Acute Gastroenteritis
in pediatric population
Definitions and Terms:
Acute Gastroenteritis (AGE): diarrheal disease of rapid
onset, with or without accompanying symptoms,
signs, such as nausea, vomiting, fever, or abdominal
pain
Diarrhea: the frequent passage of unformed liquid
stools (3 or more loose, watery stool per day)
Dysentery: blood or mucus in stools
Diarrhea
Acute diarrhea:
Short in duration (less than 2 weeks).
Chronic diarrhea:
6 weeks or more
Statistics in the United States:
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> 1.5 million outpatient visits/year
200,000 hospitalizations/year
300 deaths/year
9% of all hospitalizations of children <5yo
Children <3yo estimated at 1.3-2.3
episodes/child/year
Statistics Worldwide:
• diarrheal disease is leading cause of
pediatric morbidity and mortality
• 1.4 billion episodes of diarrhea annually
• 1.5-2.5 million deaths annually in
children <5yo (19% of all child deaths- 98% of these deaths
occurring in the developing world)
Etiologies:
Viral
70-85% of AGE in developed countries
• Rotavirus: 1/3 of all pediatric AGE hospitalizations in
U.S. Seasonal variation: increased in winter and
decreased in summer.
• Caliciviruses, astroviruses, and enteric adenoviruses
Presentaion:
• Low-grade fever
• Vomiting followed by copious watery diarrhea (up to 1020 bowel movements per day)
• Symptoms persisting for 3-8 days
Etiologies:
Bacterial
Campylobacter, Salmonella, Shigella, E.
coli, Yersinia, Clostridium difficile
Presentation:
High fevers
Shaking chills
Bloody bowel movements (dysentery)
Abdominal cramping & fecal leukocytes
*ETEC is unlikely to cause dysentery.
Etiologies:
Parasitic
Giardia and Cryptosporidium
<10% of cases
Presentation:
• Watery stools
• Low-grade fever
• differentiated from viral gastroenteritis by a
protracted course or history of travel to
endemic areas
Pathophysiology
The 2 primary mechanisms
(1) Damage to the villous brush border of the
intestinemalabsorption of intestinal contents an
osmotic diarrhea
(2)
Release of toxins that bind to specific enterocyte
receptorsrelease of chloride ions into the intestinal
lumensecretory diarrhea
Sign & Symptoms
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Nausea & Vomiting
Diarrhea
Loss of appetite
Fever
Headaches
Abdominal pain
Abdominal cramps
Bloody stools
Fainting and Weakness
Heartburn
Dehydration
Lethargic
Complication
• Dehydration
 Excessive loss of fluids and minerals (electrolytes)
from the body
 Common in infants and young children with viral
gastroenteritis or bacterial infection
 Kidney failure, eg in infection by E.coli
• Electrolyte deficiency
• Irritation
DDX
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Food poisoning
Lactose intolerance
Malabsorption syndromes
Irritable bowel syndrome
Diabetic Ketoacidosis
Appendicitis
Peptic Ulcer Disease
Foreign Body Ingestion
Intussusception
Volvulus
Hemolytic Uremic Syndrome
Pyloric Stenosis
Hepatitis
Urinary Tract Infections and Pyelonephritis
Inflammatory Bowel Disease
Septic shock
Pancreatitis
Work-Up
Diagnosing gastroenteritis is mainly an exclusion procedure
History & Physical
2 vital functions:
(1) Differentiating gastroenteritis from other causes
of vomiting and diarrhea in children
(2) Estimating the degree of dehydration.
Consider: Duration, frequency, quality, quantity, last
episode, +/- factors, associated symptoms,
diet/med/travel/sick contact hx.
Work-Up
Assessment of Dehydration
Ideally, acute change in weight is the best way to determine
degree of dehydration.
