2DIARRHEA O.P. 7 months, male August 20, 2010 157-2 M. Dela Fuente St. Sampaloc, ManilaRoman CatholicInformant: ParentsReliability: GoodDIARRHEA
3HISTORY OF PRESENT ILLNESS 3 episodes of vomitingamounting to 15mL/episode1 hr PTA- 4 episodes of loose, mucoid, yellowish stool, altogether amounting to 200mL- Noted to be weak-looking, w/ cold clammy skin30 min PTAADMISSION
5REVIEW OF SYSTEMS Genitourinary: (-) dysuria (-) hematuria Musculoskeletal: (-) weakness, (-)swellingHematopoietic: (-) easy bruisability, (-) bleedingEndocrine: (-) polyuria, polydipsia, polyphagiaNervous/Behavior: (-) headache, (-) seizures, (-)tremors, (-) loss of consciousness
6GESTATIONAL HISTORYBorn to a 22 y/o G1P0 mother with a common law 27 y/o policeman partnerRegular prenatal check-up since 5 mo AOGHep B screening and OGCT were not doneNo history of alcohol intake, smoking or exposure to radiationNo illnesses noted during pregnancy
7NEONATAL HISTORY Born at 39-40 weeks AOG Live, singleton, delivered via NSDAPGAR score 8-9Birth weight = 2.7 kgBirth length – unrecalled1-day stay at the nurseryNo complications noted during delivery
8FEEDING HISTORY Breastfed exclusively for 1 month More than 8 times per day or everytime child criesShifted to milk formulaMother claimed she was not producing enough milkBottlefed since 2 months until present2-5 months: S26 – 1:2 dilution, 4 oz per feeding, 6x /day6 months to present: Bonamil – 1:2 dilution, 8 oz per feeding, 4-5x/dayComplementary feeding started at 6 monthsCerelac and pureed food
924 – HR FOOD RECALL Amount Macronutrients Total CHO (4 cal/g) CHON (4 cal/g)Fats (9 cal/g)KilocaloriesBREAKFASTMilk 1:2 8 oz12810170SNACKLUNCHMilkCerelac32,583DINNERACI763RENI720%106%
10DEVELOPMENT/BEHAVIORAL HISOTRY Gross motorWith good head control, can crawl, rolls over, sits with supportFine motorTransfers object from 1 hand to anotherLanguageImitates speech soundsPersonal SocialLaughs and plays with examiner
11IMMUNIZATIONS HEALTH CENTER BCG – 1 dose Hep B – 1 dose DPT – 3 doses OPV – 3 dosesHib – 1 dose
12PAST MEDICAL HISTORYOctober 2010 – PneumoniaJanuary Diarrhea
14Educational Attainment FAMILY PROFILERelationAgeEducational AttainmentOccupationHealthMother22High school graduatenoneHealthyFather27College graduatePoliceman
15PERSONAL, SOCIOECONIMIC AND ENVIRONMENTAL HISTORY Apartment with both parentsWell-ventilated, well-litDrinking water is purifiedGarbage is not segregated but collected everydayNo nearby factories, no pets
16PHYSICAL EXAMINATIONAlert, awake, weak-looking, with moderate signs of dehydration, drinks eagerly, not in cardiorespiratory distressVS: CR 160 RR 40 T 36.9Wt 6 kg. (z= 0)Lt. 73 cm (z= 0)AC: 43 cmBMI 11 (z= below -3)wt. for Ht. (z= below -3)
17PHYSICAL EXAMINATION Warm, dry skin, no active dermatoses Pink palpebral conjunctiva, anicteric sclerae, (+) sunken eyeballsNo tragal tenderness, non-hyperemic EAC, (+) retained cerumen, AU, intact tympanic membrane, no aural discharge AUMidline septum, turbinates not congested, no nasal discharge
18PHYSICAL EXAMINATIONDry buccal mucosa, no oral lesions, to non-hyperemic posterior pharyngeal wall, tonsils not enlargedSupple neck, no palpable cervical lymphadenopathies or anterior neck massesSymmetrical chest expansion, no retractions, clear breath soundsAdynamic precordium, apex beat 4th LICS MCL, no heaves, thrills, murmurs
19PHYSICAL EXAMINATIONGlobular abdomen, NABS, soft, non- tender, no mass palpatedPulses full and equal, no cyanosis, no edemaNo genital lesions, no phimosisDRE: tight sphincteric tone, no tenderness, no masses, brown fecal material on tactating finger, non-blood tinged
