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GASTROENTERITIS Dr. Bikha Ram Devrajani MBBS(SINDH),FCPS(PAK),FACP(USA),FRCP(LONDON) Professor Medicine Professor Medicine Liaquat University of Medical.

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Presentation on theme: "GASTROENTERITIS Dr. Bikha Ram Devrajani MBBS(SINDH),FCPS(PAK),FACP(USA),FRCP(LONDON) Professor Medicine Professor Medicine Liaquat University of Medical."— Presentation transcript:

1 GASTROENTERITIS Dr. Bikha Ram Devrajani MBBS(SINDH),FCPS(PAK),FACP(USA),FRCP(LONDON) Professor Medicine Professor Medicine Liaquat University of Medical & Health Sciences Jamshoro

2 Gastroenteritis Gastroenteritis is a nonspecific term for a variety of pathologic states of the gastrointestinal tract. Gastroenteritis is a nonspecific term for a variety of pathologic states of the gastrointestinal tract. The primary manifestation is diarrhea, but it may be accompanied by nausea, vomiting, and abdominal pain. The primary manifestation is diarrhea, but it may be accompanied by nausea, vomiting, and abdominal pain. A universal definition of diarrhea does not exist, although patients seem to have no difficulty defining their own situation. A universal definition of diarrhea does not exist, although patients seem to have no difficulty defining their own situation.

3 Gastroenteritis Although most definitions center around the frequency, consistency, and water content of stools, the author prefers the definition that diarrheal stools take the shape of their container. Although most definitions center around the frequency, consistency, and water content of stools, the author prefers the definition that diarrheal stools take the shape of their container.

4 Gastroenteritis Severity of illness may vary from mild and inconvenient to severe and life threatening. Severity of illness may vary from mild and inconvenient to severe and life threatening. Appropriate management requires extensive history and assessment and appropriate general supportive and, often, etiology-specific treatment. Appropriate management requires extensive history and assessment and appropriate general supportive and, often, etiology-specific treatment. Diarrhea associated with nausea and vomiting is referred to as gastroenteritis. Diarrhea associated with nausea and vomiting is referred to as gastroenteritis.

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6 Diarrhea is…….. A symptom characterized by an abnormal increase in stool frequency or liquidity A symptom characterized by an abnormal increase in stool frequency or liquidity Acute diarrhea is usually self limiting and lasts hours, sometimes up to 7 days Acute diarrhea is usually self limiting and lasts hours, sometimes up to 7 days Chronic diarrhea lasts more than 4 weeks, should seek medical care Chronic diarrhea lasts more than 4 weeks, should seek medical care

7 Global Problem 4.6 million children less than 5 years of age die of diarrheal diseases. 4.6 million children less than 5 years of age die of diarrheal diseases. Diarrhea accounts for 19% of all deaths among children ages 0-4. Diarrhea accounts for 19% of all deaths among children ages 0-4. Eighty-five percent of diarrheal deaths occur in the first year of life. Eighty-five percent of diarrheal deaths occur in the first year of life. World Health Organization WHO Fact Sheet: Reducing Mortality from Major Childhood Killer Diseases. Fact Sheet Number Centers for Disease Control and Prevention Diarrhea: The Management of Acute Diarrhea in Children: Oral Rehydratioin, Maintenance, and Nutritional Therapy. Graph.

8 OUTBREAKS July 1998: E coli 0157:H7 infection outbreak from contaminated water supply in Wyoming, more than 60 infected July 1998: E coli 0157:H7 infection outbreak from contaminated water supply in Wyoming, more than 60 infected July 1995: 77 cases of cryptosporidiosis at a day camp in Florida, most likely secondary to water hose contamination July 1995: 77 cases of cryptosporidiosis at a day camp in Florida, most likely secondary to water hose contamination August-September 1999: E coli 0157:H7 infections secondary to contaminated well water in Washington County Fair (New York) August-September 1999: E coli 0157:H7 infections secondary to contaminated well water in Washington County Fair (New York)

9 OUTBREAKS Three to five billion cases of acute diarrhea occur yearly, and it is the leading cause of death in many underdeveloped countries. Three to five billion cases of acute diarrhea occur yearly, and it is the leading cause of death in many underdeveloped countries. Approximately 30-50% of visitors to developing countries will develop, and perhaps return with, diarrhea. Approximately 30-50% of visitors to developing countries will develop, and perhaps return with, diarrhea.

10 Age Gastroenteritis may occur at any age. Gastroenteritis may occur at any age. Morbidity and mortality are much higher in the very young and the very old. Morbidity and mortality are much higher in the very young and the very old.

11 Transmission Diarrheal agents are mostly spread via the fecal-oral route. Diarrheal agents are mostly spread via the fecal-oral route. –physical contact with infected feces –eating or drinking contaminated food or water –person to person relay World Health Organization The Epidemiology and Etiology of Diarrhea.

12 Socioeconomic factors Poverty Poverty Overcrowding Overcrowding Poor sanitation Poor sanitation Contamination of water Contamination of water Inadequate food hygiene Inadequate food hygiene UNICEF The State of the World’s Children, Oxford and New York: Oxford University Press.

13 Risk Factors Household crowding Household crowding Low maternal education Low maternal education Low birth weight Low birth weight Claeson, M., & Merson, M Global progress in the control of diarrheal diseases. Pediatric Infectious Diseases Journal, 9:

14 Behavioral Factors Failure to breast-feed exclusively for the first 4-6 months of life Failure to breast-feed exclusively for the first 4-6 months of life Failure to continue breast-feeding until one year of age Failure to continue breast-feeding until one year of age Using infant bottles Using infant bottles Storing food at room temperature Storing food at room temperature Contaminated drinking water Contaminated drinking water Failure to wash hands Failure to wash hands Failure to dispose of feces hygienically Failure to dispose of feces hygienically Claeson, M., & Merson, M Global progress in the control of diarrheal diseases. Pediatric Infectious Diseases Journal, 9:

15 Host Factors Immunosuppression Immunosuppression Measles Measles Malnutrition Malnutrition

16 Prevention Strategies Breast Feeding Breast Feeding Improved weaning practices Improved weaning practices Proper use of water Proper use of water Hand washing Hand washing Disposing feces properly Disposing feces properly Effectiveness of measles vaccination Effectiveness of measles vaccination

17 Diarrhea The passing of 3 or more watery or loose stools in a 24-hour period. The passing of 3 or more watery or loose stools in a 24-hour period. Three types: acute watery Three types: acute waterypersistentdysentery World Health Organization The Epidemiology and Etiology of Diarrhea. World Health Organization WHO Fact Sheet: Reducing Mortality from Major Childhood Killer Diseases. Fact Sheet Number 180.

18 Diarrheal illnesses also may be classified Osmotic, due to an increase in the osmotic load presented to the intestinal lumen, either through excessive intake or diminished absorption Osmotic, due to an increase in the osmotic load presented to the intestinal lumen, either through excessive intake or diminished absorption Inflammatory (or mucosal), when the mucosal lining of the intestine is inflamed. Inflammatory (or mucosal), when the mucosal lining of the intestine is inflamed. Secretory, when increased secretory activity occurs Secretory, when increased secretory activity occurs Motile, caused by intestinal motility disorders Motile, caused by intestinal motility disorders

19 Etiological Agents Etiological Agents Bacterial, Viral, and Parasitic Agents Bacterial, Viral, and Parasitic Agents Rotavirus Enterotoxigenic E. Coli Shigellae Salmonellae Vibrio Cholerae Campylobacter jejuni Cryptosporidium Protozoans Protozoans Giardia Entamoeba Rotavirus E.Coli Giardia World Health Organization

20 Etiology of diarrhea Diarrhea is a symptom of an underlying pathology or infection Diarrhea is a symptom of an underlying pathology or infection Viral gastroenteritis Viral gastroenteritis Bacterial gastroenteritis Bacterial gastroenteritis Protozoal diarrhea Protozoal diarrhea Antibiotic associated diarrhea Antibiotic associated diarrhea AIDS associated diarrhea AIDS associated diarrhea Food-induced diarrhea Food-induced diarrhea

21 Etiology of diarrhea Viral (50-70%) Viral (50-70%) –The Norwalk virus is the leading cause of viral gastroenteritis in the United States. Norwalk virus belongs to the species of Noroviruses (formerly known as Norwalk-like viruses). Noroviruses, along with the Sapoviruses (formerly known as Sapporo-like viruses) are members of the Caliciviridae family of viruses. –Caliciviruses: Various caliciviruses, other than Norwalk, are likely responsible for many out breaks of previously unidentified viral gastroenteritis. –Rotavirus: A leading cause of gastroenteritis in children, but can also be found in adults. May cause severe dehydration. –Adenovirus –Parvovirus –Astrovirus –Coronavirus –Pestivirus –Torovirus

