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P36 Pediatrics
Gastroenterology
Toronto Notes 2019
Common Antibiotics that Can Lead to C. difficle Infection
• Fluoroquinolones
• Clindamycin
• Penicillin (broad spectrum)
• Cephalosporincs (broad spectrum)
History
• frequency,duration,qualityofdiarrhea
• associatedsymptoms(e.g.fever,abdominalpain,hematochezia,etc.) • recentantibioticuseorrecenttravel
• elementsofdiet
Physical Findings
• vitalsignstodetermineclinicalstatusandhydrationstate
Investigations
• acutediarrhea
■ stool for C&S, O&P, electron microscopy for viruses, C. difficile toxin, microscopy (leukocytes
suggestive of invading pathogen), blood and urine cultures, blood work • chronicdiarrhea
■ serial heights, weights, growth percentiles
■ ifchildgrowingwellandthriving,workupislimited(stoolculturesasabove,stoolreducingsubstances) ■ red flags: poor growth, chronic rash, other serious infections, hospitalizations for dehydration
(require full workup)
◆ stool: consistency, pH, reducing substances, microscopy, occult blood, O&P, C&S, C. difficile
toxin, 3 d fecal fat, α-1-antitrypsin clearance, fecal elastase
◆ urinalysis, urine culture
◆ CBC, differential, ESR/CRP, smear, electrolytes, total protein, albumin, carotene, Ca2+, PO43–,
Mg2+, Fe, ferritin, folate, fat-soluble vitamins, PTT, INR
◆ sweat chloride, celiac screen, thyroid function tests, urine VMA and HVA, HIV test, lead levels
◆ CXR, upper GI series and follow-through
◆ specialized tests: endoscopy, small bowel biopsy
Differential Diagnosis
Table 16. Differential Diagnosis of Diarrhea
Acute
Chronic
No FTT FTT
Infectious
Viral
Rotavirus Norwalk
Enteric adenovirus
0 – 3 mo
GI infection
Disaccharidase deficiency
Cow’s milk protein intolerance
CF
Bacterial
Salmonella Campylobacter Shigella Pathogenic E. coli Yersinia
C. difficile
3 mo – 3 yr
GI infection Toddler’s diarrhea
Celiac disease
Parasitic
Giardia lamblia Entamoeba histolytica
3 – 18 yr
GI infection
Lactase deficiency Irritable bowel syndrome
IBD
Endocrine (thyrotoxicosis, Addison’s)
Neoplastic (pheochromocytoma, lymphoma)
Non-infectious
Antibiotic-induced Non-specific: associated with systemic infection Hirschsprung’s disease
Toxin ingestion
Primary disaccharidase deficiency
Uncommon
Drug-induced Chronic constipation UTI
Short bowel syndrome Schwachman-Diamond syndrome
Gastroenteritis
History
• non-specific: diarrhea, vomiting, fever, anorexia, headache, myalgias, abdominal cramps • bacterialandparasiticagentsmorecommoninolderchildren(2-4yr)
• recentinfectiouscontacts:symptomsusuallybegin24-48hafterexposure
Physical Exam
• febrile
• dehydrated:mustassessextent(seeApproachtoInfant/ChildwithDehydration,P32)
Investigations
• notusuallynecessaryinyoungchildren
• stoolanalysis:leukocytes/erythrocytessuggestsbacterialorparasiticetiology;pH<6andpresenceof
reducing substances suggests viral etiology
Complications
• viralgastroenteritisusuallyself-limiting(lasts3-7dinmostcases)
• adverseeffectsrelatedtohypovolemia,shock,tissueacidosis,andrapidonsetandover-correctionof
electrolyte imbalances
• deathinseveredehydration(rareindevelopedcountries)