6. Acute Gastroenteritis

1. Case presentation
Presented by: Nor Aini binti Mohamad
Mohd Izaan Hassan bin Haron
Adam Safin bin Abdul Mutti

2. Demografic detail
Patient’s initial : MSR
R/N : SB00305473
Age : 4 y 10 m
Gender : Boy
Height : 106 cm
Weight : 16 kg
Ethnic group : Malay (Indonesian)
DOA : 18
th
December 2010
DOD : 21
st
December 2010
Informant : Mother
Address : Bandar Sri Damansara

3. Presenting Complaint
MSR, a 4 years and 10 months old Indonesian boy was
admitted to Sg Buloh Hospital on 18
th
December 2010
at 11.00 pm due to severe diarrhea 2 days prior to
admission associated with fever and vomiting on the
day of admisssion.

4. History of presenting complaint
MSR was well until 2 days prior to admission when he
started to develop diarrhea. It started at 2.00 am and it
was sudden in onset and occurred about 8-10 times per
day. The diarrhea was watery in nature, yellowish to
brown in colour with no blood stained. His mother
had to wear him diapers to reduce his frequency to go
to the toilets. Since then, he had loss of appetite and
only ate little amount of foods and drinks. There was
no recent history of taking outside food or travelling.

5. On Saturday morning which was 2 days after diarrhea
occurred, his mother brought him to the clinic and
the doctor prescribed him Oral Rehydration
Salt(ORS). However, the problem was not resolved.
His fever and vomiting was started a few hours after he
was brought to the clinic. His mother measured the
temperature at home and it was 39.2 (high grade fever)
with no rigor. His mother said that there was no rash
or joint pain and no episode of fit since he had the
fever. No cough or runny nose.

6. The vomiting was started on the same time with fever.
It occurred once and non-projectile. His mother
described the amount of vomitous was about half of
cup, contained fluid but no blood or bilious with slight
offensive smell. There was no history of changing
formula milk.
His mother said that MSR was appeared lethargic and
less active than usual during that period. She brought
him back to the same clinic at the evening on the same
day. The doctor gave PCM per rectally and antiemetic
drugs to reduce his fever and vomiting. He was then
referred to HSB and his parents brought him to ED at
8.30pm and was admitted to ward 8C at 11.oopm.

7. Systemic Review
System Complaints
CVS No pedal edema, no cyanosis
Resp No SOB, no cough, no hemoptysis
Genitourinary Normal urine output, no hematuria
CNS No LOC, no drowsiness, no blurring
vision, no altered speech, no headache
ENT No runny nose, no ear discharge, no
feeding difficulty, no dysphagia
MSK No abnormal movement, no joint
swelling, no joint pain
Endocrine No tremor, no heat intolerance
Hematological No gum bleeding or epistaxis
Impression : No abnormal finding except for GIT part

8. Past medical/surgical history
He was once admitted to Hospital Selayang at the age
of 2 years old due to shortness of breath. He was
suspected to have asthma but after the first attack, he
did not have SOB anymore.

9. Drug history & Allergy
He was on vitamin C given by his parents once in a day.
No known allergy to any drug, food or medication.

10. Birth history
Antenatal – his mother developed GDM and was
managed with insulin therapy during her pregnancy.
Natal – he was born full term at HBKL, via ELLSCS due
to DM, birth weight was about 2.6 kg and cried right
after birth.
Postnatal – his mother was informed that MSR
developed respiratory problems and was admitted for
6 days in NICU. He developed mild jaundice after 4
days of life for 1 week.

11. Feeding history
He was exclusively breastfeed until 3 months and
started to mix with infant formula. Start weaning at
the age of 6 months and wasv breastfeed up to 2 years
of age. Now, he was on family diet.

12. Immunization history
He received last immunization at 1 year and 6 months
old. No postponed vaccination or complication after
vaccination. The latest immunization was DTaP, IPV
and Hib.
Impression : Immunization is up to his age

13. Developmental history
Gross motor : he can skips on both feets, running,
kicking and climbing
Vision & fine motor : he was able to draw straight line,
circle and cross line without seeing how it is done. He
can draw recognisable features such as cartoon and
and ice-cream.
Speech & language : He knows his age, names 4
colours, he can talks constantly in 4-5 words and
understand command.
Personal & social : able to dress and undress alone,
plays with other friends.
Impression : Development milestones is corresponding to his chronological age

14. Family history
He is the youngest out of three siblings. The first and
second siblings aged 18 and 8 years old respectively.
Both are females and well. His parents were well and
there was no history of chronic illness such as asthma,
HTN, DM or any malignancy run in his family.

15. History of contact
His mother claimed that the children in same
kindergarten with MSR did not have any symptoms
like him.
No history of contact in this patient.

16. Social and environmental history
He was the youngest child out of three siblings.
Currently entered kindergarten and performed well in
class. His father, 48 y/o works as contractor worker and
his mother, 38 y/o works as a cleaner. Total gross
monthly income is about RM1000.
They live in Bandar Sri Damansara in a flat house,
level 5, with good basic amenities. His older sister age
18 y/o lived in Jawa Timur, Indonesia and currently
continue studying in IT course. His second sister age 8
years old was taken cared by their neighbour since
MSR is on admission.

