1. INFECTIOUS DISEASE CONFERENCE
Mendoza, Donne
mendoza, gracielle
Mendoza, trisha
Mindanao, malvin ace

2. DIARRHEA O.P. 7 months, male August 20, 2010
157-2 M. Dela Fuente St. Sampaloc, Manila
Roman Catholic
Informant: Parents
Reliability: Good
DIARRHEA

3. HISTORY OF PRESENT ILLNESS
3 episodes of vomiting
amounting to 15mL/episode
1 hr PTA
- 4 episodes of loose, mucoid, yellowish stool, altogether amounting to 200mL
- Noted to be weak-looking, w/ cold clammy skin
30 min PTA
ADMISSION

4. REVIEW OF SYSTEMS Cutaneous: (-) rashes, (-) pruritus
HEENT: (-) nasoaural discharge, (-) eye discharge, (-) sore throat
Respiratory: (-) dyspnea, (-) chest pain
Cardiovascular: (-) palpitations, (-) cyanosis, (-) easy fatigability
Gastrointestinal: SEE HPI

5. REVIEW OF SYSTEMS Genitourinary: (-) dysuria (-) hematuria
Musculoskeletal: (-) weakness, (-)swelling
Hematopoietic: (-) easy bruisability, (-) bleeding
Endocrine: (-) polyuria, polydipsia, polyphagia
Nervous/Behavior: (-) headache, (-) seizures, (-)tremors, (-) loss of consciousness

6. GESTATIONAL HISTORY
Born to a 22 y/o G1P0 mother with a common law 27 y/o policeman partner
Regular prenatal check-up since 5 mo AOG
Hep B screening and OGCT were not done
No history of alcohol intake, smoking or exposure to radiation
No illnesses noted during pregnancy

7. NEONATAL HISTORY Born at 39-40 weeks AOG
Live, singleton, delivered via NSD
APGAR score 8-9
Birth weight = 2.7 kg
Birth length – unrecalled
1-day stay at the nursery
No complications noted during delivery

8. FEEDING HISTORY Breastfed exclusively for 1 month
More than 8 times per day or everytime child cries
Shifted to milk formula
Mother claimed she was not producing enough milk
Bottlefed since 2 months until present
2-5 months: S26 – 1:2 dilution, 4 oz per feeding, 6x /day
6 months to present: Bonamil – 1:2 dilution, 8 oz per feeding, 4-5x/day
Complementary feeding started at 6 months
Cerelac and pureed food

9. 24 – HR FOOD RECALL Amount Macronutrients Total CHO (4 cal/g)
CHON (4 cal/g)
Fats (9 cal/g)
Kilocalories
BREAKFAST
Milk 1:2 8 oz 12 8 10
170
SNACK
LUNCH
Milk
Cerelac 3
2,5 83
DINNER
ACI
763
RENI
720 %
106%

10. DEVELOPMENT/BEHAVIORAL HISOTRY
Gross motor
With good head control, can crawl, rolls over, sits with support
Fine motor
Transfers object from 1 hand to another
Language
Imitates speech sounds
Personal Social
Laughs and plays with examiner

11. IMMUNIZATIONS HEALTH CENTER BCG – 1 dose Hep B – 1 dose DPT – 3 doses
OPV – 3 doses
Hib – 1 dose

12. PAST MEDICAL HISTORY
October 2010 – Pneumonia
January Diarrhea

13. FAMILY HISTORY (+) HPN – maternal grandmother
(-) DM, goiter, asthma, cancer, TB

14. Educational Attainment
FAMILY PROFILE
Relation
Age
Educational Attainment
Occupation
Health
Mother 22
High school graduate
none
Healthy
Father 27
College graduate
Policeman

15. PERSONAL, SOCIOECONIMIC AND ENVIRONMENTAL HISTORY
Apartment with both parents
Well-ventilated, well-lit
Drinking water is purified
Garbage is not segregated but collected everyday
No nearby factories, no pets

