Acute Gastroenteritis

Dr. Galoș Felicia

Could be also known as:

• Acute Enterocolitis
• Acute Gastroenterocolitis
• Acute Diarrhea
• Acute Diarrheal Disease
Definitions

• ACUTE DIARRHEA– generally defined by stool consistency and duration

(less than 7 days) (not by the number of stools per day – infant
variability)

• EXTENDED DIARRHEA (7-14 DAYS)

• CHRONIC/PERSISTENT DIARRHEA – More than 14 days

The causes of acute diarrhea (modified and adapted after Ciofu E, Ciofu
C. Pediatria - Tratat 1st Edition, 2001 )
1. Enteral infections (bacterial, viral, parasitic)
2. Parenteral infections (UTI, etc)
3. Inflammatory intestinal disease
4. Anatomical/functional causes (short intestine, de l'anse borgne
syndrome, etc)
5. Pancreatic/hepatic diseases (cistic fibrosis, etc)
6. Biochemical causes(disaccharides deficit, chloride diarrhea)
7. Celiac disease
8. Neoplasia (lymphoma, neuroblastoma, etc)
9. Immunodeficiency (hypogammaglobulinemia, Iga selective deficiency,
AIDS)
10. Endocrinopathy (hyperparathyroidism , Addison's disease)
11. Malnutrition
12. Diet factors (over-alimentation, introduction of new foods)
13. Alimentary intolerances/allergies
14. Psychogenic diseases (irritable bowel)
15. Toxic diarrhea (heavy metal poisoning)
The causes of acute diarrhea (from a
practical point of view)
1. Enteral infections
1. bacterial
2. viral
3. Parasitic
2. Parenteral infections (UTI, etc)
3. Medication (antibiotics, etc)
4. Alimentary allergies
5. Food factors (over-alimentation, introduction of new
foods)
There are many pathogenetic mechanisms that are both
self-explanatory and asociated with acute diarrhea:
• Secretory - secretagogue agents, ex. cholera toxin, which
attach to the receptors of the intestinal ephitelium and
determine an intracellular accumulation of cAMP and cGMP
Osmotic – determined by unabsorbable solutions,
carbohydrate malabsorption (caused by the damage of the
small intestine’s brush border)
• Intestinal motility disorders – ex thyrotoxicosis, bacterial
overgrowth (the transit is slowed down)
• Reduce intestinal surface (short intestinal syndrome)
• Mucosal invasion (inflammation, decreased colonic
reabsorption, increase motility)
Nelson, Textbook of Pediatrics 20 Edition
 Practical differential diagnosis: osmotic
diarrhea e secretory diarrhea

Parameters Osmotic Diarrhea Secretory Diarrhea

Stool Volume < 200 ml/day > 200 ml/day

Answer to fasting Answer No answer

Stool Na < 60 mOsm/l > 90 mOsm/l

Fecal osmolarity < plasma osmolarity = plasma osmolarity

 Definition acute gastroenteritis (AGE)

• Decrease of fecal consistency (soft or liquid) and/or

increase of stool evacuation frequency (tipically ≥3/24
hours) with or without fever and vomiting
• A change in stool consistency versus previous stool
consistency is more indicative of diarrhea than stool
number, particularly in the first months of life

A. Guarino et al. European Society for Pediatric Gastroenterology, Hepatology, and

Nutrition/European Society for Pediatric Infectious Diseases Evidence-Based Guidelines for the
Management of Acute Gastroenteritis in Children in Europe: Update. 2014JPGN Volume 59,
Number 1, July 2014
When we talk about acute gastroenteritis

We also talk about “infectious diarrhea”

Pathogeny- AGE

• Enterotoxigenic Mechanism - major pathogenic

mechanism (if not exclusive) production of
enterotoxin and its action on the intestinal mucus,
with the distruction of villus cells
• Enteroinvasive mechanism - direct invasion of the
intestine, as well as cytokines production that
causes the increase of water secretion and
electrolytes in the intestinal lumen.
•The main pathogenic mechanism
consists in blocking or decrease water
and electrolytes absorption at the
intestinal level
 Epidemiology

