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Acute gastroenteritis Flashcards

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1
Q

Could be also known as:

A

*Acute Enterocolitis
*Acute Gastroenterocolitis
*Acute Diarrhea
*Acute Diarrheal Disease

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2
Q

ACUTE DIARRHEA–

A

generally defined by stool consistency and duration
(less than 7 days) (not by the number of stools per day – infant
variability)

  • EXTENDED DIARRHEA (7-14 DAYS)
  • CHRONIC/PERSISTENT DIARRHEA – More than 14 days
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3
Q

The causes of acute diarrhea (modified and adapted after Ciofu E, Ciofu
C. Pediatria - Tratat 1st Edition, 2001 )

A

1. Enteral infections (bacterial, viral, parasitic)
2. Parenteral infections (UTI, etc)
3. Inflammatory intestinal disease
4. Anatomical/functional causes (short intestine, de l’anse borgne
syndrome, etc)
5. Pancreatic/hepatic diseases (cistic fibrosis, etc)
6. Biochemical causes(disaccharides deficit, chloride diarrhea)
7. Celiac disease
8. Neoplasia (lymphoma, neuroblastoma, etc)
9. Immunodeficiency (hypogammaglobulinemia, Iga selective deficiency,
AIDS)
10. Endocrinopathy (hyperparathyroidism , Addison’s disease)
11. Malnutrition
12. Diet factors (over-alimentation, introduction of new foods)
13. Alimentary intolerances/allergies
14. Psychogenic diseases (irritable bowel)
15. Toxic diarrhea (heavy metal poisoning)

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4
Q

The causes of acute diarrhea (from a
practical point of view)

A
  1. Enteral infections
  2. bacterial
  3. viral
  4. Parasitic
  5. Parenteral infections (UTI, etc)
  6. Medication (antibiotics, etc)
  7. Alimentary allergies
  8. Food factors (over-alimentation, introduction of new
    foods)
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5
Q

There are many pathogenetic mechanisms that are both
self-explanatory and asociated with acute diarrhea:

A
  • Secretory - secretagogue agents, ex. cholera toxin, which
    attach to the receptors of the intestinal ephitelium and
    determine an intracellular accumulation of cAMP and cGMP
    Osmotic – determined by unabsorbable solutions,
    carbohydrate malabsorption (caused by the damage of the
    small intestine’s brush border)

*Intestinal motility disorders – ex thyrotoxicosis, bacterial
overgrowth (the transit is slowed down)

*Reduce intestinal surface (short intestinal syndrome)

*Mucosal invasion (inflammation, decreased colonic
reabsorption, increase motility)

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6
Q

There are many pathogenetic mechanisms that are both
self-explanatory and asociated with acute diarrhea:

A
  • Secretory - secretagogue agents, ex. cholera toxin, which
    attach to the receptors of the intestinal ephitelium and
    determine an intracellular accumulation of cAMP and cGMP
    Osmotic – determined by unabsorbable solutions,
    carbohydrate malabsorption (caused by the damage of the
    small intestine’s brush border)

*Intestinal motility disorders – ex thyrotoxicosis, bacterial
overgrowth (the transit is slowed down)

*Reduce intestinal surface (short intestinal syndrome)

*Mucosal invasion (inflammation, decreased colonic
reabsorption, increase motility)

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7
Q

Practical differential diagnosis: osmotic
diarrhea e secretory diarrhea

A

Parameters Osmotic Diarrhea Secretory Diarrhea

Stool Volume < 200 ml/day > 200 ml/day

Answer to fasting Answer No answer

Stool Na < 60 mOsm/l > 90 mOsm/l

Fecal osmolarity < plasma osmolarity = plasma osmolarity

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8
Q

Definition acute gastroenteritis (AGE)

A

*Decrease of fecal consistency (soft or liquid) and/or
increase of stool evacuation frequency (tipically ≥3/24
hours) with or without fever and vomiting
* A change in stool consistency versus previous stool
consistency is more indicative of diarrhea than stool
number, particularly in the first months of life

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9
Q

Pathogeny- AGE

A
  • Enterotoxigenic Mechanism - major pathogenic
    mechanism (if not exclusive) production of
    enterotoxin and its action on the intestinal mucus,
    with the distruction of villus cells
  • Enteroinvasive mechanism - direct invasion of the
    intestine, as well as cytokines production that
    causes the increase of water secretion and
    electrolytes in the intestinal lumen.
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10
Q

