acute diarrhea

Diagnosis, treatment and prophylaxis of

acute bowel infections in children

Acute bowel infections in children: definition

Acute bowel infections (ABІ) – is a heterogenic group of acute infectious diseases of gastro-intestinal tract with peroral way of contamination, which are caused by enterothropic causative agents (viruses, bacteria, protozoa, fungi) and/or their toxins; the main presentation of which is the acute diarrhea syndrome .

Kośek M., Bulletin of the World Health Organization, 2003

Acute bowel infections in children: importance

Kośek M., Bulletin of the World Health Organization, 2003

ABI posses the leading place in pediatric morbidity worldwide, the second place after respiratory diseases;

In general, 3,2 episodes of ABI per year per one child under 5 years in developing countries and 1,3 episodes in developed countries;

Annually about 2,5 millions of children die from ABI in the world (2,1-4,7);

In developing countries it is the main cause of mortality for children under 5 years. Mean mortality is 4,9 per 1000.

Etiological structure of ABI in children

Viruses: 65%

Rotavirus A, B, C, GEnteric adenoviruses 31, 40, 41Caliciviruses (Norwalkvirus, Snow-Mountainvirus, Sapporovirus)Astrovirus, Pararotavirus, Parvovirus, Enteroviruses (68, 69), CMV


Bacteria: 27%

Salmonella spp.Shigella spp. Esherichia coli (ETEC, EHEC (O157:H7), EIEC, EPEC, EaggEC, DAEC)Campilobacter spp. Yersinia enterocoliticaListeria monocytogenesStaphylococcus aureus , Bacillus cereus Clostridium difficile , Klebsiella oxytoca Vibrio cholerae, Vibrio parahaemolyticus


Protozoa: 7%Giardia lamblia, Entamoeba hystolitica, Cryptosporidia, Cyclospora, Isospora

Fungi: 1% Candida albicans

Diarrhea syndrome

Diarrhea is the syndrome of intestine affection, which in characterized by increase of defecation number more than typical for the specific child with daily amount of stool more than 5g/kg, which contains more than 80% of fluid.

Diarrhea syndrome

By mechanism

By topics By stool character

By duration

OsmolarSecretory Invasive Dyskinetic

Enteritis Gastroenteritis Enterocolitis Colitis Gastroenterocolitis

Watery Bloody (dysentery)Mixed

Acute (< 14days)Chronic (>14 days)

Clinical and pathogenical variants of diarrhea syndrome

Diarrhea syndrome

What is not a

diarrhea

Frequent defecation but with formed stool

Semi-liquid stool at breast feeding

Stool just after feeding (in 1st year infants)

Yellow-green liquid stool on 3rd – 6th days after birth

ABI clinics depending on causeCDC,2004

Causative agent

Incubation period

Clinics

Salmonella spp. (except S.typhi, S.paratyphi )

1-3 days

Watery or mixed diarrhea, fever, abdominal pain, in infants – sepsis

Shigella spp. 1-2 days

Bloody diarrhea, abdominal pain, prominent toxicosis

ABI clinics depending on cause CDC,2004

Causative agent

Incubation period

Clinics

E.Coli

ETEC 1-3 days Watery diarrhea, colicky abdominal pain, vomiting

EHEC (O157:H7)

1-8 days Severe bloody diarrhea, subfebrile or normal fever, HUS, thrombocytopenia, children under 4 years

EPEC 1-3 days Watery diarrhea in 1st year children

EIEC 1-6 days Bloody diarrhea in any age

EAggEC 1-3 days Chronic diarrhea in infants under 6

months

ABI clinics depending on cause CDC,2004

Causative agent

Incubation period

Clinics

Campylobacter jejuni 2-5 days Watery or mixed diarrhea, fever,

cramping abdominal pain, vomiting

Yersinia spp. 1-2 days

Watery diarrhea, fever, acute abdomen, possible scarlet – like rash

Rotavirus and other viruses

1-3 days Watery diarrhea, vomiting, subfebrile fever, often – severe exicosis

Gardia lamblia 2-28 days

Watery diarrhea, meteorism, cramping gastric pain, chronic diarrhea

Intestinal dehydration

Intestinal dehydration (intestinal toxico - exicosis) is a pathological condition characterized by acute fluid loss with or without electrolyte disturbances, which develops due to vomiting and/or diarrhea. The main clinical marker of dehydratation is acute body weight loss.


