Diarrhea Contd….

Dr Shreedhar Paudel26/03/2009

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

Dysentery…• Causes:– Shigella dysenteriae type 1

– S. flexneri

–Campylobacter jejuni

– Enteroinvasive E.coli

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

Investigations

• Stool routine and microscopic examination

• Stool culture and sensitivity

• CBC

• USG abdomen

Management of dysentery

• Dysentery should be treated in the line of shigellosis unless proven otherwise

• If diagnosed amoebic dysentery later—add antiamoebic therapy

Management…

• Four key components of the treatment

– Antimicrobials

– Fluids

– Feeding

– Follow-up

Child with loose stools with blood↓

1. antimicrobial effective for shigella in that area2. ORS to treat and prevent dehydration3. continued frequent feeding including breast feeding ↓

better in 2 days?↓ ↓NO YES↓ ↓

change to nalidixic acid complete 5-day ↓treatment

Better in 2 days?…….

…….Changed to nalidixic acid (better in 2 days??)↓

NO YES↓ ↓

Look for trophozoites of complete 5-dayE. Histolytica in stool treatment

↓Absent Present

↓ ↓Refer to hospital treat withChange to ciprofloxacin metronidazolefor shigella

Antimicrobials used in the treatment of specific causes of diarrhea in children

Cause Antibiotic of choice Alternative

Shigella dysentery

Trimethoprim(TMP)-SulfamethoxazoleTMP 5 mg/kg and SMX 25 mg/kg twice a day for 5 days

Nalidixic acid- 15mg/kg, 4 times a day for 5 daysAmpicillin- 25mg/kg 4 times a day for 5 days

Cholera Tetracycline- 12.5 mg/kg 4 times a day for 3 days

FurazolidoneTMP-SMXErythromycin

Antimicrobials used in the treatment of specific causes of diarrhea in children

Cause Antibiotic of choice

Alternative

Amoebiasis Metronidazole10 mg/kg body wt, three times a day for 5-10 days

Dihydroemetine hydrochloride in severe cases

Giardiasis Metronidazole Tinidazole

E. coli, C. jejuni None None

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

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

Risk factors for persistent diarrhea

• Malnutrition• Recent introduction of animal milk or formula• Young age• Immunodeficiency status—HIV/AIDS, measles,

malnourished child• Recent diarrhea

Persistent diarrhoea contd….• Management:

--2/3rd 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

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

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

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

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

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)

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)

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

Chronic Diarrhoea/Malabsorption Syndromes……….

• Management:–Of the underlying problem

–Avoid allergic diets

–Management of diarrhoea and dehydration- if present

Celiac Disease

• Gluten sensitive enteropathy

• Permanent intestinal intolerance to dietary wheat gliadin

• Has strong genetic association

• Immunologically mediated- cell damage

Celiac Disease……..

• Clinical features:– Chronic diarrhoea– Abdominal distension– Muscle wasting– Failure to thrive– Anorexia– Irritability– Vomiting ±

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

Celiac Disease……..

• Diagnosis:• Intestinal biopsy—villous atrophy

with hyperplasia of crypts

•A full clinical and histological remission after withdrawal of gluten from the diet

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 dramatic2) growth velocity improves very rapidly3) rice and maize are non toxic and act as wheat

substitutes

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