Pratica di Shadowing: Pediatric Diarrhea – Pediatrics | Lecturio - Impara a parlare inglese con i video
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So, what about a patient with diarrhea?
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The definition of diarrhea is more than 10 cc's per kilo per day of fluid lost through stools.
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That might be on a test.
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I find it fairly useless in terms of a definition,
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mostly because it's almost impossible to measure how many cc's per kilogram per day of stool is coming out of a child.
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The leading cause of death worldwide in terms of morbidity and mortality in children is infectious diarrhea.
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Rotavirus is a killer in the developing world.
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In the United States, much less common
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because we have a medical system where children can come and get help if they're feeling dehydrated.
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Generally, we will define diarrhea as acute or chronic.
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The vast majority of diarrhea is acute and it is less than two weeks prior to presentation.
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If a patient has more than two weeks of duration of diarrhea, we will call that chronic
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and we'll go through in a bit what the differences are in terms of etiologies of these various types of problems.
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So let's go through types of diarrhea because this is important to understand and can sometimes show up on exams as well.
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Secretory diarrhea is when intestinal epithelial cells are actively secreting water into the intra-intestinal compartment
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and electrolytes are going along with it and through osmotic forces are causing water loss out into the stools.
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The classic example here is cholera toxin.
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It is extremely rare to encounter secretory diarrhea in children in developing countries.
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Osmotic diarrhea is much more common.
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This is generally because of ingested solutes
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which are poorly absorbed causing water to get extruded into the intestinal compartment and then stooled out.
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An example of this is a child who drinks too much juice.
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Unfortunately, we see this a lot.
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We sometimes even see children who are failing to thrive because of excessive juice consumption to reduce consumption.
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So, children who eat large amounts of osmotic material will start to stool out.
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Motality disorders can occur occasionally happen which can decrease transit time.
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Generally, this is through bacterial overgrowth.
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This is not too common.
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Lastly, and especially in children with things like short gut syndrome,
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patients may have decreased surface area and thus an inability to actually absorb material creating what is effectively an osmotic diarrhea.
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Short gut syndrome is really common in some of our NICU graduates, especially those who have made it through an experience of surgical necrotizing enterocolitis.
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So let's drill down into the causes of acute diarrhea.
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By far and away the most common cause is infectious
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and among infectious causes by far and away the most common is viral etiologies.
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Viral illness used to be more in the spring with rotavirus outbreaks.
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That's less common now because of the vaccination that we do.
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So it now tends to be a little bit more in the summer and perhaps into the fall as well.
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And of course in the winter we see some viral gastroenteritis as well.
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Bacterial etiologies are not uncommon.
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We see Campylobacter, E coli,
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Salmonella, Shigella, even Yersinia and all of these can cause bloody stools.
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In patients who have been exposed to antibiotics, you may see C difficile.
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There may be systemic infections that are causing children to have acute diarrhea,
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especially younger children who may just have that as a response to their general infection and parasites are possible, although more common in developing countries.
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In older children, you may see that with food poisoning, although with food poisoning which is ingestion of a preformed toxin rather than the actual bacteria causing the problem,
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more commonly patients have vomiting as well.
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There are of course non-infectious causes of acute diarrhea.
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Antibiotic associated diarrhea is common
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with some antibiotics such as amoxicillin clavulinic acid
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which may cause diarrhea in up to 40% of the patients who are taking the drug.
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Hirschsprung toxic colitis is an unusual but important condition to know about.
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I say non-infectious because the patient has an underlying problem with Hirschsprung's disease.
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As you recall, and there is another lecture on Hirschsprung's,
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patients will have a lack of ganglions in their rectal muscular tissue which causes them to be tonically constricted and get constipation.
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However, if these patients get diarrhea, an acute viral gastroenteritis or bacterial gastroenteritis,
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they can get very, very sick because the diarrhea has a hard time getting out
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and bacteria can invade the intestinal wall and these patients can go into shock.
