Definition

Epidemiology

Types of diarrhea

Causes

Acute Diarrhea

According to WHO

- passage of 3 or more loose or liquid stools per day, or more frequently than is normal for the individual.

• Diarrheal diseases continue to be a major cause of morbidity and mortality in children in developing nations.

• In the year 2000, diarrheal diseases claimed an estimated 1.4 to 2.5 million lives; they are among the leading causes of death in children in developing countries

• In developed nations , they are an important cause of hospital admission although mortality rates may be lower.

• About 9% of all hospitalizations of children younger than 5 years were reported to be a result of diarrhea.

• A greater number of stools of decreased form from the normal lasting for less than 14 days

• 2 types:- Acute watery diarrhoea and dysenteryAcute diarrhoea

• Illness persists for more than 14 days. Persistent diarrhoea

• Duration of symptoms is longer than 1 monthChronic diarrhoea

ACUTE

Common causes:1.Gastroenteritis2.Systemic infection3.Antibiotic associated

Rare causes:1.Primary disaccharidase

deficiency1.Hirschsprung’s toxic colitis2.Adrenogenital syndrome

CHRONIC

Common causes:1. Post-infectious secondary

lactase deficiency2. Cow’s milk/ soy protein

intolerance3. Toddler’s diarrhea4. Coeliac disease5. Cystic fibrosis6. AIDS enteropathy

Rare causes:1. Primary immune deficiency2. Familial villous atrophy3. Secretory tumor4. Short bowel syndrome

ACUTE

Common causes:1. Gastroenteritis2. Food poisoning3. Systemic infection4. Antibiotics associated

Rare cause:1. Toxic ingestion

CHRONIC

Common causes:1.Post-infectious secondary lactase deficiency2.Irritable bowel syndrome3.Coeliac disease4.Lactose intolerance5.Giardiasis6.Inflammatory bowel disease7.AIDS enteropathy

Rare causes:1.Acquired immune defect2.Secretory tumor3.Pseudo-obstruction

ACUTE DIARRHEA

• Viral- Rotavirus- Norovirus

• Bacterial- Vibrio cholera- E. coli- Salmonella*- Shigella*- Campylobacter*- Clostridium defficile*

* Associated with bloody diarrhoea

• Protozoal-Giardiasis

• Food poisoning

• Drugs-NSAIDs-Antibiotics

1). History

- Foods ingested ???

- Duration & frequency of diarrhea

- Presence of blood or steatorrhoea

- Abdominal pain

- Tenesmus

- Ask whether family @ community members have been affected

2). Physical Examination

Assess degree of dehydration by :-

- Skin tugor

- Pulse and BP measurement

- Monitoring of urine output and ongoing stool loses

3). Investigation

- FBC

- Serum electrolyte

- Blood and urine culture

- Stool inspection for blood and examination for ova, cysts and parasites

- Chest X-ray

Asses based on :-1.General condition2. Sunken eyes3. Offer the child drink4. Skin turgor

Classification: -1. Mild dehydration (<5%)2. Moderate dehydration (5-10%)3. Severe dehydration (>10%)

• First, assess the state of dehydration & then choose the treatment plan A, B or C

PLAN A (mild diarrhea)

1. Give extra fluid

- Breastfeed frequently

- Give ORS and cooled boiled water

- Plus food-based fluid (not exclusively breastfed)

*10ml/kg of ORS after each loose stool

2. Continue Feeding

- Feed as usual on demand

- Avoid food high in simple sugar as osmotic load may worsen the diarrhea

3. When to Return (to clinic/hospital)

- Not able to drink

- Becomes sicker

- Develops fever

- Has blood in stool

PLAN B (moderate diarrhea)

Give recommended amount of ORS 4- hourly* Approximat amount of ORSs required = weight (in kg) x 75

After 4 hours

- Reassess the child

- Select appropriate treatment

- Begin feeding the child

Explain the 3 rules of PLAN A

PLAN C (severe diarrhea)

• Start IV or IO fluid immediately. Give 100ml/kg Ringers Lactate @ normal saline devided as :-

- 1st give 20ml/kg as fast as possible. Repeat boluses until perfusion has improved

- Give the remaining fluid 5 hrs (age < 1 year)

or 2 ½ hrs (age >1 year)

• Reassess the child after every bolus

• Reassess the child every 1-2 hour during rehydration

• Give ORS as soon as the child can drink.

