Acute Gastroentritis

Name: nur aisyah binti idris

Matrix no.: 68

Chronic diarrhea

• An insidious onset diarrhea of >2weeks duration in children & >4weeks in adults.

• Term not synonymous with persistent diarrhea

Approach• Age of onset

• Small or large bowel type of diarrhea- features in history & examination

-large volume diarrhea without blood & mucus suggest small bowel types

-small volume stool with blood & mucus suggest large bowel type.

• Gastrointestinal versus systemic causes

• Age of onset

Age < 6 month Age >6month-5years Age > 5years

Cow milk Protein Allergy (CMPA)LymphangiectasiaUTIShort Bowel syndromeImmunodeficiency statesCystic fibrosisAnatomical defectsAutoiimuneenteropathy

Cow milk protein allergyCeliac diseaseGiardiasisToddler diarrheaLymphangiectasiaShort bowel syndromeTuberculosisInflammatory Bowel DiseaseImmunodeficiencyBacterial overgrowthPancreatic insufficiency

Celiac diseaseGiardiasisGastrointestinal tuberculosisInflammatory bowel diseaseImmunodeficiencyBacterial overgrowthLymphangiectasiaTropical sprueImmunoproliferativesmall intestinal diseasePancreatic insufficiency

• Small or large bowel type of diarrhea

Features Small bowel diarrhea Large bowel diarrhea

Stool volumeBlood in stoolRectal symptoms( urgency, tenesmus)SteatorrheaCarbohydrate malabsorptionProtein malabsorptionPain

Color of stoolSmell of stoolNutrient deficiency

LargeNoNoYesYesYesPeriumbilical, no reduction after passage of stoolPaleUnusually offensivefrequent

SmallUsually presentYesNoNoNoHypogastric, reduced after passage of stool

NormalNormalCan occur due to blood loss

Celiac disease• Enteropathy caused by

permanent sensitivity to gluten

• Most common cause of chronic diarrhea in children over 2 years

• High risk group: types 1 DM, Down syndrome, selective IgA deficiency, autoimmune thyroid disease, turner syndrome, williams syndrome, autoimmune liver disease, first degree relatives of celiac disease.

Sign & symptoms:

• Small bowel diarrhea• Growth failure• Anemia• Loss of subcutaneous fat• Clubbing• Sign of other vitamin

deficiencies

Investigation• Serology IgA antibody against tissue transglutaminase Recommend for initial testing High sensitivity& specificity IgA antiendomysial antibody equal accurate test Should not based only on celiac serology

• Upper GI endoscopy Shows absence of fold/ scalloped folds Endoscopic biopsies should be taken

• Histology Increased intraepithelial lymphocytes Increased crypt length Partial–total villous atrophy Decreased Villous:crypt ratio Infiltration of plasma cells & lymphocytes in lamina propria

Treatment

• Life long GFD

• Correction of iron

• Folate

• Vitamin/ mineral supplementation

Cow Milk Protein Allergy

• Affects 2-5% of all children in west- high 1Years of life

• In India, account for 13%of all malabsorption cases in children <2years

• Family history of atopycommon in children with CMPA

• 50% outgrow of allergy by 1 year, 95% by 5 years

• 2 reactions to cow milk: 1) immediate2) delayed

Sign & symptoms• Diarrhea with blood & mucus• May have small bowel, large

bowel / mixed type diarrhea• Reflux symptoms• Hematemasis• Respiratory symptoms• Atopic manifestations• Iron deficiency anemia• Hypoprotenemia• Eosinophilia

Investigation

• Sigmoidoscopy

• Rectal biopsy

• Food allergy elimination & challenge test

Treatment

• Milk product have to be removed from diet

• Soy / extensive hydrolised formula used as alternative

• calcium supplementation.

Intestinal lymphangiectasia

• Characterized by ectasiaof the bowel lymphatic system which on rupture causes leakage of lymph in bowel.

