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![Acute Gastroenteritis
Prof. Dr. D.RAJKUMAR,
MD[PED]
Associate Prof. of Pediatrics](https://image.slidesharecdn.com/diarrheaclinical-240520190049-36609852/75/Acute-gastroenteritis-Diarrhea-Clinical-ppt-1-2048.jpg)
![DIARRHOEA
• Duration
• Onset [ Preceding URI / Preceding Vomiting / High
fever ]
• Frequency of diarrhoea](https://image.slidesharecdn.com/diarrheaclinical-240520190049-36609852/75/Acute-gastroenteritis-Diarrhea-Clinical-ppt-6-2048.jpg)
![– Consistency
– Smell [ Sour milk / Malodorous]
– Color [ Yellow / green / Black / Red]
– Blood & mucous
– Perianal excoriation](https://image.slidesharecdn.com/diarrheaclinical-240520190049-36609852/75/Acute-gastroenteritis-Diarrhea-Clinical-ppt-7-2048.jpg)
![• Icterus, Pallor, Clubbing, Pedal edema
• Signs of dehydration[ AF, Eyes, Tears,
Mucosa, Tongue, Acidotic breathing]
• Bowel sounds, Tenderness
• Abdominal organomegaly
Clinical Examination](https://image.slidesharecdn.com/diarrheaclinical-240520190049-36609852/75/Acute-gastroenteritis-Diarrhea-Clinical-ppt-13-2048.jpg)
Acute gastroenteritis/Diarrhea Clinical.ppt
- 1. Acute Gastroenteritis Prof. Dr.D.RAJKUMAR, MD[PED] Associate Prof. of Pediatrics
- 2. Definitions & Terminologies aboutDiarrhea What is Diarrhea? The passage of three or more loose or watery stools in a 24-hour period Classification depending upon duration: Acute diarrhea 3 - 7 days Prolonged or Indeterminate 8 - 14 days Persistent diarrhea > 14 days Chronic diarrhea > 14 days Parenteral diarrhea Primary pathology outside GIT
- 3. • Depending uponcharacteristics of stools: Watery diarrhea --- Secretory & Osmotic Blood & Mucus --- Dysentery
- 4. ORDER OF HISTORYTAKING • Chief complaints – Chronological order • History of Presenting illness Relevant History only from • Past history • Diet history • Socio economic history
- 5. CHIEF COMPLAINTS • Diarrhoea •Vomiting • Fever • Convulsions
- 6. DIARRHOEA • Duration • Onset[ Preceding URI / Preceding Vomiting / High fever ] • Frequency of diarrhoea
- 7. – Consistency – Smell[ Sour milk / Malodorous] – Color [ Yellow / green / Black / Red] – Blood & mucous – Perianal excoriation
- 8. Vomiting • Contents • Color/ Blood stained • Projectile or non projectile
- 9. Fever – Duration – Onset –High grade or low grade – Chills and rigors – Continuous or intermittent
- 10. Convulsions • No ofepisodes, Duration, Febrile or afebrile, … • Sensorium • Common causes of Seizures during AGE: • Febrile Hypoglycemia • Dyselectrolemia Acute CNS infections • Venous sinus thrombosis
- 11. PAST HISTORY • Similarillness in past • Any illness like measles, Asthma, jaundice .. • Previous history of hospitalization • H/o Medications
- 12. DIETARY HISTORY • Breastfed or Bottle fed • Early Weaning or Late weaning • Diet adequate or not • Hand Hygiene followed
- 13. • Icterus, Pallor,Clubbing, Pedal edema • Signs of dehydration[ AF, Eyes, Tears, Mucosa, Tongue, Acidotic breathing] • Bowel sounds, Tenderness • Abdominal organomegaly Clinical Examination
- 14. Features of Dehydration MildModerate Severe Looking at the condition Well, alert Restless, Irritable Lethargic or unconscious; floppy Eyes Normal Sunken Very sunken & Dry Tears Present Absent Absent Mouth & Tongue Moist Dry Very dry Thirst Drinks normally, no Thirst Thirst, drinks eagerly Drinks poorly or not able to drink Feel Skin pinch Goes back Quickly Goes back slowly Goes back very slowly > 2 sec Decide – Hydration Status No signs of Dehydration Has two or more signs, there is Some Dehydration Has two or more signs, there is Severe Dehydration
- 15.
