Gastroenteritis

Notes from Dr.Almazroui session Written by: Bushra Salah

Step 1: Diagnosis? (Diagnosed mainly clinically by exclusion) You have to prove 2: 1. Acute diarrhea(less than two weeks) with or without fever vomiting and abdominal pain. 2. Exclude other causes of diarrhea by History/ clinical examination and investigation Nutritional:

Wrong formula too dilated or too concentrated, wrong weaning, food poising, allergy Drugs:

From antibiotic "common" Parental infection:

Tonsillitis, Otitis media, UTI, meningitis. Step 2: How sever? Depend on the diarrhea (amount-number-consistency) More frequent/watery/bigger amount is more serious Step 3: Organism?
Example Viral -Rota virus (multiple system involvement) -Adenovirus (Isolated to GIT) Less toxic, low grade fever, CBC normal or neutropenia Bacterial -Shigella -Ecoli -Salmonella, - campylobacter -Yersinia -cholera Fever with or with out convulsions+toxic patient +bloody+ increase ESR and CRP +VE BLOOD CS+LEUKOCYTOSIS Protozoa -Amoeba -Giardia

Clinical picture

no fever mild diarhhia

Step 4: Complicated or not?

Complication

General
Dehydration

Specific
Intesspution & hemorgic cystitis

(Adenovirus)
Electrolyte disturbance

Gallie barri syndrome

Metabolic acidosis

(campylobacter)

Hemolytic uremic syndrome

Convulsion

(Enterohemorrhagic Ecoli)

Severe dehydration complication

(Enterhemo

A. General complication: Dehydration (Grade-type) moderate 10% moderate 6% sever15% sever 9%

Rule: if in infancy period: mild 5% If more than 1 year: mild 3%

Grading: specific by vital signs: If normal------------------------------------------mild Tachycardia alone-----------------------------moderate Tachycardia and low BP-----------------------sever Tachycardia and unrecoardable BP----------Shock

Nonspecific signs of dehydration (sunken eye-skin turgor- depressed fontanel capillary refill) Type (depend on soudium) Hyponatremia Hypernatremia Isonatremia less than 130 130-150 more than 150

Now, you want to give the fluid (calculate-rate)

Calculate fluid

No shock
Shock
Resuscitation 20cc/kg/1h +

Maintenance
1 10kgX 100 2 10 kgX50 More than 20kgX 25
nd st

Deficit
10X%Xweight

The same as no shock N.B: subtract the amount you gave from the 1st 8 hours

Example 1: Calculate the Maintenance and deficit for a child weight 23kg patient if he has only tachycardia? )( 5 10 50 Maintenance (10 kgX 100)+( 10kgX50)+(3kgX25)= 1575 Deficit 10X10X23= 2300 Total= 2300+1575= 3875 n.b: moderate dehydration 10%

How to give it (Depend on sodium)

Rate

Type Dextrose 5 % +

Iso &hypo(over 24 hours) Divide it by 2 in over the 1st 8 hours & next over 16 hours

Hyper(Over 48 hours) Add maintenance for the next day & divide the deficit

1/2 Saline in Iso & Hypo 1/2 Saline hyper why?

Normal saline in Hyper

Example 2: if the same patient from example 1 how would you give him his fluid in the fallowing situations? (Total body fluid was 3875) Sodium 124

It will be over 1 day 3875/2= 1947.5 Sodium 176 1937.5 in 1st 8 hours and 1937.5 in the next 16 hours

It will be over 2 days 3865(total)+ 1575(maintenance for the 2nd day)= 5450 1st day=2725/24h 2nd day =2725/24h

Electrolyte disturbance

Sodium (hypo-hypre) , hypocalcemia, hypoglycemia , hypokalemia. N.B: hyperkalemia normally doesn't occur but it can in:

If the patient is going in to acute renal failure due to hypervolemia In infancy: GE can trigger congenital adrenal hyperplasia. (Addision crisis resemble GE except in hyperkalemia) Lifesaving: if you suspect congenital adrenal hyperplasias (ambiguous gentilia- precious puberty) give cortisol. Metabolic acidosis Decrease PH, Decrease bicarbonate Convulsion due to Hypo/hypernatremia Hypoglycemia Febrile Toxic secondary to shigella Parental infection meningitis Alkalosis

Sever dehydration Brian edema (hypernatremia) Bilateral renal vein thrombosis (Abdominal mass +gross hematuria)

A. Specific complication: Organism adenovirus Disease intussusception Hemorrhagic cystitis Gallien barre Hemolytic uremic syndrome Clinical picture Colicky abdominal pain + currant jelly stool Hematouria LMNL(bilateral and symmetrical) Jaundice +RF+ thrombocytopenia

Campylobacter Ecoli

Step 4: Investigation (diagnostic and for complication) Diagnostic

Stool analysis for protozoa infection +/- blood and mucous Acidic stool for lactose intolerance Stool culture for bacterial infection Electron microscope for rotavirus

Complication Blood chemistry Urea and creatinine In ER don't give potissum because the patient may get renal failure wait for the RESULT ABG Glucose Calcium Urine analysis UTI CRP,ESR Chest X-ray Key points: if there is convulsions if the patient is below 3 or 5 years GE maybe presented by

if there is fever if there is parental infection

fluid calculation

grade =percentage=degree

- Deficit=percentage*10*wt total fluid=M+D M

Type of DHN(HYPO-ISO-HYPER) USED FOR 1-DURATION OF CORRECTION2-AND TYPE OF FLIUD(1/4-1/2-NS- _3 NS)