Paediatric Continuing Medical Education (CME)

Presented by : Dr Emir Afif bin Mohamad Azlan

ACUTE GASTROENTERITIS

Patient Details• Initial : CY• MRN : 597736• Age : 5 years old• Gender : female• Weight : 21 kg• Race : Chinese• Nationality : Malaysian• Current address : Mount Kiara• Duration of hospitalization : 17 – 20 January 2016 (4

days)

CASE PRESENTATION

Presented with:

1) Fever - since 1 day - started during midnight 1 day prior admission- no documented temperature at home

2) Diarrhoea - started since midnight 17/02/16 - initially had diarrhea every 30 minutes, more frequent towards next morning every 3-5 minutes - watery in nature, yellowish in colour- non blood stained, no mucus

- a/w abdominal pain, colicky in nature, mainly prior to going to toilet

HISTORY OF PRESENT ILLNESS (HOPI)

•3) vomiting - started on morning day of admission- after taking food or drinking - contained food particle and fluid - non blood stained, non billious - vomit more than 20 times

4) Reduce oral intake - only taking minimal fluid

• Usually eat at caretaker during the day. only having dinner at home. • Claimed that on the day before admission, she eat Roti canai at the caretaker. • Mother denies child took any outside food • Otherwise, no cough no other children at caretaker having same problem. claimed only had children with UTI. no rapid breathing No rashes/bleeding tendencies No recent travelling/swimming/jungle trekking

• Delivered full term via SVD• No antenatal/post natal problems. • No prior history of hospitalizations. • No known allergies / medical illness

PAST MEDICAL/BIRTH HISTORY

• Gross motor : able to ride bicycle• Fine motor : able to draw house, sea• Speech : able to make sentences • Social : able to toileting herself without help, able to

play cards

IMP : Development appropriate to age.

DEVELOPMENT HISTORY

FEEDING HISTORY

• Breastfeeding until 4 months old• Since then started on complimentary diet

• Up to age.

• Lives in Mount Kiara• Only child• Stayed with her grandmother. • went to caretaker during the day

IMMUNIZATION HISTORY

SOCIAL HISTORY

SEEN BY ED TEAM

•Acute GastroEnteritis with 5% dehydration

PROVISIONAL DIAGNOSIS

UPON PEADS REVIEW IN OBAY

Started in ED :

ivd FM HSD5% run at 63cc/hr + 5% correction NS run at 44cc/hr)

Supp pcm 250mg stat given at 7.45pmsyrup pcm 8ml given by mother at 9.45pm

ADMITTED IN WARD 2C AT 01.05AM ON 18/02/16

• 5 years old Chinese female child presented with fever 1 day prior admission, followed by diarrhea and vomiting, associated with reduce oral intake.

• During physical examination in casualty, child had signs of dehydration : mild coated tongue, very lethargic , eyes sunken

SUMMARY

Acute GastroEnteritis with 5% Dehydration

FINAL DIAGNOSIS

no Points to support Points to against

Food poisoining

fever Vomiting Diarrhea Colicky abd pain dehydration if severe

• No history of taking outside food

Acute appendicitis

Fever Vomiting Abdominal pain

• Abdominal pain not aggravated by movement

• No rebound tenderness (Blumberg sign)

DIFFENTIAL DIAGNOSIS

>>

[weight 21kg] • IVD full maintenance Half saline D5% run at 63cc/hr + 1

g KCl • IVD 5 % correction NS run at 44cc/hr over 24 Hours• FBC, RP, VBG• ORS per purge • Strict IO charting• Encourage orally• send stool culture and stool for rotavirus• smecta

MANAGEMENT :

[17/2/16 ]

FBC : Hb 13.9, WBC 13.7, Plt 398, Hct 43.4 RP : Na 134, K 3.8, urea 6.2, creat 76 BUSE : U 9.1/Na 133/K 3.3/Cl 108

[18/02/16]

RP at 1 am : U 9.2/Na 135/K 3.6/Cl 105/Creat 75 FBC : wcc 11.1/hb 12.6/hct 38.1/plt 394 CRP : 10.1 RP at 2 pm : U 10.6/K 3.8/Na 132/Creat 88/Cl 105 rotavirus : positive

