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Pediatric Gastroenteritis Clinical Presentation

  • Author: Randy P Prescilla, MD; Chief Editor: Russell W Steele, MD  more...
 
Updated: May 27, 2016
 

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, although only rarely will this affect management.

Diarrhea

Determine the duration of diarrhea, the frequency and amount of stools, the time since the last episode of diarrhea, and the quality of stools. Frequent, watery stools are more consistent with viral gastroenteritis, while stools with blood or mucous are indicative of a bacterial pathogen. Similarly, a long duration of diarrhea (>14 days) is more consistent with a parasitic or noninfectious cause of diarrhea.

Vomiting

Determine the 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

Determine if there is an increase or decrease in the frequency of urination as measured by the 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

Determine the location, quality, radiation, severity, and timing of pain, based on a report from the 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

Determine the 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

Elements include 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

A history of recent antibiotic use increases the likelihood of Clostridium difficile infection.

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

Elements of the physical examination are as follows:

  • General - Weight, ill appearance, level of alertness, lethargy, irritability
  • HEENT (head, ears, eyes, nose, and throat) - Presence or absence of tears, dry or moist mucous membranes, and whether the eyes appear sunken
  • Cardiovascular - Heart rate and quality of pulses
  • Respiratory - Rate and quality of respirations (deep, acidotic breathing suggests severe dehydration).
  • Abdomen - Abdominal tenderness, guarding and rebound, and bowel sounds; abdominal tenderness on examination, with or without guarding, should prompt consideration of diseases other than gastroenteritis
  • Back - Flank/costovertebral angle tenderness increase the likelihood of pyelonephritis
  • Rectal - Quality and color of stool, presence of gross blood or mucous
  • Extremities - Capillary refill time, warm or cool extremities
  • Skin - Abdominal rash may indicate typhoid fever (infection with Salmonella typhi), while jaundice might make viral or toxic hepatitis more likely; slow return of abdominal skin pinch suggests decreased skin turgor and dehydration, while a doughy feel to the skin may indicate hypernatremia
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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.[9] Rotavirus infection follows seasonal variation, with an increased incidence in winter and decreased incidence in summer months.

In the United States, routine rotavirus vaccination has led to a 60-75% reduction in pediatric rotavirus hospitalization since 2006.[10, 11] A 2014 retrospective analysis reported that implementation of rotavirus vaccines has reduced the diarrhea-related healthcare use in US children by as much as 94% in 2009–2010.[12, 13] 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.[14] 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(upto10-20bowelmovementsper day),with symptomspersisting for 3-8 days.[3]

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.[3] 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 Ecoli (ETEC) remains the most important bacterial cause of acute gastroenteritis in children, followed by Campylobacter, Salmonella, and Shigella, while also causing the majority of traveler’s diarrhea in all age groups.[15] Unlike other bacterial causes of gastroenteritis, ETEC is unlikely to cause dysentery.

C difficile has emerged as an important cause of antibiotic-associated diarrhea in children. Any antibiotic can trigger infection with C difficile, although penicillins, cephalosporins, and clindamycin are the most likely causes.[3] Since 50% of neonates and young infants are colonized with C difficile, symptomatic disease is unlikely in children younger than 12 months.[3]

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 presents with watery stools but can be differentiated from viral gastroenteritis by a protracted course or history of travel to endemic areas.[3]

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Contributor Information and Disclosures
Author

Randy P Prescilla, MD Instructor in Anesthesia, Harvard Medical School; Assistant in Perioperative Anesthesia, Children's Hospital Boston

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.

Joseph Domachowske, MD Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York Upstate Medical University

Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa

Disclosure: Received research grant from: Pfizer;GlaxoSmithKline;AstraZeneca;Merck;American Academy of Pediatrics<br/>Received income in an amount equal to or greater than $250 from: Sanofi Pasteur;Astra Zeneca;Novartis<br/>Consulting fees for: Sanofi Pasteur; Novartis; Merck; Astra Zeneca.

Chief Editor

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, Southern Medical Association

Disclosure: Nothing to disclose.

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Table 1. Assessment of Dehydration [2]
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 not palpable
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 [21]
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
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