16. PHYSICAL EXAMINATION
Alert, awake, weak-looking, with moderate signs of dehydration, drinks eagerly, not in cardiorespiratory distress
VS: CR 160 RR 40 T 36.9
Wt 6 kg. (z= 0)
Lt. 73 cm (z= 0)
AC: 43 cm
BMI 11 (z= below -3)
wt. for Ht. (z= below -3)

17. PHYSICAL EXAMINATION Warm, dry skin, no active dermatoses
Pink palpebral conjunctiva, anicteric sclerae, (+) sunken eyeballs
No tragal tenderness, non-hyperemic EAC, (+) retained cerumen, AU, intact tympanic membrane, no aural discharge AU
Midline septum, turbinates not congested, no nasal discharge

18. PHYSICAL EXAMINATION
Dry buccal mucosa, no oral lesions, to non-hyperemic posterior pharyngeal wall, tonsils not enlarged
Supple neck, no palpable cervical lymphadenopathies or anterior neck masses
Symmetrical chest expansion, no retractions, clear breath sounds
Adynamic precordium, apex beat 4th LICS MCL, no heaves, thrills, murmurs

19. PHYSICAL EXAMINATION
Globular abdomen, NABS, soft, non- tender, no mass palpated
Pulses full and equal, no cyanosis, no edema
No genital lesions, no phimosis
DRE: tight sphincteric tone, no tenderness, no masses, brown fecal material on tactating finger, non-blood tinged

20. NEUROLOGIC EXAMINATION
Mental Status: alert, awake
Cranial Nerves are intact: intact EOM; no ptosis; no jaw deviation; smiles, open and close his eyes, no facial asymmetry; midline uvula, no tongue atrophy, no fasciculations, no deviation
No Babinski, no nuchal rigidity

21. SALIENT FEATURES POSITIVE NEGATIVE 7 mo/male Diarrhea – mucoid stools
Vomiting
Weak-looking, with cold clammy skin
Past medical history of diarrhea
(+) sunken eyeballs
dry buccal mucosa
drinks eagerly
NEGATIVE
(-) fever
(-) abdominal pain

22. ADMITTING IMPRESSION DIARRHEA

23. APPROACH TO DIAGNOSIS
Look for a symptom, sign, or laboratory finding pointing to a group of diseases

24. COURSE IN THE WARDS

25. DAY 1
CBC with platelet count and fecalysis were done. CBC showed normal results, while fecalysis showed pus cells of over 100/hpf, RBC of (+), and macrophage of (+), and stool culture was then requested.
ORS 75 to replace losses volume per volume
Zinc sulfate 10mg/ml, 2ml once a day for 14 days
IVF started at D5 0.3% NaCl 100%.

26. DAY 2 & DAY 3
Ciprofloxacin 16.6 mg/kg/day given for 3 days.
IVF given was D5 0.3 NaCl at 100%. 
DAY 4 & DAY 5
Discharged improved and stable

27. Diarrhea: definition
Increased total daily stool output, usually associated with increased stool water content
Stool output more than 10g/kg/24hr or more than the adult limit of 200 g/24hr
Results from altered intestinal water and electrolyte transport
GIT of infant handles approx 285 ml/kg/24hr of fluid (intake plus intestinal secretion) with a stool output of 5-10g/kg/24hr

28. Diarrhea: chronicity Acute Less than 2 weeks Chronic/Persistent
More than two weeks

29. Diarrhea: pathophysiology
Osmotic
Secretory
Increased/decreased intestinal motility
Decreased surface area

30. Diarrhea: pathophysiology
PRIMARY MECHANISM
DEFECT
STOOL EXAMINATION
EXAMPLES
COMMENT
Secretory
Decreased absorption, increased secretion, electrolyte transport
Watery, normal osmolality; osmoles = 2 × (Na+ + K+)
Cholera, toxigenic E. coli; carcinoid, VIP, neuroblastoma, congenital chloride diarrhea, Clostridium difficile, cryptosporidiosis (AIDS)
Persists during fasting; bile salt malabsorption may also increase intestinal water secretion; no stool leukocytes
Osmotic
Maldigestion, transport defects ingestion of unabsorbable
Watery, acidic, and reducing substances; increased osmolality; osmoles >2 × (Na+ + K+)
Lactase deficiency, glucose-galactose malabsorption, lactulose, laxative abuse
Stops with fasting; increased breath hydrogen with carbohydrate malabsorption; no stool leukocytes

