DIARRHOEA

IN PEDIATRICS

ATAN BAAS SINUHAJI

1

ATAN BAAS SINUHAJI

SUB DIVISION OF PEDIATRICS GASTROENTERO-HEPATOLOGY

DEPARTMENT OF CHILDHEALTH

SCHOOL OF MEDICINE,UNIVERSITY OF SUMATERA UTARA

ADAM MALIK HOSPITAL MEDAN

DIARRHOEA

VOLUME OF WATER

IN THE STOOLS

2

IN THE STOOLS

LOOSE WATERY

STOOL

WATER 75-80 %

3

STOOL

NON WATER

Difference of only 10 % in hydration marked change

in stool consistency

WATER

HYPERSECRETION

4

WATER

MALABSORPTION

•MALDIGESTION

•HYPEROSMOLAR

•PERISTALSIS

•AREA FOR

ABSORPTION

DIARRHOEA

- FREQ. ≥ 3X / DAY

- CHANGING OF CONSISTENCY

- WITH/ WITHOUT VOMITING

- WITH/ WITHOUT BLOODY STOOL

5

ACUTE WATERY

DIARRHOEADYSENTERY

FORM

PERSISTENT

< 14 DAYS BLOODY

DIARRHOEA > 14 DAYS

SEVERE

MALNUTRITION

BABIES FED ONLY BREAST MILK OFTEN

FREQUENT PASSING OF FORMED STOOLS

( 5-6 x / DAY ) ( 5-6 x / DAY )

THIS ALSO NOT DIARRHOEATHIS ALSO NOT DIARRHOEA

INFLAMMATION

INFECTION - VIRAL

- FUNGAL

- BAKTERIA

- PARASITE

- ALLERGYDIARRHOEA

NONINFLAMMATION

NON INFECTION - ALLERGY

- etc

- HORMONAL

- ANATOMICAL

- etc

VIRAL DIARRHOEA

1. ROTAVIRUS ���� 6 MONTHS TO 2.5 YEARS

2. NORWALK VIRUS

3. ENTERIC ADENOVIRUS

4. ASTROVIRUS

5. CALICI VIRUS

8

5. CALICI VIRUS

6. CORONA VIRUS

7. SMALL ROUND VIRUS

- PARVOVIRUS LIKE AGENT

- MINI ROTAVIRUS

- MINI REOVIRUS

PRACTICALY

-LIQUID STOOLS ≥ 3 X/ DAY

-WITH/ WITHOUT VOMITING

-WITH/ WITHOUT MUCOUS/

BLOOD IN THE STOOLS

9

CLASSIFICATION

1. AGE

2. ONSET

3. ETIOLOGY

4. SEVERITY

5. PATHOGENESIS

10

5. PATHOGENESIS

6. HOST DEFENCES

7. SOURCE OF INFECTION

8. EPIDEMIOLOGY

9. SITE OF PATHOLOGY

10. WHO ( 2OO5 )

1.AGE

-NEONATAL DIARRHOEA

-INFANTILE DIARRHOEA

-CHILDHOOD DIARRHOEA

2. ONSET

-ACUTE DIARRHOEA : < 7 DAYS (90-95%)

