8951863 Acute Gastroenteritis

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    by

    Harold Rugnao

    DIARRHEA

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    ESSENTIAL CONCEPTS OF DIARRHEA DIARRHEA

    passage of unusually loose or watery stools, at least 3x ina 24 hr period

    CLINICAL TYPES OF DIARRHEA

    Acute watery diarrhea

    Acute bloody diarrhea

    Persistent diarrhea Diarrhea with severe malnutrition

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    ESSENTIAL CONCEPTS OF DIARRHEA Dehydration

    Deficit of water and electrolyte

    Malnutrition Zinc Deficiency

    Use of antimicrobials and anti-diarrheal drugs

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    Important Microbial Causes of Acute Diarrhea

    in Infants and Children Rotavirus

    Escherichia Coli

    Enterotoxigenic

    Localized adherent

    Diffuse Adherent

    Enteroinvasive

    Enterohemorrhagic

    Shigella

    Campylobacter jejuni

    Vibrio cholerae 01 and0139

    Salmonella

    Giardia duodenalis

    Entamoeba histolytica

    Cryptosporidium

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    ASSESSMENT OF CHILD WITH DIARRHEA1. History

    2. Physical Exam

    3. Determine Degree of Dehydration and selecttreatment plan

    4. Diagnose other important problems

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    ASSESSMENT OF DIARRHEA PATIENTS FOR

    DEHYDRATION

    A B C

    LOOK AT: CONDITION

    EYES

    THIRST

    Well, alert

    Normal

    Drinksnormally, notthirsty

    Restless, irritable

    Sunken

    Drinks eagerly,thirsty

    Lethargic orunconscious

    Sunken

    Drinks Poorly or not

    able to drink

    FEEL: SKIN PINCH Goes backquickly

    goes back slowly goes back very slowly

    DECIDE NO SIGNS

    OFDEHYDRA-TION

    SOME SIGNS OF

    DEHYDRATION

    SEVERE SIGNS OF

    DEHYDRATION

    TREAT Usetreatment

    plan A

    Weigh the patient,use Treatment

    Plan B

    Weigh the patient, useTreatment Plan C

    URGENTLY

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    ESTIMATED FLUID DEFICIT

    Assessment Fluid deficit as%of body wt

    Fluid deficit inml/kg body wt

    No signs of

    dehydration

    10% >100 ml/kg

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    Management of Acute Diarrhea (without

    blood) Objectives:

    Prevent dehydration, if there are no signs of dehydration

    Treat dehydration, when it is present Prevent nutritional damage

    Reduce the duration and severity of diarrhea and theoccurrence of future episodes

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    Plan A

    Treat Diarrhea at Home1. GIVE EXTRA FLUID TELL THE MOTHER

    Breastfeed frequently and for longer at each feed

    If the child is exclusively breastfed, give ORS or clean waterin addition to breastmilk

    If the child is not exclusively breastfed give one or more ofthe following: ORS, food base fluids, or clean water

    TEACH THE MOTHER HOW TO MIX ORS

    Home made solution: 3g/l of table salt (one level tspful)and 18g/l of common sugar

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    SHOW THE MOTHER HOW MUCH FLUID TO GIVE INADDITION TO THE USUAL FLUID INTAKE

    Up to 2 years 50 to 100ml after each loose

    stool

    2 years or more 100 to 200 ml after each loose

    stool

    Oldre children as much fluid as they want

    Tell the mother to

    give frequent small sips from a cup

    If the child vomits, wait 10 mins. Then continue, but more slowly

    Continue giving extra fluid until the diarrhea stops

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    2. GIVE SUPPLEMENTAL ZINC- 10 20mg to the child everyday for 10 14 days

    3. CONTINUE FEEDING- To prevent malnutrition

    4. TAKE THE CHILD TO A HEALTH WORKER IF

    THERE ARE SIGNS OF DEHYDRATION OROTHER PROBLEMS- Starts to pass many watery stools- Repeated vomiting- Becomes very thirsty

    - Eating or drinking poorly- Develops fever- Blood in the stool- Child does not get better in 3 days

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    Plan B

    Treat Some Dehydration with ORSGive in clinic recommended amount of ORS over 4-hour period

    DETERMINE AMOUNT OF ORS TO GIVE

    DURING FIRST 4 HOURS*AGE Up to 4 mos 4 mos up to

    12 mos12 mos to 2yrs

    2 yrs to 5yrs

    WT < 6 kg 6 < 10 kg 10

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    AMOUNT OF ORS TO GIVE DURING FIRST 4HOURS

    *AGE Up to 4mos

    4 mos upto 11mos

    12 mosto 23mos

    2 yrs to 4yrs

    5 14yrs

    15 yrs orolder

    WT < 5 kg 5 7.9kg

    8 10.9kg

    11 15.9kg

    16 29.9kg

    30 kg ormore

    In ml 200

    400

    400

    700

    700

    900

    900

    1400

    1200

    2200

    2200

    4000

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    *Use the childs age only when you do not know the weight. Theapproximate amount of ORS required (in ml) can also becalculated by multiplying the childs weight (in kg) times 75

    for infants under 6 mos who are not breatfed, if using the oldWHO ORS solution containing 90mmol/L of sodium also give100-200ml clean water during this period. However if using thenew reduced (low) osmolarity ORS solution contining

