DiarrheaJulie Anne Ting

ObjectivesTo review the common causes of acute diarrhea in childhood.

To review the current approach to outpatient management of acute diarrheal illness.

To review bloody diarrhea and its etiology.

To discuss the causes of chronic diarrhea.

Case

Julie is a 2 year-old girl seen in your office for a 4 day history of diarrhea. She initially had fever and 2 episodes of vomiting but this has since resolved. Her father has been giving her flat coke.

What else would you like to know?

Hx (1)

HPI

diarrhea: quantity and quality

associated GI symptoms: vomiting, abdominal pain, tenesmus, dysuria

constitutional symptoms

intake and output

travel history, sick contacts

Hx (2)

PMHx (incl. immunosuppressive illnesses, chronic diarrheal illness)

Family Hx (incl. IBD, celiac)

Rx (incl. recent Abx use)

Allergies (incl. food intolerances)

Immunizations (incl. Rotarix)

Red Flags on Hx

< 3m.o. with fever for >2d

<3m.o. with diarrhea for >2d

hematochezia or melena

bloody or green bilious vomit

diarrhea >10d

progressively worsening abdominal pain

lethargy, decreased urine output

What are important things not to miss on

P/E?

P/E

General appearance: toxic vs. non-toxic

Vitals

Growth parameters

Hydration status

Abdominal exam: bowel sounds, masses, tenderness, guarding, rebound, (DRE)

Hydration Status (1)

Mild Moderate Severe

% Weight Loss

<5% 5-10% >10%

HR N N/↑ increased

Radial Pulse N weak absent

RR N increasedincreased, grunting

Skin Ncool,

↓turgorcyanosis, tenting

Hydration Status (2)

Mild Moderate Severe

Eyes + Ant. Fontanelle

N sunkenmarkedly sunken

Mucous Membranes

slightly dry dry parched

Cap. Refill N increasedmarkedly increased

LOC N lethargystupor, coma

UO N/slight↓ <q8h, <4x/d

anuria

Julie’s Story

Julie just returned from a family trip to the Caribbean. She has bloody diarrhea.

She has mild dehydration.

She has non-localizing abdominal pain. There are no signs of peritonitis.

What are possible causes of Julie’s diarrheal illness?

DDx Acute DiarrheaVery Common:

GI infection: virus (usu. non-bloody) > bacteria > parasite

Antibiotic-associated diarrhea

Very Life-Threatening

Systemic infection

Surgical abdomen: intussusception, appendicitis, toxic megacolon

Which of these investigations would you order for Julie?

CBC

BUN, Cr

electrolytes

stool C&S

stool O&P

C. difficile toxin screen

urinalysis

abdominal ultrasound

abdominal CT

Indications for Investigations

Cause other than gastroenteritis is suspected

Severe dehydration

Bloody diarrhea

How would you manage Julie’s

diarrhea?

Rx ChoicesRehydration: ORT (mild-mod) or IVF (severe)

Early refeeding: increases speed of bowel recovery

Antibiotics: consider if bloody diarrhea, systemic illness

Empiric Abx for bloody diarrhea: ciprofloxacin 20mg/kg/d div BID x 5d or ceftriaxone 50mg/kg/d (max 1.5g) x 5d

Zinc supplementation: a first-line Rx in developing countries

Probiotics: some evidence of benefit

Smectite: adsorbent

Oral Rehydration Therapy

Pedialyte (no juice, no pop, no salty chicken noodle soup, no cow’s milk, no plain water)

for mild-moderate (<10%) dehydration

not for patients with protracted vomiting, worsening diarrhea, stupor/coma, or intestinal ileus

Oral Rehydration Therapy

20mL/kg/h over the 1st hour,

then 10mL/kg/h for mild (<5%) dehydration and 15-50mL/kg/h for severe (5-10%) dehydration

reassess in 6-8h

(or if you’re at CHEO, follow the pre-printed handouts)

Does Julie need follow-up?

Hemolytic Uremic syndrome (HUS)

A potential complication of EHEC (esp. O157:H7), also Campylobacter, Shigella, and some viruses

usually starts 3 days after resolution of diarrhea

increased risk if <5y.o. and bloody diarrhea

warn parents to watch out for bruising, oliguria, neurological changes

Rx: dialysis prn

Summary: Approach to Acute Diarrhea

Hydration Status

mild to moderate volume loss (<10%): ORT

severe volume loss (>10%): admit for IVF resuscitation

Toxic vs. Non-Toxic

if suspect severe/systemic illness: cultures, Abx

if suspect surgical abdomen: imaging, consult surgery

Julie Says Thank You for saving

her!

Causes of Chronic Diarrhea

Chronic Diarrhea Without FTT

Toddler’s Diarrhea (Chronic Nonspecific Diarrhea)

cause: excess fluid intake, carbohydrate malabsorption, low dietary fat intake, disordered GI motility, excess fecal bile acids

Rx: 4Fs: fibre, normal fluid intake, 35-40% fat, D/C fruit juice

Infection

Lactose Intolerance

IBS

Chronic Diarrhea with FTT

Intestinal: celiac disease, milk protein allergy, IBD

Pancreatic: CF, Schwachman-Diamond Syndrome

Other: osmotic, endocrine, immunodeficiency, neoplastic, food allergy, laxative abuse