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Year 4 - Paediatrics > Paeds - Diarrhoea and Vomiting > Flashcards

Paeds - Diarrhoea and Vomiting Flashcards

1
Q

What questions might you want to ask of a parent of a child who is presenting with vomiting and diarrhoea?

A
  • Vomit - duration, frequency / number, volume, colour, blood
  • Stool - duration, frequency / number, volume, colour, blood
  • Current oral intake vs normal feeding pattern
  • Urination - frequency (no. of wet nappies), last urination, volume
  • Recent contact with someone with vomiting & diarrhoea
  • Recent abroad travel
  • Ingestion of contaminated food or water?
  • Red flags:
    • fever
    • weight loss
    • bile in vomit
    • blood (vomit or stool)
    • projectile vomiting (pyloric stenosis)
    • abdominal tenderness / distention
    • bulging fontanelle
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2
Q

What are the physical features of clinical dehydration in an infant?

A
  1. Sunken anterior fontanelle
  2. Sunken eyes
  3. Altered responsiveness (e.g. irritable / lethargic)
  4. Reduced level of conciousness
  5. Dry mucous membrane
  6. Reduced skin turgor
  7. Tachypnoea
  8. Tachycardia
  9. Hypotension / Normal BP
  10. Prolonged / Normal capillary refill time
  11. Oliguria (urine output < 0.5 ml/kg/hour)
  12. Sudden weight loss
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3
Q

What are the features of clinical shock (child & adult)?

A
  • Decreased level of conciousness
  • Hypotension
  • Tachycardia
  • Tachypnoea
  • Weak peripheral pulses
  • Prolonged capillary refill time
  • Cold peripheries (peripheral vasoconstriction)
  • Pale or mottled skin
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4
Q

Which of the following are common causes of gastroenteritis in young children?

  • Adenovirus
  • E. Coli
  • Norovirus
  • Salmonella
  • Rotavirus
A

Rotavirus & Adenovirus

  • Rotavirus - most common cause of gastroenteritis in UK children (most have an episode by 5yrs and develop immunity)
  • Adenovirus - 2nd most common
  • Salmonella, E.Coli and Norovirus:
    • cause some cases of diarrhoea & food poisoning
    • more common in adults
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5
Q

Blood in stool associated with diarrhoea and vomiting is caused by which of the following?

  • Intussusception
  • E. coli
  • Campylobacter
  • Rotavirus
  • Shigella
A

All of them!!

  • Intussusception - ‘red-currant’ jelly stool containing blood & mucus
  • E.Coli - associated with diarrhoea /w blood and heamolytic uremic syndrome
  • Rotavirus - fever, vomiting, diarrhoea with/without blood
  • E.Coli - associated with diarrhoea /w blood and heamolytic uremic syndrome. HUS features:
    • Triad: AKI, microangiopathic haemolytic anaemia, thrombocytopenia
    • Abdo pain
    • Bloody diarrhoea
    • Fever
    • Lethargy
    • Seizures
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6
Q

What are the ‘red flag’ questions regarding child vomiting?

A
  • fever
  • weight loss / poor growth
  • bile in vomit
  • blood in vomit
  • blood in stool
  • projectile vomiting + < 2 months old
  • abdominal tenderness / distention
  • bulging fontanelle
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7
Q

What can the following symptoms each indicate in a child?

  • severe dehydration + shock
  • weight loss / poor growth
  • bile in vomit
  • blood in vomit
  • blood in stool
  • projectile vomiting + < 2 months old
  • abdominal tenderness / distention
  • bulging fontanelle
  • vomiting + paroxysmal cough
A
  • severe dehydration + shock - severe gastroenteritis, UTI, meningitis, DKA
  • weight loss / poor growth - GORD, coeliac disease, chronic GI conditions
  • bile in vomit - intestinal obstruction
  • blood in vomit (haematemesis) - oesophagitis, gastric ulcer, oral or nasal bleeding then vomiting up swallowed blood
  • blood in stool - gastroenteritis, intussusception
  • projectile vomiting + < 2 months old - pyloric stenosis
  • abdominal tenderness / distention - intestinal obstruction, strangulated inguinal hernia, surgical abdomen
  • bulging fontanelle - raised ICP due to meningitis / hydrocephalus
  • vomiting + paroxysmal cough - whooping cough
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8
Q

What features suggest a UTI on a urine dipstick?

A

Leucocyte esterase +ve

Nitrites +ve

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9
Q

What does elevated ketones without elevated glucose mean on a urine dipstick?

