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Identify the causes of diarrhea and vomiting Differentiate between infective versus non-infective causes Classify the severity of dehydration Formulate the emergency management of hypovolemic shock Determine fluid therapy after initial resuscitation (type & volume)
Vomiting
forceful expulsion of gastric contents
Often preceded by nausea Regurgitation passive, non-forceful ejection of gastric contents due to reflux through a relaxed esophageal sphincter
Physiology of Vomiting
Classification of Vomiting
According to nature: 1. Projectile---------- ICP or pyloric stenosis 2. Non Projectile------ GERD or any other causes. According to quality : 1. Bilious ( dark green) ----------- Always pathological and indicate obstruction beyond the ampulla of vater. 2. Bloody: red blood-------- Upper GI or massive lower GI bleed, coffee ground--------- old upper GI or lower GI bleeding 3. Non bloody, non bilious: usually clear or yellowish with remnants of previously ingested food--------most types of vomiting.
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According to quality : 1.Bilious ( dark green) ----------- Always pathological and indicate obstruction beyond the ampulla of vater. 2.Bloody: red blood-------- Upper GI or massive lower GI bleed, coffee ground--------- old upper GI or lower GI bleeding 3.Non bloody, non bilious: usually clear or yellowish with remnants of previously ingested food--------most types of vomiting.
c) Nature: 1. Projectile---------- ICP or pyloric stenosis 2. Non Projectile------ GERD or any other causes
d)Timing - Nocturnal & morning : GERD - Soon after meal : Hyperthrophic Pyloric Stenosis ( common in infants) - Delayed vomiting( after more than 1 hour ingested food) : motility disorder - Cyclic vomiting***
Cyclic Vomiting:
stereotypic recurrent episodes of nausea and vomiting without an identifiable organic cause Idiopathic, happened in early childhood, unknown pathogenesis. Characterized by
I. Numerous of vomiting interspersed with well intervals II. Intervals of normal health between episodes III. Episodes that are stereotypic with regard to symptom onset and duration IV. lack of laboratory or radiographic evidence to support an alternative diagnosis V. high intensity
e) Vomitus 1.Bilious (dark green)- indicate obstruction beyond the ampulla of vater (intussusceptions,malrotation ) 2.Fresh Blood: upper GI bleed (Esophagitis, Peptic ulceration, Oral/nasal bleeding) 3.Coffee ground color : old upper GI or lower GI bleeding 4.Non bloody, non bilious(ingested food) pyloric stenosis 5.Feaculent : Lower intestinal obstruction
f) Associated features :
GI symptoms
Anorexia, nausea, retching, abdominal pain (common), diarrhoea
Neurologic symptoms
Headache, photophobia, neck stiffness
UTI symptoms
Dysuria, hematuria, incontinence
Physical examination
Assess hydration status Abdominal examination eg: to look for tenderness, organomegaly, abdominal distension, presence of bowel sounds. Look for signs of severe infection eg: tense anterior fontanelle, meningism for meningitis. Examine for extraintestinal cause such as inflamed tympanic membrane in otitis media and renal punch in pyelonepritis and neurological examination
Investigation
Laboratory Investigations FBC, electrolyte ,BUN, ESR, venous blood gases, amylase Urine, blood, stool C&S
GI radiology Barium swallow/ meal, AXR, ultrasound abdomen, endoscopy Metabolic investigations blood gas,ammonia, blood and urine organic acids
Management
Depends on specific cause While investigating/ treating underlying pathology replace lost fluids, maintain hydration
Causes of vomiting
Infant GERD(most common) Over feeding Infection : - Gastroenteritis - meningitis - whooping cough - Otitis media - UTI intestinal obstruction - pyloric stenosis - Duodenal atresia - intussusception - malrotation - volvulus - hirschsprung ds Congenital adrenal hyperplasia Renal failure Child(pre-school) Gastroenteritis(most common) Systemic infection Intestinal obstruction Whooping cough GERD Coeliac disease Otitis media Meningitis Raised ICP School-age & Adolescent Gastroenteritis(most common) Peptic ulcer Systemic infection - pyelonephritis - meningitis -septicaemia Coeliac ds Appendicitis Migraine Pregnancy Medication Bulimia Anorexia
Diarrhoea
WHO definition: diarrhoea is the passage of three or more loose or liquid stools per day, or more frequently than is normal for the individual. Excessive daily stool liquid volume (>10 mL stool/kg body weight/day (Nelson , Essential of Paediatrics,5th Edition) Normally, a young infant has about 5g/kg of stool output per day Childhood diarrhea represents an excessive loss of fluid and electrolytes in stools and is defined quantitatively as a total daily volume exceeding 20g/kg.