Urine C&S : not takenUrine FEME : not takenStool C&S : No enteric pathogen isolated  Blood C&S : no growth

BLOOD INVESTIGATION

19/2/16 RP: U 8.4/ Na 136/ Creat 73/ K 3.8/ Cl 109

20/2/16 RP: u 4.6/ Na 137/ K 3.5/ Cl 112/ creat 64

BLOOD INVESTIGATION

Child was allowed home on 20/01/2016 in view of : afebrile >24Hours Oral intake improving BO back to normal consistency, no more loose stool Clinically improved

• Rotavirus Acute GastroEnteritis with 5% dehydration

FINAL DIAGNOSIS

ACUTE GASTROENTERITIS

• Acute gastroenteritis is a leading cause of childhood morbidity and mortality and an important cause of malnutrition.

• Dehydration and electrolyte losses associated with untreated diarrhea are the main causes of morbidity and mortality of childhood AGE

• Diarrhea can also be the initial signs of non-gastrointestinal tract illness, including meningitis, bacterial pneumonia, otitis media, intussusception and UTI

INTRODUCTION

• The passage of unusually loose or watery stools, usually at least 3 times in a 24-hour period.

- College of Paediatrics, Academy of Medicine of Malaysia (AMMCOP) , 2011

DEFINTION

ETIOLOGY

Acute Gastroenteritis

Viruses.

•Rotavirus (most common).•Calicivirus.•Astrovirus.

Bacteria•Campylobacter jejuni.•Salmonella.•Shigella.•E.coli.•Clostridium difficile.

Parasites.•Entamoeba histolytica.•Giardia lamblia.

CLINICAL TYPES OF DIARRHOEAL DISEASES

• Moderate to severe dehydration. • Need for intravenous therapy (as above). • Concern for other possible illness or uncertainty

of diagnosis. • Patient factors, e.g. young age, unusual

irritability/drowsiness, worsening symptoms. • Caregivers not able to provide adequate care at

home. • Social or logistical concerns that may prevent

return evaluation if necessary.

INDICATIONS FOR ADMISSION TO HOSPITAL

• Objectives : to assess whether the child is dehydrated and to determine the etiology of the acute gastroenteritis

HISTORY AND PHYSICAL EXAMINATION

PHYSICAL EXAMINATION

ASSESMENT & MANAGEMENT OF

ACUTE GASTROENTERITIS

DEGREE OF DEHYDRATION

• Start intravenous (IV) or intraosseous (IO) fluid immediately. • If patient can drink, give ORS by mouth while the drip is

being set up. • Initial fluids for resuscitation of shock: 20 ml/kg of NaCl

0.9% or Hartmann solution as a rapid IV bolus. • Repeated if necessary until patient is out of shock or if fluid

overload is suspected. • Review patient after each bolus. • Calculate the fluid needed over the next 24 hours: • Fluid for Rehydration (fluid deficit) + Maintenance (minus

the fluids given for resuscitation). • Fluid for Rehydration: % dehydration X body weight (g) • Maintenance fluid (NaCl 0.45 / D5%) 1st 10 kg = 100 ml/kg; 10-20 kg = 1000 ml/day + 50 ml/kg for each kg above 10 kg >20 kg = 1500 ml/day + 20 ml/kg for each kg above 20 kg.

PLAN C: TREAT SEVERE DEHYDRATION QUICKLY

CLINICAL FEATURES OF SHOCK

• Unconscious child. • Continuing rapid stool loss ( > 15-20ml/kg/hour). • Frequent, severe vomiting, drinking poorly. • Abdominal distension with paralytic ileus, usually caused

by some antidiarrhoeal drugs (e.g. codeine, loperamide ) and hypokalaemia.

• Glucose malabsorption, indicated by marked increase in stool output and large amount of glucose in the stool when ORS solution is given (uncommon).

• IV regime as for Plan C but the replacement fluid volume is calculated according to the degree of dehydration. (5% for mild, 5-10% for moderate dehydration).

OTHER INDICATIONS FOR INTRAVENOUS THERAPY

• Stool culture is required if the child appears septic, if there is blood or mucus in the stool or child is immunocompromised• Full blood count• Renal profile (plasma electrolytes, urea, creatinine) & blood glucose if IVD required or there is features suggestive of hypernatremia• Blood culture if to start antibiotics

INVESTIGATIONS

• Oral rehydration therapy.– Use to treat mild to moderate dehydration.– Consist of :

i. Sodium chloride (NaCl).ii. Potassium chloride (KCl).iii. Trisodium citrate.iv. Glucose.

