Pediatric Diarrhea – Pediatrics | Lecturio

[Music] so what about a patient with diarrhea the definition of diarrhea is more than 10 cc's per kilo per day a fluid loss 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 and 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 ideologies 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 isn't in 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 ex croute extruded into the intestinal compartment and then stool doubt an example 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 so children who eat large amounts of osmotic material will start to stool out motility 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 ideologies viral illness used to be more in the spring with rotavirus outbreaks that's less common now because of the vaccinations 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 ideologies are not uncommon we see Campylobacter ecoli Salmonella Shigella even your cine ax 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 ER 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 clavulanic acid which may cause diarrhea in up to 40 percent 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 a 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 withdraw from opiate exposure patients with congenital adrenal hyperplasia will often have diarrhea at birth in older children we again see the antibiotic diarrhea appendicitis may cause diarrhea but it's more common to 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 leftover 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 transient lactose intolerant patients can have food protein intolerance or allergy children can get cystic fibrosis celiac disease toddlers 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 eosinophils gastroenteritis and in older children we would add in the diet 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 hypo parathyroid ism so endocrine op these can also cause chronic diarrhea other problems can cause chronic diarrhea as well rare things like lymph inject asia's and 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 an caprices liquid stool squirting around The Hardball 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 path 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 it's 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 suspicious foods are always a potential cause and we hear about outbreaks all the time for example eco lion spinach this happens periodically and so when such a thing happened you might ask about suspicious or also undercooked foods things like uncooked eggs which might show up in raw cookie dough ask about recent travel recent travel is important because there are some causes of diarrhea that are unusual in the United States that may be more prevalent in developing countries and of course ask about recently antibiotic use because see diff is a possibility as well as antibiotic associated diarrhea so on exam critically important to look for signs of dehydration tenting is rare and is only at extreme ends of dehydration mostly you're gonna look at mucous membranes and see if they're moist see if the child is making tears when they cry look for signs of systemic infection is there something else going on the abdominal exam is critical especially looking for rebound guarding things like that where the job doesn't want you pressing on their abdomen in babies this can be tricky the baby if you're careful will seem to resist you if you squeeze on their belly but in a crying baby who doesn't want to be examined in the first place this can be a challenge a perianal is inspection is important on children especially if you're concerned about inflammatory bowel disease sometimes a rectal tag or fissure is the best clue you have that the child has Crohn's disease so what lab work would you get again serum electrolytes you might get stool bacterial cultures the question is is this is cost effective because the reality is the vast majority of bacterial and titus we do not treat with antibiotics they get better on their own in fact there is some evidence that the varieties of e.coli that cause hemolytic uremic syndrome may be more likely to cause hemolytic uremic syndrome if treated we really reserve treatment of bacteria Lander itis for Shigella Salmonella that's severely bad or in children under three months of age or a child who simply isn't getting better from their bacterial enteritis there is now emerging stool PCR panels that are very effective at picking up a variety of illnesses that can cause gastroenteritis these panels are available through rectal swab or through tisha through stool collected and sent to the lab right now the cost for these panels is very high at our hospital it cost upwards of eight hundred dollars so it's important to have a very good reason why you're getting this test if it's preventing a child from going to the operating room for endoscopy it's probably worth it but if it's just to see what it is it might not be waiting for the child to get better may be your best option stool microscopy for Auvergne para sites may be effective in a child who you suspect has an overrun parasite however remember this is also costly it's labor intensive in the lab and so don't send it on every patient really limit it to patients where you strongly suspect a parasite for example someone who's recently been abroad if you're suspecting hemolytic uremic syndrome and we will talk about that more in another lecture it's critically important to assess renal function to test for e.coli o157 h7 and of course to get a CBC to look for thrombocytopenia and anaemia if you suspect failure thrive in a child the child is not gaining weight and this is associated with prolonged diarrhea it's important to consider cystic fibrosis tests we can get include stool elastase but the cheapest test and the easiest test is simply a sweat test for inflammatory bowel disease patients we might check for in elevated inflammatory markers such as the ESR the sed rate or the CRP but remember that those tests may be normal even during an inflammatory bowel disease flare probably the best test we can get is the fecal calprotectin for patients where we suspect malabsorption a child with for example edema who might have a low protein level causing them to be a dentist it can be done that we can check for things like stool reducing substances which would check for sugar fecal fat or alpha want any trypsin in the stool if we suspect immunodeficiency of course getting HIV test should be on everyone's priority as well as checking for lymphocyte counts and looking at their immunoglobulin profile 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 we will usually proceed to endoscopy or colonoscopy depending on which side has it has the problem so examples of this would be a child where we suspect inflammatory bowel disease these children really endoscopy is the best way to make that diagnosis if there's an unclear cause of malabsorption will do endoscopy to try and figure out what's going on sometimes the biopsies can show us a problem with the brush border and the colon for example which may give us a clue as to what's going on and why that child is not able to absorb nutrients in patients with celiac disease we think about getting the ttg and the IgA levels from the blood and that is how we can make a presumptive diagnosis but most physicians will want an actual biopsy of the intestinal wall to Vera by that that's the diagnosis because the diagnosis of celiac disease is a tough one to give to a patient remember they have to change their diet for the rest of their lives obviously in any patient with a severe GI bleed we want to go do endoscopy to try and stop the bleed remember GI bleeds can happen very quickly and can be very severe at life-threatening lastly certainly if we suspect suspicion for enteric disease such as eosinophils esophagitis or yes anagh philic gastritis a biopsy is necessary to truly make that diagnosis also visualization of the enteric wall may give us clues as to what's going on so that's my summary of everything that has to do with children who are vomiting or have diarrhea and it's a good overview for to keep in mind as we delve into more of these diseases and further lectures thanks for your time [Music]

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Keywords: Medicine, Exam Preparation, Medical Videos, Meducation, Pediatric Diarrhea, Pediatric Vomiting, Diagnosis of Pediatric Diarrhea, Infectious Diarrhea, Treatment of Pediatric Diarrhea, Pediatric gastrointestinal disturbances, Pediatrics, Pediatrics lecture, Pediatrics USMLE, USMLE Step 1, Pathology of pediatric diarrhea

Id: oCIQ8j8X9Vs

Length: 16min 49sec (1009 seconds)

Published: Tue Mar 19 2019