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Flashcards in Gastroenteritis Deck (76):
1

Most common cause of acute diarrhea

Viral gastroenteritis

2

Vomiting is feature in which GE

Viral
Toxin mediated

3

Viral causes (4)

Rotavirua
Norovirus
Enteric adenovirus
Astrovirus

4

Symptoms suggestive of norovirus

Prominent vomiting, cramping, abdominal pain.

5

What increases liklihood of bacterial

Systemic- fever

6

What should be investigation for if recent antibiotic use/hospitalisation

C difficile

7

If used, what is the role of antibiotics

Reduce time and severity
Prevent extra-intestinal complications
Reduce spread

8

Characteristics of toxin mediated

Abrupt onset
Closely clustered contacts
NV, abdominal pain prominent symptoms
Diarrhea occur late if present

9

Antibiotics most commonly used in bacterial (if used)

Azithromycin
Ciprofloxacin
Doxycyclin for cholera

10

Definition

Inflammation (infectious) of stomach and small intestine leading to NVD

11

Bacterial causes food borne illness

Bacillus cereus
Campylobacter jejuni
E. coli
Salmonella
Shigella
Yersinia enterocolitica

12

Risk factors

Young
Day care
Exposure to sick contacts
Travelling
Immunocompromised
Sick contact
Antibiotic use

13

History

NVD, abdominal pain, volume depletion, fever
Hx of travel, contact with contaminated food, consumption of unprocessed meat/milk/cheese
Contact with infected person

14

Hydration status examination

General: stable, breathless, fever, evidence of infection
Input/output: IV fluids, catheter, NG tube, bowels
Chart: obs, fluid balance, drug chart
Hands: Temp, pulse volume and rate, collapsing, BP sitting and standing
HN: sunken eyes, dry mucous membrane, depressed/elevated JVP,
carotid pulse/volume
Chest: cap refill, skin turgor, apex beat, 3rd heart sound in overload + pulmonary edema.
Abdomen: ascites
Legs: peripheral edema
To complete my examination i would take further history, look at UEC, obs and fluid balance chart.
Serial weights, catheterise, UEC, ABG, serum lactate

15

Investigations

Generally not required in young children
Stool culture X3 for MCS and C diff toxins, Campylobacter, Salmonella, Shigella
FBC- +WCC
Renal function- +U:Cr, hypokalemia
Glucose, ABG, lactate

16

Management

Rehydration
Nutrition

17

Important differentials for VD in children

Appendicitis
UTI
Sepsis
Intusussception, enterocolitis, malrotation, Hirschsprung
HUS

18

Presentation in children

Poor feeding
Vomiting
Fever
Diarrhea
Watery and frequent stools

19

Best indication of fluid depletion in children

Recent change in body weight

20

Signs to discriminate dehydration and hydration

-ve skin turgor
-ve peripheral perfusion
deep acidotic breathing

21

Mild dehydration classifcation, signs and management

22

Moderate dehydration classifcation and signs

5-9%
Same as mild + rapid pulse, -ve peripheral perfusion, sunken eyes and fontanelle, deep acidotic breathing, slow skin retraction

23

Management of moderate dehydration in children

Rehydration ?NGT
Reassess at 6 hours
If fluid replete, maintenance fluids then used
Weigh every 6 hours for first 24 hours of admission
Introduce food after hydration

24

Severe dehydration classification and signs

>9% weight loss
All same signs +
in infants->drowsy, limp, cold, sweaty cyanosed, altered MS
In children->apprehension, cold, sweaty, cyanosed, feeble resp effort, hypotensive

25

Management of severe dehydrationq

Get senior medical help
Shocked->20ml/kg IV NS
IV/IO access
Measure UEC, glucose, VBG
May require NGTR
If NGTR not successful IV fluids
Treat hypoglycemia w/ 5ml/kg 10% dextrose
Septic workup
ORS start after initial resus->frequent small amounts 10-20ml/kg over 1 hour
Give over 6 hours
Admit
Re-evaluate
Ongoing fluids: 5% dextrose + NS, 20mmol/L if K

26

What mechanism used in ORS

Glucose facilitated sodium transport in small intestine

27

Current ORS available

Gastrolyte Na 60 K 20 Cl 60 Citrate 10 Glucose 90
Replayte
Hydralyte

28

Suitable fluids for non dehydrated

Sugar water (1 teaspoon in 200ml)
Fruit juice 1 in 6 with water
Cordial 1 in 16
Lemonade 1 in 6

29

Why is early refeeding following rehydration important

Enhances mucosal recovery
Reduces duration of diarrhea

30

What can children have after rehydration

Complex carbohydrates, yoghurt, fruits, vegetables

31

One possibility if persistent diarrhea following recommencement of feeding

Transient lactose intolerance

32

Indication for admission to hospital

Moderate to severe dehydration
High risk for dehydration
High risk infants
When patient/carers thought not to be able to manage
If diagnosis is in doubt

33

High risk for dehydration

4/24 hours
Observe for 4-6 hours to ensure maintenance of hydrations

34

High risk infants for dehydration

Ileostomy, short gut, CHD, chronic renal disease, metabolic disorders, malnutirtions

35

When would biochemistry tests be required in children

History of prolonged diarrhea with severe dehydration
Altered conscious state
Convulsions
Short bowel syndrome, ileostomy, Cardiac/renal, metabolic disorders
Infants

36

Complications in children

Hypernatremic dehydration
Hyponatremic dehydration

37

How much should sodium levels fall by

No more than 0.5mmol/L per hour

38

General Advice to parents treating mil/moderate at home

Give small amounts of fluid often
Start solids after 24 hours
Continue breastfeeding or start bottles after 24 hours
Provide maintenance fluids and fluid loss

