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GASTROENTERITIS, DIARRHEAL
DISEASE AND DEHYDRATION
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objectives
At the end of this session, you will be able to:
• Define gastroenteritis
• Describe diarrhea
• Discuss dehydration, its classification and approaches
of management
• Provide preventive and curative care for
gastroenteritis and diarrheal disease
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Definition

• gastroenteritis denotes infections of the

gastrointestinal (GI) tract caused by bacterial,
viral, or parasitic pathogens.
• Gastroenteritis is associated with poverty and poor
environmental hygiene
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Diarrheal disease

Definition
• passage of three or more loose or watery stools per 24
hours or increase in stool frequency or liquidity that
is considered abnormal by the mother.
• Diarrheal disorders in childhood account for a large
proportion (18%) of childhood deaths
• an estimated 1.5 million deaths per year globally
• the second most common cause of child deaths
worldwide.
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Classifications
1. Acute watery - episode that begins acutely and <14
days with passage of watery stools without blood.
2. Persistent diarrhea - diarrheal episode that starts
acutely and lasts for 14 days or longer.
3. Dysentery – diarrhea with blood in the stool.
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• Acute watery diarrheal episodes are the commonest

form of childhood diarrhea, accounting 80 to 82% of
the cases.
• Children of 6 to 11 months of age are the most
commonly affected, a time that coincides with
initiation of complementary feeding.
• Highest mortality is encountered among infants.
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Risk factors
Behavioral
 Suboptimal BF
 using feeding bottles
 Drinking contaminated water
 Not washing hands
 young age
 Host factors
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Etiology
Rota virus is the commonest cause of acute watery
diarrhea.
• E.coli
• Salmonella
• Shigella
• giardia lamblia
• Cryptosporidium
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cont.
The commonest cause of dysentery is shigella
• campylobacter jejuni
• entero invasive E.coli
• entamoeba histolytica
The transmission the fecal-oral
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pathophysiology
Two mechanisms of diarrhea have been identified.
Secretary diarrhea
• occurs when there is active secretion of water
into the gut lumen, increased secretion of fluid
and electrolytes.
• resulting from either the inhibition of neutral NaCl
absorption in villous enterocytes or an increase in
electrogenic chloride secretion in secretory crypt cells
• e.g vibrio cholerae, EC
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Osmotic diarrhea
• digestion and absorption is impaired due to
intestinal damage (such as in enteric infection)
defective digestive enzyme or nutrient carrier (such
as in lactase deficiency)
decreased intestinal transit time (such as in functional
diarrhea)
 nutrient overload exceeding the digestive capacity
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Clinical manifestations
• diarrhea, abdominal cramps, and vomiting
• nausea and vomiting indicate infection in the upper
intestine
• Severe abdominal pain and tenesmus indicate
involvement of the large intestine and rectum.
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Classification of dhn & s/s

• No DHN
• SOME DHN
• SEVER DHN
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Stool specimens should be examined

Complication
• Dehydration
• hypovolemic shock
• Electrolyte imbalance
• Hypoglycemia
• Malnutrition
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• Other signs & symptoms of dehydration

- decreased urine output
- feeble radial pulse
- delayed capillary refill
- dry tongue & buccal mucosa
- depressed fontanel, etc.
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Treatment

Treat dehydration as follows:

• No dehydration Treatment plan A
• Some dehydration Treatment plan B
• Severe dehdration Treatment plan C
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Treatment Plan A: for diarrhoea with no DHN

1. GIVE EXTRA FLUID (as much as the child will take)
2. GIVE ORS and ZINC SUPPLEMENTATION
3. CONTINUE FEEDING
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• GIVE EXTRA FLUIDS (as much as the child will take)

- Breastfeed frequently and for longer at each feed.

- If the child is exclusively breastfed, give ORS in
addition to breast milk.
- If the child is not exclusively breastfed, give one or
more of the following: ORS solution, food-based
fluids (such as soup, rice water and yoghurt drinks),
or water.
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Composition of ORS solution

• It more or less goes in conjunction with the diarrheal
losses:
• Composition mmol/lit Essential features
• Na+ 90 replaces lost Na+
• K+ 20 prevents hypokalemia
• Citrate/Hco3 10/30 correct acidosis
• Glucose 111 facilitates Na absorp.
• Osmolality 310 Isotonia
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HOW MUCH ORS TO GIVE IN ADDITION TO THE USUAL FLUID

INTAKE:

Up to 2 years 50 to 100 ml after each loose stool

2 years or more 100 to 200 ml after each loose stool

- Give frequent small sips from a cup.

- If the child vomits, wait 10 minutes, continue, but slowly.
- Continue giving extra fluid until the diarrhea stops.

