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Acute Gastroenteritis (AGE) -Definition?

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A syndrome of inflammatory/ secretory diarrhea (and typically vomiting), where the diarrhea may contain blood or mucous; comes on suddenly, but resolves in 2 weeks

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Diarrhea:

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An increase in stool frequency or a decrease in stool consistency Usually results in the passage of loose or watery stools In children, diarrhea defined as stool loss >10g/kg/day

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Acute Gastroenteritis -Etiology, viral?

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Rotavirus, norwalk virus, Adenovirus, Hep A Most cases have no specific pathogen noted

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Acute Gastroenteritis -Etiology, bacterial?

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Campylobacter, E. coli, Salmonella, Shigella, Aeromonas

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Acute Gastroenteritis -Etiology, parasitic?

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giardia, Cryptosporidium, Entamoeba

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Viral AGE -Pathophysiology?

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Short incubation (1-2 days); Day 1 → virus infects enterocytes in jejunum/ileum → destroys villus epithelium → loss of water/electrolytes in feces Day 2-5 → adjacent villi fuse, reducing surface area of injury & fluid loss Day 6-10 → restoration of normal villus architecture *Can cause a transient lactose intolerance for 1-3 weeks after the acute infection. rotavirus produces toxins alter membrane transport → secretory diarrhea

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Viral AGE -Clinical manifestations?

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-diarrhea (20x/day) -vomiting -fever -anorexia -headache -abdominal pain -myalgia !look for signs of dehydration!

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Acute Gastroenteritis -Signs of dehydration?

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-tachycardia (1st sign) -↓skin turgor -dry mucous membranes -depressed fontanelle -↓tearing -weight loss

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Acute Gastroenteritis -Extraintestinal manifestations?

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-Reactive arthritis -Guillain-Barre syndrome -IgA Nephropathy -Erythema Nodosum -Hemolytic uremic syndrome (sudden onset renal failure, d/t E Coli 0157:H7, Shigella) -Hemolytic anemia -Systemic spread of infection

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Acute Gastroenteritis -Entities that mimic AGE?

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-Extraintestinal infections Otitis media UTI -Rule out acute surgical abdomen appendicitis pancreatitis volvulus peritonitis DKA inflammatory bowel disease celiac disease cystic fibrosis GI anomalies (intussusception, Hirschsprung disease)

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Acute Gastroenteritis -Management?

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1) Determine viral/bacterial/mimic 2) assess severity PE → assess for dehydration & VS stability, abdominal exam to rule out acute abdomen Labs → viral suspected- nothing - if prolonged symptoms: bloody stools, urine changes, severe dehydration, travel/animal/exposure Then get: UA, culture, fecal WBC, stool culture, electrolytes,CBC, fecal occult

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Acute Gastroenteritis -Treatment?

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1) Adequate rehydration, !anti-diarrheal agents NOT recommended for kids If non-viral: entamoeba, giardia, shigella, campylobacter/salmonella OR in immunocompromised, children w/ sickle cell, neonates GIVE antibiotics! Ceftriaxone, TMP/SMX + ampicillin, erythromycin, metronidazole

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Acute Gastroenteritis -Prevention?

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-Rotavirus vaccine -clean water - ↓ contamination of food supply -improved personal sanitation -improved nutrition of infants (breast feeding for first 6 months)

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Dehydration -Epidemiology?

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During illness, the homeostatic adjustments of children may be less efficient than adults → dehydration may ensure -dehydration is responsible for ~10% of pediatric admissions

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Dehydration -Cause?

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-↓ intake -excess GI loss -excess urinary loss -excess insensible losses (skin breakdown, fever, burns) -blood loss -combination of these factors

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Dehydration -Types: Isotonic/Isonatremic?

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Most common; net loss of isotonic fluid containing both Na and K

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Dehydration -Types: Hypertonic/Hypernatremic?

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Net water loss exceeds solute loss; Must rehydrate slowly to prevent cerebral edema

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Dehydration -Types: Hypotonic/Hyponatremic?

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Net solute loss exceeds water loss

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Dehydration -Mild=

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3% loss of body weight in older children and adults o 5% loss of body weight in younger children and infants

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Dehydration -Moderate=

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6% loss of body weight in older children and adults 10% loss of body weight in younger children and infants

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Dehydration -Severe=

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9% loss of body weight in older children and adults 15% loss of body weight in younger children and infants (usually requires hospital admission for intensive fluid therapy)

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Dehydration -Symptoms?

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Decreased skin turgor, dry mucous membranes, depressed fontanelle, diminished tearing, tachycardia; these symptoms worsen with as the dehydration worsens

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Evaluation of Dehydration -Percent dehydration?

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% = [(pre-illness weight - current weight)x100]/pre-illness weight

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Evaluation of Dehydration -Lab testing?

