Gastroenteritis in a child Flashcards
Define gastroenteritis.
Gastroenteritis is a transient disorder due to enteric infection, usually caused by viruses, characterized by sudden onset of diarrhoea, with or without vomiting.
Define dysentery.
Dysentery is an acute infectious gastroenteritis characterized by diarrhoea with blood and mucus, often with fever and abdominal pain
Define acute diarrhoea.
Three or more episodes of liquid or semi-liquid stool in a 24-hour period, lasting for less than 14 days, where the stool takes the shape of the sample pot
Do viruses cause bloody stools in gastroenteritis?
Usually no
Are most gastroenteritis caused by viruses or bacteria? How long do they usually last?
Viruses
Usually last less than 1 day
What is a typical presentation of gastroenteritis?
- Sudden-onset diarrhoea; blood or mucus in the stool; faecal urgency.
- Nausea or sudden onset of vomiting.
- Fever or general malaise - headache, myalgia, bloating, flatulence, weight loss, and malabsorption, depending on the underlying cause of infection.
- Abdominal pain or cramps
What are the most likely causes of gastroenteritis in a child with bloody stools?
E coli
Salmonella
What is the route of transmission of gastroenteritis pathogens?
faecal-oral, foodborne, environmental, and airborne routes
What is the pathophysiology of gastroenteritis caused by food poisoning?
Primarily caused by enterotoxins produced by the microorganism (rather than the microorganism itself)
List the main 3 pathogens responsible for food poisoning and where they are found.
- Clostridium perfringens* — contaminated meat dishes or cooked meats or meat products; often reheated
- Bacillus cereus* — contaminated or inadequate post-cooking temperature control that has allowed bacterial growth (e.g. reheated rice, pasta, meat or vegetable dishes, and dairy products).
- Staphylococcus aureus* — usually found in cooked meats and cream products.
What is the most common cause of viral gastroenteritis in children?
Rotavirus - but incidence has gone down in recent years because of the vaccine
What are the symptoms of rotavirus? How long does it last? Which parts of the year is it most common in?
- watery diarrhoea and vomiting with or without fever and abdominal pain.
- Vomiting usually settles within 1–3 days
- diarrhoea settles within 5–7 days, but can persist for 2 weeks
- winter and spring
What is the most common cause of viral gastroenteritis in England and Wales? When is it most commonly seen?
- Norovirus
- winter months
What are the symptoms of norovirus and their duration? Why is reinfection common?
- projectile vomiting occurs 24-36 hours after infection , diarrhoea, fever, headache, abdominal pain, myalgia
- symptoms last 12-60 hours
- symptoms resolve within 1-2 days
- immunity is short lasting
Which virus can cause both RTI and gastroenteritis?
adenovirus
What are the most common causes of travellers’ diarrhoea in the UK?
Campylobacter jejuni and campylobacter coli
Can be asymptomatic in 25-50% or cause bloody diarrhoea, vomiting, fever, abdominal cramps, nausea. Resolves within 1 week.
What is the most common serogroup of STEC causing infections in the UK?
E coli 0157
Who is most affected by E. coli 0157 infections? What are the symptoms and their duration?
- Children 1-4 years old
- Can cause bloody diarrhoea, vomiting, abdominal cramps and fever
- Resolves within 10 days
Which gastroenteritis bacteria occurs most commonly in children less than 5 years of age, but infection can occur in all ages and has infections which peak in late summer in the UK?
Shigellosis
When should you suspect HUS in gastroenteritis?
E coli 0157:H7 serotype most commonly triggers HUS
If the child coming in with diarrhoea develops pallor and janudice
List 3 parasitic causes of gastroenteritis.
- Cryptosporidiosis - most common; especially after foreign travel; last 1-2 weeks; can recur.
- Entamoeba histolytica (amoebiasis) - 90% asymptomatic
- Giardia intestinalis or Giardia lamblia - can cause faltering growth from malabsorption
What complication are Campylobacter spp., Shigella flexneri, and Yersinia enterocolitica associated with?
Reiter’s syndrome (uveitis, arthritis, urethritis)
Which gastroenteritis can cause faltering growth?
Giardia spp.
When can meningitic occur as a result of gastroenteritis?
Infants <3 months with Salmonella
Which gastroenteritis can have a complication of Guillain Barre syndrome?
Campylobacter spp.
What complication can occur post giardiasis gastroenteritis ?
Lactase deficiency can persist for several weeks after giardia eradication
What is can be long term complication following gastroenteritis with non-typhoidal salmonella, Campylobacter spp., and Clostridium difficile infections?
Increased risk of incident IBD
What % of people are affected by IBS following infectious gastroenteritis?
3-30%
What are 3 complications of gastroenteritis with Cryptosporidium spp. , particularly in the immunocompromised?
- Pancreatitis
- Sclerosing cholangitis
- Liver cirrhosis
What are two complications of gastroenteritis with Salmonella spp. and Yersinia spp.
- Sepsis
- Also: aortitis, osteomyelitis
What are 3 common complications of gastroenteritis?
- Dehydration
- Electrolyte disturbance
- Acute kidney injury (AKI)
What syndrome may be triggered in a child presenting with bloody diarrhoea as a result of E Coli?
Haemolytic uraemic syndrome
Name 3 complications of shiga toxin-producing Escherichia coli (STEC) gastroenteritis.
- Haemorrhagic colitis - bloody diarrhoea, severe abdominal pain lasting 2 weeks
- Haemolytic uraemic syndrome - usually in <5years, 10% of infections preceded by haemorrhagic colitis
- Thrombotic thrombocytopaenia purpura (TTP)
What is the triad of haemolytic uraemic syndrome?
