ACUTE GASTROENTERITIS

I. READINGS

1.1 DEFINITIONAcute Gastroenteritis is a sudden inflammation of the gastric or stomach mucosa. It is defined as a diarrheal disease of rapid onset involving inflammation of the stomach and intestines, a disturbance in intestinal motility and absorption. It interferes with water and electrolytes absorption and accelerates the exertion of intestinal content

Typically, the illness usually lasts 3-5 days. The hallmark of this disease is stool frequency accompanied by vomiting. This disease is common and a costly clinical problem in children during the first 3 years of life and up to 5 years because children are susceptible to catching germs and diseases and their gastrointestinal tract are not strongly and well developed to fight off certain pathogens. A child will likely experience about 1 to 3 acute diarrheal illnesses. Nearly all diarrheal infections are transmitted via the fecal-oral route. Many bacterial etiologies are also food borne.

Symptoms usually appear within 12 to 48 hours after exposure to a gastroenteritis-causing agent and last for 1 to 3 days. Some foreign agent cause symptoms that last longer. Severe diarrhea can be fatal because it causes fluid and electrolyte imbalance in the body which can lead to death if not treated immediately and can cause serious health problems such as organ damage, shock, or coma—a sleeplike state in which a person is not conscious. Severe dehydration may require intravenous fluids and hospitalization. In addition, a capillary refill lasting over 2 seconds is a sign of dehydration.

SIGNS OF DEHYDRATION IN BABIES AND YOUNG CHILDREN ARE:dry mouth and tonguelack of tears when cryingno wet diapers for 3 hours or more

high feverunusually cranky or drowsy behavior

sunken eyes, cheeks, or soft spot in the skull

DEGREE OF DEHYDRATION

Mild (3-5%)

Normal or increased pulseDecreased urine outputThirstyNormal physical exam

Moderate (7-10%)

TachycardiaLittle/no urine outputIrritable/lethargicSunken eyes/fontanelle Decreased tearsDry mucous membranesSkin- tenting, delayed cap refill, cool, pale

Severe (10-15%)Rapid, weak pulseDecreased blood pressureNo urine outputVery sunken eyes/fontanelle No tearsParched mucous membranesSkin- testing, delayed cap refill, cold, mottled

1.2 CAUSESAcute Gastroenteritis is often caused by dietary indiscretion- the person eats food that is contaminated with disease-causing microorganisms that are irritating or too highly seasoned. Other causes of acute gastroenteritis include use of aspirin, other non-steroidal anti-inflammatory drugs, bile reflux, and radiation therapy.

These cause the irritation of the GI wall, causing an inflammatory response, giving emphasis on the main cause, which is ingestion of contaminated food. This then leads to the presence of manifestations of inflammation, which includes increase in white blood cell count, fever and rare episodes of chills, nausea and vomiting.

Nausea and vomiting are neurotoxic effects of toxins, as well as factors and substances produced by WBC’s, which has systemic direct effect in the GIT. This, if not addressed could lead to fluid and electrolyte imbalance.

These are usually the manifestations seen in acute gastroenteritis. If the disease is left untreated or is chronic in duration, the inflammation of the GI lining worsens and could lead to erosion of the mucosal wall and blood vessels.

This causes bleeding which is manifested as blood streaked stool or melena. When the erosion is on the upper tract of intestine it causes hematemesis. This could lead to hemorrhage, and eventually, anemia, with signs and symptoms as weakness, paleness, diaphoresis and dizziness.

The untreated could cause hypovolemic shock with manifestations as RR, PR, BP, cold clammy, palpitation, and diaphoresis.

On the other hand, the erosion of the GI lining could lead to perforation. This causes its contents to leak out and lead to pancreatitis and paralytic ileus.

CAUSATIVE AGENT

VIRALViruses cause about 70% of episodes of infectious diarrhea in children both in the developed and developing world. Viral gastroenteritis is a leading cause of severe diarrhea in both adults and children. Many types of viruses can cause gastroenteritis

THE MOST COMMON ONES ARE:•Rotavirus, the leading cause of severe gastroenteritis in children.

•Astrovirus– a genus in the family Astroviradae; small, non enveloped, single stranded

RNA virus associated with enteric infections in several species including cattles, sheep and dogs.

