Advancing Learners Pediatric Clinical Reasoning and Knowledge
Key Points
Diarrhea is usually defined as loose, watery stools that are more than 3 times a day, or much more than the usual frequency for the person. Usually this equates to a Bristol Stool Scale of 6 or 7.
The differential diagnosis is large, but often is infectious with one of the most common causes being viral enteritis.Usually diarrhea is short-lived with resolution in a few days.
An important point to remember that viral enteritis is the most common cause of bloody diarrhea overall. Blood in the stool is more likely to occur in any given case with bacterial diarrhea like Salmonella, Shigella, Yersinia, Campylobacter, Clostridium, and E. coli or parasitic infections like Entamoeba. However these infections do not happen as often as viral enteritis. Although bloody diarrhea is less likely to occur in any given case of viral enteritis, there are so many more viral infections than bacterial or parasitic infections, that the viral enteritis is the most common cause of bloody diarrhea.
Gastroenteritis is not the same as enteritis and gastritis. Enteritis is the diarrhea; gastritis is the emesis. If the patient has both then it becomes gastroenteritis. This is important because the differential diagnosis is different for all 3 problems. There is much overlap though.
Especially in children, patients can become dehydrated quickly with ongoing fluid losses. Evaluation of hydration status needs particular attention. Objectively weight changes are the best data sources. Physical examination findings such as slow capillary refill, poor skin turgor, and tacky mucous membranes also help with hydration evaluation. Urination is also a helpful measure by noting its frequency and sometimes its volume. It can be difficult to tell if a child has urinated because of mixed urine/stool, especially in diapered children. One can try to place cotton balls to create a “diaper dam” between the urethra and anus to try to identify urination frequency. In males, the penis can also be pointed toward the top of the diaper and that area checked for urine as it is less likely to be contaminated with stool.
It is notoriously hard to evaluate stool volume. Most people are not diapered and even if they are weighing the diapers is very hard to do. Estimations of stool frequency through how many toiletings or diaper changes can assist. If diapered, volume can be estimated if parents describe them as “a blow out” or leaking outside the diaper.
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Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa