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Diarrhoea in children
Dr. K.A.W.Karunasekera
Department of Paediatrics
Faculty of Medicine
University of Kelaniya
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Clinical impact
A major cause of childhoodmorbidity and mortality
3 million die each year in the world
80% deaths occur < 2 years of age
Most die due to severe dehydrationRepeated attacks causemalnutrition
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DefinitionPassage of 3 or more liquid motions
/day
Acute diarrhoea usually for 7 days
Persistent diarrhoea (3-10%) >14 days
Watery (AGE)
Acute diarrhoeaInvasive diarrhoea
Bloody (Dysentery)
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Aetiology - AGEViruses: rotavirus , adenovirus,calicivirus, Astor & measlesviruses
Bacteria: Vibrio cholarae, ETEC,Campylobacter jejuni, Shigella, EPEC
Parasitic: Cryptosporidium, giardiaMixed infection with 2 or more up to20%
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Aetiology- invasive diarrhoea
Bacteria:Shigella spp. Shiga toxins
EIEC, EHEC, Campylobacter
jejuni, Yersiniaenterocolitica,
non-typhoidal salmonella
Parasites: Entamoeba histolytica
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Site of pathology
Small intestine: secretory diarrhoealpathogens e.g. rotavirus, vibrio, ETEC
Large intestine: invasive diarroealpathogens e.g. Shigella spp. Rectosigmoid and progress up, Entamoeba
caecum and adjacent colon
Both small and large bowel e.g. C.jejuni
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Rotavirus
The commonest pathogen for AGEbetween 6-24 months of age
More common during dry season, andduring monsoons
Neonatal and adult infections are mild
Faeco-oral transmissionPatchy damage to the epitheliumcauses blunting of villi watery D
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Rotavirus contd.Results in transient lactase deficiency
Intestine regenerates in 2-3 days, longer inmalnourished
IP 2-3 days
Abrupt onset vomiting and D
Severity vary mild to severeLasts up to a week, improves in 2-3 days
Low grade fever
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Stool macroscopy, microscopy
Management of dehydration
Continuation of BFContinuation of solid food
No AB
No antidiarrhoeal agentsExtra meal for 2-3 weeks to catch-upWt.
Rotavirus - management
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Vibr io choleraeThe most important cause forsevere dehydration
Outbreaks occur in Sri Lanka fromtime to time
Common age is 2-9 years
A large infective dose is requiredOrganisms adhere to the intestine,X and produce enterotoxin D
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Cholera contd.
2 biotypes: El tor & classical2 serotypes: Ogava & Inaba
Enterotoxins secrete water,Na & Cl in to small intestine
Exchange of K with Na and HCO3with Cl in large intestine
Hence net loss of water, Na, K, Cl,Hco3
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Cholera contd.
IP hours to few days
Mild to severe disease
Rice water stoolMuscle cramps
Notifiable disease to regionalepidemiologist by telephone
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Cholera management
Stool culture
Management of dehydrationContinuation of food
Notification
Antibiotics furazolidone,chloramphenicol
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Shigella spp.
S. dysenteriae has 15 serotypes.responsible for epidemics. Type 1 is themost severe form
S. flexneri - responsible for endemic disease
S. boydii
S. sonneiInfective dose is very small (10 organisms)
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Shigella spp.
Faeco-oral transmission
Shigella can survive in gastric juice
Shiga toxin an endotoxin, whichhas a cytotoxic property fluidsecrete in to small intestine
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ShigellosisCommon under 5 years
Uncommon under 6 months asthere is no specific enterocytereceptors
IP 2-3 days
Severity varies from very mild tofulminating disease
Prominent systemic symptoms
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Shigellosis contd.High fever, anorexia, headache,malaise
Frequent passage of small volumestool mixed with blood and mucous& less amount of stool particles
Intense cramps in LIF, tenesmus,tender abdomen
Rectal prolapse in malnourished
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Stool macroscopy and microscopy
Stool culture & ABST
Management of dehydrationDietary management: loss of protein ishigh. Thus continue feeding during acute
illness and extra meal duringconvalescence. Near normal energyintake can be ensured by small, butfrequent feeding.
