Acute gastroenteritis (AGE) - PowerPoint Presentation

Slide1

Acute gastroenteritis (AGE)

Common

condition

in

childhood

5

million

deaths

per

year

<5 yo in

developing

countries

2

million

deaths

annually

worldwide

Rotavirus

is

the

most

important

cause

but

other

intestinal

viruses

such

as

norwalk

,

noroviruses

and

enteroviruses

,

bacteria

(

Salmonella

,

Shigella

)

and

V

ibrio

cholerae

,

protoza

(

such

as

criyptosporidium

)

are

also

important

causesSlide2

AGE

The

hallmark

is

diarrhea

Change

in

bowel

habit

resulting

in

substantially

more

frequent

and

/

or

looser

stools

Diarrhea

may

be

associated

with

vomiting

Two

important

clinical

suggestions

:

-

diarrhea

and

/

or

vomiting

can be

non

-

specific

presenting

signs

in

children

with

systemic

sepsis

e.g

meningococcal

infection

,

septicemia

and

urinary

tract

infection

.

Assess

each

child

carefully

-

if

a

child

has

vomiting

alone

consider

the

possibility

of

other

diagnoses

e.g

intestinal

obstruction

,

diabetes

or

meningitisSlide3

Degree of dehydration in AGE

Clinical

signs

become

apparent

at 3-4%

Minimal

or

no

dehydration

if

<3%

Mild

to

moderate

if

3-8%

dehydrated

Severely

dehydrated

if

>9%Slide4

Assessment of degree of

dehydration

and

recommended

management

Minimal

or

no

deydration

(<3%): no

signs

-

manage

at

home

generally

-normal

fluids

,

continue

breast

-

feeding

, normal

diet

-

admit

if

very

young

,

diagnosis

in

doubt

,

or

large

lossesSlide5

Assessment of degree of

dehydration

and

recommended

management

Mild

to

moderate

dehydration

(3-8%)

-general appearance abnormal (looks unwell)

-

dry

oral

mucosa

-

absent

tears

-

sunken

eyes

-diminished skin turgor (skin recoil after pinching skin>2s, capillary return >2s)

-

Manage

in

hospital

with

ORS

-

if

ORS not

tolerated

,

may

require

NG

tube

feeds

or

IV

fluids

-

resume

normal

diet

when

toleratedSlide6

Assessment of degree of

dehydration

and

recommended

management

Severe

dehydration

(>9%):

-

signs

from

mild

to

moderate

+

deep

acidotic

breathing

-

altered

neurological

status

(

drowsiness

,

irritability

)

-

decreased

peripheral

perfusion

-

circulatory

collapse

-

measure

BUN,

electrolytes

,

acid

-

base

balance

-

resuscitate

with

IV

bolus

if

shocked

-

rehydrate

IV

over

2-6

hrs

with

regular

clinical

and

lab

reviewSlide7

Assessment of degree of

dehydration

and

recommended

management

Fluid

requirement

calculated

as:

volume

needed

to

replace

the

deficit

+

maintenance

fluids

+

ongoing

lossesSlide8

Daily maintenance

fluid

requirement

(MFR)

Weight

of

the

child

MFR

First

10 kg 100ml/kg

Second

10 kg 50 ml/kg

Subsequent

20 ml/kg

Example

:

if

the

child

weighs

8 kg MFR is 800ml

İf

the

child

weighs

12 kg MFR is(10x100)+(2x50):1100 ml

İf

the

child

weihgs

23 kg MFR is (10x100)+(10x50)+(3x20):1560 mlSlide9

Route of rehydration

Question

: is oral

rehydration

as

effective

and

safe

as IV

rehydration

?

Compared

to

children

treated

with

IV

rehydration

children

treated

with

oral

rehydration

has

significantly

fewer

major

adverse

events

including

death

or

seizures

and

significant

reduction

in

lenght

of

hospital

stay

Fonseca

BK,

Holdgate

A.