Classification
Acute < 2 weeks. Persistent 2- 4 weeks Chronic > 4 weeks.
Types of Diarrhoea
Primary Mechanism: Secretory Osmotic Inflammatory Motility related diarrhea
- Increased motility - Decreased motility
Secretory Diarrhoea
In this type of diarrhea there is both active intestinal secretion and decreased absorption of fluid and electrolytes. Little or no structural defects. Produce watery, normal osmalality stools. No stool leucocytes detected in the stool examination. Persists during fasting . Common cause:
a. b. c. Infection-cholera,E.coli Bile salt malabsorption following ileal resection Laxative(docusate sodium)
Osmotic Diarrhoea
Involve secretion of fluid into the bowel. This occurs because: a. Ingestion of non absorbable substance(Magnesium Sulphate) b. Patient has generalized malabsorption so that high concentration of solute remain in the lumen. c. Patient has transport defects such as disaccharide deficiency(lactase) or glucose-galactose malabsorption . Diarrhea stops when stop eating the malabsorptive substance or fasting. The stool is watery, acidic with the presence of reducing substances. There is an increase osmolality . No stool leucocytes detected.
Inflammatory Diarrhoea
There is damage of the intestinal mucosal cell
Common cause are infective conditions (Shigella, Salmonella) and inflammatory conditions(UC and CD)
It occurs due to abnormal motility of intestine which is increase or decrease in motility. A. Increased Motility Decreased transit time and increase frequency of defecation. Stool produced is loose to normal appearing stool, stimulated by gastro-colic reflex. Examples: Irritable bowel syndrome, postvagotomy ,hyperthyroid and dumping syndrome.
B. Decreased motility
due to defect in neuromuscular unit or stasis due to bacterial overgrowth. Stool is loose to normal appearing. Examples: 1) pseudoobstruction 2) blind loop
Toxic bacteria E coli Clostridium perfringens Cholera species Vibrio species Parasites Giardia species Cryptosporidium species
Investigations:
Stool analysis
Macroscopic appearance Blood Blood , pus Blood, mucus Watery Rice-water stool Frothy Bloodstained Causes E.Coli (enterohaemorrhagic) Colitis Salmonella Shigella Inflammatory bowel disease Giardiasis Cryptosporidiosis Cholera Carbohyrate intolerance Campylobacter infection
Stool culture & sensitivity Stool for Ova and Cyst - Giardiasis, crytospridiosis Stool PH level - <5.5 or presence of reducing substances indicates carbohydrate malabsorption. FBC, CRP, ESR UFEME BUSE Colonoscopy and endoscopy - Non-infectious etiology
Postinfectious secondary lactase deficiency Cows milk/soy protein intolerance Chronic nonspecific diarrhoea of infancy Celiac disease Cystic fibrosis AIDS enteropathy
Postinfectious secondary lactase deficiency Toddlers diarhea Irritable bowel syndrome Celiac disease Lactose intolerance Giardiasis Inflammatory bowel disease
GIT infection Inflammatory bowel disease Celiac ds Lactose intolerance Giardiasis Laxative abuse(anorexia nervosa)
Organisms
Viral
Rotavirus
Presentation
Watery stool - no blood @ mucus low grade fever, Vomiting Dehydration prominent
Bacterial
sp
Typhoid fever - Dysentry Differs from child vs adult Infants and child: diarrhea Adult: lesions of terminal ileum @ mesenteric lympadenitis
Enterocolitis Dysentery , High fever febrile convulsions Travelers diarrhea Profuse, rapidly dehydrating diarrhoea)
enterocolitica
Campylobacter Shigella
jejuni
Presentation Acute onset , Ameobic dysentry Mild watery diarrhea (healthy) Severe prolonged diarrhea (immunocompromised)
Chemicals
Malabsorbed substance/ malabsorption Lactose intolerance Post infectious secondary lacrase deficiency Pancratic insufficiency (cystic fibrosis ) -Steatorrhea, - Failure to thrive(FTT) Cows milk/ soy product insifficiency Celiac ds - FTT after introduce gluten, - Abdominal distension - Buttock wasting Short bowel syndrome
Inflammation
Nonabsorb laxative Laxative abuse (anorexia nervosa ) Antibiotic associated Toxic ingestion Excess fruit juice (sorbitol) ingestion
Inflammatory bowel disease Crohn disease Ulcerative Colitis Irritable bowel ds Necrotizing enterocolitis
Causes
Causetive agents
Presentation
Fever Diarrhea Sudden onset Absence of pain Fever +/- bloody diarrhea
Gastroenteritis Viral
Bacterial
Extra-GIT Infection
