Acute gastroenteritis

PRESENTED BY:
 DARMINI
 DIYANAH
 WENG SOON
 TECK WAI

SUPERVISOR: DR. KELVIN

 INTRODUCTION

 Acute gastroenteritis (AGE) is a leading cause of

childhood morbidity and mortality and an
important cause of malnutrition.
 Many diarrhoeal deaths are caused by
dehydration and electrolyte loss.
 Commonest cause is ROTAVIRUS (up to 60 %
of cases in children <2years old).
ETIOLOGY
VIRUSES:
 ROTAVIRUS (COMMONEST)
 HUMAN CALICIVIRUS
 ASTROVIRUS

BACTERIA:
 CAMPYLOBACTER JEJUNI
 SALMONELLA
 SHIGELLA
 ESCHERICHIA COLI
 CLOSTRIDIUM DIFFICILE

PARASITES:
 ENTAMOEBA HISTOLYTICA
 GIARDIA LAMBLIA
HISTORY
 Diarrhoea : duration, frequency per day ,consistency, any blood or mucus in stool
 Vomiting : duration, frequency per day, associated with postprandial, any food particles or
blood in vomitus
 Fever : duration, documented temp at home
 Reduced oral intake /feeding
 Less active
 History of consuming outside food
 History of sick contact, any family members with similar symptoms
 INDICATION FOR ADMISSION TO HOSPITAL

 Moderate to severe dehydration

 Need for intravenous therapy
 Concern for other possible illness and uncertainty of diagnosis
 Patient factors : young age, unusual irritability/drowsiness.
worsening symptoms
 Caregivers unable to provide adequate care at home
 HYDRATION STATUS CIRCULATION OTHER PARAMETERS

• Active/lethargy • BP (to plot BP centile) • Urine output

• Anterior fontanelle <2years • Heart rate • Fluid intake

old :normotensive or
depressed • Pulse volume

• Skin turgor • CRT

• Eyes sunken • Peripheries:warm or coolish

• Mucous membrane :moist or

dry
Assess the state of perfusion of the child

SIGNS OF SHOCK:
 Tachycardia
 Weak peripheral pulses
 Delayed capillary refill time > 2 seconds
 Cold peripheries
 Depressed mental state with or without hypotension
ASSESSMENT OF DEGREE OF
DEHYDRATION
Look at child’s general Well,alert Restless or irritable Lethargic or
condition unconscious
Look for sunken eyes No sunken eyes Sunken eyes Sunken eyes
Offer the child fluid Drinks normally Drinks eagerly, thirsty Not able to drink or
drinks poorly
Pinch skin of abdomen Skin goes back Skin goes back slowly Skin goes back very
immediately slowly
Classify MILD DEHYDRATION ≥ 2 above signs: ≥ 2 above signs:
<5% Dehydrated MODERATE SEVERE
DEHYDRATION DEHYDRATION
IMCI: No signs of 5-10% Dehydrated >10% dehydrated
dehydration
IMCI: Some signs of
dehydration
Treat Plan A Plan B Plan C
Give fluid and food to treat Give fluid and food for Give fluid for severe
diarrhoea at home some dehydration dehydration.Provide food
as soon as child tolerates
INVESTIGATIONS AND
MANAGEMENT
INVESTIGATIONS
 Diagnosis is mainly by clinical recognition, confirmation by lab
investigations if indicated
 FBC: hemoconcentration (increased Hb or Hct) in children with
volume depletion
 Serum electrolytes:
 Suggested for children who require IV hydration
 For children with symptoms or signs suggestive of hypernatremia (eg: skin
feels doughy, irritable, high pitched cry, lethargic, thirsty, nausea, fever,
hyperreflexia, ataxia) or hypokalemia (muscle weakness or cramps, slow GI
motility, urinary retention, arrhythmia)
 Stool examination:
 Stool cultures required if
 child appears septic
 Presence of blood or mucus in the stool
 Immunocompromised child
 Recent foreign travel
 No improvement of diarrhea even after 7 days
 Uncertain diagnosis
 Microscopic examination:
 Examine for mucus, blood, leukocytes
 Fecal leukocytes indicate bacterial invasion of colonic mucosa
MANAGEMENT