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Neonates, and we're seeing more of this than ever before, are exposed to opium or opiates in utero and as they come out,
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diarrhea is a common result of withdrawal from opiate exposure.
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Patients with congenital adrenal hyperplasia will often have diarrhea at birth.
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In older children, we again see the antibiotic-associated diarrhea.
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appendicitis may cause diarrhea but it's more common that they have vomiting and abdominal pain.
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Chronic diarrhea can also cause problems in children although it's much less rare than acute diarrhea.
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Examples in both infants and older children include parasites
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and abscesses around the appendix as in an old perforated appendix that's healed up and there have some residual diarrhea left over.
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Patients may have malabsorption problems and again this will cause more of that osmotic diarrhea.
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So examples would be post-infectious,
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after their diarrhea, children can rub off the lactase in their intestinal wall and be transiently lactose intolerant.
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Patients can have food protein intolerance or allergy.
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Children can get cystic fibrosis, celiac disease, toddler's diarrhea.
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In older children, we do see true lactose intolerance even though that's much rarer in the younger children and infants.
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Adolescents who are trying to lose weight inappropriately may use laxatives.
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Celiac disease and very, very rarely secretory neoplasms can cause a secretory diarrhea.
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Of course, auto-inflammatory processes occur.
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In younger children, we see eosinophilic gastroenteritis and in older children we would add in the potential diagnosis of inflammatory bowel disease.
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All of these diseases are where children would have prolonged areas
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of diarrhea going on for a long period of time
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and you'd start to drill down into some of these diagnoses in such a patient.
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Additionally, you may see children with immunodeficiency.
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These children will usually get other infections as well, things like severe combined immune deficiency or HIV.
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Again, adrenal insufficiently can cause this, as can hyper or hypoparathyroidism.
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So, endocrinopathies can also cause chronic diarrhea.
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Other problems can cause chronic diarrhea as well.
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Rare things like lymphangiectasis in children, toxin exposure, and rarely congenital bowel disorders.
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In older children, you may see constipation causing what appears to be diarrhea when in fact it's not.
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It's just enkopresis, liquid stool squirting around the hard ball of stool that the child can no longer get out.
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Irritable bowel syndrome starts to happen in older children and of course toxins can rarely cause this as well.
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So if you see a child with vomiting and or diarrhea, what are key things you want to ask?
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First is obviously fever.
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Children with infectious diarrhea typically may have a fever.
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Ask about blood or mucus in the stool.
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This may tip you off that this is a bacterial as opposed to a viral pathogen.
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Most bacterial gastroenteritis requiring treatment is bloody.
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Ask about exposure to farm animals or reptiles.
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This is actually a really important question
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because a common cause of salmonella in children is reptile pets and a common cause of E coli
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and especially the variety that causes hemolytic uremic syndrome is from farm animal exposure.
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Petting zoos are a big problem in the United States
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if children don't wash their hands with alcohol after they pet the animals.
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Suspicious foods are always a potential cause and we hear about outbreaks all the time, for example, E coli and spinach.
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This happens periodically and so when such a thing happened you might ask about suspicious
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or also undercooked foods things like uncooked eggs which might show up in raw cookie dough.
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Ask about recent travel.
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Recent travel is important because there are some causes of diarrhea
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that are unusual in the United States that may be more prevalent in developing countries.
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And of course, ask about recent antibiotic use because C diff is a possibility as well as antibiotic associated diarrhea.
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So on exam, critically important to look for signs of dehydration.
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Tenting is rare and is only at extreme ends of dehydration.
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Mostly you're going to look at mucous membranes and see if they're moist.
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See if the child is making tears when they cry.
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Look for signs of systemic infection.
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Is there something else going on?
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The abdominal exam is critical, especially looking for rebound, guarding, things like that where the child doesn't want you pressing on their abdomen.
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In babies, this can be tricky.
