Acute diarrhea in children Its management and complications.
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Transcript of Acute diarrhea in children Its management and complications.
ACUTE DIARRHEA
By: Ritu Rajan
Diarrhea Definition
Term ‘diarrhea’ (Greek) means ‘to flow through’
Diarrhea is defined as a change in consistency and frequency of stool, i.e. liquid or watery stools, that occur > 3 times a day.
However it is the recent change in consistency & character of stools rather than the number of stools that is more important.
If there is associated blood in the stools, it is termed as dysentery.
ClassificationDiarrhoea is classified as:-On the basis of duration:-Acute ------------------------------------------ if <1weeks,
Persistent ----------------------------------- if 1–2 weeks,
Chronic -------------------------------------- if >2weeks
On the basis of site of pathologySmall Bowel Diarrhea
Large Bowel Diarrhea (Dysentery/ Colitis/ Invasive diarrhea)
What is not a diarrhea ???????
Frequent defecation but with formed stool.Semi-liquid stool at breast feeding.Stool just after feeding (in 1st year infants) Yellow-green liquid stool on 3rd – 6th days
after birth .
Epidemiology of childhood diarrhea Globally it is the 2nd most common cause of child deaths. Diarrhea accounts for 9% of all under five deaths. A loss of more than 0.71 million child live per year. It killed more than 1,600 children under five years of age
every day. Most of these deaths occurs among children less than 2 years. For a children aged under 5 years a median of 3 episodes of
diarrhea occurred per child year.
Cont.…
In India Acute diarrheal disease account for about 8% of death
in under 5 years age group. During the year 2013, about 10.7 million cases with
1,535 deaths were reported in India.
EDIDEMILOGICAL DETERMINANTSETIOLOGYBacterial Viral ParasiticOthers
COMMON CAUSES OF DIARRHEA- BACTERIA Escherichia coli:
(ETEC,EPEC,EIEC, EHEC, EAEC),
Shigella: S.sonnei, S.flexneri, S.boydii & S.dysenteriae,
Vibrio cholera, Salmonella, Campylobacter
species
Areomanas species Bacillus cereus Clostridium difficile
& pefringens, Staphylococcus
aureus, Vibrio
parahemolyticus, Yersinia
enterocolitica, Plesiomonas
shigelloides
COMMON CAUSES OF DIARRHEA- VIRUS
Rotavirus Human caliciviruses: Norovirus spp.;Sapovirus spp. Enteric adenoviruses Astroviruses, Coronaviruses, Cytomegalovirus, Picornavirus
COMMON CAUSES OF DIARRHEA- PARASITE
Giardia lamblia,Cryptosporidium parvum,Entamoeba histolytica,Cyclospora caytanensis,Isospora belli,Balandidium coli,Blastocystis hominis,Encephalitozoon intestinalis ,Trichuris trichiura
COMMON CAUSES OF DIARRHEA-OTHERS
• Metabolic diseaseHyperthyroidismDiabetes mellitusPancreatic insufficiency
• Food allergyLactose intolerance
• Antibiotics• Irritable bowel syndrome
CRYTOSPORIDIUM
ST OR ST/LT ETECSHIGELLA SPP.
ADENOVIRUS
AREOMONAS SPP.
EPEC
NOROVIRUS
V.CHOLERAE
E.HISTOLYTICA
ROTAVIRUS
For age group0-11 months
CRYTOSPORIDIUMST OR ST/LT ETEC
SHIGELLA SPP.
ADENOVIRUS
AREOMONAS SPP.
EPEC
NOROVIRUS
V.CHOLERAE
SAMONALLA
ROTAVIRUS
For age group12-23 months
ROTAVIRUS
CRYTOSPORIDIUM
ST OR ST/LT ETEC
SHIGELLA SPP.
E. HISTOLYTICA
AREOMONAS SPP.
