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SEMPA 360 CONFERENCE

March 16-18, 2020
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Diagnosis and Management March 2020

Volume 22, Number 3
of Acute Gastroenteritis in Author

Brian Geyer, MD, PhD, MPH

the Emergency Department

Assistant Clinical Professor, Department of Emergency Medicine,
University of Arizona College of Medicine – Phoenix; Vice Chairman,
Department of Emergency Medicine, Banner Estrella Medical Center,
Phoenix, AZ

Abstract Peer Reviewers

Alexis Halpern, MD, FACEP

There are approximately 178 million cases of acute gastro-
enteritis annually in the United States, resulting in 473,000
hospitalizations and 5000 deaths. The vast majority of these
cases are of viral etiology, self-limited, and require only sup-
portive care; nonetheless, patients at high risk due to extremes
of age or immunosuppression often require specific therapy to
ensure resolution of symptoms. With this common ED presen-
tation, there are many potential decisions related to resource
utilization and management. This review provides a best-ev-
idence approach to diagnosis and management supported by
recent guidelines from the American College of Gastroenterol-
ogy and the Infectious Diseases Society of America.
Assistant Professor of Emergency Medicine, Department of
Emergency Medicine, New York-Presbyterian – Weill Cornell
Medicine, New York, NY
Ellen Sano, DO, MPH
Assistant Professor of Emergency Medicine, Department of
Emergency Medicine, Columbia University Irving Medical Center, New
York, NY
Prior to beginning this activity, see “CME Information”
on the back page.
This activity is eligible for 2 Pharmacology CME credits.

Editor-In-Chief
Andy Jagoda, MD, FACEP
Professor and Chair Emeritus,
Department of Emergency Medicine;
Director, Center for Emergency
Medicine Education and Research,
Icahn School of Medicine at Mount
Sinai, New York, NY
Associate Editor-In-Chief
Kaushal Shah, MD, FACEP
Associate Professor, Vice Chair
for Education, Department of
Emergency Medicine, Weill Cornell
School of Medicine, New York, NY
Editorial Board
Saadia Akhtar, MD, FACEP
Associate Professor, Department of
Emergency Medicine, Associate Dean
for Graduate Medical Education,
Program Director, Emergency
Medicine Residency, Mount Sinai
Beth Israel, New York, NY
William J. Brady, MD
Professor of Emergency Medicine
and Medicine; Medical Director,
Emergency Management, UVA
Medical Center; Operational Medical
Director, Albemarle County Fire
Rescue, Charlottesville, VA
Calvin A. Brown III, MD
Director of Physician Compliance,
Credentialing and Urgent Care
Services, Department of Emergency
Medicine, Brigham and Women's
Hospital, Boston, MA
Peter DeBlieux, MD Medicine, NYU/Langone and
Professor of Clinical Medicine,
Louisiana State University School of
Medicine; Chief Experience Officer,
University Medical Center, New
Orleans, LA
Deborah Diercks, MD, MS, FACEP,
FACC
Professor and Chair, Department of
Emergency Medicine, University of
Texas Southwestern Medical Center,
Dallas, TX
Daniel J. Egan, MD
Associate Professor, Vice Chair of
Education, Department of Emergency Associate Professor, Department
Medicine, Columbia University
Vagelos College of Physicians and
Surgeons, New York, NY
Marie-Carmelle Elie, MD
Associate Professor, Department
of Emergency Medicine & Critical
Care Medicine, University of Florida
College of Medicine, Gainesville, FL
Nicholas Genes, MD, PhD
Associate Professor, Department of
Emergency Medicine, Icahn School
of Medicine at Mount Sinai, New
York, NY
Michael A. Gibbs, MD, FACEP
Professor and Chair, Department
of Emergency Medicine, Carolinas
Medical Center, University of North Ali S. Raja, MD, MBA, MPH
Carolina School of Medicine, Chapel Executive Vice Chair, Emergency
Hill, NC
Steven A. Godwin, MD, FACEP
Professor and Chair, Department
of Emergency Medicine, Assistant
Dean, Simulation Education,
University of Florida COM-
Jacksonville, Jacksonville, FL
Joseph Habboushe, MD MBA
Assistant Professor of Emergency
Bellevue Medical Centers, New York, Alfred Sacchetti, MD, FACEP
NY; CEO, MD Aware LLC
Eric Legome, MD
Chair, Emergency Medicine, Mount
Sinai West & Mount Sinai St. Luke's;
