Gut Feelings

PGI Irenea, Rachel

PGI Magno, Angela
 TABLE OF CONTENTS

01
Objectives 02 03
Definition Case

04 05 06
Diagnostics Management Prevention
 Objectives
01
 Objectives

- Identify the type of gastroenteritis based

on the clinical features of patients
- Provide appropriate management for
patients based on hydration status and
etiology of infection
- Advise prevention and control
measures for the family and the
community
 02
Definition of Terms
AGE vs AID
 Acute Gastroenteritis Acute Infectious Diarrhea

● characterized by changes
in the character and
frequency of stool ● passage of 3 or more loose,
● defined as the passage of a greater watery or bloody stools within 24
number of stools of decreased form hours that may be accompanied
from the normal lasting less than 14 by any of the following symptoms:
days
○ Nausea and vomiting,
● associated with other signs or ○ abdominal pain,
symptoms including: ○ fever

○ Nausea and vomiting, ○ passage of bloody

○ abdominal pain and cramps, stools (dysentery),
○ increase in intestinal gas-related ○ tenesmus (constant
complaints, sensation of urge to
○ fever move bowels),
○ fecal urgency
 03
Cases
Children vs Adult
Case # 1

Patient’s Data:
- A.M.
- 6y 3mo/ Female
- Buhangin, Davao City

Chief complaint: loose watery stools

 History of Present Illness

2 days
3 days 10 hours
Loose watery stools x 2
Attended a birthday party episodes Loose watery stool x 1 episode
of her classmate
Vomiting x 1 episode Low grade fever of Tmax 38C
Ate macaroni salad amounting to 2 tbsp
Thirsty and drinks eagerly
Abdominal pain
Adequate urine output for x 8
Decrease of appetite hours
9
 Physical Examination

- VS: 90/60 mmHg, 128bpm, 28bpm, 38.1C O2 99% RA

- Anthropometric: Wt: 19kg Ht: 134cm
- General: Awake, irritable, drinks eagerly, NIRD
- HEENT: slightly sunken eyes, moist lips and oral mucosa,no alar flaring, no nasal discharge, no
CLAD
- Chest and lungs: no chest lag, clear breath sounds, equal tactile fremitus, adynamic precordium,
distinct heart sounds, no murmur
- GIT: Globular, non distended, hyperactive bowel sounds, soft non-tender abdomen
- GUT: no dysuria, no hematuria
- Extremities: full pulses, skin pinch goes back slowly, CRT 2s
 IMPRESSION:
ACUTE GASTROENTERITIS WITH
MODERATE DEHYDRATION
Case # 2

Patient’s Data:
- L.M.
- 52/M
- Tibungco, Davao City

Chief complaint: loose watery stools

 HISTORY OF PRESENT ILLNESS

3 1 15
DAYS DAY HOURS

LBM x10 episodes

Vacation from Undocumented fever
Thailand Vomiting x 5, watery, non mucoid
Took Paracetamol (food vomitus) approximately 1/2
500mg/tab with relief
per episode last episode was
minutes prior to consult.

associated with generalized

abdominal pain ps (5-6/10), fever
(tmax: 38.1)
13
 PHYSICAL EXAMINATION

- VS: 130/70 mmHg, 108bpm, 25bpm, 38.4C

- Anthropometric: Wt: 60kg Ht: 154cm BMI: 25.3 Obese I
- General: Awake, weak-looking, thirsty, in respiratory distress
- HEENT: sunken eyeballs, dry lips and oral mucosa, no CLAD
- Chest and lungs: equal chest expansion, clear breath sounds, equal tactile fremitus, adynamic
precordium, distinct heart sounds, no murmur
- GIT: Globular, non distended, hyperactive bowel sounds, soft tender abdomen on deep palpation at
the umbilical region
- GUT: no dysuria, no hematuria
- Extremities: full pulses, good skin turgor, CRT >2s, pale nail beds, (-) edema
- DRE: (-) lesions, (-) masses, (-) fistula, non tender, non erythematous perianal skin, no blood or
stool at the examining finger
 IMPRESSION:
ACUTE INFECTIOUS DIARRHEA WITH
MODERATE DEHYDRATION
 What pre-treatment clinical evaluations are recommended
for immunocompetent patients presenting with acute
infectious diarrhea?