20NEUROLOGIC EXAMINATION Mental Status: alert, awakeCranial Nerves are intact: intact EOM; no ptosis; no jaw deviation; smiles, open and close his eyes, no facial asymmetry; midline uvula, no tongue atrophy, no fasciculations, no deviationNo Babinski, no nuchal rigidity
21SALIENT FEATURES POSITIVE NEGATIVE 7 mo/male Diarrhea – mucoid stools VomitingWeak-looking, with cold clammy skinPast medical history of diarrhea(+) sunken eyeballsdry buccal mucosadrinks eagerlyNEGATIVE(-) fever(-) abdominal pain
25DAY 1CBC with platelet count and fecalysis were done. CBC showed normal results, while fecalysis showed pus cells of over 100/hpf, RBC of (+), and macrophage of (+), and stool culture was then requested.ORS 75 to replace losses volume per volumeZinc sulfate 10mg/ml, 2ml once a day for 14 daysIVF started at D5 0.3% NaCl 100%.
26DAY 2 & DAY 3Ciprofloxacin 16.6 mg/kg/day given for 3 days.IVF given was D5 0.3 NaCl at 100%. DAY 4 & DAY 5Discharged improved and stable
27Diarrhea: definitionIncreased total daily stool output, usually associated with increased stool water contentStool output more than 10g/kg/24hr or more than the adult limit of 200 g/24hrResults from altered intestinal water and electrolyte transportGIT of infant handles approx 285 ml/kg/24hr of fluid (intake plus intestinal secretion) with a stool output of 5-10g/kg/24hr
28Diarrhea: chronicity Acute Less than 2 weeks Chronic/Persistent More than two weeks
29Diarrhea: pathophysiology OsmoticSecretoryIncreased/decreased intestinal motilityDecreased surface area
30Diarrhea: pathophysiology PRIMARY MECHANISMDEFECTSTOOL EXAMINATIONEXAMPLESCOMMENTSecretoryDecreased absorption, increased secretion, electrolyte transportWatery, normal osmolality; osmoles = 2 × (Na+ + K+)Cholera, toxigenic E. coli; carcinoid, VIP, neuroblastoma, congenital chloride diarrhea, Clostridium difficile, cryptosporidiosis (AIDS)Persists during fasting; bile salt malabsorption may also increase intestinal water secretion; no stool leukocytesOsmoticMaldigestion, transport defects ingestion of unabsorbableWatery, acidic, and reducing substances; increased osmolality; osmoles >2 × (Na+ + K+)Lactase deficiency, glucose-galactose malabsorption, lactulose, laxative abuseStops with fasting; increased breath hydrogen with carbohydrate malabsorption; no stool leukocytes
31Decreased transit time PRIMARY MECHANISMDEFECTSTOOL EXAMINATIONEXAMPLESCOMMENTIncreased motilityDecreased transit timeLoose to normal-appearing stool, stimulated by gastrocolic reflexIrritable bowel syndrome, thyrotoxicosis, postvagotomy dumping syndromeInfection may also contribute to increased motilityDecreased motilityDefect in neuromuscular unit(s) Stasis (bacterial overgrowth)Loose to normal appearing stoolPseudoobstruction, blind loopPossible bacterial overgrowthDecreased surface area (osmotic, motility)Decreased functional capacityWateryShort bowel syndrome, celiac disease, rotavirus enteritisMay require elemental diet plus parenteral alimentationMucosal invasionInflammation, decreased colonic reabsorption, increased motilityBlood and increased WBCs in stoolSalmonella, Shigella, infection; amebiasis; Yersinia, Campylobacter infectionsDysentery evident in blood, mucus, and WBCs
34Acute infectious diarrhea InflammatoryUsually bacteria that directly invades the intestines or produce cytotoxins with consequent fluid, protein and cells that enter the intestinal lumenPresents as bloody mucoid stoolFecalysis: + fecal leukocytesNon-inflammatoryEnterotoxin production by some bacteria (cholera), destruction of villous cells by viruses (rotavirus), adherence by parasites (G lamblia), and adherence and or translocation by bacteria
