Diarrhea (peds): Difference between revisions
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{{Peds top}} [[diarrhea]] | |||
==Background== | ==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]]) | |||
===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== | ==Clinical Features== | ||
[[File:BristolStoolChart.png|thumb|Bristol Stool Chart.]] | |||
===History=== | |||
*Possible food poisoning? | |||
**Symptoms occur within 6hr | |||
*Does it resolve (osmotic) or persist (secretory) with fasting? | |||
*Are the stools of smaller volume (large intestine) or larger volume (small intestine) | |||
*[[Fever]] or [[abdominal pain]]? ([[diverticulitis]], [[gastroenteritis]], [[IBD]]) | |||
*[[GI bleeding|Bloody or melenic]]? | |||
*Tenesmus? ([[shigella]]) | |||
*Malodorous? ([[giardia]]) | |||
*Recent travel? ([[Traveler's Diarrhea]]) | |||
*Recent antibiotics? ([[C. diff]]) | |||
*[[HIV]]/immunocompromised/high risk behaviors? | |||
*Heat intolerance and anxiety? ([[thyrotoxicosis]]) | |||
*[[Paresthesias]] or reverse temperature sensation? ([[Ciguatera]]) | |||
===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]] | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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===Miscellaneous=== | ===Miscellaneous=== | ||
*[[Inflammatory bowel disease]] | *[[Inflammatory bowel disease]] | ||
*Antibiotic-associated diarrhea | *[[Antibiotic]]-associated diarrhea | ||
*Secondary lactase deficiency | *Secondary lactase deficiency | ||
*Irritable colon syndrome | *Irritable colon syndrome | ||
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==Management== | ==Management== | ||
===General Treatment=== | ===General Treatment=== | ||
*If bloody diarrhea, use caution with beginning antibiotics in ED before stool culture results | *[[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) | *Some studies demonstrate antibiotic treatment in setting of ''[[E.coli]]'' O157:H7 leads to increasing risk of [[hemolytic uremic syndrome]] (HUS) | ||
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|- | |- | ||
| align="left" | ''[[Salmonella]]'' species | | align="left" | ''[[Salmonella]]'' species | ||
| 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" | ''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 12mg/kg/day PO for 5 days ''or'' | | align="left" | [[Azithromycin]] 12mg/kg/day PO for 5 days ''or'' | ||
|- | |- | ||
| align="left" | [[Trimethoprim-sulfamethoxazole]] 10mg (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 |
Latest revision as of 20:40, 6 March 2024
This page is for pediatric patients. For adult patients, see: diarrhea
Background
- 85% of diarrhea is infectious in etiology
- Viruses cause vast majority of infectious diarrhea
- Bacterial causes are responsible for most cases of severe diarrhea
- Foreign travel associated with 80% probability of bacterial diarrhea (see Traveler's 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
History
- Possible food poisoning?
- Symptoms occur within 6hr
- Does it resolve (osmotic) or persist (secretory) with fasting?
- Are the stools of smaller volume (large intestine) or larger volume (small intestine)
- Fever or abdominal pain? (diverticulitis, gastroenteritis, IBD)
- Bloody or melenic?
- Tenesmus? (shigella)
- Malodorous? (giardia)
- Recent travel? (Traveler's Diarrhea)
- Recent antibiotics? (C. diff)
- HIV/immunocompromised/high risk behaviors?
- Heat intolerance and anxiety? (thyrotoxicosis)
- Paresthesias or reverse temperature sensation? (Ciguatera)
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
Differential Diagnosis
Infection
- Viral
- Rotavirus
- Norovirus, Norwalk virus
- Enterovirus
- Adenovirus
- Bacterial
- Parasitic
Dietary disturbances
- Overfeeding
- Food allergy
- Starvation stools
Anatomic abnormalities
- Intussusception
- Hirschsprung's disease
- Partial SBO
- Appendicitis
- Blind loop syndrome
- Intestinal lymphangiectasia
- Short bowel syndrome
Malabsorption or secretory diseases
- Cystic fibrosis
- Celiac disease
- Disaccharidase deficiency
- Secretory neoplasms
Systemic diseases
- Immunodeficiency
- Endocrinopathy
Miscellaneous
- Inflammatory bowel disease
- Antibiotic-associated diarrhea
- Secondary lactase deficiency
- Irritable colon syndrome
- Neonatal abstinence syndrome
- Toxins
- Hemolytic uremic syndrome
Evaluation
Management
General Treatment
- Reduced-osmolarity oral rehydration solution
- If 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)
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 |