Gastroenteritis,

also known as stomach flu or gastro, is defined as a diarrheal disease of rapid onset with or without accompanying manifestations such as nausea vomiting, fever and abdominal pain.

 On

the basis of duration of diarrhea, gastroenteritis can be classified into 3 categories: 1. Acute < 2weeks (mostly viral) 2. Persistent 2-4 weeks (bacterial, protozoal) 3. Chronic > 4 weeks (bacterial, protozoal, non-infectious).

Infectious Diarrhea 1. Viral: 50-70% In adults: norovirus In children: rotavirus Others: adenovirus, parvovirus, coronavirus. 2. Bacterial: 15-20% Shigella is the most common cause Other causes include: salmonella, campylobacter, E. coli, aeromonas, V. cholera, C. difficile. 3. Parasitic: 10-15% Giardia, amebiasis, cryptosporidium. 4. Food borne S. aureus, E. Coli, V. cholera, C. Perfringens

 Non-

Infectious Diarrhea 1. Drug Induced: Antibiotics: due to alteration of normal flora Others: laxatives, quninidine, cholinergics, sorbitol. 2. GI bleed 3. Ischemic gut 4. Diverticulitis 5. Endocrine disorders

Inflammatory diarrhea Bacterial Aeromonas Campylobacter jejuni Clostridium dificile E. coli: enteroinvasive, O157:H7 Salmonella Shigella Yersinia enterocolitica

Viral
CMV

Parasitic
Entamoeba histolytica

 Non-inflammatory
Bacterial

E. coli: enteropathogenic, enterotoxigenic Vibrio cholerae

Rotavirus Enteric adenovirus Astroviruus Calcivirus Norwalk HSV

 Parasites

Giardia lamblida Balantidium coli Cryptosporidium parvum

Cyclospora cayetanensis
Isospora belli

 Watery,

noninflammatory(secreto ry, osmotic) No fever No blood or pus Pain is mild Voluminous stool Generally Supportive care only

Inflammatory

Fever, significant pain Small frequent stools Fecal leukocytes,

blood May benefit from antibiotics

 Duration

of illness: Duration and rapidity of symptom onset are important in determining the incubation period and possible infecting organism and in directing further care. Fever: The presence of high fever (with or without chills) generally suggests that an invasive organism is the cause of diarrhea.

Vomiting:

Vomiting, a symptom common to a host of illnesses, implies proximal bowel involvement, especially with preformed neurotoxin, as elaborated by S aureus and B cereus. Pain: The location and character of pain may be indicative of the area of infection because colonic involvement is usually associated with tenesmus and pain in either of the lower quadrants or the lower back, whereas jejunoileal infection may result in periumbilical pain. Cramps may be caused by an electrolyte imbalance. Pain, especially in patients older than 50 years, should raise the suspicion of an ischemic process.

Stools: Ask about frequency, amount, color, consistency (ie, watery, semisolid, odor), and presence of blood and/or mucus. Large volumes of stool are usually associated with enteric infection, whereas colonic infection results in many small stools. The presence of blood may indicate colonic ulceration (bacterial infection, inflammatory disease, ischemia). White bulky feces that float (high fat content) are due to a small bowel pathology that leads to malabsorption. Copious (rice water) diarrhea is a hallmark of cholera.

 The

most important element of the physical examination is the assessment of the patient's hydration status. Diminished skin turgor, resting hypotension and tachycardia, dry mucus membranes, decreased frequency of urination, changes in mental status, and orthostasis can be used to gauge dehydration. Mild (3-5%)

Normal or increased pulse Decreased urine output Thirsty Normal physical exam

 Moderate

(7-10%)

Tachycardia Little/no urine output Irritable/lethargic

Sunken eyes/fontanelle
Decreased tears Dry mucous membranes

Skin- tenting, delayed cap refill, cool, pale

 Severe

(10-15%)

Rapid, weak pulse Decreased blood pressure No urine output

Very sunken eyes/fontanelle

Skin- tenting, delayed cap refill, cold, mottled

rectal examination should be performed, involving checking for blood and mucus. Abdominal examination should be done to exclude causes of diarrhea that may require surgical intervention

Gastroenteritis is typically diagnosed clinically, based on a person's signs and symptoms. Determining the exact cause is usually not needed as it does not alter management of the condition. However, patients who require further workup include: those who appear seriously ill or dehydrated; those who have high fevers, bloody stools, severe abdominal pain, or persistent diarrhea; and those who are immunocompromised or whose condition is suspected of having an epidemic diarrheal etiology

 Stool examination Mucus Blood Leukocytes Stool culture:

poisoning, traveled to the developing world. Serum glucose: S. Electrolytes and Kidney function: should be checked when there is severe dehydration.

food

LIFESTYLE:
Avoid

contaminated water. Good sanitation practices such as hand washing Alcohol-based gels may also be effective. Avoiding contaminated food.

