Acute Gastroenteritis

byHarold Rugnao

DIARRHEA

ESSENTIAL CONCEPTS OF DIARRHEADIARRHEA

passage of unusually loose or watery stools, at least 3x in a 24 hr period

CLINICAL TYPES OF DIARRHEAAcute watery diarrheaAcute bloody diarrheaPersistent diarrheaDiarrhea with severe malnutrition

ESSENTIAL CONCEPTS OF DIARRHEADehydration

Deficit of water and electrolyte MalnutritionZinc DeficiencyUse of antimicrobials and anti-diarrheal

drugs

Important Microbial Causes of Acute Diarrhea in Infants and Children

RotavirusEscherichia Coli

EnterotoxigenicLocalized adherent Diffuse AdherentEnteroinvasiveEnterohemorrhagic

Shigella

Campylobacter jejuni

Vibrio cholerae 01 and 0139

SalmonellaGiardia duodenalisEntamoeba

histolyticaCryptosporidium

ASSESSMENT OF CHILD WITH DIARRHEA1. History2. Physical Exam3. Determine Degree of Dehydration and

select treatment plan4. Diagnose other important problems

ASSESSMENT OF DIARRHEA PATIENTS FOR DEHYDRATION

A B C

LOOK AT: CONDITION

EYES

THIRST

Well, alert

Normal

Drinks normally, not thirsty

Restless, irritable

Sunken

Drinks eagerly, thirsty

Lethargic or unconscious

Sunken

Drinks Poorly or not able to drink

FEEL: SKIN PINCH Goes back quickly

goes back slowly goes back very slowly

DECIDE NO SIGNS OF DEHYDRA-TION

SOME SIGNS OF DEHYDRATION

SEVERE SIGNS OF DEHYDRATION

TREAT Use treatment plan A

Weigh the patient, use Treatment Plan B

Weigh the patient, use Treatment Plan C URGENTLY

ESTIMATED FLUID DEFICITAssessment Fluid deficit as

%of body wtFluid deficit in ml/kg body wt

No signs of dehydration

<5% < 50ml/kg

Some dehydration 5 – 10 % 50 – 100 ml/kg

Severe dehydration

>10% >100 ml/kg

Management of Acute Diarrhea (without blood)Objectives:

Prevent dehydration, if there are no signs of dehydration

Treat dehydration, when it is presentPrevent nutritional damageReduce the duration and severity of diarrhea

and the occurrence of future episodes

Plan A – Treat Diarrhea at Home1. GIVE EXTRA FLUID

TELL THE MOTHER Breastfeed frequently and for longer at each feed If the child is exclusively breastfed, give ORS or

clean water in addition to breastmilk If the child is not exclusively breastfed give one

or more of the following: ORS, food base fluids, or clean water

TEACH THE MOTHER HOW TO MIX ORS Home made solution: 3g/l of table salt (one level

tspful) and 18g/l of common sugar

SHOW THE MOTHER HOW MUCH FLUID TO GIVE IN ADDITION TO THE USUAL FLUID INTAKE Up to 2 years50 to 100ml after each loose

stool 2 years or more 100 to 200 ml after each loose stool Oldre children as much fluid as they want

Tell the mother to give frequent small sips from a cup If the child vomits, wait 10 mins. Then continue, but

more slowly Continue giving extra fluid until the diarrhea stops

2. GIVE SUPPLEMENTAL ZINC- 10 – 20mg to the child everyday for 10 – 14

days

3. CONTINUE FEEDING - To prevent malnutrition

4. TAKE THE CHILD TO A HEALTH WORKER IF THERE ARE SIGNS OF DEHYDRATION OR OTHER PROBLEMS

- Starts to pass many watery stools- Repeated vomiting- Becomes very thirsty- Eating or drinking poorly- Develops fever- Blood in the stool- Child does not get better in 3 days

Plan B – Treat Some Dehydration with ORSGive in clinic recommended amount of ORS over 4-hour period

DETERMINE AMOUNT OF ORS TO GIVE DURING FIRST 4 HOURS

*AGE Up to 4 mos 4 mos up to 12 mos

12 mos to 2 yrs

2 yrs to 5 yrs

WT < 6 kg 6 – < 10 kg 10 – <12 kg 12 – 19 kg

In ml 200 – 400 400 – 700 700 – 900 900 – 1400

*Use the child’s age only when you do not know the weight. The approximate amount of ORS required (in ml) can also be calculated by multiplying the child’s weight (in kg) times 75

AMOUNT OF ORS TO GIVE DURING FIRST 4 HOURS

*AGE Up to 4 mos

4 mos up to 11 mos

12 mos to 23 mos

2 yrs to 4 yrs

5 – 14 yrs

15 yrs or older

WT < 5 kg 5 – 7.9 kg

8 – 10.9 kg

11 – 15.9 kg

16 – 29.9 kg

30 kg or more

In ml 200 – 400

400 – 700

700 – 900

900 – 1400

1200 – 2200

2200 – 4000

*Use the child’s age only when you do not know the weight. The approximate amount of ORS required (in ml) can also be calculated by multiplying the child’s weight (in kg) times 75

for infants under 6 mos who are not breatfed, if using the old WHO ORS solution containing 90mmol/L of sodium also give 100-200ml clean water during this period. However if using the new reduced (low) osmolarity ORS solution contining 75mmol/L of sodium, this is not necessary

