Vomiting & Diarrhea Cases: peads

Vomiting and Diarrhea Cases in Children

General Approach to Vomiting

• Vomiting is commonly due to infection, but not always gastroenteritis.
• Consider other infections like:
  • UTI
  • Pneumonia
  • Other non-GI infections
• Also consider:
  • Gastrointestinal obstruction (e.g., strangulated hernia)
  • Testicular torsion (especially with abdominal pain and vomiting)
  • Gastroesophageal reflux
  • Intussusception
  • Diabetic ketoacidosis (DKA)

Importance of Structure

• Use a structured approach to cover all differentials.

Initial Assessment

• Assess hemodynamic stability.

Parental Diarrhea

• Diarrhea due to infection outside the GI tract.
• Common with coughs, pneumonias, and upper respiratory infections.

History Taking – Initial Questions

• Start with open-ended questions to address the mother's concerns.
• Explore the complaint:
  • Timing: When did vomiting and diarrhea start?
  • Progression: Is it getting worse?
  • Pattern: Is it continuous or intermittent?

Vomiting Specific Questions

• Frequency: How many times has the child vomited?
• Content:
  • Describe the vomit: Food or fluid?
  • If fluid, what color? (Especially greenish)
• Ability to keep fluids down: Can the child keep anything down?

Diarrhea Specific Questions

• Characterize stools: Watery or loose?
• Color (less important)
• Content:
  • Blood (most important)
  • Undigested food (consider toddler's diarrhea)
• Odor: Foul-smelling stools?

Differentials and Questions to Ask

• Gastroenteritis:
  • Contact with sick individuals
  • Recent travel
  • Immunization status (Rotavirus vaccine in Australia)
• Other Infections:
  • Meningitis: Rash
  • Respiratory infections: Flu-like symptoms, coughing
  • Otitis media: Ear pulling, ear pain, ear discharge (especially in a six-month-old)
  • UTI: Foul-smelling urine, crying when changing nappies or passing urine
• Hernia: Lumps or redness in the groin
• Intussusception:
  • Intermittent crying and paleness
  • Drawing legs up to chest (unspecific)

Well-Baby Questions

• Focus on binds (bowel and bladder habits).
• Immunizations.
• Past medical history and family history.

Example Case: Abnormal Gastroenteritis Case

• Positive findings:
  • Loose stools
  • Vomiting three times
  • Sister has gastroenteritis
• Nutrition: Breastfed
• Weight loss (likely due to dehydration): e.g., from 8.5 kg to 7.3 kg.
• Physical exam:
  • Greenish stools
  • Mild dehydration
  • No fever

Diagnosis and Differentials

• Most likely viral gastroenteritis
• Broad differential list:
  • UTI
  • Otitis media
  • Meningitis
  • Strangulated hernia (especially in young children)
  • DKA (in older children)

Management of Acute Gastroenteritis

• Hydration: Fluids or ORS (e.g., Gastrolate, Hydrolate)
• Fever: Paracetamol
• Antiemetics: Ondansetron wafers (from six months old)
• Red flags and early review: Do not let them go without ensuring a review process is in place.

Case: Nine-Month-Old with Fever and Vomiting

• History: Vomiting (two episodes).
• Fever: Improved with paracetamol.
• Urine questions: Foul-smelling urine, crying during urination/nappy changes.
• Physical Examination:
  • Temperature: 38°C
  • ENT/Respiratory: Normal
  • Urine bag specimen:
    • 3+ Leukocytes
    • Nitrates positive
    • Trace protein (less significant)

Interpreting Urine Bag Specimen

• Urine bag specimens can easily be contaminated.
• Leukocytes alone in asymptomatic child are not indicative of UTI.
• Nitrate positive is highly suggestive of UTI.

Diagnosis and Investigation

• Diagnosis: UTI.
• Immediate investigation: Obtain a more reliable urine sample.
  • Suprapubic aspiration (most reliable).
  • Catheter sample (if suprapubic aspiration not possible).
• Send urine for microscopy, culture, and sensitivity.
• In boys with UTI, consider KUB ultrasound to investigate potential underlying issues.