31. Decreased transit time
PRIMARY MECHANISM
DEFECT
STOOL EXAMINATION
EXAMPLES
COMMENT
Increased motility
Decreased transit time
Loose to normal-appearing stool, stimulated by gastrocolic reflex
Irritable bowel syndrome, thyrotoxicosis, postvagotomy dumping syndrome
Infection may also contribute to increased motility
Decreased motility
Defect in neuromuscular unit(s) Stasis (bacterial overgrowth)
Loose to normal appearing stool
Pseudoobstruction, blind loop
Possible bacterial overgrowth
Decreased surface area (osmotic, motility)
Decreased functional capacity
Watery
Short bowel syndrome, celiac disease, rotavirus enteritis
May require elemental diet plus parenteral alimentation
Mucosal invasion
Inflammation, decreased colonic reabsorption, increased motility
Blood and increased WBCs in stool
Salmonella, Shigella, infection; amebiasis; Yersinia, Campylobacter infections
Dysentery evident in blood, mucus, and WBCs

32. Diarrhea: pathophysiology
OSMOTIC DIARRHEA
SECRETORY DIARRHEA
Volume of stool
<200 mL/24 hr
>200 mL/24 hr
Response to fasting
Diarrhea stops
Diarrhea continues
Stool Na+
<70 mEq/L
>70 mEq/L
Reducing substances[*]
Positive
Negative
Stool pH
<5
>6
fasting
stops
persists
example
Lactose intolerance
Cholera, ETEC

33. Acute diarrhea Non-infectious Protein intolerance Intussusception
Bacteria
B. cereus
C. jejuni
C. perfringens
E. Coli (STEC, EIEC)
Salmonella spp
Shigella spp
S. aureus
V. cholerae
V. parahaemolyticus
V. vulnificus
Virus
Norovirus
Calicivirus
Rotavirus
Astrovirus
Adenovirus
Parvovirus
Protozoa
G. Lamblia
Non-infectious
Protein intolerance
Intussusception
Meckel’s diverticulum
Food hypersensitivity
Food-induced enterocolitis
Ciguater fish poisoning
Mushroom poisoning
Nitrite poisoning
Organophosphates
Puffer fish (tetrodotoxin)
Scombroid (histamine)
Shellfish poisoning
Heavy metals
Sb, As, Cd, Cu, Hg, Zn, Th

34. Acute infectious diarrhea
Inflammatory
Usually bacteria that directly invades the intestines or produce cytotoxins with consequent fluid, protein and cells that enter the intestinal lumen
Presents as bloody mucoid stool
Fecalysis: + fecal leukocytes
Non-inflammatory
Enterotoxin production by some bacteria (cholera), destruction of villous cells by viruses (rotavirus), adherence by parasites (G lamblia), and adherence and or translocation by bacteria

