Diarrhoea in Children Flashcards
Is it normal for children who are breast fed to have watery poo?
Yes
However, Diarrhoea and vomiting may be an early sign of sepsis.
If a child has gastroenteritis how long does vomiting and diarrhoea normally last?
Diarrhoea normally lasts 5-7days and stops within 2 weeks
Vomiting usually lasts 1-2 days and stops within 3 days
What are the common causes of gastroenteritis in children?
Rotavirus is most common in children (part of vaccination schedule)
Norovirus (mostly adults)
Astrovirus and adenovirus
Cow’s Milk intolerance
How should a child with suspected gastroenteritis be investigated?
Stool culture – look at consistency and look for blood and parasites
FBC
Us and Es
How should gastroenteritis be managed?
Regular weighing to assess fluid intake
Assess fluid status
If dehydrated start ORT then Dioralyte – 50ml per kg over 4 hours + maintenance and re-hydration plus continue breastfeeding
If refusal of ORT then offer other fluids and if refuses this then NG tube fed
IV feed reserved for severe cases or those in shock
Reintroduce milk within 4 hours of starting ORT
Ondansetron or other antiemetic
Discourage anti-diarrhoea medication and fruit juices
How do you assess the fluid needs of a child?
Calculating Fluids needs Maintenance First 10kg = 100ml/kg Second 10kg = 50ml/kg Anything else = 20ml/kg
Rehydration calculations % x weight x 10 Given over: 24hours in hypo/isonatraemic state 48 hours in hypernatraemic state (but remember to give 2 days’ worth of maintenance
How can you distinguish between early shock and late shock in a young child?
Hypotension is a late sign of shock. In early, compensated shock the blood pressure is maintained by increased heart rate and respiratory rate, redistribution of blood from venous reserve volume and diversion of blood flow from non-essential tissues (which explains why the peripheries will be cold and pale). In late or uncompensated shock, the compensatory mechanism fails, blood pressure falls and lactic acidosis increases.
Early shock normal BP tachycardia tachypnoea pale or mottled extremities reduced urine output
Late shock hypotension bradycardia acidotic (Kussmaul) breathing blue skin absent urine output
What complications can occur from gastroenteritis?
Electrolyte imbalance
Dehydration
Malnutrition
Transient lactose intolerance
What are the clinical signs of dehyrdation?
Reduced urine output, sunken eyes, sunken fontanelles, dry mucous membranes, reduced skin turgor, increased CAP refill, tachycardia/tachypnoea, weight loss and appears unwell.
What is coeliac disease?
Example of malabsorption caused by an autoimmune condition with sensitivity to gluten. Repeated exposure to gluten leads to villus atrophy and malabsorption.
What are the risk factors for coeliac disease?
Other autoimmune disease such as thyroid disease, T1DM, first degree relative with coeliac Dermatitis herpetiformis (itchy burning blisters on elbows, scalp, shoulders and ankles) Usually presents prior to 3 years
How does coeliac disease usually present?
Chronic or intermittent diarrhoea
Failure to thrive or faltering growth
Persistent or unexplained GI symptoms
Prolonged fatigue
Recurrent abdominal pain cramping or distention
Unexplained iron deficiency anaemia
Dermatitis hyerpetiformis - itchy burning blisters on elbows, scalp, shoulders and ankles.
How is coeliac disease diagnosed?
Immunoglobulin A-tissue transglutaminase or anti-endomysial (NICE) and anti-gliadin (not recommended by NICE) antibodies
Duodenal or Jejunal biopsy showing subtotal villous atrophy, crypt hyperplasia and infiltration of lymphocytes
Note prior to testing patients need to be eating gluten for 6 weeks
Other investigations
FBC and blood smear
How should coeliac disease and a coeliac crisis be managed?
Gluten free diet
Check compliance by testing for antibodies
Pneumococcal vaccine due to Hyposplenism and influenza if patient requests
Calcium and vit D supplementation
Coeliac Crisis
Rehydration and correction of electrolyte balance
Steroids if needed
What complications can occur form coeliac disease that we should be aware of?
