Diarrhoea and Vomiting Flashcards
What is gastroenteritis in children?
Infective gastroenteritis in young children is characterised by the sudden onset of diarrhoea, with or without vomiting.
Most cases are due to a viral infection but some are caused by bacterial or protozoal infections.
The illness usually resolves without treatment within days but severe diarrhoea can rapidly cause dehydration, which may be life-threatening
What is the most common pathogen that causes gastroenteritis?
Gastroenteritis is caused by a variety of viral, bacterial and parasitic pathogens.
Of the infectious agents isolated from children with enteric infections in 2009 in England, rotavirus was found most commonly (56%), followed by Campylobacter spp. (28%), Salmonella spp. (11%), norovirus (3%), Shigella spp. (1%), and Escherichia coli O157 (1%).
What are the risk factors for gastroenteritis?
Poor hygiene and lack of sanitation increase the incidence - eg, bad water in the developing world.
Compromised immune system.
Infection may arise from poorly cooked food, cooked food that has been left too long at room temperature or from uncooked food.
Insufficient reheating of food not only fails to kill bacteria but may speed up multiplication and increase the bacterial load ingested. Even if reheating of cooked food kills bacteria, enterotoxins such as staphylococcal exotoxin are not destroyed.
How do you assess a patient presenting with gastroenteritis?
Gastroenteritis should be suspected if there is a sudden change in stool consistency to loose or watery stools and/or a sudden onset of vomiting.
If gastroenteritis is suspected then ask about recent contact with someone with acute diarrhoea and/or vomiting, exposure to a possible or known source of bowel infection (eg, contaminated water or food) and any recent travel abroad.
Children are often febrile with any type of infective gastroenteritis.
Antibiotics may cause Clostridium difficile colitis.
Bloody diarrhoea is usually caused by either Campylobacter spp. (mainly Campylobacter jejuni), where bloody diarrhoea may be present in up to 29% of cases, and E. coli O157 infections, where bloody diarrhoea may be present in up to 90% of cases.
Always consider other possible diagnoses (eg, other causes of fever) and always reassess the diagnosis if vomiting or diarrhoea becomes prolonged.
Most children do not become significantly dehydrated but always assess for the presence and degree of dehydration.
Always perform an abdominal examination (including any areas of tenderness, any masses, distension and bowel sounds). Record findings, even if negative. Always repeat a thorough examination if the situation changes or doesn’t settle as expected.
What are the red flags for gastroenteritis?
Appears to be unwell or deteriorating.
Altered responsiveness (e.g., irritable, lethargic).
Sunken eyes.
Tachycardia.
Tachypnoea.
Reduced skin turgor.
Shock
What are the signs of shock?
Emergency transfer to secondary care if: o Decreased level of consciousness. o Pale or mottled skin. o Cold extremities. o Decreased level of consciousness. o Tachycardia. o Tachypnoea. o Weak peripheral pulses. o Prolonged capillary refill time. o Hypotension.
What are the differentials for gastroenteritis?
Other sites of infection: UTI, otitis media, meningitis, pneumonia.
Toddler’s diarrhoea
Constipation with overflow
Acute appendicitis but always consider mesenteric adenitis
Intussusception
Coeliac disease
Pyloric stenosis- projectile vomiting
GORD
DKA
Addison’s disease
What are the investigations to assess gastroenteritis?
Stool samples - for microscopy (include ova, cysts and parasites), culture and sensitivity. Usually samples are not required but should be sent for microbiological investigation in outbreaks.
Blood tests - FBC, renal function and electrolytes for patients in the hospital setting.
Perform a blood culture if giving antibiotic therapy.
Children with E. coli O157 infection require specialist advice on monitoring for HUS.
Other tests will depend on the individual case and the need to rule out other possible diagnoses.
Both dysentery and food poisoning are notifiable diseases.
What is the management for gastroenteritis without clinical dehydration?
Emergency transfer to secondary care for children with symptoms suggesting shock.
In children with gastroenteritis but without clinical dehydration:
o Continue breast-feeding and other milk feeds.
o Encourage fluid intake.
o Discourage the drinking of fruit juices and carbonated drinks, especially in those at increased risk of dehydration.
o Offer oral rehydration salt (ORS) solution as supplemental fluid to those at increased risk of dehydration.
What is the management for gastroenteritis with clinical dehydration?
In children with clinical dehydration, including hypernatraemic dehydration:
o Use low-osmolarity ORS solution (240-250 mOsm/L).
o Give 50 ml/kg for fluid deficit replacement over four hours as well as maintenance fluid for oral rehydration therapy.
o Give the ORS solution frequently and in small amounts.
After rehydration:
o Give full-strength milk straightaway.
o Re-introduce the child’s usual solid food.
o Avoid giving fruit juices and carbonated drinks until the diarrhoea has stopped.
When is IV fluid therapy indicated for clinical dehydration?
Use intravenous fluid therapy for clinical dehydration if:
o Shock is suspected or confirmed.
o A child with red flag symptoms or signs shows clinical evidence of deterioration despite oral rehydration therapy.
o A child persistently vomits the ORS solution, given orally or via a nasogastric tube.
What is racecadotril?
Racecadotril is an intestinal antisecretory enkephalinase inhibitor that inhibits the breakdown of endogenous enkephalins. It reduces the hypersecretion of water and electrolytes into the intestine.
It is licensed for the complementary symptomatic treatment of acute diarrhoea in infants aged over 3 months, together with oral rehydration and the usual support measures (dietary advice and increased daily fluid intake), when these measures alone are insufficient to control the clinical condition.
What are the complications of gastroenteritis?
There is an increased risk of dehydration in:
- Children younger than 1 year, particularly those younger than 6 months.
- Infants who were of low birth weight.
- Children who have passed more than five diarrhoeal stools in the previous 24 hours.
- Children who have vomited more than twice in the previous 24 hours.
- Children who have not been offered or have not been able to tolerate supplementary fluids before presentation.
- Infants who have stopped breast-feeding during the illness.
- Children with signs of malnutrition.
HUS is a serious complication.
Loss of lactase from the gut (causing lactose intolerance) may occur, especially after viral infection. This is quite common but usually not a problem
What is the prognosis of gastroenteritis?
Usually there is uneventful recovery. Diarrhoea usually lasts for 5-7 days and in most it stops within two weeks. Vomiting usually lasts for 1-2 days and in most it stops within three days.
Infants and those with immunological compromise are more likely to have more severe disease and to require admission to hospital for rehydration. In severe cases, hypovolaemic shock and even death can occur.
Which clinical features suggest an alternative diagnoses to gastroenteritis?
The following features if associated with diarrhoea and vomiting suggest a diagnosis other than gastroenteritis and should be considered during clinical evaluation:
o Fever – temperature >38 degrees or higher in children younger than 3 months & >39 degrees or higher in children aged 3 months and older
o Tachypnoea
o Altered consciousness level
o Neck stiffness
o Bulging fontanelle in infants
o Non-blanching rash
o Blood and /or mucus in stool
o Bilious vomit
o Severe or localised abdominal pain
o Abdominal distension or rebound tenderness