• Classify the degree of dehyration

• Choose appropriate treatment

Maintenance Fluid Therapy

Volume of fluid required

< 6 months age : 150 ml/kg/day

6 to 1 year : 120 ml/kg/day

>1 year : 1st 10 kg = 100 ml/kg

10- 20 kg = + 50 ml/kg for the subsequent kg

> 20 kg = + 20 ml/kg for the subsequent kg

Antimicrobial Treatment

• Indicators:-

- Toxic looking

- Severe dehydration

- Blood in stool

• Types of Antibiotics:-

- Ampicilin

- Trimethoprim (TMP)

- Sulfamethoxazole

Chief Complaint:

“Sally has a fever and is vomiting.”

History of Present Illness

A 4-year-old female is brought to the emergency dept. by her parents.

She started complaining of abdominal pain 3 hrs ago and then had an onset of vomiting episodes x 4.

No blood noted in the emesis or bile appearance.

Temperature taken at home one half hour ago, temperature was 38.2 C.

Mother has also commented on Sally’s increased level of thirst over the

past week, and has attributed Sally’s new onset of night time bedwetting to her increased consumption of fluids.

Vomiting is a coordinated, sequential series of events that leads to forceful oral emptying of gastric contents.

–Duration, frequency, bilious material, abdominal pain, diarrhea, hematemesis, hematochezia, melena, headache, fever, dysuria, weight loss, urine output

–Sick contacts, cough, rhinorrhea, neck stiffness

Family history: Genetic disease

–Vital signs, weight, mucous membranes, nasal discharge, breath sounds, rashes

–Abdominal pain/distension, hepatosplenomegaly, abdominal masses, Murphy/obturator/psoas sign

–Skin turgor, capillary refill

–Neuro exam including funduscopy for papilledema

Bilateral vomition centers in the reticular formation of the medulla integrate signals triggers vomition.The vomition centers receive afferent signals from four major sources:

The chemoreceptor trigger zone -bilateral set of centers in the brainstem lying under the floor of the fourth ventricle. The chemoreceptor trigger zones function as emetic chemoreceptors for the vomition centers - chemical abnormalities in the body (e.g. emetic drugs, uremia, hypoxia and diabetic ketoacidosis) are sensed by these centers, which then send excitatory signs to the vomition centers.

Visceral afferents from the gastrointestinal tract (vagus or sympathetic nerves)

Visceral afferents from outside the gastrointestinal tract - this includes signals from bile ducts, peritoneum, heart and a variety of other organs.

Afferents from extramedullary centers in the brain - certain psychic stimuli (odors, fear), vestibular disturbances (motion sickness) and cerebral trauma

1. Nausea - unpleasant psychic experience.

2. Retching phase - abdominal muscles undergo a few rounds of coordinated contractions together with the diaphragm and the muscles used in respiratory inspiration.

3. Expulsive phase - intense pressure is formed in the stomach brought by enormous shifts in both the diaphragm and the abdomen. The vigorous contractions of these muscles last much longer than a normal period of muscular contraction. The pressure is then suddenly released when the upper esophageal sphincter relaxes resulting in the expulsion of gastric contents.

VOMITING

Manifested by nausea, pallor and diaphoresis, followed by forceful gagging and retching.

REGURGITATION

Effortless and not preceded by nausea.

But , the unpleasant sensations of gastric contents in mouth during regurgitation, may trigger gagging and true vomiting.

Gastric secretions are highly acidic. Recent food Malodorous. Blood “coffee ground vomiting"(as the iron in the blood is

oxidized) Bile Fecal vomiting-consequence of intestinal obstruction or a

gastrocolic fistula non-productive emesis or dry heaves-vomiting reflex

continues for an extended period with no appreciable vomitus

Bright red-bleeding from the oesophagus

Dark red vomit with liver-like clots- profuse bleeding in the stomach (e.g.; perforated ulcer)

Coffee ground-like vomit-less severe bleeding in the stomach-gastric acid has had time to change the composition of the blood

Yellow vomit-bile indicates that the pyloric valve is open and bile is flowing into the stomach from the duodenum.

FBC

U & E

Creatinine

Stool serology

Abdominal X-Ray

Surgical opinion if obstruction

Exclude systemic disease

Aspiration of vomit

Under normal circumstances the gag reflex and coughing will prevent this from occurring. The individual may choke and asphyxiate or suffer an aspiration pneumonia.

Dehydration and electrolyte imbalance

Tears in GIT

1. If these tears are limited to the inner lining of esophagus, they are called Mallory-Weiss tears-Passing of bright red or dark blood in the vomitus.

