Diarrhoea + Vomiting Flashcards
What questions do you want to ask in a history of d+v?
- Duration, frequency/number, volume and colour of vomitus/stools
- Current oral intake and usual feeding pattern
- Passage of urine - number of wet nappies, if nappies are as heavy as before and how long ago did the child have a wet nappy
- Hx of fever and other red flag symptoms
- Recent contact with someone with d+v, ingestion of contaminated food or water and recent travel abroad
What are the physical features of dehydration in an infant?
- Sunken anterior fontanelle (usually closes at 18-24 months)
- Decreased consciousness
- Eyes sunken and tearless
- Dry mucous membranes
- Tachycardia (+ hypotension) - peripheral vasoconstriction
- Tachypnoea
- Decreased CRT and skin turgor
- Sudden weight loss
- Oliguria
What are common causes of gastroenteritis in young children?
- Rotavirus: most common, most children in the UK have this by age 5 and develop immunity. More common in infants and young children, than in teenagers
- Adenovirus: more common in infants and young children than in teenagers
What are the causes of blood in stool with d+v?
- Intussusception: invagination of proximal bowl into distal segment commonly involving invagination of ileum into caecum through the ileocecal valve
- Rotavirus: presenting symptoms are fever, vomiting and diarrhoea with/without blood in stool
- E.coli: associated with diarrhoea with blood in stool and haemolytic uraemic syndrome. Occurs in clusters after ingestion of contaminated food.
- Campylobacter
- Shigella
What is the presentation of intussusception?
- Peak presentation between 3 months to 2 years of age with history of paroxysmal, severe colicky pain when the child draws his/her legs up, pallor during episodes of pain followed by recovery from the painful episodes and lethargy
- The child may refuse to feed, have vomiting and pass characteristic red currant jelly stool containing blood and mucus (late sign due to mucosal breakdown)
What are red flag features associated with vomiting?
- Blood
- Bile in vomitus
- Projectile vomiting
- Abdominal tenderness/distension
- Blood in stool
- Bulging fontanelle
What does vomiting indicate in infancy and childhood?
- Vomiting is a common symptom in infancy and childhood. It is usually benign and is caused by feeding issues, gastroesophageal reflux and gastroenteritis.
- Vomiting can be a symptom of potentially serious underlying problem in infants and young children if persistent or associated with fever when it may be associated with infections such as UTI or meningitis.
- Proximal intestinal obstruction can cause bilious vomiting with abdominal distension.
What can cause:
- bile stained vomit
- projectile vomiting >2 months
- vomiting with paroxysmal cough
- bulging fontanelle/fits
- Bile stained vomit: intestinal obstruction
- Projectile vomiting >2 months: pyloric stenosis
- Vomiting with paroxysmal cough: whooping cough
- Bulging fontanelle/fits: increased ICP due to meningitis/hydrocephalus
What causes haematemesis?
- Oesophagitis
- Gastric ulcer
- Oral or nasal bleeding and vomiting up swallowed blood
What causes abdominal distension/tenderness?
- Intestinal obstruction
- Strangulated inguinal hernia
- Surgical abdomen
What causes blood in the stool?
- Gastroenteritis - salmonella or campylobacter
- Intussusception
What causes severe dehydration and shock?
- Severe gastroenteritis
- Systemic infection - UTI
- Meningitis
- DKA
What causes faltering growth?
- GORD
- Coeliac disease
- Chronic GI conditions
How is the clinical diagnosis of gastroenteritis made?
It is based on a sudden change in stool consistency to loose or watery stools +/or sudden onset of vomiting.
What do urine dipstick results mean?
- If leucocyte esterase and nitrite are negative - diagnosis of UTI unlikely
- If leucocyte esterase and nitrites positive - suggests UTI
- Negative leucocyte esterase and positive nitrites - preliminary diagnosis of UTI can be made, can start abx treatment whilst awaiting urine culture result
- Trace of blood and protein can present in child with intercurrent illness
- Positive ketones - indicates starvation
- Raised glucose and ketones - DKA
- Increased blood and protein - nephritis
What are the common food poisoning organisms?
- Campylobacter are the most common cause of food poisoning in the UK and are found in raw or undercooked meat, particularly poultry
- Salmonella are often present in raw or undercooked meat, raw eggs, milk etc
- Listeria may be found in chilled ready to eat foods - pre-packed sandwiches, cooked sliced meats pate and brie cheese etc - listeria infection in pregnant women can cause miscarriage and infection of newborn
How is food poisoning spread?
Contamination can occur through touching infected animals, their faeces, or coming into contact with people who have the illness - especially if correct handwashing practices are not followed after using the toilet or before handling food. Suspected food poisoning is a notifiable condition and it is statutory duty of registered medical practitioners to notify PHE of any suspected infectious diseases.
How do you manage mildly dehydrated children?
- Fluid challenge with oral rehydration solution (ORS) - frequently and in small amounts
- Consider giving 5ml/kg of ORS after each large watery stool in children who are at increased risk of dehydration - low birth weight, age <1yr, had >2 vomiting episodes and >5 diarrhoea episodes in previous 24hrs
- Continue breastfeeding or other milk feeds. Discourage use of fruit juices and carbonated drinks which increase the risk of dehydration
- Consider giving ORS via NG tube if unable to drink or persistent vomiting. Monitor rehydration: oral intake, passage of urine, no. and volume of vomits and loose stools, signs of dehydration
