Acute Gastroenteritis

dr Tjatur Winarsanto SpPD.

 Definitions
 Diarrhea : excessive loss of fluids &
electrolytes in stool
 More than 5g /kg /day
 Increase in liquidity & frequency
 Pseudodiarrhea & hyperdefecation
 Encopresis
 Dysentery : small volume ,
frequent,bloody, tenesmus , urgency
 Diarrhea
 9 liters of fluid enter the GI tract
 4-5l absorbed in jejunum , 3-4
ileum, 800 ml in colon.
 Water transport follows Na & nutrient
active & passive transport .
 The basis for ORS treatment
 Mechanisms of diarrhea
 Disturbed intestinal solute transport,
water movement across intestinal
wall.
 Secratory
 Osmotic
 Dysmotility
 Inflammatory
 Secretory Diarrhea
 Agent that binds to surface receptors ,
increasing cAMP,increased secretion.
 Watery , large volume , normal
osmolality( 2* Na+K )
 Persists during fasting,no stool leukocytes.
 Examples; cholera, toxigenic
E.coli,carcinoid ,VIP, congenital chloride
diarrhea,Clostridium
difficile,cryptosporidium.
 Osmotic Diarrhea
 Occurs after ingesting a poorly absorbed
solute .
 Stools are of less volume, acidic, reducing
substances, high osmolality > 2* Na + K.
 Stops with fasting , increased breath
hydrogen with malabsorption,no stool
leukocytes.
 Examples : lactase deficiency , glucose-
galactose malabsorption,lactulose,
laxative abuse.
 Motility Diarrhea
 Increased motility :
 decreased transit time.
 Stimulated by gastro-colic reflex
 Irritable bowel syndrome
 Thyrotoxicosis
 Post vagotomy
 Infections
 Decreased motility:
 Stasis : bacterial overgrowth.
 Pseudo-obstruction, blind loop
 Inflammatory
 Inflammation .
 decreased mucosal surface area
&/Or colonic reabsorption.
 Blood & increased WBC`s in stool.
 Infectious gastroenteritis
 dysentery
 Acute diarrhea
 Common  Rare
• Infant: • Infant:
 Gastroenteritis
 Primary
Systemic infection

disaccharidase
 Antibiotic use deficiency
• Child:  Adrenogenital s.
Gastroenteritis
Hirchsprung colitis


 Food poisoning
 Systemic infection • Child:
• Adolescent:  Toxic ingestion
 Gastroenteritis • Adolescent:
 Food poisoning  thyrotoxicosis
 antibiotic
 Gastroenteritis
 Most common cause of acute diarrhea in
all age groups.
 Clinical manifestations depend on the
organism & the host response to infection.
 A presumptive diagnosis can be made
from epidemiological clues, good history &
physical examination,laboratory
investigations ( not required always )
 Approach
 Considerations

• Rule out acute/surgical abdomen

• Hydration status
 Acute Abdomen
Intraluminal Extraluminal Gastrointestin Paralytic Blunt Miscellaneous
Obstruction Obstruction al Ileus Trauma
Disease

Foreign Body Hernia Appendicitis Sepsis Accident Lead poisoning

Bezoar Intussusceptio Crohn disease Pneumonia Battered child Sickle cell
Fecalith n Ulcerative Pyelonephritis syndrome disease
Gallstone Volvulus colitis Peritonitis Familial
Parasites Duplication Vasculitis Pancreatitis Mediterranean
Stenosis Peptic ulcer fever
Cystic fibrosis Cholecystitis
Tumor disease Porphyria
Tumor Renal stones
Mesenteric cyst Meckel’s DKA
Fecaloma Gallstones
SMA syndrome AGE Addisonian
PID crisis
Pyloric stenosis Lymphadenitis Testicular
torsion
Ovarian Torsion
 Approach
 History
• Symptoms
 Nausea, emesis, retching
 Abdominal pain
 Bowel movements
 Timing
• Age
• Onset
• Relation to feeds
• Focus of infection, other affected
individuals
 Approach
 Physical examination
• Temperature, heart rate, blood
pressure, pain
• Abdominal examination
 Auscultation before palpation
 Palpation
• Masses
• Tenderness
 Auscultation for bowel sounds
 Approach
 Objectives
• Assess the degree of dehydration
• Prevent spread of the enteropathogen
• Selectively determine etiology and
provide specific therapy
 Dehydration
 Mild (3-5%)
• Normal or increased pulse
• Decreased urine output
• Thirsty
• Normal physical exam
 Dehydration
 Moderate (7-10%)
• Tachycardia
• Little/no urine output
• Irritable/lethargic
• Sunken eyes/fontanelle
• Decreased tears
• Dry mucous membranes
• Skin- tenting, delayed cap refill, cool,
pale
 Dehydration
 Severe (10-15%)
• Rapid, weak pulse
• Decreased blood pressure
• No urine output
• Very sunken eyes/fontanelle
• No tears
• Parched mucous membranes
• Skin- tenting, delayed cap refill, cold,
mottled
 Tanda dan
Ringan Sedang Berat
gejala
Takikardi Tidak ada Ada Ada
Nadi teraba Ada Ada (lemah) Menurun
Hipotensi
Tekanan darah Normal Hipotensi
ortosatik

