Download E. coli

Gastroenteritis
in Children
Presented by:
pourmirzaei (MD)
References:
UpToDate
• THE TYPES OF DIARRHEA IN CHILDREN:
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ACUTE DIARRHEA : less than 14 days.
(PROLONGED DIARRHEA : 7 – 13 days.)
PERSISTENT DIARRHEA : lasts 14 days or more.
DYSENTERY : diarrhea with blood in the stool.
EPIDEMIOLOGY
• 10% of childhood deaths.
• 700 000 deaths per year .
• Almost 1.7 billion episodes of diarrhea in
children younger than 5 yr of age .
• More than 80% of the episodes occurring
in Africa and South Asia .
ETIOLOGY
• Gastroenteritis is the result of infection
acquired through the fecal–oral route or by
ingestion of contaminated food or water .
• Gastroenteritis is associated with poverty,
poor environmental hygiene, and
development indices.
• In the United States, rotavirus and the
noroviruses (such as Norwalk-like) are the
most common viral agents, followed by
sapoviruses, enteric adenoviruses.
• Bacterial causes, which are most commonly
Salmonella, Clostridium perfringens,
Campylobacter, and Staphylococcus aureus,
followed much less often by E. coli,
Clostridium botulinum, Shigella,
Cryptosporidium, Yersinia, Listeria, Vibrio, and
Cyclospora species .
RISK FACTORS FOR GASTROENTERITIS
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Exposure to enteropathogens
Immune deficiency, measles, malnutrition
Lack of exclusive or predominant breastfeeding
Young age,
Vitamin A deficiency
Zinc deficiency
Mechanisms of Diarrhea
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Osmotic
Defect present:
Digestive enzyme deficiencies
Ingestion of unabsorbable solute
Examples:
Viral infection
Lactase deficiency
Sorbitol/magnesium sulfate
Infections
Comments:
Stop with fasting
No stool WBCs
Mechanisms of Diarrhea
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Secretory:
Defect:
Increased secretion
Decreased absorption
Examples:
Cholera
Toxinogenic E.coli
Comments:
Persists during fasting
No stool leukocytes
Mechanisms of Diarrhea
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Exudative Diarrhea:
Defects:
Inflammation
Decreased colonic reabsorption
Increased motility
Examples:
Bacterial enteritis
Comments:
Blood, mucus and WBCs in stool
Common Causes of Acute Diarrhoea
• Infection – highly contagious
Viral gastroenteritis
 Usually cause explosive,
watery diarrhoea
 Typically last only 4872hrs
 Usually no blood and
pus in stool
Rotavirus
Bacterial enterocolitis
 Sign of inflammation – blood or pus in stool,
fever
E. Coli bacteria
•Contaminated food or water
•Usually affect small kids
Bacterial enterocolitis
 Sign of inflammation – blood or pus in stool,
fever
Salmonella enteritidis bact
•In contaminated raw or
undercooked chicken and eggs
Bacterial enterocolitis
 Sign of inflammation – blood or pus in stool,
fever
Shigella bacteria
Campylobacter
bacteria
Parasites
Cryptosporidium
Giardia lamblia
• in contaminated water –
can survive chlorination
• in contaminated water
•Usually not associated
with inflammation
• Food Poisoning
Staphylococcus aureus
• Produces toxins in food before it is eaten
•Usually food contaminated left unrefrigerated
overnight
• Food Poisoning
Clostridium perfringens
• Multiplies in food
•Produces toxins after contaminated food is eaten
CLINICAL MANIFESTATION
• Most of the clinical manifestations of
diarrhea are related to the infecting
pathogen.
