Diarrhea (Pedi)


  • 3 diarrhea stools in 24 hour period

Causes


 

Causes of Bloody Diarrhea
Cause Comments
NEC Preterm neonate, Abdominal distension
Abd XR
: pneumotosis intestinalis.

SURGICAL EMERGENCIES

Infectious Seeping stool in diaper
(+) Mucous
(+) Blood
Malrotation/Volvulus Bilious Emesis
Milk Protein Allergy Switch to Alimentum
Anal Fissure  
Obstruction  
Neonatal Vaginal Bleeding Secondary to maternal estrogen exposure. Goes away in 2-3 wks.


 

Causes of Diarrhea
Infection
  Viral: rotavirus, Norwalk virus, enteroviruses, astroviruses, adenoviruses, caliciviruses
  Bacterial: Salmonella, Shigella, Yersinia, Campylobacter, Escherichia coli, Aeromonas hydrophila, Vibrio species, Clostridium difficile, tuberculosis
  Parasitic: Giardia lamblia, Entamoeba histolytica, Cryptosporidia 
Dietary disturbances
  Overfeeding
  Food allergy
  Starvation stools
Anatomic abnormalities
  Intussusception
  Hirschsprung disease
  Partial obstruction
  Appendicitis
  Blind loop syndrome
  Intestinal lymphangiectasia
  Short bowel syndrome
Inflammatory bowel disease
Malabsorption or secretory diseases
  Cystic fibrosis
  Celiac disease
  Disaccharidase deficiency
  Acrodermatitis enteropathica
  Secretory neoplasms
Systemic diseases
  Immunodeficiency
  Endocrinopathy (hyperthyroidism, hypoparathyroidism, congenital adrenal hyperplasia)
Miscellaneous
  Antibiotic-associated diarrhea

 

 

Mechanism Of Diarrhea

Mechanisms of Infectious Diarrheal Disease
Pathogen Type Characteristic Examples Mechanism Pathologic Impact Clinical Impact
Viral enteropathogens
Rotaviruses Adenoviruses
Invade small intestinal mucosa villous epithelium Loss of mature absorptive cells, producing a proliferative response, resulting in repopulation of intestinal epithelial lining with poorly differentiated cells. Salt and water absorption is decreased
Carbohydrate malabsorption and osmotic diarrhea
Bacterial enteropathogens Invasive Adhere to mucosal cells followed by invasion and multiplication, primarily in large intestine Intramucosal multiplication elicits an acute mucosal inflammatory reaction, resulting in ulceration and synthesis of a variety of secretagogues. Salt and water absorption is decreased (secretory diarrhea)
  Shigella 
  Salmonella 
  Yersinia enterocolitica 
  Campylobacter jejuni 
  Vibrio parahaemolyticus 
Cytotoxic Elaboration of cytotoxins Cause cell damage and death by inhibiting protein synthesis or by inducing the secretion of one or more inflammatory mediator substances. Decreased intestinal absorptive surface
  Shigella 
  Enteropathogenic Escherichia coli 
  Enterohemorrhagic E. coli 
  Clostridium difficile 
Toxigenic Colonize small intestine and secrete enterotoxins Enterotoxin binds to specific mucosal receptors, increasing the concentration of an intracellular mediator (adenosine 3':5'-cyclic phosphate or cyclic guanosine monophosphate). Alter intestinal salt and water transport without affecting mucosal morphology
  Shigella 
  Enterotoxigenic E. coli 
  Y. enterocolitica 
  Aeromonas 
  V. cholerae 
Adherent Colonization and adherence to intestinal surface of small and large intestine Binding to epithelial cells indents the surface, causes glycocalyx dissolution and microvilli flattening. Decreased intestinal absorptive surface
  Enteropathogenic E. coli 
  Enterohemorrhagic E. coli 
 

Etiology & Treatment

Clinical Features and Treatment of Etiologic Agents of Bacterial Gastroenteritis
Organism Clinical Features Risk Factors Complications Antimicrobial Therapy
Shigella 
Mild: watery stools without constitutional symptoms

