3rd year, 3rd rotation

1. DIARRHEABy: Syed Ariff Amir Syed Awaly

2. TOPICS Definition Epidemiology Types of diarrhea Causes Acute Diarrhea

3. DEFINITION According to WHO - passage of 3 or more loose or liquid stools per day, or more frequently than is normal for the individual.

5. In the year 2000, diarrheal diseases claimed an estimated 1.4 to 2.5 million lives; they are among the leading causes of death in children in developing countries

6. In developed nations , they are an important cause of hospital admission although mortality rates may be lower.

8. CAUSES OF DIARRHEA IN INFANT ACUTE Common causes: Gastroenteritis Systemic infection Antibiotic associated Rare causes: Primary disaccharidase deficiency Hirschsprung’s toxic colitis Adrenogenital syndrome CHRONIC Common causes: Post-infectious secondary lactase deficiency Cow’s milk/ soy protein intolerance Toddler’s diarrhea Coeliac disease Cystic fibrosis AIDS enteropathy Rare causes: Primary immune deficiency Familial villous atrophy Secretory tumor Short bowel syndrome

9. CAUSES OF DIARRHEA IN CHILDREN ACUTE Common causes: Gastroenteritis Food poisoning Systemic infection Antibiotics associated Rare cause: Toxic ingestion CHRONIC Common causes: Post-infectious secondary lactase deficiency Irritable bowel syndrome Coeliac disease Lactose intolerance Giardiasis Inflammatory bowel disease AIDS enteropathy Rare causes: Acquired immune defect Secretory tumor Pseudo-obstruction

10. ACUTE DIARRHEA

12. Giardiasis

13. Food poisoning

14. Drugs

15. NSAIDs

16. Antibiotics

17. Viral

18. Rotavirus

19. Norovirus

20. Bacterial

21. Vibrio cholera

22. E. coli

23. Salmonella*

24. Shigella*

25. Campylobacter*

26. Clostridium defficile** Associated with bloody diarrhoea

28. Duration & frequency of diarrhea

29. Presence of blood or steatorrhoea

30. Abdominal pain

31. Tenesmus

33. Pulse and BP measurement

35. Serum electrolyte

36. Blood and urine culture

37. Stool inspection for blood and examination for ova, cysts and parasites

40. Give ORS and cooled boiled water

41. Plus food-based fluid (not exclusively breastfed)*10ml/kg of ORS after each loose stool

44. Becomes sicker

45. Develops fever

47. Select appropriate treatment

48. Begin feeding the childExplain the 3 rules of PLAN A

50. Reassess the child every 1-2 hour during rehydration

51. Give ORS as soon as the child can drink.

52. Classify the degree of dehyration

54. 6 to 1 year : 120 ml/kg/day

55. >1 year : 1st 10 kg = 100 ml/kg 10- 20 kg = + 50 ml/kg for the subsequent kg > 20 kg = + 20 ml/kg for the subsequent kg

57. Toxic looking

58. Severe dehydration

59. Blood in stool

60. Types of Antibiotics:-

61. Ampicilin

62. Trimethoprim (TMP)

64. Chief Complaint: “Sally has a fever and is vomiting.” History of Present Illness A 4-year-old female is brought to the emergency dept. by her parents. She started complaining of abdominal pain 3 hrs ago and then had an onset of vomiting episodes x 4. No blood noted in the emesis or bile appearance. Temperature taken at home one half hour ago, temperature was 38.2 C. Mother has also commented on Sally’s increased level of thirst over the past week, and has attributed Sally’s new onset of night time bedwetting to her increased consumption of fluids. CASE SCENARIO

65. Vomiting is a coordinated, sequential series of events that leads to forceful oral emptying of gastric contents. DEFINITION

66. –Duration, frequency, bilious material, abdominal pain, diarrhea, hematemesis, hematochezia, melena, headache, fever, dysuria, weight loss, urine output –Sick contacts, cough, rhinorrhea, neck stiffness Family history: Genetic disease Hx of vomiting

67. –Vital signs, weight, mucous membranes, nasal discharge, breath sounds, rashes –Abdominal pain/distension, hepatosplenomegaly, abdominal masses, Murphy/obturator/psoas sign –Skin turgor, capillary refill –Neuro exam including funduscopy for papilledema Physical exam

68. Bilateral vomition centers in the reticular formation of the medulla integrate signals triggers vomition.Thevomition centers receive afferent signals from four major sources: The chemoreceptor trigger zone -bilateral set of centers in the brainstem lying under the floor of the fourth ventricle. The chemoreceptor trigger zones function as emetic chemoreceptors for the vomition centers - chemical abnormalities in the body (e.g. emetic drugs, uremia, hypoxia and diabetic ketoacidosis) are sensed by these centers, which then send excitatory signs to the vomition centers. Visceral afferents from the gastrointestinal tract (vagus or sympathetic nerves) Visceral afferents from outside the gastrointestinal tract - this includes signals from bile ducts, peritoneum, heart and a variety of other organs. Afferents from extramedullary centers in the brain - certain psychic stimuli (odors, fear), vestibular disturbances (motion sickness) and cerebral trauma Physiology of vomiting

70. Nausea - unpleasant psychic experience. Retching phase - abdominal muscles undergo a few rounds of coordinated contractions together with the diaphragm and the muscles used in respiratory inspiration. Expulsive phase - intense pressure is formed in the stomach brought by enormous shifts in both the diaphragm and the abdomen. The vigorous contractions of these muscles last much longer than a normal period of muscular contraction. The pressure is then suddenly released when the upper esophageal sphincter relaxes resulting in the expulsion of gastric contents. VOMITING PHASES

71. VOMITING Manifested by nausea, pallor and diaphoresis, followed by forceful gagging and retching. REGURGITATION Effortless and not preceded by nausea. But , the unpleasant sensations of gastric contents in mouth during regurgitation, may trigger gagging and true vomiting.

