Gastro - Enteritis (NICE)

Question 1

At which age dies toddler’s diarrhoea (chronic nonspecific diarrhoea of childhood) usually present

Answer 1

6 months to 5 years old

Question 2

What are the symptoms of toddler’s diarrhoea?

Answer 2

5-10, large watery stools per day.
Diarrhoea for weeks, followed by normal weeks.
Stool with undigested food particles.
varying consistency of poo

No precipitating dietary factor (although excessive fruit juice can exacerbate and fat and fibre can improve it)

Growth and development normal. No red flags.
It is not a serious condition and reassurance should be offered.

Question 3

What is mesenteric adenitis?

Answer 3

Inflammation of lymph nodes around intestines. Most often from infection.
Sometimes malignancy.
Abdo pain

Question 4

What are the differentials of mesenteric lymphadenopathy

Answer 4

Infection (mostly viral, eg gastroenteritis )

Malignancy (lymphoma > carcinoma of breast > lung > pancreas)

Local inflammation (appendicitis, diverticulitis, pancreatitis, cholecystitis)

Systemic inflammation (Crohn’s, SLE, RA)

Question 5

Features of clinical dehydration in gastroenteritis (not shock, yet)

Answer 5

Appears unwell, lethargic, irritable (#REDFLAG)
Sunken Eyes (#REDFLAG)
Tachycardia (#REDFLAG)
Tachypnoea (#REDFLAG)

decreased urine output

Question 6

Risk factors for dehydration?

Answer 6

<1 year
Low birth weight
>5 diarrhoeal stools in 24h
>2 vomits in 24h

Stopped breastfeeding during illness or signs of malnutrition

Question 7

What are the signs of shock due to dehydration?

Answer 7

Decreased level of consciousness
Pale, mottled skin
Cold extremities
Tachycardia
Tachypnoea
Weak peripheral pulses and prolonged cap refill (bad)

Hypotension (sign of decompensation)

Question 8

Which signs are suggestive of hypernatraemic dehydration?

Answer 8

Jittery movements
Increased muscle tone
Hyperreflexia
Convulsions
Drowsiness or coma

Question 9

What are the main aspects of management of gastroenteritis in <5 year olds?

Answer 9

Fluid management
Nutritional management
Antibiotic therapy (possible)

Question 10

What advice is given if there is no clinical dehydration?

Answer 10

Continue breastfeeding

Encourage fluid intake, but not carbonated drinks and juices

Question 11

How is dehydration managed?

Answer 11

Oral Rehydration Therapy (low osmolarity 240mOsm/L)

50ml/kg for fluid deficit replacement over 4 hours - give frequently

Consider NG tube if vomiting/unable to drink

Monitor response with clinical assessment

Continue breastfeeding

Question 12

When is IV fluid therapy indicated?

Answer 12

Suspected shock
Red flag symptoms or deterioration despite ORT
Persistent vomiting despite NGT

Question 13

What bolus of iv fluid is given in shock? What if it fails?

Answer 13

20ml/kg of 0.9% sodium chloride

If fails, immediately give another 20ml/kg and consider other causes of shock

Question 14

What nutritional support is given during rehydration therapy?

Answer 14

Continue breastfeeding and no solid foods

If REDFLAG symptoms, do not give oral fluids other than ORT

Question 15

What nutritional support is given after rehydration therapy?

Answer 15

Full-strength milk straight away or reintroduce previous solid foods
Drink plenty of fluids
No juices/carbonated drinks until diarrhoea stopped

Question 16

What is the NICE guideline on antibiotics in gastroenteritis?

Answer 16

Not routinely given.
If suspected sepsis, extra-intestinal bacterial spread,
OR
Salmonella and <6months or immunocompromised or malnourished
C. difficile associated pseudomembranous enterolcolitis, giardiasis,dysenteric shigellosis, amoebiasis, cholera

Question 17

Commonest cause of gastroenteritis in the UK

Answer 17

rotavirus

Question 18

Diagnostic indications of gastroenteritis

Answer 18

> 38°C (<3 months)
39°C (>3 months)

SOB
Tachypnoea
Altered state of consciousness
Neck stiffness
Bulging fontanelle

Non-blanching rash
Blood/mucus in stool
Bilious vomit
Severe abdo pain
Distension and rebound tenderness

Question 19

How is fluid deficit replaced?

Answer 19

100ml/kg (if 10% body weight is lost - eg. shock)

50ml/kg if not shocked (5% body weight)

0.9% sodium chloride with or without 5% glucose

MONITOR electrolytes, urea, creatinine, glucose

Question 20

Symptoms of cow’s milk protein intolerance

Answer 20

Symptoms depend on site of allergic inflammation

Vomiting, feeding adversion, pain (upper GI)

Diarrhoea, abdo pain, protein losing enteropathy, FTT (small intestine)

Diarrhoea, acute colitis with blood and mucusin stools and rarely chronic constipation (large intestine)

Question 21

Treatment of cow’s milk protein intolerance

Answer 21

Limit intake:
hydrolysed formula or if still symptomatic:

elemental formula

AVOID: goat or sheep’s milk - 25% chance of cross-reactivity leading to allergy

Same with Soy milk UNDER <6 months