Acute Gastroenteritis with

Moderate Dehydration
 Table of Contents

01 02 03
History
Physical Exam Salient Features

04 05 06
Admitting Differential Course in the
Diagnosis Diagnosis Ward
 Table of Contents

07 08 09
Discussion Journal
Final Diagnosis
 HKR
6-month old male from Cavite
Filipino, SDA

Chief complaint: Diarrhea

(“Tatlong araw nang nagtatae”)

Mother - Good Reliability

01
History
HISTORY OF PRESENT ILLNESS

3 Days PTA ● Px was fed with Cerelac (AM) and mashed potato (NN) for the first time.
● Evening: green-colored mucoid stool
○ 6-7 diapers; first diaper upon waking up in the morning is full
○ BM: 30 min to 1 hr after feeding

2 Days PTA ● Green-colored mucoid stool; 6-7 diapers

● Seen in Greengate Medical Clinic → given Erceflora
○ Fecalysis: (+) E. Histolytica cysts 2-4/hpf

3 Hours PTA ● OPD: advised to be admitted for observation

● BM twice
REVIEW OF SYSTEMS
General No weight loss, no poor activity

Cutaneous No rash, no discoloration

HEENT No throat pain

Respiratory No difficulty of breathing

Cardiovascular No cyanosis

Gastrointestinal No abdominal pain, no vomiting, no abdominal enlargement, no

erythema

Genitourinary No changes in urine output, no discharge

Extremities No edema on upper and lower extremities

Nervous System No dizziness, no headache

Past Medical History No known allergy
No past hospitalization

Birth and Maternal Delivered via CS due to nuchal cord

G3P3 (3003)
History
Nutritional History Breastmilk - bottle feeding, Cerelac, Mashed potato
Mixed Feeding
Mineral water
 Schedule
Birth 6 wks 10 wks 14 wks 18 wks 6 mos

BCG

Hep B

DTwP/
DTap

OPV
Family History Father: Admission, June 2022 d/t Allergic reaction after intake
of mefenamic and amoxicillin with alcoholic beverage
(-) DM
(-) Hypertension
(-) Allergies

Personal and Social Lives with both parents and two siblings
No other family members with the same set of symptoms
History Uses sterilized bottles and drinks mineral water
 02
Physical Exam
General Survey Active, not dehydrated, happy baby

Vital Signs Heart Rate 137

Respiratory Rate 41

Blood Pressure 90/60

Temperature 37.3

Anthropometric Data Weight 9 kg

Height 67.31 cm

BMI 19.9
PHYSICAL EXAMINATION
Skin (-) Petechiae, (-) rash, (-) discoloration

HEENT Normocephalic. Open, flat anterior fontanel. Anicteric sclerae, pink

palpebral conjunctiva, moist lips and oral mucosa (-) CLAD (-) gum
bleeding, (-) palatal petechiae, non-sunken eyeballs

Respiratory Clear breath sounds, symmetric chest expansion, (-) retractions

Cardiovascular Adynamic precordium, normal rate, regular rhythm, no murmurs

Gastrointestinal Full, soft non-tender abdomen; liver, spleen, kidney not palpable;
normoactive bowel sound

Genitourinary Grossly normal genitalia

Extremities Full pulses, good ROM

 03
Salient Features
 Salient Features
History Physical Examination

● 6 mos old ● Afebrile

● Diarrhea 6-7x ● Non-sunken eyeballs
● Mucoid stool, green-yellow ● Moist lips, oral mucosa
● Complementary feeding
● Presence of E. Histolytica cysts
● No vomiting
● No presence of blood in the stool
 04
Admitting Diagnosis
Acute Gastroenteritis
Probable Infectious
ADMITTING DIAGNOSIS

