So youre walkin up a ladder, and ya hear somethin splatter

1
So youre walkin up a ladder, and ya hear
somethin splatter

• By
• Bryant Benson
• Mathew Kraus

2
Goals

• Definition
• Mechanism
• Acute
• Chronic
• Infectious
• Malabsorption
• Other
• Evaluation
• Management

3
Diarrhea

• Increased frequency, amount, or change in
  consistency from an individuals normal daily
  stool pattern.
• Practical- more than three loose stools a day
• Arguably- it is relative (concerns mom, dad, or
  the kid)

4
Epidemiology

• Infectious Diarrhea
• Developing country 3-9 episodes per year
• North America 2 episodes per year
• Less than 5 yrs old, 37 million episodes
  nationally per year
• 300 deaths in America alone secondary to
  complications
• Incidence inc after weaning, peaks at 2, decline
  there after

5
The problem with plethoric pedi pooping (I.e. the
runs in kids lt5)

• Increased enterotoxic intestinal secretions
• Less efficient colonic water reclamation
• Inc BSA/volume more insensible fluid loss
• Exaggerated febrile response

6
Mechanisms of the terrible trots

• Secretory
• Increased enterocyte secretion of sodium
• Osmotic
• Osmol prevents small bowel and colonic
  reabsorption of water
• Increased Motility
• Neuromuscular imbalance
• Decreased surface area
• Loss of intestinal villi or colonocytes
• Mucosal invasion
• Infectious damage to intestinal villi

7
Acute Diarrhea Infectious

• Viral
• Bacterial
• Parasite

8
Viral Gastroenteritis

• Causes 75 of cases, poopie phase lasts 1-4 days,
  Emesis prominent symptom
• Viral diarrhea typically involves only the
  stomach and small intestine (hence the name)
• Usual suspects are Rota, Calici, Astro, Toro,
  Adeno

9
Rotavirus (cleans you out like roto-rooter)

• Causes 25-65 of severe infantile gastroenteritis
• By age 3 most everyone is rota ab positive
• Usual course mild fever, 2-3 days emesis, 3-5
  days watery diarrhea, (may have greenish hue)
• Many various genotypes and phenotypes resulting
  in easy re-infection, albeit less severe and
  shorter duration
• Vaccine effective but related to intussusception

10
Bacterial Diarrhea

• Campylobacter jejuni
• Salmonella
• E. coli
• Shigella
• C. Difficle
• Yersinia
• Staph Aureus and Bacillus Cereus

11
Campylobacter

• For the test- bird shaped, Guillien barre
• 15 of bacterial diarrhea
• Mech Invasion of enterocytes and production of
  enterotoxin
• Trans fecal oral, water, food (i.e. poultry)
• Treat speeds recovery, reduces carrier state,
  BUT usually resolves before culture results

12
E. coli

• ETEC
• produces shigella like toxin
• Major component of travelers diarrhea
• EIEC-Invasive
• EHEC- hemorrhagic
• 0157H7 associated with HUS (dont eat jack in
  the box)
• EPEC-?cytotoxic, responsible for daycare
  epidemics out of the E. colis

13
Montezuma's E. coli revenge

• Cook your meat, dont eat feces, and for heavens
  sake dont drink the water
• Treatment- dont doo it. Does not effect severity
  of disease nor course of HUS

14
Salmonella

• Wash your eggs, dont pet that turtle, cook your
  chicken, and pasteurize your milk
• Mech invasions (less important toxin), bloody
  poop
• Treatment Dont doo it. Increases length of
  carrier state. (except Typhoid Mary's, ectopic
  foci, sickos)
• Test pearl sicklers get salmonella osteo

15
Shigella

• Dont eat the food, stay at home, wash your hands
• Mech toxin (A-B) gt invasion, bloody diarrhea
• Treat Please TREAT this one. 80 cure within 48
  hrs. Treat with bactrim
• Pearl kid with bloody diarrhea and seizure. (can
  have neurologic effects- ?toxin mediated)

16
Yersenia

• Transmission- pet your dog, not his poop. Dont
  eat the chitterlings
• Mech Invasion and toxin
• Treat Dont treat
• Pearl
• mesenteric lyphadenitis mimics appendicitis
• can be lead for intussusception

