10/02/16

ACUTE GASTROENTERITIS
IN PAEDIATRICS
Dr Ho Kit Lum

CASE PRESENTATION
10/02/16

Patient Biodata
Name
DOB
Age
Race
Sex
Address
Date of admission

: Y.X L
: 11/08/2013
: 1 year 6 month old
: Chinese
: Male
: Taman Mawar
: 8th of March 2015
2

10/02/16

Chief complaints:
Vomiting

for 5 days
Diarrhoea for 5 days
Fever for 5 days
Lethargy for 1 day
Reduce oral intake for 1 day

10/02/16

Day 3 of illness
Symptoms

10/02/16

of diarrhoea and vomiting reduced

Day 4 of illness
Vomited

> 10times, vomitus contain food particles

Diarrhoea 6 times, yellowish watery stool with no blood
no mucus

Day 5 of illness
Came

to ETD at 10am when patient getting more

lethargy and reduce oral intake.
Otherwise no abdominal pain, no rash, no hematuria,
UTI symptoms.

10/02/16

1st hospitalization
Antenatal/Perinatal history: SVD at term, BW
2.60 kg.
Immunization up to age.
History of eating food at parents friends open
house.
Dietary history: exclusively breastfed till 6 month
and weaning at 6 months. Currently tolerating
infant formula 6 ounze 6 bottle/day with normal
adult diet.

Family history

10 year old

7 year old

Developmental milestone
up to age

30 year old
Housewife

10/02/16

34 year
Businessman

5 year old

PHYSICAL EXAMINATION

10/02/16

Alert, pink, fretful on examination, dry lips mucosa,

eye sunken, good pulse volume, good skin turgor, eager
to drink.
Vital signs: BP 95/66, PR 137 (>130 PR tarchycardia),
T: 37.8C RR: 35
Abdomen: Umbilical central located and inverted.
Abdomen fullness but soft. No hepatosplenomegaly, no
mass palpable, no ascites. Bowel sound hyperactive.
Respi: clear, a/e equal bilaterally.
CVS: s1s2 heard no murmur
Weight : 9 kg ( above 5th centile)
Height : 79cm ( above 10th centile)

IN SUMMARY

10/02/16

My patient, a 1 year old 6 month boy presented

with persistent vomiting and diarrhoea for 5/7
associated with on and off fever. He has 2 sisters
who have similar presentations and history of
outside food at friends open house together. On
examination patient dry mucosa lip, sunken eyes
and irritable but still can tolerate orally.
Impression: Acute Gastroenteritis with moderate
dehydration 5%.
9

INVESTIGATION

Full blood count (8/3/2015) :

WBC
8.88 (N- 4.12, L-3.61)
HB
12.8
HCT
39.6%
Platelet 299

VBG :
8/3/15

pH
pCo2
pO2
Hco3
BE

7.37
31.1
45.3
17.6
-6.4

10/02/16

Buse / creatinine
8/3/2015
Sodium

134

Potassium

4.2

Urea

4.8

Creatinine

29

10

MANAGEMENT
10/02/16

Full IVD maintenance 38cc/hour HSD5%

5% correction IVD NS over 24 hours 19cc/ hour
Strict I/O charting
Monitor vital signs 4 hourly
Encourage orally as tolerated
ORS 10ml/kg per purge

11

PATIENT PROGRESS

We off deficit after 6 hours and encourage orally by giving

75ml x 9kg = 675ml in 4 hours.

10/02/16

Patient able to tolerate well after 6 hours of IVD deficit 5%

correction + IVD full maintenance.

Patient still have 1 episode of vomiting in the ward and 3

episodes diarrhea on 1st day of admission. Resolved on the
next day.
Potassium correction (mist KCL 500mg TDS)
Memo letter to JPL to repeat buse/creat and review when
discharge in view of hypokalemia 3.0
8/3/2015

9/3/2015

Sodium

134

139

Potassium

4.2

3.0

Urea

4.8

1.5

Creatinine

29

18

12

DEFINITION OF DIARRHEA
10/02/16

Diarrhoea is defined as the passage of unusually

loose or watery stools, usually at least 3 times in
a 24-hour period.
It is the consistency of the stools that is most
important, rather than the frequency.