- 16. Clinical Picture incertain special situations Conditions Physical Signs Acidosis Breathing increased in depth and rate Hypokalemia Abdominal distention, paralytic ileus, hypotonia, hyporeflexia, mental apathy ECG changes Hypomagnesemia Tetany, Muscular twitching Hypernatremic Doughy skin Dehydration
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- 18. Failure tobreast-feed exclusively for 4- 6 months. Failure to breast-feed until at least one year of age. Using infant feeding bottles. Storing cooked food at room temperature for long periods. Drinking water contaminated with fecal bacteria. Risk factors for acute diarrhea
- 19. Predisposing host factors Under nutrition. Recent measles (In previous four weeks). Immunodeficiency Age: First two years of life, maximum at 6-11 months Why ? Weaning period - Declining levels of maternal antibodies. - Lack of active immunity in the infant. - Infant starts to crawl. Seasonal : Rotavirus throughout the year. Bacterial in summer & rainy season. Epidemics: Vibrio cholerae, Shigella.
- 20. Mechanisms Of Diarrhea Osmotic diarrhea Secretory diarrhea Invasive/Inflammatory diarrhea
- 21. Osmotic Diarrhea Smallbowel mucosa is a porous epithelium; water and salts move across it rapidly to maintain osmotic balance Diarrhea occurs when a poorly absorbed, osmotically active substance is present in the gut . If substance is isotonic, the water and solute will simply pass through the gut unabsorbed, causing diarrhea. Eg ; lactose, magnesium sulfate
- 22. Markers of OsmoticDiarrhoea • Children often stable • Stools – Small or large volume, watery or loose • Stool sodium < 50 mEq/L • Stool Osmolality – Less than the ionic Constituents • Stool Reaction – Acidic (pH < 5.5) • Discontinuation of feed results in improvement. • Perianal excoriation • Abdominal distention before passing stool. • Reducing substance positive E.g. Rota virus diarrhoea & Disaccharide Malabsorption
- 23. SECRETORY DIARHOEA ACTIVE SECRETION Caused by the abnormal secretion (water and salt) into the small bowel. Occurs when Sodium absorption by the villi is impaired. Chloride secretion in crypts continues/increased. Mediators : Cyclic A.M.P of Cholera Cyclic G.M.P of E.T.E.C
- 24. Markers of SecretoryDiarrhoea • Dehydration • Dyselectrolemia • Large Volume Stool • Stool Sodium > 70mEq/L • Stool often Alkaline • No effect with Discontinuation of feeding • Reducing substance – Negative
- 25. Invasive/Inflammatory diarrhea A. Infective –Shigellosis, Amebiasis. B. Non infective – Ulcerative colitis. How to diagnose ? Fever Blood in stool, Increased fecal leucocytes Abdominal pain, cramps, tenesmus.
- 26. • Dehydration • Acuterenal failure • Venous Thrombosis - Cerebral, Renal • HUS ( Hemolytic Uremic Syndrome) • Malabsorption • Food Intolerance • Intussusceptions • Disseminated Intravascular Coagulation • Persistent Diarrhea • Dyselectrolemia Complications of Acute Diarrhoea
- 27. 1. Stool -Ova, Cysts, Trophozoites, Leucocytes Hanging drop for V. cholerae Culture practically not required 2. Blood tests - CBC, PBF for band cells Serum Electrolytes BUN and Creatinine Culture and sensitivity 3. Urine - R/M, Culture may be required Investigation in a child with acute severe diarrhoea
- 28. Management • Treatment ofDehydration • Nutritional support • Zinc therapy • Antimicrobials • Others
- 29.
