Diarrhea in pediatrics patients

 Diarrhea in pediatrics

Content:

1.  Definition
2. Clinical features
3. Causes
4. Sign and symptoms
5. Investigation
6. Treatment
7. Prevention

Definition:

1. The term 'diarrhea refers to frequent loose stool' (example: more than three times a day.)
2. Most children with diarrhea have an viral infection.
3. Diarrhea is not a disease it is a symptoms of certain illness.
4. Although the diarrhea is common and rarely serious because it can leads to dehydration. Which alters the child natural balance of water, and to electrolyte ( sodium, potassium, chloride) imbalance.
5.   A more exact definition is excessive daily stool liquid volume (>10 ml stool/kg body weight/day)

What is not a diarrhea?

Frequent passage of soft and semi solid stools in an exclusively breast feeding children No changes in no of consistency or number of stools

Dysentery

 Diarrhea with visible blood in the faeces is called as dysentery. Important effect of dysentery include anorexia, rapid weight loss, and damage to the intestinal mucus.

Classification

 Depending on the onset; 

1. Acute diarrhea, (>2weeks)
2. Persistent diarrhea. (long lastin for2 weeks)
3. chronic diarrhea,(2– 4 weeks)

1. Acute diarrhea:

• Acute diarrhea has rapid onset usually infective in origin along with fever, headache, myalgia, anorexia,malaise and vomiting. Diarrhea evolving over a minutes to hours and lasting for not more than two weeks. It could be due to viral, bacterial or protozoal infection. So it is called as non-specific diarrhea or gastro enteritis

2. chronic diarrhea:

• Chronic diarrhea is defined as diarrhea lasting for>4 weeks usually as a symptom of systemic disease. Chronic diarrhea is due to disease that causes inflammation of the bowel and/or malabsorption of nutrients

3. Persistant diarrhea: 

•  Diarrhea that starts as anacute episode,and lasts at least 14 days is said to be persistent(PD).

Causes:

Acute causes:

 Bacterial ; 

1. Staphylococcus aureus
2. Bacillus cereus
3. Clostridium perfrigens
4. E.coli
5. Vibrio parahaemolyticus
6. Salmonella
7. N.gonorrhoeae
8. Listeria monocytogenes
9. Clostridium difficile

Viral:

1. Rota virus
2. Cytomegalo virus
3. Noro virus

Protozoal; 

1. Cryptosporidium Cyclospora
2. Entamoeba histolytica

CAUSES OF CHRONIC DIARRHEA:

• Osmotic diarrhea[intake of sorbitol, lactulose]
• Secretory diarrhea
• Hormonally mediated[medullary carcinoma of thyroid, zollinger –ellison syndrome 
• laxatives 
• Bile salt malabsorption
• 3. Inflammatory bowel disease[ulcerative colitis,crohn’s disease] 
• 
•  4. Motility disorder[post surgical;vagotomy,partial gastroctomy, irritable bowel syndrome]
•  5.   Malabsorption syndrome[celiac sprue ,Whipple’s disease ,chronic pancreatitis] 
• 6.   Chronic infections[parasites;entameoba histolytica,giardia lamblia,intestinal TB] 
• 7.  Intake of antacids and laxatives 
• 8.  Lymphoma of intestine,adenocarcinoma colon  

3.persistant diarrhea:

infectious diarrhea 

• There is no single microbial cause of presistance diarrhea. cryptospordia and E coli bacteria may play a greater role than other agents.
• Persistant diarrhea should not confused with chronic diarrhea.

Non infectious diarrhea 

• Which refer to recurrent or long lasting diarrhea, due to inherited metabolic disorder or sensitivity to gluten  

4.traveller diarrhea:

1. Travelers diarrhea refers to diarrhea occuring in person travelling from resource rich to resource poor region of the world 
2. Mostly benign and self-limited usually due to contaminated food and water in diving habits and poor sanitation
3. Pathogens responsible;E.coli,salmonella, campylobacter, rota virus,giardia,entamoeba histolytica.
4. Mostly ocurs between 4-14 d after arrival with abdominal cramps,vomiting,fever,malaise

• 
  

Weaning of babies:

1. Weaning is the process of stopping your body with breast milk
2. Idealy the first step toward weaning your body is introducing complementary foods alongside your breast milk around the age of 6month
3. The weaning process- continues until breastmilk is completely replaced by other  drinks and vegetables.
4. You can start with single vegetables & fruits.  