-PROLONGED DIARRHOEA: 7-14 DAYS

11

-PROLONGED DIARRHOEA: 7-14 DAYS

-CHRONIC DIARRHOEA : > 14 DAYS

3. ETIOLOGY

-INFLAMMATION : INFECTION/NON INFECTION

-NON INFLAMMATION

4. SEVERITY( WHO, 1984)

-MILD DIARRHOEA : < 1x / 2 hours or < 5cc / KgBW /hours

-SEVEREDIARRHOEA: > 1x / 2 hours or > 5 cc/KgBW/hours

5.HOST DEFENCE

-IMMUNOCOMPETENT

-IMMUNOCOMPROMISED

12

-IMMUNOCOMPROMISED

6. SOURCE OF INFECTION

-NOSOCOMIAL

-COMMUNITY

7. PATHOGENESIS

ABSORPTIVE/ SECRETORY

OSMOTIC

1. FASTING STOPS CONTINUES

2. STOOL OSM. 400 280

3. Na + 30 100

13

3. Na 30 100

4. K+ 30 40

5. (Na+K)x 2 120 280

6. SOLUTE GAP 280 0

8. EPIDEMIOLOGI

-ENDEMIC

-EPIDEMIC

-MIXED

14

9. SITE OF PATHOLOGY

-SMALL INTESTINE : CHOLERA, ETEC, ROTAVIRUS

AND G. LAMBLIA DIARRHOEA

-LARGE INTESTINE: SHIGELLOSIS, AMOEBIASIS

-BOTH : CAMPYLOBACTERIOSIS, SALMONELLOSIS

10. WHO (2005)

-ACUTE WATERY DIARRHOEA

-PERSISTENT DIARRHOEA

-DYSENTERY DIARRHOEA

-DIARRHOEA WITH SEVERE MALNUTRITION

15

MIKROORGANISMS

GASTRIC ACID

MULTIPLICATION

COLONIZATION

ADHERENT

16

- INVASION

- DAMAGE

ENTEROTOXIN

MALABSORPTIONHYPERSECRETION

HYPERPERISTALIS

DIARRHOEA

PATHOGENESIS OF ACUTE INFECTIOUS DIARRHOEA

COLONIC SALVAGE

DIAREDIARE

Cleasing effect• Pathogens

Defense

Loss of• Water and Electrolytes• Nutrients

17

Defense

Self LimitedSelf Limited

•••• Water and Electrolytes

•••• Diets

•••• Water and Electrolytes

•••• Diets

• Dehydration

• Hypoglicemia

Starvation

Malnutrition

D

I

A

R

R

WATER DEHYDRATION

BASE METABOLIC ACIDOSIS

ELEKTROLIT Na+ ==> � atau �

K+ ==> �

Ca2+ ==> �

Mg2+ ==> �

Zn ==> ACRODERMATITIS ENTEROPATHICA

ELECTROLYTES Na+ � atau �

K+ �

Ca2+ � ==> TETANY

Mg2+ � ==> TETANY

Zn � ==>ACRODERMATITIS ENTEROPATHICA

18

R

H

O

E

A

NUTRIENTS - HYPOGLYCEMIA

- STARVATION

- PCM

MUCOSAL

INJURY

- MALABSORPTION

- PROTEIN LOSING ENTEROPATHY.

