1. Diarrhea Parasitic Infection By Dana Hogan Linsy Ogden Teresa Pearson

2. Diarrhea in Children

3. Diarrhea -Anatomy-Physiology- Pathophysiology Definition  Doctors Classify Diarrhea as osmotic, secretory or exudative. Usual stool output is 10g/kg/day in children and 100g/day in adults. Stool loss of >10g/kg/day in infants and young children or >200g/day in older children or adults is considered diarrhea. Acute vs. Chronic  Acute Diarrhea is > 3 loose or watery stools per day.  Chronic Diarrhea is diarrhea lasting more than 14 days. (Arcara, & Tschudy, 2012)

4.  Diarrhea is the reversal of the normal net absorptive status of water and electrolyte absorption to secretion. Such a derangement can be the result of either an osmotic force that acts in the lumen to drive water into the gut or the result of an active secretory state induced in the enterocytes. In the former case, diarrhea is osmolar in nature, as is observed after the ingestion of nonabsorbable sugars such as lactulose of lactose in lactose malabsorbers. Instead, in the typical active secretory state, enhanced anion secretion is best exemplified by enterotoxin-induced diarrhea. Pathophysiology

5. Epidemiology  In the United States, one estimate assumes a cumulative incidence of 1 hospitalization for diarrhea. Rotavirus is associated with 4-5% of all childhood hospitalizations, and 1 in 67 to 1 in 85 children are hospitalized due to rotavirus by age 5 years. Acute diarrhea is responsible for 20% of physician referrals in children younger than 2 years and for 10% in children younger than 3 years. (Medscape, 2012)

6.  Infection by bacteria (cause of most types of food poisoning)  Infections by other organisms  Eating foods that upset the digestive system  Allergies to certain foods  Medications  Radiation therapy  Diseases of the intestines  Malabsorption  Hyperthyroidism  Some cancers  Laxative abuse  Alcohol abuse  Digestive tract surgery  Competitive running Causes of Diarrhea

7. Acute vs. Chronic Causes Acute  Viral gastroenteritis  Staphylococcus aureus  Clostridium perfringens  Salmonella  Shigella  Cryptosporidiosis  Drug-induced diarrhea  Clostridium difficile Chronic  Irritable bowel syndrome  Inflammatory bowel disease  Pseudomembranous colitis  Diabetic enteropathy  Dumping syndrome  Malabsorption of lactose  Chronic laxative use

8. Diarrhea Continued  Small bowel diarrheas 1.Large, loose stools 2.Periumbilical or RLQ pain  Large bowel diarrheas 1.Frequent, small loose stools 2.Crampy, LLQ pain or tenesmus

9. Osmotic Diarrhea  Osmotic diarrhea means that something in the bowel is drawing water from the body into the bowel. A common example of this is “diabetic candy” or “chewing gum” diarrhea, in which a sugar substitute, such as sorbitol, is not absorbed by the body but draws water from the body into the bowel, resulting in diarrhea.

10.  Decretory diarrhea occurs when the body is releasing water into the bowel when it’s not supposed to. Many infections, drugs, and other conditions cause secretory diarrhea.  Exudative diarrhea refers to the presence of blood and pus in the stool. This occurs with inflammatory bowel diseases, such as Crohn’s disease or ulcerative colitis, and several infections. Secretory and Exudative Diarrhea

11. Clinical Findings Symptoms Uncomplicated  Non-serious  Abdominal bloating or cramps  Thin or loose stools  Watery stools  Sense of urgency to have a bowel movement  Nausea and vomiting Complicated  May be sign of more serious illness  Blood, mucus, or undigested food in the stool  Weight loss  Fever (WebMd, 2011).

12. Clinical Findings Continued  Physical examination should note the patient’s general appearance, mental status, volume status, and the presence of abdominal tenderness or peritonitis.  Peritoneal findings may be present in C. difficile and enterohemorrhagic E coli. Hospitalization is required in patients with severe dehydration, toxicity, or marked abdominal pain. Stool specimens should be sent in all cases for examination for fecal leukocytes and bacterial cultures.