• The incidence of diarrhea ranges from 0.5 to 2 episodes

per child per year in children <3 years in Europe.
• Gastroenteritis is a major reason for hospitalization in this
range of age.
• Rotavirus is the most frequent agent of AGE;
• norovirus is becoming the leading cause of medically
attended AGE in countries with high rotavirus vaccine
coverage.
• The most common bacterial agent is either Campylobacter
or Salmonella depending on country.
• Intestinal infections are a major cause of nosocomial
infection.
 Frequency of enteropathogens in European
children (0–5 y)
Pathogen Frequency, %
• Rotavirus 10–35
• Norovirus 2–20
• Campylobacter 4–13
• Adenovirus 2–10
• Salmonella 5–8
• EPEC 1–4.5
• Yersinia 0.4–3
• Giardia 0.9–3
• Cryptosporidium 0–3
• EAggEC 0–2
• Shigella 0.3–1.4
• STEC 0–3
• ETEC 0–0.5
• Entamoeba 0–4
• No agent detected 45–60
EPEC=enteropathogenic Escherichia coli; EAggEC=enteroagenteroaggregative E coli; STEC=Shiga toxin–producing E
.
coli;ETEC=enterotoxigenic strains of E coli
Etiology of age divided in age groups

•<a 1year: rotavirus, norovirus, adenovirus,

salmonella
•1-4 ani: rotavirus, norovirus, adenovirus,
salmonella, campylobacter, yersinia
•>5 years: campylobacter, salmonella,
rotavirus
Clinical Signs

• Diarrheic stool
• Vomitting
• Fever
• Abdominal pain
• Anorexia
• Seizures
• Tenesmus
• Erythema nodosum
Clinical signs of acute dehydration are to be added to the
clinical representation of acute diarrhea, as they severely
affect the disease
Clinical research has focused on the following:

• Fever (different definitions of absent, low, moderate, and high)

• Vomiting (absent, present, and different definitions of frequent)
• Onset (abrupt or more gradual)
• Stool frequency (different definitions of low, moderate, and high)
• Fecal mucus (present or not)
• Fecal blood (present or occult)
• Abdominal pain (present or not)
• Respiratory symptoms (rhinorrhea, cough)
• CNS involvement (irritability, apathy, seizures, or coma)
ATTENTION ASOCIATION DIARRHEA, OLIGURIA, EDEMA = suspicion
of hemolytic uremic syndrome
Risk factors that cause severe/persistent forms
of disease

• Clinical signs of severity: severe dehydration, repeated

vomiting, persistent/high fever
• Age < 6 months
• Etiology: rotavirus, norovirus, astrovirus, E Coli
enteropatogen
• Socio-economic conditions
• Artificial nutrition
• Community: prekindergarden, kindergarden
• Immunodeficiency
Are there any clinical signs that could lead to
the etiology?

•Fever > 40 ˚C, blood in the stool, abdominal

pain, irritability, seizures, coma = suggestive
for bacterial etiology

•Signs of vomiting and respiratory symptoms =

suggestive for viral etiology
Is a child with diarrhea dehydrated?

• The degree of dehydration is essential for the

therapeutic approach!
(expressed in loss weight)
• Minimal dehydration : <3% (Child) (5%) (Infant)
• Mild to moderate dehydration : 3-9% (6-10%)
• Severe dehydration> 9% (10%)

A. Guarino et all. ESPGHAN/European Society for Pediatric Infectious Disease Evidence-

based. Guidelines for the Management of Acute Gastroenteritis in Chlidren in Europe. JPGN
2008
When are electrolytes /astrup
needed?

• In cases of moderate and severe dehydration

• In case of parenteral rehydration
• Hypovolemic shock
• Neurological abnormalities (lethargy, seizures)
• Incoercible vomiting

A. Guarino et all. ESPGHAN/European Society for Pediatric Infectious Disease Evidence-based. Guidelines for the
Management of Acute Gastroenteritis in Chlidren in Europe. JPGN 2008
 When should one go to the doctor?

• Diarrhea: ≥ 8 episodes/day
• Persistent vomiting
• Infants < 2 months
• Severe underlying disease (diabetes mellitus or renal
failure)
• Family reported sign of severe dehydration

A. Guarino et all. ESPGHAN/European Society for Pediatric Infectious Disease Evidence-based. Guidelines for the Management of
Acute Gastroenteritis in Chlidren in Europe. JPGN 2008/update 2014
 When is hospitalization recommended?

• Shock
• Severe dehydration
• Somnolence, seizures, etc
• Persistent /bilious vomiting
• Lack of response to oral rehydration
• Social/family causes
• Suspected of surgical disease causes

A. Guarino et all. ESPGHAN/European Society for Pediatric Infectious Disease Evidence-based. Guidelines for the Management of
Acute Gastroenteritis in Chlidren in Europe. JPGN 2008/update 2014
Microbiological investigations

• Stool samples (Coprocultures)

• Microscopic examination of faecal samples (evaluation
of the number of leukocytes )
• Stool antigen (Rotavirus, Campylobacter etc)
• Verotoxina (shiga-like toxin) - EHEC O157:H7
(suspicion of hemolytic uremic syndrome)
Treatment - ACUTE GASTROENTERITIS

•Rehydration
•Diet
•Pharmacological therapy
Alimentation of the child with AGE

• Minimal or no dehydration– fed according to age

• Mild to moderate dehydration – reintroduction of normal

feeding after 4-6 hours from the start of rehydration (shortens
the length of diarrhea by 0,43 days, reduces ponderal decrease
thanks to hypocaloric diets)

•This recommendation is not often

followed.
“….optimal management of mild-to-moderately
dehydrated children in Europe should consist of
• A) oral rehydration with ORS over 3 to 4 hours, and
• B) rapid reintroduction of normal feeding
thereafter….”

(ESPGHAN Working Group)

Should breastfeeding be interupted for
children with diarrhea?

•NO
Enteral feeding and diet selection

• Continued enetral feeding in diarrhea aids in

recovery from the episode, and a continued age-
appropiate diet after rehydration is the norm
• Intestinal brush-border surface and luminal
enzymes can be affected in children with prolonged
diarrhea or malnourished children – lactose free
formula and possible specific diet. Alternative
strategies: addition of milk to cerreals and
replacement of milk with fermeted milk products
such as yogourt
• Fatty food and food high in simple sugars (juices,
carbonated sodas) should be avoide
Is progressive reintroduction of milk fomula
necessary?

•No

A. Guarino et all. ESPGHAN/European Society for Pediatric Infectious Disease Evidence-based. Guidelines for the Management of
Acute Gastroenteritis in Chlidren in Europe. JPGN 2008
When is the introduction of lactose-free
formulas necessary?

• Not routinely done

Studies that show the benefits of this recommendation were
published before1980
• Recomended in
- Severe dehydration
- Severe malnourished children

A. Guarino et all. ESPGHAN/European Society for Pediatric Infectious Disease Evidence-based.

Guidelines for the Management of Acute Gastroenteritis in Chlidren in Europe. JPGN 2008
Pharmalogical therapy
• ANTIBIOTICS – indications

• In GEA with Salmonella typhi, Shigella, Entamoeba hystolytica, v.

cholerae, Giardia lamblia, Campylobacter
• Despite the etiology, in the presence of signes of sepsis or in
neurological complications or in persistent diarrhea(>14 zile)
• Neonatal period
• Malnutrition
• Imune defficiencies

A. Guarino et all. ESPGHAN/European Society for Pediatric Infectious Disease Evidence-based. Guidelines for the Management of Acute Gastroenteritis in Chlidren in
Europe. JPGN 2008
Pharmcological therapy
• Racecadotril (a potent enkephalinase inhibitor) (Hidrasec, Tiorfan,
Racecadotril etc) – reduces the number of watery stools

• Smectita - improves the consistent of the stools

• Probiotics – active on gut microflora and intestinal absorption

• Lactobacillus GG
• Saccaromyces boulardi

• Loperamid – NO

• Antiemetice (Ondasetron)– NOT USSUALLY

Pharmcological therapy

• In malnourished children (mostly in developing countries):