35. Acute infectious inflammatory diarrhea
Shigella
Salmonella
E coli: EPEC, EIEC, EAEC, ETEC, STEC
C jejuni

36. ETIOLOGY
INCUBATION PERIOD
SIGNS AND SYMPTOMS
DURATION OF ILLNESS
ASSOCIATED FOODS
LABORATORY TESTING
TREATMENT
Campylobacter jejuni
2–5 days
Diarrhea, cramps, fever, and vomiting; diarrhea may be bloody.
2–10 days
Raw and undercooked poultry, unpasturized milk, contaminated water
Routine stool culture; Campylobacter requires special media and incubation at 42°C to grow.
Supportive care. For severe cases, antibiotics such as erythromycin and quinolones may be indicated early in the diarrheal disease. Guillain-Barré syndrome can be a sequela.
Enterotoxigenic E. coli (ETEC)
1–3 days
Watery diarrhea, abdominal cramps, some vomiting
3 to >7 days
Water or food contaminated with human feces
Stool culture. ETEC requires special laboratory techniques for identification. If suspected, must request specific testing.
Supportive care. Antibiotics are rarely needed except in severe cases. Recommended antibiotics include TMP-SMX and quinolones.

37. ETIOLOGY
INCUBATION PERIOD
SIGNS AND SYMPTOMS
DURATION OF ILLNESS
ASSOCIATED FOODS
LABORATORY TESTING
TREATMENT
Enterohemorrhagic E. coli (EHEC) including E. coli O157 : H7 and other Shiga toxin–producing E. coli (STEC)
1–8 days
Severe diarrhea that is often bloody, abdominal pain and vomiting. Usually, little or no fever is present. More common in children <4 yr old.
5–10 days
Undercooked beef especially hamburger, unpasteurized milk and juice, raw fruits and vegetables (e.g., sprouts), salami (rarely), and contaminated water
Stool culture; E. coli O157 : H7 requires special media to grow. If E. coli O157 : H7 is suspected, specific testing must be requested. Shiga toxin testing may be done using commercial kits; positive isolates should be forwarded to public health laboratories for confirmation and serotyping.
Supportive care, monitor renal function, hemoglobin, and platelets closely. E. coli O157 : H7 infection is also associated with hemolytic uremic syndrome (HUS), which can cause lifelong complications. Studies indicate that antibiotics may promote the development of HUS.

38. ETIOLOGY INCUBATION PERIOD SIGNS AND SYMPTOMS DURATION OF ILLNESS
ASSOCIATED FOODS
LABORATORY TESTING
TREATMENT
Salmonella spp.
1–3 days
Diarrhea, fever, abdominal cramps, vomiting. S. typhi and S. paratyphi produce typhoid with insidious onset characterized by fever, headache, constipation, malaise, chills, and myalgia; diarrhea is uncommon, and vomiting is not usually severe.
4–7 days
Contaminated eggs, poultry, unpasteurized milk or juice, cheese, contaminated raw fruits and vegetables (alfalfa sprouts, melons). S. typhi epidemics are often related to fecal contamination of water supplies or street-vended foods.
Routine stool cultures
Supportive care. Other than for S. typhi and S. paratyphi, antibiotics are not indicated unless there is extra-intestinal spread, or the risk of extra-intestinal spread, of the infection. Consider ampicillin, gentamicin, TMP-SMX, or quinolones if indicated. A vaccine exists for S. typhi.
Shigella spp.
24–48 hr
Abdominal cramps, fever, and diarrhea. Stools may contain blood and mucus.
Food or water contaminated with human fecal material. Usually person-to-person spread, fecal-oral transmission. Ready-to-eat foods touched by infected food workers, e.g., raw vegetables, salads, sandwiches.
Supportive care. TMP-SMX recommended in the U. S. if organism is susceptible; nalidixic acid or other quinolones may be indicated if organism is resistant, especially in developing countries.

39. Escherichia coli Pathotype Epidemiology Type of diarrhea
Mechanism of pathogenesis
STEC
Hemorhagic colitis and HUS in all ages and postdiarrheal thrombotic thrombocytopenic purpura in adults
Bloody or non-bloody
Large bowel adherence and effacement (AE), shiga toxin production
EPEC
Acute and chronic endemic and epidemic in infants
Watery
Small bowel AE
ETEC
Infantile diarrhea in resource-limited countries and traveler’s diarrhea in all ages
Small bowel AE, heat stable/ heat labile enterotoxin production
EIEC
Diarrhea with fever in all ages
Bloody or non-bloody; dysentery
Adherence, mucosal invasion and inflammation of large bowel
EAEC
Acute and chronic diarrhea in all ages
Watery, occasionally bloody
Small and large bowel adherence, enterotoxin and cytotoxin production

