Acute Diarrhea & Gastroenteritis

Acute diarrhea
Normal bowel phenomena Definition Mechanisms of diarrhea Acute diarrhea Gastroenteritis General approach to children with acute diarrhea

Normal phenomena
The number ,color & consistency of stools varies with age & diet :
Meconium Transitional stools Milk stools

Color of stools Presence of solid particles

Diarrhea cont
Toddler`s diarrhea 1-3 years Healthy child Excessive ingestion of beverages with high carbohydrate content. Typically during the day Limit sugar containing beverages, increase fat in the diet

Definitions
Diarrhea : excessive loss of fluids & electrolytes in stool More than 5g /kg /day Increase in liquidity & frequency Pseudodiarrhea & hyperdefecation Encopresis Dysentery : small volume , frequent,bloody, tenesmus , urgency

Diarrhea
9 liters of fluid enter the GI tract 4-5l absorbed in jejunum , 3-4 ileum, 800 ml in colon. Water transport follows Na & nutrient active & passive transport . The basis for ORS treatment

Mechanisms of diarrhea
Disturbed intestinal solute transport, water movement across intestinal wall. Secratory Osmotic Dysmotility Inflammatory

Secratoy Diarrhea
Agent that binds to surface receptors , increasing cAMP,increased secretion. Watery , large volume , normal osmolality( 2* Na+K ) Persists during fasting,no stool leukocytes. Examples; cholera, toxigenic E.coli,carcinoid ,VIP, congenital chloride diarrhea,Clostridium difficile,cryptosporidium.

Osmotic Diarrhea
Occurs after ingesting a poorly absorbed solute . Stools are of less volume, acidic, reducing substances, high osmolality > 2* Na + K. Stops with fasting , increased breath hydrogen with malabsorption,no stool leukocytes. Examples : lactase deficiency , glucosegalactose malabsorption,lactulose, laxative abuse.

Motility Diarrhea
Increased motility :

decreased transit time. Stimulated by gastro-colic reflex Irritable bowel syndrome Thyrotoxicosis Post vagotomy Infections

Decreased motility:

Stasis : bacterial overgrowth. Pseudo-obstruction, blind loop

Inflammatory
Inflammation . decreased mucosal surface area &/Or colonic reabsorption. Blood & increased WBC`s in stool. Infectious gastroenteritis dysentery

Acute diarrhea
Common

Rare

Infant:

Gastroenteritis Systemic infection Antibiotic use Gastroenteritis Food poisoning Systemic infection Gastroenteritis Food poisoning antibiotic

Infant:

Child:

Primary disaccharidase deficiency Adrenogenital s. Hirchsprung colitis Toxic ingestion thyrotoxicosis

Child:

Adolescent:

Adolescent:

Gastroenteritis
Most common cause of acute diarrhea in all age groups. Clinical manifestations depend on the organism & the host response to infection. A presumptive diagnosis can be made from epidemiological clues, good history & physical examination,laboratory investigations ( not required always )

Etiology
Non- inflammatory :
enterotoxin production Villus destruction Adherence to surface

Inflammatory:
Direct invasion cytotoxins

Bacterial enteropathogens
Inflammatory:

Aeromonas, campylobacter jejuni,clostridium deficile,enteroinvasive E. coli,shiga toxin producing E. coli, salmonella, shigella, yersinia enterocolitica.

Non- inflammatory:
Enteropathogenic E.coli, Vibrio cholera

Viral enteropathogens
Rotavirus Enteric adenoviruses Astrovirus Norwalk agent-like virus Calicivirus

Parasitic enteropathogens
G. lamblia Entamoeba histolytica Strongyloides stercoralis Cryptosporedium Cyclospora & isospora

Epidemiology
Major cause of mortality & morbidity in children world wide. Transmission:
person-to-person feco-oral route Water & food borne

High risk groups

Young age groups Immune deficient individuals Measles Malnutrition Travel to endemic areas Lack of breast feeding Exposure to unsanitary conditions Attendance to child care centers Poor maternal education

General approach
Clinical assessment:Historical points :

Diarrhea :

duration & severity Stool consistency Mucous & blood GI Fever Neurological Symptoms Others

Associated symptoms :

Risk factors Social & family History

Clinical assessment
Physical examination:
General appearance Hydration Status

Mild Moderate severe

Systemic Examination Extraintestinal manifestations

Extraintestinal manifestations

Reactive arthritis :Salmonella ,shigella , Yersinia, campylobacter C.difficile Guillain-Barre Syndrome: campylobacter Glomerulonephritis:Shigella , campylobacter ,Yersinia IgA nephropathy :campylobacter Erythema nodosum: Yersinia ,campylobacter, salmonella Hemolytic anemia : Yersinia ,campylobacter HUS: shigella , E. coli

Diagnostic Methods
Stool samples :

fresh collected Mucous,bld,white cells Ova & parasites:

Recent travel to endemic area,-ve stool cultures,diarrhea > 1wk Part of an outbreak Immunocompromised

Stool cultures:

As early as possible Suspected HUS Bloody diarrhea outbreaks

Diagnostic Methods
Stool cultures : Routine : Salmonella, shigella,yersinia,campylobacter. Toxin assays: C. difficle,E.coli Special stains:Aeromonas, cryptosporidium & vibrio sp. Duodenal aspirate & Biopsy: Giardia, Isospora,cryptosporidium. ELISA E.M. Colonoscopy & sigmoidoscopy.

Even with the application of all available laboratory studies , 20-40 % of all acute infectious diarrhea remain undiagnosed.

Management
Fluids & electrolytes & refeeding:
Treating dehydration is the corner stone in managing diarrhea. Infants are more susceptible to dehydration Oral rehydration therapy Home remedies feeding

Specific therapy
Anti-microbial therapy :

Indications are organism-dependant. Salmonella : Infants< 3months, typhoid fever, bacteremia , disseminated disease with local suppuration. Shigella : all cases Vibrio cholera : all cases Aeromonas: dysentery like, prolonged diarrhea. C. difficile: moderate to severe disease. E.coli.

Anti diarrheal agents

Prevention
Precautions during hospitalization Education Child care attendance Health authority notification. Vaccines ??

Thank you !