*The main pathogenic mechanism
consists in

A

blocking or decrease water and electrolytes absorption at the intestinal level

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11
Q

Epidemiology

A
  • The incidence of diarrhea ranges from 0.5 to 2 episodes
    per child per year in children <3 years in Europe.
  • Gastroenteritis is a major reason for hospitalization in this range of age.
  • Rotavirus is the most frequent agent of AGE;
  • norovirus is becoming the leading cause of medically attended AGE in countries with high rotavirus vaccine coverage.
  • The most common bacterial agent is either Campylobacter or Salmonella depending on country.
    *Intestinal infections are a major cause of nosocomial infection.
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12
Q

Etiology of age divided in age groups

A

*<a 1year: rotavirus, norovirus, adenovirus,
salmonella
*1-4 ani: rotavirus, norovirus, adenovirus,
salmonella, campylobacter, yersinia
*>5 years: campylobacter, salmonella,
rotavirus

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13
Q

Clinical Signs

A

*Diarrheic stool
*Vomitting
* Fever
*Abdominal pain
*Anorexia
* Seizures
* Tenesmus
* Erythema nodosum

Clinical signs of acute dehydration are to be added to the
clinical representation of acute diarrhea, as they severely
affect the disease

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14
Q

Clinical research has focused on the following:

A
  • Fever (different definitions of absent, low, moderate, and high)
  • Vomiting (absent, present, and different definitions of frequent)
  • Onset (abrupt or more gradual)
  • Stool frequency (different definitions of low, moderate, and high)
  • Fecal mucus (present or not)
  • Fecal blood (present or occult)
  • Abdominal pain (present or not)
  • Respiratory symptoms (rhinorrhea, cough)
  • CNS involvement (irritability, apathy, seizures, or coma)

ATTENTION ASOCIATION DIARRHEA, OLIGURIA, EDEMA = suspicion
of hemolytic uremic syndrome

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15
Q

Risk factors that cause severe/persistent forms
of disease

A
  • Clinical signs of severity: severe dehydration, repeated vomiting, persistent/high fever
    *Age < 6 months
  • Etiology: rotavirus, norovirus, astrovirus, E Coli enteropatogen
  • Socio-economic conditions
    *Artificial nutrition
  • Community: prekindergarden, kindergarden
    *Immunodeficiency
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16
Q

Are there any clinical signs that could lead to
the etiology?

A

*Fever > 40 ̊C, blood in the stool, abdominal
pain, irritability, seizures, coma = suggestive
for bacterial etiology
*Signs of vomiting and respiratory symptoms =
suggestive for viral etiology

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17
Q

Is a child with diarrhea dehydrated?

A
  • The degree of dehydration is essential for the
    therapeutic approach!
    (expressed in loss weight)
    *Minimal dehydration : <3% (Child) (5%) (Infant)
    *Mild to moderate dehydration : 3-9% (6-10%)
  • Severe dehydration> 9% (10%)
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18
Q

When are electrolytes /astrup
needed?

A

*In cases of moderate and severe dehydration
*In case of parenteral rehydration

*Hypovolemic shock
*Neurological abnormalities (lethargy, seizures)
*Incoercible vomiting

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19
Q

When should one go to the doctor?

A

*Diarrhea: ≥ 8 episodes/day
* Persistent vomiting
*Infants < 2 months
* Severe underlying disease (diabetes mellitus or renal failure)
* Family reported sign of severe dehydration

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20
Q

When is hospitalization recommended?

A
  • Shock
  • Severe dehydration
  • Somnolence, seizures, etc
  • Persistent /bilious vomiting
  • Lack of response to oral rehydration
  • Social/family causes
  • Suspected of surgical disease causes
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21
Q

Microbiological investigations

A
  • Stool samples (Coprocultures)
    *Microscopic examination of faecal samples (evaluation
    of the number of leukocytes )
  • Stool antigen (Rotavirus, Campylobacter etc)
    *Verotoxina (shiga-like toxin) - EHEC O157:H7
    (suspicion of hemolytic uremic syndrome)
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22
Q

Treatment - ACUTE GASTROENTERITIS

Study These Flashcards
A

*Rehydration
*Diet
*Pharmacological therapy

23
Q

Alimentation of the child with AGE

Study These Flashcards
A
  • Minimal or no dehydration– fed according to age
  • Mild to moderate dehydration – reintroduction of normal
    feeding after 4-6 hours from the start of rehydration (shortens
    the length of diarrhea by 0,43 days, reduces ponderal decrease
    thanks to hypocaloric diets)
    *This recommendation is not often followed.
24
Q

“….optimal management of mild-to-moderately
dehydrated children in Europe should consist of

