Diarrhea

Childhood Diarrhea Junying Qiao the department of pediatrics the third affiliatted hospital of zhengzhou university

Definition  An incr ease in the number of stools or a decrease in their consistency

 A syndrome that r esults from disor der s involving digestive , absor ptive, and secretor y functions

Definition 6m-2y Can r esult in child malnutrition and disturbance of g r owth and development

classification infectious etiology noninfectious

duration

acute ： <2weeks persistent ： 2weeks∼ 2months chronic ： >2months Mild diarrhea

degree Severe diarrhea

Susceptible factors  Immature

digestive system

 Hypoimmunity  dysbacteria  Bottle-feeding

infants

Etiology

（ Ⅰ） Infectious factors Enteropathologic infection a) Viruses rotavirus , norwalk virus , adenovirus and coronavirus b) Bacteria salmonella, shigella ， escherichia coli （ enteropathogenic E.coli,enterotoxigenic E.coli ,enteroinvasive E.coli,enterhemorrhagic E.coli,enteroadherent-aggregative E.coli). and campylobacter organisms c) Fungus candida albicans d) Parasite giardiasis , cryptosporisiosis , amebiasis, ascariasis

Parenteral infection      

upper respiratory tract infections pneumonia urinary tract infections skin infections Tympanitis communicable diseases

Parenteral infection  Abuse

antibiotics (antibiotics related diarrhea)

(Ⅱ)Noninfectious factors Dietary diarrhea overfeeding, introduction of new foods and unripe food Symptomatic diarrhea URI , pneumonia , urinary tract infections , tympanitis ~~~ Allergic milk

diarrhea

milk protein or soybean

(Ⅱ)Noninfectious factors  Lactose  Cold

enzyme deficiency

or hot weather and emotional tension

Pathogenesis

Classification • • • •

Osmotic diarrhea Secretory diarrhea Infiltrated diarrhea Altered motility diarrhea

Mechanisms of noninfectious diarrhea

 Osmotic factors • osmotic gradients cause water to passively cross intestinal mucosa in isotonic proportions • Unabsorbed solutes create osmotic gradient that results in movement of sodium and water in the intestinal lumen

Mechanisms of noninfectious diarrhea

 Diminished

absorption or increased secretion of water and electrolytes

 Altered motility both hypermotility and hypomotility reduce the amount of substance absorbed by the intestinal mucosa

Mechanisms of infectious diarrhea

Enterotoxin production organisms

multiplication

enterotoxin

mucosa

Secretion of water and electrolytes

Mechanisms of infectious diarrhea

Invasion and destruction of epithelial cells • Cause superficial ulcerations of mucosa • Infection proceeds from the upper to the lower intestines, producing bloody mucoid stools

Mechanisms of infectious diarrhea

Penetration and systemic invasion Organisms

mucosa

infection elsewhere

to the systemic circulation

(hyperemic and edematous )

Clinical manifestations

classification infectious etiology noninfectious

duration

acute ： <2weeks persistent ： 2weeks∼ 2months chronic ： >2months Mild diarrhea

degree Severe diarrhea

Acute diarrhea

(A)general Clinical manifestation Mild

diarrhea

Dietary factors, parenteral infection or enterovirus • Mainly exhibits GI symptom • Signs of dehydration and toxicosis are usually absent • Stools tests only show a few leukocytes and a great deal of lipocytes •

Severe diarrhea  Serious gastrointestinal symptoms  Disturbance of fluid ,electrolyte and acid-base balance a) Dehydration b)Metabolic acidosis c) Hypokalemia d)Hypocalcemia and hypomagnesemia

(B) characteristics of gastroenteritis  Autumn

diarrhea

 fecal-oral

Rotavirus enteritis

route or respiration

 6~24

months of age

 with

URI, fever and vomiting

 stool ：

large, watery, frequent

 dehydration

: mild / moderate

 Self-limited

3-8days

 No

specific therapy

 Higher  The

Escherichia coli. enteritis

incidence In summer

onset is gradual or abrupt

 Clinical

manifestations are variable: most-green, watery stools with blood and mucus

 Stools  3-7

cultivation

days

 Candida albicans  Ususlly associated with abuse of antibiotics

Fungal enteritis stools ： water ,bubble, mucus and bean clinker  Sporophyte and mycelium exists in stool examination

Prolonged and chronic diarrhea

Prolonged and chronic diarrhea  Associated

with malnutrion and inadequate management of acute diarrhea

 It

often occurs in children with bottlefeeding and malnutrition

Prolonged and chronic diarrhea  The

children with malnutrition have susceptibility for diarrhea. Moreover, diarrhea deteriorates malnutrition and leads to hypoimmmunity , secondary infection and functional abnormity of multi-organs.

physiological diarrhea  Commonly

appears in infants less than 6 months of age

 Diarrhea

after birth, puffiness and eczema

 Grow normally ,

good appetite, no malnutrition, no blood in their stool.

 After

increase supplemental food , stools gradually turn to normal

Laboratory test  Blood

routine  Stool examination  Biochemical examination  Blood-gas analysis

Diagnosis Clinical manifestation  physical examination  laboratory findings  Stools appearance 

Diagnosis Notice 1 Etiological diagnosis  2 Complication(dehydration disturbance of electrolyte and acid-base banlance) 

Diagnosis Judge Etiology from stool routine 1 No or little leukocyte virus, noninvasive bacteria ,parasite 　 infection or dietary factor.  2 many leukocyte or with red blood cell invasive bacteria . 

