CLIPP case 15. Two siblings with vomiting Flashcards
4yo boy presents to clinic with vomiting and diarrhea for two days, with tactile fever. On exam has mild-moderate dehydration.
- Acute gastroenteritis
* Start oral rehydration therapy (pedialyte) in clinic and monitor
8 week-old boy presents to ED with persistent vomiting. No fever or diarrhea. On exam has moderate-severe dehydration. Labwork shows hypochloremic hypokalemic metabolic alkalosis.
- Labwork and abdominal US or upper GI contrast study (string sign, indentation on antrum, delayed gastric emptying)
- Pyloric stenosis
- Start IV rehydration with 20cc/kg boluses until clinically improved, then 1.5 x MIVF.
- Surgery when electrolytes and hydration status normalized
- Other DDx: Gastroenteritis, UTI, GERD, Intussusception, Lower gastrointestinal obstruction, Metabolic disorder, Central nervous system disease
Mild-moderate (5-9%) dehydration treatment
50–100 mL/kg ORS over 2–4
hours; begin with teaspoons frequently. Give 10 mL/kg ORS for each additional diarrheal stool and 2 mL/kg ORS for each additional emesis
Moderate-severe (10-15%) dehydration treatment
1) IV bolus therapy, using an isotonic,
non-dextrose containing solution (NS or LR):
20 mL/kg IV fluid bolus, repeated until clinically improved (awake, alert, well-perfused, interested in and tolerating oral fluids, urine output present). Often 60–100 mL/kg total.
2) Depending on the clinical situation, rehydration can be completed with oral rehydration therapy, or with IV fluids at a
rapid rate (1.5 x maintenance fluids with D5 1⁄2 normal saline)
Calculating MIVF (e.g. patient cannot access free orals)
*Weight method: 100 ml/kg/day for first 10kg + 50 ml/kg/day for next 10kg + 20 ml/kg/day for each additional. 3-4 mEq Na per 100mL fluid. 2-3 mEq K per 100ml fluid.
Viral gastroenteritis
- Large watery stools are the hallmark of infectious gastroenteritis.
- Hand washing to prevent further spread
Pyloric stenosis
- Forceful (projectile), non-bilious vomiting and hypochloremic, hypokalemic metabolic alkalosis with dehydration
- Non-bilious because obstruction above LOT
- Can have streaks of blood in emesis
- Rapid rehydration, but typically vigorous appetite until late in clinical course
UTI
- Important cause of vomiting in children.
- Symptoms nonspecific: fever, poor feeding, and vomiting—potentially dehydration
Malrotation of the gut with volvulus
- Without volvulus may be asymptomatic.
- With volvulus causes bilious emesis (below LOT).
- Bowel ischemia can cause significant abdominal pain.
- May present with shock, which may initially be difficult to distinguish from dehydration
GERD
-Regurgitation/spitting up may be difficult
to distinguish from vomiting.
-Pain from reflux or esophagitis may lead to
feeding aversion when severe.
-Dehydrated due to severe GE reflux may also have significant FTT.
Inborn error of metabolism
-Uncommon, but need to consider in any
infant with recurrent vomiting, since symptoms of the underlying disorder
may be triggered by intercurrent illness.
-May present in shock, which may difficult to distinguish from severe dehydration.
CNS disease
- Hydrocephalus, intracranial neoplasm, and trauma must be considered in vomiting children, especially in absence of fever and diarrhea.
- Head CT if pyloric stenosis ruled out
Intussusception
- Bilious emesis, abdominal pain.
- “Currant jelly” stools may be misidentified as diarrhea
- “Sausage-like” mass on exam
ORT
- For mild-mod dehydration, even when vomiting present
- As effective as IVF, less expensive, safer
- Naturalyte, Pediatric Electrolyte, Pedialyte, Infalyte, Rehydralyte (all with Na 45-50 mmol/L)
Solid foods
- Children who have vomiting and diarrhea and are NOT dehydrated should continue to be fed age-appropriate diets.
- Children who are dehydrated should be fed as soon as they have been rehydrated.
