VIRAL GASTROENTERITIS

OPPONG-KYEKYEKU KWADWO

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DEFINITION

 Viral gastroenteritis is an infection of the GI tract by a virus, usually rotavirus.

 It is usually self-limiting, but if untreated may result in morbidity and mortality
secondary to:
 dehydration,
 electrolyte imbalance and
 metabolic acidosis.

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AETIOLOGY

 Viruses account for approximately 70% to 87% of episodes of acute gastroenteritis in

children.
 Rotavirus - the most common identifiable cause.[ Webb et al., 2005] [Dalby-Payne et
al,2005]
 Other viral pathogens include
 caliciviruses,
 astroviruses, and
 adenoviruses.[Rosenfeldt et al, 2005]
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PATHOPHYSIOLOGY OF ROTAVIRUS INFECTION

 Rotavirus preferentially infects enterocytes in the mature small intestine after it has
been activated by cleavage of VP4 by trypsin-like proteases.
 Infection is initiated in the proximal end of the intestine and spreads distally but is
generally confined to the intestinal mucosa.
 Multiplication of the rotavirus particles in mature enterocytes leads to destruction of
these cells.
 Villous tips receive the most extensive damage, with sparing of the crypts.
 Viable crypt cells undergo rapid division.

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PATHOPHYSIOLOGY OF ROTAVIRUS INFECTION

 Mechanisms of excessive secretion

• Loss of villous tips and the filling of crypts with rapidly multiplying cells results in a
marked decrease in the surface area of the gut lumen.
• Villous cell dysfunction during infection leads to an imbalance between absorption and
secretion, resulting in a net secretion (villous cells are largely absorptive and crypt cells
are secretory).
• Increased enterocyte turnover results in immature enterocytes that have impaired
absorptive capacity.
• The virus destroys disaccharidases in the small intestine.
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PATHOPHYSIOLOGY OF ROTAVIRUS INFECTION

• Rotavirus enterotoxin (NSP4) may cause release of calcium from the endoplasmic
reticulum, with resultant increased secretion from the villous cells.
• Stimulation of the enteric nervous system by NSP4 and villous ischaemia may further
aggravate the diarrhoea.

 Substantial fluid and electrolyte loss may result in dehydration, electrolyte imbalance,
and metabolic acidosis.
 If uncorrected, this may lead to circulatory collapse, shock, end-organ hypoperfusion,
and tissue damage.
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CASE PRESENTATION

 Patient K.A.
 7 months old male
 Managed as a case of Gastroenteritis.
 He was admitted to CWB on 07/02/18
 On arrival at OPD and on subsequent examination and review by the admitting
doctor the following information was obtained:

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PRESENTING COMPLAINT

 Fever 1/52.
 Vomiting 1/52.
 Cough+
 Diarrhoea+

PAST MEDICAL HISTORY

NIL

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SOCIAL HISTORY

 Pupil
 Stays at Bantama
 Christian
 National Health Insurance

FAMILY HISTORY
 No history of any chronic diseases in family

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DRUG HISTORY

 Co-trimoxazole
 Zinc tablet

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DIAGNOSIS

 Gastroenteritis
 RVI
 R/O Malaria

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LABS

 BF for MPs-Negative
 FBC
 Sickling- Negative
 Spot Test-279 type I confirmed

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DRUGS ON ADMISSION

 Prescribed drugs are

 Ringers Lactate 150ml

 Tab Zinc 20mg odx10
 Syrup Paracetamol 5ml tds x5
 Suspension Metrolex-F 2.5ml tds x 5

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SIGNS AND SYMPTOMS ON EXAMINATION

 Looks quiet unwell

 Febrile 38.5
 Moderately dehydrated

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REVIEW 08/02/18

 Child ill looking with very sunken eyes, lethargic and irritable with cold extremities
 Peripheral pulses not palpable
 Retro exposed baby reported with diarrhea and vomiting
 Has oral thrush
 RR 46cpm
 HR 160 bpm
 ABD
 CNS irritable, lethargic AF sunken
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REVIEW 08/02/18

Dx Hypovolemic shock
Severe Dehydration
RVI + oral thrush
Iron deficiency

Shock corrected by given 3 boluses of 20ml/kg R/L

Severe Dehydration correction started 560mls R/L over 5hrs
To reassess after hydration
Tx Daktarin oral gel to apply tds x 14
ORS 3sachets
1.5L of R/L 16

Septrin 5mls dly x 30

 CARE ISSUES

The volume of Ringers Lactate given was inappropriate

Ringers Lactate was not administered due to challenge in getting I.V access.

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 OPTIMISING THE MANAGEMENT OF VIRAL GASTROENTERITIS
 SUBJECTIVE DATA
 Vomiting- one of the most common symptoms of viral gastroenteritis
 Diarrhoea- Voluminous watery diarrhoea is common after an incubation period of 10 to 50
hours and frequently lasts 12 to 72 hours
 Malaise-Viral illness often causes body ache and feeling of unwellness
 Dehydration
 OBJECTIVE DATA
 Fever - not a common symptom but when present the temperature is typically about
37.7˚C (100˚F).
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 Spot Test-279 type I confirmed

ASSESSMENT

 CONFIRMATION OF DIAGNOSIS
 Viral gastroenteritis is the acute inflammation of the lining of the stomach and
intestines caused by enteropathogenic viruses.
 The typical presentation is an increased frequency of defecation lasting less than 14
days, which may be accompanied by nausea, vomiting, anorexia, abdominal cramps,
and fever.
 Presence of immunosuppression or chronic illness increases susceptibility.
 The subjective and objective data confirms the diagnosis of Viral gastroenteritis.

