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Pediatrics, Gastroenteritis: Differential Diagnoses & Workup
Updated: Nov 17, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Differential Diagnoses
Other Problems to Be Considered
Pseudomembranous colitis
Malrotation
Volvulus
Food poisoning
Lactose intolerance
Malabsorption syndromes
Irritable bowel syndrome
Workup
Laboratory Studies
- The vast majority of children presenting with acute gastroenteritis do not require lab tests, as they are unlikely to affect management.
- In a recent meta-analysis of 6 studies, BUN, Cr, pH, anion gap, and urine specific gravity were not found to be useful measures of dehydration.4
- Only serum bicarbonate (<17) had statistically significant likelihood ratios for detecting moderate dehydration.
- Clinically significant electrolyte abnormalities are rare in children with moderate dehydration.
- Any child being treated with intravenous fluids for severe dehydration should have baseline electrolytes, bicarbonate, and urea/creatinine drawn.
- Electrolytes are also indicated in patients with moderate dehydration whose history and physical are inconsistent with straightforward gastroenteritis or whose skin has a "doughy" feel, which might indicate hypernatremia.
- Fecal leukocytes and stool culture may be helpful in children presenting with dysentery.
- Children older than 12 months with a recent history of antibiotic use should have stool tested for C difficile toxins.
- Children with a history of prolonged watery diarrhea (>14 d) or travel to an endemic area should have stool sent for ova and parasites.
- Any child with evidence of systemic infection should have a complete workup including CBC count and blood cultures. If indicated, urine cultures, chest radiography, and/or lumbar puncture (LP) should be performed.
Imaging Studies
- Abdominal films are not indicated in the management of acute gastroenteritis. If the clinician suspects a diagnosis other than acute gastroenteritis based on history and physical examination, appropriate imaging modalities should be pursued.
Other Tests
- Workup of acute gastroenteritis should begin by using elements of the history and physical examination to determine the level of dehydration. Both the Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP) recommend using a simple dehydration scale to classify the total body water loss occurring with dehydration as minimal/none (<3%), mild/moderate (3-9%), or severe (>10%) (see Table 1). The World Health Organization (WHO) recommends a simpler system for use by both physicians and health care workers, which classifies dehydration as none, some, or severe (see Table 2).
- A recent meta-analysis of 13 separate studies looking at individual signs and symptoms of dehydration found only abnormal capillary refill (>2 sec), decreased skin turgor, and abnormal respiratory pattern (hyperpnea) had statistically significant positive and negative likelihood ratios for detecting dehydration in children.
- A study by Gorelick et al assessed the validity of a combination of 10 signs and symptoms similar to those recommended by the AAP. They found that the presence of 3 or more signs had a sensitivity of .87 and a specificity of .82 for detecting moderate dehydration. The presence of 7 or more signs had a sensitivity of .82 and a specificity of .90 for detecting severe dehydration.5
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Table
| 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 |
| 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 |
Table 2: Assessment of Dehydration*
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Table
| 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 |
| 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 |
More on Pediatrics, Gastroenteritis |
| Overview: Pediatrics, Gastroenteritis |
 Differential Diagnoses & Workup: Pediatrics, Gastroenteritis |
| Treatment & Medication: Pediatrics, Gastroenteritis |
| Follow-up: Pediatrics, Gastroenteritis |
| References |
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References
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Further Reading
Keywords
acute gastroenteritis, gastroenteritis treatment, gastroenteritis symptoms, gastroenteritis causes, diarrhea, dysentery, gastroenteritis in children, gastroenteritis in infants, vomiting, dehydration, norovirus, rotavirus,
