A 2-year-old girl is brought to the office for evaluation of persistent watery diarrhea. Five days ago, the patient began having watery diarrhea and vomiting multiple times throughout the day. The vomiting resolved within 24 hours, but the patient has since refused to eat her normal meals because of nausea, preferring to drink apple and pear juice throughout the day. She has had large, watery stools 4 or 5 times a day with no visible blood and she passes gas frequently, but she has no diarrhea overnight. The patient takes no medications and has no allergies. Immunizations are up to date. Family history is significant for celiac disease in her mother and maternal grandmother. Temperature is 36.7 C (98 F), blood pressure is 100/70 mm Hg, and pulse is 120/min. Height is 85 cm (33.5 in, 50th percentile) and weight is 10.8 kg (23.8 lb, 40th percentile), down 1 kg (2.2 lb) from her well-child visit a month ago. The lips appear dry but the oral mucosa is moist and has no oral lesions. Auscultation reveals hyperactive bowel sounds. The abdomen is mildly tender to palpation in all quadrants, but there is no rebound or guarding. Skin examination shows perianal erythema and irritation but no jaundice or other abnormalities. Capillary refill is brisk. Which of the following is the best next step in management of this patient?

Question

A 2-year-old girl is brought to the office for evaluation of persistent watery diarrhea.  Five days ago, the patient began having watery diarrhea and vomiting multiple times throughout the day.  The vomiting resolved within 24 hours, but the patient has since refused to eat her normal meals because of nausea, preferring to drink apple and pear juice throughout the day.  She has had large, watery stools 4 or 5 times a day with no visible blood and she passes gas frequently, but she has no diarrhea overnight.  The patient takes no medications and has no allergies.  Immunizations are up to date.  Family history is significant for celiac disease in her mother and maternal grandmother.  Temperature is 36.7 C (98 F), blood pressure is 100/70 mm Hg, and pulse is 120/min.  Height is 85 cm (33.5 in, 50th percentile) and weight is 10.8 kg (23.8 lb, 40th percentile), down 1 kg (2.2 lb) from her well-child visit a month ago.  The lips appear dry but the oral mucosa is moist and has no oral lesions.  Auscultation reveals hyperactive bowel sounds.  The abdomen is mildly tender to palpation in all quadrants, but there is no rebound or guarding.  Skin examination shows perianal erythema and irritation but no jaundice or other abnormalities.  Capillary refill is brisk.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c14a_d575_8f63_6ba1ba42bca6_MD0005_00 This patient with emesis, watery diarrhea, abdominal tenderness, and hyperactive bowel sounds most likely has viral gastroenteritis. Symptoms can be exacerbated by fruit juice, as seen in this patient. Excessive consumption of juice high in fructose (eg, apple juice) or sorbitol increases osmotic load and leads to fructose malabsorption in the small intestine. In addition, a mild, transient lactase deficiency with dairy intake can result from gastroenteritis due to inflammation and damage to the intestinal epithelium. Fluid repletion is the first-line treatment for viral gastroenteritis. This child has signs of mild dehydration (ie, dry lips, normal vital signs, brisk capillary refill) and is able to tolerate oral intake. Therefore, oral rehydration with a hypo-osmolar solution containing electrolytes and small amounts of glucose is the best rehydration option for her. Hydration with water alone, however, could result in dangerous hypoglycemia or hyponatremia. An age-appropriate diet can be resumed as tolerated; however, fruit juice should be avoided until symptoms resolve. (Choice A) Antibiotics may be prescribed for severe or prolonged bacterial gastroenteritis (eg, Campylobacter, Shigella) with high fevers, blood in the stool, and intense abdominal pain, findings not seen in this patient. (Choice B) Fat and protein malabsorption (eg, cystic fibrosis) typically presents with failure to thrive and chronic steatorrhea rather than acute watery diarrhea. (Choice C) Tissue transglutaminase IgA is elevated in celiac disease, which presents as chronic diarrhea, abdominal distension, and failure to thrive. This patient's normal growth percentiles and acute onset of symptoms are not characteristic. (Choice D) Although viral gastroenteritis is generally self-limited, this child's diarrhea is exacerbated by excessive fruit juice consumption during the daytime; discontinuing juice may help her symptoms. Educational objective: Viral gastroenteritis commonly causes acute watery diarrhea in children, and excessive fruit juice consumption may exacerbate symptoms. Treatment involves oral rehydration therapy and avoidance of fruit juice during illness. References: Recent advances of oral rehydration therapy (ORT). (http://www.ncbi.nlm.nih.gov/pubmed/21468201) Fruit juice in infants, children, and adolescents: current recommendations. (http://www.ncbi.nlm.nih.gov/pubmed/28562300)

A 2-Year-Old Girl Is Brought to the Office for Evaluation