BASED ON HYDRATION STATUS AND PRESENCE OF SHOCK

 Plan A: treat diarrhea at home
 Plan B: treat some dehydration with ORS
 Plan C: treat severe dehydration quickly
PLAN A
3rules of home treatment: give extra fluids, continue feeding,
when to return
 Give extra fluids:
 Breastfeed frequently and longer each feed
 If exclusively breastfed: give ORS or cooled boiled water in addition to
breastmilk
 If not exclusively breastfed: give one or more → ORS, food-based fluids
(soup and rice water) or cooled boiled water
 Especially important to give ORS at home when child has
been treated with plan B or C during this visit
 ORS (if weight is available, give 10 mL/kg after each loose
stool)
Up to 2 years: 50 to 100 mL after each loose stool
2 years or more: 100 to 200 mL after each loose stool
 Small sips from cup or spoon
 If vomits, wait 10 mins and continue slowly
 Continue extra fluids until diarrhea stops
 Continue feeding
 Breastfed on demand
 Formulafed infants should continue usual formula
immediately on rehydration
 Lactose-free or lactose-reduced formula usually unnecessary
 Continue semi-solid or solid foods as usual
 Avoid foods high in simple sugar (osmotic load may worsen
diarrhea)
When to return (clinic/hospital)
Unable to tolerate orally or drinking poorly
Becomes sicker
Develops fever
Blood in stool
PLAN B
 Give the recommended amount of ORS over 4 hour period

 Show mother how to give ORS:

 Frequent small sips
 If vomits, wait 10 mins then continue slowly
 Continue breastfeeding on demand
 After 4 hours: reassess and classify dehydration, then select appropriate plan (A, B,
C)
 If mother must leave before completing treatment,
 Show how to prepare ORS at home
 Show how much ORS to give to finish 4-hour treatment at home
 Give enough ORS packets to complete rehydration and 8 packets ORS as
in plan A
 Explain to mother regarding Plan A

 Observe child at least 6 hours after rehydration to be sure mother

can maintain hydration by giving child ORS solution by mouth
 Ifthere is cholera outbreak, give appropriate oral antibiotics after
patient is alert
PLAN C
 Airway, breathing, circulation should be assessed and established
quickly
 Start
IV or IO fluids immediately. If patient can drink, give ORS
by mouth while setting drip

 Initial
fluids for resuscitation of shock: 20 mL/kg of 0.9% NS or
hartmann’s solution as rapid bolus. Repeat if necessary till out of
shock or suspect fluid overload
 Review patient after each bolus, consider other causes of shock if not
responding to bolus
 Once circulation restored, commence rehydration, provide
maintenance and replace ongoing losses
 For rehydration:
 useisotonic solution (0.9% NS or hartmann’s solution, 0.45%
NS in neonates)
 Fluid deficit: percentage dehydration x body weight in grams
(give over 12-24 hours)
 Give daily maintenance fluid
Indications for IV fluids
 Unconscious child
 Failed
ORS treatment due to continuing rapid stool loss (> 15-20
mL/kg/hour)
 Failed ORS treatment due to frequent severe vomiting, drinking
poorly
 Abdominal distension with paralytic ileus (due to antidiarrheal or
hypokalemia)
 Glucose malabsorption (increased stool output and large amount
of glucose in stool when ORS given
INDICATIONS FOR ADMISSION
 Shock or severe dehydration
 Failed ORS treatment and need for IV fluids
 Concern of other possible illness or uncertainty of diagnosis
 Patient
factors: young age, unusual irritability/drowsiness,
worsening symptoms
 Unable to provide adequate care at home
 Socialor logistics issues that may prevent return evaluation if
necessary
Pharmacological
 Antibiotics should not be used routinely (only in children with bloody
diarrhea, probable shigellosis, suspected cholera with severe dehydration)
 Antidiarrheal: diosmectite (smecta)
 Kaolin, loperamide, diphenoxylate NOT RECOMMENDED
 Antiemetics: not recommended, potentially harmful
 Probiotics: only for probiotic strains or strains with proven efficacy in
appropriate doses
 Zinc supplements: may benefit in children 6 months and above living in
areas with prevalence of zinc deficiency or malnutrition
 Prebiotics not recommended
complications
 Volume depletion
 Electrolyte imbalance
 Metabolic acidosis
 Hypoglycemia
 Secondary bacteremia
 Afebrile seizures
 shock
prevention
 Promotion of exclusive breastfeeding
 Improved complementary feeding practice
 Rotavirus immunization
 Improved water and sanitary facilities
 Promotion of personal and domestic hygiene
sources