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The baby, if you're careful, will seem to resist you if you squeeze on their belly.
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But in a crying baby who doesn't want to be examined in the first place, this can be a challenge.
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A perianal inspection is important on children, especially if you're concerned about inflammatory bowel disease.
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Sometimes a rectal tag or fissure is the best clue you have that the child has Crohn's disease.
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So what lab work would you get?
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Again, serum electrolytes.
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You might get stool bacterial cultures.
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The question is, is this cost effective?
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Because the reality is the vast majority of bacterial enteritis we do not treat with antibiotics.
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They get better on their own.
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In fact, there is some evidence that the varieties of E coli
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that cause hemolytic uremic syndrome may be more likely to cause hemolytic uremic syndrome if treated.
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We really reserve treatment of bacterial enteritis for Shigella, Salmonella that's severely bad or in children under three months of age,
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or a child who simply isn't getting better from their bacterial enteritis.
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There is now emerging stool PCR panels that are very effective at picking up a variety of illnesses that can cause gastroenteritis.
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These panels are available through rectal swab or through stool collected and sent to the lab.
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Right now the cost for these panels is very high.
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At our hospital it costs upwards of $800.
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So it's important to have a very good reason why you're getting this test.
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If it's preventing a child from going to the operating room for endoscopy, it's probably worth it.
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But if it's just to see what it is, it might not be.
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Waiting for the child to get better may be your best option.
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Stool microscopy for ovum parasites may be effective in a child who you suspect has an ovum parasite.
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However, remember this is also costly.
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It's labor intensive in the lab.
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And so don't send it on every patient.
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Really limit it to patients where you strongly suspect a parasite.
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For example, someone who's recently been abroad.
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If you're suspecting hemolytic uremic syndrome, and we will talk about that more in another lecture,
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It's critically important to assess renal function, to test for E coli 0157H7
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and of course to get a CBC to look for thrombocytopenia and anemia.
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If you suspect failure to thrive in a child, the child is not gaining weight and this is associated with prolonged diarrhea,
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it's important to consider cystic fibrosis.
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Tests we can get include stool elastase, but the cheapest test and the easiest test is simply a sweat test.
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For inflammatory bowel disease patients, we might check for elevated inflammatory markers, such as the ESR, the SED rate,
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or the CRP, but remember that those tests may be normal even during an inflammatory bowel disease flare.
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Probably the best test we can get is the fecal calprotectin or tectin.
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For patients where we suspect malabsorption, a child with for example, edema, who might have a low protein level causing them to be edematous,
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it can be done that we can check for things like stool reducing substances, which would check for sugar,
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fecal fat, or alpha-1-anytrypsin in the stool.
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If we suspect immunodeficiency, of course getting an HIV test should be on everyone's priority
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as well as checking for lymphocyte counts and looking at their immunoglobulin profile.
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So if we have a patient who has prolonged diarrhea and emesis and we, despite all those labs, cannot figure out what's going on,
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we will usually proceed to endoscopy or colonoscopy depending on which side has the problem.
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So examples of this would be a child where we suspect
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inflammatory bowel disease these children really endoscopy is the best way to make that diagnosis.
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If there's an unclear cause of malabsorption, we'll do endoscopy to try and figure out what's going on.
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Sometimes the biopsies can show us a problem with the brush border in the colon, for example, which may give us a clue as to what's going on
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and why that child is not able to absorb nutrients.
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In patients with celiac disease, we think about getting the TTG and the IgA levels from the blood.
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And that is how we can make a presumptive diagnosis.
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But most physicians will want an actual biopsy of the intestine wall to verify
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that that's the diagnosis because the diagnosis of celiac disease is a tough one to give to a patient.
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Remember, they have to change their diet for the rest of their lives.
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Obviously, in any patient with a severe GI bleed, we want to go to endoscopy to try and stop the bleed.
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Remember, GI bleeds can happen very quickly and can be very severe and life-threatening.
