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Pediatric Gastroenteritis in Emergency Medicine Clinical Presentation

  • Author: Adam Levine, MD, MPH; Chief Editor: Kirsten A Bechtel, MD  more...
 
Updated: Jul 23, 2015
 

History

The history and physical examination serve 2 vital functions: (1) differentiating gastroenteritis from other causes of vomiting and diarrhea in children, and (2) estimating the degree of dehydration. In some cases, the history and physical examination can also aid in determining the type of pathogen responsible for the gastroenteritis, though only rarely will this affect management.

  • Diarrhea: Duration of diarrhea, the frequency and amount of stools, the time since last episode of diarrhea, and the quality of stools. Frequent, watery stools are more consistent with viral gastroenteritis, whereas stools with blood or mucus are indicative of a bacterial pathogen. Similarly, a long duration of diarrhea (>14 d) is more consistent with a parasitic or noninfectious cause of diarrhea.
  • Vomiting: Duration of vomiting, the amount and quality of vomitus (eg, food contents, blood, bile), and time since the last episode of vomiting. When symptoms of vomiting predominate, one should consider other diseases such as gastroesophageal reflux disease (GERD), diabetic ketoacidosis, pyloric stenosis, acute abdomen, or urinary tract infection.
  • Urination: Increase or decrease in frequency of urination measured by number of wet diapers, time since last urination, color and concentration of urine, and presence of dysuria. Urine output may be difficult to determine with frequent watery stools.
  • Abdominal pain: Location, quality, radiation, severity, and timing of pain, per report of parents and/or child. In general, pain that precedes vomiting and diarrhea is more likely to be due to abdominal pathology other than gastroenteritis.
  • Signs of infection: Presence of fever, chills, myalgias, rash, rhinorrhea, sore throat, cough, known immunocompromised status. These may indicate evidence of systemic infection or sepsis.
  • Appearance and behavior: Weight loss, quality of feeding, amount and frequency of feeding, level of thirst, level of alertness, increased malaise, lethargy, or irritability, quality of crying, and presence or absence of tears with crying.
  • Antibiotics: History of recent antibiotic use increases the likelihood of Clostridium difficile.
  • Travel: History of travel to endemic areas may make prompt consideration of organisms that are relatively rare in the United States, such as parasitic diseases or cholera.
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Physical

See the list below:

  • General: Weight, ill appearance, level of alertness, lethargy, irritability as depicted in the video below.
    Child with lethargy/poor general appearance.
  • Head, ears, eyes, nose, and throat (HEENT): Presence or absence of tears, dry or moist mucous membranes, and whether the eyes appear sunken as shown in the videos below.
    Child with absent tears.
    Child with sunken eyes.
  • Cardiovascular: Heart rate and quality of pulses
  • Respiratory: Rate and quality of respirations (The presence of deep, acidotic breathing suggests severe dehydration.). See the video below.
    Child with hyperpnea (deep, acidotic breathing)
  • Abdomen: Abdominal tenderness, guarding, and rebound, bowel sounds. Abdominal tenderness on examination, with or without guarding, should prompt consideration of diseases other than gastroenteritis.
  • Back: Flank/costovertebral angle (CVA) tenderness increases the likelihood of pyelonephritis.
  • Rectal: Quality and color of stool, presence of gross blood or mucus
  • Extremities: Capillary refill time, warm or cool extremities
  • Skin: Abdominal rash may indicate typhoid fever (infection with Salmonella typhi), whereas jaundice might make viral or toxic hepatitis more likely. The slow return of abdominal skin pinch suggests decreased skin turgor and dehydration (see the video below), while a doughy feel to the skin may indicate hypernatremia.
    Child with slow skin pinch (reduced skin turgor).
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Causes

Identifying the specific etiologic agent responsible for the acute gastroenteritis rarely changes management. However, it may be helpful to differentiate between viral, bacterial, parasitic, and noninfectious causes of diarrhea.

By far, viruses remain the most common cause of acute gastroenteritis in children, both in the developed and developing world. Rotavirus represents the most important viral pathogen worldwide, responsible for 37% of diarrhea-related deaths in children younger than 5 years.[20] In the United States, routine rotavirus vaccination has led to a 60-75% reduction in pediatric rotavirus hospitalization since 2006.[21, 22] Rotavirus infection follows seasonal variation, with an increased incidence in winter and decreased incidence in summer months. A 2014 retrospective analysis reported that implementation of rotavirus vaccines has reduced diarrhea-related healthcare use in US children by as much as 94% in 2009–2010.[23, 24]

