ACUTE GASTROENTERITIS

&
FLUID MANAGEMENT
CASE PRESENTATION

• Patient Details •
• Initial : SYED AZRIEL
• Age : 2 years old
• Gender : BOY
• Weight : 10 kg
• Duration of hospitalization : 8-11 FEBRUARY 2020 (4 days) 
HISTORY

• Presented with:
1) Vomiting x 2/7
>7 episodes /day
milk and fluid content,blood tinged
2) Loose stool x2/7
7 episodes/day
watery ,moderate in amount
yellowish in colour - non blood stained, no mucus 
3) Fever 1/7
+reduced oral intake,only taking milk,no solid food
+increase in thirst
+less active
• o/w
• No other family members having same sx,No hx of taking outside food , no rapid breathing ,No
rashes/bleeding tendencies,No recent travelling/swimming/jungle trekking,No fitting ,No UTI/URTI sx
PAST MEDICAL AND BIRTH HX

• Delivered full term via SVD

• No antenatal/post natal problems.
• No prior history of hospitalizations.
• No known allergies / medical illness 
DEVELOPMENT AND FEEDING HX

• Gross motor : able to ride bicycle

• Fine motor : able to draw house, sea
• Speech : able to make sentences
• Social : able to toileting herself without help, able to play cards
IMP : Development appropriate to age
• Breastfeeding until 6 months old • Since then started on
complimentary diet
IMMUNIZATION HISTORY & SOCIAL HISTORY

• Immunization Up to age.
• Only child
• Stayed both parents
AT ED

• O/E
Lethargic looking,mild pallor, mild coated tongue, normal
skin turgor,Sunken eyes,Crying without tears
T:39
Pr 140
VBG :ph 7.2/hco 16/ lact 3.7
Impression
1.Infective AGE with 5% dehydration
2.Mallory Weiss tear sec to 1

• Given NS bolus 10cc/kg (100cc) and started with NS

7.5%
Correction over 12 hours (54cc/hr)
Syr PCM 145mg stat
• o/e
ADMIT TO WARD 6EF ON 8/2/2020
• Lethargic looking,sunken eyes,molted skin,drinks
eagerly,cold peripheries,good pv
• Started with IVD NS with 5% correction for 12 hour
47cc/hr
• Reassesment on same day pm rv
Cold peripheries ,good pv,not tachypnoeic ,no sunken eyes,
-given NS bolus 100cc/1hr
VBG post bolus :ph 7.213/lac 1.7/hco 12
HOSPITAL COURSE
• Given nahco3 10cc over 1 hour,cont 5% correction and cont IVD full maintenance
• Post NAHCO3
• VBG :ph 7.272/hco3 14/lact 1.3/K 2.8
• For another 5% correction,7cc/hr in 12 hr and add on 1g KCL 40ml/hr (2.6mmol/kg/day) in full drip maintenance
• Has spiking temperature started with IV cpen escalated to IV cefotaxime 50mg/kg tds for 5/7
• At night
no sunken eyes ,warm peripheries,good pv,mild periorbital edema
VBG ph 7.26/hco3 15./lact 0.8/k 2.6
calcium on VBG :0.25, total calcium :2.3
• Given IV calcium gluconate 5cc dilute 5cc water given for 30 min,IVD half maintenance (20cc/hr )with 1g KCL 40cc/hr ,off ivd
correction
ALLOWED TO GO HOME ON 11/2/2020

• Afebrile >24 h
• Tolerating feeding well
• No more vomiting
• BO back to normal consistency,no loose stool
• Clinically improved
SUMMARY
• 2 years old boy presented with diarrhea and
vomiting,fever 1 day prior to admission, associated
with reduce oral intake,increase in thirst ,less active

• During physical examination in ED , child had signs

of dehydration : mild coated tongue, very lethargic ,
eyes sunken,no tears
With VBG showing metabolic acidosis
DIAGNOSIS
• AGE with 5% dehydration
• Mallory Weiss tear sec to 1

Points to support
Hx : diarrhea,vomiting,fever sign of
ehydration:lethargic looking,mild coated
tongue,sunken eyes ,no tears
DIFFERENTIAL DIAGNOSIS
1.Food poisoning
• -point to support –vomiting,diarrhea ,fever
• Point to against –no outside food taken

