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Surgery- UGIT (2) > Paeds: Chronic Diarrhoeal Disease In Children > Flashcards

Paeds: Chronic Diarrhoeal Disease In Children Flashcards

1
Q

Define diarrhea and when is it most prominent in children?

A

Diarrhea can be defined as increased frequency and and volume of stool being passed, that has a decreased consistency.
Mostly infectious and self-limiting.
- Numerous episodes seen in the first 5 years of life

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2
Q

Aside from infectious diseases, what are 3 other causes for diarrhea in children?

A
  • Inherited/acquired disorders of digestion and absorption.
    • Motility disturbances.
    • Drugs
    • Food intolerances: I.e. lactose intolerance
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3
Q

Name a few bacteria that cause diarrhea:

A 
Shigella 
Staphylococcus aureus 
Vibrio Cholera
E.Coli 
Yersinia enterocolicta 
Clostridium difficile 
Campylobacter Jejuni
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4
Q

What is acute gastroenteritis?

A

This is a GIT infection cause by bacterial, viral or paralytic infections

  • Commonly manifests as vomiting or diarrhea
  • May also be a result of food-borne illnesses
  • Associtaed with systemic features such as Abdominal pain and fever.
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5
Q

What percentage of child deaths is attributed to diarrheal diseases?

A

18%

- 50% of these diarrheal diseases being persistent/chronic diarrhea

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6
Q

Dehydration is defined as the loss of body water leading to compensatory mechanisms.
- What are these compensatory mechanism ?

A

Loss of body water leading to compensatory mechanisms:

  • Thirst
  • Anti-diuretics
  • Catecholamine release as a stress response
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7
Q

What happens if there is continued water loss in dehydration?

A

Continued water loss in will result in the failure of Compensatory mechanisms (Thirst, anti-duress and catecholamine release).
- Patient enters a state of circulatory insufficiency.

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8
Q

Name a few features dehydration:

A 
Dry mouth and dry mucosa
Reduced urine and sweat 
Reduced skin turgor
Sunken eyes and frontanel
Acidiotic breathing 
Restlessness and irritability 
Prolonged capillary filling 
Hypotension and shock, tachycardia 
Apathy to coma and convulsions
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9
Q

Name a few bacteria that cause diarrhea:

A 
Salmonella
Shigella 
Staphylococcus aureus 
Vibrio Cholera
E.Coli 
Yersinia enterocolicta 
Clostridium difficile 
Campylobacter Jejuni
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10
Q

Name a few viruses that cause diarrhea:

A 
Norovirus 
Astrovirus 
Calicivirus 
Rotavirus
Enteric Adenovirus 
CMV 
HSV 
HIV
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11
Q

Name a few parasites, specifically Protozoa that cause diarrhea:

A 
Cryptosporidium 
Entamoeba histolytica
Isospora 
Giardiasis Lamblia 
Microsporidium
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12
Q

Name a few parasites, specifically Helminths that cause diarrhea:

A

Strongyloides stercoralis
Trichurus Triichura
Schistosomiasis
Trichinella

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13
Q

Note: viral and bacterial gastric infections leading to pediatric diarrhea do not present the same.
How does a viral infection clinically present itself?

A

Example given: Rotavirus

  • Typically seen in winter months.
  • Seen in babies that are between 6 and 24 months.
  • There are preceding respiratory symptoms.
  • Profuse vomiting is seen before the onset of diarrhea.
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14
Q

Note: viral and bacterial gastric infections leading to pediatric diarrhea do not present the same.
How does a bacterial infection clinically present itself?

A

Example given: Shigella

  • Typically seen in summer months.
  • Seen in babies that are younger than 6 months.
  • Abrupt onset
  • Vomiting is not seen
  • Blood and mucous are seen in stool.
  • CNS symptoms
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15
Q

What is the mechanism of infection seen in viral gastroenteritis?

A

There is small intestinal mucosa damage

  • Tips of the villi of mucosal cells are invaded.
  • Shedding.
  • Dissacharide deficiency is seen (Dec. in carb digestion)
  • Dec. in reabsorption of fluids.
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16
Q

What is the mechanism of infection seen in bacterial gastroenteritis?

A

Adherence to small intestine mucosa, causing damage
Two types of toxins are produced: Enterotoxins and cytotoxins.