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Lastly, certainly if we suspect suspicion for enteric disease, such as eosinophilic esophagitis or eosinophilic gastritis,
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a biopsy is necessary to truly make that diagnosis.
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Also, visualization of the enteric wall may give us clues as to what's going on.
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So that's my summary of everything that has to do with children who are vomiting or have diarrhea.
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And it's a good overview for you to keep in mind as we delve into more of these diseases in further lectures.
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Thanks for your time.
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you
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Di cosa tratta questa lezione
In questa lezione, gli studenti avranno l'opportunità di praticare l'inglese attraverso una discussione approfondita sulla diarrea pediatrica, una condizione comune nei bambini. Apprenderanno non solo i termini medici fondamentali e le varie cause di diarrea, ma anche come descrivere i sintomi e i trattamenti. Questo argomento è particolarmente utile per coloro che desiderano ampliare il proprio vocabolario in campo medico e migliorare le capacità di conversazione attraverso la tecnica dello shadowing in inglese, che include pratiche come il shadow speak. Gli studenti eserciteranno la loro pronuncia e comprenderanno meglio le differenti terminologie utilizzate dai professionisti della salute.
Vocabolario e frasi chiave
- Diarrea - Diarrhea
- Rottavirus - Rotavirus
- Disidratazione - Dehydration
- Diarrhea acuta - Acute diarrhea
- Diarrhea cronica - Chronic diarrhea
- Infezione virale - Viral infection
- Disturbi di motilità - Motility disorders
- Antibiotici - Antibiotics
Consigli per la pratica
Per massimizzare i benefici dell'esercizio di shadowing, ascolta attentamente il video e ripeti immediatamente dopo il narratore, cercando di imitare l'intonazione e il ritmo. La velocità del video, sebbene rapida, è chiara, il che facilita la comprensione. Se necessario, rallenta il video per sentirti più a tuo agio e assicurati di concentrarti sulle connessioni tra le parole. Utilizza il shadowspeak per affermare la tua pronuncia e il lessico appreso, ripetendo frasi chiave più volte. Non aver paura di fare degli errori: il shadow speech è un ottimo modo per costruire fiducia e fluidità nell'inglese parlato. Infine, prova a registrarti mentre parli e ascolta le tue registrazioni per identificare aree di miglioramento.
La grammatica di questo video
Le strutture che chi parla usa di più, con le parole esatte del video:
| Struttura | Nel video |
|---|---|
| Frasi condizionali if + frase, will/would + verbo — una condizione e il suo risultato | if you're careful, will seem |
| Forma passiva be + participio passato — conta ciò che accade, non chi lo fa | are poorly absorbed · have been exposed · be tonically constricted |
| Frasi relative who / which + frase — un’informazione in più su una persona o una cosa | children who are · children who eat · happen which can |
| Present perfect have/has + participio passato — un’azione passata che conta ancora adesso | have made · have been exposed · who's recently been |
Cos'è la tecnica dello Shadowing?
Shadowing è una tecnica di apprendimento delle lingue supportata da studi scientifici, originariamente sviluppata per la formazione dei traduttori professionisti e resa popolare dal poliglotta Dr. Alexander Arguelles. Il metodo è semplice ma potente: ascolti un audio in inglese di madrelingua e lo ripeti immediatamente ad alta voce — come un'ombra che segue il parlante con un ritardo di solo 1–2 secondi. A differenza dell'ascolto passivo o degli esercizi di grammatica, lo shadowing costringe il tuo cervello e i muscoli della bocca a elaborare e riprodurre simultaneamente i modelli di discorso reale. La ricerca dimostra che migliora significativamente la precisione della pronuncia, l'intonazione, il ritmo, il discorso connesso, la comprensione dell'ascolto e la fluidità del parlato — rendendolo uno dei metodi più efficaci per la preparazione alla prova di speaking dell'IELTS e per la comunicazione reale in inglese.