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MBBS V - Senior Clerkship - Block C CCT > Paediatrics - Vomiting and Diarrhoea > Flashcards

Paediatrics - Vomiting and Diarrhoea Flashcards

1
Q

Differential diagnosis of acute-onset bloody stool, fever and abdominal cramps

A 
Infective pathogens: 
Campylobacter 
Shigella 
Salmonella 
Enteroinvasive E.coli 
Enterohemorrhagic E. coli (O157:H7)
Clostridium difficile 
Yersinia enterocolitis 
Vibrio parahaemolyticus
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2
Q

Ddx causative pathogens of watery vs bloody diarrhea

A

Watery:
 Enterotoxin
 Virus
 Protozoan

Bloody with mucus:
 Cytotoxin-producing bacteria causing mucosal inflammation
 Enteric parasite

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3
Q

Outline history taking questions for acute diarrhea in children

A
  1. Confirm diarrhea: alteration in bowel movement with change in stool consistency to loose/ watery, and increase stool frequency and volume
  2. Character of diarrhea: watery vs bloody, presence of mucus
  3. Severity:
    - Frequency
    - Number of episodes
    - Estimated amount/ trend over time
  4. Any associated symptoms:
    - Vomiting: appearance, frequency, volume, projectile
    - Fever
    - Appetite and recent food intake
    - Abdominal pain/ colic
    - Irritability
  5. Risk of dehydration
  6. Source of infection: TOCC
  7. Past health, recent management and birth history
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4
Q

Symptoms of dehydration in children

Risk factors of dehydration

A

Symptoms:
 Dry lips
 Cool limbs
 Urine output

Risk factors:
 Children <1 year, particularly <6 months
 Infants of low birthweight
 Frequent profuse watery diarrhea
 Vomiting (>2 in previous 24hrs)
 Poor fluid intake: malnutrition, intolerance to fluid
 Concurrent fever (increased insensible fluid loss)

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5
Q

Possible sources of infection causing diarrhea in children

A

Contacts having similar symptoms (most common)

Change in food content

Change in preparation: the person, the method, the utensils

‘Unhygienic food’, e.g. undercooked food, raw food, eating out

Nursery outbreak

Family member occupations:

a) Cooks, kitchen workers (contact with raw food or carriers of Salmonella)
b) Health care workers (exposure to enteric pathogens)

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6
Q

Causes of diarrhea in an immunocompromised child

A

Chemotherapy, prolonged antibiotics use
» hospital-acquired, multiple antibiotic-resistant enteral bacteria

X-linked agammaglobulinemia (absent B cells, reduced humoral immunity)&raquo_space; Giardia infection

Antimicrobial-associated diarrhea&raquo_space; Clostridium infection

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7
Q

Birth, family and social history relevant to diarrhea in a child

A

Birth:
Preterm babies at risk of necrotizing enterocolitis
bowel surgery: short gut syndrome, blind loop syndrome (bacterial overgrowth)

Family history:
 Recent GE, GI symptoms in immediate family members
 Chronic diarrhea in childhood
 Inborn errors of immunity: cellular immunodeficiency or lack of IgA protective mucosal response

Social history (who look after child, change in carer)

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8
Q

Ddx acute diarrhea in a child

A

Infective:
 Bacterial vs. virus (majority in children)
 Secretory (toxins cause secretion of electrolytes and fluids into gut)
 Inflammatory (cytotoxic effect damages mucosal cells, influx of white
cells and immune cells)

Food intolerance

Osmotic agents

Drugs

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9
Q

Acute infective gastroenteritis in children

Most common causative pathogens

A

Virus: Rotavirus

Bacteria:
 Campylobacter spp.
 Salmonella spp.
 E. coli: O157, Non-O157

Protozoa: Cryptosporidium parvum (uncommon, specific to T cell defects)

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10
Q

List all viruses that can cause Acute infective gastroenteritis in children

A

Rotavirus

 Norovirus
 Adenovirus group F
 Calicivirus
 Astrovirus
 Small round structured virus
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11
Q

List all bacteria that can cause Acute infective gastroenteritis in children

A

 Campylobacter spp.
 Salmonella spp.
 E. coli

 Shigella spp.
 Clostridium difficile
 Clostridium perfringens
 Staphylococcus aureus
 Bacillius spp.
 Vibrio spp.
 Yersinia spp.
 Aeromonas spp.
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12
Q

