Nelson Textbook of Pediatrics 20th

ed.
 Reporter: PUNAM CHAUDHARY
IGN: 3-2
Date of Report: NOVEMBER 15, 2019
OUTLINE

I. Definition
II. Epidemiology
III. Etiology
IV. Pathogenesis
V. Risk factors
VI. Complication
VII.Diagnosis
VIII.Treatment
IX. IMCI
X. Prevention
Definition

• Gastroenteritis
infections of GI tract caused by bacteria,
viral, or parasitic
most common manifestations:
 diarrhea and vomiting
 abdominal pain and fever
• Diarrhea is present if one of the following
criteria is fulfilled:
1.frequent defecation>= 3 times/ day
2.altered stool consistency:water
content>75%
3.increase in stool quantity:>200-250 g/day
ACUTE DIARRHEA PERSISTENT CHRONIC
DIARRHEA DIARRHEA

LASTING<=14 DAYS LASTING>14 DAYS LASTING>30 DAYS

Epidemiology

• Diarrheal disorder in childhood accounts

for large proportion (9%) of childhood
deaths (0.71 million deaths per year)
• Second most common cause of child
deaths
• Preventive rotavirus vaccination and
improved case management and nutrition
of infants and children declines diarrheal
mortality
Etiology
• Acquired through fecal oral route or by
ingestion of contaminated food or water
• Associated with poverty, poor
environmental hygiene and development
indices
• Viral, Bacterial, & Parasitic
 Etiology
• Viral
- 70-85% of AGE in developed countries
- Rotavirus and norovirus are the most
common viral agents
- Sapoviruses,
enteric adenoviruses
and astroviruses
Etiology

• Bacterial
- Foodborne
- salmonella, C. Pefringens, Campylobacter,
& S. Aureus,
- E.coli (ETEC), C. Botulinum, shigella, and
Vibrio
Etiology

• Parasitic
- Giardia Lamblia & Cryptosporidium
(E. Histolytica)
- <10% cases
Pathogenesis
 Pathogenesis
• Non inflammatory diarrhea
-enterotoxin
-destruction of villus (surface) cells by
viruses
-Adherence by parasites
-Translocation by bacteria
Pathogenesis

• Inflammatory diarrhea
- Directly invade the intestine
-produce cytotoxins with consequent
fluid, protein and cells (erythrocytes and
leukocytes) enter intestinal lumen
Pathogenesis

• Some enteropathogen posses more than 1

virulence property
• ROTAVIRUS
- target the microvillus tips of the
enterocytes
- direct invasion of the cells
- villous shortening
 RISK FACTORS
• Environmental contamination
• Increased exposure to enteropathogens
• Young age
• Immunodeficiency
• Lack of exclusive breast feeding
• Malnutrition
• Micronutrient Deficiency (Vit. A & Zinc)
• Crowding (>8 persons/kitchen)
• Unwashed hands
• Poor water quality
• Inappropriate excreta disposal
 Complication
• Dehydration
Diagnosis
Clinical Evaluation of Diarrhea:
• Diarrhea
• Abdominal cramps
• Vomiting
• Fever
Diagnosis
• Assessing the degree of dehydration
• Obtaining appropriate contact, travel, or
exposure history
- travellers diarrhea
• Clinically determining the etiology of
diarrhea
Diagnosis
• Stool Examination
- fecal leukocytes indicate bacterial
invasion of colonic mucosa
- should be obtained early as possible
from children with bloody diarrhea in whom
stool microscopy indicates fecal leukocytes
upper intestine. large intestine and small intestine
rectum

nausea and vomiting Severe abdominal pain • nauseaand vomiting

and tenesmus • absent or low-grade
• fever mild to
moderate
• periumbilical pain
• watery diarrhea
Treatment

• oral rehydration
• Enteral feeding
• Zinc
supplementation
• Antibiotic therapy
 Treatment

- oral rehydration solution (ORS):

sodium, chloride potassium, glucose per total
liter osmolarity

75 mEq 64 mEq 20 mEq 75 mmol 245 mOsm/L

• IV resucitation
- <6 mos - poor urine output
- prematurity - sunken eyes
- chronic illness - depressed level of
conciousness
- fever >38
- bloody diarrhea
- persistent emesis
ENTERAL FEEDING AND DIET
SELECTION

Continued enteral feeding in diarrhea aids in recovery from the episode,

and a continued age-appropriate diet after rehydration is the norm.

Breastfeeding or nondiluted regular formula should be resumed as soon

as possible.

Fatty foods or foods high in simple sugars (juices, carbonated sodas)

should be avoided

Usual energy density of any diet used for the therapy of diarrhea should be
around 1 kcal/g, aiming to provide an energy intake of a minimum of 100
kcal/kg/day and a protein intake of 2-3 g/kg/day.

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ZINC SUPPLEMENTATION
Zinc supplementation in children with diarrhea in developing
countries leads to reduced duration and severity of diarrhea
and could potentially prevent a large proportion of cases from
recurring

All children older than 6 mo. of age with acute diarrhea in at

risk areas should receive oral zinc (20 mg/day) in some form
for 10-14 days during and continued after diarrhea.
IMCI
Prevention

• Promote exclusive breast feeding

promote passive immunity
• Improved complementary feeding
practices
• Rotavirus immunization
• Improve water and sanitary facilities and
promotion of personal and domestic
hygeine