ACUTE GASTROENTERITIS

GASTROENTERITIS
 Infections of the GIT are caused by a wide
variety of enteropathogens, including bacterias,
viruses, and parasites.
 Clinical manifestations depend on the organism
and host and include asymptomatic infection,
watery diarrhea, bloody diarrhea, chronic
diarrhea and extraintestinal manifestations of
infection
2 BASIC TYPES OF ACUTE INFECTIOUS DIARRHEA

 Inflammatory
 Non inflammatory
NON INFLAMMATORY DIARRHEA

 Enteropathogens elicit noninflammatory diarrhea

through enterotoxin production by some bacteria,
destruction of the villus (surface) cells by the
viruses, adherence of parasites, and adherence
and/or translocation by bacteria
INFLAMMATORY DIARRHEA
 Is usually caused by bacteria that invade the
intestine directly or produce cytotoxins
EPIDEMIOLOGY
 Diarrheal diseases are one of the leading causes
of morbidity and mortality in children worldwide,
causing 1 billion episodes of illness and 3-5
million deaths annually
 The major mechanism of transmission for
diarrheal pathogens are person to person through
the fecal-oral route or by ingestion of
contaminated food or water
FACTORS THAT INCREASE SUSCEPTIBILITY TO INFECTION

 Young age
 Immune deficiency
 Measles
 Malnutrition
 Travel to endemic area
 Lack of breastfeeding
 Exposure to unsanitary conditions
 Ingestion if contaminated food or water
 Level of maternal education
 Child-care center attendance
ACUTE DIARRHEA
 Diarrhea of short duration
 May be associated with any of the bacteria,
viruses, or parasites
CHRONIC DIARRHEA
 Persistent diarrhea
 Lasting 14 days or longer may be due to
 Infectious agent including G. lamblia,
Cryptosporidium, and enteroaggregative or
enteropathogenic E. coli
 Any enteropathogen that infects an
immunocompromised host
 Residual symptoms due to damage to the intestine by
an enteropathogen following an infection
BACTERIAL ENTEROPATHOGENS
 May cause either inflammatory or noninflammatory diarrhea and
specific enteropathogens may be associated with clinical
manifestation
 Inflammatory diarrhea- Aeromonas spp, Campylobacter jejuni,
Clostridium difficile, ETEC, EHEC, Plesiomonas shigelloides,
Salmonella spp, Shigella spp, Vibrio parahaemolyticus, and
Yersinia enterocolitica
PARASITIC ENTEROPATHOGENS

 G. lamblia- most common parasitis causing

diarrhea in US
 C. parvum, Cyclospora cayetanensis, E.
histolytica, Strongyloides stercoralis
 Isospora belli, Enterocytozoon bieneusi, and
Enterocytozoon intestinalis – found most often in
patients with AIDS
VIRAL ENTEROPATHOGENS
Four causes of viral gastroenteritis
 Rotavirus
 Enteric adenovirus
 Astrovirus
 Calicivirus

 Cytomegalovirus and herpes simplex virus have been associated

and other GI tract signs and symptoms, generally in
immunocompromised hosts
CLINICAL MANIFESTATION
 GIT involvement – diarrhea, cramps and emesis
 Systemic manifestation- fever, malaise and
seizures
 Extraintestinal infections – related to bacterial
enteric pathogens include local spread, causing
vulvovaginitis, UTI and keratoconjunctivitis
MAIN OBJECTIVES IN THE APPROACH TO A CHILD WITH ACUTE
DIARRHEA

 Assess the degree of dehydration and provide

fluid and electrolyte replacement
 Prevent spread of the enteropathogen
 In select episodes determine the etiologic agent
and provide specific therapy if indicated
EXAMINATION OF STOOL
 Stool specimens should be examined for mucus, blood and
leukocytes, the presence of which indicates colitis
 Fecal leukocytes are produced in response to bacteria that invade
the colonic mucosa diffusely
 A (+) fecal leukocyte examination indicates the presence of an
invasive or cytotoxin-producing organism such as Shigella,
Salmonella, C. jejuni, Invasive E. coli, C. difficile, Y.
enterocolitica, V. parahaemolyticus
EXAMINATION OF STOOL
 Stool cultures should be obtained as early in the
course of the disease as possible from patients in
whom the diagnosis of hemolytic uremic
syndrome is suspected
MANAGEMENT OF FLUIDS AND ELECTROLYTES AND REFEEDING

