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Gastroenteritis: Diarrhea & Dehydration

Jennifer Bergquist, M.D. July 20, 2005

Definition

Gastroenteritis: Acute inflammation of the lining of the stomach/intestines

Anorexia, nausea, vomiting, diarrhea, abd pain (hallmark is diarrhea)

Acute diarrhea: (<14 days)


>10ml/kg/d in infants/children (frequency) Watery, loose stools at least 3 times in 24hrs (consistency)

Epidemiology

Diarrheal disease and dehydration account for 1/3 of all deaths among infants and children under the age of 5 (worldwide) 1.5 million ED visits per year in the U.S. 200,000 hospitalizations and 300 deaths per year in the U.S. In developing countries- estimated 2 million deaths annually in children under 5

Etiology

Viral: 80% of all cases of gastroenteritis


Rotavirus- 1/3 of all gastroenteritis hospitalizations Others: Adenovirus (40/41), Norwalk, calicivirus, astrovirus

Bacterial:

Campylobacter jejuni, Salmonella, Shilgella, Yersinia, E.coli*, Vibrio Cholera*


*major causes of travelers diarrhea

Parasitic

Giardia, Cryptosporidium

Associated with outbreaks in day care centers Chronic clinical course

Diarrhea: Differential Diagnosis


Gastroenteritis (see previous slide) Other infections


OM, UTI, meningitis, pneumonia, sepsis, HIV Intussusception*, Hirschsprung disease*, partial bowel obstruction*, appendicitis* IBD, CF, celiac, lactase deficiency, IBS Congenital adrenal hyperplasia, hyperthyroidism Antibiotic-associated diarrhea, toxins, overfeeding

GI (anatomic) GI (functional)

Endocrine

Misc.
* Life-threatening conditions that should be considered during an evaluation of a child with diarrhea

Pathophysiology

Viral Invasion of enterocytes causing inflammation and cell lysis

Total gut infection within 24hrs

Immature cells repopulate the villi which have decreased absorptive capacity (decreased enzyme activity) leading to diarrhea Stimulation of water and electrolyte secretion

Diagnosis of Gastroenteritis

Clinical diagnosis Stool studies rarely indicated


Stool culture if +bloody diarrhea or recent travel history

Bacteria present in only 15-20% of these cases

C. Difficile if recently on antibiotics or prolonged hospitalization Viral studies (rotavirus, adenovirus) indicated for admission to the hospital (infection control)

Consider UA/Urine Cx <12mo w/ fever and diarrhea to r/o UTI

Dehydration

Volume depletion or dehydration occurs when fluid is lost from the extracellular space at a rate that exceeds intake. The most common sites for extracellular fluid loss are:

Gastrointestinal tract (eg, diarrhea, vomiting) Skin (eg, fever, burns) Urine (eg, glucosuria, diuretic therapy, diabetes insipidus)

Dehydration

Infants w/ diarrhea are at increased risk for dehydration for the following reasons:

Higher body surface area-to-volume ratio when compared to older children or adults Higher metabolic rate Dependent on others for fluid

Dehydration: Severity Assessment

Clinical diagnosis:

Mild (3-5%)

Moderate (6-9%) Severe (>10%)

Clinical signs are usually not evident until ~3-4% dehydration

Pre-illness weight to determine degree of dehydration is ideal but usually not realistic Determined by examiner and is based on clinical signs/symptoms Prospective study w/ 137 pts using 4 item dehydration scale (gen appearance, eyes, mucous membranes, tears). Sensitivity to predict dehydration:

Mild dehydration: 74% Moderate dehydration: 33% Severe dehydration: 70%

Physical Exam: Severity Assessment

Literature Review

Systematic review of the literature


(Steiner, et al. Is this child dehydrated? JAMA 2004; 291)

Most useful signs for predicting 5% dehydration:


Capillary refill Skin turgor Respiratory pattern

Combinations of signs are markedly better than any individual sign in predicting dehydration Laboratory tests have only modest utility for assessing dehydration

bicarbonate was the most useful laboratory test. A value below 17 meq/L differentiated children with moderate and severe hypovolemia from those with mild hypovolemia

Diagnostic Studies

Laboratory studies: No gold standard for confirming dehydration BMP indicated in pt with moderate to severe dehydration requiring IVF therapy Urinalysis for urine specific gravity?

Not found to be significantly correlated with dehydration (Steiner, et al. Is this child dehydrated? JAMA 2004; 291)

Electrolyte abnormalities

Sodium: high, low, but usually normal

Degree of dehydration can be underestimated in hypernatremic dehydration

Potassium: low or normal

Loss of potassium in stool can lead to hypokalemia; However, may be higher than expected if acidosis is present

Bicarbonate: low or normal

Metabolic acidosis occurs from: loss of bicarbonate in stool, lactic acidosis from decreased tissue perfusion and decreased acid excretion from decreased renal perfusion

BUN/Cr: normal or high

May be elevated secondary to decreased renal perfusion (BUN will increase before Cr due to incr. absorption of urea with Na and H20)

Treatment Calculation of Deficits

Estimate the degree to which the child is dehydrated (mild, moderate, severe) Estimate the fluid deficit:

10kg child, estimated at 7% dehydration Calculate weight loss: .07 X 10 = 0.7kg

Acute wt loss from diarrhea is due to water loss (not fat, bone, etc)

1 Liter = 1 Kg; therefore 700ml = 0.7kg Estimated fluid deficit is 700ml to be replaced over 3-4 hours.

Treatment: How do I replace the fluid?


