vomiting, diarrhoea, abdominal pain & fluid therapy
DESCRIPTION
Vomiting, Diarrhoea, Abdominal Pain & Fluid Therapy. Department of Paediatrics CUHK. Vomiting. vomiting forceful ejection of gastric contents often preceded by nausea and retching possetting gentle expulsion of gastric contents with swallowed air (“wind”) regurgitation - PowerPoint PPT PresentationTRANSCRIPT
Vomiting, Diarrhoea, Vomiting, Diarrhoea, Abdominal PainAbdominal Pain&&Fluid TherapyFluid Therapy
Department of PaediatricsCUHK
VomitingVomiting
vomiting– forceful ejection of gastric contents– often preceded by nausea and retching
possetting– gentle expulsion of gastric contents with swal
lowed air (“wind”)regurgitation
– similar to possetting, but larger lossretching
– laboured rhythmic respiratory activity that precedes vomiting
Mechanism of vomitingMechanism of vomiting
Vomiting process
• patent upper GI tract
• retro-peristalsis
• lower esophageal sphincter
relaxation
• contraction of abdominal
muscles and diaphragm
Causes of VomitingCauses of Vomiting
infection/inflammation• gastroenteritis
• viral• bacterial• toxin
• immunological• cow-milk• coeliac• food allergy
• inflammatory• appendicitis• mesenteric adenitis
GI obstruction• pyloric stenosis• intussusception• volvulus• strangulated hernia• Hirschsprung• tumour• post-operative ilieus
CNS irritation• infection• raised ICP• drugs / poisons• metabolites
Incompetent LES• possetting• reflux• hiatus hernia
DiarrhoeaDiarrhoea
Diarrhoea: increase in frequency (> 3 times) and change in character of stool (volume and liquidity)
Lead to rapid dehydration and progressive acidosis
Acute - within 2 weeks
Chronic or persistent - beyond 2 weeks
WHO: 2.6 episodes/child/year, global mortality 3.3 million/year
Acute gastroenteritisAcute gastroenteritis
Morbidity in developed world, yet mortality in developing world
Complicated in developed world with secondary lactase deficiency
Complicated in developing world with recurrent episodes and malnutrition, like deficiency of zinc, vitamin A etc,
Especially affecting children < 2 years
Infective causes of diarrhoea and voInfective causes of diarrhoea and vomitingmitingViruses BacteriaRotavirus Enteroinvasive E. coliAdenovirus Camphylobacter jejuniCoronavirus Salmonella sp.Astrovirus Shigella sp.Calcivirus Vibrio choleraParvovirus Yersinia enterocoliticaEchovirus
Protozoa Bacterial toxinsGiardia lamblia Enterotoxic E. coliCrytosporidium Staphylococcus aureusEntamoeba histolytica Bacillus cereusMalaria Clostridium difficile
Bacterial GastroenteritisBacterial Gastroenteritis
Salmonella, E coli (EPEC, EIEC, EHEC, VTEC-0157), Shigella (neurotoxin), Yersinia, Campylobacter
Adherence and invasion of bacteria to gut structures
Bloody diarrhoea, Fever, Tenesmus, Severe or persistent symptoms
Antibiotic use, Clostridium(toxin is common in healthy newborn)
CholeraCholera
cause secretory diarrhoea
enterotoxin production leading to generation of intracellular cAMP (adenyl cyclase)
result in stimulation of the chloride channel leading to fluid and electrolytes secretion
could also cause increased production of prostaglandins
absorption of fluid and e- remains intact
Virus GastroenteritisVirus Gastroenteritis
Rotavirus attacks the villus epithelium of the small intestine
Norwalk virus - vomit
Enteric adenoviruses
increase in epithelial renewal with crypt proliferation, interfering the process of maturation
repair takes 4 - 5 days, affected by chronic protein-calorie malnutrition
Rotavirus gastroenteritisRotavirus gastroenteritis
Most common cause in infants and young children (6 - 12 months), occurs in winter
Within two days of exposure, low grade fever,anorexia, & vomiting lasting up to 48 hours. Watery diarrhea and cramps follow
Highly infective, resistant to drying and chlorine in tap water. Nosocomial outbreaks occur in hospital and nurseries
Fecal-oral transmission
Rotavirus gastroenteritisRotavirus gastroenteritis
Infect the villi of small intestine, causing damage to transport mechanisms, secondary lactase deficiency and malabsorption
Local IgA response, no life-long protection
Diagnosis by viral antigen detection
Self-limiting disease with complete recovery
Prevention by improving overall standard of nutrition and hygiene (handwashing, disposal of diapers), ?oral vaccine
Norwalk / Norwalk-like / Norwalk / Norwalk-like / NorovirusNorovirus
Norwalk virus was named after the strain that was responsible for an outbreak of gastroenteritis in a school in Norwalk, Ohio, USA
Recently approved name: Norovirus, a RNA virus
More common during cooler months
As of November 17, there were 41 reported cases of viral gastroenteritis caused by Norwalk-like virus, affecting about 1,000 persons and occurring in institutions like schools, child care centres and homes for the elderly.
