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== DDX  ==
{{Peds top}} [[diarrhea]]
==Background==
[[File:Figure 34 01 10f.png|thumb|Gasterointestinal anatomy.]]
[[File:Layers of the GI Tract english.png|thumb|Layers of the Alimentary Canal. The wall of the alimentary canal has four basic tissue layers: the mucosa, submucosa, muscularis, and serosa.]]
*85% of diarrhea is infectious in etiology
**[[Viruses]] cause vast majority of infectious diarrhea
**[[Bacteria]]l causes are responsible for most cases of severe diarrhea
***Foreign travel associated with 80% probability of bacterial diarrhea (see [[Traveler's Diarrhea]])


=== Infection ===
===Definitions===
*[[Diarrhea]]: Increased frequency of defection, usually >3 bowel movements per day
*Hyperacute: 1-6 hr
*Acute: less than 3 weeks in duration
*[[Gastroenteritis]]: Diarrhea with nausea and/or vomiting
*Dysentery: Diarrhea with blood/mucus/pus
*Invasive = Infectious


#Viral
==Clinical Features==
##Rotavirus
[[File:BristolStoolChart.png|thumb|Bristol Stool Chart.]]
##Norwalk virus
===History===
##Enteroviruses
*Possible food poisoning?
##Adenoviruses
**Symptoms occur within 6hr
#Bacterial
*Does it resolve (osmotic) or persist (secretory) with fasting?
##Salmonella
*Are the stools of smaller volume (large intestine) or larger volume (small intestine)
##Shigella
*[[Fever]] or [[abdominal pain]]? ([[diverticulitis]], [[gastroenteritis]], [[IBD]])
##Yersinia
*[[GI bleeding|Bloody or melenic]]?
##Campylobacter
*Tenesmus? ([[shigella]])
##Escherichia coli
*Malodorous? ([[giardia]])
##Vibrio species
*Recent travel? ([[Traveler's Diarrhea]])
##Clostridium difficile
*Recent antibiotics? ([[C. diff]])
##TB
*[[HIV]]/immunocompromised/high risk behaviors?
#Parasitic
*Heat intolerance and anxiety? ([[thyrotoxicosis]])
##Giardia
*[[Paresthesias]] or reverse temperature sensation? ([[Ciguatera]])
##Entamoeba
##Cryptosporidia


=== Dietary disturbances ===
===Physical Exam===
*[[Thyroid]] masses
*Oral ulcers, erythema nodosum, episcleritis, [[anal fissure]] ([[IBD]])
*[[Reactive arthritis]] ([[Arthritis]], [[conjunctivitis]], urethritis)
**Suggests infection with [[salmonella]], [[shigella]], [[campylobacter]], or [[yersinia]]


#Overfeeding
==Differential Diagnosis==
#Food allergy
===Infection===
#Starvation stools
*Viral
**[[Rotavirus]]
**[[Norovirus]], Norwalk virus
**[[Enterovirus]]
**[[Adenovirus]]
*Bacterial
**[[Salmonella]]
**[[Shigella]]
**[[Yersinia]]
**[[Campylobacter]]
**[[Escherichia coli]]
**[[Vibrio]] species
**[[Clostridium difficile]]
**[[TB]]
*Parasitic
**[[Giardia]]
**[[Entamoeba]]
**[[Cryptosporidium]]


=== Anatomic abnormalities ===
===Dietary disturbances===
*Overfeeding
*Food [[allergic reaction|allergy]]
*Starvation stools


#Intussusception  
===Anatomic abnormalities===
#Hirschsprung disease  
*[[Intussusception]]
#Partial obstruction
*[[Hirschsprung's disease]]
#Appendicitis  
*Partial [[SBO]]
#Blind loop syndrome  
*[[Appendicitis]]
#Intestinal lymphangiectasia  
*Blind loop syndrome  
#Short bowel syndrome
*Intestinal lymphangiectasia  
*[[Short bowel syndrome]]


=== Malabsorption or secretory diseases ===
===Malabsorption or secretory diseases===
*[[Cystic fibrosis]]
*Celiac disease
*Disaccharidase deficiency
*Secretory neoplasms


##Cystic fibrosis
===Systemic diseases===
##Celiac disease
*Immunodeficiency
##Disaccharidase deficiency
*Endocrinopathy
##Secretory neoplasms
**[[Hyperthyroidism]]
**[[Hypoparathyroidism]]
**[[Congenital adrenal hyperplasia]]