History Physical Exam

• Consumption of raw, ill-
prepared, or rotten food • Done to assess
disease severity, degree
• Intake of contaminated
of dehydration, presence
water
of complications
• History of travel
THE MOST COMMON COMPLICATION
OF DIARRHEA IS:

DEHYDRATION
 Parameters No signs of dehydration Mild to Moderate dehydration Severe dehydration

Fluid deficit (% body weight )

Infant <5% 5-10% >10%

C Child 3% 6% 9%

H
Condition well,alert Restless, irritable Lethargic or unconscious

I
Thirst Drinks normally, not thirsty Thirsty, drinks eagerly Drinks poorly, or not able to drink

Fontanel/Eyes Normal Slightly depressed/ slightly sunken Sunken

L Tears Present Present or Decreased No tears

D Cutaneous Perfusion/
Capillary Refill
<2 seconds Around 2 seconds > 3 seconds

R Respiration Normal Deep, may be rapid Deep and rapid

2mo-12mo:≥50breaths/min

E
12mo-5yo: ≥40breaths/min

N
Skin Pinch Goes back quickly Goes back slowly Goes back very slowly

History of Urine Normal Decreased (<0.5ml/kg/hr x8hours) Little (<0.3 ml/kg/hr in 16hrs) or none (no urine
Output output in 12hrs)

Interpretation If the patient has two or more signs, there If the patient has two or more signs, there is
is MILD to MODERATE DEHYDRATION SEVERE DEHYDRATION
 Mild Moderate Severe

fatigue +/- + +

thirst +/- + +

Sunken eyes - + +

A
Blood pressure normal Orthostatic hypotension shock

D
Respiratory rate normal 21 - 25 >25
(breaths/minute)

U
Heart rate (w/o fever) > 80bpm >100 bpm Faint or thready

L
Peripheral Warm to touch Cold, clammy skin Cold, clammy skin
extremities

T
Level of consciousness alert lethargic coma/stupor

Oral mucosa moist dry dry

Muscle weakness none mild-moderate severe

Skin turgor <2s >2s >2s

Capillary refill time <2s >2s >2s

Urine output (ml/kg/hr) > 0.5 <0.5 <0.5

 Mild Moderate Severe

fatigue +/- + +

thirst +/- + +

Sunken eyes - + +

A
Blood pressure normal Orthostatic hypotension shock

D
Respiratory rate normal 21 - 25 >25
(breaths/minute)

U
Heart rate (w/o fever) > 80bpm >100 bpm Faint or thready

L
Peripheral Warm to touch Cold, clammy skin Cold, clammy skin
extremities

T
Level of consciousness alert lethargic coma/stupor

Oral mucosa moist dry dry

Muscle weakness none mild-moderate severe

Skin turgor <2s >2s >2s

Capillary refill time <2s >2s >2s

Urine output (ml/kg/hr) > 0.5 <0.5 <0.5

Stool Consistency
04 ETIOLOGY AND
DIAGNOSTICS
Major Etiologies of Childhood diarrhea in developing countries
 Clinical use of diagnostic tests in children and adults with acute
infectious diarrhea
● Diagnostic tests should be requested based on the patient’s clinical
status

● Routine stool examination is not indicated in acute watery diarrhea,

except in cases where parasitism is suspected or in the presence of
bloody diarrhea

● Stool cultures are indicated only for

○ severe cases, high risk of transmission of enteric pathogens (food
handlers);
○ high risk of complications;
○ epidemiologic purposes (when there is suspicion of an outbreak that
is enteric in origin)
 Clinical use of diagnostic tests in children and adults with acute
infectious diarrhea

● There is insufficient evidence to support the use of biomarkers (CRP,

calprotectin, ESR, procalcitonin) in distinguishing the cause of acute
infectious diarrhea

● Rapid diagnostic tests may be used during outbreaks of cholera and

shigella but confirmation with stool culture is still recommended

● Clinical correlation is necessary in interpreting tests done using

molecular diagnostics

26
 STOOL CULTURE
ETIOLOGIC AGENT CULTURE MEDIUM or other diagnostic tests

Cholera Thiosulfate-citrate-bile salts-sucrose (TCBS); tellurite-taurocholate-

gelatin (TTG) agar; rapid diagnostic test

Rotavirus Latex agglutination test

Norovirus Reverse transcriptase PCR and specific antigen enzyme

immunoassays

Giardia cyst or cryptosporidium Immunofluorescence-based rapid assays or PCR or standard

microscopy (less sensitive)

Salmonella and Shigella Macconkey agar non lactose fermenting (colorless) colonies or in
Salmonella-Shigella agar or in selenite enrichment broth

Clostridium difficile Rapid enzyme immunoassays, latex agglutination test, ot PCR

27
 Management 05
Children and Adult
CHILDREN

29
33
34
35
 CHILDREN
No Dehydration Mild-moderate dehydration Severe dehydration

Reduced oral rehydration solution is Reduced osmolarity ORS via oral Rapid intravenous rehydration is
recommended to replace on-going route is recommended to replace recommended with either plain
losses ongoing losses. If oral rehydration is Lactated Ringer’s Solution or 0.9%
not feasible, nasogastric tube is Sodium Chloride (with or without 5%
preferred before IV hydration. glucose).

