Acute diarrhea and Gastroenteritis in Children.pptx

Acute diarrhea and
Gastroenteritis in
Children
By:-
Jwan Ali Ahemd AlSofi

Contents:-
• General approach to diarrhoea
• Approach to Acute gastroenteritis
• Approach to dehydration due to Acute diarrhea

Diarrhea is defined as:-
• Diarrhea is a term used to describe an
increase in fluidity, volume, and
frequency of stools relative to the usual
habit of each individual.
• Is the passage of 3 or more of loose or
watery stools in a 24-hour period
• >10mL of stool/kg of body
weight/day.

Normal stool patterns
0-4 months Breast-fed 2-4 per day (range 1-7),
yellow to green,
Porridgy consistency,
pH of 5.
Infrequency of stool is also
normal (up to once per week).
Bottle-fed 2-3 per day,
pale yellow to light green,
firm,
pH of 7.
4 months-1
year
1-3 per day,
darker yellow,
firmer.
After 1 year Formed, like adult stool in
odor and color.

Types of Diarrhea
• Acute watery diarrhea: it’s the commonest type that
occurs withing 24hr, the main danger is
- Dehydration and weight loss.
- Electrolyte imbalance
• Dysentery: is the diarrheal stool that contain blood,
mucus and associated with abdominal cramps,
tenesmus, and/or fever.
• Persistent diarrhea: Begins as acute (infective) watery
diarrhea and lasts for at least 14 days. Malnutrition
and dehydration may occur.
• Chronic diarrhea: long lasting diarrhea of at least 14
days of insidious onset.

Classification of Diarrhoea:-
Aetiology
• viruses,
• bacteria or their
toxins,
• chemicals,
• parasites,
• malabsorbed
substances
• inflammation.
Physiological
mechanisms
• secretory
• osmotic.
Diarrhea may be classified by:-

Secretory diarrhoea:-
•Occurs when the intestinal mucosa directly secretes
fluid and electrolytes into the stool
•Causes:-
1. Is the result of inflammation (e.g., IBD, chemical stimulus).
2. Secretion is stimulated by mediators of inflammation
and by various hormones, such as vasoactive intestinal
peptide secreted by a neuroendocrine tumor.
3. Cholera is a secretory diarrhea stimulated by the
enterotoxin of Vibrio cholerae, which causes increased
levels of (cAMP) within enterocytes and leads to secretion
into the small-bowel lumen.

Osmotic diarrhea:-
•Occurs after malabsorption of an ingested substance,
which “pulls” water into the bowel lumen.
•Fermentation of malabsorbed substances (e.g., lactose)
often occurs, resulting in gas, cramps, and acidic stools.
•Causes:-
▫ lactose intolerance.
▫ Generalized maldigestion, such as that seen with
pancreatic insufficiency or with intestinal injury.
▫ Certain nonabsorbable laxatives, such as polyethylene
glycol and milk of magnesia, also cause osmotic diarrhea.

Differences between osmotic and secretory
diarrhea
Stool Osmotic diarrhea
Secretory
diarrhea
Electrolytes Na < 70 mEq/L Na > 70 mEq/L
Stool osmotic gap > (Na+K)*2
>50
= (Na+K)*2
<50
pH <5 (sugars get fermented by
flora, leading to acid
production)
>6
Reducing substances Positive Negative
Volume <200mL/day >200mL/day
Response to fasting –
NPO
Diarrhea Improves Diarrhea continues

Pathophysiology of Diarrhea:-
Secretory
diarrhea:
• Means that there is an increase in the active secretion, or
there is an inhibition of absorption.
• There is little to no structural damage.
• Exhibits little change when fasting.
• E.g., cholera.
Osmotic
diarrhea:
• caused by ingestion of poorly absorbed osmotically-active
substance into the lumen.
• This type is relieved by fasting.
• E.g., lactose intolerance.
Exudative
diarrhea:
• occurs in diseases that damage the intestinal mucosa,
leading to inflammation, and leaking of fluids, blood, and pus
in stool.
• E.g., salmonella, shigella, and IBD.
Increased
motility:
• leads to decreased contact time for absorption.
• E.g., IBS, and hyperthyroidism.
Decreased
surface area:
• decreased functional area
• as in short bowel syndrome (SBS).