Vaccination
Recommended

in children. rotavirus inection.

 Prehospital

care is directed toward early and aggressive fluid therapy. Goals of ED therapy Rehydrate orally or intravenously as needed. Treat symptoms (eg, fever, pain) as indicated. Identify complications. Prevent the spread of infections. Identify public health concerns and treat certain cases with specific or empiric antibiotic therapy.

 Mild

to moderate dehydration can be treated with oral rehydration solutions. Severe: needs aggressive fluid therapy until mental status and signs of perfusion and pulse are normal.

 Drink

small amount of clear fluids such as water, lemonade and tea until diarrhea settles. Eat low-fat foods such as apples, boiled rice, soups, poultry, boiled poatoes, mashed vegetables, honey, dried skimmed milk or condensed milk. Avoid

 Antiemetics:

may be useful in the treatment of nausea and vomiting Antidiarrheals: discouraged in people with bloody diarrhea or diarrhea that is complicated by fever. Loperamide, an opioid analogue, is commonly used for the symptomatic treatment of diarrhea.

 Empiric

therapy for infectious diarrhea is sometimes indicated. Food-borne toxigenic diarrhea usually requires only supportive treatment, not antibiotics. Generally, fluoroquinolones are the drugs of choice for acute infectious gastroenteritis when used empirically. They do not appear to increase carrier states; however, they are contraindicated in pregnant women and in children.

SOME

SPECIFIC INFECTIONS

 Traveler's diarrhea Ingestion of contaminated food (raw meat). Generally lasts 5-10 days. Severe abdominal pain, low grade fever,

vomiting. Avoid antibiotics unless severe. Trimethoprim-Sulfamethoxazole (TMP/SMZ) or ciprofloxacin administered for 3 days. Single doses have also been used effectively. The duration of treatment may be extended by 2-3 days for moderate-to-severe cases.

 Campylobacter

occurs by the consumption of raw or undercooked poultry meat. Campylobacter is also associated with unpasteurized milk or contaminated water. Bloody motions possible. Abdominal pain. May mimic appendicitis. Duration is 5-14 days. Erythromycin or azithromycin is 1st line. Resistance growing to quinolones. Erythromycin may cause vomiting.

 Recent

treatment with anticiotics (clindamycin fluoroquinolones, cephalosporins, penicillins). Affects hospitalized adult patients. Mild-to-moderate watery diarrhea that is rarely bloody. Cramping abdominal pain. Anorexia. Malaise. Fever, especially in more severe cas Metronidazole or vancomycin (oral or parenteral) is effective. Watch for toxic megacolon.

 Mild

cases of suspected Yersinia infection should be treated with TMP/SMZ or a fluoroquinolone, while patients who are more ill and require admission benefit from IV ceftriaxone.

Accounts for 10-15% of all food poisoning. >2 million/year. Cafeteria, family outbreaks. Eggs(unbroken), poultry, meat, other raw food, improperly washed veggies. Pets, lizards etc Inc: 8-24 hrs Recovery in 2-5 days. Prodromal headache, fever, myalgia, abdominal pain. Antidiarrheals not advised Antibiotics may prolong the carrier phase. Treat bacteremia or at risk patients e.g. sickle cell patients with oral quinolones or TMP-SMX.

Extremely contagious; transmitted between people by Fecal/oral route, including pools. Inc: 24-48 hrs Very few organisms needed for clinical infection. Exotoxin causes secretory diarrhea followed by more severe symptoms signaling invasion. (only 20-30%) 4-7 days duration Neurologic symptoms common in children. Reactive arthritis. Relapsing in 10% if not treated. Treat more severe cases and prolonged cases. Fluoroquinolones, TMP-SMX

 Tinidazole

is effective against parasitic infestations with Giardia or Entamoeba and is superior to metronidazole.

THE

END