سشنات د.ربيع pdf - طلاب كروب C

Diarrhea: increase frequency, consistency and liquidity of stool that is
observed by the mother.
Diarrhea (WHO): > 3 bowel motions/day (except for babies who are
exclusively breast fed.

Approach to acute diarrhea: <14 days.

 History: Same history but should include (thirst and UOP) to estimate the

severity of dehydration.
Feeding Hx: should include:



Type of feeding: breast, Bottle or mixed.



If Bottle feeding:
-sterilization method (boiling for 10 min.)
-preparation of milk.
-No. o bottles (should be= No. of feds +1)
-Type of milk.

 Examination: we have to look for signs of dehydration:

1.  Ant. Fontanel → should be: At sitting position + baby not crying ( .)مهم
2.  Sunken eyes.
3.  Mucus membrane.
4.  Skin Turgor → should be <2 seconds, if >2 seconds → dehydration.
5.  UOP.

 Investigations:

1.  Serum electrolytes:
2.  RBS (random blood sugar).
3.  Blood urea and serum creatinine.
4.  CBC:  -RBC and HB: Normal or ↓

-shift to left {e.g: neutrophia +band cells (bandemia)}

→ suggest shigellosis.

          -PCV {normal or ↑(hemoconsitration)}
          -platelet: normal or ↓ (in case of HUS)

-Na

(N.R 135-145 mEq/l)

-Ca

(N.R 8.5-11 mg/dl)

- K

(N.R 3.5-4.5 mEq/l)

-HCO

-PH

HUS: is a triad of:
1.Microangiopathic anemia (helmet and
fragmented RBC in blood film).
2. Thrombocytopenia.
3. Uremia.
Note: presence of 2 out 3 + predisposing
factors can make the Dx.

6th stage Pediatrics Lec.2
د.ربيع Session notes 2016/8/21

5. General stool exam: Mcroscopic, chemical and microscopic exam:

 Macroscopic: volume, consistency, color …etc
 Chemical: -PH→

-Reducing agents: if +ve

→ (e.g lactose intolerance)

-Occult blood.

 Microscopic:

1.  RBC
2.  Pus cells
3.  Fatty cells
4.  Cysts or trophozoits.

_______________________________________________________________________

Approach to a pt. with chronic diarrhea: >14 days

We can classify chronic diarrhea into 3 types:

1)  Chronic diarrhea without FTT.
2)  Chronic diarrhea with FTT.
3)  Chronic diarrhea with blood.

________________________
1)DDx of Chronic diarrhea without FTT:

Lactose intolerance.

Giardiasis.

Toddler’s diarrhea.

Color of stool:
-red →blood
-Non-bilious→ Cholera,
obst. Jaundice.
-Green → rapid transient
time (benign)

-Normal PH is alkaline (because of HCO

Whenever it’s acidic→ considered abnormal
(e.g lactose intolerance) except in breast fed baby.

DDx:

.Infection: Bacterial (shigella

, salmonella, yersenia,capelobacter…etc)

or protozoal.
2

. Cow’s milk allergy.

. IBD.

. Post antibiotic

psuedomembranous

colitis.

FFT: definitions:

 Child with weight persistently <5

centile.

 Child who had crossed 2 major percentiles

in a period of 2 months.

 Child’s weight < 80% of the median

weight for the height

of the child.

NOTES: مهم باألمتحان
CASE1: Pt. with diarrhea get improving →develops
abdominal distention → what is the Dx? And how to prove
it?
A/-Dx: paralytic ileus from hypokalemia .
-Proof: by
##Auscultation →sluggish bowel sounds
##serum K

(If there’s no facility to do serum K

) then we

can do:
##ECG (flattening of T wave, prolonged QT interval)
CASE2: Pt with chronic diarrhea →develops bloody diarrhea
→ what is the Dx?
A/ Vit. K deficiency, because of antibiotic use →Kills bact.
Flora which can produce Vit. K.

Lactose intolerance:



Types:
1.Primary.
2. Developmental (very rare) → temporary →eg. Prematurity.
3.Secondary to (very common): celiac dis., Rota virus inf.,cow’s milk allergy…etc



How to Dx:
-Clinical: diarrhea, abd. pain & distension, exaggerated bowel sounds and
perianal excoriation.
-PH of stool: ↓
-Reducing substances: +ve
-Jejunal biopsy →Histochemical study→reduced lacose in brush border.
-lactose tolerance test: flat (no ↑ in glucose after CHO meal).
-H

breath test: ↑ (as aresult of bacterial fermentation of undigested lactose)



Rx: Lactose free formula (LF) → Isomil
Soy milk(isomil)→ for 2-4 wks then re-introduce
into ordinary formula.
_______________

Giardiasis:

 How to Dx:

1. Finding trophozoites (not cyst) in FRESH stool: (25% +ve).
2. Dudenal aspirate: (75% +ve).
3. Metronidazol trial.

 Rx: 20-30 mg/kg metronidazole for 10 days.

