Download Acute bowel diseases in children. Toxicosis and exicosis

The chair of pediatrics with children’s surgery, course of children infectious diseases
Methodological Instructions to lesson for 6th year students No 3
(practical classes - 7 hours)
Theme: Acute bowel diseases in children. Toxicosis and exicosis.
Aim: to learn how to diagnose toxicosis and exicosis syndrome in children, determine its
type, period and phase, perform differential diagnosis, and treatment.
Professional motivation: Toxicosis and exicosis are nonspecific generalized answer on
infectious agent or its products in case of massive toxins’ income in blood with
development of endotoxemia. Main pathologic processes in organism are connected with
development of dehydration and loss of electrolytes. Progress of these processes leads to
impairment of blood circulation, hypoxia of tissues, metabolic acidosis, toxic shock
syndrome, and polyorganic insufficiency. That’s why it requires from the doctor to know
diagnostic criterions, duration, treatment and prevention of this pathology.
Basic level
1. To know how to ask complaints, history of the disease and life in children with acute
bowel diseases [propedeutic pediatrics, children infectious diseases].
2. To perform clinical examination of the child with acute bowel disease [propedeutic
pediatrics, children infectious diseases].
3. To diagnose toxicosis with exicosis after clinical, laboratory and instrumental
examination of the child [infectious diseases, propedeutic pediatrics].
4. Pathogenetical and symptomatical treatment of toxicosis with exicosis (pharmacology,
infection diseases).
Students’ independent study program.
1. Objectives for students' independent studies.
You should prepare for the practical class using the existing textbook and lectures. Special
attention should be paid to the following:
Diarrhea Classification
Diarrhea's type
Diagnostic's criteria
Invasive
(bacterial)
Secretory
(watery)
Prolonged
Liquid excrements with pathological
admixture (mucus, verdure, blood)
Excrements are liquid, massive,
without pathological admixtures
Long-lasting diarrhea (more 2
weeks) with pathological admixtures
Watery, don’t fermentated
excrements without signs of the
inflammation in koprogram,
associated with food ingredients
Chronic enzymeassociated
Severity
Mild
Moderate
Severe
Main clinical
syndrome
 Primary toxicosis
(neurotoxicosis)
 Toxicosis with
exicosis I, II and III
degree
 Infectious-toxic
shock
 Toxic-dystrophic
syndrome
 Hemolytic-uremic
syndrome
Criteria of the Diarrhea Severity
Criteria
Mild current
Moderate current
Severe current
Local
manifestations
regurgitation, vomiting 1-2
times per day, excrements
Multiple vomiting, as a
rule after receiving the
Multiple vomiting not only
after receiving the food, but
1
General
manifestations
less than 7-8 times per day,
changed nature with small
amount of mucus, but with
increase of stools,
moderate metheorism
food, excrements to 15
times per day, liquid, with
much mucus, can be
bloody mucus, metheorism
also independent, can be
with bile, sometimes - as
coffee lees, excrements more 15 times per day,
sometimes - with each
diaper, much mucus, there is
blood, sometimes - an
intestinal bleeding
General condition is
broken little, falls appetite,
body temperature is normal
or subfebrile, deceleration
or delay of the body
weight, visible signs of
toxicosis and exicosis are
absent
General condition is
moderately broken, malaise
or excitement, appetite is
reduced, poor sleeping,
moderate signs of toxicosis
and exicosis, body
temperature is 38-39º С,
body weight decreases
General condition is sharply
worsened, changes in all
organs and systems, quite
often - sopor, loss of the
consciousness, cramps,
expressed toxicosis and
exicosis, significant weight
loss
Differential-Diagnostic Criteria of Diarrheal Diseases
Criteria
Epidemiological
anamnesis
functional Diarrhea
Sporadic diseases on
background of wrong
feeding, care, etc.