    75mmol/L of sodium, this is not necessary For infants under 6 mos who are not breastfed, also give 100

    200 ml of clean water during this period

    If the child wants more ORS than shown, give more

    Note: during initial stages of therapy, while still dehydratedadults can consume upto 750ml/hr if necessagry, children up to20ml/kg/hr

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    SHOW THE MOTHER HOW TO GIVE ORSSOLUTION

    AFTER 4 HOURS

    Reassess the child and classify the child for dehydration

    Select the appropriate plan

    Begin feeding the child

    MEET NORMAL FLUID NEEDS

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    IF THE MOTHER MUST LEAVE BEFORECOMPLETING TREATMENT

    Show her how to prepare ORS Show her how much ORS to give to finish the 4-hour

    treatment at home

    Give her enough ORS packets to complete hydration

    Explain the 3 rules of HOME TREATMENT1. Give extra fluid

    2. Continue feeding

    3. When to return

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    WHEN ORAL REHYDRATION FAILS

    Continuing rapid stool loss (>1520 ml/kg/hr)

    Insufficient intake of ORS owing to fatigue or lethargy Frequent, severe vomiting

    GIVING ZINC

    GIVING FOOD

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    Treatment Plan C for patients with severe

    dehydration1. GUIDELINES FOR INTRAVENOUSREHYDRATION

    Give 100ml/kg Ringers Lactate Solutiona divided asfollows:

    Age First give 30ml/kg in: Then give 70ml/kg in:

    Infants (under12 months)

    1 hourb 5 hours

    Older 30 minutesb

    2 hoursReassess the patient every 1 2 hrs. If hydration is not improving, give the IV dripmore rapidlyAfter 6 hrs (infants) or 3 hrs (older patients), evaluate patient using the assessmentchart. Then choose the appropriate Treatment Plana

    if Ringers Lactate Solution is not available, nomal saline may be usedb Repeat once if radial pulse is still very weak or not detectable

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    2. MONITOR THE PROGRESS OF INTRAVENOUSREHYDRATION

    3. ELECTROLYTE DISTURBANCES Hypernatremia

    Serum Na > 150mmol/L

    Can cause convulsions

    Hyponatremia Serum Na < 130mmol/L

    Lethargy, less often, seizures

    Hypokalemia

    Serum K+

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    Management of Suspected

    Cholera Cholera differs from acute diarrhea of other causes in 3ways: It occurs in large epidemics that involve both children

    and adults

    Voluminous watery diarrhea may occur, leading rapidlyto sever dehydration with hypovolemic shock

    For cases with sever dehydration appropriate antibioticsmay shorten the duration of the illness

    Antimicrobial Therapy

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    Management of Acute Bloody Diarrhea

    (Dysentery) Shigella is the most common cause of bloody diarrhea

    Ciprofloxacin for 3 days

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    Out Patient Management of Bloody Diarrhea

    CHILD WITH LOOSE STOOLSWITH BLOOD

    SEVERELY MALNOURISHED?

    GIVE ANTIMICROBIAL FORSHIGELLA

    BETTER IN 2 DAYS?

    No

    No

    REFER TO

    HOSPITALYes

    COMPLETE 3DAYSTREATMENTYes

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    INITIALLY DEHYDRATEDAGE< 1Y/O OR MEASLES

    IN PAST 6 WEEKS

    CHANGE TO SECONDANTIMICROBIAL FORSHIGELLA b

    BETTER IN 2 DAYS?

    No

    COMPLETE 3DAYS

    TREATMENTYes

    REFER TOHOSPITALYes

    REFER TO HOSPITAL ORTREAT FOR AMOEBIASIS

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    Management of Persistent

    Diarrhea Persistent Diarrhea Diarrhea, with or without blood, that begins acutely and lasts at

    leat 14 days.

    Usually associated with weight loss, and often, with seriousnon-intestinal infections

    Objective of treatment is to restore weight gain and

    normal intestinal function by: Appropriate fluids to prevent or treat dehydration

    A nutritious diet that does not cause diarrhea to worsen

    Supplementaryvitamins and minerals

    Antimicrobials to treat diagnosed infections

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    Treat in the Hospital:

    Children with serious systemic infection

    Children with signs of dehydration

    Infants below 4 months of age

    Prevent or treat dehydration

    Identify and treat specific infections

    Give a nutritious diet

    Give supplementary multivitamins and minerals

    Monitor response to treatment

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    Management of Diarrhea with Severe

    MalnutritionAssess for Dehydration

    Manage Dehydration

    Feeding Use of antimicrobials

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    Prevention of Diarrhea Breastfeeding

    Improved feeding practices

    Use of safe water Handwashing

    Food safety

    Use of latrines and safe disposal of stools

    Measles immunization

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