GASTROENTERITIS

& MALABSORPTION
I Putu Gede Karyana
IGN Sanjaya Putra
Ni Nyoman Metriani Nesa

DEPARTMENT OF PEDIATRICS
FACULTY OF MEDICINE UDAYANA UNIVERSITY/ SANGLAH UNIVERSITY
HOSPITAL
GASTROENTERITIS
 INTRODUCTION
 Global problem  morbidity & mortality
 Definition: - Frequency & consistency
- Acute watery diarrhea
Dysentery
- Persistent diarrhea
- Chronic diarrhea
- Osmotic diarrhea
Secretory diarrhea
 EPIDEMIOLOGY
 Transmission of agents cause diarrhea
 Routes of transmission
 Behaviours   the risk of diarrhea
 Host factors   susceptibility to diarrhea
 Age
 Seasonality
 Epidemic
 HOST - malnutrition
- immune deficiency

ENVIRONMENT AGENT
- sanitation - bacteria
- hygiene - viruses
- protozoa
 BEHAVIOURS
 Failing to breast-feed for the first 4-6 mos
 Failing to continue breast-feeding  1 yr
 Using infant feeding bottles
 Storing cooked food at room temperature
 Drinking water  contaminated
 Failing to wash hands
 Failing to dispose of faeces hygienically
 HOST FACTORS

 Undernutrition
 Current or recent measles
 Immunodeficiency or immunosuppresion
 ETIOLOGY
 Pathogenetic mechanisms:
• Viruses  patchy epithelial cell destruction &
villous shortening
• Bacteria mucosal adhesion, invasion, toxin
• Protozoa mucosal adhesion,
microabcess/ulcers
 Important enteropathogens
Rotavirus, ETEC, Shigella, C.jejuni, V. cholerae
01, Salmonella, Cryptosporidium
 Pathophysiology

Mechanism of watery diarrhea:

 Secretory diarrhea

 Osmotic diarrhea
SECRETORY DIARRHEA
Bacteria

Toxin

Stimulation of c-AMP, c-GMP

Stimulation of water/electrolyte secretion

Diarrhea
OSMOTIC DIARRHEA
BOWEL LUMEN
nutrient
not absorbed
fermented bacteria

organic acid + gas

increased osmotic pressure

fluid dragged into lumen

diarrhea
Consequences of watery diarrhea:

 Dehydration:
- Isotonic (isonatraemic) dehydration
- Hypertonic (hypernatraemic) dehydration
- Hypotonic (hyponatraemic) dehydration
 Base deficit acidosis (metabolic acidosis)
 Potassium depletion
 Composition of electrolytes
in stool and New ORS

Etiology Electrolytes (mmol/L) Osmolarity

Na K Cl HCO3 (mOsm/L)

Cholera 88 30 86 32 300
Rotavirus 37 38 22 6 300
ETEC 53 37 24 18 300
New ORS 70 20 80 30 245
Assessing a child for dehydration:

 Ask, look, and feel for signs of dehydration

• Condition & behaviour, eyes, tears, mouth & tongue
thirst, skin pinch
• Anterior fontanelle, arms & legs, pulse, breathing
 Determine the degree of dehydration
 Select a treatment plan:
• C: Severe dehydration (loss of >10% of Body Weight)
• B: Some dehydration (loss of 5-10% of BW)
• A: No signs of dehydration (loss of <5% of BW)
 Weight the child
 Signs & symptoms of some
dehydration

 Restless, irritable
 Sunken eyes
 Dry mouth and tongue
 Thirst  drink eagerly
 Slowly skin pinch (skin turgor)
Signs & symptoms of severe dehydration

