Acute Gastroenteritis: A Case Discussion

1. Ryan Em C. Dalman MD MBA - 070070 Acute Gastroenteritis: A Case Discussion

2. Outline • Objectives • Case Presentation • Case Discussion

3. Objectives • Present a case of Acute Gastroenteritis • Discuss the pathophysiology and management of Acute Gastroenteritis

4. Case Presentation Patient History

5. General Data • JM • 1-year-old born on July 9, 2009 • Female • Admitted for the first time • Roman Catholic • Pasig City

6. Chief Complaint • Vomiting

7. History of Present Illness • Vomiting 1x ingested food • Non-projectile • Non-bilous • Non-bloody 3 days PTA No associated symptoms, no medications, no consults • Loose bowel movement 3x • Watery • Non-bloody • Non-mucoid • Non-foul smelling 1 day PTA

8. History of Present Illness • Symptoms persisted 12 hours PTA Consult at the ER Sent home after successful trial feeds

9. History of Present Illness • Vomiting 3x ingested food • Post-prandial • Non-projectile • Non-bilous • Non-bloody Few hours PTA Consult at the ER Admitted

10. Review of Systems General: no weight loss, no change in appetite Cutaneous: no lesions, no pigmentation, no hair loss, no pruritus HEENT: no redness no aural discharge no neck masses no sore throat

11. Review of Systems Cardiovascular: no easy fatigability, or fainting spells Gastrointestinal: no constipation Genitourinary: no genital discharge, no pruritus no problems in urination Endocrine: polydypsia, no heat/cold intolerance

12. Review of Systems Muskuloskeletal: no joint or muscle swelling, no limitation of movement, no stiffness Hematopoietic: no easy bruisability, or bleeding

13. Maternal and Birth History • Born full term via NSD to a 31 year old G4P3 (3013) by an obstetrician at PCGH • with complete prenatal consults • No intake of any medications except for multivitamins • No maternal illnesses • No complications at birth

14. Nutritional History • Breastfed from birth to 3 months old • Bona • Supplementary foods were given at 6 month old • Current diet • Milk 4-5 bottles a day • Rice + (chicken, vegetables, w/ soup) 3x a day • Bread every morning

15. Immunizations • BCG – 1 dose • DPT – 3 doses • Hep B – 3 doses • Measles – 1 dose

16. Developmental History • Stands alone • Throws toys • Obeys commands or requests • Attempts to use a spoon

17. Past Medical History No Tuberculosis, Asthma, Trauma No previous surgeries No previous hospitalizations No Allergies

18. Family History • Diabetes, Hypertension – father • No heart disease, cancer, stroke, kidney disease, asthma, or allergies

19. Personal and Social History • Father works for Reagent • Mother is a housewife • Private Subdivision in Pasig City

20. Environmental • Not exposed to environmental hazards like chemicals, pollution, cigarette smoking, etc • Generally clean environment • Has their own toilet • Water comes from Manila Waters • Drinking water  mineral water

21. Case Presentation Physical Exam

22. General Survey • awake, active, with good cry but consolable • Not in cardiorespiratory distress

23. Vital Signs/ Anthropometrics Vital signs Temperature – 36.5oC CR – 112 (70-110) RR – 28(20-30) Weight: 10.4 kg (50-75th) Length: 75cm (50th) HC: 45.5cm (50-75th) CC: 45 cm AC: 42 cm

24. Skin • Light brown • No rashes, hemorrhages, scars • Moist • good skin turgor • CRT 1-2 seconds

25. HEENT Head normocephalic no lesions, fontanels closed Eyes anictericsclerae, pink palpebral conjunctiva, not sunken pupils 2-3mm Ears cone of light present inferomedially on both ears no discharge noted Nose septum medline, moist mucosa Throat mouth and tongue moist no TPC

26. Chest and Lungs Neck no cervical lymphadonapathy Supple Chest adynamicprecordium no heaves, thrills, or lifts, PMI at 4th ICS MCL slightly tachycardic, normal rhythm, distinct S1 and S2 no murmurs Lungs symmetrical chest expansion, no retractions Equal vocal fremiti Clearbreath sounds

27. Abdomen/ Perineum Abdomen Distended, no scars, no lesions Hyperactive bowel sounds tympanitic on all quadrants no tenderness on all quadrants no masses, no organomegally liver edge palpated kidneys and spleen not appreciated

28. Neurologic Examination Glasgow Coma Scale verbal response: 5 eye opening: 4 motor response: 6 total: 15 Cerebrum awake and active Cerebellum no nystagmus, tremors, or abnormal movements

29. Neurologic Examination Sensory responds to pain Motor Symmetrical general movement with good activity DTR ++ on all extremities

30. Neurologic Examination Cranial Nerves I: not elicited II: 2-3mm pupils, equally reactive to light III,IV,VI: EOM’s intact V: corneal reflex present V1, V2, V3 intact (responds to touch) VII: no facial asymmetry VIII: turns to sound IX, X: gag reflex present XI: turns head from side to side XII: tongue midline

31. Case Presentation Salient Features, Admitting Impression, Differentials, Course in the Ward

32. Salient Features • 1 year month old, female • Vomiting • Acute Loose watery stools • Non-bloody, non-mucoid, non-foul smelling • Distended abdomen • Skin – good turgor, CRT 1-2 sec • Eyes not sunken • Moist oral mucosa • Hyperactive bowel sounds

33. Admitting Impression • Acute Gastroenteritis, probably viral, with no signs of dehydration

34. Differential Diagnosis

35. Differential Diagnosis

36. Differential Diagnosis

37. Differential Diagnosis

38. Differential Diagnosis

39. Diagnostic and Therapeutic Plan • Diagnostic • CBC with platelet count • Blood chemistry (sodium and potassium) • Urinalysis • Fecalysis • Therapeutic • IV for Hydration • Increased oral hydration • Antipyretics • Zinc supplementation • Probiotics

40. Course in the Ward 1st Hospital Day

41. Course in the Ward 1st Hospital Day

42. Course in the Ward 2nd Hospital Day

43. Case Discussion

44. Definition • Infections of the gastrointestinal tract caused by bacterial, viral, or parasitic pathogens • Diarrheal disorders • Term used in public health setting • Diarrhea • 3 or more unusually watery stools passed in 24 hours WHO – Treatment of Diarrhea

45. Etiology > 3 years old • Viral • Rotavirus • Enteric adenovirus • Astrovirus • Norovirus • Calicivirus • E. coli, Salmonella

46. Epidemiology • 18% of childhood deaths • >700 million episodes of diarrhea annually • < 5 years old (WHO) • Philippines • 2nd leading cause of morbidity • 6th leading cause of mortality for all ages • 3rd leading cause of infant deaths • Predominance of rotavirus and enterotoxigenicE. coli Nelson/ Carlos and Saniel, Etiology and Epidemiology of Diarrhea (1990)

47. Manifestation • Most common • Diarrhea • Vomiting • May also have systemic symptoms • Abdominal pain • fever

48. Clinical types of Diarrhea • Acute watery diarrhea • Several hours to days • Acute bloody diarrhea • Persistent diarrhea • > 14 days • Diarrhea with severe malnutrition

49. Pathophysiology NSP4 cause release Ca2+ intracellularly Enters villi and releases viral proteins (NSP4) Feca-oral route Paracellular flow of water and electrolytes NSP4 produced disrupts tight junctions Virus infects adjacent cell Ramig (2004), Pathogenesis of intestinal and systemic rotavirus infection

50. Ramig (2004), Pathogenesis of intestinal and systemic rotavirus infection