Gastrointestinal (GI) Disorders

Diarrhea

It is estimated that 500 million children worldwide suffer with diarrhea each year.
Approximately 20% of all deaths in children living in developing countries are related to
diarrhea and dehydration. For general practical purposes, diarrhea is usually classified as
acute or chronic. Acute diarrhea is a leading cause of illness in children younger than 5
years of age; each year, the dehydration it causes is fatal for approximately 300 of these
children in the United States.

Most cases of acute diarrhea are caused by infectious agents, including viral, bacterial,
and parasitic pathogens.

Chronic diarrhea is usually caused by conditions such as malabsorption syndromes,

inflammatory bowel disease, immune deficiency food allergy, lactose intolerance, and
chronic, nonspecific diarrhea. I may also be a result of inadequate management of acute
infectious diarrhea.

Diarrhea is difficult to define because stool frequency and consistency vary among
individuals. Generally, diarrhea is present when there is an increase in stool frequency
with an increased water content. Diarrhea varies in relation to its severity, duration,
associated symptoms, the age of the child, and the child’s nutritional status.

Pathophysiology

Diarrhea is caused by abnormal intestinal water and electrolyte transport. The transport
of fluid and electrolytes in the developing GI tract is related to the child’s age. The
intestinal mucosa of the young infant is more permeable to water than that of an older
child. Therefore in young infants with increased intestinal luminal osmolality due to
diarrhea, more fluid and electrolytes are lost than in older children. Diarrhea results from
several pathophysiologic processes.

Secretory diarrhea is generally due to bacterial enterotoxins that stimulate fluid and
electrolyte secretion from the mucosal crypt cell, the principal secretory cells of the small
intestine. Cytotoxic diarrhea is characterized by viral destruction of the mucosal cells of
the villi of the small intestine. This results in a smaller intestinal surface area, with a
decreased capacity for fluid and electrolyte absorption. Osmotic diarrhea is commonly
seen in malabsorption syndromes, such as lactose intolerance, because the intestine
cannot absorb nutrients or electrolytes. Dysenteric diarrhea is associated with an
inflammation of the mucosa and submucosa in the ileum and colon caused by infectious
agents such as Campylobacter, Salmonella, or Shigella. Edema, mucosal bleeding and
leukocyte infiltration occur.
 Consequences of Diarrhea
DEHYDRATION
Voluminous losses of fluid in frequent, watery stools
Losses when there is also vomiting
Reduced fluid intake resulting from nausea or anorexia
Increased insensible losses from fever, hyperpnea and, sometimes, high environmental
temperature
Continued (although diminished) obligatory renal losses

ELECTROLYTE IMBALANCE
Losses of sodium, chloride, potassium and, in some cases, bicarbonate
Inadequate replacement of electrolytes when hypotonic or hypertonic solutions are used

METABOLIC ACIDOSIS
Increased absorption of short-chain fatty acids produced in the colon from bacterial
fermentation of unabsorbed dietary carbohydrates
Accumulation of lactic acid from tissue hypoxia secondary to hypovolemia
Loss of bicarbonate in stools
Ketosis from fat metabolism when glycogen stores are depleted in untreated diarrheal
dehydration or inadequate carbohydrate intake; may result in malnutrition.

Acute Diarrheal Disease

Acute diarrhea, a sudden increase in frequency and a change in the GI tract. It may also
be associated with upper respiratory or urinary tract infections. Antibiotic therapy or
laxative use can also lead to acute diarrhea in children. Acute diarrhea is usually sel-
limited (less than 14 days’ duration) and ultimately subsides without specific treatment if
dehydration does not create a serious complication.

Acute infectious diarrhea (infectious gastroenteritis) is caused by a wide variety of

viral, bacterial, and parasitic pathogens. Infants and young children are at a high risk for
the development of dehydration and malnutrition – the two major consequences of
diarrhea.

Etiology

Most pathogens that cause diarrhea are spread by the fecaloral route through
contaminated food or water, or they are spread from person to person, especially where
there is close contact (e.g. daycare centers). Living conditions play a role in infectious
diarrhea. Lack of clean water crowding, poor hygiene, nutritional deficiency, and poor
sanitation are major risk factors, especially for bacterial or parasitic pathogens. The
increased frequency and severity of diarrheal disease in infants is also related to age-

2
specific alterations in susceptibility to pathogens. The immune system of infants has not
previously been exposed to many pathogens and has not acquired protective antibodies.