A

Could be due to weight loss

only if ketones +ve & glucose +ve is it DKA

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10
Q

Which organisms are more commonly responsible for food poisoning in the UK?

A
  1. Campylobacter (most common) - raw / uncooked meat, particularly poultry
  2. Salmonella - raw / uncooked meat, raw egg, milk
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11
Q

In what food can Listeria be found?

For whom is a Listeria infection particularly dangerous?

A

Listeria Food (chilled ready to eat foods):

  • Prepacked sandwiches
  • Cooked sliced meats
  • Pate
  • Brie cheese

Listeria infection in pregnant women can cause miscarriage and infection of new born

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12
Q

For how long does diarrhoea due to gastroenteritis normally last in children?

A

Usually lasts 5-7 days and stops within 2 weeks

NICE

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13
Q

For how long does vomiting due to gastroenteritis normally last in children?

A

Usually lasts 1-2 days and stops within 3 days

NICE

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14
Q

What factors might make children at greater risk of dehydration?

A
  • child < 1 yr (especially < 6 months)
  • low birth weight
  • children passed 6 or more diarrhoeal stools in past 24 hours
  • children who have vomited 3 times or more in the past 24 hours
  • infants who have stopped breastfeeding during the illness
  • children with signs of malnutrition
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15
Q

What is Hypernatremic dehydration?

A

Define: serum [Na+] > 150 mEq/L - despite the elevated sodium concentration, the child actually has total body sodium deficiency, but the water loss > sodium loss

Extracellular fluid is hypertonic –> H2O moves from intracellular compartment to extracellular –> can cause cerebal shrinkage

  • Causes:
    • insensible fluid loss - high fever, hot environment
      • insensible fluid loss = fluid loss that is not easily measured e.g. from respiration, perspiration or stool
    • low-sodium diarrhoea
  • Less common that isonatremic or hyponatremic dehydration
  • Infants & children with diabetes insipudus can develop hypernatremic dehydration
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16
Q

How does hyponatremic dehydration occur?

A

When a patient is dehydrated (often losing Na+ and H2O in proportional quantities) then drinks lot of water or hypotonic solutions then –> the net loss of sodium is > than water –> hyponatremia

In hyponatremic dehydration H2O moves from the extracellular / intravascular compartment into the intracellular compartment causing:

  • increase in brain volume (oedema) –> convulsions
  • extracellular dehydration
  • shock
17
Q

What features might be suggestive of hypernatemic dehydration?

A
  • jittery movements
  • increased muscle tone
  • hyperreflexia
  • convulsions
  • multiple small cerebral haemorrhages
  • drowsiness or coma
18
Q

When should you do a stool culture in a child with diarrhoea and vomiting?

A
  1. suspect septicaemia or
  2. blood and/or mucus in the stool or
  3. the child is immunocompromised

Also consider doing a stool culture for the following:

  1. the child has recently been abroad or
  2. the diarrhoea has not improved by day 7 or
  3. you are uncertain about the diagnosis of gastroenteritis
19
Q

For children with gastroenteritis but no evidence of dehydration what advice should you give to parents?

A
  • usual duration of diarrhoea = 5-7 days (should stop within 2 weeks)
  • usual duration of vomiting = 1-2 days
  • continue breastfeeding and other milk feeds
  • encourage fluid intake
  • discourage fruit juices and carbonated drinks (these increase risk of dehydration)
  • no school until 48hrs after last episode of diarrhoea / vomiting
20
Q

For children with gastroenteritis and evidence of dehydration but not shock what measures should be taken?

A
  1. 50 ml/kg low osmolarity oral rehydration solution (ORS) solution over 4 hours
    1. plus ORS solution for maintenance, often and in small amounts
  2. continue breastfeeding
  3. consider supplementing with usual fluids (including milk feeds or water, but not fruit juices or carbonated drinks)
21
Q

What does the term safety-netting refer to?

A

Informing parents / patients of key symptoms (red flags) to look out for - appearance of these should cue the parents / patient to seek further medical attention

e.g. stiff neck, rash, photophobia for meningitis

22
Q

What is Oral Rehydration Solution (ORS) and how does it work?

A

Intestines have surface sodium-glucose cotransporters which absorb sodium more effectively in the presence of glucose

ORS are soluable tablets that provide the correct mixture of glucose, electrolytes and salts to aid absorption of sodium and consequently H2O (rehydration)

23
Q

Why are infants more vulnerable to poor nutrition?