Enteric adenovirus – produces gastroenteritis Clinical Diarrhea; keratoconjunctivitis and nasopharyngitis- typical infection with other adenoviruses.

•Norovirus (also called Norwalk-like virus). It is common among school-age children.These viruses are often found in contaminated food or drinking water. Symptoms of viral gastroenteritis usually appear within 4 - 48 hours after exposure to the contaminated food or water.

BACTERIALIn the developed world is the primary cause of bacterial gastroenteritis with half of these cases associated with. In children bacteria are the cause of about 15% of cases.

The most common types are Salmonella, Shigella, Escherichia Coli and Campylobacter. If food becomes contaminated with bacteria and remains at room temperatures for a period of hours, the bacteria can multiply and increase the risk of infection in those who eat the food.

Some foods commonly associated with illness include raw or undercooked meat, chicken, seafood, and eggs; raw sprouts; unpasteurized milk and soft cheeses; and fruit and vegetable juices.

Infants can carry these bacteria without developing symptoms. is usually a type of bacterial gastroenteritis

PROTOZOALA number can cause gastroenteritis, most commonly  and . These as a group make up about 10% of cases in children.

TRANSMISSIONTransmission may occur via consumption of contaminated water, or when people share personal objects. In places with wet and dry seasons, water quality typically worsens during the wet season, and this correlates with the time of outbreaks.

Bottle-feeding of babies with improperly sanitized bottles is a significant cause on a global scale.

Transmission rates are also related to poor hygiene, especially among children, in crowded households,

and in those with pre-existing poor nutritional status. After developing tolerance, adults may carry certain organisms without exhibiting signs or symptoms, and thus act as  natural reservoirs of contagion.

1.3 PREDISPOSING AND PRECIPITATING FACTORSAgeLifestyleSocio-culturalPoor hygiene

1.4 SIGNS AND SYMPTOMS

DiarrheaVomitingFeverWeaknessIrritabilityDehydration

TREATMENT AND MANAGEMENTREHYDRATION - The primary treatment of gastroenteritis in both children and adults is rehydration. This is preferably achieved by oral rehydration therapy although intravenous delivery may be required if there is a decreased level of consciousness or dehydration is severe.

Complex-carbohydrate-based ORT such as those made from wheat or rice may be superior to simple sugar-based ORT. Sugary drinks such as soft drinks and fruit juice are not recommended in children under 5 years of age as they may increase diarrhea. 

Plain water may be used if specific ORT are unavailable or not palatable. A nasogastric tube can be used in young children to administer fluids.

DIETARY - It is recommended that breastfed infants continue to be nursed per usual and that formula-fed infants continue their formula immediately after rehydration with ORT.

Lactose-free or lactose-reduced formulas usually are not necessary. Children should continue their usual diet during episodes of diarrhea with the exception that foods high in simple sugar should be avoided.

The BRAT diet (bananas, rice, applesauce, toast and tea) is no longer recommended, as it contains insufficient nutrients and has no benefit over normal feeding.  

Some probiotics have been shown to be beneficial in reducing both the duration of illness and the frequency of stools. Fermented milk products (such as yogurt) may also be beneficial.

Zinc supplementation appears to be effective in both treating and preventing diarrhea among children in the developing world.

ANTIBIOTICS - Antibiotics are usually used for gastroenteritis, although they are sometimes recommended if symptoms are severe or a susceptible bacterial cause is isolated or suspected.

If antibiotics are decided on, a macrolide such as azithromycin is preferred over a flouroquinolones due to the higher rates of resistance to the latter. Pseudomembranous colitis,

usually caused by antibiotics use, is managed by discontinuing the causative agent and treating with either metronidazole or  vancomycin.

ANTIMOTILITY - Antimotility medication has a theoretical risk of causing complications; clinical experience, however, has shown this to be unlikely. They are thus discouraged in people with bloody diarrhea or diarrhea complicated by a fever.

Loperamide, an opoid analogue, is commonly used for the symptomatic treatment of diarrhea. Loperamide is not recommended in children as it may cross the immature blood brain barrier and cause toxicity. 

Bismuth subsalicylate, an insoluble complex of trivalent bismuth and salicylate, can be used in mild to moderate cases.