indexesType of dehydration

Isotonic Hypertonic Hypotonic

Type of watery balance disturbance

General Intracellular Extracellul

ar

Na+level, mmol/l

135-150 >150 <135

Plasma osmolarity, mOsm/l

308-310 >310 <308

Frequency at ABI

85% 3-5% 8-10%


Severity of dehydration

% of body weight loss (adults/children)

Mild (І) 3% / 5%

Moderate (ІІ)

4-6% / 6-9%

Severe (ІІІ) >6% / >9%


Risk factors for dehydration development

Age less than 6 months Stool > 8 times per day Vomiting, combined with diarrhea, > 4 times per day

Clinical criteria of dehydration severity

Symptoms

Degree o dehydration

Mild (І) Moderate (ІІ) Severe (ІІІ)

Blood pressure

Normal NormalNormal or hypotension

Pulse tension

NormalNormal or decreased

Moderately decreased

HR Normal Tachycardia Tachy – or bradycardia

Skin turgor

Normal, =1sec.

Decreased,=2sec.

Decreased, >2sec.

Gross fontanel

Normal Depressed Strongly depressed


Symptoms

Degree o dehydration

Mild (І)Moderate

(ІІ)Severe (ІІІ)

Mucosa Little dry Dry Dry

Eyes Normal Depressed eye balls

Strongly depressed, tears are absent

Extremities

Warm, capillary refill is normal

Capillary refill is decreased

Cold, mottled, pale, capillary refill >2sec.


Symptoms Degree o dehydration

Mild (І) Moderate (ІІ) Severe (ІІІ)

Awareness

Normal Normal or apathy / irritation

Normal to coma

Urination =1ml/kg/y <1ml/kg/y <<1ml/kg/y

Thirst Slightly increased

Increased Strong or absent

Breezing Normal Deep (acidosis)Deep or pathological

Differential diagnosis of ABI Category Example

Other infections Pneumonia, otitis media, UTI, meningitis

Surgery Appendicitis, intestinal obstruction, short bowel syndrome

Systemic diseases

Diabetes mellitus, hyperthyroiditis, inborn adrenal hyperplasia, Addison disease, hypoparathyroiditis, immunodeficiency

Connected to antibiotics

During antibiotic treatment, pseudomembranous enterocolitis

Poisoning Botulism, pesticides, nitrites, nitrates, fungi, heavy metals salts, some medicaments, Reye syndrome

Differential diagnosis of ABICategory Example

Feeding disturbances

Food allergy, lactose intolerance, milk protein intolerance, fasting stool

Malabsorption Cystic fibrosis, celiac disease, lactase insufficiency, protein entheropathy

Inflammatory diseases of GI

Ulcerative colitis, Crone disease

Psychogenic Irritable colon syndrome

Others Constipations with hyperdefecation, Hirschsprung’s colitis, HUS

Laboratory diagnosis of ABIGoal Methods of diagnosis

Etiology discovery

Stool culture (cholera, campylobacter, yersinia)Electronic stool microscopy (viruses)Immunologic labs (RIHA, IFA, latex-agglutination, ELISA)PCR Stool for parasites and protozoa

General clinical

CBCUrinalysis Coprocytogram

Laboratory diagnosis of ABI

Goal Methods of diagnosis

Water, electrolyte and metabolic disturbance diagnosis

Urine Creatinin Natrium Potassium Chlorides РН of blood Bicarbonates Glucose level

Therapy of ABI

Diet

For breast-fed children, to continue breast-feeding

For formula-fed children, not to dilute formulas; special formulas are generally not needed

Restore age-adequate feeding as soon as dehydration managed

BRAT (banana-rice-apple-tea) has no advantages comparing to feeding

Therapy of ABI

Rehydration / detoxication

Main method of treatment. Effective as monotherapy in 80-90% cases of ABI

Etiotropic therapy

indications: bloody or mixed diarrheaseptic forms of ABItyphoid feverCholeraABI in immunodeficient children3rd degree dehydrationABI caused by protozoa

Therapy of ABIProbiotics

Lactobacillus GG at rotaviral gastroenteritis (questionable efficacy)

Sorbents Smectites (smecta) at rotaviral watery diarrhea (questionable efficacy)

Anti-diarrheal

Loperamid (contraindicated), Bismuth subcitratis (prolonged watery diarrhea), zinc (prolonged watery diarrhea, WHO recommended, frequent vomiting)

Therapy of ABI

Indications for hospitalization

Children with risk factors of dehydration development Dehydration of 2nd and 3rd degree Bloody diarrhea Prominent abdominal pain Decreased awareness Immunodeficient children Children with severe somatic pathology Inability to perform rehydration at home Inadequate parents

