أسئلة الـ Gastroenteritis - حورس

• Gastroenteritis (GE) in infants and children involves diarrhea and/or vomiting
• GE is usually caused by an infective etiology
• GE is considered acute if it lasts less than 2 weeks
• Diarrhea is defined as an increase in stool frequency, fluidity, or volume

Etiology

• Suboptimal breastfeeding, contaminated complementary foods, poor water quality, poor sanitation/hygiene and malnutrition are risk factors for childhood diarrhea
• Vitamin A and Zinc deficiencies also can cause childhood diarrhea

Causes

• Gastrointestinal tract infections caused by viruses, bacteria or protozoa can cause GE
• Viruses, such as Rota virus, are causes of GE, and are considered infectious agents
• Bacteria such as E. coli, Salmonella, Campylobacter and Clostridium are causes of GE, and are considered infectious agents
• Protozoa such as E. histolytica or G. lamblia are causes of GE, and are considered infectious agents
• Systemic infections, such as respiratory, urinary, or central nervous system infections can cause GE
• Non-infectious causes of GE include malabsorption, excess intake of osmotically active substances, endocrinopathies, and food poisoning

Causative Agents and Differentiating Points

• Bacterial infections can present with a temperature greater than 38.5 degrees, frequent motions, abdominal pain, positive CRP and peripheral PNL
• Helpful notes to consider for bacterial gastroenteritis cases include hematochasia, mucus in stool, shellfish/contaminated food, travel, and requests for stool cultures
• Campylobacter, Shigella, Salmonella, E. coli enterotoxigenic and V. cholera are bacterial agents that can cause GE
• Viral infections can present with a temperature less than 38.5 degrees, frequent motions, noticeable emesis, and last less than 5 days
• Helpful notes to consider for viral gastroenteritis cases include prodromal symptoms, painless watery diarrhea, and seasonal epidemics
• Parasitic infections cause gastroenteritis can present without fever, vomiting, abdominal pain and distension
• Helpful notes to consider for parasitic gastroenteritis cases include tenesmus, hematochasia, mucus in stool, and systemic manifestations

Differentials

• Systemic infections such as septicaemia or meningitis can mimic GE
• Local infections such as respiratory tract infections, otitis media and UTIs can mimic GE
• Surgical disorders such as pyloric stenosis, intussusception, blocked intestine, and acute appendicitis can mimic GE
• Metabolic disorders such as DKA, adrenal insufficiency and hyperthyroidism can mimic GE
• Renal disorders such as haemolytic uraemic syndrome can mimic GE
• Other disorders such as Coeliac disease, cow's milk protein intolerance, food allergy, malabsorption syndrome, overeating/overfeeding, and food poisoning can mimic GE

Mechanisms of Diarrhea

• Secretory diarrhea is caused by decreased absorption or increased secretion
• Stool exam results of secretory diarrhea will indicate watery or volumnious stool
• The symptoms of secretory diarrhea are caused by viruses, Cholera, and E.coli
• Osmotic diarrhea is caused by maldigestion, absorption issues or ingestion of non absordable solutes
• Stool exam results of osmotic diarrhea will indicate watery, lesser volume, acidic ph, and higher osmolarity
• Symptoms of osmotic diarrhea are Lactase deficiency and side effects of laxatives
• Increased motility diarrhea is caused by decreased transit time
• Stool exam results of increased motility diarrhea will indicate loose to normal stool
• Symptoms of increased motility diarrhea are irritable bowel syndrome and thyrotoxicosis
• Decreased surface area diarrhea is caused by decreased functional capacity
• Stool exam results of decreased surface area diarrhea will indicate watery stool
• Decreased surface area diarrhea is a symptom of short bowel syndrome
• Mucosal invasion diarrhea is caused by inflammation, decreased absorption and increased motility
• Stool exam results of mucosal invasion diarrhea will indicate blood, mucus and WBCs present
• Mucosal invasion diarrhea is a symptom of salmonella, shigella, yersinia, campylobacter, and amoebiasis

Inflammatory vs Non-Inflammatory Diarrhea

• Non-inflammatory diarrhea presents with nausea, vomiting, abdominal pain, and large volumes of watery stool, originating in the proximal small intestine
• Non-inflammatory diarrhea is caused by osmotic or secretory issues
• Non-inflammatory diarrhea is caused by viruses, toxigenic E. Coli, cholera, cryptosporidium and G. Lamblia
• Inflammatory diarrhea presents with fever, abdominal pain, tenesmus, frequent small volumes of blood-stained stool with pus and mucus, originating in the distal ileum and colon
• Inflammatory diarrhea is caused by mucosal invasion and inflammation
• Inflammatory diarrhea is caused by enteroinvasive E. coli, shigella, salmonella, yersinia, campylobacter, and E. histolytica.

