Download Question 1

Case 1023: A 2-year-old boy with diarrhoea and vomiting
Authors and Affiliations
Richard Pow
School of Medicine, Sydney.
University of Notre Dame Australia
Professor Rakesh Seth
Consultant Paediatrician
Wagga WaggaPaediatric vomiting and diarrhoea represent common reasons for presentation to the
emergency department in the rural setting. This case outline the process for the assessment,
investigation and management of a child with diarrhoea and vomiting.
Case Overview
Learning Objectives
At the end of this module, the student will be able to:
1. Understand the clinical features of gastroenteritis and dehydration
2. Formulate differential diagnoses for the presentation of vomiting and diarrhoea
3. Know the investigations used in suspected viral gastroenteritis
4. Know some of the common causal pathogens of infectious gastroenteritis
5. Understand the principles of management of acute gastroenteritis
Question 1 : MS
Question Information:
Madeleine Parker presents with her two year old son, Benjamin, to the emergency department of a
hospital in regional New South Wales where you are working as a medical resident on a rural
secondment.
Madeleine reports that Benjamin has been unwell with diarrhoea and vomiting for the previous 24
hours. Madeleine has brought him in this evening because his temperature has increased to 37.9
degrees Celsius (measured with an axillary thermometer) and he is having difficulty tolerating oral fluids
and food. On further questioning, you ascertain that the diarrhoea is watery and non-bloody.
You take a further history.
Question:
Which of the following questions should you consider asking to elucidate the cause of the vomitting and
diarrhoea?
Choice 1: How many episodes of diarrhoea and vomiting have there been? Score : 1
Choice Feedback:
The answer to this response may indicate the severity of the diarrhoea and provide you with some clues
regarding the level of fluid loss.
Choice 2: What percentage of his normal oral intake has Benjamin been consuming? Score : 1
Choice Feedback:
This is a useful question as a significantly decreased oral intake may indicate the need for hospital
admission for rehydration and feeding.
Choice 3: Are all of Benjamin†™s vaccinations up to date? Score : 1
Choice Feedback:
With any paediatric history, it is important to enquire about the vaccination status of the child. Rotavirus
is a common cause of viral gastroenteritis and is largely vaccine preventable.
Choice 4: Has there been any recent travel? Score : 1
Choice Feedback:
Enquiry should be made about recent travel and the location of the travel. Certain enteric pathogens
have well defined geographical territories.
Choice 5: Has Benjamin been his normal active self? Score : 1
Choice Feedback:
Lethargy and a reduced level of activity may indicate significant dehydration or may be a non-specific
sign of being unwell.
Choice 6: Is there a family history of irritable bowel syndrome or inflammatory bowel disease? Score : -1
Choice Feedback:
This is unlikely to be of any significance at this stage in this case.
Choice 7: Has there been any antibiotic use recently? Score : 1
Choice Feedback:
Recent antibiotic use may indicate antibiotic associated diarrhoea.
Choice 8: Has Benjamin been in contact with anyone who is unwell recently? Score : 1
Choice Feedback:
Contact with individuals displaying similar symptoms may indicate a transmissible infectious cause.
Enquiry should be made about any siblings or other contacts displaying similar symptoms and if
Benjamin spends anytime at a day care facility.
Choice 9: Has he been wetting his nappy as frequently as usual? Score : 1
Choice Feedback:
This is important information for assessing fluid balance and renal function.
Choice 10: Does anyone in the home smoke cigarettes? Score : -1
Choice Feedback:
This is not relevant to the symptomatology.
Question 2 : MS
Question Information:
Madeleine describes Benjamin†™s oral intake as
Further history reveals that Benjamin has had no previous episodes similar to this. He is generally well
and his mother reports an insignificant medical history besides one previous hospital admission for
bronchiolitis at 10 months of age. There has been no recent travel or antibiotic use. Benjamin is fully
vaccinated. Madeleine informs you that some of the mothers at Benjamin†™s day care centre have
reported that there has been some †˜ gastro†™going around recently.