Severe: fever, abdominal pain, tenesmus, mucoid stools, hematochezia

Poor sanitation, crowded living, day care Bacteremia, Reiter syndrome, hemolytic uremic syndrome, toxic encephalopathy, seizures, dehydration, toxic megacolon ± perforation
Typically self limited (48–72 h)
Treat if: immunocompromised, severe disease, dysentery or systemic symptoms
Options: azithromycin, trimethoprim-sulfamethoxazole, ceftriaxone, ciprofloxacin
Salmonella 
Mild: Watery diarrhea, mild fever, abdominal cramps

Typhoid fever: high fever, constitutional symptoms, abdominal pain, hepatosplenomegaly, rose spots, altered mental status

Direct contact with animals: poultry, livestock, reptiles, pets

Contact/ingestion of contaminated food: beef, poultry, eggs, dairy, water

Meningitis, osteomyelitis, bacteremia, dehydration, endocarditis, typhoid fever
Typically self limited
Treat if: <3 mo of age, hemoglobinopathy, immunodeficiency, chronic GI tract disease, malignancy, severe colitis, bacteremia, sepsis
Gastroenteritis: ampicillin, amoxicillin, trimethoprim-sulfamethoxazole, cefotaxime, ceftriaxone, fluoroquinolone
Invasive disease: cefotaxime, ceftriaxone
Campylobacter 
Diarrhea, abdominal pain, fever, malaise
Often hematochezia in infants
Improperly cooked poultry, untreated water, unpasteurized milk, pets (dogs, cats, hamsters, birds)
Acute: dehydration, bacteremia, focal infections

Convalescence: reactive arthritis, Reiter syndrome, erythema nodosum, idiopathic polyneuritis, Miller Fisher syndrome

Typically self limited; 20% have relapse or prolonged symptoms
Treat if: moderate-severe symptoms, relapse, immunocompromised, day care and institutions
Options: erythromycin, azithromycin, ciprofloxacin
Yersinia 
Bloody diarrhea with mucus, fever, abdominal pain

Pseudoappendicitis syndrome: fever, right lower quadrant pain, leukocytosis

Contaminated food: improperly cooked pork, unpasteurized milk, untreated water
Acute: bacteremia, pharyngitis, meningitis, osteomyelitis, pyomyositis, conjunctivitis, pneumonia, empyema, endocarditis, acute peritonitis, liver/spleen abscess

Convalescence: Erythema nodosum, glomerulonephritis, reactive arthritis

Typically self limited
Treat if: sepsis, non-GI infections, immunocompromised, excess iron storage condition (desferrioxamine use, sickle cell anemia, thalassemia)
Options: trimethoprim-sulfamethoxazole, aminoglycosides, cefotaxime, fluoroquinolones, tetracycline, doxycycline, chloramphenicol
Escherichia coli–Shiga toxin producing  Bloody or nonbloody diarrhea, severe abdominal pain Food or water contaminated with feces, undercooked beef, unpasteurized milk Hemorrhagic colitis, hemolytic uremic syndrome, thrombotic thrombocytopenic purpura None indicated; debated risk of increased incidence of hemolytic uremic syndrome with treatment
E. coli–enteropathogenic  Severe watery diarrhea Food or water contaminated with feces Dehydration Options: trimethoprim-sulfamethoxazole, azithromycin, ciprofloxacin
E. coli–enterotoxigenic  Moderate watery diarrhea, abdominal cramps Food or water contaminated with feces Dehydration
Treat if severe
Options: trimethoprim-sulfamethoxazole, azithromycin, ciprofloxacin
E. coli–enteroinvasive  Fever, bloody or nonbloody dysentery Food or water contaminated with feces Dehydration
Treat if dysentery
Options: trimethoprim-sulfamethoxazole, azithromycin, ciprofloxacin
E. coli–enteroaggregative  Watery, occasionally bloody diarrhea Food or water contaminated with feces Dehydration Options: trimethoprim-sulfamethoxazole, azithromycin, ciprofloxacin
 

