DIARRHEAL DISEASES

BY
Dr. Maysa Amer
Professor of Pediatrics
Adapted From:
P. Dr. A.S Madkour presentation
Updated:Dr Amel Mahfouz
 OBJECTIVES
At the end of this cession you will be able to:
• Define Diarrhea
• Identify the magnitude of the problem of Diarrhea in
children
• Classify types of diarrhea
• Identify the etiology & pathophysiology of acute diarrhea
• Assess the patient for dehydration
• Classify & treat Dehydration
• Describe feeding during and after diarrhea
• List other required treatment.
 Definition
In Pediatrics,
Diarrhea is defined as an increase in the :
• Fluidity
of
• Volume
stools
• Number
relative to the usual habits of each individual.
 Definition
In epidemiological studies,
Diarrhea is defined as:
Passage of three or more loose or
watery stools in a 24-hour period,

a loose stool being one that would take

the shape of a container.
Importance of Diarrhea

In under five years children

Diarrhea is a leading cause of:
–Morbidity
–Mortality
–Malnutrition
 Epidemiology

Worldwide, children younger than 5

years have an estimated 1.7 billion
episodes of diarrhea each year, leading
to 124 million clinic visits, 9 million
hospitalizations, and 1.34 million
deaths, with more than 98% of these
deaths occurring in the developing
world
 MORBIDITY 30 million/ year

25% of infant & Preschool Mortalities

 Types of Diarrhea

• Acute watery diarrhea 10

10

• Dysentery
80
(Bloody diarrhea)
Acute Watery
Dysentery
• Persistent diarrhea Persistent
 Acute Watery Diarrhea
• Passage of frequent loose or watery stools
without visible blood.
• Constitutes 80% of cases of diarrhea
• Begins acutely (abruptly)
• Lasts less than 14 days (usually < 7 days)
• May be accompanied by:
– Flatulence, Abdominal pain and cramps
– Nausea and Vomiting
– Fever
The history and physical examination
serve 2 vital functions:
(1) differentiating gastroenteritis from
other causes of vomiting and diarrhea
in children and
(2) estimating the degree of
dehydration.
• Nausea and vomiting are non specific
symptoms but they indicate infection in the
upper intestine
• Fever suggest inflammatory process but
also indicate dehydration or co-infection
• Severe abdominal pain and tenesmus
indicate involvement of large intestine and
rectum
 Acute Watery Diarrhea

• Main sequelae:
– Dehydration that can be fatal

– Contributes to malnutrition

– Electrolytes and acid base

disturbances
 Etiology of diarrhea

Diarrhea

acute chronic

1. infective
2. Non infective like
Malabsorption
 Etiology of Diarrhea
• The most important causes of acute
Infective diarrhea in developing
countries are:
• Rotavirus
• Enterotoxigenic Escherichia coli
• Shigella
• Campylobacter jejuni
• Cryptosporidium
 Causes of acute gastroenteritis in
children
• Viruses (∼70%)
• Rotaviruses
• Noroviruses (Norwalk-like viruses)
• Enteric adenoviruses
• Caliciviruses
• Astroviruses
• Enteroviruses
• Protozoa (<10%)
• Cryptosporidium
• Giardia lamblia
• Entamoeba histolytica
• Bacteria (10-20%)
• Campylobacter jejuni
• Non-typhoid Salmonella spp
• Enteropathogenic Escherichia coli
• Shigella spp
• Yersinia enterocolitica
• Shiga toxin producing E coli
• Salmonella typhi and S paratyphi
• Vibrio cholerae
 Pathogenesis
Secretory : (most important) the release of
toxins that bind to specific enterocyte
receptors and cause the release of chloride
ions into the intestinal lumen, leading to
secretory diarrhea.
Osmotic:damage to the villous brush border
of the intestine, causing malabsorption of
intestinal contents and leading to an osmotic
diarrhea
Intestinal Physiology

