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RIME - Diarrhea Sarah Horvath, MSIII February,
2011 |
History Intake
Characters
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Onset:
Abrupt (infection or medication) or gradual?
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Pattern
& duration? Large or small volume – hydration status
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Aggravating
and relieving symptoms?
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Associated
symptoms - abdominal pain, weight loss, fever, vomiting
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Association
with new or particular foods or travel?
*Children
from developing countries are more likely to suffer from chronic enteric
infection & malnutrition
*Celiac
may present with the introduction of wheat cereals
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Stool
character: Bloody (bacterial infection, dietary protein intolerance, IBD),
White/light tan (Celiac, lack bile), Watery (infection), Fatty (pancreatic
insufficiency, malabsorption)
Causes
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Acute
(<2 weeks): Viral, bacterial or parasitic infection
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Chronic:
Dietary, postinfectious- lactose intolerance, Enteric (Parasitic, bacterial,
viral), Immunologic,
Physical Exam
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Weight
change – objective signs for dehydration
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Acute
abdomen – tenderness, distention, rebound, guarding
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Hepatosplenomegaly,
ascites, associated rash
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Anorectal:
occult blood, sphincter competence, skin tags, fistulas
Labs
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Anti-tTG & endomysial
IgA antibodies (celiac disease).
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Stool pH, electrolytes and osmotic gap (<50mOsm/kg secretory, >125mOsm/kg osmotic)
Differential
Diagnosis and Management
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Viral |
Bacterial |
Dietary |
IBD |
Other |
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Causes |
CMV, Rotavirus, enteric
adenovirus, parvovirus, HIV |
EHEC, EPEC, ETEC, EAEC, Shigella, Salmonella, Yersinia,
Campylobacter, V. cholera, C. difficile |
Excess sucrose, fructose or sorbitol in the diet, Excess fluid
intake, too little fiber, |
Ulcerative Colitis, Crohn’s |
Parasitic -More frequent stools, gas,
abdominal cramps, -Uncommon in US except
following recent travel to or emigration from endemic countries -Tx: ORT, metronidazole Immunologic -Primary immunodeficiency,
secondary immunodeficiency (HIV), Celiac disease, dietary-protein induced
enteropathy, Autoimmune d/o, GVHD -Chronic diarrhea, (immunodef), reaction
to wheat (celiac) or other particular protein (dietary-protein induced), - Treat the underlying
disease, modify & supplement diet, provide “catch up” calories if
underweight Neuroendocrine tumors (gastrinoma, VIPoma),
Eating disorder, Factitious (laxatives or stool sample manipulation), Antibiotic-associated |
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S & S |
Less frequent stools, vomiting, fever, (-) stool culture |
More frequent stools, gas, abdominal cramps, may be bloody |
Frequent large
watery stools > 3 weeks & without associated sxs.
May begin following a GE infection |
Hematochezia abdominal cramps, anorexia and weight loss, comes &
goes |
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Treatment |
Comfort care, Oral Rehydration Therapy,
prevention (wash your hands!) |
ORT, +/- antibiotics (depending on the organism) |
Decrease fluid
intake (especially juice), increase fiber and fat intake (fresh fruits &
vegetables, high fiber cereals & breads, cheese & yogurt) |
Corticosteroid 5-ASA, immunomodulators, antibiotics, probiotics |
Ref. www.uptodate.com , pedsinreview.aappublications.org: Inflammatory Bowel Disease, Viral Causes of Diarrhea