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ASSESSMENT OF THERAPY

 Ringers Lactate 150ml

 Tab Zinc 20mg odx10
 Syrup Paracetamol 5ml tds x5
 Suspension Metrolex-F 2.5ml tds x 5

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ASSESSMENT OF THERAPY
 Ringers Lactate 150ml
 It is indicated to replace lost fluids
 Intravenous (IV) Ringer’s lactate, 20 mL/kg, should be given over 1hour.
Vital signs should be monitored and the patient re-assessed on a regular basis.
 Boluses of IV fluid may be required until pulse, perfusion, and mental status return to
normal.
 Choice of IV fluid appropriate
 Volume of R/L prescribed not appropriate --- R/L was not given due to IV access
 Wt of infant=9.45kg 21

 20ml/kg = 189ml : but patient was prescribed 150ml

ASSESSMENT OF THERAPY

 Tab Zinc 20mg odx10

 Zinc has been recommended by the World Health Organization (WHO) for use in
developing countries
 Zinc supplementation has been found to reduce the duration and severity of
diarrhoeal episodes and likelihood of subsequent infections for 2–3 months (Baqui et
al, 2002)
 zinc supplementation is given at a dosage of 20 milligrams per day for children older
than six months or 10 mg per day in those younger than six months, for 10–14 days
 Appropriate 22
 ASSESSMENT OF THERAPY

 Syrup Paracetamol 5ml tds x5

 Paracetamol is indicated for fever and it works by inhibiting PG synthesis in the central
nervous system and blocking the actions of endogenous pyrogens at the hypothalamic
thermoregulatory centres. (Clinical Pharmacology [database online])
 The dosage for infants is 10-15 mg/kg/dose PO every 4-8hrs as needed. Max Single
dose: 15mg/kg/dose. Max Daily dose: 75mg/kg/day(Clinical Pharmacology [database
online])
 Appropriate
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 ASSESSMENT OF THERAPY

 Suspension Metrolex-F 2.5ml tds x 5

 Metrolex-F contains Metronidazole and furazolidone
 Metronidazole is a nitroimidazole antibacterial and antiprotozoal which works by
inhibiting bacterial DNA synthesis. Active against G-ve bacteria
 Furazolidone is an oxazolidine anti-infective agent which works by inhibiting various
bacterial enzyme systems. Active against G-ve, G+ve and protozoa
 The choice of drug is not appropriate

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PLAN

 MONITORING
 Ringers Lactate
 EFFICACY
 Correction of dehydration
 TOXICITY
 Hypersensitivity/infusion reactions
 Hyperkalaemia
 Hypervolemia
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PLAN

 MONITORING
 Zinc Tablet
 EFFICACY
 decreased risk of gastrointestinal infections
 TOXICITY
 Sideroblastic anemia

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PLAN

 MONITORING
 Syrup Paracetamol
 EFFICACY
 Resolution of fever
 TOXICITY
 Malaise and skin reactions

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COUNSELLING

 If your child has diarrhoea, he or she has loose, runny stools (poo).
 Most children recover completely in about a week, but there is a danger that they
could lose too much fluid (become dehydrated). It’s important to prevent this and
to treat it quickly if it happens.
 Diarrhoea is usually caused by a virus.
 Most children get diarrhoea at least once before the age of 5.

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 COUNSELLING

But you can do a lot to stop the infection spreading.

 Make sure everyone in the family washes their hands properly after using the toilet
or changing a baby's nappy, and before preparing food or eating.
 Dispose of nappies properly. Keep your children away from anyone who has
diarrhoea or vomiting.

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OUTCOME

Patient was discharged home with a resolved diarrhoea.

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 REFERENCES

1. Standard Treatment Guidelines (2017)

Ghana National Drugs Programme
Ministry of Health
Pages 287,288,289
2. Bhutta ZA, Bird SM, Black RE, Brown KH, Gardner JM, Hidayat A, et al.
Therapeutic effects of oral zinc in acute and persistent diarrhea in children in
developing countries: pooled analysis of randomized controlled trials. American
Journal of Clinical Nutrition. 2000; 72(6):1516–22.

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 REFERENCES

3. WHO. Reduced osmolarity oral rehydration salts (ORS) formulation. Geneva:

World Health Organization; 2001. (http://apps.who.int/iris/handle/10665/67322)
4. Baqui AH, Black RE, El Arifeen S,Yunus M, Chakraborty J, Ahmed S,Vaughan JP.
Effect of zinc supplementation started during diarrhoea on morbidity and mortality
in Bangladeshi children: community randomised trial. BMJ. 2002; 325(7372):1059.
5. Water with sugar and salt. The Lancet, 1978, 2(8084):300–1.
6. Clinical Pharmacology [database online]. Tampa, FL: Gold Standard, Inc.; 2006.
URL: http://cp.gsm.com. Updated December 2017
7. Webb A, Starr M. Acute gastroenteritis in children. Aust Fam Physician.
2005;34:227-231. Abstract 32
 REFERENCES

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10. Lundgren O, Svensson L. Pathogenesis of rotavirus diarrhea. Microbes Infect.
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11. Dalby-Payne J, Elliott E. Gastroenteritis in children. Clin Evid. 2005;13:343-353.
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