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Edit Comment Close Premium member Presentation Transcript Acute Diarrhoea : Acute Diarrhoea Dr.Somashekhar chikkanna LLRM Medical college Meerut Problem statement : Problem statement Acute diarrhea is the 2nd M.C cause of morbidity on a world wide scale Approx 4 million children die each year of the dehydration caused by diarrhea ORT prevents 1 million dehydration deaths a year In the tropical belt, 15 to 40 % of all deaths among children under 5 years are diarrhea related Definition : Definition …….a change in the bowel habit for the individual child resulting in substantially more frequent and/or looser stools -Delphi consensus Dysentry : Dysentry ….. is characterised by the presence of blood & pus in the stools, abdominal cramps & fever Gross blood in the stools is the most reliable sign Malena or episodes where blood streaks are present on the surface of foemed stools are not considered Infectious agents : Infectious agents VIRUSES BACTERIA OTHERS Rotaviruses E.coli E.histolytica Astroviruses C.jejuni G.intestinalis Adenoviruses Shigella Trichuriasis Calcivruses Salmonella Cryptosporidium Coronaviruses V.cholerae Int. worms Enteroviruses V.parahaemolyticus Norwalk group B.cereus Common pathogens : Common pathogens Pathogen % of cases Viruses Rotavirus 15-25 Bacteria Enterotoxigenic E.coli 10-20 Shigella 5-15 C.jejuni 10-15 V.cholerae 5-10 Salmonella(non thyphoid) 1-5 Enteropathogenic E.coli 1-5 Protozoans Cryptosporidium 5 -15 No pathogen found 20-30 Pathophysiology : Pathophysiology Osmotic Diarrhea Secretory Diarrhea Mutations in apical membrane transport proteins Reduction in anatomic surface area Alteration in intestinal motility Inhibition of transport of electrolytes by inflammatory mediators Osmotic Vs Secretary diarrhoea : Osmotic Vs Secretary diarrhoea Assessment of a child : Assessment of a child HISTORY:The following Q. are important to plan therapy Duration of illness Did the child vomit during preceding 6-8 hours? Did he pass urine during the same period? What is the nature of fluids that the child has been taking? Was the child receiving optimum feeding before the illness Has feeding been reduced or modified during diarhoea in a way that reduced the quantity of total energy intake or the quality of food consumed? Assess severity of Dehydration : Assess severity of Dehydration Slide 12: Weight loss is the best parameter Signs of dehydration are unlikely if <3% weight loss Dry mucous membranes,sunken eyes,diminished skin turgor,altered neurological status & deep breathing-3%-8% Above combined with circulatory collapse & poor perfusion->9% -Duggan & Mackenzie INVESTIGATIONS : INVESTIGATIONS STOOL R/M: Fecal WBC >10/hpf is an indicator of invasive diarrhoea requiring antibiotic therapy but has low specificity STOOL CULTURE: Little value in routine Mx of Ac.diarrhoea E.coli is often reported on stool cultures but most lab lack the ability to identify whether these are diarrhoeagenic or commensals BLOOD GAS ESTIMATIONS , S.ELECTROLYTES , RFT: performed only if clinical cond of the child suggests acid-base imbalance ,dyselectrolytemia or oligouria/anuria Management : Management ORS should be the standard treatment for mild to moderate dehydration Sharifi 1985, Tamer 1985,vesikari 1987, Mackenzie1991 WHO –ORS & LOW OSMOLALITY -ORS : WHO –ORS & LOW OSMOLALITY -ORS W OSMOLAR ORS CONC. IN TERM OF mmol/ltr Sodium 75 Potassium 20 Chloride 65 Citrate 10 Dextrose 75 ------------------------------ 245 ------------------------------- CONC. IN TERM OF mmol/ltr Sodium 90 Potassium 20 Chloride 80 Citrate 10 Glucose 111 -------------------------------- 311 ------------------------------- Why low osmolality ORS ? : Why low osmolality ORS ? Fewer unscheduled IV infusions Lower stool