Salmonellosis
More often group diseases,
connected with source of
infection (products, contact
with ill person or carrier of
salmonellas)
Salmonellae
Shigellosis
Both sporadic, and group
diseases, contact with ill
person, connection with
infected products
Etiology
Poor fermentation
(dyspepsia)
Short (2-3 days), or normal
7 and more days
5-7 days and more
Short, small on background
of the diarrhea
Moderate degree, 5-7 days,
prevails on diarrhea
Exicosis
Duration
Little denominated or absent
2-3 days
Often denominated
7-30 days
Different degree, 3-7 days,
precedes intestinal
manifestations
Moderately denominated
7 and more days
Excrements
looks like cut eggs, liquid
Dark-green with mucus (as
mud), with blood
Big amount of mucus, sometimes
- blood and pus - rectal spit
Vomiting
Short (1-2 days), or absent
Metheorism
Sparingly denominated,
short (1-2 days)
Enzyme changes
is not enlarged
is not enlarged
Moderate or long-lasting (5-7
days)
Always denominated, longlasting
Mainly enzyme changes
is increased
is increased
Expressed, is not long-lasting (35 days)
Abdomen is sealed
High
temperature
Toxicosis
Koprogram
Liver
Spleen
Criteria
Epidemiological
anamnesis
Escherichiosis
Sporadic diseases of
children before 1 year old,
more often in hospital,
contact with ill person
Staphylococcal enterocolitis
Sporadic diseases of children
before 1 year old on
background of
Staphylococcal damage of
other organs, or
Staphylococcal diseases of
the mother
Shigellae
Inflammatory changes
Can be increased
Not increased
Viral diarrhea
Group, less sporadic diseases,
on background of other
catarrhal manifestations in the
upper respiratory tract
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Pathogenic Escherichia
7-14 days and more, quite
often - wave-like
More often moderately
denominated, as a rule not
less 7 days, prevails over
dyspeptic phenomena
Often denominated, longlasting
7-30 days
Staphylococci
Long-lasting subfebril (during
weeks, months)
Little denominated, longlasting (weeks, months)
Viruses, more often rotaviruses
5-7 days, subfebril, rare - high
Absent, or little denominated
Little denominated or absent
Weeks, months
5-7 days
Excrements
Big amount weakly painted
or brightly yellow liquid
Rare, yellow, sometimes with blood
Watery
Vomiting
Moderate or long-lasting
(5-7 days)
Is absent
Metheorism
Always denominated, longlasting
enzyme changes
is Increased
is not increased
Small denominated, but longlasting
Inflammatory changes
is increased
More often is increased
Short (1-3 days), small (2-3
times in day) or, more often, is
absent
Moderately denominated, short
(1-2 days)
Enzyme changes
is not increased
is not increased
Etiology
High
temperature
Toxicosis
Exicosis
Duration
Koprogram
Liver
Spleen
Moderately denominated, 3-5
days
Dehydration Dehydration means the body does not have enough fluids to function at an
optimal level. Dehydration can be caused by fluid loss (through vomiting, diarrhea or
excessive urination), inadequate intake, or a combination of both. The most common cause
of dehydration in infants and children is acute gastroenteritis, with its associated vomiting
and diarrhea.
Main Differential Signs of the Dehydration Types
Symptom, sign
Hypertonic
dehydration
Normal, subfebril
Body temperature
Thirst
CNS reaction
Concentration of the
sodium in blood
Loss of body weight
Isotonic dehydration
Highly increased
Severe
Exiting
Increased
Moderate
Some exiting or
depression
Normal
5-10 %
Less than 5 %
Hypotonic
dehydration
subnormal
Refuse to drink
Adynamia
Decreased
More than 10 %
Additional Differential-Diagnostic Signs of the Dehydration’s Types
Symptom, sign
Reflexes
hypertonic type
Raised
Hypotonic type
Reduced
Noticeably reduced
Isotonic type
Normal, seldom reduced
Noticeably not reduced
Turgor of the soft
tissue and skin
elasticity
Skin covers
Sparingly pale, dry,
limbs are warm
Pale, sparingly moist,
limbs are moist, cool
Gray-ashen color, dry,
acrocyanosis
Sharply reduced
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Mildly dry, usual
Mucous membranes Dry, brightly
hyperemied, covered by coloration
viscous mucus (seldom)
expressed dyspnea
Moderate shortness of
Breathing
breath, sometimes
breathing rate
corresponds to age
Tones are weakened
Moderate tachycardia,
Cardiac activity
tones are clean,
weakened
Increased
Increased
Blood pressure
porridge-like or watery Often, dyspeptic
Feces
(frequent)
absent
Present
Vomiting
Preserved
Preserved
Diuresis
First 1001-1018,
Normal or is sparingly
Specific density of
afterwards - 1025-1035 increased
the urine
dry, pale, rare - rose,
often covered by
tractile mucus
moderate dyspnea
Tachycardia, tones are
weak, often systolic
murmur on the apex
Reduced
Thick, watery or
dyspeptic
Often multiple
Oliguria
First is high (over
1025), afterwards 1010
and less
Management of Dehydration
Oral rehydration is effective in case of I-II st. of dehydration in 80-95%.
It is performed in 2 stages by glucose-saline fluids:
І — water-saline deficiency liquidation for the first 4-6 hours after hospitalization (50
ml/kg).
ІІ — maintenance therapy of the fluid loss (80-100 ml/kg for 6-8 hours).
Oral intakes should be small –– 0.5-1 tea spoon every 5-10 minutes. water and saline
fluids correlation is 1:1, in neonates –– 2:1.