ED Care & Disposition

  1. Treat dehydration and hypoglycemia.
    • Vomiting is not a contraindication for oral rehydration; the key is to give small amounts of the solution frequently. Use of a commercially available oral rehydration solution (ORS) containing 45-60 mmol/L of sodium is recommended. Many other beverages traditionally suggested for children with vomiting & diarrhea, such as tea, juice, or sports drink, are deficient in Sodium & may provide excessive sugar, resulting in amplified fluid losses.
    • Give 50-100 mL of ORS/kg of body weight, plus additional ORS to compensate for ongoing losses. Aim for about 1 oz (30 ml) or ORS per kg of body weight per hr.
    • Administer IV or IO isotonic crystalloid to children with severe dehydration, hemodynamic compromise, or when altered mental status precludes safe oral administration of fluid.
      • Give IV NS as 20 cc/kg bolus over 20 min. until perfusion improves and urine output is adequate.
    • Treat hypoglycemia with 10% dextrose (5 mL/kg) in infants or 25% dextrose (2 mL/kg) in toddlers and older children.
  2. Mild Diarrhea with NO dehydration:
    • Continue routine feeding
    • Do not withhold feeding > 4 hours in a dehydrated child or for any length of time in a child who is not dehydrated.
    • There is no need to dilute formula because > 80% of children with acute diarrhea can tolerate full-strength mild safely.
  3. Antidiarrheal and antimotility agents such as loperamind, are not recommended in children and contraindicated in young childen.
  4. All infants & children who appear toxic or have high-risk social situations, significant dehydration, significant ongoing fluid losses, altered mental status, inability to drink, or laboratory evidence of hemolytic anemia, thrombocytopenia, azotemia, or a significant dysnatremia should be admitted.
  5. Children who respond to oral or IV hydration can be discharged.
    • Instructions should be given to return to the ED or seek care with PCP if the child becomes unable to tolerate PO hydration, develop bilious vomiting, become less alert, or exhibit signs of dehydration (no wet diapers).
    • Dietary recommendations include a diet high in complex carbohydrates, lean meats, vegetables, fruits, & yogurt.
    • Fatty foods & foods high in simple sugars should be avoided.
    • The BRAT diet is discouraged because it does not provide adequate energy source.

Admit Orders: Acute Gastroenteritis

1. Admit to:

2. Diagnosis: Acute Gastroenteritis.

3. Condition:

4. Vital Signs: Call MD if:

5. Activity:

6. Nursing: Inputs and outputs, daily weights, urine specific gravity.

7. Diet: Rehydralyte, Pedialyte or soy formula (Isomil DF), bland diet.

8. IV Fluids: See Dehydration, page 107.

9. Special Medications:

Severe Gastroenteritis with Fever, Gross Blood and Neutrophils in Stool (E coli, Shigella, Salmonella):

-Ceftriaxone (Rocephin) 50-75 mg/kg/day IV/IM q 12-24h, max 4 gm/day OR

-Cefixime (Suprax) 8 mg/kg/day PO bid-qd, max 400 mg/day [susp: 100 mg/5 mL; tabs: 200, 400 mg] OR

-Trimethoprim/sulfamethoxazole (Bactrim, Septra) 10 mg of TMP component/kg/day PO bid x 5-7d, max 320 mg TMP/day [susp per 5 mL: TMP 40 mg/SMX 200 mg; tab DS: TMP 160 mg/SMX 800 mg; tab SS: TMP 80mg/SMX 400 mg]

Salmonella (treat infants and patients with septicemia):

-Ceftriaxone (Rocephin) 50-75 mg/kg/day IV/IM q12-24h, max 4 gm/day OR

-Cefixime (Suprax) 8 mg/kg/day PO bid-qd, max 400 mg/day [susp: 100 mg/5 mL; tabs: 200, 400 mg] OR

-Ampicillin 100-200 mg/kg/day IV q6h, max 12 gm/day or 50-100 mg/kg/day PO qid x 5-7d, max 4 gm/day [caps: 250, 500 mg; drops: 100 mg/mL; susp: 125 mg/5 mL, 250 mg/5 mL, 500 mg/5 mL] OR

-Trimethoprim/sulfamethoxazole (Bactrim, Septra) 10 mg TMP/kg/day PO bid x 5-7d, max 320 mg TMP/day [susp per 5 mL: TMP 40 mg/SMX 200 mg; tab DS: TMP 160 mg/SMX 800 mg; tab SS: TMP 80mg/SMX 400 mg]OR

-If >18 years: Ciprofloxacin (Cipro) 250-750 mg PO q12h or 200-400 mg IV q12h [inj: 200, 400 mg; susp: 100 mg/mL; tabs: 100, 250, 500, 750 mg]

Antibiotic Associated Diarrhea and Pseudomembranous Colitis (Clostridium difficile):

-Treat for 7-10 days.