• ZINC is recommended to reduce the severity and duration
of diarrhea
• And should be added to treatment with ORS
Dehydration

•Water decrease in the organism

•Usually associated with electrolyte
concentration decrease
Symptoms associated with minimal or no
dehydration < 3% loss of body weight)
• Mental status • Well, alert
• Thirst • Drinks normally, might refuse
liquids
• Heart rate • Normal
• Quality of pulses • Normal
• Breathing • Normal
• Eyes • Normal
• Tears • Present
• Mounth and tougue • Moist
• Skinfold • Instant recoil
• Capillary refil • Normal
• Extremites • Warm
• Urine output • Normal to decreased
Symptoms associated with mild to moderate
dehydration 3-9 % loss of body weight)
• Mental status • Normal, fatigued or restless,
irritable
• Thirst • Thirsty, eager to drink
• Heart rate • Normal to increasead
• Quality of pulses • Normal to decreased
• Breathing • Normal, fast
• Eyes • Slightly sunken
• Tears • Decreased
• Mounth and tougue • Dry
• Skinfold • Recoil in < 2 sec
• Capillary refil • Prolonged
• Extremites • Cool
• Urine output • Decreased
Symptoms associated with severe
dehydration > 9% loss of body weight)
• Mental status • Apathetic, lethargic,
unconscious
• Thirst • Drinks poorly, unable to drink
• Heart rate • Tachycardia or bradycardia
• Quality of pulses • Weak, thready, or impalpable
• Breathing • Deep
• Eyes • Deeply sunken
• Tears • Absent
• Mounth and tougue • Parched
• Skinfold • Recoil > 2 sec
• Capillary refil • Prolonged; minimal
• Extremites • Cold, mottled, cyanotic
• Urine output • Minimal
Dehydration classification depending
on osmolarity
“SURROGATE” FOR THE OSMOLARITY
SODIUM VALUES--- CONSIDERING NORMAL GLYCEMIA
VALUES!---
• ISOTONIC (130-150 mEq/l) (normal osm.)
• HYPOTONIC(<130 mEq/l) (decreased osm)
• HYPERTONIC (>150 mEq/l) (increased osm)
ATTENTION!!!

• The knowledge of the type of dehydration(hypo, iso

or hypertonic) is crucial in minimizing risks
associated with volemic reexpansion
• In hyponatremia ideal 10 mEq/24 hours (not more than 2
mEq/hour) –long term neurological effects due to pontine
myelinolysis
• In hypernatremia – correction of dehydration within 48
hours - lethal massive cerebral edema risk
 ATTENTION!!

• the principle that must guide the volemic resuscitation is maintaining a

full vascular bed – euvolemia = main target

• correction of ionic imbalances = secondary target

 Access routes

• For patients in shock, with hypotension – venous

access attempts should be limited to 3 ATTEMPS
• No blood vessel obtained– INTRA-BONE access
• THE INTRA-BONE APPROACH SHOULD BE THE MAIN
OPTION FOR PATIENTS IN CARDIAC ARREST
• IT HAS A SUCCESS RATE OF 83% AS OPPOSED TO 17%
IN THE CASE OF INTRAVENOUS CANNULATION
 ACCESS ROUTES - INTRA-BONE APPROACH
• THE INTRA-BONE APPROACH
• Indicated:
• Cardiac arrest
• Shock
• Intravenous cannulation failure
• For patients in shock, with hypotension – venous access attempts should be
limited to 3 ATTEMPS
• No blood vessel obtained– INTRA-BONE access
• THE INTRA-BONE APPROACH SHOULD BE THE MAIN OPTION FOR PATIENTS
IN CARDIAC ARREST
• IT HAS A SUCCESS RATE OF 83% AS OPPOSED TO 17% IN THE CASE OF
INTRAVENOUS CANNULATION
• Places of puncture:
• Proximal tibia/distal tibia
• Distal femur
INTRA-BONE APPROACH
INTRA-BONE APPROACH

