Acute gastroenteritis Flashcards
Could be also known as:
*Acute Enterocolitis
*Acute Gastroenterocolitis
*Acute Diarrhea
*Acute Diarrheal Disease
ACUTE DIARRHEA–
generally defined by stool consistency and duration
(less than 7 days) (not by the number of stools per day – infant
variability)
- EXTENDED DIARRHEA (7-14 DAYS)
- CHRONIC/PERSISTENT DIARRHEA – More than 14 days
The causes of acute diarrhea (modified and adapted after Ciofu E, Ciofu
C. Pediatria - Tratat 1st Edition, 2001 )
1. Enteral infections (bacterial, viral, parasitic)
2. Parenteral infections (UTI, etc)
3. Inflammatory intestinal disease
4. Anatomical/functional causes (short intestine, de l’anse borgne
syndrome, etc)
5. Pancreatic/hepatic diseases (cistic fibrosis, etc)
6. Biochemical causes(disaccharides deficit, chloride diarrhea)
7. Celiac disease
8. Neoplasia (lymphoma, neuroblastoma, etc)
9. Immunodeficiency (hypogammaglobulinemia, Iga selective deficiency,
AIDS)
10. Endocrinopathy (hyperparathyroidism , Addison’s disease)
11. Malnutrition
12. Diet factors (over-alimentation, introduction of new foods)
13. Alimentary intolerances/allergies
14. Psychogenic diseases (irritable bowel)
15. Toxic diarrhea (heavy metal poisoning)
The causes of acute diarrhea (from a
practical point of view)
- Enteral infections
- bacterial
- viral
- Parasitic
- Parenteral infections (UTI, etc)
- Medication (antibiotics, etc)
- Alimentary allergies
- Food factors (over-alimentation, introduction of new
foods)
There are many pathogenetic mechanisms that are both
self-explanatory and asociated with acute diarrhea:
- Secretory - secretagogue agents, ex. cholera toxin, which
attach to the receptors of the intestinal ephitelium and
determine an intracellular accumulation of cAMP and cGMP
Osmotic – determined by unabsorbable solutions,
carbohydrate malabsorption (caused by the damage of the
small intestine’s brush border)
*Intestinal motility disorders – ex thyrotoxicosis, bacterial
overgrowth (the transit is slowed down)
*Reduce intestinal surface (short intestinal syndrome)
*Mucosal invasion (inflammation, decreased colonic
reabsorption, increase motility)
There are many pathogenetic mechanisms that are both
self-explanatory and asociated with acute diarrhea:
- Secretory - secretagogue agents, ex. cholera toxin, which
attach to the receptors of the intestinal ephitelium and
determine an intracellular accumulation of cAMP and cGMP
Osmotic – determined by unabsorbable solutions,
carbohydrate malabsorption (caused by the damage of the
small intestine’s brush border)
*Intestinal motility disorders – ex thyrotoxicosis, bacterial
overgrowth (the transit is slowed down)
*Reduce intestinal surface (short intestinal syndrome)
*Mucosal invasion (inflammation, decreased colonic
reabsorption, increase motility)
Practical differential diagnosis: osmotic
diarrhea e secretory diarrhea
Parameters Osmotic Diarrhea Secretory Diarrhea
Stool Volume < 200 ml/day > 200 ml/day
Answer to fasting Answer No answer
Stool Na < 60 mOsm/l > 90 mOsm/l
Fecal osmolarity < plasma osmolarity = plasma osmolarity
Definition acute gastroenteritis (AGE)
*Decrease of fecal consistency (soft or liquid) and/or
increase of stool evacuation frequency (tipically ≥3/24
hours) with or without fever and vomiting
* A change in stool consistency versus previous stool
consistency is more indicative of diarrhea than stool
number, particularly in the first months of life
Pathogeny- AGE
- Enterotoxigenic Mechanism - major pathogenic
mechanism (if not exclusive) production of
enterotoxin and its action on the intestinal mucus,
with the distruction of villus cells - Enteroinvasive mechanism - direct invasion of the
intestine, as well as cytokines production that
causes the increase of water secretion and
electrolytes in the intestinal lumen.
*The main pathogenic mechanism
consists in
blocking or decrease water and electrolytes absorption at the intestinal level
Epidemiology
- The incidence of diarrhea ranges from 0.5 to 2 episodes
per child per year in children <3 years in Europe. - Gastroenteritis is a major reason for hospitalization in this range of age.