Vice Chair, Academic Affairs for
Emergency Medicine, Mount Sinai
Health System, Icahn School of
Medicine at Mount Sinai, New York, NY
Keith A. Marill, MD, MS
of Emergency Medicine, Harvard
Medical School, Massachusetts
General Hospital, Boston, MA
Angela M. Mills, MD, FACEP
Professor and Chair, Department
of Emergency Medicine, Columbia
University Vagelos College of
Physicians & Surgeons, New York,
NY
Charles V. Pollack Jr., MA, MD,
FACEP, FAAEM, FAHA, FESC
Professor & Senior Advisor for
Interdisciplinary Research and
Clinical Trials, Department of
Emergency Medicine, Sidney Kimmel
Medical College of Thomas Jefferson Associate Professor of Emergency
University, Philadelphia, PA
Medicine, Massachusetts General
Hospital; Associate Professor of
Emergency Medicine and Radiology, Scott D. Weingart, MD, FCCM
Harvard Medical School, Boston, MA Professor of Emergency Medicine;
Robert L. Rogers, MD, FACEP,
FAAEM, FACP
Assistant Professor of Emergency
Medicine, The University of
Maryland School of Medicine,
Baltimore, MD
Assistant Clinical Professor,
Department of Emergency Medicine,
Thomas Jefferson University,
Philadelphia, PA
Robert Schiller, MD International Editors
Chair, Department of Family Medicine,
Peter Cameron, MD
Beth Israel Medical Center; Senior
Academic Director, The Alfred
Faculty, Family Medicine and
Emergency and Trauma Centre,
Community Health, Icahn School of
Monash University, Melbourne,
Medicine at Mount Sinai, New York, NY
Australia
Scott Silvers, MD, FACEP
Associate Professor of Emergency Andrea Duca, MD
Attending Emergency Physician,
Medicine, Chair of Facilities and
Planning, Mayo Clinic, Jacksonville, FL Ospedale Papa Giovanni XXIII,
Bergamo, Italy
Corey M. Slovis, MD, FACP, FACEP
Suzanne Y.G. Peeters, MD
Professor and Chair, Department
Attending Emergency Physician,
of Emergency Medicine, Vanderbilt
Flevo Teaching Hospital, Almere,
University Medical Center, Nashville, TN
The Netherlands
Ron M. Walls, MD
Edgardo Menendez, MD, FIFEM
Professor and COO, Department of
Professor in Medicine and Emergency
Emergency Medicine, Brigham and
Medicine; Director of EM, Churruca
Women's Hospital, Harvard Medical
Hospital of Buenos Aires University,
School, Boston, MA
Buenos Aires, Argentina
Critical Care Editors Dhanadol Rojanasarntikul, MD
Attending Physician, Emergency
William A. Knight IV, MD, FACEP, Medicine, King Chulalongkorn
FNCS Memorial Hospital; Faculty of
Medicine, Chulalongkorn University,
Medicine and Neurosurgery, Medical Thailand
Director, EM Advanced Practice
Provider Program; Associate Medical Stephen H. Thomas, MD, MPH
Director, Neuroscience ICU, University Professor & Chair, Emergency
of Cincinnati, Cincinnati, OH
Medicine, Hamad Medical Corp.,
Weill Cornell Medical College, Qatar;
Emergency Physician-in-Chief,
Hamad General Hospital,
Chief, EM Critical Care, Stony Brook
Medicine, Stony Brook, NY Doha, Qatar
Edin Zelihic, MD
Research Editors Head, Department of Emergency
Aimee Mishler, PharmD, BCPS Medicine, Leopoldina Hospital,
Emergency Medicine Pharmacist, Schweinfurt, Germany
Program Director, PGY2 EM
Pharmacy Residency, Maricopa
Medical Center, Phoenix, AZ
Joseph D. Toscano, MD
Chief, Department of Emergency
Medicine, San Ramon Regional
Medical Center, San Ramon, CA
Case Presentations
You are working in the ED on a busy morning when you
meet an otherwise healthy 42-year-old man reporting 2
days with 5 to 10 watery, nonbloody, unformed stools
and persistent nausea, anorexia, and 1 to 2 episodes of
nonbloody emesis each day. He is mildly tachycardic, but
afebrile, and is normotensive. He is alert and conversant
but appears mildly uncomfortable. He has dry mucous
membranes and diffuse abdominal pain, with minimal
tenderness on exam. He denies any recent hospitaliza-
tions, antibiotic use, foreign travel, or sick contacts. The
patient requests that you “check blood work” and provide
him with IV fluids and antibiotics for his infection. You
wonder how best to educate him about the best use of his
time and healthcare resources for his condition…
Your next patient is a 68-year-old woman with non–
insulin-dependent diabetes, hypothyroidism, and previous
cholecystectomy, who resides in an assisted-living facility.
