acute diarrhea
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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
Etiological structure of ABI in children
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
Etiological structure of ABI in children
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.
Intestinal dehydration
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%
Intestinal dehydration
Severity of dehydration
% of body weight loss (adults/children)
Mild (І) 3% / 5%
Moderate (ІІ)
4-6% / 6-9%
Severe (ІІІ) >6% / >9%
Intestinal dehydration
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
Clinical criteria of dehydration severity
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.
Clinical criteria of dehydration severity
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)
Antibacterial therapy of ABI
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
Antibacterial therapy of ABI
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)
Algorithm of rehydration therapy
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)
Algorithm of rehydration therapy
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
Typical cause / condition
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
Typical cause / condition
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
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