In the United States, rotavirus is the most common pathogen identified in young children
who are hospitalized for diarrhea and dehydration; each year it accounts for up to 55,000
hospitalization and causes 20 to 40 deaths (Glass and others, 1996, Guarino and others,
1994). In addition, rotavirus is a significant nosocomial (hospital-acquired) pathogen.
Salmonella, Shigella, and Campylobacter are the most commonly isolated bacterial
pathogens, and Giardia and Cryptoporidium are the parasites that most commonly
produce acute, infectious diarrhea.

Other Causes of Acute Diarrhea

In addition to enteropathogens, acute diarrhea in children may be associated with

respiratory and urinary tract infections. The mechanism for this is not clear, Ingestion of
laxatives will also produce acute diarrhea, and excessive ingestion of sorbitol and
fructose in common foods such as apple juice or in gum or candy can cause osmotic
dietary diarrhea from the poorly absorbed carbohydrate.

Antibiotics such as ampicillin, amoxicillin, penicillin, cephalothin, and cefaclor are

commonly associated with diarrhea. Antibiotics are though to cause diarrhea because
they alter the normal intestinal flora; the decreased colonic bacteria results in excessive
malabsorbed carbodydrate and osmotic diarrhea. Antibiotics can also lead to
colonization and toxin production by Celostridium difficile, which may cause diarrhea
and pseudomembranous colitis.

Clinical Manifestations

The severity of the diarrhea, including the frequency and consistency of stools, is variable
and depends on the individual and the etiologic agent. The most serious consequences of
acute diarrheal diseases are dehydration, electrolyte disturbances, and malnutrition.
Dehydration may be mild, moderate, or severe. Metabolic acidosis may be present with
severe diarrhea and dehydration. Malnutrition may contribute to the severity of the
diarrhea and may be a consequence of diarrheal disease due to decreased dietary intake,
malabsorption, and the catabolic response to infection. The infant’s metabolic rate is
higher than that of the adult, a difference that predisposes an infant to more rapid
depletion of nutritional reserves during periods of malabsorption or diminished intake.
Prolonged withholding of feeding or hypocaloric diets contribute to malnutrition in
diarrheal disease.

Diagnostic Evaluation

The history provides valuable information regarding the duration, severity associated
symptoms, and potential cause of diarrhea. A complete history should include present
drugs the child is taking, possible ingestions, family history, and recent travel history.
Specific questions include the onset and duration of diarrhea, presence of fever and other

3
symptoms, frequency of vomiting, frequency and character of the stool (e.g., watery,
bloody), urinary output, and the child’s dietary habits and recent food and fluid intake.

Extensive laboratory evaluation is not indicated in a child with uncomplicated diarrhea

and no evidence of dehydration. Laboratory tests are indicated when a child is
moderately to severely dehydrated. Stool specimens should be examined in all children
with diarrhea that persists for more than a few days.

Watery, explosive stools suggest sugar intolerance, and foul-smelling, greasy, bulky
stools suggest fat malabsorption. Diarrhea that develops after the introduction of cow’s
milk fruits, or cereals may be related to an enzyme deficiency or protein intolerance.
Neutrophilis or red blood cells in the stool indicate bacterial gastroenteritis or
inflammatory bowel disease. The presence of eosinophils suggests protein intolerance or
parasitic infection.

Cultures of the stool should be performed when blood or mucus is present in the stool,
when symptoms are severe, when there is a history of travel to a developing country, and
when polymorphonuclear leukocytes are found in the stool. An enzyme-linked
immunosorbent assay may be used to confirm the presence of rotavirus, and the stool
may be tested for the presence of C. difficile (“C. dif) toxin if there is a history of recent
antibiotic use. The stool may need to be examined for ova and parasites when bacterial
and viral cultures are negative and when diarrhea persists for more than a few days.

A stool pH of less than 6 and the presence of reducing substances may indicate the
presence of carbohydrate malabsorption or secondary lactase deficiency. Measurement
of stool electrolytes may help identify children with secretory diarrhea.

The urine specific gravity should be determined if dehydration is suspected. A complete

blood count, serum electrolytes, creatinine, and blood urea nitrogen (BUN) may also be
obtained in the child who appears dehydrated. The hemoglobin, hematocrit, creatinine,
and BUN are often elevated in acute diarrhea and should normalize with rehydration.