She describes 1 day of diarrhea, with a fever of 38.9°C
(102°F) this morning. She is tachycardic and febrile, but
normotensive. She reports some generalized abdominal
cramping and has a soft abdomen. She denies any recent
hospitalizations, antibiotic use, or foreign travel. She tells
you that she heard that one of the kitchen staff had to leave
early yesterday because “he looked sick and kept vomit-
ing.” You wonder if there is a connection between this
history and the current presentation, as you ask the clerk
to call the assisted-living facility…
You leave that room to see a 34-year-old man who
was diagnosed with acquired immunodeficiency syndrome
(AIDS) last week with a CD4 count of 180 cells/mcL. He
has an appointment at the end of this week with an infec-
tious disease specialist to start antiretroviral treatment.
He tells you that he has lost 30 lb in the last 4 months,
with persistent watery diarrhea for the last 2 weeks. He
denies fevers but has had relatively constant nausea with
a few episodes of vomiting over this time. He looks frail
and cachectic, is mildly tachycardic with a blood pressure
of 100/60 mm Hg, and is afebrile. His abdomen is slightly
tender with no rebound. You begin generating a differ-
ential diagnosis and wonder how extensive a workup he
needs in the ED…
Introduction
Acute gastroenteritis (AGE) is broadly defined as
inflammation of the stomach and intestine due to an
infectious cause, generally presenting with diarrhea
and vomiting, fever, and abdominal pain;1,2 how-
ever, there is no universal definition of the specific
clinical criteria that correlate with this disease entity.
The long-standing notion that a diagnosis of AGE
requires both vomiting and diarrhea is not support-
ed by recent literature or clinical guidelines. Over
the last several decades, there has been movement
toward using diarrhea as the defining characteristic
of AGE, initially with the 1996 American Association
Copyright © 2020 EB Medicine. All rights reserved. 2
of Pediatrics practice guidelines for the manage-
ment of AGE in young children.3 The 2016 American
College of Gastroenterology (ACG) guidelines use
a definition that emphasizes diarrhea in the diag-
nostic criteria, but acknowledges that AGE can also
be a “vomiting-predominant illness with little or
no diarrhea.”4 The most recent guidelines from the
Infectious Diseases Society of America (IDSA) adopt
a similar approach.1
In the clinical studies where specific inclusion
criteria are required, we generally see more-vague
criteria that allow for either a vomiting-predominant
or diarrhea-predominant presentation. This is
reflected in the literature, with studies classifying
AGE patients as those with ≥ 1 episode of vomiting
and/or ≥ 3 episodes of diarrhea in a 24-hour period,
without a known chronic cause for their symptoms
(such as inflammatory bowel disease).5 The clinical
definition for diarrhea is much more standardized,
being defined as the passage at least 3 unformed
stools (or more than 250 g) per day.2 On the basis of
duration, an acute episode lasts for < 14 days, while
longer courses of illness are classified as persistent
(14-29 days), or chronic (> 29 days). For the purposes
of an emergency department (ED) evaluation, all of
the expected symptoms need not be present to make
a presumptive diagnosis of AGE. Patients present at
different times in their course of illness, and it may
not have evolved to include all of the classic signs
and symptoms. Furthermore, depending on the
mechanism of disease and host factors, patients with
inflammation of the stomach and intestine due to an
infectious cause may not ever develop any vomiting
or diarrhea.
There are 178.8 million cases of acute gastro-
enteritis annually in the United States, resulting in
473,000 hospitalizations (0.26%) and 5000 deaths
(0.0028%). In approximately 79% of these cases, a
causative organism is never identified.6 Among ED
patients with AGE, a causative organism is identi-
fied in only 25% of all cases; in cases where a stool
sample is obtained and analyzed, 49% reveal a caus-
ative organism.5
Many common exposures increase the risk of
developing AGE, such as domestic or internation-
al travel to areas with poor sanitation practices;
antibiotic use; exposure to zoonoses; and time
spent in healthcare settings, long-term care facili-
ties, and childcare settings. Host features also play
a significant role, particularly immunosuppression
(due to medication or primary disease) and vac-
cination status. A careful history is essential to risk
stratify patients.
This issue of Emergency Medicine Practice focuses
on the evaluation and management of patients with
AGE who present to the ED. Current literature and
relevant subspecialty guidelines are evaluated to
show where there is strong agreement regarding
Reprints: www.ebmedicine.net/empissues
diagnosis and treatment, as well as where there are
gaps in the literature. After completing this review,
the reader should be able to rapidly and accurately
evaluate and risk stratify ED patients with AGE and
formulate a safe and comprehensive treatment plan
and disposition.
