GASTROINTERITIS

Gastrointeritis is an infection of the gastrointestinal tract, usually viral,

which present with a combinational of diarrhoea and vomiting (D&V).
Incidence an aetiology
In developed countries it is usually mild and self limiting (affecting 1 in 10
children under the age of 2 years) but in the developing world approximately 5
million children under 5 years old die from gastroenteritis each year.
Rotavirus is the most common pathogen in the UK but gastroenteritis cn
also be caused by :
-

Bacteria, including Shigellae, Salmonellae and Camplylobacter species

and Escherichia coli.
Three parasites: Entamoeba histolytica, Giardia lamblia and
Cryptosporidium species.

Clinical features
Viral infection can cause a prodmoral illness followed by vomiting and diarrhoea:
-

The vomiting might precede diarrhoea and is not usually stained with
bile or blood
Abdominal pain and blood or mucus in the stool suggest an invasive
bacterial pathogen.
The severity of diarrhoea can be underestimated if it pools in the large
bowel or if very watery stool is mistaken for urine in the nappy.

On examination, the most important physical sign relate to the presence and
severity of dehydration. The high surface area to bodyweight ratio in babies and
infants renders them susceptible to rapid derangement of fluid and electrolyte
balance.
Diagnosis
The differential diagnosis includes at least two important surgical conditions:
-

In young infants, especially boys (aged 2-12 weeks), vomiting might be

due to pyloric stenosis. Stool output is reduced and visible peristalsis
with a palpable pyloric mass might be evident.
In older infants and toddlers (aged 1-2 years) intussusception present
with vomiting .
Paroxysmas abdominal pain and the eventual passage of redcurrant
jelly stools should raise suspicion of this condition, which is lethal if
over looked.

Investigations should include:

-

Measurement of the plasma urea and electrolytes if dehidrated.

Stool culture and microscopy.

Stool viral antigen detection.

Gastroenteritis, by definition, includes diarrhoea. It is important to look for other

causes when a child presents with vomiting alone.
Dehydrtion can be further classified according to whether the plasma sodium
concentration is normal, low (hyponatraemia) or high ( hypernatraemia). This has
a bearing on the fluids used for rehydration (see below).
Management
Rehydration
The key to management is rehydration with correction of the fluid and electrolyte
imbalance. The strategy depends on the severity of dehydration.

It is important to emphasize the importance of oral dehydration. Unless the child

has persistent vomiting, oral fluids is the best means for dehydration.
Smaller,more frequent sips may better tolerated and should be encouraged.
Disorders of the gastrointestinal system.

Mild dehydration
Oral dehydration solutions (ORS; e.g Dioralyte, Rehidrat) are used. These contain
dextrose to stimulate sodium and water reabsorption across the bowelwall.
Metode to severe dehydration
Oral dehydration is still indicated if tolerated. IV rehydration should be reserved
for those with vomiting or severse dehydration.

Early refeeding reduces duration of diarrhoeal illness caused by gastrointestinal.

IV therapy os over-used.

If there are signs of circulatory failure,immediate resuscitation is achieved

by intravenous admistration of 10-20 ml./kg of o.9 % NaCl (normal saline).
Further rehydration can usually be achieved satisfactorily with 5%
dextrose/0.45% saline with KCl added at a concentration of 20-40 mmol/L.
The volume required in24 hours is calculated from estimated deficit +
maintenance + ongoing losses:
DeficitDeficit = % dehydration + bodyweight in 1 kg (1 kg =1000 mL.
Maintenance Allow:

100 mL/kg/24 h for 0-10 kg bodyweight .

50 mL/kg/24 h for 20-40 kg bodyweight.
20 mL/kg/24 h for > 20 kg bodyweight.

Ongoing losses
Estimate the volume of vomit and diarrhoea. Calculate the volume required as
shown in the following axample of a child weighing 10 kg with estimated 10%
dehydration.
- Deficit = 10% of 0 kg = 1000 mL.
- Maintenance in 24 h = 100 mL/kg = 1000 mL.
- Total required in 24 h = 2000 mL.
1. Give Iv o.9% NaCl 20 mL/kg over 30 min = 200 mL.
2. Give1800 mL 4% dextrose/0.18% NaCl over 24 h, i.e. IV infusion at
75mL/h.

Medication
There is no role for antiemetic or antimedication in gastroenteris. ..........