 Paediatric Protocols for Malaysian Hospitals (4th Edition)

 Nelson Textbook of Pediatrics (Edition 20)
 Doctrina Perpetua: Guides on Clinical Paediatric Part 1
Case Scenario
A5 years old female child (Body weight 20kg) presented
with fever since 1day followed by diarrhoea for 10
episodes, vomiting and reduced oral intake.

 During physical examination noted child has signs of

dehydration: sunken eyes, irritable and eager to drink

 Q1: What is your provisional diagnosis?

 Q2: What is the hydration status of the child?
 Final Diagnosis

Acute gastroenteritis with moderate dehydration

Signs of dehydration >2 signs :

Sunken eyes
irritable
Eager to drink

Q3: What would be your management?

 Q3 Answer:

 Plan B
 Give ORS 1500 mL over 4 hours
 (75 mL x body weight 20kg) = 1500mL
 Strict observation and monitor I/O closely

 Ifpatient unable to tolerate ORS despite small sips and

worsening GI losses, need to consider IV drip
administration (even before completing 4 hours)
Electrolyte imbalance
(sodium imbalance)
Electrolyte Imbalance in AGE

Dehydration in child can be divided into

1. Isotonic dehydration
2. Hypertonic (hypernatraemic) dehydration
3. Hypotonic (hyponatraemic) dehydration
 Isotonic dehydration
 Type of dehydration most frequently caused by diarrhoea. It occurs when the net
losses of water and sodium are in the same proportion as normally found in the ECF.

 The principal features of isotonic dehydration are:

-there is a balanced deficit of water and sodium;
-serum sodium concentration is normal (130-150 mmol/l);-
-serum osmolality is normal (275-295 mOsmol/l);
-hypovolaemia occurs as a result of a substantial loss of extracellular fluid.
 Hypertonic (hypernatraemic) dehydration

 a net loss of water in excess of sodium, when compared with the proportion normally
found in ECF and blood.

 The hypertonic fluids create an osmotic gradient that causes a flow of water from ECF
into the intestine, leading to a decrease in the ECF volume and an increase in sodium
concentration within the ECF
 The principal features of hypernatraemic dehydration are:
 there is a deficit of water and sodium, but the deficit of water is greater;
 serum sodium concentration is elevated (>150 mmol/l);
 serum osmolality is elevated (>295 mOsmol/l);
 thirst is severe and out of proportion to the apparent degree of dehydration
 the child is very irritable
 seizures may occur, especially when the serum sodium concentration exceeds
165 mmol/l.
Hypotonic (hyponatraemic) dehydration
 Children with diarrhoea who drink large amounts of water or other hypotonic
fluids containing very low concentrations of salt and other solutes. This occurs
because water is absorbed from the gut while the loss of salt (NaCl) continues,
causing net losses of sodium in excess of water

 The principal features of hyponatraemic dehydration are:

 there is a deficit of water and sodium, but the deficit of sodium is greater
 serum sodium concentration is low (<130 mmol/l);
 serum osmolality is low (<275 mOsmol/l)
 the child is lethargic; infrequently.
Hyponatremia
 Normal serum sodium is between 135-145mmol/L
 Hyponatremia is when serum na is <135mmol/l
 Symptoms
 Headache
 Nausea
 Vomit
 Confusion
 Disorietation
 Irratibility
 Lethargy
 reduce consciousness
 Coma
 apnoe
 Correction of sodium in hyponatremia
 Sodium deficit-
(135-serum NA) X 0.6 X body weight(KG)
 Daily requirement -2-3mmol/kg/day
 Inpatient with hyponatremia- total sodium requirement is sodium deficit
+daily requirement
1 pint NS-500mls
-0.9%NS=154mmol/L
-1/2NS=77mmol/L
-1/5NS=39mmol/L
-3%NACL-513mmol/L
 In acute symptomatic hyponatremia (eg: seizure)
-correct with bolus 3% NS (2mL/KG) over 15 mins
-after symptoms resolved,ensure rate of increase of plasma
sodium does no exceed 12mmol/l in 24 hour period