Critical Appraisal of the Literature
A literature search was performed on PubMed for
English language articles published from 1984 to
2018 using the search terms: diarrhea, emergency de-
partment (412 articles); acute gastroenteritis, emergency
department (133 articles); Clostridium difficile, emergen-
cy department (30 articles); acute gastroenteritis clinical
trials only (130 articles); ondansetron, gastroenteritis
clinical trials only (13 articles); and antiemetic, gas-
troenteritis clinical trials only (119 articles). Pertinent
articles returned from this search were examined
for citations that would be relevant to this review. A
review of leading emergency medicine texts as well
as United States Centers for Disease Control and
Prevention (CDC) guidelines, the 2017 IDSA guide-
lines,1 and the 2016 ACG clinical guidelines4 were
also evaluated for additional relevant citations.
There appears to be a discordance between
the frequency of AGE in the United States and the
number of publications investigating this disease.
The literature is sparse in many key areas, such
as indications for diagnostic testing and empiric
antibiotic treatment. This paucity of data is reflected
in subspecialty guidelines that lack specific recom-
mendations for ED management of AGE. A notable
contrast to this is the relative abundance of United
States studies that guide evaluation and treatment of
pediatric ED patients with AGE. As a consequence,
many recommendations in this review for adult pa-
tients are extrapolated from the pediatric literature.
Etiology and Pathophysiology
The principle symptoms of AGE—vomiting, diar-
rhea, and abdominal pain—result from inflamma-
tion in the stomach and small- and/or large-bowel
mucosa from infectious agents or the toxins they
produce. (See Appendix 1, pages 18-19.) This
inflammation results in an imbalance between fluid
ingestion/secretion and absorption, which produces
increased intraluminal fluid, resulting in fluid losses
through diarrhea. This can lead to dehydration, vol-
ume contraction, and electrolyte deficiencies. The in-
cubation period for AGE is highly variable, depend-
ing on the agent and mode of toxicity. Preformed
toxins (eg, from Staphylococcus aureus or Bacillus
cereus) may cause symptoms in as little as 1 hour fol-
lowing exposure. Viral and bacterial pathogens have
incubation periods in the range of a few days.
