Acute Gastroenteritis: A Case Discussion

Ryan Em C. Dalman MD MBA - 070070

Outline

Objectives Case Presentation Case Discussion

Objectives

Present a case of Acute Gastroenteritis

Discuss the pathophysiology and management of Acute Gastroenteritis

Case PresentationPatient History

General Data

JM 1-year-old born on July 9, 2009 Female Admitted for the first time Roman Catholic Pasig City

Chief Complaint

Vomiting

History of Present Illness

Vomiting 1x ingested food Non-projectile Non-bilous Non-bloody

3 days PTA

1 day PTA Loose bowel movement 3x

Watery Non-bloody Non-mucoid Non-foul smelling

No associated symptoms, no medications, no consults

History of Present Illness Symptoms persisted 12 hours PTA

Consult at the

ER

Sent home after successful trial feeds

History of Present Illness

Vomiting 3x ingested food Post-prandial Non-projectile Non-bilous Non-bloody

Few hours PTA

Consult at the

ER

Admitted

Review of Systems

General: no weight loss, no change in appetite

Cutaneous: no lesions, no pigmentation, no hair loss, no pruritus

HEENT: no rednessno aural dischargeno neck massesno sore throat

Review of Systems

Cardiovascular: no easy fatigability, or fainting spells

Gastrointestinal: no constipationGenitourinary: no genital discharge, no

pruritusno problems in

urinationEndocrine: polydypsia, no heat/cold

intolerance

Review of Systems

Muskuloskeletal: no joint or muscle swelling, no limitation of movement, no stiffness

Hematopoietic: no easy bruisability, or bleeding

Maternal and Birth History Born full term via NSD to a 31 year

old G4P3 (3013) by an obstetrician at PCGH

with complete prenatal consults No intake of any medications except

for multivitamins No maternal illnesses No complications at birth

Nutritional History

Breastfed from birth to 3 months old Bona Supplementary foods were given at

6 month old Current diet

Milk 4-5 bottles a day Rice + (chicken, vegetables, w/ soup) 3x

a day Bread every morning

Immunizations

BCG – 1 dose DPT – 3 doses Hep B – 3 doses Measles – 1 dose

Developmental History

Stands alone Throws toys Obeys commands or requests Attempts to use a spoon

Past Medical History

No Tuberculosis, Asthma, TraumaNo previous surgeriesNo previous hospitalizationsNo Allergies

Family History

Diabetes, Hypertension – father No heart disease, cancer, stroke,

kidney disease, asthma, or allergies

Personal and Social History Father works for Reagent Mother is a housewife Private Subdivision in Pasig City

Environmental

Not exposed to environmental hazards like chemicals, pollution, cigarette smoking, etc

Generally clean environment Has their own toilet Water comes from Manila Waters

Drinking water mineral water

Case PresentationPhysical Exam

General Survey

awake, active, with good cry but consolable

Not in cardiorespiratory distress

Vital Signs/ Anthropometrics

Vital signsTemperature – 36.5oCCR – 112 (70-110) RR – 28

(20-30)

Weight: 10.4 kg (50-75th) Length: 75cm (50th) HC: 45.5cm (50-75th) CC: 45 cmAC: 42 cm

Skin

Light brown No rashes, hemorrhages, scars Moistgood skin turgorCRT 1-2 seconds

HEENTHead

normocephalicno lesions, fontanels closed

Eyesanicteric sclerae, pink palpebral conjunctiva, not sunkenpupils 2-3mm

Earscone of light present inferomedially on both earsno discharge noted

Noseseptum medline, moist mucosa

Throatmouth and tongue moistno TPC

Chest and LungsNeck

no cervical lymphadonapathySupple

Chestadynamic precordiumno heaves, thrills, or lifts, PMI at 4th ICS MCLslightly tachycardic, normal rhythm, distinct S1 and S2no murmurs

Lungssymmetrical chest expansion, no retractionsEqual vocal fremitiClearbreath sounds

