acute gastroenteritis in chİldren prof. dr. tufan kutlu
TRANSCRIPT
ACUTE GASTROENTERITIS IN CHİLDREN
Prof. Dr. Tufan KUTLU
• Each day,the adult human gut handles 7 liters of endogenous secretions (salivary, gastric, biliary, pancreatic, intestinal) and 2 liters of ingested fluids. Of this large volume, 3 to 5 liters are absorbed by the jejunum, 2 to 4 liters by the ileum, and 1 to 2 liters by the colon. Only 100 to 200 ml are lost in the stools.
• Diarrhea– Increase in the number of stools
or a decrease in their consistency
Acute gastroenteritis
• In Europe the incidence of diarrea ranges from 0.5 to 1.9 episodes per child per year in children up to 3 years of age
• In low and middle income countries the incidence of acute diarrhea has declined from 3.4 episodes/child/year in 1990 to 2.9 episodes/child/year 2010
Causes of acute gastroenteritis in children
• Bacteria
• Viruses
• Parasites
Bacteria causing diarrhea
• Vibrio sp• Escherichia coli• Salmonella sp• Campylobacter sp• Clostridium difficile• Clostridium perfringens• Bacillus cereus• Staphylococcus aureus• Yersinia enterocolitica
• Aeoromonas hydrophila• Klebsiella sp• Enterobacter sp• Proteus sp• Citrobacter sp• Edwardsiella tarda• Pseudomonas aeroginosa• Plesiomonas shigelloides..
Viral agents causing diarrhea
• Reoviridae: rotavirus, astrovirus
• Parvo-like viruses: Norwalk virus
• Picornavirus: calicivirus, adenovirus, coronavirus
Parasites causing diarrhea
• Giardia lamblia
• Cryptosporidium
• Entamoeba histolytica
• Isospora belli
• Cyclospora sp
• Blastocystis hominis
• Microsporidium
Patophysiology of infectious diarrhea• Invasion and destruction of the villous intestinal
epithelial cells: Shigella dysenteria, E. coli (EIEC), Yersinia enterocolitica, Campylobacter jejuni, Entamoeba histolytica, Salmonella, rotavirus
• Enterotoxin production: Vibrio cholera, E. Coli (ETEC), Shigella dysenteria, Campylobacter jejuni, Clostridium difficile, Yersinia enterocolitica, Salmonella, Staphylococcus aureus, Bacillus cereus, Clostridium perfringens
• Adherence to enterocytes: E. coli• Invasion of the lamina propria: Salmonella
Diagnosis
• Vomiting, profuse watery diarrhea (non blood, non mucus): secretory diarrhea– Bacteria: Vibrio cholera, E. coli (ETEC), S. aureus,
B. cereus, C. perfringens– Viruses: Rotavirus, Norwalk virus– Parasites: Giardia lamblia, Cryptosporidium
Diagnosis
• Fever, abdominal pain, tenesmus: inflammatory colitis, ileitis– Bacteria: Shigella, Yersinia, C. difficile– Parasite: Entamoeba histolytica
Diagnosis
• Bloody diarrhea– Bacteria: Shigella, E. Coli (EIEC), Yersinia, C. jejuni,
C. difficile, Salmonella– Parasite: Entamoeba histolytica
• Fever and abdominal pain like acute appendicitis: Yersinia enterocolitica
Diagnosis
• Recent exposure to antibiotics: Clostridium difficile
• Many cases affected simultaneously: S. Aureus, C. perfringens
• Immunodeficiency, malnutrition: Salmonella, Rotavirus, Isospora, Cryptosporidium, Candida
Diagnosis
• Stool examination– Presence of erithrocytes and leucocytes: Shigella, E.
coli (EIEC, EHEC), Campylobacter,Yersinia, Clostridium
– Presence of erithrocytes: Entamoeba histolytica
Diagnosis
• Stool examination– Microscopic: Parasites (entamoeba, giardia..)– Antigens: Entamoeba, Giardia, Rotavirus, Adenovirus– Culture ?
