1. Ryan Em C. DalmanMD MBA - 070070

2.  Objectives  Case Presentation  Case Discussion

3.  Present a case of Acute Gastroenteritis  Discuss the pathophysiology and management of Acute Gastroenteritis

4. Patient History

5.  JM  1-year-old born on July 9, 2009  Female  Admitted for the first time  Roman Catholic  Pasig City

6.  Vomiting

7.  Vomiting 1x  ingested food  Non-projectile  Non-bilous  Non-bloody 3 days PTA 1 day PTA  Loose bowel movement 3x  Watery  Non-bloody  Non-mucoid  Non-foul smelling No associated symptoms, no medications, no consults

8.  Symptoms persisted 12 hours PTA Consult at the ER Sent home after successful trial feeds

9.  Vomiting 3x  ingested food  Post-prandial  Non-projectile  Non-bilous  Non-bloody Few hours PTA Consult at the ER Admitted

10. General: no weight loss, no change in appetite Cutaneous: no lesions, no pigmentation, no hair loss, no pruritus HEENT: no redness no aural discharge no neck masses no sore throat

11. Cardiovascular: no easy fatigability, or fainting spells Gastrointestinal: no constipation Genitourinary: no genital discharge, no pruritus no problems in urination Endocrine: polydypsia, no heat/cold intolerance

12. Muskuloskeletal: no joint or muscle swelling, no limitation of movement, no stiffness Hematopoietic: no easy bruisability, or bleeding

13.  Born full term via NSD to a 31 year old G4P3 (3013) by an obstetrician at PCGH  with complete prenatal consults  No intake of any medications except for multivitamins  No maternal illnesses  No complications at birth

14.  Breastfed from birth to 3 months old  Bona  Supplementary foods were given at 6 month old  Current diet  Milk 4-5 bottles a day  Rice + (chicken, vegetables, w/ soup) 3x a day  Bread every morning

15.  BCG – 1 dose  DPT – 3 doses  Hep B – 3 doses  Measles – 1 dose

16.  Stands alone  Throws toys  Obeys commands or requests  Attempts to use a spoon

17. No Tuberculosis, Asthma, Trauma No previous surgeries No previous hospitalizations No Allergies

18.  Diabetes, Hypertension – father  No heart disease, cancer, stroke, kidney disease, asthma, or allergies

19.  Father works for Reagent  Mother is a housewife  Private Subdivision in Pasig City

20.  Not exposed to environmental hazards like chemicals, pollution, cigarette smoking, etc  Generally clean environment  Has their own toilet  Water comes from Manila Waters  Drinking water  mineral water

21. Physical Exam

22.  awake, active, with good cry but consolable  Not in cardiorespiratory distress

23. Vital signs Temperature – 36.5 o C CR – 112 (70-110)RR – 28 (20-30) Weight: 10.4 kg (50-75 th ) Length: 75cm (50 th ) HC: 45.5cm (50-75 th )CC: 45 cm AC: 42 cm

24.  Light brown  No rashes, hemorrhages, scars  Moist  good skin turgor  CRT 1-2 seconds

25. Head normocephalic no lesions, fontanels closed Eyes anicteric sclerae, pink palpebral conjunctiva, not sunken pupils 2-3mm Ears cone of light present inferomedially on both ears no discharge noted Nose septum medline, moist mucosa Throat mouth and tongue moist no TPC

26. Neck no cervical lymphadonapathy Supple Chest adynamic precordium no heaves, thrills, or lifts, PMI at 4 th ICS MCL slightly tachycardic, normal rhythm, distinct S1 and S2 no murmurs Lungs symmetrical chest expansion, no retractions Equal vocal fremiti Clearbreath sounds

27. Abdomen Distended, no scars, no lesions Hyperactive bowel sounds tympanitic on all quadrants no tenderness on all quadrants no masses, no organomegally liver edge palpated kidneys and spleen not appreciated

28. Glasgow Coma Scale verbal response: 5 eye opening:4 motor response: 6 total: 15 Cerebrum awake and active Cerebellum no nystagmus, tremors, or abnormal movements

29. Sensory responds to pain Motor Symmetrical general movement with good activity DTR ++ on all extremities

30. Cranial Nerves I:not elicited II:2-3mm pupils, equally reactive to light III,IV,VI:EOM’s intact V:corneal reflex present V1, V2, V3 intact (responds to touch) VII:no facial asymmetry VIII:turns to sound IX, X:gag reflex present XI:turns head from side to side XII:tongue midline

31. Salient Features, Admitting Impression, Differentials, Course in the Ward

32.  1 year month old, female  Vomiting  Acute Loose watery stools  Non-bloody, non-mucoid, non-foul smelling  Distended abdomen  Skin – good turgor, CRT 1-2 sec  Eyes not sunken  Moist oral mucosa  Hyperactive bowel sounds

33.  Acute Gastroenteritis, probably viral, with no signs of dehydration

34. Viral AGE 1 year old+ Vomiting+ Loose watery stools+ Acute+ Bloody stool- Mucoid stool- Foul smelling- Hyperactive bowel sounds+ Abdominal distention+/- Enterotoxigenic E. coli + + + + - - - + +/-

35. Viral AGEGiardia lamblia 1 year old++ Vomiting++ Loose watery stools++ Acute++ Bloody stool-- Mucoid stool-+ Foul smelling-+ Hyperactive bowel sounds++ Abdominal distention+/- Oily stool Explosive fever