Enterotoxin production:- Toxigenic E.Coli, Vibrio Cholera
- Stimulates the secretion of large amounts of fluid and electrolytes

Cytotoxin prod. :- Shigella dysentry, campylobacter, entero-invasive E.coli.
- Mucosal damage
> Deceased absorptive surface
> Secondary inflammatory response: Inc fluid secretion.

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17
Q

What’s up with vomitting in gastroenteritis?

A

There is impaired gastric emptying
Starvation ketoacidosis
- Hepatic glycogen stores are depleted
- Liver produces ketones as an energy substrate
Local irritation
Toxins stimulate chemoreceptors in the vomitting center

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18
Q

What is the process of resuscitation in children that have been hospitalized due to gastroenteritis diarrhea?

A

IV fluids are given via IV access: IV Line/ Interosseus line
Ringers
0,9% Saline solution: Isotonic fluids
20ml/kg bolus

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19
Q

Briefly list 4 complications of diarrhea:

A

Dehydration
Acidosis and electrolyte disturbance
Dysfunctional it’s of the gut.
Additional features

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20
Q

Explain the 4 complications of diarrhea:

A
  1. Dehydration
    - Shock
    - Acute Renal Failure
    - Cerebral complications (hypoxic ischemia, cerebral vascular thrombosis)
    - Shock Lung
  2. Acidosis and electrolytes disturbances
    - Sodium, Potassium, Bicarbonate, Chloride.
    - Hepatic glycogen stores are depleted
    - Liver produces ketones as an energy substrate
  3. Additional features
    - Fever
    - Convulsions
    - Protein losing enteropathy
    - Necrotizing enterocolitis
  4. Dysfunctional gut :
    • Decrease in absorption and digestion.
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21
Q

Name 4 electrolytes lost in diarrhea:

A

Sodium
Potassium:
Bicarbonate
Chloride

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22
Q

Briefly list the 3 main clinical features of electrolyte disturbances:

A

Hypokalaemia
Hyponatremia
Hypernatremia

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23
Q

How does Hypokalaemia present?

A
  • Weakness
    • Paralysis
    • Areflexia
    • Cardiac arrythmias
    • Ileus (Inability of gastric bowel to contact and remove waste.)
    • Prolonged renal tubular defects
    • Reduced concerntration ability
    • Nephritis
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24
Q

How does Hyponatraemia present?

A

Less than 125mmol/l

  • Nausea
  • Vomitting

Less than 115mmol/l
- Seizures and Coma

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25
Q

What are few causes of convulsions?

A 
Cerebral venous Thrombosis 
Fever 
Hypoglycemia 
Hyponatraemia 
Hypernatraemia 
Toxins: Shigella 
Cerebral edema, rapid infusion hypotonic fluid.
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26
Q

What is one important management procedure to remember when treating a child suffering from acute gastroenteritis and diarrhea?

A

Prevent dehydration

- Continue feeds allowing maximal digestion and absorption.

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27
Q

What advice can be given with regards to dehydration ?

A

Prevention is the best cure.
- Prevent dehydration
Replace the amount that is least in each stool.
- +/- additional 15-30kg/ml to each feed
ORS small frequent quantities, teaspoon
Once child appears stronger, more alert, is passing urine:
- Introduce smaller feeds

28
Q

How can one prepare a home-made solution?

A

8 teaspoons of salt
1/2 teaspoon of salt
1L cleanest water available.

29
Q

What advice can you give regarding feeing?

A

Maintaining nutrient intake is important in recovery:
Continue milk feeds
Select solid foods that are easily digested, bland and soft
- Starchy porridge
- Mashed banana
Small quantities as frequently as tolerated.
Aim to restore normal intake by the 2nd or 3rd day

30
Q

What is Lopermide and should it be administered to a child with gastroenteritis?

A

Lopermide is an anti-motility agent

- It is contraindicated in children and should not be administered to children.

31
Q

What are phenothiazines (what are the side effects if any) and should it be administered to a child with gastroenteritis?

A 
Phenothiazines are anti-emetics
Side effects include: 
  - Lethargy
  - Dystonia 
  - Malignant hyperpyrexia 
Because of the potentially serious Sid effects, these ani-emetics should not be administered to children
32
Q

What is the most important therapy to start?

A

Oral rehydration.

33
Q

What additional therapies can you suggest for gastric enteritis and diarrhea?

A

Ondansetron.

