GASTROENTERITISPresented byBScN.KRCHN. Paul Mutie CyrusPwani university

PEDIATRIC GASTROENTERITIS.Causative agentsPathophysiologyTypes of diarheaClassification of diarheaManagement.

DEFINITION;Gastroenteritis is an

inflamatory disease of the gastric,and enteric sites of the gastrointestinal tract.

It is characterised by a sudden onset of diarhea with or without vomiting.

Diarhea in infants and small children may quikly dehydrate or get hypovolemic shock if fluids and electrolytes are not admistered immediately.

Causes include;virus,bacteria,protozoal,and non infectious causes.

1.Viral causes.

Viruses account for the largest causes of diarhea in pediatricsRotavirus is the leading viral

pathogen worldwide.Others;calivirus,astovirus,norovir

us,and adenovirus in gastroenteritis.

Symptoms of viral gastroenteritis.Low grade fever.VomitingCopious watery diarhea.Symptoms persist in 3-8 days.

2.Bacterial agentsAlso called food poisoning.Bacteria is the second leading cause

of diarhea in peaeiatrics.Compylobacter Jejuni is the leading

bacterial cause of gastroenteritis developed countries.

Other forms of bacteria include;shigella,Enterohemorhagic Escherichia coli,and salmonella enterica in developed countries.

In developing countries;Enterotoxigenic ecoli is the leading cause of gastroenteritis of the paediatrics.

Others include;compylobacter jejuni,shigella and salmonela enterica.

Symptoms of Bacterial gastroenteritis.High fevers.Shaking chills.Dysentery,(bloody bowel

movements).Abdominal cramping.Fecal leukocytes.

3.History of antibiotics use.A history of recent use of

antibiotics like;penicillins,cephalosporins,and clyndamycim, to the pediatrics may increase the likelyhood of toxix chlostridium difficile infexion,which causes gastroenteritis.

50% of neonates are colonised with chlostridium difficile hence symptomatic diesease is unlikely to occur in them.

4.ParasitesA number of protozoans

like;Giardia lamblia,Entamoeba hystolitica,and crystosporidium,remain the leading cause of gastroenteritis inpaediatrics.

Symptoms include;watery stool,and travel to an endemic area.

Transmission.Bottle feeding of babies with

unsanitized bottles.Poor hygiene among children in

crowded areas.Prexisting poor nutritional status.

5.Non-infectious causes.Include medications like NSAIDS.Foods like lactose(to those who

are intolerant)Crohns diesease.

Pathophysiology of gastroenteritis.GE is defined as vomiting or diarhea due to

infections of the small or large intestines.Changes are majorly non-inflammatory,in

the small intestines,but inflammatory in large intestines.

Abdominal crambs,increased thirst,due to excessive water dehydration and scanty urine occurs.

Most dangerous symptoms include,high fever above 38.9 degrees celcius,blood or mucus in the diarhea,blood in the vomit,and severe abdominal pains or swellings.

cntd, Phathophysiology Most of the infective microrganisms

mentioned like;viruses,bacteria,and protozoans,damage the mucosal lining or the brushborder in the small intestines.

Loss of protein-rich fluids and decreased ability to absorb the lost fluids occurs.

Invasion of the intestinall wall may cause bleeding especially incase of shigella,E.hystolytica and salmonella enterica.

Loss of a lot of water salts causes dehydration.

TYPES OF DIARRHEA.A.Secretory diarrhea.

Caused by increased active secretion or due to inhibition of absorption.

Occurs due to secretion of anions especially the chloride ions.

Main cause is cholera toxins.Intestinal fluid secretion is isotonic

with plasma even during fasting.To maintain a charge balance in the

lumen,sodium is carried along with water.

2.Osmotic diarrhea.Occurs when water is drawn into

the bowels.Excessive drinking of fluids with

excess sugar and salt may also be a cause.

May also result from mal-absorption e.g pancreatic disease or celiac disease.

Laxatives,constipation,or too much of magnesium,vitamin c,or undigested lactose may also be a cause.

3.Motility related diarrhea.Hypermotility diarrhea.Due to hypermotility of the

intestines,no sufficient time for sufficient nutrient and water absorption.

Its may be due to a vagotomy or diabetic neouropathy.

4.Exudative diarrhea.Caused by presence of pus and

blood in the lumen.Occurs with inflammatory bowel

disease like chrohns disease,ulcerative colitis,and severe infections like E.coli.

5.Inflammatory diarrhea.Occurs due to the mucosal

damage to the mucosal lining or brush border,causing passive loss of protein-rich fluids and a decreased ability to absorb the lost fluid.

Majorly due to viral infections,parasitic infections,or autoimmune problems.

6.Dysentery.It’s a blood stained diarrhea.Blood presence indicates

invasion of the bowel tissue by microrganisms like shigella,Entamoeba hystolitica and salmonella enterica.