With the continued decline of rotavirus-associated gastroenteritis, noroviruses (Norwalk-like viruses) have become the leading cause of medically attended acute gastroenteritis in children younger than 5 years in the United States, accounting for 14,000 hospitalizations, 281,000 emergency department visits, 627,000 outpatient visits, and more than $273 million in treatment costs each year.[3] Caliciviruses, astroviruses, and enteric adenoviruses make up the remainder of cases of viral gastroenteritis. Viral gastroenteritis typically presents with low-grade fever and vomiting followed by copious watery diarrhea (up to 10-20 bowel movements per day), with symptoms persisting for 3-8 days.[16]

In developed countries, bacterial pathogens account for a small portion, perhaps 2-10%, of all cases of pediatric gastroenteritis. In the United States, the most important pathogens, in order of prevalence, are Campylobacter, Salmonella, Shigella, and enterohemorrhagic Escherichia coli (EHEC) species.[16] Relative to viral gastroenteritis, bacterial disease is more likely to be associated with high fevers, shaking chills, bloody bowel movements (dysentery), abdominal cramping, and fecal leukocytes.

In developing countries, enterotoxigenic Escherichia coli (ETEC) remains the most important bacterial cause of acute gastroenteritis in children, followed by Campylobacter, Salmonella, and Shigella species, while also causing the majority of traveler's diarrhea cases in all age groups.[25] Unlike other bacterial causes of gastroenteritis, ETEC is unlikely to cause dysentery.

Clostridium difficile has emerged as an important cause of antibiotic-associated diarrhea in children. Any antibiotic can trigger infection with C difficile, though penicillins, cephalosporins, and clindamycin are the most likely causes.[16] Since 50% of neonates and young infants are colonized with C difficile, symptomatic disease is unlikely in children younger than 12 months.[16]

Parasites remain yet another source of gastroenteritis in young children, with Giardia and Cryptosporidium the most common causes in the United States. Parasitic gastroenteritis generally present with watery stools but can be differentiated from viral gastroenteritis by a protracted course or history of travel to endemic areas.[16]

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Contributor Information and Disclosures
Author

Adam Levine, MD, MPH Assistant Professor of Emergency Medicine, Brown University Alpert School of Medicine

Adam Levine, MD, MPH is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, American Public Health Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Karen A Santucci, MD, MD 

Karen A Santucci, MD, MD is a member of the following medical societies: Alpha Omega Alpha, Academic Pediatric Association, American Academy of Pediatrics, Sigma Xi, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Wayne Wolfram, MD, MPH Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center; Chairman, Pediatric Institutional Review Board, Mercy St Vincent Medical Center, Toledo, Ohio

Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Kirsten A Bechtel, MD Associate Professor of Pediatrics, Section of Pediatric Emergency Medicine, Yale University School of Medicine; Co-Director, Injury Free Coalition for Kids, Yale-New Haven Children's Hospital

Kirsten A Bechtel, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Additional Contributors

James Li, MD Former Assistant Professor, Division of Emergency Medicine, Harvard Medical School; Board of Directors, Remote Medicine

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, David W Marby, MD †, to the development and writing of this article.

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Child with sunken eyes.
Child with slow skin pinch (reduced skin turgor).
Child with absent tears.
Child with lethargy/poor general appearance.
Child with hyperpnea (deep, acidotic breathing)
Table 1. Assessment of Dehydration*
Symptom or Sign No or Minimal Dehydration Mild to Moderate Dehydration Severe Dehydration
Mental status Alert Restless, irritable Lethargic, unconscious
Thirst Drinks normally Drinks eagerly Drinks poorly
Heart rate Normal Normal to increased Tachycardia
Quality of pulses Normal Normal to decreased Weak or unpalpable
Breathing Normal Normal or fast Deep
Eyes Normal Slightly sunken Deeply sunken
Tears Present Decreased Absent
Mouth and tongue Moist Dry Parched
Skin fold Instant recoil Recoil < 2 seconds Recoil >2 seconds
Capillary refill Normal Prolonged Prolonged or minimal
Extremities Warm Cool Cold, mottled, cyanotic
Urine output Normal Decreased Minimal
*Adapted from King et al. MMWR Recomm Rep. 2003;52(RR-16):1-16.[15]
Table 2. Assessment of Dehydration According to the World Health Organization*
Severe Dehydration Two of the following signs:



-Lethargic or unconscious



-Sunken eyes



-Not able to drink or drinking poorly



-Skin pinch goes back very slowly



Some Dehydration Two of the following signs:



-Restless, irritable



-Sunken eyes



-Thirsty, drinks eagerly



-Skin pinch goes back slowly



No Dehydration Not enough of the above signs to classify as some or severe dehydration
*Adapted from World Health Organization.[10]
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