  • Prevent nausea and vomiting
  • Reduced need for IV fluids and hospitalization
  • Selective serotoninergic 5HTC3 receptor antagonist.
  • No sedative effect or extra-pyramidal reaction
34
Q

Acute gastric enteritis is typically self limiting.

When is antibiotic use required and which drug in specific?

A

Antibiotic therapy is used in the case of dysentery

- Ciprobay 15mg dose po x3days.

35
Q

How can acute gastroenteritis be prevented in children?

A

Improve hygiene and sanitation.
Exclusive breastfeeding for the first 6 months of life.
Prevent malnutrition through early intervention
Get the child immunized for measles and rotavirus

36
Q

What is chronic diarrhea?

A

The passage of loose stool for more than 14 days

It is most common in developing countries

37
Q

What are some “other” causes of chronic diarrhea?

A 
Inherited abnormalities of the intestinal mucosa
Motility disturbances
Protein sensitization
Anatomical abnormalities 
Immune deficiency 
Chronic inflammation disorders.
38
Q

Differentiate between persisting diarrhea and chronic diarrhea?

A 
Persistent diarrhea:
   - Between 7 and 14 days 
   - Risk factors include: 
       > Formula feeding
       > Older than 3 months 
       > Malnutrition 
       > Immune suppression
       > Associated illness

Chronic diarrhea
- 2-4 weeks without improvement.
- Persisting diarrhea is the related acute infective onset.
Risk factors include:
> Long-standing intestinal dysfunction
> Maldigestion and malnutrition

39
Q

Name 8 disorders associated with chronic diarrhea in children:

A
  1. Congenital disorders.
  2. Endocrine disorders.
  3. Enzymatic deficiencies/disorders.
  4. Pancreatic insufficiency.
  5. Metabolic abnormalities.
  6. Mucosal damage abnormalities.
  7. Immune deficiency.
  8. Anatomic abnormalities.
    Other.
40
Q

Name the 3 categories that paedriatic Chronic diarrhea can be divided into:

A
  1. Nutritional deterioration with dehydration.
  2. Nutritional deterioration without dehydration.
  3. Normal nutrition and dehydration.
41
Q

A mother brings her child that has been suffering from chronic diarrhea, to your practice. After clinical examination, it is found that the child is experiencing nutritional deterioration and dehydration.
Diagnose the following child, that also presents with:
- Chronic diarrhea from Neonatal onset

A

Congenital gut abnormalities

42
Q

A mother brings her child that has been suffering from chronic diarrhea, to your practice. After clinical examination, it is found that the child is experiencing nutritional deterioration and dehydration.
Diagnose the following child , that also presents with:
- An acute onset of Chronic diarrhea with prior normality.

A

Intestinal mucosal injury.

43
Q

A mother brings her child that has been suffering from chronic diarrhea, to your practice. After clinical examination, it is found that the child is experiencing nutritional deterioration WITHOUT dehydration.
Diagnose the following child, that also presents with:
- A maintained appetite .

A

Exocrine pancreatic abnormalities.

44
Q

A mother brings her child that has been suffering from chronic diarrhea, to your practice. After clinical examination, it is found that the child is experiencing nutritional deterioration WITHOUT dehydration.
Diagnose the following child, that also presents with:
- Anorexia.

A

Enteropathy malabsorption.

45
Q

A mother brings her child that has been suffering from chronic diarrhea, to your practice. After clinical examination, it is found that the child shows no signs of nutritional deterioration or dehydration.
Diagnose the following child, who also presents with:
- Characteristic findings .

A

Toddlers diarrhea.

46
Q

What are the risk factors of persistent dehydrating diarrhea?

A
  1. Immune deficiency
  2. Measels/ Shigella
  3. Malnutrition :- Vitamin A, Zinc
  4. Percent
  5. Environmental contamination :- Exposure to enteropathogens
47
Q

What causes post enteritis persisting diarrhea?

A
  1. Malnutrition/ HIV that fails to clear.
  2. Nosocomial infection and reinfection
  3. More than one pathogen
  4. Specific pathogens associated
    • Giardia, Cryptosporidium
48
Q

What are the 3 main category causes of persisting diarrhea?

