2. Presentation outline
• Introduction and Epidemiology
• Aetiology
• Pathophysiology
• Signs and symptoms
• Work-up including Classification
• Management
• Fluid and Electrolytes
• Feeding and Nutrition
• Prevention
3. Definitions and Terms:
Acute Gastroenteritis (AGE): diarrheal disease of rapid
onset, with or without accompanying symptoms,
signs, such as nausea, vomiting, fever, or abdominal
pain
Diarrhea: the frequent passage of unformed liquid
stools (3 or more loose, watery stool per day)
Dysentery: blood or mucus in stools
4. Diarrhea
• Acute: short in duration of < 7 days
• Persistent diarrhea: starts acutely and lasts longer than 1 week
5. Epidemiology
• One of the most common illness of infancy
• Second to respiratory illness as a cause of childhood deaths WW
• It represents a major cause of morbidity and mortality
• 3-10 episodes of diarrhea/year/subject in children <5 yrs and
decreases to < 1 for children >5
• Deaths are usually a result of dehydration but malnutrition plays an
important role as it increases the incidence and severity of diarrhea
• By 3 years, virtually all children become infected by the most common
agent
6. Aetiologies
• AGE is a clinical syndrome produced by a variety of Viral, Bacterial and
Parasitic enteropathogens.
• AGE is almost entirely caused by infections acquired through fecal-
oral route, but ingestion of contaminated food or water also plays a
role
• We have: Non-enteric, Non-infectious and Infectious causes of the
Gastro-intestinal tract
• Episodes usually last 5-10 days
7. Causes of acute diarrhoea in infancy and
childhood
Non-enteric causes:
otitis media. Meningitis, sepsis generally
Non-infectious causes:
milk/food allergies, drug side effects, malabsorption
Infections of the gastrointestinal tract
Viral
Bacterial
Protozoal
8. Common infectious causes of AGE
Viral
Rotavirus
Enterovirus, Calicivirus
Adenovirus, Astrovirus
Bacterial
E.Coli, Shigella
Salmonella, Campylobacter
C.difficile, V. Cholera
10. Aetiolgy cont
• Rotavirus is known to be the most common pathogen in children
• It is more severe than other causes and more often results in
dehydration, Hospitalization, Shock, Metabolic disturbances and
Death
• Bacterial pathogens are more common where poor sanitation,
hygiene and water supply play a role causing dysenterey
11. Pathophysiology
The 2 primary mechanisms
(1) Damage to the villous brush border of the
intestinemalabsorption of intestinal contents an
osmotic diarrhea
(2) Release of toxins that bind to specific enterocyte
receptorsrelease of chloride ions into the intestinal
lumensecretory diarrhea
12. Pathophysiology
• Rotavirus attach and enter mature enterocytes at the tip of the small
intestinal villi
• Cause structural changes to the bowel mucosa, including villous shortening
and mononuclear inflammatory infiltrates in the lamina propria
• This virus induce maldigestion of carbohydrates and their accumulation in
the intestinal lumen (in the absence of lactase)
• Malabsorption of nutrients and concomitant inhibition of water
reabsorption can lead to a malabsorption component of diarrhea
• Rotavirus secretes an enterotoxin, NSP4 which leads to a calcium-
dependent chloride secretory mechanism
14. • Vomiting is largely attributed to local factors and poor gastric
emptying, and should not be treated with antiemetic drugs
• Abdominal pains are usually spasmodic due to disordered motility or
is associated with colitis in dysentery
• Diarrhea is the manifestation of secretion or absorption disturbance
and disordered motility, a symptom of damage already done in the
infected gut.
15. clinical assessment of Hydration
• Recognize poor perfusion and other signs of shock
• Cold peripheries
• Depressed LOC
• Increase capillary refill time (>3sec)
• Poor/weak peripheral pulses
• Reduced urine-output
• signs of dehydration.docx
16. Work-up
• After resuscitation, in children with severe dehydration, shock or
other signs of metabolic, nutritional or other co-morbidities
• Electrolytes and serum acid base determination
• All severely dehydrated patients, mod dehydration with an atypical
presentation, malnourished children
• Blood glucose disturbances occur in severely ill patients as a result of
glycogen depletion with lack of intake, or associated with the stress response
of dehydration
17. Electrolyte disturbances
• Large amounts of Sodium are lost in diarrheal stools
• In acidosis, a shift of intracellular potassium to EC compartment
results in a spurious elevation of the serum level despite intracellular
potassium loss
• Give K+ to all patients with severe diarrhea until dehydration and
acidosis are corrected
• Sodium disturbances occur frequently
• Sodium content of the stool water varies from plasma-like in
secretory diarrhea , to very low in pure Osmotic diarrhea
19. First treat SHOCK if present
• Always SHOUT for HELP
• A…….B…..
• Circulation
• Establish vascular access or IO if failed venous access after 2 good attempts
• Give 20ml/kg of R/L or Normal Saline rapid infusion or 5ml/kg in aliquots X4 is much
safer
• Watch for signs of circulatory overload i.e hepatomegaly, gallop rhythm or basal
crackles, puffiness of the eyelids, tachy-pnoea and –cardia.