Approximately 70% of cases of AGE in the
March 2020 • www.ebmedicine.net
United States are estimated to be caused by viral
pathogens, with norovirus being the most common
causative organism.2 In a study of ED patients with
AGE, the most common pathogens identified were
norovirus (26%) and rotavirus (18%). The most com-
mon bacterial pathogens identified were Salmonella
species (5.3%), Clostridium difficile (5.3%) and Campy-
lobacter species (3%). Parasitic infections were identi-
fied in 3% of total cases, although there seemed to be
approximately 24% less testing performed for these
organisms compared to viral and bacterial organ-
isms.5 Mixed infections constituted 9% of total cases,
mostly mixed viral infections or viral co-infection
along with C difficile infection, while no causative
organism was identified in 51% of cases.5
Foodborne Illness
In a well-designed observational study of 52,840 pop-
ulation-based surveys administered through Food-
Net, a clinical research and epidemiology surveillance
network conducted by the CDC (www.cdc.gov/
foodnet/index.html), only 5.2% of cases of AGE are
estimated to result from contaminated food.6 How-
ever, foodborne illness results in 30.2% of deaths from
AGE. Salmonella, Clostridium perfringens, and Campylo-
bacter were the most common bacterial causes, identi-
fied in a total of 30% of cases. Viral causes still remain
responsible for the majority of foodborne illness, with
norovirus causing 58% of these cases.6
Escherichia coli Infections
Escherichia coli is a normal component of the human
gut microbiome, and generally does not cause dis-
ease. Of the pathogenic E coli subtypes, the 2 most
commonly discussed as causative organisms for
AGE are Shiga toxin-producing E coli (STEC) and
enterotoxigenic E coli (ETEC). STEC, also referred to
as enterohemorrhagic E coli (EHEC) or verocytotoxin-
producing E coli (VTEC), is a relatively rare but
important cause of infectious diarrhea and AGE due
to the severity of infection and its association with
hemolytic uremic syndrome. Shiga toxin is a protein
that inhibits protein synthesis in host cells, and is
principally associated with Shigella dysenteriae and
E coli serotypes O157:H7 and O104:H4. The most
commonly identified serogroup in North America
is E coli O157:H7. The CDC estimates that STEC
causes 265,000 illnesses, 3600 hospitalizations, and
30 deaths in the United States annually. Most cases
of STEC infection are self-limited after 5 to 7 days
of symptoms; however, STEC infection is associated
with hemolytic uremic syndrome in approximately
5% to 10% of cases. Patients may have severe ab-
dominal pain and visible blood in stools, as in other
bacterial etiologies. Interestingly, patients with
STEC infection are more likely to be afebrile at the
time of presentation as compared to other bacterial
causes of AGE.1
3 Copyright © 2020 EB Medicine. All rights reserved.
Traveler's Diarrhea
ETEC is associated with so-called “traveler’s diar-
rhea,” due to its being endemic in many lower-
resource countries. The term traveler’s diarrhea refers
to 3 or more unformed stools in a 24-hour period
that is associated with abdominal cramps, tenes-
mus, nausea, vomiting, fever, or fecal urgency in
a recent traveler who is generally returning to a
high-resource nation from a lower-resource nation.7,8
The incidence of traveler’s diarrhea is estimated to
be 10% to 40% during a 2-week trip to a resource-
limited environment. Studies of this population have
demonstrated a much higher incidence of bacterial
etiology than in nontravelers, although viral causes
remain extremely common.7,9 Dominant causative
bacterial species include ETEC, Campylobacter, and
Shigella. The majority of cases are self-limited, lasting
a few days, but patients may benefit from empiric
antibiotic treatment.
Patients returning from low-resource environ-
ments who have symptoms consistent with AGE
may have traveler’s diarrhea, but clinicians should
also consider other more complex and concerning
etiologies. Depending upon the region and dura-
tion of travel, bacterial pathogens such as Vibrio
cholerae as well as parasitic infections such as
Giardia, Cryptosporidium, and Entamoeba histolytica
are possible considerations.10 With Giardia infec-
tion, predominant symptoms include diarrhea,
abdominal distension, flatulence, steatorrhea, and
abdominal cramping. Risk factors for giardiasis in-
clude exposure to untreated fresh water; childcare
environments; or anal-genital, oral-anal, or digital-
anal contact. Recent antibiotic use or exposure to
someone with known C difficile infection should
raise concern for C difficile colitis.
Cryptosporidium Infection
Cryptosporidium is a relatively common and un-
derrecognized cause of infectious diarrhea in the
United States, responsible for an estimated 9300
cases annually.11 The intracellular protozoan parasite
Cryptosporidium is passed in the stool of an infected
person or animal to a new host by direct contact
with the stool, such as from contaminated diapers,
sexual contact, etc, or by contamination of untreated
or undertreated swimming or drinking water.
Uncooked food, particularly fruits and vegetables,
can also be contaminated with Cryptosporidium.
There is a large diversity of clinical presentation for
cryptosporidiosis, from asymptomatic infection to
severe volume depletion and death. Most patients
will report nausea, anorexia, generalized weakness,
crampy abdominal pain, and watery diarrhea. Fever
and vomiting are possible. Bloody diarrhea is rare.
Symptom onset in seronegative patients follows
an incubation period of 3 to 12 days, but can be as
much as 25 days.12 Otherwise healthy patients will
Copyright © 2020 EB Medicine. All rights reserved. 4
generally clear their infection without antimicrobial
treatment in < 3 weeks.
Differential Diagnosis
Many common life-threatening conditions en-
countered in the ED can present with abdominal
pain, vomiting, and diarrhea, mimicking AGE and
confounding diagnosis and treatment. See Table 1,
page 5 for a summary of distinguishing factors on
the differential of AGE.
Acute Appendicitis
Of the alternative diagnoses noted in Table 1 (page
5), acute appendicitis deserves further discussion.
Suspected AGE is a major factor contributing to di-
agnostic delay in acute appendicitis in that both may