13.  In over 90% of patients with acute diarrhea, the illness is mild and self-limited and responds within 5 days to simple rehydration therapy or antidiarrheal agents.  Patients with signs of inflammatory diarrhea manifested by any of the following require prompt medical attention: high fever (>38.5), bloody diarrhea, abdominal pain, or diarrhea not subsiding after 4-5 days. Patients with symptoms of dehydration must be evaluated (excessive thirst, dry mouth, decreased urination, weakness, lethargy, volume depleted.) Evaluation

14.  Measurement of blood pressure in the upright and supine position may demonstrate orthostatic hypotension and confirm the presence of dehydration.  Examination of a small amount of stool, bacterial cultures, C. difficile, Hemocult  History: travel, Giardia, and parasites. Recent antibiotic usage, food poisoning, new medications and personal contact

15.  Gram’s stain for leukocytes  Stool for C&S  CBC  Electrolytes  Stool of O&P. (Ova and Parasites) C. Difficile (if indicated)  LFT’s & PT time  Amylase, lipase, glucose  Upper gastrointestinal X-rays (UGI series), Abdominal CT  Barium enema  Esophago-gastro-duodensoscopy (EDG)  Colonoscopy  Hydrogen breath testing Diagnostics Diarrhea

16. Other Laboratory Tests  In secretory diarrhea: Serum VIP (VIPoma), gastrin (Zollinger-Ellison syndrome), Calcitonin (medullary thyroid carcinoma), cortisol (Addison’s disease), and urinary 5-HIAA (carcinoid syndrome) levels should be obtained.  Proctosigmoidoscopy with mucosal biopsy: Examination may be helpful in detecting inflammatory bowel disease and melanosis coli, indicative of chronic use of anthraquionone laxatives.

17. Differential Diagnosis  Appendicitis  Carcinoid tumor  Congenital microvillus atrophy  Crohns disease  Cystic fibrosis  Giardiasis  Glucose-galactose malabsorption  Hyperthyroidism  Intestinal enterokinase deficiency

18. Differential Diagnosis Continued  Intestinal protozoal diseases  Intussusception  Irritable bowel syndrome  Malabsorption syndrome  Meckel diverticulum  Protein intolerance  Shigella infection  Short bowel syndrome  Ulcerative colitis

19. Management of Care and Indications  Indications for medical evaluation of children with acute diarrhea include:  Older than 3 months  Weight of more than 8 kg  HX of premature birth, chronic medical conditions, concurrent illness  Fever of 38 C or higher in infants 3-36 months.  Visible blood in stool  High-output diarrhea

20. Management of Care and Indications Continued  Persistent emesis  S/S of dehydration as reported by the caregiver, including sunken eyes, decreased tears, dry mucous membranes, and decreased urine output  Mental status changes  Inadequate responses to oral rehydration therapy (ORT) or caregiver unable to administer ORT (CDC, 2003)

21.  Oral Rehydration Therapy (ORT) First-Line  Peripheral fluid therapy may be indicated in more severe cases  Diet: Continue breastfeeding. Older children: Restart regular diet once patient is rehydrated.  Other non-specific antidiarrheal agents such as kaolin- pectin, antimotility agents such as lopermide, antisecretory drugs, and toxin binders have limited data regarding efficacy.  Infectious: antimicrobial therapy may be indicated  Probiotics: data is limited but efficacy has been demonstrated in antibiotic-resistant diarrhea Management of Care Continued

22. ORT Therapy Minimal-Mild Losses  Minimal-not indicated  Mild: <10 kg body weight; 60- 120 ml ORT for each diarrhea stool or vomiting episode  >10 kg: 120-140 ml ORT for each episode Mild-Moderate Losses  ORT solution: 50-100 ml/kg over 3-4 hours  <10 kg: 60-120 ml for each episode  >10 kg: 120-140 ml for each episode

