Diarrhea Julie Anne Ting

Objectives To review the common causes of acute diarrhea in childhood. To review the current approach to outpatient management of acute diarrheal illness. To review bloody diarrhea and its etiology. To discuss the causes of chronic diarrhea.

Case Julie is a 2 year-old girl seen in your office for a 4 day history of diarrhea. She initially had fever and 2 episodes of vomiting but this has since resolved. Her father has been giving her flat coke.

What else would you like to know?

Hx (1) HPI diarrhea: quantity and quality associated GI symptoms: vomiting, abdominal pain, tenesmus, dysuria constitutional symptoms intake and output travel history, sick contacts

Hx (2) PMHx (incl. immunosuppressive illnesses, chronic diarrheal illness) Family Hx (incl. IBD, celiac) Rx (incl. recent Abx use) Allergies (incl. food intolerances) Immunizations (incl. Rotarix)

Red Flags on Hx < 3m.o. with fever for >2d <3m.o. with diarrhea for >2d hematochezia or melena bloody or green bilious vomit diarrhea >10d progressively worsening abdominal pain lethargy, decreased urine output Why are these findings worrisome?

What are important things not to miss on P/E?

P/E General appearance: toxic vs. non-toxic Vitals Growth parameters Hydration status Abdominal exam: bowel sounds, masses, tenderness, guarding, rebound, (DRE)

Hydration Status (1) Mild Moderate Severe % Weight Loss <5% 5-10% >10% HR N N/↑ increased Radial Pulse weak absent RR increased, grunting Skin cool, ↓turgor cyanosis, tenting

Hydration Status (2) Mild Moderate Severe Eyes + Ant. Fontanelle N sunken markedly sunken Mucous Membranes slightly dry dry parched Cap. Refill increased markedly increased LOC lethargy stupor, coma UO N/slight↓ <q8h, <4x/d anuria other: no tears

Julie’s Story Julie just returned from a family trip to the Caribbean. She has bloody diarrhea. She has mild dehydration. She has non- localizing abdominal pain. There are no signs of peritonitis.

What are possible causes of Julie’s diarrheal illness?

DDx Acute Diarrhea Very Common: GI infection: virus (usu. non-bloody) > bacteria > parasite Antibiotic-associated diarrhea Very Life-Threatening Systemic infection Surgical abdomen: intussusception, appendicitis, toxic megacolon

Which of these investigations would you order for Julie? CBC BUN, Cr electrolytes stool C&S stool O&P C. difficile toxin screen urinalysis abdominal ultrasound abdominal CT

Indications for Investigations Cause other than gastroenteritis is suspected Severe dehydration Bloody diarrhea

How would you manage Julie’s diarrhea?

Rx Choices Rehydration: ORT (mild-mod) or IVF (severe) Early refeeding: increases speed of bowel recovery Antibiotics: consider if bloody diarrhea, systemic illness Empiric Abx for bloody diarrhea: ciprofloxacin 20mg/kg/d div BID x 5d or ceftriaxone 50mg/kg/d (max 1.5g) x 5d Zinc supplementation: a first-line Rx in developing countries Probiotics: some evidence of benefit Smectite: adsorbent

Oral Rehydration Therapy Pedialyte (no juice, no pop, no salty chicken noodle soup, no cow’s milk, no plain water) for mild-moderate (<10%) dehydration not for patients with protracted vomiting, worsening diarrhea, stupor/coma, or intestinal ileus

Oral Rehydration Therapy 20mL/kg/h over the 1st hour, then 10mL/kg/h for mild (<5%) dehydration and 15-50mL/kg/h for severe (5-10%) dehydration reassess in 6-8h (or if you’re at CHEO, follow the pre-printed handouts)

Does Julie need follow-up?

Hemolytic Uremic syndrome (HUS) A potential complication of EHEC (esp. O157:H7), also Campylobacter, Shigella, and some viruses usually starts 3 days after resolution of diarrhea increased risk if <5y.o. and bloody diarrhea warn parents to watch out for bruising, oliguria, neurological changes Rx: dialysis prn

Summary: Approach to Acute Diarrhea Hydration Status mild to moderate volume loss (<10%): ORT severe volume loss (>10%): admit for IVF resuscitation Toxic vs. Non-Toxic if suspect severe/systemic illness: cultures, Abx if suspect surgical abdomen: imaging, consult surgery

Julie Says Thank You for saving her!

Causes of Chronic Diarrhea

Chronic Diarrhea Without FTT Toddler’s Diarrhea (Chronic Nonspecific Diarrhea) cause: excess fluid intake, carbohydrate malabsorption, low dietary fat intake, disordered GI motility, excess fecal bile acids Rx: 4Fs: fibre, normal fluid intake, 35-40% fat, D/C fruit juice Infection Lactose Intolerance IBS

Chronic Diarrhea with FTT Intestinal: celiac disease, milk protein allergy, IBD Pancreatic: CF, Schwachman-Diamond Syndrome Other: osmotic, endocrine, immunodeficiency, neoplastic, food allergy, laxative abuse