1. Diarrhea in infancy & childhood

2. Objectives 1-To define the subject and to evaluate it’s importance. 2-Approaching and discussing it’s prevalence,pathogenesis and management.

3. Definition:- Diarrhea is the most important health problem world wide which causes great morbidity and mortality in the developing and the developed world. Definition: The changes in the frequency, consistency and the amount of the stool which is considered by the mother to be abnormal. Passing of more than 3-5 loose stool/day or one bowel motion which is mucusy with or without blood is considered diarrhea

4. Etiology of diarrhea: Infectious causes and non infectious causes. Infectious causes: A-Viral: Rota virus (50%), Parvovirus, coxsackie and echo virus. It affects the intestine itself and usually preceded by upper respiratory tract infection in children below 2 years of age. B-Bacterial: E.coli, shigella, yersenia enterocoletica, salmonella, staph.aureus (food poisoning).vibrio cholera. C-Parasitic: Entamoeba histolytica, Giardiasis

5. Non infectious causes: A-Feeding problem: such as the type of milk, conc. of milk and the technique of feeding. B-Anatomical defects: malrotation. C-Surgical causes: Hirschsprung’s dis.(congenital mega colon), Short bowel syndrome. D-Malabsorption: Di, & monosaccharidase def., celiac dis., fructose intolerance. E-Endocrine causes: Thyrotoxicosis, Addison’s dis., congenital adrenal hyperplasia. F-Neoplasms: Neuroblastoma, ganglioneuroma, pheochromocytoma, carcinoid tumor. G-Miscellaneous : milk allergy, inflamatory bowel dis. (crohn’s dis. ulcerative colitis), immune def., protein losing enteropathy, hemolytic uremic syndrome, Acrodermatitis enteropathica, Laxative abuse, Antibiotic therapy.

6. Types of Diarrhea: 1- Acute watery diarrhea. 2- Dysentery ( mucus with or without blood) 3- Persistent (post- infectious) diarrhea. 4- Chronic diarrhea. 5- Paranteral diarrhea. 6- Toddler diarrhea.

7. Acute watery diarrhea: : Definition : The diarrhea that starts acutely and lasts for less than 7 days without visible blood. It may be associated with fever and vomiting. It is the most important and common type. The dangers of this type are: 1-Dehydration. 2-Potassium depletion. 3-Metabolic acidosis. In severe and recurrent cases or mismanaged,it may lead to 4-malnutrition

8. Causes: Rota virus (50%), shigella, Entero toxogenic E.coli(ETEC), Salmonella, Vibrio cholera,Campylobacter jejune, Enter pathogenic E coli (EPEC).

9. Dysentery (bloody diarrhea): Definition: It is the diarrhea that is accompanied by mucus with or without blood. The dangers of this type are : 1-Septicemia (because of the invasive organisms that cause this type of diarrhea.) 2-Hemolytic Uremic syndrome. 3-Malnutrition (because of the anorexia and the intestinal mucosal damage). Causes: Shigella, salmonella, Entamoeba Histolytica,, Compylobacter jujeni,enteroinvasive E.Coli (EIEC), Enterohaemorrahgic E.coli (EHEC).

10. Persistent Diarrhea(Post-infectious diarrhea): Definition: It is the diarrhea that begins as acute watery or bloody diarrhea and lasts for at least 14 days. There is usually an infectious cause or the damage that results from the infection. So the dangers of this type of diarrhea are : dehydration. Septicemia. Secondary disaccharidase deficiency. Cow’s milk protein allergy and malnutrition, Causes: Any organism but especially shigella, Entero adherant E. coli (EAEC), Cryptosporidium.

11. Chronic diarrhea Definition: It is the recurrent or long lasting diarrhea due to non- infectious etiology as Celiac disease, cystic fibrosis, auto immune villous atrophy, abetalipoprotienemia….etc,. The most important danger is malnutrition

12. Paranteral diarrhea: Definition: The diarrhea that occurs due to infection else were in the body as otitis media, meningitis, pneumonia or UTI. This is because of the inflammatory mediators. Treatment of the original cause will stop the diarrhea. Toddler diarrhea(non-specific): Definition: It is the diarrhea that occurs in the children of the pre school age. It is usually watery with undigested food,the child is thriving very well, no evidence of malabsorption, no dehydration, no RBC and no WBC in the stool. It is of unknown etiology.

13. Pathophysiology: Rapid colonic transit time with family history of functional bowel syndrome. Reassurance of the parents is important that it is a self limiting condition, and no diet restriction is needed.