二零零三年 * 受諾沃克類病毒影響人數Number of Persons Affected of Norwalk-like D
isease 2003*
安老院舍 Elderly home
48%
家居Home
5%
院舍Institutions
9%
幼兒中心Child care centre
10%
幼稚園Kindergarten
4%
小學Primary school
19%
中學Secondary school
4%
醫院 Hospital
1%
* 截至二零零三年十月。
*Up to October 2003
Norovirus gastroenteritisNorovirus gastroenteritis
Incubation 1 - 2 daysUsually self-limited, lasts 1 - 10 days
Symptoms• Vomiting• Diarrhoea• Fever• Abdominal cramps• Headache
Clinical Approach to a Clinical Approach to a child who presents with child who presents with vomiting or diarrhoeavomiting or diarrhoea
History: VomitingHistory: Vomiting
Onset• Present since birth ?• Present since weaning ?• Present since introduction of new food?• Sudden or gradual ?
Vomit• Size, frequency and timing to feed• Undigested food ? bile ? blood ? coffee-gro
und ?
History: DiarrhoeaHistory: Diarrhoea
Onset• Sudden or gradual ?
Stool• Volume, frequency and timing to feed• Loose, watery, rice watery• Blood, mucus, steatorrhoea
History:History:
Associated symptoms• Abdominal pain / Abdominal distension• Fever• Change in appetite / feeding habit• Weight loss ? or gain ?• General: playfulness, activities, urine outpu
t
Social history• Family members having vomiting / diarrho
ea• Recent traveling
ExaminationExamination
Full examination is necessary in all childrenGeneral examination
• Activity• Nutritional status• Weight and Height (and compare with prev
ious)• Temperature• Anaemia• Jaundice• Degree of dehydration• Cleft palate• Neurological
Mild Moderate Severe
Body weight <5% 5-10% > 10%General Appearance
Thirsty, Alert Thirsty, restless or lethargic
Drowsy, cold, sweating
Tears Present Absent Absent
Anterior Fontanelle
Normal Sunken Very sunken
Eyes Normal Sunken Very sunken
Tissue Turgor Normal Absent Absent
Mucous Membranes
Moist Dry Very Dry
Pulse Normal Rapid Rapid, weak, may be
impalpable
Urine flow Normal Reduced, concentrated
Oliguria
Blood pressure
Normal Normal or low Low, may be unrecordable
Fluid deficit 50ml/kg 60-90ml/kg 100ml/kg
In hypertonic dehydration, signs not prominent because of intracellular dehydration; skin of doughy consistency with abnormal behaviour
ExaminationExamination
Abdomen: Inspection• Distension
• Constipation• Gastroenteritis• Obstruction / Ileus• Coeliac Disease
• Surgical Scar
ExaminationExamination
Abdomen: Palpation• Local tenderness• Generalized tenderness• Guarding and rebound tenderness
• Peritoneal irritation• Masses
• Organomegaly• Pyloric mass• Sausage shaped mass
• Hernial orifices• Genitalia
ExaminationExamination
Abdomen: Auscultation• Bowel sounds
• Normal• Hyperactive: irritation, obstruction• Diminished, absent: paralytic ileus
Abdomen: Rectal examination• Anal fissures• Sphincter• Faeces• Blood• Masses
InvestigationsInvestigations
Ordered according to index of suspicion
• Examine stool for consistency, blood, mucus, and steatorrhoea
• Stool for bacterial culture and virus isolationPositive yield ~50%
• Commonest: rotavirus• Commonest bacterial: Salmonella
• Stool for Clostridial difficile toxin• Blood for cell counts, U&Es, culture
InvestigationsInvestigations
• Test feed for infant 2 to 10 weeks
• Examine urine for RBC, WBC and organism under microscope, urine for culture
• AXR: Supine, Erect for intestinal obstruction
• USG abdomen
TreatmentTreatment
RehydrationRehydrationRehydration fluid and electrolytes
• Oral glucose-electrolyte solution• Intravenous glucose-electrolyte solution• Nutritional treatment - continuation of bre
ast feeding (lactadherin), or formula feeding