13

10/02/16

14

CLINICAL TYPES OF DIARRHOEL

DISEASES

Acute bloody diarrhoea

(dysentry)

Persistent diarrhoea
Diarrhoea with severe
malnutrition

Lasts for several hours or days. The

main concern is dehydration. Weight
loss can also occur if feeding is being
withheld for too long.
Should be considered when blood and
mucous are present in the stools. The
main dangers are damage to the
intestinal mucosa, sepsis and
malnutrition.
Defined as diarrhoea that lasts 14 days
or longer.
A serious condition and warrants special
attention to exclude severe systemic
infection, dehydration, severe
electrolytes imbalance, heart failure,
and vitamin and mineral deficiencies

10/02/16

Acute watery diarrhoea

15

IMPORTANT CAUSATIVE AGENTS OF

GASTROENTERITIS
10/02/16

16

10/02/16

Rice water stool

Cholera

dysentery shigella
and salmonella
17

ASSESS
Well, alert

Restless, irritable

Lethargic,
unconscious

Condition
Eyes

Normal

Sunken

Sunken

Tears

Present

Absent

Absent

Mouth and

Moist

Dry

Very dry

Drinks normally

Drink eagerly,
thirsty
Skin goes back
slowly

Not drinking, poor

General

tongue
Offer fluids
2. Feel

Pinch skin
(abdomen)
3. Decide

Skin goes back

immediately

10/02/16

1. Look

Skin goes back

slow >2 secs

no signs of
2 or more signs
2 or more signs
DEHYDRATION dehydration
18
Mild (<5%)
Moderate (5-10%) Severe (>10%)
Signs of shock = Tachycardia, weak peripheral pulse, delayed CRT, cold
peripheries, depressed mental state

Sunken
eyes
10/02/16

19

DEHYDRATION

Moderate (5-

Severe (>10%)

Plan A (tx at home)

ors 10ml/kg per purge

Plan B
give ors 75ml/kg in
4 hours

Plan C
Start IVD
immediately

10%)

GIVE EXTRA FLUIDS

Return when poor oral
intake, fever, bloody
stool
ORS 8 sachets at home
<2 yo: 50-100ml after BO
>2 yo: 100-200ml after BO
Give small frequent small
sips from cup/spoon
If vomit, wait 10mins then
give slowly (1 spoon/ 23mins)

After 4 hours,
reaccess the child
and classify the child
for dehydration
Continue feeding
ORS over 4 hours

<6kg / up to 4months :
200-400ml

10/02/16

Treatment

Mild (<5%)

0.9% NS bolus
20mls/kg then reaccess
Maintenance +
Correction

6-10kg / 4-12month:
400-700ml
10-12kg /12- 2years:
700-900ml

20

IVD MAINTENANCE
D31 - 6 mo : 150cc/kg/day (1/5NSD5%)

6mo 1 year : 120cc/kg/day (1/5NSD5%)

10/02/16

> 1 yo : Holliday segar formula (1/2 NSD5%)

1st 10kg = 100ml/kg (10kg = 1000ml)
2nd 10kg =50ml/kg (20kg = 1500ml)
> 20kg = 20ml/kg

21

CORRECTION (FLUID DEFICIT)

10/100

10/02/16

% dehydration x BW in grams (= % x BW(kg) x

10)
Eg: 10% dehydration, BW 15kg

x 15kg x 1000 = 10 x 15 x 10 = 1500cc

Run over 12 / 24 / 48 hours

22

TREATMENT PLAN C

Yes

Age

No

<12 months old

> 12months old

First give 20
ml/kg as fast as
possible. Repeat
fluid boluses as
necessary until
perfusion has
improved

10/02/16

Can you give

intravenous or
intraosseous fluids
immediately?

Start IV or IO fluids immediately.

If patient can drink, give ORS by
mouth while the drip is being set
up. Give 100ml/kg Ringers
lactate or nomal saline divided as
follows:
Then give the
remaining fluid
over
5 hours
2 hours

Reassess the patient after every bolus and stop boluses once
perfusion improves or when fluids overload.
Consider septic shock, toxic shock syndrome, myocarditis,
23
mycardiopathy or pericarditis.
Give ORS 5ml/kg/hour. After 3-4 hour for infants, 1-2 hours for
older child. Reassess 6 hour for infants/ 3 hours for older child

No

Are you
trained to use
NG tube for
rehydration?

