Vomiting, Diarrhoea, Abdominal Pain & Fluid Therapy Department of Paediatrics CUHK

Vomiting, Diarrhoea, Vomiting, Diarrhoea, Abdominal PainAbdominal Pain&&Fluid TherapyFluid Therapy

Department of PaediatricsCUHK

VomitingVomiting

TerminologyTerminology

vomiting– forceful ejection of gastric contents– often preceded by nausea and retching

possetting– gentle expulsion of gastric contents

with swallowed 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

HistoryHistory

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-

ground ?

HistoryHistory

Associated symptoms• Stool:

• Diarrhoea ? • constipation ? • Smelly stool that is difficult to

flush ?

• Abdominal pain / Abdominal distension• Fever• Change in appetite / feeding habit• Weight loss ? or gain ?

HistoryHistory

Social history• Family members having vomiting /

dirrhoea• Recent traveling

ExaminationExamination

Full examination is necessary in all childrenGeneral examination

• Activity• Nutritional status• Weight and Height (and compare with

previous)• Temperature• Anaemia• Jaundice• Degree of dehydration• Cleft palate• Neurological status


Abdomen: Inspection• Distension

• Constipation• Gastroenteritis• Obstruction / Ileus• Coeliac Disease

• Surgical Scar


Abdomen: Palpation• Local tenderness• Generalized tenderness• Guarding and rebound tenderness

• Peritoneal irritation• Masses

• Organomegaly• Pyloric mass• Sausage shaped mass

• Hernial orifices• Genitalia


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• Examine urine for RBC, WBC and organism

under microscope• Stool for bacterial culture and virus

isolation• Urine for culture• Blood for cell counts, U&Es, culture• Test feed for infant 2 to 10 weeks• AXR: Supine, Erect for intestinal obstruction• USG abdomen

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

oesophagusUsually resolve by 1 year oldUsually mild but severe cases with

complications:• pulmonary aspiration• oesophagitis, peptic stricture• failure to thrive, feeding problems


Investigation– usually not required– 24-h oesophageal pH monitoring

• contrast study


management• often requiring no treatment• mild: positioning at 30° head-up prone

& thickening 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


visible peristalsis “olive”-shaped mass at

right upper quadrant


Investigation• ultrasonography & contrast study

antrum

thickened pyloricmuscle

elongated pyloriccanal


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

pelvic 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

DiarrhoeaDiarrhoea

Clinical manifestationsClinical manifestations

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 Infective causes of diarrhoea and vomitingand vomitingViruses 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

HistoryHistory

Onset• Sudden or gradual ?

Stool• Volume, frequency and timing to feed• Loose, watery, rice watery• Blood, mucus, steatorrhoea

HistoryHistory

Associated symptoms• Vomiting• Abdominal pain / Abdominal distension• Fever• Change in appetite / feeding habit• Weight loss ?

Social history• Family members having vomiting /

dirrhoea• Recent traveling


Full examination is necessary in all childrenGeneral examination most important

• Activity• Nutritional status• Weight and Height (and compare with

previous)• Temperature• Anaemia• Jaundice• Degree of dehydration


Abdomen: Inspection• Distension

• Constipation (with overflow diarrhoea)

• Gastroenteritis

Abdomen: Palpation• Local tenderness• Generalized tenderness• Guarding and rebound tenderness

• Peritoneal irritation


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• Examine urine for RBC, WBC and

organism under microscope• Stool for bacterial culture and virus

isolation• Urine for culture• Blood for cell counts, U&Es, culture

Mild Moderate Severe

Body weight 5% 6-9% 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

TreatmentTreatment

Rehydration fluid and electrolytes (po/iv)glucose-electrolyte solutionNutritional treatment - continuation of breast

feeding (lactadherin), or formula feedingAntidiarrhoeal drugsNew agent: mucoprotective agents such as

dioctahedral smectite, or probiotic bacteria such as killed lactobacillus acidophilus

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

dehydrated 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

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

Fluid requirement increases by 10% per degree Celcius rise in body temperature

Sodium 3 mmol/kg/dayPotassium 2 mmol/kg/day

Daily fluid requirementDaily fluid requirement

Example for a 25-kg boy• Daily fluid requriement

• First 10kg = 100 x 10 = 1000 ml

• Second 10kg = 50 x 10 = 500 ml• After 20 kg = 20 x 5 = 100

ml• Total = 1000 + 500 +

100 = 1600ml

• Daily Na requirement = 75 mmol• Daily K requirement = 50 mmol

Phase I: Treat shock(0 - 30 minutes)

Phase II: Initial Rehydration(½ - 8 hours)

Phase III: Continued Replacement(8 - 24 hours)

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 and maintenance

Replacement with saline-dextrose solution

Half the calculated fluid deficit and maintenance

Hypertonic dehydrationHypertonic dehydration

Difficult to assess degree of dehydration, unless the child in clinically shock (>10% dehydration)

The plan – replace total fluid deficit slowly over 48

hours– To lower serum sodium slowly:

10mmol/L/day

Rapid correction may cause cerebral oedema

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,

worsen 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

diarrhoeaAssociates 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

salicylate 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 Agents that alter intestinal microfloramicroflora

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,

duration of diarrhoea, weight gainprevention strategy

• Public health measures - sanitation• Food preparation and storage• Promotion of breast feeding

Chronic DiarrhoeaChronic Diarrhoea

Birth to 6mo InfectionSecondary lactose deficiency

Persisting diarrhoeaCow’s milk intoleranceOther food intoleranceCystic fibrosisIn-born errorsAntuoimmune

enteropathySurgery

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(b-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,

rebound tenderness, absent bowel sounds– The younger the child the more vague the

signsSigns 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

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Vomiting, Diarrhoea, Abdominal Pain & Fluid Therapy Department of Paediatrics CUHK