Diarrhoea

Question 1

Cause of bile stained vomit

Answer 1

Intestinal obstruction until excluded by a barium swallow and follow through.

Question 2

Cause of intermittent vomiting immediately after feeds in n infant who is growing well

Answer 2

Likely due to uncomplicated gastro-oesophageal reflux.
Resolves spontaneously by about 6m old.
Response poorly to medication
Mx with simple measures

Question 3

Common causes of dehydration in children

Answer 3

Gastroenteritis
Poor oral intake
Polyuria - DM
Fluid loss due to burns.

Question 4

Common causes of bloody diarrhoea

Answer 4

Salmonella
Shigella
Campylobacter

Question 5

Serious causes of dehydration

Answer 5

Intussusception
Hypernatraemia dehydration
Pyloric stenosis
Diabetic ketoacidosis

Question 6

Symptoms and signs of mild dehydration

Answer 6

Symptoms - thirsty, restless
Signs - None or slightly dry buccal mucosa
5% - 50ml/kg deficit

Question 7

Symptoms and signs of moderate dehydration

Answer 7

Symptoms - lethargic, irritable
Signs - Dry buccal mucosa, absent tears, Sunken eyes and fontanelle, decreased urine output, altered skin elasticity, signs kerosis (rapid shallow breathing, smell of ketones)

Question 8

Symptoms and signs of severe dehydration

Answer 8

Symptoms - limp, drowsy
Signs - Drowsiness, shock (tachycardia,poor volume peripheral pulses, cool peripheries), Hypotension is late/ominous signs, Skin retraction time greater then 2 sec, capillary refill time greater then 3 secs.
10-15% deficit - 100ml/kg

Question 9

Rule of 3s of survival

Answer 9

3 mins of breathing
30s no cardiac output
3 days no water
3 weeks no food

Question 10

Causes of acute diarrhoea and dehydration

Answer 10

Excessive fluid loss
- excessive sweating - High fever, hot climate, CF
- Vomiting - Pyloric stenosis, viral infections, gastroenteritis
- Acute diarrhoea - viral gastroenteritis, bacterial gastroentroenteritis (Shigella, E.coli, Salmonella, campylobacter), antibiotic induced, food poisoning eg toxins, any acute infection.
- Fluid loss - burns, post surgery
- Polyuria - DM, especially Diabetic ketoacidosis
Inadequate intake
- Inability to drink - Herpes stomatitis, acute tonsillitis
- Inadequate access to water - red flag.

Question 11

Hx Q to ask for acute diarrhoea and dehydration

Answer 11

Diarrhoea or vomiting?
Projectile?
How many loose stools
Less urine then normal? How many wet nappies
How often and how long is there vomiting
FmHx of CF or diabetes.

Question 12

Ex on a child with diarrhoea and dehydration

Answer 12

Weight over time
Pyloric mass during test feed.
Assess dehydration

Question 13

Ix for diarrhoea and dehydration

Answer 13

Only if moderate to severe diarrhoea or very ill child
U and E - electrolyte imbalance and renal function
Blood gases - metabolic acidosis or alkalosis
Urinalysis - for osmolatity or specific gravity
Blood sugar - to exclude DKA
Stool culture - if gastroenteritis, and food poisoning.

Question 14

Tx for acute diarrhoea and dehydration

Answer 14

Use oral rehydration
Tx shock with blouses of IV fluids
Rehydrate slowly to replace fluid loss over at least 24hr
Correct any electrolyte imbalance.

Question 15

What is the commonest cause of dehydration

Answer 15

Vomiting and diarrhoea due to gastroenteritis

Question 16

Rotavirus

Answer 16

Winter epidemics
Diarrhoea follow 1-2days after low-grade fever, vomiting and anorexia
May have acute abdo pain and malaise
Self limiting in a week
Mx is adequate hydration

Question 17

Bacterial gastroenteritis

Answer 17

Same as rotavirus but with blood.

