Core Clinical Cases In Paediatrics PDF

9Diarrhoea and vomiting Questions Clinical cases Key concepts Answers  98 Diarrhoea and vomiting ? Questions for each of the clinical cases Q1: What is the likely differential diagnosis? Q2: What issues in the given history support the given diagnosis? Q3: What addit...

9Diarrhoea and vomiting Questions Clinical cases Key concepts Answers  98 Diarrhoea and vomiting ? Questions for each of the clinical cases Q1: What is the likely differential diagnosis? Q2: What issues in the given history support the given diagnosis? Q3: What additional features in the given history would you seek to support a particular diagnosis? Q4: What clinical examination would you perform, and why? Q5: What investigations would be most helpful, and why? Q6: What treatment options are appropriate? Clinical cases CASE 9.1 – My 6-month-old son started screaming with pain and drawing up his legs. There is nothing I can do to console him. A previously well child has developed sudden onset episodes of screaming and drawing up his legs; he has not opened his bowels recently, and looks very pale. CASE 9.2 – My toddler has developed sickness and diarrhoea. Most of the other children at his nursery have developed it as well. A 14-month-old boy has started vomiting and has loose watery stools up to eight times a day. He has a slight fever and is rather quiet. Other mothers at the nursery report similar findings. CASE 9.3 – My 4-week-old boy has suddenly started vomiting up all his feeds and can’t stop, even though he still wants to feed. This baby was born at term after a normal pregnancy. He fed well initially, but recently he has been vomiting after every feed. Sometimes, the vomiting is forceful and shoots out of his mouth. He still seems hungry and feeds vigorously.  OSCE counselling cases 99 OSCE counselling cases OSCE COUNSELLING CASE 9.1 – My child cries all the time with colic, what shall I do? OSCE COUNSELLING CASE 9.2 – My baby keeps being sick after feeds, I am changing clothes all the time, what should I do?  100 Diarrhoea and vomiting Key concepts In order to work through the core clinical cases in this chapter, you will need to understand the following key concepts. Assessment of dehydration Dehydration is assessed clinically. The symptoms and signs to look for include: z Thirst, irritability, lethargy. z Dry mucous membranes. z Sunken eyes. z Rapid, thready pulse. z Sunken fontanelle (in babies). z Reduced tissue turgor (this is a reduction in the elasticity of the skin). z Reduced capillary return. z Pallor and mottled extremities. z Reduced urine output. z Reduced level of consciousness (in severe cases). Stool frequency and diarrhoea z Newborn babies pass sticky black stools (meconium) after birth. z Breast-fed babies pass frequent, loose, seedy yellow stools. z Breast-fed infants may pass up to 8–10 stools a day. Bottle-fed babies usually pass stools less frequently (2–3 times a day). z Stools that are watery or soak into the nappy with no solid material are abnormal. z The presence of blood in the stool indicates pathology, e.g. infection, mucosal tear, gastrointestinal bleeding. z Diarrhoea is the passage of frequent, loose stools. z The causes of diarrhoea are acute (e.g. gastroenteritis, associated with antibiotic treatment) and chronic (e.g. post- infectious malabsorption, coeliac disease and inflammatory bowel disease). z Treatment involves correction of any dehydration, and is then directed to the underlying cause. z Note: Oral rehydration therapy consists of a glucose and electrolyte powder which is reconstituted with water. The principle is the linked active transport of sodium and glucose absorption in the small intestine. Glucose and sodium are co-transported across the intestinal mucosa with water. z Give maintenance fluids plus replacement of deficit and ongoing losses. Aim to correct dehydration within 4–12 hours with 50–100 ml/kg oral rehydration fluid given as frequent small amounts.  Key concepts 101 Infantile colic z This is very common in infancy, and consists of paroxysmal, inconsolable crying or screaming together with drawing up of the knees. This can occur several times a day, but it is more common in the evening. z The cause is unknown, but is benign, and it is not associated with other disease. Indeed, it is not recognized in some countries. z Babies are well between episodes. z Management is by swaddling the child up for comfort, and cuddling. z It resolves usually by 3 months of age. Gastro-oesophageal reflux z This is common in infancy, and ranges from the ‘posset’ of a mouthful of milk after a feed to vomiting up most of the feed. If severe it may lead to failure to thrive, anaemia, and aspiration pneumonitis. z Most reflux resolves by 12 months of age. z Complications can include oesophagitis causing pain, bleeding and anaemia; dystonic movements of the head and neck (Sandifer syndrome); apnoeas in preterm infants. It is more common in infants with cerebral palsy (q.v.). z The cause is thought to be functional immaturity of the lower oesophageal sphincter, leading to inappropriate relaxation. z