ACUTE GASTROENTERITIS PROBABLE INFECTIOUS

Suggestive Non-suggestive

● Diarrhea ● (-) fever

● (+) Mucoid stool ● (-) vomiting
● (+) Entamoeba histolytica cyst on
Fecalysis 2 days PTA
 05
Differential Diagnoses
DIFFERENTIAL DIAGNOSES

AMOEBIASIS
Suggestive Non-suggestive

● Infant ( 6 month old) (-) Parasite and ova seen in Fecalysis

● Diarrhea with mucus upon admission
● (+) Entamoeba histolytica cyst on
Fecalysis 2 days PTA
DIFFERENTIAL DIAGNOSES

ALLERGIC ENTERITIS
Suggestive Non-suggestive

● Infant ( 6 month old) ● irritability

● Diarrhea ● (-) postprandial vomiting
● Flavorings and preservatives ● (-) chronic diarrhea
(Cerelac)
DIFFERENTIAL DIAGNOSES

CELIAC DISEASE
Suggestive Non-suggestive

● Infant ( 6 month old) ● Chronic diarrhea

● Diarrhea
● Start of complementary feeding
(cerelac)
 06
Course in the Ward
COURSE IN THE WARD
HOSPITAL DAY 0 - UPON ADMISSION (JULY 5, 2022)

Subjective Objective Assessment Plan

● BM 2x ● Day 4 of illness Acute gastroenteritis Diagnostics:

● No vomiting ● Afebrile since admission probable infectious ● CBC
● Vital signs ● Urinalysis
● No abdominal pain
○ HR: 102-119 ● COVID 19 RT-PCR
○ RR: 28-32 ● Fecalysis
○ Temp: 36.2 - 37 °C ● Stool CS
● I/O: BF 11x vs 650 cc UO + Therapeutics:
BM 6x ● Zinc drops 2 mL OD
● Moist lips and oral mucosa ● ORS vol per vol
● Non-sunken eyeballs replacement
● Symmetric chest expansion, ● Probiotics, Erceflora 1
clear breath sounds tube BID
● Soft abdomen
● Full equal pulses, CRT
<2secs
COURSE IN THE WARD HOSPITAL DAY 0 - UPON ADMISSION (JULY 5, 2022)

CBC Urinalysis Fecalysis

Hct 0.34
Color Yellow Blood Negative Color Yellow, green

Hgb 112
Consistency Soft, formed
Transparency Slightly hazy Protein Negative
WBC 12.70
Mucus +
Lymphocytes 61
Volume 10 Urine Nitrite Negative

pH Neutral
Segmenters 29
Specific Leucocyte
1.005 Negative
gravity Esterase
Plt Ct 397 Occult Blood Negative

pH 6.0 WBC 3.0

Pus cells 5-10

Glucose Negative Bacteria 29.0 WBC 0-1

Parasite and
None Seen
Ketone Negative Ova
COURSE IN THE WARD
HOSPITAL DAY 1 - JULY 6, 2022

Subjective Objective Assessment Plan

● BM 5x ● Day 5 of illness Acute gastroenteritis Diagnostics:

● Good appetite and ● Afebrile since admission probable infectious ● Follow up COVID 19
● Vital signs RT-PCR
activity
○ HR: 106-116
○ RR: 27-32 Therapeutics:
○ Temp: 36.3 - 36.8 °C ● Continue present
● I/O: 240 cc + BF 8x vs 910 management
cc UO + BM 6x
● Asleep, comfortable, well-
hydrated
● Flat fontanel
● Clear breath sounds
● Soft abdomen
● Good pulses
COURSE IN THE WARD
HOSPITAL DAY 2 - JULY 7, 2022

