Pediatric Gastroenteritis in Emergency Medicine Clinical Presentation

Updated: Apr 18, 2023
  • Author: Adam C Levine, MD, MPH; Chief Editor: Kirsten A Bechtel, MD  more...
  • Print


The history and physical examination serve two 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, and "rice water" diarrhea is typically associated with cholera. Similarly, a long duration of diarrhea (>14 d) is more consistent with a parasitic or noninfectious cause of diarrhea. It is important to note that the WHO definition of diarrhea is 3 or more loose stools per day.

  • 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.


Physical Examination

Physical findings are as follows:

  • General appearance: 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.
  • 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

  • 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).