PREVALENCE RATE - NationalAccording to Department of Health in the Philippines, incidence rate of Acute Gastroenteritis belongs to the top 10 leading cause of infant mortality and morbidity rate.

INFANT MORTALITY and MORBIDITY: TEN (10) LEADING CAUSES

NUMBER AND RATE/per 1000 live births AND

PERCENTAGE DISTRIBUTION

Philippines, 2006

Cause Number Rate Percent

1.Bacterial sepsis of newborn

3,194 1.9 14.7

2. Respiratory distress of newborn

2,400 1.4 11.0

3. Pneumonia 1,947 1.2 8.9

4.Disorders related to short gestation and low birth weight, not elsewhere classified

1,608 1.0 7.4

5. Congenital malformations of the heart

1,409 0.8 6.5

6. Congenital pneumonia 1,290 0.8 5.9

7. Neonatal aspiration syndromes

1,145 0.7 5.3

8. Other congenital malformation 1,046 0.6 4.8

9. Intrauterine hypoxia and birth asphyxia

1,005 0.6 4.6

10.Diarrhea and gastro-enterities of presumed infectious origin

984 0.6 4.5

1.7 PREVALENCE RATE - LOCAL

ACUTE GASTROENTERITIS AT LAOAG CITY GENERAL HOSPITAL (LCGH)

JANUARY-MAY 2012

Under 1 1-4 5-9 10-14 15-19 20-44 45-64 = >65 total TOTAL

M F M F M F M F M F M F M F M F M F

Jan. 3 2 2 4 2 1 1 2 3 9 2 2 1 2 15 21 36

Feb 3 1 5 2 5 1 2 1 2 1 1 3 1 20 8 28

Mar 4 2 7 5 6 1 1 1 1 1 7 6 2 2 2 3 30 21 51

Apr 3 3 9 9 7 3 2 1 1 7 10 5 3 1 31 33 64

May 1 1 13 5 3 1 1 1 2 5 3 2 25 13 38

TOTAL 14 9 36 25 23 5 6 3 3 6 21 26 9 13 9 9 121 96 217

ANALYSIS:The data above shows the prevalence rate for AGE taken from Laoag City General Hospital from January to May of 2012. Based on this data, occurrence of AGE is highest in total in the male population of 121 from under 1 to over 65 years of age.

The overall total prevalence rate from January to May 2012 is 217 both male and female. The highest incidence of AGE for 2012 so far is 36, from age 1-4 years old males and 25 in females. This concludes that AGE can affect any age but most frequent in children at the age 1-4 years old.

II. ANATOMY AND PHYSIOLOGY

The stomach is an enlarged segment of the digestive tract in the left superior portion of the abdomen. It lies obliquely from left to right across the upper abdomen directly beneath the diaphragm.

When empty, the stomach resembles a J-shaped tube, a when full, a giant pear. The normal capacity of the stomach is 1-2 liters. Anatomically, the stomach is divided into the fundus, the body, and the pyloric antrum or pylorus.

The concave lesser curvature forms the upper right border of the stomach and the convex greater curvature forms the left and lower borders. Sphincters at each end of the stomach regulate inflow and outflow.

The cardiac sphincter or lower esophageal sphincter (LES) allows foods to flow into the stomach and prevents reflux of the gastric contents into the esophagus. The area of the stomach into which the cardiac sphincter opens is known as the cardiac region.

The terminal pyloric sphincter relaxes to permit food to enter the duodenum, and when contracted prevents backflow of the intestinal contents of the stomach.

The pyloric sphincter is of particular clinical interest because obstructive narrowing (stenosis) may occur as a complication of peptic ulcer disease.

Pyloric stenosis or pylorospasm results when hypertrophied or spastic muscle fibers surrounding the opening fail to relax sufficiently to permit food to pass easily from the stomach to the duodenum.

The stomach is composed of four layers. The serosa, or outer layer, is a part of the visceral peritoneum. The two layers of the visceral peritoneum come together at the lesser curvature of the stomach

and the duodenum and extend upward to the liver, forming the lesser omentum. Peritoneal folds reflected from one organ to another are distinguished as ligaments. Thus, the lesser omentum

(also known as the hepatogastric and hepatoduodenal ligaments) suspense the stomach along its lesser curvature to the liver. At the greater curvature, the peritoneum continuous downward as the greater omentum, dropping over the intestines like a large apron.

