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

Bacteria causing diarrhea

• 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..

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

Traditional treatment of diarrheaTreatment Disadvantages

Intravenous rehydration

Diet

Antibiotic and antidiarrheal drugs

HospitalizationIncreased risk of infectionUnnecesssary laboratory investigationsEmotional traumaIncreased cost

Weight lossRisk of malnutrition

IneffectiveToxicAllergicRisk of secondary infections

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

Assessment of dehydration in children

Non Moderate Severe

General appearance

Eyes

Tears

Mucous membranes

Thirst

Skin elasticity

Treatment

Good

Normal

Present

Moist

Absent

Pinc retracts immediately

At home

İrritable

Sunken

Absent to reduced

Dry

Present

Pinc retracts slowly

ORS

Lethargic, hipotonic or comatose

Grossly sunken

Absent

Very dry

Can’t drink

Pinc retracts very slowly

IV

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 aged six months

or more.– Children aged less than six months showed no benefit

with zinc. – Vomiting was more common 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)

Composition of the ORS recommended by WHO

g/L Mmol/L

NaCl

KCl

Citrate(Bicarbonate)

Glucose(Rice-flour)

3.5

1.5

2.9(2.5)

20(50)

NaKCl

Citrate(Bicarbonate)

Glucose

902080

1030

110

Electrolyte losses in diarrheal disease (mmol/L)

Na K Cl HCO3 Glucose

Normal stoolsCholera Adult ChildEnteritis ChildORS

5

140101

5690

10-12

1327

2520

2-3

10492

5580

3

4432

1430

111

Comparison of some fluids used for rehydration

Fluid CHOmmol/L

Nammol/L

CHO/Na Kmmol/L

Basemmol/L

OsmolaritymOsm/L

ColaApple juiceChicken soupWHO-ORSPedialyteRehydralyteOsmosal

700690

0111140140144

23

25090457560

350230

01.23.11.92.4

0.1328.220202020

1300

10101010

750730500311250310304

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…

ORS treatment at home

Age Amount of ORS after every watery stools

<2

2-10

>10

50-100 ml

100-200 ml

Not limited

ORS treatment

Mild Moderate Severe*

RehydrationDuration

Maintenance*Duration

50 ml/kg4-6 hours

100 ml/kg18-20 hours

100 ml/kg4-6 hours

100 ml/kg18-20 hours

100-150 ml/kg4-6 hours

100 ml/kg18-20 hours

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