Approach to a patient with diarrhea in pediatrics.

1. APPROACH TO A PATIENT WITH
DIARRHEA

2. DIARRHEA
 According to WHO
Diarrhea refers to as the passage of three or more loose or watery stools per day.
 any deviation from the child's usual pattern should raise concern (particularly with
ill appearance, the passage of blood or mucus, or dehydration
 ACUTE – onset < 2 weeks prior to presentation
 CHRONIC – > 2 weeks duration

3. PATHOPHYSIOLOGY
Osmotic Diarrhea:
 when an ingested solute is not
absorbed properly, the higher
concentration gradient within the gut
lumen acts to draw water into
intestinal lumen and greatly
increases the water content of the
stool.
Secretory Diarrhea
 caused by the intestine actively
secreting water into the gut lumen.
 Cholera
 Shigella
 Clostridia Difficile
 E. Coli
taph.Aureus

4. Inflammatory Diarrhea
 Intestinal inflammation can lead to blood,
mucus, and protein exudate losses,
accompanied by fluid and electrolytes.The
most common cause of this type of diarrhea
is infection but can also be due to chronic
diseases such as IBD or Celiac Disease.
Diarrhea due to Motility Disorders
 although uncommon,both an increase and a
decrease in gut motility can be a cause of
diarrhea

5. HISTORYTAKING
 Introduction & Consent
 When did the current problem start?
 How many bowel movements per day?
 What is the normal pattern for this child?
 Are the loose movements interspersed by normal ones?
 Has the child ever experienced this before?
 What is the child’s dietary history (rule out overfeeding)?

6.  What is the consistency of the stool?
 What is the volume of stool that the child is passing?
 Is there blood or pus contained within the stool?
 Is it extremely foul-smelling or contain oil droplets (malabsorption)?
 Bloody diarrhea may suggest specific infectious agents, inflammatory bowel disease, bowel ischemia (or
necrotizing enterocolitis) or cow’s milk protein allergy.

7.  Does the child have a fever?
 Has the child also been vomiting (very common and can exasperate dehydration)?
 What is the child’s current urine output (oliguria or anuria suggests a large volume deficit)?
 Has the child been able to take in any fluids?
 Do we have records of the child’s weight (useful to compare these to the current to assess the degree of
dehydration)?

8.  Is the child immunocompromised (if yes, think unusual infections)?
 Has the child been exposed to anyone else with a similar illness?
 Has there been any travel or has the child newly immigrated?
 Has there been any recent use of antibiotics?

10. DIFFERENTIAL DIAGNOSIS

11. Malabsorption
• Lactase Deficiency
• Celiac Disease
• Short gut syndrome (after bowel resection), fistula or blind loop
• Defective sodium absorption
Feed related
• Overfeeding (infants)
• Excessive diet gum/ sorbitol/ lactulose ingestion

12. Toxin related
• Antibiotics Associated Diarrhea
• Toxin ingestion, chemotherapy, radiation
• Laxative abuse/ accidental ingestion
Psycho-social
• • Irritable bowel syndrome

13. EXAMINATION
 Check vitals and commend on general inspection
 Inspection: Contour, symmetry, pulsation, peristalsis, vascular irregularities, skin
markings, wall protrusion (hernia), signs of trauma, abdominal distension
 Palpation : assess tenderness with light and deep palpation
 Assess guarding, rebound tenderness
 Palpate liver, spleen, kidney, abdominal masses

14.  Percussion : tympanic or dull, percuss liver span, spleen tip
 Auscultation : bowel sound, abdominal bruits
 DRE: Look at anus for fissure,skin tags, assess tone, stool , blood
 Examine testis and hernial orifice

15. LAB
 Complete blood count with differential
 Peripheral blood smear
 Rapid blood glucose
 Serum electrolytes, blood urea nitrogen (BUN), and creatinine
 Blood culture
 Stool culture
 Stool for C. difficile toxin
 Abdominal ultrasound in patients with findings suggesting intussusception or appendicitis

16. RED FLAGS
 ill-appearing
 moderate to severe dehydration
 febrile
 has bloody diarrhea
 has risks factors for a bacterial or parasitic infection
 travel to developing countries, backcountry camping, food
exposures

17. TREATMENT
The majority of children with infectious diarrhea have mild to moderate dehydration and can be managed
as outpatients after receiving appropriate assessment and oral rehydration therapy.
 Fluid resuscitation -with normal saline should be initiated promptly in children with moderate to severe
dehydration particularly important in preventing oliguric renal failure in those patients with HUS.
Patients with toxic megacolon and intussusception may also have significant ongoing third space losses
that must be replaced.
 Antibiotics – Antibiotics should not be used routinely for well-appearing children with acute bloody
diarrhea unless a specific pathogen has been isolated. Antibiotic therapy may be a risk factor for the
development of HUS in patients with bloody diarrhea due to E. coli

18. The cornerstone of management of acute diarrhea with concomitant dehydration is rehydration
 Mild to moderate dehydration - oral rehydration
 Severe dehydration - a bolus of IV fluids

19. for IV therapy
 Depressed level of consciousness
 Moderate dehydration when there is no
improvement after the first 4 hours of treatment
with ORS.
 Uncontrolled vomiting, poor urine output
 Patient unable to drink from extreme fatigue, stupor,
or coma
for Antibiotic
o Acute bloody diarrhea with gross blood
o Severe invasive bacterial diarrhea
o Associated systemic infection
o Severe malnutrition
o Sepsis

20. OTHER AGENTS
Zinc
 reduces the severity and duration of diarrhea
 reduces the incidence of subsequent episodes of diarrhea for several
Vitamin A
 resource-limited countries - high risk of vitamin A deficiency
Probiotics
 products derived from food sources, especially cultured milk products, are effective in reducing the incidence of
diarrhea in patients who are taking antibiotics.

21. REFERENCE
 https://www.uptodate.com/contents/approach-to-the-child-with-acute-
diarrhea-in-resource-limited-
countries?topicRef=6456&source=see_link#H1159942460
 https://www.uptodate.com/contents/approach-to-diarrhea-in-children-in-
resource-rich-countries#H20
 http://pedscases.com/sites/default/files/Approach%20to%20Acute%20Diarrhea
%20Script.pdf
 Amboss
 Accesspeds