Subjective Objective Assessment Plan

● Good suck, good ● Day 6 of illness Acute gastroenteritis with May go home
appetite, good ● Afebrile since admission moderate dehydration Follow up at OPD on July 14.
● Vital signs 2022
activity
○ HR: 120-142
○ RR: 28-30 Diagnostics:
○ Temp: 36.6 - 36.8 °C ● Follow up COVID 19
● Moist lips and oral mucosa RT-PCR
● Non-sunken eyeballs ● Follow up Stool CS
● Symmetric chest expansion,
clear breath sounds Therapeutics (Take home
● Soft abdomen medications):
● Full equal pulses, CRT ● Erceflora BID to
<2secs complete for 5 days
● Zinc drops 2 mL OD to
complete for 10 days
COURSE IN THE WARD HOSPITAL DAY 2 - JULY 7, 2022

Stool CS COVID-19 RT-PCR

Moderate Growth Negative

No Salmonella nor Shigella Isolated

No Enteropathogenic E. Coli Isolated *Correlate

Escherichia coli
Identified Organisms
Klebsiella pneumoniae
 07
Final Diagnosis
Acute Gastroenteritis
With Moderate
Dehydration
 08
Discussion
INTRODUCTION
Acute Diarrhea &
Gastroenteritis
Diarrhea Vomiting
● Passage of 3 or more ● Inflammation of ● Most common
loose stool in a 24- gastrointestinal tract manifestations
hr period ● Result of infections ● Associated with
● Duration < 14 days with bacterial, viral, or abdominal pain and
parasitic pathogens fever
INTRODUCTION

Reference: https://doh.gov.ph/sites/default/files/publications/CPGAID_Fullversion.pdf
EPIDEMIOLOGY

04 In 2015, diarrheal disease caused an estimated 499,000 or 8.6% of all childhood

deaths, making it the 4th most common cause of childhood mortality
worldwide.
EPIDEMIOLOGY
Most common pathogens:
● Rotavirus
● Cryptosporidium
● Shigella
● ETEC

Agents associated with most deaths among children < 5

yrs:
● Rotavirus (29%)
● Cryptosporidium (12%)
● Shigella (11%)
EPIDEMIOLOGY
INFANCY
● Rotavirus
● NTS

1-4 YRS
● Shigella

YOUNG ● Campylobacter
INFANTS
CHILDREN
● Cryptosporidium
EPIDEMIOLOGY
Additional risk factors:
● Immunodeficiency
● Measles
● Malnutrition
● Lack of exclusive or predominant breastfeeding
ETIOLOGY
Inflammatory C. jejuni, C. difficile, EIEC (Enteroinvasive E. coli), Salmonella, Shigella,
Yersinia

Noninflammatory EPEC (Enteropathogenic E. coli), ETEC (Enterotoxigenic E. coli), V.

cholera

Viral Rotavirus, Adenovirus, Astrovirus, Norwalk, Calicivirus

Parasitic G. lamblia, E. histolytica, B. coli, Strongyloides, spore-forming protozoa

Others Malabsorption, endocrinopathies, food poisoning, neoplasms

Miscellaneous: milk allergy, immunodeficiency states, laxative abuse,
ulcerative colitis, motility disorders
PATHOPHYSIOLOGY
Osmotic Diarrhea ● Presence of nonabsorbable solutes in the GIT due to:
○ Intestinal damage
○ Reduced absorptive surface area
○ Defective digestive enzyme
○ Decreased intestinal transit time
○ Nutrient overload
● Example: Lactose intolerance due to lactase enzyme deficiency

Secretory Diarrhea ● Activation of intracellular mediators that stimulate active chloride