-Metronidazole (Flagyl) 30 mg/kg/day PO/IV (PO preferred) q8h x 7 days, max 4 gm/day. [inj: 500 mg; tabs: 250, 500 mg; suspension] OR

-Vancomycin (Vancocin) 40 mg/kg/day PO qid x 7 days, max 2 gm/day

[caps: 125, 250 mg; oral soln: 250 mg/5 mL, 500 mg/6 mL]. Vancomycin therapy is reserved for patients who are allergic to metronidazole or who have not responded to metronidazole therapy.

10. Extras and X-rays: Upright abdomen.

11. Labs: SMA7, CBC; stool Wright stain for leukocytes, Rotazyme. Stool culture and sensitivity for enteric pathogens; C difficile toxin and culture, ova and parasites; occult blood. Urine specific gravity, UA, blood culture and sensitivity.


 

Shigella Sonnei

-Treat x 5 days. Oral therapy is acceptable except for seriously ill patients. Ciprofloxacin should be considered for resistant strains but is not recommended for use for persons younger than 18 years of age.

-Ampicillin (preferred over amoxicillin) 50-100 mg/kg/day PO q6h, max 3 gm/day [caps: 250, 500 mg; drops: 100 mg/mL; susp: 125 mg/5 mL, 250 mg/5 mL; 500 mg/5 mL] OR

-Trimethoprim/sulfamethoxazole (Bactrim, Septra) 10 mg TMP/kg/day PO/IV q12h x 5 days [inj per mL: TMP 16mg/SMX 80mg; susp per 5 mL: TMP 40 mg/SMX 200 mg; tab DS: TMP 160 mg/SMX 800 mg; tab SS: TMP 80mg/SMX 400 mg] OR

-Ampicillin 50-80 mg/kg/day PO q6h, max 4 gm/day; or 100 mg/kg/day IV/IM q6h for 5-7 days, max 12 gm/day [caps: 250, 500 mg; susp: 125 mg/5 mL, 250 mg/5 mL]OR

-Ceftriaxone (Rocephin) 50-75 mg/kg/day IV/IM q 12-24h, max 4 gm/day OR

-Cefixime (Suprax) 8 mg/kg/day PO bid-qd, max 400 mg/day [susp: 100 mg/5 mL; tabs: 200, 400 mg].

Yersinia (sepsis):

-Most isolates are resistant to first-generation cephalosporins and penicillins.

-Trimethoprim/sulfamethoxazole (Bactrim, Septra) 10 mg/kg/day TMP PO q12h x 5-7days [susp per 5 mL: TMP 40 mg/SMX 200 mg; tab DS: TMP 160 mg/SMX 800 mg; tab SS: TMP 80mg/SMX 400 mg].

Campylobacter jejuni:

-Erythromycin 40 mg/kg/day PO q6h x 5-7 days, max 2 gm/day

Erythromycin ethylsuccinate (EryPed, EES)

[susp: 200 mg/5 mL, 400 mg/5 mL; tab: 400 mg; tab, chew: 200 mg]

Erythromycin base (E-Mycin, Ery-Tab, Eryc)

[cap, DR: 250 mg; tabs: 250, 333, 500 mg] OR

-Azithromycin (Zithromax)

10 mg/kg PO x 1 on day 1 (max 500 mg), followed by 5 mg/kg/day PO qd on days 2-5 (max 250 mg)

[cap: 250 mg; susp: 100 mg/5mL, 200 mg/5mL; tabs: 250, 600 mg]

Enteropathogenic E coli (Travelers Diarrhea):

-Trimethoprim/sulfamethoxazole (Bactrim, Septra) 10 mg/kg/day TMP PO/IV bid [inj per mL: TMP 16 mg/SMX 80 mg; susp per 5 mL: TMP 40 mg/SMX 200 mg; tab DS: TMP 160 mg/SMX 800 mg; tab SS: TMP 80mg/SMX 400 mg].

-Patients older than 8 years old: Doxycycline (Vibramycin) 2-4 mg/kg/day PO q12-24h, max 200 mg/day [caps: 50, 100 mg; susp: 25 mg/5mL; syrup: 50 mg/5mL; tabs 50, 100 mg].

