CASE DISCUSSION

Salient Features:

The case is of a 3 year old girl who presents with acute abdominal pain, specifically at the
hypogastric region of 1 day duration. Patient also had fever, nausea, and difficulty defecating as
associated symptoms. Prior to admission, patient had diarrhea, cough and colds, increased tears
and discharges from the eyes, and also fever, which were all controlled by medications prescribed
at a private clinic. No other family member had experienced such symptoms.

Primary Impression:

ACUTE GASTROENTERITIS (BACTERIAL)

Acute gastroenteritis remains to be a major cause of pediatric morbidity and mortality
around the world, accounting for 1.87 million deaths annually in children younger than 5 years,
or roughly 19% of all child deaths.
The disease usually presents with diarrhea, vomiting, increase or decrease in
urinary frequency, abdominal pain, signs and symptoms of infection (fever, chills,
myalgias, rash, rhinorrhea, sore throat, cough), changes in appearance and behavior
(weight loss and increased malaise, lethargy, or irritability), or changes in the amount
and frequency of feeding and in the childs level of thirst. A history of recent
antibiotic use increases the likelihood of Clostridium difficile, and a history of travel to
endemic areas may point to certain causative agents.

In the case of our patient, she has presented with abdominal pain, high grade
fever, and a history of recent antibiotic use, all of which are consistent with acute
gastroenteritis. Initially, she also had diarrhea, however, vomiting was not noted on
her. Patient didnt also have a history of recent travel.

Differential Diagnoses:

ACUTE APPENDICITIS
Patients with acute appendicitis usually presents with abdominal pain, nausea, anorexia,
vomiting and diarrhea or constipation. Complete blood count would also reveal an elevated white
blood cell count, typically the neutrophils. Features of the abdominal pain typically begin as
periumbilical or epigastric pain then migrates to the RLQ. Patients usually lie down, flex their
hips, and draw their knees up to reduce movements and to avoid worsening their pain.

Our patient had similar symptoms of abdominal pain, nausea, some degree of anorexia,
and difficulty of defecating like those seen in appendicitis. She also experienced fever as high as
40 C. However, appendicitis may be ruled out since the typical pain seen in patients with
appendicitis was not the type of pain she manifested. Her blood count also didnt reflect an
elevated neutrophil count.

URINARY TRACT INFECTION

One of the most common infections in a child is Urinary Tract Infection. It is more
common in girls than in boys after the 1 st year of life. The incidence of UTI in children aged 1-2
years is 8.1% in girls and 1.9% in boys. No one specific symptom can point directly to UTI as a
disease. Children of 2-6 years of age would display symptoms of vomiting, abdominal pain,
fever, strong-smelling urine, enuresis, and other urinary symptoms such as dysuria, urgency, and
frequency. Pain would depend on the site of the tract involved. Children with acute cystitis have
voiding symptoms with little or no temperature elevation. Voiding dysfunction may include
urgency, frequency, hesitancy, dysuria, or urinary incontinence. Suprapubic or abdominal pain
may be present, and the urine sometimes has a strong or foul odor.

Our patient who is 3 years old manifested signs and symptoms such as abdominal pain
and fever. Her abdominal pain was specifically at the hypogastric or suprapubic region, which
could strongly point to cystitis. However, a strong ruling out criteria could be the absence of
urinary symptoms such as dysuria or the presence of a foul-smelling urine.

Therapeutic Management:

Laboratory Studies
Fecal leukocytes and stool culture may be helpful in children presenting with dysentery. Children
older than 12 months of age with a recent history of antibiotic use should have stool tested for C.
difficile toxins. The patient may also be ordered with CBC and blood cultures. Dehydration is one
of the important things to watch out for in this case. As such, serum electrolytes may also be
checked.

Treatment
Fluid and Electrolyte Replacement
A crucial thing to remember once patient has acute gastroenteritis is that dehydration and
electrolyte loss are the common causes for mortality. Therefore, the therapeutic goals for the
patient are rehydration, to replace existing losses and maintenance of calories and fluids
administered. CDC, AAP and WHO, recommends oral rehydration solution (ORS) as the
treatment of choice for children with mild-moderate dehydration in acute gastroenteritis.

Pharmacotherapy
The goals of pharmacotherapy are to reduce morbidity, to prevent complications, and for
prophylaxis. Antidiarrheal and antimotility agents are contraindicated in the treatment of acute
gastroenteritis in children because of their lack of benefit and increased risk of side effects,
including ileus, drowsiness, and nausea. If a certain causative agent is found, proper use of
medications should be instituted.

Prevention:

Rotavirus is the common cause of diarrhea among infants and children. Children aged 1
months up to 3 months are required to be immunized with Rotavirus vaccine. Vaccination is
available in barangay health centers as part of the EPI of the DOH.

Another effective way of preventive measure is to make sure that water used in feeding is
clean and safe to drink. Personal hygiene and handwashing among the patients caregiver should
also be promoted to reduce diarrhea incidence.