Pathogens a/w traveler’s diarrhea

A

Most common: Salmonella

Others: Campylobacter, E. coli, Cryptosporidium

Shigella, Giardia, Entamoeba (Indian subcontinent, sub-Saharan, southern Africa)

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13
Q

Ddx non-gastrointestinal infection causes of diarrhea and vomiting

A 
1. Non-enteric infections: 
 Pneumonia
 Urinary tract infection
 Meningitis
 Acute otitis media
 Toxic shock syndrome
  1. Non-infective gastrointestinal disorders
     Ulcerative colitis
     Crohn’s disease
     Coeliac disease
  2. Surgical disorder
     Bowel obstruction
     Intussusceptions
     Ischemic bowel
  3. Drug-related: antibiotics esp.
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14
Q

Key symptoms and signs of meningitis in children

A 
Key symptoms
 Persistent vomiting
 Altered consciousness
 Irritability
 Photophobia

Key signs
 Petechial purpuric rash
 Neck stiffness
 Bulging fontanelle in infants

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15
Q

Key symptoms and signs of toxic shock syndrome in children

A

Key symptoms
 Non-specific muscle aches
 Faintness

Key signs
 Clinical shock
 Red non-specific rash
 Possible site of bacterial entry (e.g. small burn, injury)

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16
Q

Factors a/w more prolonged course of infective gastroenteritis

A

Co-infection of enteric pathogen

Bloody and/ or mucoid stools

Malnutrition

Indiscriminate use of antibiotics

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17
Q

Explain why infants are more susceptible to dehydration from diarrhea

A

 A greater portion of their bodies is made of water
 Higher surface to mass ratio - higher loss through skin
 Children have a high metabolic rate
 A child’s kidneys do not conserve water as well as an adult’s kidneys
 Low ability to express thirst

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18
Q

Define mild, moderate and severe dehydration in a child

Signs to define severity of dehydration

A

% weight loss:

Mild, 3-5%
Moderate, 6-9%
Severe, >10%

Signs:

  • BP, HR, rhythm
  • Skin turgor
  • Sunken fontanelle
  • Mucous membrane dryness
  • Sunken orbits
  • Cool, mottled extremities with delayed capillary refill
  • Mental status: lethargy or coma
  • Urine output
  • Thirst
19
Q

Electrolyte disturbance associated with dehydration in children with severe diarrhea

Manifestations

A

Hypernatremic dehydration:

  • dehydration with plasma Na >150mmol/L
  • Severity of dehydration often underestimated compared to normo- natremic dehydration (fluid drawn into subcutaneous tissue&raquo_space; reduced skin turgor not apparent)
Manifestations: 
 Jittery movement
 Increased muscle tone
 Hyperreflexia
 Convulsions
 Drowsiness/ coma
20
Q

Indications for hospital admission of a child with diarrhea

A
  1. Red flag signs for significant dehydration:
     Appears to be unwell/ deteriorating
     Altered responsiveness (e.g. irritable, lethargic)
     Sunken eyes
     Tachycardia
     Tachypnea
     Reduce skin turgor
  2. Risk factors for significant ongoing loss, especially with severe vomiting compromising the chance of success with oral rehydration (give IV fluid)
  3. Patients with grossly bloody stool
  4. Patients with immunocompromised states at risk of opportunistic infection
21
Q

First-line investigations for child with severe diarrhea

A

Assess dehydration, electrolyte imbalance, acid-base imbalance:

  1. Measure plasma Na, K, renal function (urea, creatinine) & glucose if:
    - Require IV fluid therapy (adjust Na, K levels)
    - Symptoms/signs suggest hypernatremia
    - Infant with unexplained drowsiness – rule out hypoglycemia
  2. Measure venous blood acid-base status and chloride concentration if shock
  3. Stool microbiological investigations:
    - Indicated if diarrhea and systemic illness, sepsis
    - Presence of blood and mucus in stool
22
Q

Acid-base disturbance a/w severe diarrhea in children

A

Severe diarrhea causes:
 Loss of bicarbonate in diarrhea
 Lactic acidosis in hypovolemic shock