NOROVIRUS
SAPOVIRUS
V.CHOLERAE
SAMONELA
For age group24-59 months
Risk factors Poor sanitation Personal hygiene Non availability of safe drinking water Unsafe food preparation &practices Lack of exclusive or predominant breast feeding Malnutrition (with micronutrient malnutrition vitamin A & zinc deficiency) Measles Hypo- or achlorhydria Selective IAg deficiency HIV
SEASONALITY
Disease Common season
Cholera Winter
Rotavirus diarrhea Winter
Shigellosis Dry summer and rainy season
Modes of transmission Most of the diarrheal agents are transmitted by the faecal-
oral route.•Faecal-oral transmission may be: water- borne;
food –borne: ordirect transmission which implies via fingers, or fomites
or dirt which may be ingested by young children
Physiological disturbance in diarrhea TOTAL BODY WATER (TBW) 65%-75%
ECF (25%) ICF (45%)
CIRCULATING BLOOD
INTESTINAL FLUID
SECRETION
DIARRHEA LOOSE FROM ECFWHICH IS RICH IN SODIUM & LOW POTTASSIUM
LOSS OF WATER FROM BOBY
REDUCTION OR SHRINKAGE OF ECF VOLUME
EXCESSIVE SODIUM LOSS IN STOOLS
RELATIVE DECLINE IN SERUM SODIUM
FALL IN ECF OSMOLALITY
MOVEMET OF WATER FROM ECF TO ICF CAUSES FURTHER SHRINKAGE OF ALREADY REDUCE ECF
COMPARTEMENT
HYPONATREMIC DEHYDRATION
Mechanisms of DiarrheaPRIMARY MECHANISM DEFECTSecretory Decreased absorption, increased
secretion, electrolyte transportOsmotic Maldigestion, transport defects ingestion
of unabsorbableIncreased motility Decreased transit timeDecreased motility Defect in neuromuscular unit(s) Stasis
(bacterial overgrowth)Decreased surface area (osmotic, motility)
Mucosal invasion
Decreased functional capacity
Decreased Inflammation, decreased colonic reabsorption, increased motility
VIRAL AGENTS CAUSING diarrheaGASTROENTERITISMAJOR VIRUSES OTHER VIRUSES (MINOR):
1. Rotavirus2. Enteric adenoviruses3. Noroviruses : a. Norwalk-like
viruses b. Calicivirus c. Astrovirus
1. Coronaviruses2. Parvoviruses
ROTAVIRUS
Family Reoviridae
Genus Rotavirus
ROTAVIRUS
• 60-80nm in size
• Non-enveloped virus
• Double capsid
• EM appearance of a wheel with radiating spokes
• Icosahedral symmetry• double stranded (ds) RNA in 11 segments
•Genome is composed of 11 segments of double-stranded RNA,
six structural VP1-7
coding for proteins
six nonstructural NSP1-6
PATHOGENESISTRANSMISSION:- Person to person via the faeco-oral routeAfter oral inoculation ---------- infect cells in the villi and enterocytes of small intestine -------- leads to cell death and sloughing of villus ---------- ---resulting in villus blunting ----------causes loss of absorptive function due to the destruction of mature enterocytes --------- causes osmotic diarrhea Also produces secretory diarrheaRotavirus --------- opening of calcium channel ---------- influx of calcium and efflux of sodium and water (NSP4)INTRAENTROCYE CALCIUM ALSO LEAD TO CELL DEATH
WATER FOLLOWS THE MOVEMENT OF ELECTROLYTES AND GLUCOSE
Glucose, Na+, K+, Cl-, Water
Gut lumen
Enterocyte
Villus Tip: Absorption
Crypt: Secretion
NORMAL STATE
NORMAL VILLI BLUNTED VILLI
Destruction of enterocytes:
rotavirus,
Defective absorption
Hypersecretion:
rotavirus,
IMBALANCE BETWEEN ABSORPTION AND SECRETION
ACUTE WATERY DIARRHEA (VIRAL)
Clinical features
Vomiting Diarrhea watery & without blood or visible mucus Fever Dehydration(lethargy and even shock) Transient lactose intolerance --- perianal excoriation
Bacterial AGENTS CAUSING diarrhea
Vibrio cholera (serogroups O1 & O139) Escherichia coli (EHEC,ETEC) Shigella Salmonella Campylobacter
cholera
Vibrio cholereamotile, gram negative, non spore forming
v.choleraeo139
o1Classic
Eltor
pathogenesis
Bacteria -------- reaches to small intestine -------- multiplying in intestinal epithelium -------- produces enterotoxin (CT) -------- attached to GM1(ganglioside receptor) -------- cAMP -------- fluid secretion (rich in k+ & bicarbonates)
CT also inhibit absorption of sodium and chloride Cause massive water and electrolyte loss.
CLINICAL FEATURE: CHOLERA
Rice-watery stool Marked dehydration Projectile vomiting No fever or abdominal pain Muscle cramps Hypovolemic shock Scanty urine
E.coliGram negative, rod shaped, motile by peritrichate flagella.Types of diarrheagenic E.coli:-
Enterotoxigenic E. coli (ETEC)Enteroinvasive E. coli (EIEC)Enteropathogenic E. coli (EPEC)Enterohemorrhagic E. coli (EHEC) (E. coli O157:H7)
Enteroaggregative E. coli (EAggEC)
Pathogenesis
CLINICAL FEATURE: E. COLI DIARRHEA
Watery stoolsVomiting is commonDehydration moderate to severeFever– often of moderate gradeMild abdominal pain
shigella
Gram negative, rod shaped, non motile, non capsulated.Cause bacillary dysentery.The major serotypes of Shigella that cause diarrhea are:
Dysenteriae type 1 or Shigella shigaShigella flexneriShigella sonneiShigella boydii
pathogenesis
Shigella spp.Superficial invasion of colonic mucosa
Which invade through M cell located over peyer patchesAfter phagocytosis
Transmigration of neutrophils in the lumen of colon
Neutrophilic necrosis & degranulation
Further breach of the epithelial barrier
Mucosal destruction
CLINICAL FEATURE:SHIGELLOSISFrequent passage of scanty amount of stools, mostly
mixed with blood and mucusModerate to high grade feverSevere abdominal crampsTenesmus– pain around anus during defecationUsually no dehydration
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