ACUTE GASTROENTERITIS
Dr nabiha najati
MBCHB,CABP
2020
Objectives:
• Def. of diarrhea
types of diarrhea
• Causative agents
• DDx of diarrhea
• Assessment of dehydration
• Types of dehydration
• Complication of diarrhea
• Investigations
Reference :
• WHO guidelines for management of acute gastroenteritis
• Nelson textbook of pediatrics
• Illustrated pediatrics
ACUTE GASTROENTERITIS
Definition
• It is the process of malabsorbtion or increase secretion of fluid &
electrolyte that lead to increase frequency, volume & fluidity of the
stool apart from normal.
• Excessive loss of fluid and electrolyte in the stool.acute diarrhea
is defined as sudden onset of excessive loose stool more than10
cc/kg/day in infants or more than 200 g/24 hr in older children.
•
persistent diarrhea: is defined as episode that begun acutely but last
for 14 or more days, it has a case fatality rate of 60%
EPIDEMIOLOGY
Diarrhea is the leading cause of morbidity and the second most
common disease in children in the developing world; it is a major
cause of childhood mortality.
CAUSES Rotavirus
Viruses: Responsible For
More Than 50% Of All Cases
Of GE In Summer Time &
80% In Winter Time. adenovirus virus Astrovirus
calicivirus
• Enteropathogenic (EPEC) Campylobacter
• Enterotoxigenic (ETEC) (Traveler's Jejuni
Diarrhea (
• Enteroinvasive (EIEC) Clostridium
• Enterohemorrhagic (EHEC) (Includes Difficile
O157:H7 ……. Causing HUS hemolytic Escherichia Coli
uremic syndrome)
Bacteria
Shigella Salmonella
Yersinia Enterocolitica Vibrio
Cholerae
Other Spore forming
Intestinal Protozoa
Cryptosporidium
• Entamoeba Histolytica • Giardia lamblia
Parvum,
Parasite
MECHANISMS OF DIARRHEA
Secretory diarrhea
occurs when the intestinal mucosa directly secretes fluid and
electrolytes into the stool.
Cholera is a secretory diarrhea stimulated by the enterotoxin of
vibrio cholerae. This toxin causes increased levels of CAMP within
enterocytes, leading to secretion into the small bowel lumen.
Osmotic diarrhea
occurs after malabsorption of ingested substances, which pull
water into the bowel lumen.
A classic example is lactose intolerance. Certain nonabsorbable
laxatives, such as polyethylene glycol and magnesium hydroxide
(milk of magnesia) also cause osmotic diarrhea.
Another way to differentiate between osmotic and secretory diarrhea is
to stop all feedings and observe.
This observation must be done only in a hospitalized patient receiving IV
fluids to prevent dehydration.
If the diarrhea stops completely while the patient is receiving nothing by
mouth (NPO), the patient has osmotic diarrhea.
Neither of these methods for classifying diarrhea works perfectly
because most diarrheal illnesses are a mixture of secretory and osmotic
components.
Clinical Manifestation;
Gastroenteritis may be accompanied by systemic findings, such as fever,
lethargy, and abdominal pain.
1. VIRAL DIARRHEA
Is characterized by watery stools, with no blood or mucus. Vomiting
may be present, and dehydration may be prominent. Fever, when
present, is low grade.
2. DYSENTERY
Is diarrhea involving the colon and rectum, with blood and mucus, possibly foul smelling, and fever.
Shigella must be differentiated from infection with
EIEC, EHEC,
E. Histolytica (amebic dysentery),
C. Jejuni,
Y. Enterocolitica,
and nontyphoidal salmonella.
Gastrointestinal bleeding and blood loss may be significant.
3. ENTEROTOXIGENIC DISEASE
is caused by agents that produce enterotoxins, such as v. Cholerae and ETEC( this organism
associated with 40% to 60% of cases of traveler's diarrhea).
In this diarrhea fever is absent or only low grade.
Diarrhea usually involves the ileum with watery stools without blood or mucus and usually
lasts 3 to 4 days with four to five loose stools per day.
Insidious onset of progressive anorexia, nausea, gaseousness, abdominal distention, watery
diarrhea, secondary lactose intolerance, and weight loss is characteristic of GIARDIASIS.
Ddx of GE
A chief consideration in management of A child with diarrhea
is to assess the degree of dehydration. The degree of
dehydration dictates the urgency of the situation and the
volume of fluid needed for rehydration.
NEW WAY FOR ASSESSMENT OF DEGREE OF DEHYDRATION:
NO SOME SEVERE
Lethargic ,unconscio
Condition Well,alert Restless, irritable
us
Eyes Normal Sunken Very sunken
Tears present Absent Absent
Mouth&tongue Moist Dry Very dry
Thirsty or drinks
Thirst Drinks normally Unable to drink
eagerly
Skin turgor Go back quickly Goes back slowly Goes back very slowly
19
Table 33-5. Assessment of Degree of Dehydration
Mild Moderate Severe
Infant 5% 10% 15%
Adolescent 3% 6% 9%
Infants and young Thirsty; restless or Drowsy; limp, cold,
Thirsty; alert; restless
children lethargic but irritable or sweaty, cyanotic
drowsy extremities; may be
Usually conscious (but at
reduced level)
Older children Thirsty; alert; restless Thirsty; alert(usually)
apprehensive; cold,
sweaty, cyanotic
Signs and Symptoms extremities; wrinkled skin
Tachycardia Absent Present Present
Palpable pulses Present Present (weak) Decreased
Blood pressure Normal Orthostatic hypotension Hypotension
Cutaneous perfusion Normal Normal Reduced and mottled
Skin turgor Normal Slight reduction Reduced
Fontanel Normal Slightly depressed Sunken
Mucous membrane Moist Dry Very dry
Tears Present Present or absent Absent
Respirations Normal Deep, may be rapid Deep and rapid
Urine output Normal Oliguria Anuria and severe
Types of dehydration
1. Isotonic dehydration
2. Hyponatremic dehydration (hypotonic)
3. Hypernatremic dehydration (hypertonic)
Isotonic dehydration
It is the most common type 70%,
it occur when the net loss of water &Na is the same proportion to
that found in the normal ECF.