 Floppy (listless), lethargic, or

unconscious
 Very sunken & dry eyes
 No tears when he cries
 Very dry mouth & tongue
 unable to drink / drink poorly
 Skin pinch: very slowly (take  2
seconds)
Assessing the child for other problems
 Dysentery
 Persistent diarrhea
 Under-nutrition
 Feeding history
 Physical findings: marasmic &/ kwashiorkor
 Vitamin A deficiency
 Fever
 Measles vaccination status
MANAGEMENT OF DIARRHEA
(Lintas Diare)
According to WHO recommendation 2004
1. Rehydration
2. Diet/nutrition
3. Zinc elemental during 10-14 days
- Age < 6 month with dose 10 mg
- Age > 6 month with dose 20 mg
4. Selective antibiotic
5. Education
 TREATMENT OF DIARRHEA
WITH NO DEHYDRATION
AT HOME (Plan A)
 Prepare & give appropriate fluids for ORT
 Give ORS 10 ml/kg for each diarrhea
 Feed a child with diarrhea correctly
 Recognize when a child should be taken
to health worker
 TREATMENT OF DIARRHEA
WITH SOME DEHYDRATION
Plan B: Manage in ORS corner
 Continue breast-feeding
 Give ORS 75 ml/kg/3 hours
 Monitor Tx & reassess the child
periodically until rehydration is complete 
send home (Plan A)
 Give ORS 10 ml/kg for each diarrhea
 FAILURE OF ORT
 The passage of many watery stools
 Repeated vomiting
 Increased thirst
 Failure to eat or drink normally
 Severe dehydration
 Meteorism
 Preparing & giving ORS not correctly
WHEN TO TAKE THE CHILD TO A HEALTH WORKER

 There is no improvement in 3 days

 The passage of many watery stools
 Repeated vomiting
 Increased thirst
 Failure to eat or drink normally
 Fever
 Blood in the stool
 INDICATION OF IV FLUID

 Severe dehydration or with hypovolemia

 Unable to drink (unconscious)
 Persisted vomiting
 Prolonged oligouria or anuria
 Other complications that influenced
ORS
COMPOSITION OF IV FLUID

Solution Glukosa K+ Na+ Cl- Lactate/

(g/L) Acetate

Hartmann / RL - 4 130 109 28

DGaa 150 17.5 61 52 26
NaCl 0.9% - - 154 154 0
KaEN 3B 27 20 50 50 20
 TREATMENT OF DIARRHEA
WITH SEVERE DEHYDRATION

PLAN C
Give 100ml/kg:
Age 30ml/kg 70ml/kg
<12 months 1 hour* 5 hours
>12 months 30min*-1hour 2-2 ½ hours

*can be repeated if the pulse is still weak or unpalpable

ANTIBIOTICS FOR DIARRHEA

 Cholera  tetracycline or doxycycline

(if resistant: furazolidone, cotrimoxazole
or chloramphenicol may be used)
 Dysentery (treated as shigellosis):
co-trimoxazole, ampicillin, nalidixid
acid
ANTIPARASITIC FOR DIARRHEA

 Amoebiasis  metronidazole; if:

 E. histolytica trophozoites containing RBC
(+)
 Bloody stools persist after tx for shigellosis
 Giardiasis  metronidazole; if:
 Diarrhea more than 14 days
 Giardia containing stools
 PREVENTION
 Breast milk for the first 4-6 months of life
 Avoiding the use of infant feeding bottles
 Using clean water for drinking
 Washing hands
 Safely disposing of stool
 Measles vaccination
 Rotavirus Immunization
 Improving nutritional status  weaning food
MALABSORPTION
Normal Digestion and Absorption
Ebert EC. Dis Month 2001;47:49
Protein  Oligopeptides  AA

Pancreatic proteases Mucosal peptidases

Digestion Absorption Distribution

CHO  Oligosaccharides  Sugars

Pancreatic amylase Mucosal disaccharidases

Classification of Malabsorption
Stevens T et al. AJG 2006
 Serum trypsinogen/trypsin
 Fecal chymotrypsin
 Fecal elastase-1

 Pancreolauryl test “Tubeless tests”

 Bentiromide test

 Trial of pancreatic enzymes

Breath Tests
< 100 cm

Bile Acid

> 100 cm

Fat
THANK YOU
FOR YOUR ATTENTION