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Diarrhea
Parasitic Infection
By
Dana Hogan
Linsy Ogden
Teresa Pearson
Diarrhea in Children
Diarrhea -Anatomy-PhysiologyPathophysiology
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)
Pathophysiology
 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.
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)
Causes of Diarrhea
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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
Acute vs. Chronic
Causes
Acute
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Viral gastroenteritis
Staphylococcus aureus
Clostridium perfringens
Salmonella
Shigella
Cryptosporidiosis
Drug-induced diarrhea
Clostridium difficile
Chronic
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Irritable bowel syndrome
Inflammatory bowel disease
Pseudomembranous colitis
Diabetic enteropathy
Dumping syndrome
Malabsorption of lactose
Chronic laxative use
Diarrhea Continued
Small bowel diarrheas
1. Large, loose stools
2. Periumbilical or RLQ
pain
Large bowel diarrheas
1. Frequent, small loose
stools
2. 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.
Secretory and Exudative
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.
Clinical Findings
Symptoms
Uncomplicated
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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.
Evaluation
 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
 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
Diagnostics Diarrhea
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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
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)
Management of Care Continued
 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 kaolinpectin, 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
ORT Therapy
Minimal-Mild Losses
 Minimal-not indicated
 Mild: <10 kg body weight; 60120 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
Management of Care Continued
 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.
Severe Diarrhea with Fluid Loss ORT
 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.
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 selflimiting and does not require
therapy.
Therapies Recommended for some
Nonviral Diarrheas
 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 Continued
 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
 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
Patient Education
Basic Prevention Measures
 WASH YOUR AND YOUR CHILDS HANDS!
 Before handling food.
 Between preparation and consumption.
 After voiding or bowel movements.
 After changing diapers.
Patient Education
Basic Prevention Measures
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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.
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.
References
 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/toolkitchildsurvival-globalcauses/