2. Tears through the entire wall of the esophagus resulting in perforation and the escape of stomach contents outside the gut- “Boerhaave’s syndrome

3. Painful bruises or tears in the abdominal wall muscles.

Dentistry

Recurrent vomiting may lead to destruction of the tooth enamel due to the acidity of the vomit and also can degrade tissue of the gum.

If prolonged, weight loss or malnutrition may occur.

Stabilize patient and fluid resuscitation as initial therapy with electrolyte correction

Surgical consultation if obstruction suspected Oral rehydration with small amounts of liquids if tolerated Treat infections if indicated

Remove toxins and allergens Surgical interventions for volvulus, Hirschprung, intracranial

masses, pyloric stenosis, other anatomic causes Correct metabolic derangements

Lifelong gluten-free diet for celiac disease

Rare use of antiemetics/promotility agents for chemotherapy, motion sickness, postsurgery, gastroesophageal reflux disease

Acute and recurrent

ABDOMINAL PAINDEFINITION

Abdomen – the part of body

lying between the thorax and

pelvis, containing the abdominal

cavity & viscera

Pain – feeling of distress,

suffering, caused by

stimulation of specialized

nerve endings.

Visceral pain

•nerves within gut detect

injury,affecting soft organ

n&body tissue

•‘’discomfort’’ and poorly

localized

Somatic pain

•overlying body

structures are injured

•Described as MSK

pain

•Pain is sharp, intense,

discrete & localized

Referred pain

•Painful sensation in a body

region distant from true

source of pain

•Caused by activation of

spinal cord somatic sensory

cell bodies by intense

signaling from visceral

afferent nerves located at

the same level.

CATEGORIES

Can signal presence of dangerous intra-abdominal process

-Eg: appendicitis, bowel obstruction

Or originate from extraintestinal sources

-Eg: lower lobe pneumonia or urinary tract stone

history

onset- sudden or gradual, episodes, association w meals, history of injuryNature – sharp vs dull, colicky or constant, burningLocation – epigastric, periumbilical,generalized, R or L lower quardrant, change in location over timeFever – presence suggests appendicitis or other infection Extraintestinal symptoms – cough, dyspnea, dysuria, urinary frequency, flank painCourse of symptoms – worsening or improving, changes in nature or location of pain

General – growth & nutrition, general appearance,

hydrational status, degree of discomfort, body position

Abdominal – tenderness, distention, bowel sounds, rigidity,

guarding, mass

Genitalia – testicular torsion, hernia, PID, ectopic pregnancy

Surrounding structures – breath sounds, rales(crepitation),

wheezing, flank tenderness, tenderness of abd. wall

structures, ribs, costochondral joints

Rectal examination – perianal lesions, stricture, tenderness,

fecal impaction, blood

LABORATORY

CBC, C-Reactive protein, ESR – evidence of infection/

inflammation

AST, ALT, GGT, Bilirubin – biliary or liver dss

Amylase, lipase - pancreatitis

Urinalysis – UTI, bleeding d/t stone, trauma or obstruction

Pregnancy test (older females) – ectopic pregnancy

RADIOLOGY

Plain flat & upright abdominal films – bowel obstruction,

appendiceal fecalith, free intraperitoneal, kidney stones

CT scans – rule out abscess, appendicitis, Crohn dss,

pancreatitis, gallstones, kidney stones

Barium enema - Intussusception, malrotation

Ultrasound – gallstones, appendicitis, intussusception,

pancreatitis, kidney stones.

ENDOSCOPY

Upper endoscopy – suspected PU/ esophagitis

DIFFERENTIAL DIAGNOSISCATEGORIES DIAGNOSIS

Traumatic Duodenal hematoma, ruptured spleen, perforated viscus

Functional Constipation*, IBS*, dysmenorrhea*, Mittelschmerz,

infantile colic*

Infectious Appendicitis*, viral/bact. gastroenteritis, abscess,

bacterial peritonitis, PID, cholecystitis, UTI*, pneumonia,

hepatitis

Genital Testicular torsion, Ovarian torsion, ectopic pregnancy

Genetic Sickle cell crisis*, Familial Mediterranean fever,

porphyria

Metabolic Diabetic ketoacidosis

Inflammatory Inflammatory bowel disease, vasculitis, Henoch-

Schonlein purpura*, pancreatitis

Obstructive intussusception*, malrotation, ileus, incarcerated

hernia, postoperative hernia

Biliary Gallstones, gallbladder hydrops

Peptic Gastric or duodenal ulcer, gastritis*, esophagitis

Renal Kidney stones, hydronephrosis

DISTINGUISHING C.FEATURESDISEASE ONSET LOCATION REFERRAL QUALITY ADD. FEAT.