Hypernatemic (hypertonic)dehydration :
It is less frequent15-%20,
but the most dangerous type ,as it is associated with serious
neurological damage (CNS hemorrhage or thrombosis)
these complications occur secondary to movement of water from the
brain cells into the hypertonic ECF, causing brain cell shrinkage &
tearing of blood vess .within the brain.
occur when Na loss <water loss )i.e. s.Na>150meq/L& s.osmol.>295
mosm ,
it may occur during the course of diarrhea when oral homemade
electrolyte solutions with high concentrations of salt are
administered .
increases with increased evaporative water loss as a result of fever,
high environmental temperatures, and hyperventilation, and with
decreased availability of free water
Hyponatremic dehydration
is seen in approximately 10–15% of all patients with diarrhea.
It occurs when large amounts of electrolytes, especially sodium,
are lost in the stool out of proportion to fluid losses.
It occurs more frequently with bacillary dysentery or cholera.
Hyponatremia may develop or worsen if there is a considerable
oral intake of low-electrolyte or electrolyte-free fluids during
diarrhea
Isotonic dehydration Hypertonic Hypotonic
Water &Na loss Balanced deficit of water &Na Deficit of water >Na Water loss>Na
S.Na)mmol/L( Normal)130-150( Elevated>150 Decrease<130
S.osmolarity)mOsmol/L( Normal )275-295( Elevated >295 Decrease<275
Thirst is severe & out of proportion
to the apparent degree of
dehydration.
Irritability, hypertonia ,hyperreflexia
Convulsions esp>s.Na>165mmol/L
Normal or full fontanel Lethargy
The usual signs of dehydration as
Clinical manifestation Normal eyes Infreq.convulsion
mentioned in table
U.O.P preserved longer than other
type
Brought to medical attention with
profound dehydration
Doughy abd.
Woody tongue
Clinical assessment of dehydration is only an estimate; the
patient must be continually reevaluated during therapy.
The degree of dehydration is underestimated in hypernatremic
dehydration because the osmotically driven shift of water from
the intracellular space to the extracellular space helps to
preserve the intravascular volume. The opposite occurs with
hyponatremic dehydration.
Complications
1. Dehydration, metabolic acidosis, shock and acute renal shutdown.
2. Electrolyte disturbance; hypokalemia (abdominal distention), hypernatremia &
hyponatremia.
3. Convulsion; might be due to:
A. Hyper or hyponatremia.
B. Fever either because of the primary infection or dehydration fever.
C. Hypoglycemia (due to fasting & glycogen mass is small in children).
D. Hypocalcemia usually associated with hypernatremia.
E. Toxic convulsion (e.G. Toxin secreted by shigella).
F. GE may present as prodromal period of CNS infection like meningitis.
4. EHEC, especially the E. Coli O157:H7 strain, produce a shiga-like toxin that is responsible for a
hemorrhagic colitis and most cases of hemolytic uremic syndrome (HUS), which is a syndrome of
microangiopathic hemolytic anemia, thrombocytopenia, and renal failure.
5. Post AGE syndrome (persistent diarrhea):
a. Secondary (transient) lactose deficiency.
Can be diagnosed by finding of low ph & positive reducing substance in stool, hydrogen breath test or
by measurement of mucosal lactase concentration with small bowel biopsy. Diagnostic testing is not
mandatory & often simple dietary changes (reduce or eliminate lactose from the diet) result in symptom
relief.
B. Cow s milk/ soy protein intolerance.
C. Persistent infection. E.G. Giardia.
LABORATORY EVALUATION;
1. Stool specimens should be examined
macroscopically for mucus, blood, and
microscopically for RBC & leukocytes, which indicate
colitis.
Fecal leukocytes are present in response to
bacteria that diffusely invade the colonic mucosa.
such as shigella, salmonella, C. Jejuni, and invasive E.
Coli.
Also to look for trophozoites and/or cysts of
E.Histolytica or giardia.
▶ If the stool test result is negative for blood and WBCs, and there is no
history to suggest contaminated food ingestion, a viral etiology is most likely.
▶ A rapid diagnostic test for rotavirus in stool should be performed,
especially during the winter.
Enzyme-linked immunosorbent assays, which offer >90% specificity and
sensitivity, are available for detection of group A rotavirus. Latex agglutination
assays are also available for group A rotavirus and are less sensitive
►► Stool cultures are recommended
for
patients with fever, profuse diarrhea,
and dehydration , bloody diarrhea
and
in cases when you suspect organisms
that need antibiotic therapy or
if HUS is suspected.
2 Electrolytes, BUN, creatinine, a
complete blood count,
Hemoconcentration from dehydration
causes an increase in the hematocrit and
hemoglobin.
3. Urinalysis for specific gravity as an indicator of hydration. The
urine specific gravity is usually elevated (≥1.025). Urinanalysis may
show hyaline and granular casts, a few WBC and RBC, and 30 to
100 mg/dl of proteinuria.
►If UTI is suspected, urine should be send for C&S test.
4. Positive blood cultures are uncommon with bacterial enteritis
except for S. typhi (typhoid fever) and for nontyphoidal Salmonella
and E. coli enteritis in very young infants.