2.Intusucception
Point to support –age in between 6-36 months
Vomiting,fever,diarrhea
Point against –intermittent ,progressive abdominal pain,red currant jelly stool,palpable sausage like
abdominal mass
Others DDX :gerd, milk protein allergy ,UTI,
INVESTIGATION
• Initial Busec 8/2
Urea 5.8/na 3/k 4.6/cl 100/cr 31

Busec 8/2
Urea 2.9/na 143/k 3.2/cl 102/cr 29

Busec 9/2
Urea 2.7/na 10/k 3.2/cl 113/cr 21

Busec 10/2
Urea 1.4/na 138/k 3.2/cl112/cr 32
• Ca 2.3/mg 0.75/phosp 1.13
• Crp 12.7
• Blood c&s NG
• Stool -rotavirus +ve
HOSPITAL MANAGEMENT
• Bolus NS 100cc for 1hour
• IVD correction 47cc/hr for 12 hours
• Ivd full maintenance NSD5% with 1g KCL 40cc/hr (2.6mmol/kg/day)
• Reduce ivd HM 20cc/hr
• For nahco310 over 1 hr
• For iv calcium gluconate 5cc dilute 5cc water for 30 minutes
• Ors per purge 100cc
• Syr pcm 145mg qid
• Starte with Iv cpen iv cefotaxime 50mg/kg tds = 75mg tds for 5/7off 10/2
• Syr cloxacillin 15mg/kg =150mg qid x1/7
• Strict i/o chart
• Monitor vitals sign
FINAL DIAGNOSIS

•ROTAVIRUS AGE WITH

MODERATE DEHYDRATION
•MALLORY WEISS TEAR SEC TO 1
•ACUTE
GASTROENTERITIS WITH
FLUID MANAGEMENT
•  Acute gastroenteritis is a leading cause of
childhood morbidity and mortality and an
important cause of malnutrition.
• Dehydration and electrolyte losses associated
with untreated diarrhea are the main causes of
morbidity and mortality of childhood AGE
• Diarrhea can also be the initial signs of non-
gastrointestinal tract illness, including meningitis,
bacterial pneumonia, otitis media,
intussusception and UTI
DEFINITION

• •The passage of unusually loose or watery stools, usually

at least 3 times in a 24-hour period.
• - College of Paediatrics, Academy of Medicine of Malaysia
(AMMCOP) , 2011
AETIOLOGY
• Rotavirus is known to be the most common pathogen in
children
• It is more severe than other causes and more often results in
dehydration, Hospitalization, Shock, Metabolic disturbances
and Death
• Bacterial pathogens are more common where poor sanitation,
hygiene and water supply play a role causing dysenterey
• Rotavirus attach and enter mature enterocytes at the tip of the
small intestinal villi
• Cause structural changes to the bowel mucosa, including villous
shortening and mononuclear inflammatory infiltrates in the
lamina propria
• This virus induce maldigestion of carbohydrates and their
accumulation in the intestinal lumen (in the absence of lactase) •
• Malabsorption of nutrients and concomitant inhibition of water
reabsorption can lead to a malabsorption component of diarrhea
• Rotavirus secretes an enterotoxin, NSP4 which leads to a
calcium- dependent chloride secretory mechanism
INDICATIONS FOR ADMISSION TO HOSPITAL

• Moderate to severe dehydration.

• Need for intravenous therapy (as above).
• Concern for other possible illness or uncertainty of diagnosis.
• Patient factors, e.g. young age, unusual
irritability/drowsiness, worsening symptoms.
• Caregivers not able to provide adequate care at home.
• Social or logistical concerns that may prevent return
evaluation if necessary.
•ASSESMENT &
MANAGEMENT OF ACUTE
GASTROENTERITIS
WORK UP

•After resuscitation, in children with severe dehydration, shock

or other signs of metabolic, nutritional or other co-morbidities
• Electrolytes and serum acid base determination
• All severely dehydrated patients, mod dehydration with an
atypical presentation, malnourished children
• Blood glucose disturbances occur in severely ill patients as a
result of glycogen depletion with lack of intake, or associated
with the stress response of dehydration
 INVESTIGATIONS

