Gastroenteritis

Gastroenteritis (also known as gastro, gastric flu, and stomach flu, although unrelated
to influenza) is inflammation of the gastrointestinal tract, involving both the stomach and
the small intestine (see also gastritis and enteritis ) and resulting in acute diarrhea. The inflammation is caused most
often by infection with certain viruses, less often by bacteria or their toxins, parasites, or adverse reaction to
something in the diet or medication. Worldwide, inadequate treatment of gastroenteritis kills 5 to 8 million people per
year, and is a leading cause of death among infants and children under 5.

At least 50% of cases of gastroenteritis as foodborne illness are due to norovirus. Another 20% of cases, and the
majority of severe cases in children, are due to rotavirus. Other significant viral agents include adenovirus and
astrovirus.

Different species of bacteria can cause gastroenteritis, includingSalmonel la,Shigella,

Staphylococcus, Campylobacter jejuni, Clostridium, Escherichia coli, Yersinia, and

others. Some sources of the infection are improperly prepared food, reheated meat dishes, seafood, dairy, and
bakery products. Each organism causes slightly different symptoms but all result in diarrhea. Colitis, inflammation of
the large intestine, may also be present.

Risk factors include consumption of improperly prepared foods or contaminated water and travel or residence in
areas of poor sanitation. It is also common for river swimmers to become infected during times of rain as a result of
contaminated runoff water. The incidence is 1 in 1,000 people.

Gastroenteritis can be classified as either viral or bacterial.

Symptoms and signs

Gastroenteritis often involves stomach pain or spasms (sometimes to the point of being crippled), diarrhea and/or
vomiting, with noninflammatory infection of the upper small bowel, or inflammatory infections of the colon.

It usually is of acute onset, normally lasting 1-6 days (fewer than 10 days) and self-
limiting.
• Nausea and vomiting
• Diarrhea
• Loss of appetite
• Abdominal pain
• Abdominal cramps
• Bloody stools (dysentery - suggesting infection by amoeba,Campylobac ter, Salmonella, Shigella or some
pathogenic strains of Escherichia coli)
• Fainting and Weakness

The main contributing factors include poor feeding in infants. Diarrhea is common, and may be (but not always)
followed by vomiting. Viral diarrhea usually causes frequent watery stools, whereas blood stained diarrhea may be
indicative of bacterial colitis. In some cases, even when the stomach is empty, bile can be vomited up.

A child with gastroenteritis may be lethargic, suffer lack of sleep, run a low fever, have signs of dehydration (which
include dry mucous membranes), tachycardia, reduced skin turgor, skin color discoloration, sunken fontanelles,
sunken eyeballs, darkened eye circles, glassy eyes, poor perfusion and ultimately shock.

Symptoms occur for up to 6 days on average. Given appropriate treatment, bowel

movements will return to normal within a week after that.
Laboratory tests
•
Examination of stool for toxins, (e.g. Clostridium difficile toxin)
•
Stool cultures for the organisms that causes the disease, (e.g. Salmonella,
Shigella, Campylobacter and enterotoxic Escherichia coli)
•
Microscopy for parasites and their ova and cysts
•
EIA for viruses
It is important to consider infectious gastroenteritis as a diagnosis per exclusionem. A
few loose stools and vomiting may be the result of systemic infection such as
pneumonia, septicemia, urinary tract infection and even meningitis.Surgical
conditions such as appendicitis, intussusception and, rarely, evenHirschsprung's
disease may mislead the clinician.
Noninfectious
Non-infectious causes to consider are poisoning with heavy metals (e.g. arsenic,
cadmium ), seafood (e.g. ciguatera, scombroid, toxic encephalopathic shellfish poisoning) or mushrooms (e.g.
Amanita phalloides). Secretory tumours (e.g. carcinoid, medullary tumour of the thyroid, vasoactive intestinal peptide-
secreting adenomas ) and endocrine disorders (e.g. thyrotoxicosis and Addison's disease ) are disorders that can
cause diarrhea. Also, pancreatic insufficiency, short bowel syndrome, Whipple's disease, coeliac disease, and
laxative abuse should be excluded as possibilities.

Infectious
Infectious gastroenteritis is caused by a wide variety of bacteria and viruses. For a list of bacteria causing
gastroenteritis, see above. Pseudomembranous colitis is an important cause of diarrhea in patients often recently
treated with antibiotics. Viruses causing gastroenteritis include rotavirus, norovirus, adenovirus and astrovirus.
If gastroenteritis in a child is severe enough to require admission to a hospital, then it is important to distinguish
between bacterial and viral infections. Bacteria,Shigella and Campylobacter, for example, and parasites like Giardia
can be treated with antibiotics, but viruses do not respond to antibiotics and infected children usually make a full
recovery after a few days. Children admitted to hospital with gastroenteritis routinely are tested for rotavirus A to
gather surveillance data relevant to the epidemiological effects of rotavirus vaccination programs. These children are
routinely tested also for norovirus, which is extraordinarily infectious and requires special isolation procedures to
avoid transmission to other patients. Other methods, electron microscopy and polyacrylamide gel electrophoresis, are
used in research laboratories.

