule out septicemia
(Infection) indicator of hydration •Child appears septic required •Done if - antibiotics are
•Presence of blood or •Done if - features started
mucus in stool suggestive of
•Immunocompromised hypernatremia present
state
•Recent foreign travel
•Diarrhoea not improved
by day 7
•Diagnosis uncertain
Based on :
• Clinical recognition
• Evaluation of its severity by rapid assessment
• Confirmation by appropriate laboratory
investigations (if indicated)
History Taking for Diarrhoea
• Obtain appropriate contact, travel, or exposure
history
• Exposure to contacts with similar symptoms
• Intake of contaminated foods or water
• Child-care center attendance
• Recent travel of patient
• Contact with a person who traveled to a diarrhea-
endemic area
• Use of antimicrobial agents
Clinically determine the etiology of
diarrhoea
• Although nausea and vomiting are nonspecific symptoms,
they indicate infection in the upper intestine.
• Fever suggests an inflammatory process but also occurs as
a result of dehydration or co-infection (e.g., urinary tract
infection, otitis media). Fever is common in patients with
inflammatory diarrhoea.
• Severe abdominal pain and tenesmus indicate involvement
of the large intestine and rectum.
• Nausea, vomiting and absent/low-grade fever with mild to
moderate periumbilical pain and watery diarrhoea indicate
small intestine involvement and also reduce the likelihood
of a serious bacterial infection.
Systemic infection i. Septicaemia
ii. meningitis
Local infections i. Respiratory tract infection
ii. otitis media
iii. hepatitis A
iv. urinary tract infection
Surgical disorders i. Pyloric stenosis
ii. Intussusception
iii. acute appendicitis
iv. necrotising enterocolitis
v. Hirschsprung disease
Metabolic disorder i. Diabetic ketoacidosis
Renal disorder i. Haemolytic uraemic syndrome
Other i. Coeliac disease
ii. cow’s milk protein intolerance
iii. adrenal insufficiency
• Dehydration
• Shock
• Death
Clinical features of shock from dehydration in an infant
Treatment of dehydration and shock
Risk of dehydration :
• Infants (particularly those under 6 months of age
or those born with low birth weight)
The losses of sodium and water are There is a greater net loss of sodium than Water loss exceeds the relative sodium loss
proportional and plasma sodium remains water , leading to a fall in plasma sodium and plasma sodium concentration increases.
within the normal range. (when children with diarrhoea drink large
quantities of water or hypotonic solutions). Usually results from high insensible water
losses (high fever or hot, dry environment)
Water shifts from extra- to intracellular or from profuse, low sodium diarrhoea.
compartments :
1. Increase in intracellular volume > Water shifts from intra- to extracellular
increase in brain volume compartments.
(convulsions)
2. Marked extracellular depletion > a Signs of extracellular fluid depletion :
greater degree of shock per unit of 1. Depression of fontanelle
water loss 2. Reduced tissue elasticity
3. Sunken eyes (less obvious)
More common in poorly nourished infants in More difficult to recognise in an obese
developing countries. infant.
Signs of shock :
Tachycardia
Weak peripheral pulses
Delayed capillary refill time (>2 seconds)
Cold peripheries
Depressed mental state with or without hypotension
OR
• Start giving more of the maintenance fluid as oral feeds (e.g. ORS
about 5 ml/kg/hour as soon as the child can drink, usually after 3 to
4 hours for infants, and 1 to 2 hours for older children, this fluid
should be administered frequently in small volumes).
IV regime as for Plan C but the replacement fluid volume is calculated according to
the degree of dehydration. (5% for mild, 5-10% for moderate dehydration)
Management of hypernatraemic dehydration :
• Antidiarrhoeal medications
The locally available diosmectite has been shown to be safe and effective in reducing stool
output and duration of diarrhoea. It acts by restoring integrity of damaged intestinal
epithelium, also capable to bind to selected bacterial pathogens and rotavirus. Other
antidiarrhoeal agents like kaolin (silicates), loperamide (anti-motility) and diphenoxylate
(anti-motility) are not recommended.
• Antiemetic medication
Not recommended, potentially harmful.
• Probiotics
Probiotics has been shown to reduce duration of diarrhoea in several randomized controlled
trials. However, the effetiveness is very strain and dose specific. Therefore, only probiotic
strain or strains with proven efficacy in appropriate doses can be used as an adjunct to
standard therapy.
• Zinc supplements
It has been shown that zinc supplements during an episode of diarrhoea reduce the duration
and severity of the episode and lower the incidence of diarrhoea in the following 2-3 months.
WHO recommends zinc supplements as soon as possible after diarrhoea has started. Dose up
to months of age is 10 mg/day, and age 6 months and above 20 mg/day, for 10-14 days.
• In developing countries,
ORS saves the lives of millions of children
worldwide each year.
• In developed countries,
ORS is effective in most, but IV fluid is
required for shock, ongoing vomitting or
clinical deterioration.
Electrolyte imbalance
Paediatric Fluid and Electrolyte
Guideline
• Paediatric Protocol for Malaysian Hospitals ,
3rd ed.
Sodium disorder
Hypernatriemia
• Defined as serum Na+ > 150 mmol/L
• Moderate = 150-160 mmol/L ; Severe = >160
mmol/L
• Due to :
Water loss in excess of sodium
Water deficit
Sodium gain
• Clinical sign of Hypernatremia dehydration
Irritability
Doughy skin
Ataxia, tremor, hyperreflexia
Seizure
Reduce awareness, coma
• Look of sign of hypernatremia dehydration
• Shock occurs late
Management – refer to paediatric
protocol
• Treat underlying cause
• Shock – bolus resuscitation with 0.9% NS
• Avoid rapid correction – cerebral edema
• Aim of correction – serum Na+ falls not more
than 0.5 mmol/L/hr
• Repeat BUSE 6 hourly
• Check calcium and glucose level
Hyponatriemia
• Definition : serum Na+ < 135 mmol/L
• Causes
Administration of hypotonic fluid – D5%
GI loss
Adrenal insufficiency
Impaired water secretion – SIADH
Cerebral salt wasting
Renal tubular disorder
Psychogenic polydipsia
Diuretics
• Symptomatic < 125 mmol/L
apathy, nausea, vomiting, weakness, lethargy, malaise
Headache
Muscle cramps, hyperreflexia, restlessness
Convulsion
• Complication
seizure , coma, permanent brain damage , respiratory
arrest
Hyponatraemia encephalopathy (EMERGENCY!)
• Diagnosis – based on osmolality ( Serum Osm = 2(Na) =
Glucose + Urea)
Aldosterone
Na
Hypokalemia
Vomiting Cl
Metabolic
H
alkalosis
K
ECG changes of hypokalemia
These occur when K < 2.5mmol/l
• Prominent U wave
• ST segment depression
• T wave inversion
• Prolonged PR interval
• Sinoatrial block
Treatment
Urgency of repletion is dependent upon
• Rate at which hypokalemia is develop
• Presence of high co-morbidity