Mrs. Motto brings in her 3 m/o son, Guido, to your emergency room on Friday night.

Guido is having vomiting and diarrhea and a low-grade temp for 2 days.
Possible Diagnosis Factors in History, Physical Exam, Laboratory/Diagnostic Information Supporting diagnosis Mechanisms that explains symptoms and signs Likelihood of diagnosis given the patients age and other factors pertinent negative pertinent positive 3 mo3 years males > females Other information needed to make diagnosis

Intussception
*want to R/O because life threatening*

HPI: Diarrhea Vomiting Abdominal Pain o Sudden, severe, colicky Hematochezia (blood in stool) currant jelly stool (blood+ mucus) Irritability o Crying, Colicky Abdominal distention Complete obstruction (>24hrs)

-invagination of proximal segment of intestine (intussusceptum) into adjacent distal segment (intussuscipiens) -progressive edema + inflammation + vessel occlusion bowel obstruction & ischemia

RFs: -CF -Bleeding disorders -trauma -recent adenovirus infection -rotavirus vaccine (now d/c) -VIRAL causes likely PE: Abdomen -mass in RUQ(sausage shape) -abdominal distention -increased peristalsis Rectal -(+) guaiac -mass if prolapsed through anus Imaging: -plain abdominal X-ray empty RLQ with mass @ flexure -U/S bulls eye mass

Making the Dx: (+) Abdominal X-ray (with air pressure enema) (+) hematochezia

Mrs. Motto brings in her 3 m/o son, Guido, to your emergency room on Friday night. Guido is having vomiting and diarrhea and a low-grade temp for 2 days.

Hemolytic Uremic Syndrome (HUS)

HPI: Diarrhea o often bloody o may not become blood until 2-3 days post onset Abdominal pain Vague clinical prodromal GI sx o Nausea, vomiting, cramping Neurological sx: o Irritability, lethargy Anemia Sx: o Lightheadedness, fatigue

-shiga-toxin producing E. coli or STEC is most common -circulating Shiga toxin is cause of systemic complication - proinflammatory and prothrombotic changes in coagulation pathway and damage to endothelial cells lead to endorgan damage

children <5 yo & elderly

RF: -recent E. coli infxn (specifically shiga-toxin producing E. coli or STEC) -recent infxn (other bacteria) - recent abx use -antimotility Rx WBC Thrombin or D-dimer PAI-1 PE: Skin -pallor (anemia) -jaundice (hemolysis) -petechiae and purpura UNCOMMON findings Neuro -irritability Labs: -CBC -UA -peripheral blood smear -haptoglobin -BUN -Serum Cr -stool culture -PCR for txin gene Making the Dx: -Hct < 30% -platelets<150 - Serum Cr RF: -Child care in < 1 yo PE:

Acute Gastroenteritis

HPI: Diarrhea Vomiting nausea

The rotavirus is resistant to stomach acid, so it is not degraded but instead attaches to the beta receptor

common in young children most common in

Mrs. Motto brings in her 3 m/o son, Guido, to your emergency room on Friday night. Guido is having vomiting and diarrhea and a low-grade temp for 2 days.
6mo2 yo up to 1/3 have fever >102 -General -fever > 102 -evidence of dehydration (response to stimulation, overall appearance, skin turgor, bp) -tachycardia -hyperpnea (may indicate acidosis) Labs: -CBC -BMP -BUN -Cr -Stool cultures -Shiga toxin assay Imaging: -U/S rarely used Making the Dx: -definitive diagnosis cannot be solely on clinical grounds, but confirmatory tests not routinely performed due to high-cost RF: -attending child care center? -Hispanic? -international travel?

Hepatitis A

HPI: diarrhea vomi

-primarily transmitted fecal oral -hepatitis A virus travels to intestine (viral replication may occur in gastrointestinal epithelial cells) causing symptoms described -viral particles also travel to liver , SI, bile duct

infected children < 6 yo usually not symptomatic

HPI: diarrhea

DDx:

acute diarrhea with bloody stools

Reasoning for/against:

Mrs. Motto brings in her 3 m/o son, Guido, to your emergency room on Friday night. Guido is having vomiting and diarrhea and a low-grade temp for 2 days.
rotavirus gastroenteritis norovirus infection Enterotoxigenic E. coli (ETEC) Enteropathogenic E. coli infection (EPEC) cholera Vibrio parahaemolyticus diarrhea * Staphylococcus aureus gastroenteritis * giardiasis * cyclosporiasis
(-) Most common in 6 mo- 2 yo -also called cruise ship virus infection, all ages affected, RFs include populations like cruise ships, healthcare, schools, nursing homes, hotels and barracks in military -most usually associated with travelers diarrhea -mostly affects infants in developing countries -RARE before age 1 -RARE in the US , most commonly seen in Japan -from eating, onset within 2-4 hours of ingestions (severe vomiting, diarrhea, abdominal pain, cramps) -infants > adults (only slightly), usuallyin immigrants and international travelers???maybeGuido-foreign? spore-forming protozoa, coccidian parasite, transmission from oralfecal route, which could happen in infantpossible Reasoning for/against Affects all ages, sx most severe in infants and elderly, through transmission of bacteria through food (usually eggs), antibiotic tx not recommendation in healthy adults Transmission through milk?? -shiga toxin causes hemorrhagic colitic and HUS, acute bacterial diarrhea more common in developing countries, only 3.8/100,000 in US but most severe and deaths from this in <5 yo 2nd most common cause of infectious diarrhea, transmitted through undercooked meats, fecal-oral countact and sexual contact -most common in MSM, low gastric acid, travel-associated? Several days1 week onset, severe RLQ abdominal pain, fever and diarrhea -less likely is vomiting, nausea, pharyngitis -associated with iron storage diseases, immunosuppression, eating undercooked meat, contact with zoonotic reservoris mainly watery, but small proportion of patients may present with bloody diarrhea typically watery, but some patients may present with bloody diarrhea mucoid stool, no nausea/vomiting

*= still possible Dx but more unlikely acute diarrhea without bloody stools consider * Salmonella ileocolitis

- Shigellosis -Campylobacter enterocolitis -Yersinia enterocolitis

-Enterohemorrhagic E. coli, including O157:H7 Shiga toxin-producing E. coli -Enteroinvasive E. coli infection (EIEC) - enteroaggregative E. coli (EAEC) infection -Clostridium difficile infection amebiasis

Mrs. Motto brings in her 3 m/o son, Guido, to your emergency room on Friday night. Guido is having vomiting and diarrhea and a low-grade temp for 2 days.
Aeromonas infection Cryptosporidiosis balantidiasis schistosomiasis (S. haematobium, S. japonicum, S. mansoni) typically watery and self-limited, but some patients may have bloody diarrhea bloody stool relatively rare may be watery or bloody