36ETIOLOGYINCUBATION PERIODSIGNS AND SYMPTOMSDURATION OF ILLNESSASSOCIATED FOODSLABORATORY TESTINGTREATMENTCampylobacter jejuni2–5 daysDiarrhea, cramps, fever, and vomiting; diarrhea may be bloody.2–10 daysRaw and undercooked poultry, unpasturized milk, contaminated waterRoutine stool culture; Campylobacter requires special media and incubation at 42°C to grow.Supportive care. For severe cases, antibiotics such as erythromycin and quinolones may be indicated early in the diarrheal disease. Guillain-Barré syndrome can be a sequela.Enterotoxigenic E. coli (ETEC)1–3 daysWatery diarrhea, abdominal cramps, some vomiting3 to >7 daysWater or food contaminated with human fecesStool culture. ETEC requires special laboratory techniques for identification. If suspected, must request specific testing.Supportive care. Antibiotics are rarely needed except in severe cases. Recommended antibiotics include TMP-SMX and quinolones.
37ETIOLOGYINCUBATION PERIODSIGNS AND SYMPTOMSDURATION OF ILLNESSASSOCIATED FOODSLABORATORY TESTINGTREATMENTEnterohemorrhagic E. coli (EHEC) including E. coli O157 : H7 and other Shiga toxin–producing E. coli (STEC)1–8 daysSevere diarrhea that is often bloody, abdominal pain and vomiting. Usually, little or no fever is present. More common in children <4 yr old.5–10 daysUndercooked beef especially hamburger, unpasteurized milk and juice, raw fruits and vegetables (e.g., sprouts), salami (rarely), and contaminated waterStool culture; E. coli O157 : H7 requires special media to grow. If E. coli O157 : H7 is suspected, specific testing must be requested. Shiga toxin testing may be done using commercial kits; positive isolates should be forwarded to public health laboratories for confirmation and serotyping.Supportive care, monitor renal function, hemoglobin, and platelets closely. E. coli O157 : H7 infection is also associated with hemolytic uremic syndrome (HUS), which can cause lifelong complications. Studies indicate that antibiotics may promote the development of HUS.
38ETIOLOGY INCUBATION PERIOD SIGNS AND SYMPTOMS DURATION OF ILLNESS ASSOCIATED FOODSLABORATORY TESTINGTREATMENTSalmonella spp.1–3 daysDiarrhea, fever, abdominal cramps, vomiting. S. typhi and S. paratyphi produce typhoid with insidious onset characterized by fever, headache, constipation, malaise, chills, and myalgia; diarrhea is uncommon, and vomiting is not usually severe.4–7 daysContaminated eggs, poultry, unpasteurized milk or juice, cheese, contaminated raw fruits and vegetables (alfalfa sprouts, melons). S. typhi epidemics are often related to fecal contamination of water supplies or street-vended foods.Routine stool culturesSupportive care. Other than for S. typhi and S. paratyphi, antibiotics are not indicated unless there is extra-intestinal spread, or the risk of extra-intestinal spread, of the infection. Consider ampicillin, gentamicin, TMP-SMX, or quinolones if indicated. A vaccine exists for S. typhi.Shigella spp.24–48 hrAbdominal cramps, fever, and diarrhea. Stools may contain blood and mucus.Food or water contaminated with human fecal material. Usually person-to-person spread, fecal-oral transmission. Ready-to-eat foods touched by infected food workers, e.g., raw vegetables, salads, sandwiches.Supportive care. TMP-SMX recommended in the U. S. if organism is susceptible; nalidixic acid or other quinolones may be indicated if organism is resistant, especially in developing countries.