• Additional manifestations depend on the
development of complications (e.g.,
dehydration and electrolyte imbalance)
Degree of Dehydration
Factors
Mild < 5%
Moderate
5-10%
Severe >10%
General Condition
Well, alert
Restless, thirsty,
irritable
Drowsy, cold
extremities, lethargic
Eyes
Anterior
fontanelle
Tears
Normal
Sunken
Very sunken, dry
Normal
depressed
Very depressed
Present
Absent
Absent
Mouth + tongue
Skin turgor
Pulse
Moist
Sticky
Dry
Slightly decrease
Decreased
Very decreased
Slightly increase
Rapid, weak
Rapid, sometime
impalpable
Blood pressure
Normal
Deceased
Deceased, may be
unrecordable
Respiratory rate
Urine output
Slightly increased
Increased
Deep, rapid
Normal
Reduced
Markedly reduced
Types of dehydration
Isotonic
(isonatremic)
Hypertonic
(hypernatremic)
Hypotonic
(hyponatremic)
Loses
H2O = Na
H2O < Na
H2O > Na
Plasma
osmolality
Normal
Increase
Decrease
Serum Na
Normal
Increase
Decrease
ECV
ICV
Decrease
maintained
Decrease
Decrease +++
Decrease +++
Increase
Thirst
++
+++
+/-
++
Not lost
+++
Mental state
Irritable/lethargic
Very irritable
Lethargy/coma
shock
In severe cases
Uncommon
Common
Skin turgor
HOW WILL YOU ASSESS DEHYDRATION?
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1- LOOK AT THE CHILD’S GENERAL CONDITION
lethargic or unconscious. restless and irritable
2- LOOK FOR SUNKEN EYES
3- LOOK: TO SEE HOW THE CHILD DRINKS
not able to drink ,drinking poorly. drinking
eagerly and acts thirsty
• 4- PINCHING THE SKIN OF THE ABDOMEN
HOW DO YOU CLASSIFY DEHYDRATION?
• 1. SEVERE DEHYDRATION
• 2. SOME DEHYDRATION
• 3. NO DEHYDRATION
Complications of Diarrhea
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Dehydration
Metabolic Acidosis
Gastrointestinal complications
Nutritional complications
STOOL EXAMINATION
Fecal leukocytes are indicative of bacterial
invasion of colonic mucosa, although some
Patients with shigellosis have minimal
leukocytes at an early stage of infection
, as do patients infected with Shiga toxinproducing E. coli and E. histolytica
XTAG GPP

An FDA-approved gastrointestinal
pathogen panel using multiplexed nucleic
acid technology that detects
Campylobacter, C. difficile, E. coli 0157,
enterotoxigenic E. coli, Salmonella,
Shigella, Shiga-like toxin E. coli, norovirus,
rotavirus , Giardia, and Cryptosporidium.
Stool culture
In children with bloody diarrhea in whom
stool microscopy indicates fecal leukocytes; in
outbreaks with suspected hemolytic-uremic
syndrome (HUS); and in immunosuppressed
children with diarrhea.
Important comment

In most previously healthy children
with uncomplicated watery diarrhea,
no laboratory evaluation is needed
except for epidemiologic purposes.
Management
 Non-specific
 Oral Rehydration Solution (ORS):
• Effective in all types & all degrees of dehydration.
• Can prevent dehydration if given early in the
disease.
• Cheap, easy to administer; can be given by
mother at home.
• No chance of overhydration or electrolyte
overdose.
 Methods of administration: spoon, cup, dropper,
syringe, naso-gastric tube .
Types of ORS
New WHO (ORS) containing 75 mEq of sodium, 64 mEq
of chloride, 20 mEq of potassium, and 75 mmol of
glucose per liter, with total osmolarity of 245 mOsm/L
Solution
Glu
g/dl
Na
mEq/L
K
meq/L
Cl
meq/L
WHO
2.0
90
20
80
2.5
75
20
64
Pedialyte
2.5
45
20
35
Infalyte
2.0
50
20
40
(OLD)
Rehydralyte
(New WHO)
HOW WILL YOU TEACH THE CAREGIVER TO GIVE ORS
IN THE CLINIC?
• 1. DETERMINE AMOUNT of ORS to give during
first 4 hours.