Arch

Pediatr

Adolesc

Med

2004;158:483-90 (meta

analysis

, 16

trials

1545

children

)Slide10

Route of rehydration

A

cochrane

review

of 17

trials

, 1811

participants

,

all

poor

to

moderate

quality

More

treatment

failures

with

ORT

No significant differences in weight gain, hyponatremia, hypernatremia, duration of diarrhea or total fluid intake

ORT

group

stayed

in

the

hospital

for

1.2

days

less

Phlebitis

occured

more

often

in

the

IVT

group

and

paralytic

ileus

in

the

ORT

group

Six

deaths

occured

in

the

IVT

and

two

in

the

ORT

group

For

every

25

children

treated

with

ORT

one

would

fail

and

require

IVT

Hartling

L,

Bellemare

S et al

The

Cochrane

Database

of

Systematic

Reviews

2006;(3) Art no CD004390Slide11

Route of rehydration

Both

oral

and

IV

rehydration

are

safe

and

effective

In

developing

countries

where

mothers

nurse

their

infants

and

give

frequent

oral

feeds

,

ORT is

preferred

In

industrialized

countries

, ORT is

cheaper

and

with

fewer

adverse

effects

Parents

and

nursing

staff

should

be

encouraged

to

give

ORT

and

be

informed

that

if

they

do

so

the

child

will

avoid

IV

line

and

get

home

quicker

Slide12

Route of rehydration

Rapid

IV

rehydration

over

4

hrs

was

advocated

by

WHO in 1980s

for

children

in

developing

countries

for

moderate

to

severe

dehydration

In industrialized countries the practice of rapid IVT to rehydrate children over 1-3 hrs and send them home if they can tolerate oral fluids has been found to be safe and effective

The main potential danger is fluid overload and/or electrolyte imbalance especially if the degree of dehydration is overestimated which is common.

There

is

also

risk of

sending

home

some

children

who

are

in

need

of

hospital

care

Slide13

Route of rehydration

Severe

dehydration

(>9%) is life

threatining

and

there

is

consensus

that

one

should

rehydrate

severely

dehydrated

children

using

IV

fluidsSlide14

Choice of ORS

Since 1980s

the

WHO has

recommended

a standart ORS

with

relatively

high

Na

and

glucose

content

(90

mmol

/L

Na

, 111mmol/L

glucose

, total

osmolality

311mmol/L)

A

number

of

studies

compared

standart ORS

with

reduced

osmolality

ORS (

rORS

) (total

osmolality

250

mmol

/L)

rORS

Has

been

found

to

be

associated

with

fewer

unscheduled

IV

infusions

,

lower

stool

output

and

less

vomiting

. No

additional

risk of

hyponatremia

was

found

The

WHO

now

recommends

rORS

for

non

-

cholera

diarrheaSlide15

Mode of delivery of ORS

Giving

ORS

by

a NG

tube

is

increasingly

common

in

some

industrialized

countries

NG

tube

feeds

have

the

advantage

of

getting

fluid

in

if

a

child

refuses

to

drink

or

is

vomiting

frequently

They

are

far

less

invasive

,

cheaper

and

less

traumatic

then

IV

fluids

On the other hand they are more invasive then oral feeds, unpleasant and have not been shown to have any advantage over oral rehydrationSlide16

Choice of IV fluids

In

many

industrialized

countries

N/2

or

N/4

saline

are

chosen

for

IV

fluids

and

they

are

made

isotonic

by

adding

dextrose

But as

dextrose

is

rapidly

metabolized

the

fluid

becomes

rapidly

hypotonic

The

use

of

low

Na

fluids

has

recently

been

questioned

following

episodes

of

catastrophic

hyponatremia

associated

with

IV

rehydration

for

AGESlide17

Choice of IV fluids

Hyponatremia

is

particularly

likely

to

develop

in

children

who

concurrently

have

the

syndrome

of

inappropriate

ADH

secretion

(SIADH)