40. DEHYDRATION Mental status Thirst Heart rate Quality of pulses
SYMPTOM
MINIMAL OR NO DEHYDRATION (<3% LOSS OF BODY WEIGHT)
MILD TO MODERATE DEHYDRATION (3–9% LOSS OF BODY WEIGHT)
SEVERE DEHYDRATION (>9% LOSS OF BODY WEIGHT)
Mental status
Well;alert
Normal, fatigued or restless, irritable
Apathetic, lethargic, unconscious
Thirst
Drinks normally; might refuse liquids
Thirsty;eager to drink
Drinks poorly; unable to drink
Heart rate
Normal
Normal to increased
Tachycardia, with bradycardia in most severe cases
Quality of pulses
Normal to decreased
Weak, thready, or impalpable
Breathing
Normal;fast
Deep
Eyes
Slightly sunken
Deeply sunken
Tears
Present
Decreased
Absent
Mouth and tongue
Moist
Dry
Parched
Skinfold
Instant recoil
Recoil in <2 sec
Recoil in >2 sec
Capillary refill
Prolonged
Prolonged;minimal
Extremities
Warm
Cool
Cold;mottled;cyanotic
Urine output
Minimal

41. CLINICAL IMPRESSION
ACUTE INFECTIOUS DIARRHEA WITH MODERATE SIGNS OF DEHYDRATION

42. CONFIRMATION OF WORKING DIAGNOSIS

43. STOOL EXAMINATION Examine for mucus, blood and leukocytes
Fecal leukocytes are indicative of bacterial invasion of colonic mucosa
Examine for parasites causing diarrhea such Giardia lamblia and E. histolytica
Shouldd be obtained as early in the course of disease as possible from children with bloody diarrhea

44. STOOL CULTURE
Should be obtained as early in the course of disease as possible from children with bloody diarrhea in whom stool microscopy indicates fecal leukocytes

45. TREATMENT

46. Principles of Management
Oral Rehydration Therapy
Enteral feeding and diet selection
Zinc supplementation
Antibiotic therapy

48. Oral Rehydration Therapy
Children especially infants are more susceptible than adults to dehydration because of the greater basal fluid and electrolyte requirements.
Dehydration must be evaluated rapidly and corrected 4-6hrs according to the degree of dehydration.

49. Oral Rehydration Therapy
Those in shock or unable to tolerate fluids, require initial intravenous rehydration but oral rehydration is the preferred mode of replacing ongoing losses.

50. Risks associated with severe dehydration that necessitate IV resuscitation
Age <6mos
Prematurity
Chronic illness
Fever >38C if <3mos or 39C if 3-36mos
Bloody diarrhea
Persistent emesis
Poor urine output
Sunken eyes
Depressed level of consciousness

51. Oral Rehydration Therapy
Decarbonated soda beverages, fruit juices are not suitable for rehydration as they have inappropriately high osmolalities and low sodium concentrations
ORS should be given to infants and children slowly, especially if they have emesis
It can be given by a dropper, teaspoon or syringe.
The volume is increased as tolerated.

52. Enteral Feeding and Diet Selection
Continued enteral feeding in diarrhea aids in recovery and age appropriate diet after rehydration is the norm.
Once rehydration is complete, food should be reintroduced while oral rehydration can be continued to replace ongoing losses from emesis or stools.

53. Enteral feeding and Diet Selection
Breast feeding should be resumed as soon as possible
Foods with complex carbohydrates, yogurt, fruits and vegetables are also tolerated
Fatty foods or foods high in simple sugars should be avoided.