• Repeat R/L 20ml/kg if patient is still shocked. Re-assess and give more if still shocked
• Don’t-Ever-Forget-Glucose
• Re-assess ABC and response so far
• Give 1st dose Ceftriaxone 80mg/kg stat to cover sepsis
20. Treating Shock in severely Malnourished
• ABC still as essential as the normally nourished patients
• Give 15ml/kg infusion over 30 minutes
• Re-assess and repeat if still shocked
• Give up to 4 boluses and thereafter, T/F to HC or ICU
• Patient response should guide further fluid therapy
• When shock has been treated successfully, proceed to the
management of dehydration.
• But remember your patient can go back into shocked if improperly
rehydrated
21. Rehydration fluids
• Its NB to use solutions with sufficient Na conc. To prevent Hyponatremia
• ½ DD is appropriate if IV route is used, or ORS for enteral replacements
• Where vomiting is the main source of fluid loss, rehydration fluid (0.45%NaCl and
5% Dextrose) with added K is appropriate
• Dose of ½ DD or ORS for rapid rehydration over 4 hours
• Some Dehydration: 50ml/kg over 4 hrs (12.5ml/kg/hour)
• Severe Dehydration: 100mls/kg/4hours (25mls/kg./hour)
• Rapid rehydration over 4hrs should not be used in severe malnutrition, cardiac
failure, severe pneumonia, encephalopathy etc.
• However, rehydrate over 24hours or even 48 hours
• APPROPRIATE RESPONSE AT 4.docx
• Severely malnourished have a deficient K and elevated Na levels, thus require a
special ORS: ReSolMal
22. Maintenance fluids
• Should be given enterally wherever possible but intravenously where
nil per Os is absolute
• Fluid restriction to approximately 50-60% of maintenance should be
adhered to, where there is a risk of inadequate secretion e.g in Renal
failure
• NORMAL MAINTENANCE FLUID REQUIREMENTS.docx
23. Never forget the ongoing losses
• Losses need to be replaced by equal volumes of fluids of similar
composition
• For moderate losses, add 30mls/kg to maintenance requirements. But give
more if there’s a need
• For those taking enterally:
• <2years: 50-100mls AELS
• >2years: 100-200mls AELS
• Small frequent volumes of home based sugar salt solution as little as 5mls
every minute, can be effective in preventing dehydration even in vomiting
cases
• Continue Breast feeding and oral feeding once perfusion is restored
24. What else might help?
• Zinc: reduces the duration and severity of diarrhea
• Antimotility agents like loperamide are C/I due to potentially serious
side effects (malignant hyperpyrexia, lethargy and dystonia)
• Vit A: reduces the severity of diarrhea, but do not give if a dose was
given in the previous month
• All children with diarrhea get vit A and Zinc according to age
• Other drugs, Any use?
25. Electrolyte abnormalities
• Hypokalemia (<3): even when the serum K conc. Is normal, these
patients have a depletion of the total body potassium
• Plasma k level doesn’t always provide an accurate est of total body
deficit. There may be K shift from intracellular space to the plasma.
• <3mmol/l: stat dose oral K <5kg= 250mg. 5-10kg=500mg and
>10kg=1g stat
• Ongoing losses: < 5kg: 125mg, 5-10kg:250mg and >10kg: 500mg tds
• Re-assess after 4 hours
• Stop when abnormal losses stop
26. Hypokalemia
K<2>1.5
• Attach ECG: prolonged QT and Flat
T waves
• Give stat doses as previous slide
• Oral KCl: 100mg/kg 6hrly with max
dose 3g/day
• Plus IV correction
• Add to iv fluids (200mls): ½ DD=2ms
15%KCl, Saline=4mls 15%KCl
• Recheck in 4hrs and manage
accordingly
K<1.5: paralysis, muscle
weakness,apnoea
• Admit to HC/ICU
• Give stat dose accordingly
• Oral K: 100mg/kg 6hrly
• Plus IV correction
• If ICU: 0.3mml/kg in 50mls N saline
via C.Vein over 1hour
• Recheck in 2hours
• Manage ongoing losses and
replacement
29. References
• Handbook of Paediatrics 7th edition pg 121-129, 461-481
• Std Rx guidelines and Essential Medicines List 2013 (Dept ofHealth)
pg 2.9-2.17
• Gastroenteritis presentation by Prof T Rogers Dept of Clinical
Microbiology
• South African medical journal, vol 102,no.2 2012 (Management
guidelines for Acute infective diarrhea in infants) prof F Wittenburg
• Acute gastroenteritis in children by Dr Alta Terblanche, Professional
Nursing Today 2010
Cyclizine and prochloperazine have not been proven useful and may carry a higher risk of toxic side-effects.
Aniti-diarrheal formulations aim to reduce intestinal motility, reduce secretion of water and electrolytes, and adsorp fluid and toxins, thereby reducing the number of stools seen in the diaper, but none treat the cause of diarrhoe or the actual pathology and their use can be associated with more side effects.
In severe malnutrition, or in the young infant; bacterial co-infection is common therefore do: FBC and C-RP.
Remember that the loss of water and electrolytes is the principal cause of death. Lets prevent this terrific thing called Death.
Treatment therefore focuses on preventing and treating these complications
Restore intravascular space
Hypovolaemic shock is situation where IV fluids cannot be avoided and where inadequate fluid resuscitation will increase mortality in any patient.
Severe dehydration or some dehydration
To restore interstitial compartment
1ml of 15%=2mmol K
Symptoms of Hyponatremia: lerthagic, confusion, seizures, headache, vomiting andcoma