Antibacterial therapy of ABI

Disease First choice antibiotics (AB)

Alternative antibiotics

Shigellosis Cefalosporins of 3rd generation (ceftriaxon, cefotaxim)

Biseptol, Azitromycin

Salmonellosis

Cefalosporins of 3rd generation

Biseptol, Nitofuranes

Escherichiosis

Enterohemorrhagic – АB contraindicated

Еnterotoxigenic –Biseptol, Nitofuranes (questionable efficacy)

Enteroinvasive – Biseptol, Nitofuranes (questionable efficacy)


Disease First choice antibiotics (AB)

Alternative antibiotics

Intestinal yersiniosis

Biseptol, Gentamycin, Doxicyclin (questionable efficacy)

Cholera Doxicyclin, Biseptol

Azitromycin

Listeriosis Ampicillin+/- Gentamycin

Biseptol

Campylobacteriosis

Azitromycin Erythromycin

Typhoid fever Ceftriaxon+dexame-tasone

Azitromycin

Giardia Tinidazole Metronidazole, Furazolidone


Fluoroquinolones (Ciprofloxacin, norfloxacin) are first-choice antibiotics for adults; and children older 16 years. For younger children - only in critical, life-threatening cases.

Rehydration therapy at ABI ESPGAN, 2005

For 1st and 2nd degree dehydration oral rehydration solutions (ОRS) must be used

Peroral rehydration must be performed quickly (during 3-4 hours)

Additional ORS must be used at further fluid loss due to diarrhea or vomiting

3rd degree treatment must be performed by bolus IV infusion of normal saline (Ringer lactate)

Rehydration therapy at ABIM. Grossman, R. Dieckmann, Pediatric Emergency Medicine,

2004

Hypovolemic shock must be managed during 1 hour

After hypovolemic shock treatment, further dehydration can be performed with ORS

Additional correction of electrolyte disturbances must be performed according to laboratory data

Algorithm of rehydration therapy

20 hours: PR+AL (ORS)

Degree

Stage of urgent dehydration

Supporting stage

0

І

ІІ

24 hours: PR (physological requirements)+AL (additional losses) –

ORS 3-4 hours: 50 ml/kg (or % of body weight loss) ORS3-4 hours: 100 ml/kg (or % of body weight loss) ORS

20 hours: PR+AL (ORS)


ІІІ17-18 hours: PR+AL (ORS)

1st hour: IV bolus 0,9% NaCl (Ringer lactate) 20 ml/kg (max. 60ml/kg)3-5 hours: ORS (amount according to dehydration degree after shock management)

AL – additional losses (10ml/kg per episode of diarrhea, 2ml/kg – per episode of vomiting, or calculated during follow-up of the child)


Calculation of physiological requirements (PR) of fluid (Holliday-Segar)

Under 10kg –

100ml/kg

11-20kg – 1000+50 x n (n-

kg over 10)

>20kg – 1500+20 x n (n-

kg over 20)

Complications of ABI Type of complication

Typical cause / condition

Sepsis Salmonella, Yersinia

Encephalopathy, seizures

Shigella, Salmonella, Campylobacter or severe dehydration with electrolyte disturbances

Extraintestinal infections

Salmonella ( other bacteria very seldom )

Syndrome of Julienne–Barr

Campylobacter jejuni

Hemolytic – uremic syndrome

Е.Coli (O157H7), Sh.disenteriae

Complications of ABIType of complication


Reiter syndrome Campylobacter, Shigella, Salmonella, Yersinia

Intestinal perforation, toxic megacolon, secondary bacteremia

Any invasive pathogen

Thrombosis of dural sinus, kidneys veins thrombosis, transitory methemoglobinemia, septic shock

Severe dehydration caused by any pathogen

Complications of ABIType of complication


Subdural fluidHypernatremic dehydration caused by any pathogen

Encephalitis/meningitis

Salmonella (newborns, infants) , Rotavirus (seldom)

Lactase insufficiency Any non-invasive pathogen (seldom)

Prophylaxis of ABI (according to WHO)

Directions of prophylaxis Creation of «super» ORS

Development of effective vaccines

Support of breast feeding

Education of parents

Immunization against measles

Improvement of drinking water quality

Improvement of social and economical status

Vitamin A deficit prophylaxis

acute diarrhea

Health & Medicine

diarrhea syndrome diarrhea

days bloody diarrhea

days watery diarrhea

acute diarrhea syndrome

mixed diarrhea

days severe bloody diarrhea

children protozoa

children bacteria