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Paediatrics > Diarrhoea and Vomiting > Flashcards

Diarrhoea and Vomiting Flashcards

1
Q

Important features in a history to assess a child with diarrhoea and vomiting:

A

Duration, frequency, volume, (any blood in the stools)

Current oral intake and usual feeding pattern

Passage of urine - no. of wet nappies, how heavy

History of fever and other red flag symptoms

Recent contact with someone with diarrhoea and vomiting, ingestion of contaminated food or water, recent travel abroad

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2
Q

Physical features of dehydration in an infant

A 
Sunken anterior fontanelle
Dry mucous membrane
Tachycardia
Reduced CR
Reduced skin turgor
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3
Q

Most common causes of gastoenteritis

A

Rotavirus - most children under 5 will have rotavirus and develop immunity (causes gastroenteritis in 60% of children <2)

Adenovirus

Bacterial less common - Campylobacter jejuni

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4
Q

Causes of blood in stool associated with D and V in children

A 
Campylobacter
Rotavirus
Intussusception
E. Coli
Shigella
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5
Q

What is intussusception?

A

Invagination of proximal bowel into a distal segment commonly involving invagination of ileum into caecum through the ileocecal valve.
Peak presentation is between 3 months to 2 years of age with history of paroxysmal, severe colicky pain when the child draws his/her legs up, pallor during the episodes of pain followed by recovery from the painful episodes and lethargy. The child may refuse to feed, have vomiting and pass characteristic red currant jelly stool containing blood and mucus.

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6
Q

Red flags associated with vomiting

A 
Blood
Bile
Projectile vomiting
Abdominal tenderness/distention
Blood in stool
Bulging fontanelle
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7
Q

Common causes of vomiting in children

A

Feeding issues
GORD
Gastroenteritis

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8
Q

Symptom:

Bile stained vomit

A

Possible Cause:

Intestinal obstruction

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9
Q

Symptom:

Haematemesis

A

Possible Cause:

Oesophagitis
Gastric ulcer
Oral or nasal bleeding and vomiting up swallowed blood

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10
Q

Symptom:

Projectile vomiting under 2 months of age

A

Possible Cause:

Pyloric stenosis

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11
Q

Symptom:

Abdominal distention/tenderness

A

Possible Cause:

Intestinal obstruction
Strangulated inguinal hernia
Surgical abdomen

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12
Q

Symptom:

Blood in stool

A

Possible Cause:

Gastroenetritis – salmonella or campylobacter
Intussusception

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13
Q

Symptom:

Severe dehydration and shock

A

Possible Causes:

Severe gastroenteritis
Systemic infection – UTI
Meningitis
Diabetes ketoacidosis

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14
Q

Symptom:

Bulging fontanelle/fits

A

Possible Cause:

Raised intracranial pressure due to meningitis/ hydrocephalus

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15
Q

Symptom:

Faltering growth

A

Possible Causes:

Gastroesophageal reflux
Coeliac disease
Chronic gastrointestinal conditions

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16
Q

Symptom:

Vomiting with paroxysmal cough

A

Possible Cause:

Whooping cough

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17
Q

Actions to take based on leucocytes and nitrites on urine dipstick

A

Leu - neg
Nitrites - neg - UTI unlikely

Leu - pos
Nitrites - pos - suggests UTI

Leu - neg
Nitrites - pos - prelim diagnosis of UTI(and vice versa), commence Abx await culture
(most commonly E. coli)

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18
Q

What is ORS?

A

Oral rehydration salts

Mix of glucose, electrolyes and salts to help the absorption of sodium via the sodium-glucose cotransporter, and in turn water is absorbed helping the body to rehydrate

19
Q

Advice for a parent of a child with gastroenteritis

A

No IV therapy necessary
Diarrhoea usually last 5-7 days
Encourage usual fluid intake
Give 5ml/kg ORS after each passage of loose stool

Wash hands after nappy change and before preparing, serving or eating food
No nursery for 48 hours after last episode

Seek help if child becomes unwell, mottled skin, vomiting (shouldnt last longer than 3 days), decreased urine output/wet nappies, irritable/lethargic and cold extremities

20
Q

Can you breastfeed during gastroenteritis?

A

Continue if tolerated

Reintroduced by 24 hours if stopped due to persistent vomiting

Usually reduces the risk of gastroenteritis, life saving in developing countries

21
Q

Properties of breast milk

Anti infective

A

Secretory IgA - provides mucosal protection

Bifidus factor - promotes growth of lactobacillus bifidus which metabolises lactose to lactic acid and acetic acid. Low pH may prevent growth of GI pathogens

Lysozyme - bacteriolytic enzyme

Lactoferrin - iron binding protein inhibits growth of E.coli

Interferon - antiviral

22
Q

Properties of breast milk

Cellular

A

Macrophages - phagocytic and synthesise lysozyme, lactoferrin, C3, C4

Lymphocytes - B cells synthesise IgA and T cells may offer delayed hypersensitivity response§