Yes

Arrange and send the patient to the nearest hospital or

clinic (where IV or IO assess can be given) as you start to
rehydrate the child via NG or oral feed at your centre.
Continue rehydration along the journey

Yes

Start rehydration by tube with ORS solution,

give 20 ml/kg/hour for 6 hours (total 120 ml/kg)

Yes

Start re-hydration by mouth with ORS solution,

give 20ml/kg/hour for 6 hours (total 120 ml/kg)

10/02/16

Is I/V or I/O
treatment available
within 30 mins

Send the patient for I/V treatment

immediately.
If the patient can drink, provide the mother
with ORS and show her how to feed the
child on the journey

No
Then
Can patient
drink?

Reassess the patient at 1 or 2 hours intervals

24
If repeated vomiting and abdominal distension, give the
fluid more slowly.
Reassess after 6 hours, select appropriate plan.

No
10/02/16

URGENTLY send the

patient for IV or NG
treatment
If possible, observe the patient at least 6 hours after re-hydration making sure
that the mother maintains hydration by feeding ORS fluids
If there is a n outbreak of cholera, give an appropriate oral antibiotic after the
patient is alert.

25

CRITERIA FOR ADMISSION TO

HOSPITAL

Care givers cannot provide adequate care at home

Substantial difficulties exist in giving ORS including
intractable vomiting, ORS refusal or inadequate ORS intake

10/02/16

Concern exist for other possible illness complicating the

clinical course
ORS treatment fails including worsening diarrhoea or
dehydration despite adequate volume
Severe dehydration (>9% of body weight)
Social or logistical concerns that might prevent return
evaluation if necessary
Factors especially young age, unusual irritibility/drowsiness,
progressive course of symptoms, or uncertainty of diagnosis
that might need closer observation.

26

INVESTIGATIONS
10/02/16

Full blood count,

Venous blood gas,
Renal profile,
Stool C&S, FEME and Rotavirus Antigen
Ddx lactose intolerance: stool reducing sugar
(diarrhoea >14 days) using Clinitest/Benedicts
test

27

ELECTROLYTE CORRECTION
Eg Na: 128 , BW 15 kg , 2yo

Na deficit = (135 Se Na) x 0.6 x Wt

Deficit : (135 128) x 0.6 x 15 = 63mmol

Daily req Na = 2-3mmol/kg/day

Daily requirement = 3 x 15 = 45mmol Total

1pint = 500ml 0.9%

= 63+45 = 108 mmol

NS = 154 mmol / L

1 pint NS = 39 mmol Na

1/2NS = 77mmol / L

TF = 1150ml/ day ; 1150/24Hr = 48cc/hr

1/5 NS = 39mmol / L
Correction of K,

(90mmol Na)
Eg: Se K : 2.5 , weight 15 kg

K deficit = (4-Se K) x 0.4 x Wt)

Daily req K= 2-3mmol/kg/day 1g KCL =
13.3mmol 10ml Mist KCL = 1g K
1g = 13.3mmol, 1 pint 500ml, 1 ml=0.02
*no
more
than 0.05mmol/ml
ECG
changes:
Prominent U wave
ST segment depression
Flat, low or diphasic T waves
Prolonged PR interval (severe hypo K)
Sinoatrial block (severe hypo K)
Metabolic acidosis, pH <7.1

Repeat BUSE 6
hourly

10/02/16

Correction of Na

Deficit: (4 - 2.5) x 0.4 x 15 = 9 mmol

Daily requirement = 2 x 15 = 30mmol
Total = 9 + 30mmol = 39 mmol
39 mmolg = 39/13.3 = 3g ,therefore if
a)IVD = 1.5 g in each pint check: no more
than 0.05mmol/mL/min in each pint (1.5g x
13.3mmol ) / 500ml = 0.03mmol/ml ( not
more than 0.05)
b) Mist KCL = 3g x 10 = 30ml
IV 8.4% NaHCO3 = 1/3 base deficit x Wt

28

Hypernatraemic dehydration
Def:

10/02/16

Serum Na >145 mmol/L

Clinical features:
1. Clinical presentation is notoriously deceptive
2. Shock is late and ominious sign
3. Skin having a characteristic doughy appearance
4. Anterior fontanelle is typically not sunken
Treatment:

Resuscitation:

If in shock, give normal saline/ Ringers lactate

20ml/kg IV over to 1 hour and repeat as
necessary

29

Rehydration:

Aim: to reduce sodium slowly, dramatic fall

results in cerebral oedema and convulsions.
Rehydrate over 48 to 72 hours

Reduction in plasma sodium should not exceed

10mmol/L per 24 hour

Oral rehydration is the method of choice and the

safest.

