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Paeds: Gastro and Growth > Gastroenteritis > Flashcards

Gastroenteritis Flashcards

1
Q

What is the most frequent cause of gastroenteritis in developed countries and what proportion does this account for?

A

Rotavirus, 60% of children under 2

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2
Q

What time of year is gastroenteritis caused by rotavirus most common?

A

Winter and early spring

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3
Q

What rotavirus vaccination is available?

A

Oral rotavirus vaccine - liquid into baby’s mouth. First dose at 8 weeks, second at 12 weks

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4
Q

In addition to rotavirus what are 5 other virus types that may cause gastroenteritis in children?

A
  1. Adenovirus
  2. Norovirus
  3. Calicivirus
  4. Coronavirus
  5. Astrovirus
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5
Q

What feature of gastroenteritis may suggest a bacterial cause?

A

Presence of blood in stools

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6
Q

What is the most common cause of bacterial gastroenteritis in developed countries?

A

Campylobacter jejuni

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7
Q

In addition to diarrhoea ± blood in stool, what feature is common in gastroenteritis caused by campylobacter jejuni?

A

Severe abdominal pain

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8
Q

What are 5 bacterial causes of gastroenteritis in addition campylobacter jejuni?

A
  1. Shigella
  2. Salmonellae
  3. Cholera
  4. enterotoxigenic Escherichia coli
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9
Q

What features may be seen in gastroenteritis caused by shigella and some salmonellae?

A

dysenteric type; blood and pus in stool, pain and tenesmu

Shigella may have high fever

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10
Q

What features are common in gastroenteritis caused by E coli and cholera?

A

profuse, rapidly dehydrating diarrhoea

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11
Q

What are 2 types of protozoa that can cause gastroenteritis?

A
  1. Giardia
  2. Cryptosporidium
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12
Q

What are the 2 key features of gastroenteritis?

A

sudden change to loose or watery stools

vomiting

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13
Q

What are 2 key things to ask in the history of diarrhoea?

A

Recent travel abroad

Contact with person with diarrhoea ± vomiting

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14
Q

What is the most serious complication of gastroenteritis?

A

dehydration leading to shock

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15
Q

What are 6 groups of conditions that can mimic gastroenteritis?

A
  1. Systemic infection
  2. Local infections
  3. Surgical disorders
  4. Metabolic disorder
  5. Renal disorder
  6. Other
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16
Q

What are 2 systemic infections which can mimic gastroenteritis?

A

Sepsis, meningitis

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17
Q

What are 4 local infections that can mimic gastroenteritis?

A
  1. Respiratory tract infection
  2. Otitis media
  3. Hepatitis A
  4. Urinary tract infection
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18
Q

What are 5 surgical disorders which can mimic gastroenteritis?

A
  1. Pyloric stenosis
  2. Intussusception
  3. Acute appendicitis
  4. Necrotising enterocolitis
  5. Hirschprung disease
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19
Q

What is a key metabolic disorder that can mimic gastroenteritis?

A

Diabetic ketoacidosis

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20
Q

What is a key renal disorder that can mimic gastroenteritis?

A

Haemolytic uraemic syndrome

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21
Q

What are 4 ‘other’ conditions that can mimic gastroenteritis?

A
  1. Coeliac disease
  2. Cow’s milk protein allergy
  3. Lactose intolerance
  4. Adrenal insufficiency
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22
Q

What are 5 groups of children that are at increased risk of dehydration in gastroenteritis?

A
  1. Infants, particularly <6 months or born with low birthweight
  2. 6 or more diarrhoeal stools passed in 24 hours
  3. vomited 3 or more times in past 24 hours
  4. unable to tolerate (or not been offered) extra fluids
  5. malnutrition
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23
Q

What are 4 reasons infants are at particular risk of dehydration in gastroenteritis?

A
  1. Greater surface are to weight ratio than older children leading to greater insensible losses
  2. Higher basal fluid requirements (100-120ml/kg/day, 10-12% bodyweight)
  3. Immature renal tubular absorption
  4. Unable to obtain fluids for themselves when thirsty
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24
Q

What is the most accurate measure of dehydration in children with gastroenteritis?

