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.