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Diarrhea is defined as an increase in the: Fluidity Volume Number relative to the usual habits of each individual.

(Essential element is the increased Fluidity= loose stools)

‡ Children can have acute and chronic forms of diarrhea: ‡ Acute diarrhea may be in the form of:
± Acute watery diarrhea. ± Dysentery. ± Persistent diarrhea

10 10

80 Acute Watery Dysentery Persistent

‡ Chronic diarrhea.

‡ Passage of frequent loose or water stools without visible blood. ‡ Constitutes % of cases of diarrhea ‡ Begins acutel (abruptl ) ‡ Lasts less than 14 days (usuall < 7 da s) ‡ Ma be accompanied b :
± Flatulence, bdominal pain and cramps ± Nausea and Vomiting ± Fever

Infectious diarrhea

Non infectious diarrhea
Drug-induced Antibiotic-associated Laxatives Antacids that contain magnesium Food allergies or intolerances Cow's milk protein allergy Soy protein allergy Nutrients digestive/absorptive processes Surgical conditions Dietary practices

y Gastrointestinal infections:
1-Viral 2. Bacteria 3-Protozoa

Extraintestinal infections
Otitis media Urinary tract infections Pneumonia

‡The most common pathogens causing diarrhea are :

Rotavirus ( 5-25%)

Enterotoxigenic Escherichia coli -2 %

Shigella 5- 5%

Camp lobacter jejuni - 5%

Secretor diarrhea

Osmotic diarrhea

Motilit -related iarrhea

Inflammator diarrhea

oMaldigestion o Osmotic laxatives o Lactose intolerance o Fructose malabsorption

water is drawn into the bowels

Intestinal Physiology

NET ABSORPTION

Pathogenesis of Secretory Diarrhea

X

Impaired absorption of Na

NET SECRETION

Cl , HCO3

++++

+++++

Motilit -related iarrhea
food moves too quickl through the GI tract not enough time for sufficient nutrients and water to be absorbed

Inflammator diarrhea damage to the mucosal lining or brush border a passive loss of protein-rich fluids , and a decreased abilit to absorb these lost fluids It can be caused by:bacterial infection viral infection parasitic infections autoimmune problems such as inflammatory bowel diseases

s in :vagotom diabetic neuropath , acomplication of menstruation. H perth roidism

I)

eh dration

Dehydration is caused by the loss of water and electrolytes in the liquid stool and vomitus.
The Clinical signs of dehydration are the result of 2 important factors:

. egree of deh dration: Mild, Moderate or Severe

2. T pe of deh dration: Isotonic,Hypertonicor Hypotonic

I.
‡

egree of deh dration:
No deh dration (or No signs of deh dration): eight loss <5%) of bod weight accompanied b an signs or s mptoms of deh dration. Some (or moderate) deh dration: eight loss 5- % of bod weight (average 7.5%). Severe deh dration: eight loss > %of bod weight.

‡ ‡

II. T pe of deh dration:
Isotonic (Isonatremic)
Prevalence Losses Plasma Osmolarit (mOsm/L) Serum Sodium (mEq/L) ECF volume ICF volume Thirst Loss of skin turgor Seizures Mental state Shock

H pertonic (H pernatremic

H potonic
(H ponatrmic)

>75% Water = Sodium 275 - 295 130-150

10-15% Water > Sodium >295 >150

5-10% Water <Sodium <275 <130

Maintained ++ ++ In severe cases Irritable/ lethargic In severe cases ++++ Not lost Common Very irritable Uncommon +/+++ Uncommon Lethargy/ Coma Common

II) H pokalemia: III) Base-deficit acidosis (metabolic acidosis):
Mechanisms: ‡ Loss of large amount of bicarbonate in stools. ‡ Excessive lactic acid production when patient is in a state of shock. ‡ Formation of inorganic acids in bowel from incomplete breakdown of carbohydrates.

H penatremic or h ponatremic deh dration: Post-acidotic tetan :
cidosis
Ca++

fter correction of acidosis

h pocalcaemia

tetan Ca++

CNS complications:
convulsions

Gastrointestinal complications
‡ Secondar carboh drate malabsorption or intolerance. ‡ Protein intolerance and protein losing enteropath . ‡ Persistent diarrhea. ‡ Intestinal perforation ‡ Pseudo-membranous colitis

toxic mega-colon

Nutritional complications:

Cardiovascular complications:
‡ Shock ‡ Phlebitis and thrombosis ‡ Pulmonar edema

Renal complications:
‡ Pre-renal failure ‡ Renal vein thrombosis ‡ DIC

‡ Histor Taking: ‡ sk:
Does the child have diarrhea? ( ccording to definition of diarrhea). Duration of diarrhea: For how long? Diarrhea which lasts 4 da s or more is persistent diarrhea. Consistenc , frequenc and volume of stools. Presence of mucus and blood in stools (blood and mucus in the stools, with associated fever, suggest an invasive organism). Presence of fever, vomiting, convulsions or other problems (e.g. cough, discharging ear, etc). Frequenc of vomiting and color of vomitus (coffee ground vomitus occurs in DIC). T pe and quantit of fluids, milk and food consumed during the illness. Drugs received.

‡ Nutritional histor ‡ Vaccination histor ‡ Past history of similar attacks ‡ Famil histor

‡ Clinical examination:
General look: Vital signs: ‡ Pulse:
Exclude signs of shock: rapid, weak pulse (with cold cyanotic extremities).

‡ Blood pressure:
Hypotension may be present in severe cases. ‡ Temperature: fever due to the infection and dehydration.

