X:VIMSUPDATES 6AprilNew IAP UG Teacing Module ......• Secondary carbohydrate intolerance – by...
Transcript of X:VIMSUPDATES 6AprilNew IAP UG Teacing Module ......• Secondary carbohydrate intolerance – by...
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IAP UG Teaching slides 2015‐16
PERSISTENT DIARRHOEA
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IAP UG Teaching slides 2015‐16
DEFINITION
• Prolongation of acute diarrhoea / dysentery for more than 14 days
• Generally associated with weight loss.
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IAP UG Teaching slides 2015‐16
PROTRACTED DIARRHOEA
• Prolongation of acute diarrhoea or dysentery >14 days – Persistent Diarrhoea
• Persistent diarrhoea – associated weight loss & extreme malnutrition – Protracted Diarrhoea
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IAP UG Teaching slides 2015‐16
CAUSE OF PERSISTENT DIARRHOEA
• Persistent infection with one or more enteric pathogens
• Secondary malabsorption of carbohydrates & fat.• Intestinal parasitosis.• Dietary protein allergy/intolerance.
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IAP UG Teaching slides 2015‐16
PATHOLOGY
• Damage to the absorptive mucosal surface of small intestine
• Delay in repair of the damaged epithelium (Normal <5 days)
• Carbohydrate, fat and protein mal ‐ absorption ensues as consequence
• Direct absorption of macromolecules leads to protein allergy.
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IAP UG Teaching slides 2015‐16
• Mild form– Several motions– No significant weight loss– No significant dehydration
• Moderate form– Several motions– Marginal weight loss– Without dehydration– Non tolerance to
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PATHOLOGY CONT..
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• Severe form– Dehydration with several motions– Weight loss– Non tolerance to milk & cereals– Secondary infection often coexists
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IAP UG Teaching slides 2015‐16
DIAGNOSIS
• Assess dehydration.
• Assess malnutrition.
• Stool ‐ R/E, Culture, Reducing sugar
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IAP UG Teaching slides 2015‐16
MANAGEMENT
• Mild form ‐ Try low milk formula feeds.
• Moderate form ‐ Do not try milk, permit cereal based feeds.
• Severe form– Phase I: Resuscitation < 24 hours– Phase II: Partial parenteral nutrition (1‐4 days), IV fluids, colloid, antimicrobials, electrolyte balance
– Phase III: Nutritional rehabilitation with calorie dense, > 5 days, lactose free formulae
If fails ‐ Chicken/egg white, glucose, oil ‐ feedIf fails ‐ Total parenteral nutrition
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IAP UG Teaching slides 2015‐16
INDICATIONS FOR ANTIMICROBIALS
• Presence of gross blood in stool/Dysentery• Associated systemic infection.• Severe malnutrition.• Cholera
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IAP UG Teaching slides 2015‐16
VITAMIN AND MINERAL SUPPLEMENTATION
• Twice the RDA of vitamins and minerals.• Special attention for Vit. A and Zn.• In malnutrition :
– Magnesium sulphate IM– Potassium oral.
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IAP UG Teaching slides 2015‐16
PREVENTION
• Promotion of breast feeding.• Active management of acute diarrhoea.• Appropriate dietetic management.• Judicious administration of drugs.
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IAP UG Teaching slides 2015‐16
CHRONIC DIARRHOEADefinition
• Diarrhoea of more than 2 weeks duration.
OR
• 3 attacks during last 3 months, without specific congenital, biochemical or metabolic disorders.
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IAP UG Teaching slides 2015‐16
COMMON CAUSES OF CHRONIC DIARRHOEA
• Post gastroenteritis malabsorption syndrome.• Protein‐energy malnutrition.• Cow’s milk /soy protein intolerance.• Primary/Secondary disaccharidase deficiencies.• Cystic fibrosis.• Intestinal parasites – Giardia, EH, Cryptosporidia.• Excessive consumption of carbonated fluids.• Intestinal infection – Enteropathogens, M.tuberculosis.• Tropical sprue.• Inflammatory bowel disease – • Crohn’s disease, Ulcerative colitis.
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IAP UG Teaching slides 2015‐16
EVALUATION OF PATIENTS WITH CHRONIC DIARRHOEA
PHASE – I• Clinical History.• Nutrition assessment.• Stool exam – pH, reducing substances,
leukocyte count, fat, ova, parasites.• Stool culture.• Stool for Clostridium difficile toxin.• Blood studies – CBC, ESR, Electrolytes, Urea, Creatinine
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IAP UG Teaching slides 2015‐16
EVALUATION OF PATIENTS WITH CHRONIC DIARRHOEA – Contd..
