1. Dr. Adnan Hamawandi Professor of Pediatrics
Diarrhea
Dr. Adnan Hamawandi
Professor of Pediatrics

2. Dysentery Is defined as diarrhea with visible blood in stools.
The most important and frequent cause of acute dysentery is Shigella. Other causes include Campylobacter jujeni, Salmonella, and enteroinvasive E. coli.
Entameba histolytica causes dysentery in older children but rarely in children under 5 years of age.

3. Dysentery Dysentery is specially severe in :-
1. Malnourished infants and children Those who develop clinically evident dehydration during their illness. 3. Those who are not breast fed. 4. Children with measles or had measles in the preceding month.
5. Those who present with convulsion or develop coma.

4. Dysentery Clinical features and diagnosis
The clinical diagnosis of dysentery is based solely on the presence of visible blood in the diarrheal stool. The stool will also contain pus cells which are visible microscopically, and it may contain large amounts of mucus, the later features suggest infection with an invasive microorganism, but alone are not sufficient to diagnose dysentery.

5. Dysentery Clinical features and diagnosis
Patients frequently
have fever,
cramping abdominal
pain and tenesmus.
The cause is identified
by stool culture.

6. Dysentery-Diagnosis
Stool microscopy may help in differentiating E.histolytica which can only be diagnosed with certainty when trophozoites containing RBCs are seen in fresh stools or in mucus from rectal ulcers obtained
during colonoscopy.

7. Dysentery Complications
Intestinal perforation.
Toxic megacolon.
Rectal prolapse.
Convulsions.
Septicemia.
Hemolytic uremic syndrome.
Prolonged hyponatremia.

8. Dysentery Management
Children with dysentery should be presumed to have Shigellosis and treated accordingly. This is because Shigellae cause 60% of dysentery cases seen at health facilities and nearly all cases of sever life threatening disease.
1. Antimicrobial therapy:
Trimethoprim sulfamethoxazole is the usual choice for five days.

9. Dysentery Management
There should be substantial improvement after 2 days i.e. reduced fever, less pain and fecal blood, and fewer loose stools. If this does not occur the antimicrobial should be stopped and a different one used like Naladixic acid, Cefixime, or Ceftriaxone according to the local culture and sensitivity. 2. Fluid: Assess and correct any dehydration. 3. Feeding: Continue feeding.

10. Persistent diarrhea
Is a diarrheal episode that last for 14 days or longer. About 10% of acute diarrheal episodes become persistent.
Persistent diarrhea is largely a nutritional disease, it occur more frequently in children who are already malnourished and is itself an important cause of malnutrition. It is associated with increased mortality causing about 30% of all diarrhea associated death.

11. Persistent diarrhea
There is no single microbial cause although Shigella, Salmonella, Enteroinvasive E.coli and Cryptosporidium play a greater role than other agents. Irrespective of the cause, persistent diarrhea is associated with extensive changes in the bowel mucosa, specially flattening of the villi and reduced production of disaccharidase enzymes; these cause reduced absorption of nutrients and

12. Persistent diarrhea
perpetuate the illness after the original infectious cause has been eliminated.
Risk factors:
1. Malnutrition.
2. Young age.
3. Recent introduction of animal milk(formula
4. Immunological impairment.
5. Recent diarrhea.

13. Persistent diarrhea Management
Fluid and electrolyte replacement.
Nutritional therapy: the goals are
1. Reduce temporarily the amount of animal milk or lactose in the diet. 2. Provide a sufficient amount of energy, protein, vitamins and minerals. 3. Avoid foods or drinks that may aggravate diarrhea. 4. Ensure adequate food intake during convalescence to correct malnutrition.

14. Persistent diarrhea Management
Drug therapy:
Antimicrobials and antiprotozoal agents should be given only when indicated and according to culture and sensitivity. However, blind use of these drugs is not effective and should not be given as they may make the illness worse. Likewise antidiarrheal drugs has no proven value and should not be given.

15. Conditions that can mimic gatstroenteritis
Systemic infections. Septicemia, meningitis.
Local infections. Otitis media, Respiratory tract infections, UTI
Surgical conditions. Pyloric stenosis, intussusception, necrotizing enterocolitis, Hirschsprung disease, acute appendicitis.
Metabolic disorders. Diabetic ketoacidosis, Hartnup disease
Renal disorders. Hemolytic uremic syndrome, Renal tubular acidosis
Inflammatory bowel diseases. Ulcerative colitis, Crohn’s dis
Others. Cow milk protein allergy, Adrenal insufficieny, Acrodermatitis enteropathica