Page 51 - 15Diarrhoeaandvomiting

Diarrhoea and vomiting caused by gastroenteritis in children under 5 years

Clinical question
In children presenting with diarrhoea and/or vomiting, what characteristics may suggest a
diagnosis other than gastroenteritis?
Acute diarrhoea is not always due to an intestinal infection. Other non-enteric infections and
non-infective gastrointestinal disorders may be responsible. Diarrhoea is a common side effect
of antibiotic therapy. Many other drugs and certain dietary constituents (for example, sorbitol
and xylitol), may occasionally be responsible and on rare occasions certain toxins (for example,
organophosphate insecticides). 55

Evidence overview

In the absence of comparative studies, the literature search for this question was undertaken to
identify case series with sample sizes more than 100. Another source of information was the
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NICE published guideline Feverish illness in children. It had recommended signs and symptoms
for identifying children with fever who are at high risk for serious illness. The list of various
alternative diagnoses based upon the published evidence and the consensus view of the GDG
are given in Table 3.3.

GDG translation from evidence to recommendation
Based on consensus, the GDG identified a number of key points that they considered were
important in the history and examination of the child. It would be important to be aware of any
history of contact with an individual with symptoms of gastroenteritis. Also, exposure of the child
to a known source of enteric infection or a history of recent travel abroad would be important.
Certain symptoms and signs might point to diagnosis other than gastroenteritis. For example,
although fever may occur in children with gastroenteritis, high fever is somewhat unusual.
Therefore the possibility of other disorders would require careful consideration in such cases.

Table 3.3 Key symptoms and signs in the differential diagnosis of children presenting with
diarrhoea and/or vomiting a

Alternative diagnosis Key symptoms Key signs b
Non- enteric infections:
• pneumonia Cough, shortness of breath, chest pain Tachypnoea, tachycardia
• urinary tract infection Frequency and dysuria
• meningitis Persistent vomiting, altered Petechial purpuric rash, neck
consciousness, irritability, photophobia stiffness, bulging fontanelle in
infants
• acute otitis media Earache
• toxic shock syndrome Non-specific muscle aches, faintness Clinical shock, red non-specific
rash, possible site of bacterial entry
such as small burn or injury
Non-infective gastrointestinal disorders:
• ulcerative colitis, Crohn’s Prolonged diarrhoea (>14 days), Failure to thrive or weight loss
disease or coeliac disease bloody diarrhoea
Surgical disorders:
• Bowel obstruction, Bilious vomiting, severe or localised Abdominal distension, rebound
intussusceptions or abdominal pain, bloody diarrhoea tenderness, mucoid/bloody stools
ischaemic bowel
Drug-related:
Review drug history (e.g.
antibiotic therapy)
a Children younger than 12–18 months commonly present with non-specific symptoms and signs of non-enteric
infections and non-infective gastrointestinal disorders.
b High fever (temperature ≥ 38 °C for children younger than 3 months and ≥ 39 °C for children 3 months or older) may
occur in gastroenteritis, but may also be a pointer to non-enteric infections.

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