54. Zinc supplementation
Zinc leads to reduced duration and sseverity of diarrhea and could potentially prevent 300,000 deaths.
WHO and UNICEF recommend that all children with acute diarrhea should recive oral zinc for days during and after diarrhea
10mg/day for infants <6mos
20mg/day >6mos

55. Antibiotic Therapy
Timely antibiotic therapy may reduce the duration and severity of diarrhea and prevent complications.
While these agents are important to use in specific cases, their widespread and indiscriminate use leads to development of resistance.

56. ORGANISM
DRUG OF CHOICE
DOSE AND DURATION OF TREATMENT
Shigella (severe dysentery and EIEC dysentery)
Ciprofloxacin, ampicillin, ceftriaxone, or trimthoprim-sulfamethoxazole
Ceftriaxone IV, IM 50–100 mg/kg/d qd, bid × 7 d
Most strains are resistant to many antibiotics
Ciprofloxacin PO 20–30 mg/kg/d bid × 7–10 d
10 mg/kg/d of TMP and 50 mg/kg/d of SMX bid × 5 d
Ampicillin PO, IV 50–100 mg/kg/d qid × 7 d
EPEC, ETEC, EIEC
TMP-SMX or ciprofloxacin
Ciprofloxacin PO 20–30 mg/kg/d qid for 5–10 d
Salmonella
No antibiotics for uncomplicated gastroenteritis in normal

59. GASTROENTERITIS Community-acquired Viruses, E. coli
Antibiotic therapy strongly discouraged because of increased risk of HUS occurring in patients with E. coli 0157:H7 treated with antibiotics
Primary treatment: fluid and electrolyte replacement
Salmonella
Cefotaxime or Ceftriaxone
10-14 days for infants <6 mo,
toxicity or immuno-compromised
status. Antibiotics generally not
indicated otherwise.
Shigella
TMP/SMX; Alt: Cefixime
5 days

60. GASTROENTERITIS
Community acquired
Yersinia
TMP/SMX, aminoglycosides,
cefotaxime, tetracycline (>8 yr).
Usually no antibiotic therapy is
recommended except with
bacteremia, extraintestinal
infections, or immunocompromised
hosts.
Nosocomial
Clostridium difficile
Metronidazole
7 days. Community organisms
unlikely after 72 hr of
hospitalization.

61. N. Pashapour, S. Golmahammadloo Pediatrics Department, Imam Hospital
EVALUATION OF YOGHURT EFFECT ON ACUTE DIARRHEA ON 6-24 MONTHS-OLD HOSPITALIZED INFANTS
N. Pashapour, S. Golmahammadloo
Pediatrics Department, Imam Hospital
Health Department, Kosar Hospital, Urmia, Iran The Turkish Journal of Pediatrics 2006; 48:

62. OBJECTIVES
To determine the efficacy of local factory pasteurized yoghurt consumption in acute nonbloody and mucoid diarrhea on hospitalized 6-24 months infants as compared with that of routine treatment

63. SUBJECTS
6 to 24 months of age children with non-bloody and mucoid diarrhea with less than four days duration hospitalizing in Urmia; Imam Hospital
2 GROUPS (20 EACH)
Control group: routine hospital treatment only
Case group: received at least 15 ml/kg/day of pasteurized cow milk yogurt orally plus routine hospital treatment
Weight gain, period of hospitalization and reduction of diarrhea were compared

64. EXCLUSION
Malnutrition
Bloody stools
Non-alimentary causes

65. RESULTS  reduction of diarrhea episodes
Mean hospitalization days : 2.85 – 3.1
Mean weight gain : 350 – 287.5
Mean reduction of diarrhea episodes : 4.35 – 3.95
Significant difference (P<0.50)
 reduction of diarrhea episodes

66. CONCLUSION
Use of local pasteurized yoghurt in the treatment of acute diarrhea had positive effects
As a probiotic, it can promote recovery from diarrhea in children, mainly non-bloody
Universal use of yoghurt is recommended in acute non-bloody diarrhea