Calculate the fluid deficit and give together with

maintenace fluids over at least 48 hour hours.

If fluid was given to resuscitate, the amount given

should be substracted from the fluid deficit.

Use normal saline/D5% until Serum sodium is

<145 mmol/l

10/02/16

30

Hyperkalemia
10/02/16

Signs and symptoms

Muscle weakness
arrythmia

31

TYPES OF FLUID IN THE WARD

10/02/16

32

10/02/16

33

10/02/16

34

ADJUNCTIVE THERAPY FOR ACUTE

DIARRHOEA
10/02/16

Recommendations: Antibiotics are indicated in

the following situations:
Shigella dysentery - in cases presenting as bloody
diarrhoea, these should be treated with an
antimicrobial effective for Shigella
When cholera is suspected
When diarrhoea is associated with another acute
infection such as pneumonia and urinary tract
infection
May be indicated for Salmonella gastroenteritis
in very young babies (< 3 months), immunecompromised, immuno-suppressed, systemically
ill, achlorhydia

35

Recommended Antibiotic for Acute Diarrhoea

10/02/16

36

10/02/16

Anti-emetic
Examples: dimenhydrinate, metoclopromide,
domperidone and promethazine
These may cause sedation that can interfere with
oral rehydration therapy
Not recommended

37

Anti-diarrhoeal Agents and Other Therapies Commonly Used in

Childhood Acute Diarrhoea, According to Efficacy on Diarrhoea
and Safety Profile

10/02/16

Anti-diarrhoeal agents and other therapies

38

 Not

recommended

10/02/16

Anti-motility (intestinal transit inhibitor; opiate

agonists)
Loperamide (Imodium)
Diphenoxylate HCl (Lomotil)
usage

in Shigella invasive illness, prolonged fever,

prolonged excretion of Shigella
Not recommended

Intraluminal agents (adsorbents, bulk-forming,

etc.)
Silicates

- kaolin/pectin not recommended

Silicates diosmectite (Smecta) - Can be considered
as an adjunctive therapy

39

 Enkephalinase

inhibitors (racecadotril*)

10/02/16

Anti-secretory

enkephalinase-inhibitor, preserving endogenous

enkephalinase
significantly reduces stool output (~50%) by 48 hour
well tolerated
no side effects
Can be considered as an adjunctive therapy

40

NUTRITIONAL THERAPY / SPECIAL

INFANT FORMULA
10/02/16

Children who require rehydration should

continue to be fed.
Food should not be withdrawn for longer than 4
6 hours after the onset of rehydration.
Breastfeeding should be continued during acute
gastroenteritis

41

Sign and
symptoms

Pathophysio
-logy

Treatment

HUS

Appendicitis

Triad of:
1.Acute renal failure
2.Microangiopathic haemolytic
anemia
3.Thrombocytopenia
- Bloody diarrhea, oliguria,
haematuria, kidney failure,
thrombocytopenia, hypertension,
destruction of red blood cell.

Symptoms:
Anorexia
Vomiting
Abdominal pain, initially central,
then localising to right illiac fossa
Signs:
Flushed face with oral fetor
Low grade fever 37.2-38 celcius
Abdominal pain aggravated by
movement
Persistent tenderness with
Very
uncommon
<3 year
old.
guarding
in the right
illiac
fossa (Mc
Inflammed
appendix due to fecolith
Burney point)
(in children)

Typical HUS is secondary to

gastrointestinal infection with
verocytotoxin producing E. coli
(EHEC)/ Shigella.
HUS develop about 5-10 days
often
onset of diarrhea
Dialysis

10/02/16

HAEMOLYTIC URAEMIC SYNDROME

(HUS)
AND APPENDICITIS

42
Appendicectomy

REFERENCE
10/02/16

Guidelines on management of Acute Diarrhoea in

children 2011
Paediatric Protocols 3rd edition

43