Vomiting, Diarrhea, Dehydration Flashcards
differential diagnosis of bilious vomiting in infants and children
R/O serious causes
With neonates: “never let the sun set on bilious vomiting”
malrotation with/ without volvulus
Intussusception is MC than malrotation (is MCC of obstruction in kids under 3– rare in adults)
usually AFTER neonatal period →prolapse of one portion of bowel into the adjacent segment
Sx: abdominal pain, bilious or non-bilious vomiting, currant jelly stools (mucus from inflammation mixed with blood)
Dx: barium or air enema
*In older children, bilious vomiting can occur with any syndrome with repeated bouts of vomiting (As food is expelled, all that remains in the GI tract is saliva and bile.)
clinical presentation:
malrotation without volvus
- developmental error in the formation of the GI tract
- intestine does not complete its normal rotational pattern of fetal development
- incomplete/intermittent obstruction, susceptible to volvus - Classic Sx is BILIOUS vomiting in neonate
- also “failure to thrive”, intermittent episodes of severe abdominal pain - can be missed in infancy–> Dx later in life with barium enema
- surgical treatment
clinical presentation of malrotation with volvus
- intermittent/resolve spontaneously or can be persistent → strangulation of the bowel within hours
- severe abdominal pain, and unremitting vomiting
necrosis of bowel can affect extensive segments of the small bowel–> high risk of short bowel syndrome in Pts with mesenteric ischemia from this condition
clinical presentation, lab and imaging results of pyloric stenosis
4:1 male predominance, (+) FHx in 13%, first born 30%
Vomiting, usually starting at 2-4 weeks of age, progresses to projectile vomiting (NON-Bilious)
Vomiting is immediately post-prandial and infant will feed following emesis (“hungry vomiter”)
Diagnosis: Abdominal U/S
Treatment: Correction of fluid/electrolyte imbalance followed by surgery (pyloromyotomy)
clinical presentation, lab and imaging results of gastroesophageal reflux (GERD)
Passage of gastric contents into the esophagus due to transient relaxation of the LES (lower esophageal sphincter)
Postprandial regurgitation (rarely vomiting)
May have irritability, feeding aversion, back arching
Clinical diagnosis, but can use prolonged monitoring of esophageal pH to diagnose
managment of GERD
Limit regurgitation with smaller feedings at frequent intervals, positioning
– >Typically self-limiting, resolving between 6-12 months
Medications:
H2-receptor blockers e.g ranitidine (Zantac)
Proton pump inhibitors e.g. omeprazole (Prilosec)
Antacids(e.g. Al hydroxide) NOT recommended at this age
Given the criteria for Ped Appendicitis Score, determine liklihood child has appendicitis:
Anorexia: 1 point
Nausea or vomiting: 1 point
Migration of pain: 1 point
Fever > 38º C (100.5º F): 1 point
Tenderness with cough, percussion, or hopping: 2 points
Right-lower-quadrant tenderness: 2 points
WBC count > 10,000 cells/mm3: 1 point
PMNs plus band forms > 7500 cells/mm3: 1 point
Patients with appendicitis had a mean score of 7
Patients without appendicitis had a mean score of 1.9
A score of 3-6 was indeterminate for appendicitis
evaluation for a pediatric patient with gastroenteritis
History and exam should first focus on determining if patient is seriously ill and assessing hydration status
Stool culture and smear for WBCs, ova and parasites:
Febrile, non-bloody diarrhea: Usually viral
Afebrile, non-bloody: Usually viral
Febrile, bloody diarrhea: Usually bacterial
Afebrile, bloody diarrhea: Usually bacterial, consider non-infectious source
what is AAP definition of gasteroenteritis?
3 classes of causitive organisms?
diarrheal disease of rapid onset, with or without accompanying symptoms and signs such as nausea, vomiting, fever, or abdominal pain
bacteria, virus, parasite
Tx for acute viral GE:
Estimate degree of hydration
Rehydration is mainstay of therapy
Do NOT use antiemetics/ antidiarrheals in acute gastroenteritis
Continue breast-feeding and re-initiate solid foods as as soon as rehydration is complete
comment on medications used to treat acute GE in kids
True antidiarrheal medications are ineffective / dangerous for smaller children (kaopectate, loperamide, tincture of opium, diphenoxylate with atropine).
Cholestyramine (Questran) helps to bind the stools to decrease diarrhea.** **Rx: Questran 1/3 packet mixed with food TID until formed stools.
Promethazine (Phenergan) suppositories: They work for vomiting, but potential for respiratory depression and toxicity when used in younger kids. Contraindicated under age 2
what is UNNECESSARY to Dx dehydration in kids?
LABs are NOT needed or helpful to Dx dehydration in kids
Describe the physical exam for assessing dehydration:
Change in body weight before and after rehydration is the standard method for Dx
To identify dehydration before treatment, many factors can be used but are not helpful in isolation. The most useful individual signs are:
Increased capillary refill time
Abnormal skin turgor
Abnormal respiratory pattern
In one validated study, four factors predicted dehydration:
- Capillary refill > 2 seconds
- Absence of tears
- Dry mucous membranes
- Ill general appearance
Design a fluid replacement management plan for a child 0-5 year of age
- Oral rehydration solution (ORS) should be used
- Oral rehydration should be performed rapidly (within 3-4 hours)
- Age-appropriate, unrestricted diet is recommended as soon as dehydration is corrected
- For breastfed infants, nursing should be continued
- For formula-fed infants, diluted formula is not recommended, special formula usually is not necessary
- Additional ORS should be given for ongoing losses through diarrhea
- No unnecessary laboratory tests or medications should be administered
what amounts/ methods are used to deliver rehydration in kids with GE who are:
mildly, moderately, or severely dehydrated?
