DEPARTMENT OF PEDIATRICS

CASE PROTOCOL

Barion, Catherine M.
Junior Intern
Pediatrics July-August 2018

OBJECTIVES:

1. To be able to present a case of acute gastroenteritis

2. To discuss epidemiology, etiology, risk factors and pathogenesis of acute gastroenteritis
3. To correlate the clinical manifestation, diagnostics, therapeutics, prevention and complications
of acute gastroenteritis

GENERAL DATA:

This is a case of E.D., 8 year old female, Roman Catholic, Filipino, child, born on June 18,
2010, residing at Binan, Laguna came to our institution last July 18, 2018 at 12:10PM

INFORMANT: Mother RELIABILITY: 90%

CHIEF COMPLAINT: Vomiting

HISTORY OF PRESENT ILLNESS:

Two days prior to admission, patient had undocumented fever associated with 3 episodes of
previously ingested food, non-bilous, non-blood streak, non-projectile, approximately ½ cup per bout.
Patient was given 3 times a day which afforded temporary relief of fever. No consult was done.
One day prior to admission, still with undocumented fever, now had 2 episodes of vomiting of
previously ingested food, non-bilous, non-blood streak, non-projectile, approximately ½ cup per bout
and associated with body weakness and decreased appetite. Paracetamol 500mg/tab, ½ tab (11.36
mg/kg/dose) 3 times a day was given which afforded temporary relief of fever. No consult was done.
Few hours prior to admission, still with fever, undocumented, with 2 episodes of vomiting of
previously ingested food, non-bilous, non-blood streak, non-projectile, approximately ½ cup per bout,
associated with abdominal pain, 5/10 pain scale, crampy in character, non-radiating, 3 episodes of
bowel movement, soft in consisteny, dark green in color, non mucoid, non-bloody. Patient was then
brought to our institution and was subsequently admitted.

REVIEW OF SYSTEM:
General: no loss of appetite, no early satiety, no weight loss
Cutaneous: no rash, no pruritus, no skin pigmentation
Nervous: no loss of consciousness, no convulsions
Respiratory: no cough, no cold, no difficulty of breathing
Cardiovascular: no easy fatigability, no cyanosis, no chest pain
Gastrointesinal: no belching, no constipation
Genitourinary: no dysuria, no hematuria, no oliguria
Muskuloskeletal: no limitation of movement, no muscle spasms
Hematologic: no easy bruising, no bleeding tendencies, no pallor

OBSTETRICAL-MATERNAL HISTORY
Patient was born to a 24 year old G2P1 (1001) mother who had regular prenatal checkup at
health clinic, started at 8 weeks AOG of regular intake of multivitamins, ferrous sulfate, folic acid and
calcium. No history of exposure to radiation. Maternal and paternal blood types were unknown.
BIRTH HISTORY
Patient was born term live baby girl, 37 weeks AOG via NSD in a lying-in clinic assisted by a
midwife and had spontaneous respiration, good cry and activity. No meconium staining and no cord
coiling noted.

NEONATAL HISTORY
Patient was able to pass out urine and meconium within 24 hours of life. No jaundice
and cyanosis noted. No neonatal illnesses noted. Newborn screening was not done.

NUTRITIONAL HISTORY:
Patient was exclusively breastfeed until 2 months of age and started bottlefeeding thereafter.
Complementary feeding was done at 11 months old.

THREE DAY DIET RECALL

MEAL Monday Tuesday Wednesday
1 cup of fried rice with 1 cup of fried rice with 1 cup of fried rice with
Breakfast hotdog hotdog hotdog
154+140=290 cal 154+140=290 cal 154+140=290 cal
1 cup of rice with pork 1 cup of rice with 1 cup of rice with
Lunch sinigang porkchop chicken
131+290=421 cal 131+180 = 311 cal 131+90 = 221 cal
1 cup of rice with pork 1 cup of rice with pork
1 cup noodles and egg
Dinner adobo adobo and vegetable
280 +120 = 400 cal
131+328 = 459 cal 131+328+47 = 506
TOTAL 1,170 cal 1,107 cal 920 cal
Average: 1,065.67 kcal (48.44 kcal/kg/day)
Recommended energy and nutrient intake per day: 1470 kcal (66.81 kcal/kg/day)
Interpretation: Patient does not meet the recommended energy and nutrient intake per day for his
age group