 Oral hydration usually is the treatment of choice

for all but the most severely dehydrated patients
whose caretakers cannot administer fluids
 Rapid rehydration with replacement of ongoing
losses during the first 4-6 hr should be carried out
using an appropriate oral rehydration solution
MANAGEMENT OF FLUIDS AND ELECTROLYTES AND REFEEDING

 Home remedies including decarbonated soda

beverages, fruit juices, jell-O, Kool-Aid and tea
are not suitable for use because they contain
inappropriately high osmolalities due to
excessive carbohydrate concentrations, which
may cause hyponatremia, and inappropriate
carbohydrate to sodium ratios
MANAGEMENT OF FLUIDS AND ELECTROLYTES AND REFEEDING

 Once rehydration is complete, food should be

reintroduced while the oral electrolyte solution is
continued to replace ongoing losses from stools
and for maintenance
 Breast feeding of infants should be resumed as
soon as they can tolerate feeding
 Fatty foods or food high in simple sugars
( including juices and carbonated sodas) should
be avoided
ANTIDIARRHEAL COMPOUNDS

 These agents are classified by their mechanism of

action, which includes alteration of intestinal
motility, adsorption of fluid or toxins, alteration
of intestinal microflora, and alteration of fluid
and electrolyte secretion
PREVENTION
 Patients who are hospitalized should be placed under contact
precautions, including hand washing before and after patient
contact, gowns when soiling is likely and gloves when touching
infected material
 Proper education about method of acquisition
 Methods to decrease transmission
 Vaccines are available to prevent or modify infection by rotavirus,
which is recommended for all infants, and Salmonella typhi,
which is recommended for international travelers to endemic areas
of developing countries
ACUTE FOOD BORNE AND WATER BORNE DISEASE

 Food-borne and water-borne disease is a major cause of morbidity

and mortality in all developed countries
 The diagnosis of a food-borne or water-borne illness should be
considered when two or more persons who have ingested
common food or water develop a similar acute illness that usually
is characterized by nausea, emesis, diarrhea, or neurologic
symptoms.
 Pathogenesis and severity of bacterial disease
depend on whether organisms have preformed
toxins ( S. aureus, B. cereus), produce toxins or
are invasive and whether they replicate in food.
 The severity of disease due to viral, parasitic and
chemical causes depends on the amount of
inoculated into the food or water.
CLINICAL SYNDROMES
 Nausea and vomiting within 6 hour
 Paresthesia ( scombroid or neurotoxic shellfish poisoning, Chinese restaurant
syndrome, niacin poisoning, ciguatera fish poisoning)) within 6 hour
 Neurologic and GIT symptoms within 2 hr
 Abdominal cramps and watery diarrhea within 16-48 hr
 Fever, abdominal cramps and diarrhea within 8-72 hr
 Abdominal cramps and bloody diarrhea without fever within 72-120 hr
 Neurologic signs and symptoms within 6-24 hr
 Vomiting and paralysis within 18-48 hr
 CHARACTERISTICS OF FOOD-BORNE ILLNESS BY SYMPTOMS
AND INCUBATION PERIOD
Nausea and vomitng <1-6 S. aureus, B. cereus, heavy metal

Paresthesia 0-6 Fish and shellfish, monosodium glutamate, niacin

Neurologic, 0-2 Mushroom (early onset)

gastroenteristis

Watery diarrhea, 8-16 B. cereus, C. perfringens, Calicivirus, ETEC, V.

abdominal cramps Cholerae 01 and non 01, Cryptosporidium,
Cyclospora

Diarrhea, fever, 16-72 Salmonella, Shigella, Clostridium jejuni, Y.

abdominal cramps enterolitica, EIEC, V. parahaemolyticus

Bloody diarrhea, 72-120 EHEC

abdominal cramps

Neurologic, hepatorenal 6-24 Mushroom( late onset)

Paralysis, nausea, 18-48 C. botulinum

vomiting
THERAPY
 Supportive- self limited
 Except for botulism, paralytic shellfish poisoning
and long-acting mushroom poisoning – fatal even
in healthy persons
FLUID THERAPY