Benjamin†™s vital signs are:
Heart
rate - 135/min
Respiratory
rate - 26/min
Temperature
Blood
- 37.8C
pressure - 100/65 mmHg
Benjamin is alert, oriented and appears moderately dehydrated. He is irritable and difficult to settle and
this limits your examination. You do manage to feel his abdomen which is soft and does not appear
tender. There are no palpable masses. His weight is 12 kg.
Question:
Which of the following features on physical examination suggest moderate dehydration?
Choice 1: Dry mucous membranes Score : 1
Choice Feedback:
Dry mucous membranes may be a feature of mild or moderate dehydration and can also be a false
positive for children who are mouth breathers.
Choice 2: Decreased skin turgor Score : 1
Choice Feedback:
Decreased skin turgor, that is the slow retraction of pinched skin, may be a feature of moderate
dehydration and may be difficult to elucidate.
Choice 3: Hypotension Score : -1
Choice Feedback:
Hypotension is not a feature of moderate dehydration. It may be associated with severe dehydration
and hypovolaemic shock.
Choice 4: Slow capillary refill Score : 1
Choice Feedback:
Slow capillary refill may indicate moderate or severe dehydration. This should be tested on the sternum.
Choice 5: Sunken eyes Score : 1
Choice Feedback:
Sunken eyes may indicate moderate dehydration.
Choice 6: Altered level of consciousness Score : -1
Choice Feedback:
Altered level of consciousness may be associated with severe dehydration, it is not a manifestation of
moderate dehydration.
Choice 7: Cold, sweaty and cyanotic limbs Score : -1
Choice Feedback:
These features are more indicative of severe dehydration .
Choice 8: Sunken fontanelle Score : -1
Choice Feedback:
This physical sign would be an important indication of moderate to severe dehydration, however, only in
children in which the fontanelle remains open. Generally the fontanelle is closed in children by 18
months of age.
Choice 9: Absence of tears Score : -1
Choice Feedback:
This observation would indicate severe dehydration.
Choice 10: Acute body weight loss of >10% Score : -1
Choice Feedback:
This finding would indicate severe dehydration.
Question 3 : MS
Question Information:
Based on the results of your history and examination, you need to formulate a diagnosis.
Question:
Which of the following should be considered as differential diagnoses?
Choice 1: Pseudomembranous colitis Score : -1
Choice Feedback:
Pseudomembranous colitis is unlikely to be the cause of Benjamin†™s symptoms.
Pseudomembranous colitis is an acute inflammatory disease of the colon usually associated with
clostridium difficile infection and antibiotic use. Clinical features may include fever, abdominal cramps,
tenesmus, diarrhoea which may be bloody and a history of recent antibiotic use.
Choice 2: Acute appendicitis Score : 0
Choice Feedback:
Although acute appendicitis may present with vomiting, diarrhoea and fever, abdominal pain and
localised peritonitis are usually prominent features of the presentation. An abdominal ultrasound is
generally the first line imaging investigation of choice in children with suspected appendicitis. It can only
be ruled out after a meticulous examination - it is always important to be considered in a child
presenting with vomiting and diarrhoea. In the absence of any abdominal signs, it is unlikely in this
case.
Choice 3: Intussusception Score : 0
Choice Feedback:
Intussusception is a common cause of abdominal pain in children less than two years. Intussusception
is characterised by telescoping of part of the intestine into an adjacent intestinal lumen. It is
characterised by vomiting, colicky abdominal pain, pallor and †˜ redcurrant jelly stools†™(a late
sign). It can only be ruled out after a meticulous examination due to its life-threatening nature - it is
always important to be considered in a child presenting with vomiting and diarrhoea. In the absence of
any abdominal signs, it is unlikely in this case.
Choice 4: Bacterial gastroenteritis Score : 1
Choice Feedback:
Infectious gastroenteritis is the most likely diagnosis. Bacterial and viral gastroenteritis are often
clinically indistinguishable and are characterised by diarrhoea, vomiting, fever, anorexia, headache and
abdominal cramps. Features favouring a bacterial aetiology may include fever >39 degrees Celsius,
bloody diarrhoea, significant abdominal tenderness and toxicity.