- 30. Features of Dehydration MildModerate Severe Looking at the condition Well, alert Restless, Irritable Lethargic or unconscious; floppy Eyes Normal Sunken Very sunken & Dry Tears Present Absent Absent Mouth & Tongue Moist Dry Very dry Thirst Drinks normally, no Thirst Thirst, drinks eagerly Drinks poorly or not able to drink Feel Skin pinch Goes back Quickly Goes back slowly Goes back very slowly > 2 sec Decide – Hydration Status No signs of Dehydration Has two or more signs, there is Some Dehydration Has two or more signs, there is Severe Dehydration
- 31. Acute Diarrhoea withoutDehydration ( Plan - A ) Asses Risk of Dehydration High Risk Low Risk Age < 6 months Age ≥ 6 months Vomiting > 4 times/day Vomiting ≤ 4 times/day Liquid motions > 8 times/day Stool ≤ 8 times/day Continue Breast feeding & usual fluids-HAF Encourage to take more Discharge
- 32. Home Available Fluids Recommended •Salt sugar solution • Lemon water • Rice water / Kanjee • Soups • Dal water • Lassi • Coconut water • Diluted Tea Not recommended • Simple sugar solution • Glucose solution • Carbonated soft drinks • Fruit juices-tinned or fresh
- 33. High Risk Admitfor Observation (Plan - A Contd…) Maintenance fluid On going loss - ORS 10 ml/kg/each stool/vomiting Reassess every 4 hours Good hydration Dehydration ensues Stable on ORS treat as Some Dehydration Discharge with ORS Packets and advise
- 34. ACUTE DIARRHOEA WITHSOME DEHYDRATION (Plan - B) ADMIT ORS 75 ml./kg. in 4 hours Reasses after 4 hours Dehydration No Dehydration Persists (Treat as Plan - A) Consider NGT . For rehydration with ORS Dehydration Continues No Dehydration (Treat as Plan - A) Contd……
- 35. PLAN - BContd.. Dehydration Continues Review every 2 hours Commence IV. Fluid Dehydration continues Calculate for Dehydration NGT/IV Fluids. Maintenance, Ongoing losses Invest - Urea creatinine No Dehydration And electrolytes (Treat as Plan - A) No signs of dehydration (Treat as Plan - A) Maintenance fluid - 100 ml/kg ORS for 1st 10 kg. then 50 ml./kg. for next 10 kg.
- 36. Indications of IVfluids • 1. Severe dehydration • 2. Some Dehydration- – Persistent vomiting – Paralytic ileus – Altered sensorium – High Purge rate
- 37. ACUTE DIARRHOEA WITHSEVERE DEHYDRATION (Plan - C) Rapid bolus of Ringer lactate/Normal saline, 20 ml./kg. Circulation Circulation Restored not restored Further bolus of NS max. 40 ml./kg. Improve Not Improved ADMIT to Intensive care unit With Circulatory Compromise Admit Age 30 ml per kg 70 ml per kg Less than 1 year 1 hour 5 hours More than 1 year 30 minutes 2 and half hours
- 38. Composition of Fluidsfor Intravenous & Oral Rehydration Oral Osmolarity mOsm/L Glucose mmol/L Sodium mmol/L Chloride mmol/L Potassium mmol/L Base (Citrate) mmol/L WHO ORS 311 111 90 80 20 10 WHO Low Osmolar ORS 245 75 75 65 20 10 IAP Recomnd. ORS 224 84 60 50 20 10 INTRA VENOUS FLUID Ringer’s lactate 280 130 110 04 25 (Bicarb) Normal Saline 308 154 154
- 39. Composition of WHOHigh & Low Osmolality ORS ------------------------------------------------------------------------------------------------------------------------------------ Ingredients / L High Osmolality Low Osmolality Components / Lit Sodium Chloride 3.5 2.6 Na 90 75 Sodium Citrate 2.9 2.9 Citrate 10 10 or Sodium Carbonate 2.5 2.5 H CO3 30 30 Potassium Chloride 1.5 1.5 K 20 20 Glucose 20 13.5 Glucose 111 75 Osmolality 311 245 --------------------------------------------------------------------------------- --------------------------------
- 41. Oral Rehydration Therapy(ORT) •Oral Rehydration Solution (ORS) + •Other Fluids & Liquid Diets
- 42. Limitations of WHOHigh Osm-ORS Does not lower volume, frequency and duration of diarrhea Induces vomiting due to taste, acceptability poor Enhances volume, purge rate & duration of diarrhea due to high osmolality More chances of dehydration – Dehydrating fluid So more oftenly IV fluids required Hypernatremia Good to correct deficit fluids but not good for maintenance therapy
- 43. Advantages of LowOsm-ORS • Does lower volume, frequency & duration • Equally effective in cholera, toxin related & RV diarrhea : Deficit & maintenance therapy • No need of IV fluids • Good for all ages infancy to adulthood • Asymptomatic hyponatremia.
- 44. Super ORS Ricepowder when digested releases twice the amount of glucose than in ORS. This is enough to support the absorption of water & electrolytes in ORS Protein in rice adds to this effect by release & absorption of amino acids. Osmotic activity of rice-ORS ( 220 mOsm/l) is lower than that of blood or other tissues (290 mOsm/l). Calories in rice may help prevent malnutrition Trials show lower rate of stool volume in cholera.
- 45.