_______________

Toddler’s diarrhea:

 How to Dx: by exclusion of other causes of

chronic diarrhea. (Correlate to IBS in adults).

Isomil used only in:
1.Galactossemia.
2. Lactose intolerance.
3. Cow’s milk allergy

Q/What is the difference in metronidazol use in
amebiasis and Giardiasis?
A/ in amebiasis:
50 mg/kg metronidazole for 2 wks in divided
dose to be followed by diloxanide furoateor
paromomycin to get rid of cysts in order to
prevent relapses

2)DDx of Chronic diarrhea with FTT:

Lactose intolerance.

Giardiasis.

Celiac Dis.

Cystic fibrosis.

Bact. Overgrowth.

UTI.

Endocrinpaties→ thyrotoxicosis, Addison’s dis., VIPomas

Cows milk allergy.

___________________

Celiac Dis.:

 Presentation: Abd. pain & distension, chronic diarrhea (greasy, offensive stool)

poor weight gain, anorexia, vomiting …etc .

 How to Dx:

1.Serology: anti-tissue transglutaminase IgA ab
and total IgA.
If anti-tissue transglutaminase Ab is ↑
and total IgA is normal then we have to do:
2. Dudenal or jejuna biopsy: Histopathological findings:
-Total or subtotal villous atrophy.
-Deepening of the crypts of langerhans (cryptitis)
-Intraepithelial and submucosal infiltration of lymphocytes and plasma cells.
## If the above findings was found + serology ↑ titer → definitive Dx.

 Rx: Gluten-free diet for life long.

___________________

Can cause chronic diarrhea
WITH or WITHOUT FTT

NOTE: celiac dis. Is never diagnosed
<9 months age.

Celiac syndrome: diseases similar to
celiac dis. But it’s not celiac dis.:
-Tropical sprue.
- Giardiasis
-Malnutrition.
-Eosinophilic enteritis.

Note: Malignancy (lymphoma and
pancreatic CA) is a possible
complication of celiac dis.
Note: Gluten-free diet dose not
eliminate the risk of malignancy.

Cystic fibrosis:

 How to Dx:

1. It can be diagnosed 1 hr. after birth because it can cause meconium ileus.
2. Sweet chloride test →>60 mmol/L .
3. DNA diagnosis.

 Can cause bronchiectasis as result of recurrent chest infection→ can cause death.
 Rx: Antibiotics + physiotherapy.

__________________

UTI: Very important → DDx of many complaints.

 How to Dx:

1. GUE → >5 pus cells/HPF
2.Urine culture (main diagnostic method) : specimen:
   - Mid-steam urine :
      ## >100,000 colony/ml of the same M.O →UTI
##10,000 colony/ml→ NOT UTI.
  ##10,000 - 100,000 → Suspicious → Repeat the test or do more accurate
method

    -Suprapubic aspiration→ if single colony is recovered→ definitive Dx of UTI.
Or- Urine obtained by foly’s catheter→If single colony is recovered→UTI.

3. U/S
4. MCUG

If the above mentioned investigations are:
- Norml → No need for IVU.
-Abnormal → we have to do IVU to estimate the remaining functioning part of the
kidney →If the kidney is still functioning →it’s worth to do surgery for VUR dis.
→If the kidney is scarred → No need to do the corrective surgery.

To Diagnosis Vesicouretric reflux dis. In pt. with recurrent UTI.

 Rx: cystitis →symptmatic Rx + Antibiotic (amoxicillin or 3

generation

cephalosporin as cefixime) orally for 7-10 days.
Pyelonephritis→ Hospitalization +symptomatic Rx + Antibiotic (combination of
3

generation cephalosporin + amynoglycoside) parenterally for 10-14 days to be

switched into oral therapy once the pt. is able to.

Cow’s milk protein allergy: (Casein protein):

 Presentation: bloody diarrhea, abdominal pain, urticaria, runny nose and even

FTT.

 How to Dx:

1. Challenge test.
2. Specific Ab

 Rx: Extensively hydrolyzed formula.

____________________

3)DDx of Chronic diarrhea with Blood:

Post-antibiotic pseudomembranous colitis.

Note:
30-50 % of pt. with cow’s milk
allergy have soy protein allergy