- SENSITIZATION

- NEC

TETANY

HYPOCALCEMIC

HYPOMAGNESEMICTETANY HYPOMAGNESEMIC

ALKALOTIC

LOSS OF WATER VIA STOOLS

DEHYDRATION

PLASMA WATER

FEVER HEMOCONCENTRATION HYPOVOLEMIAFEVER HEMOCONCENTRATION HYPOVOLEMIA

SHOCK RBF* SYMPATH. DISCHARGE

- HEART RATE

- VASOCONSTRICTION

COMA ARF**

* Renal Blood Flow

** Acute Renal Failure

SIGNS OF DEHYDRATION

1. LETHARGICS TO

COMATOSE

2. SHUNKEN

ANTERIOR

7. HYPOTENSION

8. WEAKNESS OF

RADIAL PULSE

9. OLIGURIA/ANURIA

21

ANTERIOR

FONTANELLA

3. SHUNKEN EYES

4. ABSENT OF

TEARS

5. DRY OF MOUTH

AND TONGUE

6. TACHYCARDIA

9. OLIGURIA/ANURIA

10.TURGOR

11. COOL MOIST

EXTREMITES

12. BW

DEHYDRATION

VOLUME PLASMA SODIUM

-SOME DEHYDRATION

= 5 - 10 % BB

-SEVERE DEHYDRATION

= > 10% BB

• ISONATREMIA

= 135 - 150 mEq/L

• HYPO/HYPER

NATREMIA

THE OBJECTIVE OF TREATMENT ACUTE DIARRHOEA

DEHYDRATION PROTEIN CALORI MALNUTRITION

PREVENTION TREATMENT

DURATION,

SEVERITY,

EPISODES

23WATER & ELECTROLYTES FEEDING ZINC

A NEW EPISODE OF DIARRHOEA

24

DIARRHOEA OCCUR AFTER TWO FULL DAYS

WITHOUT DIARRHOEA

MANAGEMENT

ASSESSMENT TREATMENT

1. Degree of 1. Water & elektrolytes

25

1. Degree of

Dehydration

2. Associated :

• Malnutrition

• Pneumonia

• etc

1. Water & elektrolytes

2. Diets

3. Drugs

- Zinc

- anti microbial

- Symptomatic

- antidiarrhoeal

NO SIGN OF NO SIGN OF

DEHYDRATIONDEHYDRATION

SOME SOME

DEHYDRATIONDEHYDRATION

SEVERE SEVERE

DEHYDRATIONDEHYDRATION

CONDITION CONDITION WELL, ALERTWELL, ALERT RESTLESS / RESTLESS /

IRRITABLEIRRITABLE

LETHARGIC, LETHARGIC,

FLOPPY, COMAFLOPPY, COMA

EYESEYES NORMALNORMAL SUNKENSUNKEN SUNKENSUNKEN

DEGREE OF DEHYDRATION (WHO,2005)

THIRSTTHIRST NORMALLY, NOT NORMALLY, NOT

THIRSTYTHIRSTY

THIRSTY, DRINK THIRSTY, DRINK

EAGERLYEAGERLY

DRINKS POORLYDRINKS POORLY

SKIN TURGOR SKIN TURGOR QUICKLYQUICKLY SLOWLYSLOWLY VERY SLOWLYVERY SLOWLY

NB : 1. READING FROM RIGHT TO LEFT

2. CONSIDERED SEVERE OR SOME DEHYDRATION

IF TWO OR MORE OF THE SIGN ARE PRESENT

FLUIDS TREATMENT

REHYDRATION MAINTENANCE

INITIAL REPLETION NORMAL ABNORMAL

27

INITIAL REPLETION NORMAL

HOLLIDAY –

SEGAR

CHOLERA

COT

ABNORMAL+

HOLLIDAY - SEGAR≤ 10 kg 100 mL / kg

10 - 20 kg 1000 mL + 50 mL/ kg

for each > 10 kg

> 20 kg 1500 mL + 20 mL/ kg> 20 kg 1500 mL + 20 mL/ kg

for each > 20 kg

NB : 100 mL ≡ 2,5 mEq Na+

≡ 2 mEq K+

≡ 100 calori

REHYDRATION

ORAL I.V.

29

ORS*

( ORALIT@)

• RINGER’S LACTAT

• RINGER’S ACETATE

* Oral Rehydration Salts

PREVIOUS STANDART WHO ORAL

REHYDRATION SALTS (ORS)

1.ISOTONIC

2.Na+ equivalent with plasma (90 mEq/l)

3. GLUCOSE = 2 - 3%

30

3. GLUCOSE = 2 - 3%

4. K+ ( higher than plasma →→→→ 20 mEq/l )

5. BASE = 30 - 48 mEq/L

Na+

2K+ENTEROCYTES

LUMEN• CHO

• Peptide

• Amino Acid

Na+

water

31

LAMINA

PROPRIA

BASEMENT

MEMBRANE

3Na+

BLOOD VESSELS

MECHANISM OF ACTION ORS

ORAL REHYDRATION SALTS (WHO)

PREVIOUS

(mmol/L)

NEW

(mmol/L)

