A 3-year-old boy is brought to the office due to bloody stools. Two days ago, the stools were small, soft, and blood-streaked; today, the stools increased in frequency and volume, and he began having crampy abdominal pain. The child has had decreased intake of solid foods but is drinking sips of water and juice without vomiting. He has been urinating, but not as frequently as his baseline. The parents report that he has been more tired and "clingy" but is otherwise acting appropriately. The family recently attended a relative's birthday party, after which several other guests had similar symptoms. The patient had an ear infection 2 months ago that was treated with a course of antibiotics. He is currently not taking any medications. Temperature is 38.1 C (100.5 F), blood pressure is 100/60 mm Hg, and pulse is 114/min. On examination, the boy is tired-appearing but follows commands appropriately. His lips are dry but the buccal mucosa is moist, and there is no erythema of the pharynx. Heart sounds are regular and no murmurs are present. Capillary refill time is 2 seconds. Abdominal examination demonstrates hyperactive bowel sounds and generalized tenderness to palpation. Stool culture for bacteria is obtained. Which of the following is the most appropriate next step in management of this patient?

Question

A 3-year-old boy is brought to the office due to bloody stools.  Two days ago, the stools were small, soft, and blood-streaked; today, the stools increased in frequency and volume, and he began having crampy abdominal pain.  The child has had decreased intake of solid foods but is drinking sips of water and juice without vomiting.  He has been urinating, but not as frequently as his baseline.  The parents report that he has been more tired and "clingy" but is otherwise acting appropriately.  The family recently attended a relative's birthday party, after which several other guests had similar symptoms.  The patient had an ear infection 2 months ago that was treated with a course of antibiotics.  He is currently not taking any medications.  Temperature is 38.1 C (100.5 F), blood pressure is 100/60 mm Hg, and pulse is 114/min.  On examination, the boy is tired-appearing but follows commands appropriately.  His lips are dry but the buccal mucosa is moist, and there is no erythema of the pharynx.  Heart sounds are regular and no murmurs are present.  Capillary refill time is 2 seconds.  Abdominal examination demonstrates hyperactive bowel sounds and generalized tenderness to palpation.  Stool culture for bacteria is obtained.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf1b_e6d5_8f63_ebc819a166c4_MD0005_00 This child's clinical presentation (fever, crampy abdominal pain, bloody diarrhea [dysentery]) is consistent with bacterial enteritis. The most common causes of dysentery in the United States include Salmonella, Shigella, Escherichia coli (enterohemorrhagic or enteroinvasive), Campylobacter, and Yersinia. These bacteria produce symptoms either by direct invasion of enterocytes or by production of toxins (eg, Shiga toxin). First-line therapy is correction of hypovolemia due to dehydration. This patient shows signs of only mild dehydration (ie, dry lips, moist oral mucosa, slight decrease in urine output, normal vital signs). Therefore, he can be managed at home with oral rehydration therapy as tolerated. Rehydration solutions should have low osmolality to avoid exacerbating diarrhea, and should contain glucose and electrolytes to replace ongoing losses. Plain water may exacerbate electrolyte disturbances and lead to dangerous hyponatremia or hypoglycemia. Juice is also not recommended as its high sorbitol content can exacerbate diarrhea. Antibiotic therapy (Choice D) should be avoided until a pathogen is identified. Antimicrobials may prolong symptoms or carriage of certain organisms (eg, Salmonella). In addition, antibiotic therapy may predispose children with E coli O157:H7 infection to develop hemolytic uremic syndrome. Empiric treatment is reserved for patients with invasive disease (eg, sepsis) or those at higher risk for invasive disease, such as infants age <3 months or immunocompromised hosts. (Choice A) Severe, crampy abdominal pain and bloody stools can occur in intussusception, which can be identified by abdominal ultrasound. However, the presence of an acute fever makes an infectious etiology more likely, and this patient is older than the typical age for intussusception (age <2).(Choice B) Parasitic enteritis typically presents with chronic or watery diarrhea rather than acute fever and bloody diarrhea. It is also unusual without travel to endemic areas or exposure to untreated water. Therefore, ova and parasite assay is unnecessary. (Choice C) The most common cause of diarrhea is viral enteritis, which generally presents with watery rather than bloody stools. Viral stool studies (eg, PCR, culture) are usually not indicated, as they do not alter management. Educational objective: Bacterial enteritis is characterized by fever, abdominal pain, and bloody diarrhea. An oral electrolyte solution is the first-line treatment for mild dehydration. Antibiotics are indicated only for patients with invasive disease. References: The patient presenting with acute dysentery--a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/22266388) Acute infectious diarrhea in children. (http://www.ncbi.nlm.nih.gov/pubmed/19738921) Clinical practice. Bacterial diarrhea. (http://www.ncbi.nlm.nih.gov/pubmed/19828533)

A 3-Year-Old Boy Is Brought to the Office Due to Bloody