- Rotavirus is the most frequent agent of AGE;
- norovirus is becoming the leading cause of medically attended AGE in countries with high rotavirus vaccine coverage.
- The most common bacterial agent is either Campylobacter or Salmonella depending on country.
*Intestinal infections are a major cause of nosocomial infection.
Etiology of age divided in age groups
*<a 1year: rotavirus, norovirus, adenovirus,
salmonella
*1-4 ani: rotavirus, norovirus, adenovirus,
salmonella, campylobacter, yersinia
*>5 years: campylobacter, salmonella,
rotavirus
Clinical Signs
*Diarrheic stool
*Vomitting
* Fever
*Abdominal pain
*Anorexia
* Seizures
* Tenesmus
* Erythema nodosum
Clinical signs of acute dehydration are to be added to the
clinical representation of acute diarrhea, as they severely
affect the disease
Clinical research has focused on the following:
- Fever (different definitions of absent, low, moderate, and high)
- Vomiting (absent, present, and different definitions of frequent)
- Onset (abrupt or more gradual)
- Stool frequency (different definitions of low, moderate, and high)
- Fecal mucus (present or not)
- Fecal blood (present or occult)
- Abdominal pain (present or not)
- Respiratory symptoms (rhinorrhea, cough)
- CNS involvement (irritability, apathy, seizures, or coma)
ATTENTION ASOCIATION DIARRHEA, OLIGURIA, EDEMA = suspicion
of hemolytic uremic syndrome
Risk factors that cause severe/persistent forms
of disease
- Clinical signs of severity: severe dehydration, repeated vomiting, persistent/high fever
*Age < 6 months - Etiology: rotavirus, norovirus, astrovirus, E Coli enteropatogen
- Socio-economic conditions
*Artificial nutrition - Community: prekindergarden, kindergarden
*Immunodeficiency
Are there any clinical signs that could lead to
the etiology?
*Fever > 40 ̊C, blood in the stool, abdominal
pain, irritability, seizures, coma = suggestive
for bacterial etiology
*Signs of vomiting and respiratory symptoms =
suggestive for viral etiology
Is a child with diarrhea dehydrated?
- The degree of dehydration is essential for the
therapeutic approach!
(expressed in loss weight)
*Minimal dehydration : <3% (Child) (5%) (Infant)
*Mild to moderate dehydration : 3-9% (6-10%) - Severe dehydration> 9% (10%)
When are electrolytes /astrup
needed?
*In cases of moderate and severe dehydration
*In case of parenteral rehydration
*Hypovolemic shock
*Neurological abnormalities (lethargy, seizures)
*Incoercible vomiting
When should one go to the doctor?
*Diarrhea: ≥ 8 episodes/day
* Persistent vomiting
*Infants < 2 months
* Severe underlying disease (diabetes mellitus or renal failure)
* Family reported sign of severe dehydration
When is hospitalization recommended?
- Shock
- Severe dehydration
- Somnolence, seizures, etc
- Persistent /bilious vomiting
- Lack of response to oral rehydration
- Social/family causes
- Suspected of surgical disease causes
Microbiological investigations
- Stool samples (Coprocultures)
*Microscopic examination of faecal samples (evaluation
of the number of leukocytes ) - Stool antigen (Rotavirus, Campylobacter etc)
*Verotoxina (shiga-like toxin) - EHEC O157:H7
(suspicion of hemolytic uremic syndrome)
Treatment - ACUTE GASTROENTERITIS
*Rehydration
*Diet
*Pharmacological therapy
Alimentation of the child with AGE
- Minimal or no dehydration– fed according to age
- Mild to moderate dehydration – reintroduction of normal
feeding after 4-6 hours from the start of rehydration (shortens
the length of diarrhea by 0,43 days, reduces ponderal decrease
thanks to hypocaloric diets)
*This recommendation is not often followed.
“….optimal management of mild-to-moderately
dehydrated children in Europe should consist of
- A) oral rehydration with ORS over 3 to 4 hours, and
- B) rapid reintroduction of normal feeding
thereafter….”
Should breastfeeding be interupted for
children with diarrhea?
*NO
Enteral feeding and diet selection
- Continued enetral feeding in diarrhea aids in recovery from the episode, and a continued age- appropiate diet after rehydration is the norm
*Intestinal brush-border surface and luminal enzymes can be affected in children with prolonged diarrhea or malnourished children – lactose free
formula and possible specific diet. Alternative strategies: addition of milk to cerreals and replacement of milk with fermeted milk products
such as yogourt
* Fatty food and food high in simple sugars (juices, carbonated sodas) should be avoide
Is progressive reintroduction of milk fomula
necessary?