- 46. Advantages of DietaryTherapy • Maintains nutrition, helps in absorption • Faster recovery • Take care of infection and avoids malnutrition • Prevents prolongation of diarrhea • Corrects malnutrition in mal-nourished children. • Extra diet in convalescence / on recovery
- 47. What are theDiets to be Continued or Given ? • Age appropriate diets • Breast feeding : Aseptic paint. • Artificially fed – milk • Whatever child taking earlier • Rice, khichri, pulses/ curd/yogurt • Small frequent aliquots – Spoon & Katori
- 48. Breast Fed :Continue Breast feeding throughout rehydration and Maintenance phases. Formula fed : Restart feed at full strength as soon as rehydration is complete (ideally after 4 hours) Weaned Children : Child’s normal fluids and solids following rehydration. Avoid fatty foods or foods high in simple sugar. Management of feeding during Acute Diarrhoea
- 49. Diet in Indeterminateand Persistent &Chronic Diarrhea • Breast feeds continue • Diet A : Low lactose diet • Diet B : Lactose free diet, if no response to Diet A. • Diet C : Monosaccharide based diet if no response to Diet B.
- 50. Foods to beAvoided • Fat rich • Fruits and fruit juices • Junk foods • Spicy foods • Carbonated fluids • Sugar & glucose rich foods
- 51. • Indicated in –Dysentery – Cholera – Infants under 6 months of age. – Immunocompromised infants. – Clinical suspicion of bacteremia. Indication of Chemotherapy / Antibiotics
- 52. Other Special Indicationsof Antibiotics Severity of symptoms Host related risk factors * Severely sick child * Neonatal age * Septicemia * Malnutrition * Neurological involvement * HIV Infection * Septic shock State * Other immune deficiency * Invasive diarrhea Socio- environmental indications * Cholera * Nosocomial infection * At risk contacts. * Epidemics
- 53. Chemotherapy For Bacterial& Protozoal Diarrhoea Etiologic agent Chemotherapy Shigella Nalidixic acid, Cotrimoxazole, Ampicillin Enteroinvasive E:coli Nalidixic acid, Cotrimoxazole, Ampicillin, Inj Gentamicin (in case of septicemia) Salmonella Ampicillin, Chloramphenicol Campylobacter jejuni Erythromycin, Furazolidin, Chloramphenicol, Gentamicin Vibrio cholerae Furazolidin, Cotrimoxazole, Tetracycline, Erythromycin, Ent. histolytica Metronidazole, Tinidazole, Secnidazole, Paromomycin Giardia Metronidazole, Tinidazole, Secnidazole, Ornidazole, Furazolidine
- 54. Role of Zincin Acute Diarrhea Acute as well as persistent diarrhea Tremendous loss in stools. Absorption of Zinc intact Deficiency during diarrhea results into lowering of Cell division & maturation. Tissue growth & repair. Maturation of enterocytes. Brush border enzymes. Water & electrolyte absorption. Immune functions.
- 55. Zinc Supplementation ! Responsiblefor > 200 enzymes in body. ! Improves the immune function & absorption. ! Supplementation in AD and PD helpful in 20-30% reduction in diarrhea. ! 42% lower rate of treatment failure or death. Dosages o Infants 10mg daily x 2 weeks. o Older children 20mg daily x 2 weeks. o Persistent diarrhea x 4 week
- 56. PROBIOTICS • Duration ofacute diarrhea decreases by one day in meta-analysis • Saccharomyces boulardii : Strong benefit • Lactobacillus sps. , Bifidobacterium sps. , Bacillus Coagulans, Streptococcus Fecalis….
- 57. RACECADOTRIL Anti-secretory agent. * Effectivein treatment of acute diarrhea. * Reduction in hyper secretion of water and electrolytes. * Reduces diarrhea duration & number of stools significantly.
- 58. Prevention • Improvement ofNutritional status. • Safe drinking Water Supply in community. • Exclusive Breast feeding till 6 Months. • Easy availability of ORS sachets. • Hand washing before handling food. • Vaccines : – Rotavirus vaccine – Cholera Vaccine – Typhoid Vaccine – ETEC Vaccine
- 59. Traditional Practices tobe Avoided • Antimotility & antispasmodic drugs • Stool binding agents • Enzyme preparations & steroids • Antimicrobial agents in combination • Bottle feeding • IV fluids to every case • Starvation-Nothing like bowel rest • These will hamper natural clearance, lower immunity, promote growth of unusual organisms & PEM
- 60. PRACTICES TO BEADOPTED • Breast feeding: Aseptic paint for GIT • Cereal supplementation • Spoon & katori/ directly from pot • Judicious use of antimicrobials • Proper hygiene & sanitation • Rotavirus vaccine
- 61.