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ACUTE GASTROENTERITIS IN CHİLDREN. Prof. Dr. Tufan KUTLU.
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ACUTE GASTROENTERITIS IN CHİLDREN Prof. Dr. Tufan KUTLU
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.
Diarrhea • Increase in the number of stools or a decrease in their consistency
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
Causes of acute gastroenteritis in children • Bacteria • Viruses • Parasites
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
Viral agents causing diarrhea • Reoviridae:rotavirus, astrovirus • Parvo-like viruses:Norwalk virus • Picornavirus:calicivirus, adenovirus, coronavirus
Parasites causing diarrhea • Giardia lamblia • Cryptosporidium • Entamoeba histolytica • Isospora belli • Cyclospora sp • Blastocystis hominis • Microsporidium
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
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
Diagnosis • Fever, abdominal pain, tenesmus: inflammatory colitis, ileitis • Bacteria: Shigella, Yersinia, C. difficile • Parasite: Entamoeba histolytica
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
Diagnosis • Recent exposure to antibiotics: Clostridium difficile • Many cases affected simultaneously: S. Aureus, C. perfringens • Immunodeficiency, malnutrition: Salmonella, Rotavirus, Isospora, Cryptosporidium, Candida
Diagnosis • Stool examination • Presence of erithrocytes and leucocytes: Shigella, E. coli (EIEC, EHEC), Campylobacter,Yersinia, Clostridium • Presence of erithrocytes: Entamoeba histolytica
Diagnosis • Stool examination • Microscopic: Parasites (entamoeba, giardia..) • Antigens: Entamoeba, Giardia, Rotavirus, Adenovirus • Culture ?
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
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
Viral gastroenteritis • Diagnosis • Rota/adenovirus antigen in stools • Treatment • Continue with unrestricted oral feeding • Dehydration • Mild/moderate: oral rehydration treatment • Severe: intravenous fluid
Shigella dysenteriae (flexneri, boydii, sonnei) • Clinical manifestations • Fever, malaise • Watery diarrhea, blood and mucus • Cramping abdominal pain • Seizures • Arthritis • Purulent keratitis • Hemolytic-uremic syndrome
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
Yersinia enterocolitica (pseudotuberculosis, pestis) • Clinical manifestations • Fever • Abdominal pain • Diarrhea • Pseudoappendicular syndrome • Erythema nodosum • Reactive arthropathy
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
Cholera • Clinical manifestations • Vomiting • Profuse vatery diarrhea (rice-vater appearence) • Treatment • Rehydration (ORT, IV) • Antibiotics: Tetracycline, furazolidone, ampicillin, chloramphenicol, trimethoprim-sulfometoxazole
Salmonella enteridis, cholerasuis, typhi • 1. Acute gastroenteritis • 2. Focal non intestinal infection • 3. Bacteremia • 4. Asymptomatic carrier state • 5. Enteric fever
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
Escherichia coli • Enteropathogenic • Enterotoxigenic • Enteroinvasive • Enterohemorragic • Enteroaggregative and diffuse-adherant
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
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
Treatment of diarrhea • Protective factors • Human milk: IgA, lactoferrin, leucocytes, antiviral factors, bifidobacteries • Gastric acid • Secretory IgA • Intestinal motility
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
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
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)
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
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…
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
Rice-based ORS • Cheaper • Better taste • Hypoosmolar (280 mOsm/L) • Prevent vomiting • Decrease frequency and duration of diarrhea • More nutritive • Traditional
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