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Gastroenteritis: Diarrhea & Dehydration

Jennifer Bergquist, M.D. July 20, 2005

Definition
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Gastroenteritis: Acute inflammation of the lining of the stomach/intestines
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Anorexia, nausea, vomiting, diarrhea, abd pain (hallmark is diarrhea)

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Acute diarrhea: (<14 days)
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>10ml/kg/d in infants/children (frequency) Watery, loose stools at least 3 times in 24hrs (consistency)

Epidemiology ‡ Diarrheal disease and dehydration account for 1/3 of all deaths among infants and children under the age of 5 (worldwide) 1.S. In developing countries.S. 200.estimated 2 million deaths annually in children under 5 ‡ ‡ ‡ .5 million ED visits per year in the U.000 hospitalizations and 300 deaths per year in the U.

Cryptosporidium Associated with outbreaks in day care centers Chronic clinical course .Etiology ‡ Viral: 80% of all cases of gastroenteritis „ „ Rotavirus. Shilgella. Salmonella. calicivirus.coli*. astrovirus ‡ Bacterial: „ ‡ Campylobacter jejuni. Yersinia.1/3 of all gastroenteritis hospitalizations Others: Adenovirus (40/41). Vibrio Cholera* *major causes of travelers diarrhea ‡ Parasitic „ ‡ ‡ Giardia. Norwalk. E.

appendicitis* IBD. IBS Congenital adrenal hyperplasia. toxins. Hirschsprung disease*. lactase deficiency. UTI. CF. pneumonia. meningitis. hyperthyroidism Antibiotic-associated diarrhea. overfeeding GI (anatomic) GI (functional) „ ‡ ‡ ‡ Endocrine „ „ Misc. partial bowel obstruction*. sepsis.Diarrhea: Differential Diagnosis ‡ ‡ ‡ Gastroenteritis (see previous slide) Other infections „ „ OM. HIV Intussusception*. celiac. * Life-threatening conditions that should be considered during an evaluation of a child with diarrhea .

Pathophysiology ‡ Viral Invasion of enterocytes causing inflammation and cell lysis „ Total gut infection within 24hrs ‡ Immature cells repopulate the villi which have decreased absorptive capacity (decreased enzyme activity) leading to diarrhea Stimulation of water and electrolyte secretion ‡ .

Diagnosis of Gastroenteritis ‡ ‡ Clinical diagnosis Stool studies rarely indicated „ „ „ Stool culture if +bloody diarrhea or recent travel history ‡ Bacteria present in only 15-20% of these cases C. adenovirus) indicated for admission to the hospital (infection control) ‡ Consider UA/Urine Cx <12mo w/ fever and diarrhea to r/o UTI . Difficile if recently on antibiotics or prolonged hospitalization Viral studies (rotavirus.

vomiting) Skin (eg. fever.Dehydration ‡ Volume depletion or dehydration occurs when fluid is lost from the extracellular space at a rate that exceeds intake. glucosuria. The most common sites for extracellular fluid loss are: „ „ „ ‡ Gastrointestinal tract (eg. diabetes insipidus) . burns) Urine (eg. diarrhea. diuretic therapy.

Dehydration ‡ Infants w/ diarrhea are at increased risk for dehydration for the following reasons: „ „ „ Higher body surface area-to-volume ratio when compared to older children or adults Higher metabolic rate Dependent on others for fluid .

Dehydration: Severity Assessment ‡ Clinical diagnosis: „ „ „ Mild (3-5%) ‡ Moderate (6-9%) Severe (>10%) Clinical signs are usually not evident until ~3-4% dehydration ‡ Pre-illness weight to determine degree of dehydration is ideal but usually not realistic Determined by examiner and is based on clinical signs/symptoms Prospective study w/ 137 pts using 4 item dehydration scale (gen appearance. tears). mucous membranes. Sensitivity to predict dehydration: „ „ „ ‡ ‡ Mild dehydration: 74% Moderate dehydration: 33% Severe dehydration: 70% . eyes.

Physical Exam: Severity Assessment .

Is this child dehydrated? JAMA 2004. A value below 17 meq/L differentiated children with moderate and severe hypovolemia from those with mild hypovolemia . 291) „ Most useful signs for predicting 5% dehydration: ‡ ‡ ‡ Capillary refill Skin turgor Respiratory pattern „ Combinations of signs are markedly better than any individual sign in predicting dehydration Laboratory tests have only modest utility for assessing dehydration ‡ „ bicarbonate was the most useful laboratory test. et al.Literature Review ‡ Systematic review of the literature (Steiner.

291) .Diagnostic Studies ‡ Laboratory studies: No gold standard for “confirming” dehydration BMP indicated in pt with moderate to severe dehydration requiring IVF therapy Urinalysis for urine specific gravity? „ ‡ ‡ Not found to be significantly correlated with dehydration (Steiner. et al. Is this child dehydrated? JAMA 2004.

lactic acidosis from decreased tissue perfusion and decreased acid excretion from decreased renal perfusion ‡ BUN/Cr: normal or high „ May be elevated secondary to decreased renal perfusion (BUN will increase before Cr due to incr. However. low. absorption of urea with Na and H20) . may be higher than expected if acidosis is present ‡ Bicarbonate: low or normal „ Metabolic acidosis occurs from: loss of bicarbonate in stool. but usually normal „ Degree of dehydration can be underestimated in hypernatremic dehydration ‡ Potassium: low or normal „ Loss of potassium in stool can lead to hypokalemia.Electrolyte abnormalities ‡ Sodium: high.

