Download - 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