Appendicitis Acute Periumbilical

or epigastric,

localizes to

RLQ

Back or

pelvis

Sharp,

steady

Nausea,

emesis, local

tenderness +-

fever

Intussuscepti

on

Acute Periumbilical

– lower

abdomen

None Cramping w

painless

periods

Guarded

position with

knees pulled

up, currant

jelly stool,

lethargy

Cholecystitis

&

cholelithiasis

Acute RUQ Right

shoulder

Severe,

colicky pain

Hemolysis +-

jaundice,

nausea, emesis

Urolithiasis Acute,

sudden

Back Groin Severe,

colicky pain

Hematuria

Pancreatitis Acute Epigastric-

hypogastric

Back Constant,

sharp

Nausea,

emesis,

marked

tenderness

DISEASE ONSET LOCATION REFERRAL QUALITY ADD. FEAT.

Intestinal

obstruction

Acute or

gradual

Periumbilic

al- lower

abdomen

Back Alternating

cramping

(colic) &

painless

periods

Distension,

obstipation,

bilious emesis

Pyelonephritis Acute,

sudden

Back None Dull to

sharp

Fever,

costochondral

tenderness,

dysuria,

urinary

frequency,

emesis

A P P E N D I C I T I S

Clinical Features

Lower abdominal pain- right iliac fossa,Nausea and

vomiting,loss of appetite,Diarrhoea,Dysuria

Physical Findings

quiet ,dehydrated.Tenderness on palpation or

percussion ,discomfort, Guarding signifies

peritonitis,

Rectal examination is only required if other

diagnosis are suspected e.g. ovarian or adnexal

pathology.

APPENDICITIS

invagination of one portion of intestine into another with involving the ileocaecal junction

peak age group being 2 months to 2 years

Clinical Features

Pain - Sudden onset ,severe intermittent cramping pain lasting seconds to minutes

vomiting –undigested food ,Stools- dark red and mucoid(redcurrant jelly)

Physical Findings

well- looking/ drowsy/ dehydrated

abdominal mass may be difficult to palpate

in a distended abdomen

Abdominal distension is a late sign

INTUSSUSCEPTION

APPENDICITIS

Laparoscopic surgery

INTUSSUSCEPTION

Barium enema in early

intussusception

Surgery

DEFINITION CRITERIA

Occurrence of multiple

episodes of abdominal

pain over at least 3

months that are severe

enough to cause some

limitation of activity

At least 3 bouts of

significant abd. pain

over 3 months

Severe phase lasting at

least 3 mins

Usually in children

above 3 yr old.

DIAGNOSTIC APPROACH

When taking history, pediatrician should ask about the

warning signs for underlying diseases

If any warning signs are presents, further investigation

is necessary.

Even if they are absent, some laboratory evaluation is

warranted.

Vomiting

Abnormal

screening lab.

study

feverBilious emesis

Growth failure

Pain awakening child

from sleep

Weight loss

Location away from periumbilical

region

Blood in stools or emesis

Delayed puberty

CBC

ESR

Amylase, lipase

Urinalysis

Abdominal ultrasound

Trial of 3- day lactose-

free diet

CT scan

Celiac disease serology

Barium upper GI

Endoscopy

Colonoscopy

INVESTIGATIONSFOLLOW UP

Functional abdominal pain* -

IBS*

Chronic pancreatitis

Gallstones

Peptic disease - duodenal ulcer, gastric ulcer, esophagitis

Lactose intolerance*

Fructose malabsorption

Inflammatory bowel disease* - crohn’s disease, ulcerative colitis

Constipation*

Obstructive uropathy

Congenital intestinal malformation – stricture or web, malrotation, duplication cyst

Celiac disease*

Pain that characteristically occurs daily or nearly every

day

Not assoc. with or relieved by eating/ defecation

Assoc. with sig. loss of ability to function normally.

These kids have personality traits that include tendency

towards anxiety & perfectionism – results in stress

Parents noted that child enjoys going to school, but the

pain often worst at the start of school day & before

returning to school after vacations.

• cramping, abdominal pain, bloating, constipation, and diarrhea.

• Pain begin with a change in stool frequency

/consistency.

• A stool pattern fluctuating between diarrhea and

constipation.

• Relief of pain with defecation

• Symptom are link to gut motility

• Modulated by psychosocial factor such as stress and

anxiety.

- Treat underlying conditions

- Allows children to resume with daily activities

- Reassures that the although pain is there, will not harm

the children physically (in case of FAP)

- IBS-can control symptoms with diet, stress management, and prescribed medications.