Local infection
Otitis media
UTI URTI
Pneumonia / LRTI
Systemic infection Septicaemia Meningitis
Causes Gastrointestinal
Example GERD
Presentation Effortless not preceded by nausea chronic Epigastric pain Blood @ coffee ground vomitus Pain relieved by acid blockade Jaundice , Hx of exposure Fever Abd pain migrating to right lower quadrant/ tenderness Particular formula/ food Blood in stool
Allergic
In older children
Presentation Neonate, premature ~ polyhydromnious Sudden onset pain, GI bleed Shock Colicky pain Lethargy Red currant jelly stool Mass occsionally Colicky pain Mass
Intussusception
Duplication of cyst
Pyloric stenosis
<4 months old Nonbilious vomiting, postprandial Hunger state Visible peristalsis wave
Causes
Example
Presentation
Migraine syndrome
Hydrocephalus Cyclic Vomiting Syndrome
Brain tumors
Metabolic disorder
Others
Poisons/drugs
Dehydration
Causes of dehydration
Physical Examination
Accurate body weight Vital signs (temperature, heart rate, respiratory rate, blood pressure) General conditions Eyes: sunken eyes, presence / absence of tears Mucous membrane moist or dry Respiratory pattern Bowel sounds Extremities (perfusion, capillary filling time) Skin turgor (anterior abdominal wall) Inspection of stool (presence of blood or mucous)
Investigation
Depends on clinical assessment
Renal profile Stool culture and sensitivity Urinalysis Full blood count
Assessment of dehydration
Percentage loss of body weight
Is essential for appropriate fluid management. Repeated assessment is often necessary. Most useful signs for significant dehydration
Prolonged capillary refill time (normal < 2 seconds) Reduced skin turgor Abnormal respiratory pattern
Assessment of dehydration
Symptom No signs of dehydration (<3% loss of BW) Well, alert Mild to moderate dehydration (3-9% loss of BW) Normal/ fatigue/ restless/ irritable Severe dehydration (>9% loss of BW) Apathetic, lethargic unconscious Drinks poorly, unable to drink Tachycardia, with bradycardia in most severe cases Weak, thready, or impalpable Deep Mental status Thirst Heart rate
Drinks normally, Thirsty, eager to might refuse liquids drink Normal Normal to increased Normal to decreased Normal, fast
Normal Normal
Continue
Symptom No signs of dehydration (<3% loss of BW) Normal Present Moist Instant recoil Normal Warm Normal to decreased Mild to moderate dehydration (3-9% loss of BW) Slightly sunken Decreased Dry Recoil in < 2 seconds Prolonged Cool Decreased Severe dehydration (>9% loss of BW) Deeply sunken Absent Parched (very dry) Recoil in > 2 seconds Prolonged, minimal Cool, mottled, cyanotic Minimal
Eyes Tears Mouth and tongue Skin fold Capillary refill Extremities Urine output
Sunken eyes
Dry tongue Diffuse mottled, bluish-gray appearance of this infant's skin suggestive of systemic poor perfusion
Common symptoms
Hyperpnoea Muscle weakness Restlessness A characteristic high-pitched cry Insomnia Lethargy And even coma Convulsions are typically absent except in cases of inadvertent sodium loading or aggressive rehydration
EMERGENCY MANAGEMENT
1) Initial resuscitation -Secure airway, support breathing & restore circulation 2) Fluid Resuscitation Rapid restoration of intravascular volume Complications of rapid fluid given : Cerebral edema, hyponatremia, osmotic demyelination, death.
Bolus 20 ml/kg of isotonic crystalloid over 510 minutes Assess vital signs and perfusion 1) Blood pressure 2) Quality of central and peripheral pulses 3) Skin perfusion 4) Mental status 5) Urine output
If not improve, 20 ml/kg boluses to a total 60 ml/kg, ideally within first 30 to 60 minutes of treatment.
Further management
Once the patient stable, find and treat the cause Continue fluid therapy Assess the sodium level 1) Normal isotonic saline 2) Mild to moderate hyponatremia isotonic saline 3) Severe serum sodium at rate 0.5 mEq/L per hour
Most often, diarrhoea kills a child by dehydration, which means that too much liquid has been drained out of the child's body. So as soon as diarrhoea starts, it is essential to give the child extra drinks to replace the liquid being lost.
ORT is the giving of fluid by mouth to prevent and/or correct the dehydration that is a result of diarrhoea. As soon as diarrhoea begins, treatment using home remedies to prevent dehydration must be started.