present with nausea, vomiting, abdominal pain, and
fever. In a retrospective study of 115 children who
eventually received a diagnosis of acute appendici-
tis, Cappendijk et al reported that over half of those
with a delay in diagnosis were initially diagnosed
with AGE. In this study, delay to diagnosis of acute
appendicitis was associated with a 47% absolute
increased risk of perforation at diagnosis.13 Migra-
tion of pain to the right lower quadrant, right lower
quadrant tenderness on initial or repeat examina-
tion, an absence of diarrhea, or pain that is not
improved by each episode of diarrhea are suggestive
of appendicitis. A history of high-risk food con-
sumption (as in a returning international traveler),
multiple household contacts with similar symptoms,
or the presence of diarrhea are negative predictors
of appendicitis. Note that for diarrhea to serve as a
negative predictor, it should be clearly documented
as being 3 or more loose stools in a 24-hour pe-
riod.13,14
Ciguatera Fish Poisoning
Patients who have recently eaten fish and are pre-
senting with symptoms concerning for AGE may be
experiencing ciguatera fish poisoning. Patients will
develop nausea, vomiting, diarrhea, and abdominal
pain within 6 to 24 hours of ingesting an otherwise
normal-tasting fish contaminated with ciguatera
toxin. The toxin originates in algae that enter the
food chain after being consumed by herbivorous
reef fish such as grouper, red snapper, sea bass, and
Spanish mackerel.15 Within a few days, patients may
develop neurologic symptoms such as extremity
paresthesias, generalized pruritus, and occasionally
a reversal of hot/cold sensation that is extremely
unpleasant. Treatment is generally supportive, al-
though there is some suggestion that mannitol
(0.5-1 mg/kg IV) may reduce symptom severity and
duration through osmotic reduction of neuronal
edema; however, this is controversial.16
Reprints: www.ebmedicine.net/empissues
Table 1. Distinguishing Factors in the Differential Diagnosis of Acute Gastroenteritis
Disease Patient History
Acute appendicitis Migration of pain, not usually
associated with diarrhea
Bowel obstruction History of previous
abdominal surgeries,
decreased stool/flatus;
possible initial diarrhea
from passing stool distal to
the obstruction
Peptic ulcer disease/ History of alcohol abuse,
upper GI bleed NSAID use, liver disease
Pancreatitis History of gallstones, alcohol
abuse, abdominal trauma;
medication use, including
sulfonamides, valproic
acid, tetracycline, diuretics,
azathioprine, estrogen,
et al
Diverticulitis Older age, LLQ tenderness
Mesenteric ischemia Older age, history of atrial
fibrillation or vascular
disease; also consider
chronic mesenteric
ischemia
Inflammatory bowel Personal or family history
disease of inflammatory bowel
disease, recurrent
episodes, younger age,
weight loss, mucus in stool
Food allergy/intolerance Association with particular
foods, family history of
same
Opioid withdrawal History of opioid use
Organophosphate History of exposure, large
toxicity numbers of people with
similar symptoms
Lithium overdose History of ingestion, previous
suicide attempts
Colchicine poisoning Patient with access to
colchicine, history of
arthritis or gout
Abbreviations: AGE, acute gastroenteritis; CT, computed tomography; ED, emergency department; GI, gastrointestinal; IV, intravenous; LLQ, left lower
quadrant; LUQ, left upper quadrant; NSAID, nonsteroidal anti-inflammatory drug; RLQ, right lower quadrant.
*Ranson criteria can be accessed at www.mdcalc.com/ransons-criteria-pancreatitis-mortality
March 2020 • www.ebmedicine.net
Clinical Examination
Focal RLQ tenderness
Distended abdomen,
tympanic to percussion
LUQ tenderness, melena
Epigastric tenderness
Focal LLQ tenderness (can
be LUQ or RLQ as well)
Extreme pain with palpation
of soft abdomen (pain
out of proportion to
examination)
May have uveitis or
erythema nodosum
Generally benign
examination
Hypertension, mydriasis,
vomiting, body aches, flu-
like appearance
Bronchorrhea and
bronchospasm,
hypersalivation,
incontinence, miosis
and blurred vision with
lacrimation
Nonspecific
Hypotension, cardiovascular
compromise
5 Copyright © 2020 EB Medicine. All rights reserved.
Laboratory/Imaging
Finding
Dilated appendix on CT or
ultrasound
Dilated bowel on CT
Melena, decreased
hemoglobin
Elevated serum lipase
Inflamed diverticuli on CT
Increased lactate (not
sensitive or specific);
arterial cutoff of focal
bowel edema on contrast-
enhanced CT
Increased inflammatory
markers, colonic thickening
on CT; + colonoscopy for
definitive diagnosis
Not helpful
Urine drug screen is not
sensitive or specific
Cholinesterase activity
assay, but usually not
available rapidly; clinical
diagnosis in ED setting.
Lithium level (highly
dependent on renal
function and electrolyte
levels)
Laboratory evidence of
multiorgan dysfunction,
neutropenia
Comments
Most commonly missed
diagnosis with AGE
Nasogastric tube
decompression indicated
for severe pain, persistent
nausea and vomiting,
or complete/high-grade
obstruction noted on CT
Brisk upper GI bleed may
have hematochezia
Can risk stratify with Ranson
criteria*
Evidence of abscess or
perforation requires
admission
Very high morbidity and
mortality; antibiotics, IV
fluids and immediate
surgical consult needed
May develop strictures if
repeated episodes occur
Most commonly cow’s milk,
eggs, peanuts, tree nuts,
wheat, fish, shrimp, clams,
oysters, and mussels
Treat supportively with
hydration, loperamide, and
clonidine
Treat with supportive care,
large doses of atropine,
and pralidoxime
Treat with hydration, whole-
bowel decontamination, or
hemodialysis; no role for
activated charcoal
Very high morbidity and
mortality
www.ebmedicine.net
Scombroid Poisoning
Scombroid poisoning, also known as histamine
fish poisoning, is another AGE mimic that results
from the ingestion of fish in the Scombroidae and
Scomberesocidae families (including mackerel,
bonito, albacore, and skipjack) that have been stored
improperly.17 Bacterial contamination and produc-
tion of bacterial histidine decarboxylase enables
conversion of histidine to histamine and other
biogenic amines. Patients will generally experi-
ence abdominal pain and diarrhea within 20 to 30
minutes following consumption of the spoiled fish.