17. Effect of illness to the pt & family
Economical effect is the most common problem in this
case. As they are not Malaysian, they need to pay more
than our people pay for hospital’s bill. Their total
income also will be affected since his mother need to
take leave from the workplace to take care of him.

18. Mohd Izaan Hassan bin Haron
2008402242

19. General condition

MSR was lying comfortably in supine position,
supported by 1 pillow.
-He was conscious, alert and responsive to people.
-Not in pain
-Nutritional and hydration status was good

20. Anthropometry
Weight : 16kg
Height : 106cm
Impression: His weight is in 25
th
centile
and his height is in 50
th
centile.

21. Vital signs
Temperature : 36°C
Blood pressure : 117/45 mmHg
Pulse : 98 beat per minute,
normal volume, normal rhythm
Respiratory rate : 31 breathe per minute
Oxygen saturation : 100%
Impression : He is currently stable.

22. Examination for Hydration status
tongue and mucous membranes in the oral
cavity were moist
Normal skin turgor.
 Capillary refill time was less than 2 seconds
 Impression: His hydration status was good.

23. Examination of Face, Head & Neck, Limbs
Appearance : no abnormality detected
Hands : no abnormality detected
Pallor : no pallor
Cyanosis : no cyanosis
Oral cavity : Good oral hygiene, moist mucous membrane, pink
tongue
Eyes : no pallor, jaundice, discharge, sunken eyes
ENT : no ear and nose discharge
Shape of head : Normal head shape
Neck : no thyroid enlargement, abnormal pulsation
Hair : no abnormality detected
Extremities : no cyanosis at nail bed, finger clubbing, palmar
erythema, capillary refill time is less than two
seconds,
Oedema : no oedema
Impression : no abnormality detected

24. Examination of back
No spinal deformities such as scoliosis, lordosis and
kyphosis
no tenderness
No sacral oedema
Impression: No abnormality detected
Examination of lymph nodes
 no palpable lymph nodes in cervical, occipital, axillary
and inguinal areas
Impression: No abnormality detected

25. Cardio-vascular system
On inspection,
his chest moves symmetrically with respiration. There was
no chest wall deformity, no scar, no dilated veins, no
precordial bulge, no sign of respiratory distress and no
visible pulsation noted.
On palpation,
apex beat was felt at 4
th
intercostals space, mid-clavicular
line. There was no left parasternal heaves and no thrills at
left sternal edge, pulmonary area and aortic area.

On auscultation,
normal 1
st
and 2
nd
heart sound was heard. There was no
additional heart sound or murmur.

Impression: No abnormal findings

26. Respiratory system
On inspection,
the chest moves symmetrically with respiration on both sides. There was
no suprasternal, intercostals and subcostal recession. There was no chest
deformity and no scar seen. The chest was not hyperinflated.
On palpation,
the trachea is centrally located and chest expansion was symmetrical on
both sides. The apex beat was located at 4
th
intercostals space, mid-
clavicular line. Normal vocal fremitus was noted
On percussion,
both sides of his mid clavicular, mid axillary, and scapular line segments of
lungs were resonance. There was normal liver and cardiac dullness.
On auscultation,
the air entry was adequate on both sides of the lung. Normal
vesicular breath sound was heard. There were no added sounds
heard.
Impression: No abnormal findings

27. Abdominal examination
On inspection, his abdomen was symmetrically distended
and moves with respiration. The umbilicus was centrally
located and inverted. There was no abnormal scar, no dilated
vein, no visible pulsation and peristalsis noted.
On light palpitation, his abdomen was soft and non tender.
On deep palpation, there was no tenderness, no mass felt
and no hepatospleenomegaly. Both his kidneys were not
ballotable

On percussion, there was no dullness

On auscultation, normal bowel sound present with no renal
bruit.

Impression: no abnormality detected

28. Musculoskeletal system
No muscle wasting or hypertrophy on
upper and lower limbs
no bony deformity
No signs of inflammation
normal movement of joint
Impression: No abnormal findings.

29. Nervous system
Higher function:
-Mental status: good
-Speech: good
Cranial nerves: cranial nerves were intact.
Motor function: Muscle bulk and muscle tone was normal. Muscle
power for all extremities grading 5/5. Biceps, triceps, supinator,
knee, and ankle reflexes were present. Plantar response was
normal with negative Babinski’s sign. The abdominal reflex was
also normal.
Sensory functions:
A) Sensory: Normal sensation to touch, pain, temperature,
vibration and joint position sense.
B) Signs of meningeal irritation: No neck stiffness with negative
Brudzinski’s sign and Kernig’s sign.

30. SUMMARY
MSR, a 4 years and 10 months old Indonesian boy was admitted
to Sg Buloh Hospital on 18
th
December 2010 at 11.00 pm due to
severe diarrhea 2 days prior to admission associated with fever
and vomiting on the day of admisssion. On physical examination,
there was no abnormality detected.