14. Mechanisms of Diarrhea: 1- Osmotic diarrhea: It is the diarrhea that occurs due to the ingestion of poorly absorbed osmotically active subs. that cause shifting of the water into the intes. Lumen i.e.: If you stop oral feeding the diarrhea will stop. E.g.: 1- Ingestion of high CHO diet., 2- Congenital Lactase, sucrase, isomaltase def.(primary) 3- Infection with Rota virus or Salmonella, Enter hemorrhagic E.coli,Giardiasis. causing severe shedding of the villi that contain the disaccharidase enzyme ( secondary lactase def.). 4- Celiac disease. 5- Autoimmune enteropathy. 6- Antibiotic use and abuse of laxatives.

15. 2- Secretory Diarrhea: It occurs due to active secretion of anions CL and HCO3 followed by passive water secretion. For this type of diarrhea, if you stop feeding the diarrhea will not stop Causes of secretory diarrhea: A - Luminal factors: 1-Bacterial entero-toxins as in Cholera, ETEC, Staph and clostridium. 2- Hydroxy Fatty acids that is produced by bacterial digestion of malabsorbed dietary lipids. 3- Non absorbed bile acid.

16. B-Endogenous factors: 1-Hormones secreted by the tumors like VAP. 2-Inflammatory mediator released in response to food allergy, inflammatory bowel disease or systemic diseases. 3-Activation of adenylate cyclase enzymes by some bacteria which stimulate the formation of CAMP which leads to the activation of protein phosphorelation that triggers Cl secretion and impaired Na absorption

17. DIFFERENTIAL DIAGNOSIS OF OSMOTIC VS SECRETORY DIARRHEA 1-Volume of stool 200 mL /24 hr 2-Response to fasting Diarrhea stops Diarrhea continues. 3-Stool Na+ 70 mEq /L. 4-Reducing substances:Positive, Negative 5-Stool pH 6.

18. 3- Deranged motility : Due either to hypo or hyper motility of the intestine : 1-Hyper motility in thyrotoxicosis, intestinal infection,laxative abuse. 2-Hypomotiltity in blind loop syndrome,leading to intestinal pseudoobstruction,bacterial contamination and bacterial overgrowth.

19. 4-Combined mechanism: Here we have ulceration and exudation of the mucosa as in IBD, collagen vascular dis., or dysentery ( shigella, E.Histolytica, EIEC,EHEC). The stool will be Full of blood, mucus and exudates. But there is no much loss of fluid while protein loss is more ( protein loosing enteropathy)  generalized edema.

20. Complications and consequences of watery diarrhea 1-Dehydration. 2-K depletion. 3-Base deficit acidosis. 4-Renal Failure. 5-Convulsion. 6-Cerebral damage and cerebral venous thrombosis.

21. Thank u. for attending.

22. Dehydration

23. OBJECTIVES 1-What is state of dehydration. 2-Physiology of fluids in a body of a child. 3-Mechanisms and types of dehydration. 4-Approach to diagnose and correct dehydration according to degrees and types.

24. Dehydration: It is the most important complication of watery diarrhea and vomiting. It is the loss of water and electrolytes due to diarrhea and vomiting.

25. Normal Intestinal physiology: The intestine have an important role in balancing water and electrolytes and any abnormality will lead to disturbance. In term baby the total body water is approximately70%-75% of body Water. Post nataly the TBW will be adjusted to approx. 65% of the total body wt. This fraction remains constant until puberty, when the TBW decreases to 55-60% of the body wt. *Approximately 2/3 of the TBW is intracellular & 1/3 is extra cellular..

26. These two fluids are separated by the cell membranes of the which is water permeable. *Normally the volume of both ECF & ICF do not change because the conc. of dissolved particles are identical on each side of the membrane

27. *The normal osmolality is 285 mosm/L. *Normally Na,Cl &HCO3 ions are primarily excluded from most of the cellular environment whereas K ion is maintained within the cell. *In addition to the iso-osmolality maintained between fluid compartments,electronaturality is also maintained within body fluids so that the conc. of Cations are equal to the conc. of the Anions.

28. Extra cellular fluid includes(ECF): 1-Plasma water (5-7%) of body weight. 2-Interstitial fluid, ISF,(25-30%) of body weight. 3-Trans cellular fluid (1-3%) of body weight. It includes CSF,GIT, bile, intra-ocular, pleural and peritoneal fluids. 4-Bone fluids and connective tissue( minimum amount). *When the volume of the ISF is depleted poor skin turger, depressed fontanels and sunken eyes result.( Signs of dehydration). *Whereas an expanded ISF volume will result in edema.