The muscularisis composed of 3 layers of smooth muscles ; an outer longitudinal, a middle circular layer, and an inner oblique layer. This unique arrangement of fibers provides the variety of contractions necessary to break food into the parietal cells, chum and mix it with gastric juices, and propel it into the duodenum.

The submucosa is composed of loose areolar tissue that connects the muscularis and mucosal layer. It permits the mucosa to move with peristaltic motion. This layer also contains the nerve plexuses, blood vessels and lymph channels.

Nerve plexuses; compose of parasympathetic nerve fibers and cell bodies are found in the submucosa and muscularis layers. Together, the nerve plexuses of both layers compose the intramural plexuses, which extremely important for control of digestive tract functions.

The mucosa, the inner layer of the stomach, is arranged in longitudinal folds called rugae, which allow for distention as the stomach becomes filled with food. Several types of glands are located in this layer and are categorized according to anatomic portion of the stomach in which they are located.

Cardiac glands lie near the cardiac orifice and secrete mucus. The fundicor gastric glands are located in the fundus and over the greater part of the stomach. Gastric glands have three main types of cells.

The Zymogenic or chief cells secrete pepsinogen. Pepsinogen is converted into pepsin in acid environment. Parietal cells secrete hydrochloric acid and intrinsic factor. Intrinsic factor is necessary for the absorption of vitamin B12 in the small intestine.

Mucous cells found in the neck of the fundic or gastric glands secrete mucous. The hormone gastrin is produce by G cells located in the pyloric region of the stomach. Gastrin stimulates the gastrin glands to produce hydrochloric acid and pepsinogen.

DIGESTIVE AND SECRETORY FUNCTIONS

Digestion of protein by pepsin and HCl is begun; digestion of starches and fats by gastric amylase and lipase is of little importance in the stomach.

Gastrin synthesis and release are affected by ingestion of protein, distention of the antrum,

alkalinization of the antrum and vagal stimuli.

Intrinsic factor secretion enables the absorption of Vitamin B12 from the distal small bowel to take place.

Mucus secretion forms a protective shell for the stomach as well contributing to lubrication of food easier transport.

MOTOR FUNCTIONSReservoir function stores until it can be partially digested and moved on in GI tract; adapts to increased volume without an increase in pressure by receptive relaxation of the smooth muscle; this is mediated by the vagus nerve and induced by gastrin.

Mixing function breaks food into small particles and mixes it with gastric juice through contractions of muscular coat; peristaltic contractions controlled by a basic intrinsic electrical rhythm.

Gastric emptying function controlled by opening of pyloric sphincter, which is influenced by viscosity, volume, acidity, osmotic activity and physical state, as well as by emotions, drugs and exercise; gastric emptying is controlled by nervous and hormonal factors.

III. PERTINENT DATA

NAME: Christyfanie Parillo Samonte

AGE: 19 months old

SEX: Female

ADDRESS: Brgy. 27, Laoag City

DATE OF BIRTH: January 01, 2011

PLACE OF BIRTH:Laoag City

TYPE OF DELIVERY:NSVD

RELIGION: Roman Catholic

HOSPITAL NO.: 24296

CHIEF COMPLAINTS: weakness, loose bowel

movement, fever INITIAL DIAGNOSIS:

AGE with moderate signs of dehydration

FINAL DIAGNOSIS: AGE with dehydration

corrected

ATTENDING PHYSICIAN:Dr. Rodrigo L. Catcatan Jr.

DATE OF ADMISSION:July 27, 2012

TIME OF ADMISSION:5:30 PM

DATE OF DISCHARGE: July 29, 2012

TIME OF DISCHARGE:1:45 PM

Admitting vital signs

TEMP: 40°c PR: 148 bpm RR: 58 bpm WT: 9 kgs.

IV. FAMILY HEALTH

HISTORY

A. FAMILY BACKGROUND

Name Relationship to

the Client

Age Sex Civil Status Religion Occupation Educ.Attai

nment

Eugenio

Samonte Jr.

