Diarrhoea Flashcards
Cause of bile stained vomit
Intestinal obstruction until excluded by a barium swallow and follow through.
Cause of intermittent vomiting immediately after feeds in n infant who is growing well
Likely due to uncomplicated gastro-oesophageal reflux.
Resolves spontaneously by about 6m old.
Response poorly to medication
Mx with simple measures
Common causes of dehydration in children
Gastroenteritis
Poor oral intake
Polyuria - DM
Fluid loss due to burns.
Common causes of bloody diarrhoea
Salmonella
Shigella
Campylobacter
Serious causes of dehydration
Intussusception
Hypernatraemia dehydration
Pyloric stenosis
Diabetic ketoacidosis
Symptoms and signs of mild dehydration
Symptoms - thirsty, restless
Signs - None or slightly dry buccal mucosa
5% - 50ml/kg deficit
Symptoms and signs of moderate dehydration
Symptoms - lethargic, irritable
Signs - Dry buccal mucosa, absent tears, Sunken eyes and fontanelle, decreased urine output, altered skin elasticity, signs kerosis (rapid shallow breathing, smell of ketones)
Symptoms and signs of severe dehydration
Symptoms - limp, drowsy
Signs - Drowsiness, shock (tachycardia,poor volume peripheral pulses, cool peripheries), Hypotension is late/ominous signs, Skin retraction time greater then 2 sec, capillary refill time greater then 3 secs.
10-15% deficit - 100ml/kg
Rule of 3s of survival
3 mins of breathing
30s no cardiac output
3 days no water
3 weeks no food
Causes of acute diarrhoea and dehydration
Excessive fluid loss
- excessive sweating - High fever, hot climate, CF
- Vomiting - Pyloric stenosis, viral infections, gastroenteritis
- Acute diarrhoea - viral gastroenteritis, bacterial gastroentroenteritis (Shigella, E.coli, Salmonella, campylobacter), antibiotic induced, food poisoning eg toxins, any acute infection.
- Fluid loss - burns, post surgery
- Polyuria - DM, especially Diabetic ketoacidosis
Inadequate intake
- Inability to drink - Herpes stomatitis, acute tonsillitis
- Inadequate access to water - red flag.
Hx Q to ask for acute diarrhoea and dehydration
Diarrhoea or vomiting? Projectile? How many loose stools Less urine then normal? How many wet nappies How often and how long is there vomiting FmHx of CF or diabetes.
Ex on a child with diarrhoea and dehydration
Weight over time
Pyloric mass during test feed.
Assess dehydration
Ix for diarrhoea and dehydration
Only if moderate to severe diarrhoea or very ill child
U and E - electrolyte imbalance and renal function
Blood gases - metabolic acidosis or alkalosis
Urinalysis - for osmolatity or specific gravity
Blood sugar - to exclude DKA
Stool culture - if gastroenteritis, and food poisoning.
Tx for acute diarrhoea and dehydration
Use oral rehydration
Tx shock with blouses of IV fluids
Rehydrate slowly to replace fluid loss over at least 24hr
Correct any electrolyte imbalance.
What is the commonest cause of dehydration
Vomiting and diarrhoea due to gastroenteritis
Rotavirus
Winter epidemics Diarrhoea follow 1-2days after low-grade fever, vomiting and anorexia May have acute abdo pain and malaise Self limiting in a week Mx is adequate hydration
Bacterial gastroenteritis
Same as rotavirus but with blood.
Common pathogens - E.coli, shigella, salmonella, campylobacter
Causes of chronic diarrhoea
Non pathological - Toddler diarrhoea, Non specific diarrhoea
Infection - parasites
Inflammation - Crohn’s disease, cow’s milk protein intolerance, Ulcerative colitis
Malabsorption - CF, Coeliac disease, secondary lactose intolerance
Other - Overflow diarrhoea in constipation
Toddler diarrhoea
Probably due to a rapid gastro colic reflex.
Symptoms - drinking excessive fluids, particularly fruit juices and food particles in stool.
Dx is only made if the child is thriving
Mx - reassurance.
Non-specific diarrhoea
Loose watery stools
Thriving child may follow on from acute gastroenteritis
Parasites causing diarrhoea
Giardia lamblia
Weight loss and abdo pain or symptomatic
Watery stools
Common in nurseries
Dx on microscopic examination of the stool.
Need 3 separate specimens as excreted cysts can be irregular
FBC may show eosinophilia
Tx metronidazole
IBD Presentation
Symptoms : alternating diarrhoea and constipation +/- bleeding +/- mucus. Urgency and tenesmus. Abdominal pain, Crampy. +- fever.
Interval of symptomatic periods and asymptomatic periods. Wt loss, Anorexia, Lethargy
Signs
GI
aphthous oral ulcers
Tender abdominal: Distension UC>CD, RIF mass CD, Perianal disease CD - abscess, sinus, fistula, skin tags, fissure and stricture
Non GI signs and association: Fever, finger clubbing, Anaemia
Skin :erythema nodosum, Pyoderma gangrenous
Joints: arthritis - migratory, Ankylosing spondylitis, Sacrolitis
eyes: Iritis, Conjunctivitis, Episcleritis
poor growth
delayed puberty
Sclerosing cholangitis
Renal stones
Nutritional deficiencies e.g. Vit B12
Cx of IBD
Toxic colon dilation UC>CD GI perforation or strictures Pseudopolyps Massive GI haemorrhage Colon carcinoma UC Fistula bowel only, bowel to skin, vigina, bladder CD abscesses CD Fuminant Colitis - Medical emergency
Cow’s milk protein intolerance
Occurs in babies
Rare and often over-diagnosed, rarer in BF baby
Watery stools may be bloody
may have urticaria, strider or bronchospasm, eczema and rarely anaphylaxis
Dx clinical and symptoms should subside within a week of withdrawing cow’s milk.