Diagnosis is usually made by the history, although a contrast swallow or 24-hour oesophageal pH study may be indicated in more severe cases. z Infants with mild uncomplicated reflux can be diagnosed clinically and managed with thickening agents added to the feeds. z Sometimes, drugs which help to reduce acid in the stomach (e.g. ranitidine) or help bowel peristalsis may be necessary. z The most severe cases are treated by fundoplication, where the stomach fundus is wrapped around the intra- abdominal oesophagus. Intussusception z This is the invagination of one segment of bowel into an adjacent lower segment, cutting off the blood supply to the invaginated segment as it progresses. z It usually begins proximal to the ileocaecal valve. z Intussusception is the commonest cause of bowel obstruction in infants after the neonatal period, occurring most commonly at the age of 6–9 months. z It characteristically presents with paroxysmal, colicky abdominal pain and pallor. The infant draws up the legs with the pain. z Vomiting and diarrhoea are common, and sometimes a sausage-shaped mass is palpable in the abdomen. z Late presentations may include passage of ‘redcurrant jelly’ stools, which contain blood and mucus.  102 Diarrhoea and vomiting z It is possible that viral infection leads to swelling of Peyer’s patches (lymph tissue in the small intestine) from which the intussusception may begin. z An abdominal X-ray may show small bowel obstruction. Treatment is usually by reduction of the intussusception with air per rectum; alternatively contrast medium may be used. z Profound shock may occur due to pooling of fluid in the gut. Intravenous fluids are usually required to prevent circulatory failure. Pyloric stenosis z Affects infants from 2–8 weeks of age, more frequently males, and first-born children. z There may also be a family history, especially in the mother. z The cause is hypertrophy of the pylorus muscle at the exit of the stomach. z There is persistent uncontrollable vomiting which is not bile-stained. z The vomiting is projectile, i.e. it shoots out with force. z Vomiting usually occurs within 30 minutes of a feed, and the infant is hungry afterwards. z The infant may be constipated and become dehydrated. z A hypochloraemic alkalosis develops from vomiting the acid stomach contents. Some infants are mildly jaundiced. z On examination, gastric peristalsis may be visible in the epigastrium following a feed. z The diagnosis is made by palpation of an enlarged hard pylorus in the right upper quadrant during a test feed (see below). An ultrasound scan of the pyloric region may also be diagnostic. z A test feed is performed as follows. Place the child on its mother’s lap and allow to feed, while positioning yourself kneeling to the left side of the child’s abdomen. Observe the abdomen for signs of peristalsis, particularly a wave occurring across the abdomen. Palpate using your left hand in the infant’s right upper quadrant for a mass the size and consistency of the end of your nose. z The management is to correct the dehydration and electrolyte imbalance, and undertake a pyloromyotomy: the pylorus is incised to divide the hypertrophied muscle fibres, but not the pyloric mucosa.  Answers 103 Answers CASE 9.1 – My 6-month-old son started screaming with pain and drawing up his legs. Q1: What is the likely differential diagnosis? A1 z Acute infantile colic. z Acute intussusception. z Acute gastroenteritis. z Testicular torsion (in boys). z Strangulated inguinal hernia. z Other cause of intestinal obstruction. z Urinary tract infection. z Non-accidental injury z Serious bacterial illness of any cause, e.g. meningitis, septicaemia. Q2: What issues in the given history support the diagnosis? A2 Acute intussusception is supported by the sudden onset of the condition in a previously well child, inconsolable pain, and drawing up of the legs. Infantile colic would have presented earlier and be intermittent, with the child completely well between episodes. A Q3: What additional features in the history would you seek to support a particular diagnosis? A3 z Ask about any vomiting and diarrhoea which may occur in gastroenteritis and also intussusception. z What colour are the stools? (i.e. is there blood present) z Ask about pallor or any recent viral infection.  104 Diarrhoea and vomiting Q4: What clinical examination would you perform, and why? A4 z Assess the level of dehydration and shock (acute circulatory failure). z Examine the abdomen between bouts of pain for any tenderness or masses. z Listen for bowel sounds (in intestinal obstruction bowel sounds are characteristically tinkling). z Examine the hernial orifices and testes for erythema, tenderness or swelling. Q5: What investigations would be most helpful, and why? A5 z Check a blood sample for acidosis, urea and electrolytes, and full blood count. z A plain abdominal X-ray would assist in the diagnosis of obstruction. z Urinalysis, blood culture, full blood count. Q6: What treatment options are appropriate? A6 z If present, correct shock with intravenous fluids. z Reduction of the intussusception with air insufflation under radiological control. z An obstructed hernia will require urgent surgery. CASE 9.2 – My toddler has developed sickness and diarrhoea, and most of the children at his nursery have developed it as well. Q1: What is the likely differential diagnosis? A1 z Acute viral gastroenteritis. z Bacterial gastroenteritis, e.g. Salmonella, Campylobacter, Shigella dysentery. z Lactose intolerance. z Coeliac disease.  