Na 90 75

32

Na 90 75

K 20 20

Cl 80 65

Citrat 10 10

Glukose 111 75

311 245

NEW (LOW OSMOLARITY) WHO

ORAL REHYDRATION SALTS

§§ STOOL OUTPUT STOOL OUTPUT ↓↓↓↓↓↓↓↓↓↓↓↓↓↓↓↓ = 20%= 20%

§§ VOMITING VOMITING ↓↓↓↓↓↓↓↓↓↓↓↓↓↓↓↓ = 30%= 30%§§ VOMITING VOMITING ↓↓↓↓↓↓↓↓↓↓↓↓↓↓↓↓ = 30%= 30%

§§ THE NEED FOR SUPPLEMENTAL I.V THE NEED FOR SUPPLEMENTAL I.V

FLUID FLUID ↓↓↓↓↓↓↓↓↓↓↓↓↓↓↓↓ = 33%= 33%

BOWEL LUMEN BLOOD VESSELS

SUGAR SOLUTION

SALT SOLUTION

ORS SOLUTION

DIARRHOEA

RESOMAL(REHYDRATION SOLUTION FOR MALNUTRITION

=Dissolve 1 “new ORS “ packed into 2 L of clean water

=Add 45 mL of KCl solution ( from stock solution containing

100 g KCl/L)

=Add and dissolve50 g sucrose

35

Na= 37,5 mEq/L

K=40 mEq/L

Sugar= 25 g/L

INDICATION OF I.V FLUIDS

1. SEVERE DEHYDRATION

WITH/WITHOUT SHOCK

2. SEVERE DIARRHOEA

3. INTAKE BY MOUTH↓↓↓↓↓↓↓↓

4. GLUCOSE MALABSORPTION

36

4. GLUCOSE MALABSORPTION

5. ABDOMINAL DISTENTION /

PARALYTIC OBSTRUCTION

6. OLIGURIA / ANURIA FOR

SEVERAL HOURS

DEHYDRATION

NO SIGN OF SOME SEVERE

> 10%< 5% 5 - 10% > 10%

A B C

A. NO SIGN OF DEHYDRATION

1. ORALIT

• < 2 years = 50 - 100 mL / x loose stool

• 2 – 10 years = 100 - 200 mL/ x loose stool

• older children : as much fluid as they want

2. GIVE THE CHILD MORE FLUIDS AND FOOD

38

2. GIVE THE CHILD MORE FLUIDS AND FOOD

THAN USUAL

TO PREVENT DEHYDRATION & MALNUTRITION

3. ZINC 10 – 20 mg/day…10 - 14 days

B. SOME DEHYDRATION

ORALIT →→→→ 75 mL/kg BW /3 a 4 hours

39

INDICATION

• Ringer’s Lactate

• Ringer’s Acetate

C. SEVERE DEHYDRATION

100mL/ kgBW/3-6 hours

• < 1 years���� * initial = 30 CC/kgBW/1 hours

* repletion= 70 cc/kgBW/5 hours

40

* repletion= 70 cc/kgBW/5 hours

• > 1 years →→→→ * initial = 30 cc/kgBW/ ½ hours

* repletion = 70 cc/kgBW/2½ hours

ORALIT

• PREVENTION

• TREATMENT

41

• TREATMENT

• MAINTENANCE

DEHYDRATION DIARRHOEA

DIARHOEA

REHYDRATION

ANURIA/OLIGURIA ADEQUATE

URINE *

42

RENAL

FAILURE

PHYSIOLOGIC

OLIGURIANO PROBLEM

FLUIDS ↓↓↓↓ FLUIDS ↑↑↑↑↑↑↑↑

NB : 1. * 1 cc / kg BB / jam

2. Oliguria : < 400 cc / m2 / hari

Renal

Failure

Physiologic

Oliguria

Lasix diuresis (-) diuresis (+)

Laboratorium

� Urine osmolality

(mOsm/kgH O)