• Often associated with abnormal lymphatics in extremities

Sign & symptoms:• Peripheral edema(bilateral & pitting /asymmetrical & non pitting)• Diarrhea• Abdominal distension• Abdominal pain• Abdominal/thoracic

chylous effusion• Hypoalbuminemia• Low immunoglobulins• Hypocalcemia• lymphopenia

Investigation

• Barium meals

• Endoscopy

• Duodenal biopsy

Treatment

• Low fat, high protein diet with MCT oil, calcium & fat soluble vitamin supplementation

• Iv albumin( symptomatic management)

• Total parenteral nutrition ( manage chylous effusion)

• resection

Inflammatory bowel disease

• Chronic inflammatory disease of GIT

• 2types: Crohn disease , ulcerative colitis

• 25% of all IBD presents in pediatric age group

• Age presentation ~10-11yr

• Genetic risk factor

Clinical features

• UC-diarrhea & rectal bleeding

• CD-abdominal pain, diarrhea & growth failure, fever, fatigue, anorexia

• Extraintestinalmanifestation-altralgia, uveitis,erythemanodosum, sclerosingcholangitis

Crohn disease Ulcerative colitis

Distribution

Bloody diarrheaAbdominal painGrowth failurePerianal diseaseSerology

Endoscopy

Histopathology

Entire gastrointestinal tractDiscontinuous lesionLess commonCommonCommonAbscess, fistulaeAnti sacchromyces cereviisaeantibody (ASCA) positiveDeep irregular serpigenous/ aphthous ulcers with normal intervening mucosa

Transmural inflammation with non caseatinggranuloma

Colon onlyContinuous involvementCommonLess commonLess commonAbsentPerinuclear anti neutrophiliccytoplasmic antibody (p-ANCA) positiveGranularity, loss of vascular pattern, diffuse ulceration

Mucosal disease with cryptitis, crypt distortion, crypt abscess & goblet cell depletion.

Evaluation

• Detailed clinical, family & treatment history

• Rectal examination

• Simple lab test- ESR, hemogram, c reactive protein, total protein

• Upper GI endoscopy with biopsy

• BMFT, CT enteroclysis

Treatment

• 5-aminosalicylates

• Steroids

• Immunomodulators

• Monoclonal antibodies

• Calcium& vitamin D supplementation

• Surgery- hemorrhage, perforation, obstruction

Abdominal tuberculosis

• GIT, peritoneum, lymph node & solid vicera can involved in abd. TB

• Peritoneal 2 types: wet & dry type

• Intestinal – ulcerative, hypertrophic/ ulcerohypertrophic type

Clinical presentation

• Chronic diarrhea

• Features of subacuteintestinal obstruction

• Ascites

• Lump in abdomen

• Systemic manefestation

Investigation

• FNAC from lymph node

• Endoscopic biopsies

• Ziehl-Neelson staining

• CT abdomen- shows enlarged lymph nodes with central necrosis

Treatment

• Antitubercular drugs

Isoniazid

Rifampicin

Pyrazinamide

Ethambutol

• Surgery- bowel perforation, obstruction, massive hemorrhage

Acute gastroentritis

EtiologyViral: norovirus, rotavirus, calcivirus, astrovirus, enteric adenovirus

Bacterial: campylobacter, salmonella, shigella, EHEC, ETEC, clostridium difficile

Parasite: giardia, cryptosporidium

Non infectious: food allergy, intolerance & malabsorption

pathophysiology• Damage to the villous brush

border of the intestine, causing malabsorption of intestinal contents & leading to osmotic diarrhea

• Release of toxins that bind to specific enterocyte receptor & cause release of chloride ions into the intestinal lumen ,leads to secretory diarrhea.

• Sign & symptoms

• Diarrhea

• Vomitting

• Abdominal pain

• Increase / decreaase in urinary frequency

• Fever, chills, myalgias

• Weight loss, lethargy, irritability

Investigation

• CBC

• Stool culture

• Urine culture

Treatment

• Plan A

• Plan B

• Plan C

Reference

• Essential Pediatrics, OP Ghai, 8th edition

• www.medscape.com

Thank You