Therapy

Therapy principles • • • • •

Dietary adjustment Prevent and correct dehydration Reasonable treatment Enhance nursing Prevent complication

①adjustment of

dietary 

The foods should be continued



Adjusted to meet physiological needs and supply consumes in order to shorten the duration of recovery

②Correction of disturbance

Dehydration  Mild

and moderate diarrhea —— ORS

 Moderate

and severe dehydration —— intravenous rehydration

ORs(oral rehydration salts) (The world health organization recommended)

 Composition: – sodium chloride 3.5g – Bicarbonate sodium 2.5g – Potassium chloride 1.5g – glucose 20.0g – And water 1000ml to dissolve

 2/3

isotonic

 The

concentration of potassium is 0.15%



The goal is to maintain or restore the

normal volume and composition of body and normalize optimize cell and organ function.

The therapy has three phases • Cumulated losing volume • Losing continuing • Physiological need

A. Volume Degree

Total volume

Cumulated losing volume

physiological need, losing continuing

Mild

100 ～ 120 ml/kg

30 ～ 50ml/kg

80 ～ 100ml/kg

Moderate

120 ～ 150 ml/kg

50 ～ 100ml/kg

Severe

150 ～ 180 ml/kg

100 ～ 120 ml/kg

B. Quality Dehydrant category

Hypotonic

Cumulated physiological need, losing volume losing continuing 3:4:2

Isosmotic

3:2:1

Hyperosmotic

1/3 Sodium solution

1 /3 ～ 1 /4 Sodium solution

C. Speed Total volume

Cumulated physiological need, losing volume losing continuing

24 h

8 ～ 12 h

12 ～ 16 h

－

8 ～ 10ml / kg /h

5ml / kg /h

D. Shock volume expansion Volume

20ml/kg

Solution

Speed

2:1 or 1.4 ％ NaHCO3

30 ～ 60min

Total volume ≤ 300ml

Intravenous rehydration  Principle

1 first rapidly secondly slowly 2 first sodium secondly glucose 3 Supply potassium after urination 4 Supply calcium and magnesium when tetany and convulsion

Intravenous rehydration

 Fluid

therapy in the first day  1 Volume of fluid  2 Composition of fluid  3 Rapidity of therapy A Initial phase B Repletion phase C Stabilization Correction of metabolic acidosis 、 hypokalemia 、 Hypocalcemia and hypomagnesemia

4

Treatment of metabolic acidosis Mild or moderate metabolic acidosis metabolic acidosis: No special treatment Severe metabolic acidosis ： 5%NaHCO3 1ml/kg [HCO3-] level can increase about 1 mmol.

Treatment of hypokalemia noticed  Daily dosage of supplemental potassium is 3~4mmol/kg(200~300mg/kg)  Concentration less than 0.3% by IV  Transfusion duration more than 8 hours daily  Avoiding IV push  Supplement lasting 4 to 6 days  Normal renal function (Supply kalium after urination urination 6 hours of preadmission)

Treatment of Hypocalcemia and hypomagnesemia 　 — 10% calcium gluconate5-10ml 　 dissolved 　 10% glucose solution10-20ml intravenous IV slowly ，平均 1ml/min 。 ----25%magnesium sulfate 0.1mg/Kg each time injection intromusculari in deep part ， once every 6h 。

Intravenous rehydration

 The

second day  1 Volume  2 Solution  3 Speed  4 Correction of metabolic acidosis and hypokalemia § Supply what losed

Drug therapy 1

Control infection  2 Micecological therapy  3 Intestinal mucosa protective agent (protectant)  4 Avoid using antidiarrheal

Control of infection Etiologic treatment  Virus infection dietary therapy supportive therapy self-limited  Bacteria ,fungus and parasite specific antimicrobial therapy

Control of infection  Dietary 、

Virus and noninvasive bacteria diarrhea----Need

no antibiotics  Invasive

bacteria diarrhea---- Need antibiotics  G+ coccus----penicillin, vancocin 万古霉素 ,  rifampin 利福平  G- bacillus---- 头孢曲松 ceftriaxone, 　 ofloxacin 氧氟沙星 　庆大霉素 cidomycin  Fungus ---- 氟康唑 fluconazol 　

Micoecological therapy ： help recove the normal bacteria population in intestinal lumen, prohibit the pathogen permanent planting and invasion, control the diarrhea.  Drug : 双歧杆菌 bacillus bifidus 　 bacillus acidi-lactici 乳酸杆菌　粪链球菌 fecal streptococci, 　　需氧芽孢杆菌 aerobic sporebearing bacilli, 　 Such as jinshuangqi mamiai  Aim

 Intestinal

mucosa protective drug can absorb the pathogen and toxin ， maintain the absorb and secetory function of enterocyte ， prevent the attack of pathogen (montmorillonite powder) 蒙脱石散．  Avoid using antidiarrheal 　洛哌丁醇　 　 inhibit gasenterokinesia, increase bacteria multiplication and toxin absorption ， it is dangeriou to infectious diarrhea.

Treatment of prolonged and chronic diarrhea 1.Look fof cause positively 2. Disturbance of fluid ,electrolyte and acid-base

balance

3Dietary adjustment 4.Drug Supply microelement and vitamin ； cautiously using antibiotics ； use micoecological therapy and intestinal mucosa protective drug 5.Chinese medicin

Prevention