17
C. Difficile

• Antibiotic associated overgrowth
• Clindamycin gets the rap, but any will do
• Treat with oral vancomycin or metronidazole
• Cause of pseudomembranous colitis dx by scope
• Tissue assay gold standard, but three ag ELISA
  approx 95 sensitive

18
Clostridrium Cholera

• Water borne, fecal oral, poor sewage
• Mech Toxin causes extreme secretory diarrhea
• Treat Yes. Doxycyline gt8
• Pearl rice water diarrhea, cholera cot

19
Fast food poisoning facts

• Bacillus cereus- fried rice, onset 1-6 hrs
• Staph A toxin- potato salad, onset 1-6 hrs
• Vibrio parahaemolyticus- undercooked shellfish,
  alcoholic fisherman with hook in finger
• C. botulinum- muscular junction, in honey, home
  canned foods (floppy baby)
• Clostridium perfringes- leftover meats and gravy,
  onset 8-16 hrs
• Dont forget- E. coli and salmonella

20
Chronic

• Infectious
• Giardia, E. histolyticum
• Immunocompromized patients crypto, Histo, CMV,
  EBV
• Malabsorption
• Other such as IBS, IBD, CF, Celiac Sprue,
  Toddlers Diarrhea

21
Giardiasis

• Protozoan (looks like smile face on light micro)
  presents acutely but becomes chronic
• Presents with foul smelling, gaseous diarrhea.
  In infants may cause failure to thrive
• Mech unkown
• Treat metronidazole
• Pearls daycares or recent camping (contaminated
  mountain streams)

22
Entamoeba histolytica

• Invasive causing loss of intestinal lining.
  Results in abd pain and bloody diarrhea.
• If severe may get liver abscess. Important to US
  or CAT scan abd.
• Treat Metronidazole

23
Immuno-compromised hosts

• Think viral EBV, CMV, ROTA
• Opportunistic- Cryptosporidium, histoplasmosis
• Details usually not tested, read at your leisure

24
Malabsorption

• Lactose intolerance
• Cow protein allergy
• Post-infectious malabsorption
• Glucose-galactose malabsorption

25
Lactose malabsorption

• Two types congenital (rare) and adult
  type(common, presents starting ages 3-5)
• Congenital presents with change from breast milk
  to formula (galactose to lactose), loose stools,
  failure to thrive. Relieved with avoidance or
  change to soy based formula
• Adult type more common in Asian, Latino, and
  African American populations 69, versus 10-15
  in Caucasian. Diagnose with lactose hydrogen
  breath test

26
Glucose-Galactose malabsorption

• Autosomal recessive (chromosome 22)
• Defect in active transport of these sugars
• Patients have explosive diarrhea, glucosuria, and
  metabolic acidosis
• Fructose is default source of carbohydrate

27
Cow/soy protein allergy

• Not the same pathophys, but present the same
• Classical presentation- painless bloody diarrhea
  with change from breast to formula, stool studies
  blood and eosinophils. May have eosinophila
• 30 cross over intolerance between cow protein
  and soy protein
• Treatment is non-casein hydrosylate based formula

28
Post infectious malabsorption

• Transient loss of micro-villi with their
  disaccharidases
• Therefore present with recrudescence of diarrhea
  with initiation of feeds
• Incidence is low following viral gastroenteritis
  (but keep it in mind)

29
Other causes of chronic diarrhea

• IBS (irritable bowel syndrome)
• IBD Crohns and ulcerative colitis
• Cystic Fibrosis
• Celiac disease
• Chronic nonspecific diarrhea of the toddler

30
Irritable bowel syndrome

• Classically- patient reports abd pain/bloating
  postparandial relieved with defecation
  (constipation or diarrhea)
• Pathophys unclear etiology, increased
  sensitivity to bowel distention
• Extremely prevalent 30 US population. Only 1/3
  seek treatment
• Difficult to treat. Mainstay is fiber. (not
  zelnorm)

31
Inflammatory bowel disease

• Crohns
• Skipped lesions from mouth to anus
• Systemic arthropathies
• Affects submucosa
• Ulcerative
• Continuous in large colon only
• Superficial mucosa
• Bloody stool
• More likely to be associated with CA