A

degree of weight loss during the diarrhoeal illness 0 however recent weight measurement often not available

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25
Q

What are 3 groups that dehydration in gastroenteritis can be classed into and what body weight percentage loss to they correspond to?

A
  1. No clinically detectable dehydration (<5% loss of body weight)
  2. Clinical dehydration (5-10% loss of body weight)
  3. Shock (>10% loss of body weight) - must be identified without delay
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26
Q

What are 13 clinical features of shock from dehydration in an infant?

A
  1. reduced urine output
  2. cold extremities
  3. decreased level of consciousnes
  4. sunken fontanelle
  5. dry mucous membranes
  6. eyes sunken and tearless
  7. tachypnoea
  8. prolonged capillary refill time
  9. tachycardia, weak peripheral pulses
  10. pale or mottled skin
  11. reduced tissue turgor
  12. sudden weight loss
  13. hypotension
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27
Q

What are 13 things found in the clinical assessent of dehydration that is not yet shock?

A
  1. General appearance: unwell or deteriorating
  2. Conscious level: altered responsiveness e.g. irritable, lethargic
  3. Urine output: decreased
  4. Skin colour: normal
  5. Extremities: warm
  6. Eyes: sunken
  7. Mucous membranes: dry
  8. Heart rate: tachy
  9. Breathing: tachy
  10. Peripheral pulses: normal
  11. Capillary refill time: normal
  12. Skin turgor: reduced
  13. Blood pressure: normal
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28
Q

What are 13 things found in the clinical assessment of dehydration in shock?

A
  1. General appearance: appears unwell or deteriorating
  2. Conscious level: decreased level of consciousness
  3. Urine output: decreased
  4. Skin colour: pale or mottled
  5. Extremities: cold
  6. Eyes: grossly sunken
  7. Mucous membranes: dry
  8. Heart rate: tachycardia
  9. Respiratory rate: tachypnoea
  10. Peripheral pulses: weak
  11. CRT: prolonged (>2s)
  12. Skin turgor: reduced
  13. Blood pressure: hypotension (indicates decompensation)
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29
Q

What are 3 types of dehydration?

A
  1. Isonatraemic
  2. Hyponatraemic
  3. Hypernatraemic
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30
Q

What is dehydration?

A

total body deficit of sodium and water

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31
Q

What is isonatraemic dehydration?

A

losses of sodium and water are proportional and plasma sodium remains within the normal range

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32
Q

What is the most common type of dehydration in gastroenteritis?

A

isotonatraemic dehydration

33
Q

What is hyponatraemic dehydration and what causes it?

A

greater net loss of sodium than water, when children with diarrhoea drink large quantities of water or other hypotonic solutions, leading to fall in plasma sodium

leads to shift of water from extracellular to intracellular compartments

34
Q

What is the risk associated with hyponatraemic dehydration?

A

shift of water from extracellular to intracellular compartments down osmotic gradient; may result in seizures, and marked extracellular depletion leads to greater degree of shock per unit of water los

35
Q

In what group of children is hyponatraemic dehydration in gastroenteritis more common?

A

poorly nourished infants in developing countries

36
Q

What is hypernatraemic dehydration?

A

when water loss exceeds relative sodium loss and plasma sodium concentration increases (rare)

37
Q

What usually causes hypernatraemic dehydration?

A

high insensible water losses e.g. high fever or hot, dry environment; or profuse, low-sodium diarrhoea

38
Q

What can hypernatraemic dehydration lead to?

A

extracellular fluid becomes hypertonic with respect to intracellular fluid, which leads to a shift of water into the extracellular space from the intracellular compartment

therefore signs of extracellular depletion are less per unit of fluid los, and depression of fontanelle, reduced tissue eleasticity, and sunken eyes less obvious

39
Q

Why is hypernatraemic dehydration more difficult to recognise clinically, and when is it particularly difficult?

A

extracellular fluid becomes hypertonic so intracellular fluid moves to extracellular compartment. depression of fontanelle, reduced tissue elasticity, sunken eyes are less obvious

particularly in obese infant

40
Q

Why is hypernatraemic dehydration a particularly dangerous form of dehydration?