Complications of GE

• Dehydration, shock (peripheral circulatory failure), electrolyte/acid-base imbalances and convulsions are all complications from GE
• Other complications include intussusception, persistent diarrhea (post-infectious), protein-calorie malnutrition (PCM), disseminated intravascular coagulation (DIC), renal failure and septicemia

Dehydration

• Mild dehydration presents with alert demeanor
• Moderate dehydration presents with fatigued or restless behavior
• Severe dehydration presents with drowsy, apathetic, or lethargic behavior.
• Mild dehydration presents with Normal eyes
• Moderate dehydration presents with sunken eyes
• Severe dehydration presents with very sunken eyes
• Mild tears are present with dehydration
• Moderate tears will presents with decreased amount during dehydration
• Severe dehydration will present with no tears

Base and Electrolyte Deficit

• Base deficit (acidosis) results from excess loss of intestinal bicarbonate
• Base deficit (acidosis) results from the failure of renal compensation in cases of hypovolemia and decreased RBF.
• Base deficit (acidosis) results from excess production of lactic acid in shocked patients
• Base deficit (acidosis) manifestations include rapid deep breathing and vomiting
• Hypokalemia results from intestinal losses
• Hypokalemia manifests as muscle weakness, arrhythmia, and ileus.

Investigation & Treatment

• GE investigation includes CBC, S.creatinine, ABG, S.electrolytes, stool analysis, and fecal calprotectin
• Principles of treatment include an ESR and CRP
• Treatment includes medical evaluation, home vs hospital management, fluid replacement, dietary adjustments, other medications and management of other complications

Principles of Management

• Oral rehydration solutions (ORS) are recommended for rehydration and should be performed rapidly (within 3-4 hours)
• Early return to an age-appropriate diet is recommended as soon as dehydration is corrected
• Breastfeeding should continue, and diluted formula is not recommended for formula-fed infants
• Additional ORS should be administered to compensate for ongoing losses from diarrhea
• Unnecessary laboratory tests or medications should be avoided

Home vs Hospital Management

• Therapy should begin at home with clear instructions regarding signs of dehydration and the importance of ORS
• Initiate early administration of ORS for uncomplicated cases
• Continue feeding during diarrheal episodes and re-consult if the child appears ill or does not respond to treatment

Hospitalization Indications

• Severe dehydration and complications requiring hospitalization are indications for hospitalization
• Other indications for hospitalization include other illnesses complicating the clinical course, inability of caregivers to provide adequate care, and social or logistical concerns
• Problems with ORT such as vomiting, refusal, or inadequate intake are indications for hospitalization; ORS treatment failure
• Factors such as young age, unusual irritability or drowsiness, progressive symptoms, or uncertainty of diagnosis may require hospitalization

Feeding

• For children with persistent diarrhea who are still breastfeeding, increase frequency
• For children taking other milk it is best to replace with increased breastfeeding or products such as yoghurt
• Give frequent small meals, at least 6 times a day and follow feeding recommendations

Pharmacological Treatment

• Antimicrobials are indicated in cases of inflammatory diarrhea or dysentery
• Empiric treatment should be directed at shigella, with caution in watery diarrhea where antimicrobials are often not indicated, except in cases of cholera
• Antidiarrheal medications should be avoided
• Trials of zinc supplementations can be effective, along with probiotics such as Lactobacillus casei

Prevention

• Promoting exclusive breastfeeding and vitamin A supplementation can assist in the prevention of GE
• Rotavirus immunization along with improved water and sanitary facilities along with personal and domestic hygiene

Points to Remember

• GE is acute and self-limited, not caused by GE alone
• Fluid replacement with ORS is the mainstay of management
• Breastfeeding should be continued and pharmacological agents may be of no value