Microsoft PowerPoint - Topazian - Diarrhea 2009.ppt [Read-Only]

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  • 1. DiarrheaA messy subject

2. CaseA 1 year old girl is brought to clinic with 3 days ofwatery brown diarrhea, vomiting, and irritability. Onexam the child is lethargic, afebrile, with sunkeneyes and a weak pulse of 140/minute. Which of thefollowing is the best management plan?A) Check CBC and stool tests for pathogensB) Prescribe oral rehydration solutionC) Prescribe oral antibioticsD) Begin IV fluids and hospitalize 3. More than 70 per cent of almost 11million child deaths every year areattributable to six causes: diarrhoea,malaria, neonatal infection, pneumonia,preterm delivery, or lack of oxygen atbirth.- UNICEF 4. Deaths per year from diarrheal illness United States: 6,000 Developing world: 1.5 to 2 million(children < 5 years old)World Gastroenterology Organization (WGO) Practice GuidelineAcute Diarrhea (March 2008) 5. Classification of diarrheaWGO Practice Guideline Acute Diarrhea March 2008 6. Acute diarrhea Acute diarrhea is usually a self-limited infectious illness Usually viral (Norwalk) or bacterial Vomiting:- Viral- Ingestion of a pre-formed toxin Profuse watery diarrhea:- Viral- Cholera- Giardia- Ingestion of a pre-formed toxinhttp://bepast.org/docs/photos/cholera/rice-water %2520stool.jpg Risk factors for death:- Extremes of age, malnutrition, immunocompromise 7. Acute diarrhea: clinical priorities Look at the stool- rice water stool: cholera- bloody stool: dysentery Assess severity- signs of dehydration, malnutritionhttp://spirochetesunwound.blogspot.com- abdominal exam- body temperature O + P exam formoderate/severe illness Hgb if pt looks anemichttp://biology.unm.edu/ccouncil/Biology_203/Images 8. Exam: nutritional and volume status 9. Kwashiorkor:Marasmus: lack of proteinprotein + calorie malnutritionwww.cs.stedwards.edu www.glahaiti.orgMalnutrition is a major risk factor for diarrhea mortality 10. Exam: volume status Adults and Children Tachycardia, postural hypotension Jugular venous distension Mucous membranes Children Urine output, dry mouth/eyes Sunken fontanelle Skin turgor Irritable or lethargic, drinking poorly 11. WGO Practice Guideline Acute Diarrhea March 2008 12. If the gut works, use it 13. Oral rehydration saves livesWGO Practice Guideline Acute Diarrhea March 2008 14. Oral rehydration solution (ORS) Rice-based ORS is superiorto glucose-based ORS in patients with choleraWGO Practice Guideline Acute Diarrhea March 2008 15. Rx of mild/moderate dehydrationWGO Practice Guideline Acute Diarrhea March 2008 16. Rx of severe dehydrationWGO Practice Guideline Acute Diarrhea March 2008 17. Acute diarrhea Rx - children Admit to hospital if malnourished, severelydehydrated, age < 1 year, recent measles ORS if dehydrated; IV fluids (RL, NS) if severelydehydrated; rehydrate over 3 to 6 hours Re-feed as soon as rehydration is accomplished Zinc 20 mg daily x 14 days Antibiotics not usually indicated Give antibx for: Dysentery Suspicion of cholera or enteric fever Giardiasis or amebiasis 18. Acute diarrhea Rx - adults ORS or IV fluids (RL, NS) if severely dehydrated Bismuth or loperamide (contraindicated if there is fever or bloody stool) Antibiotics not usually indicated Give antibx for: Dysentery (some cases) Suspicion of cholera or enteric fever Giardiasis or amebiasis 19. Dysentery Bloody stools Shigella, enterohemorrhagicE coli (EHEC), other bacteria often with fever Enteric fever (salmonellatyphi) Amebiasis no fever (unlessin liver) Less likely causes: ischemiccolitis or inflammatory boweldisease Infectious dysentery isusually a self-limited diseasethat does not requireantibiotic therapy 20. Dysentery: Antibiotics Antibiotics recommended for: Salmonella typhi, ameoba Extremes of age Immunocompromised or malnourished patients Toxic patients, suspicion of sepsis Antibiotic Rx may precipitatehemolytic-uremic syndromein children, especially in library.thinkquest.org/26260/pg1.htmlindustrialized countries 21. Antimicrobials Cholera Adults: doxycycline 300 mg once, or tetracycline 500 mg daily x 3 days Children: azithromycin, TMP/SMX, furazolidone, norfloxacin Shigellosis Adults: ciprofloxacin 500 BID x 2 days, or azithromycin or ceftriaxone Children: ciprofloxacin 15 mg/kg BID x 2 days, or azithromycin, or ceftriaxone 50-100 mg/kg daily i.m. x 2-5 days Resistance is common Giardia Metronidazole, tinidazole, nitazoxanide, or paromomycin Ameoba Metronidazole followed by iodoquinol or paromomycin 22. Persistent diarrhea - children Among infants in developingcountries, 20% of acutediarrheal illnesses becomechronic Enteropathogenic E coli (EPEC),Giardia Vicious cycle of diarrhea andmalabsorption leading to death Consider HIV Rx is largely nutritional: Iso-osmolar carbohydrateporridge, via feeding tube ifneeded MVI and zinc Antibiotics 23. Persistent diarrhea - adults Consider HIV Campylobacter ileitis: chronicdiarrhea, RLQ tenderness,signs of inflammation TB enteritis: doughy abdomen Parasites: Giardia, ameoba,cryptosporidium, isosporabelli, cyclospora Wasting, or fat in stool?Consider sprue, chronicpancreatitis Inflammatory bowel disease ormalignancy http://scanned.files.wordpress.com/ 2007/10/aidspatient2.jpg 24. Lab tests Stool for ova and parasites Especially in severe or persistent diarrhea Fecal leukocytes Suggests colitis, invasive organism CBC Wont alter acute Rx, unless there are signs ofsevere anemia Stool culture Usually not available or required Stool Sudan stain (fecal fat) In chronic diarrhea with weight loss X-Ray: if concern for toxic megacolon 25. CaseA 1 year old girl is brought to clinic with 3 days ofwatery brown diarrhea, vomiting, and irritability. Onexam the child is lethargic, afebrile, with sunkeneyes and a weak pulse of 140/minute. Which of thefollowing is the best management plan?A) Check CBC and stool tests for pathogensB) Prescribe oral rehydration solutionC) Prescribe oral antibioticsD) Begin IV fluids and hospitalize 26. ResourcesWGO Practice Guideline Acute Diarrhea March 2008