Body
weight, kg
5
10
15
20
25
The Volume of Rehydration Fluids on the First Stage of Rehydration
The amount of solutions in case of dehydration
І st. per 1 hour
І st. per 6 hours
ІI st. per 1 hour
ІI st. per 6 hours
42
250
66
400
83
500
133
800
125
750
200
1200
167
1000
266
1600
208
1250
333
2000
Adequate rehydration criterions:
 Improvement of the clinical status;
 Progressive decreasing of dehydration;
Peroral rehydration should be stopped when it is ineffective, edema, oliguria develop.
Parenteral rehydration should be performed in case of:
 Severe dehydration with hypovolemic shock;
 Toxic shock syndrome;
 Combination of exicosis with hard intoxication;
 Oliguria, anuria;
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 Nonstop vomiting;
 Ineffective peroral rehydration during one day.
Solutions for rehydration should be input in 2 days: 2/3 during the first day, 1/3 –– during
the second. From the third day – supporting of the hydration.
Accounting of the Fluids for Rehydration (in ml) per 1 kg of the Body Weight (by Dennis)
Dehydration stage
Fluid deficit , %
Before 1 year old
1-5 years 6-10 years
5%
130-150
100-125
75-100
І
5-10 %
170-200
130-170
100-110
ІІ
> 10%
200-230
170-200
110-150
ІІІ
Correlation of IV fluids (water to saline):
 In case of isotonic dehydration –– 1:1;
 In case of hypertonic dehydration –– 2:1 or 3:1;
 In case of hypotonic dehydration –– 1:2.
Start fluids:
 In case of hypertonic dehydration –– 5 % glucose;
 In case of hypotonic dehydration –– 0,9 % NaCl;
 In case of isotonic dehydration –– 10 % glucose.
In case of nonstop vomiting during 4-6 hours fluids should be intake only
parenterally, its’ amount may be 70-80 % of need. The speed of the infusion is: 25 drops
per minute during first hour, 20 drops per minute during second hour, then –– 10-15 drops
per minute.
Correction of the electrolytes:
 Na, Cl deficit – by 0,9 % NaCl not more 100 ml/kg,
 К deficit – 4 % KCl 2-5 ml/kg, or 1-2 ml/kg 7,5 % KCl(1 ml of which is adequate to 1
mmol/l К)
 Mg deficit – 25 % MgSO4 0,75-1,0 ml/kg.
Correction of the toxicosis:
 Oral rehydration in case of toxicosis and exicosis I and II st.;
 Lytic suspension 0,1 ml/kg, seduxen 0,3 mg/kg, prednisone 2-3 mg/kg, dehydration –
lasix 1-2 mg/kg (in case of neurotoxicosis);
 Infusion therapy (toxicosis and exicosis II and III st.);
 hormones IV 5-20 mg/kg per day in 2-4 takes (by prednisone), albumin 5-15 ml/kg,
rheopolyglucin 10-20 ml/kg, trental 0,1-0,2 ml/kg, contrical 1000 U/ kg, heparin 100200 U/ kg (toxic shock syndrome);
 hemodyalis (in case of HUS).
Etiotrope treatment for 5-7 days: – for mild forms – without antibiotics, but furazolidon
10 mg/kg day in 4 doses, or ercefuril (niphuroxazide) may be used; for moderate, severe
(nosocomial) cases – Cefotaxim 100-150 mg/kg/day, Ceftriaxon 100mg/kg/day, or
ciprophloxacin 10-20 mg/kg per day in 2 equal doses. Specific bactheriophage: Children
before 6 months – 10 ml per day; 6 months – 36 months – 20 ml; older than 36 months –
50 ml 5-7 days.
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Pathogenetical therapy: - probiotics for 2-3weeks; enterosorption during 5-7 days; diet;
enzymes.
Symptomatic therapy: antipyretics, multivitamins.
Prophylaxis of acute bowel diseases:
- Epidemiological control.
- Isolation and sanation of ill person and carriers.
- Reconvalescent may be discharged from hospital after one negative feces culture (taken
2 days after stop of antibiotic therapy).
- Dispensarisation of reconvalescents for 3 months.
- Feces culture in contacts, carriers.
- Looking after contacts for 7 days without quarantine.
- Disinfection in epidemic focus.
Tests and assignments for self-assessment
Choose the correct answer / statement:
1. In a child, 3 months old, has appeared the dyspepsia in the manner of the repeated
vomiting, right after the meal, and often (12 times per day) defecation. The Child during
examination is wilted, moveless, big fontanel is sunken, skin is pale with marble tone,
mucous membranes are dry, bright, and oliguria is present. Feces are liquid, bright-yellow
with large amount of water. What infection is possible?
А. Cholera
B. Shigellosis
C. Salmonellosis
D. Escherichiosis
E. Iersiniosis
2. The child, 3 years old, is treated in infectious department because of acute Shigellosis.
During objective examination: the body temperature is 39.9 ºС, skin is pale, dry, periodic
tonic twitches of the muscles, limbs are cool, abdomen is sealed, sensitive in left inguinal
region, anus is open. Name the diagnose.