Dehydration

,

vomiting

and

stress

are

potential

causes

of SIADH

and

occur

commonly

in AGE

Investigations

showed

that

for

resuscitation

of

children

with

severe GE

using

IV

fluids

, normal

saline

with

or

without

added

dextrose

is

recommended

Slide18

Antibiotics and AGE

Antibiotics

are

not

routinely

recommended

for

AGE

Most

episodes

of AGE

are

caused

by

viruses

Most

episodes

are

self-

limiting

,

including

those

caused

by

bacteria

and

antibiotic

use

is

likely

to

select

for

antibiotic

resistance

Antibiotics

might

increase

gastrointestinal

motility

and

cause

bacterial

overgrowth

and

thus

worsen

diarrheaSlide19

Antiemetics in AGE

Ondansetron

and

metoclopramide

reduces

the

number

of

episodes

of

vomiting

in AGE in

children

compared

to

placebo

but

increases

the

incidence

of

diarrhea

Use

of

antiemetics

is not

recommended

in

childhood

AGESlide20

Diet in AGE

There

is

widespread

consensus

that

breast

-fed

babies

with

dehydration

from

AGE

should

be

rehydrated

orally

or

IV but

continue

breast

feeding

Breast

milk

contains

as

much

lactose

as

formula

feeds

.

Despite

this

,

many

people

advocate

low

lactose

or

lactose

-

free

formulas

,

supposedly

because

of risk of

lactose

intolerance

secondary

to

AGESlide21

Diet in AGE

A meta analysis of 29 trials (2215 patients) found no advantage of lactose-free formulas over lactose-containing formulas for the majority of infants, although infants with malnutrition or severe dehydration recovered more quickly when given lactose-free formula

Brown KH,

Peerson

JM et al.

Pediatrics

1994;93:17-2

Using

diluted

food

in

children

recovering

from

AGE is not

recommended

because

it is

unnecessary

and

also

prolongs

symptoms

and

delays

nutritional

recoverySlide22

Diet in AGE

Formulas

containing

soy fiber has

been

reported

to

reduce

liquid

stools

without

changing

the

stool

output

.

This

might

reduce

diaper

rash

and

encourage

early

resumption

of normal

diet

, but

the

benefits

are

probably

insufficient

to

merit

its

use

as a

standard

of

careSlide23

Diet in AGE

Children

receiving

semisolid

or

solid

foods

should

continue

to

receive

their

usual

diet

.

Routinely

witholding

food

is

inappropriate

.

Early

feeding

reduces

changes

in

intestinal

permeability

caused

by

infection

,

reduces

the

duration

of

illness

,

and

improves

nutrition

Slide24

Zinc in diarrheal disease

Severe

zinc

deficiency

is

associated

with

diarrhea

(

acrodermatitis

enteropathica

)

In

developing

countries

,

prophylactic

dietary

oral

zinc

supplementation

reduces

the

incidence

and

severity

of

acute

diarrheal

disease

in

childhood

The

WHO

recommends

that

oral

zinc

is

given

to

children

in

developing

countries

at

the

onset

of

diarrheaSlide25

Probiotics in AGE

Probiotics are live microorganisms in fermented foods or components of microbial cells that have a beneficial effect on the health and well-being of the host

No

serious

adverse

effects

of

probiotics

have

been

reported

in

well

people

, but

infections

have

been

reported

in

people

with

impaired

immune

systemsSlide26

In

one

systematic

review

, probiotics reduce

the

risk of

diarrhea

lasting

3

or

more

days

by

60%

and

reduce

the

duration

of

diarrhea

by

18

hrs

A

cochrane

review

on 1917

adult

and

pediatric

patients

showed

that probiotics reduced the risk of diarrhea at 3 days by 34% and the main duration of diarrhea by 30.5 hrsThere is great variability among probiotics, further research is needed to to determine the optimal type, dosage and regimenTheir routine use is not recommended in AGE in children but it is likely that their benefit outweighs their harm

Probiotics

in AGESlide27

Antibiotic associated diarrhea

In

most

cases

no

pathogen

is

identified

Toxin

producing

C.