+++
NET ABSORPTION

++
Pathogenesis of Secretory Diarrhea

X NET SECRETION

+++++
 Dehydration
Degree of dehydration
-No dehydration

-Some dehydration

-Severe dehydration
 Types of dehydration
isotonic hypertonic hypotonic

prevalence >75% 10-15% 5-10%

losses W=Na W>Na W<Na
ECF ++ + +++
THITST ++ ++++ +
SKIN ++ NOT +++
TURGOR LOST
MENTAL Lethargy irritable lethargy
STATE \irritable
 Differential diagnoses
• Other infections:such as urinary tract infection,
otitis media, pneumonia, septicaemia
• Surgical causes: such as intussusception,
appendicitis, small intestinal obstruction
(including malrotation)
• Taking antibiotics or other drugs
• Spurious diarrhoea; for example, in chronic
constipation with overflow incontinence
• Non-infectious diseases such as diabetic
ketoacidosis, inborn errors of metabolism
• Occasionally acute infectious gastroenteritis
unmasks gastrointestinal disease (such as
coeliac disease, chronic inflammatory bowel )
 Complications of acute
diarrhea
1. Hypernatremia and hyponatremia
2. Post acidotic tetany
3. Post acidotic hypokalemia
4. Seizures
5. Gastrointestinal Complications
6. Nutritional Complications
7. other Complications
Assessment
Of
Dehydration
 Assessment of Dehydration

• General condition: lethargic, irritable, normal

• Eyes : sunken,or normal
• Mouth (offer water & watch the child): is he
drinking poorly, eagerly, or normally

• Skin turgor (skin pinch): is it returning very

slowly, slowly or immediately
Assessment of Dehydration

• How to examine for skin pinch?

• Classification of skin pinches:
– Normal: it goes back immediately

– Slowly: the fold is visible for < 2 seconds

– Very slowly: the fold is visible for > 2 seconds.

 Assessment of Dehydration
SIGNS No signs of Some (mod.) Severe
dehydration dehydration dehydration
G General well, restless, lethargic,
condition alert irritable unconscious
E Eyes normal sunken sunken

M Mouth & normal thirsty, drink poor or una-

Drinking eagerly ble to drink
S Skin pinch returns rapidly returns slowly very slowly
Always start from Red Column

2 or more signs in 1 column indicate that the child falls

in that column
 Additional signs of
dehydration
• Anterior fontanel
• Mouth, tongue
• Tears
• Pulse
• Extremities
• Breathing
• Urine output
• Body weight
 Main Lines of Management

• FLUID THERAPY
• FEEDING
• Zinc supplementation

•  Further Management ?
 Management of Dehydration
SIGNS No signs of Some (mod.) Severe
dehydration dehydration dehydration
General well, restless, lethargic,
G condition alert irritable unconscious
Eyes normal sunken sunken
E
Mouth & normal thirsty, drink poor or una-ble
M Drinking eagerly to drink
Skin pinch returns rapidly returns slowly very slowly
S
Management Plan A Plan B Plan C
of dehydration at Home At OR Center At Hospital
 Fluid Therapy
• Initial Rehydration Therapy:
– Replacement of Fluid Deficit according to the
degree of dehydration ( no, some, severe )

• Subsequent Fluid Therapy:

1- Maintenance Fluids:
• Supplies normal Daily Fluid requirements
2- Replacement of On-going losses:
• Replacement of losses in stools & vomitus
Initial Rehydration
Therapy
 Initial Fluid Therapy
• Amount:
– No Signs of dehydration (mild): >50 ml/ kg
– Some (moderate) dehydration: 75 (50-100)ml/kg
– Severe dehydration: >100 ml/kg

• How Given:
– Oral route: for “No dehydration”
– Oral or NGT : for “Some dehydration”
– Intravenous : for “Severe dehydration” or
failure of oral or NGT rehydration
 Plan A: Fluid Therapy
Home – Based Fluids :
•ORS solution •Cereal water

•Soup (salted or unsalted) •Plain clean water

•Yoghurt-based drinks •Fresh fruit juice

•Breast milk •Weak herbal tea

 Plan B: Fluid Therapy
Type of Fluid :O R S (g/L)
Rehydran Hydro-Safe
Sodium Chloride 3.5g 2.1g