<350 >500

43

Fractionalexcretionof Na+

%100plasma urin/Cr. .Cr

plasmaurin/Na Na×=

++

(mOsm/kgH2O)

� Na+ urin (mEq/l) > 40 <20

� Fr. excr of Na+ >1% <1%

FEEDING

AFTER REHYDRATION

NO RETURN OR WORSENING

OF DIARRHOEA

TOLERANCE TEST

44

TOLERANCE TEST

● BREASTMILK

● SUB BAGIAN GE BIKA FKUSU: FORMULA MILK���� STOPPED

● ≥ 4-6 MONTHS OF AGE : BREAST MILK + OTHER FOODS

● PROBLEM: < 4 MONTHS OF AGE WHO ARE NOT

BREASTFED

●MTBS : FORMULA MILK(-)

●WHO ( 2005 ) : FORMULA MILK ����CONTINUED

45

BUKU MANAJEMEN TERPADU BALITA SAKIT (MTBS) WHO

ANTIMICROBIAL

Acute Diarrhoea

(WHO)

46

1. Cholera

2. Shigellosis

3. Amoebiasis

4. Giardiasis

ANTIMICROBIAL (WHO)

1. CHOLERA TETRACYCLIN 12,5 mg/Kg BW - 4 x a day

3 days

2. SHIGELLA DYSENTERI 5 mg TMP + 25 mg SMX/Kg BW - 2 x a day

5 days

47

5 days

3. AMOEBIASIS METRONIDAZOLE 10mg/Kg BW - 3 x a day

5 days

4. GIARDIASIS METRONIDAZOLE 5 mg / Kg BW - 3 x a day

5 days

SIDE EFFECT OF ANTIMICROBIAL

1. CHANGING OF INTESTINAL FLORA

2. OVERGROWTH:

- MONILIA

- ENTEROCOCCUS

- ANAEROB

48

- ANAEROB

- PSEUDOMONAS

3. MUCOSAL INJURY

4. IRRITATION

5. PSEUDOMEMBRANOUS ENTEROCOLITIS

6. BLOOD DYSCRASIA

7. VOMITING

ANTIDIARRHOEAL(United States F.D.A)

A drug that can be shown by objective

measurement to treat or control the symptoms

49

1. Bowel Movement

2. Stool Consistency

3. Cramps

of diarrhea

1.UNABSORBED

ANTIMICROBIAL :