output Reduced vomiting However no evidence of hyponatremia Cochrane systematic review Santosham M, Fayad I, Zinkri MA, Hussein A, Ampansah A, Duggan C, et al. J Pediatr Gastroenterol Nutr 1996; 128: 45-51 In Indian scenario……. : In Indian scenario……. Isolated beneficial effects were seen with the hypo-osmolar ORS in cholera and non-cholera childhood diarrhea. An increase in the amount of intravenous fluids needed was documented with the hypo-osmolar ORS. Hypo-osmolar ORS had better efficacy in malnourished children. Financial considerations and lack of clinical benefit with hypo-osmolar ORS preclude recommendations for replacing WHO-ORS. S. Alam, K. Afzal, M. Maheshwari and I. Shukla* From the Diarrhea Training and Treatment Unit, Department of Pediatrics and *Department of Microbiology, JNMC, AMU, Aligarh, India. Indian Pediatrics 2000;37: 952-960 Plan A : Plan A Age Amount after each loose stool <24months 50-100 ml 2-10 years 100-200ml >10 years as much as wanted Plan B : Plan B The fluid therapy has 3 components: a)REHYDRATION THERAPY : correction of the existing water & electrolyte deficit as indicated by the presence of signs of dehydration b)MAINTENANCE THERAPY : replacement of ongoing losses d/t continuing diarrhea to prevent recurrence of dehydration c)PROVISION OF NORMAL DAILY FLUID REQUIREMENT: Rehydration Therapy : Rehydration Therapy Give 75ml/kg of ORS in the first 4 hrs Use child age, when wt is not known approx. amount of ORS to give in first 4 hours <4mths 4-11m 12-23m 2-4yrs 5-14yr 200-400 400-600 600-800 800-1200 1200-2200 child has some dehydration after 4 hrs , repeat another 4 hrs t/t with ORS(as in rehydration therapy) & start to offer feeds , milk & breastfeed frequently MAINTENANCE THERAPY : MAINTENANCE THERAPY Begins when signs of dehydration disappears ORS administered in volume equal to diarrhoea losses , approx 10-20 ml/kg for each liquid stool ORS is administered in this manner till diarrhea stops Offer plain water in b/w Breastfeed even during rehydration & offer semisolid foods after deficit replacement Similarly , in non breast feeds babies , milk preferably mixed with cereals can be used together with other semisolid foods after they have been rehydrated WHEN IS ORT INEFFECTIVE? : WHEN IS ORT INEFFECTIVE? High stool purge:- >5ml stool/kg/hr Persistent vomiting :- >3vomitings/hr Incorrect preparation Abdominal distension & ileus Glucose malabsorption PLAN -C : PLAN -C Start i.v fluids immediately The best iv fluid solution is RL An ideal preparation would be RL with 5% dextrose However it is not available If RL is not available, NS can be used Dextrose on its own is not effective Give 100ml/kg : Give 100ml/kg THEN GIVE 70ml/kg in 5 hours 70ml/kg in 2 hours 30 min AGE FIRST GIVE <1yr 30ml/kg in 1hour 1yr-5yr 30ml/kg in 30min Along with….. : Along with….. Start some ORS solution (5ml/kg/hr) during IV fluids If one is unable to give IV fluids , immediately start rehydration with ORS using NG tube at 20 ml/kg/h(total of 120 ml/kg) Reassess child every 1-2 h - if there is vomiting or abdominal distention , give fluids more slowly If there is no improvement in hydration after 3 hrs, try to start IV fluids as early as possible Monitoring : Monitoring Reassess the child every 15-30 min until a strong radial pulse is present If hydration is not improving, give the IV fluids more rapidly When full amount of IV fluid has been given , reassess the childs hydration status If signs of severe dehydration are still present , repeat the IV fluids infusion as outlined earlier Monitoring….. : Monitoring….. If child is improving but still shows signs of some dehydration , discontinue IV t/t & give ORS solution for 4 hrs(as for PLAN B) If child is normally breast fed, encourage the mother to continue breastfeeding frequently