Gastroenteritis Flashcards
Most common cause of acute diarrhea
Viral gastroenteritis
Vomiting is feature in which GE
Viral
Toxin mediated
Viral causes (4)
Rotavirua
Norovirus
Enteric adenovirus
Astrovirus
Symptoms suggestive of norovirus
Prominent vomiting, cramping, abdominal pain.
What increases liklihood of bacterial
Systemic- fever
What should be investigation for if recent antibiotic use/hospitalisation
C difficile
If used, what is the role of antibiotics
Reduce time and severity
Prevent extra-intestinal complications
Reduce spread
Characteristics of toxin mediated
Abrupt onset
Closely clustered contacts
NV, abdominal pain prominent symptoms
Diarrhea occur late if present
Antibiotics most commonly used in bacterial (if used)
Azithromycin
Ciprofloxacin
Doxycyclin for cholera
Definition
Inflammation (infectious) of stomach and small intestine leading to NVD
Bacterial causes food borne illness
Bacillus cereus Campylobacter jejuni E. coli Salmonella Shigella Yersinia enterocolitica
Risk factors
Young Day care Exposure to sick contacts Travelling Immunocompromised Sick contact Antibiotic use
History
NVD, abdominal pain, volume depletion, fever
Hx of travel, contact with contaminated food, consumption of unprocessed meat/milk/cheese
Contact with infected person
Hydration status examination
General: stable, breathless, fever, evidence of infection
Input/output: IV fluids, catheter, NG tube, bowels
Chart: obs, fluid balance, drug chart
Hands: Temp, pulse volume and rate, collapsing, BP sitting and standing
HN: sunken eyes, dry mucous membrane, depressed/elevated JVP,
carotid pulse/volume
Chest: cap refill, skin turgor, apex beat, 3rd heart sound in overload + pulmonary edema.
Abdomen: ascites
Legs: peripheral edema
To complete my examination i would take further history, look at UEC, obs and fluid balance chart.
Serial weights, catheterise, UEC, ABG, serum lactate
Investigations
Generally not required in young children Stool culture X3 for MCS and C diff toxins, Campylobacter, Salmonella, Shigella FBC- +WCC Renal function- +U:Cr, hypokalemia Glucose, ABG, lactate
Management
Rehydration
Nutrition
Important differentials for VD in children
Appendicitis UTI Sepsis Intusussception, enterocolitis, malrotation, Hirschsprung HUS
Presentation in children
Poor feeding Vomiting Fever Diarrhea Watery and frequent stools
Best indication of fluid depletion in children
Recent change in body weight
Signs to discriminate dehydration and hydration
-ve skin turgor
-ve peripheral perfusion
deep acidotic breathing
Mild dehydration classifcation, signs and management
Moderate dehydration classifcation and signs
5-9%
Same as mild + rapid pulse, -ve peripheral perfusion, sunken eyes and fontanelle, deep acidotic breathing, slow skin retraction
Management of moderate dehydration in children
Rehydration ?NGT
Reassess at 6 hours
If fluid replete, maintenance fluids then used
Weigh every 6 hours for first 24 hours of admission
Introduce food after hydration
Severe dehydration classification and signs
> 9% weight loss
All same signs +
in infants->drowsy, limp, cold, sweaty cyanosed, altered MS
In children->apprehension, cold, sweaty, cyanosed, feeble resp effort, hypotensive
Management of severe dehydrationq
Get senior medical help Shocked->20ml/kg IV NS IV/IO access Measure UEC, glucose, VBG May require NGTR If NGTR not successful IV fluids Treat hypoglycemia w/ 5ml/kg 10% dextrose Septic workup ORS start after initial resus->frequent small amounts 10-20ml/kg over 1 hour Give over 6 hours Admit Re-evaluate Ongoing fluids: 5% dextrose + NS, 20mmol/L if K
What mechanism used in ORS
Glucose facilitated sodium transport in small intestine
Current ORS available
Gastrolyte Na 60 K 20 Cl 60 Citrate 10 Glucose 90
Replayte
Hydralyte
Suitable fluids for non dehydrated
Sugar water (1 teaspoon in 200ml)
Fruit juice 1 in 6 with water
Cordial 1 in 16
Lemonade 1 in 6
Why is early refeeding following rehydration important
Enhances mucosal recovery
Reduces duration of diarrhea
What can children have after rehydration
Complex carbohydrates, yoghurt, fruits, vegetables
One possibility if persistent diarrhea following recommencement of feeding
Transient lactose intolerance
Indication for admission to hospital
Moderate to severe dehydration High risk for dehydration High risk infants When patient/carers thought not to be able to manage If diagnosis is in doubt
High risk for dehydration
4/24 hours
Observe for 4-6 hours to ensure maintenance of hydrations
High risk infants for dehydration
Ileostomy, short gut, CHD, chronic renal disease, metabolic disorders, malnutirtions
When would biochemistry tests be required in children
History of prolonged diarrhea with severe dehydration
Altered conscious state
Convulsions
Short bowel syndrome, ileostomy, Cardiac/renal, metabolic disorders
Infants
Complications in children
Hypernatremic dehydration
Hyponatremic dehydration
How much should sodium levels fall by
No more than 0.5mmol/L per hour
General Advice to parents treating mil/moderate at home