A
  1. Small intestine bacterial overgrowth.
  2. Small intestine mucosal damage.
  3. Nutritional deterioration.
49
Q

Explain how the destruction of small intestinal mucosa could play a role in persistent diarrhea:

A
  1. Destruction of intestinal mucosal villi results in carb malabsorption.
  2. Decreased intestinal absorption surface.
  3. Osmosis of bacterial agents :-aggravates stool water loss.
  4. Absorption of foreign proteins leading to 2 immunological reactions in host
    • Further damage
50
Q

Explain how small intestinal bacterial overgrowth could play a role in persistent diarrhea:

A
  1. Damage mucosa

2. Deconjugation of bile acids

51
Q

Explain how nutritional deterioration could play a role in persistent diarrhea:

A
  1. Nutrient loss is associated with severity of diarrhea.
  2. The body can’t afford to lose too much nitrogen and energy
    • Tissue repair is important (especially enterally).
  3. Vicious cycle
    • Malnutrition -> Diarrhea -> progressive malnutrition -> worse diarrhea
52
Q

What foods should be administered for children where dissacharide deficiency is suspected?

A

Usually
- Normal cows milk based formula.
Alternatively for lactose intolerant patients
- Lactose free formula.
Monosaccharide intolerances (Glucose, fructose, sucrose intolerance)
- Semi-elemental feed (Alfare).

53
Q

What is NPO?

A

Feeding and dieting “Nothing by mouth”

54
Q

What 3 clinical signs indicate monosaccharide intolerance?

A
  1. Glucose can’t be absorbed
    • Mucosal damage
  2. Increased amount of glucose found in stool
  3. Dehydration despite adequate oral hydration

Note: NPO should be method of feeding

55
Q

What feeding scheme should be used in patients with monosaccharide intolerance and diarrhea?

A

NPO until diarrhea resolves
Slowly reintroduce semi-elemental foods (Alfare)
Continuous Alfare feeds, small amounts with a gradual increase.

Note: NPO lines pose infection risk

56
Q

What is Coeliac disease?

A

Auto-immune enteropathy triggered by gluten exposure.

This disease manifests at different ages and has a wide range of manifestations.

57
Q

Name a few clinical manifestations of Coeliac disease:

A 
Diarrhea. 
Steatorrhea. 
Constipation. 
Anorexia. 
Abdominal pain. 
Abdominal distention. 
Weight loss. 
Failure to thrive.
58
Q

Name a few atypical manifestations of Coeliac disease:

A 
Iron deficiency: Anaemia. 
Peripheral neuropathy. 
Short stature. 
Alopecia. 
Dental enamel hypoplasia.
59
Q

What is the gold standard for Coeliac disease diagnosis?

A

Intestinal biopsy.

After that step wise approach is taken: 
  - High degree clinical suspicion 
  - Serological testing. 
Screening! 
  - Symptoms 
  - Associated disease. 
All testing must be done on a gluten diet.
60
Q

Name the 3 antibodies that are Coeliac specific:

A
  1. EMA
    • Endomysial antibody
  2. anti-TG2
    • Transglutaminase 2 antibody
      3 anti-DPG
    • Deaminated gliadin-specific antibody
61
Q

Explain non-dehydrating diarrhea that presents with FTT (failure to thrive) and maintained appetite:
- Give another example of this kind of disease:

A

This disorder is due to exocrine pancreatic disorders

- Another example is Schachman syndrome

62
Q

What are the symptoms of exocrine pancreatic disorders?

What is the diagnosis method?

A

Foul smelling diarrhea.
Good/ Increased appetite.
Bloated abdomen.
Undigested food.

The most common disorder is: Cystic fibrosis.
Diagnosis: Sweat test.

63
Q 
Name 3 disorders that lead to chronic diarrhea presenting a: 
  - Non- dehydrating. 
  - Failure to thrive.
  - Maintained appetite. 
What is the method of diagnosis?
A
  1. Exocrine pancreatic disorders
  2. Schwanchan syndrome.
  3. Cystic fibrosis.

Diagnosis: Sweat test.

64
Q

What is toddlers diarrhea?

A

This is a digestive condition characterized by motility disturbances .
These children are found to have normal digestion and absorption.

65
Q

Give a few facts about toddlers diarrhea. how does it present?

A
  • Children between 6 months to 4 years old.
    • Child appears to be healthy.
    • Episodes of diarrhea that never happen at night.
    • Stool becomes progressively more loose later in the day.
    • There is familial history of bowel disturbances.
    • children experience normal growth.

Surgery- UGIT (2) (6 decks)

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