-Streptomycin

-Neomysin

-Hydroxyquinoline

-Unabsorbed Sulfa

3. ADSORBENT :

-Kaolin/pektin

-Charcoal

-Atapulgit / smectite

4. ANTISECROTORY:

Antidiarrheal

50

-Unabsorbed Sulfa

2. ANTIMOTILITY :

-- Loperamide

-- Diphenoxylate

4. ANTISECROTORY:

- Salicylate Acid

- Chlorpromazine

5. TRIAL :

-Lactobacillus

-Fructooligosaccharide

NB : Gol 1 s/d 4 →→→→ NO RECOMMENDED

KAOLIN

1. Stimulate viral-tissue penetration

2. No benefit in improving stools consistency

3. Suppress the effect of antibiotics

4. Cosmetic effect

5. Malabsorption

IODOHIDROXY QUINOLINE

1. No benefit

2. In Japan � Subacute Myelo Optic Neuropathy

OPIATES & SPASMOLYTICA

1. INCREASE DURATION OF FEVER

2. PROLONG PASSAGE OF PATHOGENS

3. DECREASE OF BOWEL PEWRISTALSIS

52

4. INCREASE THE DURATION OF

PROLIFERATION,TOXIN PRODUCTION

AND INVASIVE BY MICROORGANISMS

5. GUT PARALYSIS

DIARRHOEA

DEHYDRATION COMPLICATION

REHYDRATION - ELECTROLYTES

IMBALANCE

-RINGER’S LACTATE

-RINGER’S ACETATE

-ORS

IMBALANCE

- METABOLIC ACIDOSIS

- FEVER

- CONVULTION

- HYPOGLICEMIA

ELECTROLYTES - ACID BASE

INITIAL REHYDRATION

DIAGNOSIS TREATMENT

ELECTROLYTES – ACID BASE

INITIAL

ISONATREMIA

DEHYDRATION

REHYDRATION

HYPONATREMIA

DEHYDRATION

DILUTIONAL

DIARRHOEA

METABOLIC ACIDOSIS

ANION GAP

56

NORMAL

LOSS OF HCO3-

INCREASED

• STARVATION

• RENAL

HYPOPERFUSION

• TISSUE HYPOXIA

• SALICYLATE

INTOXICATION

• INBORN ERROR

ANION GAP = Na+ - (Cl + HCO3-)

57

NORMAL = 8 – 16 mEq/L

METABOLIC ACIDOSIS

1.NAUSEA, VOMITING & ANOREXIA2.DEPRESSION OF CNS (COMA,

CONVULSION)

3.ARTERIAL DILATATION → HYPOTENSION4.CARDIAC CONTRACTILITY ↓↓4.CARDIAC CONTRACTILITY ↓↓5.HEART FAILURE6.VENTRICULAR FIBRILLATION

7.O2 AFFINITY OF Hb ↓ → ANOXIA8.KUSSMAUL BREATHING → HYPO-

CARBIA → vasoconstriction → Cerebral Blood Flow ↓↓ → drowsiness

REHYDRATION

pH , HCO3- , pCO2

DEHYDRATION + METABOLIC ACIDOSIS

pCO2 (calculated) = (1.54 X HCO3-) + 8.36 + 1.11

59

pH < 7.2 ATAU HCO3- < 10 mEq/L

HCO3- = 1-2 mEq/Kg BB

- LUNG DYSFUNCTION (-)

- HYPOKALEMIA (-)

APPOPRIATE NO APPROPRIATE

METABOLIC ACIDOSIS

NO APPROPRIATE

pCO2 (c) > pCO2 (lab) pCO2 (c) < pCO2 (lab)

60

METABOLIC ACIDOSIS

+

RESPIRATORY ALKALOSIS

METABOLIC ACIDOSIS

+

RESPIRATORY ACIDOSIS

OVERSHOOT METABOLIC ALKALOSIS PARADOXAL ACIDOSIS

HCO3-

DOSAGE OF HCO3- ( mεεεεg)

HCO3- = (HCO3

-desired - HCO3

-actual) X 0,3 X BB(kg)

HCO3- d ?

HCO3- d

H2CO3

20

HCO3- d 20 x 0,03 pCO2 = 0,6 pCO2 ……..(1)=

=

61

HCO3 d 20 x 0,03 pCO2 = 0,6 pCO2 ……..(1)

pCO2 ( 1,54 X HCO3-a ) + 8,36 ± 1,11 ……(2)

HCO3-a

pCO2 - 8,36

1,54± (O.6 pCO2 - 5)

HCO3-

=

= ± 1,5 m εεεεg/kgBB

= 1 - 2 m εεεεg/kgBB

=

=

=

0,6 pCO2 - ( 0,6 pCO2 - 5) X 0,3 BB(KG)

BICARBONATE

1.SLOW INFUSION � TO PREVENT :1.SLOW INFUSION � TO PREVENT :