Principles of fluid Principles of fluid replacement : replacement : volume requiredvolume required= maintenance + deficit + = maintenance + deficit + ongoing lossongoing loss
Daily fluid requirementDaily fluid requirement
Fluid First 10 kg 100 ml/kg/daySecond 10 kg 50 ml/kg/dayAfter first 20 kg 20 ml/kg/day
Increase by 10% per degree Celcius rise in body temperature
Electrolytes Sodium 3 mmol/kg/dayPotassium 2 mmol/kg/day
For a 25-kg boyDaily fluid requirement for a 25-kg boy
= 1000 ml + 500 ml + 100 ml = 1600 ml
Daily Na requirement = 75 mmolDaily K requirement = 50 mmol
Fluid deficit calculationFluid deficit calculation
Volume depleted = estimated % of dehydration x body weight
For a 25 kg boy with 10 % dehydrationVolume deficit (1 L water = 1 kg)
= 10% x 25 kg = 2.5 L
AAP Practice Parameter 1996AAP Practice Parameter 1996
ORS is the preferred treatment for fluid and electrolyte losses caused by diarrhoea in children who have mild to moderate dehydration
Use of cola, fruit juice and sports beverages is not recommended– Inappropriate electrolyte content– Too much carbohydrate
ORSORS
Commercially available ORS contain 45-50mmol/l of sodium– Best suitable for maintenance– Can also be used in mild to moderate dehydra
ted otherwise healthy children– Taste better than the saltier solution
WHO recommended ORS– High sodium content 90mmol/l– Suitable for secretory diarrhoea eg. Cholera
ORS Therapy in mild to ORS Therapy in mild to moderate dehydrationmoderate dehydration
50-100ml/kg ORS to be given over a 4-hour period
Replacement of stool (10ml/kg for each stool) and vomitus will require adding appropriate amounts of solution to the total
Administering in small but frequent amounts– 10 ml every two minutes = 500 ml over 4 hours
Labour intensive, time consuming
Intravenous fluid therapyIntravenous fluid therapy
Although oral rehydration is encouraged, clinician must be prepared to administer IV fluids who do not respond to oral regimen
Severely dehydrated or who are in a state of shock must receive immediate and aggressive intravenous fluid therapy
Phase I: Treat shock(0 - 30 minutes)
Phase II: Initial Rehydration(½ - 8 hours)
Phase III: Continued Replacement(8 - 24 hours)
10-20ml/kg 0.9% NaCl
Reassess
Improved
No Change
Measure plasma electrolytes
Calculate fluid deficit and maintenance
Review plasma electrolytes and fluid status
Initial replacement with saline-dextrose solution
Half the calculated fluid deficit plus maintenance
Replacement with saline-dextrose solution
Half the calculated fluid deficit plus maintenance
Sodium replacementSodium replacement
Sodium deficit in mmol required = (140 - [Na+] x 0.65 x body weight in kg)
• 0.65 is the volume of distribution of NaSodium replacement
= sodium daily requirement + sodium deficit
If due to water intoxication (iatrogenic, SIADH)• Restrict fluid
Treatment of metabolic Treatment of metabolic acidosisacidosis
For full correction of acidosis, NaHCO3 required (mmol)
= Base deficit x body weight x 0.3
In most cases, metabolic acidosis is self-corrected once dehydration corrected and hence effective circulation volume restored
In rare situation, half of the calculated required NaHCO3 may be given: watch out for Na overload and pulmonary oedema
Hypertonic dehydrationHypertonic dehydration
Difficult to assess degree of dehydration, unless the child in clinically shock (>10% dehydration)
The plan – Fluid resuscitation 10-20 ml/kg NaCl over first 1
hr– replace total fluid deficit plus maintenance slo
wly over 48-72 hours– To lower serum sodium slowly: 10mmol/L/da
