Case 15: Vomiting, Age 4 Years And Sibling 8 Weeks Old

Front 1

Main modes of transmission of viral gastroenteritis?

Back 1

1. at home

2. daycare

3. young infants at risk

Front 2

Why give fluid therapy for severe dehydration?

Back 2

The primary recommended mode of therapy for severe dehydration is to provide volumerestoration via IV bolus therapy with an isotonic saline solution.

Front 3

Key questions to ask when assessing vomiting?

Back 3

• sick contacts?
  
• abdo pain?
  
• character of emesis (stomach contents, bilious, bloody)
  
• character of stool (bloody, watery, mucous containing?)
  
• fever?
  
• is he eating and drinking? how much?
  

Front 4

sick contacts

Back 4

Asking about sick contacts is important because viralgastroenteritis is easily transmitted from person toperson.

Front 5

significant abdominal pain?

Back 5

Severe or localized abdominal pain would suggest amore serious condition than viral gastroenteritis.

Front 6

Character of emesis?

Back 6

Bloody or bilious emesis would suggest a moreserious condition than viral gastroenteritis.

Front 7

Character of stool?

Back 7

Bloody stool would suggest a more serious conditionthan viral gastroenteritis.

Front 8

Fever?

Back 8

If yes, is consistent with an infectious cause.

Front 9

Eating? Drinking? How much?

Back 9

A child with a serious illness typically is notinterested in eating or drinking.Knowing the quantity of fluid taken in over a certaintime period is helpful in assessing hydration status.

Front 10

Two key questions to ask when assessing hydration by telephone?

Back 10

• child's level of activity
  
• ability/desire to take fluids by mouth
  

Front 11

How to determine degree of dehydration?

Back 11

to subtract thepatient's current weight from his or her weight immediately prior to the illness.

Front 12

DDx of recurrant emesis in infant?

Back 12

• GER
  
• Viral gastro
  
• Malrotation +/- volvulus
  
• Inborn error of metabolism
  
• Pyloric stenosis
  
• Intussusception
  
• CNS disease
  
• UTI
  

Front 13

GER

Back 13

• regurg/spitting up
  
• overfeeding
  
• severe esophagitis may lead to blood streaked emesis
  
• pain may lead to feeding aversion
  
• dehydration
  
• FTT
  

Front 14

Viral gastroenteritis

Back 14

large watery stools

Front 15

Malrotation +/- volvulus

Back 15

• bilious emesis
  
• blood in stool
  
• shock
  

Front 16

Inborn error of metabolism

Back 16

• diminished oral intake
  
• lethargy
  
• irritability
  
• shock
  
• recurrent emesis

Front 17

Pyloric stenosis

Back 17

• An escalating pattern of forceful (projectile), non-bilious vomiting is ahallmark of pyloric stenosis.
  
• rapid dehydration
  
• vigorous appetite
  
• hypochloremic, hypokalemic metabolic alkalosis withdehydration is another hallmark of pyloric stenosis
  
• visible peristaltic wave
  
• palpable "olive"
  

Front 18

Intussusception

Back 18

• bilious emesis
  
• crampy or severe abdo pain
  
• "currant jelly" stools
  
• "sausage like" mass on XRAY
  

Front 19

CNS disease

Back 19

hydrocephalus, intracranial neoplasm, trauma (especially in absence of fever and diarrhea)

Front 20

UTI

Back 20

• fever
  
• poor feed and vomiting
  
• watery diarrhea
  
• loose stools
  

Front 21

How to work up probable pyloric stenosis?

Back 21

• Pyloric ultrasound
  
• Upper GI contrast study
  
• Electrolytes
  

Front 22

Pyloric ultrasound

Back 22

In experienced hands, a pyloric ultrasound is the study of choice to confirm pylorichypertrophy.

Front 23

Upper GI contrast study

Back 23

If ultrasound is unavailable, an upper GI contrast study will demonstrate a very narrowpyloric channel (the "string sign"), indentation of the hypertrophied pylorus on the antrum ofthe stomach, and delayed gastric emptying.

Front 24

Electrolytes

Back 24

hypochloremia,hypokalemia, and alkalosis.

Front 25

Oral rehydration therapy

Back 25

glucose and electrolytes is used in cases of mild-moderate dehydra

Front 26

Solid foods in setting of vomiting and diarrhea?

Back 26

if not dehydrated

feed asap

breast/formula feeds can continue through period of rehydration

Front 27

How to calculate rehydration volume?

Back 27

50-100 mL/kg

Example:Patient's weight = approx. 18 kg1500 mL total ORS = about 80 mL/kg