Diarrhoea in Children

Question 1

Is it normal for children who are breast fed to have watery poo?

Answer 1

Yes

However, Diarrhoea and vomiting may be an early sign of sepsis.

Question 2

If a child has gastroenteritis how long does vomiting and diarrhoea normally last?

Answer 2

Diarrhoea normally lasts 5-7days and stops within 2 weeks

Vomiting usually lasts 1-2 days and stops within 3 days

Question 3

What are the common causes of gastroenteritis in children?

Answer 3

Rotavirus is most common in children (part of vaccination schedule)
Norovirus (mostly adults)
Astrovirus and adenovirus
Cow’s Milk intolerance

Question 4

How should a child with suspected gastroenteritis be investigated?

Answer 4

Stool culture – look at consistency and look for blood and parasites
FBC
Us and Es

Question 5

How should gastroenteritis be managed?

Answer 5

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

Question 6

How do you assess the fluid needs of a child?

Answer 6

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

Question 7

How can you distinguish between early shock and late shock in a young child?

Answer 7

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

Question 8

What complications can occur from gastroenteritis?

Answer 8

Electrolyte imbalance
Dehydration
Malnutrition
Transient lactose intolerance

Question 9

What are the clinical signs of dehyrdation?

Answer 9

Reduced urine output, sunken eyes, sunken fontanelles, dry mucous membranes, reduced skin turgor, increased CAP refill, tachycardia/tachypnoea, weight loss and appears unwell.

Question 10

What is coeliac disease?

Answer 10

Example of malabsorption caused by an autoimmune condition with sensitivity to gluten. Repeated exposure to gluten leads to villus atrophy and malabsorption.

Question 11

What are the risk factors for coeliac disease?

Answer 11

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

Question 12

How does coeliac disease usually present?

Answer 12

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.

Question 13

How is coeliac disease diagnosed?

Answer 13

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

Question 14

How should coeliac disease and a coeliac crisis be managed?

Answer 14

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

Question 15

What complications can occur form coeliac disease that we should be aware of?

Answer 15

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

Question 16

If a child is in shock due to dehydration how should this be managed?

Answer 16

If in clinical shock, then 20ml/kg bolus of 0.9% normal saline
If no improvement, then repeat
If still no improvement contact CICU

Question 17

How does Crohn’s disease present?

Answer 17

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

Question 18

What conditions is Crohn’s disease associated with?

Answer 18

Gallstones are more common
Arthritis 
Increased risk of bowel caner 
Osteoporosis
Erythema nodosum and pyoderma gangrenosum

Question 19

How should Crohn’s disease be investigated?

Answer 19

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

Question 20

How is Crohn’s disease managed?

Answer 20

Management
Stop smoking

Inducing Remission

1. Glucocorticoids to induce remission
2. 5-ASA drugs such as mesalazine are second line to nduce remission
3. Azathioprine/Methotrexate can be used as an add-on to induce remission but not alone
4. Infliximab used in refractory disease and fistulating Crohn’s along side azathioprine or methotrexate
5. Metronidazole for isolated peri-anal disease

Maintaining remission

1. Azathioprine or mercaptopurine
2. Methotrexate
3. 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.

Question 21

How does Ulcerative colitis present?

Answer 21

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

Question 22

How do you classify UC flares?

Answer 22

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

Question 23

What conditions is UC associated with?

Answer 23

Primary sclerosing cholangitis more common
Increased risk of colorectal cancer compared to CD
Erythema nodosum and pyoderma gangrenosum
Arthritis

Question 24

How is UC investigated?

Answer 24

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

Question 25

How is UC managed?

Answer 25

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