difficile

is

responsible

for

a

minority

Stopping

antibiotics

usually

relieves

the

problem

Dietary

manipulation

may

help

If it is not possible to stop the antibiotic, it is recommended to change to a regimen less likely to cause diarrhea

Amoxicillin

,

broad

-

spectrum

cephalosporins

,

quinolones

are the antibiotics most commonly associated with diarrheaWhen C. difficile is identified, metronidazole 10 mg/kg (max 400 mg) orally 8 hourly for 7-10 days Slide28

Campylobacter enteritis

Usually

self-

limited

Antibiotics

have

relatively

little

clinical

benefit

and

because

of

the

risk of

resistance

are

not

routinely

indicated

Antibiotherapy

is

indicated

only

when

there

is

high

fever

or

severe

illness

suggesting

septicemia

, usually in infants. If antibiotics are indicated: eryhtromycin 10mg/kg PO q6hrs or azitromycin 10 mg/kg PO dailyFor bacteriemia gentamicin <10y 7.5mg/kg IV daily; >10 y 6mg/kg IV or ciprofloxacin 10mg/kg (max400mg) IV q12hrsSlide29

cholera

Rehydration

is

the

basis

of treatment

and

can

usually

be

achieved

orally

Standart ORS

or

rice

-

based

ORS is

recommended

Antibiotic therapy reduces the volume and duration of diarrhea

Azitromycin

20mg/kg POI as a

single

dose

or

doxycycline

child

>8yrs:2.5mg/kg (max100mg) PO q12h x3d

or

ciprofloxacin

25 mg/kg (

max

1 g) PO as a

single

dose

or

erythromycin

12.5 mg/kg (

max 500mg) PO q6hx3dSlide30

EHEC enteritis

Infection

with

some

EHEC strains e.g 0157:H7

and

0111:H8 can

lead

to

development

of HUS

and

TTP

The

use

of

antibiotics

is

controversial

because

they

increase

the

release

of

shiga

-

like

toxin

and

increase

the

incidence

of HUS

and

TTP in humansStudies do not show any benefit of antibiotic use and some associate antibiotics with a higher risk of HUS and/or longer duration of diarrheaSlide31

EPEC enteritis

Most

EPEC

infections

occur

in developing

countries

and

organism

is

never

cultured

If serotype 0111:B4 is cultured mecillinam (extd spectrum penicillin) showed a clinical cure 79%, trimethoprim-sulfamethoxazole 73% and placebo only 7%

The

main

significance

is

for

traveler’s

diarrheaSlide32

Non-typhoid

Salmonella

enteritis

(NTS)

NTS

infections

are

food

-

borne

Extraintestinal

complications

such

as

septicemia

,

meningitis

and

osteomyelitis

are

rare

Outbreaks

are

associated

especially

with

infected

meat

or

eggs

,

cattle

or pigsIn developing countries, particularly tropical Africa, NTS are important cause of invasive extraintestinal diseaseSlide33

Non-typhoid

Salmonella

enteritis

(NTS)

Antibiotics

result

more

negative

stool

cultures

during

the

1st

week

but

cause

more

frequent

clinical

relapses

and

prolongation

of

detection

of

salmonella

in

stools

after

3

wks

Adverse

drug

reactions are more common with antibioticsAntibiotics are not indicated for asymptomatic short-term carriersAntibiotics are indicated for suspected or proven septicemia (infants<3m , malnourished infants or immunocompromised children with bloody diarrhea and fever and /or Salmonella isolated from fecesSlide34

Non-typhoid

Salmonella

enteritis

(NTS)

Antibiotics are also recommended for Salmonella infection occurring in association with chronic gastrointestinal disease, malignant neoplasms, hemoglobinopathies or severe colitis

Amoxicillin

is

preferred

if

the

organism

is

susceptible

For

empiric

therapy

ciprofloxacin

10 mg/kg POq12h OR

azithromycin

20mg/

kgPO

1st

day

and

10mg/kg

daily

If

PO not

tolerated

ciprofloxacin

10 mg/kg (

max

400mg)IV q12h OR

ceftriaxone

50mg/kg (

max

2g) IV

dailySlide35

Typhoid and paratyphoid

fevers

S.

typhi

and

S,

paratyphi

are

endemic

in

many

developing

countries

.