secretion and inhibit the neutral coupled NaCL absorption
● Toxin-mediated injury to the tight junctions
● Results in extremely watery stool
● Example: Cholera, E. coli enterotoxins; C. difficile, vasoactive
peptides
PATHOPHYSIOLOGY
● Intrinsic properties of the organism help to define the mode of
transmission and incubation period.
● Other properties affecting transmissibility are bioavailability as
conferred by a copious and/or prolonged fecal shedding, extended
infectivity in the environment, and resistance to disinfection, or a large
environmental or animal reservoir.
● Viral AGE causes a cytolytic infection of the small intestinal villus tips
resulting in decreased absorption of water, disaccharide malabsorption,
inflammation, and cytokine activation.
PATHOPHYSIOLOGY
DIAGNOSTICS
● Fecalysis - not indicated in acute watery diarrhea, except in
cases where parasitism is suspected or in the presence of
bloody diarrhea
● Stool culture - indicated only for severe cases and should be
requested within 3 days of symptom onset and before
administration of antibiotics to ensure that its yield is highest
● Complete blood count
● Urinalysis
● Serum electrolytes (Na, K, Cl)
● BUN and creatinine
● Serum bicarbonate or total CO2 (if available) or ABG (optional)
MANAGEMENT

1. FEEDING: Diet for age. Exclusive breastfeeding is recommended for

infants < 6 months old and combined with proper, adequate and safe
complementary foods from 6 months to 2 years of age.
2. FLUIDS: Give fluids as tolerated.
3. ORS: preparation will depend on the type and brand
4. MONITORING
MANAGEMENT
● WHO and the United Nations Children’s Fund (UNICEF) recommend 10-20
mg of zinc per day for children with diarrhea. Zinc supplementation could
help reduce the duration and severity of diarrhea

● Racecadotril (1.5 mg/kg/dose) 3 times a day during the first 3 days of

watery diarrhea may be given to infants and children as adjunctive therapy
to shorten duration of diarrhea. [Weak recommendation, low quality of
evidence]

● 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. [Strong recommendation, moderate quality
of evidence]
COMPLICATIONS

● Dehydration
● Electrolyte, or acid-base derangements (hyponatremia,
hypernatremia and hypokalemia)
● Acute kidney injury - Delayed restoration of gastrointestinal losses
may result in AKI due to decreased blood supply to the kidneys.
● HUS - which is best explained by microvascular injury caused by
Shiga-toxin-producing organisms such as Shigella dysenteriae and
Shiga-toxin-producing E. coli
PREVENTION

● Handwashing is recommended as the primary means of

preventing gastroenteritis.
● All children should receive an oral live, attenuated rotavirus
vaccine, which can be initiated between six and 15 weeks of life,
to reduce the risk of severe gastroenteritis, hospitalization, and
death from rotavirus infection.
● Drinking water should be clean and safe.
● Wash raw foods. Cook food well. Store foods properly
 09
Journal Report
BACKGROUND
Rotavirus gastroenteritis (RVGE) remains a leading cause of hospitalization and death in
children under five years of age in the Philippines. Rotavirus (RV) vaccination was introduced
into the national immunization program (NIP) in 2012 but has since been limited to one region
due to cost considerations and conflicting local cost-effectiveness estimates. Updated estimates
of the cost-effectiveness of RV vaccination are required to inform prioritization of national
immunization activities