Therapeutic Management

Therapeutic management is directed at correcting the fluid and electrolyte imbalances

and preventing or treating malnutrition. The major goals in the management of acute
diarrhea include (1) assessment of the fluid and electrolyte imbalance, (2) rehydration, (3)
maintenance fluid therapy and (4) reintroduction of adequate diet. Infants and children
with acute diarrhea and dehydration should be treated first with oral rehydration therapy
(ORT). In cases of severe dehydration and shock, parenteral fluids may be necessary.
Early reintroduction of food is an important aspect of treating acute diarrhea in children.
Antimicrobial agents are indicated for a few specific pathogens.

ORT is one of the major worldwide health care advances of the past decade. ORT is
effective, safer, less painful, and less costly than intravenous rehydration. As a result of
studies conducted in the United States, the American Academy of Pediatrics, World

4
Health Organization, and Centers for Disease Control and Prevention recommend the use
of ORT as the treatment of choice for most cases of dehydration cause by diarrhea.

Nursing Alert – Diarrhea is not managed by encouraging intake of clear fluids by

mouth, such as fruits juices, carbonated soft drinks, and gelatin. These fluids
usually have a high carbohydrate content, a very low electrolyte content, and a high
osmolality. Caffeinated soda is avoided because caffeine is a mild diuretic and may
lead to increased loss of water and sodium. Chicken or beef broth is not given
because it contains excessive sodium and inadequate carbohydrate. A BRAT diet
(bananas, rice, apples, and toast or tea) is contraindicated for the child, and
especially for the infant, with acute diarrhea because this diet has little nutritional
value (low in energy and protein), is too high in carbohydrates, and is low in
electrolytes.

Early reintroduction of nutrients is desirable and is gaining more widespread acceptance.

Continued feeding or early reintroduction of a normal diet is beneficial because of an
improved nutritional outcome and because it may reduce the number of stools, reduce
weight loss, and shorten the duration of illness.

Infants who are breast-feeding should continue breast-feeding; ORSs should be used to
replace ongoing losses. Available evidence indicates that continued human milk feeding
during diarrheal illness results in reduced severity and duration of illness. Tolerance to
human milk may result from its low osmolality and its antimicrobial, enzymatic and
hormonal factors. Tolerance to human milk may result from its low osmolality and its
antimicrobial, enzymatic, and hormonal factors.

The use of nonhuman milk for infants and children with diarrhea remains controversial.
Cow’s milk and cow’s milk formulas are of concern because maldigestion of lactose can
occur in children with infectious diarrhea. Studies indicate that well-hydrated infants and
children may resume full-strength nonhuman milk feeding immediately without adverse
reactions. Many infants and children can be safely managed with a diet containing cow’s
milk. Some health care providers advocate the use of a lactose-free formula in infants
only if milk or regular formula is not tolerated.

For older children, a regular diet can generally be offered once rehydration has been
achieved. In toddlers, there is no contraindication to continuing soft or pureed foods of
all groups. A diet of easily digestible foods such as cereals, cooked vegetables, and
meats is adequate for the older child.

Intravenous fluids are required for severe dehydration and vomiting. A saline solution
containing 5% dextrose in water is usually administered. The initial volume should be 20
to 30 ml/kg and should be administered as a bolus. Therapy during the remainder of the
first 24 hours should be aimed at completely correcting the remaining fluid and sodium
deficits and replacing ongoing abnormal losses.

5
Enteric infections are generally self-limited conditions. Antimicrobial therapy is not
indicated in the majority of children with acute diarrhea and is not available for enteric
viruses. Specific antimicrobial therapy is indicated only for culture-proven bacterial or
parasitic infections in which this therapy can reduce the duration of the illness, the
severity of the symptoms, or the shedding and secondary spread of organisms.
Antibiotics may be warranted before culture results are available in the febrile, ill-looking
infant with dysenteric diarrhea (blood and polymorphonuclear cells in the stool).
Indiscriminate use of antibiotics may lead to pseudomembranous colitis.

Antidiarrheal drug therapy with agents such as loperamide (Imodium A-D), Kaopectate,
or Diasorb is not indicated in acute infectious diarrhea in infants and young children.
Toxicity and adverse side effects may occur, such as worsening of the diarrhea because
of showing of motility and ileus or a decrease in diarrhea with continuing fluid losses and
dehydration.

The treatment of antibiotic-associated diarrhea is discontinuation of the antibiotic if

possible and investigation for the presence of C. difficile. If laxatives or certain foods are
the cause of diarrhea, their use should be discontinued.