22 Etiology of diarrhea Bacterial (15-20%) Bacterial (15-20%) –Shigella –Salmonella –C jejuni –Yersinia enterocolitica –E coli - Enterohemorrhagic 0157:H7, enterotoxigenic, enteroadherent, enteroinvasive –V cholera –Aeromonas –B cereus –C difficile –Clostridium perfringens –Listeria –Mycobacterium avium-intracellulare (MAI), immunocompromised –Providencia –Vibrio parahaemolyticus –Vibrio vulnificus

23 Etiology of diarrhea Parasitic (10-15%) Parasitic (10-15%) –Giardia –Amebiasis –Cryptosporidium –Cyclospora Food-borne toxigenic diarrhea Food-borne toxigenic diarrhea –Preformed toxin - S aureus, B cereus –Postcolonization - V cholera, C perfringens, enterotoxigenic E coli, Aeromonas

24 Etiology of diarrhea Shellfish poisoning and poisoning from other marine animals Shellfish poisoning and poisoning from other marine animals –Paralytic shellfish poisoning (PSP) - Saxitoxin –Neurologic shellfish poisoning (NSP) - Brevotoxin –Diarrheal shellfish poisoning (DSP) - Okadaic acid –Amnesic shellfish poisoning - Domoic acid –Ciguatera (ciguatoxins) –Scombroid (conversion of histidine to histamine)

25 Etiology of diarrhea Drug-associated diarrhea Drug-associated diarrhea –Antibiotics due to alteration of normal flora –Laxatives, including magnesium-containing antacids –Colchicine –Quinidine –Cholinergics –Sorbitol Pseudomembranous colitis Pseudomembranous colitis –Overgrowth of C difficile –Positive C difficile assay

26 Etiology of diarrhea Other causes Other causes –Unknown agents, especially in developing countries –Ischemic colitis –Ulcerative colitis –Crohn disease –Carcinoid tumor or vasoactive intestinal peptide tumor (VIPoma) –AIDS –Dumping or short bowel syndrome –Radiation or chemotherapy

27 Viral gastroenteritis 80-85% of episodes of acute diarrhea are caused by viruses 80-85% of episodes of acute diarrhea are caused by viruses Virus transmitted by contaminated food or water Virus transmitted by contaminated food or water Clinical features include 12-48hr incubation period followed by vomiting, watery diarrhea and low grade fever Clinical features include 12-48hr incubation period followed by vomiting, watery diarrhea and low grade fever Illness lasts 5-8 days, treatment is fluid and electrolyte therapy Illness lasts 5-8 days, treatment is fluid and electrolyte therapy

28 Bacterial gastroenteritis Common pathogens are Campylobacter, Salmonella, Shigella, E.coli, Staphylococcus, Clostridium Common pathogens are Campylobacter, Salmonella, Shigella, E.coli, Staphylococcus, Clostridium If attack is in small intestine patients usually experience abrupt onset of large volume, watery stools, upper abdominal pain, nausea, vomiting, cramps, and low grade fever If attack is in small intestine patients usually experience abrupt onset of large volume, watery stools, upper abdominal pain, nausea, vomiting, cramps, and low grade fever If attack is in large intestine, patients may experience dysentery like syndrome including bloody or mucousy diarrhea If attack is in large intestine, patients may experience dysentery like syndrome including bloody or mucousy diarrhea

29 Traveler’s diarrhea A form of bacterial gastroenteritis Usually occurs when people travel to warmer climates with poor sanitation Most commonly caused by E.coli Characterized by sudden onset of loose stools, nausea, occasional vomiting, cramps, bloating, malaise and low grade fever Usually subsides over 3-4 days

30 Protozoal diarrhea Giardia lamblia and entamoeba histolytica are protozoa associated with diarrhea Usually acquired traveling to mountainous or recreational water areas, drinking stream or pond water No nonprescription therapy for protozoal diarrhea, metronidazole is treatment of choice

31 Antibiotic associated diarrhea Frequency of diarrhea is largely dependent on the extent to which the drug disrupts the normal intestinal flora Frequency of diarrhea is largely dependent on the extent to which the drug disrupts the normal intestinal flora Abx that have broad spectrum activity against aerobes and anaerobes can produce diarrhea Abx that have broad spectrum activity against aerobes and anaerobes can produce diarrhea AAD may be caused by an overgrowth of abx resistant bacteria, fungi, or toxin producing C.difficile AAD may be caused by an overgrowth of abx resistant bacteria, fungi, or toxin producing C.difficile Diarrhea caused by C.difficile is usually watery and greenish-mucoid Diarrhea caused by C.difficile is usually watery and greenish-mucoid There are no nonprescription treatments for eradicating C.difficile There are no nonprescription treatments for eradicating C.difficile