7.Infectious diarrhea.Mainly caused by virus,and

bacteria.Norovirus,rotavirus,and

adenovirus are the most significant causes of viral diarrhea.

Compylobacter spp. Is the most common cause of bacterial diarrhea.

Salmonella,shigella spp.and some strains of E.coli too contribute as causative agents.

Diagnostic investigations of GE.Stool samples are collected for microscopy.A

stoll sample in viral GE does not contain any recognisable exudate,and its free from inflamatory cells,blood and fibrin.

Presence of leukocytes indicates presence of bacterial agent.

Cysts and trophozoites indicate parasitic GE.Blood tests for;FBC,renal function and

electrolytes can also be done to rule any systemic effects.

Blood culture if giving antibiotics therapy.

Dehydration due to diarrhea according to WHO. Dehydration is defined as an

incident in which water and electrolytes(sodium,pottasium,and bicarbonate)are lost through liquid stools,vomit,sweat,urine and breathing.

Dehydration occurs when these losses are not replaced.

Classification of dehydration.

1.Early dehydration .The body has lost about 2%of its total fluids.No signs or symptoms.

2.Moderate dehydration.Its characterised by; Thirst Restless or irritable behaviour. Decreased skin elasticity. Sunken eyes. Decreased urine output.Less than six diapers in

babies and eight hours of older children without urination.

Few or no tears when crying. Lghtheadedness or dizziness. Sleeplessnes or tiredness. Muscle weaknes.

3.Severe dehydration.Its characterised by;1. Shock2. Diminished consciousnes and delirium.3. Little or no urine output.4. Cool and moist extremities5. Low blood pressure 6. Sunken eyes.7. Very dry mouth,mucus membranes.8. Infants will have sunken fontanels.9. Shrivelled and dry skin which lacks

elasticity.

Management of gastroeneritis.According to(Integrated management of

child illnesses,IMCI)Protocol plan A,B and C.

Plan A;Management of the dehydration.Fluid management.

A. Early dehydration.a) Rehydration therapy is not required.b) Replacement of losses.Less than

10kgs,give 60-120 oral dehydration solution for each diarrhea stool or vomiting episode.

Cntd,of early dehydration managent. More than 10kgs,body give 120-

140mls oral rehydration for each diarrhea stool or vomiting episode.

B.Moderate dehydration.Rehydration therapy.Give oral

rehydration solution 50 to 100mls/kg for 3 to hours.

Replacement of losses.Less than 10kgs body weight,60 to 120mls oral ryhydration solutions for each diarrhea stool or vomiting episode.

Those who are more than 10kgs, body weight 120 to 140 mls,oral rehydration solution for each diarrhea stool or vomiting episode.

Severe dehydration management.Rehydration therapy.Adminster

intravenous Ringers lactate or N/S(20mls per kg)untill perfusion and mental states improve,followed by 100ml/kg oral rehydration salution over four hours,or 50% dextrose half N/S intravenous at twice maintenance rates.

Replacement therapy.10kgs,body weight 60 to 120mls oral

rehydration solution for dehydration stool or vomiting episode.

More than 10kgs body weight give 120 to 140 mls,oral rehydration solution for each diarhea stool or vomiting episode.

If unable to drink adminster through nasogastric tube or intravenously adminster 5% dextrose on fourth N/S,with 20mEq/L pottasium chloride.

Plan B;Medical management.Compylobacter spp,its treated with Erythromycin.Clostridium difficile,discontinue the causative

antibiotic.If antibiotics cant be stopped,oral mentronidazole or vancomycin is adminstered.

Entamoeba hystolytica;metronidazole followed by iodoquimol,or paramomycin.

E.coli;sulfamethoxazole in moderate diarrhea,while third and fourth cephalosporin are indicated for systemic complications.

Zinc suplements are given to reduce severity of diarrhea,10-20mg/day for 10-14 days for chidren younger 5yrs.

Don’t give antidiarrheal drugs.

Plan C;Nutritional management.

During rehydration therapy;Continue breast feeding.Don’t give solid foods.In children without flag symptoms

and signs,don’t routinely give oral fluids other than ORS,however consider supplementation with the childs fluids;breast milk or water but not fruit juices or carbonated drinks,if they refuse the ORS solution.

Cntd, In children with red flag symptoms or signs,don’t

give oral fluids other than ORS SOLUTION.After rehydration;Give full-strength milk straight

away.Re-introduce the childs usual solid foods.Avoid giving fruit juices and carbonated drinks until

the diarrhea has stopped.NB;Not all commercial ORS formulas promote

optimal absorption of electrolytes,water and nutrients.

An ideal solution should have an osmolarity of(210-250)and sodium content of 50-60mmol/litre.

WHO recomends use of the ORT form of ORS.

THANK YOU. QUESTIONS.

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