- Thrombocytopenia
- Microangiopathic haemolytic anaemia
- Acute renal failure
Usually occurring 10 days after onset of bloody diarrhoea
What are the signs and symptoms of thrombotic thrombocytopaenic purpura/?
present with:
- fever
- flu-like symptoms,
- petechial haemorrhages on the lower limbs,
- haematuria,
- anaemia,
- renal dysfunction,
- and possible neurological deficits
What should you consider if there is gastroenteritis with recent antibiotic exposure?
C difficile
What should you consider in gastroenteritis with blood or mucus in the stools?
E coli 01567 (STEC)
Dysentery
What should you check for on examination?
- dehydration or shock - general appearance, temperature, pulse, BP, breathing pattern
- “Is this sepsis?”
- Abdominal examination
- Weight and malnutrition
What investigations would you do for gastroenteritis?
- Stool culture and sensitivity (depends on clinical judgement)
- Do not routinely arrange blood tests
Which category (no dehydration/clinical dehydration/shock) would these be classified as:
- warm extremities
- irritability
- mottled/pale skin
- sunken eyes
- dry mucous membranes
reduced skin turgor, sunken eyes and tachycardia all in a child indicate red flag symptoms of progression to shock
Which category of dehydration would these be classified as?
- tachycardia
- weak peripheral pulses
- normal capillary refill
- reduced skin turgor
- hypotension
reduced skin turgor, sunken eyes and tachycardia all in a child indicate red flag symptoms of progression to shock
(table only for dehydration in children)
What are the differentials for gastroenteritis?
What are the drug treatments for…?
- STEC
- giardiasis
- shigellosis
- amoebiasis
- campylobacteriosis
- cryptosporidiosis
- no effective antibiotic treatment
- tinidazole
- not usually needed unless severe, seek specialist advice
- recommended for all cases, seek specialist advice
- not required
- no specific treatment licensed in the UK
How do you diagnose clearance of the infection?
2 stools taken at least 24 hours apart, once the child is symptom free for at least 48hrs
What is the osmolarity of low-osmolarity oral rehydration solution?
240-250 mOsm/L
How much ORS should you give in different age groups to rehydrate a child with gastroenteritis? (fluid management of dehydration)
- <5years - 50ml/kg for fluid deficit + maintenance over 4 hours
- 5-11 years - 200mL after each loose stool
- 12-16 years - 200-400 mL after each loose stool
How is gastroenteritis managed in primary care?
- Provide a leaflet on gastroenteritis
- Do not routinely give antibiotics, antiemetics, zinc supplements, antidiarrhoeals or probiotics to children
Advice:
- Monitor fluid intake and treat dehydration e.g. offer ORS, discourage fruit juice/carbonated drinks
- Prevent transmission - wash hands with soap, flush toilet and clean surfaces, do not share towels and wash at 60 degrees
- DO NOT ATTEND SCHOOL for at least 48 hours after last vomiting/diarrhoea episode (do not go swimming for 2 weeks if parasitic)
Safety net:
- Blood, mucus or pus in the stool
- Diarrhoea over usual 5-7 days, vomiting over usual 3 days.
- Severe dehydration
- Billous vomiting
- Acute-onset painful bloody diarrhoea
- HUS
Notifiy:
- Notify local health protection team if
- food poisoning
- HUS
- Infectious bloody diarrhoea
- Enteric fever
- Cholera
When should you not prescribe tinidazole?
- Pregnancy first trimester
- Breastfeeding
Drug interactions:
- Alcohol
- Warfarin
When should you not prescribe clarithromycin?
- Pregnancy first trimester and breastfeeding
- MG
- Electrolyte disturbance - can cause long QT
- Hepatic and renal impairment (half dose if GFR <30mL/min/1.73m)
- Interact with many drugs
When would you see..?
- isonatraeamic dehydration
- hyponatraemic dehydration
- hypernatraemic dehydration
- isonatraeamic dehydration - normal dehydration
- hyponatraemic dehydration - children with dehydration drinking hypotonic solutions, greater net loss of sodium than intake
- hypernatraemic dehydration* - water loss exceeds sodium loss e.g. high fever, hot, dry environment, profuse low-sodium diarrhoea
*can cause neurological signs - jittery movements, increased muscle tone with hyperreflexia, altered consciousness, seizures, and multiple, small cerebral haemorrhages
What % weight loss is:
- no clinically detectable dehydration
- clinical dehydration
- shock
- no clinically detectable dehydration (<5%)
- clinical dehydration (5-10%)
- shock (>10%)
Why should Coca cola and apple juice be avoided in dehydration due to gastroenteritis ?
they have low sodium content
Why are antiemetics/anntidiarrhoeals not used in children?
- are ineffective
- may prolong the excretion of bacteria in stools
- can be associated with side-effects
- add unnecessarily to cost
- focus attention away from oral rehydration.
When are antibiotics indicated in gastroenteritis?
- sepsis,
- extraintestinal spread of bacterial infection,
- salmonella if aged <6 months,
- malnourished or immunocompromised children,
- for specific bacterial or protozoal infections (e.g. Clostridium difficile associated with pseudomembranous colitis, cholera, shigellosis, giardiasis).
What is post-gastroenteritis syndrome?
Return to normal diet results in water diarrhoea which requires ORS use again
Why is it better to rehydrate with a solution containing both glucose and sodium?
Sodium is reabsorbed in the intestine via a glucose-sodium co-transporter
In which type of dehydration (iso/hypo/hypernatraemic) must dehydration be corrected over 48 hours?
Hypernatraemic - rapid change in sodium concentration will lead to a shift of water into cells cause cerebral oedema and seizures
Reduce plasma sodium by less than 0.5mmol/l per hour (must be measured frequently)