Viral gastroenteritis• Diarrheal diseases caused by viral agents occurs for
more frequently than does similar disease of bacterial origin
• Rotavirus is responsible for 20 to 70 % of hospitalization for diarrhea among children worldwide
• Transmission is primarly from person to person
• Most commonly in children between 6 and 24 months of age
Viral gastroenteritis
• Clinical manifestations– Incubation period: 48-72 hours– Sudden onset of diarrhea and vomiting– Diarrhea is watery, rarely bloody, 2-8 days– Fever– Respiratory symptoms
Viral gastroenteritis
• Diagnosis– Rota/adenovirus antigen in stools
• Treatment– Continue with unrestricted oral feeding– Dehydration
• Mild/moderate: oral rehydration treatment
• Severe: intravenous fluid
Shigella dysenteriae (flexneri, boydii, sonnei) • Clinical manifestations
– Fever, malaise– Watery diarrhea, blood and mucus– Cramping abdominal pain– Seizures– Arthritis– Purulent keratitis– Hemolytic-uremic syndrome
Shigella dysenteriae
• Treatment– Trimethoprim-sulfometoxazole, ampicillin, nalidixic
acid, ceftriaxone– Antimicrobial treatment is recommended to
• shorten the course of the disease
• decrease the period of excretion of the organisms
• decrease the secondary attack
Yersinia enterocolitica (pseudotuberculosis, pestis)• Clinical manifestations
– Fever– Abdominal pain– Diarrhea– Pseudoappendicular syndrome– Erythema nodosum– Reactive arthropathy
• Campylobacter jejuni– C. jejuni is a significant cause of diarrhea in children
jounger than 2 years of age.– Treatment: erythromicin
• Clostridium difficile– Antibiotic associated diarrhea– Treatment: metronidazole, vancomicin, probiotics
Cholera
• Clinical manifestations– Vomiting– Profuse vatery diarrhea (rice-vater appearence)
• Treatment– Rehydration (ORT, IV)– Antibiotics: Tetracycline, furazolidone, ampicillin,
chloramphenicol, trimethoprim-sulfometoxazole
Salmonella enteridis, cholerasuis, typhi
• 1. Acute gastroenteritis
• 2. Focal non intestinal infection
• 3. Bacteremia
• 4. Asymptomatic carrier state
• 5. Enteric fever
Salmonella• Salmonella is spread with cotaminated water,
foods (meat, eggs, milk)
• Clinical manifestations– Incubation periode 12-72 hours– Fever, watery diarrhea, blood and/or mucus
• Treatment– Patients at high risk (immunocompromized patients,
hematologic disease, artificial inplants, severe colitis)– Ampicillin, chloramphenicol, trimethoprim-
sulfometoxazole, cephalosporins
Escherichia coli
• Enteropathogenic
• Enterotoxigenic
• Enteroinvasive
• Enterohemorragic
• Enteroaggregative and diffuse-adherant
Traditional treatment of diarrheaTreatment Disadvantages
Intravenous rehydration
Diet
Antibiotic and antidiarrheal drugs
HospitalizationIncreased risk of infectionUnnecesssary laboratory investigationsEmotional traumaIncreased cost
Weight lossRisk of malnutrition
IneffectiveToxicAllergicRisk of secondary infections
Treatment of acute gastroenteritis
• Treatment of a child with moderate dehydration in hospital (USA)– ORT: 11 hours and 270 USD– IV : 103 hours and 2300 USD
Treatment of acute gastroenteritis• Rehydration: IV, ORT
• Nutrition
• Medical– Antibiotics: bloody diarrhea, infants <3-6 months– Antisecretory drugs
• Racecadotril
– Adsorbant drugs• Smectite
– Anti motility agents– Zinc– Probiotics
Assessment of dehydration in children
Non Moderate Severe
General appearance
Eyes
Tears
Mucous membranes
Thirst
Skin elasticity
Treatment
Good
Normal
Present
Moist
Absent
Pinc retracts immediately
At home
İrritable
Sunken
Absent to reduced
Dry
Present
Pinc retracts slowly
ORS
Lethargic, hipotonic or comatose
Grossly sunken
Absent
Very dry
Can’t drink
Pinc retracts very slowly
IV
Treatment of diarrhea
• Protective factors– Human milk: IgA, lactoferrin,
leucocytes, antiviral factors, bifidobacteries
– Gastric acid– Secretory IgA– Intestinal motility
Zinc for diarrhea
• Twenty four trials , 9128 children – Zinc is clearly of benefit in children aged six months
or more.– Children aged less than six months showed no benefit
with zinc. – Vomiting was more common in zinc-treated children
with acute diarrhoea
• Lazzerini M, Ronfani L. Oral zinc supplementation for treating diarrhea in children. Cochrane Database of Systematic Reviews 2012
Treatment of acute gastroenteritis
• Rehydration– ORT > 90 %– IV < 10 %
• Continue with unrestricted oral feeding
• Antibiotic when necessary (age<3-6 months, dysenteria, cholera..)