Causes of acute diarrhea at different age groups:-
•Common causes:-
1. Acute Gastroenteritis:
viral especially rotavirus > bacterial and protozoal
2. Food poisoning
3. Systemic infection:
Parenteral diarrhea is defined as diarrhea due to infections
outside the gastrointestinal tract. E.g., otitis media and UTI (most
commonly).
4. Antibiotic-associated diarrhea (AAD): is defined as
diarrhea occurring during or after antibiotic administration
for which no other cause can be identified.
5. Overfeeding

•Rare causes:
▫ Primary disaccharidase deficiency
▫ Hirschsprung toxic colitis
▫ Adrenogenital syndrome
▫ Neonatal opiate withdrawal
▫ Toxic ingestion
▫ Hemolytic uremic syndrome
▫ Intussusception
▫ Hyperthyroidism
▫ Appendicitis

Differential Diagnosis of Diarrhea:-
21

1. History:-
• What is the illness like?
▫ the onset of diarrhea,
▫ Frequency and character of stools,
▫ estimates of stool volume,
▫ blood in the stool,
▫ Presence of vomiting, blood, mucus, or fever. (Bacterial
infection)
▫ Constitutional symptoms:- Fever, weight loss, malaise
▫ dietary factors should be investigated,
▫ a list of medications recently used should be obtained.
▫ Factors that seem to worsen or improve the diarrhea should be
determined.
▫ Vomiting and diarrhea developing within hours of food ingestion suggests
exposure to preformed toxins in the food, rather than the acquisition of an
enteric pathogen from the food; which is characterized by a predominantly
diarrheal illness developing within days of exposure.

• Is the child likely to be dehydrated?
▫ Clues for dehydration (urine output and/or color – tears – drinking )
▫ If he or she urinating infrequently (<3 time/day)
▫ History of weight loss
•Presence of other symptoms?
▫ Earache, dysuria  to look for infection outside the GIT –
parenteral diarrhea
▫ Hematuria or oliguria  HUS
▫ Convulsion and/or pain  Shigella
•Exposure to health-care settings.
▫ Suggests nosocomial diarrhea.
•Anyone else affected in the family?
▫ indicates food contamination.
•Travel history?
•Vaccination history?
•Nutritional status?
Diarrhea+seizure=Shigella

2. Physical Examination:-
1. Assessment of hydration.
2. Weight (always weigh the child!): weight loss provides
important evidence of dehydration, and in any event the
weight is a valuable basic line if the child deteriorates.
3. Signs of any extra-GIT infection.
4. Abdominal examination:-
1. evaluating for abdominal distention
2. tenderness,
3. quality of bowel sounds,
4. Rectal examination:-
 presence of blood in the stool
 a large fecal mass – Constipation with overflow incontinence can be
mislabeled as diarrhea
 anal sphincter tone.

3. General Investigations:-
GSE and stool
culture.
• Mucus, blood, and
leukocytes, which
indicate colitis in
response to
bacteria that
diffusely invade
the colonic
mucosa.
• Patients infected
with Shiga toxin–
producing E. coli
and E. histolytica
generally have
minimal fecal
leukocytes.
Blood tests.
• CBC –
Hemoconcentratio
n from
dehydration
increases the
hematocrit and
hemoglobin.
• Urea &
creatinine
• Volume
depletion
without renal
insufficiency 
disproportionate
increase in the
BUN, with little
or no change in
the creatinine
concentration.
• Renal injury 
A significant
elevation of the
creatinine
Electrolytes:-
• Hyponatremia
is common;
hypernatremia
is less common.
• Metabolic
acidosis results
from losses of
bicarbonate in
stool,
• lactic acidosis
results from
shock,
• Phosphate
retention results
from transient
prerenal-renal
insufficiency.
Urinalysis:-
• The urine
specific gravity
is usually
elevated
(≥1.025) in cases
of significant
dehydration but
decreases after
rehydration.
• Hyaline and
granular casts,
• a few white blood
cells and red blood
cells,
• 30-100 mg/ dL of
proteinuria.
• ** These findings
usually are not
associated with
significant renal
pathology, and
they remit with
therapy.

3. Specific Investigations:-
1. Rotavirus immunoassay.
2. Urine culture, and radiography to rule out extra-GIT
infection.
3. If diarrhea occurs after a course of antibiotics, a Clostridium
difficile toxin assay should be ordered
4. If stools are reported to be oily or fatty, fecal fat content or fecal
elastase to test for pancreatic insufficiency should be measured.
5. Bacterial stool cultures are recommended for patients with
1. fever,
2. profuse diarrhea,
3. Dehydration
4. if HUS or pseudomembranous colitis is suspected.
6. Stool evaluation for parasitic agents should be considered for
1. acute dysenteric illness,
2. in returning travelers,
3. in protracted cases of diarrhea in which no bacterial agent is identified.

