ACUTE GASTROENTERITIS IN CHİLDREN Prof. Dr. Tufan KUTLU

Each day,the adult human gut handles 7 liters of endogenous secretions (salivary, gastric, biliary, pancreatic, intestinal) and 2 liters of ingested fluids. Of this large volume, 3 to 5 liters are absorbed by the jejunum, 2 to 4 liters by the ileum, and 1 to 2 liters by the colon. Only 100 to 200 ml are lost in the stools.

Diarrhea Increase in the number of stools or a decrease in their consistency

Acute gastroenteritis In Europe the incidence of diarrea ranges from 0.5 to 1.9 episodes per child per year in children up to 3 years of age In low and middle income countries the incidence of acute diarrhea has declined from 3.4 episodes/child/year in 1990 to 2.9 episodes/child/year 2010

Causes of acute gastroenteritis in children Bacteria Viruses Parasites

Bacteria causing diarrhea Vibrio sp Escherichia coli Salmonella sp Campylobacter sp Clostridium difficile Clostridium perfringens Bacillus cereus Staphylococcus aureus Yersinia enterocolitica Aeoromonas hydrophila Klebsiella sp Enterobacter sp Proteus sp Citrobacter sp Edwardsiella tarda Pseudomonas aeroginosa Plesiomonas shigelloides..

Viral agents causing diarrhea Reoviridae: rotavirus, astrovirus Parvo-like viruses: Norwalk virus Picornavirus: calicivirus, adenovirus, coronavirus

Parasites causing diarrhea Giardia lamblia Cryptosporidium Entamoeba histolytica Isospora belli Cyclospora sp Blastocystis hominis Microsporidium

Patophysiology of infectious diarrhea Invasion and destruction of the villous intestinal epithelial cells: Shigella dysenteria, E. coli (EIEC), Yersinia enterocolitica, Campylobacter jejuni, Entamoeba histolytica, Salmonella, rotavirus Enterotoxin production: Vibrio cholera, E. Coli (ETEC), Shigella dysenteria, Campylobacter jejuni, Clostridium difficile, Yersinia enterocolitica, Salmonella, Staphylococcus aureus, Bacillus cereus, Clostridium perfringens Adherence to enterocytes: E. coli Invasion of the lamina propria: Salmonella

Diagnosis Vomiting, profuse watery diarrhea (non blood, non mucus): secretory diarrhea Bacteria: Vibrio cholera, E. coli (ETEC), S. aureus, B. cereus, C. perfringens Viruses: Rotavirus, Norwalk virus Parasites: Giardia lamblia, Cryptosporidium

Diagnosis Fever, abdominal pain, tenesmus: inflammatory colitis, ileitis Bacteria: Shigella, Yersinia, C. difficile Parasite: Entamoeba histolytica

Diagnosis Bloody diarrhea Bacteria: Shigella, E. Coli (EIEC), Yersinia, C. jejuni, C. difficile, Salmonella Parasite: Entamoeba histolytica Fever and abdominal pain like acute appendicitis: Yersinia enterocolitica

Diagnosis Recent exposure to antibiotics: Clostridium difficile Many cases affected simultaneously: S. Aureus, C. perfringens Immunodeficiency, malnutrition: Salmonella, Rotavirus, Isospora, Cryptosporidium, Candida

Diagnosis Stool examination Presence of erithrocytes and leucocytes: Shigella, E. coli (EIEC, EHEC), Campylobacter,Yersinia, Clostridium Presence of erithrocytes: Entamoeba histolytica

Diagnosis Stool examination Microscopic: Parasites (entamoeba, giardia..) Antigens: Entamoeba, Giardia, Rotavirus, Adenovirus Culture ?

Viral gastroenteritis Diarrheal diseases caused by viral agents occurs for more frequently than does similar disease of bacterial origin Rotavirus is responsible for 20 to 70 % of hospitalization for diarrhea among children worldwide Transmission is primarly from person to person Most commonly in children between 6 and 24 months of age

Viral gastroenteritis Clinical manifestations Incubation period: 48-72 hours Sudden onset of diarrhea and vomiting Diarrhea is watery, rarely bloody, 2-8 days Fever Respiratory symptoms

Viral gastroenteritis Diagnosis Rota/adenovirus antigen in stools Treatment Continue with unrestricted oral feeding Dehydration Mild/moderate: oral rehydration treatment Severe: intravenous fluid

Shigella dysenteriae (flexneri, boydii, sonnei) Clinical manifestations Fever, malaise Watery diarrhea, blood and mucus Cramping abdominal pain Seizures Arthritis Purulent keratitis Hemolytic-uremic syndrome

Shigella dysenteriae Treatment Trimethoprim-sulfometoxazole, ampicillin, nalidixic acid, ceftriaxone Antimicrobial treatment is recommended to shorten the course of the disease decrease the period of excretion of the organisms decrease the secondary attack

Yersinia enterocolitica (pseudotuberculosis, pestis) Clinical manifestations Fever Abdominal pain Diarrhea Pseudoappendicular syndrome Erythema nodosum Reactive arthropathy

Clostridium difficile Campylobacter jejuni C. jejuni is a significant cause of diarrhea in children jounger than 2 years of age. Treatment: erythromicin Clostridium difficile Antibiotic associated diarrhea Treatment: metronidazole, vancomicin, probiotics

Cholera Clinical manifestations Treatment Vomiting Profuse vatery diarrhea (rice-vater appearence) Treatment Rehydration (ORT, IV) Antibiotics: Tetracycline, furazolidone, ampicillin, chloramphenicol, trimethoprim-sulfometoxazole