• Do not use antidiarrheal agents
WHO-ORS
• Should contain carbohydrate (glucose) and sodium (glucose/sodium: between 1/1 and 2/1)– Glucose: 74-111 mmol/L (rice-flour: 50 g/L)– Sodium
• Rehydration: 60-90 mmol/L
• Maintenance: 40-60 mmol/L
• Osmolarity < 290 mOsm/L
• Potassium: 20 mmol/L
• Bicarbonate: 30 mmol/L (or citrate: 10 mmol/L)
Composition of the ORS recommended by WHO
g/L Mmol/L
NaCl
KCl
Citrate(Bicarbonate)
Glucose(Rice-flour)
3.5
1.5
2.9(2.5)
20(50)
NaKCl
Citrate(Bicarbonate)
Glucose
902080
1030
110
Electrolyte losses in diarrheal disease (mmol/L)
Na K Cl HCO3 Glucose
Normal stoolsCholera Adult ChildEnteritis ChildORS
5
140101
5690
10-12
1327
2520
2-3
10492
5580
3
4432
1430
111
Comparison of some fluids used for rehydration
Fluid CHOmmol/L
Nammol/L
CHO/Na Kmmol/L
Basemmol/L
OsmolaritymOsm/L
ColaApple juiceChicken soupWHO-ORSPedialyteRehydralyteOsmosal
700690
0111140140144
23
25090457560
350230
01.23.11.92.4
0.1328.220202020
1300
10101010
750730500311250310304
Treatment of diarrhea at home
• Recommended foods– Water, soup (rice), yoghurt, fruit juice…– <6 months: breast-feeding, formula
• Recommended amount of fluids– After every watery stools
• <2 ages: 50-100 ml
• >2 ages: 100-200 ml
Treatment of diarrhea at home
• To prevent malnutrition– Don’t stop breast feeding or
formula feeding– Don’t dilute formula or milk– Older children: give rice cereal,
bananas, fruit juices, potatoes, yoghurt, good cooked meat, fish…
ORS treatment at home
Age Amount of ORS after every watery stools
<2
2-10
>10
50-100 ml
100-200 ml
Not limited
ORS treatment
Mild Moderate Severe*
RehydrationDuration
Maintenance*Duration
50 ml/kg4-6 hours
100 ml/kg18-20 hours
100 ml/kg4-6 hours
100 ml/kg18-20 hours
100-150 ml/kg4-6 hours
100 ml/kg18-20 hours
Probiotics for acute gastroenteritis
• Lactobacillus GG administered in oral rehydration solution to children with acute diarrhea: a multicenter European trial.
Guandalini et al. J Pediatr Gastroenterol Nutr 2000
Rice-based ORS
• Cheaper
• Better taste
• Hypoosmolar (280 mOsm/L)
• Prevent vomiting
• Decrease frequency and duration of diarrhea
• More nutritive
• Traditional
Contraindication of ORS use
• Shock, stupor, coma
• Severe electrolyte imbalence and dehydration
• Severe and repeated vomiting
• Acidosis
• Oliguria or anuria
• Abdominal distention, ileus
• Glucose-galactose malabsorption