Diarrhea Parasitic Infection

ByDana HoganLinsy Ogden

Teresa Pearson

Diarrhea in Children

Diarrhea -Anatomy-Physiology-Pathophysiology

Definition Doctors Classify Diarrhea as

osmotic, secretory or exudative. Usual stool output is 10g/kg/day in children and 100g/day in adults. Stool loss of >10g/kg/day in infants and young children or >200g/day in older children or adults is considered diarrhea.

Acute vs. Chronic Acute Diarrhea is > 3

loose or watery stools per day.

Chronic Diarrhea is diarrhea lasting more than 14 days.

(Arcara, & Tschudy, 2012)

Diarrhea is the reversal of the normal net absorptive status of water and electrolyte absorption to secretion. Such a derangement can be the result of either an osmotic force that acts in the lumen to drive water into the gut or the result of an active secretory state induced in the enterocytes. In the former case, diarrhea is osmolar in nature, as is observed after the ingestion of nonabsorbable sugars such as lactulose of lactose in lactose malabsorbers. Instead, in the typical active secretory state, enhanced anion secretion is best exemplified by enterotoxin-induced diarrhea.

Pathophysiology

Epidemiology

In the United States, one estimate assumes a cumulative incidence of 1 hospitalization for diarrhea. Rotavirus is associated with 4-5% of all childhood hospitalizations, and 1 in 67 to 1 in 85 children are hospitalized due to rotavirus by age 5 years. Acute diarrhea is responsible for 20% of physician referrals in children younger than 2 years and for 10% in children younger than 3 years.

(Medscape, 2012)

Infection by bacteria (cause of most types of food poisoning)

Infections by other organisms Eating foods that upset the digestive system Allergies to certain foods Medications Radiation therapy Diseases of the intestines Malabsorption Hyperthyroidism Some cancers Laxative abuse Alcohol abuse Digestive tract surgery Competitive running

Causes of Diarrhea

Acute vs. ChronicCauses

Acute Viral gastroenteritis Staphylococcus aureus Clostridium perfringens Salmonella Shigella Cryptosporidiosis Drug-induced diarrhea Clostridium difficile

Chronic Irritable bowel

syndrome Inflammatory bowel

disease Pseudomembranous

colitis Diabetic enteropathy Dumping syndrome Malabsorption of

lactose Chronic laxative use

Diarrhea Continued

Small bowel diarrheas1. Large, loose stools2. Periumbilical or RLQ

painLarge bowel diarrheas1. Frequent, small loose

stools2. Crampy, LLQ pain or

tenesmus

Osmotic Diarrhea Osmotic diarrhea

means that something in the bowel is drawing water from the body into the bowel. A common example of this is “diabetic candy” or “chewing gum” diarrhea, in which a sugar substitute, such as sorbitol, is not absorbed by the body but draws water from the body into the bowel, resulting in diarrhea.

Decretory diarrhea occurs when the body is releasing water into the bowel when it’s not supposed to. Many infections, drugs, and other conditions cause secretory diarrhea.

Exudative diarrhea refers to the presence of blood and pus in the stool. This occurs with inflammatory bowel diseases, such as Crohn’s disease or ulcerative colitis, and several infections.

Secretory and Exudative Diarrhea

Clinical Findings Symptoms

Uncomplicated Non-serious Abdominal bloating or

cramps Thin or loose stools Watery stools Sense of urgency to

have a bowel movement Nausea and vomiting

Complicated May be sign of more

serious illness Blood, mucus, or

undigested food in the stool

Weight loss Fever(WebMd, 2011).

Clinical Findings Continued

Physical examination should note the patient’s general appearance, mental status, volume status, and the presence of abdominal tenderness or peritonitis.

Peritoneal findings may be present in C. difficile and enterohemorrhagic E coli. Hospitalization is required in patients with severe dehydration, toxicity, or marked abdominal pain. Stool specimens should be sent in all cases for examination for fecal leukocytes and bacterial cultures.