7kg Estimated fluid deficit is 700ml to be replaced over 3-4 hours. . bone. etc…) „ „ 1 Liter = 1 Kg. severe) Estimate the fluid deficit: „ „ ‡ 10kg child. moderate.07 X 10 = 0.7kg ‡ Acute wt loss from diarrhea is due to water loss (not fat.Treatment Calculation of Deficits ‡ Estimate the degree to which the child is dehydrated (mild. estimated at 7% dehydration Calculate weight loss: . therefore 700ml = 0.

.Treatment: How do I replace the fluid? Oral Rehydration Therapy is recommended by the AAP as: "the preferred treatment of fluid and electrolyte losses caused by diarrhea in children with mild to moderate dehydration".

e glucose) . which is reduced to <100ml/day of formed stool due to a large capacity to absorb water. Water absorption is passive and depends on the osmotic gradient created by sodium/carbohydrate transport ‡ ‡ ‡ „ Na/H exchangers Electrochemical gradient (Na/K ATPase) Sodium-coupled transport with carrier solutes (i.Oral Rehydration Therapy (ORT) ‡ Physiologic Basis: „ Intestine “sees” 6500ml/fluid/day.

Oral Rehydration Solutions .

ORT: Rehydration Phase ‡ Rapid replacement of fluid deficit over 3-4 hours Begin at 5ml Q5min and increase as tolerated Mild (3-5%): 50ml/kg ORS over 4hrs Moderate (6-9%): 100ml/kg ORS over 4hrs ‡ ‡ ‡ .

ORT: Maintenance Phase ‡ ‡ Maintain maintenance fluid requirements *Rapid realimentation w/ age appropriate unrestricted diet „ „ Continued feeding slows the progression of dehydration by adding to overall available fluids and promotes mucosal recovery and improves fluid absorption Use of diluted or special formulas is unjustified ‡ Ongoing Losses: „ „ Replace 1cc per cc stool loss OR… 10ml/kg per stool and/or 2ml/kg per emesis .

e short gut. intervention with IVF is indicated: „ „ If there is severe and persistent vomiting.Limitations to ORT ‡ ORT should NOT be used when: „ „ „ Altered mental status with concern for aspiration Abdominal Ileus Underlying disorder that limits intestinal absorption of ORT (i. and inadequate intake of ORS If stool output continues to be excessive. and ORT is unable to adequately rehydrate the child. malabsorption) ‡ Once ORT has been initiated. .

IV Rehydration ‡ Enteral Rehydration for mild and moderate dehydration has been shown to have: „ „ „ „ Fewer side effects Lower cost Shorter treatment times Fewer admissions .Enteral vs.

9NS or LR using 20-60ml/kg over 1-3hrs. followed by introduction of ORS This approach should ONLY be used in pts w/ routine gastroenteritis w/out complicating factors (CHF. etc) . DKA.IVF Rehydration ‡ Indicated for severe dehydration or moderate dehydrated pt failing ORT “Rapid” rehydration approach: „ ‡ „ Rapid IV replacement with 0. increased ICP. renal disease.

1= 1.2kg= 1.IVF Rehydration ‡ Standard IVF Therapy w/Replacement over 24hrs „ Initial fluid resuscitation: 20ml/kg bolus w/ normal saline or LR „ Determine fluid deficit: ‡ ‡ ‡ Example: 12kg patient with estimated 10% dehydration Weight loss= 12 X 0.2L or 1200ml fluid deficit to replace over 24hrs „ „ „ Replace first ½ (600ml) over first 8hrs Replace second ½ (600ml) over next 16hrs Remember to replace ongoing losses .2kg 1.

cholera. Shigella. loperamide) „ „ Slows intestinal transit time Side Effects: Ileus.e. abdominal distention. sedation ‡ Bismuth salts (i.Medications: Generally NOT indicated ‡ Anti-emetics „ „ Generally not used in pediatrics secondary to high side-effect profile Ondansetron has been found to be safe and effective in decreasing vomiting and need for admission ‡ Antidiarrheal agents (i. pepto-bismol) „ „ ? Prevention of attachment of microorganisms to the intestinal mucosa Pediatric dosing no longer on labels due to concerns of salicylate toxicity and/or Reye syndrome ‡ Antimicrobials „ „ Exceptions: Giardia. ETEC Can prolong carrier state in some infections ‡ Probiotics (Lactobacillus GG)? .e. amoebiasis.

Pediatrics in Review 2002. Pediatrics in Review 2001. JH.References: ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Behrman: Nelson Textbook of Pediatrics.33:S31-S33.35:S143-S150 Farthing. KB. Pediatric Emergency Medicine Practice. Hoekstra.1(5):1-17 King CK. MMWR Recomm Rep 2003. Hepatology and Nutrition. Bresee J.34:S64-S67. MA. . Oral Rehydration: An Evolving Solution. Fasano A. Is this child dehydrated? JAMA 2004. Infectious Diarrhea in Children: Working Group Report of First World Congress of Pediatric Gastroenterology. Guandalini S.23(8)277-282. 2004. Dehydration in Infancy and Childhood. Fluid and Electrolytes: Parental Fluid Therapy. Deficit Therapy: 245-251 Davidson G. Fontaine O. and nutritional therapy. Barnes G. maintenance. 17th ed. Byerley JS. Oral rehydration. Hostetler. Acute Gastroenteritis in Industrialized Countries: Compliance with Guidelines for Treatment. Gastroenteritis: An Evidence-Based Approach to Typical Vomiting. Diarrhea and Dehydration.291(22):2746-2754. 2004. JPGN 2002. JPGN 2001. L. Bass D.22(11):380-387 Steiner MJ. MJ. Managing Acute Gastroenteritis Among Children. Duggan C.52(RR-16):1-14 Roberts. Glass R. Cohen M. JPGN 2002. Findberg. Dewalt DA.