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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