GROWTH AND DEVELOPMENT:

Patient’s development is at par with age. Patient gets along very well and has a close
relationship with parents and siblings but more with her mother since the father is mostly at work.
Patient is a Grade 2 student, likes school teachers and had good relationship with friends. Favorite
subject is Arts. Patients studies very well at home and very diligent. Patient has bestfriend and group
of friends at school but mostly stays at home with siblings and plays with her toys.

IMMUNIZATION HISTORY:
(+) BCG- 1 dose (-) Pneumococcal
(+) Hepatitis B - 3 doses (-) Chickenpox
(+) DPT- 3 doses (-) Hepatitis A
(+) MMR – 3 doses (-) Flu vaccine
(+) OPV/IPV – 3 doses (-) Rotavirus
(+) HiB – 3 doses

PAST MEDICAL HISTORY:

(-) Childhood disease such as measles, mumps and varicella
(-) Bronchial Asthma
(+) Hospitalization (2013), Febrile Seizure
(-) Allergies to food and drugs
(-) G6PD deficiency

FAMILY HISTORY:
Parents: Patient’s mother is 34 years old machine operator and father is 33 years old bus conductor.
No illnesses or maintenance medications were taken.
Siblings: Patient is the second child; 1 older brother, 10 years old, younger sister 6 years and 4 years
old. No known illness.
Family illness: Patient had history of hypertension, diabetes mellitus, heart disease, kidney disease on
paternal side and bronchial asthma on maternal side

ENVIRONMENTAL HISTORY
Patient lives with her parents and 3 siblings in one story house with 3 rooms and 2 comfort
rooms, well-ventilated and well-lit. Mineral water is the main source of drinking water. Garbage is
being collected every day.

PERTINENT PHYSICAL EXAMINATION:

General Survey awake, weak, not in cardiorespiratory distress
Vital signs CR: BP: 90/60 CR: 134bpm RR: 26cpm T: 38.8OC
Anthropometrics: Weight: 22 kg Height: 121 cm BMI: 15.02 kg/m 2

Parameter Ideal Actual Z score Interpretation

BMI: 17.70 kg/m 2
15.02 kg/m 2
Between -1 and 0 Normal
Height: 120 cm 121 cm At -1 Normal
Weight: 25.5 kg 22 kg Between -1 and 0 Normal

INTEGUMENTARY
INPECTION: Brown, smooth, warm, no skin lesions, no rashes noted
PALPATION: Good skin turgor and mobility

HEENT
HEAD: INPECTION: Symmetrical with no deformities, no lesions, no lice, no scaling. Hair is black,
abundant and equally distributed.
PALPATION: No masses and no tenderness.

EYES: INSPECTION: Slightly sunken eyeballs, anicteric sclera with pink palpebral conjunctiva.
Pupils are round and symmetrical, equally reactive to light. No opacities noted.
Accommodation and convergence are normal.
PALPATION: No lid edema or tenderness.

EARS: INSPECTION: External pinna and auditory canals are normal, symmetrical, no lesions over the
auricles and mastoid. No cerumen noted on both ears.
PALPATION: No tragal tenderness.

NOSE: INSPECTION: Symmetrical, no alar flaring, no secretions, no perforations and no mucoid

discharge seen. Nasal septum is at the midline

MOUTH AND THROAT

INSPECTION: Lips are symmetrical, dry with scaling, no lesions and pigmentation. Tongue is
pinkish and is in the midline upon protrusion and retraction, no deviation and lesion. Uvula is
in the midline. No tonsillopharyngeal congestion.
NECK
INSPECTION: Symmetrical, no deformity. The neck is flexible with trachea in midline.
PALPATION: No swelling or tenderness. No enlarged lymph nodes noted.

