acute gastroenteritis

2nd Department of Pediatrics

Dr. Dániel Erdélyi

ACUTE

GASTROENTERITIS Pediatrics, lecture for 5th year students

at the Faculty of Medicine

10th March 2020

Definitions

Epidemiology

Etiology

Clinical features

Diagnostics

Therapy

Dániel Erdélyi, 2nd Dept. Pediatrics, Semmelweis University

Acut gastroenteritis (AGE):

• Loose or liquidy stools ≥ 3x daily

(infants: change in stool consistency)

• Time span < 7 days

• Possibly associated: fever, vomitin, abdo. pain

„Prolonged diarrhoea”: 7-14 days

„Persistent diarrhoea” : 2-4 weeks

Chronic diarrhoea: > 4 weeks

Definitions


• 0,5-2 episodes per year per child

(below 3 years, Europa)

• 66 hospital admissions / 10 000 children /year (below 5 years, UK)

Epidemiology


1. Viral

2. Bacterial

3. Protozoon

Etiology

• Rotavirus • Calici viruses • Astroviruses • Adenovirus • …

• Campylobacter • Salmonella • E. coli (ETEC,

EHEC, EIEC, …) • Shigella • Yersinia • C. difficile

• Giardia lamblia, Cryptosporidium, Entamoeba Whyte LA, et al. Arch Dis Child Educ Pract Ed 2015;100:308–312.


„FOOD POISONING”

Diarrhoea and vomiting caused by toxins, produced by bacteria culturing in food.

No bacterial infection. Toxin effect only.

E.g.: - Staphylococcus aureus enterotoxin

- Bacillus cereus enterotoxin

Toxins not deactivated by heat.

Short latency, short disease course.


• Typically short latency: 12-96 hrs

• Description: frequency, consistency, volume, presence of blood, mucus

• Accompanying symtpoms (fever, vomit, pain)

• Grade of dehydrations

• Differential diagnostics?

Clinical features


Small intestine: watery, large volume Likely viral. Rotavirus, all other viruses, ETEC

Colitis: bloody, small volume, tenesmus, abdo pain, T>40°C. Likely bacterial. Shigella, Campylobacter, EIEC, EHEC

Vomit, URTI signs: likely viral

< 3 years: predominantly viruses > 3 years: bacteria, protozoa more freqent

None of these signs differentiate totally reliably!


• Age <6 months: more severe diarrhoea more prolonged diarrhoea more frequently results in dehydration

• Breastfeeding: milder course

• Chronic comorbidities e.g. immunodeficiency, IBD, malnutritiom, malignancies: risk of severe, prolonged course of gastroenteritis

Risk factors (for more severe course)


Compared to other viral AGEs:

• Higher stool frequency, fever more usual

• Severe dehydration more frequent

• Persistent (>14 days) diarrhoea more typical

ROTAVIRUS

Rotavirus mortality below 5 years of age in 2008, WHO


• Severe dehydration, hypovolaemic shock

• Electrolyte abnormalities, acidosis

• Convulsions (febrile conv., ↓Na, neuroinfection?)

• Bacteriaemia - osteomyelitis, meningitis, etc.

• Prolonged/persistent diarrhoea (small intestine bact. overgrowth SIBO, lactose-intolerance, malnutrition, etc.)

• Post-infective immun-mediated disease

• Haemolytic uraemis syndrome (HUS): shigatoxin producing EHEC, Shigella dysenteriae

Complications


Bacteria – stool culture

Viral – stool quick tests (immunoassays)

Protozoa – stool microscopy

Diagnostics

Toxins: immunoassays C. difficile, E. coli Shigatoxinja

More recently: PCR tests

Recently: immunoassaya and PCR tests

Giannattasio et al. F1000Research 2016, 5(F1000 Faculty Rev):206


Usually unnecessary!

Indicated:

• Severe symptoms

• Very high temperature

• Dysentery syndrome (e.g. bloody stool)

• Chronic comorbidities

• Prolonged course (>1 week) with weight loss

Indications of stool microbiology testing


Electrolytes: • in case of relevant dehydration • before and during i.v. fluid therapy

Full blood count, CRP, PCT: • unnecessary, usually no therapeutic effect

Stool markers (calprotectin, lactoferrin) • nem indikált, nem informatív

Endoszkópia nem indikált, kivéve IBD diff. diagn.

Further lab diagnostics


Normalise fluids- electrolytes

modyfied (hypoosmotic) ORS

isotonic iv fluids

(see seminars, next lecture)

Hygienic, isolation measures

Feeding *

Pharmacotherapy *

Therapy


Diet

What did your grandparents teach you?

• when is it allowed to eat?

• what is allowed to eat?

• what medications may help?


Early feeding:

Immediately or after fluids tolerated!

Associated with shorter disease course

No adverse effects found

No diet has been underpinned by evidence!

Only „expert advice” is available

Avpod fruit juices and sugary drinks

Low lactate diet : useful only in severe or

persistent diarrhoe

Otherwise free diet!


Antiemetics

Ondansetron effective

warnings: electrolytes, long QT

Other antiemetics were found to be uneffective in large studies

dimenhydrianate, domperidone, etc.

side effects are well known, however


Antiperistaltic agents

E.g. loperamide

Contraindicated in young children

• effective against diarrhoea, but:

• severe complications, higher mortality

is some studies


Adsorbents and anti-secretion agents

Diosmectite – adsorbent

Racecadotril – encephalinase inhibitor

both reduce stool volume

both shorten disease course

Effect of many other drugs could not be proven

Charcoal: no relevant studies


Probiotics

Proven, but little effect

Only certain probiotics

lower intensity of diarrhoea shorter disease course

Not true for probiotics in general, only for certain bacterium strains!


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Main recommendations:

• Lactobacillus rhamnosus GG

• Lactobacillus reuteri DSM 17938

• Saccharomyces boulardii


Patro-Golab et al., Nutrients 2019, 11, 2762

Points to consider: antibiotic sensitivity – effective at all? associated severe infections transfer of antibiotic resistance genes

Prebiotics, synbiotics: no evidencie


Antibiotics

Ususally not indicated,

exceptions:

• < 2-3 months of age

• immunodeficient/-suppressed patient

• based on cultrure reports


Guarino et al. J Pediatr Gastroenterol Nutr. 2014 Jul;59(1):132-52.

symptomatic advantage decreased infectivity less complicatons (HUS as well↓)

same course, symptoms same complication rate stay carriers longer

some symptomatic advantage, somewhat lower infectivity


no antibiotics are indicated for E. coli, apart from rare exceptions

Guarino et al. J Pediatr Gastroenterol Nutr. 2014 Jul;59(1):132-52.


Two different live Rotavirus vaccines are available

recommended from 6 weeks onward

Rotavirus related AGE:

• hospitalisation ↓ by 30-45%

• out patient attendance ↓ by 60-70%

Vaccines


Thanks for your attention!

Recommended literature:


acute gastroenteritis

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