 Types of Dehydration Electrolyte Status

 Hypotonic or Hyponatremic serum Na < 130

mEq/L
 Isotonic or isonatremic serum Na 130-150
 Hypertonic or hypernatremic serum Na > 150
mEq/L
CLINICAL EVALUATION OF DEHYDRATION
 Mild dehydration (<5% in an infant; <3% in
an older child or adult): normal or increased
pulse; decreased urine output; thirsty; normal
physical findings   
 Moderate dehydration (5–10% in an infant; 3–
6% in an older child or adult): tachycardia;
little or no urine output;
irritable/lethargic;sunken eyes and fontanel;
decreased tears; dry mucous membranes; mild
delay in elasticity (skin turgor); delayed
capillary refill (>1.5 sec); cool and pale   
 Severe dehydration (>10% in an infant; >6%
in an older child or adult): rapid and weak or
absent peripheral pulses; decreased blood
pressure; no urine output; very sunken eyes
and fontanel; no tears; parched mucous
membranes; delayed elasticity (poor skin
turgor); very delayed capillary refill (>3 sec);
cold and mottled; limp, depressed
consciousness
 SYMPTOMS ASSOCIATED WITH DEHYDRATION

MILD TO
MINIMAL OR NO MODERATE SEVERE
DEHYDRATION DEHYDRATION (3– DEHYDRATION
(<3% LOSS OF 9% LOSS OF BODY (>9% LOSS OF
SYMPTOM BODY WEIGHT) WEIGHT) BODY WEIGHT)
Mental status Well;alert Normal, fatigued or Apathetic, lethargic,
restless, irritable unconscious

Thirst Drinks normally; might Thirsty;eager to drink Drinks poorly; unable to

refuse liquids drink

Heart rate Normal Normal to increased Tachycardia, with

bradycardia in most
severe cases

Quality of pulses Normal Normal to decreased Weak, thready, or

impalpable
 MINIMAL OR NO MILD TO MODERATE SEVERE
DEHYDRATION (<3% DEHYDRATION (3– DEHYDRATION (>9%
LOSS OF BODY 9% LOSS OF BODY LOSS OF BODY
SYMPTOM WEIGHT) WEIGHT) WEIGHT)
Breathing Normal Normal;fast Deep

Eyes Normal Slightly sunken Deeply sunken

Tears Present Decreased Absent

Mouth and tongue Moist Dry Parched

Skinfold Instant recoil Recoil in <2 sec Recoil in >2 sec

Capillary refill Normal Prolonged Prolonged;minimal

Extremities Warm Cool Cold;mottled;cyanotic

Urine output Normal to decreased Decreased Minmal

 SUMMARY OF TREATMENT BASED ON DEGREE OF
DEHYDRATION

DEGREE OF REHYDRATION REPLACEMENT OF

DEHYDRATION THERAPY LOSSES NUTRITION
Minimal or no Not applicable <10 kg body weight: Continue breast-
dehydration 60–120 mL oral feeding, or resume age-
rehydration solution appropriate normal diet
(ORS) for each after initial hydration,
diarrheal stool or including adequate
vomiting episode; >10 caloric intake for
kg body weight: 120– maintenance[*]
240 mL ORS for each
diarrheal stool or
vomiting episode

