1. ACUTE GASTROENTERITIS IN CHİLDREN
Prof. Dr. Tufan KUTLU

2. Each day,the adult human gut handles 7 liters of endogenous secretions (salivary, gastric, biliary, pancreatic, intestinal) and 2 liters of ingested fluids. Of this large volume, 3 to 5 liters are absorbed by the jejunum, 2 to 4 liters by the ileum, and 1 to 2 liters by the colon. Only 100 to 200 ml are lost in the stools.

3. Diarrhea
Increase in the number of stools or a decrease in their consistency

4. Acute gastroenteritis
In Europe the incidence of diarrea ranges from 0.5 to 1.9 episodes per child per year in children up to 3 years of age
In low and middle income countries the incidence of acute diarrhea has declined from 3.4 episodes/child/year in 1990 to 2.9 episodes/child/year 2010

5. Causes of acute gastroenteritis in children
Bacteria
Viruses
Parasites

6. Bacteria causing diarrhea
Vibrio sp
Escherichia coli
Salmonella sp
Campylobacter sp
Clostridium difficile
Clostridium perfringens
Bacillus cereus
Staphylococcus aureus
Yersinia enterocolitica
Aeoromonas hydrophila
Klebsiella sp
Enterobacter sp
Proteus sp
Citrobacter sp
Edwardsiella tarda
Pseudomonas aeroginosa
Plesiomonas shigelloides..

7. Viral agents causing diarrhea
Reoviridae: rotavirus, astrovirus
Parvo-like viruses: Norwalk virus
Picornavirus: calicivirus, adenovirus, coronavirus

8. Parasites causing diarrhea
Giardia lamblia
Cryptosporidium
Entamoeba histolytica
Isospora belli
Cyclospora sp
Blastocystis hominis
Microsporidium

9. Patophysiology of infectious diarrhea
Invasion and destruction of the villous intestinal epithelial cells: Shigella dysenteria, E. coli (EIEC), Yersinia enterocolitica, Campylobacter jejuni, Entamoeba histolytica, Salmonella, rotavirus
Enterotoxin production: Vibrio cholera, E. Coli (ETEC), Shigella dysenteria, Campylobacter jejuni, Clostridium difficile, Yersinia enterocolitica, Salmonella, Staphylococcus aureus, Bacillus cereus, Clostridium perfringens
Adherence to enterocytes: E. coli
Invasion of the lamina propria: Salmonella

10. Diagnosis
Vomiting, profuse watery diarrhea (non blood, non mucus): secretory diarrhea
Bacteria: Vibrio cholera, E. coli (ETEC), S. aureus, B. cereus, C. perfringens
Viruses: Rotavirus, Norwalk virus
Parasites: Giardia lamblia, Cryptosporidium

11. Diagnosis
Fever, abdominal pain, tenesmus: inflammatory colitis, ileitis
Bacteria: Shigella, Yersinia, C. difficile
Parasite: Entamoeba histolytica

12. Diagnosis Bloody diarrhea
Bacteria: Shigella, E. Coli (EIEC), Yersinia, C. jejuni, C. difficile, Salmonella
Parasite: Entamoeba histolytica
Fever and abdominal pain like acute appendicitis: Yersinia enterocolitica

13. Diagnosis Recent exposure to antibiotics: Clostridium difficile
Many cases affected simultaneously: S. Aureus, C. perfringens
Immunodeficiency, malnutrition: Salmonella, Rotavirus, Isospora, Cryptosporidium, Candida

14. Diagnosis Stool examination
Presence of erithrocytes and leucocytes: Shigella, E. coli (EIEC, EHEC), Campylobacter,Yersinia, Clostridium
Presence of erithrocytes: Entamoeba histolytica

15. Diagnosis Stool examination
Microscopic: Parasites (entamoeba, giardia..)
Antigens: Entamoeba, Giardia, Rotavirus, Adenovirus
Culture ?

16. Viral gastroenteritis
Diarrheal diseases caused by viral agents occurs for more frequently than does similar disease of bacterial origin
Rotavirus is responsible for 20 to 70 % of hospitalization for diarrhea among children worldwide
Transmission is primarly from person to person
Most commonly in children between 6 and 24 months of age

17. Viral gastroenteritis
Clinical manifestations
Incubation period: hours
Sudden onset of diarrhea and vomiting
Diarrhea is watery, rarely bloody, 2-8 days
Fever
Respiratory symptoms

18. Viral gastroenteritis
Diagnosis
Rota/adenovirus antigen in stools
Treatment
Continue with unrestricted oral feeding
Dehydration
Mild/moderate: oral rehydration treatment
Severe: intravenous fluid

19. Shigella dysenteriae (flexneri, boydii, sonnei)
Clinical manifestations
Fever, malaise
Watery diarrhea, blood and mucus
Cramping abdominal pain
Seizures
Arthritis
Purulent keratitis
Hemolytic-uremic syndrome

20. Shigella dysenteriae Treatment
Trimethoprim-sulfometoxazole, ampicillin, nalidixic acid, ceftriaxone
Antimicrobial treatment is recommended to
shorten the course of the disease
decrease the period of excretion of the organisms
decrease the secondary attack

21. Yersinia enterocolitica (pseudotuberculosis, pestis)
Clinical manifestations
Fever
Abdominal pain
Diarrhea
Pseudoappendicular syndrome
Erythema nodosum
Reactive arthropathy

22. Clostridium difficile
Campylobacter jejuni
C. jejuni is a significant cause of diarrhea in children jounger than 2 years of age.
Treatment: erythromicin
Clostridium difficile
Antibiotic associated diarrhea
Treatment: metronidazole, vancomicin, probiotics

23. Cholera Clinical manifestations Treatment Vomiting
Profuse vatery diarrhea (rice-vater appearence)
Treatment
Rehydration (ORT, IV)
Antibiotics: Tetracycline, furazolidone, ampicillin, chloramphenicol, trimethoprim-sulfometoxazole

24. Salmonella enteridis, cholerasuis, typhi
1. Acute gastroenteritis
2. Focal non intestinal infection
3. Bacteremia
4. Asymptomatic carrier state
5. Enteric fever

25. Salmonella
Salmonella is spread with cotaminated water, foods (meat, eggs, milk)
Clinical manifestations
Incubation periode hours
Fever, watery diarrhea, blood and/or mucus
Treatment
Patients at high risk (immunocompromized patients, hematologic disease, artificial inplants, severe colitis)
Ampicillin, chloramphenicol, trimethoprim-sulfometoxazole, cephalosporins

26. Escherichia coli Enteropathogenic Enterotoxigenic Enteroinvasive
Enterohemorragic
Enteroaggregative and diffuse-adherant

27. Traditional treatment of diarrhea
Disadvantages
Intravenous rehydration
Diet
Antibiotic and antidiarrheal drugs
Hospitalization
Increased risk of infection
Unnecesssary laboratory investigations
Emotional trauma
Increased cost
Weight loss
Risk of malnutrition
Ineffective
Toxic
Allergic
Risk of secondary infections

28. Treatment of acute gastroenteritis
Treatment of a child with moderate dehydration in hospital (USA)
ORT: 11 hours and 270 USD
IV : 103 hours and 2300 USD

29. Treatment of acute gastroenteritis
Rehydration: IV, ORT
Nutrition
Medical
Antibiotics: bloody diarrhea, infants <3-6 months
Antisecretory drugs
Racecadotril
Adsorbant drugs
Smectite
Anti motility agents
Zinc
Probiotics

30. Assessment of dehydration in children
Non
Moderate
Severe
General appearance
Eyes
Tears
Mucous membranes
Thirst
Skin elasticity
Treatment
Good
Normal
Present
Moist
Absent
Pinc retracts immediately
At home
İrritable
Sunken
Absent to reduced
Dry
Pinc retracts slowly
ORS
Lethargic, hipotonic or comatose
Grossly sunken
Very dry
Can’t drink
Pinc retracts very slowly IV

31. Treatment of diarrhea Protective factors
Human milk: IgA, lactoferrin, leucocytes, antiviral factors, bifidobacteries
Gastric acid
Secretory IgA
Intestinal motility

32. Zinc for diarrhea Twenty four trials , 9128 children
Zinc is clearly of benefit in children aged six months or more.
Children aged less than six months showed no benefit with zinc.
Vomiting was more common in zinc-treated children with acute diarrhoea
Lazzerini M, Ronfani L. Oral zinc supplementation for treating diarrhea in children. Cochrane Database of Systematic Reviews 2012

33. Treatment of acute gastroenteritis
Rehydration
ORT > 90 %
IV < 10 %
Continue with unrestricted oral feeding
Antibiotic when necessary (age<3-6 months, dysenteria, cholera..)
Do not use antidiarrheal agents

34. WHO-ORS
Should contain carbohydrate (glucose) and sodium (glucose/sodium: between 1/1 and 2/1)
Glucose: mmol/L (rice-flour: 50 g/L)
Sodium
Rehydration: mmol/L
Maintenance: mmol/L
Osmolarity < 290 mOsm/L
Potassium: 20 mmol/L
Bicarbonate: 30 mmol/L (or citrate: 10 mmol/L)

35. Composition of the ORS recommended by WHO
g/L
Mmol/L
NaCl
KCl
Citrate
(Bicarbonate)
Glucose
(Rice-flour)
3.5
1.5
2.9
(2.5) 20
(50) Na K Cl 90 80 10 30
110

36. Electrolyte losses in diarrheal disease (mmol/L)Na K Cl
HCO3
Glucose
Normal stools
Cholera
Adult
Child
Enteritis
ORS 5
140
101 56 90
10-12 13 27 25 20
2-3
104 92 55 80 3 44 32 14 30
111

37. Comparison of some fluids used for rehydration
CHO
mmol/L Na
CHO/Na K
Base
Osmolarity
mOsm/L
Cola
Apple juice
Chicken soup
WHO-ORS
Pedialyte
Rehydralyte
Osmosal
700
690
111
140
144 2 3
250 90 45 75 60
350
230
1.2
3.1
1.9
2.4
0.1 32
8.2 20 13 10
750
730
500
311
310
304

38. Treatment of diarrhea at home
Recommended foods
Water, soup (rice), yoghurt, fruit juice…
<6 months: breast-feeding, formula
Recommended amount of fluids
After every watery stools
<2 ages: ml
>2 ages: ml

39. Treatment of diarrhea at home
To prevent malnutrition
Don’t stop breast feeding or formula feeding
Don’t dilute formula or milk
Older children: give rice cereal, bananas, fruit juices, potatoes, yoghurt, good cooked meat, fish…

40. Amount of ORS after every watery stools
ORS treatment at home
Age
Amount of ORS after every watery stools
<2
2-10
>10 ml ml
Not limited

41. ORS treatment Mild Moderate Severe* Rehydration Duration Maintenance*
50 ml/kg
4-6 hours
100 ml/kg
18-20 hours
ml/kg
ml/kg

42. Probiotics for acute gastroenteritis
Lactobacillus GG administered in oral rehydration solution to children with acute diarrhea: a multicenter European trial.
Guandalini et al. J Pediatr Gastroenterol Nutr 2000

43. Rice-based ORS Cheaper Better taste Hypoosmolar (280 mOsm/L)
Prevent vomiting
Decrease frequency and duration of diarrhea
More nutritive
Traditional

44. Contraindication of ORS use
Shock, stupor, coma
Severe electrolyte imbalence and dehydration
Severe and repeated vomiting
Acidosis
Oliguria or anuria
Abdominal distention, ileus
Glucose-galactose malabsorption