*No
When is the introduction of lactose-free
formulas necessary?
- Not routinely done
Studies that show the benefits of this recommendation were
published before1980 - **Recomended in
- Severe dehydration
- Severe malnourished children**
Pharmalogical therapy
- ANTIBIOTICS – indications
- In GEA with Salmonella typhi, Shigella, Entamoeba hystolytica, v.
cholerae, Giardia lamblia, Campylobacter - Despite the etiology, in the presence of signes of sepsis or in
neurological complications or in persistent diarrhea(>14 zile) - Neonatal period
- Malnutrition
- Imune defficiencies
Pharmcological therapy
- Racecadotril (a potent enkephalinase inhibitor) (Hidrasec, Tiorfan,
Racecadotril etc) – reduces the number of watery stools - Smectita - improves the consistent of the stools
- Probiotics – active on gut microflora and intestinal absorption
- Lactobacillus GG
- Saccaromyces boulardi
- Loperamid – NO
- Antiemetice (Ondasetron)– NOT USSUALLY
Pharmcological therapy
- In malnourished children (mostly in developing countries):
- ZINC is recommended to reduce the severity and duration
of diarrhea - And should be added to treatment with ORS
Dehydration
*Water decrease in the organism
*Usually associated with electrolyte concentration decrease
Symptoms associated with minimal or no
dehydration < 3% loss of body weight)
- Mental status
- Thirst
- Heart rate
- Quality of pulses
- Breathing
- Eyes
- Tears
- Mounth and tougue
- Skinfold
- Capillary refil
- Extremites
- Urine output
* Well, alert
Drinks normally, might refuse
liquids
Normal
Normal
Normal
Normal
Present
Moist
Instant recoil
Normal
Warm
Normal to decreased
Symptoms associated with mild to moderate
dehydration 3-9 % loss of body weight)
- Mental status
- Thirst
- Heart rate
- Quality of pulses
- Breathing
- Eyes
- Tears
- Mounth and tougue
- Skinfold
- Capillary refil
- Extremites
- Urine output
* Normal, fatigued or restless,
irritable
Thirsty, eager to drink
Normal to increasead
Normal to decreased
Normal, fast
Slightly sunken
Decreased
Dry
Recoil in < 2 sec
Prolonged
Cool
Decreased***
Symptoms associated with severe
dehydration > 9% loss of body weight)
- Mental status
- Thirst
- Heart rate
- Quality of pulses
- Breathing
- Eyes
- Tears
- Mounth and tougue
- Skinfold
- Capillary refil
- Extremites
- Urine output
** Apathetic, lethargic,
unconscious
* Drinks poorly, unable to drink
* Tachycardia or bradycardia
* Weak, thready, or impalpable
* Deep
* Deeply sunken
* Absent
* Parched
* Recoil > 2 sec
* Prolonged; minimal
* Cold, mottled, cyanotic
* Minimal**
Dehydration classification depending
on osmolarity
“SURROGATE” FOR THE OSMOLARITY
SODIUM VALUES— CONSIDERING NORMAL GLYCEMIA
VALUES!—
* ISOTONIC (130-150 mEq/l) (normal osm.)
* HYPOTONIC(<130 mEq/l) (decreased osm)
* HYPERTONIC (>150 mEq/l) (increased osm)
ATTENTION!!!
- The knowledge of the type of dehydration(hypo, iso
or hypertonic) is crucial in
minimizing risks associated with volemic reexpansion
* In hyponatremia ideal 10 mEq/24 hours (not more than 2
mEq/hour) –long term neurological effects due to pontine
myelinolysis
* In hypernatremia – correction of dehydration within 48
hours - lethal massive cerebral edema risk
the principle that must guide the volemic resuscitation is maintaining a
full vascular bed – euvolemia = main target
- correction of ionic imbalances = secondary target
Access routes
- For patients in shock, with hypotension – venous
access attempts should be limited to 3 ATTEMPS
*No blood vessel obtained– INTRA-BONE access
** THE INTRA-BONE APPROACH SHOULD BE THE MAIN
OPTION FOR PATIENTS IN CARDIAC ARREST
*IT HAS A SUCCESS RATE OF 83% AS OPPOSED TO 17%
IN THE CASE OF INTRAVENOUS CANNULATION
ACCESS ROUTES - INTRA-BONE APPROACH
- THE INTRA-BONE APPROACH
- Indicated:
- Cardiac arrest
- Shock
- Intravenous cannulation failure
- For patients in shock, with hypotension – venous access attempts should be limited to 3 ATTEMPS
- No blood vessel obtained– INTRA-BONE access
- THE INTRA-BONE APPROACH SHOULD BE THE MAIN OPTION FOR PATIENTS IN CARDIAC ARREST
- IT HAS A SUCCESS RATE OF 83% AS OPPOSED TO 17% IN THE CASE OF
INTRAVENOUS CANNULATION - Places of puncture:
- Proximal tibia/distal tibia
- Distal femur
INTRA-BONE APPROACH
Necessary material
- Special needles
- Short
- Stop protection
*trocarul - Xilina1%;
*Antiseptic measures
INTRA-BONE APPROACH
Complications:
*Osteomyelitis (1%)
* Cellulitis;
* Comprising syndrome
* Fatty embolism
*Growth cartilage destruction
* Sepsis.