Abdomen/ Perineum

AbdomenDistended, no scars, no lesionsHyperactive bowel soundstympanitic on all quadrantsno tenderness on all quadrantsno masses, no organomegallyliver edge palpatedkidneys and spleen not appreciated

Neurologic Examination

Glasgow Coma Scaleverbal response: 5eye opening: 4motor response: 6total: 15

Cerebrumawake and active

Cerebellumno nystagmus, tremors, or abnormal movements

Neurologic Examination

Sensoryresponds to pain

MotorSymmetrical general movement with good activity

DTR++ on all extremities

Neurologic Examination

Cranial NervesI: not elicited II: 2-3mm pupils, equally reactive to lightIII,IV,VI: EOM’s intactV: corneal reflex presentV1, V2, V3 intact (responds to touch)VII: no facial asymmetry VIII: turns to soundIX, X: gag reflex presentXI: turns head from side to sideXII: tongue midline

Case PresentationSalient Features, Admitting Impression, Differentials, Course in the Ward

Salient Features

1 year month old, female Vomiting Acute Loose watery stools

Non-bloody, non-mucoid, non-foul smelling Distended abdomen Skin – good turgor, CRT 1-2 sec Eyes not sunken Moist oral mucosa Hyperactive bowel sounds

Admitting Impression

Acute Gastroenteritis, probably viral, with no signs of dehydration

Differential DiagnosisViral AGE

1 year old +Vomiting +Loose watery stools +Acute +Bloody stool -Mucoid stool -Foul smelling -Hyperactive bowel sounds +Abdominal distention +/-

Enterotoxigenic E. coli++++---+

+/-

Differential DiagnosisViral AGE Giardia lamblia

1 year old + +Vomiting + +Loose watery stools + +Acute + +Bloody stool - -Mucoid stool - +Foul smelling - +Hyperactive bowel sounds + +Abdominal distention +/- +/-

Oily stoolExplosive

fever

Differential DiagnosisViral AGE Fecal impaction

1 year old + +Vomiting + +Loose watery stools + +Acute + -Bloody stool - -Mucoid stool - -Foul smelling - -Hyperactive bowel sounds + +Abdominal distention +/- +

- With Hx of constipation

-Vomitus with fecal material

Differential DiagnosisViral AGE Food Allergy

1 year old + +Vomiting + +Loose watery stools + +Bloody stool - +/-Mucoid stool - -Foul smelling - -Hyperactive bowel sounds + +Abdominal distention +/- +/-

Associated with other symptoms

Differential DiagnosisViral AGE Shigellosis

1 year old + +Vomiting + +Loose watery stools + +Acute + -Bloody stool - +Mucoid stool - +/-Foul smelling - +Hyperactive bowel sounds + +Abdominal distention +/- +/-

Diagnostic and Therapeutic Plan Diagnostic

CBC with platelet count Blood chemistry (sodium and potassium) Urinalysis Fecalysis

Therapeutic IV for Hydration Increased oral hydration Antipyretics Zinc supplementation Probiotics

Course in the Ward

1st Hospital DayS O A P

Poor suckComfortableNo vomiting3 BM-2x watery with some formed-soft

T: 36oC CR: 104 RR: 30-U/O: 1.84 cc/hr-Awake, with good cry-Good activity-Eyeballs not sunken-With tears-Clear breath sounds-Regular cardiac rate with normal rhythm-Normoactive bowel sounds-Soft and non-tender abdomen

Course in the Ward

1st Hospital DayS O A P

Poor suckComfortableNo vomiting3 BM-2x watery with some formed-soft

Fecalysis-negative

Blood Chemistry-Normal Na and K+

Urinalysis -normal

CBC-normal

Acute gastroenteritis with no signs of dehydration-resolving

IVF D5LR 1L 42-43ml/hr-Small frequent feeding-avoid oily and fatty food-encourage apples and bananas-continue hydration-monitor input and output

