Gastroenteritis af völdum veira Geir Hirlekar Læknanemi

VIRAL GASTROENTERITIS Eftirtaldar veirur eru vel þekktar að valda gastroenteritis: Rotavirus Enteric adenoveirur Caliciviruses Astrovirus

Rotaveirur Fundust 1973 með EM Tvíþátta RNA veira Veiran lítur út eins og hjól í rafeindasmásjá

Faraldsfræði Algengast í nóvember til maí Hefur aðlega áhrif á ung börn en fullorðnir fá væg einkenni. < 4mán með humoral ónæmi frá móður 4mán – 2ára fá alvarlegan niðurgang og dehydration Incubation tími < 4 daga Rotavirus appears to be responsible for approximately 5%-10% of all diarrheal episodes among children aged less than 5 years in the United States, and for a much higher proportion of severe diarrheal episodes. Rotavirus is responsible for 30%-50% of all hospitalizations for diarrheal disease among children aged less than 5 years, and more than 50% of hospitalizations for diarrheal disease during the seasonal peaks. Among children aged less than 5 years in the United States, 72% of rotavirus hospitalizations occur during the first 2 years of life, and 90% occur by age 3 years.

Smitleiðir Smitast með fecal-oral. Smitandi áður en niðurgangurinn byrjar og í nokkra daga á eftir Getur einnig smitast með fæðu og vatni. Hugsanlega öndunarúða?

Pathophysiologia Sýkir þekjufrumur í smágirninu. Frumurnar brjóta niður carbohydröt og frásoga vökva og electrolyta.  Veirurnar trufla niðurbrot carbohydrata minna frásog vatns niðurgangur Aukið motility garnar vegna functional breytinga á villus þekjunni. Rotavirus, like other viruses that cause enteritis, primarily infects the cells of the small intestinal villi, especially those cells near the tips of the villi. Because these particular cells have a role in the digestion of carbohydrates and in the intestinal absorption of fluid and electrolytes, rotavirus infections lead to malabsorption by impaired hydrolysis of carbohydrates and excessive fluid loss from the intestine. A secretory component of the diarrhea is present, with increased motility further exacerbating the illness; this increased motility appears to be secondary to virus-induced functional changes at the villus epithelium. The pathologic changes to the intestinal lining may not correlate well with the clinical manifestations of the illness. In normal hosts, infections rarely occur in another organ system, although extraintestinal infections have been seen in immunocompromised hosts. The virus is shed in high titers in the stool starting before the onset of symptoms and persists for up to 10 days after symptom appearance.

Klíník 4 mán til 2 ára börn Hiti – 40% fá 39°C Ógleði og uppköst undanfari niðurgangs Vatnskenndur niðurgangur í 3-9 daga í heilbrigðum börnum. Börn verða hitalaus og hætta að kasta upp eftir 2-3 daga en hafa niðurgang í < 9 daga.

Kliník

Meta vökvastatus Einkenni dehydration eru ma þorsti, pirruð, munnþurrkur, sokkin augu, restlessness og lethargy. Fylgjast með þvagútskilnaði

Greining Hægðasýni sent í: Antigen leit í hægðum með ELISA Rafeindasmásjá PCR

Rautt flagg Er blóð eða hbk í hægðum ? Ónæmisbældir og malnourished einstaklingar Hætta á nectrotizerandi enterocolitis og hemorrhagic gastroenteritis í neonötum.

Stuðningsmeðferð Rehydration og leiðrétta electrolyta truflanir Alvarleg hypovolemia krefst isotinísk vökva hydrationar en nóg að gefa vel að drekka ef væg hypovolemía. Brjóstamjólk í rehydration fækkar tíðni, rúmmáli og tímalengd hægða Kúamjólk í lagi

Lyfjameðferð Almennt þarf gastroenteritis enga lyfjameðferð. Í sérstökum kringumstæðum, t.d. ónæmisbældum einstaklingum þá er hægt að gefa Ig til að flýta fyrir bata. In general, viral gastroenteritis is an acute and self-limited disease that does not require pharmacologic therapy

Fylgikvillar Hætta á sjokki vegna hypovolumemíu, hypoxíu og acidosu. Dauði oftast af völdum ónógrar dehydrationar. Skyndilega hyponatremía getur valdið myelinolysu og cerebral odem eða of hröð leiðrétting hyponatremíu. Immunocompromised patients can develop unremitting or fatal symptoms. Factors important for clearing viral infection include an intact cellular immune system and the presence of specific neutralizing antibody [46]. In special situations, administration of immunoglobulins enterically as milk, colostrum, or specific globulin preparations may facilitate clearance of the organism [47]. The specific antiviral antibody content in such preparations required for clinical efficacy is unknown. The efficacy of lactobacillus and similar organisms is under evaluation in this clinical setting [41]. Although rotavirus infection of the liver and kidney has been documented in a few immunocompromised children, the clinical significance of this finding is unknown [48]. When to refer — The decision to refer the patient to the Emergency Department will be guided by the practitioner's experience with the treatment of severe dehydration and metabolic imbalance. There are no absolute indications for referral. Consultation should be considered for any child with viral gastroenteritis who has multisystem compromise, does not respond to therapy as expected, has multiple episodes of illness, has an underlying immunodeficiency, or has an underlying disease complicating the treatment or course of the illness (show table 1). Situations in which referral is warranted include: Prolonged (more than seven days) diarrhea with no response to usual treatment Severe dehydration associated with cardiovascular instability Hypernatremic dehydration requiring a longer period of rehydration Those potentially associated with severe complications, such as seizures, hypotonia, hematemesis or hematochezia, and anuria >12 hour duration An immunocompromised host

Forvarnir Handþvottur Smitgát Gott viðnám gegn mörgum hreinsiefnum. Klórlausnir eða 70% etOH notaðar til hreinsunar Bóluefni ? Rotashield® tekið af markaði 1999 Murphy et al. N Engl J Med 2001; 344:564-572, Feb 22, 2001 Flest börn smitast fyrir 5ára Vaccine sett á markað í USA en aukaverkunin var intussusception.

Heimildir www.uptodate.com www.emedicine.com/emerg/byname/pediatrics-rotavirus.htm