Acute Gastroenteritis
Transcript of Acute Gastroenteritis
byHarold Rugnao
DIARRHEA
ESSENTIAL CONCEPTS OF DIARRHEADIARRHEA
passage of unusually loose or watery stools, at least 3x in a 24 hr period
CLINICAL TYPES OF DIARRHEAAcute watery diarrheaAcute bloody diarrheaPersistent diarrheaDiarrhea with severe malnutrition
ESSENTIAL CONCEPTS OF DIARRHEADehydration
Deficit of water and electrolyte MalnutritionZinc DeficiencyUse of antimicrobials and anti-diarrheal
drugs
Important Microbial Causes of Acute Diarrhea in Infants and Children
RotavirusEscherichia Coli
EnterotoxigenicLocalized adherent Diffuse AdherentEnteroinvasiveEnterohemorrhagic
Shigella
Campylobacter jejuni
Vibrio cholerae 01 and 0139
SalmonellaGiardia duodenalisEntamoeba
histolyticaCryptosporidium
ASSESSMENT OF CHILD WITH DIARRHEA1. History2. Physical Exam3. Determine Degree of Dehydration and
select treatment plan4. Diagnose other important problems
ASSESSMENT OF DIARRHEA PATIENTS FOR DEHYDRATION
A B C
LOOK AT: CONDITION
EYES
THIRST
Well, alert
Normal
Drinks normally, not thirsty
Restless, irritable
Sunken
Drinks eagerly, thirsty
Lethargic or unconscious
Sunken
Drinks Poorly or not able to drink
FEEL: SKIN PINCH Goes back quickly
goes back slowly goes back very slowly
DECIDE NO SIGNS OF DEHYDRA-TION
SOME SIGNS OF DEHYDRATION
SEVERE SIGNS OF DEHYDRATION
TREAT Use treatment plan A
Weigh the patient, use Treatment Plan B
Weigh the patient, use Treatment Plan C URGENTLY
ESTIMATED FLUID DEFICITAssessment Fluid deficit as
%of body wtFluid deficit in ml/kg body wt
No signs of dehydration
<5% < 50ml/kg
Some dehydration 5 – 10 % 50 – 100 ml/kg
Severe dehydration
>10% >100 ml/kg
Management of Acute Diarrhea (without blood)Objectives:
Prevent dehydration, if there are no signs of dehydration
Treat dehydration, when it is presentPrevent nutritional damageReduce the duration and severity of diarrhea
and the occurrence of future episodes
Plan A – Treat Diarrhea at Home1. GIVE EXTRA FLUID
TELL THE MOTHER Breastfeed frequently and for longer at each feed If the child is exclusively breastfed, give ORS or
clean water in addition to breastmilk If the child is not exclusively breastfed give one
or more of the following: ORS, food base fluids, or clean water
TEACH THE MOTHER HOW TO MIX ORS Home made solution: 3g/l of table salt (one level
tspful) and 18g/l of common sugar
SHOW THE MOTHER HOW MUCH FLUID TO GIVE IN ADDITION TO THE USUAL FLUID INTAKE Up to 2 years50 to 100ml after each loose
stool 2 years or more 100 to 200 ml after each loose stool Oldre children as much fluid as they want
Tell the mother to give frequent small sips from a cup If the child vomits, wait 10 mins. Then continue, but
more slowly Continue giving extra fluid until the diarrhea stops
2. GIVE SUPPLEMENTAL ZINC- 10 – 20mg to the child everyday for 10 – 14
days
3. CONTINUE FEEDING - To prevent malnutrition
4. TAKE THE CHILD TO A HEALTH WORKER IF THERE ARE SIGNS OF DEHYDRATION OR OTHER PROBLEMS
- Starts to pass many watery stools- Repeated vomiting- Becomes very thirsty- Eating or drinking poorly- Develops fever- Blood in the stool- Child does not get better in 3 days
Plan B – Treat Some Dehydration with ORSGive in clinic recommended amount of ORS over 4-hour period
DETERMINE AMOUNT OF ORS TO GIVE DURING FIRST 4 HOURS
*AGE Up to 4 mos 4 mos up to 12 mos
12 mos to 2 yrs
2 yrs to 5 yrs
WT < 6 kg 6 – < 10 kg 10 – <12 kg 12 – 19 kg
In ml 200 – 400 400 – 700 700 – 900 900 – 1400
*Use the child’s age only when you do not know the weight. The approximate amount of ORS required (in ml) can also be calculated by multiplying the child’s weight (in kg) times 75
AMOUNT OF ORS TO GIVE DURING FIRST 4 HOURS
*AGE Up to 4 mos
4 mos up to 11 mos
12 mos to 23 mos
2 yrs to 4 yrs
5 – 14 yrs
15 yrs or older
WT < 5 kg 5 – 7.9 kg
8 – 10.9 kg
11 – 15.9 kg
16 – 29.9 kg
30 kg or more
In ml 200 – 400
400 – 700
700 – 900
900 – 1400
1200 – 2200
2200 – 4000
*Use the child’s age only when you do not know the weight. The approximate amount of ORS required (in ml) can also be calculated by multiplying the child’s weight (in kg) times 75