OBJECTIVE: With the passage of Universal Healthcare Act of 2019, the Philippines has
institutionalized the Health Technology Assessment (HTA) as a mechanism integrating CEAs
in the determination of services, including vaccines, to recommend to two governmental
bodies: the Department of Health (DOH) and the Philippine Health Insurance Corporation
(PhilHealth). These developments underscore the need for a local re-evaluation of RV
vaccination to guide decision-makers on its expansion in the NIP.
INTRODUCTION
● Rotavirus (RV) has been a major etiology of diarrhea. It has comprised approximately 44% of
diarrheal hospitalizations and 28% of deaths globally.
● In the Philippines, the RV-positivity rate among children hospitalized with diarrhea has ranged
from 30 to 53%. It is estimated that 3.7% of all-cause under-five deaths in the country are due
to rotavirus diarrhea.
● Accordingly, in 2009, the WHO recommended the inclusion of RV vaccination into national
immunization programs (NIPs) , and Rotarix was introduced in the Philippine NIP in 2012.
● However, vaccine distribution was limited to a single region in 2014 due to operational issues
in targeting infants belonging to households in the poorest quintile
● To date, there has been no scale-up of the program due to cost considerations and conflicting
local cost-effectiveness estimates.
METHODS
● A universal vaccine decision-support model (UNIVAC version 1.4.13) was used to calculate
the potential cost-effectiveness and health impact of rotavirus vaccination over a 10-year
period (2021–2031) in the Philippines.
● Primary outcome measure was the cost (in USD) per DALY averted of rotavirus vaccination,
from government and societal perspectives, compared to no vaccination.
● also compared the cost-effectiveness of the RV vaccines to the willingness-to-pay thresholds
of 0.5 and 1 times the national Gross Domestic Product (GDP) per capita
● The potential benefits of RV vaccination were projected by estimating the number of RVGE
disease cases, visits, hospitalizations, deaths, and Disability-Adjusted Life Years (DALYs),
with and without vaccination, among children less than five years of age
 RESULTS
● Introducing any of the four rotavirus vaccines would avert around 40% of RVGE
visits, hospitalizations, and deaths over the period 2021–2031.
● Over the same ten-year period, the incremental cost of vaccination from a
government perspective was estimated to be around $104, $105, $220, and $277
million for Rotavac, Rotasiil, Rotarix and Rotateq, respectively.
● The equivalent cost from a societal perspective was $58, $60, $178 and $231
million.
● The cost-effectiveness of the least costly product (Rotavac) was $1,148 ($830–
$1682) from a government perspective and $646 ($233–1277) from a societal
perspective.
● Over a 10-year period (2021–2031), total healthcare costs of RVGE without
vaccination would be about $71 and $175 million USD from a government and a
societal perspective, respectively.
RESULTS
● With an RV vaccination program in place, healthcare costs of RVGE would
reduce by 42–44% over 10 years compared to no vaccination, with an
estimated $30–31 million USD averted from a government perspective and
about $72–76 million USD averted from a societal perspective
● All other products offered similar benefits but at a higher cost. There is a
>99% probability that Rotavac would be cost-effective at a willingness-to-
pay threshold set at 0.5 times the national GDP per capita
RESULTS
DISCUSSION
● Vaccine price is a crucial determinant of differential cost-effectiveness by
vaccine type.
● To demonstrate, a Rotarix program with only two vaccine doses would incur
less incremental health system costs than the three-dose vaccines; yet, due to a
higher vaccine price per dose, the overall vaccination program cost for Rotarix
was among the highest.
● The importance of vaccine price has been previously illustrated in a local CEA
by Lam et al., who concluded that the 2015 prices of Rotarix and Rotateq
warranted a reduction of about 70% in price for the vaccines to be cost-
effective
CONCLUSION
● A rotavirus vaccination program over a 10-year period using any of the four
WHO-prequalified RV vaccines (Rotavac, Rotasiil, Rotarix, and Rotateq)
compared to no vaccination would avert 30–50% of visits, hospitalizations,
and deaths from RVGE.
● Rotavac vaccination had the best value-for-money with the lowest ICER
compared to no vaccination. However, given the uncertainty in actual vaccine
prices, both Rotavac and Rotasiil are likely to be cost-effective options in the
Philippines.
● Rotarix and Rotateq are expected to offer similar benefits but at a higher cost,
so would need to be priced far more competitively for introduction
consideration.
 Bibliographical References

● https://pps.org.ph/wp-content/uploads/2020/04/GUIDELINES-FOR-HEALTH-
CARE-PROFESSIONALS-ON-THE-TREATMENT-OF-ACUTE-
GASTROENTERITIS
● https://doh.gov.ph/sites/default/files/publications/CPGAID_Fullversion.pdf
● AUTHOR (YEAR). Title of the publication. Publisher
● AUTHOR (YEAR). Title of the publication. Publisher
● AUTHOR (YEAR). Title of the publication. Publisher
● AUTHOR (YEAR). Title of the publication. Publisher
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