Assessment and treatment
• Treatment is usually supportive: rehydration or prevent
dehydration.
• If the signs of dehydration are mild or absent, the child
can be managed at home.
• Breast feeding is continued.
• If the baby is on bottle, give oral rehydration solution
(ORS) and not dilute the formula.
Anti-diarrhoeal drugs/Antimotility agents (e.g.,
Loperamide, Lomotil) and antiemetics have no place for
medications for the vomiting or diarrhoea of acute
gastroenteritis.
Ondansetron may be administered to reduce emesis when this
is persistent.
• Zinc supplementation.

Antibiotics in acute diarrhea:-
• Antibiotics are not routinely required to treat gastroenteritis,
even if there is a bacterial cause. They are only indicated for:
1. Those with severe disease or bacteremia
2. Suspected or confirmed sepsis.
3. Extraintestinal spread of bacterial infection e.g. meningitis.
4. High-risk patients:- malnourished or immunocompromised.
5. For specific bacterial or protozoal infections (e.g., Clostridium
difficile associated with pseudomembranous colitis, cholera, shigellosis,
giardiasis).
6. For salmonella gastroenteritis if <6 months old.

•Salmonella:
▫ Antibiotic only indicated in:
 Young infants<3 months
 Immune deficient
 Malnutrition
 Malignancy
▫ Cefotaxime 150-200 mg/kg/day or TMP.
•Shigella:
▫ Previously it was:-
 Oral ampicillin 100mg/kg/day in 4 divided doses for 5 days.
 TMP/SMX 10mg/kg/day in 2 divided doses for 5 days.
 Parenteral ceftriaxone 50 mg/kg single dose for 5 days.
▫ Many Shigella sonnei isolates, the predominant strain affecting
children, are resistant to amoxicillin and TMP/SMX.
▫ Azithromycin is first-line oral therapy for children.

• Treatment of C. difficile (pseudomembranous colitis) includes
discontinuation of the inciting antibiotic and oral metronidazole or
vancomycin.
• E. histolytica dysentery is treated with metronidazole followed by a
luminal agent, such as iodoquinol.
• The treatment of G. lamblia is metronidazole, tinidazole, or nitazoxanide.

• Acute gastroenteritis refers to a clinical syndrome of diarrhea
(>3 stool episodes in 24 hours) with or without vomiting that
generally lasts for several days.
• Gastrointestinal infections are generally acquired via fecal-oral
transmission or through ingestion of contaminated food or water.
• Viral gastroenteritis is the most common cause of diarrhea in
children globally.
38

Mechanism of infectious Diarrhea:-
39

Pathogens causing Diarrhea and
their mechanism:-
40

Features suggestive Viral diarrhoea:-
1. watery stools
2. no blood or mucus.
3. Vomiting may be present
4. dehydration may be prominent, especially in infants and
younger children.
5. Fever, when present, is low grade.
6. Stool test result is negative for blood and leukocytes
7. There is no history to suggest contaminated food ingestion,
42

Rotavirus:-
• Commonest cause of GE in young children.
• Responsible for 20-70% of hospitalization of children with
acute diarrhea worldwide.
• Common in winter months,
• Affects young children (6 month to 2 year),
• Symptomatic illness is uncommon in older children.
• Clinical features
▫ Diarrhea usually begin after 1-2 days of low-grade
fever, vomiting, anorexia, and cough.
▫ Frequent watery stool.
▫ Usually not bloody nor purulent.
▫ The shedding of virus start on day 3 of illness and continue
for 3 weeks.
▫ Lactose intolerance is seen in approximately 50% of
cases.

Diagnosis:-
•In most cases, a satisfactory diagnosis can be
made on the basis of the clinical and
epidemiologic features.
•ELISA , which offer >90% specificity and
sensitivity, are available for detection of group A
rotavirus in stool samples.
•Latex agglutination assays are also available
for group A rotavirus and are less sensitive
than ELISA .

Treatment:-
•Is supportive (rehydration)
•If the signs of dehydration is mild or absent the
child can be managed at home.
•breast feeding is continued.
•If the baby is on bottle, give (ORS) and not dilute
the formula.