2. GIVE ZINC SUPPLEMENTS

Up to 6 months - 1/2 tablet for 10 days
6 months or more- 1 tablet for 10 days
• Zinc supplementation decreases stool output, duration and severity
of acute diarrhea.
3. continue feeding
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Treatment Plan B: treat some DHN

• Oral glucose-electrolyte solution mainly used
- these rely on coupled transport of sodium & glucose in the
intestine
- ORT (Oral Rehydration Therapy) has significantly ↓ the
morbidity & mortality from acute diarrhea & lessened the
associated malnutrition
- less expensive & has lower complication rates
Give ORS 75ml/kg for 4-6hrs.
- IV therapy is reserved for :
severe DHN, those with persistent vomiting, those with
gastric or intestinal distension.
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Plan C
• Start IV fluid immediately.
• If the child can drink, give ORS by mouth
while the drip is set up.
• Give 100ml/kg Ringer’s Lactate Solution (or,
if not available, normal saline), divided as
follows:
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• Repeat once if radial pulse is still very weak or

not detectable
• Reassess the child every 1-2 hours.
• Also give ORS (about 5 ml/kg/hour) as soon
as the child can drink: usually after 3-4 hours
(infants) or 1-2 hours (children).
• Reassess an infant after 6 hours and a child
after 3 hours. Classify dehydration
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Treatment of Severe Dehydration

in malnourished child
• Give ReSoMal 5ml/kg every 30 mins for first
2 hours
• Then 5-10mls/kg for the next 4-10 hours using
NG tube
• Give more ReSoMal if child wants more or
large stool loss or vomiting
• Check blood glucose and treat if <3mmol/l
• Treat malnutrition as per guidelines
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All concentrations are in Lactate*

mmol/l Na +
K +
(HCO3-)
Glucose

WHO / UNICEF
90 20 10 111
ORS
Rehydration Solution
for Malnutrition – 45 40 5 ~ 200
ReSoMal*.

*Add to WHO ORS ‘1sachets to 2 litres water rather then 1 litre,

then add 50g (5 teaspoons) sugar and 60 mmols Potassium
Chloride (3 10ml iv vials of strong potassium, 20mmols/10mls)
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Antibacterial or antiparasitic therapy

indications
Dysentery - oral antibiotics for 5 days should be given.
• first line – cotrimoxazole 60 mg/kg/day bid for 5
days.
• Ceftriaxone 50-100 mg/kg/day IV or IM, qd or bid 7
days
• Ciprofloxacin 20-30 mg/kg/day PO bid 7-10 days
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• Shigella :
▫ Ceftriaxone 50-100 mg/kg/day IV or IM, qd or
bid × 7 days
▫ Ampicillin PO, IV 50-100 mg/kg/day qid × 7
days
• E. Coli:
▫ TMP 10 mg/kg/day and SMX 50 mg/kg/day bid
× 5 days
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Antibiotic.... seyoum.G 04/09/2025

• Campylobacter jejuni:
▫ Erythromycin PO 50 mg/kg/day divided tid ×
5 days
▫ Azithromycin PO 5-10 mg/kg/day qid × 5 days

• Entamoeba histolytica, Giardia lamblia:

▫ Metronidazole PO 30-40 mg/kg/day tid × 7-10
days
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Persistent Diarrhea

• a diarrheal episode that starts acutely and lasts for

fourteen days or longer.
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Nutritional Impact

• Persistent diarrhea is a nutritional disease.

• It usually occurs in malnourished children and is
itself an important cause of weight loss and severe
malnutrition.
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Nutritional therapy

• The most important aspect -for persistent

diarrhea is proper feeding.
Goals of treatment:
• Temporary reduction amount of animal
milk /or lactose in the diet.
• To provide a sufficient intake of;
 energy
 protein
vitamins and minerals to improve
nutritional status.
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Strengthening host defenses

 EBF till 6 months and continue breast feed at

least for 2 years.
 Start complementary feeds at age of 6 months
 Give balanced diet in adequate amount
 Immunize against measles
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Assignment
G– inflammatory bowel disease
 2. Intussusceptions
• Intussusception is the invagination or telescoping of a
portion of the intestine into an adjacent, more distal
section of the intestine, which creates a mechanical
obstruction.
• one of the most common causes of intestinal
obstruction in infancy.
• It can occur at any time in life but most commonly
occurs in children younger than age 3, with the
greatest incidence between ages 5 and 10 months.

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Intussusceptions cont…

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 Intussusceptions cont…
• Etiology
• idiopathic, lead point, or postoperative.

