ACUTE

GASTROENTERIT
IS
 INTRODUC TION

• Acute gastroenteritis is a leading cause of childhood

morbidity and mortality and an important cause of
malnutrition.

• Dehydration and electrolyte losses associated with

untreated diarrhea are the main causes of morbidity
and mortality of childhood AGE.
DEFINTION
• The passage of unusually loose or watery stools,
usually at least 3 times in a 24-hour period.
- College of Paediatrics, Academy of Medicine of
Malaysia (AMMCOP) , 2011
 ETIOLOGY

Acute Gastroenteritis

Bacteria
• Campylobacter
Viruses. jejuni.
• Salmonella. Parasites.
• Rotavirus (most • Shigella. • Entamoeba
common). • E.coli. histolytica.
• Calicivirus. • Clostridium difficile. • Giardia lamblia.
• Astrovirus.
CLINICAL TYPES OF DIARRHOEAL
DISEASES
INDICATIONS FOR ADMISSION TO
HOSPITAL
• Moderate to severe dehydration.
• Need for intravenous therapy
• Concern for other possible illness or uncertainty of
diagnosis.
• Patient factors, e.g. young age, unusual
irritability/drowsiness, worsening symptoms.
• Caregivers not able to provide adequate care
at home.
• Social or logistical concerns that may prevent return
evaluation if necessary.
HISTORY AND PHYSICAL
EXAMINATION
• Objectives : to assess whether the child is
dehydrated and to determine the etiology of the
acute gastroenteritis
PHYSICAL
EXAMINATION
 ASSESMENT &
MANAGEMENT OF ACUTE
GASTROENTERITIS
 INVESTIGATIONS
• Stool culture is required if the child appears septic, if
there is blood or mucus in the stool or child is
immunocompromised
• Full blood count
• Renal profile & blood glucose
• Blood culture if to start antibiotics
• VBG, to determine any metabolic acidosis
 PHARMACOLOGICAL AGENTS
• Oral rehydration therapy.
– Use to treat mild to moderate dehydration.
– Consist of :
i. Sodium chloride (NaCl).
ii. Potassium chloride (KCl).
iii. Trisodium citrate.
iv. Glucose.

Dilution: 1 sachet dilute with 250ml, plain drinking

water, to give frequent sips
 PHARMACOLOGICAL AGENTS
Antimicrobials Antibiotics

• Majority of gastroenteritis cases in children are viral in origin

(rotavirus, norovirus, adenovirus). Thus, antibiotics are only needed
for specific pathogens or defined clinical settings.
• Antibiotics are indicated in the following situations:
Shigella dysentery - in cases presenting as bloody diarrhoea, should
be treated with an antimicrobial effective for Shigella
 When cholera is suspected
 Whendiarrhoea is associated with another acute infection such as
pneumonia and UTI
 May be indicated for Salmonella gastroenteritis in very young babies
(< 3 months), immune-compromised, immuno- suppressed,
systemically ill
THE MANAGEMENT OF ACUTE
DIARRHOEA
THE MANAGEMENT OF ACUTE
DIARRHOEA
 ANTI-DIARRHOEAL AGENTS AND
OTHER THERAPIES
Silicates – diosmectite (Smecta®)

• Binds to selected bacterial pathogens and rotavirus

• restore integrity of damaged intestinal epithelium
• reduce stool output and duration of diarrhoea
• shown to be effective in rotavirus diarrhoea
• maybe used as adjunctive to ORS
• no side effects
 PHARMACOLOGICAL AGENTS
• Probiotics
– Probiotics has been shown to reduce duration of diarrhoea in several randomized
controlled trials.
– However, the effectiveness is very strain and dose specific.
– Only probiotic strain or strains with proven efficacy in appropriate doses can be used as an
adjunct to standard therapy.

• Zinc supplements
– Able to reduce the duration and severity of the episode and lower the incidence of
diarrhoea in the following 2-3 months.
– WHO recommends zinc supplements as soon as possible after diarrhoea has started.
– Dose up to 6 months of age is 10 mg/day, and age 6 months and above 20mg/day, for 10-14
days.
Nutritional therapy / Special infant formula
• Should continue to be fed, food should not be withdrawn
for longer than 4 – 6 hours
• Breastfeeding - continue
• In children on infant formula- not to dilute the formula
• Change to lactose-free formula – Not Recommended
(without evidence of lactose intolerance)
Prevention of AGE
• 2 types of Rotavirus vaccine available in Malaysia – safe and highly efficacious