The New Reduced Osmolarity formula for the ORS packet recommended by WHO and UNICEF contains:
Osmolarity (ORS) Sodium Chloride Glucose, anhydrous Potassium Citrate Total Osmolarity mmol/litre 75 65 75 20 10 245
INTRAVENOUS FLUID
Indication: Severely dehydrated. Moderate dehydration if there is no improvement after ORS Unconscious child Continuing rapid stool loss (> 15-20ml/kg/h) Frequent, severe vomiting, drinking poorly Abdominal distension with paralytic ileus, usually caused by some anti-diarrhea drug ( eg; codeine, loperamide) and hypokalaemia Glucose malabsorption
Types of solution
Solution (mmol/L) Na K Ca Cl lactate
NS 0.9%
0.45%NS in 5% dextrose (children) 0.18 % NS in 4.0% dextrose (up to 2 year) Hartmann s solution (Ringers lactate)
150 77 30 -
150
77 30 112
27
130 5
Give frequent small sips from a cup or spoon If chlid vomit, wait 10 minutes then continue but more slowly Continue giving extra fluid until diarrhea stop
2. Continue feeding
But avoid food with high simple sugar (osmotic load may worsen diarrhea)
2. Inform mother to: Give frequent small sips from cup or spoon If child vomit, wait 10 minutes then continue but more slowly Continue breastfeeding whenever child wants
3. After 4 hours: Reassess child and classify child for dehydration Select appropriate plan to continue (Plan A, B or C)
4. If mother must leave before completing treatment: Give her enough ORS packets to complete rehydration and 8 packets as recommended in Plan A Explain the 3 Rules (Plan A)
reassess child after every bolus and stop bolus once perfusion improve or when fluid overload suspected reassess child every 1-2 h during rehydration give ORS (5ml/kg/h) as soon as child can drink reassess an infant after 6h and child after 3h. Classify dehydration and choose appropriate plan
If IV/IO line fail to set up arrange for the child to be sent to nearest centre meanwhile as arrangements are made to send the child, try further attempts : try to rehydrate child with ORS (20ml/kg/h over 6h orally/orogastric tube. Continue to give ORS along the journey reassess child every 1-2 h give fluid more slowly if repeated vomiting or increasing abdominal distension reassess child after 6h classify dehydration choose appropriate plan
Total fluid required (ml) = fluid deficit + maintenance fluid given over 24 hours
EXAMPLE
8 months old child weighing 5kg is 5% dehydrated and not tolerate oral intake.
Age < 6 months Maintenance Fluid Required 150 ml/kg/day
6 months to 1 year
> 1 year a)first 10 kg b)10 20 kg c)> 20 kg
120 ml/kg/day
100 ml/kg + 50 ml/kg for next 10 subsequent kg + 20 ml/kg for any subsequent kg
Rehydrating over 24 hours 1. Fluid deficit 5% x 5000 = 250ml 2. Fluid maintenance 120ml/kg/24h 120ml x 5kg = 600ml /24 h 3. Total fluids in first 24 hours 250ml + 600ml = 850ml 4. Rate of infusion 850ml/24h = 35ml /h
EXAMPLE
12 years old child weighing 30kg is 5% dehydrated and not tolerate oral intake.
Age < 6 months 6 months to 1 year > 1 year a)first 10 kg b)Second 10 kg c)Subsequent kg 150 ml/kg/day 120 ml/kg/day 100 ml/kg 50 ml/kg 20 ml/kg Maintenance Fluid Required
Rehydrating over 24 hours 1. Fluid deficit 5% x 30000 = 1500ml 2. Fluid maintenance First 10kg = 100ml/kg x 10kg = 1000ml Second 10kg = 50ml/kg x 10kg = 500ml Next 10kg = 20ml/kg x 10kg = 200ml Total = 1700ml 3. Total fluids in first 24 hours 1500ml + 1700ml = 3200ml 4. Rate of infusion =3200ml/24h = 133ml /h
Hyponatraemic Dehydration
Daily Na+ requirement 2 3 mmol/kg/day Na+ deficit (140 serum Na+) x 0.6 x weight (kg)
Definition = serum Na <130 mmol/l ORS solution is a safe and effective therapy for nearly all children with hyponatraemia 1/2 normal saline 5 % dextrose with 20 mEq/L KCl
Hypernatraemic Dehydration
Definition = serum Na > 150mmol/l If child shock, first resuscitation then rehydrate with ORS over 48 to 72 hours If fluid has been given to resuscitate, amount given should be subtracted from the fluid deficit (important to avoid giving too much fluid) Reduce serum Na+ slowly and not exceed 10 mmol/L per 24 hours (dramatic fall lead to cerebral oedema and seizures) Use normal saline 5 % dextrose for the duration of fluid replacement until serum Na+ is < 145 mmol/L Then use 1/2 NS 5 % dextrose or 1/5 NS 5 % dextrose Add KCl after the child passes urine Monitor blood urea serum electrolytes 6 hourly