Diarrhoea

Definitions
- Diarrhoea: increase in frequency (>3x/day), watery consistency of stools
- Acute diarrhoea: <2 weeks
- Chronic diarrhoea: >4 weeks
- Subacute/persistent diarrhoea: 2-4 weeks

Causes of Diarrhoea in Children

Diarrhoea

Acute (<2 weeks) Chronic (>4 weeks)

Gastroenteritis
Viral (rotavirus, norovirus) Organic Functional
Bacterial (Shigella, E. coli, salmonella, campylobacter)
Lactase deficiency I: chronic infections
Toddler’s Diarrhoea
Primary Parasites: giardia, E. histolytica, cryptosporidium
Irritable Bowel Syndrome
Secondary (post GE) Fungus
Cow’s milk allergy HIV, TB
Intussusception T
Antibiotics
A: Inflammatory bowel disease
M: hyperthyroidism
I: Short bowel syndrome
N: malignancy
C: Lactase deficiency
Primary
Secondary (post GE)

Causes of bloody diarrhoea in children:

- I: Bacterial diarrhoea
- T:
 Anal fissure
 Intussusception
- A:
 IBD
 Cow’s milk allergy
- N: Polyps
- C: Meckel’s diverticulum

Clues to Etiology
Gastroenteritis - Frequent, watery stools
- Abdo pain relieved by defecation
- a/w nausea & vomiting, fever, dehydration, drowsiness
- Travel, diet, contact hx
- Recent antibiotics? Hospital stay? (consider C-diff)
Rotavirus - Epi: 6 months to 2 years old
- Clinical features
  8-10 days illness
 Watery diarrhoea, vomiting, fever, abdominal pain
 +/- dehydration
- Vaccine should be taken before 6 months
Cow’s milk allergy - Symptoms start within days to weeks of formula milk
- Bloody stools
- Severe, persistent infant colic
- Failure to thrive, vomiting
- Eczematous, urticaria
- Improves with trial protein hydrolysate formula / cow’s milk free
formula
Lactase deficiency - Primary: shortly after starting formula feeds
- a/w abdominal pain, bloating, flatulence
- Recent GE – secondary deficiency
Intussusception - 3 months to 3 years (peak at 9 months)
- Vomiting
- Paroxysmal, colicky abdominal pain a/w drawing up of legs
- Mucoid stools followed by red currant stools
- May have abdominal mass
Hyperthyroidism - Tremors, palpitations, weight loss
- Eye symptoms and signs
- Neck mass
- Family history of hyperthyroidism
Inflammatory bowel - Associated GI symptoms: mouth ulcers, dysphagia, abdominal pain,
disease urgency, tenesmus, incontinence, bloody mucoid stools, weight loss
- Extra-GI symptoms: eye pain, rashes, fever, anemia, joint pain,
jaundice
- Family history of autoimmune conditions
Short bowel - Small intestine resection
syndrome - PMH NEC, congenital anomalies
- Liver failure, infections, nutrient deficiencies
Toddler’s Diarrhoea - Varying consistency of stools
- Presence of undigested vegetables in the stools
- No failure to thrive
Irritable bowel - Intermittent
syndrome - May be a/w abdominal pain relieved by defecation
- No LOW
- No night diarrhoea
- Common triggers: milk, dairy products, caffeine, stress

History
Demos
- Infant: shortly starting cow milk formulacow’s milk allergy/ lactase deficiency
- 3 months – 3yo: MUST rule out intussuception!
- Teens: IBD, hyperthyroid

Presenting Complaint
- Duration, onset
- Amount? Frequency?
- Consistency – Bristol stool chart
- Contents
  Blood? Malena?
 Mucus?
- Associated symptoms
 Etiology
 Fever
 Abdominal pain
 Colicky, episodic, child draws up legs – intussusception (especially if <2 years)
 Vomiting
 Rashes
 Eye pain, joint pain
 Tremors, palpitations, anxiety
 LOW LOA
 Complications
 Dehydration
 Drowsiness
 Urine output – dry/wet diapers?
 Mucous membranes, sunken eyes
 Thirst
 Crying without tears
 Anemia – pallor, dizziness, chest pain, palpitations
 Failure to thrive, LOW

AEIOU
- Activity
- Eating
 Changes in diet?
 Just started lactose/ cow’s milk formula?
- Immunisation
- Output/ urine

BD
- Maternal history, birth history
- Developmental history

PMH
- Past medical history, drugs (antibiotics)
- Past surgeries – bowel resection

Family history
- Autoimmune conditions

Social History
- Travel, contact history?

Physical Examination
General
- Vital signs
 HR, BP, SpO2, RR
- Assess dehydration
 General appearance
  Sunken eyes
 Sunken fontanelle
 Conscious level
 Skin turgor
 Capillary refill
 Mucous membranes
 Pulses

Abdomen
- Distension
- Tenderness
- Masses
- Bowel sounds

Systemic
- Heart, lungs
- Eyes
- Mouth ulcers
- Neck masses
- Joints
- Rash

Investigations
- Bloods
 FBC
 CRP
 Renal panel
 ABG: metabolic acidosis
- TB spot
- Stool
 Stool culture, ova, cyst, parasites
 Stool calprotectin (able to quantify inflammation, but not specific)
- Imaging: ultrasound scan (looking for bowel thickening)
- Others: OGD, colonoscopy

Investigations for small bowel evaluation

- MRI E (preferred choice)
 No radiation
 Able to pick up fistula/abscesses
- CT
- Barium