Oral Rehydration Therapy is recommended by the AAP as: "the preferred treatment of fluid and electrolyte losses caused by diarrhea in children with mild to moderate dehydration".

Oral Rehydration Therapy (ORT)

Physiologic Basis:

Intestine sees 6500ml/fluid/day, which is reduced to <100ml/day of formed stool due to a large capacity to absorb water. Water absorption is passive and depends on the osmotic gradient created by sodium/carbohydrate transport

Na/H exchangers Electrochemical gradient (Na/K ATPase) Sodium-coupled transport with carrier solutes (i.e glucose)

Oral Rehydration Solutions

ORT: Rehydration Phase

Rapid replacement of fluid deficit over 3-4 hours Begin at 5ml Q5min and increase as tolerated Mild (3-5%): 50ml/kg ORS over 4hrs Moderate (6-9%): 100ml/kg ORS over 4hrs

ORT: Maintenance Phase


Maintain maintenance fluid requirements *Rapid realimentation w/ age appropriate unrestricted diet

Continued feeding slows the progression of dehydration by adding to overall available fluids and promotes mucosal recovery and improves fluid absorption Use of diluted or special formulas is unjustified

Ongoing Losses:

Replace 1cc per cc stool loss OR 10ml/kg per stool and/or 2ml/kg per emesis

Limitations to ORT

ORT should NOT be used when:


Altered mental status with concern for aspiration Abdominal Ileus Underlying disorder that limits intestinal absorption of ORT (i.e short gut, malabsorption)

Once ORT has been initiated, intervention with IVF is indicated:


If there is severe and persistent vomiting, and inadequate intake of ORS If stool output continues to be excessive, and ORT is unable to adequately rehydrate the child.

Enteral vs. IV Rehydration

Enteral Rehydration for mild and moderate dehydration has been shown to have:

Fewer side effects Lower cost Shorter treatment times Fewer admissions

IVF Rehydration

Indicated for severe dehydration or moderate dehydrated pt failing ORT Rapid rehydration approach:

Rapid IV replacement with 0.9NS or LR using 20-60ml/kg over 1-3hrs, followed by introduction of ORS This approach should ONLY be used in pts w/ routine gastroenteritis w/out complicating factors (CHF, renal disease, increased ICP, DKA, etc)

IVF Rehydration

Standard IVF Therapy w/Replacement over 24hrs Initial fluid resuscitation: 20ml/kg bolus w/ normal saline or LR

Determine fluid deficit:


Example: 12kg patient with estimated 10% dehydration Weight loss= 12 X 0.1= 1.2kg 1.2kg= 1.2L or 1200ml fluid deficit to replace over 24hrs

Replace first (600ml) over first 8hrs Replace second (600ml) over next 16hrs Remember to replace ongoing losses

Medications: Generally NOT indicated

Anti-emetics

Generally not used in pediatrics secondary to high side-effect profile Ondansetron has been found to be safe and effective in decreasing vomiting and need for admission

Antidiarrheal agents (i.e. loperamide)


Slows intestinal transit time Side Effects: Ileus, abdominal distention, sedation

Bismuth salts (i.e. pepto-bismol)


? Prevention of attachment of microorganisms to the intestinal mucosa Pediatric dosing no longer on labels due to concerns of salicylate toxicity and/or Reye syndrome

Antimicrobials

Exceptions: Giardia, Shigella, cholera, amoebiasis, ETEC Can prolong carrier state in some infections

Probiotics (Lactobacillus GG)?

References:

Behrman: Nelson Textbook of Pediatrics, 17th ed. 2004. Deficit Therapy: 245-251 Davidson G, Barnes G, Bass D, Cohen M, Fasano A, Fontaine O, Guandalini S. Infectious Diarrhea in Children: Working Group Report of First World Congress of Pediatric Gastroenterology, Hepatology and Nutrition. JPGN 2002;35:S143-S150 Farthing, MJ. Oral Rehydration: An Evolving Solution. JPGN 2002;34:S64-S67. Findberg, L. Dehydration in Infancy and Childhood. Pediatrics in Review 2002;23(8)277-282. Hoekstra, JH. Acute Gastroenteritis in Industrialized Countries: Compliance with Guidelines for Treatment. JPGN 2001;33:S31-S33. Hostetler, MA. Gastroenteritis: An Evidence-Based Approach to Typical Vomiting, Diarrhea and Dehydration. Pediatric Emergency Medicine Practice. 2004;1(5):1-17 King CK, Glass R, Bresee J, Duggan C. Managing Acute Gastroenteritis Among Children. Oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep 2003;52(RR-16):1-14 Roberts, KB. Fluid and Electrolytes: Parental Fluid Therapy. Pediatrics in Review 2001;22(11):380-387 Steiner MJ, Dewalt DA, Byerley JS. Is this child dehydrated? JAMA 2004;291(22):2746-2754.