In over 90% of patients with acute diarrhea, the illness is mild and self-limited and responds within 5 days to simple rehydration therapy or antidiarrheal agents.

Patients with signs of inflammatory diarrhea manifested by any of the following require prompt medical attention: high fever (>38.5), bloody diarrhea, abdominal pain, or diarrhea not subsiding after 4-5 days. Patients with symptoms of dehydration must be evaluated (excessive thirst, dry mouth, decreased urination, weakness, lethargy, volume depleted.)

Evaluation

Evaluation

Measurement of blood pressure in the upright and supine position may demonstrate orthostatic hypotension and confirm the presence of dehydration.

Examination of a small amount of stool, bacterial cultures, C. difficile, Hemocult

History: travel, Giardia, and parasites. Recent antibiotic usage, food poisoning, new medications and personal contact

Gram’s stain for leukocytes Stool for C&S CBC Electrolytes Stool of O&P. (Ova and Parasites) C. Difficile (if

indicated) LFT’s & PT time Amylase, lipase, glucose Upper gastrointestinal X-rays (UGI series),

Abdominal CT Barium enema Esophago-gastro-duodensoscopy (EDG) Colonoscopy Hydrogen breath testing

Diagnostics Diarrhea

Other Laboratory Tests

In secretory diarrhea: Serum VIP (VIPoma), gastrin (Zollinger-Ellison syndrome), Calcitonin (medullary thyroid carcinoma), cortisol (Addison’s disease), and urinary 5-HIAA (carcinoid syndrome) levels should be obtained.

Proctosigmoidoscopy with mucosal biopsy: Examination may be helpful in detecting inflammatory bowel disease and melanosis coli, indicative of chronic use of anthraquionone laxatives.

Differential Diagnosis

Appendicitis Carcinoid tumor Congenital microvillus

atrophy Crohns disease Cystic fibrosis Giardiasis Glucose-galactose

malabsorption Hyperthyroidism Intestinal enterokinase

deficiency

Differential Diagnosis Continued

Intestinal protozoal diseases

Intussusception Irritable bowel

syndrome Malabsorption

syndrome Meckel diverticulum Protein intolerance Shigella infection Short bowel syndrome Ulcerative colitis

Management of Care and Indications

Indications for medical evaluation of children with acute diarrhea include:

Older than 3 months Weight of more than 8 kg HX of premature birth,

chronic medical conditions, concurrent illness

Fever of 38 C or higher in infants <3 months or 39 C >3-36 months.

Visible blood in stool High-output diarrhea

Management of Care and Indications Continued

Persistent emesis S/S of dehydration as

reported by the caregiver, including sunken eyes, decreased tears, dry mucous membranes, and decreased urine output

Mental status changes Inadequate responses

to oral rehydration therapy (ORT) or caregiver unable to administer ORT

(CDC, 2003)

Oral Rehydration Therapy (ORT) First-Line Peripheral fluid therapy may be indicated in

more severe cases Diet: Continue breastfeeding. Older children:

Restart regular diet once patient is rehydrated. Other non-specific antidiarrheal agents such as

kaolin-pectin, antimotility agents such as lopermide, antisecretory drugs, and toxin binders have limited data regarding efficacy.

Infectious: antimicrobial therapy may be indicated

Probiotics: data is limited but efficacy has been demonstrated in antibiotic-resistant diarrhea

Management of Care Continued

ORT Therapy

Minimal-Mild Losses Minimal-not indicated Mild: <10 kg body

weight; 60-120 ml ORT for each diarrhea stool or vomiting episode

>10 kg: 120-140 ml ORT for each episode

Mild-Moderate Losses

ORT solution: 50-100 ml/kg over 3-4 hours

<10 kg: 60-120 ml for each episode

>10 kg: 120-140 ml for each episode

ORT is the cornerstone of treatment, especially for small-bowel infections that produce a large volume of watery stool output. ORT with a glucose-based oral rehydration syndrome must be viewed as by far the safest, most physiologic, and most effective way to provide rehydration and maintain hydration in children with acute diarrhea, as recommended by WHO; by the ad hoc committee of European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN); and the American Academy of Pediatrics.