Course in the Ward

2nd Hospital DayS O A P

Good suckComfortableNo vomiting1 BM, soft

T: 36.7oC CR: 103 RR: 28-U/O: 1.77 cc/hr-Awake, with good cry-Good activity-Eyeballs not sunken-With tears-Clear breath sounds-Regular cardiac rate with normal rhythm-Normoactive bowel sounds-Soft and non-tender abdomen

Acute Gastroenteritis with no signs of dehydration-resolved

-May go home tomorrow-consume IVF then switch to oral hydration-home medications:Zinc sulfite syrupProbiotics

Case Discussion

Definition

Infections of the gastrointestinal tract caused by bacterial, viral, or parasitic pathogens

Diarrheal disorders Term used in public health setting

Diarrhea 3 or more unusually watery stools

passed in 24 hours

WHO – Treatment of Diarrhea

Etiology

> 3 years old Viral

Rotavirus Enteric adenovirus Astrovirus Norovirus Calicivirus

E. coli, Salmonella

Epidemiology

18% of childhood deaths >700 million episodes of diarrhea

annually < 5 years old (WHO)

Philippines 2nd leading cause of morbidity 6th leading cause of mortality for all ages 3rd leading cause of infant deaths Predominance of rotavirus and

enterotoxigenic E. coliNelson/ Carlos and Saniel, Etiology and Epidemiology of Diarrhea (1990)

Manifestation

Most common Diarrhea Vomiting

May also have systemic symptoms Abdominal pain fever

Clinical types of Diarrhea Acute watery diarrhea

Several hours to days Acute bloody diarrhea Persistent diarrhea

> 14 days Diarrhea with severe malnutrition

Pathophysiology

Enters villi and releases viral proteins

(NSP4)

Feca-oral route NSP4 cause release Ca2+

intracellularly

Virus infects adjacent cell

NSP4 produced disrupts tight

junctions

Paracellular flow of water

and electrolytes

Ramig (2004), Pathogenesis of intestinal and systemic rotavirus infection

Ramig (2004), Pathogenesis of intestinal and systemic rotavirus infection

Pathophysiology

Intracellular Ca2+

cascade

NSP4 causes release of more

Ca2+

Disruption of

microvillar cytoskeleton

Intracellular Ca2+ cascade

Induces chloride secretion

Ramig (2004), Pathogenesis of intestinal and systemic rotavirus infection

Ramig (2004), Pathogenesis of intestinal and systemic rotavirus infection

Diagnostics

Clinical evaluation Fecalysis

Suspected amoebiasis or giardiasis Acute watery diarrhea▪ Very young/elderly▪ Immuno-compromised▪ Severely dehydrated

Clinical presentation is atypical

UMED Acute infectious diarrhea and common intestinal parasitism workbook

Treatment

Assess for the level of dehydration

Treatment

Treatment

No signs of dehydration Home therapy to prevent

dehydration More fluids than usual▪ ORS, salted drinks (salted rice water), chicken

soup with salt▪ Add salt (3g/L) for unsalted drinks and food▪ Usual milk feed every 3 hours▪ As much as the child wants

Frequent small feedings every 3-4 hours

Failure of oral

rehydration

Treatment

For failure of ORT ORS via nasogastric tube IV Ringer’s Lactate Solution

75 ml/kg in 4 hours Reassess

Treatment

Some signs of Dehydration Oral rehydration therapy with ORS

solution 75 ml/kg/hour

If a child wants more than the estimated amount of ORS solution, and there are no signs of over-hydration, give more

Teaspoonful every 1-2minutes Reassess

Treatment

Severe signs of Dehydration Admit in the Hospital If patient can still drink poorly, give ORS

until IV drip is running 5 ml/kg for 3-4 hours

IV Ringer’s lactate Solution (100 ml/kg) 1st 30ml/kg in 1 hour Then 70 ml/kg in 5 hours

Reassess every 15-30 minutes until strong radial pulse is present, then 1-2 hours

Prevention

Promotion of exclusive breast-feeding

Improved complementary feeding practices

Rotavirus immunization Proper food preparation/ hygiene

Prognosis

Good prognosis as long as adequate hydration has been given