for infants under 6 mos who are not breatfed, if using the old WHO ORS solution containing 90mmol/L of sodium also give 100-200ml clean water during this period. However if using the new reduced (low) osmolarity ORS solution contining 75mmol/L of sodium, this is not necessary
For infants under 6 mos who are not breastfed, also give 100 – 200 ml of clean water during this period
If the child wants more ORS than shown, give more
Note: during initial stages of therapy, while still dehydrated adults can consume upto 750ml/hr if necessagry, children up to 20ml/kg/hr
SHOW THE MOTHER HOW TO GIVE ORS SOLUTION
AFTER 4 HOURSReassess the child and classify the child for
dehydrationSelect the appropriate planBegin feeding the child
MEET NORMAL FLUID NEEDS
IF THE MOTHER MUST LEAVE BEFORE COMPLETING TREATMENT
Show her how to prepare ORS Show her how much ORS to give to finish the
4-hour treatment at home Give her enough ORS packets to complete
hydration Explain the 3 rules of HOME TREATMENT
1. Give extra fluid2. Continue feeding3. When to return
WHEN ORAL REHYDRATION FAILSContinuing rapid stool loss (>15–20 ml/kg/hr) Insufficient intake of ORS owing to fatigue or
lethargyFrequent, severe vomiting
GIVING ZINC
GIVING FOOD
Treatment Plan C – for patients with severe dehydration1. GUIDELINES FOR INTRAVENOUS
REHYDRATION Give 100ml/kg Ringer’s Lactate Solutiona
divided as follows:
Age First give 30ml/kg in: Then give 70ml/kg in:
Infants (under 12 months)
1 hourb 5 hours
Older 30 minutesb 2 ½ hours
• Reassess the patient every 1 – 2 hrs. If hydration is not improving, give the IV drip more rapidly•After 6 hrs (infants) or 3 hrs (older patients), evaluate patient using the assessment chart. Then choose the appropriate Treatment Plana if Ringers Lactate Solution is not available, nomal saline may be usedb Repeat once if radial pulse is still very weak or not detectable
2. MONITOR THE PROGRESS OF INTRAVENOUS REHYDRATION
3. ELECTROLYTE DISTURBANCES Hypernatremia
Serum Na > 150mmol/L Can cause convulsions
Hyponatremia Serum Na < 130mmol/L Lethargy, less often, seizures
Hypokalemia Serum K+ <3 mmol/L Muscle weakness, paralytic ileus, impaired
kidney function and cardiac arrhythmia
Management of Suspected CholeraCholera differs from acute diarrhea of other
causes in 3 ways:It occurs in large epidemics that involve both
children and adultsVoluminous watery diarrhea may occur,
leading rapidly to sever dehydration with hypovolemic shock
For cases with sever dehydration appropriate antibiotics may shorten the duration of the illness
Antimicrobial Therapy
Management of Acute Bloody Diarrhea (Dysentery) Shigella is the most common cause of bloody
diarrhea Ciprofloxacin for 3 days
Out Patient Management of Bloody DiarrheaCHILD WITH LOOSE STOOLS WITH BLOOD
SEVERELY MALNOURISHED?
GIVE ANTIMICROBIAL FOR SHIGELLA
BETTER IN 2 DAYS?
No
No
REFER TO HOSPITAL
Yes
COMPLETE 3 DAYS TREATMENTYes
INITIALLY DEHYDRATED AGE< 1Y/O OR MEASLES IN PAST 6 WEEKS
CHANGE TO SECOND ANTIMICROBIAL FOR SHIGELLA b
BETTER IN 2 DAYS?
No
COMPLETE 3 DAYS TREATMENTYes
REFER TO HOSPITALYes
REFER TO HOSPITAL OR TREAT FOR AMOEBIASIS
Management of Persistent Diarrhea Persistent DiarrheaDiarrhea, with or without blood, that begins acutely
and lasts at leat 14 days. Usually associated with weight loss, and often, with
serious non-intestinal infections
Objective of treatment is to restore weight gain and normal intestinal function by:Appropriate fluids to prevent or treat dehydrationA nutritious diet that does not cause diarrhea to
worsenSupplementaryvitamins and mineralsAntimicrobials to treat diagnosed infections
Treat in the Hospital:Children with serious systemic infectionChildren with signs of dehydrationInfants below 4 months of age
Prevent or treat dehydrationIdentify and treat specific infectionsGive a nutritious dietGive supplementary multivitamins and
mineralsMonitor response to treatment
Management of Diarrhea with Severe MalnutritionAssess for DehydrationManage DehydrationFeedingUse of antimicrobials
Other Problems Associated with DiarrheaFeverConvulsionsVitamin A deficiency
Prevention of DiarrheaBreastfeedingImproved feeding practicesUse of safe waterHandwashingFood safetyUse of latrines and safe disposal of stoolsMeasles immunization