Download 1 Pediatrics – Dr. `Adnan – Lecture 4 – Diarrhea IV

Pediatrics – Dr. ‘Adnan – Lecture 4 – Diarrhea IV
Dysentery
It is defined as diarrhea with visible blood in stools. The most important and frequent cause
of acute dysentery is Shigella. Other causes include Campylobacter jujeni, Salmonella, and
enteroinvasive E. coli. Entameba histolytica causes dysentery in older children but rarely in
children under 5 years of age.
Dysentery is specially sever in:
1. Malnourished infants and children.
2. Those who develop clinically evident dehydration during their illness.
3. Those who are not breast fed.
4. Children with measles or had measles in the preceding month.
5. Those who present with convulsion or develop coma.
Clinical features and diagnosis
The clinical diagnosis of dysentery is based solely on the presence of visible blood in the
diarrheal stool. The stool will also contain pus cells which are visible microscopically, and it
may contain large amounts of mucus, the later features suggest infection with an invasive
microorganism, but alone are not sufficient to diagnose dysentery.
Patients frequently have fever, cramping abdominal pain and tenesmus.
The cause is identified by stool culture. Stool microscopy may help in differentiating
E.histolytica which can only be diagnosed with certainty when trophozoites containing RBCs
are seen in fresh stools or in mucus from rectal ulcers obtained during colonoscopy.
Complications
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Intestinal perforation.
Toxic megacolon.
Rectal prolapse.
Convulsions.
Septicemia.
Hemolytic uremic syndrome.
Prolonged hyponatremia.
Management
Children with dysentery should be presumed to have Shigellosis and treated accordingly.
This is because Shigellae cause 60% of dysentery cases seen at health facilities and nearly all
cases of sever life threatening disease.
1. Antimicrobial therapy:
Trimethoprim sulfamethoxazole is the usual choice for five days. There should be substantial
improvement after 2 days i.e. reduced fever, less pain and fecal blood, and fewer loose
stools. If this does not occur the antimicrobial should be stopped and a different one used
like Naladixic acid, Cefixime, or Ceftriaxone according to the local culture and sensitivity.
2. Fluid: Assess and correct any dehydration.
3. Feeding: Continue feeding.
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Persistent diarrhea
It is a diarrheal episode that last for 14 days or longer. About 10% of acute diarrheal
episodes become persistent. Persistent diarrhea is largely a nutritional disease, it occur more
frequently in children who are already malnourished and is itself an important cause of
malnutrition. It is associated with increased mortality causing about 30% of all diarrhea
associated death.
There is no single microbial cause although Shigella, Salmonella, Enteroinvasive E.coli and
Cryptosporidium play a greater role than other agents. Irrespective of the cause, persistent
diarrhea is associated with extensive changes in the bowel mucosa, specially flattening of
the villi and reduced production of disaccharidase enzymes; these cause reduced absorption
of nutrients and perpetuate the illness after the original infectious cause has been
eliminated.
Risk factors:
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Malnutrition.
Young age.
Recent introduction of animal milk(formula
Immunological impairment.
Recent diarrhea.
Management
Fluid and electrolyte replacement
Nutritional therapy: the goals are
1. Reduce temporarily the amount of animal milk or lactose in the diet.
2. Provide a sufficient amount of energy, protein, vitamins and minerals.
3. Avoid foods or drinks that may aggravate diarrhea.
4. Ensure adequate food intake during convalescence to correct malnutrition.
Drug therapy:
Antimicrobials and antiprotozoal agents should be given only when indicated and according
to culture and sensitivity. However, blind use of these drugs is not effective and should not
be given as they may make the illness worse. Likewise antidiarrheal drugs has no proven
value and should not be given.
Conditions that can mimic gastroenteritis
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Systemic infections: Septicemia, meningitis.
Local infections: Otitis media, Respiratory tract infections, UTI
Surgical conditions: Pyloric stenosis, intussusception, necrotizing enterocolitis, Hirschsprung
disease, acute appendicitis.
Metabolic disorders: Diabetic ketoacidosis, Hartnup disease
Renal disorders: Hemolytic uremic syndrome, Renal tubular acidosis
Inflammatory bowel diseases: Ulcerative colitis, Crohn’s dis
Others: Cow milk protein allergy, Adrenal insufficieny, Acrodermatitis enteropathica
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