Dysentery and diarrhoea in paediatrics

1. Dr Balafama. A. Alex-Hart
Consultant Paediatrician

2.  Definition—Diarrhoea with visible blood in
the stools
Etiology
 Shigella-most important cause in under fives
S. flexneri-responsible for worldwide
epidemics
S. dysenteriae type 1-causes deadly epidemics
S. Sonnei
S. boydii-restricted to Indian subcontinent

3. Other causes
 Campylobacter jejuni-especially in infants
 Salmonella
 Enteroinvasive Escherichia coli-severe
dysentery, infection is uncommon
 Entamoeba histolytica---causes dysentery in
older children and adults but rarely in children
under 5 years of age

4.  Important cause of morbidity and mortality
associated with diarrhoea
 15% of all diarrhoea episodes in children
under 5 years are dysentery
 25% of all diarrhoea deaths

5. Dysentery is severe in
 Infants and in children who are
undernourished
 Those who develop clinically evident
dehydration during their illness
 Those who are not breastfed
 Occurs with increased frequency and severity
in children who have measles or have had
measles in the preceding month
 Diarrhoea episodes that begin with dysentery
are more likely to become persistent

6.  The organism invade the large intestine
following the ingestion of contaminated
water or food or oral contact with
contaminated objects or hands.
 Shegella secretes cytotoxins which damage
the intestinal tissue on contact, leading to
Inflammatory Immune Response

7.  Inflammatory immune response leads to
1. Fever
2. Spams of the intestinal muscles-cramp
3. Water leaks out from the damaged intestine
4. More cytokines release and more tissue
damage.
5. Impaired nutrient absorption
6. Excessive loss of water and minerals
through the stool due to impairment of the
protective mechanisms in the intestine
which reduces fluid loss

8.  Excessive loss of water and minerals from the
stool due to impairment of the protective
mechanisms in the intestine which reduces
fluid loss.
 In severe cases-entry of pathogenic organism
into the blood stream.

9. Incubation period-2 to 7 days
Clinical diagnosis
 Based sorely on the presence of visible blood
in the diarrhoeal stool.
 Stool will also contain numerous pus cells
 It may contain abundant mucus
 Dysentery stools are numerous in frequency
and small in quantity and may not cause
dehydration.
 Sometimes the quantity may be much and
result in dehydration

10.  Fever
 Cramping abdominal pain
 Pain in the rectum during defecation or
attempted defecation (tenesmus)

11.  Intestinal perforation
 Rectal prolapse
 Convulsion
 Septicaemia
 Haemolytic uraemic sydrome
 Prolonged hyponatraemia
 Anorexia
 Weight loss

12.  Extensive damage to the ileum and colon
 Complications of sepsis
 Secondary infection-pneumonia
 Severe malnutrition

13.  Stool culture-to detect pathogenic bacteria-
sometimes impossible. Takes at least 48hrs
 Stool microscopy-amoebasis can be
diagnosed if trophozoites of E. histolytica
containing red blood are seen in fresh stool
or in mucus from rectal ulcerations

14.  Shigella causes 60% of dysentery. Children
with dysentery should be presumed to have
shigellosis
 If stool microscopy show trophozoites of E-
histolytica containing erythrocytes, give
antiamoebic therapy

15.  Antibiotics
 Fluids
 Feeding
 Follow-up
Four key components of treatment of dysentery

16. Antibiotics
 Cotrimoxazole, Ceftriaxone, ofloxacin
 Ampicillin
 Nalidixic acid
 Ciprofloxacin---Drug of choice. 15mg/kg
b.d 3/7, oral

17.  Fluids—evaluate children for dehydration and
treat accordingly—offer water and other
drinks if there is fever
 Children should be encouraged to eat so that
nutritional damage can be prevented or
minimized.

18.  Continue breast feeding
 Give small meals at least 6x a day
 Encourage child to eat
 Choose energy and nutrient rich foods
 Give one extra meal a day for at least 2wks
after diarrhoea stops

19. Follow-up
 Children who do not show signs of
improvement within 2 days
 Infants
 Undernourished
 Those not breastfed
 Those with dehydration
 Those with severe malnutrition should be
admitted

20.  Good hand washing with soap and water
 The microorganism that causes dysentery are
spread by faecally contaminated hands, food
and water
 Number of shigella required to cause
infection is very small---10-100 organisms

21.  Definition---diarrhoea episodes that lasts for
14 days or longer
 20% of acute diarrhoea episodes become
persistent
 It causes nutritional status to deteriorate
 Causes 30-50% of all diarrhoea associated
deaths
 15% of episodes of persistent diarrhoea
results in to death

22.  No single microbial cause
 Shigella
 Salmonella
 Enteroaggregative ecoli
Others
 Cryptosporidium-malnurished and
immunocopromised

23.  Causes flattening of the villi
 Reduced production of disaccharides
enzymes
 Reduced absorption of nutrients

24.  Malnutrition-delays repair of damaged
intestinal epithelium
 Recent introduction of animal milk-lactose
intolerance, hypersensitivity to milk,
bacteria contamination of milk
 Young age-most episode occur in children
under 18 months of age
 Immunological impairment
 Recent diarrhoea-either acute or persistent

25.  Persistent diarrhoea is a nutritional disease
 Occurs most frequently in malnourished
children
 Single episode can last 3-4 weeks causing
significant weight loss
 Weight loss during persistent diarrhoea –
reduced absorption of all nutrients especially
fat and lactose in some children
 Poor food in take

26.  History
 Observe whether stool is bloody
 Stool culture
 Stool microscopy
 Stool pH-<5.5 and large amount of reducing
substance in the stool-carbohydrate
malabsorbtion
 Fluid and electrolyte replacement

27.  Proper feeding-most important therapy
 Temporarily reduce the amount of animal
milk or lactose in the diet
 Provide a sufficient intake of energy, protein,
vitamins, minerals
 Avoid giving foods or drinks that may
aggravate the diarrhoea
 Ensure that the child’s food intake is
adequate

28.  Children under 6 months of age or with
dehydration should be rehydrated and
referred to the hospital
 Older children
 Continue breastfeeding
 Dilute any animal milk given with equal
amount of water or replace with a fermented
milk product-yoghurt
 Ensure a full energy intake

29.  Avoid foods that are hyperosmolar
 Give food frequently in small meals, at least
6x a day
 Provide supplementary vitamins and
minerals-folate, vit B12, vit A, Zinc and iron

30.  If diarrhoea has not stopped, refer the child
to hospital for specialized care
 If the diarrhoea has stopped
 Continue to give same foods for one more
week
 Gradually reintroduce the usual animal milk
or formula over several days and shift to a full
strength diet
 Give extra meal each day for 1mth

31.  Dysentery-antibiotics
 Treat result of microscopy

32.  Measles-diarrhoea-incidence increased
during 4wks -6 mths
 Mechanism-direct effect of measles virus on
the bowel epithelium
 Virus induced immunosuppression

33.  Correct dehydration
 Treat dysentery
 Mouth care
 Prophylactic vitamin A

34.  Organisms implicated
Usual
 Rota virus
 shigella,
 Giardia lamblia,
 Salmonella,
 Campylobacter,
 Clostridium deficile

35. Unusual
 Mycobacterium avium complex-effective ARV
therapy.
 Cytomegalovirus-Ganciclovia, foscanet
 Cryptosporidium-Paromomycin-
aminoglcoside
 microsporidiosis
 Isospora belli-Trimethoprime-
sulphamethoxazole
 Cyclospora cayetanensis-septrin