•Immunoglobulins have been administered orally
to both normal and immunodeficient patients with
severe rotavirus gastroenteritis, but this treatment
is currently considered experimental.
•Therapy with probiotic organisms such as
Lactobacillus species has been shown to be
helpful only in mild cases and not in
dehydrating disease.

Prevention:-
•Oral Rota virus vaccine is effective
• probiotic has been shown to prevent the
rotavirus infection.

Features suggestive bacterial diarrhoea:-
1. Much more severe illness – high grade fever, ill-appearing toxic
child
2. typically are seen in food- associated outbreaks or in regions
with poor public sanitation.
3. when there is dysentery (bloody diarrhea with fever)
4. whenever severe symptoms are present.
5. Presence of extra-intestinal manifestations of enteric pathogens.
6. These infections can be diagnosed by stool culture or other
assays for specific pathogens.
49

Bacterial AGE:-
• Shigella dysenteriae – producing Shiga toxin.
▫ High fever and febrile seizures may occur in addition to diarrhea.
• E. coli:-
▫ E. Coli Strains associated with enteritis are classified by the mechanism of
diarrhea: (ETEC), (EHEC) or (STEC), (EIEC), (EPEC), or (EAEC).
▫ Enterotoxigenic – ETEC is a frequent cause of traveler’s diarrhea.
▫ Enterohemorrhagic (EHEC) or Shiga toxin–producing (STEC),
especially the E. coli O157:H7 strain, produces a Shiga-like toxin that is
responsible for
 a hemorrhagic colitis
 most cases of diarrhea associated with hemolytic uremic syndrome (HUS),
which presents with microangiopathic hemolytic anemia, thrombocytopenia, and
renal failure
 can present with nonbloody diarrhea that then becomes bloody.
 Usually no fever
• Campylobacter jejuni:-
▫ associated with GBS
50

Bacterial AGE:-
• Yersinia enterocolitica:-
▫ Infants and young children characteristically have a diarrheal disease,
▫ Older children usually have acute lesions of the terminal ileum or
acute mesenteric lymphadenitis mimicking appendicitis or Crohn
disease.
▫ Postinfectious arthritis, rash, and spondylopathy may develop.
• Clostridium difficile:-
▫ causes diarrhea and/or colitis
▫ associated with prior antibiotic exposure
▫ Infection is generally hospital-acquired, but community acquisition of
infection is increasingly reported.
▫ Diagnosis is made by detection of toxin in the stool.
 Infants <12 months of age should not be tested for C. difficile as they are
frequently asymptomatically colonized with the organism in their stool, possibly
due to a lack of the receptor required for infection.
▫ Of note, patients on antibiotics often experience diarrhea related to
alterations in their intestinal flora that are unrelated to C. difficile
infection.
51

Vibrio Cholera
• Incubation period is 1 -3 days. The onset may be sudden with profuse
watery diarrhea, but some patients have a prodrome of anorexia and
abdominal discomfort and the stool may initially be brown. Vomiting
with clear watery fluid is usually present initially. Diarrhea can
progress to painless purging of profuse rice-water stools (due
to mucus) with fishy smell.
• Cholera gravis: the most severe form results when purging rates
reach to 500-1000mL/hr. Charactarized by rapid development of
signs of severe dehydration including shriveled hands and feet
(washerwoman’s hands).
• Patients with metabolic acidosis present with Kussmaul breathing.
• As fluid losses continue, patients progress to obtundation and coma,
then death.

• Investigations:
▫ Blood chemistry: hypokalemia, hypoglycemia, and metabolic acidosis.
• Treatment:
▫ Rehydration:
 Children with mild – moderate dehydration can be treated with rice-based ORS
(superior to standard).
 Severely dehydrated patients, shock, obtundation, and intestinal ileus require IV
fluid therapy, preferably with Ringer lactate. Monitor closely, especially during
the first 24 hours.
▫ Antibiotic:
 Tetracycline or doxycycline.
 Erythromycin or Azithromycin.
 Ciprofloxacin
▫ Zinc
• Complications:
▫ Renal failure due to prolonged hypotension.
▫ Hypokalemia can lead to nephropathy and focal myocardial necrosis.
▫ Hypoglycemia is common among children and can cause seizures.

