diarrhea in peediatrics

8/12/2019 Diarrhea in Peediatrics

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Meconium Dark (almost black)

color, sticky

consistency, and

odorless nature.

Normal passage ofmeconium should

include at least one

stool in the first 48

hours after birthand end with the

onset of transitional

stools by day 4.


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Transitional

Stool Change from meconium

to the normal yellow,

seedy stools that

characterize infants

feeding on milk only

Here, the dark color ofmeconium is still visible,

but lighter, yelowish

curds can also be seen.

Exclusively breastfed

infants should havetransitional stools by

day4 if feeding is

adequate


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Normal

stool This is the stool of a 2

weeks old infant who

was fed extensively on

hydrolyzed formula.

The stool is normal, but

has less of bright yellow,seedy consistency of a

breast-fed infant stool.


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Meconium

Plug Not a normal stool

It is a very viscous

congealed mass of

meconium that may

either be spontaneously

passed or may create anobstruction and be the

cause of delayed

stooling.

Typically, after the

infant passed the plug,the subsequent stool is

normal.


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Normal phenomena

The number ,color &

consistency of stools

varies with age & diet :

Meconium

Transitional stools

Milk stools

Color of stools

Presence of solid

particles


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Definitions Diarrhea : excessive loss of fluids &

electrolytes in stool

More than 10ml(5g)/kg /day

Defined based on:

consistency of the stool (loose or watery) &

frequency (usually at least three stools in a 24

hour period)


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Definitions (cont)

Pseudodiarrhea & hyperdefecation

Increase in number of bowel movement

Encopresis

the voluntary or involuntary passage of feces intoinappropriate places at least once a month for 3consecutive months once a chronologic ordevelopmental age of 4 yr has been reached.

Dysentery : small volume , frequent, bloody,tenesmus , urgency


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Pathophysiology

A total of 8 to 9 L of fluid enters the healthy intestines on a daily basis. Only 1 to 2 L are derived from food and liquid intake; the rest is from

salivary, gastric, pancreatic, biliary, and intestinal secretions.

Each day, about 90% of this fluid is absorbed in the small intestine, ~1 L

enters the colon, and about 100 mL is excreted in stool.


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Normal stool output is approximately 100

to 200 g/day.

Diarrhea is defined as stool outputgreater than 200 g/day in children older

than 2 years of age and greater than 10

mL/kg/day in children younger than 2

years of age.

It is also described more practically as anincrease in liquidity and frequency of

bowel movements.


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Categorizing

Diarrhea

Duration:

acute (2 weeks) or chronic (>2 weeks), or by

Mechanism:

osmotic or secretory.

It can also be categorized by the presence orabsence of malabsorption


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Both secretory and osmotic

diarrhea are caused by defective

or impaired mucosal absorption.


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Osmotic Diarrhea

Excess amounts of non-absorbed substances, such as lactose,lactulose, fructose, or sorbitol, remain in the intestinal lumen,

causing luminal water retention.

After these luminal substances enter the colon, they are processed by

colonic flora, producing large amounts of organic acids, increasedflatulence, and faster transit.


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The fecal osmolar gap [290 mOsm/L {2 (measured stool sodium + measured stoolpotassium)}] is usually greater than 50 mOsm/L inthe setting of osmotic diarrhea.

When an abnormal gap is found, reducingsubstances, stool pH, and fecal fat should bemeasured.

Osmotic diarrhea improves with fasting.

Examples of osmotic diarrhea include lactasedeficiency, celiac disease, and short bowelsyndrome.


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Secretory diarrhea

Abnormal ion transport in epithelial cells, leading to decreased absorptionof electrolytes and increased secretion of fluid.

The fecal osmolar gap is less than 50 mOsm/L, and the diarrhea persists

despite fasting.

Examples include congenital chloride and sodium diarrhea, cholera, and

neuroendocrine tumors.


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Dysmotility

Another important underlying mechanism of

diarrhea is dysmotility.

For example, pseudo-obstruction may result in

bacterial stasis, overgrowth and resultant

diarrhea, while hyperthyroidism may be

associated with diarrhea because of rapid

intestinal transit.


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Stool Character

The character of the stool can help to

determine the origin of diarrhea.

Disease of small intestine origin:

Watery, voluminous, non-bloody stool with few or

no white blood cells (WBCs) and low pH (


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The most common electrolyte

abnormalities related to diarrhea

include hypokalemic metabolicacidosiscaused by bicarbonate and

potassium losses in stool.


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Bloody Diarrhea

A concerning symptom.

The most common cause is infection, especially ina setting of fever and acute onset.

If bloody diarrhea is progressive and persistent,chronic inflammatory causes should beconsidered.

The age of the patient is also important.

In infants, milk proteininduced enterocolitis is acommon cause of bloody stools.


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AcuteDiarrhea


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Etiology & Pathogenesis

The most common cause of acutediarrhea is infection.

In young children, this is most often

viral, with the most common agents

being rotavirus, adenovirus,astrovirus, and norovirus.