Choice 5: Coeliac sprue Score : -1
Choice Feedback:
Coeliac disease (gluten-sensitive enteropathy) is intolerance to gliadin, a component of the protein
gluten which is commonly found in wheat, rye and barley. Coeliac disease typically presents with
diarrhoea or steatorrhoea, vomiting, failure to thrive and weight loss. The onset of symptoms may
coincide with the introduction of gluten into the diet.
Choice 6: Whipple†™s disease Score : -1
Choice Feedback:
Whipple†™s disease is a rare systemic disease caused by infection with the bacterium Tropheryma
whipplei. It classically presents in adulthood with diarrhoea, weight loss, abdominal pain and arthralgia.
Choice 7: Inflammatory bowel disease Score : -1
Choice Feedback:
Inflammatory bowel disease, comprising Crohn†™s disease and ulcerative colitis are chronic diseases
characterised by diarrhoea (which may be bloody), abdominal cramps, perianal disease, tenesmus and
extra-intestinal manifestations.
Choice 8: Viral gastroenteritis Score : 2
Choice Feedback:
Infectious gastroenteritis is the likely diagnosis. Viruses are the most common cause of infectious
gastroenteritis in Australia. Common causes of viral gastroenteritis include rotavirus, adenovirus,
astrovirus and norovirus.
Choice 9: Protozoal gastroenteritis Score : -1
Choice Feedback:
An acute onset of diarrhoea and vomiting is unlikely to be protozoal gastroenteritis. Viral and bacterial
causes of gastroenteritis are more likely. Protozoal gastroenteritis may be more likely with a history of
prolonged diarrhoea or overseas travel. Common causes of protozoal gastroenteritis include infection
withGiardia lamblia, Entamoeba histolytica, Dientamoea fragilis and Cryptosporidium parvum.
Choice 10: Haemolytic uraemic syndrome Score : -1
Choice Feedback:
Haemolytic uraemic syndrome (HUS) is often preceded by a diarrhoeal illness with verotoxin
producingEscherichia coli. HUS is characterised by purpuric spots, pain (arthralgias), progressive renal
failure, microangiopathic haemolytic anaemia and thrombocytopenia.
Choice 11: Cystic fibrosis Score : -1
Choice Feedback:
Cystic fibrosis (CF) is a systemic, autosomal recessive disease caused by a mutation in the cystic
fibrosis transmembrane conductance regulator protein. The clinical features of CF include recurrent
respiratory tract infections, chronic diarrhoea, failure to thrive, sinus disease and pancreatic
insufficiency.
Choice 12: Urinary tract infection Score : 1
Choice Feedback:
Urinary tract infections are common in children and may present with non-specific symptoms such as
vomiting and diarrhoea, particularly in young infants and new-born babies. Risk factors for UTI in
children include female gender, age
Question 4 : MS
Question Information:
You discuss the case with your senior medical colleague who believes that the most likely cause of the
symptoms is viral gastroenteritis. He states that he has seen several similar cases in the previous week
among children who attend the same day care facility as Benjamin. Your colleague asks you what
investigations you would like to perform.
Question:
Which of the following investigations are indicated?
Choice 1: Serum electrolytes, urea and creatinine (EUC) Score : -1
Choice Feedback:
Measurement of serum electrolytes, urea and creatinine is not indicated in this case. These tests should
be considered if there is severe dehydration or if the patient is receiving intravenous fluid therapy. Other
indications for EUC measurement may include if the child has been managed with inappropriate fluids,
there is a history of prolonged illness or if there is co-morbid renal or gastrointestinal disease.
Choice 2: Blood glucose level Score : -1
Choice Feedback:
Blood glucose level should be measured if there is a clinical suspicion of hypoglycaemia, if there is
severe dehydration or a need for intravenous fluid therapy.
Choice 3: Full blood count Score : -1
Choice Feedback:
A FBC is often part of a †˜ septic workup†™ and may be indicated in the case of an unwell febrile
child >3 months or is a febrile child
Choice 4: Urine examination Score : 1
Choice Feedback:
Investigation of the urine may be helpful in the assessment of dehydration and to look for indicators of a
urinary tract infection which may present with diarrhoea, vomiting and fever. This information may be
initially gained from a urine dipstick analysis and not necessarily a formal urine collection for microscopy
and culture.