y
Rapid correction may cause cerebral oedema
MonitorMonitor
Body weightVital signs, heart rate, blood pressure,
respiratory rateSubsidence of signs of dehydration Input and output chartsContinuous lossSerum electrolytes In severe cases blood glucose, blood gases,
osmolality
Antibiotics in special Antibiotics in special circumstancecircumstance
Salmonella GE in infantShigella with trimethoprim-sulfamethoxazoleCampylobacter with erythromycinCholera with tetracyclineAmoebic dysentery - giardiasis (metronidazole)NB: drug resistance, promote carrier state, worse
n the course of diarrhoea
RefeedingRefeeding
Children who have diarrhoea and are not dehydrated should continue to be fed regular diet
Children who require rehydration should be fed regular diet as soon as they have been rehydrated
Early feeding of regular diet does not worsen the course or symptoms of mild diarrhoea and may reduce the duration of diarrhoea modestly
RefeedingRefeeding
Avoid fatty foods and foods high in simple sugars
Rice, wheat, potatoes, bread and cereals (complex carbohydrate), lean meats, yogurt, fruits and vegetables are usually well tolerated
Most children who have diarrhoea will tolerate full-strength milk
Lactose-free formula may be used if secondary lactase deficiency is suspected
Antidiarrhoeal compoundsAntidiarrhoeal compounds
Decrease stool water and electrolyte lossesChange toward more formed stoolRelieve discomfortFalse sense of securityDelaying more effective therapyGenerally not recommended
Drugs that alter intestinal Drugs that alter intestinal motilitymotility
LoperamideDecreases transit velocity Increases the ability of gut to maintain fluidReduces stool losses, shortens the course of diar
rhoeaAssociates with serious adverse effect
– Lethargy, ileus, respiratory depression and coma
– Death has been reported
Drugs that alter secretionDrugs that alter secretion
Bismuth compounds, eg. Bismuth subsalicylate Inhibit intestinal secretionModest beneficial effectsDose of every 4 hours for 5 daysTheoretical risk of Reye syndrome from salicylat
e absorption
Drugs that absorb fluid and Drugs that absorb fluid and toxinstoxins
Kaolin-pectin, fiber, activated charcoal, attapulgite
Adsorb bacterial toxinsBind waterSerious toxic effects are not a concernEvidence of their efficacy has been contradictory
Agents that alter intestinal microfloAgents that alter intestinal microflorara
Patients with diarrhoea undergo reduction fecal flora, which leads to increased water losses
Lactobacillus sp.– Alter the bacterial colonization of the gut
therapeuticallyToxic effects are not a concernHowever efficacy of lactobacillus-compounds
in treating diarrhoea yet to be demonstrated
Treatment outcome/evaluationTreatment outcome/evaluation
hospitalization or notextent of investigationeffectiveness of rehydration (IV <=> PO)use of antimicrobials relief of symptoms - frequency of stools, duratio
n of diarrhoea, weight gainprevention strategy
• Public health measures - sanitation• Food preparation and storage• Promotion of breast feeding
Other common paediatric Other common paediatric gastrointestinal gastrointestinal conditionsconditions
Gastro-oesophageal refluxPyloric stenosisCyclic vomitingChronic diarrhoeaConstipationAcute abdominal pain
Gastro-oesophageal refluxGastro-oesophageal reflux
Small, effortless vomits of semi-digested milk soon after feeding
Common in infants because of• immature lower oesophageal sphincter• short intra-abdominal length of oesophagu
sUsually resolve by 1 year oldUsually mild but severe cases with complications:
• pulmonary aspiration• oesophagitis, peptic stricture• failure to thrive, feeding problems
Gastro-oesophageal refluxGastro-oesophageal reflux Investigation
– usually not required– 24-h oesophageal pH monitoring
• contrast study
Gastro-oesophageal refluxGastro-oesophageal reflux
management• often requiring no treatment• mild: positioning at 30° head-up prone & th
ickening agent• drugs enhancing gastric emptying• H2 antagonists• fundoplication
Pyloric StenosisPyloric Stenosis
hypertrophy of pyloruspresented between 2 and 7 weeks of ageM:F = 4:1presentation
• large, non-bilious, projectile vomiting after each feed
• dehydration, weight loss
Pyloric StenosisPyloric Stenosis
Investigation• ultrasonography & contrast study
antrum
thickened pyloricmuscle
elongated pyloriccanal
Pyloric StenosisPyloric Stenosis
Management
• fluid resuscitation• electrolyte correction
• hypochloraemic alkalosis with hypokalaemia
• Ramstedt’s pyloromyotomy
Persistent & Chronic VomitingPersistent & Chronic Vomiting
CNS: raised intracranial pressure• early morning vomiting• headache worsen on lying down
Appendicitis• uncommon before 3 years old• atypical presentation in retrocaecal and pe
lvic appendices
Persistent & Chronic VomitingPersistent & Chronic Vomiting
Cyclical vomiting• psychogenic, with stressful factors• of school age• prodromal symptoms: pale, withdrawn• associated with migraine
Anorexia or bulimia nervosa– adolescent– deranged body image– weight-fear– induced vomiting
Chronic DiarrhoeaChronic Diarrhoea
Birth to 6mo InfectionSecondary lactose deficiency
Persisting diarrhoeaCow’s milk intoleranc
eOther food intoleranceCystic fibrosisIn-born errorsAntuoimmune enteropa
thySurgery
Chronic DiarrhoeaChronic Diarrhoea
6mo to 1yr InfectionCoeliac diseaseGiardia lambliaSurgery
1+ years Post-infectionCoeliac diseaseGiardia lamblia
10+ years Inflammatory bowel disease
Chronic diarrhoeaChronic diarrhoea
Postinfectious diarrhoea - persistence of diarrhoea and failure to gain weight more than 7 days after admission
Due to disaccharide intolerance(brush-border damage), cow milk protein hypersensitivity(-lactoglobulin), persistent infection
Managed by soy-base formula, lactose-free formula, or semielemental diet
Chronic nonspecific diarrhoeaChronic nonspecific diarrhoea
“Toddler” diarrhoeaaffecting children 6 months to 2 yearsself-limitingpass 4 - 10 loose stool per daymay be intermittent, explosiveMay contain undigested foodNegative stool culture and reducing
substancesgrowth and development normal
Acute abdominal pain:Acute abdominal pain:“Does the child require “Does the child require emergency surgery?”emergency surgery?”
Signs of peritonism, appendicitis– Fever, localized tenderness, guarding, reboun
d tenderness, absent bowel sounds– The younger the child the more vague the sign
sSigns of obstruction
– Vomiting, abdominal distension, high pitch bowel sounds, empty rectum
Gastrointestinal bleeding– Haematemesis, bloody stool, “Current-jelly
” stool, malaena
Require early surgical referral
Abdominal cause but does not require immediate surgical referral
Systemic cause
AppendicitisPeritonitisIntussusceptionVolvulusStrangulated herniaTraumaGI Bleeding
GastroenteritisInfantile colicIngestionConstipationPeptic ulcerPancreatitis / mumpsCholecystitis / cholangitisUrinary tract infectionNephrotic syndromeHepatitisDysmenorrhoea
Any febrile illness but especially ENT infectionLower lobe pneumoniaAbdominal migraineDiabetic ketoacidosisSexual abusePorphyriaLead poisoningHenoch Scholein purpura