Gastroenteritis

Saima Alam Afridi

Definition

 Gastroenteritis is a pathologic state of diarrhea associated with

nausea and vomiting
 A universal definition of diarrhea does not exist
 The severity of illness may vary from mild and inconvenient to severe
and life threatening
pathophysiology
 Diarrhea is caused by several mechanisms, including adherence,
mucosal invasion, enterotoxin production, and/or cytotoxin
production.
 The main pathology is increased fluid secretion and/or decreased
absorption
 This produces an increased luminal fluid content that cannot be
adequately reabsorbed, leading to dehydration and the loss of
electrolytes and nutrients.
 The small intestine is the prime absorptive surface of the
gastrointestinal tract. The colon then absorbs additional fluid,
transforming a relatively liquid fecal stream in the cecum to
well-formed solid stool in the rectosigmoid.
 Disorders of the small intestine result in increased amounts of
diarrheal fluid with a concomitantly greater loss of electrolytes
and nutrients.
Classification based on
pathophysiology

 Osmotic, due to an increase in the osmotic load presented to the intestinal

lumen, either through excessive intake or diminished absorption

 Inflammatory (or mucosal), when the mucosal lining of the intestine is

inflamed

 Secretory, when increased secretory activity occurs

 Motile, caused by intestinal motility disorders

etiology

 Viral (50-70%)
 Bacterial (15-20%)
 Parasitic (10-15%)
 Food-borne toxigenic diarrhea
 Drug-associated diarrhea
 Other causes : ischemic colitis, inflammatory bowel disease,
VIPOMA, AIDS, dumping syndrome and radiotherapy/
chemotherapy
 Viral- Nora virus
 Norovirus is the leading cause of viral gastroenteritis
 The norovirus is a small, 26-40 nm, non-enveloped, single-stranded RNA virus
classified as a Calicivirus
 Five norovirus genogroups have been identified: GI, GII, GIII, GIV, and GV
 Norovirus is often called the "winter vomiting disease" in Britain and the
incidence seems to be higher in colder weather
 it is a highly infectious virus—with as few as 10-100 particles necessary for
transmission—and is quite resistant to quaternary ammonia compounds,
alcohol, detergent-based compounds, freezing, and heat (to 60o C)
 It is a very difficult virus to culture and measure; thus, studies on norovirus are
limited
 Various modes of transmission exist including fecal-oral transmission
(predominant), person to person, fecal contamination of food and/or water,
fomite transmission, and airborne spread when in close proximity to someone
vomiting, as the virus is easily aerosolized
• The incubation period for the norovirus is between 12 and 48 hours.

• Some of the early symptoms include nausea, a sudden onset of

vomiting, moderate diarrhea, headache, fever (~50%), chills, and
myalgia and will last 12-60 hours.

• The classic sign suggestive of norovirus is uncontrolled vomiting. Usually,

more vomiting than diarrhea occurs

• The virus is noninvasive; therefore, white blood cells (WBCs) are not
seen in the stool, and hematochezia is rare.

• The natural course of this illness usually provides resolution within 36

hours. Unless the patient is very young, very old, debilitated with severe
underlying disease, or immunocompromised

• The only therapy is oral and/or intravenous hydration with occasional

need for antiemetics
Rota virus

 Rotavirus is a nonenveloped, double-stranded RNA virus of the

Reoviridae family with a wheel-like appearance under electron
microscopy
 Nearly all children are infected with rotavirus at some point before
age 5 years, unless immunized
 The illness lasts 3-8 days and usually starts with some vomiting,
followed by severe foul-smelling (distinctive) diarrhea, potentially
leading to severe dehydration.
 Adults can be infected with rotavirus, although symptoms are
usually not as severe
 The peak rotavirus season is November to April (cooler weather) in
temperate weather and year-round in tropical climates
Other viral agents

 Adenovirus
 Parvovirus
 Astrovirus
 Coronavirus
 Pestivirus
 torovirus
Bacterial causes- salmonella

 Salmonella appears as the second most common agent among

outbreaks with known pathogens.
 It is manifested by acute enterocolitis, with abdominal pain,
diarrhea, nausea, headache, sometimes vomiting, and almost
always fever.
 Infected persons may develop a localized infection or septicemia.
Clostridium difficile
 Also known as “C diff,” is a gram-positive, spore-forming, toxin-
producing bacillus that typically affects patients receiving antibiotic
treatment, especially with broad-spectrum drugs (eg,
cephalosporins, clindamycin, fluoroquinolones).
 Presentation is with watery diarrhea, fever, nausea, loss of appetite,
and abdominal pain or tenderness
 Complications that may result from infection include
pseudomembranous colitis, toxic megacolon, perforations of the
colon, sepsis, and even death
 In some cases, infection resolves within 2-3 days of discontinuing the
offending antibiotic. However, there are cases that require a full
course of an appropriate antibiotic; several antibiotics are effective
against C difficile. Severe cases may require surgery to remove the
infected portion of the intestine.
• The bacterium is shed in feces and can be acquired from contact
with contaminated surfaces, devices, or hands