A

water is drawn out of the brain and cerebral shrinkage within rigid skull may lead to jittery movements, increased muscle tone with hyperreflexia, altered consciousness, seizures, and multiple, small erebral haemorrhages

41
Q

What are 6 things that can occur in hypernatraemic dehydration as a result of cerebral shrinkage?

A
  1. Jittery movements
  2. Increased muscle tone
  3. Hyperreflexia
  4. Altered consciousness
  5. Seizures
  6. Multiple, small cerebral haemorrhages
42
Q

What metabolic derangement can also be seen in the blood tests in hypernatraemic dehydration and what is the outcome?

A

Transient hyperglycaemia - self-correcting and does not require insulin

43
Q

What 3 investigations may be performed in gastroenteritis?

A

Usually none indicated

  1. Stool cultlure - if child appears septic, blood or mucus in stools, or immunocompromsed. recent foreign travel
  2. Plasma, electrolytes, urea, creatinine, glucose - if IV fluids required, features suggestive of hypernatraemia
  3. Blood culture - if abx started
44
Q

What are 6 reasons why you would perform a stool culture in gastroenteritis?

A
  1. Child appears septic
  2. Blood or mucus in stools
  3. Child immunocompromised
  4. Recent foreign travel
  5. Diarrhoea has not improved by day 7
  6. Diagnosis uncertain
45
Q

Wha are 2 things that would prompt you to measure plasma electroltyes, urea, creatinine and glucose in gastroenteritis?

A
  1. IV fluids required
  2. Features suggestive of hypernatraemia
46
Q

When should a blood culture be taken in gastroenteritis?

A

if antibiotics are started

47
Q

What is the management of gastroenteritis based upon?

A

Degree of dehydration: no clinical dehydration, clinical dehydration, shock

48
Q

What is the management of gastroenteritis if there is no clinical dehydration?

A
  • prevent dehydration
  • continue breastfeeding and other milk feeds
  • encourage fluid intake to compensate for increased GI losses
  • discourage fruit juices and carbonated drinks
  • oral rehydration solution (ORS) as supplemental fluid if at increased risk of dehydration
49
Q

When should you use ORS (oral rehydration solution) in gastroenteritis with no clinical dehydration?

A

if at increased risk of dehydration

50
Q

What is the management of gastroenteritis with clinical dehydration?

A
  • Oral rehydration solution
  • Give fluid deficit replacement (50ml/kg) over 4 hours as well as maintenance fluid requirement
  • Give ORS often and in small amounts
  • Continue breastfeeding
  • Consider supplementing ORS with usual fluids if inadequate intake of ORS
  • If inadequate fluid intake or vomits persistently, consider giving ORS via nasogastric tube
51
Q

What amount of ORS should be given in clinical dehydration in gastroenteritis?

A

50ml/kg over 4 hours as well as maintenance fluid requirement

often and in small amounts

52
Q

What should you do when managing a patient with clinical dehydration with ORS and they have inadequate fluid intake or vomit persistently?

A

consider ORS via nasogastric tube

53
Q

What should you do in clinical dehydration if there is deterioration or persistent vomiting?

A

IV therapy for rehydration

54
Q

What is the management of gastroenteritis with shock?

A

IV therapy: bolus of 0.9% sodium chlorid solution.

If remain shocked, consider consulting paediatric intensive care specialist

55
Q

What should you do in shock due to gastroenteritis, if symptoms and signs of shock improve after the initial 0.9% NaCl bolus?

A

IV therapy for rehydration

56
Q

What does IV therapy for rehydration involve?

A

replace fluid deficit over 24 hours in most cases, and give maintenance fluids. Give 0.9% sodium chloride solution ± 5% glucose

Monitor plasma electrolytes, urea, creatinine, and glucose.

Consider IV potassium supplementation

Continue breasteeding if possible

57
Q

What should you assume fluid deficit to be in shock, to replace with IV therapy if rehydration carried out?

A

100ml/kg (10% body weight)

58
Q

What should you assume fluid deficit to be if not in shcok, to replace with IV therapy if rehydration carried out?

A

50ml/kg (5% body weight)

59
Q

What should be monitored when carrying out IV therapy for rehydration?

A

Plasma electrolytes, urea, creatinine, glucose

60
Q

In addition to IV fluids for rehydration, what may also be given as IV supplementation?

