Types of diarrhea
According to WHO
- passage of 3 or more loose or liquid stools per day, or more frequently than is normal for the individual.
Diarrheal diseases continue to be a major cause of morbidity and mortality in children in developing nations.
In the year 2000, diarrheal diseases claimed an estimated 1.4 to 2.5 million lives; they are among the leading causes of death in children in developing countries
In developed nations , they are an important cause of hospital admission although mortality rates may be lower.
About 9% of all hospitalizations of children younger than 5 years were reported to be a result of diarrhea.
Foods ingested ???
Duration & frequency of diarrhea
Presence of blood or steatorrhoea
Ask whether family @ community members have been affected
2). Physical Examination
Assess degree of dehydration by :-
Pulse and BP measurement
Monitoring of urine output and ongoing stool loses
Blood and urine culture
Stool inspection for blood and examination for ova, cysts and parasites
Asses based on :-
2. Sunken eyes
3. Offer the child drink
4. Skin turgor
1. Mild dehydration (<5%)
2. Moderate dehydration (5-10%)
3. Severe dehydration (>10%)
First, assess the state of dehydration & then choose the treatment plan A, B or C
PLAN A (mild diarrhea)
Give extra fluid
Give ORS and cooled boiled water
Plus food-based fluid (not exclusively breastfed)
*10ml/kg of ORS after each loose stool
2. Continue Feeding
Feed as usual on demand
Avoid food high in simple sugar as osmotic load may worsen the diarrhea
3. When to Return (to clinic/hospital)
Not able to drink
Has blood in stool
PLAN B (moderate diarrhea)
Give recommended amount of ORS 4- hourly
* Approximat amount of ORSs required = weight (in kg) x 75
After 4 hours
Reassess the child
Select appropriate treatment
Begin feeding the child
Explain the 3 rules of PLAN A
PLAN C (severe diarrhea)
Start IV or IO fluid immediately. Give 100ml/kg Ringers Lactate @ normal saline devided as :-
- 1st give 20ml/kg as fast as possible. Repeat boluses until perfusion has improved
- Give the remaining fluid 5 hrs (age < 1 year)
or 2 ½ hrs (age >1 year)
Reassess the child after every bolus
Reassess the child every 1-2 hour during rehydration
Give ORS as soon as the child can drink.
Classify the degree of dehyration
Choose appropriate treatment
Maintenance Fluid Therapy
Volume of fluid required
< 6 months age : 150 ml/kg/day
6 to 1 year : 120 ml/kg/day
>1 year : 1st 10 kg = 100 ml/kg
10- 20 kg = + 50 ml/kg for the subsequent kg
> 20 kg = + 20 ml/kg for the subsequent kg
Blood in stool
Types of Antibiotics:-
“Sally has a fever and is vomiting.”
History of Present Illness
A 4-year-old female is brought to the emergency dept. by her parents.
She started complaining of abdominal pain 3 hrs ago and then had an onset of vomiting episodes x 4.
No blood noted in the emesis or bile appearance.
Temperature taken at home one half hour ago, temperature was 38.2 C.
Mother has also commented on Sally’s increased level of thirst over the
past week, and has attributed Sally’s new onset of night time bedwetting to her increased consumption of fluids.
Vomiting is a coordinated, sequential series of events that leads to forceful oral emptying of gastric contents.
Bilateral vomition centers in the reticular formation of the medulla integrate signals triggers vomition.Thevomition centers receive afferent signals from four major sources:
The chemoreceptor trigger zone -bilateral set of centers in the brainstem lying under the floor of the fourth ventricle. The chemoreceptor trigger zones function as emetic chemoreceptors for the vomition centers - chemical abnormalities in the body (e.g. emetic drugs, uremia, hypoxia and diabetic ketoacidosis) are sensed by these centers, which then send excitatory signs to the vomition centers.
Visceral afferents from the gastrointestinal tract (vagus or sympathetic nerves)
Visceral afferents from outside the gastrointestinal tract - this includes signals from bile ducts, peritoneum, heart and a variety of other organs.
Afferents from extramedullary centers in the brain - certain psychic stimuli (odors, fear), vestibular disturbances (motion sickness) and cerebral trauma
Physiology of vomiting
Nausea - unpleasant psychic experience.
Retching phase - abdominal muscles undergo a few rounds of coordinated contractions together with the diaphragm and the muscles used in respiratory inspiration.
Expulsive phase - intense pressure is formed in the stomach brought by enormous shifts in both the diaphragm and the abdomen. The vigorous contractions of these muscles last much longer than a normal period of muscular contraction. The pressure is then suddenly released when the upper esophageal sphincter relaxes resulting in the expulsion of gastric contents.
Manifested by nausea, pallor and diaphoresis, followed by forceful gagging and retching.
Effortless and not preceded by nausea.
But , the unpleasant sensations of gastric contents in mouth during regurgitation, may trigger gagging and true vomiting.
Gastric secretions are highly acidic.
“coffee ground vomiting"(as the iron in the blood is oxidized)
Fecal vomiting-consequence of intestinal obstruction or a gastrocolic fistula
non-productive emesis or dry heaves-vomiting reflex continues for an extended period with no appreciable vomitus
Bright red-bleeding from the oesophagus
Dark red vomit with liver-like clots- profuse bleeding in the stomach (e.g.; perforated ulcer)
Coffee ground-like vomit-less severe bleeding in the stomach-gastric acid has had time to change the composition of the blood
Yellow vomit-bile indicates that the pyloric valve is open and bile is flowing into the stomach from the duodenum.