Almost

all

infection

in

industrialzed

countries

are

acquired

by

travelers

It

is a

septicemic

illness

rather

then

diarrheal

illness

Fever, hepatomegaly, abdominal pain, diarrhea, vomiting, cough, malaise and headache are prominent findings. Rose spots and bradycardia are rare in childrenFebrile convulsions, jaundice, ileus, perforation and impaired consciousness are other manifestationsHematologic abnormalities include neutropenia, leucopenia and thrombocytopeniaSlide36

Typhoid and paratyphoid

fevers

For

antibiotherapy

:

ciprofloxacin

15mg/kg (max500mg) PO q12hx 7-10d OR

Azithromycin

20mg/kg (max1g)x5d

If

PO not

tolerated

ciprofloxacin

10mg/kg (max400mg) IV q12hx 7-10d OR

Azithromycin

20mg/kg (max1g) IVx5d

If

clinical

response

delayed

ceftriaxone

50mg/kg (

max

2g) IV

dailySlide37

Shigellosis

Antibiotic

therapy

is

recommended

for

children

with

shigella

dysentery

,

even

if

mild

,

for

public

health

reasons

because

a

very

low

inoculum

causes

infection

Effective

antibiotics

,

if

the

organism

is sensitive include quinolones, ceftriaxone, azithromycin, cefixime, and cotrimoxazoleciprofloxacin 15mg/kg (max500mg) PO q12hx 3d OR Azithromycin 20mg/kg (max1g)x5d OR Cotrimoxazole 4+20mg/kg PO q12hx5dSlide38

Traveler’s diarrhea

At

least

11

million

people

develop

traveler’s

diarrhea

worldwide

Passage

3

or

more

unformed

stools

over

24h

with

symptoms

sterting

during

or

shortly

after

a

foreign

travel

,

nausea

,

vomiting

,

abdominal

pain, fever, tanesmus, and blood or mucus in stoolsAbout 85% are bacteria and ETEC is the most common one, campylobacter jejuni is responsible in 30% of cases, salmonella and shigella each accounts for 15%2/3 of ETEC produce a heat-labile toxin similar to cholera toxin which induces secretory diarrheaFor prevention boil

it,

cook

it,

peel

it

or

forget

it.

Avoid

drinking

local

water

,

consider

tap

water

and

ice

cubes

as

contaminated

.

Bottled

water

is not

always

safe

.

Swimming

pool

is

also

a

potential

riskSlide39

Althogh there

are

no

efficacy

data in

children

, an oral, killed, recombinant

B-

sub

-

unit

,

whole

-

cell

vaccine

against

cholera

and

ETEC is

available

.

Two

doses

given

at

least

one

week

apart

create

immunization

one

week

after

the

second doseVaccine is licenced in only a few countries including Sweden and CanadaProphylactic antibiotics are recommended only in immunucompromised child traveling for a short period of time, in which case ciprofloxacin may be the antibiotic of chioceTraveler’s diarrheaSlide40

