Acute Gastroenteritis in Children

Acute Gastroenteritis in Children
Ira Mikkaella Genobis

PGI-RMCI
• Inflammation of the gastrointestinal tract
commonly due to bacterial, viral, or
parasitic pathogens
• Most common manifestation – Diarrhea

and vomiting
• Dysentery – syndrome of frequent small

stools with visible blood
• Prolonged diarrhea vs persistent

diarrhea
 Majority – male
 Age <1month – 89yo (median: 8yo)
 Majority
Majority – male
– male
 Age:
Age 1<1month
month to––94 years
4 years old(median
old (median:
25yo): 1 yo)
Age - <1 month
Majortity – male 92yo (median:
8yo)
 Most– not
Age vaccinated
1 month -74yo (median: 17yo)
Pathogenesis Of
Infectious Diarrhea
• Transmission: • Other properties of transmission

• Prolonged fecal shedding
– Fecal-oral route • Extended infectivity in the
environment
– Food or water vehicles • Resistance to disinfection
• Incubation period
– Preformed toxins – 1-6 hours
– Enterotoxins in situ – 1-5 days
Viral AGE Bacterial AGE Parasite AGE
• Cytolytic to the • Shigella – most • Sporozoites

small intestinal common cause of penetrate intestinal
villus tips – bacillary dysentery epithelia, develop
decrease water into trophozoites
absroption, • Produce intracellularly,
disaccharide enterotoxins undergo asexual
malabsorption, producing a multiplication and
inflammation and secretory diarrhea sexual
cytokine activation development,
released into the
• Destruction and colon as oocysts
• Activates ENS inflammation of
decreasing gastric and is the one that
intestinal epithelium is capable of
acid emptying and producing ulcers
increasing intestinal causing
and autoinfections
mobility microabscesses –
stools with blood
and gas
CLINICAL MANIFESTATIONS
• General findings
– 3 or more abnormally loose or liquid
stools per day
– Signs of dehydration
• Capillary refill time > 2 seconds
• Abnormal skin turgorr
• Hypernea
• Dry mucous membranes
• Absent tears
Viral diarrhea
• Begin with
vomiting Bacterial diarrhea
• Watery nonbloody
stools; fever in half • No vomiting Protozoal diarrhea
of cases before diarrhea
onset • More prolonged,
• Lacks fecals WBCs sometimes 2wk or
• Complete • Fever >40C
more of episodes
resolution in 7days • Overt fecal blood
of sometimes-
• Abdominal pain explosive diarrhea,
• 5 syndromes nausea,abdominal
cramps, abd
bloating
• Stools are watery,
greasy and foul
smelling
• Self-limited
5 syndromes of bacterial Diarrhea
1. Acute diarrhea
 Most common; accompanied with fever and vomiting
2. Frank dysentery
 Bloody diarrhea; Shigella; Occur hours to days
3. Enteric fever
 Febrile illness with bacteremia w/o localized infection & diarrhea minimal
or absent; S. tyhpi and S. paratyphi A and B
4. Extraintestinal invasive infections
 Local invasion or bacteremic spread
5. Vertical transmission
 Spectrum from Isolated diarrhea, hematochezia to fulminant neonatal
sepsis
 Chorioamnionitis, abortion, neonatal sepsis, meningitis
• Major – dehydration, electrolyte or acid-base
derangements
Viral
Intussusception
Bacterial
bacteremia, toxic megacolon, intestinal
perforation, rectal prolapse, HUS,
pseudoappendicitis
Parasite
 Weight loss, malnutrition, ulcerating colitis,
colonic dilation, perforation (Entamoeba)
Diagnosis
• Suspected if:
• Passage of 3 or more
loose, watery or
bloody stools within
24hours
accompanied by any
of the ff:
– Nausea
– Vomiting
– Abdominal pain
– fever
PRE-TREATMENT EVALUATION
• Extensive clinical history

