Which essential questions will you ask a pediatric patient or his or her caregiver when the presenting complaint is bloody diarrhea? Will these questions vary depending upon the child’s age? Why or why not?
Dysenteric diarrhea, with invasion and penetration of the colon mucosa and sometimes of the terminal ileum, are characterized by fever high, frequent, small stools with mucus and blood, accompanied by colic, pushes and tenesmus For example: Shigella, Escherichia enteroinvasive coli (ECEI) and rarely Salmonella, Campylobacter yeyuni, Yersinia enterocolitica and Entamoeba hystolitica.
Not all bloody diarrheas are dysentery. To do a better differential diagnosis, I would ask the parents if the child had recently consumed ground beef foods, unpasteurized milk, unpasteurized eggs, or things like raw cookie dough. I would ask if they had recently been exposed to insecticides, rodenticides, weed killer, wood preservatives, and fireworks. If they have had recently antibiotic use or travel to foreign countries such as Mexico or South America. We will ask the parents for medical history of familial colonic polyposis, hemorrhagic diseases, gastroduodenal ulcers, and liver diseases. It is important to investigate about the possible presence of pathologies that affect to the bronchial tree and/or the otorhinolaryngologic area, that very often affect children in the period of infants and preschoolers, which frequently cause febrile syndromes, epistaxis, and subsequently gastrointestinal hemorrhage (Fleisher & Duryea, 2017). Assess episodes of rectal bleeding, and recurrence of them, relating them to age and stool characteristics, always discarding the ingestion of certain foods or medications that can alter the color of the stool, which would be reddish before the ingestion of some sweets, punch fruits, beets, some laxatives and rifampin, or of a more blackish color after ingestion of food like licorice, spinach, black pudding or medicines such as activated carbon, iron, and food coloring E-120. Investigate if it is the first time that the patient had rectal bleeding and if it is associated with symptoms such as vomiting, abdominal pain, fever, tenesmus (inflammatory disease), pain when defecating (rectal fissure), or associated to dermatological findings with the presence of petechiae, purples, angiomas, spots or pigmentations on the skin, etc., in order to try to clarify the origin, the amount and duration of bleeding, or by contrary if the patient have had previous episodes, trying to relate them with the age of presentation and with the characteristics of feces, assessing the recurrence of episodes. It is important to ask about the type of bleeding, trying to clarify the origin, magnitude and duration of bleeding.
What clinical or historical findings will indicate the need for diagnostic studies and why?
Assessment of the general state, of the hemodynamic state monitoring the heart rate, pressure arterial and capillary perfusion, the color of the skin, which if it is pale and coincident with signs of anemia will tell us that blood loss can have been important, as well as possible jaundice and pigmentations. A nasopharyngeal exploration looking for signs of bleeding coming of the nose (rhinitis, trauma), or of the tonsils (hypertrophy, tonsillar congestion) is a part of the PE.
With palpation and abdominal percussion, we will discard the presence of organomegalies, masses, distension, and pain on palpation in the different organs. The exploration of the perianal and rectal areas is obligatory, not only with the inspection visual, but also with careful palpation that will help discover possible fissures, fistulas, indurations, or polyps, not forgetting the possible appearance of vaginal bleeding in girls. In these cases, is advisable to practice the exploration of the genital area in presence of at least one other staff member.
Which diagnostic studies will you initially order and why?
Initial tests that I would order if the child was ill appearing would include a CBC, BMP, blood culture, stool culture, stool for C. diff, stool for ova and parasites, KUB for intussusception, and/or ultrasound/CT for suspected appendicitis.
What would be three differential diagnoses in this case?
Differential diagnosis:
1. Anal fissures: frequent proctologic disease in childhood, usually have, beyond the period of infant, a location posterior, sometimes covered with a cutaneous cap (ectropion cutaneous). The bleeding is minimal, a few drops of blood that line the stool or stain the paper when cleaned. Usually it happens by the passage of broad, hard stools through the anal canal that is accompanied by pain and sometimes of tenesmus, irritability, and colicky pain. The identification of a one or several fissures in the inspection of the anal canal with the child in the proper position contraindicates making a rectal examination.
2. Juvenile polyps: The appearance of small rectorrhages, covering and mixed with the feces, isolated but recurrent, without painful defecation in a child so other healthy, expressed in most patients, the presence of a juvenile polyp. Frequently it deals with unique polyps located in the recto-sigmoid. Colonoscopy with polypectomy confirm the diagnosis.
3. Intussusception: Although more frequent in the first 2 years, can also happen beyond this age. In these children the presence of polyps, intestinal duplications or Meckel diverticulum, triggers of intestinal intussusception, must be investigated. Both intestinal duplication with heterotopic gastric mucosa, as Meckel’s diverticulum are the cause of the appearance of blood, bright red or dark, and usually painless bleeding. These hemorrhages can be particularly important causing anemization of the child and even shock.
How do the common causes of vomiting differ in infants, children, and adolescents?
Vomiting consists of violent expulsion by the mouth of the contents of the stomach and from the duodenum caused by an increase in the motor activity of the gastrointestinal wall and abdomen. Vomiting is a frequent cause of consultation in pediatrics, most of the time in relation to benign pictures, although in others they can be reflex of a serious illness. In practice, any illness can occur with vomiting.The causes in childhood according to age. Common causes of vomiting in infants include GERD, pyloric stenosis, and inborn errors of metabolism (Lorenzo, 2018). Common causes of vomiting in children include gastroenteritis, intussusception, migraines, or medical child abuse (Lorenzo, 2018). Common causes of vomiting in adolescents include appendicitis, IBS, pregnancy, bulimia, or functional dyspepsia (Lorenzo, 2018).
What clinical or historical findings will indicate the need for diagnostic studies and why? Which diagnostic studies will you initially order and why?
Diagnostic studies may be ordered after determining if the nausea and vomiting are acute, chronic, or episodic. The physical examination will provide information such as pain with palpation in specific quadrants which would lead one to suspect causes such as appendicitis, cholecystitis, intussusception, pyloric stenosis, Chron’s disease, pancreatitis, or pyelonephritis (Lorenzo, 2018). Tests such as a CT for appendicitis or ultrasound for intussusception may be ordered depending on physical findings. When vomiting is severe and prolonged it would be important to rule out an infectious cause and determine the fluid status of patients. Labs tests that may be ordered include CBC, CMP, amylase, lipase, and urinalysis. In the case of an infant with projectile vomiting an ultrasound may be ordered to rule out pyloric stenosis. In a child who is ill appearing and presents with symptoms of nausea and vomiting I would order a CBC, BMP, and urinalysis for lab work and if any physical exam findings are present I would order imaging as appropriate. I would want to make sure the patient was not dehydrated to prevent further complications. These initial tests would help rule out the most life threatening causes first.
References
Benninga, M. A., Nurko, S., Faure, C., Hyman, P. E., Roberts, I. S. J., & Schechter, N. L. (2016). Childhood functional gastrointestinal disorders:neonate/toddler. Gastroenterology, 150(6), 1443-1455.
Fleisher, G. R., & Duryea, T. K. (2017). Approach to diarrhea in children in resource-rich countries. UpToDate. Waltham, MA, 2-150.
Lorenzo, C. (2018). Approach to the infant or child with nausea and vomiting. Retrieved from https://www.uptodate.com/contents/approach-to-the-infant-or-child-with-nausea-and-vomiting?search=pediatric%20vomiting&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
Palle, S. K., Prasad, M., &Kugathasan, S. (2016). Approach to a Child with Colitis. The Indian Journal of Pediatrics, 83(12-13), 1444-1451.