A
  • infants have inadequate stores of fat and protein
  • extra nutritional demands for growth
  • frequent illness which causes reduction of oral intake + increased nutritional demand
24
Q

Even though most gastroenteritis cases in young children (e.g. < 2yrs) is due to viral causes, what is the most common bacterial organism which causes gastroenteritis?

A

Campylobacter jejuni

25
Q

What investigations need to be done if IV fluid therapy is required for dehydration?

A

U&Es + Glucose

26
Q

Prior to starting any Abx for diarrhoea and vomiting - what test needs to be done ideally?

A

Blood culture

27
Q

Summarise the investigations that might need to be done for suspected gastroenteritis?

A
  1. Stool culture:
    • suspected septicaemia
    • blood and/or mucus in the stool
    • child is immunocompromised
    • recent travel abroad
    • diarrhoea has not improved by day 7
    • uncertain about the diagnosis of gastroenteritis
  2. Blood culture - if starting Abx
  3. U&Es + Glucose - if dehydrated and starting IV fluids
28
Q

Which fluids are considered isotonic?

For each is it given for resuscitation or mainenance?

A

Isotonic solutions

  1. 0.9% sodium chloride - resuscitation & maintanance
  2. 4.5% albumin - resuscitation
  3. Hartman’s solution - resuscitation
  4. 5% dextrose - maintanance
29
Q

How are maintenance fluid calculated?

A
  • 0 - 10 kg = 100 ml/kg (A)
  • 10 - 20 kg = 50 ml/kg (B)
  • 20 kg and over = 20 ml/kg (C)

Total fluid volume for 24 hrs (A + B + C = D)

Maintenance fluid (ml/hour) = D divided by 24 hours

30
Q

How is ORS to be used for varying degrees of dehydration?

e.g. mild, moderate, ongoing losses (stool)

A
  • Mild dehydration = 50 ml/kg over 4 hours
  • Moderate dehydration = 100 ml/kg over 4 hours
  • Ongoing losses (stool) = 5 - 10 ml/kg

Reduce fluid intake when patient appears clinically hydrated!

Breast / formula feed can continue and should NOT be delayed for more than 24 hrs

31
Q

What Abx are given for treatment of diarrhoea due to Clostridium difficile?

A

metronidazole or vancomycin

32
Q

What Abx are given for treatment of diarrhoea due to Campylobacter difficile?

A

Erythromycin - shortens duration of illness & shedding of bacteria

33
Q

What condition is the following suggestive of?

A previously well 12 year old boy develops abdominal pain on a Friday morning. After going to school he is taken to A+E at lunchtime. His right leg limps as he walks in. Temperature 37.2 degrees C. Abdomen is soft – he is tender in the right iliac fossa with guarding. No loin tenderness. No vomiting. Bowel sounds normal.

A

Acute appendicitis

Leg limping + progression of abdo pain from central to right iliac fossa

34
Q

Which organism is known for causing Haemolytic uraemic syndrome (HUS)?

A

E. Coli

35
Q

Which anti-diarrhoeal medications are used in the management of gastroenteritis in children?

A

NONE!

36
Q

Are Abx often used to treat bacterial gastroenteritis?

A

No!

  • Abx are rarely used to treat any form of gastroenteritis
  • They are only indicated in suspected or confirmed sepsis and specific bacteria / protozoa e.g. C.dif, cholera, shigellosis and giardiasis
37
Q

What is Toddler’s Diarrhoea?

A

Toddler’s diarrhoea or chronic non-specific diarrhoea is the commonest cause of chronic loose stool in preschool children

Features:

  • stool of varying consistency e.g. sometimes well formed, sometimes loose
  • undigested vegetables in stool is common ‘peas and carrots diarrhoea’
  • children are well + thriving
  • normally grown out of by 5 yrs old

Cause:

  • underlying maturational delay in intestinal motility

Management:

  • Ensure diet contains fat (slows gut transit) + fibre
  • Avoid excessive fruit juice consumption (can exacerbate symptoms)
38
Q

How is Fluid Replacement calculated?

A

Replacement fluid volume (ml) = dehydration (%) x weight (kg) x 10

  • Dehydration is assessed using clinical acumen / experience
39
Q

How are drugs which are dissolved by the Liver different

when prescribing them in children?

A

Drugs metabolised by the Liver or that are water-soluable require higher doses in children per kg as their liver & water make up a larger % of their weight

Year 4 - Paediatrics (16 decks)

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