72. Gastric secretions are highly acidic. Recent food Malodorous. Blood “coffee ground vomiting"(as the iron in the blood is oxidized) Bile Fecal vomiting-consequence of intestinal obstruction or a gastrocolic fistula non-productive emesis or dry heaves-vomiting reflex continues for an extended period with no appreciable vomitus Contents

73. Bright red-bleeding from the oesophagus Dark red vomit with liver-like clots- profuse bleeding in the stomach (e.g.; perforated ulcer) Coffee ground-like vomit-less severe bleeding in the stomach-gastric acid has had time to change the composition of the blood Yellow vomit-bile indicates that the pyloric valve is open and bile is flowing into the stomach from the duodenum. Color

74. FBC U & E Creatinine Stool serology Abdominal X-Ray Surgical opinion if obstruction Exclude systemic disease INVESTIGATIONS

75. Aspiration of vomit Under normal circumstances the gag reflex and coughing will prevent this from occurring. The individual may choke and asphyxiate or suffer an aspiration pneumonia. Dehydration and electrolyte imbalance Tears in GIT If these tears are limited to the inner lining of esophagus, they are called Mallory-Weiss tears-Passing of bright red or dark blood in the vomitus. Tears through the entire wall of the esophagus resulting in perforation and the escape of stomach contents outside the gut- “Boerhaave’s syndrome Painful bruises or tears in the abdominal wall muscles. Dentistry Recurrent vomiting may lead to destruction of the tooth enamel due to the acidity of the vomit and also can degrade tissue of the gum. If prolonged, weight loss or malnutrition may occur. Complications

76. Stabilize patient and fluid resuscitation as initial therapy with electrolyte correction Surgical consultation if obstruction suspected Oral rehydration with small amounts of liquids if tolerated Treat infections if indicated Remove toxins and allergens Surgical interventions for volvulus, Hirschprung, intracranial masses, pyloric stenosis, other anatomic causes Correct metabolic derangements Lifelong gluten-free diet for celiac disease Rare use of antiemetics/promotility agents for chemotherapy, motion sickness, postsurgery, gastroesophageal reflux disease Treatment

77. ABDOMINAL PAIN Acute and recurrent

80. Described as MSK pain

83. Diagnostic Approach history onset- sudden or gradual, episodes, association w meals, history of injury Nature – sharp vs dull, colicky or constant, burning Location – epigastric, periumbilical,generalized, R or L lower quardrant, change in location over time Fever – presence suggests appendicitis or other infection Extraintestinal symptoms – cough, dyspnea, dysuria, urinary frequency, flank pain Course of symptoms – worsening or improving, changes in nature or location of pain

85. Abdominal – tenderness, distention, bowel sounds, rigidity, guarding, mass

86. Genitalia – testicular torsion, hernia, PID, ectopic pregnancy

87. Surrounding structures – breath sounds, rales(crepitation), wheezing, flank tenderness, tenderness of abd. wall structures, ribs, costochondral joints

89. AST, ALT, GGT, Bilirubin – biliary or liver dss

90. Amylase, lipase - pancreatitis

91. Urinalysis – UTI, bleeding d/t stone, trauma or obstruction

93. CT scans – rule out abscess, appendicitis, Crohn dss, pancreatitis, gallstones, kidney stones

94. Barium enema - Intussusception, malrotation

97. DISTINGUISHING C.FEATURES

99. APPENDICITIS

100. APPENDICITIS Clinical Features Lower abdominal pain- right iliac fossa,Nausea and vomiting,loss of appetite,Diarrhoea,Dysuria Physical Findings quiet ,dehydrated.Tenderness on palpation or percussion ,discomfort, Guarding signifies peritonitis, Rectal examination is only required if other diagnosis are suspected e.g. ovarian or adnexal pathology.

109. Severe phase lasting at least 3 mins

110. Usually in children above 3 yr old.Occurrence of multiple episodes of abdominal pain over at least 3 months that are severe enough to cause some limitation of activity

112. If any warning signs are presents, further investigation is necessary.

115. ESR

116. Amylase, lipase

117. Urinalysis

118. Abdominal ultrasound

119. Trial of 3- day lactose-free diet

120. CT scan

121. Celiac disease serology

122. Barium upper GI

123. Endoscopy

125. IBS*

126. Chronic pancreatitis

127. Gallstones

128. Peptic disease - duodenal ulcer, gastric ulcer, esophagitis

129. Lactose intolerance*

130. Fructose malabsorption

131. Inflammatory bowel disease* - crohn’s disease, ulcerative colitis

132. Constipation*

133. Obstructive uropathy

134. Congenital intestinal malformation – stricture or web, malrotation, duplication cyst

136. Not assoc. with or relieved by eating/ defecation

137. Assoc. with sig. loss of ability to function normally.

138. These kids have personality traits that include tendency towards anxiety & perfectionism – results in stress

140. Pain begin with a change in stool frequency /consistency.

141. A stool pattern fluctuating between diarrhea and constipation.

142. Relief of pain with defecation

143. Symptom are link to gut motility

145. Allows children to resume with daily activities

146. Reassures that the although pain is there, will not harm the children physically (in case of FAP)

147. IBS-can control symptoms with diet, stress management, and prescribed medications.