 In asymptomatic- for oral fluids and IVD,

No need bolus 3% NS correction
 Hypernatremia
 Hypernatremia is defined as serum NA more than 150mmol/L
moderate hypernatremia-150-160mmol/L
severe is >160mmol/L
 Clinical sign of hypernatremia
-irritability
-skin feels doughy
-ataxia,tremor,hyperreflexia
-seizure
-reduced awareness,coma
 Shock usually presented late because intravasular volume is relatively preserved
hypernatremia
 Management

-If patient is in shock-for fluid resuscitation with 0.9% normal saline and with bolus as
required

-AVOID RAPID CORRECTION- may cause cerebral oedema, convulsion and death
-Aim correct over 48-72 hour and fall of serum NA 0.5mmol/L/hr
-Remember to give maintenance fluid and replace ongoing loses
-Repeat RP every 6 hours till stable

*ensure that the rate of fall of plasma sodium less than 12mmol/L in 24 hour
period(0.5mmol/l/hr)
Electrolyte imbalance
(potassium imbalance)
Potassium disorder

• The daily potassium requirement is 1-2mmol/kg/day.

• Normal values of potassium are:

 Birth - 2 weeks: 3.7 - 6.0mmol/l

 2 weeks – 3 months: 3.7 - 5.7mmol/l

 3 months and above: 3.5 - 5.0mmol/l

Hyperkalemia
 Defined as potassium level of more than 5.5mmol/L
 Causes of hyperkalemia:
 Tumor lysis syndrome
 Acute kidney injury
 Adrenal insufficiency
 Drugs: potassium sparing diuretics, ACEI inhibitors
ECG changes in hyperkalemia
Management of Hyperkalemia
 Put patient on cardiac monitoring to see for any ECG changes

 Stop all medications causing hyperkalemia

 Stop all potassium supplements

 Send VBG to exclude pseudo-hyperkalemia

 Repeat potassium and ensure its not difficult blood taking.

Hypokalemia
 Defined as serum potassium of less than 3.4 mmol/L

 Causes:
• GI loss (vomiting or diarrhea)
• Sepsis
• DKA
• Renal tubular acidosis
• Treatment related: diuretic therapy, salbutamol
ECG changes in Hypokalemia
Management of Hypokalemia
 Treatwhen potassium < 3.0 mmol/L or clinically
symptomatic and < 3.4 mmol/L
 Identify and treat the underlying condition and causes
 Mild hypokalemia can be treated with oral KCL
 IV supplementation (1g KCL = 13.3 mmol KCL):
• Maximum concentration via a peripheral vein is 40mmol/L
(concentration up to 60mmol/L can be used after discussed with senior
medical staffs)

 IV correction:
• Given when potassium < 2.5 mmol/L (associated with significant CVS
compromise)
• Max infusion rate: 0.4 mmol/kg/hr into a central vein until K is restored
• Cardiac monitoring during potassium correction

* IV KCL is a drug, use with caution

Calculation

 Potassiumrequirement = potassium deficit + potassium

maintenance
 Potassium deficit: (4- current potassium) X weight in kg X
0.4
 Potassium maintenance: 2 mmol/L x weight in kg
Case scenario
 5 years old boy presented with diarrhea,
 Potassium deficit = (4-2.9) x
abdominal pain and vomiting for 2 days. 12.5 kg X 0.4 = 5.5 mmol
Body weight of the boy is 12.5kg. He was  Potassium maintenance = 2
diagnosed with acute gastroenteritis in our
ward. Noted that the Renal profile taken: mmol x 12.5kg = 25 mmol
• Urea: 4.1  Potassium requirement = 5.5
• Sodium: 136 + 25 = 30.5 mmol/day
• Potassium 2.9  Gram of KCL needed = 30.5
• Chloride: 81
/13.3 = 2.29gm
• Creatinine: 29
(approximately 2 g KCL)
• How much KCL can we give to him?