Choice 5: Stool microscopy, culture and sensitivity Score : -1
Choice Feedback:
Stool MCS is not recommended in this case. Stool MCS may be performed to examine for a bacterial
cause if there is bloody diarrhoea, recent travel or for epidemiological study purposes.
Choice 6: Enzyme immunoassay for viral pathogens Score : 0
Choice Feedback:
Enzyme immunoassay is not indicated. This investigation may identify a causal viral pathogen however
it is rarely used except for research or epidemiological purposes.
Choice 7: No investigations are needed Score : 2
Choice Feedback:
Benjamin almost certainly has a self-limiting infectious gastroenteritis and investigations are unlikely to
alter management. However, it might be appropriate to conduct a urinary dipstick.
Question 5 : FT
Question Information:
You recommend a trial period of oral rehydration in the emergency department. The nurse administers
15mL (approximately 1mL/kg) of an oral electrolyte-rich rehydration solution (ORS) every ten minutes
and with parental encouragement, Benjamin drinks the fluid using a cup.
After the third round of fluids, Benjamin vomits several times. It is late in the evening and you decide
that Benjamin will require admission for rehydration. You place a nasogastric tube and provide the oral
rehydration solution via a continuous nasogastric infusion.
The ORS infusion is commenced at 150mL/hour (10mL/kg) and continued for four hours. Benjamin
tolerates the nasogastric rehydration well, apart from one small episode of vomiting. The following
morning Benjamin is switched to oral fluids, which he tolerates without complication.
As you are in a regional hospital, you are also covering the ward the next morning. On the ward round
that morning the medical student asks you why you have not yet started the patient on antibiotics and
an anti-diarrhoeal agent such as loperamide.
Question:
What is your response? Discuss the role of antibiotics and antidiarrhoeal agents in the management of
paediatric infectious gastroenteritis.
Choice 1: null Score : 0
Choice Feedback:
Antidiarrhoeal agents such as loperamide are not recommended for the treatment of acute
gastroenteritis in infants or children. Antibiotics are not indicated in the treatment of viral gastroenteritis.
Some indications for antibiotic use in the management of bacterial gastroenteritis may include:
Shigellosis
Suspected
Clostridium
cholera with severe dehydration
difficile infection
Antibiotic treatment is only indicated in Salmonella infection if complicated by bacteraemia, systemic
involvement, immunocompromised or age
Question 6 : MS
Question Information:
Your response clears the student's misunderstanding. Benjamin has significantly improved with the
nasogastric rehydration. He is now tolerating oral fluids well and passing urine frequently. You reassess
him and conclude that he is now ready for discharge. The senior medical officer enjoys quizzing his
junior colleagues and asks you to list some of the viruses commonly responsible for viral gastroenteritis
in children.
Question:
Which of the following pathogens represent a common cause of viral gastroenteritis in children?
Choice 1: Rotavirus Score : 1
Choice Feedback:
Rotavirus is the commonest cause of viral gastroenteritis requiring admission in children. The incidence
of Rotavirus is decreasing following the introduction of the vaccine into the recommended Vaccination
Schedule of Australian children.
Choice 2: Campylobacter jejuni Score : -1
Choice Feedback:
Campylobacter jejuni is a common cause of bacterial gastroenteritis, it is not a cause of viral
gastroenteritis.
Choice 3: Rhinovirus Score : -1
Choice Feedback:
Rhinoviruses are unable to replicate in the gastrointestinal tract and therefore, do not cause viral
gastroenteritis. Rhinoviruses account for at least half of all upper respiratory tract infections
Choice 4: Adenovirus Score : 1
Choice Feedback:
Adenoviruses are a common cause of viral gastroenteritis in children. There have been over 100
serotypes of adenovirus recognised. Adenoviruses cause a range of clinical syndromes including
conjunctivitis, pharyngitis and respiratory tract disease. The enteric adenoviruses (serotypes 40 & 42)
are the agents responsible for adenovirus gastroenteritis.
