Pratica di Shadowing: Pediatric Diarrhea – Pediatrics | Lecturio - Impara a parlare inglese con i video

So, what about a patient with diarrhea?

The definition of diarrhea is more than 10 cc's per kilo per day of fluid lost through stools.

That might be on a test.

I find it fairly useless in terms of a definition,

mostly because it's almost impossible to measure how many cc's per kilogram per day of stool is coming out of a child.

The leading cause of death worldwide in terms of morbidity and mortality in children is infectious diarrhea.

Rotavirus is a killer in the developing world.

In the United States, much less common

because we have a medical system where children can come and get help if they're feeling dehydrated.

Generally, we will define diarrhea as acute or chronic.

The vast majority of diarrhea is acute and it is less than two weeks prior to presentation.

If a patient has more than two weeks of duration of diarrhea, we will call that chronic

and we'll go through in a bit what the differences are in terms of etiologies of these various types of problems.

So let's go through types of diarrhea because this is important to understand and can sometimes show up on exams as well.

Secretory diarrhea is when intestinal epithelial cells are actively secreting water into the intra-intestinal compartment

and electrolytes are going along with it and through osmotic forces are causing water loss out into the stools.

The classic example here is cholera toxin.

It is extremely rare to encounter secretory diarrhea in children in developing countries.

Osmotic diarrhea is much more common.

This is generally because of ingested solutes

which are poorly absorbed causing water to get extruded into the intestinal compartment and then stooled out.

An example of this is a child who drinks too much juice.

Unfortunately, we see this a lot.

We sometimes even see children who are failing to thrive because of excessive juice consumption to reduce consumption.

So, children who eat large amounts of osmotic material will start to stool out.

Motality disorders can occur occasionally happen which can decrease transit time.

Generally, this is through bacterial overgrowth.

This is not too common.

Lastly, and especially in children with things like short gut syndrome,

patients may have decreased surface area and thus an inability to actually absorb material creating what is effectively an osmotic diarrhea.

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.

So let's drill down into the causes of acute diarrhea.

By far and away the most common cause is infectious

and among infectious causes by far and away the most common is viral etiologies.

Viral illness used to be more in the spring with rotavirus outbreaks.

That's less common now because of the vaccination that we do.

So it now tends to be a little bit more in the summer and perhaps into the fall as well.

And of course in the winter we see some viral gastroenteritis as well.

Bacterial etiologies are not uncommon.

We see Campylobacter, E coli,

Salmonella, Shigella, even Yersinia and all of these can cause bloody stools.

In patients who have been exposed to antibiotics, you may see C difficile.

There may be systemic infections that are causing children to have acute diarrhea,

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.

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,

more commonly patients have vomiting as well.

There are of course non-infectious causes of acute diarrhea.

Antibiotic associated diarrhea is common

with some antibiotics such as amoxicillin clavulinic acid

which may cause diarrhea in up to 40% of the patients who are taking the drug.

Hirschsprung toxic colitis is an unusual but important condition to know about.

I say non-infectious because the patient has an underlying problem with Hirschsprung's disease.

As you recall, and there is another lecture on Hirschsprung's,

patients will have a lack of ganglions in their rectal muscular tissue which causes them to be tonically constricted and get constipation.

However, if these patients get diarrhea, an acute viral gastroenteritis or bacterial gastroenteritis,

they can get very, very sick because the diarrhea has a hard time getting out

and bacteria can invade the intestinal wall and these patients can go into shock.

Neonates, and we're seeing more of this than ever before, are exposed to opium or opiates in utero and as they come out,

diarrhea is a common result of withdrawal from opiate exposure.

Patients with congenital adrenal hyperplasia will often have diarrhea at birth.

In older children, we again see the antibiotic-associated diarrhea.

appendicitis may cause diarrhea but it's more common that they have vomiting and abdominal pain.

Chronic diarrhea can also cause problems in children although it's much less rare than acute diarrhea.

Examples in both infants and older children include parasites

and abscesses around the appendix as in an old perforated appendix that's healed up and there have some residual diarrhea left over.

Patients may have malabsorption problems and again this will cause more of that osmotic diarrhea.

So examples would be post-infectious,

after their diarrhea, children can rub off the lactase in their intestinal wall and be transiently lactose intolerant.

Patients can have food protein intolerance or allergy.

Children can get cystic fibrosis, celiac disease, toddler's diarrhea.

In older children, we do see true lactose intolerance even though that's much rarer in the younger children and infants.

Adolescents who are trying to lose weight inappropriately may use laxatives.

Celiac disease and very, very rarely secretory neoplasms can cause a secretory diarrhea.

Of course, auto-inflammatory processes occur.

In younger children, we see eosinophilic gastroenteritis and in older children we would add in the potential diagnosis of inflammatory bowel disease.

All of these diseases are where children would have prolonged areas

of diarrhea going on for a long period of time

and you'd start to drill down into some of these diagnoses in such a patient.

Additionally, you may see children with immunodeficiency.

These children will usually get other infections as well, things like severe combined immune deficiency or HIV.

Again, adrenal insufficiently can cause this, as can hyper or hypoparathyroidism.

So, endocrinopathies can also cause chronic diarrhea.

Other problems can cause chronic diarrhea as well.

Rare things like lymphangiectasis in children, toxin exposure, and rarely congenital bowel disorders.

In older children, you may see constipation causing what appears to be diarrhea when in fact it's not.

It's just enkopresis, liquid stool squirting around the hard ball of stool that the child can no longer get out.

Irritable bowel syndrome starts to happen in older children and of course toxins can rarely cause this as well.

So if you see a child with vomiting and or diarrhea, what are key things you want to ask?

First is obviously fever.

Children with infectious diarrhea typically may have a fever.

Ask about blood or mucus in the stool.

This may tip you off that this is a bacterial as opposed to a viral pathogen.

Most bacterial gastroenteritis requiring treatment is bloody.

Ask about exposure to farm animals or reptiles.

This is actually a really important question

because a common cause of salmonella in children is reptile pets and a common cause of E coli

and especially the variety that causes hemolytic uremic syndrome is from farm animal exposure.

Petting zoos are a big problem in the United States

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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Pratica di Shadowing: Pediatric Diarrhea – Pediatrics | Lecturio - Impara a parlare inglese con i video

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