• Complete Physical Examination
• Stool characteristics
– Watery stool – rotavirus(mucoid) and V. cholerae
– Bloody stool – Shigella, Salmonella
CLINICAL USE OF DIAGNOSTIC TESTS
Should be requested based on patient`s

clinical status
Routine stool exam is not indicated except
parasitism is suspected or presence of
dysentery
Stool cultures are indicated only for severe cases, high
risk of transmission, complications, epidemiologic
purposes
Insufficient evidence in use of biomarkers
Rapid tests may be used during outbreaks
Molecular diagnostics have high sensitivity but unable to distinguish

viable and non-viable organisms
LABORATORY TESTS TO ASSESS
PRESENCE OF COMPLICATIONS
Complete blood count

Urinalysis
Serum electorlytes (Na, K, Cl) – electrolyte
imbalances
BUN and creatinine – Acute kidney injury
Serum bicarbonate or total CO2(if available) or ABG
(optional) - acid-base distrubances
Clinical Parameters Of Dehydration
• Dehydration must be evaluated rapidly and corrected
in 4-6 hours according to the degree of dehydration
CRITERIA FOR ADMISSION
History: unable to tolerate fluids
suspected electrolyte abns, safe
follow-up & home management
are not met
ACUTE
INFECTIOUS
DIARRHEA
Co-existing medical conditions
such as pnuemonia,
meningitis/encephalits, sepsis;
moderate to severe malnutrition
PROTOCOL FOR MILD TO MODERATE
DEHYDRATION
Idications for IV hydration
- Shock
- Dehydration w/altered level of
consciousness
- Lack of improvement
- Persistent vomiting
- Severe abd distention
- Ileus
- Glucose malabsorption
Protocol for Severe Dehydration
EMPIRIC ANTIBIOTIC TREATMENT
• Routine empiric antibiotic therapy is NOT

recommended
• Recommended if
– Suspected cholera
– Bloody diarrhea
– Diarrhea associated with other acute infections
Recommended Antimicrobials For The
Following Etiologies
Non-typhoidal
Cholera Shigella amoebiasis
Salmonella (NTS)
• Azithromycin • Ceftriaxone IV 75- • Metronidazole • Not recommended
10mkdose OD x 100mkday q12- 10mkdose IV/PO 3x unless in high-risk
3days 24hrs x 2-5 days a day for 10-14days children
• Doxycycline (>8yo) • Ciprofloxacin to avoid relapse • <3months old
2mg/kg SD 30mkday PO in 2 • Immunodeficient
• Co-trimixazole 8- divided doses x 3 • Asplenia,
12mkday in 2 days corticosteroid or
divided doses x 3- • Azithromycin 10mg immunosuppressive
5days PO OD x 3 days therapy,
• Chloramphenicol inflammatory bowel
50-100mkday PO q6 disease, achlorydia
x 3 days
• Erythromycin
12.5mkday q6 x 3
days
Adjuncts
• Zinc
– >6months – 20mg/day for 10-14days
– <6months – not routinely given as it may cause diarrhea to persist
• Racecadotril
– 1.5mkdose 3x/day during the first 3 days of watery diarrhea to shorten
duration of diarrhea
• Loperamide
– Not recommended due to serious adverse events such as ileus,
lethargy or death were reported in 8/927 children in loperemide group
• Anti-emetics
– Not recommended
• Probiotics
- Recommended, maybe extended for 7 or more days
Saccharomyces boulardi
• Antibiotic-accodiated diarrhea
• 250-70mg/dayx 5-7days
Lactobacillus rhamnosus GG
• >/= 10 ^10 CFU/day x 5-7days
Lactobacillus reuteri
• DSM 17938 10^8 to 4x10^8 CFU/day x 5-7 days
Bacillus clausii – insufficient evidence
Diet
Continue breastfeeding
Continue age-appropriate diet when feeding is
tolerated and early refeeding as soon as the child is
able
Diluted lactose milk is not recommended
BRAT diet (banana, rice, apple, tea) is not
recommended – risk of malnutrition from its
inadequate nutritional value

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Acute Gastroenteritis in Children

Ira Mikkaella Genobis

• Most common manifestation – Diarrhea

• Dysentery – syndrome of frequent small

• Prolonged diarrhea vs persistent

• Transmission: • Other properties of transmission

• Cytolytic to the • Shigella – most • Sporozoites

• Extensive clinical history

Should be requested based on patient`s

Molecular diagnostics have high sensitivity but unable to distinguish

Complete blood count

• Routine empiric antibiotic therapy is NOT

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