Study These Flashcards
A
  • A) oral rehydration with ORS over 3 to 4 hours, and
  • B) rapid reintroduction of normal feeding
    thereafter….”
25
Should breastfeeding be interupted for children with diarrhea?
*NO
26
Enteral feeding and diet selection
* Continued enetral feeding in diarrhea aids in recovery from the episode, and a continued age- appropiate diet after rehydration is the norm *Intestinal brush-border surface and luminal enzymes can be affected in children with prolonged diarrhea or malnourished children – lactose free formula and possible specific diet. Alternative strategies: addition of milk to cerreals and replacement of milk with fermeted milk products such as yogourt * Fatty food and food high in simple sugars (juices, carbonated sodas) should be avoide
27
Is progressive reintroduction of milk fomula necessary?
*No
28
When is the introduction of lactose-free formulas necessary?
* Not routinely done Studies that show the benefits of this recommendation were published before1980 * **Recomended in - Severe dehydration - Severe malnourished children**
29
Pharmalogical therapy * ANTIBIOTICS – indications
* In GEA with Salmonella typhi, Shigella, Entamoeba hystolytica, v. cholerae, Giardia lamblia, Campylobacter * Despite the etiology, in the presence of signes of sepsis or in neurological complications or in persistent diarrhea(>14 zile) * Neonatal period * Malnutrition * Imune defficiencies
30
Pharmcological therapy
* Racecadotril (a potent enkephalinase inhibitor) (Hidrasec, Tiorfan, Racecadotril etc) – reduces the number of watery stools * Smectita - improves the consistent of the stools * Probiotics – active on gut microflora and intestinal absorption * Lactobacillus GG * Saccaromyces boulardi * Loperamid – NO * Antiemetice (Ondasetron)– NOT USSUALLY
31
Pharmcological therapy * In malnourished children (mostly in developing countries):
* ZINC is recommended to reduce the severity and duration of diarrhea * And should be added to treatment with ORS
32
Dehydration
*Water decrease in the organism *Usually associated with electrolyte concentration decrease
33
Symptoms associated with minimal or no dehydration < 3% loss of body weight)
* Mental status * Thirst * Heart rate * Quality of pulses * Breathing * Eyes * Tears * Mounth and tougue * Skinfold * Capillary refil * Extremites * Urine output *** Well, alert Drinks normally, might refuse liquids Normal Normal Normal Normal Present Moist Instant recoil Normal Warm Normal to decreased**
34
Symptoms associated with mild to moderate dehydration 3-9 % loss of body weight)
* Mental status * Thirst * Heart rate * Quality of pulses * Breathing * Eyes * Tears * Mounth and tougue * Skinfold * Capillary refil * Extremites * Urine output *** Normal, fatigued or restless, irritable Thirsty, eager to drink Normal to increasead Normal to decreased Normal, fast Slightly sunken Decreased Dry Recoil in < 2 sec Prolonged Cool Decreased*****
35
Symptoms associated with severe dehydration > 9% loss of body weight)
* Mental status * Thirst * Heart rate * Quality of pulses * Breathing * Eyes * Tears * Mounth and tougue * Skinfold * Capillary refil * Extremites * Urine output ** Apathetic, lethargic, unconscious * Drinks poorly, unable to drink * Tachycardia or bradycardia * Weak, thready, or impalpable * Deep * Deeply sunken * Absent * Parched * Recoil > 2 sec * Prolonged; minimal * Cold, mottled, cyanotic * Minimal**
36
Dehydration classification depending on osmolarity
“SURROGATE” FOR THE OSMOLARITY SODIUM VALUES--- CONSIDERING NORMAL GLYCEMIA VALUES!--- * ISOTONIC (130-150 mEq/l) (normal osm.) * HYPOTONIC(<130 mEq/l) (decreased osm) * HYPERTONIC (>150 mEq/l) (increased osm)
37
ATTENTION!!! * The knowledge of the type of dehydration(hypo, iso or hypertonic) is crucial in
minimizing risks associated with volemic reexpansion * In hyponatremia ideal 10 mEq/24 hours (not more than 2 mEq/hour) –long term neurological effects due to pontine myelinolysis * In hypernatremia – correction of dehydration within 48 hours - lethal massive cerebral edema risk
38
the principle that must guide the volemic resuscitation is maintaining a
full vascular bed – euvolemia = main target * correction of ionic imbalances = secondary target
39
Access routes