Enteroinvasive E coli:

-Antibiotic selection should be based on susceptibility testing of the isolate. If systemic infection is suspected, parenteral antimicrobial therapy should be given.

Giardia Lamblia:

-Metronidazole is the drug of choice. A 5-7 day course of therapy has a cure rate of 80-95%. Furazolidone is 72-100% effective when given for 7-10 days. Albendazole is also an acceptable alternative when given for 5 days.

-Metronidazole (Flagyl) 15 mg/kg/day PO q8h x 5-7 days (max 4 gm/day)

[tabs: 250, 500 mg; suspension] OR

-Furazolidone (Furoxone) 5-8.8 mg/kg/day PO qid for 7-10 days, max 400 mg/day [susp: 50 mg/15 mL; tab: 100 mg] OR

-Albendazole (Albenza): if > 2 years, 400 mg PO qd x 5 days [tab: 200mg; suspension]

Entamoeba Histolytica:

Asymptomatic cyst carriers:

-Iodoquinol (Yodoxin) 30-40 mg/kg/day PO q8h (max 1.95 gm/day) x 20 days [tabs: 210, 650 mg; powder for reconstitution] OR

-Paromomycin (Humatin) 25-35 mg/kg/day PO q8h x 7 days [cap: 250 mg] OR

-Diloxanide: 20 mg/kg/day PO q8h x 10 days, max 1500 mg/day. (Available only through CDC).

Mild-to-moderate intestinal symptoms with no dysentery:

-Metronidazole (Flagyl): 35-50 mg/kg/day PO q8h x 10 days, max 2250 mg/day [tabs: 250, 500 mg; suspension] followed by:

-Iodoquinol (Yodoxin) 30-40 mg/kg/day PO q8h (max 1.95 gm/day) x 20 days [tabs: 210, 650 mg; powder for reconstitution] OR

-Paromomycin (Humatin) 25-35 mg/kg/day PO q8h x 7 days [cap: 250 mg] OR

-Diloxanide: 20 mg/kg/day PO q8h x 10 days, max 1500 mg/day. (Available only through CDC).

Dysentery or extraintestinal disease (including liver abscess):

-Metronidazole (Flagyl): 35-50 mg/kg/day PO q8h x 10 days, max 2250 mg/day [tabs: 250, 500 mg; suspension] followed by:

-Iodoquinol (Yodoxin) 30-40 mg/kg/day PO q8h (max 1.95 gm/day) x 20 days [tabs: 210, 650 mg; powder for reconstitution] OR

-Paromomycin (Humatin) 25-35 mg/kg/day PO q8h x 7 days [cap: 250 mg] OR

-Diloxanide: 20 mg/kg/day PO q8h x 10 days, max 1500 mg/day. (Available only through CDC).

 

Admit Orders: Dehydration

1. Admit to:

2. Diagnosis: Dehydration

3. Condition:

4. Vital Signs: Call MD if:

5. Activity:

6. Nursing: Inputs and outputs, daily weights. Urine specific gravity q void.

7. Diet: Renal diet of high biologic value protein of 0.6-0.8 g/kg, sodium 2 g, potassium 1 mEq/kg, and at least 35 kcal/kg of nonprotein calories.

8. IV Fluids:

Maintenance Fluids:

<10 kg 100 mL/kg/24h

10-20 kg 1000 mL plus 50 mL/kg/24h for each kg >10 kg

>20 kg 1500 mL plus 20 mL/kg/24h for each kg >20 kg

Electrolyte Requirements:

Sodium: 3-5 mEq/kg/day

Potassium: 2-3 mEq/kg/day

Chloride: 3 mEq/kg/day

Glucose: 5-10 gm/100 mL water required (D5W - D10W)

Estimation of Dehydration

Degree of Dehydration

Mild

Moderate

Severe

Weight Loss - Infants

5%

10%

15%

Weight Loss - Children

3%-4%

6%-8%

10%

Pulse

Normal

Slightly increased

Very increased

Blood Pressure

Normal

Normal to orthostatic, >10 mm Hg change

Orthostatic to shock

Behavior

Normal

Irritable

Hyperirritable to lethargic

Thirst

Slight

Moderate

Intense

Mucous Membranes

Normal

Dry

Parched

Tears

Present

Decreased

Absent, sunken eyes

Anterior Fontanelle

Normal

Normal to sunken

Sunken

External Jugular Vein

Visible when supine

Not visible except with supraclavicular pressure

Not visible even with supraclavicular pressure

Skin

Capillary refill <2 sec

Delayed capillary refill, 2-4 sec (decreased turgor)

Very delayed capillary refill (>4 sec), tenting; cool skin, acrocyanotic, or mottled

Urine Specific Gravity (SG)

>1.020

>1.020; oliguria

Oliguria or anuria

Approximate Fluid Deficit

<50 mL/kg

50-100 mL/kg

> 100 mL/kg

Electrolyte Deficit Calculation:

Na+ deficit = (desired Na - measured Na in mEq/L) x 0.6 x weight in kg

K+ deficit = (desired K - measured K in mEq/L) x 0.25 x weight in kg

Cl− deficit= (desired Cl - measured Cl in mEq/L) x 0.45 x weight in kg

Free H2O deficit in hypernatremic dehydration = 4 mL/kg for every mEq that serum Na >145 mEq/L.

Phase 1, Acute Fluid Resuscitation (Symptomatic Dehydration):

-Give NS 20-30 mL/kg IV at maximum rate; repeat fluid boluses of NS 20-30 mL/kg until blood pressure and pulse are normal.

Phase 2, Deficit and Maintenance Therapy (Asymptomatic dehydration):

Hypotonic Dehydration (Na+ <125 mEq/L):<125>

-Calculate total maintenance and deficit fluids and sodium deficit for 24h (minus fluids and electrolytes given in phase 1). If isotonic or hyponatremic dehydration, replace 50% over 8h and 50% over next 16h

-Estimate and replace ongoing losses q6-8h.

-Add potassium to IV solution after first void.

-Usually D5 1/2 NS or D5 1/4 NS saline with 10-40 mEq KCL/liter 60 mL/kg over 2 hours. Then infuse at 6-8 mL/kg/h for 12h.

-See hyponatremia, page 111.

Isotonic Dehydration (Na+ 130-150 mEq/L):

-Calculate total maintenance and replacement fluids for 24h (minus fluids and electrolytes given in phase 1) and give half over first 8h, then remaining half over next 16 hours.

-Add potassium to IV solution after first void.

-Estimate and replace ongoing losses.

-Usually D5 1/2 NS or D5 1/4 NS with 10-40 mEq KCL/L.

Hypertonic Dehydration (Na+ >150 mEq/L):

-Calculate and correct free water deficit and correct slowly. Reduce serum sodium by 10 mEq/L/day; do not reduce sodium by more than 15 mEq/L/24h or by >0.5 mEq/L/hr.

-If volume depleted, give NS 20-40 mL/kg IV until adequate circulation, then give 1/2-1/4 NS in 5% dextrose to replace half of free water deficit over first 24h. Follow serial serum sodium levels and correct deficit over 48-72h.

-Free water deficit: 4 mL/kg x (serum Na+ -145)

-Also see “hypernatremia” page 111.

-Add potassium to IV solution after first void as KCL.

-Usually D5 1/4 NS or D5W with 10-40 mEq/L KCL. Estimate and replace ongoing losses and maintenance.

Replacement of ongoing losses (usual fluids):

-Nasogastric suction: D5 1/2 NS with 20 mEq KCL/L or 1/2 NS with KCL 20 mEq/L.

-Diarrhea: D5 1/4 NS with 40 mEq KCl/L

Oral Rehydration Therapy (mild-moderate dehydration <10%):

-Oral rehydration electrolyte solution (Rehydralyte, Pedialyte, Ricelyte, Revital Ice) deficit replacement of 60-80 mL/kg PO or via NG tube over 2h. Provide additional fluid requirement over remaining 18-20 hours; add anticipated fluid losses from stools of 10 mL/kg for each diarrheal stool.

Oral Electrolyte Solutions

Product

Na (mEq/L)

K (mEq/L)

Cl (mEq/L)

Rehydralyte

75

20

65

Ricelyte

50

25

45

Pedialyte

45

20

35

 

ITE 2012, Q77.
In symptomatic young children with Campylobacter enterocolitis that is refractory to conservative management, the preferred treatment is

A) erythromycin
B) ciprofloxacin (Cipro)
C) ampicillin
D) trimethoprim (Primsol)
E) metronidazole (Flagyl)

ANSWER: A