ÇOCUKLARDA AKUT İNFEKSİYÖZ GASTROENTERİTLERE GENEL YAKLAŞIM

Dünya Sağlık Örgütü (DSÖ), ishali günde üç veya daha f azla sayıda ve normale göre daha yumuşak veya sulu dışkılama olarak tanımlanmış- tır. Akut ishal tipik olarak beş gün veya daha az devam eden ishal olarak tanımlanır. Akut gastroenterit (AGE) ise mide ve bağırsakların (ince veya kalın bağırsaklar) inf lamasyonuyla birlikte giden akut kusma ve ishal ataklarıyla karakterize bir sendromdur. Sağlık Bakanlığı ve Hacettepe Nüf us Etütleri Enstitüsü taraf ından yapılan ve tüm Türkiye verilerinin değerlendirildiği Ulusal Hastalık Yükü çalışmasına göre, AGE Türkiyede 0-14 yaş grubunda ölüme yol açabilen hastalıkların % 8.4ünü oluşturmakta olup, bunlar arasında dördüncü sırayı almaktadır. AGE kreş çocuklarında aynı yaştaki ev bakımı alan çocuklara göre iki-üç kat daha sık görülür ve daha f azla salgına yol açar. Bu etkenler genel- likle kişiden kişiye geçerler. Çevreyi kontamine edebilir, bazen çevreden bulaşabilir. Seyahat ishalleri özellikle gelişmekte olan ve geri kalmış ülkelere seyahat eden kişilerde (çocuklar dahil) görülen en sık hastalıktır. Etkenler sıklıkla bakteriyel (enterotoksijenik Escherichia coli, Campylobacter jejuni, Salmonella spp. ve Shigella spp.), daha az sıklıkla parazitlerdir (Giardia spp.). Son yıllarda norovirusların da önemli bir seyahat ishali etkeni olduğu belirtilmektedir. Gıda veya su kaynaklı AGEler bizzat inf eksiyona (bakteri, parazit, virus özellikle norovirus) veya inf eksiyöz ajanların oluşturduğu toksinlere bağlı olarak gelişebilir. Akut otitis media, üriner sistem inf eksiyonu, pnömoni gibi ekstraintestinal inf eksiyonlar genellikle haf if ve kendili- ğinden geçen AGEye yol açabilir. Shigella dışında asemptomatik inf eksiyonlar sıktır ve bulaşta rolü olabilir. Viruslar AGEnin en sık nedenidir. Çocuklarda en sık gastroenterite yol açan viruslar rotavirus, insan kalisivirusları (norovirus ve sapovirus- lar), adenovirus 40/41, astrovirus olarak sayılabilir. Beş yaş altındaki çocuklarda hastaneye yatan viral AGE etkenleri arasında rotavirus (% 25-50), norovirus (% 5-30), toplum kaynaklı viral AGE etkenleri arasında ise gene rotavirus (% 5-40), Norovirus (% 10-25), en sık görülür. Rotavirus aşısının rutin uygulandığı ülkelerde norovirus en sık görülen AGE etkeni olarak dikkati çekmektedir. Viral gastroenteritlerde ekstraintestinal hastalık nadir- dir. Akut gastroenteritli bir çocukta öncelikle ciddi veya hayati risk oluşturan bir durum olup olmadığı değerlendirilmeli ve ekarte edilmelidir. Bunlar arasında ağır dehidratasyon (> % 10 volüm kaybı) ve/veya şok durumu, invajinasyon, hemolitik üremik sendrom, psödomembranöz ülseratif kolit, apandisit sayılabilir. Fizik muayenede dehidratasyon bulgularının klinik kanıtları aranmalıdır. AGEli bir çocuğun değerlendirilmesinde ateş, dışkı niteliği (kanlı veya mukuslu ishal), dışkı mikroskopisinde kan ve lökosit varlığı ayrıcı tanıda önemlidir. Viral gastroenterit genellikle kusmayla başlar, sıklıkla bol, sulu, mukussuz, kansız ishal ile karakterizedir. Ateşli kansız ve mukussuz gastroenteritlerin çoğu viral kökenlidir. Ateşli, kanlı ve/ veya mukuslu AGEler tipik olarak bakteriyel AGEye bağlıdır, dışkıda eritrosit ve gizli kan pozitif olabilir. Dışkıda lökosit sıklıkla saptanır. Bazen amip gibi parazitler de benzer tablo yapabilir. Ateşsiz kanlı ishal invajinasyon, HÜS ve psödomembranöz enterokolite bağlı olabilir ve hastanın dikkatli şeklide değerlendirilerek etkenin belirlenmesi gerekir. Çocuklarda AGE genellikle izotonik dehidratasyona yol açar, sıklıkla laboratuvar tetkikini gerek- tirecek önemli bir elektrolit dengesizliği gelişmez.