39Escherichia coli Pathotype Epidemiology Type of diarrhea Mechanism of pathogenesisSTECHemorhagic colitis and HUS in all ages and postdiarrheal thrombotic thrombocytopenic purpura in adultsBloody or non-bloodyLarge bowel adherence and effacement (AE), shiga toxin productionEPECAcute and chronic endemic and epidemic in infantsWaterySmall bowel AEETECInfantile diarrhea in resource-limited countries and traveler’s diarrhea in all agesSmall bowel AE, heat stable/ heat labile enterotoxin productionEIECDiarrhea with fever in all agesBloody or non-bloody; dysenteryAdherence, mucosal invasion and inflammation of large bowelEAECAcute and chronic diarrhea in all agesWatery, occasionally bloodySmall and large bowel adherence, enterotoxin and cytotoxin production
40DEHYDRATION Mental status Thirst Heart rate Quality of pulses SYMPTOMMINIMAL OR NO DEHYDRATION (<3% LOSS OF BODY WEIGHT)MILD TO MODERATE DEHYDRATION (3–9% LOSS OF BODY WEIGHT)SEVERE DEHYDRATION (>9% LOSS OF BODY WEIGHT)Mental statusWell;alertNormal, fatigued or restless, irritableApathetic, lethargic, unconsciousThirstDrinks normally; might refuse liquidsThirsty;eager to drinkDrinks poorly; unable to drinkHeart rateNormalNormal to increasedTachycardia, with bradycardia in most severe casesQuality of pulsesNormal to decreasedWeak, thready, or impalpableBreathingNormal;fastDeepEyesSlightly sunkenDeeply sunkenTearsPresentDecreasedAbsentMouth and tongueMoistDryParchedSkinfoldInstant recoilRecoil in <2 secRecoil in >2 secCapillary refillProlongedProlonged;minimalExtremitiesWarmCoolCold;mottled;cyanoticUrine outputMinimal
41CLINICAL IMPRESSIONACUTE INFECTIOUS DIARRHEA WITH MODERATE SIGNS OF DEHYDRATION
43STOOL EXAMINATION Examine for mucus, blood and leukocytes Fecal leukocytes are indicative of bacterial invasion of colonic mucosaExamine for parasites causing diarrhea such Giardia lamblia and E. histolyticaShouldd be obtained as early in the course of disease as possible from children with bloody diarrhea
44STOOL CULTUREShould be obtained as early in the course of disease as possible from children with bloody diarrhea in whom stool microscopy indicates fecal leukocytes
48Oral Rehydration Therapy Children especially infants are more susceptible than adults to dehydration because of the greater basal fluid and electrolyte requirements.Dehydration must be evaluated rapidly and corrected 4-6hrs according to the degree of dehydration.
49Oral Rehydration Therapy Those in shock or unable to tolerate fluids, require initial intravenous rehydration but oral rehydration is the preferred mode of replacing ongoing losses.
50Risks associated with severe dehydration that necessitate IV resuscitation Age <6mosPrematurityChronic illnessFever >38C if <3mos or 39C if 3-36mosBloody diarrheaPersistent emesisPoor urine outputSunken eyesDepressed level of consciousness
51Oral Rehydration Therapy Decarbonated soda beverages, fruit juices are not suitable for rehydration as they have inappropriately high osmolalities and low sodium concentrationsORS should be given to infants and children slowly, especially if they have emesisIt can be given by a dropper, teaspoon or syringe.The volume is increased as tolerated.
52Enteral Feeding and Diet Selection Continued enteral feeding in diarrhea aids in recovery and age appropriate diet after rehydration is the norm.Once rehydration is complete, food should be reintroduced while oral rehydration can be continued to replace ongoing losses from emesis or stools.