Common pathogens - E.coli, shigella, salmonella, campylobacter

Question 18

Causes of chronic diarrhoea

Answer 18

Non pathological - Toddler diarrhoea, Non specific diarrhoea
Infection - parasites
Inflammation - Crohn’s disease, cow’s milk protein intolerance, Ulcerative colitis
Malabsorption - CF, Coeliac disease, secondary lactose intolerance
Other - Overflow diarrhoea in constipation

Question 19

Toddler diarrhoea

Answer 19

Probably due to a rapid gastro colic reflex.
Symptoms - drinking excessive fluids, particularly fruit juices and food particles in stool.
Dx is only made if the child is thriving
Mx - reassurance.

Question 20

Non-specific diarrhoea

Answer 20

Loose watery stools

Thriving child may follow on from acute gastroenteritis

Question 21

Parasites causing diarrhoea

Answer 21

Giardia lamblia
Weight loss and abdo pain or symptomatic
Watery stools
Common in nurseries
Dx on microscopic examination of the stool.
Need 3 separate specimens as excreted cysts can be irregular
FBC may show eosinophilia
Tx metronidazole

Question 22

IBD Presentation

Answer 22

Symptoms : alternating diarrhoea and constipation +/- bleeding +/- mucus. Urgency and tenesmus. Abdominal pain, Crampy. +- fever.
Interval of symptomatic periods and asymptomatic periods. Wt loss, Anorexia, Lethargy
Signs
GI
aphthous oral ulcers
Tender abdominal: Distension UC>CD, RIF mass CD, Perianal disease CD - abscess, sinus, fistula, skin tags, fissure and stricture
Non GI signs and association: Fever, finger clubbing, Anaemia
Skin :erythema nodosum, Pyoderma gangrenous
Joints: arthritis - migratory, Ankylosing spondylitis, Sacrolitis
eyes: Iritis, Conjunctivitis, Episcleritis
poor growth
delayed puberty
Sclerosing cholangitis
Renal stones
Nutritional deficiencies e.g. Vit B12

Question 23

Cx of IBD

Answer 23

Toxic colon dilation UC>CD
GI perforation or strictures
Pseudopolyps
Massive GI haemorrhage
Colon carcinoma UC
Fistula bowel only, bowel to skin, vigina, bladder CD
abscesses CD
Fuminant Colitis - Medical emergency

Question 24

Cow’s milk protein intolerance

Answer 24

Occurs in babies
Rare and often over-diagnosed, rarer in BF baby
Watery stools may be bloody
may have urticaria, strider or bronchospasm, eczema and rarely anaphylaxis
Dx clinical and symptoms should subside within a week of withdrawing cow’s milk.
Mx - hydrolysed protein formula milk should be used
Prognosis - most resolved in 1-2 years.

Question 25

Cystic fibrosis

Answer 25

Starts in infancy Failure to thrive with chest infections Fatty stools Diagnosis by sweat test.

Question 26

Coeliac disease

Answer 26

Red flag Common 1 in 100 Associated with diabetes and Down's syndrome. Intolerance of gluten - in wheat, rye and barley Present before 2yrs of age Failure to thrive with irritability, anorexia, vomiting and diarrhoea Muscle wasting, abdominal distension Often presents after introduction of wheat into diet Fatty stools Signs - abdominal distension, wasted buttocks, irritability and pallor Dx by jejunal biopsy - subtotal villus atrophy Ix - show iron deficiency anaemia and steatorrhoea, Coeliac antibodies (IgA anti-tissue transglutaminase or anti-endomysial ab) in blood. Mx - gluten free diet, Rechallange gluten in 2 yrs and repeat biopsy.

Question 27

Secondary lactose intolerance

Answer 27

Baby or toddler Follows acute gastroenteritis Watery stools with low pH and reducing substances

Question 28

Overflow diarrhoea in constipation

Answer 28

Soiling rather than diarrhoea | Constipated stool palpable abdominally or rectally

Question 29

Hx Q for chronic diarrhoea

Answer 29

Bowel patterns - volume, appearance and consistency of stools, blood or mucus. Precipitating factors eg lactose intolerance is precipitated by acute diarrhoea. Association with certain foods. Sick contacts Associated symptoms - wt loss or abdo pain, Review of symptoms - non GI disease may cause diarrhoea and failur to thrive.