Traveler’s diarrhea

All trials reported a significant reduction in duration

of diarrhea in participants treated with antibiotics

compared with placebo

The most effective antibiotics

for empiric

t

herapy

from trials are

quinolones

,

azithromycin, and rifaximin

All patients should

take fluids and electrolytes. Rehydration with ORS is

particularly important for young children

Antimotility

drugs, such as

loperamide

, should be

avoided in children, because of the danger of causing

paralytic

ileus

. Mild cases do not usually need

antibiotics

For moderate to severe disease,

azithromycin

20 mg/kg (max 1 g) orally, as a

single dose OR

ciprofloxacin 20 mg/kg (max 750 mg) orally, as a

single dose OR

norfloxacin

20 mg/kg (max 800 mg) orally, as a

single dose OR trimethoprim+sulfamethoxazole 4+20 mg/kg

(max 160+800 mg) orally, 12-hourly for 3 days

OR

rifaximin

10 mg/kg orally, 12-hourly for 3 daysSlide41

Amebiasis

E. histolytica infection can cause non-invasive intestinal

infection, which can be

symptomatic or cause

amebic dysentery or colitis, a

meboma

,

a

nd

/or liver

abscess

Passage of

Entamoeba

cysts or

trophozoites

in the absence of acute dysenteric illness does

not warrant antimicrobial therapy

Patients with amebic colitis characteristically present

with dysenteric symptoms of bloody diarrhea, abdominal

pain, and tenderness. Children can have rectal

bleeding without diarrhea. The onset can be gradual,

with several weeks of symptoms: often multiple, small

volume,

mucoid

stools, but sometimes profuse, watery

diarrhea Slide42

Amebiasis

Toxic megacolon complicates

amebic colitis in about 0.5% of patients

Amebomas are localized

inflammatory,

annular masses of the

cecum

or

ascending colon which can cause obstruction and be

confused with carcinomas

The diagnosis of amebic colitis rests on the demonstration

of

E.

histolytica

in the stool or colonic mucosa

of patients with diarrhea.

Commercially available ELISA assays

are more sensitive and less user-dependent

than microscopySlide43

Amebiasis

Serum antibodies against

amebae

are detected by

indirect

hemagglutination in >70% of patients

w

ith

symptomatic

E.

histolytica

infection

and are particularly

sensitive (>94%) in amebic liver abscess

For acute amebic dysentery, the

nitroimidazoles

(metronidazole, tinidazole, ornidazole) are

>90%

effective

metronidazole 15 mg/kg (max 600 mg) orally,

8-ourly for 7–10 days OR

tinidazole

50 mg/kg (max 2 g) orally, daily for 3

daysSlide44

Cryptosporidium

Cryptosporidium parvum infection causes frequent,

watery diarrhea, without blood in

immunocompetent

children.

Other prominent symptoms include

crampy

abdominal pain, fever, and vomiting. Asymptomatic

infection is rare. Infections are often waterborne;

the cysts are resistant to chlorine, and contaminated

water

and swimming pools have been the source

of large outbreaks.

In

immunocompetent

children,

infection usually

r

esolves

after 10 days (range 1–20)

and requires no specific treatment.

In contrast,

Cryptosporidium

infection can be life-

t

hreatening

in

immunocompromised children. To treat

Cryptosporidium infection in immunocompromised

children,

nitazoxanide

1–3 years: 100 mg 12-hourly; 4–11

years: 200 mg 12-hourly; 12 years or older:

500 mg orally 12-hourly, for 3 daysSlide45

Giardiasis

Giardia lamblia

is a flagellate protozoan parasite with

a worldwide distribution. Infection is primarily waterborne,

and although humans are the main reservoir

of infection, animals such as dogs and cats can

contaminate water with infectious cysts.

Infection can

be asymptomatic, can be acute with watery diarrhea

and abdominal pain, or protracted with chronic or

intermittent foul-smelling stools, abdominal distension,

flatulence, and anorexiaSlide46

Giardiasis

Diagnosis is by detecting

cysts in stool.

A

lthough

ELISA tests on stool are

slightly more sensitive than direct microscopy for ova

and parasites,

one study suggested that both tests

need to be

p

erformed

to achieve a sensitivity >90%.

Diagnosis

in difficult cases may require

e

xamination

of

aspirated duodenal fluid.

M

ost

authorities agree that treatment

of patients with asymptomatic passage of

Giardia

cysts

is unwarranted. The traditional treatment of symptomatic

patients is with

metronidazole

5 mg/kg (max 250 mg) orally, 8-hourly for 5 days

, which is 80–

95%effective

For immunocompetent

children who fail therapy, it is usual to repeat

the original course while investigating whether

reinfection

may have occurred from a family member

or water source