00:02
In this lecture, we'll be speaking
about gastroenteritis,
and vomiting, and diarrhea
in children.
00:09
Let's first talk about vomiting.
00:11
Vomiting is obviously a forceful,
coordinated expulsion
of stomach contents.
00:17
If you see a patient with vomiting,
you need to take a very good
history and a complete history.
00:21
You need to do
a focus physical exam,
you need to do some lab work,
and you may need to do
some imaging studies.
00:28
Let's talk about what exactly we do
and under what circumstances.
00:33
So, in terms of the history,
it's key to figure out
if the child is dehydrated.
00:39
In a child with vomiting,
dehydration can happen
relatively quickly.
00:45
And typically in children,
they can look very, very well
and then suddenly get much sicker.
00:50
So a good history about
whether the child is drinking
and whether the child has
good urine output is important.
00:57
It's important to assess
what the color of the vomit is,
especially in babies.
01:02
Bloody emesis may be indicative
of something in the esophagus
like Mallory-Weiss tears
or problems in the stomach
like gastritis.
01:11
But in particular in baby's
green emesis
may indicate bilious emesis.
01:17
And while in adults,
we think of bilious emesis,
as just the end result of a
prolonged period of vomiting.
01:25
In infants, this may be indicative
of a malrotation of the intestines,
which may be a surgical emergency.
01:33
You should ask about
associated symptoms,
it's perhaps this vomiting is from
something other than the GI tract.
01:40
A couple examples.
01:41
For example,
if a patient has hydrocephalus
or an increased
intracranial pressure,
vomiting may occur,
and it's the vomiting
you're noticing
and not the fact that the child
is having some problems
with the pressure
inside their head.
01:55
The renal tract also
can cause vomiting,
either through stones
or urinary tract infection.
02:01
It's important to ask about
the duration of symptoms
and we'll discuss chronic versus
acute episodes of gastroenteritis.
02:08
But understanding how long
this has been going on for
may give you clues
as to the etiology.
02:14
Typically, viral illness
is reasonably short,
only a few days.
02:19
Other illnesses can last
a much longer time.
02:23
Timing in relation to feeds
is important
because it may give you a clue
as to what organ is involved.
02:30
A few examples.
02:31
If a baby has a problem
with their esophagus,
they'll often spit up immediately
after the feed.
02:37
If the problem is in the stomach,
there may be a slight delay.
02:41
If the problems in the pancreas,
a patient may not feel pain
for up to an hour after eating.
02:49
Social history is always important
and may give you some clues
as to what's actually
going on with this patient.
02:55
I have, in the last month
seen a patient who had vomiting
and it turned out
the cause was in fact,
child abuse and blunt head trauma.
03:05
So, let's shift the gear and look
towards physical exam findings.
03:08
And there are some key
physical exam findings
that are important
in any child with vomiting.
03:12
Signs of dehydration,
as in addition to the history
can be found on physical exam.
03:18
Dry mucous membranes,
a delayed capillary refill
things along that nature.
03:25
If a patient has peritonitis,
or an acute abdomen,
you know this is going to be
a very different problem
than just acute viral illness.
03:35
A patient with an appendicitis
can have pain with palpation,
or rebound or guarding
over the abdomen.
03:42
And remember,
diseases like appendicitis
can be very tricky to pick up
in small children.
03:48
In fact, a sizeable percentage
are missed until they perforate.
03:53
A complete physical exam
is important
understand all the extra
abdominal etiologies of vomiting.
04:00
So, understanding for example,
their pupillary reflex is important
if you're worried about
increased ICP.
04:07
So, if you're seeing a child
who's vomiting
and you're curious
what labs you might get,
let's go through them
a little bit at a time.
04:16
First, the Chem-7
is generally a reasonable lab
to get in a child who's vomiting
and you're not sure what's going on.
04:23
A high BUN and creatinine ratio
is going to be indicative
of dehydration.
04:30
If the patient has
a very high creatinine
but not a very high BUN,
you might think about
renal causes of emesis
as opposed to just dehydration.
04:41
Generally, in patients
with significant dehydration,
there will be some acidosis.
04:46
Some practitioners
like to use a cutoff
of say about 14
for the bicarb on a chem 7
in terms of where you would worry
about a child
in terms of their ability
to continue hydration.
04:58
Others feel, that it's simply
a matter of giving the child a drink
and seeing how they do
and using their clinical appearance
to determine whether these
children need to be hospitalized
or whether they can be sent home.
05:11
Excessive vomiting
may cause an alkalosis.
05:15
The classic example would be
an infant with pyloric stenosis,
and we'll talk about
pyloric stenosis in another talk.
05:22
But an infant with pyloric stenosis
will have excessive vomiting
and loss of acid
out of their vomit.
05:29
And that will present as an
alkalosis on the chem-7.
05:34
A urinalysis is commonly performed
because infants
especially can't tell you
when they have symptoms
of urinary tract infections.
05:43
And urinary tract infections
are more common in infants.
05:48
A lumbar puncture is absolutely
indicated if meningitis is concern.
05:53
However, we must remember
the clinical context
because we wouldn't want
to do a lumbar puncture
in someone with acutely raised ICP
unless you knew exactly
what was going on.
06:05
LFTs and a lipase are useful.
06:10
Don't always forget,
adolescents can get pregnant.
06:13
And a pregnancy test
is almost always indicated
in an adolescent female who presents
with vomiting of unclear etiology.
06:21
So let's talk about imaging studies,
you might get in a vomiting child.
06:26
Well, first, the abdominal X ray.
06:28
Generally, will get an upright
picture in an older child,
because that'll allow us
to see things
like free air under the diaphragm
and as you can see
on the slide here,
you might see air fluid levels.
06:41
This patient with
multiple air fluid levels
probably has an gastroenteritis.
06:46
You can see that fluid contents
will layer out with nice lines.
06:50
And that gives us a sense
that the issue here
is that the
intra intestinal compartment
is carrying containing liquid
as opposed to solid material.
07:02
We will get an upper GI
in some circumstances
where we suspect
intra-abdominal pathology.
07:08
Remember that the regular upper GI
does follow through
the ligament of Treitz.
07:14
That means that if you have
that bilious emesis infant
where you're worried about
malrotation,
a regular upper GI
is all that you need.
07:23
An upper GI will also show you
something like pyloric stenosis.
07:28
A small bowel follow through
is really only used
where you're concerned
about small bowel disease.
07:35
We don't need to get that
for a patient with concern
for malrotation.
07:40
We might get that test
for some one, for example,
with inflammatory bowel disease.
07:45
Where you're worried there might be
some small intestine abnormalities.
07:50
However, we're really moving
more towards intestinal MRI
as opposed to small bowel
follow through for those patients.
07:59
Ultrasound is a mainstay
for many diseases in children.
08:04
We'll use an ultrasound
for things like
pyloric stenosis, and interception.
08:10
And actually some practitioners
are getting much better at it
and we can even evaluate
for things like malrotation.
08:18
The abdominal CAT scan
is a very useful test
for patients where we're worried
about intra abdominal pathology.
08:26
But remember, there's quite a bit
of risk for radiation in children.
08:31
Children who are young
have more mitosis
and are greater risk for
developing cancer down the line.
08:38
As a result,
most centers are moving gradually
away from the abdominal CAT scan,
and more towards ultrasound.
08:46
Abdominal MRI is an evolving tool
and we're getting better at using it
in certain circumstances.
08:52
Certainly we use it for
inflammatory bowel disease
as a way of assessing
the small bowel and children.