ACUTE GASTROENTERITIS

&
DEHYDRATION
 Learning objectives

By the end of this lecture, the student should:

– know the causes of gastroenteritis
– recognise the clinical signs of gastroenteritis
– know the assessment of the degree of dehydration
– know about different types of dehydration
– know fluid management in different types of dehydration
Importance:

■ Gastroenteritis remains a major cause of child mortality and

morbidity worldwide.
■ In developed countries, it is a cause of significant morbidity,
particularly in younger children.
■ In developing countries, gastroenteritis remains a major cause
of child mortality.
■ It remains a common reason for hospital admission in young
children.
■ Children under 5 years of age are particularly affected.
Etiology:

Viral infection:
■ Rotavirus:
– The most frequent cause of gastroenteritis,
– it accounts for up to 60% of cases in children under 2
years of age,
– Particularly occur during the winter and early spring
– An effective vaccine against it is available
■ Other viruses, particularly adenovirus, norovirus, calicivirus,
coronavirus and astrovirus may cause outbreaks.
Etiology:
■ Bacterial causes:
– less common
– Suggested by the presence of blood in the stools.
– Clinical features act as a poor guide to the pathogen.
■ Campylobacter jejuni infection is often associated with severe
abdominal pain.
■ Shigella and some salmonellae produce a dysenteric type of
infection, with blood and pus in the stool, pain and
tenesmus. Shigella infection may be accompanied by high fever.
■ Cholera and enterotoxigenic Escherichia coli infection are
associated with profuse, rapidly dehydrating diarrhoea.
■ Protozoan parasite infection:
Giardia and Cryptosporidium .
History
■ In gastroenteritis there is a sudden change to loose or watery
stools often accompanied by vomiting.
■ There may be contact with a person with diarrhoea and/or
vomiting or
■ recent travel abroad.
■ A number of disorders may present as gastroenteritis and, when
in doubt, hospital referral is essential.
 Conditions that can mimic gastroenteritis
■ Systemic infection
Septicaemia, meningitis.
■ Local infections
Respiratory tract infection, otitis media, hepatitis A, urinary tract infection.
■ Surgical disorders
Pyloric stenosis, intussusception, acute appendicitis, Hirschsprung disease.
■ Metabolic disorder
Diabetic ketoacidosis
■ Renal disorder
Haemolytic uraemic syndrome
■ Others
Coeliac disease, cow's milk protein allergy, lactose intolerance, adrenal
insufficiency
Complications
■ Dehydration leading to shock is the most serious complication
and its prevention or correction is the main aim of treatment.
■ Risk of dehydration is increased in case of:
– Age: infants, particularly those under 6 months of age or
those born with low birth weight
– Frequency of diarrhea: six or more stools in the previous
24 hours
– Vomiting: three or more times in the previous 24 hours
– Inability to tolerate (or not been offered) extra fluids.
– Children with malnutrition.
Why infants are at greater risk of dehydration?

■ They have a greater surface area-to-weight ratio leading to greater insensible

water losses.

■ They have higher basal fluid requirements (100–120 ml/kg per day, i.e. 10%
to 12% of bodyweight).

■ Immature renal tubular reabsorption.

■ They are unable to obtain fluids for themselves when thirsty.

 Assessment
■ The most accurate measure of dehydration is the degree of
weight loss during the diarrhoeal illness however:
– A recent weight measurement is often not available.
– may be misleading if the child had clothes on or measuring
scales are not accurate.
■ The history and examination are used to assess the degree of
dehydration as:
– No clinically detectable dehydration (<5% loss of body
weight)
– Clinical dehydration (5% to 10% loss of body weight)
– Shock (>10% loss of body weight), must be identified
without delay.
An infant with mottled skin Severely dehydrated baby with sunken eye
 No clinical Clinical dehydration Shock
dehydration

General appearance Appears well Appears unwell or Appears unwell or deteriorating

deteriorating
 The more numerous Conscious level Alert and responsive Altered Decreased level of consciousness
and more responsiveness, e.g.
pronounced the irritable, lethargic
symptoms and
Urine output Normal Decreased Decreased
signs, the greater
Skin colour Normal Normal Pale or mottled
the severity of
dehydration. Extremities Warm Warm Cold
 ‘Red flag’ sign – Eyes Normal Sunken Grossly sunken
helps to identify Mucous membranes Moist Dry Dry
children at risk of
progression to Heart rate Normal Tachycardia Tachycardia
shock. Breathing Normal Tachypnoea Tachypnoea
Peripheral pulses Normal Normal Weak

Capillary refill time Normal Normal Prolonged (>2 s)

Skin turgor Normal Reduced Reduced

Blood pressure Normal Normal Hypotension (indicates
decompensated)
Types of dehydration

In dehydration, there is a total body deficit of sodium and water.

1. Isonatraemic dehydration:
In most instances, the losses of sodium and water are proportional and
plasma sodium remains within the normal range (isonatraemic
dehydration).
 Types of dehydration
2. Hyponatraemic dehydration
– When children with diarrhea drink large quantities of water or other
hypotonic solutions, there is a greater net loss of sodium than water,
leading to a fall in plasma sodium (hyponatremic dehydration).
– This leads to a shift of water from extracellular to intracellular
compartments.
– The increase in intracellular volume leads to an increase in brain
volume, which may result in seizures.
– The marked extracellular depletion leads to a greater degree of
shock per unit of water loss.
– It is more common in poorly nourished infants.
Types of dehydration
3. Hypernatraemic dehydration:
When water loss exceeds the relative sodium loss, plasma sodium concentration
increases (hypernatraemic dehydration).
It is usually due to:
■ high insensible water losses (high fever or hot, dry environment)
■ profuse, low-sodium diarrhoea.
■ water shifts into the extracellular space from the intracellular compartment.
■ Signs of extracellular fluid depletion are less.
■ depression of the fontanelle, reduced tissue elasticity, and sunken eyes are less
obvious.
■ This makes this form of dehydration more difficult to recognize clinically,
particularly in an obese infant.
Hypernatraemic dehydration cont.:
Hypertonia hyperglycaemia hyperreflexia