DIETARY Mx OF ACUTE DIARRHOEA : DIETARY Mx OF ACUTE DIARRHOEA Continue feeding during ac.diarrhoea to prevent or minimizes the deterioration of the nutritional status Breastfeeding should be continued uninterrupted even during rehydration with ORS Optimally energy dense foods with least bulk in small quantities but frequently, at least once every 2-3 hrs Slide 29: Staple foods do not provide optimal calories/unit wt & these should be enriched with fats &oils or sugar e.g. , khichri with oil, rice with milk or curd , mashed potatoes with oil & lentil Avoid Foods with high fiber content e.g. coarse fruits & vegetables Why antibiotics not recommended..? : Why antibiotics not recommended..? Since large majority of cases of diarrhoea are caused by viruses or toxigenic bacteria Antibiotics do not shorten the duration of illness except in case of Cholera Their indiscriminate use leads to emergence of resistant strains of harmful bacteria & eliminates resident flora which protect the gut All drug are potentially toxic & hazardous WHEN RECOMMENDED : WHEN RECOMMENDED …… Should be used only for infectious agents such as Shigella,V.cholerae , E.histolytica & Giardia Decreases mortality,reduces duration of anorexia & malabsorption & hastens elimination of shigella If no improvement in 48hrs,suspect antimicrobial resistance Which antibiotics….? : Which antibiotics….? Ampicillin,co-trimaxazole-No longer recommended Some resistance to Nalidixic Acid has been shown Ciprofloxacin is the DOC irrespective of age 15mg/kg twice daily-3days Ofloxacin can be used-15mg/kg/day Second line drugs-ceftriaxone,Azithromycin& cefixime should be used cautiously In cholera : In cholera TETRACYCLINE 12.5 mg/kg/dose qid for 3 days COTRIMOXAZOLE TMP 5mg/kg/dose+SMX 25 mg/kg/dose bd for 3 days ERYTHROMYCIN 12.5 mg/kg/dose for 3 days FURAZOLIDONE 1.25 mg/kg/dose qid for 3 days OTHER INDICATIONS : OTHER INDICATIONS PEM PRETERM INFANT IN WELL NOURISHED INFANTS WITH DIARRHOEA , IF AFTER CORRECTION OF DIARRHOEA ONE OF THE FOLLOWING IS PRESENT: a)sucking is absent or attachment to breast is poor. b)abdominal distention c)fever or hypothermia d)fast breathing e)significant letharginess or inactivity. Other drugs… : Other drugs… Adsorbants like kaolin,pectin,activated charcoal & bismuth are not indicated Motility suppressants decrease intestinal peristalsis and delay the elimination of causative organisms,causes paralytic ileus,respiratory depression,abdominal distension,Bacterial overgrowth & sepsis Anti-secretary like racecadotril inactivates encephalins.More evidences are required Probiotics…. : Probiotics…. Currently insufficient data to recommend Earlier studies have shown some beneficial effect ROLE OF ZINC : ROLE OF ZINC Zn supplementation in children with diarrhea leads to reduced duration & severity of diarrhea & could potentially prevent deaths WHO & UNICEF recommend that all children with acutediarrhea should receive oral Zn for 10 -14 days during & after diarrhea 10mg/day for infants <6 m age & 20 mg/day for >6 m Conclusions : Conclusions ORS remains the mainstay Zinc as an adjuvant additional benefits Antimicrobials should be restricted to children with bloody diarrhoea No evidence for using probiotics,Adsorbants & motility suppresants You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.
