Introduction
Background
Gastroenteritis is a very common pediatric condition and is second only to respiratory infectionsas the most common reason for unscheduled visits to pediatricians.
Pathophysiology
Gastroenteritis is a clinical syndrome caused by various viral, bacterial, and parasiticenteropathogens. The mechanisms potentially responsible for viral diarrheainclude lysis of
enterocytes, interference with the brush border function that leads to malabsorption of electrolytes, stimulation of cyclic adenosine monophosphate (cAMP), and carbohydratemalabsorption. The proposed pathophysiology of bacterial gastroenteritis involves theelaboration of toxin by enterotoxigenic pathogens and the invasion and inflammation of mucosa by invasive pathogens. Parasitic organisms invade epithelial cells and cause villus atrophy andeventual malabsorption.
Frequency
United States
Incidence rates for diarrhea are 1-2.5 episodes per child per year, which annually leads toapproximately 38 million cases, 2-3.7 million physician visits, 320,000 hospitalizations, and 325-425 deaths.
International
More than 1 billion cases and at least 4 million deaths per year are attributed to diarrheaworldwide.
Mortality/Morbidity
Mortality and morbidity from diarrhea relate to the degree of dehydration. Most deaths in theUnited States correlate to lower maternal socioeconomic factors and prematurity.
Age
Dehydrationrisk in children relates to age, and infants are most susceptible.
Clinical
History
•
Pertinent information in individuals with suspected gastroenteritis includes the following:
o
Presence or absence of vomiting
o
Frequency, duration, and character of diarrhea
o
Travel history
o
Contacts with sick individuals
o
Antibiotic use
o
Seafood ingestion
o
Possible ingestion of toxic substances
o
Chronic illness
•
Determine the amount and type of fluids ingested for the past 24 hours and the child'surine output.
•
Seizures in a patient with diarrhea should raise the possibility of gastroenteritis caused by
Shigella
species, enterohemorrhagic
Escherichia coli,
or an electrolyte imbalance.Hyponatremiais more common thanhypernatremia.
o
Consider hyponatremic dehydration in children who have been fed bland anddilute fluids (eg, tea, rice water, dilute formula).
o
Consider hypernatremic dehydration in patients who have been drinking mainlysalt solutions and other hypertonic solutions, who have been losing hypotonicfluids (eg, profuse watery diarrhea), and who present with a depressed sensorium beyond what would be expected from the apparently mild signs of dehydration.
Physical
•
The criterion standard and most accurate clinical indicator of the extent of dehydration isthe percentage loss of body weight during the illness, which represents the child's fluiddeficit.
•
Other vital clinical findings include the following:
o
Thirst
o
Listlessness
o
Dry mucous membranes
o
Sunken fontanelles
o
Sunken eyes
o
Absence of tears
o
Decreased skin turgor
o
Decreased capillary filling time
o
Tachycardia
o
Weak pulse
o
Reduced blood pressure
•
Examine the stools to check for mucus, blood streaks, or gross blood.
•
Tenting or loss of skin turgor (eg, when pinched skin does not return to the original flatshape) usually occurs in moderate-to-severe cases of dehydration yet is not always present in dehydration. Tenting or skin turgor loss seldom occurs with hypernatremicdehydration, a condition in which doughy skin is more common.
Causes
•
Bacterial infections cause most gastroenteritis cases in less affluent nations.
o
The most important causal agent in these countries is diarrhea-causing
E coli
(eg,enteropathogenic [EPEC], enterotoxigenic [ETEC], enteroaggregative [EAEC],enteroinvasive [EIEC], enterohemorrhagic [EHEC]).
o
Other bacteria that cause gastroenteritis less often include
Campylobacter, Aeromonas, Shigella,
and
Salmonella
species.
o
Vibrios
species, especially
Vibrios cholerae,
play major roles in epidemics. Inseafood poisoning,
Vibrio parahaemolyticus
is associated with gastroenteritis.
•
Viral infections cause 30-40% of gastroenteritis cases in affluent countries.
o
Rotavirus accounts for about 3.5 million cases per year and as many as 110,000hospital admissions for diarrhea.
Rotavirus is the single most important cause of dehydrating diarrhea in both developed and developing countries. It produces severe diarrhea,accounting for most episodes in children younger than 2 years who requirehospitalization for diarrhea and dehydration.
Rotavirus incidence has a distinct seasonal pattern.
Rotavirus infection occurs most frequently in children aged 3-15 monthsand may occur in children as old as 24 months, although the vast majorityof children have acquired antibodies by that age.
Rotavirus is transmitted by fecal oral spread with secondary spread viarespiratory route.
o
Norwalk virus is responsible for outbreaks of gastroenteritis in older children andadults. Unlike rotavirus, which affects mainly children, the Norwalk virus causesillness in all age groups.
o
Enteric adenoviruses account for 5-20% of hospitalizations for acute diarrhea.Compared to rotavirus and Norwalk virus, enteric adenoviruses have a longer incubation period (ie, 8-10 d compared with 1-3 d), and the diarrhea associatedwith adenoviruses lasts longer (ie, 5-12 d compared with 5-7 d for rotavirus and1-2 d for Norwalk). Astroviruses and caliciviruses each account for 3-5%hospitalizations for acute diarrhea.
o
Additional information about viral gastroenteritis can be obtained fromTheCenters for Disease Control and Prevention (CDC).
•
The most common bacterial agents in the United States are
Salmonella, Shigella,Campylobacter,
and
Yersinia
species and
E coli
. Enteroaggregative
E coli
has recently been shown to be an unrecognized cause of community-acquired diarrhea in infants in theUnited States.
Campylobacter jejuni
affects approximately 2 million people in the UnitedStates annually.
Clostridium difficile
is the most common cause of pseudomembranouscolitis, a condition often observed in patients who develop severe diarrhea during or following a course of antibiotics. Clindamycin is the most common antibiotic identified,although almost all antibiotics have been implicated.
o
In patients withsickle cell disease,
Salmonella
species are the most frequent causeof gastroenteritis.
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