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ACUTE GASTROENTERITIS IN CHİLDREN

ACUTE GASTROENTERITIS IN CHİLDREN. Prof. Dr. Tufan KUTLU.

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ACUTE GASTROENTERITIS IN CHİLDREN

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  1. ACUTE GASTROENTERITIS IN CHİLDREN Prof. Dr. Tufan KUTLU

  2. Each day,the adult human gut handles 7 liters of endogenous secretions (salivary, gastric, biliary, pancreatic, intestinal) and 2 liters of ingested fluids. Of this large volume, 3 to 5 liters are absorbed by the jejunum, 2 to 4 liters by the ileum, and 1 to 2 liters by the colon. Only 100 to 200 ml are lost in the stools.

  3. Diarrhea • Increase in the number of stools or a decrease in their consistency

  4. Acute gastroenteritis • In Europe the incidence of diarrea ranges from 0.5 to 1.9 episodes per child per year in children up to 3 years of age • In low and middle income countries the incidence of acute diarrhea has declined from 3.4 episodes/child/year in 1990 to 2.9 episodes/child/year 2010

  5. Causes of acute gastroenteritis in children • Bacteria • Viruses • Parasites

  6. Vibrio sp Escherichia coli Salmonella sp Campylobacter sp Clostridium difficile Clostridium perfringens Bacillus cereus Staphylococcus aureus Yersinia enterocolitica Aeoromonas hydrophila Klebsiella sp Enterobacter sp Proteus sp Citrobacter sp Edwardsiella tarda Pseudomonas aeroginosa Plesiomonas shigelloides.. Bacteria causing diarrhea

  7. Viral agents causing diarrhea • Reoviridae:rotavirus, astrovirus • Parvo-like viruses:Norwalk virus • Picornavirus:calicivirus, adenovirus, coronavirus

  8. Parasites causing diarrhea • Giardia lamblia • Cryptosporidium • Entamoeba histolytica • Isospora belli • Cyclospora sp • Blastocystis hominis • Microsporidium

  9. Patophysiology of infectious diarrhea • Invasion and destruction of the villous intestinal epithelial cells:Shigella dysenteria, E. coli (EIEC), Yersinia enterocolitica, Campylobacter jejuni, Entamoeba histolytica, Salmonella, rotavirus • Enterotoxin production:Vibrio cholera, E. Coli (ETEC), Shigella dysenteria, Campylobacter jejuni, Clostridium difficile, Yersinia enterocolitica, Salmonella, Staphylococcus aureus, Bacillus cereus, Clostridium perfringens • Adherence to enterocytes:E. coli • Invasion of the lamina propria:Salmonella

  10. Diagnosis • Vomiting, profuse watery diarrhea (non blood, non mucus): secretory diarrhea • Bacteria: Vibrio cholera, E. coli (ETEC), S. aureus, B. cereus, C. perfringens • Viruses: Rotavirus, Norwalk virus • Parasites: Giardia lamblia, Cryptosporidium

  11. Diagnosis • Fever, abdominal pain, tenesmus: inflammatory colitis, ileitis • Bacteria: Shigella, Yersinia, C. difficile • Parasite: Entamoeba histolytica

  12. Diagnosis • Bloody diarrhea • Bacteria: Shigella, E. Coli (EIEC), Yersinia, C. jejuni, C. difficile, Salmonella • Parasite: Entamoeba histolytica • Fever and abdominal pain like acute appendicitis: Yersinia enterocolitica

  13. Diagnosis • Recent exposure to antibiotics: Clostridium difficile • Many cases affected simultaneously: S. Aureus, C. perfringens • Immunodeficiency, malnutrition: Salmonella, Rotavirus, Isospora, Cryptosporidium, Candida

  14. Diagnosis • Stool examination • Presence of erithrocytes and leucocytes: Shigella, E. coli (EIEC, EHEC), Campylobacter,Yersinia, Clostridium • Presence of erithrocytes: Entamoeba histolytica

  15. Diagnosis • Stool examination • Microscopic: Parasites (entamoeba, giardia..) • Antigens: Entamoeba, Giardia, Rotavirus, Adenovirus • Culture ?

  16. Viral gastroenteritis • Diarrheal diseases caused by viral agents occurs for more frequently than does similar disease of bacterial origin • Rotavirus is responsible for 20 to 70 % of hospitalization for diarrhea among children worldwide • Transmission is primarly from person to person • Most commonly in children between 6 and 24 months of age

  17. Viral gastroenteritis • Clinical manifestations • Incubation period: 48-72 hours • Sudden onset of diarrhea and vomiting • Diarrhea is watery, rarely bloody, 2-8 days • Fever • Respiratory symptoms

  18. Viral gastroenteritis • Diagnosis • Rota/adenovirus antigen in stools • Treatment • Continue with unrestricted oral feeding • Dehydration • Mild/moderate: oral rehydration treatment • Severe: intravenous fluid

  19. Shigella dysenteriae (flexneri, boydii, sonnei) • Clinical manifestations • Fever, malaise • Watery diarrhea, blood and mucus • Cramping abdominal pain • Seizures • Arthritis • Purulent keratitis • Hemolytic-uremic syndrome