Trisodium Citrate 2.9g 2.9g

Potassium Chloride 1.5g 1.5g

GLUCOSE 20g 20g

Osmolarity 95 mmol 65 mmol

Glucose is added to ensure maximum

absorption of Na+ & Water
 Plan B: Fluid Therapy

• Type of Fluid : O R S
• Amounts:
50-100 ml ( + 75 ml) / Kg of body weight

• How given:
SLOWLY (1 spoon / 1-2 min) for 4-6 hours
By Cup & spoon, Cup alone, Dropper,
Syringe or by Nasogastric Tube (NGT)
 Plan B: Fluid Therapy
Reassess after 4 hours
• If NO Signs of Dehydration:
 Shift to Plan A: Food-based Home Fluids + Feeding, etc
• If NO Improvement
 Repeat Plan B (ORS + Feeding)
• If Worsening, i.e. Severe Dehydration:
 Shift to Plan C : I.V. Fluids
‫محلول معالجة الجفاف‬
• The American Academy of Pediatrics
(AAP), the European Society of Pediatric
Gastroenterology and Nutrition
(ESPGAN), and the World Health
Organization (WHO) all recommend oral
rehydration solution (ORS) as the
treatment of choice for children with mild-
to-moderate gastroenteritis in both
developed and developing countries
It is recommended that a child be admitted for
inpatient care when:
• The child is severely dehydrated
• The child has intractable vomiting
• The child is unable to maintain hydration
orally due to vomiting or diarrhea losses
• Caregivers cannot provide adequate care
at home and/or there are social or
logistical concerns
• The child has ileus ,shock ,abdominal
distension or intestinal obstruction
• Treatment failure, such as worsening diarrhea or
dehydration despite adequate ORS intake,
occurs
• Factors are present necessitating closer
observation, such as young age, decreased
mental status, or uncertainty of diagnosis
• Children with mild-to-moderate dehydration,
children younger than 6 months, or children with
a high frequency of stools/vomits should be
monitored in the emergency department for a
minimum of 4-6 hours before discharge.
 Plan C: Fluid Therapy
• Route of Administration: IV
• Type of Fluid : for ALL types of dehydration
Pansol, Polyelectrolyte, Ringer’s lactate
• Amount:
 100 ml / Kg of body weight.

• Rate: ( slower for younger )

• 1/3 (30 ml/kg): rapidly in 1/2 - 1 hour
• 2/3 (70 ml/kg): slowly in 2.5 - 5 hours
• Laboratory studies (not routinely
recommended)
– Serum electrolytes for children who require
intravenous (IV) fluids
– Stool testing in cases of specific pathogen
community outbreak
– Stool examination in case with bloody
diarrhea (fecal leukocytes indicate bacterial
invasion of colonic mucosa)
– Stool culture in case of bloody diarrhea,
outbreaks HUS and in immunosuppression
The patient with severe dehydration should
be assessed hourly
Look for these signs:
• Return of a strong radial pulse
• Level of consciousness
• Skin turgor
• Urine output
 Progress of I.V.Rehydration Therapy

• If NO Improvement (i.e: severe dehydr):

 Repeat Plan C (I.V. Fluid therapy)

• If there is still “Some” Dehydration:

 Start Plan B : ORS + Feeding

• If NO Signs of Dehydration:
 Start Plan A: Food-based Home Fluids + Feeding, etc.
 Oral Subsequent Fluid Therapy
• Maintenance Fluids:
Give “Normal” Foods & Drinks

On-going losses:
After Each Loose Stool:
• Age < 1 y : 50 - 100 ml (1/4 - 1/2 Cup)
• Age > 1 y : 100-200 ml (1/2 - 1 Cup)
ongoing fluid losses should be replaced with 10 mL/kg
body weight of additional ORS for each loose stool and
2 mL/kg body weight of additional ORS for each
episode of emesis (both for breastfed and nonbreastfed
children).
Feeding during
Diarrhea
 For Breast-fed
Continue breast feeding as
usual during and after
rehydration therapy.
 For Formula-fed
• Continue same “normal” formula and same
“normal” concentration AFTER rehydration
• Low lactose or Lactose-free formula ONLY
in case of 2ry lactose intolerance.
 Children on Mixed Diet
• Continue normal feeding
as usual
• Give repeated small
frequent feeds (every 3-4
hours)
• Avoid too sweetened foods
• Avoid foods containing a
high fiber content
• Avoid foods known to have
a laxative effect
• Avoid fatty foods
 Zinc supplementation
-in all types of diarrhea
In all degree of dehydration
-<6 months:10 mg for 10- 14 days
->6 months:20 mg for 10- 14 days
Further Management ?
Drugs in the Management
of Diarrhea

?
 Approved for use
• Other treatment :
– Antibiotics : only in certain indications
– Adsorbents
– Anti motility
– Anti emetics
 Rational Use of Drugs