More specific symptoms include a metallic, bitter,
or peppery taste in the mouth and facial flushing.
In an ED setting, it can sometimes be confused with
an allergic reaction. Symptoms are generally self-
limited and will resolve within 6 to 8 hours, which is
accelerated with antihistamine treatment. A key role
for the emergency clinician is to notify the health
department of these cases in order to prevent others
from being poisoned.
Prehospital Care
Prehospital care for patients with suspected AGE
focuses on fluid resuscitation and attempts to
contain and reduce transmission of the infectious
agent. Emergency medical services (EMS) are in
a unique position to obtain information about the
patient that can assist in appropriate diagnosis and
treatment. There are many clues often available at
the scene that would not be available to ED staff,
such as the overall home environment, presence
of any medication bottles, or close contacts with
similar symptoms. Information about the duration
of symptoms and any care provided prior to calling
EMS can also be useful, particularly if the patient
is not able to communicate this. EMS must provide
an accurate initial evaluation (vital signs, blood
glucose, etc), as well as fluid resuscitation and
antiemetic medications, if available and indicated.
EMS crews should initiate infection containment
precautions immediately upon patient contact, and
have clear communication with the ED team prior
to arrival to allow for appropriate and immediate
isolation and contact precautions.
Emergency Department Evaluation
History
Within the timeframe of ED evaluation, AGE is
essentially a clinical diagnosis. There are many
high-risk conditions that can present similarly, and
a comprehensive history is essential for accurate
diagnosis. A discussion of the timing and evolution
of symptoms can inform the decision on whether
to obtain laboratory testing, as patients who report
many episodes of vomiting or diarrhea or decreased
Copyright © 2020 EB Medicine. All rights reserved. 6
oral intake and/or urine output are at higher risk for
moderate to severe dehydration. A thorough travel
and exposure history can reveal factors supportive
for AGE diagnosis, including whether there is a his-
tory of similar illness in contacts. Routinely ask all
patients with AGE symptoms about recent antibiotic
use (< 3 months), hospitalizations, foreign travel,
and any time spent in rural areas. It is also valuable
to ask about the home environment, particularly
for residents of care facilities and those with small
children or pets (such as reptiles). (See Table 2.)
These brief questions provide useful information for
presumptive pathogen identification (viral, bacterial,
or parasitic). Carefully evaluate the patient's age,
medical comorbidities, and medications to assist in
risk stratification. Extremes of age, pregnancy, and
immunosuppression (medication-induced or patho-
logic) should be identified early and will generally
lead to more-aggressive workup and treatment.
Elderly patients with acute infectious diarrhea are
at very high risk for mortality, independent of the
causative organism, with 83% of deaths occurring in
patients aged ≥ 65 years.
Physical Examination
Evaluate the vital signs for evidence of moderate to
severe dehydration, which would manifest first as
tachycardia, then hypotension. Associated physical
examination findings include dry mucous mem-
branes, sunken eyes, decreased skin turgor, and
altered mental status. Bedside evaluation of stool,
Table 2. Key Patient History Questions for
Acute Gastroenteritis in the Emergency
Department
• What was the first symptom you noticed?
• How many episodes of loose or watery stool have you had each
day?
• Did you notice any blood in your stool?
• Have you had fevers?
• How many times have you vomited each day?
• Where is your abdominal pain? Is it improved after vomiting or
diarrhea?
• Have you had similar symptoms in the last year?
• Have you been on antibiotics for any reason in the last 3 months?
• Have you recently been out of the country or in any rural areas?
• Is anyone around you sick with similar symptoms?
• Do you live at home or in a care facility?
• Are there any small children or reptiles in the home?
• Do you engage in any anal sexual contact?
• Do you have medical conditions that affect your immune system?
• What medications do you take? Do you take any over-the-counter
medications or supplements?
• Have any of your medications changed recently or have you run out
of any of your medications?