Lolo 50 Male Deceased Roman

Catholic

N/A College

Graduate

Mila Samonte Lola 51 Femal

e

Widow Roman

Catholic

House keeper,

store owner

High school

Graduate

Jerry Clemente Lolo 36 Male Single Roman

Catholic

Unemployed College

Graduate

Stephanie

Samonte

Mother 16 Fem

ale

Single Roman

Catholi

c

N/A 3rd yr

H.S.

Christyfanie

Samonte

Self 19

mos.

Femal

e

N/A Roman

Catholic

N/A N/A

Christyfanie belongs to an extended family consisting of 4 members. Christyfanie’s mother Stephanie, is 16 years old with a 3rd year high school completion. Her lola Mila, is a 51 years old widow, high school graduate, a housekeeper and a sari sari store owner. Lolo Jerry Clemente, is lola Mila’s brother.

He is 36 years old, single male, unemployed with a college degree. They are currently living in Brgy. 27, Laoag City. Their home is a bungalow style made out of concrete with a shared living space of about 10x25ft.

Mila’s husband Eugenio Samonte Jr., died 5 years ago from a head injury. Since then, the family became a matriarchal family structure which is headed by Mila. She is the only breadwinner and decision maker for the whole family.

As far as religious belief, the family celebrates religious holidays such as the holy week, all soul’s day and Saint Joseph feast even though they are not a devout catholic.

FAMILY EXPENSESAlthough the family has no formal occupation, the source of income comes solely from Mila’s sari sari store which generates about Php 6,000.00 per month.

Stephanie said that their source of income is enough to sustain their needs even though there are moments when the family runs out of money. One time for example, was when the baby was hospitalized, Mila actually went to ask for help at their barangay.

Stephanie and her baby, Christyfanie, are still financially dependent on her mother, Mila. According to Stephanie, the family income is spent on the following each month:

Php 1,500.00 for food, which includes vegetables, fish, meat and rice

Php 700.00 for electric billPhp 500.00 for NawasaPhp 1,000.00 for baby supplies (diapers, clothes, etc.)

Php 1,000.00 for the sari sari store inventory (can goods and noodles)

Php 250.00 for wilkins mineral water for the whole family and

Php 100.00 for Stephanie’s cell phone

Php 250.00 for medical expensesPhp 200.00 for transportationPhp 300.00 for miscellaneous expenses, and Php 100.00 savings or extra cash

MONTHLY INCOME Php 6,000.00 %

Monthly expenses

FOOD Php 1,500.00 25

ELECTRIC BILL Php 700.00 12

NAWASA WATER Php 500.00 8

BABY Php 1000.00 17

INVENTORY Php 1000.00 17

WILKINS Php 250.00 4

CELL PHONE Php 200.00 3

MEDICAL EXPENSES Php 250.00 4

TRANSPORTATION Php 200.00 3

MISC. Php 300.00 5

SAVINGS Php 100.00 2

TOTAL MONTHLY EXPENSES: Php 6000.00

FOOD25%

ELECTRIC BILL12%NAWASA

8%

BABY 17%

INVENTORY17%

WILKINS4%

CELL PHONE

3%

MEDICAL EXP4% TRANS.

3% MISC.5%

SAVINGS2%

monthly expenses

B.FAMILY HEALTH HISTORY

Our patient Christyfanie Samonte, is a 19 months old female living with her family in Laoag City, Ilocos Norte. Her grandmother Mila Samonte, stated that her grandfather Guillermo Parillo was diagnosed with asthma at the age of 70 at Provincial Hospital. His physician was Dr. Pechay

Mila does not remember the medications he took during his illness. Guillermo died from asthma at the age of 80 in the year 2000 at Mariano Marcos Memorial Hospital and Medical Center at Batac, Ilocos Norte.

Mila’s mother Florentina Fajardo, was diagnosed with DM TYPE II in the United States. Mila does not remember Florentina’s medications and who her physician was. When her mother arrived in Philippines, she continued her medical check-up at Our Lady of Fatima Clinic and Hospital. Dr. Castillo was her physician

Florentina was using a glucometer to monitor her blood sugar level. She said she used it as a way to monitor her condition to determine whether she would take her medications or not.