U & E
Surgical opinion if obstruction
Exclude systemic disease
Aspiration of vomit
Under normal circumstances the gag reflex and coughing will prevent this from occurring. The individual may choke and asphyxiate or suffer an aspiration pneumonia.
Dehydration and electrolyte imbalance
Tears in GIT
If these tears are limited to the inner lining of esophagus, they are called Mallory-Weiss tears-Passing of bright red or dark blood in the vomitus.
Tears through the entire wall of the esophagus resulting in perforation and the escape of stomach contents outside the gut- “Boerhaave’s syndrome
Painful bruises or tears in the abdominal wall muscles.
Recurrent vomiting may lead to destruction of the tooth enamel due to the acidity of the vomit and also can degrade tissue of the gum.
If prolonged, weight loss or malnutrition may occur.
Stabilize patient and fluid resuscitation as initial therapy with electrolyte correction
Surgical consultation if obstruction suspected
Oral rehydration with small amounts of liquids if tolerated
Treat infections if indicated
Remove toxins and allergens
Surgical interventions for volvulus, Hirschprung, intracranial masses, pyloric stenosis, other anatomic causes
Correct metabolic derangements
Lifelong gluten-free diet for celiac disease
Rare use of antiemetics/promotility agents for chemotherapy, motion sickness, postsurgery, gastroesophageal reflux disease
Pain– feeling of distress, suffering, caused by stimulation of specialized nerve endings.
Abdomen – the part of body lying between the thorax and pelvis, containing the abdominal cavity & viscera
Painful sensation in a body region distant from true source of pain
Caused by activation of spinal cord somatic sensory cell bodies by intense signaling from visceral afferent nerves located at the same level.
overlying body structures are injured
Described as MSK pain
Pain is sharp, intense, discrete & localized
nerves within gut detect injury,affecting soft organ n&body tissue
‘’discomfort’’ and poorly localized
Acute Abdominal Pain
Can signal presence of dangerous intra-abdominal process
-Eg: appendicitis, bowel obstruction
Or originate from extraintestinal sources
-Eg: lower lobe pneumonia or urinary tract stone
onset- sudden or gradual, episodes, association w meals, history of injury
Nature – sharp vs dull, colicky or constant, burning
Location – epigastric, periumbilical,generalized, R or L lower quardrant, change in location over time
Fever – presence suggests appendicitis or other infection
Extraintestinal symptoms – cough, dyspnea, dysuria, urinary frequency, flank pain
Course of symptoms – worsening or improving, changes in nature or location of pain
General – growth & nutrition, general appearance, hydrational status, degree of discomfort, body position
Abdominal – tenderness, distention, bowel sounds, rigidity, guarding, mass
Genitalia – testicular torsion, hernia, PID, ectopic pregnancy
Surrounding structures – breath sounds, rales(crepitation), wheezing, flank tenderness, tenderness of abd. wall structures, ribs, costochondral joints
Rectal examination – perianal lesions, stricture, tenderness, fecal impaction, blood
CBC, C-Reactive protein, ESR – evidence of infection/ inflammation
AST, ALT, GGT, Bilirubin – biliary or liver dss
Amylase, lipase - pancreatitis
Urinalysis – UTI, bleeding d/t stone, trauma or obstruction
Pregnancy test (older females) – ectopic pregnancy
Lower abdominal pain- right iliac fossa,Nausea and vomiting,loss of appetite,Diarrhoea,Dysuria
quiet ,dehydrated.Tenderness on palpation or percussion ,discomfort, Guarding signifies peritonitis,
Rectal examination is only required if other diagnosis are suspected e.g. ovarian or adnexal pathology.
invagination of one portion of intestine into another with involving the ileocaecal junction
peak age group being 2 months to 2 years
Pain - Sudden onset ,severe intermittent cramping pain lasting seconds to minutes
vomiting –undigested food ,Stools- dark red and mucoid (redcurrant jelly)
well- looking/ drowsy/ dehydrated
abdominal mass may be difficult to palpate
in a distended abdomen
Abdominal distension is a late sign
Barium enema in early
RECURRENT ABD. PAIN
At least 3 bouts of significant abd. pain over 3 months
Severe phase lasting at least 3 mins
Usually in children above 3 yr old.
Occurrence of multiple episodes of abdominal pain over at least 3 months that are severe enough to cause some limitation of activity
When taking history, pediatrician should ask about the warning signs for underlying diseases
If any warning signs are presents, further investigation is necessary.
Even if they are absent, some laboratory evaluation is warranted.
Abnormal screening lab. study
Pain awakening child from sleep
Location away from periumbilical region
Blood in stools or emesis
Trial of 3- day lactose-free diet
Celiac disease serology
Barium upper GI
Pain that characteristically occurs daily or nearly every day
Not assoc. with or relieved by eating/ defecation
Assoc. with sig. loss of ability to function normally.
These kids have personality traits that include tendency towards anxiety & perfectionism – results in stress
Parents noted that child enjoys going to school, but the pain often worst at the start of school day & before returning to school after vacations.
Irrittable Bowel Syndrome
cramping, abdominal pain, bloating, constipation, and diarrhea.
Pain begin with a change in stool frequency /consistency.
A stool pattern fluctuating between diarrhea and constipation.
Relief of pain with defecation
Symptom are link to gut motility
Modulated by psychosocial factor such as stress and anxiety.
Treat underlying conditions
Allows children to resume with daily activities
Reassures that the although pain is there, will not harm the children physically (in case of FAP)
IBS-can control symptoms with diet, stress management, and prescribed medications.