General Evaluation of Acute Gastroenteritis in Children

World Health Organization (WHO), def ines diarrhea as three or more and watery or loose passage per day. Acute diarrhea is typically def ined diarrhea lasting f or f ive days or less. Acute gastroenteritis (AGE) is a syndrome characterized as gastric and intestinal inf lammation with acute vomi- ting and diarrhea. According to the National Diseases Burden Study conducted and evaluated by Ministry of Health and Hacettepe University Institute of Population Studies, AGE constitutes 8.4 % of the diseases causing mortality in 0-14 age group ranking 4th of top. AGE is two to three times more f requent in children in childcare f acilities than home-care children; these children have more AGE epidemics as well. The agents usually are transmitted person to person, can contaminate the environment and acquisition of inf ection can be possible f rom envi- ronmental transmission. Travel AGE is the most f requent inf ection in people traveling especially developing or undeveloped countries. The etiologic agents are usually bacterial (enterotoxigenic Escherichia coli, Campylobacter jejuni, Salmonella spp. and Shigella spp.), and less f requently parasitic (Giardia spp.). Recently, it has been reported that noroviruses are one of the most f requent agents of travel AGE. Food and water-born AGE can deve- lop due to direct inf ections (bacteria, parasites or viruses especially noroviruses), and/or toxins produced by bacteria. Extraintestinal inf ections such as acute otitis media, urinary tract inf ection, and pneumonia can cause mild acute gastroenteritis resolving usually spontaneously. Asymptomatic inf ec- tions are f requent except Shigella and these asymptomatic inf ections can have a role in the transmission of the disease. Viruses are the most f requent agents of AGE. The most f requent viral agents causing AGE in children are rotavirus, human calicivirus (noro- virus, sapovirus), adenoviruses 40/41 and astrovirus. Rotaviruses are encountered in 25-50 % of all hospitalized children less than f ive years due to AGE, and norovirus 5-30 %. Again, of community based AGE in children, 25-50 % is rotavirus and 10-25 % is norovirus. In countries where routi- ne rotavirus vaccines are employed, noroviruses are usually the most f requent AGE agents. Extraintestinal diseases are rare in viral AGE. It should be evaluated and ruled out if there is a severe or lif e threatening status in a child with AGE. These include severe dehydration (> 10 % weight loss) and/or presence of shock, intussusception, hemolytic uremic syndrome, pseudomembranous ulcerative colitis, and appendicitis. In physical examination, the evidence of dehydration should be searched. In diff erential diagnosis, it is important to detect the presence of f ever, nature of stool (bloody stool, presence of mucus), blood in the stool (macroscopic or microscopic, presence of hemoglobin), leukocyte in the stool. Viral AGE usually begins with vomiting; usually there is usually a remarkable watery diarrhea without mucus and blood. The most of AGE with f ever however without mucus and blood in stool (and with normal stool microscopic appearance) is due to viral etiologies. AGE with f ever and mucus and/or blood in stool and presence of leucocytes in the stool are usually due to bacterial AGE and sometimes parasites such as amoebas. Bloody diarrhea with mucus and without f ever can usually be seen due to hemolytic uremic syndrome and pseudomembraneous enterocolitis, and the agent should be searched af ter a detailed evaluation. AGE in children usually causes isotonic dehydration and there is no routine need of evaluation f or electrolytes or other bioche- mistry tests.

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