PHARMACOLOGICAL AGENTS

Antimicrobials Antibiotics

• Majority of gastroenteritis cases in children are viral in origin (rotavirus, norovirus, adenovirus). Thus, antibiotics are only needed for specific pathogens or defined clinical settings.

• Antibiotics are indicated in the following situations:Shigella dysentery - in cases presenting as bloody diarrhoea, should be treated with an antimicrobial effective for

ShigellaWhen cholera is suspectedWhen diarrhoea is associated with another acute infection

such as pneumonia and UTIMay be indicated for Salmonella gastroenteritis in very

young babies (< 3 months), immune-compromised, immuno- suppressed, systemically ill, achlorhydia

PHARMACOLOGICAL AGENTS

THE MANAGEMENT OF ACUTE DIARRHOEA

THE MANAGEMENT OF ACUTE DIARRHOEA

Silicates – diosmectite (Smecta®)

• Binds to selected bacterial pathogens and rotavirus• restore integrity of damaged intestinal epithelium• reduce stool output and duration of diarrhoea• shown to be effective in rotavirus diarrhoea• maybe used as adjunctive to ORS• no side effects

ANTI-DIARRHOEAL AGENTS AND OTHER THERAPIES

Antiemectics• Anti-emetics such as dimenhydrinate, metoclopromide, domperidone and promethazine may cause sedation that can interfere with oral rehydration therapy

PHARMACOLOGICAL AGENTS

ANTI-DIARRHOEAL AGENTS AND OTHER THERAPIES

• Probiotics – Probiotics has been shown to reduce duration of diarrhoea in

several randomized controlled trials. – However, the effectiveness is very strain and dose specific.– Only probiotic strain or strains with proven efficacy in

appropriate doses can be used as an adjunct to standard therapy.

• Zinc supplements – Able to reduce the duration and severity of the episode and

lower the incidence of diarrhoea in the following 2-3 months. – WHO recommends zinc supplements as soon as possible after

diarrhoea has started. – Dose up to 6 months of age is 10 mg/day, and age 6 months and

above 20mg/day, for 10-14 days.

PHARMACOLOGICAL AGENTS

• Undiluted vs diluted formula - No dilution of formula is needed for children taking

formula milk.

• Soy based or cow milk-based lactose free formula - Not recommended routinely. - Indicated only in children with suspected lactose

intolerance.

NON PHARMACOLOGICAL / NUTRITIONAL STRATEGIES

SPECIAL CONSIDERATION

Type of Dehydration.

Isonatraemic.

•Sodium losses = water losses.

•Plasma sodium remains within normal range

Hyponatraemic

•Sodium losses > water loses.

•E.g : children with diarrhea drink large quantities of water or other hypotonic solutions

•Shift of water water from extra- to intracellular compartment

•Increase in brain volume convulsion

•More common in poorly nourished infants (in developing countries)

Hypernatraemic.

•Water losses > sodium losses.

•Usually result from high insensible water losses (high fever or hot, dry environment) or from profuse, low sodium diarrhea

•Shift of water from intra-cellular into extracellular space

•Transient hyperglycemia occurs in some

• Acute gastroenteritis is usually self-limiting, but if untreated it can lead to morbidity and mortality secondary to water loss and electrolyte and acid-base disturbance. • Dehydration secondary to gastroenteritis is a

significant cause of morbidity and hospital admission• Parent should diligent hand washing and do

not sharing same towel with infected child• Child should not return to childcare or school

until 48 weeks after last episode of diarrhea

TAKE HOME MESSAGE

1. Paediatric Protocol (Malaysia) – 3rd Edition2. Guideline on the Management of Acute Diarrhea in

Children, College of Paediatrics, Academy of Medicine of Malaysia (AMMCOP), (2011)

3. Nelson Textbooks of Pediatric 20th edition (2016)4. Ilustrated Textbooks of Paediatrics – Elsevier 4th

Edition, (2012)

REFERENCE

THANK YOU