If commercial ORS is not available,

home-made ORS may be given

Homemade ORS

4-5 teaspoons of sugar

1 teaspoon of salt
1 liter of clean drinking water

36
 CHILDREN
Monitoring
- Check the child from time to time during rehydration to ensure
that ORS is being taken satisfactorily and that signs of
dehydration are not worsening
- Evaluate the child’s hydration status at least hourly

Breastfeeding should be continued in addition to hydration therapy for

breastfed infants

Carbonated, sweetened, caffeinated and sports beverages are not

recommended for fluid replacement

37
 CHILDREN
Advice for admission:

1. Clinical History: 3. Co-existing medical

- unable to tolerate fluids conditions:
- suspected electrolyte - Pneumonia
abnormalities - Meningitis
- conditions for a safe - Encephalitis
follow-up and home - sepsis
management are not - moderate to severe
met malnutrition
- suspected surgical
2. Physical findings: condition
- altered consciousness
- abdominal distention
- respiratory distress
- hypothermia
(temperature <36C)
38
 CHILDREN
Indications for empiric antibiotic treatment in children:

- Primary management of acute infectious diarrhea in children is

still rehydration therapy. Routine empiric antibiotic therapy is
NOT recommended

- Antimicrobials may be recommended for the following conditions:

- Suspected cholera
- Bloody diarrhea
- Diarrhea associated with other acute infections
 CHILDREN

Cholera Shigella Amoebiasis

• Azithromycin • Ciprofloxacin 30mg/kg/day • Metronidazole

10mgkg/dose OD x 3 days PO into 2 doses 10mg/kg/dose TID for 10-14
days to avoid relapse
• Doxycycline (if >8yrs old): • Azithromycin 10mg PO
2mg/kg single dose OD x 3days

• Ceftriaxone IV 75-
100mg/kg/day
 CHILDREN

- Zinc medication as adjunctive therapy for children >6 months to

shorten the duration of diarrhea and reduce frequency of stools

- Racecadotril may be given to infants and children as adjunctive

therapy to shorten the duration of diarrhea

- Loperamide is NOT recommended for children with acute infectious

gastroenteritis due to serious adverse events

- Anti-emetics are NOT recommended due to potential adverse

events
 Role of Probiotics
● Probiotics are recommended as an adjunct therapy throughout the
duration of the diarrhea in children.

● Probiotics have been shown to reduce symptom severity and duration

of diarrhea.

● The following probiotics may be used:

○ Saccharomyces boulardii - Normagut capsule 250mg/cap; 2-12
yo 1 cap OD 5-7 days; >12yo 1 cap OD or BID 5-7 days
○ Lactobacilllus rhamnosus - 1 sachet 2x a day for 5-7 days
 CHILDREN

- Breastfeeding should be continued in breastfed infants

- In general, feeding should be continued. However, if feeding is not

tolerated, early refeeding may be started as soon as the child is able

- If diarrhea persists for >7 days or if patients are hospitalized due to

severe diarrhea, lactose-free diet may be given to children who are
predominantly bottle-fed to reduce treatment failure and decrease
the duration of diarrhea.
ADULT
ADULT
ADULT
ADULT
ADULT
 ADULT
Mild dehydration Oral rehydration solution is recommended at 1.5 to 2 times estimated amount
of volume deficits plus concurrent gastrointestinal losses.

Moderate dehydration 500 to 1000 ml of PLRS IV in the first two hours is recommended.

Once hemodynamically stable, give 2 – 3 ml/kg/hr PLRS for patients with

actual or estimated body weight of < 50 kg and 1.5 – 2 ml/kg/hr PLRS for
patients with actual or estimated body weight of > 50 kg. Use ideal body
weight for overweight or obese patients.

PLR boluses vol/vol to replace ongoing losses or oral rehydration solution if

tolerated may be used for moderate dehydration.
 ADULT
Severe 1000 to 2000 ml of PLRS within the first hour is recommended.
dehydration
Once hemodynamically stable, give 2 – 3 ml/kg/hr PLRS for patients with actual
or estimated body weight of < 50 kg and 1.5 – 2 ml/kg/hr PLRS for patients with
actual or estimated body weight of > 50 kg. Use ideal body weight for overweight
or obese patients.

