Abstract
Vomiting and diarrhea are among the most common presenting complaints for pediatric patients. There are myriad causes for these symptoms. The clinical approach for the child presenting with vomiting and/or diarrhea (stratified by age group), as well as assessment and treatment of pediatric dehydration, will be discussed.
Keywords
dehydration, diarrhea, gastroenteritis, intussusception, oral rehydration, vomiting
3
If vomiting is so common, how can I know if a dangerous condition might be present ( Table 20.1 )?
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Appearance of the vomit: bright green or yellow (bilious)
Table 20.1
Infancy
Early Childhood
Adolescence
Volvulus from malrotation
Intussusception
Appendicitis
Pyloric stenosis
Toxic ingestion
Toxic ingestion
Increased intracranial pressure
Increased intracranial pressure
Increased intracranial pressure
Inborn errors of metabolism
Diabetic ketoacidosis
Diabetic ketoacidosis
Other causes of obstruction
Appendicitis
Torsion of ovary/testis
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Pain: especially severe or constant
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Exam: marked tenderness or distension
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Symptoms or signs of elevated intracranial pressure
5
A 13-day female patient presents with two episodes of vomiting in the past few hours. The parents show you a blanket with a small bright yellow stain from her emesis. What should you do?
Bilious emesis in young infants should be considered an emergency until proven otherwise. This is a classic presentation (even if well appearing!) for neonatal obstruction, the most common cause being intestinal malrotation (entraining volvulus). This child should be urgently referred for an upper gastrointestinal (GI) study.
6
How do I know if the baby I’m seeing simply has reflux?
Physiologic reflux (“spitting up”) is the most common cause of vomiting in infants. Clues to this diagnosis are well appearance, normal growth, and nonacute presentation. Reflux typically peaks in the second month of life and usually does not require pharmacologic intervention.
7
A 7-week infant has had worsening vomiting for 5 days. There is no bile. The caregiver thinks that the emesis is becoming more forceful. What diagnosis should you consider?
Hypertrophic pyloric stenosis usually presents in the second month of life, and it is more common in males. Given the anatomic location of the obstruction, vomitus is nonbilious. Babies are often well appearing, and unless they present later in the course of their illness, the “classic” electrolyte pattern of a hypochloremic, hypokalemic metabolic alkalosis will be absent. They have progressive “projectile” vomiting and lack satiety. It is diagnosed by ultrasound.
9
My patient has fever and diarrhea but now is complaining of blood in the stool. Guaiac testing is positive. The child looks well. Given the presence of blood, is there anything different that should be done?
While routine stool cultures are not recommended for children with acute diarrhea, up to 20% of cultures will grow a bacterial pathogen when gross blood is present. Therefore, it is advisable to obtain a stool culture in this setting. Nevertheless, antibiotic treatment is not recommended for healthy children in most cases of bacterial enteritis.
10
A 4-month-old female patient presents with 2 days of diarrhea, vomiting, and fever. She is well appearing, and you think the most likely diagnosis is viral gastroenteritis. What one test should you consider for this patient?
Urinary tract infections (UTIs) are common in young children, more so in girls. Data are conflicting as to whether gastrointestinal symptoms are more common in children with UTI. Although young infants can lack the expected findings on urinalysis, consider obtaining urine for this child. While a catheter specimen is preferred, a bagged urine that is “clean” may reassure against UTI; if the bag urinalysis suggests infection, obtain a catheterized specimen for culture.
11
What diagnosis should always be considered in older infants and young children with isolated vomiting?
Ileocolic intussusception is the most common gastrointestinal emergency in young children. The usual age range is 6–36 months of age, but all the “classic” findings (vomiting, pain, lethargy, abdominal mass, “currant jelly” stools) are not usually present. Kids can appear well, especially if the obstruction is intermittent. The preferred diagnostic modality is ultrasound, and hydrostatic enema is usually successful for reducing the intussusception.