=== Systemic diseases ===
===Miscellaneous===
*[[Inflammatory bowel disease]]
*[[Antibiotic]]-associated diarrhea
*Secondary lactase deficiency
*Irritable colon syndrome
*[[Neonatal abstinence syndrome]]
*[[Toxins]]
*[[Hemolytic uremic syndrome]] (HUS)


#Immunodeficiency
==Evaluation==
#Endocrinopathy
##Hyperthyroidism
##Hypoparathyroidism
##Congenital adrenal hyperplasia


=== Miscellaneous ===
==Management==
===General Treatment===
*[[Reduced-osmolarity oral rehydration solution]]
*If [[rectal bleeding|bloody diarrhea]], use caution with beginning antibiotics in ED before stool culture results
*Some studies demonstrate antibiotic treatment in setting of ''[[E.coli]]'' O157:H7 leads to increasing risk of [[hemolytic uremic syndrome]] (HUS)


#Inflammatory bowel disease
===Diarrheal Pathogens in Children and Specific Therapy===
#Antibiotic-associated diarrhea
#Secondary lactase deficiency
#Irritable colon syndrome
#Neonatal drug withdrawal
#Toxins
#Hemolytic uremic syndrome


== Treatment  ==
{| class="wikitable"
 
=== General Treatment ===
 
If bloody diarrhea, use caution with beginning antibioitics in ED before stool culture results.  Some studies demonstrate antibiotic treatment in setting of ''E.coli'' O157:H7 leads to increasing risk of hemolytic uremic syndrome (HUS).
 
See [[Diarrhea]]
 
=== Diarrheal Pathogens in Children and Specific Therapy ===
 
{| cellpadding="2" border="1"
|-
|-
! align="left" | AGENT  
! align="left" | AGENT  
! align="left" | SPECIFIC THERAPY BEYOND SUPPORTIVE CARE
! align="left" | SPECIFIC THERAPY BEYOND SUPPORTIVE CARE
|-
|-
| align="left" rowspan="2" | ''Campylobacter jejuni''  
| align="left" rowspan="2" | ''[[Campylobacter jejuni]]''  
| align="left" | Azithromycin 12 mg/kg/day PO for 5 days ''or''
| align="left" | [[Azithromycin]] 12mg/kg/day PO for 5 days ''or''
|-
|-
| align="left" | Erythromycin 30–50 mg/kg/day, divided, tid PO for 5–7 days
| align="left" | [[Erythromycin]] 30–50mg/kg/day, divided, tid PO for 5–7 days
|-
|-
| align="left" | ''Clostridium difficile''  
| align="left" | ''[[Clostridium difficile]]''  
| align="left" | Metronidazole 30 mg/kg/day, divided, qid PO for 7–10 days ''or''
| align="left" | [[Metronidazole]] 30mg/kg/day, divided, QID PO for 7–10 days ''or''
|-
|-
| align="left" rowspan="2" | ''Escherichia coli''  
| align="left" rowspan="2" | ''[[Escherichia coli]]''  
| align="left" | Azithromycin 12 mg/kg/day PO for 5 days ''or''
| align="left" | [[Azithromycin]] 12mg/kg/day PO for 5 days ''or''
|-
|-
| align="left" | Trimethoprim-sulfamethoxazole 10 mg (TMP)/kg/day PO divided bid for 5–7 days
| align="left" | [[Trimethoprim-sulfamethoxazole]] 10mg (TMP)/kg/day PO divided BID for 5–7 days
|-
|-
| align="left" | ''Giardia'' lamblia  
| align="left" | ''[[Giardia]]'' lamblia  
| align="left" | Metronidazole 15 mg/kg/day PO, divided, tid for 5 days
| align="left" | [[Metronidazole]] 15mg/kg/day PO, divided, tid for 5 days
|-
|-
| align="left" | ''Salmonella'' species  
| align="left" | ''[[Salmonella]]'' species  
| align="left" | ''In toxic infants &lt;3'' ''mo''<nowiki>:</nowiki><br>Ampicillin 200 mg/kg/24 hours q6h for 7–10 days ''and''<br>Gentamicin 5–7.5 mg/kg/24 hours q8h IV
| align="left" | ''In toxic infants <3'' ''mo''<nowiki>:</nowiki><br>[[Ampicillin]] 200mg/kg/24 hours q6h for 7–10 days ''and''<br>[[Gentamicin]] 5–7.5mg/kg/24 hours q8h IV
|-
|-
| align="left" rowspan="2" | ''Shigella'' species  
| align="left" rowspan="2" | ''Shigella'' species  
| align="left" | Azithromycin 12 mg/kg/day PO for 5 days ''or''
| align="left" | [[Azithromycin]] 12mg/kg/day PO for 5 days ''or''
|-
|-
| align="left" | Trimethoprim-sulfamethoxazole 10 mg (TMP)/kg/day, divided, bid for 5–7 days if susceptible
| align="left" | [[Trimethoprim-sulfamethoxazole]] 10mg (TMP)/kg/day, divided, BID for 5–7 days if susceptible
|-
|-
| align="left" | ''Yersinia enterocolitica''  
| align="left" | ''[[Yersinia enterocolitica]]''  
| align="left" | If patient is immunosuppressed, treat as for presumed sepsis
| align="left" | If patient is immunosuppressed, treat as for presumed sepsis
|-
|-
| align="left" | ''Vibrio''  
| align="left" | ''[[Vibrio cholera]]''  
| align="left" | None; severe diarrhea or cholera may benefit from antibiotics
| align="left" | None; severe diarrhea or cholera may benefit from antibiotics
|}
|}