CHEST AND LUNGS

INSPECTION: Symmetrical chest expansion. Breathing pattern is normal. No retractions
noted.
PALPATION: No masses and tenderness noted.
AUSCULTATION: Clear breath sound, vocal and whispered sounds normal.

HEART
INSPECTION and PALPATION: No thrills noted.
AUSCULTATION: Tachycardic with regular rhythm. No murmurs noted.
ABDOMEN
INSPECTION: Symmetrical and flat, no discoloration and no scars noted.
AUSCULTATION: No bruits noted. Hyperactive bowel sounds.
PALPATION: No masses on all quadrants. Direct tenderness on epigastric area on deep
palpation. No rebound tenderness and no guarding noted. Negative Murphy’s sign, negative,
rovsing’s sign, negative obturator sign, negative psoas sign. No CVA tenderness.

EXTREMITIES
INSPECTION: No clubbing, no cyanosis and no swelling of nail folds.
PALPATION: No tenderness or edema noted. Full and equal peripheral pulses, Capillary refill
time less than 2 seconds.

NEUROLOGIC EXAMINATION
Mental Status: oriented to three spheres
Cranial Nerves:
CN I: N/A
CN II: Pupils 2-3mm equally reactive to light
CN III, IV, VI: intact extraocular muscles
CN V: Can clench teeth
CN VII: No facial asymmetry
CN VIII: can hear on both ears
CN IX, X: Can swallow, (+) gag reflex
CN XI: Can shrug shoulders
CN XII: tongue at midline

SENSORY MOTOR REFLEXES

SALIENT FEATURES:
- Fever
- Vomiting
- Abdominal pain
- 3 episode of bowel movement
- Weakness
- Slightly sunken eyeballs with dry lips

INITIAL ASSESSMENT:

Acute gastroenteritis with moderate signs of dehydration

DIFFERENTIAL DIAGNOSIS:
Acute gastroenteritis
RULE IN RULE OUT
 Fever
 Vomiting
 Abdominal Pain
 3 episodes of bowel Cannot be totally rule out
movement
 Weakness
 Sunken eyeballs with dry lips
 Non-ulcerative dyspepsia
RULE IN RULE OUT
 Vomiting No early satiety
 Abdominal pain No belching
Fever

Urinary Tract Infection

RULE IN RULE OUT
 Fever
No dysuria
 Episodes of Vomiting
 Abdominal Pain No CVA tenerness

Acute Appendicitis
RULE IN RULE OUT
 Fever
Negative Rovsing’s
 Vomiting
 Abdominal Pain Negative Psoas sign
Negative obturator sign

FINAL DIAGNOSIS:
Acute gastroenteritis with moderate signs of dehydration

PLAN: Admitted
 Diet: NPO temporarily
 IVF: PLR 500cc run 350cc at 165cc/hr for 2 hours then D5 0.3 NaCl 1L to run at 165cc/hr for 6
hours
 Diagnostics: Post hydration complete blood count with platelet count and urinalysis; fecalysis
 Paracetamol 250mg/5ml, 5ml (11.36 mg/kg/dose) q4h if fever 37.8-38.4 OC
 Paracetamol 320mg (14.54 mg/kg/dose) TIV q4h if fever >38.5 OC
 Special Orders: Replace losses with Plain Lactated Ringers Solution every episode of vomiting
and loose stools
 Watch out for persistence of vomiting and episodes of loose stools
 Input and output every shift
 Vital signs every 2 hours and record

Ludan’s Hydration
Moderate:
22 x 60 = 1320 mL
1st 2 hours: ¼ PLR to run 330 at 165cc/hr
Next 6 hours: ¾ D5 0.3 NaCl 990 to run at 165cc/hr

DISCUSSION
ACUTE GASTROENTERITIS
Gastroenteritis
 Denotes infections of the gastrointestinal tract caused by bacterial, viral, or parasitic pathogens.
Many of these infections are foodborne illnesses.
 Most common manifestations: diarrhea and vomiting, also associated with systemic features such
as abdominal pain and fever
 Gastroenteritis captures the bulk of infectious cases of diarrhea.
 Diarrheal disorders denote infectious diarrhea in public health settings.
 Persistent diarrhea is defined as episodes that began acutely but last for 14 or more days.