Mila Samonte herself was diagnosed with low blood pressure at a young age during high school. Dr. Gertes was her physician at Gertes Hospital. SG-Gluthergen was her prescribed medication. She was confined for 3 days in the hospital. According to Mila, 1 week after hospitalization, she felt much better than before even though she still experienced a low blood pressure.

To relieve her condition, she to use OTC drugs such as SG-Gluthergen for mild symptoms with Revicon forte multivitamins tablets, taken once a day. When her condition would get worse, she would take twice the dosage of the OTC and the multivitamins.

Jerry Clemente who is the brother of Mila Samonte, used to drink alcohol such as beer at 6 bottles per day and gin at 2 bottles per week. Jerry also used to smoke 2 packs of marlboro red per day for 6 years during college. He was diagnosed with high blood pressure at their barangay health center in Brgy. 27 Laoag City 2 years ago. His doctor administered Calciblock for 1 month.

Jerry stopped after one month with the medication and maintained his prescribed diet of low fat and low sodium food only. After 6 months from his diagnosis of High Blood Pressure, he encountered gastritis which was diagnosed by Dr. Deborah Dela Cruz. Jerry was prescribed Maalox for 1week. After that, his gastritis occurred only once in a while and was managed it by eating sky flakes plus taking Maalox to relieve the condition. As of now, Jerry doesn’t have any known allergies.

Stephanie, who is the mother of Christyfanie, was hospitalized when she was in sixth grade at Gertes hospital, San Nicolas I.N. She was diagnosed with gastritis by Dr. Gertes, and was admitted for two days with treatment IV fluid and medications which she can’t remember.

After that,Dr. Gertes then prescribed her with Maalox for 3 days, twice daily. She was advised to minimized her consumption of soft drinks, avoid spicy and fatty foods, and eat small frequent meals to prevent the recurrent of the gastritis. Now, when times she experienced stomach pain, she would take kremil-s as OTC drug along with sky flakes.

Based on our interview, the family had already received their immunizations. Mila said that she has only gotten one vaccination so far on her arm. She added that back in her childhood days, she believes that the vaccines we get now might not have been available back then. The same is true for her brother Jerry. Stephanie on the other hand, has not completed her immunizations.

She said she had taken her BCG, and believes that she had taken most of the initial vaccines given at school. For Christyfanie, she had already completed her immunization such as BCG (Bacillus Calmette-Guerin) and Hepatitis B vaccine which were given at birth. DPT (Diptheria Pertusis Tetanus) and Oral Polio Vaccine were administered 6 weeks after her birth.

The family is superstitious and believes in “albularios”. At one time, Mila went to the health center for check-up when she said “nagbudo-budo toy imak”. At that point they gave her medications which she’s unable to remember the medications. After 3 days, her condition didn’t change so she decided to go to an “albularyo”. The “albularyo” gave her “pauli nga lana” and advised her to boil guava and avocado leaves for her bathing, she she followed it for 3 days and her condition got better.

When they were children Mila would use moringa oleifera or “malungay” extract as a topical application for her injuries or bruises, and discovered that it was a very effective cure.

C.PAST HEALTH HISTORY

Christyfanie is the first and only baby of Stephanie and her boyfriend Christopher Cacaluan. Christyfanie was born at GRAMH on January 1, 2011 through normal spontaneous vaginal delivery (NSVD).

Like other children, Christyfanie had gone through many common ailments such as fever, cough and colds. With fever, the mother would usually give her baby OTC drugs such as Tempra ,1ml every 4hours and Myracof syrup for cough and colds. As far as communicable diseases, Christyfanie already had measles when she was 9 months old and was vaccinated at that point.

The mother managed her baby’s illness by dressing her with a long black shirt believing that measles will easily fade. Christyfanie’s mother concluded that her baby had never experienced any major injuries and had never been hospitalized before.

D. PRESENT HEALTH HISTORY

Christyfanie is usually a playful child. She can interact with other people, and can play alone while her mother is doing household chores. During bathing, Christyfanie normally use the “palanggana” as bathtub for her to swim in.

On occasion, she would drink small amounts of water from bathing. One day prior to admission, her mother and her lola observed that Christyfanie was experiencing frequent watery stools with a yellowish color at 6 pm just last July 26. But before that, Christyfanie ate 3 pieces of fish crackers, a small amount of pancit and a snack in the morning.