Give small amounts of fluid often
Start solids after 24 hours
Continue breastfeeding or start bottles after 24 hours
Provide maintenance fluids and fluid loss
Advice to parents for mild/moderate dehydration on Day 1, 2 and 3, day 4
Day 1: General 50ml/15 mins. 200ml for every watery stool
Ideal is gastrolyte, hydralyte or home made solutions
Day 2 and 3: reintroduce babys formula/milk, dilute to half strength (equal milk to water)
Day 4: increase milk to normal strength, gradually reintroduce normal diet
Aim to give more fluid in first 6 hours
Maintenance for 1-3 months, 4-12months, 12 months >
1-3 month 120ml/kg/hr
4-12 month 100ml
>12 month 80ml
Calculating total
Maintenance + fluid loss
Calculate fluid loss
%body weight loss X body weight X 10
Daily maintenance IV fluid based on weight
3-10kg, 10-20kg, >20kg
3-10= 100ml/kg/day
10-20- 1000ml + 50ml/kg for each kg >10kg
>20- 1500ml + 20ml/kg for each kg >20kg
Types of E. Coli
Enterohemorrhagic Enteroinvasive Enteropathogenic Enteroaggregative Enterotoxigenic
Most important type of E. coli
EHEC
Toxin produced by EHEC
Verotoxin
O157
Identical to Shiga toxin
What does the Shiga toxin do
Attaching effacing mechanism
Hemorrhagic colitis
HUS
Food borne illnesses associated with preformed toxins
S aureus
B cereus
Presentation of salmonella typhi
Rose spots
Abdominal pain
Fever
Malaise
Complications of S typhi
Hemorrhagic ulcerations of GIT Myocarditis Hepatic/bone marrow toxicity Meningitis Osteomyelitis
Pathogenesis of typhoid
Ingested->penetrate mucus via PP in jejunum/ileum->intestinal LN->multiply in macrophages->mesenteric LN->thoraci duct->blood->organs->intestine= ++iflammation in PP, ulceration, intestinal perforation
What food has HUS
Fast food burgers
How does C jejuni present
Bloody diarrhea
fever
Abdominal cramps
Reasons antibiotics are rarely indicated
Most commonly cause by viral
Can eradicate normal GIT flora->predisposing to C difficile
Prolong shedding of Salmonela and other bacterial diarrhea
EHEC w/ antibiotics may increase risk of HUS
Causes of acute bloody diarrhea
Campylobacter EHEC Entameoba histolytica Salmonella Shigella
Indications to investigate
fever, blood in stool Severe abdominal pain, peritonism Profuse diarrhea, signs of hypovolemia Hospitalised, recent antibiotics Age >65, comorbidities Immunocompromised Diarrhea >7 days Exposure to suspicious food Sexual contacts- MSM
Indications to do stool OCP for Giardia, Cryptosporidium, E histolytica
Diarrhea >7 days
Exposure to untreated water
HIV
MSM
Source and mode of transmission for 1. B cereus, 2. C jejuni, 3. C diff 4. EIEC 5. ETEC 6. EHEC 7. S typhi 8 S enteritis 9. Shigella 10. S aureus 11. Cholera 12. Yersinia
- rice, meats, vegetables, beans
- Uncooked meat
- Normal colon, antibiotics
4/5. Contaminated water/food - Hamburger, raw milk
- FO route, contaminated water, travel to endemic
- Contaminate food animal eggs, poultry, meat, milk
- FO, water
- Unrefrigerated meat, dairy, custard
- Water, shellfish
- Contaminated food, unpasteurised milk
Which infections have short IP- within 24 hours
B cereus, C perfringens, S enteritis, S aureus
Infections that present 1-3 days
EHEC, C jejuni, Shigella
Presents at 5 days
Yersinia
IP of 10-14 days
Salmonella typhi
Which infection is associated with GBS
Campylobacter jejuni
Complications of Shigella
Toxic megacolon
HUS
What increases risk of toxic megacolon in Shigella
Antidiarrheals
What can occur in Yersinia infection which may mimic appendicitis
Mesenteric adenitis and terminal ileus without diarrhea
Parasites causing diarrhea
Cryptosporidium
Entamoeba histolytics
Giardia
Risk factors for Giardia
Day care childre
Untreated water
MSM
Immunodeficiency
What should be monitored with EHEC and why
Hb, platelet count, renal function as evidence of developing HUS
Red flags in children which require SMO assessment
Short gut syndrome
Ileostomy
Complex/cyanotic heart disease
Renal transplant/insufficiency
Monitoring rehydration
Bare weight patient 6 hourly in moderate and severe, NGTR or IVF Reassess early at 4-6 hours, then 8 hourly Look for: Weight change Clinical signs of deH Urine output Ongoing losses Signs of overload Consider early feeding
In what circumstances is medical review required before D/C
= 3 large stools during reH
Abdominal pain worsening
Principles of early feeding
Stop any fortifications
Early feeding
If diarrhea ++ after initial refeeding consider hydrolysed formula temporarily
Key points for parents
- Babies and young children w/ gastro can become deH very quickly, need small amounts of fluid regularly
- Babies 12-24 hours
- Give older children 1 cup of fluid for every big vomit/diarrhea
- Continue to give food to a hungry child, do not stop food for >24 hours
- Wash hands of child and family, was before and after nappy changes, feeding
- Keep away from child as much as possible until the diarrhea has settled
Which antibiotic is typically associated with pseuomembranous colitis
Clindamycin
If antibiotics indicated for diarrhea, most commonly used
Ciprofloxacin