=OVERSHOOT METABOLIC ALKALOSIS

=ACIDOSIS INTRACELLULER

2.HYPOKALEMIA�RESPIRATORY PARALYSIS

3.LUNG DYSFUNTION �PARADOXAL ACIDOSIS

4.CIRCULATORY INSUFFICIENCY

NaHCO3

I.V. ADMINISTRATION

SERUM : HCO3- + H +

CORRECTION OF

ACIDOSIS

DECREASING

RESPIRATORY

DRIVE

H2O + CO2

63

BLOOD BRAIN BARRIER

BRAIN : HCO3- + H+

SLOW

H2O + CO2

RAPID

CEREBRAL ACIDOSIS

AND DEPRESSION

MECHANISM OF PARADOXAL ACIDOSISMECHANISM OF PARADOXAL ACIDOSIS

vasodilatation ⇒⇒⇒⇒ ICP↗↗↗↗↗↗↗↗

acidosis intracellulerHypercarbia

64

anoxia

acidosis intracellulerHypercarbia

BICARBONAT

1 mEq/kgBB/X

DILUTES : 5-6 X 1 HOUR

TO PREVENT

65

TO PREVENT

INTRACRANIAL • OVERSHOOT

BLOOD VESSEL METAB.ALKALOSIS

RUPTURE • ACIDOSIS

INTRACELLULARE

REHYDRATION

HYPERNATREMIA

DEHYDRATION + HYPERNATREMIA

HYPERNATREMIA

( > 150 mEq/l)

- IVFD STOPPED

- PLAIN WATER

REHYDRATION

HYPONATREMIA

( < 135 mEq/L)

DEHYDRATION + HYPONATREMIA

Sympt

HypoNa

After

Rehydration

Asympt

HypoNa

NaCl 3% Fluid RestrictionRL

Na+(mEq) = (135 – Na+ plasma) x 0,6 x BW (kg)

REHYDRATION

HYPOKALEMIA

Diarrhoea (+) Diarrhoea↓↓

HYPERKALEMIA

Renal Function

DEHYDRATION HYPO/ HYPERKALEMIA

Diarrhoea (+) Diarrhoea↓↓

ECGRL

N abN

K+ oral K+ drip (upto 3 mEq / kgBW / day)

Acute Renal Failure

Fluids

Restriction

FEVER

TEMPERATURE DOWN

COOLING DRUGS

- Unclothed- Unclothed

- Wipe of sweat

- Fanning

- Tepid sponging

1. Paracetamol :

30 mg/Kg/day - 3 doses

2. - Acetyl Salicylic Acid

- Mefenamic Acid

No recommended

CONVULSION

Diazepam: 1 mg/Kg/day

3 - 4 doses iv/per rectal

Hypoglicemia (<50 mg%)

Coma

Dextr. 10% IV � 5 mL /Kg BW

within 5 minutes

Alert

V. CHOLERAE

O1 Non O1

(Non Agglutinable)- Biotip - Eltor

- Classic

71

- Serotip - Ogawa

- Inaba

- Hikojima O2 - 138

O140 - 142

O139

“Bengal Strain”

ENTEROTOXIN

Absorption of Na+

in Villous Cells are intact

Surface Receptor

Adenyl Cyclase

Secretion of Cl-

in Crypt Cells

C - AMP

VilliBowel Lumen

Absorption

Secretion

Crypt

Secretion

V. CHOLERAE

JEJUNUM

- COPIOUS DIARRHOEA

- FISHY RICE WATER STOOLS- FISHY RICE WATER STOOLS

- FEVER (-)

- ABDOMINAL PAIN (-)

- RAPID DEHYDRATION & SHOCK

- BIOCHEMICAL (+)

- HISTOLOGY (-)

V. CHOLERAE

JEJUNUM

- COPIOUS DIARRHOEA

- FISHY RICE WATER STOOLS- FISHY RICE WATER STOOLS

- FEVER (-)

- ABDOMINAL PAIN (-)

- RAPID DEHYDRATION & SHOCK

- BIOCHEMICAL (+)

- HISTOLOGY (-)

DIAGNOSIS

- CLINIC

CHILDREN > 2 YEARS

SEVERE DEHYDRATION

THE OTHER CHILDREN (+)

- LAB

DARK FIELD MICROSCOPE

CULTURE

DIAGNOSIS

- CLINIC

CHILDREN > 2 YEARS

SEVERE DEHYDRATION

THE OTHER CHILDREN (+)

- LAB

DARK FIELD MICROSCOPE

CULTURE

Th Water & Electrolytes → Ringer’s

Lactate I.V.