• Antibiotics: ONLY for Cholera & Dysentery

• Antiparasitics: Ent. Histolytica trophozoites,
• Giardia Lamblia
• Nitazoxanide is anti infective agent ,used in
R of Giardia , Ent. Histolytica ,C difficle and
rotavirus
• Specific antibiotic for associated infections
Antimotility: Not used for children
diphenoxylate HCl, Loperamide
Adsorbants: Mainly cosmetic effect are
contraindicated in the treatment of acute
gastroenteritis in children because of their lack of
benefit and increased risk of adverse effects,
including ileus, drowsiness, and nausea.
 antiemetic
• It is recommended that antiemetics not be
routinely used in the management of
children with AGE
• A review of 7 randomized, controlled trials
in children found that oral ondansetron
reduced vomiting and the need for
intravenous (IV) rehydration and hospital
admission, IV ondansetron and
metoclopramide reduced the number of
episodes of vomiting and hospital
admission,
and A previous large, prospective,
randomized, double-blind trial compared a
single dose of an orally disintegrating
ondansetron tablet with placebo in children
presenting to an emergency department with
acute gastroenteritis. This study also found
that children treated with ondansetron were
less likely to vomit and that they had greater
oral intake, were less likely to require IV
rehydration, and had a reduced length of
stay in the emergency department
compared with children treated with placebo.
– Its use may decrease vomiting during the first hours
after presentation
– Its use may decrease the need for IV fluids in the
emergency department
– Its use may reduce hospitalization rates in those
patients who require IV fluids
– Its use may increase diarrheal episodes
– It has a relatively high cost
– Most studies of ondansetron use in children with AGE
have
• Been performed only on mildly dehydrated children
• Received funding from the manufacturer of
ondansetron
– Its use may increase risk for long QT interval
Patients at risk for adverse outcomes
include those with underlying heart
conditions, such as congenital long QT
syndrome, those who are predisposed to
low levels of potassium and magnesium in
the blood, and those taking other
medications that lead to QT prolongation
 Adjuvant Therapy

Probiotics are live microbial feeding

supplements commonly used in the
treatment and prevention of acute diarrhea.
Possible mechanisms of action include
synthesis of antimicrobial substances,
competition with pathogens for nutrients,
modification of toxins, and stimulation of
nonspecific immune responses to pathogens
 Probiotics
Two large systematic reviews have found
probiotics (especially Lactobacillus GG) to
be effective in reducing the duration of
diarrhea in children presenting with acute
gastroenteritis. A recent meta-analysis found
probiotics may be especially effective for the
prevention of C difficile –associated diarrhea
in patients receiving antibiotics. type,
regimen, and dosage of probiotics not yet
established.further work up is needed
 Dysentery
• 5-10% in Egypt
• Causes:
– Shigella 60%
– Campylobacter jujeni
– Salmonella
– E. Histolytica
• Importance ?
 Diagnosis & treatment
• Diagnosis
– Clinical
– Lab
• Treatment:
– Fluids , Feeding and zinc as acute watery diarrhea
– Antibiotics: Start with: TMP/SMX
then modify (after 2 days if no improvement)

Severe Shigella : Amebiasis ( Lab)

Ceftriaxone Metronidazole
 Discharge Criteria

• It is recommended that for children

receiving care in a hospital setting, prompt
discharge be considered when the
following levels of recovery are reached:
– Sufficient rehydration achieved as indicated
by weight gain and/or clinical status
– IV fluids not required
– Oral intake equals or exceeds losses
– Medical follow up is available via telephone or
office visit
– Adequate family teaching has occurred,
including:
• Hand hygiene at home, day care and elsewhere
for prevention of AGE transmission
• Expected course of illness
• Prevention of dehydration
• Signs of dehydration
 When to return
• Baby not able to drink or breast feed
• Becomes sicker (no improvement)
• Develops fever
• Blood in stool
• Repeated vomiting
• Increased thirst
 prevention
• It is recommended that infants be
immunized against rotavirus according to
the Advisory Committee on Immunization
Practices (ACIP) recommendations,
Committee on Infectious Diseases &
American Academy of Pediatrics
• is recommended that families be
instructed on the benefit of:
– Hand hygiene in the prevention of
transmission of AGE in the home and at day
care
– Breastfeeding as a protective practice against
severe AGE in infants
• Improved complementary feeding
practices ( Vit A)

• Improved case management of diarrhea

( role of ORS,zinc and antibiotic for
dysentery)
 References
• Pediatric Gastroenteritis,medscape Updated: Sep 29,
2014
• Cincinnati Children's Hospital Medical Center. Evidence-
based care guideline for prevention and management of
acute gastroenteritis (AGE) in children aged 2 months to
18 years. Cincinnati (OH): Cincinnati Children's Hospital
Medical Center; 2011 Dec 21. 21 p.
• Acute gastroenteritis in children BMJ. 2007 Jan 6;
334(7583): 35–40.
• MADKOUR essentials of pediaterics 2014

•
Thank You