* For patients in shock, with hypotension – venous access attempts should be limited to 3 ATTEMPS *No blood vessel obtained– INTRA-BONE access ** THE INTRA-BONE APPROACH SHOULD BE THE MAIN OPTION FOR PATIENTS IN CARDIAC ARREST *IT HAS A SUCCESS RATE OF 83% AS OPPOSED TO 17% IN THE CASE OF INTRAVENOUS CANNULATION
40
ACCESS ROUTES - INTRA-BONE APPROACH
* THE INTRA-BONE APPROACH * Indicated: * Cardiac arrest * Shock * Intravenous cannulation failure * For patients in shock, with hypotension – venous access attempts should be limited to 3 ATTEMPS * No blood vessel obtained– INTRA-BONE access * THE INTRA-BONE APPROACH SHOULD BE THE MAIN OPTION FOR PATIENTS IN CARDIAC ARREST * IT HAS A SUCCESS RATE OF 83% AS OPPOSED TO 17% IN THE CASE OF INTRAVENOUS CANNULATION * Places of puncture: * Proximal tibia/distal tibia * Distal femur
41
INTRA-BONE APPROACH Necessary material
* Special needles * Short * Stop protection *trocarul * Xilina1%; *Antiseptic measures
42
INTRA-BONE APPROACH Complications:
*Osteomyelitis (1%) * Cellulitis; * Comprising syndrome * Fatty embolism *Growth cartilage destruction * Sepsis.
43
INTRA-BONE APPROACH
* The duration of infusion should not exceed 12 hours *Needles must avoid the growth cartilage destruction *Do not use excessive force/ you can pass both cortices *If you do not aspirate marrow or blood / instilate saline solution – pink liquid – confirm the correct place of needles in the medullary cavity *Urgent medication (adrenalina, atropina, Na bicarbonat, xilina,blood, etc.) - performed without problem.
44
ACCESS ROUTES
*ORAL REHYDRATION MUST NOT BE IGNORED * when the dehydration is not severe * when the child’s status allows it (without altered sensorium) * when the gastric tolerance allows it REHYDRATING WITH REHYDRATION SALTS – FOR 4 HOURS - 50 ml/kg for mild dehydrations - 100 m/kg for /severe ones
45
Rehydration salts
* Classical/standard solutions- Na 90 mmol/l –among the most important medical discoveries – they saved the lifes of many children with cholera *Reduced osmolarity solutions – Na 75 mml/l (recommended by the OMS) *Hypotonic solutions– Na 60 mmol/l (recommended by ESPGHAN,less by OMS)
46
STANDARD ORS
* Glucose 111 mmol/l * Sodium 90 mEq/l * Potasium 20 mEq/l * Chlorine 80 mEq/l * Bicarbonate 30 mmol/l * Osmolarity 311 mmol/l
47
REDUCED OSMOLARITY ORS
* Glucose 75 mml/l * Sodium 75 mEq/l * Potasium 20 mEq/l * Chlorine 65 mEq/l * Citrate – 10 mml/l * Osmolarity 245 mOsmol/l
48
ESPGHAN ORS
* Glucose 90 mml/l * Sodium 60 mEq/l * Potasium 20 mEq/l * Chlorine 60 mEq/l * Citrate – 10 mml/l * Osmolarity 240 mOsmol/l
49
Replacement of losses
* <10 kg body weight: 60-120 ml ORS for each diarrheal stool or vomiting episode * >10 kg body weight: 120-240 ml ORS for each diarrheal stool or vomiting episodes
50
IMPORTANT The choice for the hypovolemic patient is
is saline solution (nacl 0.9%) – regardless of the glycemic index!!! * 20 ml/kg as quickly as possible * If after maximum 3 tries the reexpansion has not been obtained – coloidal solutions: glucose oligomers, albumin
51
Why is it important to use saline solution (NaCl 0,9%) in rebuilding volemia and not 5% glucose?
- In order for the administered solutions to reach the cells a vascular bed is required - Glucose administered without rebuilding the volemia – hyperglycemia (often observed by us) - Therapeutically induced hyperglicemia accentuates dehydration through osmotic diuresis
52
Frequent mistakes * Administering during the inital approach:
* antibiotics * corticosteroids * bicarbonate * Administering bicarbonate without documenting a refractary acidosis to efficient volemic expansion and without proving normal na values = vital risk complications (through hypercapnia, hypernatremia, hyperosmolarity)
53
PRACTICAL MESSAGE
* the absolute priority regarding patients with ads and severe dehydration is rebuilding the volemia * glucosate solutions will under no circumstance be used to rebuild volemia * for hypoglycemic patients this will be corrected afterwards, possibly through a different vein * the use of antibiotics and bicarbonate should be reserved for special cases, not routinely
54
PREVENTION
*Promotion of exclusive breastfeeding *Improved complementary feeding practices *Rotavirus immunisation *Improved water and sanitary facilities and promotion of personal and domestic hygiene *Improved case management of diarrhea

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