== See Also ==
==See Also==
 
*[[Diarrhea]]  
*[[Diarrhea]]  
*[[Dehydration]]  
*[[Dehydration (peds)]]  
*[[Nausea and Vomiting]]
*[[Nausea and vomiting (peds)]]
 
*[[Acute gastroenteritis (peds)]]
== Source  ==
 
*Rosen's
*Tintinalli


[[Category:Peds]] [[Category:ID]] [[Category:GI]]
==References==
<references/>
[[Category:Pediatrics]] [[Category:ID]] [[Category:GI]] [[Category:Symptoms]]

Latest revision as of 16:00, 29 January 2025

This page is for pediatric patients. For adult patients, see: diarrhea

Background

Gasterointestinal anatomy.
Layers of the Alimentary Canal. The wall of the alimentary canal has four basic tissue layers: the mucosa, submucosa, muscularis, and serosa.
  • 85% of diarrhea is infectious in etiology
    • Viruses cause vast majority of infectious diarrhea
    • Bacterial causes are responsible for most cases of severe diarrhea

Definitions

  • Diarrhea: Increased frequency of defection, usually >3 bowel movements per day
  • Hyperacute: 1-6 hr
  • Acute: less than 3 weeks in duration
  • Gastroenteritis: Diarrhea with nausea and/or vomiting
  • Dysentery: Diarrhea with blood/mucus/pus
  • Invasive = Infectious

Clinical Features

Bristol Stool Chart.

History

Physical Exam

Differential Diagnosis

Infection

Dietary disturbances

  • Overfeeding
  • Food allergy
  • Starvation stools

Anatomic abnormalities

Malabsorption or secretory diseases

  • Cystic fibrosis
  • Celiac disease
  • Disaccharidase deficiency
  • Secretory neoplasms

Systemic diseases

Miscellaneous

Evaluation

Management

General Treatment

Diarrheal Pathogens in Children and Specific Therapy

AGENT SPECIFIC THERAPY BEYOND SUPPORTIVE CARE
Campylobacter jejuni Azithromycin 12mg/kg/day PO for 5 days or
Erythromycin 30–50mg/kg/day, divided, tid PO for 5–7 days
Clostridium difficile Metronidazole 30mg/kg/day, divided, QID PO for 7–10 days or
Escherichia coli Azithromycin 12mg/kg/day PO for 5 days or
Trimethoprim-sulfamethoxazole 10mg (TMP)/kg/day PO divided BID for 5–7 days
Giardia lamblia Metronidazole 15mg/kg/day PO, divided, tid for 5 days
Salmonella species In toxic infants <3 mo:
Ampicillin 200mg/kg/24 hours q6h for 7–10 days and
Gentamicin 5–7.5mg/kg/24 hours q8h IV
Shigella species Azithromycin 12mg/kg/day PO for 5 days or
Trimethoprim-sulfamethoxazole 10mg (TMP)/kg/day, divided, BID for 5–7 days if susceptible
Yersinia enterocolitica If patient is immunosuppressed, treat as for presumed sepsis
Vibrio cholera None; severe diarrhea or cholera may benefit from antibiotics

See Also

References

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