Measure anion gap (base excess = Na + K – Cl – HCO3):
 Raised anion gap: impaired tissue perfusion (end organs respire anaerobically and produce lactate&raquo_space; negative ion accumulation increase base excess)
 Normal anion gap: bicarbonate loss

23
Q

Indications for stool microbiological investigation for diarrhea in a child

A

Most acute GE in children = viral in origin and self limiting

Indicators for extensive stool microbiology workup:
a) Child with diarrhea and systemic illness/ sepsis

b) Presence of blood and mucus in stool: EHEC, antibiotic-associated pseudomembranous colitis, Bacterial/ amoebic dysentery
c) Suspect traveler’s diarrhea
d) Immunocompromised hosts (opportunistic organism)
e) Diarrhea with prolonged course

24
Q

Which pathogens that cause diarrhea require extensive microbiological workup

A

Bacterial/ amoebic dysentery (Campylobacter, Shigella,
EIEC, EHEC, Vibrio parahaemolyticus, Entamoeba histolytica)

Enterohaemorrhagic E. coli O157:H7 (associated with hemolytic uremic syndrome)

Antibiotic-related pseudomembranous colitis, caused by Clostridium difficile

opportunistic organism in immunocompromised child

Traveler’s diarrhea

25
Q

General management options for diarrhea in a child

A
  1. Prevention of dehydration or rehydration therapies
    - ORS
    - Intraosseous fluid therapy
    - Treatment of hypernatremic dehydration
    - Intravenous fluid therapy
  2. Nutritional management - early oral feeding
  3. Symptom relief:
    - Anti-emetics
    - Anti-diarrheal agents
  4. Probiotics
  5. Antibiotics
26
Q

General fluid management in paediatric gastroenteritis without dehydration

A

Prevent hydration:

a) Continue breastfeeding and other milk feeds
b) Encourage fluid intake
c) Discourage consumption of fruit juices and carbonated drinks (sugar draws fluid into gut lumen and worsens diarrhea)
d) Offer oral rehydration solution (ORS) as supplemental fluid

27
Q

Fluid management for paediatric gastroenteritis with clinical dehydration

A
  • ORS first-line rehydration
  • ORS for first 3-4 hours of rehydration
  • Continue breast feeding and milk feeding
  • Avoid fruit juices or carbonated drinks
28
Q

Compare the content of conventional ORS solution and Rice-based ORS

A

Rice-based ORS:

  • Lower Na and Cl load
  • Low glucose with rice powder substitute
  • Sam citrate concentration

Rice powder rationale:

  • rice powder broken down into glucose by polysaccharidase and disaccharidase at brush border of intestinal villi rather than in gut lumen
  • Na-glucose co-transporter promotes absorption of salt and water across enterocytes
  • Associated with reduction in duration of diarrhea in children, better control of cholera
29
Q

Why is low-osmolarity ORS solution better for treatment of diarrhea?

A

High osmolarity/ High Na ORS increases osmotic load in gut lumen and increase fluid loss

Low osmolarity ORS reduces need for IV fluid treatment, and reduces stool output and vomiting

30
Q

Oral rehydration strategy for paediatric diarrhea and dehydration

A

Small, frequent feeds

Replace fluid deficit over 4 hours*** and then give maintenance fluid

Monitor ongoing loss and replace accordingly to body weight loss***

Reassess and adjust strategy according to tolerance and response

31
Q

Indications of more aggressive IV fluid therapy for severe diarrhea in a child

A

Signs of shock

Impaired conscious state (can be a result of shock)

Red flag symptoms of deterioration and dehydration

Failed ORS due to intolerance/ vomiting

Paralytic ileus due to anti-motility agents

32
Q

IV rehydration strategy for paediatric diarrhea and dehydration

A

IV rehydration over 3-6 hours with maintenance fluid replacement after

Early introduction of oral rehydration during IV fluid therapy (as early as tolerable)

33
Q

Treatment of hypernatremic dehydration caused by severe diarrhea in a child

A

isotonic solution 0.9% NaCl for fluid deficit replacement + maintenance

Replace fluid deficit slowly – over 48 hours*** SLOWLY to avoid central pontine myelinolysis **

Monitor plasma sodium frequently – reduce it at a rate <0.5mmol/L per hour

34
Q

Complication of correcting hypernatremic dehydration too quickly?