31. Provisional diagnosis
Acute gastroenteritis
Point to support – diarrhea
vomiting
fever

32. DIFFERENTIAL DIAGNOSIS
Points to supportPoints to against
Small bowel
obstruction
(intussusception)
-Vomiting
-Diarrhea
-The vomitous was
not bile-stained
-The abdominal
pain was not severe
- No blood stained
stool
Acute appendicitis-vomiting
-abdominal pain
Usually not
associated with
diarrhea

33. Differential dx
Systemic infection
Septicemia,meningitis
Local infections
resp tract infection
otitis media,hep A, UTI
Surgical disorder
pyloric stenosis,intussusception, acute
appendicitis,necrotising enterocolitis, Hirchsprung dz
Metabolic d/order
DKA

34. INVESTIGATION
General Investigations
full blood count
Impression: no abnormality detected
Result Normal range Remarks
WBC 12.84 4.5-13.5 x 10*9/LNormal
Hb 12.2 11.5-14.5 g/dL Normal
Plt 432 150-4– x 10*3 uL normal
Haematocrit 37.1 37-45% Normal

35. Renal profile
Impression: No abnormality detected
Result Normal range Remarks
Urea 3.5 1.7-6.4 mmol/L Normal
Sodium 138 135-150 mmol/L Normal
Potassium 3.80 3.5-5 mmol/L Normal
Chloride 102.0 98.0-107.0 mmol/L Normal
Creatinine 52.6 44-88 mmol/L Normal

36. FINAL DIAGNOSIS
Acute Gastroenteritis

37. Adam Safin bin Abdul Mutti
2008402544

38. Definition
Acute Gastroenteritis :
“diarrheal disease of rapid onset, with or without
accompanying symptoms, signs, such as nausea,
vomiting, fever, or abdominal pain.”
(American Academy of Paediatrics)

39. Continue…
Diarrhea :
“ abnormal frequency and liquidity of fecal
discharges”
(Nelson Pediatrics, 5
th
edition)
“an increase in the frequency, fluidity and volume of
stool compared to normal”
(AMMCOP CPG)

40. Possible routes of transmission
Person to person.
Contaminated water and food.
Animal to human.
Multiple routes.

41. What organism cause AGE???
Acute Gastroenteritis
Viruses.
•Rotavirus (most
common).
•Calicivirus.
•Astrovirus.
Bacteria
•Campylobacter
jejuni.
•Salmonella.
•Shigella.
•E.coli.
•Clostridium
difficile.
Parasites.
•Entamoeba
histolytica.
•Giardia lamblia.

42. Clinical Manifestation
Diarrhea.
Fever.
Reduce oral intake.
Abdominal pain.
Sign and symptoms of dehydration.

43. Indication of admission.
Need for intravenous therapy.
Uncertainty of diagnosis.
Patient factors (e.g : worsening of symptoms,
young age).
Caregivers not able to provide adequate care at
home.
Social or logistic concerns.
(Paediatric Protocol for Malaysian Hospital, 2
nd

edition)

44. What investigation should be
done???
Full blood count.
Urea and electrolytes.
Urinalysis.
Stool culture.
Blood culture (typhoid fever).

45. Sign and symptom of
dehydration.
Reduced level of consciousness.
Sunken fontanelle.
Dry mucous membrane.
Sunken eye and tearless.
Reduced skin turgority.
Tachypnoea, tachycardia, hypotension.
Prolonged CRT ( > 2 seconds)

46. Sunken
fontanelle
Eyes sunken and
tearless Reduced skin turgor

47. Management.
To correct the dehydration in patient.
As the main complication of AGE is due to
dehydration and its complication.
Thus, assessment of dehydration is very important.
Mild : < 5% dehydration
Moderate : 5-10% dehydration.
Severe : > 10% dehydration.

48. Treatment
Oral rehydration therapy.
Use to treat mild to moderate dehydration.
Consist of :
i.Sodium chloride (NaCl).
ii.Potassium chloride (KCl).
iii.Trisodium citrate.
iv.Glucose.

50. Continue…
i.Mild ( < 5%).
Give ORS.
Feed normally.
ii.Moderate ( 5-10%).
Give ORS.
Small, frequent feeding.
Assess hydration status 4 hourly.
Fail ORS  nasogastric tube.

51. Continue…
i. Severe ( > 10%).
Medical emergency.
Intravenous fluid therapy.
c.Resuscitation (normal saline).
d.Correction of the deficit (0.45% saline, 4% dextrose).
e.Maintenance (0.18% saline, 4.3% dextrose).

52. Feeding after AGE???
Should be started soon.
Avoid fatty foods and foods high in sugars.

53. Issue???
Use of anti-emetics and anti-diarrheal drugs???
Antibiotics???

54. Type of dehydration
Dehydration.
Isonatraemic.
•Sodium losses =
water losses.
Hyponatraemic.
•Sodium losses >
water loses.
•Shift of water to
intracellular
compartment.
•Can lead to
convulsion.
Hypernatraemic.
•Water losses > sodium
losses.
•Shift of water to
extracellular
compartment.
•Difficult to recognise
clinically.
•Multiple,small
cerebral hemorrhages.