Pediatric emergency medicine trisk 0535 0535
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illness, frequency (number of diarrheal stools per day), quantity (smear in the
diaper or stool fills and overflows the diaper in infants), and characteristics (e.g.,
bloody, mucoid, black) of stools, presence of concurrent vomiting, the amount of
liquid taken orally, and the frequency or volume of urination (number of wet
diaper changes in the infant).
A diagnostic approach to the pediatric patient with diarrhea is outlined in
Figure 23.1 . Inquiry about associated symptoms may be helpful in determining
possible causes and need for other acute interventions. The presence of vomiting
and fever may help determine infectious versus noninfectious causes. Vomiting in
association with diarrhea is very suggestive of viral gastroenteritis, whereas
bilious vomiting in isolation is more concerning for intestinal obstruction. Bloody
diarrhea points particularly to bacterial enteritis but occasionally occurs with viral
infections and may also herald the onset of HUS or pseudomembranous colitis.
The combination of episodic abdominal pain and blood in the stool characterizes
intussusception. The presence of abdominal pain should raise the index of
suspicion for appendicitis and intussusception. A history of ear pain, cough, or
dysuria should alert to the possibility of nonintestinal infections as the etiology of
the diarrhea.
A history of family members or close contacts with similar symptoms may
indicate a food-borne etiology. The use of recreational water facilities such as
pools and lakes may indicate a waterborne pathogen. Institutionalized children
and those recently returning from underdeveloped countries are more likely to
harbor bacterial or parasitic pathogens. A history of daycare exposure suggests a
viral infection whereas recent antibiotic use may suggest antibiotic-associated
diarrhea or pseudomembranous colitis.
Pre-existing conditions in the child may account for the diarrhea or predispose
him or her to unusual causes; in particular, the emergency physician should
search for a history of gastrointestinal surgery or chronic illnesses, such as
ulcerative colitis or regional enteritis. Immunodeficiency syndromes, neoplasms,
and immunosuppressive therapy all lead to an increased susceptibility to
infection. A child who presents with chronic diarrhea (more than 14 days) may
suggest other etiologies such as IBD, irritable bowel disease, bacterial infections,
Hirschsprung disease, human immunodeficiency infection (HIV), and assorted
malabsorptive and secretory disorders. With the possible exception of bacterial
enteritis in a febrile or toxic-appearing patient, such conditions, if uncomplicated,
do not require a definitive diagnosis emergently, but rather an evaluation over
time.