53Enteral feeding and Diet Selection Breast feeding should be resumed as soon as possibleFoods with complex carbohydrates, yogurt, fruits and vegetables are also toleratedFatty foods or foods high in simple sugars should be avoided.
54Zinc supplementationZinc leads to reduced duration and sseverity of diarrhea and could potentially prevent 300,000 deaths.WHO and UNICEF recommend that all children with acute diarrhea should recive oral zinc for days during and after diarrhea10mg/day for infants <6mos20mg/day >6mos
55Antibiotic TherapyTimely antibiotic therapy may reduce the duration and severity of diarrhea and prevent complications.While these agents are important to use in specific cases, their widespread and indiscriminate use leads to development of resistance.
56ORGANISMDRUG OF CHOICEDOSE AND DURATION OF TREATMENTShigella (severe dysentery and EIEC dysentery)Ciprofloxacin, ampicillin, ceftriaxone, or trimthoprim-sulfamethoxazoleCeftriaxone IV, IM 50–100 mg/kg/d qd, bid × 7 dMost strains are resistant to many antibioticsCiprofloxacin PO 20–30 mg/kg/d bid × 7–10 d10 mg/kg/d of TMP and 50 mg/kg/d of SMX bid × 5 dAmpicillin PO, IV 50–100 mg/kg/d qid × 7 dEPEC, ETEC, EIECTMP-SMX or ciprofloxacinCiprofloxacin PO 20–30 mg/kg/d qid for 5–10 dSalmonellaNo antibiotics for uncomplicated gastroenteritis in normal
59GASTROENTERITIS Community-acquired Viruses, E. coli Antibiotic therapy strongly discouraged because of increased risk of HUS occurring in patients with E. coli 0157:H7 treated with antibioticsPrimary treatment: fluid and electrolyte replacementSalmonellaCefotaxime or Ceftriaxone10-14 days for infants <6 mo,toxicity or immuno-compromisedstatus. Antibiotics generally notindicated otherwise.ShigellaTMP/SMX; Alt: Cefixime5 days
60GASTROENTERITISCommunity acquiredYersiniaTMP/SMX, aminoglycosides,cefotaxime, tetracycline (>8 yr).Usually no antibiotic therapy isrecommended except withbacteremia, extraintestinalinfections, or immunocompromisedhosts.NosocomialClostridium difficileMetronidazole7 days. Community organismsunlikely after 72 hr ofhospitalization.
61N. Pashapour, S. Golmahammadloo Pediatrics Department, Imam Hospital EVALUATION OF YOGHURT EFFECT ON ACUTE DIARRHEA ON 6-24 MONTHS-OLD HOSPITALIZED INFANTSN. Pashapour, S. GolmahammadlooPediatrics Department, Imam HospitalHealth Department, Kosar Hospital, Urmia, Iran The Turkish Journal of Pediatrics 2006; 48:
62OBJECTIVESTo determine the efficacy of local factory pasteurized yoghurt consumption in acute nonbloody and mucoid diarrhea on hospitalized 6-24 months infants as compared with that of routine treatment
63SUBJECTS6 to 24 months of age children with non-bloody and mucoid diarrhea with less than four days duration hospitalizing in Urmia; Imam Hospital2 GROUPS (20 EACH)Control group: routine hospital treatment onlyCase group: received at least 15 ml/kg/day of pasteurized cow milk yogurt orally plus routine hospital treatmentWeight gain, period of hospitalization and reduction of diarrhea were compared
65RESULTS reduction of diarrhea episodes Mean hospitalization days : 2.85 – 3.1Mean weight gain : 350 – 287.5Mean reduction of diarrhea episodes : 4.35 – 3.95Significant difference (P<0.50) reduction of diarrhea episodes
66CONCLUSIONUse of local pasteurized yoghurt in the treatment of acute diarrhea had positive effectsAs a probiotic, it can promote recovery from diarrhea in children, mainly non-bloodyUniversal use of yoghurt is recommended in acute non-bloody diarrhea