Answers 105 Q2: What issues in the given history support the diagnosis? A2 The presence of diarrhoea and vomiting in the child’s nursery supports the diagnosis of an infective cause (e.g. rotavirus). This also makes food-borne infections a possibility. A Q3: What additional features in the history would you seek to support a particular diagnosis? A3 z Ask about the frequency of dirty nappies. Up to four dirty nappies a day is probably normal. z Ask about the nature of the stools: profuse watery diarrhoea with little solid material suggests gastroenteritis. Ask if there is any blood in the stools or vomit. z If the vomiting is bile-stained, consider obstruction. z Ask about any foreign travel (bacterial gastroenteritis more likely). Q4: What clinical examination would you perform, and why? A4 z Examine the abdomen. z Assess the level of hydration. z Moderate (5%) dehydration gives the signs of irritability, dry lips and mouth, and eyes slightly sunken. z Severe (10%) dehydration is suggested by altered consciousness, rapid thready pulse, reduced skin turgor. Q5: What investigations would be most helpful, and why? A5 z Consider checking serum sodium to look for hyponatraemic or hypernatraemic dehydration. z Take a stool sample for culture and microscopy for ova, cysts and parasites, and immunofluorescence for rotavirus (the commonest cause of acute gastroenteritis in winter months). Q6: What treatment options are appropriate? A6 z Oral rehydration therapy rather than intravenous fluid therapy. z Reintroduce feeds as soon as possible when rehydrated. Do not stop breast feeding.  106 Diarrhoea and vomiting Case 9.3 – My 4-week-old boy has suddenly started vomiting all his feeds. Q1: What is the likely differential diagnosis? A1 z Pyloric stenosis. z Acute gastroenteritis. z Urinary tract infection. z Gastro-oesophageal reflux. z Neonatal intestinal obstruction (e.g. malrotation, Ladd’s bands, duodenal web). Q2: What issues in the given history support the diagnosis? A2 Pyloric stenosis is suggested by the timing of onset of vomiting (usually within 20 minutes of a feed); the age (2–8 weeks at presentation) and the desire to continue feeding, which is present in the early stages but is lost as the infant becomes dehydrated. A Q3: What additional features in the history would you seek to support a particular diagnosis? A3 z Birth history, early feeding and time to pass meconium. z Ask about any previous history of vomiting, particularly with feeds. z Enquire about stool frequency. z Is the child the first in the family and is there a family history of pyloric stenosis? Q4: What clinical examination would you perform, and why? A4 z Assess level of dehydration. z Examine the infant’s abdomen before, during and after a test feed (q.v.).  Answers 107 Q5: What investigations would be most helpful, and why? A5 z An ultrasound of the abdomen is most helpful, to confirm the presence of pyloric hypertrophy. z Check urea, electrolytes and chloride for evidence of dehydration and hypochloraemic metabolic alkalosis. Q6: What treatment options are appropriate? A6 z Correction of the metabolic abnormalities with intravenous fluids, including potassium. z Surgery: pyloromyotomy, only after correction of metabolic abnormalities.  108 Diarrhoea and vomiting OSCE counselling cases OSCE COUNSELLING CASE 9.1 – My child cries all the time with colic, what shall I do? z Colic is very common, and affects almost all babies at some point; the cause is unknown. z Colic is completely harmless and goes away by itself, usually by the age of 3 months. z Proprietary remedies may help some, but not all, babies. z Do not give alcohol in any form as the baby may go hypoglycaemic. z Wrap the baby up well and cuddle him. z If you just can’t cope any longer, please seek help from family and friends, or your health visitor or GP. OSCE COUNSELLING CASE 9.2 – My baby keeps being sick after feeds, I am changing clothes all the time, what should I do? z Gastro-oesophageal reflux is common, and usually harmless. z It is more inconvenient than anything else as it involves lots of washing and makes the house smell. z It happens when food in the stomach gets pushed back up the gullet, due to immaturity of the muscle at the base of the gullet that should stop this reflux. z The acid that comes up with the food may irritate the baby and cause discomfort. z Simple measures may help: nurse the baby upright or at 30 degrees after feeds; try adding a proprietary thickener to bottle feeds. z If necessary, there are drugs that will help. z Please let the doctor know if there is blood in the refluxed milk. z If it persists, further investigation and treatment may be necessary.