Diarrhoea made simple somashekharc Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 1001 Category: Education License: All Rights Reserved Like it (4) Dislike it (0) Added: July 05, 2010 This Presentation is Public Favorites: 0 Presentation Description No description available. Comments Posting comment... By: sulakshanasirur (1 week(s) ago) i am a counselor and teach life-skills. Can u mail the ppt to me on sulakshanad@rafflesis.com Saving..... Post Reply Close Saving..... Edit Comment Close By: thirukavery (7 month(s) ago) hi,nice presentation... Saving..... Post Reply Close Saving..... Edit Comment Close By: araveen (12 month(s) ago) plz can you send it plz Saving..... Post Reply Close Saving..... Edit Comment Close By: sheibz (14 month(s) ago) dear sir....diarrhoea made short & sweet....i wud like d opportunity to download it for personal storage & info...pls condiser request....thank you in anticipation Saving..... Post Reply Close Saving..... Edit Comment Close By: shamiyas (19 month(s) ago) NICE Saving..... Post Reply Close Saving..... Edit Comment Close Premium member Presentation Transcript Acute Diarrhoea : Acute Diarrhoea Dr.Somashekhar chikkanna LLRM Medical college Meerut Problem statement : Problem statement Acute diarrhea is the 2nd M.C cause of morbidity on a world wide scale Approx 4 million children die each year of the dehydration caused by diarrhea ORT prevents 1 million dehydration deaths a year In the tropical belt, 15 to 40 % of all deaths among children under 5 years are diarrhea related Definition : Definition …….a change in the bowel habit for the individual child resulting in substantially more frequent and/or looser stools -Delphi consensus Dysentry : Dysentry ….. is characterised by the presence of blood & pus in the stools, abdominal cramps & fever Gross blood in the stools is the most reliable sign Malena or episodes where blood streaks are present on the surface of foemed stools are not considered Infectious agents : Infectious agents VIRUSES BACTERIA OTHERS Rotaviruses E.coli E.histolytica Astroviruses C.jejuni G.intestinalis Adenoviruses Shigella Trichuriasis Calcivruses Salmonella Cryptosporidium Coronaviruses V.cholerae Int. worms Enteroviruses V.parahaemolyticus Norwalk group B.cereus Common pathogens : Common pathogens Pathogen % of cases Viruses Rotavirus 15-25 Bacteria Enterotoxigenic E.coli 10-20 Shigella 5-15 C.jejuni 10-15 V.cholerae 5-10 Salmonella(non thyphoid) 1-5 Enteropathogenic E.coli 1-5 Protozoans Cryptosporidium 5 -15 No pathogen found 20-30 Pathophysiology : Pathophysiology Osmotic Diarrhea Secretory Diarrhea Mutations in apical membrane transport proteins Reduction in anatomic surface area Alteration in intestinal motility Inhibition of transport of electrolytes by inflammatory mediators Osmotic Vs Secretary diarrhoea : Osmotic Vs Secretary diarrhoea Assessment of a child : Assessment of a child HISTORY:The following Q. are important to plan therapy Duration of illness Did the child vomit during preceding 6-8 hours? Did he pass urine during the same period? What is the nature of fluids that the child has been taking? Was the child receiving optimum feeding before the illness Has feeding been reduced or modified during diarhoea in a way that reduced the quantity of total energy intake or the quality of food consumed? Assess severity of Dehydration : Assess severity of Dehydration Slide 12: Weight loss is the best parameter Signs of dehydration are unlikely if <3% weight loss Dry mucous membranes,sunken eyes,diminished skin turgor,altered neurological status & deep breathing-3%-8% Above combined with circulatory collapse & poor perfusion->9% -Duggan & Mackenzie INVESTIGATIONS : INVESTIGATIONS STOOL R/M: Fecal WBC >10/hpf is an indicator of invasive diarrhoea requiring antibiotic therapy but has low specificity STOOL CULTURE: Little value in routine Mx of Ac.diarrhoea E.coli is often reported on stool cultures but most lab lack the ability to identify whether these are diarrhoeagenic or commensals BLOOD GAS ESTIMATIONS , S.ELECTROLYTES , RFT: performed only if clinical cond of the child suggests acid-base imbalance ,dyselectrolytemia or oligouria/anuria Management : Management ORS should be the standard treatment for mild to moderate dehydration