32
Cystic Fibrosis

• Problems with Cl transporters causes exocrine
  dysfunction because of thick mucus, i.e. no
  pancreatic enzymes
• Steatorrhea with loss of fat soluble vitamins.
  (ADEK)
• Pearl meconium ileaus at birth

33
Celiac Disease

• a.k.a non tropical sprue, gluten sensitive
  enteropathy
• Allergy to gluten found in wheat, rye, barley,
  and processed oats. Presents 6mos of age
  typically
• More prevalent in northern European.
• Diagnosed
• Lab TTGA (tissue transglutaminase assay), Anti
  endomysial Ab, Anti-glutan Ab
• Gold standard is duodenal bx-blunted villi and eos

34
Toddlers Diarrhea

• a.k.a chronic nonspecific diarrhea of the toddler
• Initial stool of the day is formed then
  progressively more loose, age 6mo to 3 yrs,
  normal weight and height
• Work up is negative, etiology unclear, only
  objective finding is shorter than normal transit
  time
• May be related to juice and liquid consumption

35
Evaluation

• Dont for get your history
• Frequency, duration, color, /- blood, pain
• Travel, water source, raw/undercooked meat,
  daycare
• Physical exam
• Signs of dehydration, rectal with guiac, growth
  chart
• Make sure abd not surgical (different disease)

36
Evaluation Labs

• Acute diarrhea
• Stool for WBCs, guiac for occult blood
• Viral assay if no WBCs, otherwise stool culture
  and Grams stain
• Special media when suspicious- eosine methylene
  blue for E.coli
• Chronic
• Stool for WBCs, quiac, OP

37
Management

• For mild to moderate dehydration pursue oral
  hydration first and foremost
• Oral rehydration solutions- premise is
  cotransporter of Na and glucose better than water
  alone or high glucose liquids
• Moderate dehydration with vomiting or sever
  dehydration rehydrate with IVF bolus
• Initiate normal diet as soon as patient
  rehydrated and tolerating intake
• Avoid loperamide, pepto, and kaopectate
• Try 5cc po q 1-2 minutes (150-300cc/hr)

38
Summary of tricks or treats

• Shigella- trimethoprim/sulfa
• Campylobacter- erythromycin (but usually too late
  to impact course)
• Clostridium difficile- metronidazole then oral
  vancomycin
• Giardia- metronidazole
• Entamoeba- metronidazole
• Salmonella- bactrim (ONLY if lt3mos or
  immuno-compromised)

39
Summary

• Acute think infectious
• most likely viral. If bloody diarrhea think
  shigella, salmonella, and EHEC
• Viral gastros have emesis and usually no WBCs or
  blood in stool
• Chronic
• O and P
• Expand diff dx to include non-infectious causes
• Management
• Fluids, fluids, fluids. By mouth first then IV

40
Closing

• Remember, always put the lid down when you are
  done
• A little potty humor never hurt anyone ?

41
Works Cited

• American Academy of Pediatrics.In Pickering, LK,
  ed. 2000 Red Book Report of the Committee on
  Infectious Diseases. 25th ed. Elk Grove Village,
  IL American Academy of Pediatrics2000
• Gladwin, M. Clinical Microbiology made
  ridiculously simple 2nd ed. Miami, Fl Med Master
  Inc.
• Branski, D., Olerner, A., and Lebenthal E.
  Pediatric Gastroenterology II Chronic Diarrhea
  and Malabsorption. Pediatric Clinics of North
  America. 4321996 Pgs 307-331
• Kneepkens, C., Hoekstra, J. Pediatric
  Gastroenterology II Chronic Nonspecific Diarrhea
  of Childhood. Pediatric Clinics of North
  America. 4321996. Pgs 375-390
• Ramaswamy, K., Jacobson, K. Infectious Diarrhea
  in Children. Gastroenterology Clinics. 3032001
• Goodgame, R. Viral Causes of Diarrhea.
  Gastroenterology Clinics. 3032001
• Provisional Committee on Quality Improvement,
  Subcommittee on Acute Gastroenteritis. American
  Academy of Pediatrics Practice ParameterThe
  Management of Acute Gastroenteritis in Young
  Children. Pediatrics. 9731996. Pgs424-435