32 AIDS Associated Diarrhea Patients with AIDS or HIV are known to be susceptible to intestinal infections that produce diarrhea Patients with AIDS or HIV are known to be susceptible to intestinal infections that produce diarrhea These patients should not self-manage their diarrhea, they should see their physician These patients should not self-manage their diarrhea, they should see their physician

33 Food-Induced Diarrhea Food intolerance can provoke diarrhea Food intolerance can provoke diarrhea The enzyme lactase hydrolyzes disaccharides into monosaccharides The enzyme lactase hydrolyzes disaccharides into monosaccharides When you lack the lactase enzyme, disaccharides can not be hydolyzed to monosaccharides When you lack the lactase enzyme, disaccharides can not be hydolyzed to monosaccharides Disaccharides pool in lumen causing an osmotic imbalance which draws fluid into the lumen and causes diarrhea Disaccharides pool in lumen causing an osmotic imbalance which draws fluid into the lumen and causes diarrhea

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38 Signs of Dehydration Common: dizziness, thirst, confusion, lethargy, fatigue Common: dizziness, thirst, confusion, lethargy, fatigue Serious: low BP, fever, vomiting, abdominal cramps, nausea, muscle aches, mucously stools, weight-loss Serious: low BP, fever, vomiting, abdominal cramps, nausea, muscle aches, mucously stools, weight-loss Mild dehydration: 3-5% weight-loss Mild dehydration: 3-5% weight-loss Severe dehydration: 10% weight-loss (can be very serious in infants, may lead to cardiovascular collapse and renal failure Severe dehydration: 10% weight-loss (can be very serious in infants, may lead to cardiovascular collapse and renal failure Mild/moderate diarrhea are self-treatable Mild/moderate diarrhea are self-treatable Severe diarrhea: non self-treatable Severe diarrhea: non self-treatable

39 Laboratory Investigations Stool DR, ova & cyst, and C/S. Stool DR, ova & cyst, and C/S. CBC. CBC. Serum electrolytes. Serum electrolytes. Blood urea. Blood urea. Other investigations depend upon the causative agent. Other investigations depend upon the causative agent.

40 Treatment Options Treatment Outcomes 1. Assess and Correct electrolyte and fluid loss and fluid loss 2. Manage diet or disease 3. Provide relief 4. Identify cause

41 Oral Rehydration Therapy

42 Fluid and Electrolyte Replacement Not more than mEq/L of Na for rehydration Not more than mEq/L of Na for rehydration Not more than mEq of Na for maintenance Not more than mEq of Na for maintenance Carb to Na ratio should be 2:1 Carb to Na ratio should be 2:1 Important in children and infants Important in children and infants All patients should rehydrate and maintain during diarrheal episode All patients should rehydrate and maintain during diarrheal episode

43 Loperamide Good for treatment of traveler’s diarrhea and IBD Good for treatment of traveler’s diarrhea and IBD Works by slowing intestinal motility Works by slowing intestinal motility Use 4mg initially, then 2mg after each loose stool but do not exceed 16mg/day (8 tablets) Use 4mg initially, then 2mg after each loose stool but do not exceed 16mg/day (8 tablets) Do not use in children <6 years old use electrolyte tx instead Do not use in children <6 years old use electrolyte tx instead

44 Adverse Reactions Can cause occasional dizziness and constipation Can cause occasional dizziness and constipation May worsen effects of invasive or inflammatory bacterial infection should not use for food borne illness May worsen effects of invasive or inflammatory bacterial infection should not use for food borne illness May cause toxic megacolon in ABX induced diarrhea DO NOT use for ABX associated diarrhea - refer to physician May cause toxic megacolon in ABX induced diarrhea DO NOT use for ABX associated diarrhea - refer to physician In children less than 6 years old In children less than 6 years old

45 Absorbents Include attapulgite, kaolin, pectin Include attapulgite, kaolin, pectin Do not recommend because of decreased absorption of other drugs Do not recommend because of decreased absorption of other drugs

46 Polycarbophil Used for non-specific diarrhea Used for non-specific diarrhea Bulk laxative that is also effective in treating diarrhea (can also treat constipation) Bulk laxative that is also effective in treating diarrhea (can also treat constipation) Can absorb up to 60X weight in water Can absorb up to 60X weight in water Use 2 (500mg) tablets 4 times daily or after each loose stool (up to 6g a day) Use 2 (500mg) tablets 4 times daily or after each loose stool (up to 6g a day)

47 Adverse Reactions Metabolically inert Metabolically inert No systemic toxicity has been shown No systemic toxicity has been shown Side effects include dose- related epigastric pain and bloating Side effects include dose- related epigastric pain and bloating May decrease absorption of warfarin, digoxin, tetracycline, and ciprofloxacin May decrease absorption of warfarin, digoxin, tetracycline, and ciprofloxacin