PHASE ‐ II • Sweat chloride.• 72 hours stool fat estimation.• Stool electrolytes, Osmolarity.• Stool for phenolphthalein, magnesium sulphate, phosphate.
• Breath H2 test.
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IAP UG Teaching slides 2015‐16
EVALUATION OF PATIENTS WITH CHRONIC DIARRHOEA – Contd.
PHASE ‐ III • Endoscopic studies.• Small bowel Biopsy.• Sigmoidoscopy or colonoscopy with biopsies.• Barium studies.
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IAP UG Teaching slides 2015‐16
EVALUATION OF PATIENTS WITH CHRONIC DIARRHOEA – Contd.
PHASE ‐ IV • Hormonal studies
– Vasoactive intestinal polypeptide.– Gastrin.– Secretin.– 5‐hydroxyindoleacetic assay.
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IAP UG Teaching slides 2015‐16
THERAPY
• Depends upon the cause.• Secondary carbohydrate intolerance – by reduction of the sugar load.
• Lactase for digestion of lactose.• Post gastroenteritis malabsorption – Needs predigested formula.
• Specific diseases to be treated.
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IAP UG Teaching slides 2015‐16
DYSENTERY
• It is a Syndrome of Bloody diarrhoea with visible red blood, fever, abdominal cramps, rectal pain & tenesmus, mucoid stool.
• Does not include :‐ – Blood streaks on formed stool.– Microscopic red blood cell in stool.– Melena.
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IAP UG Teaching slides 2015‐16
CAUSES OF DYSENTERY
• Shigella• Entero‐ invasive & Entero‐ hemorrhagic E.coli (EIEC&EHEC)
• Salmonella• Campylobacter jejuni• Entamoeba histolytica
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IAP UG Teaching slides 2015‐16
PATHOGENESIS
• Spread by feco‐oral contamination.• Bacterial invasion of colonic epithelium.• Results in inflammatory colitis.• Recto sigmoid area maximally affected.• Host defense
– Copious mucoid secretion – Epithelial regeneration.
• Shigella causes disease with 10 to 100 organisms
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IAP UG Teaching slides 2015‐16
CLINICAL SPECTRUM
• Watery diarrhoea to fatal dysentery.• Incubation period – 12 hours to 1 week.• High fever.• Abdominal cramps.• Vomiting• Abdominal tenderness & rectal tenderness.• Blood & mucus in the stool.• Tenesmus and straining.• Rectal Prolapse.• Self limiting course in most bacterial infection in 10 days.• Bacteremia is uncommon.
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IAP UG Teaching slides 2015‐16
COMPLICATIONS
• Seizures – Mostly with Shigella‐ shig(Type –I)• Dyselectrolytemia & dehydration• Rectal prolapse• Malnutrition – Protein losing enteropathy.• Hemolytic Uremic Syndrome.• Non suppurative arthritis.
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IAP UG Teaching slides 2015‐16
DIAGNOSIS
• Stool Examination – for leukocytes, RBCs, trophozoites of EH
• Stool Culture• Peripheral blood smear – Leukocytosis with more band cells.
• Blood culture in toxic, malnourished & very young infants.
• Electrolytes in severe dehydration.
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IAP UG Teaching slides 2015‐16
ANTIMICROBIALS IN DYSENTRY
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IAP UG Teaching slides 2015‐16
ANTIMICROBIALS THAT SHOULD NOT BE USED FOR SHIGELLOSIS
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IAP UG Teaching slides 2015‐16
HIGH RISK FACTORS IN DYSENTRY WITH
HIGHER MORTALITY RATE
• Infants < 1 year• Non breast fed babies.• Dehydration• Malnutrition • H/o Convulsion or measles• Infants
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IAP UG Teaching slides 2015‐16
THERAPY FOR AMOEBIC DYSENTRY
• Diloxanide furoate – 20mg/kg/day in 3 divided doses X 10 days
• Metronidazole – 35 – 50mg/kg/day in three divided doses X 10 days
Alternative• Paromomycin ‐ 25‐30 mg/kg/day in 3 divided doses X 5 to 10 days.
• Dehydroemetine hydrochloride – 1.0 to 1.5 mg/kg/day IM X 5 days
• For severe cases two oral medicines can be combined.
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IAP UG Teaching slides 2015‐16
CONTROL
• Prevention of feco‐oral transmission.• Breast feeding• Hand washing before handling food.
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IAP UG Teaching slides 2015‐16
Thank You
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