Stool culture is required if the child appears septic, if there is

•  

blood or mucus in the stool or child is immunocompromised

• Full blood count
• Renal profile (plasma electrolytes, urea, creatinine) & blood
glucose if IVD required or there is features suggestive of
hypernatremia
• Blood culture  if to start antibiotics
FIRST TREAT SHOCK IF PRESENT

Always SHOUT for HELP

•

• A…….B….. • Circulation
• Establish vascular access or IO if failed venous access after 2 good attempts
• Give 20ml/kg of R/L or Normal Saline rapid infusion or 5ml/kg in aliquots X4 is much
safer
• Watch for signs of circulatory overload i.e hepatomegaly, gallop rhythm or basal
crackles, puffiness of the eyelids, tachy-pnoea and –cardia.
• Repeat R/L 20ml/kg if patient is still shocked. Re-assess and give more if still shocked
• Don’t-Ever-Forget-Glucose
• Re-assess ABC and response so far
• Give 1st dose Ceftriaxone 80mg/kg stat to cover sepsis
TREATING SHOCK IN SEVERELY
MALNOURISHED
• • ABC still as essential as the normally nourished patients
• Give 15ml/kg infusion over 30 minutes
• Re-assess and repeat if still shocked
• Give up to 4 boluses and thereafter, T/F to HC or ICU
• Patient response should guide further fluid therapy
• When shock has been treated successfully, proceed to the
management of dehydration.
• But remember your patient can go back into shocked if improperly
rehydrated
ELECTROLYTE DISTURBANCES
• Large amounts of Sodium are lost in diarrheal stools
• In acidosis, a shift of intracellular potassium to EC compartment
results in a spurious elevation of the serum level despite intracellular
potassium loss
• Give K+ to all patients with severe diarrhea until dehydration and
acidosis are corrected
• Sodium disturbances occur frequently
• Sodium content of the stool water varies from plasma-like in
secretory diarrhea , to very low in pure Osmotic diarrhea
NEVER FORGET THE ONGOING LOSSES

• Losses need to be replaced by equal volumes of fluids of similar composition

• For moderate losses, add 30mls/kg to maintenance requirements. But give
more if there’s a need
• For those taking enterally:
• <2years: 50-100mls AELS
• >2years: 100-200mls AELS
• Small frequent volumes of home based sugar salt solution as little as 5mls
every minute, can be effective in preventing dehydration even in vomiting cases
• Continue Breast feeding and oral feeding once perfusion is restored
 PLAN C: TREAT SEVERE DEHYDRATION
QUICKLY
•  Start intravenous (IV) or intraosseous (IO) fluid immediately.
• If patient can drink, give ORS by mouth while the drip is being set up.
• Initial fluids for resuscitation of shock: 20 ml/kg of NaCl 0.9% or Hartmann solution as a rapid IV bolus.
• Repeated if necessary until patient is out of shock or if fluid overload is suspected.
• Review patient after each bolus.
• Calculate the fluid needed over the next 24 hours:
• Fluid for Rehydration (fluid deficit) + Maintenance (minus the fluids given for resuscitation).
• Fluid for Rehydration: % dehydration X body weight (g)
• Maintenance fluid (NaCl 0.45 / D5%)
• 1st 10 kg = 100 ml/kg;
•  0-20 kg = 1000 ml/day + 50 ml/kg for each kg above 10 kg
• >20 kg = 1500 ml/day + 20 ml/kg for each kg above 20 kg.
 OTHER INDICATIONS FOR INTRAVENOUS
THERAPY
• • Unconscious child.
• Continuing rapid stool loss ( > 15-20ml/kg/hour).
• Frequent, severe vomiting, drinking poorly.
• Abdominal distension with paralytic ileus, usually caused by some
antidiarrhoeal drugs (e.g. codeine, loperamide ) and hypokalaemia.
• Glucose malabsorption, indicated by marked increase in stool output and
large amount of glucose in the stool when ORS solution is given
(uncommon).
• IV regime as for Plan C but the replacement fluid volume is calculated
according to the degree of dehydration. (5% for mild, 5- 10% for moderate
dehydration). 
REHYDRATION FLUIDS
• Its NB to use solutions with sufficient Na conc. To prevent Hyponatremia
• ½ DD is appropriate if IV route is used, or ORS for enteral replacements
• Where vomiting is the main source of fluid loss, rehydration fluid (0.45%NaCl and
5% Dextrose) with added K is appropriate
• Dose of ½ DD or ORS for rapid rehydration over 4 hours
• Some Dehydration: 50ml/kg over 4 hrs (12.5ml/kg/hour)
• Severe Dehydration: 100mls/kg/4hours (25mls/kg./hour) •
Rapid rehydration over 4hrs should not be used in severe malnutrition, cardiac
failure, severe pneumonia, encephalopathy etc.
• However, rehydrate over 24hours or even 48 hours
• Severely malnourished have a deficient K and elevated Na levels, thus require a
special ORS: ReSolMal
MAINTENANCE FLUIDS