■ It is a particularly dangerous form of dehydration as water is drawn out of

the brain and cerebral shrinkage within a rigid skull may lead to jittery
movements, increased muscle tone with hyperreflexia, altered
consciousness, seizures, and multiple, small cerebral haemorrhages.
■ Transient hyperglycaemia occurs in some patients with
hypernatraemic dehydration; it is self-correcting and does not require
insulin.
Investigation
■ Usually, no investigations are indicated.
■ Stool culture is required if:
– the child appears septic,
– there is blood or mucus in the stools, or
– the child is immunocompromised.
■ It may also be indicated in case of:
– History of recent foreign travel,
– Diarrhoea has not improved by day 7,
– The diagnosis is uncertain.

■ Plasma electrolytes, urea, creatinine, and glucose should be checked if

intravenous fluids are required or there are features suggestive of hypernatraemia.

■ If antibiotics are started, a blood culture should be taken.

Management
■ In gastroenteritis, death is from dehydration; its prevention or
correction is the mainstay of treatment.
■ Where clinical dehydration is not present, the aim is its prevention.
■ If there is clinical dehydration, oral rehydration solution is the
mainstay of therapy, it may also be used as an adjunct in its
prevention.
■ Intravenous fluids are only indicated for shock or deterioration or
persistent vomiting.
Management
■ Hypernatraemic dehydration
■ The management of hypernatraemic dehydration can
be particularly difficult.
■ Oral rehydration solution should be used to rehydrate
hypernatraemic children with clinical dehydration.
■ If intravenous fluids are required, a rapid reduction
in plasma sodium concentration and osmolality will
lead to a shift of water into cerebral cells and may
result in seizures and cerebral oedema.
■ The reduction in plasma sodium should therefore be
slow. The fluid deficit should be replaced over at
least 48 hours (with 0.9% or 0.45% saline).
Antidiarrhoeal drugs (e.g. loperamide, Lomotil)
and Antiemetics
■ There is no place for medications for the vomiting or diarrhoea of
gastroenteritis in children as they:
– are ineffective
– may prolong the excretion of bacteria in stools
– can be associated with side-effects
– add unnecessarily to cost
– focus attention away from oral rehydration.
Antibiotics

■ Antibiotics are not routinely required to treat gastroenteritis.

■ They are only indicated for:
– suspected or confirmed sepsis,
– extra-intestinal spread of bacterial infection,
– salmonella gastroenteritis if aged under 6 months,
– in malnourished or immunocompromised children,
– specific bacterial or protozoal infections (e.g. Clostridium
difficile associated with pseudomembranous colitis, cholera, shigellosis,
giardiasis).
Nutrition
■ In developing countries, multiple episodes of diarrhoea are a major
contributing factor to the development of malnutrition.
■ Following diarrhoea, nutritional intake should be increased.
■ Diarrhoea may be associated with zinc deficiency and supplementation may be
helpful in both acute diarrhoea and as prophylaxis.
■ Postgastroenteritis syndrome
Infrequently, following an episode of gastroenteritis, the introduction of a normal
diet results in a return of watery diarrhoea. In such cases, oral rehydration therapy
should be restarted.
 CASE HISTORY

■ Darpana is 14 months old and has had a mild fever, a runny nose, and is not
interested in playing. She has been drinking only small volumes of milk,
vomited four times over the last 2 days but now has increasing loose stools,
with 9 or 10 watery nappies changed over the last 24 hours. On examination,
she has a temperature of 37.8°C, is irritable, and has clinical dehydration.
Oral rehydration solution is prescribed and her diarrhoea and vomiting settle
over the next day. Why does the diarrhoea resolve with oral rehydration
solution?
The mechanism of action of oral
rehydration solution is shown in Fig. 14.11 .
Large quantities of sodium are excreted into
the intestine, but nearly all is reabsorbed.
The primary mechanism of sodium
absorption is by a glucose–sodium
transporter, with the active absorption of
sodium allied to the absorption of glucose.
The sodium is then actively pumped from
epithelial cells into the circulation via
sodium/potassium adenosine triphosphatase,
creating an electrochemical gradient that
water moves down. A second mechanism is
via an active, linked sodium–hydrogen
exchanger.

Fig. 14.11
■ If an oral solution contains both sodium and glucose, sodium and passive water
absorption is increased. This works effectively even in the presence of
inflammation of the gut, and is therefore effective in diarrhoeal illness. The oral
rehydration solution does not ‘stop’ the diarrhoea, which often continues, but the
absorption of water and solutes exceeds secretion and keeps the child hydrated
until the infective organism is eradicated. Coca-Cola and apple juice have a
much lower sodium content and higher osmolarity than oral rehydration solution
and are unsuitable as oral rehydration solutions.
SUMMARY
Gastroenteritis:
 Results in death from dehydration of hundreds of thousands of children
worldwide every year.
 Is mostly viral, but it can be caused by Campylobacter , Shigella ,
and Salmonella and other organisms.
 Infants are particularly susceptible to dehydration.
 Dehydration is assessed as no clinical dehydration, clinical
dehydration or shock according to symptoms and signs, but clinical
assessment of severity is problematic.
 Oral rehydration solution is the mainstay of treatment and usually
effective; intravenous fluid is only required for shock or ongoing
vomiting or clinical deterioration.
REFERENCES