48 Bismuth Subsalicylate BSS Used for non-specific diarrhea, indigestion, tx and prevention of traveler’s diarrhea, as adjuvant to ABX for treating H.pylori peptic ulcer disease Used for non-specific diarrhea, indigestion, tx and prevention of traveler’s diarrhea, as adjuvant to ABX for treating H.pylori peptic ulcer disease Reported to have an antisecretory mechanism to bind bacterial toxins, and to have anti- inflammatory and antibacterial properties Reported to have an antisecretory mechanism to bind bacterial toxins, and to have anti- inflammatory and antibacterial properties Take 2 (262mg) tablets every hour up to 16 tablets a day Take 2 (262mg) tablets every hour up to 16 tablets a day Not recommended for children <2 years old Not recommended for children <2 years old

49 Adverse Reactions May reach toxic levels of salicylate if patients are taking aspirin or other salicylate containing drugs May reach toxic levels of salicylate if patients are taking aspirin or other salicylate containing drugs Patients sensitive to salicylates should not use Patients sensitive to salicylates should not use Blackened stool and tongue may occur - harmless Blackened stool and tongue may occur - harmless

50 Enzymes - lactase For lactose intolerance For lactose intolerance Take 1-3 tablets with first bite of dairy product Take 1-3 tablets with first bite of dairy product Just avoid dairy products Just avoid dairy products

51 Things to Remember Always remember to rehydrate Always remember to rehydrate Special populations (elderly, <3 years old, pregnant) require medical referral Special populations (elderly, <3 years old, pregnant) require medical referral Healthy patients usually improve within 24 to 48 hours Healthy patients usually improve within 24 to 48 hours If condition remains or worsens after 48 hours - refer to MD If condition remains or worsens after 48 hours - refer to MD

52 New Developments “Super-ORS” “Super-ORS” Rotavirus vaccine Rotavirus vaccine

53 Controversies Underuse of ORT and overuse of drugs Underuse of ORT and overuse of drugs “Boil the water” “Boil the water”

54 Complications of Diarrhea Acute diarrhea may cause severe dehydration and electrolyte imbalance Acute diarrhea may cause severe dehydration and electrolyte imbalance Infants, young children, and the elderly are most at risk for dehydration Infants, young children, and the elderly are most at risk for dehydration Children less than 2 yrs of age often have complications that require hospitalization Children less than 2 yrs of age often have complications that require hospitalization

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63 First steps for managing an outbreak of acute diarrhoea THIS PRESENTATION AIMS AT GUIDING YOU THROUGH THE VERY FIRST DAYS OF AN OUTBREAK

64 WORLD HEALTH ORGANIZATION Is this the beginning of an outbreak?

65 WORLD HEALTH ORGANIZATION You might be facing an outbreak very soon if You have seen an unusual number of acute diarrhoeal cases this week and the patients have the following points in common: You have seen an unusual number of acute diarrhoeal cases this week and the patients have the following points in common: –they have similar clinical symptoms (watery or bloody diarrhoea) –they are living in the same area or location –they have eaten the same food (at a burial ceremony for example) –they are sharing the same water source –there is an outbreak in the neighbouring community

66 WORLD HEALTH ORGANIZATION or You have seen an adult suffering from acute watery diarrhoea with severe dehydration and vomiting You have seen an adult suffering from acute watery diarrhoea with severe dehydration and vomiting If you have some statistical information from previous years or weeks verify if the actual increase of cases is unusual over the same period of time. If you have some statistical information from previous years or weeks verify if the actual increase of cases is unusual over the same period of time.

67 WHAT DO I HAVE TO DO WHEN I SUSPECT AN OUTBREAK? 1. Inform and ask for help 2. Protect the community 3. Treat the patients

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72 MESSAGE TO THE COMMUNITY

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79 PROTECT YOURSELF FROM CONTAMINATION Wash your hands with soap before and after taking care of the patient Wash your hands with soap before and after taking care of the patient Cut your nails Cut your nails

80 3. TREAT THE PATIENTS 80% of the cases can be treated with Oral Rehydration Salt (ORS) 80% of the cases can be treated with Oral Rehydration Salt (ORS)

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83 Mortality/Morbidity Estimates for mortality and morbidity vary widely. In the United States, 210,000 pediatric hospitalizations occur yearly with as many as 10,000 deaths. Internationally, mortality rate is 5-10 million deaths each year. Internationally, mortality rate is 5-10 million deaths each year.

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