A

central pontine myelinolysis

Serum Na level changes too quickly, causing osmotic demyelination and draws fluid outside CNS

Must monitor plasma sodium frequently and reduce at rate under 0.5mmol/L per hour

35
Q

Urgent treatment of hypovolemic shock caused by severe diarrhea and dehydration

A
  1. Rapid IV infusion of 0.9% NaCl, 20mL/kg
     if persistent signs of shock (low BP, impaired perfusion): Another rapid IV infusion of 0.9% NaCl, 20ml/kg
     Consider possible causes of shock other than dehydration
  2. If signs of shock resolved: continue rehydration with IV fluid
  3. If persistent signs of shock: consult intensive care specialist
36
Q

Fluid management after rehydration therapy for paediatric diarrhea

A

 Continue breastfeeding and milk feeds
 Encourage fluid intake
 Avoid fruit juices/ carbonated drinks
 Prevent recurrence of dehydration by replacing ongoing loss from diarrhea with additional ORS
 Restart oral rehydration therapy if dehydration recurs after rehydration

37
Q

Nutritional management for paediatric diarrhea

A

Re-introduce usual feeding early, including solid food as long as tolerable

Give full-strength milk as usual (no evidence that diluted milk is of benefit)

No benefit from special milk formulas, e.g. lactose-free/ soy-based formula

38
Q

Symptomatic relief options for diarrhea

A

ALL of these agents are not recommended for routine use in children

Anti-emetics:

  • Ondansetron (zofran): potent, highly-selective 5-HT3 receptor antagonists; oral
  • Metoclopramide (maxolon): anti-dopamine D2, weak anti- 5HT3 activity
  • Promethazine (phenergan): anti-histamine H1, anti- cholinergic, anti-dopaminergic activity

Anti-diarrheal agents:
 Adsorbents, e.g. kaolin, smectite
 Anti-motility agents, e.g. loperamide

39
Q

Justify whether routine use of symptomatic relief medication for paediatric diarrhea is needed

A

Ondansetron (zofran): Routine use not recommended
- Frequency of stool passage increases (retained fluid and toxins that should be eliminated)

Metoclopramide, Promethazine: Use in children NOT RECOMMENDED
- Significant adverse effects (e.g. dystonic reactions of facial and skeletal muscles, oculogyric crisis)

Anti-diarrheal agents: Not recommended
Potentially serious adverse side effects: e.g. Abdominal distension, Ileus, Drowsiness (loperamide), impaired clearance of pathogens and toxins

40
Q

Probiotics for paediatric diarrhea

  • Content
  • MoA to treat diarrhea
A

E.g. Lactobacillus, Bifidobacillus, Saccharomyces yeast

Possible mechanism:
 Compete with pathogens for binding sites and substrates
 Lower intestinal luminal pH
 Upregulate genes mediating immunity
 Produce trophic short-chain fatty acids and promote mucosal cell growth and differentiation

41
Q

Antibiotics for paediatric diarrhea

  • Recommended use/ indications for use
A

Most acute GE in children = self-limiting illness caused by viral infection, do not need antibiotics

Indications for antibiotics use:
 septicemia/ Extra-intestinal spread of bacterial infection

Specific pathogens:
 Patient is <6 months/ malnourished/ immunocompromised with Salmonella gastroenteritis
 Clostridium difficile associated pseudomembranous enterocolitis (metronidazole/ oral vancomycin)
 Giardia lamblia
 Dysentery by Shigella (IV 3rd generation cephalosporin – ceftriaxone, cefotaxime) or Amoebic dysentery
 Cholera

42
Q

Indications for discharge after treatment of paediatric diarrhea

A

Indicators of safe discharge:
 Rehydration completed
 Minimal risk for recurrence of dehydration
 Uncomplicated disease course

Other considerations:
 Reliable carer: capability of child care
 Understanding of the carer to your treatment plan

43
Q

Home care plan for paediatrics diarrhea

A
  1. Continue usual feeds, encourage frequent hydration
  2. Discourage consumption of fruit juices and carbonated drinks
  3. Offer ORS solution as supplemental fluid (Sachets to take home)
  4. Seek medical hydration if signs of dehydration, or atypical/ prolonged illness

MBBS V - Senior Clerkship - Block C CCT (52 decks)

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