Mild to moderate ORS, 50–100 mL/kg Same Same

dehydration body weight over 3–4
hr
DEGREE OF REHYDRATION REPLACEMENT OF
DEHYDRATION THERAPY LOSSES NUTRITION
Severe dehydration Lactated Ringer Same;if unable to drink, Same
solution or normal administer through
saline in 20 mL/kg body nasogastric tube or
weight intravenous administer 5% dextrose
amounts until perfusion ¼ normal saline with 20
and mental status mEq/L potassium
improve; then chloride intravenously
administer 100 mL/kg
body weight ORS over
4 hr or 5% dextrose ½
normal saline
intravenously at twice
maintenance fluid rates
FLUID MANAGEMENT OF DEHYDRATION
 Restore intravascular volume    Normal saline: 20 mL/kg over
20 min   
 Repeat as needed   
 Rapid volume repletion: 20 mL/kg normal saline or Ringer
Lactate (maximum = 1 L) over 2 hr   
 Calculate 24-hr fluid needs: maintenance + deficit volume   
 Subtract isotonic fluid already administered from 24 hr fluid
needs   
 Administer remaining volume over 24 hr using D5 ½ normal
saline + 20 mEq/L KCl   
 Replace ongoing losses as they occur
ZINC SUPPLEMENTATION.
 There is strong evidence that zinc
supplementation in children with diarrhea in
developing countries leads to reduced duration
and severity of diarrhea and could potentially
prevent 300,000 deaths.
 WHO and UNICEF recommend that all children
with acute diarrhea in at-risk areas should
receive oral zinc in some form for 10–14 days
during and after diarrhea (10 mg/day for infants
<6 mo of age and 20 mg/day for those >6 mo).
 In addition to improving diarrhea,
administration of zinc in community settings
leads to increased use of ORS and reduction in
the use of antimicrobials.
ADDITIONAL THERAPIES.
 The use of probiotic nonpathogenic bacteria
for prevention and therapy of diarrhea has
been successful in developing countries. There
are a variety of organisms (Lactobacillus,
Bifidobacterium) that have a good safety
record; therapy has not been standardized and
the most effective (and safe) organism has not
been identified.
 Antimotility agents (loperamide) are
contraindicated in children with dysentery and
probably have no role in the management of
acute watery diarrhea in otherwise healthy
children.
 Similarly, antiemetic agents such as the
phenothiazines are of little value and are
associated with potentially serious side effects
(lethargy, dystonia, malignant hyperpyrexia).
 Nonetheless, ondansetron is an effective and less toxic
antiemetic agent.
 Because persistent vomiting may limit oral
rehydration therapy, a single sublingual dose of an
oral dissolvable tablet of ondansetron (2 mg children
8–15 kg; 4 mg children <15–30 kg; 8 mg children >30
kg) may be given.
 However, most children do not require specific
antiemetic therapy; careful oral rehydration therapy
is usually sufficient.
 Racecadotril, an enkephalinse inhibitor, has
been shown to reduce stool output in patients
with diarrhea. Experience with this drug in
children is limited, and for the average child
with acute diarrhea it may be unnecessary.
ANTIBIOTIC THERAPY FOR INFECTIOUS
DIARRHEA
DOSE AND DURATION OF
ORGANISM DRUG OF CHOICE TREATMENT
Shigella (severe dysentery and Ciprofloxacin, ampicillin, Ceftriaxone IV, IM 50–100
EIEC dysentery) ceftriaxone, or trimethoprim- mg/kg/d qd, bid × 7 d
sulfamethoxazole (TMP-
SMX).
  Most strains are resistant to Ciprofloxacin PO 20–30
many antibiotics. mg/kg/d bid × 7–10 d
    10 mg/kg/d of TMP and 50
mg/kg/d of SMX bid × 5 d
    Ampicillin PO, IV 50–100
mg/kg/d qid × 7 d

ORGANISM DRUG OF CHOICE
EPEC, ETEC, EIEC TMP(trimethoprim)-SMX
(sulfamethoxazole) or
ciprofloxacin
   
Salmonella No antibiotics for
uncomplicated gastroenteritis in
normal hosts caused by non-
typhoidal species.
DOSE AND DURATION OF
TREATMENT
10 mg/kg/d of TMP and 50
mg/kg/d of SMX bid × 5 d
Ciprofloxacin PO 20–30
mg/kg/d qid for 5–10 d
See treatment of Shigella

  Treatment indicated in infants  

<3 mo, and patients with
malignancy, chronic GI disease,
severe colitis
hemoglobinopathies, or HIV
infection, and other
immunoincompetent patients.

  Most strains have become  

resistant to multiple antibiotics.
Aeromonas/Plesiomonas TMP-SMX 10 mg/kg/d of TMP and 50
mg/kg/d of SMX bid for 5 d

  Ciprofloxacin Ciprofloxacin PO 20–30

mg/kg/d divided bid × 7–10 d

Yersinia spp. Antibiotics are not usually  

required for diarrhea.