A

Potassium

61
Q

What are 3 things to do following IV therapy for rehydration in gastroenteritis?

A
  1. Give full strength milk and reintroduce usual solid food
  2. Avoid fruit juices and carbonated drinks
  3. Advise parents about diligent hand washing, towel hygiene, don’t return to childcare/school for 48hours after last episode
62
Q

What is the usual mechanism of absorbing sodium from the intestine?

A

Large quantities of sodium excreted into the intestine, but nearly all is absorbed via a glucose-sodium transporter, with active absorption of sodium allied to the absorption of glucose

Sodium then actively pumped from epithelial cells into circulation via sodium/potassium adenosine triphosphatase, creating electrochemical gradient that water moves down

Second mechansim is via active, linked sodium-hydrogen exchanger

63
Q

How does oral rehydration solution work?

A

if an oral solution contains both sodium and glucose, sodium and passive water absorption is increased; works even if gut inflamed (diarrhoeal illness)

doesn’t stop diarrhoea but absorption of water and solutes exceeds secretion and keeps child hydrated until infective organism eradicated

64
Q

What is the management of hypernatraemic dehydration?

A
  • still use ORS to rehydrate if clinical dehydration
  • if IV fluid required, slow reduction in plasma sodium with IV fluids to rehydrate
  • fluid deficit replaced over at least 48 hours (0.9% or 0.45% saline)
  • plasma sodium measured regularly
  • aim to reduce at less than 0.5mmol/l per hour
65
Q

Why should a slow reduction in plasma sodium be ensured in hypernatraemic dehydration?

A

rapid reduction in plasma sodium concentration and osmolality will lead to shift of water into cerebral cells

may result in seizures and cerebral oedema

66
Q

Over what time period should fluid deficit be replaced in hypernatraemic dehydration and with what?

A

Over at least 48 hours with 0.9% or 0.45% saline

67
Q

What is the aim for the rate of correction of plasma sodium in hypernatraemic dehydration?

A

reduce it at less than 0.5mmol/l per hour

68
Q

What is thought about antidiarrhoeal drugs for gastroenteritis?

A

no place for these medications - ineffective, negative effects

69
Q

What are 5 reasons antidiarrhoeal drugs and anti-emetics have no place in gastroenteritis?

A
  1. ineffective
  2. may prolong excretion of bacteria in stools
  3. can be associated with side-effects
  4. add unnecessarily to cost
  5. focus attention away from oral rehydration
70
Q

Are antibiotics routinely used to treat gastroenteritis?

A

no, even if bacterial cause

71
Q

What are 5 of the only times when antibiotics are used to treat gastroenteritis?

A
  1. Confirmed sepsis
  2. Extra-intestinal spread of bacterial infection
  3. Salmonella gastroenteritis if <6 months
  4. Malnourished or immunocompromised children
  5. Specific bacterial or protozoal infections e.g. C. diff with pseudomembranous colitis, cholera, shigellosis, giardiasis
72
Q

What are 4 types of specific infective causes of gastroenteritis when antibiotics should be used?

A
  1. Clostridium difficule associated with pseudomembranous colitis
  2. Cholera
  3. Shigellosis
  4. Giardiasis
73
Q

What can multiple episodes of diarrhoea result in?

A

malnutrition

zinc deficiency

74
Q

What should be done following diarrhoea episodes?

A

nutritional intake should be increased - risk of developing malnutrition

Zinc supplementation in acute diarrhoea and as prophylaxis

75
Q

What deficiency can diarrhoea be associated with?

A

zinc deficiency

76
Q

When can rapid IV therapy in gastroenteritis be harmful? 4 situations

A
  1. Head injury
  2. Malnutrition
  3. DKA
  4. Severe febrile illness without shock
77
Q

What should be done when a child needs rapid IV therapy in shock but has head injury/malnutrition/DKA/severe febrile illness?

A

IV fluids should be given cautiously, clinical response monitored closely

78
Q

What is postgastroenteritis syndrome?

A

when, following an episode of gastroenteritis, introduction of normal diet results in return of watery diarrhoea

79
Q

How is postgastroenteritis syndrome managed?

A

oral rehydration therapy restarted

Paeds: Gastro and Growth (14 decks)

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