EPIDEMIOLOGY
 Diarrheal disorders in childhood account for a large proportion (9%) of childhood deaths, with
an estimated 0.71 million deaths per year globally, making it the second most common cause of child
deaths worldwide. In addition to the risk of mortality, persistently high rates of diarrhea, especially
prolonged and persistent diarrhea among young children may be associated with long-term adverse
outcomes.

ETIOLOGY
 Gastroenteritis is the result of infection acquired through the fecal–oral route or by ingestion of
contaminated food or water.
 It is associated with poverty, poor environmental hygiene, and development indices.
 Enteropathogens that are infectious in a small inoculum (Shigella, enterohemorrhagic Escherichia
coli, Campylobacter jejuni, noroviruses, rotavirus, Giardia lamblia, Cryptosporidium parvum,
Entamoeba histolytica) can be transmitted by person-to-person contact
o Cholera: from contaminated of food or water supply
 Osmotic diarrhea: Water is drawn into intestinal lumen by maldigested nutrients (e.g., celiac or
pancreatic disease, lactose) or other osmotic compounds. Stool volume depends on diet and
decreases with fasting (stool osmolar gap ≥100 mOsm/kg).
 Secretory diarrhea: Water accompanies secreted or unabsorbed electrolytes into the intestinal
lumen (e.g., excessive secretion of chloride ions caused by cholera toxin). Stool volume is
increased and does not vary with diet (stool osmolar gap <100 mOsm/kg).

RISK FACTORS
 Major risk factors:
o Environmental contamination
o Increased exposure to enteropathogens
 Young age, immunodeficiency, measles, malnutrition, and lack of exclusive or predominant
breastfeeding.
 Malnutrition increases the risk of diarrhea and associated mortality, and moderate to severe
stunting increases the odds of diarrhea-associated mortality.
 Risks are particularly higher with micronutrient deficiency such as vitamin A and zinc deficiency.

PATHOGENESIS
 Pathogenesis and severity of bacterial disease depend
on whether organisms have:
o Preformed toxins (S. aureus, Bacillus cereus);
Secretory (cholera, E. coli, Salmonella,
Shigella)
o Cytotoxic toxins (Shigella, S. aureus, Vibrio
parahaemolyticus, C. difficile, E. coli, C.
jejuni) or are invasive, and on whether they
replicate in food.
 Enteropathogens elicit non-inflammatory diarrhea
through:
o Enterotoxin production by some bacteria
o Destruction of villus (surface) cells by viruses
o Adherence by parasites
o Adherence and/or translocation by bacteria
 Inflammatory diarrhea is caused by direct invasion of
bacteria into the intestine or production of cytotoxins
with consequent fluid, protein, and cells entering the
intestinal lumen.
 Some viruses (rotavirus) target the microvillus tips of the enterocytes and can enter the cells by
direct invasion or calcium-dependent endocytosis
o Resulting to loss of enterocyte absorptive surface through cell shortening and loss of
microvilli.
o Rotavirus protein NSP4 is a viral enterotoxin
 Bacterial enterotoxins can selectively activate
enterocyte intracellular signal transduction and affect
cytoskeletal rearrangements with subsequent
alterations in the water and electrolyte fluxes across
enterocytes.
 In toxigenic diarrhea, enterotoxin produced by Vibrio
cholerae increased mucosal levels of cAMP, inhibit
electroneutral NaCl absorption
 In inflammatory diarrhea (Shigella and Salmonella)
there is extensive histologic damage, resulting in
altered cell morphology and reduced glucose-
stimulated Na+ and electroneutral NaCl absorption. In
secretory cells from crypts, Cl secretion activated by
cAMP in toxigenic and inflammatory diarrhea

 ETEC colonizes and adheres to

enterocytes of the small bowel via its
surface fimbriae (pili) and induces
hypersecretion of fluids and electrolytes
into the small intestine.
 Shigella species invades the colonic
mucosa. After phagocytosis, a series of
events occurs causing further breach of
the epithelial barrier, and
mucosal destruction.