Necessary material
• Special needles
• Short
• Stop protection
• trocarul
• Xilina1%;
• Antiseptic measures
INTRA-BONE APPROACH

Complications:

• Osteomyelitis (1%)
• Cellulitis;
• Comprising syndrome
• Fatty embolism
• Growth cartilage destruction
• Sepsis.
 INTRA-BONE APPROACH
• The duration of infusion should not exceed 12 hours
• Needles must avoid the growth cartilage destruction
• Do not use excessive force/ you can pass both cortices
• If you do not aspirate marrow or blood / instilate saline
solution – pink liquid – confirm the correct place of
needles in the medullary cavity
• Urgent medication (adrenalina, atropina, Na
bicarbonat, xilina,blood, etc.) - performed without
problem.
ACCESS ROUTES

• ORAL REHYDRATION MUST NOT BE IGNORED

• when the dehydration is not severe
• when the child’s status allows it (without altered
sensorium)
• when the gastric tolerance allows it

REHYDRATING WITH REHYDRATION SALTS – FOR 4 HOURS -

50 ml/kg for mild dehydrations - 100 m/kg for /severe
ones
 Rehydration salts
• Classical/standard solutions- Na 90 mmol/l –among
the most important medical discoveries – they saved
the lifes of many children with cholera

• Reduced osmolarity solutions – Na 75 mml/l

(recommended by the OMS)

• Hypotonic solutions– Na 60 mmol/l (recommended by

ESPGHAN,less by OMS)
Rehydration salts
REDUCED
STANDARD ORS OSMOLARITY ORS
• Glucose 111 mmol/l • Glucose 75 mml/l
• Sodium 90 mEq/l • Sodium 75 mEq/l
• Potasium 20 mEq/l • Potasium 20 mEq/l
• Chlorine 80 mEq/l • Chlorine 65 mEq/l
• Bicarbonate 30 mmol/l • Citrate – 10 mml/l
• Osmolarity 311 mmol/l • Osmolarity 245 mOsmol/l
Rehydration salts

ESPGHAN ORS
• Glucose 90 mml/l
• Sodium 60 mEq/l
• Potasium 20 mEq/l
• Chlorine 60 mEq/l
• Citrate – 10 mml/l
• Osmolarity 240 mOsmol/l
Replacement of losses

• <10 kg body weight: 60-120 ml ORS for each diarrheal stool or

vomiting episode

• >10 kg body weight: 120-240 ml ORS for each diarrheal stool or

vomiting episodes
IMPORTANT

• The choice for the hypovolemic patient is saline solution (nacl 0.9%) –
regardless of the glycemic index!!!

• 20 ml/kg as quickly as possible

• If after maximum 3 tries the reexpansion has not been obtained –

coloidal solutions: glucose oligomers, albumin
Why is it important to use saline solution
(NaCl 0,9%) in rebuilding volemia and not 5%
glucose?

- In order for the administered solutions to reach the

cells a vascular bed is required
- Glucose administered without rebuilding the
volemia – hyperglycemia (often observed by us)
- Therapeutically induced hyperglicemia accentuates
dehydration through osmotic diuresis
 Frequent mistakes
• Administering during the inital approach:
• antibiotics
• corticosteroids
• bicarbonate

• Administering bicarbonate without documenting a refractary

acidosis to efficient volemic expansion and without proving
normal na values = vital risk complications (through
hypercapnia, hypernatremia, hyperosmolarity)
PRACTICAL MESSAGE

• the absolute priority regarding patients with ads and severe

dehydration is rebuilding the volemia

• glucosate solutions will under no circumstance be used to rebuild

volemia

• for hypoglycemic patients this will be corrected afterwards,

possibly through a different vein

• the use of antibiotics and bicarbonate should be reserved for

special cases, not routinely
PREVENTION

•Promotion of exclusive breastfeeding

•Improved complementary feeding practices
•Rotavirus immunisation
•Improved water and sanitary facilities and
promotion of personal and domestic hygiene
•Improved case management of diarrhea