PEM Playbook – Diarrhea
- Sep 19th, 2020
- Tim Horeczko
Originally published at Pediatric Emergency Playbook on July 1, 2020 – Visit to listen to accompanying podcast. Reposted with permission.
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Secretory — poisoned mucosal villi — “the sieve”
Cytotoxic — destroyed mucosal villi — “the shred”
Osmotic — malabsorption — “the pull”
Inflammatory — edema, motility — “the push”
Lots of overlap, difficult to apply to clinical signs and symptoms.
Fever/No Fever, Bloody/No Blood
Non-bloody, febrile — most likely viral
Non-bloody, afebrile — may be viral
Bloody, febrile — likely bacterial
Bloody, afebrile — full stop. Eval for Hemolytic Uremic Syndrome
Ask yourself — again — why is this not… appendicitis-torsion-intussusception-etc.
Admit sick children, but most go home, so…
Non-bloody, febrile — no workup necessary; precautionary advice
Non-bloody, afebrile — be more skeptical, but generally same as above
Bloody, febrile — stool culture, follow up; do not treat empirically unless septic and admitted. Culture will dictate treat/no treat/how.
Bloody, afebrile — evaluate for hemolytic uremic syndrome, especially if under 5 years old: CBC, chemistries, UA, stool culture
Evaluate Hydration Status
American Academy of Pediatrics. Clostridium difficile Infection in Infants and Children. Committeee on Infectious Diseases. Pediatrics. 2013; 131 (1) 196-200
Khan WA et al. Central Nervous System Manifestations of Childhood Shigellosis: Prevalence, Risk Factors, and Outcome. Pediatrics. 1999 Feb;103(2):E18
Lee JY et al. Diagnostic yield of stool culture and predictive factors for positive culture in patients with diarrheal illness. Medicine (Baltimore). 2017 Jul; 96(30): e7641.
Meropol SB et al. Yield From Stool Testing of Pediatric Inpatients. Arch Pediatr Adolesc Med. 1997 Feb;151(2):142-5.
Nelson JD et al. Treatment of Salmonella gastroenteritis with ampicillin, amoxicillin, or placebo. Pediatrics 1980; 65:1125.