1. Diarrhea Contd…. Dr Shreedhar Paudel 26/03/2009

2. Dysentery Diarrhea with visible blood in the stool Important cause of mortality and morbidity associated with diarrhea Around 10% of all diarrheal cases 15% of all death attributed to diarrhea More chance of developing persistent diarrhea More chance of getting malnutrition

3. Dysentery… Causes: – Shigella dysenteriae type 1 – S. flexneri – Campylobacter jejuni – Enteroinvasive E.coli

4. Clinical features Bloody diarrhea—sometimes watery diarrhea will precede bloody one ± mucous Fever/ subnormal temperature Cramping abdominal pain Tenesmus—pain in the rectum during defecation or attempting defecation

5. Investigations Stool routine and microscopic examination Stool culture and sensitivity CBC USG abdomen

6. Management of dysentery Dysentery should be treated in the line of shigellosis unless proven otherwise If diagnosed amoebic dysentery later—add antiamoebic therapy

7. Management… Four key components of the treatment – Antimicrobials – Fluids – Feeding – Follow-up

8. Child with loose stools with blood ↓ 1. antimicrobial effective for shigella in that area 2. ORS to treat and prevent dehydration 3. continued frequent feeding including breast feeding↓ better in 2 days?↓ NOYES↓ change to nalidixic acidcomplete 5-day ↓treatment Better in 2 days?…….

9. …….Changed to nalidixic acid (better in 2 days??) ↓ NOYES↓ Look for trophozoites of complete 5-day E. Histolytica in stooltreatment ↓ AbsentPresent↓ Refer to hospitaltreat with Change to ciprofloxacin metronidazole for shigella

10. Antimicrobials used in the treatment of specific causes of diarrhea in children CauseAntibiotic of choiceAlternative Shigella dysentery Trimethoprim(TMP)- Sulfamethoxazole TMP 5 mg/kg and SMX 25 mg/kg twice a day for 5 days Nalidixic acid- 15mg/kg, 4 times a day for 5 days Ampicillin- 25mg/kg 4 times a day for 5 days CholeraTetracycline- 12.5 mg/kg 4 times a day for 3 days Furazolidone TMP-SMX Erythromycin

11. Antimicrobials used in the treatment of specific causes of diarrhea in children CauseAntibiotic of choice Alternative AmoebiasisMetronidazole 10 mg/kg body wt, three times a day for 5-10 days Dihydroemetine hydrochloride in severe cases GiardiasisMetronidazoleTinidazole E. coli, C. jejuniNone

12. Persistent Diarrhea Lasts for 14 days or longer (infective origin) Associated with increased mortality 35% of all diarrhea associated deaths Case fatality rate is 15% Dehydration and malnutrition are the main factors

13. Causes of Persistent Diarrhea Mostly no single microbial cause: – Shigella – Salmonella – E. coli – Crysptosporidium and Cyclospora in case of immunocompromised patients – Unclear role of protozoal parasites

14. Risk factors for persistent diarrhea Malnutrition Recent introduction of animal milk or formula Young age Immunodeficiency status—HIV/AIDS, measles, malnourished child Recent diarrhea

15. Persistent diarrhoea contd…. Management: --2/3 rd of the patients can be treated in home --hospitalization required when:- --age < 4 months and not breastfed --presence of dehydration --severe malnutrition --presence or suspicion of systemic infection

16. Persistent diarrhoea contd…. Management: --assess the child for signs of dehydration and give fluids according to treatment Plan A, B, C (for acute diarrhoea) --dietary management—mainstay of therapy

17. Dietary management of persistent diarrhoea Infants aged less than 6 months: Encourage exclusive breast feeding Reestablish lactation—who are not breast feeding If only animal milk can be given—replace with curd/lactose free milk (with cup or spoon) Cooked rice mixed with milk/curd/lactose free formula

18. Dietary management of persistent diarrhoea………. Older infants and young children: -breastfeeding should be continued -optimal feeding of mixed diet is important Diets: -Initial diet (Diet A) → reduced lactose diet-milk rice gruel, rice with curds -Second diet (Diet B)→ lactose free diet with reduced starch—milk protein is replaced by chicken/egg

19. Dietary management of persistent diarrhoea………. Diets: -Third diet (Diet C) → monosaccharide based diet—only glucose and a protein source as egg white or chicken -supplemental vitamins and minerals— vit A, zinc

20. Chronic Diarrhoea/Malabsorption Syndromes Chronic diarrhoea is the direct consequence of malabsorption Malabsorption →malnutrition & failure to thrive Associated with abnormal stools which continues over several months Dehydration is rare ( common in persistent D)

21. Chronic Diarrhoea/Malabsorption Syndromes………. Path physiologic categories: – Impaired intraluminal digestion → exocrine pancreatic insuffiency – Impaired intestinal malabsorption → celiac disease (total villous atrophy), partial villous atrophy (food protein sensitivity, malnutrition, giardia lamblia infestation) – Impaired fermentation →congenital deficiency of mucosal enzymes (liquid acidic stool)

22. Chronic Diarrhoea/Malabsorption Syndromes………. Investigations: – Repeated stool examination especially for Giardia lamblia – Fecal fat excretion studies – Intestinal biopsy – Specific tests→ sweat chloride for cystic fibrosis; exocrine pancreatic function tests; serology for celiac disease; breath analysis for carbohydrate malabsorption

23. Chronic Diarrhoea/Malabsorption Syndromes………. Management: – Of the underlying problem – Avoid allergic diets – Management of diarrhoea and dehydration- if present

24. Celiac Disease Gluten sensitive enteropathy Permanent intestinal intolerance to dietary wheat gliadin Has strong genetic association Immunologically mediated- cell damage

25. Celiac Disease…….. Clinical features: – Chronic diarrhoea – Abdominal distension – Muscle wasting – Failure to thrive – Anorexia – Irritability – Vomiting ±

26. Celiac Disease…….. H/O after initial normal course child starts having foul, greasy and bulky stool weeks to months after introduction of wheat into the diet Weight gain stops Child appears miserable Short stature—prominent sign

27. Celiac Disease…….. Diagnosis: Intestinal biopsy—villous atrophy with hyperplasia of crypts A full clinical and histological remission after withdrawal of gluten from the diet

28. Celiac Disease…….. Management: – Strict gluten free diet—lifelong strict gluten free diet is mandatory for children with celiac disease 1)clinical response to gluten free diet is dramatic 2)growth velocity improves very rapidly 3)rice and maize are non toxic and act as wheat substitutes

29. Milk Protein Intolerance Manifests—few weeks after the initial exposure to cow’s milk C/F—diarrhoea – vomiting – abdominal colic – Irritability – failure to thrive – GI hemorrhage Usually subsides by the second year of life