Clinical features:

1. Fever(more than 102degree or higher) 
2. Headache 
3. Dry mouth 
4. Chills
5.  Bloody stools(Hematochezia)
6.  Nausea or vomiting 
7. Abdominal pain
8.  Loss of appetite 
9. Weight loss
10.  Stools containing blood or pus

Investigation:

• History taking
• Examination
• Laboratory history

History taking:

• Resistance
• Occupational exposure
• Duration of diarrhea
• Frequency and quantity of stools
• Appearance of stools
• Presence of blood or any mucous Associated vomiting
• History of abdominal pain,
• fever
• Urine output Food history[any food poisoning or pathogens]
• Recent antibiotic use[suggest antibiotic induced diarrhea due to C.difficile]
• History of immuno compromised state

Examination:

1. Luecocyte count
2. Urea and creatinine
3. Serum electrolytes and blood culture Stool analysis-24 hrs stool fat estimation,
4.  testing for presence of laxatives USG 
5. abdomen GI 
6. scopy[colonoscopy,sigmoidoscopy]
7. CT abdomen
8. Intestinal aspirates and quantitative culture to rule out bacteria in small bowel
9. Low faecal PH suggest carbohydrate malabsorption Other findings like hormonal excess are ruled out [serum gastrin, calcitonin,thyroid function test

Treatment of Diarrhea:

• In acute diarrhea it is an emergency where extensive fluid loss and dehydration may present
• Aim of the treatment is to restore the fluids and electrolytes rapidly with monitoring pulse, BP, CVP, and urine output

Fluid and electrolytes replacement:

• It is significant in diarrhea since dehydration is a major cause of death.
• 
  
• If Pt is able to take orally oral fluid replacement in mild to moderate dehydration(ORS)
• IV rehydration in Pt who are in severe dehydration[elders,infants]

ORS (Oral rehydration salt):

1. ORS is a mixture of glucouse and electrolytes for using in treating of dehydration 
2. Mixture of salt and glucouse is termed ORS 
3. When ORS is dissolved in water

Benefits of ORS:

1. Replace water and salt losts during diarrhea 
2. Reduce dehydration
3.  Decrease in severity of diarrhea and vomiting

 ORS unsuccessful in:

1.  patient with very rapid stool loss
2.  Patient with glucouse malabsorption in such case ORS causes stool volume to increase.

Zinc therapy:

1. Zinc is a micronutrient and it's promotes the immunity.
2. Its an important antioxidant and preserve cellular membrane integrity
3. Rich sources: meet and fish it also present in nuts, seeds
4. Zinc cannot be stored in the body and zinc excretion through the gastrointestinal tract is increased during episode of diarrhea.

  Zinc benefites:

1. Zinc reduce the salt and fluied loss in stool by improving mucosal permeability.
2. Accelaration regeneration of mucosa
3. Enhanced cellular immunity
4. Zinc improve absorption of ORS

•  Reduce the severity and duration of illness 
• Reduces the need for antibiotics
•  Reduce the chance of complication   

Dosage of zinc:

1. Avaliable in zinc tablet.
2. Given for 14 days for full benefits
3. 20 mg per day for children older than six months
4. 10 mg per day in those younger than six month.

Drug therapy:

ANTIMOTILITY AGENTS: 

• [loperamide,diphenoxylate\atropine combination decrease the frequency and quantity of diarrhea]avoided in infective diarrhea.  

ANTISECRETORY AGENT: 

• Racecadotril[inhibits secretory of water and electrolytes,dose 100mg Usefull in acute watery diarrhea but contraindicated in renal failure, pregnancy and breast feeding .

ANTISPASMODIC: 

• Dicyclomine, hyoscine can be used in Pt with cramping abdomen pain 

ANTIBIOTICS:

• Moderate to severe with fibrile dysentery-quinoline like ciprofloxacin[500mg bid for3-5D
• Metronidazole for suspected giardiasis or amoebiasis[400mg tid for5-7d] 
• Antibiotic therapy should be given in immuno compromised patients

Prevention:

Primary prevention:(to reduce disease transmission) 

1. Roto virus, measles virus vaccines. 
2. Hand washing with soap.
3.  Provide adequate & safe drinking water 
4. Environment santization Avoid raw food items 

Secondary prevention:(to reduce disease severity) 

1. Promote breast feeding 
2. Vitamin A supplementation
3.  Treatment with zink 

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