INTRA-BONE APPROACH
- The duration of infusion should not exceed 12 hours
*Needles must avoid the growth cartilage destruction
*Do not use excessive force/ you can pass both cortices
*If you do not aspirate marrow or blood / instilate saline
solution – pink liquid – confirm the correct place of
needles in the medullary cavity
*Urgent medication (adrenalina, atropina, Na bicarbonat, xilina,blood, etc.) - performed without problem.
ACCESS ROUTES
*ORAL REHYDRATION MUST NOT BE IGNORED
* when the dehydration is not severe
* when the child’s status allows it (without altered
sensorium)
* when the gastric tolerance allows it
REHYDRATING WITH REHYDRATION SALTS – FOR 4 HOURS -
50 ml/kg for mild dehydrations - 100 m/kg for /severe
ones
Rehydration salts
- Classical/standard solutions- Na 90 mmol/l –among
the most important medical discoveries – they saved the lifes of many children with cholera
*Reduced osmolarity solutions – Na 75 mml/l
(recommended by the OMS)
*Hypotonic solutions– Na 60 mmol/l (recommended by
ESPGHAN,less by OMS)
STANDARD ORS
- Glucose 111 mmol/l
- Sodium 90 mEq/l
- Potasium 20 mEq/l
- Chlorine 80 mEq/l
- Bicarbonate 30 mmol/l
- Osmolarity 311 mmol/l
REDUCED
OSMOLARITY ORS
- Glucose 75 mml/l
- Sodium 75 mEq/l
- Potasium 20 mEq/l
- Chlorine 65 mEq/l
- Citrate – 10 mml/l
- Osmolarity 245 mOsmol/l
ESPGHAN ORS
- Glucose 90 mml/l
- Sodium 60 mEq/l
- Potasium 20 mEq/l
- Chlorine 60 mEq/l
- Citrate – 10 mml/l
- Osmolarity 240 mOsmol/l
Replacement of losses
- <10 kg body weight: 60-120 ml ORS for each diarrheal stool or
vomiting episode - > 10 kg body weight: 120-240 ml ORS for each diarrheal stool or
vomiting episodes
IMPORTANT
The choice for the hypovolemic patient is
is saline solution (nacl 0.9%) –
regardless of the glycemic index!!!
* 20 ml/kg as quickly as possible
* If after maximum 3 tries the reexpansion has not been obtained –
coloidal solutions: glucose oligomers, albumin
Why is it important to use saline solution
(NaCl 0,9%) in rebuilding volemia and not 5%
glucose?
- In order for the administered solutions to reach the cells a vascular bed is required
- Glucose administered without rebuilding the volemia – hyperglycemia (often observed by us)
- Therapeutically induced hyperglicemia accentuates dehydration through osmotic diuresis
Frequent mistakes
- Administering during the inital approach:
- antibiotics
- corticosteroids
- bicarbonate
- Administering bicarbonate without documenting a refractary
acidosis to efficient volemic expansion and without proving
normal na values = vital risk complications (through
hypercapnia, hypernatremia, hyperosmolarity)
PRACTICAL MESSAGE
- the absolute priority regarding patients with ads and severe
dehydration is rebuilding the volemia - glucosate solutions will under no circumstance be used to rebuild
volemia - for hypoglycemic patients this will be corrected afterwards,
possibly through a different vein - the use of antibiotics and bicarbonate should be reserved for
special cases, not routinely
PREVENTION
*Promotion of exclusive breastfeeding
*Improved complementary feeding practices
*Rotavirus immunisation
*Improved water and sanitary facilities and promotion of personal and domestic hygiene
*Improved case management of diarrhea