CLINICAL MANIFESTATIONS

 Ingestion of preformed toxins 

rapid onset of nausea and vomiting
within 6 hr, with possible fever,
abdominal cramps, and diarrhea
within 8-72 hr.
 Watery diarrhea and abdominal
cramps after an 8-16 hr incubation
period (C. perfringens and B.
cereus)
 Abdominal cramps and watery
diarrhea after a 16-48 hr
incubation  Noroviruses,
Cryptosporidium, and Cyclospora,
influenza virus H1N1 infections
 Salmonella, Shigella, C. jejuni,
Yersinia enterocolitica,
enteroinvasive or hemorrhagic
(Shigatoxin-producing) E. coli, and
V. parahaemolyticus  diarrhea with blood as well as fecal leukocytes in association with
abdominal cramps, tenesmus, and fever  bacterial dysentery and fever.
 Bloody diarrhea and abdominal cramps after a 72-120 hr incubation period  Shigella and also
Shigatoxin-producing E. coli, such as E. coli O157:H7
DIAGNOSIS
Common manifestations of gastrointestinal tract
infection in children
 Diarrhea
 Abdominal cramps
 Vomiting
The evaluation of a child with acute diarrhea includes:
 Assessing the degree of dehydration and
acidosis
 Provide rapid resuscitation and rehydration with
oral or intravenous fluids as required
History: Obtaining appropriate contact, travel, or
exposure
 Information on exposure to contacts with
similar symptoms
 Intake of contaminated foods or water, child-
care center attendance
 Recent travel of patient or contact with a
person who traveled to a diarrhea-endemic area
 Use of antimicrobial agents
Clinically determining the etiology of diarrhea for institution of prompt antibiotic therapy, if indicated.
 Although nausea and vomiting are nonspecific symptoms, they indicate infection in the upper
intestine.
 Fever suggests an inflammatory process but also occurs as a result of dehydration or coinfection.
 Fever is common in patients with inflammatory diarrhea.
 Severe abdominal pain and tenesmus indicate involvement of the large intestine and rectum.
 Nausea and vomiting and absent or low-grade fever with mild to moderate periumbilical pain and
watery diarrhea indicate small intestine involvement

Stool Examination
 Examine for mucus, blood, and leukocytes.
 Stool microscopy for parasites
 Stool cultures from children with bloody diarrhea in whom stool microscopy indicates fecal
leukocytes, in outbreaks with suspected hemolytic-uremic syndrome, and in immunosuppressed
children with diarrhea
 Polymerase chain reaction is a molecular diagnostic procedure that improved yield and diagnosis
of bacterial diarrhea

No laboratory evaluation needed in previously healthy children with uncomplicated watery diarrhea
except for epidemiologic purposes.
 WHO Assessment of diarrheal patients for dehydration

Parameters A B C
1. General Condition Well, Alert Restless, irritable Lethargic or
unconscious; floppy
Eyes Normal Sunken Very sunken and dry
Tears Present Absent Absent
Mouth and Tongue Moist Dry Very dry
Thirst Drinks normally, not Thirsty, drinks eagerly Drinks poorly or not
thirsty able to drink
2. Feel (pinch) Skin goes back Goes back slowly Goes back very slowly
quickly
3. Decide No signs of
If patient has two or If patient has two or
dehydration more signs including at more signs including at
least one  some least one  severe
dehydration dehydration
4. Treat Plan A Weigh the patient, if Weigh the patient, use
possible and use Plan B Plan C urgently
* Source: WHO. The treatment of diarrhoea, a manual for physicians and other senior health worker s.
Geneva: World Health Organization; 1995. WHO/CDR/95.3

MANAGEMENT
 Oral rehydration therapy
 Enteral feeding and diet selection
 Zinc supplementation
 Probiotics
Integrated Management of Childhood Illnesses

Oral Rehydration
Children, especially infants, are more susceptible than adults to dehydration because of the greater
basal fluid and electrolyte requirements per kg and because they are dependent on others to meet
these demands.
Risks associated with severe dehydration that might necessitate intravenous resuscitation include:
 age <6 mo; prematurity
 chronic illness
 fever >38°C (100.4°F) if younger than 3 mo or >39°C (102.2°F) if 3-36 mo of age
 bloody diarrhea
 persistent emesis
 poor urine output
 sunken eyes and a depressed level of consciousness.

