Vomiting, Diarrhea, and Dehydration in children

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Vomiting, Diarrhea, and Dehydration in children
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Newborn Newborn
Obstructive intestinal anomalies Esophageal stenosis/atresia, pyloric stenosis, intestinal stenosis/atresia, malrotation volvulus, incarcerated hernia, meconium ileus/plug, Hirschsprung disease, imperforate anus, enteric duplications
Neurologic Intracranial bleed/mass, hydrocephalus, cerebral edema, kernicterus
Renal Urinary tract infection, obstructive uropathy, renal insufficiency
Infectious Viral illness, gastroenteritis, meningitis, sepsis
Metabolic/endocrine Inborn errors of metabolism (urea cycle, amino/organic acid, carbohydrate), congenital adrenal hyperplasia
Miscellaneous Ileus, gastroesophageal reflux, necrotizing enterocolitis, milk allergy, GI perforation
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Infant (lt12 mo) Infant (lt12 mo)
Obstructive intestinal anomalies Pyloric stenosis, malrotation volvulus, incarcerated hernia, Hirschsprung disease, enteric duplications, intussusception, foreign body, bezoars, Meckel diverticulum
Neurologic Intracranial bleed/mass, hydrocephalus, cerebral edema
Renal Urinary tract infection, obstructive uropathy, renal insufficiency
Infectious Viral illness, gastroenteritis, meningitis, sepsis, otitis media, pneumonia, pertussis, hepatitis
Metabolic/endocrine Inborn errors of metabolism, adrenal insufficiency, renal tubular acidosis
Miscellaneous Ileus, gastroesophageal reflux, post-tussive, peritonitis, drug overdose
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Child (gt12 mo)
Obstructive intestinal anomalies Malrotation volvulus, incarcerated hernia, Hirschsprung disease, intussusception, foreign body, bezoars, Meckel diverticulum, acquired esophageal stricture, peptic ulcer disease, adhesions, superior mesenteric artery syndrome
Neurologic Intracranial bleed/mass, cerebral edema, postconcussive, migraine
Renal Urinary tract infection, obstructive uropathy, renal insufficiency
Infectious Viral illness, gastroenteritis, meningitis, sepsis, otitis media, pneumonia, hepatitis, streptococcal pharyngitis
Metabolic/endocrine Inborn errors of metabolism, adrenal insufficiency, renal tubular acidosis, diabetes mellitus, Reye syndrome, porphyria
Miscellaneous Ileus, gastroesophageal reflux, post-tussive, peritonitis, drug overdose, appendicitis, pancreatitis, gastritis, Crohn disease, pregnancy, psychogenic, cyclic vomiting syndrome
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diarrhea

• Loose or liquid stools
• an increase in the frequency of evacuations
• acute gastroenteritis is typically defined by the
  presence of three or more diarrheal stools in a
  24-hour period

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Infection
Viral rotavirus, Norwalk virus, enteroviruses, astroviruses, adenoviruses, caliciviruses
Bacterial Salmonella, Shigella, Yersinia, Campylobacter, Escherichia coli, Aeromonas hydrophila, Vibrio species, Clostridium difficile, tuberculosis
Parasitic Giardia lamblia, Entamoeba histolytica, Cryptosporidia
Dietary disturbances
Overfeeding, food allergy, starvation stools
Anatomic abnormalities
Intussusception, Hirschsprung disease, partial obstruction, appendicitis, blind loop syndrome, intestinal lymphangiectasia, short bowel syndrome
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Inflammatory bowel disease
Malabsorption or secretory diseases
Cystic fibrosis, celiac disease, disaccharidase deficiency, acrodermatitis enteropathica, secretory neoplasms
Systemic diseases
Immunodeficiency, endocrinopathy (hyperthyroidism, hypoparathyroidism, congenital adrenal hyperplasia)
Miscellaneous
Antibiotic-associated diarrhea, secondary lactase deficiency, irritable colon syndrome, neonatal drug withdrawal, toxins, hemolytic uremic syndrome
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Table 123-5 Causes of Diarrhea That May Result in Significant Morbidity
Infection
Salmonella gastroenteritis with bacteremia, Shigella, Clostridium difficile (pseudomembranous colitis)
Anatomic abnormalities
Intussusception
Hirschsprung disease with toxic megacolon
Partial obstruction
Appendicitis
Inflammatory bowel disease with toxic megacolon
Hemolytic uremic syndrome
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Table 123-8 Clinical Dehydration Score
Sign Score 0 Score 1 Score 2
General condition Normal Thirsty, restless, lethargic, and irritable Drowsy or not responsive, limp, cold, sweaty
Eyes Normal Slightly sunken Very sunken
Tongue Moist Sticky Dry
Tears Normal Decreased None


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• four signs (capillary refill gt2 seconds, absent
  tears, dry mucous membranes, ill general
  appearance) predicted dehydration as well an
  initial set of 10 signs

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• diagnosis
• Clinical exam
• Urinalysis
• Electrolytes
• Stool cultures
• Treatment
• Oral rehydration therapy
• Zofran .15 mg/kg
• No antidiarrheal agents
• Loperamide can cause lethary, paralytic ileus and
  death
• May be associated with HUS in e. coli
• Bisumth salicylate may be used in children gt 12

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Antibiotics?

• considered in patients with symptoms of invasive
  (inflammatory) infection
• acute onset of bloody diarrhea
• Mucus
• high fever
• Shigella species
• Campylobacter species
• S. enterica
• Numerous antibiotics options
• Azithromycin covers most
• Doxycycine or bactrim for cholera

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