It is recommend to have vol/vol replacement with PLR boluses to replace ongoing

losses for severe dehydration because at this point the mental status of the
patient may already be compromised therefore the risk for aspiration is high.
 ADULT
Advice admission:
- Clinical history and physical findings:

- Poor tolerance to oral rehydration therapy

- Moderate to severe dehydration
- Acute kidney injury and/or electrolyte abnormalities
- Unstable comorbid conditions (e.g. uncontrolled diabetes, congestive heart
failure, unstable coronary artery disease, chronic kidney disease, chronic
liver disease, immunocompromised conditions)
- Frail, elderly (60 years old and above) and/or with poor nutritional status
- Patients with unique social circumstances (living alone, with residence far
from a hospital)
 ADULT
Empiric antimicrobial treatment:
Empiric antimicrobial treatment is NOT recommended for acute diarrhea with the following
clinical features: mild to moderate dehydration only, non-bloody stools, symptoms less than 3
days.

Empiric antimicrobial treatment is recommended for patients with acute diarrhea with
moderate to severe dehydration plus any of the following clinical features: fever alone, fever
and bloody stools, symptoms persisting for more than 3 days.

The following antimicrobials are recommended for empiric treatment of acute infectious
diarrhea:
o Azithromycin 1g single dose OR
o Ciprofloxacin 500 mg twice daily for 3-5 days
o Once suspected organism is confirmed, antimicrobial therapy may be modified
accordingly
 ADULT
Etiologic agent Antimicrobial

Suspected or confirmed cholera • Azithromycin 1g single dose

• Ciprofloxacin 1-2 gm single dose or 500 mg BID for 3 days
• Alternative: Doxycyline 100 mg BID for 3 days (Strong, low to moderate)

Suspected or culture-proven shigella Ceftriaxone 1 g once a day for 5 days OR

• Ciprofloxacin 500mg twice a day for 5 days OR
• Azithromycin 1g single dose
*Once with culture, antimicrobial therapy can be modified accordingly.

Suspected or confirmed nontyphoidal salmonella Ciprofloxacin 500mg twice a day for 5 days
dysentery in adults • Ceftriaxone 1g IV OD for 5 days
*Once with culture results, antimicrobial therapy may be modified accordingly.

Confirmed amoebiasis Metronidazole 500-750 mg tab three times a day for 10 days.
• Alternative: Tinidazole 2 g OD for 3 days; secnidazole 2 g single dose
• Diloxanide furoate 500mg three times a day may be added to metronidazole, if
available
 ADULT

- Loperamide is NOT recommended in adults with acute

infectious diarrhea.

- Racecadotril (100 mg three times a day) may be given to

decrease the frequency and duration of diarrhea.
55
What laboratory tests should be done to assess for the presence of
complications for acute infectious diarrhea?

● Complete blood count

● Urinalysis
● Serum electrolytes (Na, K, Cl)
● BUN and creatinine Serum bicarbonate or
total CO2 (if available)
● ABG (optional)
 06
Prevention
 GOALS

1. Reduce subsequent episodes of

diarrhea
2. Malnutrition, and delays in
physical and mental
development
 HOW?

● Exclusive breastfeeding until age six months, and continued

breastfeeding with complementary foods until two years of age.

● The consumption of safe food and water. If available, water brought to a

rolling boil for at least five minutes is optimal for preparing food and
drinks for young children.

● Handwashing after defecating, disposing of a child's stool before

preparing meals.

● The use of latrines; these should be located more than 10 meters and
downhill from drinking water sources
Food and Water-Borne Disease Prevention and
Control Program
Administrative Order No. 29-A.s 1997

Interventions:
● institutionalization of Oral Rehydration Therapy (ORT) corners in both
the hospitals and outpatient public health facilities for the immediate
management and treatment of diarrhea cases
● integration of the identification and management of diarrhea among
the children in the IMCI protocol
● design, installation and operationalization of a FWBD surveillance and
response system to detect impending outbreaks and provide immediate
investigation and response to these cases
● provision of drugs/medicines and supplies augmentation to identified
local government units (LGUs) with high incidence of FWBDs
● developing clinical practice guidelines on the diagnosis, management
and treatment of several FWBD
References
THANK
YOU
 Mild Moderate Severe

body weight change reduction of 3% to 5% of body Current dehydration corresponded Current dehydration corresponded
weight within seven days or less, to changes of more than 5% of body to changes of more than 5% of
OR an increase of 3% to 5% of weight body weight

A
body weight within seven days as
an indication that a person was
dehydrated before rehydration

D
U
Urine specific gravity ≥1.010 ≥1.020 ≥1.020

L
Urine osmolality >800 >800 >800

T Serum osmolality 295-300 >300 >300

BUN/creatinine ratio (mg/dl) >20 >20

ABG (pH <7.35, HCO3 <22) - - +