‡ Respiratory rate:
‡ Rapid deep breathing (in acidosis). ‡ Rapid shallow (if there is associated pneumonia).

Anthropometric measurements: Head and Neck: Extremities:

Skin: Chest: 
Exclude pneumonia.

Abdomen: 
Abdominal distension with diminished peristalsis (most probably due to hypokalemia or toxic ileus).

CNS 
Exclude meningitis

Checking signs of deh dration.

Assessment of deh dration :-

SIGNS

G General E S

condition Eyes

No signs of dehydration well, alert normal

Some (mod.) Severe dehydration dehydration restless, lethargic, irritable unconscious sunken sunken

Mouth & normal thirsty, drink poor or unaDrinking eagerly ble to drink Skin pinch returns rapidly returns slowly very slowly

Always start from Red Column
2 or more signs in 1 column indicate that the child falls in that column

1-Fluid therap : prevent & correct deh dration. 2-Feeding: during & after diarrhea. 3-Zinc supplementation. 4-Treatment of possible causes. 5-Treatment of complications.

1-Fluid therap : Home based fluids
ORAL REHYDRATION SOLUTION (ORS)

Feeding during diarrhea:
Continue breast feeding as usual during and after rehydration therapy. Continue same ³normal´ formula and same ³normal´ concentration AFTER rehydration

Children on Mixed Diet
Continue normal feeding as usual

treatme nt
Where given?

planA (no signs of deh dration) At home

plan B ( some deh dration ) Outpatient reh dration center

plan C (severe deh dration) hospital I.V. Fluids: Pansol , Pol electrol te, Ringer lactate, Normal saline Zinc s rup (whenever the child can drink) 100ml/kg bod wt. in3-6 hours 1st 30ml/kg:in1/2-1hr Next 70ml/kg:in 2.5-5hrs

1-Fluid therapy What type?

MORE FLUIDS: ORS HOME MADE , Zinc ORS, BREAST supplementation MILK , PLAIN CLEAN ATER ZINC SUPPLEMENTATIO N after each loose stool <2 :50-100 ml >2 :100-200ml 75ml/kg bod weight in 4-6 hours

How much?

Zinc supplementation
< 6 mo : 10mg/d > 6mo: 20mg/d
For 14 days

Treatment of possible causes Antibiotics Antiparasitics Ant emetics Ant motilit Adsorbents Consultations

‡ Treatment of complications ‡ Probiotics
Probioict bacteria pathogens intestinal epithelium

Bind and neutralize toxins in the gut lumen or interfere with the adherence of pathogens (white) to the intestinal epithelium.

How given? Slowl (1spoon/1-2 min)
,ORALLY.

Slowly(1spoon/1- INTRAVE 2 min),ORALLY NOUSLY or NGT

2-Feeding

Breast feeding: never stop even during initial rehydration. Milk pr milk formula: usual formula used to feed the child, in normal conc. (after rehydration). Soft &semisolid weaning food: after rehydration in children >4 months old. AVOID HYPEROSMOLAR FOODS OR FOOD WITH HIGH FIBER CONTENT. Advise the mother to come back if: Baby not able to drink or breast feed Becomes sicker or no improvement Develops fever Blood in stools Repeated vomiting Increased thirst Reassess the patient condition if: No signs of dehydration : shift to plan A Some dehydration: shift to plan B Severe dehydration: repeat plan C

3-Further assessment and follow up

is defined as diarrhea with visible blood in stools.

1) 2) 3) 4) 5)

The most important and most frequent cause of acute dysentery is Shigella, Campylobacter jejuni Salmonella Escherichia coli (Enteroinvasive, Enterohemorrhagic) Entamoeba histolytica

‡ 10% of all diarrheal episodes in children under 5 years ‡ 15% of all deaths ‡

Mainl Clinical Lab ?

especially when the cause is Shigella intestinal perforation, toxic mega colon rectal prolapse

convulsions (with or without a high fever), septicaemia, hemolytic- uraemic syndrome prolonged hyponatremia. weight loss and rapid worsening of nutritional status

Antimicrobials. Fluids. Feeding. Follow-up.

Episodes of diarrhea lasting for more than 14 days

Malnutrition Recent introduction of animal milk or formula Young age Immunological impairment Recent diarrhea

Patholog
Normal intestinal epithelium

‡

Cell borders are not well visible and a bacilliform microorganism is seen tightly adhering to the epithelial surface surrounded by particles of mucus.
Enterocytes are distorted in appearance and microvilli are shortened in height.

Stool microscopy Stool culture and sensitivity Stool PH

1) Fluid therap 2) Appropriate antibiotics or anti parasitic 3) Nutritional therap

‡ Diarrhea that lasts for more than 2 weeks ‡ for someone who has a weak immune system, chronic diarrhea may represent a life-threatening illness.

ADOLESCENT INFANT CHILD

I. Intraluminal factors

Johansson-Blizzard syndrome

2.Mucosal factors

Crohn's disease Ulcerative colitis

Celiac disease

The history:
The family history The age of onset The mode of onset The dietary history Growth and developmental history The history of repeated infections history of previous abdominal surgery The type of diarrhea

The Ph sical Examination:
periorificial skin lesions acroder-matitis enteropathica Peripheral edema protein-losing enteropathy or severe malnutrition Clubbing of the fingers chronic conditions (cystic fibrosis or inflammatory bowel diseases ). Retinitis pigmentosa and ataxia abetalipoproteinemia

The Laborator Investigations positive occult blood low stool pH, positive fat globules and positivereducing substances peripheral eosinophilia serum protein and albumin cholesterol and triglycerides blood zinc blood level sweat chloride test rectosigmoidoscopy or colonoscopy and histopathology