Rehydration & Maintenance

Fecal Sodium

( 88 – 101 mEq/ L)

FEEDING

ANTIMICROBIAL → Tetracycline or

Doxycycline

( 88 – 101 mEq/ L)

DYSENTERY SINDROME = BLOODY DIARRHOEA

1. DYSENTERY

- BACILLARY

- AMOEBIC

2. Enterocolitis

- Cows milk allergy

3. Trichuriasis

4. Others - Entero invasive E coli

- C. jejuni

BACILLARY DYSENTERY

= SHIGELLOSIS

S. DYSENTERIAE

S. FLEXNERI

COLON

S. FLEXNERI

S. BOYDII

S. SONNEI

SHIGELLA

INVASIVE SHIGA TOXIN

INHIBITION OF

PROTEIN SYNTHESIS

CYTOTOXIC

SHIGELLA

- WATERY DIARRHOEA

- BLOODY DIARRHOEA

- TENESMUS

- ABDOMINAL PAIN

- URGENCY

- FEVER

- CONVULSION

- SEPTIC

- HEMOLYTIC UREMIC

SYNDROME- URGENCY SYNDROME

- TOXIC MEGA COLON

- RECTAL PROLAPS

Th

1. WATER & ELECTROLYTES

2. FEEDING

3. - SELF LIMITED

- SEVERE • TMP - SMX- SEVERE • TMP - SMX

• Cefixime:

8 mg/kg/day

2 doses

• nalidixic acid

• ampisilin

SALMONELLOSIS

• TYPHOIDAL ENTERIC FEVER :

-S. TYPHOID TYPHOID FEVER

-S. PARATYPHOID PARATYPHOID FEVER

84

• NON TYPHOIDAL : SALMONELLA

GASTROENTERITIS

INDICATION OF ANTIMICROBIAL

TREATMENT IN SALMONELLA

GASTROENTERITIS

1. ≤ 3 MONTHS OF AGE

2. OLD DEBILITATED PATIENT

3. DYSENTERY FORM ESPECIALLY 3. DYSENTERY FORM ESPECIALLY

ILLNESS > 5 DAYS

4. IMMUNOCOMPROMISED : STEROID,

MALIGNANCY

5. BACTERIAEMIA

ACUTE DIARRHOEA PERSISTENT DIARRHOEA

PROLONGED MUCOSAL INJURY

86

=MALNUTRITION

=IRON DEFICIENCY

=ANTIBIOTICS

=COW’S MILK

=INFECTION

PROLONGED MUCOSAL INJURY

MALABSORPTION OF NUTRIENT

PEMBACTERIAL OVERGROWTH

AND INFECTION

87

DECREASED

ENTERIC HORMONE

INCREASED ABSORPTION OF

NATIVE FOREIGN PROTEIN

INEFFECTIVE VILLOUS REPAIR

DEGREE OF DEHYDRATION

DEFISIT OF BW CLINIS (WHO,2005)

88

DEFISIT OF BW CLINIS (WHO,2005)

GOLD STANDART DEGREE F

DEHYDRATION

89

BW PREILLNESS( X )- BW DURING ILNESS ( Y )

X - Y

Xx 1OO %

X= 10 Kg

Y= 9,25 Kg

10-9,25

10x 100 %= 7,5 %

Fluid defisit= 10-9,25=0,75 Kg=750 cc

A.

(Some dehydration)

B. Some dehydration= 7,5 %X ?

90

B. Some dehydration= 7,5 %

BW on admission(Y)=9,25 KgX ?

C. Fact� 75 cc/Kg=75 x 9,25= 694 cc

(X-Y)100=7,5 X�92,5 X=100Y�X=100/92,5 X 9,25

=10 Kg

Fluid defisit=10-9,25 = 750 cc