Question 30

Ex in chronic diarrhoea

Answer 30

Growth - Other features - hydration, pallor, abdominal distension, tenderness and finger clubbing are particularly relevant General examination - Ill?

Question 31

Ix for Chronic diarrhoea

Answer 31

FBC - anaemia indicates blood loss, malabsorption, poor diet or inflammation Plasma viscosity/ESR - high in inflammatory bowel disease Coeliac antibodies Urine culture - UTI Sweat test - CF Breath hydrogen test - high H2 in carbohydrate maldigestion Jejunal biopsy - villainous atrophy with crypt hyperplasia in coeliac disease Barium follow through - characteristics signs in small bowel Crohn's disease Endoscopy - characteristic lesions on histology n Inflammatory bowel disease Stool - occult blood (IBD), Ova and parasites (3), Reducing substances and low pH (lactose intolerance), Fecal elastase (pancreatic insufficiency), Microscopy for fat globules , Fecal calprotectin (IBD)

Question 32

Haemolytic uraemia syndrome

Answer 32

Presents as a triad - micro angiostatin haemolytic anaemic, thrombocytopenia, acute renal failure 2 types - atypical/sporadic and epidemic form Epidemic form - diarrhoea, commonly associated with very cytotoxic producing E.coli Transmitted by eating improperly cooked beef, raw milk, faeces oral, contaminated water, farm animals Causes acute renal failure, gut - bloody diarrhoea, rectal prolapse, haemorrhaging colitis, bowel wall necrosis and perforation, DM, pancreatitis, Jaundice, encephalopathy, Cardiac myocarditis Ix - FBC, Blood cultures, U and E , LFTs, E.Coli PCR Tx - Consult nephrology, early dialysis, supportive care - Montior electrolyte and fluid balance, Nutrition, blood transfusion, Treat hypertension.

Question 33

Mx of Crohn's and UC

Answer 33

Supportive If severe Bowel rest, IV hydration and PN Pharmacology Mild to moderate disease Oral 5 aminosalicylic acid dimers e.g. Mesalazine. Reduces and maintain remission in UC Moderate to severe disease Oral prednisolone or IV until improve and until wean off over 6 to 8 weeks Antibiotics eg ciprofloxacin or metronidazole Dietary tx Polymeric or elemental diets to induce remission but relapse rate is high. better in CD. Dietary suppleentation to maintain growth. Refer to Dietitian Surgery UC: total colectomy and ileostomy and pouch creation and anal anastomosis cures UC CD: Local surgical resection for severe disease e.g. strictures, fistula.

Question 34

Ix IBD

Answer 34

Bloods FBC ESR/CRP ^ U&E LFT - albumin reduced BC Serum iron Reduce Vitamin B12 and Folate reduced Serum serological markers ASCA (antisaccharomyces cerevisiae antibody) better for CD p-ANCA(perinuclear antineutrophil cytoplasmic Ab) Better for UC Stool MCS Endoscopy - Colonoscopy and biopsy Histology - UC: crypt abscesses, mucosal inflammation only and goblet depletion. CD:cryt abscesses granulomas, transmural inflammation upper GI scope Barium radiology/USS CD: Mucosal cobblestone appearance, ulceration, dilatation, narrowed segments, fistula, skip lesions UC: Mucosal ulceration, haustration loss, colonic narrowing +/- shortening.

Question 35

Short bowel syndrome

Answer 35

Malabsorption, fluid and electrolyte loss and malnutrition Presentation Diarrhoea Steatorrhoea FTT Dehydration, electrolyte loss - Na, K, Mg, Ca Cholestasis - bile salt loss Peptic ulcer disease - due to increase gastrin Specific eg vit B12 and generalised malnutrition disorders Renal stones Treatment Correct fluid and electrolyte disturbance Supplements: or PTN PPI Anti diarrhoea drugs Cholestyramine (bile salts) Parenteral somatostatin ABX Surgery