Shigel losis- management
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Symptomatic therapy for fever
AB for 5 days: furazolidone, nalidixic
acid 15 mg/kg 6 hrly, pivmecillinam 15mg/kg 6 hrly, aminoglycosides, 3rdgene. Cephalosporines
Antispasmodic or constipating agentshave no role & it may worsen severityof the disease
Notification
Shigel losis management contd.
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Entamoeba histolyticaCauses dysentery
Extra-intestinal manifestations canoccur
Diagnosis by direct visualization of
tropozoitesMetronidazole
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E.coli
5 types: EIEC, EHEC, EPEC,ETEC,EAEC
Faeco-oral transmissionETEC causes travelers diarrhoea
Clinical features of EIEC similar to
Shigella
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CampylobacterPeak occurs in infancy
Infects through infected animals,their faeces, food or water
Causes AGE or dysentery (1/3)
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Non-typhoidal salmonellaeUncommon in developing countries
Through contaminated animalproducts
Causes watery D, vomiting and
cramps
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Complications of diarrhoea
Dehydration, hypovolaemic shock &ARF
Electrolyte imbalance: Na low or high,hypokalaemia, met. Acidosis, low Mg
Septicaemia and shock with invasive D,DIC
Hypoglycaemia, common withshigellosis
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Complications contd.
PEM: diarrhoeal disease and PEM makea vicious cycle
Haemolytic uraemic syndrome
Abnormal CNS status e.g. convulsions,encephalitis
Intestinal such as rectal prolapse,bleeding due to stress ulcers, perforation& peritonitis, paralytic ileus, persistentD, NEC
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HUSMicroangiopathic anaemia, lowplatelets & ARF
S.dysenteriae type 1 & E.coli0157:H 7
Bi-phasic illness
Crenated RBCs, neutrophilia, lowplt.
Symptomatic management
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F luid management in diarrhoeaPrinciples:
Correction of dehydrationReplacement of on-going loses
Continuation of normal requirement
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Important questions to be asked
Duration of illness
Quantity & frequency of stool
Presence of blood or mucousFrequency of vomiting
Degree of thirst
When did the child pass urine last?
Is the urine darker than usual?
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Questions to be asked contd.
Presence of fever or convulsions
Presence of other illness
Pre-illness and during illness feeding
Contact H/O diarrhoeaAny medication given
Then assess the degree of dehydration(see transparencies for assessmentand management of dehydration)
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Home managementRules of home management:
Rehydration with appropriate fluidsContinue feeding
Recognition of referral signs to a
doctor
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Rehydration at home
Suitable fluids: ORS, rice kanji,king/young coconut water, puffed rice
water, plain water, weak plain tea.(best if prepared with salt)
Substantially reduces the requirement
of hospital admission and severedehydration
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Continuation of feeding
This helps early recovery and preventsmalnutrition
Continue BF
Continue formula if the child is on (if theindication to start formula is correct)
Solid/semi-solid food 5-6 times, smallfrequent feeds are better tolerated
One additional meal for 2-3 weeks
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Warning signs for referral
Many watery stool
Repeated vomiting
Marked thirstEating or drinking poorly
Fever
Blood in the stool
Reduced UOP
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I ndications for admission
Severe dehydration
Persistent vomiting
High rate of purgingInability or refusal to drink
Ill child with complicationsBlood and mucous in stool
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Rehydration solutionsOral rehydration solution (ORS
Jeevani)Used from 1971 onwards
Composition of a packet Nacl 3.5
g, Na-citrate 2.9 g, Kcl 1.5 g &glucose 20 g.
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ORSmolar concentration mmol/L
Na 90, Cl 80, citrate 10, K 20, glucose111
Physiological basis of ORT:
Glucose & other carrier-mediatedabsorption is intact even in severe D.Citrate and K are absorbed
independently of glucose during D.Citrate absorption appears to increase Na& Cl absorption.
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Advantage of ORT over IV
> 95% of some dehydration can betreated
Less cost
Does not need much training
Easily available
Over-hydration is less likelyMothers are actively participated inmanagement
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Reasons for fai lure of ORT
High rate purging
Persistent vomiting
Severe dehydrationInability or refusal to drink
Glucose malabsorption
Incorrect preparation
Abdominal distension or ileus
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Suitable intravenous fluidsHartman (Na 130, K 4, Cl 109,
Lactate 28)N.saline (Na 154, Cl 154)