Diarrhea (peds)
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 |