• Investigations:
▫ GSE: pus cells are typically positive with EIEC.
▫ CBC: leukocytosis with left shift occur mainly with EIEC and STEC.
▫ Stool culture: STEC serotype O157:H7 can be isolated because it fails to
ferment sorbitol.
▫ Enzyme immunoassay or latex agglutination can detect Shiga toxins.
• Treatment:
▫ Supportive.
▫ Antibiotic should never be given to STEC infection because
they increase the risk of HUS.
E.Coli

58
Entamoeba
histolytica
(amebiasis)
Giardia
lamblia
Cryptosporidium
parvum
Occurs in warmer
climates
Endemic
Common among infants
in daycare centers
Infects the colon
Amebae may pass
through the bowel
wall and invade the
liver, lung, and brain.
The organism adheres to
the microvilli of the
duodenal and jejunal
epithelium.
Diarrhea is
- of acute onset,
- is bloody,
- contains
leukocytes.
Insidious onset of
- progressive anorexia,
- nausea,
- gaseousness,
- abdominal distention,
- watery diarrhea,
- secondary lactose
intolerance
- weight loss
- in immunocompetent 
mild, watery diarrhea
persons that resolves
without treatment
- In immunodeficient 
severe, prolonged
diarrhoea

Entamoeba histolytica
• Asymptomatic infection represent ≥90% of cases which should be
treated because it may become symptomatic.
• Amebic colitis usually present as gradual colicky abdominal pain
with frequent bowel motions that frequently associated with
tenesmus, the stools contain blood and mucus. Generalized
constitutional symptoms are characteristically absent.
• Amebic dysentery is associated with sudden onset of fever, chills,
and severe bloody diarrhea which may result in dehydration.
• Amebic liver abscess is a serious extraintestinal Complication of
amebiasis but fortunately it is uncommon in children (<1%); it may
appear without a clear history of intestinal disease. It commonly
presents as fever, abdominal pain & distention with tender
hepatomegaly, there may be changes at base of the right lung
demonstrated by CXR e.g., elevation of the diaphragm,
atelectasis, or effusion.

• Complications:
▫ Amebic colitis may result in necrotizing colitis, toxic megacolon,
extraintestinal extension, local perforation and peritonitis, or ameboma
which is a nodular focus of proliferative inflammation in the colonic wall
develop after chronic amebiasis.
▫ Amebic liver abscess may rupture into the peritoneum, pleural cavity, or
skin.
▫ Extraintestinal dissemination is rare other than the liver but may
include: brain, lungs, kidneys, & skin.
• Diagnosis:
▫ GSE, 3 fresh stool samples to increase sensitivity.
▫ ELISA test.
• Treatment:
▫ Metronidazole is the drug of choice for invasive amebiasis 35-50mg/kg/day
in 3 divided doses for 10 days.
▫ For eradication of cysts, we use Diloxanide furoate (furamide) 10mg/kg/day
for 10 days

Dysentery
• Dysentery is enteritis involving the colon and rectum,
with blood and mucus, possibly foul-smelling stools, and
fever.
• Several organisms, including Salmonella, Shigella, C.
Jejuni produce diarrhea that can contain blood as
well as fecal leukocytes in association with
abdominal cramps, tenesmus, and fever; these
features suggest bacterial dysentery.
• Causes:-
▫ Shigella is the prototypical cause of dysentery, which
must be differentiated from infection
▫ E. histolytica (amebic dysentery),
▫ EIEC, EHEC,
▫ C. jejuni,
▫ Y. enterocolitica,
▫ nontyphoidal Salmonella.
• GIT bleeding and blood loss may be significant.

63
Bacillary
dysentery
Amebic
dysentery
Causative agent Shigella E. histolytica
Onset Acute Gradual
General condition Poor, ill-looking child Normal
Fever High grade fever Little fever
tenesmus / cramps Sever Moderate
Dehydration Frequent Little
Eosinophil Absent Present
GSE – RBC Clumped Discreet
GSE – Pus cells Numerous Scanty
GSE – Stool Not foul smelling Foul smelling
GSE – Faeces No trophozoites trophozoites

COMPLICATIONS AND PROGNOSIS of AGE:-
• The major complication of gastroenteritis is dehydration and
hypovolemic shock.
• Shigella  Seizures may occur with high fever.
• Intestinal abscesses can form with Shigella, Yersinia, and
Salmonella infections, leading to intestinal perforation, a
life-threatening complication.
• Severe vomiting associated with gastroenteritis can cause
esophageal tears or aspiration pneumonia.
• Deaths resulting from diarrhea is due to:-
▫ dehydration,
▫ electrolyte imbalance,
▫ hemodynamic instability,
▫ shock.
64

Approach to Dehydration in
acute Diarrhea:-

•The following children are at increased
risk of dehydration (need special
attention):
1. Infants, particularly those under 6 months of
age or those born with low birthweight.
2. If they have passed ≥6 diarrhoeal stools in the
previous 24 hrs.
3. If they have vomited three or more times in the
previous 24 hrs.
4. If they have been unable to tolerate (or not
been offered) extra fluids.
5. If they have malnutrition.