• Idiopathic: 75%

• Viral infection (adenovirus or rotavirus),

• Bacterial enteritis intussusception(Salmonella, E.
coli, Shigella, or Campylobacter).
• polyp or tumor, hematoma, or vascular
malformation
• Postoperative

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 Intussusceptions cont…
• Classification of location:
• Ileocecal
• Ileocolic
• Colocolic
• Ileo-ileo

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 Intussusceptions cont…
• Pathophysiology
1. Mesentery/lymphatics/blood vessels pulled into
intestine when invagination occurs.
2. Intestine becomes curved, sausage like; blood
supply is cut off.
3. Bowel begins to swell; hemorrhage may occur.
4. Necrosis of involved segment occurs.
5. If not recognized and treated, bowel death occurs,
possibly resulting in significant loss of intestine,
shock, and death.

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 Intussusceptions cont…
• Clinical Manifestations
Classic four signs
• vomiting, abdominal pain, bloody/red currant jelly
stool, and abdominal mass.
1. Vomiting: bilious vomiting.
2. Stool may be like currant jelly: sloughed mucosa of
dark red color, with a mucoid consistency

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 Intussusceptions cont…
3. Abdominal pain is usually paroxysmal.
• Cyclic repetition of symptoms at approximately 5-
to 30-minute intervals.

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 Intussusceptions cont…
4. Abdominal mass: Sausage like mass palpable in
abdomen.
• This is pathognomonic and is known as Dance's
sign

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 Intussusceptions cont…
• Others:
• Increasing abdominal distention and tenderness.
• Unusual-looking anus; may look like rectal
prolapse
• Dehydration, fever, lethargy; shock like state with
rapid pulse, pallor, marked sweating.

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 Intussusceptions cont…
• Diagnostic Evaluation
• X-ray examination
• Ultrasonogram to locate area of telescoped bowel.
• Color Doppler sonography used more recently to
determine whether reducible or not

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 Intussusceptions cont…
• Management
• Air or barium enema:
• Surgical reduction of intussusception

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 Intussusceptions cont…
• Supportive therapy
• Inserting NG tube to decompress stomach and
irrigating at frequent intervals.
• Administer appropriate antipain
• Prepare the patient for surgery

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 Intussusceptions cont…
• Complication
• Perforation
• Peritonitis
• Shock
• Loss of bowel resulting in short bowel syndrome

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 Appendicitis

Appendicitis is inflammation of the vermiform appendix

caused by an obstruction of the intestinal lumen from
fecal mass, parasites, infection, stricture, foreign body,
or tumor.

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Appendicitis cont…

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 Appendicitis cont…
Epidemiology
• The frequency increases with age and peaks between 15
and 30 years
• rare in developing countries
• It is rare:
 in children <5 yrs of age (<5% of cases), and
extremely rare (<1% of cases) in children <3 yrs of age

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 Appendicitis cont…
• Perforation is most common in young children, with
82% for children <5 yrs and
• approaching 100% in infants
• Younger children can be particularly difficult to diagnose
because
• The presentation may be nonspecific
• Symptoms cannot be adequately expressed, and
• The child is often anxious and uncomfortable,
making the evaluation challenging.

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 Etiology

• appendiceal lumen obstruction due to swollen

lymphoid tissue.
• Obstruction of the lumen is caused by
• Fecalith
• mucosal edema
• Rarely Carcinoid tumours, foreign bodies and
Ascaris

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 Appendicitis cont…
• Pathophysiology
• Obstruction of the appendiceal lumen  bacterial
proliferation and continued secretion of mucus
increasing intraluminal pressures lymphatic and
venous congestion and edema followed by impaired
arterial perfusion ischemia of the wall of the
appendix, bacterial invasion with inflammatory
infiltrate of all layers of the appendiceal wall
necrosis gangrenous appendicitis appendiceal
perforation

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 Appendicitis cont…
• Clinical manifestations
• The classic triad s/s of appendicitis consists of:
Pain, Nausea with vomiting and Fever.
• Anorexia
• Periumbilical pain (early)
• Migration of pain to the right lower quadrant (within
2-24 hours of onset of symptoms)
• Vomiting (typically occurring after the onset of pain)
• Fever (commonly occurring 24 to 48 hours after onset
of symptoms)
• Right lower quadrant tenderness.