The low-osmolality World Health Organization (WHO) oral rehydration solution (ORS) which contains
the following, is now the global standard of care and more effective than home fluids, including
decarbonated soda beverages, fruit juices, and tea.

75 mEq of sodium
75 mmol of glucose
64 mEq of chloride
Total osmolarity of 245 mOsm/L
20 mEq of potassium
10 mmol of base

 Limitations to oral rehydration therapy include shock, an ileus, intussusception, carbohydrate

intolerance (rare), severe emesis, and high stool output (>10 mL/kg/hr).
 Ondansetron (oral mucosal absorption preparation) reduces the incidence of emesis, thus
permitting more effective oral rehydration and is well established in emergency management of
acute gastroenteritis in developed countries.

Enteral Feeding and Diet Selection

 Continued enteral feeding aids in recovery from the episode, and a continued age-appropriate
diet after rehydration is the norm.

 Once rehydration is complete, food should be reintroduced while oral rehydration is continued to
replace ongoing losses from emesis or stools and for maintenance.

 Fatty foods or foods high in simple sugars (juices, carbonated sodas) should be avoided.
Zinc Supplementation
Zinc supplementation leads to reduced duration and severity of diarrhea and could potentially prevent
a large proportion of cases from recurring.
 All children older than 6 mo of age with acute diarrhea in at-risk areas should receive oral zinc
(20 mg/day) in some form for 10-14 days during and continued after diarrhea.

Antibiotic Therapy
Timely antibiotic therapy in select cases of diarrhea related to bacterial infections can reduce the
duration and severity of illness and prevent complications. Antimicrobial use is recommended in the
following diseases:
 Suspect case if cholera with severe dehydration
 Bloody diarrhea presumed to be shigellosis
 Laboratory confirmed, symptomatic giardiasis
 Diarrhea with concomitant illnesses like pneumonia and urinary tract infection
Antimicrobials recommended in Diarrhea
Diarrheal Disease Choice of antimicrobial Alternative drug
Cholera Tetracycline 50mg/kg/day in 4 Erythromycin 50mg/kg/day in 4 divided
divided doses x 3 days doses x 3 days
Shigellosis Ciprofloxacin 30mg/kg/day in 2 Ceftriaxone 50-100 mg/kg/day once a
divided doses x 3 days day IM x 2-5 days
Amebiasis Metronidazole 30mg/kg/day in 3 divided doses x 10 days
Giardiasis Metronidazole 15mg/kg/day in 3 Tinidazole 50mg/kg/day single dose
divided doses x 5 days
Additional Therapies
 The use of probiotic nonpathogenic bacteria for prevention and therapy of diarrhea has been
successful in some settings.

 Anti-motility agents (loperamide) are contraindicated in children with dysentery and probably
have no role in the management of acute watery diarrhea in otherwise healthy children.

 Ondansetron is an effective and less-toxic antiemetic agent and is a useful adjunct to the
treatment of vomiting in ambulatory settings with reduced risk of intravenous fluid requirements
and hospitalization

 Racecadotril, an enkephalins inhibitor, has inconsistently been shown to reduce stool output in
patients with diarrhea
PREVENTION
Several strategies proven to be effective in the control of diarrheal diseases

 Breastfeeding  Food safety

 Improved weaning practices  Use of latrines (safe disposal of stool)

 Use of safe water  Measles immunization and rotavirus

 Hand washing

COMPLICATIONS
 Related to delays in diagnosis and delays in institution of appropriate treatment
 Dehydration with associated complications
 Inappropriate therapy can lead to prolongation of diarrheal episodes with consequent malnutrition
and complication such as secondary infections and micronutrient deficiencies (iron and zinc)

References:
 Nelson’s Fundamentals of Pediatrics
20th Edition
 Harriet Lane Handbook
 WHO website