  Deferoxamine therapy should

be withheld for severe
infections or associated
bacteremia. Treat sepsis as for
immunocompromised hosts,
using combination therapy with
parenteral doxycycline,
aminoglycoside, TMP-SMX, or
fluoroquinolone.
Campylobacter jejuni Erythromycin or azithromycin Erythromycin PO, 50 mg/kg/d
divided tid × 5 d

Azithromycin PO, 5–10

mg/kg/d qid × 5 d

Clostridium difficile Metronidazole (first line) PO 30 mg/kg/d divided tid × 5 d

  Discontinue initiating antibiotic  

  Vancomycin (2nd line) PO 40 mg/kg/d qid × 7 d

Entamoeba histolytica Metronidazole followed by PO 30–40 mg/kg/d tid × 7–10 d

iodoquinol or paromomycin

PO 30–40 mg/kg/d tid × 20 d

PO 25–35 mg/kg/d tid × 7 d

Giardia lamblia Furazolidone or metronidazole Furazolidone PO 25 mg/kg/d
or albendazole or quinacrine qid for 5–7 d

Metronidazole PO 30–40
mg/kg/d tid × 7 d

Albendazole PO 200 mg bid ×

10 d

Cryptosporidium spp. Nitazoxanide PO treatment may Children 1–3 yr: 100 mg bid × 3
not be needed in normal hosts. d
In immunocompromised, PO
  immunoglobulin + aggressively Children 4–11 yr: 200 mg bid
treat HIV, etc.

  Adults: 500 mg bid

Isospora spp. TMP-SMX PO 5 mg/kg/d and 25 mg/kg/d,

respectively, bid × 7–10 d
Cyclospora spp. TMP/SMX PO 5 mg/kg/d and 25 mg/kg/d
respectively, bid × 7 d

Blastocystis hominis Metronidazole or iodoquinol Metronidazole PO 30–40

mg/kg/d tid × 7–10 d

    Iodoquinol PO 40 mg/kg/d tid ×

20 d
PROMOTION OF EXCLUSIVE BREAST-
FEEDING
 Exclusive breast-feeding (administration of no other
fluids or foods for the 1st 6 mo of life) is not common.
 Exclusive breast-feeding protects very young infants
from diarrheal disease through the promotion of
passive immunity and through reduction in the intake
of potentially contaminated food and water.
 Breast milk contains all the nutrients needed in early
infancy, and when continued during diarrhea, also
diminishes the adverse impact on nutritional status.
IMPROVED COMPLEMENTARY FEEDING
PRACTICES
 There is a strong inverse association between
appropriate, safe complementary feeding and
mortality in children age 6–11 mo;
malnutrition is an independent risk for the
frequency and severity of diarrheal illness.
 Complementary foods should be introduced at
6 mo of age while breast-feeding should
continue for up to 1 yr (longer period for
developing countries).
 Complementary foods in developing countries are
generally poor in quality and frequently heavily
contaminated, thus predisposing to diarrhea.
 Contamination of complementary foods can be
potentially reduced through caregivers' education
and improving home food storage.
 Vitamin A supplementation reduces childhood
mortality by 34%; improved vitamin A status
reduces the frequency of severe diarrhea.
ROTAVIRUS IMMUNIZATION
 Most infants acquire rotavirus diarrhea early in life; an
effective rotavirus vaccine would have a major effect
on reducing diarrhea mortality in developing countries.
 In 1998, a quadrivalent Rhesus rotavirus–derived
vaccine was licensed in the United States but
subsequently withdrawn due to an increased risk of
intussusception.
 Newer vaccines are approved for both developed and
developing countries and significantly reduce diarrhea
mortality
IMPROVED WATER AND SANITARY FACILITIES AND PROMOTION
OF PERSONAL AND DOMESTIC HYGIENE

 Much of the reduction in diarrhea prevalence in the

developed world is the result of improvement in
standards of hygiene, sanitation, and water supply.
 In addition, routine handwashing with plain soap in
the home can reduce the incidence of diarrhea in all
environments.
 Behavioral change strategies through promotion of
handwashing indicate that handwashing promotion
and access to soap reduces the burden of diarrhea in
developing countries.
IMPROVED CASE MANAGEMENT OF DIARRHEA

 Improved management of diarrhea through prompt

identification and appropriate therapy significantly reduces
diarrhea duration, its nutritional penalty, and risk of death in
childhood.
 Improved management of acute diarrhea is a key factor in
reducing the burden of prolonged episodes and persistent
diarrhea.
 The WHO/UNICEF recommendations to use low osmolality
ORS and zinc supplementation for the management of diarrhea,
coupled with selective and appropriate use of antibiotics, have
the potential to reduce the number of diarrheal deaths among
children.
THANK YOU