For infants under 6 mos who are not breastfed, also give 100 – 200 ml of clean water during this period

If the child wants more ORS than shown, give more

Note: during initial stages of therapy, while still dehydrated adults can consume upto 750ml/hr if necessagry, children up to 20ml/kg/hr

SHOW THE MOTHER HOW TO GIVE ORS SOLUTION

AFTER 4 HOURSReassess the child and classify the child for

dehydrationSelect the appropriate planBegin feeding the child

MEET NORMAL FLUID NEEDS

IF THE MOTHER MUST LEAVE BEFORE COMPLETING TREATMENT

Show her how to prepare ORS Show her how much ORS to give to finish the

4-hour treatment at home Give her enough ORS packets to complete

hydration Explain the 3 rules of HOME TREATMENT

1. Give extra fluid2. Continue feeding3. When to return

WHEN ORAL REHYDRATION FAILSContinuing rapid stool loss (>15–20 ml/kg/hr) Insufficient intake of ORS owing to fatigue or

lethargyFrequent, severe vomiting

GIVING ZINC

GIVING FOOD

Treatment Plan C – for patients with severe dehydration1. GUIDELINES FOR INTRAVENOUS

REHYDRATION Give 100ml/kg Ringer’s Lactate Solutiona

divided as follows:

Age First give 30ml/kg in: Then give 70ml/kg in:

Infants (under 12 months)

1 hourb 5 hours

Older 30 minutesb 2 ½ hours

• Reassess the patient every 1 – 2 hrs. If hydration is not improving, give the IV drip more rapidly•After 6 hrs (infants) or 3 hrs (older patients), evaluate patient using the assessment chart. Then choose the appropriate Treatment Plana if Ringers Lactate Solution is not available, nomal saline may be usedb Repeat once if radial pulse is still very weak or not detectable

2. MONITOR THE PROGRESS OF INTRAVENOUS REHYDRATION

3. ELECTROLYTE DISTURBANCES Hypernatremia

Serum Na > 150mmol/L Can cause convulsions

Hyponatremia Serum Na < 130mmol/L Lethargy, less often, seizures

Hypokalemia Serum K+ <3 mmol/L Muscle weakness, paralytic ileus, impaired

kidney function and cardiac arrhythmia

Management of Suspected CholeraCholera differs from acute diarrhea of other

causes in 3 ways:It occurs in large epidemics that involve both

children and adultsVoluminous watery diarrhea may occur,

leading rapidly to sever dehydration with hypovolemic shock

For cases with sever dehydration appropriate antibiotics may shorten the duration of the illness

Antimicrobial Therapy

Management of Acute Bloody Diarrhea (Dysentery) Shigella is the most common cause of bloody

diarrhea Ciprofloxacin for 3 days

Out Patient Management of Bloody DiarrheaCHILD WITH LOOSE STOOLS WITH BLOOD

SEVERELY MALNOURISHED?

GIVE ANTIMICROBIAL FOR SHIGELLA

BETTER IN 2 DAYS?

No

No

REFER TO HOSPITAL

Yes

COMPLETE 3 DAYS TREATMENTYes

INITIALLY DEHYDRATED AGE< 1Y/O OR MEASLES IN PAST 6 WEEKS

CHANGE TO SECOND ANTIMICROBIAL FOR SHIGELLA b

BETTER IN 2 DAYS?

No

COMPLETE 3 DAYS TREATMENTYes

REFER TO HOSPITALYes

REFER TO HOSPITAL OR TREAT FOR AMOEBIASIS

Management of Persistent Diarrhea Persistent DiarrheaDiarrhea, with or without blood, that begins acutely

and lasts at leat 14 days. Usually associated with weight loss, and often, with

serious non-intestinal infections

Objective of treatment is to restore weight gain and normal intestinal function by:Appropriate fluids to prevent or treat dehydrationA nutritious diet that does not cause diarrhea to

worsenSupplementaryvitamins and mineralsAntimicrobials to treat diagnosed infections

Treat in the Hospital:Children with serious systemic infectionChildren with signs of dehydrationInfants below 4 months of age

Prevent or treat dehydrationIdentify and treat specific infectionsGive a nutritious dietGive supplementary multivitamins and

mineralsMonitor response to treatment

Management of Diarrhea with Severe MalnutritionAssess for DehydrationManage DehydrationFeedingUse of antimicrobials

Other Problems Associated with DiarrheaFeverConvulsionsVitamin A deficiency

Prevention of DiarrheaBreastfeedingImproved feeding practicesUse of safe waterHandwashingFood safetyUse of latrines and safe disposal of stoolsMeasles immunization