Mx - hydrolysed protein formula milk should be used
Prognosis - most resolved in 1-2 years.
Cystic fibrosis
Starts in infancy
Failure to thrive with chest infections
Fatty stools
Diagnosis by sweat test.
Coeliac disease
Red flag
Common 1 in 100
Associated with diabetes and Down’s syndrome.
Intolerance of gluten - in wheat, rye and barley
Present before 2yrs of age
Failure to thrive with irritability, anorexia, vomiting and diarrhoea
Muscle wasting, abdominal distension
Often presents after introduction of wheat into diet
Fatty stools
Signs - abdominal distension, wasted buttocks, irritability and pallor
Dx by jejunal biopsy - subtotal villus atrophy
Ix - show iron deficiency anaemia and steatorrhoea, Coeliac antibodies (IgA anti-tissue transglutaminase or anti-endomysial ab) in blood.
Mx - gluten free diet, Rechallange gluten in 2 yrs and repeat biopsy.
Secondary lactose intolerance
Baby or toddler
Follows acute gastroenteritis
Watery stools with low pH and reducing substances
Overflow diarrhoea in constipation
Soiling rather than diarrhoea
Constipated stool palpable abdominally or rectally
Hx Q for chronic diarrhoea
Bowel patterns - volume, appearance and consistency of stools, blood or mucus.
Precipitating factors eg lactose intolerance is precipitated by acute diarrhoea. Association with certain foods.
Sick contacts
Associated symptoms - wt loss or abdo pain,
Review of symptoms - non GI disease may cause diarrhoea and failur to thrive.
Ex in chronic diarrhoea
Growth -
Other features - hydration, pallor, abdominal distension, tenderness and finger clubbing are particularly relevant
General examination - Ill?
Ix for Chronic diarrhoea
FBC - anaemia indicates blood loss, malabsorption, poor diet or inflammation
Plasma viscosity/ESR - high in inflammatory bowel disease
Coeliac antibodies
Urine culture - UTI
Sweat test - CF
Breath hydrogen test - high H2 in carbohydrate maldigestion
Jejunal biopsy - villainous atrophy with crypt hyperplasia in coeliac disease
Barium follow through - characteristics signs in small bowel Crohn’s disease
Endoscopy - characteristic lesions on histology n Inflammatory bowel disease
Stool - occult blood (IBD), Ova and parasites (3), Reducing substances and low pH (lactose intolerance), Fecal elastase (pancreatic insufficiency), Microscopy for fat globules , Fecal calprotectin (IBD)
Haemolytic uraemia syndrome
Presents as a triad - micro angiostatin haemolytic anaemic, thrombocytopenia, acute renal failure
2 types - atypical/sporadic and epidemic form
Epidemic form - diarrhoea, commonly associated with very cytotoxic producing E.coli
Transmitted by eating improperly cooked beef, raw milk, faeces oral, contaminated water, farm animals
Causes acute renal failure, gut - bloody diarrhoea, rectal prolapse, haemorrhaging colitis, bowel wall necrosis and perforation, DM, pancreatitis, Jaundice, encephalopathy, Cardiac myocarditis
Ix - FBC, Blood cultures, U and E , LFTs, E.Coli PCR
Tx - Consult nephrology, early dialysis, supportive care - Montior electrolyte and fluid balance, Nutrition, blood transfusion, Treat hypertension.
Mx of Crohn’s and UC
Supportive
If severe Bowel rest, IV hydration and PN
Pharmacology
Mild to moderate disease
Oral 5 aminosalicylic acid dimers e.g. Mesalazine. Reduces and maintain remission in UC
Moderate to severe disease
Oral prednisolone or IV until improve and until wean off over 6 to 8 weeks
Antibiotics eg ciprofloxacin or metronidazole
Dietary tx
Polymeric or elemental diets to induce remission but relapse rate is high. better in CD.
Dietary suppleentation to maintain growth.
Refer to Dietitian
Surgery
UC: total colectomy and ileostomy and pouch creation and anal anastomosis cures UC
CD: Local surgical resection for severe disease e.g. strictures, fistula.
Ix IBD
Bloods
FBC
ESR/CRP ^
U&E
LFT - albumin reduced
BC
Serum iron Reduce
Vitamin B12 and Folate reduced
Serum serological markers
ASCA (antisaccharomyces cerevisiae antibody) better for CD
p-ANCA(perinuclear antineutrophil cytoplasmic Ab) Better for UC
Stool MCS
Endoscopy - Colonoscopy and biopsy
Histology - UC: crypt abscesses, mucosal inflammation only and goblet depletion.
CD:cryt abscesses granulomas, transmural inflammation
upper GI scope
Barium radiology/USS
CD: Mucosal cobblestone appearance, ulceration, dilatation, narrowed segments, fistula, skip lesions
UC: Mucosal ulceration, haustration loss, colonic narrowing +/- shortening.
Short bowel syndrome
Malabsorption, fluid and electrolyte loss and malnutrition
Presentation
Diarrhoea
Steatorrhoea
FTT
Dehydration, electrolyte loss - Na, K, Mg, Ca
Cholestasis - bile salt loss
Peptic ulcer disease - due to increase gastrin
Specific eg vit B12 and generalised malnutrition disorders
Renal stones
Treatment
Correct fluid and electrolyte disturbance
Supplements: or PTN
PPI
Anti diarrhoea drugs
Cholestyramine (bile salts)
Parenteral somatostatin
ABX
Surgery