39

Advice to parents for mild/moderate dehydration on Day 1, 2 and 3, day 4

Day 1: General 50ml/15 mins. 200ml for every watery stool
Ideal is gastrolyte, hydralyte or home made solutions
Day 2 and 3: reintroduce babys formula/milk, dilute to half strength (equal milk to water)
Day 4: increase milk to normal strength, gradually reintroduce normal diet
Aim to give more fluid in first 6 hours

40

Maintenance for 1-3 months, 4-12months, 12 months >

1-3 month 120ml/kg/hr
4-12 month 100ml
>12 month 80ml

41

Calculating total

Maintenance + fluid loss

42

Calculate fluid loss

%body weight loss X body weight X 10

43

Daily maintenance IV fluid based on weight
3-10kg, 10-20kg, >20kg

3-10= 100ml/kg/day
10-20- 1000ml + 50ml/kg for each kg >10kg
>20- 1500ml + 20ml/kg for each kg >20kg

44

Types of E. Coli

Enterohemorrhagic
Enteroinvasive
Enteropathogenic
Enteroaggregative
Enterotoxigenic

45

Most important type of E. coli

EHEC

46

Toxin produced by EHEC

Verotoxin
O157
Identical to Shiga toxin

47

What does the Shiga toxin do

Attaching effacing mechanism
Hemorrhagic colitis
HUS

48

Food borne illnesses associated with preformed toxins

S aureus
B cereus

49

Presentation of salmonella typhi

Rose spots
Abdominal pain
Fever
Malaise

50

Complications of S typhi

Hemorrhagic ulcerations of GIT
Myocarditis
Hepatic/bone marrow toxicity
Meningitis
Osteomyelitis

51

Pathogenesis of typhoid

Ingested->penetrate mucus via PP in jejunum/ileum->intestinal LN->multiply in macrophages->mesenteric LN->thoraci duct->blood->organs->intestine= ++iflammation in PP, ulceration, intestinal perforation

52

What food has HUS

Fast food burgers

53

How does C jejuni present

Bloody diarrhea
fever
Abdominal cramps

54

Reasons antibiotics are rarely indicated

Most commonly cause by viral
Can eradicate normal GIT flora->predisposing to C difficile
Prolong shedding of Salmonela and other bacterial diarrhea
EHEC w/ antibiotics may increase risk of HUS

55

Causes of acute bloody diarrhea

Campylobacter
EHEC
Entameoba histolytica
Salmonella
Shigella

56

Indications to investigate

fever, blood in stool
Severe abdominal pain, peritonism
Profuse diarrhea, signs of hypovolemia
Hospitalised, recent antibiotics
Age >65, comorbidities
Immunocompromised
Diarrhea >7 days
Exposure to suspicious food
Sexual contacts- MSM

57

Indications to do stool OCP for Giardia, Cryptosporidium, E histolytica

Diarrhea >7 days
Exposure to untreated water
HIV
MSM

58

Source and mode of transmission for 1. B cereus, 2. C jejuni, 3. C diff 4. EIEC 5. ETEC 6. EHEC 7. S typhi 8 S enteritis 9. Shigella 10. S aureus 11. Cholera 12. Yersinia

1. rice, meats, vegetables, beans
2. Uncooked meat
3. Normal colon, antibiotics
4/5. Contaminated water/food
6. Hamburger, raw milk
7. FO route, contaminated water, travel to endemic
8. Contaminate food animal eggs, poultry, meat, milk
9. FO, water
10. Unrefrigerated meat, dairy, custard
11. Water, shellfish
12. Contaminated food, unpasteurised milk

59

Which infections have short IP- within 24 hours

B cereus, C perfringens, S enteritis, S aureus

60

Infections that present 1-3 days

EHEC, C jejuni, Shigella

61

Presents at 5 days

Yersinia

62

IP of 10-14 days

Salmonella typhi

63

Which infection is associated with GBS

Campylobacter jejuni

64

Complications of Shigella

Toxic megacolon
HUS

65

What increases risk of toxic megacolon in Shigella

Antidiarrheals

66

What can occur in Yersinia infection which may mimic appendicitis

Mesenteric adenitis and terminal ileus without diarrhea

67

Parasites causing diarrhea

Cryptosporidium
Entamoeba histolytics
Giardia

68

Risk factors for Giardia

Day care childre
Untreated water
MSM
Immunodeficiency

69

What should be monitored with EHEC and why

Hb, platelet count, renal function as evidence of developing HUS

70

Red flags in children which require SMO assessment

Short gut syndrome
Ileostomy
Complex/cyanotic heart disease
Renal transplant/insufficiency

71

Monitoring rehydration

Bare weight patient 6 hourly in moderate and severe, NGTR or IVF
Reassess early at 4-6 hours, then 8 hourly
Look for:
Weight change
Clinical signs of deH
Urine output
Ongoing losses
Signs of overload
Consider early feeding

72

In what circumstances is medical review required before D/C

= 3 large stools during reH
Abdominal pain worsening

73

Principles of early feeding

Stop any fortifications
Early feeding
If diarrhea ++ after initial refeeding consider hydrolysed formula temporarily

74

Key points for parents

1. Babies and young children w/ gastro can become deH very quickly, need small amounts of fluid regularly
2. Babies 12-24 hours
3. Give older children 1 cup of fluid for every big vomit/diarrhea
4. Continue to give food to a hungry child, do not stop food for >24 hours
5. Wash hands of child and family, was before and after nappy changes, feeding
6. Keep away from child as much as possible until the diarrhea has settled

75

Which antibiotic is typically associated with pseuomembranous colitis

Clindamycin

76

If antibiotics indicated for diarrhea, most commonly used

Ciprofloxacin