Salmonella enteridis, cholerasuis, typhi 1. Acute gastroenteritis 2. Focal non intestinal infection 3. Bacteremia 4. Asymptomatic carrier state 5. Enteric fever

Salmonella Salmonella is spread with cotaminated water, foods (meat, eggs, milk) Clinical manifestations Incubation periode 12-72 hours Fever, watery diarrhea, blood and/or mucus Treatment Patients at high risk (immunocompromized patients, hematologic disease, artificial inplants, severe colitis) Ampicillin, chloramphenicol, trimethoprim-sulfometoxazole, cephalosporins

Escherichia coli Enteropathogenic Enterotoxigenic Enteroinvasive Enterohemorragic Enteroaggregative and diffuse-adherant

Traditional treatment of diarrhea Disadvantages Intravenous rehydration Diet Antibiotic and antidiarrheal drugs Hospitalization Increased risk of infection Unnecesssary laboratory investigations Emotional trauma Increased cost Weight loss Risk of malnutrition Ineffective Toxic Allergic Risk of secondary infections

Treatment of acute gastroenteritis Treatment of a child with moderate dehydration in hospital (USA) ORT: 11 hours and 270 USD IV : 103 hours and 2300 USD

Treatment of acute gastroenteritis Rehydration: IV, ORT Nutrition Medical Antibiotics: bloody diarrhea, infants <3-6 months Antisecretory drugs Racecadotril Adsorbant drugs Smectite Anti motility agents Zinc Probiotics

Assessment of dehydration in children Non Moderate Severe General appearance Eyes Tears Mucous membranes Thirst Skin elasticity Treatment Good Normal Present Moist Absent Pinc retracts immediately At home İrritable Sunken Absent to reduced Dry Pinc retracts slowly ORS Lethargic, hipotonic or comatose Grossly sunken Very dry Can’t drink Pinc retracts very slowly IV

Treatment of diarrhea Protective factors Human milk: IgA, lactoferrin, leucocytes, antiviral factors, bifidobacteries Gastric acid Secretory IgA Intestinal motility

Zinc for diarrhea Twenty four trials , 9128 children Zinc is clearly of benefit in children aged six months or more. Children aged less than six months showed no benefit with zinc. Vomiting was more common in zinc-treated children with acute diarrhoea Lazzerini M, Ronfani L. Oral zinc supplementation for treating diarrhea in children. Cochrane Database of Systematic Reviews 2012

Treatment of acute gastroenteritis Rehydration ORT > 90 % IV < 10 % Continue with unrestricted oral feeding Antibiotic when necessary (age<3-6 months, dysenteria, cholera..) Do not use antidiarrheal agents

WHO-ORS Should contain carbohydrate (glucose) and sodium (glucose/sodium: between 1/1 and 2/1) Glucose: 74-111 mmol/L (rice-flour: 50 g/L) Sodium Rehydration: 60-90 mmol/L Maintenance: 40-60 mmol/L Osmolarity < 290 mOsm/L Potassium: 20 mmol/L Bicarbonate: 30 mmol/L (or citrate: 10 mmol/L)

Composition of the ORS recommended by WHO g/L Mmol/L NaCl KCl Citrate (Bicarbonate) Glucose (Rice-flour) 3.5 1.5 2.9 (2.5) 20 (50) Na K Cl 90 80 10 30 110

Electrolyte losses in diarrheal disease (mmol/L) Na K Cl HCO3 Glucose Normal stools Cholera Adult Child Enteritis ORS 5 140 101 56 90 10-12 13 27 25 20 2-3 104 92 55 80 3 44 32 14 30 111

Comparison of some fluids used for rehydration CHO mmol/L Na CHO/Na K Base Osmolarity mOsm/L Cola Apple juice Chicken soup WHO-ORS Pedialyte Rehydralyte Osmosal 700 690 111 140 144 2 3 250 90 45 75 60 350 230 1.2 3.1 1.9 2.4 0.1 32 8.2 20 13 10 750 730 500 311 310 304

Treatment of diarrhea at home Recommended foods Water, soup (rice), yoghurt, fruit juice… <6 months: breast-feeding, formula Recommended amount of fluids After every watery stools <2 ages: 50-100 ml >2 ages: 100-200 ml

Treatment of diarrhea at home To prevent malnutrition Don’t stop breast feeding or formula feeding Don’t dilute formula or milk Older children: give rice cereal, bananas, fruit juices, potatoes, yoghurt, good cooked meat, fish…

Amount of ORS after every watery stools ORS treatment at home Age Amount of ORS after every watery stools <2 2-10 >10 50-100 ml 100-200 ml Not limited

ORS treatment Mild Moderate Severe* Rehydration Duration Maintenance* 50 ml/kg 4-6 hours 100 ml/kg 18-20 hours ml/kg 100-150 ml/kg

Probiotics for acute gastroenteritis Lactobacillus GG administered in oral rehydration solution to children with acute diarrhea: a multicenter European trial. Guandalini et al. J Pediatr Gastroenterol Nutr 2000

Rice-based ORS Cheaper Better taste Hypoosmolar (280 mOsm/L) Prevent vomiting Decrease frequency and duration of diarrhea More nutritive Traditional

Contraindication of ORS use Shock, stupor, coma Severe electrolyte imbalence and dehydration Severe and repeated vomiting Acidosis Oliguria or anuria Abdominal distention, ileus Glucose-galactose malabsorption