Management of Care Continued

Rehydration Therapy-IV LR or NS 20 ml/kg until perfusion and mental status improve, followed by 100 ml/kg oral rehydration solution over 4 hours of 5% dextrose (half normal saline) IV at twice maintenance fluid rates.

Replacement of Losses: <10 kg-6- 120 ml oral for each diarrhea or vomiting episode, >10 kg 120-140 ml oral hydration for each episode.

If unable to drink: administer via G-Tube or IV; administer 5% dextrose (one fourth normal saline) with 20 mEq/L potassium chloride.

Severe Diarrhea with Fluid Loss ORT

Management of Care Continued

Antimotility agents are not indicated for infectious diarrhea, except for refractory cases of Cryptosporidium infection.

Antimicrobial therapy is indicated for some nonviral diarrhea because most is self-limiting and does not require therapy.

Aeromonas species: Cefixime, most third-fourth generation cephalosporin. Significant organism in the cause of diarrhea in young children.

Campylobacter species: Erythromycin . C. Difficile: Discontinue potential causative

antibiotics-use of metronidazole or vancomycin. C. Perfringens: Do not treat with antibiotics. Cryptosporidium parvum: Paromomycin,

Nitazoxanide . Entamoeba histolytica: Metronidazole followed

by iodoquinol or paromomycinin symptomatic patients. Asymptomatic receive iodoquinol or paromomycin.

Therapies Recommended for some Nonviral Diarrheas

E coli: TMP-SMX if moderate or severe diarrhea noted.

G lamblia: Metronidazole or nitrazoxanide. Plesiomonas species: TMP-SMX or cephalosporin. Salmonella species: Treatment prolongs carrier

state, is associated with relapse, and is not indicated for nontyphoid-uncomplicated diarrhea. Treat infants <3 months and high-risk patients with TMP-SMX as first line medication. If resistance occurs use ceftriaxone and cefotaxime for invasive disease.

Therapies Continued

Therapies Continued

Shigella species: TMP-SMX is first-line; however resistance occurs. Cefixime, ceftriaxone, and cefotaxime are recommended for invasive disease.

V cholerae: Treat infected individuals and contacts. Doxycycline first-line and erythromycin second-line.

Yersinia species: TMP-SMX, cefixime, ceftriaxone, are used, reserve for complicated cases.

Possible Complications and Expectations

Diarrhea in Children Complications Mortality: 18% of the

10.6 million yearly death in children age <5.

Dehydration Electrolyte

imbalances Irritation and skin

breakdown

WASH YOUR AND YOUR CHILDS HANDS! Before handling food.

Between preparation and consumption.

After voiding or bowel movements.

After changing diapers.

Patient EducationBasic Prevention Measures

Keep your hands away from your mouth. Dispose of waste properly. Assure Tap water is safe or use bottled water. Meat preparation-meats should be thoroughly

cooked. Healthy well balanced diet- may need a bland

diet or diet excluding foods that are causative factors to diarrhea.

Encourage fluid to prevent complications- avoid caffeine and sport drinks.

Patient EducationBasic Prevention Measures

Around the World

Although our presentation has been focused on the USA it is important to note that around the world in undeveloped countries that do not have piped sewage and clean drinking water the rates of incidence and mortality increase significantly.

Diarrhea is considered the “forgotten killer” in undeveloped countries because focus is placed more on HIV, malaria, and other diseases however diarrhea is the second leading cause of death in children.

American Family Physician. Gastroenteritis and Diarrhea in Children. http://www.aafp.org/afp/topicModules/viewTopicModule.htm?topicModuleId=9

The Center for High Impact Philanthropy. University of Pennsylvania. International Issues. http://www.impact.upenn.edu/international-issues/toolkit-childsurvival-globalcauses/

References