• If no dehydration, then for each bowel movement:
▫ <2 years: 50-100mL
▫ >2 years: 100-200mL
▫ Per 24 hours, each ORS in 1L.
• Some dehydration:
▫ Kg*75 per 4 hours.
• Severe dehydration:
▫ <1 year:
 30mL per Kg in the first hour.
 70mL per Kg in the next 5 hours.
▫ >1 year:
 30mL per Kg in the first 30 minutes.
 70mL per Kg in the next 2.5 hours.
▫ For fluid: preferably ringer’s lactate but if there’s no urine output (concern
for hyperkalemia) use normal saline.
▫ After 6 hours if needed change to glucose saline. If child gets better, then no
need for glucose saline.

Summary
• Good history and examination to assess hydration status and
identify cause.
• Treatment according to IMCI guidelines for assessment of
dehydration.
• Medical treatment less likely required except in certain
conditions.

The commonest cause of acute gastroenteritis among
children is:
A. Shigella
B. E. Coli
C. Amebiasis
D. Drug induced
E. Rotavirus
E.
Rotavirus

A 3-year-old child weighing 12 Kg with 3-day history of
diarrhea and vomiting.
O/E:
• Sunken eyes
• Sunken ant fontanel
• Skin pinch >3 s
• Delayed capillary refill
• Disturbed consciousness
TASK: which plan you select?
• Plan A
• Plan B
• Plan C
Plan
C

Case 1
• Ahmed is 18 months of age, presents with 2-day history of non-
bloody diarrhea. He is passing more than 8 stools per day. He had
low grade fever but frequent vomiting.
TASKS:
1. What is the likely diagnosis and the most likely pathogen?
2. Questions you want to ask?
3. How do you manage it?
1.
Acute
gastroenteritis.
Rotavirus.
2.
Urine
frequency
and
color.
3.
Supportive???

Case 2
• Arya is a 2-year-old girl who presented with fever and frequent
bowel motion in the last 2 days. She attends a nursery and 5 other
children in the nursery suffered from diarrhea last week. The stool
contains mucus.
• We admit Arya, in the hospital she had an attack of convulsion, and
in the second day her stool contain blood, how do you manage this
problem?
She has shigella. treatment is supportive with antibiotics:
• Oral ampicillin
• TMP/SMX
• Parenteral ceftriaxone

• Bloody diarrhea is one of clinical feature of
A. Rotavirus infection.
B. Campylobacter infection.
C. Cystic fibrosis.
D. Giardia Lamb1ia.

An infant is admitted with diarrhea and a diagnosis
of Rotavirus is suspected. Which one of the
following is CORRECT regarding Rotavirus
infection?
A. It typically affects infants older than I 8 months.
B. The Rotazyme test t o detect virus particles is a direct
enzyme-linked immunosorbent assay.
C. Blood and mucus is found in the stools of about 50% of
affected babies.
D. It occurs most often in the summer months .

A 5-month-old child had diarrhea for 2 days and
irritability for 1 day. On examination the infant is
very irritable, prolonged capillary refill, bulging
anterior fontanelle. what is your first step in
management?
A. give bolus N/S.
B. give bolus ringer lactate.
C. deal to it as moderate dehydration over 24 hrs.
D. give Zinc & encourage feeding.
A. give bolus N/S

Benjamin is a 6-year-old boy who is seen in the paediatric
emergency department. He has been vomiting and has
had diarrhoea for 3 days. His stool is watery and foul
smelling but has no blood in it. He has not been out of the
UK since he was born. Examination reveals mild
dehydration but is otherwise normal. What is the most
likely organism that has caused his symptoms? Select one
answer only.
A. Campylobacter
B. Escherichia coli
C. Giardia lamblia
D. Rotavirus
E. Shigella

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