Menurun/tampak
Perfusi kulit Normal Normal tak teratur
(mottled)

Turgor kulit Normal Sedikit menurun Menurun

Fontanel Normal Sedikit cekung Cekung

Membrana
Basah Kering Amat kering
mukosa
Ada atau tidak
Air mata Ada Tidak ada
ada
Dalam, dapat
Pernafasan Normal Dalam dan cepat
cepat
Anuria dan
Curah urine Normal Oliguria
oliguria berat
 Etiology
 Enteropathogens
• Non-inflammatory vs. inflammatory
diarrhea
 Non-inflammatory
• Enterotoxin production
• Destruction of villi
• Adherence to GI tract
 Inflammatory
• Intestinal invasion
• Cytotoxins
 Etiology
 Chronic diarrhea
• Giardia lamblia
• Cryptosporidium parvum
• Escherichia coli: enteroaggregative,
enteropathogenic
• Immunocompromised host
• Non-infectious causes: anatomic,
malabsorption, endocrinopathies,
neoplasia
 Etiology
 Bacterial
• Inflammatory diarrhea
 Aeromonas
 Campylobacter jejuni
 Clostridium dificile
 E. coli: enteroinvasive, O157:H7
 Plesiomonas shigelloides
 Salmonella
 Shigella
 Vibrio parahaemolyticus
 Yersinia enterocolitica
 Etiology
 Bacterial
• Non-inflammatory
 E. coli: enteropathogenic, enterotoxigenic
 Vibrio cholerae
 Viral
• Rotavirus
• Enteric adenovirus
• Astroviruus
• Calcivirus
• Norwalk
• CMV
• HSV
 Etiology
 Parasites
• Giardia lamblida
• Entamoeba histolytica
• Strongyloides stercoralis
• Balantidium coli
• Cryptosporidium parvum
• Cyclospora cayetanensis
• Isospora belli
 Diagnosis
 History
 Stool examination
• Mucus
• Blood
• Leukocytes
• Stool culture
 Diagnosis
 Examination for ova and parasites
• Recent travel to an endemic area
• Stool cultures negative for other
enteropathogens
• Diarrhea persists for more than 1 week
• Part of an outbreak
• Immunocompromised
• May require examination of more than
one specimen
 Rehydration
 Treatment
• Calculate deficits
 Water: % dehydration x weight
 Sodium: water deficit x 80 mEq/L
 Potassium: water deficit x 30 mEq/L
• Treat mild-moderate dehydration with
oral rehydration solutions
• May treat severe dehydration with
intravenous fluids
• Hyponatremic v. isotonic v.
hypernatremic
 Antimicrobial therapy
 Aeromonas
• TMP/SMZ
• Dysentery-like illness, prolonged
diarrhea
 Campylobacter
• Erythromycin, azithromycin
 Clostridium dificile
• Metronidazole, vancomycin
 E. coli
• TMP/SMZ
 Antimicrobial therapy
 Salmonella
• Cefotaxime, ceftriaxone, ampicillin, TMP/SMZ
• Infants < 3 months
• Typhoid fever
• Bacteremia
• Dissemination with localized suppuration
 Shigella
• Ampicillin, ciprofloxacin, ofloxacin, ceftriaxone
 Vibrio cholerae
• Doxycycline, tetracycline
 Therapy
 Antidiarrheal medication
• Alter intestinal motility
• Alter adsorption
• Alter intestinal flora
• Alter fluid/electrolyte secretion
 Antidiarrheal medication generally
not recommended
• Minimal benefit
• Potential for side effects
 Prevention
 Contact precautions
 Education
• Mode of acquisition
• Methods to decrease transmission
 Exclusion from day care until
diarrhea subsides
 Surveillance
 Salmonella typhi vaccine
Any questions?