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 Appendicitis cont…
• Signs of localized or generalized peritoneal irritation
such as:
• Rebound tenderness LR quad (McBurney’s point)
• Involuntary muscle guarding with abdominal
palpation
• Positive Rovsing sign (pain in the right lower
quadrant with palpation of the left side)
• Psoas sign (pain on extension of the right hip)
• Obturator sign (pain on flexion and internal rotation
of the right hip)

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 C/M…. Cont’d

• keyaspects of the history favouring a diagnosis of

appendicitis
• Onset of pain before vomiting or diarrhoea
• Loss of appetite
• Migration of pain from periumbilical to RLQ
• Aggravation of pain during walking

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 Appendicitis cont…
• Diagnostic Evaluation
• P/E & HX
• WBC
• Urinalysis to rule out urinary disorders.
• Abdominal X-ray.
• Abdominal ultrasound, or CT scan

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Management
• IV-fluids and antibiotic for non-perforated appendix
• IV- morphine to manage pain
• Nasogastric suction if the pt has significant vomiting
or abdominal distension
• Appendectomy

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Treatment…

Antibiotics(triple) include
• Ampicillin 100 mg/kg/day in to four divided doses
• Gentamicine 5mg/kg/day in to three divided doses
and
• Clindamycine 40 mg/kg/day or Metronidazole
(flagyl) 30 mg/kg/ day tid
• Antibiotics are continued for 7-10 days

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Compilation

• 25-30% of children with appendicitis

• Appendicular perforation
• Peritonitis (local or generalized)
• Wound infection
• Multiple intra-abdominal abscess

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Compilation ….

• Liver abscess
• Intestinal obstruction and paralytic ileus

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3. Volvulus

• Bowel twists and turns on itself.

• Obstruction caused by twisting of the
intestines more than 180 degrees
about the axis of the mesentery
• 1-5% of large bowel obstructions
• Sigmoid ~ 65% (common)
• Cecum ~25%
• Transverse colon ~4%

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Pathogenesis
• The pathogenesis is unclear
• Chronic constipation
• High residue diet
• Chronic medical or psychiatric problem
• Precipitating factor: pregnancy, abdominal surgery

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 Clinical manifestation

• Majority of patients present with in the first year

of life with symptoms of acute or chronic
obstruction.
• Older infants present with recurrent abdominal
pain.

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 volvolus cont..

A. Sigmoid Volvulus
• Worldwide - up to 50% of obstruction
• More commonly seen in elderly patients in western
societies
B. Cecal Volvulus
• Less common than sigmoid volvulus
• Present in about 10% of population
C. Transverse colon volvulus
• Less common area for volvulus(4%)

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Presentation
• History:
• abdominal pain
• distension
• no flatus or
• bowel movements
• Exam:
• tympanitic abdomen
• distension
• mild tenderness
• palpable mass

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Sigmoid volvulus

• Coffee bean appearance with the

two twisted loops with a central
doubled wall component

bean
Coffee
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 Management of choice
• Endoscopic decompression
• proctosigmoidoscope
• Elective resection

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Hirsch sprung Disease
(Congenital Aganglionic Megacolon)
congenital anomaly that results in mechanical obstruction from
inadequate motility of part of the intestine
• The incidence is 1 in 5000 live birth
• It is four times more common in males than in females

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Ethiology

• Unclear most of time

• Gene mutation
• Familial hx

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 Pathophysiology
absence of ganglion cells in the affected areas
results in a lack of enteric nervous system
stimulation
decreases the internal sphincter's ability to relax
abnormal bowel and the resulting lack of peristalsis

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• Diagnostic Evaluation
• Biopsy
• Clinical sign

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clinical manifestation
• Failure to pass meconium within 24 to 48 hours after
birth
• Refusal to feed
• Failure to thrive
• Constipation
• Abdominal distention
• Fever
• foul-smelling stools
• Visible peristalsis
• Easily palpable fecal mass
• Undernourished
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Therapeutic Management

• surgery rather than medical therapy

• Fluid and electrolyte replacement

Nursing Care Management

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 Esophageal Atresia and Tracheoesophageal
Fistula
• malformations that represent a failure of the
esophagus to develop as a continuous passage and a
failure of the trachea and esophagus to separate into
distinct structures

1 in 4000 live births

higher incidence in males
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pathophysiology

• the proximal esophageal segment terminates

in a blind pouch, and the distal segment is
connected to the trachea or primary bronchus
by a short fistula at or near the bifurcation
• Diagnostic Evaluation
radiographic studies
clinical signs and symptoms

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Clinical Manifestations
• Excessive frothy mucus from nose and mouth
Three Cs of tracheoesophageal fistula (TEF):
• Coughing
• Choking
• Cyanosis
• Apnea
• Increased respiratory distress during feeding
• Abdominal distention

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management

• maintenance of a patent airway

• prevention of pneumonia
• gastric or blind pouch decompression
• supportive therapy
• surgical repair of the anomaly
• Suction
• IV fluids are initiated

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