• 2. SHOW THE MOTHER HOW TO GIVE ORS
SOLUTION.
• Tell her how much
• Show her the amount in units
• Sit with her while she gives the child the first few
sips from a cup or spoon. Ask her if she has any
questions.
Risks that might necessitate IV Therapy
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age <6 mo
Prematurity
chronic illness
fever >38°C if younger than 3 mo
fever >39°C if 3-36 mo of age
bloody diarrhea
persistent emesis; poor urine output
sunken eyes
depressed level of consciousness.
Antimotility drugs
• Opiate receptor agonists, such
as loperamide and diphenoxylateatropine combinations, reduce intestinal luminal
motility.
• These drugs have significant side effects,
including lethargy, paralytic ileus, toxic megacolon,
central nervous system depression, coma, and
even death .
• In addition, because they delay transit time, they
prolong the course of bacterial diarrheas, such
as Shigella and Escherichia coli
Indications for hospitalization
●Shock
●Severe volume depletion
●Moderate volume depletion with refusal of oral
fluids
●Clinical deterioration
●Neurologic abnormalities (eg, lethargy,
seizures)
●Intractable or bilious vomiting
●Failure of oral rehydration
●Possibility of severe illness or condition other
than acute gastroenteritis that requires specific
therapy
ENTERAL FEEDING AND DIET SELECTION
Breast-feeding or non diluted regular
formula should be resumed as soon as
possible .
 Fatty foods or foods high in simple
sugars (juices, carbonated sodas)
should be avoided.
 An energy intake of a minimum of 100
kcal/kg/day and a protein intake of
between 2 and 3 g/kg/day.
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Although children with persistent diarrhea are not
lactose intolerant, administration of a lactose load
exceeding 5 g/kg/day may be associated with
higher purging rates and treatment failure.
Alternative strategies for reducing the lactose
load while feeding malnourished children who
have prolonged diarrhea include addition of milk
to cereals and replacement of milk with
fermented milk products such as yogurt.
For persistent diarrhea

In addition to rice-lentil formulations, the
addition of green banana or pectin to
the diet has also been shown to be
effective in the treatment of persistent
diarrhea.
ANTIBIOTIC THERAPY
Nitazoxanide
an anti-infective agent, has been effective in
the treatment of :
Cryptosporidum parvum, Giardia lamblia
Entamoeba histolytica, Blastocystis hominis,
C. difficile, and rota virus.
ZINC SUPPLEMENTATION
* Reduced duration and severity of diarrhea.
* could prevent 300,000 deaths.
* WHO and UNICEF recommend
Zinc for 10-14 days during and after
Diarrhea.
* 10 mg/day for infants <6 mo of age and
20 mg/day for those >6 mo
probiotics
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the diarrhea is briefer and milder
produce higher levels of IgA
produce bacteriocins
synthesis of antimicrobial peptides
decrease enteroaggregative Ecoli
produce lactic and acetic acids
improve the integrity of the mucosal
barrier
probiotics
Cap Yomogi :
 Saccharomyces boulardii
(is effective in antibiotic-associated and in C.
difficile diarrhea )
 Kidilact or pedilact :
Bifidobacterium lactis,
Lactobacillus rhamnosus
(reduced diarrheal duration and severity, in
rotavirus diarrhea)
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Prevention
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Wash your hands frequently,
especially after using the toilet,
changing diapers.
Wash your hands before and after
preparing food.
Wash diarrhea-soiled clothing in
detergent and chlorine bleach.
Never drink unpasteurized milk or
untreated water.
Drink only bottled water.
Proper hygiene.
Points to Remember
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Gastroenteritis is acute self-limited illness.
Diarrhea and vomiting in infancy and childhood is
usually due to viral gastroenteritis.
Fluid replacement with ORS is the mainstay of
management.
Breast feeding should be continued.
Antibiotics agents are contraindicated.
Thanks
…
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