• Elderly individuals are more commonly affected; however, infection

may occur at any age and over the last few years

• In cases of community-acquired infection, obesity has been reported

to be a possible risk factor

• Other bacterial causes include: shigella, C jejuni, Yersinia

enterocolitica, E coli, V cholera, B cereus, clostridium perfringens,
listeria etc
 Parasitic –Giardia lamblia
 Giardia lamblia (also called Giardia intestinalis), is a flagellate protozoan
parasite, lives primarily in the upper part of the small intestine
 Presenting symptoms include diarrhea, bloating, greasy stools that tend to
float, abdominal cramps, nausea/vomiting, and dehydration
 The average incubation period is 7-10 days, and symptoms may persist for
1-2 weeks
 Most infections occur in children aged 1-9 years, but predominantly in
those younger than 5 years. It is also seen in adults aged 25-44 years.
 Infected individuals may excrete cysts intermittently, making it difficult to
diagnose. Several stool samples should be collected on various days and
enzyme-linked immunosorbent assay (ELISA) or direct fluorescent antibody
methods are usually performed to identify the parasite.
 Transmission occurs from person to person or even from animals to humans
via the fecal-oral route, through the ingestion of contaminated water.
• The risk of becoming infected is higher for travelers around the world,
persons participating in outdoor activities/recreational water facilities,
and those who consume unfiltered/untreated water (ie, hikers,
campers)

• The majority of cases are observed during the months of June to

October, coinciding with the months of increased travel and
outdoor/recreational water activities

• Giardiasis occurs worldwide, with higher prevalence in areas where

there is poor hygiene and sanitation.

• It has 2 stages, cyst and trophozoite. Both forms are passed in feces;
however, the cyst is the infective stage and the one that can survive
outside of a host and in the environment for weeks or months.

• It has moderate tolerance to chlorine and is capable of living in cold

water for significant periods. Individuals infected with Giardia may
shed 1 to 10 billion cysts daily, while the infectious dose is
approximately 10 cysts, sometimes even as little as 1 or 2.
Other parasitic causes include the
following:

• Amebiasis

• Cryptosporidium

• Cyclospora
 Food-borne toxigenic diarrhea
 Preformed toxins include S aureus and B cereus

Shellfish and marine animal poisoning include the following:

 Paralytic shellfish poisoning (PSP) -
 Neurologic shellfish poisoning (NSP) -
 Diarrheal shellfish poisoning (DSP) -
 Amnesic shellfish poisoning -
 Scombroid
Drug-associated diarrhea

 Antibiotics, due to alteration of normal flora

 Laxatives, including magnesium-containing antacids
 Colchicine
 Quinidine
 Cholinergics
 Sorbitol
 Proton pump inhibitors
Work-up
 Stool studies and culture is the mainstay for diagnostic confirmation
 Complete blood cell count, electrolytes, renal function may not be helpful
in making a diagnosis. These tests are useful as indicators of severity of
disease
 Electrolytes and blood urea nitrogen (BUN) measurements are indicated in
patients with severe diarrhea or dehydration to assess the state of hydration
and to specifically rule out hyponatremia or hypernatremia
 ELIZA for Giardia and Cryptosporidium organisms. C difficile toxin assays
can be performed when antibiotic-associated diarrhea is suspected. Also
useful for rotavirus and giardia
 An acute abdominal series is indicated only when bowel obstruction, toxic
megacolon, or perforation is suspected.
 Sigmoidoscopy may be indicated if pseudomembranous colitis or
inflammatory bowel disease is suspected
treatment

Goals of Emergency therapy include the following:

 Rehydrate orally (PO) or intravenously (IV) as needed.
 Treat symptoms (eg, fever, pain) as indicated.
 Identify complications and treat appropriately
 Prevent the spread of infections.
 Identify public health concerns and treat certain cases with specific
or empiric antibiotic therapy.
rehydration

 Administration of 1-2 L dextrose 5% in 0.5 isotonic sodium chloride solution

with 50 mEq NaHCO3 and 10-20 mEq KCl over 30-45 minutes may be
necessary in patients who are severely dehydrated
 To give fluids more rapidly, KCl may be given orally or in the second or third
liter bag or as a supplemental IV of 20 mEq KCl in 100 mL of isotonic sodium
chloride solution over 1 hour. Ensure normal renal function prior to KCl
administration.
 For pediatric patients, administer 20 mL/kg of isotonic sodium chloride
solution initially for resuscitation. Repeat as necessary and add KCl as
indicated.
 Other oral rehydration products include Naturalyte, Cera Lyte, Rehydralyte,
and Pedialyte.
refeeding

 Early age-appropriate refeeding in children (and adults) is

important to initiate as soon as rehydration is complete
 Early refeeding with complex carbohydrates provides additional co-
transport molecules without osmotic penalty and stimulates
mucosal repair.
 Consider rice, wheat, bread, potatoes, and lean meats, especially
chicken.
 Milk can be safely given early. Despite the potential for lactose
intolerance
Empiric therapy

 The duration of traveler's diarrhea (E coli, Shigella) can be shortened by

half or more with trimethoprim-sulfamethoxazole or ciprofloxacin
administered for 3 days.
 Erythromycin or azithromycin is effective in Campylobacter infections
 Metronidazole (oral or parenteral) is effective in mild-to-moderate
cases of C difficile diarrhea (in addition to discontinuance of the
causative agent). Patients who are severely ill may require orally
administered vancomycin, which may require delivery via nasogastric
tube.
 Antiemetics may be useful in the treatment of nausea and vomiting in
adults. They are usually not recommended in children.
 Antidiarrhoeals such as loperamide can be given in non-bloody
travelers diarrhea
Prevention
 Hand washing before meals and after opening bowels
 Avoid shellfish served in unregulated environments,
 Wash all produce prior to consumption, especially if imported
 Avoid cross-contamination of foods during preparation (eg, cutting
boards).
 Avoid raw or undercooked eggs or poultry
 Avoid water, ice, raw fruits without a skin or peel, raw vegetables,
unpasteurized milk and dairy products, and foods sold in the streets.
 Antibiotic prophylaxis can be offered to immunocompromised
adults with TMP/SMZ