23
Q

Properties of breast milk

Nutritional

A

Easily digested protein - whey to casein ratio 60:40
Lipid (rich in Oleic acid) - easy to digest and improves fat absorption
Calcium: phosphorus 2:1 - improves calcium absorption and prevents hypocalcaemic tetany
Low renal solute load - easily digestible and fat absorption
Iron 40-50% absortion
Long chain polyunsaturated fatty acids - important for retinal development

24
Q

Viral gastroenteritis

A

Rotavirus
Enteric adenovirus 40 and 41
Calcivirus (including Norovirus)
Astrovirus

25
Q

Bacteria gastroenteritis

A 
Campylobacter jejuni
C diff
E. coli
Salmonella
Shigella
Vibrio cholerae
26
Q

Parasitic gastroenteritis

A

Giardia lamblia

Cryptosporidium

27
Q

Pathology of diarrhoea

A

Caused by infective or inflammatory processes in the intestine which affect the secretory or absorptive function of enterocytes

28
Q

Two primary mechanisms of infectious diarrhoea

A

Secretory

Mucosal invasion

29
Q

Effects on secretion caused by infectious diarrhoea

A

↓ absorption
↑ secretion and electrolyte transport

Leads to watery stool
Caused by: cholera, E.coli, C diff, cryptosporidium (HIV)

30
Q

Effects on colon due to mucosal invasion

A

Inflammation
↓ mucosal surface area and/or colonic reabsorption
↑ motility

Leads to blood in stools and ↑ in WBCs
Rotavirus, campylobacter, salmonella, shigella, Yersinia

31
Q

What features associated with DandV suggests a different diagnoses

A 
Fever
Tachypnoea
Altered conscious level
Neck stiffness
Bulging fontanelle in infants
Non-blanching rash
Blood and /or mucus in stool
Bilious vomit
Severe or localised abdominal pain
Abdominal distension or rebound tenderness
32
Q

Factors considered in assessing dehydration

A 
Body weight (% loss)
General appearance
Skin turgor
Tears
Mucous membranes
BP
Urine flow
Pulse 
Eyes
Anterior fontanelle
Fluid deficit
33
Q

Risk of dehydration increased in:

A

Children younger than 1 year, particularly under 6 months of age
Low birth weight infants
If more than 5 loose stools and 2 episodes of vomiting in the previous 24 hours
Not offered or able to tolerate supplementary fluids before presentation
Malnourished children

34
Q

Types of dehydration

A

Isonatremic – loss of sodium and water are proportional
Plasma sodium remains within normal range

Hyponatremic – intake of large quantity of water / hypotonic fluids, greater net loss of sodium than water, fall in serum sodium
Results in shift of water from extracellular to intracellular compartment causes brain oedema and marked extracellular dehydration and shock

Hypernatremic – water loss exceeds the sodium loss with resultant increase in plasma sodium concentration. This can happen when there is low sodium diarrhoea or high insensible water loss. There is shift of water from intracellular to extracellular compartment and therefore less signs of dehydration

35
Q

Features of hypernatremic dehydration

A 
Jittery movements
Increased muscle tone
Hyperreflexia
Convulsions
Drowsiness or coma
36
Q

Investigations for diarrhoea

A

Stool microscopy and culture - indicated if:
- Recent travel abroad
- The diarrhoea is not improving by day 7
- Suspected septicaemia
- Blood and /or mucus in stool
Immunocompromised child

Blood culture – if starting antibiotics

U&E’s and glucose if dehydrated /starting intravenous fluids

37
Q

Indications for IV fluid treatment

A

Shock - fluid bolus 20ml/kg 0.9% sodium (2nd bolus if shock persists)

Red flag symptoms or signs
Persistent vomiting

Hypoglycaemia

38
Q

What is imperative before starting IV fluids

A

Weight and U&Es should be measured at least every 24 hours
Blood glucose

39
Q

Degree of dehydration

A

Mild dehydration 50 ml/kg over 4 hours
Moderate dehydration 100 ml/kg over 4 hours
Ongoing losses (stool) 5- 10ml/kg
Reduce fluid intake when patient appears clinically hydrated
Breast or formula feeding can be continued and should not be delayed for more than 24 hours

40
Q

Antibiotic treatment

A

Campylobacter – Erythromycin shortens the duration of illness and shedding of bacteria

Clostridium difficile – metronidazole or vancomycin

Nontyphoid salmonella, shigella , vibrio cholerae, Giardia, Yersinia and cryptosporidium

41
Q

Key differential in acute appendicitis

A

Mesenteric adenitis, especially if there was a history of sore throat

42
Q

What is Haemolytic Uraemic Syndrome?

A

Pathological Cause - E. coli 0157:H7

Triad of:
Mvgticroangiopathic haemolytic anaemia
Thrombocytopaenia
Acute renal failure (AKI)

Problem with primary haemostasis - platelet count will be low <150, bleeding time will increase

Atypical in adults

43
Q

What type of anaemia is associated with HUS?

A

Normocytic anaemia

Haemolytic
Intravascualar
Extrinsic (extra-corpuscular)
Non-immune (negative Coomb’s test)

Paediatrics (19 decks)

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