• Proper food and bottle handling

Cleansing & Sterilizing bottle
• All equipment used for infant feeding and preparing feed must be
thoroughly cleaned and sterilized
• Cleaning:
• bottle & teat brushes should be used to scrub inside & outside of the bottle
and teat
• Sterilizing:
• commercially home sterilizer / chemical sterilizing tablets or
• boil the bottle & teat in large pan (all equipments must be submerged into
the water, ensure no trapped bubbles, cover the lid of the pan & bring to
rolling boil)
Fluid management
Critical Clinical Questions
• Is the patient in shocked
• Is the patient dehydrated
• Does the patient have a significant acid-base abnormality
• Are there significant electrolyte problems

APLS, 6th edition 2016

Signs of shock
• Tachycardia
• Weak peripheral pulses
• Delayed capillary refill time > 2 seconds
• Cold peripheries
• Depressed mental state
• With or without hypotension
CLINICAL FEATURES OF SHOCK
DEGREE OF
DEHYDRATION
If shock is present
• Rapid administration of IV crystalloid 20ml/kg
• Fluid on choice – isotonic solution, glucose free solution (eg: 0.9%
saline, Hartmann’s solution*)
• Bolus can be repeated if there is inadequate clinical response
• Hypernatremia/hyponatremia – does not affect choice of fluid

* Careful in patient with renal impairment

APLS 6th edition, 2016
• Careful monitoring of patient’s response
• Can turn to management of hydration once shock adequately treated
• Frequent assessment – necessary especially ongoing loss
Maintenance
• Maintenance = insensible loss + loss from urine
• Most children can safely be managed with solution of 0.45% saline
with added glucose
• 0.45% saline in 5% glucose
• 0.45% saline in 10% glucose
• Children who are at high risk of hyponatremia should be given
isotonic solutions (i.e. 0.9% saline ± glucose) – avoid iatrogenic
hyponatremia
Maintenance
Holliday-Segar calculator
Deficit
• Calculated following an estimation of the degree of dehydration
expressed as % of body weight
• Deficit is replaced over a time period that varies according to the
child’s condition
• Use an isotonic solution for replacement of the deficit, e.g. 0.9%
saline
• Reassess clinical status and weight at 4-6hours & adjust accordingly
2 years old child with 5% dehydration, weight 10kg

• Maintenance
• 0.45% saline in 5% glucose 42mls/hr
• Deficit
• 0.9% saline 21mls/hr – over 24 hours
Urine Output
• Neonates : 2-3mls/kg/hr
• Infant : 2 mls/kg/hr
• Child : 1-2mls/kg/hr
• Adolescent : 0.5-1 mls/kg/hr
Hypernatremia
• Defined as serum Na+ > 150mmol/l
• Moderate: serum Na+ is 150-160mmol/l
• Severe: serum Na+ > 160mmol/l
• Appears sicker than expected for the degree of dehydration
• Shock occurs late because intravascular volume is relatively preserved
• Irritable, hyperreflexia, ataxia, seizure, coma
• Causes:
• water loss in excess of sodium in acute gastroenteritis
• Diabetes Insipidus
Managing hypernatremia
• Treat shock 1st (0.9% saline bolus)
• Calculate the maintenance fluid* & estimate % of deficit
• Aim to lower serum Na at a rate < 0.5mmol/h
• Correct deficit slower over 48-72 hours
• Use 0.9% saline to ensure drop not too rapid
• Risk of cerebral edema
• Check other electrolytes – hypoCa & hyperglycemia
• Monitor electrolytes frequently – every 6 hourly
• Clinically assess hydration and weigh frequently
*more recently, consensus guideline recommended starting isotonic solution such as 0.9%
saline / 0.9%saline with 5% glucose for maintenance & deficit APLS 2016
Hyponatremia
• Defined when serum Na+ < 135mmol/l
• Hyponatremic encephalopathy (hyponatremic seizure) is a medical
emergency
• bolus 4mls/kg of 3% NaCl over 30 min – will rise Na by 3mmol/l & stop the seizure
• Correct slowly < 8mmol/day using 0.9% saline
• Risk of osmotic demyelination syndrome
• Deficit:
mmol of Na required = (Desired Na level – current Na level) x 0.6 x body weight (in
kg)
• Sodium maintenance 2-3mmols/kg/day
• Asymptomatic hyponatremia
• Oral fluids
• Intravenous rehydration with 0.9% sodium chloride
• Hyponatremic and have a normal or raised volume status should be
managed with fluid restriction
Hypokalemia
• Correction of K
• K deficit = (4-Serum K) x 0.4 x Wt)
• Daily requirement K= 2-3mmol/kg/day
• 1g KCL = 13.3mmol
• 10ml Mist KCL = 1g K
• 1g = 13.3mmol, 1 pint 500ml, 1 ml=0.02 *no more than 0.05mmol/ml
• Thank you