Sharifi 1985, Tamer 1985,vesikari 1987, Mackenzie1991 WHO –ORS & LOW OSMOLALITY -ORS : WHO –ORS & LOW OSMOLALITY -ORS W OSMOLAR ORS CONC. IN TERM OF mmol/ltr Sodium 75 Potassium 20 Chloride 65 Citrate 10 Dextrose 75 ------------------------------ 245 ------------------------------- CONC. IN TERM OF mmol/ltr Sodium 90 Potassium 20 Chloride 80 Citrate 10 Glucose 111 -------------------------------- 311 ------------------------------- Why low osmolality ORS ? : Why low osmolality ORS ? Fewer unscheduled IV infusions Lower stool output Reduced vomiting However no evidence of hyponatremia Cochrane systematic review Santosham M, Fayad I, Zinkri MA, Hussein A, Ampansah A, Duggan C, et al. J Pediatr Gastroenterol Nutr 1996; 128: 45-51 In Indian scenario……. : In Indian scenario……. Isolated beneficial effects were seen with the hypo-osmolar ORS in cholera and non-cholera childhood diarrhea. An increase in the amount of intravenous fluids needed was documented with the hypo-osmolar ORS. Hypo-osmolar ORS had better efficacy in malnourished children. Financial considerations and lack of clinical benefit with hypo-osmolar ORS preclude recommendations for replacing WHO-ORS. S. Alam, K. Afzal, M. Maheshwari and I. Shukla* From the Diarrhea Training and Treatment Unit, Department of Pediatrics and *Department of Microbiology, JNMC, AMU, Aligarh, India. Indian Pediatrics 2000;37: 952-960 Plan A : Plan A Age Amount after each loose stool <24months 50-100 ml 2-10 years 100-200ml >10 years as much as wanted Plan B : Plan B The fluid therapy has 3 components: a)REHYDRATION THERAPY : correction of the existing water & electrolyte deficit as indicated by the presence of signs of dehydration b)MAINTENANCE THERAPY : replacement of ongoing losses d/t continuing diarrhea to prevent recurrence of dehydration c)PROVISION OF NORMAL DAILY FLUID REQUIREMENT: Rehydration Therapy : Rehydration Therapy Give 75ml/kg of ORS in the first 4 hrs Use child age, when wt is not known approx. amount of ORS to give in first 4 hours <4mths 4-11m 12-23m 2-4yrs 5-14yr 200-400 400-600 600-800 800-1200 1200-2200 child has some dehydration after 4 hrs , repeat another 4 hrs t/t with ORS(as in rehydration therapy) & start to offer feeds , milk & breastfeed frequently MAINTENANCE THERAPY : MAINTENANCE THERAPY Begins when signs of dehydration disappears ORS administered in volume equal to diarrhoea losses , approx 10-20 ml/kg for each liquid stool ORS is administered in this manner till diarrhea stops Offer plain water in b/w Breastfeed even during rehydration & offer semisolid foods after deficit replacement Similarly , in non breast feeds babies , milk preferably mixed with cereals can be used together with other semisolid foods after they have been rehydrated WHEN IS ORT INEFFECTIVE? : WHEN IS ORT INEFFECTIVE? High stool purge:- >5ml stool/kg/hr Persistent vomiting :- >3vomitings/hr Incorrect preparation Abdominal distension & ileus Glucose malabsorption PLAN -C : PLAN -C Start i.v fluids immediately The best iv fluid solution is RL An ideal preparation would be RL with 5% dextrose However it is not available If RL is not available, NS can be used Dextrose on its own is not effective Give 100ml/kg : Give 100ml/kg THEN GIVE 70ml/kg in 5 hours 70ml/kg in 2 hours 30 min AGE FIRST GIVE <1yr 30ml/kg in 1hour 1yr-5yr 30ml/kg in 30min Along with….. : Along with….. Start some ORS solution (5ml/kg/hr) during IV fluids If one is unable to give IV fluids , immediately start rehydration with ORS using NG tube at 20 ml/kg/h(total of 120 ml/kg) Reassess child every 1-2 h - if there is vomiting or abdominal distention , give fluids more slowly If there is no improvement in hydration after 3 hrs, try to start IV fluids as early as possible Monitoring : Monitoring Reassess the child every 15-30 min