Management

Rehydration

The principal treatment of gastroenteritis in both children and adults is rehydration, i.e. replenishment of water lost in the
stools. Depending on the degree of dehydration, this can be done by giving the person oral rehydration therapy (ORT) or
through intravenous delivery. People taking diuretics ("water pills") need to be cautious with diarrhea and may need to
stop taking the medication during an acute episode, as directed by the health care provider.

Dietary therapy

Centers for Disease Control and Prevention recommendations for infants and children include: Breastfed infants
should continue to be nursed on demand. Formula-fed infants should continue their usual formula immediately upon
rehydration in amounts sufficient to satisfy energy and nutrient requirements, and at the usual concentration. Lactose-
free or lactose-reduced formulas usually are unnecessary. Children receiving semisolid or solid foods should continue
to receive their usual diet during episodes of diarrhea. Foods high in simple sugars should be avoided because the
osmotic load might worsen diarrhea; therefore, substantial amounts of soft drinks (carbonated or flat), juice, gelatin
desserts, and other highly sugared liquids should be avoided. Fatty foods should not be avoided, because
maintaining adequate calories without fat is difficult, and fat might have an added benefit of reducing intestinal
motility. The practice of withholding food for more than 24 hours is inappropriate.

The BRAT diet (Bananas, Rice, Applesauce, Toast and Tea) was recommended in the
past; however, it is no longer recommended, as it contains insufficient nutrients.

Probiotics
Some Probiotics have been shown to be beneficial in preventing and treating various forms of gastroenteritis.
Fermented milk products ( such as yogurt ) also reduce the duration of symptoms.
Zinc
The World Health Organization recommends that infants and children receive a dietary
supplement of zinc for up to 2 weeks after onset of gastroenteritis.
Pharmacologic therapy
Viral gastroenteritis is usually an acute and self-limited disease which does not require
pharmacologic therapy.
Antibiotics
Antibiotics may however sometimes be used if symptoms are severe and a bacterial cause
is either isolated or suspected.[citation needed
] If antibiotics are decided on a fluoroquinolone is
often used.[6] Pseudomembranous colitis is treated bydiscontinuing the causative agent
and starting with metronidazole or vancomycin.
Antibiotics usually are not given for gastroenteritis, although they may be given due to
some bacteria.
Antiemetic drugs If vomiting is severe, antiemetic drugs may be helpful. Ondansetron has some clinical
utility in this condition with a single dose associated with reduced use of intravenous fluids, fewer hospitalizations,
and decreasing nausea and vomiting. Metoclopramide however has not been found to be helpful.
Complications

The most serious complication is dehydration, usually due to severe diarrhea but sometimes made worse due to
improper treatment such as withholding fluids until diarrhea stops. Severe dehydration can be lethal and requires
prompt medical care. The most common complication,[citation needed ] especially in infants, is malabsorption of
certain sugars in the diet, and consequent food intolerances. This complication may persist for weeks, during which
time it causes mild diarrhea to return when the patient resumes their normal diet. Malabsorption of lactose, the
principal sugar in milk, is the most common. Its consequent milk intolerance is caused by lactase deficiency, and the
diarrhea is caused by bacterial fermentation of excess lactose in the gut. However, this is not reason to discontinue
breastfeeding. In children with viral gastroenteritis (usually rotavirus), the viral infection also can cause a high fever,
which in turn can cause febrile convulsion. Gastroenteritis sometimes is followed by pneumonia.

Epidemiology

Globally, gastroenteritis caused 4.6 million deaths in children in 1980 alone, most of these in the third world, where
the lack of adequate safe water and sewage treatment capacity contribute to the spread of infectious gastroenteritis.
Harrison's Principles of Internal Medicine estimates the current total figure to be 2.4 to 2.9 million per year. The global
death rate has now come down significantly to approximately 1.5 million deaths annually, largely due to global
introduction of proper oral rehydration therapy. The incidence in the developed countries is as high as 1-2.5 cases
per child per year[citation needed ] and a major cause of hospitalisation in this age group. Age, living conditions,
hygiene and cultural habits are important factors. Aetiologicalagents vary depending on the climate. Furthermore,
most cases of gastroenteritis are seenduring the winter in temperate climates and during summer in the tropics.