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Gastroenteritis in Paediatrics

HKCEM College Tutorial. Gastroenteritis in Paediatrics. Author Dr. CH chung Revised by Dr. Chang Wai Yin James Oct, 2013. Introduction. Very common reason to A&E In third-world countries, gastroenteritis results in 3 million deaths annually In HK 1/3 rotavirus

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Gastroenteritis in Paediatrics

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  1. HKCEM College Tutorial Gastroenteritis in Paediatrics Author Dr. CH chung Revised by Dr. Chang Wai Yin James Oct, 2013

  2. Introduction • Very common reason to A&E • In third-world countries, gastroenteritis results in 3 million deaths annually • In HK • 1/3 rotavirus • 1/3 bacteria (mainly Salmonella) • 1/3 no organism identified (Nelson E et al; Guidelines for the Management of Acute Diarrhoea in Young Children. HK J Paediatr 2003; 8(3): 203-36)

  3. Definition • Change in stool consistency to loose or watery stools, and/or a sudden onset of vomiting • (NICE clinical guideline 84: Diarrhoea and Vomiting in children; Apr 09)

  4. Diarrhoea • Acute diarrhoea: Short in duration (less than 2 weeks). • Persistent diarrhoea Episodes of diarrhoea lasting more than 14 days

  5. Etiology of Diarrhoea Acute Diarrhea Chronic Diarrhea Gastroenteritis Post infections Systemic infection Secondary disacharidase deficiency Antibiotic association Irritable colon syndrome Overfeeding Milk protein intolerance

  6. Infectious etiology

  7. Infectious etiology

  8. Case 1

  9. Triage • M 15 months old • FTNSD • Diarrhoea x 2/7, watery, 2-3 times/day • Cat 4

  10. How to assess?

  11. History • The onset, frequency, quantity, and character of diarrhea and vomiting (i.e., the presence of bile, blood, or mucus) • Associated symptoms, including fever or changes in mental status

  12. History • Recent oral intake, including breast milk and other fluids and food • Urine output; weight before illness

  13. History • Past medical history (immunocompromised status) • Contact history with GE • Exposure to known source of enteric infection (contaminated food/water) • Travel history

  14. Case • Further questioning • No vomiting • Fever x 3/7 • Cough with productive sputum • P/E: RR 24/min, pulse 122/min, • Abdo soft, chest: crep RLL • CXR: RLZ consolidation

  15. Dx? Chest infection

  16. Other than GE…..(DDx)

  17. Case 2

  18. Triage • F 7months old • Diarrhoea 4-5 times/day and vomiting x 2-3 times in 4/7 • Another 2 year old brother also with GE symptoms • presumption Dx: GE

  19. How to assess next?

  20. Physical Exam

  21. Increased Risk of Dehydration • <1y/o, esp <6 months old • Low birth weight • >5 diarrhoeal stools in prev 24 hrs • >2 vomiting in prev 24 hrs • Not offered or cannot tolerate supplementary fluid before presentation • Stopped breast feeding during illness • Signs of malnutrition

  22. Our Case • Alert, with good social smile • Pulse 114/min, RR 28/min • Skin turgor: slightly decreased • Cap refill <2s, no sunken eye • Abd soft

  23. How to manage?

  24. Management • Investigation (stool culture) usually not indicated except: • septicemia • bloody diarrhea or chronic diarrhea • immunocompromised • Re-hydration • Continue normal feeding • +/- Drug use

  25. Treatment (without dehydration) • Prevent dehydration • Continue breast feeding and other milk feeds • Encourage fluid intake • ORS • Discourage carbonated drinks, fruit juices

  26. Case 3

  27. Triage • M 5 m/o, FTNSD • Diarrhoea x 5/7 >10 times • Vomiting 3-4 times/day • Fever x 2/7 • Poor appetite with decreased urine output today

  28. Assessment • Temp 37.8, pulse: 142/min, RR 22/min • Dry lips • Decrease skin turgor, ant fontanelle slightly depressed • Cap refill ~2-3s • Abd soft

  29. Treatment (mild to moderate dehydration)

  30. Method Of Re-hydration

  31. Management • Oral Rehydration Solution (ORS): • Very Effective • Prevent dehydration if given early in the disease. • Cheap • Easy to administer; can be given by mother at home.

  32. ORS Composition • Sodium Chloride • Tri-Sodium Citrate (bicarbonate) • Potassium Chloride • Glucose

  33. Types of ORS

  34. ORT for Mild Dehydration • Dose: 50mL/kg • correct dehydration plus replacement of continuing losses. • 4 hour period • Replacement of continuing losses: 10mL/kg for each stool • Reevaluate every 2 hours. • Begin feeding once dehydration is corrected.

  35. ORT for Moderate Dehydration • Dose: 100mL/kg • 4 hour period • Replacement of continuing losses: 10mL/kg for each stool • Reevaluate every 1 hour. • Begin feeding once dehydration is corrected.

  36. Case 4

  37. Triage • F 2y/o, preterm baby, low birth weight • Hx of NEC • Vomiting and Diarrhoea >10times in 2/7 • Decrease activity since this morning • Refuse to take fluid

  38. Examination • Temp 37.5 • RR 30/min, pulse 150/min, BP 71/42mmHg • Lethargic with dried lips/sunken eyeball • Cap refill delayed with cold extremities

  39. Treatment

  40. ORT for Severe Dehydration • Higher level of medical care (PICU) • IV NS 0.9%/Ringer’s lactate • 20mL/kg at least within 1 hour. • Repeated if remain in shock • Consider other cause of dehydration • Maintainence: 100ml/kg for fluid deficit (50ml/kg if not in shock at presentation)

  41. Monitor RFT, electrolyte, glucose • Begin ORT with IV in place when improved • Start oral feeding

  42. Inappropriate ORT • Cola • Apple juice • Chicken broth • Sports beverages

  43. Vomiting • can still be treated with ORT • Key: 1 teaspoon every 1-2 minutes • Up to 150-300 mL/h may be given by a parent at home. • As dehydration and electrolytes are corrected, the vomiting may lessen.

  44. Hypernatremic dehydration • jittery movements • increased muscle tone • hyperreflexia • convulsions • drowsiness or coma Tx: need urgent expert management; replace deficit slowly, typically over 48hr Use isotonic 0.9% NaCl or 0.9% with 5% Dextrose Reduce [Na] less than 0.5mmol/L/hr

  45. Drug Treatment • alteration of intestinal motility • alteration of secretion • adsorption of toxins or fluid • alteration of intestinal microflora Not Recommended in NICE guideline 2009

  46. Antibiotics?

  47. Indications • Suspected/Confirmed septicemia • Extraintestional spread of bacteria infection • Salmonella GE • <6 months, or • Malnourished/immunocompromised • C. difficle-associated pseudomembranous enterocolitis, giardiasis, dysenteric shigellosis, dysenteric amoebiasis or cholera

  48. Newer Treatments for Diarrhea • Shown promise in experimental basis involving adults. • derivatives of berberine, • nicotinic acid, • clonidine, • chloride channel blockers, • calmodulin inhibitors, • octreotide acetate, • Zine and nonsteroidal antiinflammatory drugs. • All of these agents must be considered experimental at this time

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