Clinical signs and symptoms can be utilized to determine degree
of dehydration
Work-Up
Labs
The vast majority of children presenting with acute gastroenteritis do not require
serum or urine tests
Moderate-severe dehydration:
Electrolytes, bicarbonate, and urea/creatinine
Fecal leukocytes and stool culture
Evidence of systemic infection-complete workup:
CBC and blood cultures. If indicated, urine
cultures, chest radiography, and/or LP
Treatment
Factors:
Severe or prolonged episode
Fever
Repeated vomiting,
Refusal to drink fluids
Severe abdominal pain
Blood or mucus in stool
Sign of dehydration
 Dry, sticky mouth
 Few or no tears when crying
 Sunken eyes
 Lack urine or wet diaper
 Dry, cool skin
 Fatigue or dizziness
Treatment
Fluid Management
Factors: Status of patient & dehydration
degree
Oral rehydration therapy -as effective as IV
fluids in treatment of mild to moderate
dehydration both OP & IP. Delivered po or ng.
• Some studies have demonstrated decreased
ER stays and increased parent satisfaction
with ORS therapy over IV
• NO difference in duration of illness or
hospitalization rates.
Treatment
Fluid Management
Oral rehydration solutions (ORS)
-carbohydrate (glucose or rice syrup) & electrolytes (Na, K, Cl, citrate, HCO3-)
-Takes advantage of a specific sodium-glucose transporter (SGLT-1) to increase the reabsorption of
sodium, which leads to the passive reabsorption of water.
Treatment
Fluid Management
Rehydration protocols:
Mild:
50-100 cc/kg of ORS plus replacement over 4 hours**
Moderate:
100cc/kg of ORS plus replacement over 4 hours
Severe:
Bolus of 20-30 cc/kg lactated Ringer's (LR) or normal saline (NS).
20cc/kg of isotonic IV fluids over one hour
Repeat as necessary
Continue replacement for stools
** ongoing losses can be matched at approximately 10cc/kg for each
stool & 2cc/kg for each emesis episode.
Treatment
Feeding and nutrition
-Normal diet as rapidly as possible.
-Early feeding reduces illness duration and improves nutritional outcome.
Breastfed infants
-Continue breastfeeding throughout the rehydration and maintenance
phases.
Formula fed infants
-Restart feeding once the rehydration phase is complete (ideally in 2-4 h).
- Fatty foods and foods high in simple sugars should be avoided.
-Lactose-free formulas are unnecessary; 80% of children could tolerate full
strength milk.
-“BRAT” diet and other restrictive diets are unnecessary and provide
suboptimal nutrition
Treatment
Medication:
Antimicrobials
Generally not indicated
C difficile- stop antibiotic & start metronidazole
Cholera-tetracycline and doxycycline
Giardia-metronidazole
Cryptosporidium-metronidazole or Nitazoxanide
Treatment
Medication:
Antidiarrheals are not recommended
Antiemetics are not recommended
Some clinical studies have demonstrated that ondansetron
can decrease vomiting and hospitalization.
Probiotics (e.g. Lactobacillus GG) alter the
composition of gut flora and assist in restoring normal
gut function.
Prevention
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Vaccination-RotaTeq & Rotarix
Probiotics
Washing hands.
Clean food preparation & preservation.
Reference
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Dennehy PH. Acute diarrheal disease in children: epidemiology, prevention, and
treatment. Infect Dis Clin North Am. Sep 2005;19(3):585-602.
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"NHS Direct: Gastroenteritis".
http://www.nhsdirect.nhs.uk/checksymptoms/topics/gastroenteritis. Retrieved
12/16/2010.
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World Health Organization – WHO http://www.who.int/topics/diarrhoea/en
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Kosek M, Bern C, Guerrant RL. The global burden of diarrhoeal disease, as
estimated from studies published between 1992 and 2000. Bull World Health
Organ. 2003;81(3):197-204.
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King CK, Glass R, Bresee JS, Duggan C. Managing acute gastroenteritis among
children: oral rehydration, maintenance, and nutritional therapy. MMWR. 2003;
52(RR16): 116.