36. Viral AGEFecal impaction 1 year old++ Vomiting++ Loose watery stools++ Acute+- Bloody stool-- Mucoid stool-- Foul smelling-- Hyperactive bowel sounds++ Abdominal distention+/-+ -With Hx of constipation -Vomitus with fecal material

37. Viral AGEFood Allergy 1 year old++ Vomiting++ Loose watery stools++ Bloody stool-+/- Mucoid stool-- Foul smelling-- Hyperactive bowel sounds++ Abdominal distention+/- Associated with other symptoms

38. Viral AGEShigellosis 1 year old++ Vomiting++ Loose watery stools++ Acute+- Bloody stool-+ Mucoid stool-+/- Foul smelling-+ Hyperactive bowel sounds++ Abdominal distention+/-

39.  Diagnostic  CBC with platelet count  Blood chemistry (sodium and potassium)  Urinalysis  Fecalysis  Therapeutic  IV for Hydration  Increased oral hydration  Antipyretics  Zinc supplementation  Probiotics

40. 1 st Hospital Day SOAP Poor suck Comfortable No vomiting 3 BM -2x watery with some formed -soft T: 36 o C CR: 104 RR: 30 -U/O: 1.84 cc/hr -Awake, with good cry -Good activity -Eyeballs not sunken -With tears -Clear breath sounds -Regular cardiac rate with normal rhythm -Normoactive bowel sounds -Soft and non-tender abdomen

41. 1 st Hospital Day SOAP Poor suck Comfortable No vomiting 3 BM -2x watery with some formed -soft Fecalysis -negative Blood Chemistry -Normal Na and K + Urinalysis -normal CBC -normal Acute gastroenteritis with no signs of dehydration -resolving IVF D5LR 1L 42- 43ml/hr -Small frequent feeding -avoid oily and fatty food -encourage apples and bananas -continue hydration -monitor input and output

42. 2 nd Hospital Day SOAP Good suck Comfortable No vomiting 1 BM, soft T: 36.7 o C CR: 103 RR: 28 -U/O: 1.77 cc/hr -Awake, with good cry -Good activity -Eyeballs not sunken -With tears -Clear breath sounds -Regular cardiac rate with normal rhythm -Normoactive bowel sounds -Soft and non-tender abdomen Acute Gastroenteritis with no signs of dehydration -resolved -May go home tomorrow -consume IVF then switch to oral hydration -home medications: Zinc sulfite syrup Probiotics

44.  Infections of the gastrointestinal tract caused by bacterial, viral, or parasitic pathogens  Diarrheal disorders  Term used in public health setting  Diarrhea  3 or more unusually watery stools passed in 24 hours WHO – Treatment of Diarrhea

45. > 3 years old  Viral  Rotavirus  Enteric adenovirus  Astrovirus  Norovirus  Calicivirus  E. coli, Salmonella

46.  18% of childhood deaths  >700 million episodes of diarrhea annually  < 5 years old (WHO)  Philippines  2 nd leading cause of morbidity  6 th leading cause of mortality for all ages  3 rd leading cause of infant deaths  Predominance of rotavirus and enterotoxigenic E. coli Nelson/ Carlos and Saniel, Etiology and Epidemiology of Diarrhea (1990)

47.  Most common  Diarrhea  Vomiting  May also have systemic symptoms  Abdominal pain  fever

48.  Acute watery diarrhea  Several hours to days  Acute bloody diarrhea  Persistent diarrhea  > 14 days  Diarrhea with severe malnutrition

49. Enters villi and releases viral proteins (NSP4) Feca-oral route NSP4 cause release Ca2+ intracellularly Virus infects adjacent cell NSP4 produced disrupts tight junctions Paracellular flow of water and electrolytes Ramig (2004), Pathogenesis of intestinal and systemic rotavirus infection

51. Intracellular Ca2+ cascade NSP4 causes release of more Ca2+ Disruption of microvillar cytoskeleton Intracellular Ca2+ cascade Induces chloride secretion Ramig (2004), Pathogenesis of intestinal and systemic rotavirus infection

53.  Clinical evaluation  Fecalysis  Suspected amoebiasis or giardiasis  Acute watery diarrhea ▪ Very young/elderly ▪ Immuno-compromised ▪ Severely dehydrated  Clinical presentation is atypical UMED Acute infectious diarrhea and common intestinal parasitism workbook

54.  Assess for the level of dehydration

56. No signs of dehydration  Home therapy to prevent dehydration  More fluids than usual ▪ ORS, salted drinks (salted rice water), chicken soup with salt ▪ Add salt (3g/L) for unsalted drinks and food ▪ Usual milk feed every 3 hours ▪ As much as the child wants  Frequent small feedings every 3-4 hours Failure of oral rehydration

57. For failure of ORT  ORS via nasogastric tube  IV Ringer’s Lactate Solution  75 ml/kg in 4 hours  Reassess

58. Some signs of Dehydration  Oral rehydration therapy with ORS solution  75 ml/kg/hour  If a child wants more than the estimated amount of ORS solution, and there are no signs of over-hydration, give more  Teaspoonful every 1-2minutes  Reassess

59. Severe signs of Dehydration  Admit in the Hospital  If patient can still drink poorly, give ORS until IV drip is running  5 ml/kg for 3-4 hours  IV Ringer’s lactate Solution (100 ml/kg)  1 st 30ml/kg in 1 hour  Then 70 ml/kg in 5 hours  Reassess every 15-30 minutes until strong radial pulse is present, then 1-2 hours

60.  Promotion of exclusive breast-feeding  Improved complementary feeding practices  Rotavirus immunization  Proper food preparation/ hygiene

61.  Good prognosis as long as adequate hydration has been given