until a strong radial pulse is present If hydration is not improving, give the IV fluids more rapidly When full amount of IV fluid has been given , reassess the childs hydration status If signs of severe dehydration are still present , repeat the IV fluids infusion as outlined earlier Monitoring….. : Monitoring….. If child is improving but still shows signs of some dehydration , discontinue IV t/t & give ORS solution for 4 hrs(as for PLAN B) If child is normally breast fed, encourage the mother to continue breastfeeding frequently DIETARY Mx OF ACUTE DIARRHOEA : DIETARY Mx OF ACUTE DIARRHOEA Continue feeding during ac.diarrhoea to prevent or minimizes the deterioration of the nutritional status Breastfeeding should be continued uninterrupted even during rehydration with ORS Optimally energy dense foods with least bulk in small quantities but frequently, at least once every 2-3 hrs Slide 29: Staple foods do not provide optimal calories/unit wt & these should be enriched with fats &oils or sugar e.g. , khichri with oil, rice with milk or curd , mashed potatoes with oil & lentil Avoid Foods with high fiber content e.g. coarse fruits & vegetables Why antibiotics not recommended..? : Why antibiotics not recommended..? Since large majority of cases of diarrhoea are caused by viruses or toxigenic bacteria Antibiotics do not shorten the duration of illness except in case of Cholera Their indiscriminate use leads to emergence of resistant strains of harmful bacteria & eliminates resident flora which protect the gut All drug are potentially toxic & hazardous WHEN RECOMMENDED : WHEN RECOMMENDED …… Should be used only for infectious agents such as Shigella,V.cholerae , E.histolytica & Giardia Decreases mortality,reduces duration of anorexia & malabsorption & hastens elimination of shigella If no improvement in 48hrs,suspect antimicrobial resistance Which antibiotics….? : Which antibiotics….? Ampicillin,co-trimaxazole-No longer recommended Some resistance to Nalidixic Acid has been shown Ciprofloxacin is the DOC irrespective of age 15mg/kg twice daily-3days Ofloxacin can be used-15mg/kg/day Second line drugs-ceftriaxone,Azithromycin& cefixime should be used cautiously In cholera : In cholera TETRACYCLINE 12.5 mg/kg/dose qid for 3 days COTRIMOXAZOLE TMP 5mg/kg/dose+SMX 25 mg/kg/dose bd for 3 days ERYTHROMYCIN 12.5 mg/kg/dose for 3 days FURAZOLIDONE 1.25 mg/kg/dose qid for 3 days OTHER INDICATIONS : OTHER INDICATIONS PEM PRETERM INFANT IN WELL NOURISHED INFANTS WITH DIARRHOEA , IF AFTER CORRECTION OF DIARRHOEA ONE OF THE FOLLOWING IS PRESENT: a)sucking is absent or attachment to breast is poor. b)abdominal distention c)fever or hypothermia d)fast breathing e)significant letharginess or inactivity. Other drugs… : Other drugs… Adsorbants like kaolin,pectin,activated charcoal & bismuth are not indicated Motility suppressants decrease intestinal peristalsis and delay the elimination of causative organisms,causes paralytic ileus,respiratory depression,abdominal distension,Bacterial overgrowth & sepsis Anti-secretary like racecadotril inactivates encephalins.More evidences are required Probiotics…. : Probiotics…. Currently insufficient data to recommend Earlier studies have shown some beneficial effect ROLE OF ZINC : ROLE OF ZINC Zn supplementation in children with diarrhea leads to reduced duration & severity of diarrhea & could potentially prevent deaths WHO & UNICEF recommend that all children with acutediarrhea should receive oral Zn for 10 -14 days during & after diarrhea 10mg/day for infants <6 m age & 20 mg/day for >6 m Conclusions : Conclusions ORS remains the mainstay Zinc as an adjuvant additional benefits Antimicrobials should be restricted to children with bloody diarrhoea No evidence for using probiotics,Adsorbants & motility suppresants