23.  ORT is the cornerstone of treatment, especially for small-bowel infections that produce a large volume of watery stool output. ORT with a glucose-based oral rehydration syndrome must be viewed as by far the safest, most physiologic, and most effective way to provide rehydration and maintain hydration in children with acute diarrhea, as recommended by WHO; by the ad hoc committee of European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN); and the American Academy of Pediatrics. Management of Care Continued

24.  Rehydration Therapy-IV LR or NS 20 ml/kg until perfusion and mental status improve, followed by 100 ml/kg oral rehydration solution over 4 hours of 5% dextrose (half normal saline) IV at twice maintenance fluid rates.  Replacement of Losses: 10 kg 120-140 ml oral hydration for each episode.  If unable to drink: administer via G-Tube or IV; administer 5% dextrose (one fourth normal saline) with 20 mEq/L potassium chloride. Severe Diarrhea with Fluid Loss ORT

25. Management of Care Continued  Antimotility agents are not indicated for infectious diarrhea, except for refractory cases of Cryptosporidium infection.  Antimicrobial therapy is indicated for some nonviral diarrhea because most is self- limiting and does not require therapy.

26.  Aeromonas species: Cefixime, most third-fourth generation cephalosporin. Significant organism in the cause of diarrhea in young children.  Campylobacter species: Erythromycin.  C. Difficile: Discontinue potential causative antibiotics-use of metronidazole or vancomycin.  C. Perfringens: Do not treat with antibiotics.  Cryptosporidium parvum: Paromomycin, Nitazoxanide.  Entamoeba histolytica: Metronidazole followed by iodoquinol or paromomycinin symptomatic patients. Asymptomatic receive iodoquinol or paromomycin. Therapies Recommended for some Nonviral Diarrheas

27.  E coli: TMP-SMX if moderate or severe diarrhea noted.  G lamblia: Metronidazole or nitrazoxanide.  Plesiomonas species: TMP-SMX or cephalosporin.  Salmonella species: Treatment prolongs carrier state, is associated with relapse, and is not indicated for nontyphoid-uncomplicated diarrhea. Treat infants <3 months and high-risk patients with TMP-SMX as first line medication. If resistance occurs use ceftriaxone and cefotaxime for invasive disease. Therapies Continued

28.  Shigella species: TMP-SMX is first-line; however resistance occurs. Cefixime, ceftriaxone, and cefotaxime are recommended for invasive disease.  V cholerae: Treat infected individuals and contacts. Doxycycline first-line and erythromycin second-line.  Yersinia species: TMP-SMX, cefixime, ceftriaxone, are used, reserve for complicated cases.

29. Possible Complications and Expectations Diarrhea in Children Complications  Mortality: 18% of the 10.6 million yearly death in children age <5.  Dehydration  Electrolyte imbalances  Irritation and skin breakdown

30.  WASH YOUR AND YOUR CHILDS HANDS!  Before handling food.  Between preparation and consumption.  After voiding or bowel movements.  After changing diapers. Patient Education Basic Prevention Measures

31.  Keep your hands away from your mouth.  Dispose of waste properly.  Assure Tap water is safe or use bottled water.  Meat preparation-meats should be thoroughly cooked.  Healthy well balanced diet- may need a bland diet or diet excluding foods that are causative factors to diarrhea.  Encourage fluid to prevent complications- avoid caffeine and sport drinks. Patient Education Basic Prevention Measures

32. Around the World  Although our presentation has been focused on the USA it is important to note that around the world in undeveloped countries that do not have piped sewage and clean drinking water the rates of incidence and mortality increase significantly.  Diarrhea is considered the “forgotten killer” in undeveloped countries because focus is placed more on HIV, malaria, and other diseases however diarrhea is the second leading cause of death in children.

33.  American Family Physician. Gastroenteritis and Diarrhea in Children. http://www.aafp.org/afp/topicModules/viewTopicModule.htm?topicModuleId=9  The Center for High Impact Philanthropy. University of Pennsylvania. International Issues. http://www.impact.upenn.edu/international-issues/toolkit- childsurvival-globalcauses/ References