А. Shigellosis typical form, moderate degree.
B. Shigellosis, atypical form.
C. Shigellosis typical form, severe degree.
D. Shigellosis typical form, severe degree with prevalence of toxicosis.
E. Shigellosis typical form, severe degree with prevalence of the local
manifestations.
3. The child, 10 days old, has entered to the infectious department with mother’s
complaints of increasing of the temperature to 38.7 ºС, repeated vomiting, porridgeconsistence feces with green mucus to 5 times per day. He was born from the first in time
pregnancy, was discharged from maternal house on the 6th day with dry umbilical wound.
There were some episodes of Salmonellosis in the maternal house. The skin is pale, nasal
breathing is free, in lungs - puerile. The heart tones are dull, 146 per minute. The abdomen
is distended; the liver emerges from beneath rib on 3 cm, spleen - on 1 cm. In 3 days in the
child was diagnosed purulent arthritis.
What is the most possible diagnosis?
A. Salmonellosis, gastrointestinal form.
B. Salmonellosis, typhoid form.
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С. Salmonellosis, septic form.
D. Salmonellosis, influenza-like form.
E. Salmonellosis, dysentery-like form.
4. In a child, 4 months old, suddenly has increased the temperature to 38.5 ºС. Later has
appeared frequent defecation near 15 times per day. Excrements are yellow-green, liquid
consistency, with mucus. During examination: skin is pale, lips are bright, dry. The child
has thirst. Big fontanel is 1.5х1.5 cm, sunken. Breathing is puerile, 42 per 1 minute. Heart
tones are loud, rhythmic, 148 per 1 minute. The abdomen is mildly distended, painful.
Salmonellas are found in excrements. Biochemical blood analyses: Nа - 163 mmol/l, K 5.7 mmol/l. What type of dehydration is possible?
A. Isotonic.
B. Hypotonic.
С. Salt deficient.
D. Hypertonic.
E. Dehydration is absent.
5. The child, 7 months old, is treated in infectious department because of Salmonellosis,
gastrointestinal form, moderate gravity, toxicosis with exicosis II degree, caused
Salmonellae enteritidis. What percent of weight loss is probable in this case?
A. 1-3 %.
B. 3-6 %.
С. Less than 5 %.
D. 10-15 %.
E. 5-10 %.
Answers for the self-control :
Tests: 1-D. 2-D. 3-C. 4-D.5-D.
Aids and material tools: Charts “Acute bowel infections”, “Toxicosis with exicosis”.
Student’s practical activities:
I. Curation of patients with acute bowel infections in children infectious department.
1. Ask complaints, anamnesis and life history.
2. Examine the patients; find clinical features of acute bowel infection, toxicosis and
exicosis.
3. Prescribe laboratory investigations to prove the diagnose.
II. To perform the diagnosis:
1. Make previous diagnose due to complaints, disease history, epidemiological
anamnesis, clinical objective features.
2. Make complete diagnose due to previous diagnose, laboratory dates, differential
diagnosis.
III Provide the treatment (diet, medicine) depending on patient’s age, severity of the
disease.
IV Prescribe measures in the focus of infection, prevention of the disease.
V Clinical analyzing of the case.
Students must know:
1. Etiology, pathogenesis of toxicosis with exicosis.
2. Classification of toxicosis with exicosis.
3. Diagnostic criterions of different types of toxicosis with exicosis.
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4. Differential diagnosis of toxicosis with exicosis between neurotoxicosis.
5. Prehospital and hospital treatment of toxicosis with exicosis, prognosis and
prophylaxis.
Student should be able to
1. Find diagnostic clinical criterions of toxicosis with exicosis during examination of
patients.
2. To perform differential diagnosis among diseases which have the same clinical features.
3. To perform prehospital and hospital treatment of children in case of toxicosis with
exicosis.
4. To prescribe measures in the focus of infection.
References:
1. Ambulatory pediatric care\ edited by Robert A. Derchewitz;-2- nd ed. Lippincot-Raven,
1992. – p. 404-411
2. Current therapy in pediatric infections disease-2\ edited by D.Nelson, M.D.-B.C.Decker
Inc. Toronto. Philadelphia, 1988. – P. 80-81,
Additional:
1. Textbook of Pediatric Nursing. Dorothy R. Marlow; R. N., Ed. D. –London, 1989.661p.
2. Pediatrics ( 2nd edition, editor – Paul H.Dworkin, M.D.) – 1992. – 550 pp.
Prepared by I.L.Goryshna
Adopted at the chair sitting 26.02.04
Minutes No 7
Revised at the chair sitting
Minutes No 1 August 29, 2006.
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