Choice 5: Respiratory syncytial virus Score : -1
Choice Feedback:
Respiratory syncytial virus is not a common cause of viral gastroenteritis. As the name suggests, RSV
produces an infection localised to the respiratory tract.
Choice 6: Norovirus Score : 1
Choice Feedback:
Noroviruses include calciviruses, astroviruses and other small gastroenteritis viruses. They represent a
common cause of viral gastroenteritis in children.
Question 7 : MS
Question Information:
You explain to Benjamin's mother that her son is now is rehydrated and his symptoms have largely
resolved. He is now able to tolerate oral fluids and you feel that he is able to be safely discharged
home.
Madeleine is happy that Benjamin has made substantial progress although is anxious about taking him
home as they live on a rural property one hour from the hospital and a thirty minute drive from
Benjamin†™s general practitioner.
You reassure Madeleine and provide her with some information on discharge regarding how to manage
Benjamin over the next few days.
Question:
Which of the following pieces of advice should you provide to Madeleine?
Choice 1: Benjamin should avoid swimming in public swimming pools until diarrhoea has settled Score : 1
Choice Feedback:
It should be emphasised that Benjamin is infectious and should avoid public swimming pools until
diarrhoea has resolved.
Choice 2: Emphasise the importance of hand washing and personal hygiene Score : 2
Choice Feedback:
The importance of personal hygiene measures for both Benjamin and Madeleine should be emphasised
to minimise the risk faecal-oral transmission.
Choice 3: Benjamin should avoid eating for the next 48 hours to †˜ rest†™ the gastrointestinal tract Score : -1
Choice Feedback:
Once the child†™s appetite returns, a healthy diet should be encouraged. There may be an increased
caloric need until any lost weight has been regained.
Choice 4: Follow up should be made with the general practitioner over the next few days to ensure resolution of
symptoms Score : 1
Choice Feedback:
It is advisable to arrange follow up with the general practitioner to ensure resolution of symptoms. It
should be emphasised to Madeleine that she should consult with either the general practitioner earlier
or return to the emergency department if she has any further concerns.
Choice 5: Benjamin should avoid lactose containing food and drink such as milk for the next two weeks Score : 1
Choice Feedback:
Routine avoidance of lactose containing products is not recommended. Some children develop a
temporary period of lactose intolerance following acute gastroenteritis, this should be suspected if there
is prolonged diarrhoea.
Choice 6: Benjamin will need to be re-vaccinated against rotavirus following the episode of viral gastroenteritis
Score : -1
Choice Feedback:
The rotavirus vaccination program was implemented in the Australian National Immunisation program in
2007. The rotavirus vaccine has significantly reduced the incidence and number of hospitalisations for
viral gastroenteritis. The vaccine would be recommended if Benjamin had not already received the
rotavirus vaccination schedule. Furthermore, we have no proof that this is rotavirus.
Choice 7: Encourage small volume, frequent intake of oral fluids Score : 1
Choice Feedback:
Frequent, small volume intake of oral fluids should be encouraged. Madeleine should be reminded that
carbonated commercial soft drinks are not considered as oral fluids and are not appropriate for
rehydration.
Synopsis
Epidemiology
Worldwide, it is estimated that there are over 1.5 billion episodes of acute diarrhoea each year. Among
children
Infectious gastroenteritis is a common cause of acute diarrhoea and vomiting in children. The majority
of episodes of infectious gastroenteritis are viral in aetiology and display a distinct seasonal variation (2,
3). Bacterial and parasitic causes of gastroenteritis should always be considered when assessing a
child with diarrhoea and vomiting, as they may require alternative management.Clinical featuresClinical
features of infectious gastroenteritis include diarrhoea, vomiting, abdominal pain, anorexia, fever,
lethargy, upper respiratory tract symptoms and dehydration (2, 4). Differentiation between bacterial and
viral causes of gastroenteritis cannot be made accurately on clinical features alone. However, the
frequent passage of small volume stools containing blood and mucus may favour a bacterial aetiology.
Assessment of the degree of dehydration is a key component of the assessment of a child with a
diarrhoeal illness and guides management. The risk of dehydration is increased with younger age
(particularly infants