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If mild or moderate → not needed If severe or oliguria → - Serum electrolytes -BUN/creatinine -possibly arterial blood gas

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Evaluation of Dehydration -Findings?

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-Non-anion gap metabolic acidosis in moderate dehydration or anion gap metabolic acidosis in more severe case -Possible electrolyte abnormalities -Elevated BUN in moderate to severe dehydration -Elevated creatinine in pre-renal azotemia

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Management of Dehydration -Route of rehydration?

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Mild or moderate → PO/NG Severe or oliguria → IV/IO

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Management of Dehydration -Oral replacement therapy?

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Mild -give 50 mL/kg every 3-4 hrs + 10 mL/kg for each stool + 5 mL/kg for each vomitus Moderate -give 100 mL/kg every 3-4 hrs + 10 mL/kg for each stool + 5 mL/kg for each vomitus Use pedialyte -do not give juice(can cause osmotic diarrhea) -try to switch back to formula or milk when vomiting resolves -if on solid food continue regular diet

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Management of Dehydration -Parenteral fluid therapy, phases?

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Initial phase (first 1-2 hrs) -restore intravascular volume Give 20 mL/kg boluses over 5-15 mins up to 3x to stabilize BP & HR Main phase (next 24 hrs) -Give first 1/2 of replacement needs over 1st 8 hrs; second 1/2 replaced over following 16 hours -if dsynatremia take up to 48-72 hrs

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Management of Dehydration -Fluid components

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1) Maintenance requirements → water & electrolytes utilized during NORMAL baseline metabolism (normal amount of fluids required, even when NOT ill) 2) Initial Deficit Repletion → based on the amount of fluid & electrolytes lost prior to patient's presentation 3) Ongoing losses → estimate for how much fluid the child is continuing to lose after resuscitation has begun

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Fluid Components (3)

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Maintenance requirements Initial Deficit Repletion Ongoing losses

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Calculating Maintenance Requirements -method to use?

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Holliday-Segar method = need 100mL of water for every 100 calories expended (No suitable for neonates < 14 days old, overstimulates their fluid needs)

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Maintenance IV Fluids/24hr (total volume needed in one day) -for: 3-10 kg 11-20kg >20 kg

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100mL/kg 1,000mL/kg + 50 mL/kg for each kg above 10 1,500 mL + 20 mL/kg for each kg above 20

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Maintenance IV Fluids/hr (4-2-1 rule) -for: 3-10 kg 11-20kg >20 kg

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4mL/kg = fluid rate per hour 40mL + 2 mL/kg for each kg over 10 60mL + 1mL/kg for each kg over 20 Round up!

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Per 100mL water, we give ______ Na+, Cl-, and K+

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3mEq Na+ 2mEq Cl- 2mEq K+

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Calculating fluid requirement

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Only if older than 14 days; First 10 kg → 100 mL/kg @ ~ 4mL/kg/hr Second 10 kg → above + 50mL/kg @ ~ 2mL/kg/hr each additional kg → above + 50mL/kg @ ~ 1mL/kg/hr Per 100 mL of H2O→ Na+=3mEq, Cl-=2mEq, K+=2mEq

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Normal saline (NS) =

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154 mEq NaCl/L

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0.45% saline =

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77 mEq NaCl/L

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0.22% saline =

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36 mEq NaCl/L

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Repletion of deficits -By cause?

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Diarrhea - could result in hypernatremic or hyponatremic dehydration Vomiting - more water than solute; might result in Hypernatremic dehydration Blood - would result in Isonatremic fluid loss Urinary loss - results in Hypernatremic dehydration

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Repletion of deficits - Na+ -If isotonic?

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Use NS or 2/3 NS

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Repletion of deficits - Na+ -If hypertonic?

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Must calculate amount of free water a patient requires to decrease their Na to normal Weight x [measured Na - desired Na] x 4 mL/kg Estimated that it takes 4mL free water /kg to lower Na 1mEq/L Correct slowly to avoid cerebral edema

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Repletion of deficits - Na+ -If hypotonic?

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Weight x [desired Na - measured Na] x 0.6 Avoid hypertonic (eg. 3% NaCl) unless symptomatic hyponatremia (eg. seizure) - if necessary give 6 mL/kg over 1 hour Avoid rapid correction which can cause central pontine myelinolysis

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Repletion of deficits -K+?

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Difficult to determine; as acidosis corrects, K+ shifts into the cell; frequently reassess K+ levels & adjust fluids as necessary !Withhold K+ in fluids until normal urine output restored (or may become hyperkalemic)! Aim to provide 3 - 4 mEq/kg/day to someone with hypokalemia and adequate urine output

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Fluid replacement per stool?

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10mL/kg

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Sodium content in stool?

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variable! -replace with 0.45% NS (or 77 mEq/1,000 mL)

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