•Should be given enterally wherever possible

but intravenously where nil per Os is absolute
• Fluid restriction to approximately 50-60% of
maintenance should be adhered to, where
there is a risk of inadequate secretion e.g in
Renal failure
PHARMACOLOGICAL AGENTS

• Oral rehydration therapy.

– Use to treat mild to moderate dehydration.
– Consist of :
i. Sodium chloride (NaCl).
ii. Potassium chloride (KCl).
iii. Trisodium citrate.
iv. Glucose
 PHARMACOLOGICAL AGENTS

• Antimicrobials Antibiotics
• Majority of gastroenteritis cases in children are viral in origin (rotavirus, norovirus,
adenovirus). Thus, antibiotics are only needed for specific pathogens or defined clinical settings.
• Antibiotics are indicated in the following situations:
Shigella dysentery - in cases presenting as bloody diarrhoea, should be treated with an
antimicrobial effective for Shigella
When cholera is suspected
When diarrhoea is associated with another acute infection such as pneumonia and UTI
May be indicated for Salmonella gastroenteritis in very young babies (< 3 months), immune-
compromised, immuno- suppressed, systemically ill, achlorhydia
ANTI-DIARRHOEAL AGENTS AND OTHER
THERAPIES
• Silicates – diosmectite (Smecta®)
• Binds to selected bacterial pathogens and rotavirus
• restore integrity of damaged intestinal epithelium
• reduce stool output and duration of diarrhoea
• shown to be effective in rotavirus diarrhoea
• maybe used as adjunctive to ORS
• no side effects 
PHARMACOLOGICAL AGENTS

• Antiemectics •
• Anti-emetics such as dimenhydrinate, metoclopromide,
domperidone and promethazine may cause sedation that
can interfere with oral rehydration therapy
PHARMACOLOGICAL AGENT

•  Probiotics – Probiotics has been shown to reduce duration of diarrhoea in several randomized
controlled trials.
– However, the effectiveness is very strain and dose specific.
– Only probiotic strain or strains with proven efficacy in appropriate doses can be used as an
adjunct to standard therapy.

• Zinc supplements
– Able to reduce the duration and severity of the episode and lower the incidence of diarrhoea in
the following 2-3 months.
– WHO recommends zinc supplements as soon as possible after diarrhoea has started.
– Dose up to 6 months of age is 10 mg/day, and age 6 months and above 20mg/day, for 10-14
days
 NON PHARMACOLOGICAL / NUTRITIONAL
STRATEGIES
•   Undiluted vs diluted formula
- No dilution of formula is needed for children taking formula
milk.
• Soy based or cow milk
-based lactose free formula
- Not recommended routinely.
- Indicated only in children with suspected lactose
intolerance. 
 TAKE HOME MESSAGE

•Acute gastroenteritis is usually self-limiting, but if

untreated it can lead to morbidity and mortality secondary
to water loss and electrolyte and acid-base disturbance.
• Dehydration secondary to gastroenteritis is a significant
cause of morbidity and hospital admission
• Parent should diligent hand washing and do not sharing
same towel with infected child
• Child should not return to childcare or school until 48
weeks after last episode of diarrhea 
REFERENCE

1. Paediatric Protocol (Malaysia) – 3rd Edition

2. Guideline on the Management of Acute Diarrhea
in Children, College of Paediatrics, Academy of
Medicine of Malaysia (AMMCOP), (2011)
3. Nelson Textbooks of Pediatric 20th edition (2016)
4. Ilustrated Textbooks of Paediatrics – Elsevier 4th
Edition, (2012)
THANK YOU