  20. Shigella dysenteriae • Treatment • Trimethoprim-sulfometoxazole, ampicillin, nalidixic acid, ceftriaxone • Antimicrobial treatment is recommended to • shorten the course of the disease • decrease the period of excretion of the organisms • decrease the secondary attack

  21. Yersinia enterocolitica (pseudotuberculosis, pestis) • Clinical manifestations • Fever • Abdominal pain • Diarrhea • Pseudoappendicular syndrome • Erythema nodosum • Reactive arthropathy

  22. Campylobacter jejuni • C. jejuni is a significant cause of diarrhea in children jounger than 2 years of age. • Treatment: erythromicin • Clostridium difficile • Antibiotic associated diarrhea • Treatment: metronidazole, vancomicin, probiotics

  23. Cholera • Clinical manifestations • Vomiting • Profuse vatery diarrhea (rice-vater appearence) • Treatment • Rehydration (ORT, IV) • Antibiotics: Tetracycline, furazolidone, ampicillin, chloramphenicol, trimethoprim-sulfometoxazole

  24. Salmonella enteridis, cholerasuis, typhi • 1. Acute gastroenteritis • 2. Focal non intestinal infection • 3. Bacteremia • 4. Asymptomatic carrier state • 5. Enteric fever

  25. Salmonella • Salmonella is spread with cotaminated water, foods (meat, eggs, milk) • Clinical manifestations • Incubation periode 12-72 hours • Fever, watery diarrhea, blood and/or mucus • Treatment • Patients at high risk (immunocompromized patients, hematologic disease, artificial inplants, severe colitis) • Ampicillin, chloramphenicol, trimethoprim-sulfometoxazole, cephalosporins

  26. Escherichia coli • Enteropathogenic • Enterotoxigenic • Enteroinvasive • Enterohemorragic • Enteroaggregative and diffuse-adherant

  27. Traditional treatment of diarrhea

  28. Treatment of acute gastroenteritis • Treatment of a child with moderate dehydration in hospital (USA) • ORT: 11 hours and 270 USD • IV : 103 hours and 2300 USD

  29. Treatment of acute gastroenteritis • Rehydration: IV, ORT • Nutrition • Medical • Antibiotics: bloody diarrhea, infants <3-6 months • Antisecretory drugs • Racecadotril • Adsorbant drugs • Smectite • Anti motility agents • Zinc • Probiotics

  30. Assessment of dehydration in children

  31. Treatment of diarrhea • Protective factors • Human milk: IgA, lactoferrin, leucocytes, antiviral factors, bifidobacteries • Gastric acid • Secretory IgA • Intestinal motility

  32. Zinc for diarrhea • Twenty four trials , 9128 children • Zinc is clearly of benefit in children agedsix months or more. • Children aged less than six months showed no benefit with zinc. • Vomiting was morecommon in zinc-treated children with acute diarrhoea • Lazzerini M, Ronfani L. Oral zinc supplementation for treating diarrhea in children. Cochrane Database of Systematic Reviews 2012

  33. Treatment of acute gastroenteritis • Rehydration • ORT > 90 % • IV < 10 % • Continue with unrestricted oral feeding • Antibiotic when necessary (age<3-6 months, dysenteria, cholera..) • Do not use antidiarrheal agents

  34. WHO-ORS • Should contain carbohydrate (glucose) and sodium (glucose/sodium: between 1/1 and 2/1) • Glucose: 74-111 mmol/L (rice-flour: 50 g/L) • Sodium • Rehydration: 60-90 mmol/L • Maintenance: 40-60 mmol/L • Osmolarity < 290 mOsm/L • Potassium: 20 mmol/L • Bicarbonate: 30 mmol/L (or citrate: 10 mmol/L)

  35. Composition of the ORS recommended by WHO

  36. Electrolyte losses in diarrheal disease (mmol/L)

  37. Comparison of some fluids used for rehydration

  38. Treatment of diarrhea at home • Recommended foods • Water, soup (rice), yoghurt, fruit juice… • <6 months: breast-feeding, formula • Recommended amount of fluids • After every watery stools • <2 ages: 50-100 ml • >2 ages: 100-200 ml

  39. Treatment of diarrhea at home • To prevent malnutrition • Don’t stop breast feeding or formula feeding • Don’t dilute formula or milk • Older children: give rice cereal, bananas, fruit juices, potatoes, yoghurt, good cooked meat, fish…

  40. ORS treatment at home

  41. ORS treatment

  42. Probiotics for acute gastroenteritis • Lactobacillus GG administered in oral rehydration solution to children with acute diarrhea: a multicenter European trial. Guandalini et al. J Pediatr Gastroenterol Nutr 2000

  43. Rice-based ORS • Cheaper • Better taste • Hypoosmolar (280 mOsm/L) • Prevent vomiting • Decrease frequency and duration of diarrhea • More nutritive • Traditional

  44. Contraindication of ORS use • Shock, stupor, coma • Severe electrolyte imbalence and dehydration • Severe and repeated vomiting • Acidosis • Oliguria or anuria • Abdominal distention, ileus • Glucose-galactose malabsorption

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