Rotavirus is a leading cause of death

in children younger than 5 years of

age worldwide

In immunocompromised hosts,

viruses, including cytomegalovirus,

Epstein-Barr virus, and BK virus,

should be considered.


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It is estimated that 70% of infectious diarrhea is

foodborne, and thus a detailed history of exposures

is very important.

E d i di i


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Exposure to untreated water may cause giardiasis.


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Use of public swimming pools poses a risk of

Shigella, Giardia, Cryptosporidium, and

Entamoeba infection, with the last three beingchlorine resistant.


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Home pets can transmit infections.

For example, turtles carry Salmonella spp.


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History of foreign travel may narrow

exposures based on the specific destination.

The most common etiology of travelersdiarrhea remains enterotoxigenic Escherichia

coli.

Cryptosporidium and Giardia spp. are

responsible for most parasitic infections in

developed countries.


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Clostridium difficile infection, previously thought toaffect only hospitalized patients or those takingantibiotics, is now responsible for 40% of community-acquired diarrhea.

A recent increase in C. difficile infections has beenobserved, some attributable to the resistant strain, BI/NAP1.

An overgrowth of toxin-producing Clostridium organ-

isms causes pseudomembranous colitis, which may bea potentially life-threatening condition.

Vibrio cholerae remains a cause of illness and death inwar zones and developing countries.


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The mechanism of infectious diarrhea is

primarily secretory.

It can quickly lead to electrolyte abnormalities

and acidosis.

Infection may result in villous atrophy, which

can add an osmotic component.

Mucosal healing after infection may lead to

transient postinfectious diarrhea.


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Other causes of Acute Diarrhea

Particularly concerning inafebrile children

Intussusception, a telescoping

of two segments of bowel that

occurs mostly in childrenbetween 6 months and 2 years

of age, may present with bloody

diarrhea.

The typical presentation is colicky

abdominal pain, vomiting, and an

abdominal mass.

Currant jelly stools do not occur

in all patients with intussusception

but are pathognomonic for the

condition.


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Hemolytic- uremic syndrome (HUS) is an

uncommon but potentially fatal illness that

may present with acute bloody diarrhea. HUS begins as a mild gastroenteritis that evolves

into hematochezia, microangiopathic hemolytic

anemia, thrombocytopenia, and acute renalfailure.

Less commonly, appendicitis may present with

abdominal pain and diarrhea as a result ofcolonic irritation from the inflamed appendix


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Other acute causes of diarrhea include

inflammatory bowel disease,

overfeeding (caused by increased osmotic loads),

antibiotic-associated diarrhea (likely caused by

changes in bowel flora),

extra-intestinal infections (otitis media, urinary

tract infection, pneumonia), and toxic ingestions.


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Clinical Presentation

In any patient presenting with acute diarrhea,

a thorough history and physical examination

should guide the immediate and subsequent

evaluation and therapy.

It is important to quantify the duration and

frequency of stooling in addition to emesis,

liquid intake, and urine output to assess forhydration status.


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A travel historyshould beobtained.

Recent antibioticuse may suggestpseudomembra

nous colitis withC. difficile.

History Taking


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The presence of

abdominal pain mayoccur in infectious

enteritis; however,

it may also be indicativeof

intussusception

(colicky, episodic) or appendicitis

(periumbilical, right

lower quadrant).


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Bloody diarrhea is usually typical in bacterial

enteritis but may be seen in viral illness, HUS,

or colitis.

Associated vomiting suggests viral

gastroenteritis.


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In infectious diarrhea, there is usually a 1- to 8-

day incubation period with a sudden onset of

symptoms.

There may be associated fever, vomiting, crampyabdominal pain, bloody stools, tenesmus, loss of

appetite, and dehydration.

The immune state of the child should bedetermined because an immunocompromised

child may present with more unusual organisms.


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Physical Examination

Begins with the general appearance of thechild

does the child look malnourished or has he or she

lost weight? Vital signs then help to guide evaluation and

management.

Fever usually indicates infection.

Pulse and blood pressure changes mayindicate dehydration, shock, or sepsis.


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A careful abdominal examination should look

for bowel sounds (to evaluate for obstruction)

and masses (to evaluate for intussusception).

A stool sample should be guaiac tested for

microscopic blood.


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Evaluation & Management

Patients should be assessed for hydration

status and electrolyte abnormalities, with

correction as indicated.

Acute viral gastroenteritis often requires

aggressive rehydration with intravenous fluids

or oral rehydration solutions.


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Stool should be sent for viral polymerase chainreaction, culture, and C. difficile toxin assay.

Most gastrointestinal (GI) infections, except for C.

difficile, do not require treatment. Antibiotics tend to prolong diarrhea and result in

a carrier state.

There are special circumstances, such as

Salmonella enteritis in young infants andimmunocompromised patients, for whichantibiotic therapy is indicated.


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Most infections resolve in 14 days

in healthy children.

Antidiarrheal agents are typicallynot effective and should be

avoided in children.


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Thankyou

diarrhea in peediatrics

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