Malabsorption and malnutrition
Anaemia from iron, folate (more common than B12) and B12
Hyposplenism
Osteoporosis and Osteomalacia
Lactose intolerance
Enteropathy-associated T-cell lymphoma of small intestine
Subfertility
If a child is in shock due to dehydration how should this be managed?
If in clinical shock, then 20ml/kg bolus of 0.9% normal saline
If no improvement, then repeat
If still no improvement contact CICU
How does Crohn’s disease present?
Diarrhoea and abdominal pain (less likely to be bloody than UC)
Weight loss
Mouth ulcers
Perianal disease
Abdominal mass
Bowel obstruction and fistulas
Lesions anywhere from mouth to anus with skip lesions
What conditions is Crohn’s disease associated with?
Gallstones are more common Arthritis Increased risk of bowel caner Osteoporosis Erythema nodosum and pyoderma gangrenosum
How should Crohn’s disease be investigated?
Endoscopy (colonoscopy) showing deep ulcers, skip lesions and cobble stone appearance
Histology – inflammation in all layers
Abdominal x-ray with small bowel enema showing strictures (Kantor’s string sign) and rose thorn ulcers
Raised CRP/ESR, faecal calprotectin
FBC for anaemia or low vitamin B12
Low vitamin D levels
How is Crohn’s disease managed?
Management
Stop smoking
Inducing Remission
- Glucocorticoids to induce remission
- 5-ASA drugs such as mesalazine are second line to nduce remission
- Azathioprine/Methotrexate can be used as an add-on to induce remission but not alone
- Infliximab used in refractory disease and fistulating Crohn’s along side azathioprine or methotrexate
- Metronidazole for isolated peri-anal disease
Maintaining remission
- Azathioprine or mercaptopurine
- Methotrexate
- 5-ASA drugs such as mesalazine if previous surgery
Surgery
Majority of patient will eventually require surgery, usually Ileocaecal resection. Colonic resection is usually not indicated as recurrence rate is high.
How does Ulcerative colitis present?
Presentation
Bloody diarrhoea
Abdominal pain in left lower quadrant
Urgency and tenesmus
Inflammation always at rectum. Is continuous and never spread beyond Ileocaecal valve
Inflammation does not spread beyond submucosa
How do you classify UC flares?
Mild - <4 stools daily with/without blood, no systemic disturbance and normal inflammatory markers
Moderate – 4-6 stools a days with minimal systemic disturbance
Severe - >6 stools a day containing blood and systemic disturbance – fever, tachycardia, abdominal pain, distention, reduced bowel sounds, anaemia and hypoalbuminemia
What conditions is UC associated with?
Primary sclerosing cholangitis more common
Increased risk of colorectal cancer compared to CD
Erythema nodosum and pyoderma gangrenosum
Arthritis
How is UC investigated?
Endoscopy – widespread ulceration with preservation of adjacent mucosa and pseudopolyps appearance
Biopsy – superficial involvement only
Abdominal X-ray with barium enema showing loss of haustra, superficial ulceration (pseudopolyps) and drainpipe colon as disease is long standing
How is UC managed?
Management
Inducing Remission
Mild-moderate disease
• Proctitis – topical aminosalicylate or rectal meslazine. If remission not achieved within 4 weeks, then add oral aminosalicylate. If remission still not achieved, then topical or oral steroid.
• Proctosigmoiditis and left sided UC – topical aminosalicylate. If remission not achieved by 4 weeks add high dose oral aminosalicylate +/- topical corticosteroid. If remission still not achieved stop topical and add oral aminosalicylate and oral corticosteroid.
• Extensive disease – topical aminosalicylate and high dose oral aminosalicylate. If remission not achieved within 4 weeks stop topical and add oral corticosteroid.
Severe colitis
• Treat in hospital with IV steroids or IV ciclosporin if steroids contraindicated
• If no improvement after 72 hours consider adding IV ciclosporin or surgery.
Maintaining remission
Mild-moderate flare
• Proctitis and proctosigmoiditis – topical aminosalicylate OR oral aminosalicylate plus topical OR oral aminosalicylate alone
• Left sided and extensive UC – low maintenance dose oral aminosalicylate
Severe or >2 exacerbation in past year
• Oral azathioprine or oral mercaptopurine
Methotrexate NOT RECOMMENDED