• Do you use marijuana, opioid medications, or alcohol?
www.ebmedicine.net
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either by direct evaluation of a sample produced
by the patient or through rectal examination, can
be helpful. The presence of bloody diarrhea can be
associated with increased probability of bacterial
etiology.1 In an observational study of 889 adult and
151 pediatric patients with AGE, a negative fecal
occult blood test was a reliable indicator of a lack of
invasive bacterial etiology, with a negative predic-
tive value of 87% in adults and 96% in children. The
positive predictive value of fecal occult blood was
poor, at 24%.18
A comprehensive abdominal examination is
essential to evaluate illness severity, as well as
alternative diagnoses. Severe or focal tenderness,
particularly with rebound or guarding, is an indica-
tion for abdominal imaging. Hyperactive bowel
sounds are common in AGE; decreased or absent
bowel sounds should raise concern for an alterna-
tive diagnosis. In a prospective study of 475 pediat-
ric patients with suspected appendicitis, decreased
or absent bowel sounds were significantly associ-
ated with a final diagnosis of acute appendicitis,
although this is not sufficiently sensitive or specific
to be used in isolation.19
Diagnostic Studies
Laboratory Studies
Although AGE is essentially a clinical diagnosis in
the ED, there are some indications for chemistry
and hematology studies. Laboratory evaluation for
dehydration is strongly recommended for patients
with a history or physical examination suspicious
for moderate to severe dehydration, particularly
in infants and the elderly, as this is a key cause of
preventable mortality in these populations.1 When
sufficient clinical concern for dehydration exists, we
recommend obtaining studies of electrolytes, blood
urea nitrogen and creatinine, and lactate to evalu-
ate for complications of AGE such as hyponatremia,
hypokalemia, acidemia, acute kidney injury, and
lactic acidosis due to hypovolemia or sepsis. Signifi-
cant increases in serum creatinine are also found in
hemolytic uremic syndrome. However, there is no
general or consistent association between laboratory
abnormalities and likelihood of a bacterial etiology.20
Furthermore, there is extremely low value in white
blood cell count and differential testing for establish-
ing the cause of infection (bacterial vs viral or para-
sitic), but it may have some clinical utility in risk
stratification and determining the severity of illness.1
Hemoglobin and platelet counts are indicated if he-
molytic uremic syndrome from STEC is suspected.
March 2020 • www.ebmedicine.net
Stool Culture Testing
The decision to perform stool testing is based on
the pretest probability of isolating a pathogen when
the diagnosis would change management. This may
include the decision to treat the patient with antimi-
crobials, admit to the hospital, or alert public health
authorities. There are a number of recommendations
and clinical guidelines that are based on the higher
incidence of a bacterial etiology in patients with
fever, bloody stools, severe or prolonged illness, or
immunosuppression. Additionally, familiarity with
common host or epidemiologic associations with
bacterial causes may increase the yield of stool cul-
ture testing. (See Table 3.)
2017 IDSA guidelines state that patients with
“fever, bloody or mucoid stools, severe abdominal
cramping or tenderness, or signs of sepsis” are at
higher risk for bacterial infection and “should be
evaluated for enteropathogens for which antimi-
crobial agents may confer clinical benefit, including
Salmonella enterica subspecies, Shigella, and Cam-
pylobacter” as well as Yersinia enterocolitica, based
on moderate-quality data.1 The 2016 ACG clinical
guidelines recommend stool testing for patients with
watery diarrhea and moderate to severe illness with
fever ≥ 38.3°C (101°F) for at least 72 hours.4 Stool cul-
tures should be considered also for immunocompro-
mised patients and those with recent antibiotic use
or hospitalization.
A retrospective review of 116 ED patients with
AGE demonstrated a significantly higher likelihood
of a positive stool culture when the patient pre-
sented with fever (> 37.6°C [> 99.7°F]) or symptoms
lasting ≥ 2 days.20 A prospective multicenter study of
364 ED patients with AGE demonstrated that send-
ing a whole stool sample for analysis increases the
ability to identify a causative organism as compared
to serology and rectal swabs.5 Patients with whole
stool sent for analysis had a causative organism
identified in 49% of cases as compared to 8.7% of
cases where only a rectal swab was sent. However,
rectal swabs avoid the common ED problem of
obtaining a stool sample when a patient is unable to
provide one in a reasonable timeframe.21 Testing for
Vibrio vulnificus and Vibrio parahaemolyticus, if avail-
Table 3. Exposure/Patient Factors Associated
With Bacterial Causes Likely to be Found on
Stool Culture and Shiga Toxin Testing1
• Foodborne outbreaks involving large numbers of people
• Consumption of raw, unpasteurized, or undercooked dairy, meat,
poultry, eggs, fruits, or vegetables
• Swimming in or drinking untreated fresh water
• Healthcare, childcare, or prison environment exposure
• Travel to low-resource countries
• Exposure to reptiles, house pets, or farm animals
• Extremes of age, immunocompromise, or anal contact
7 Copyright © 2020 EB Medicine. All rights reserved.
 Clinical Pathway for Emergency Department
Management of Acute Gastroenteritis

Patient presents with ≥ 3 episodes of diarrhea in a 24-hour period

and/or ≥ 1 episode of vomiting, abdominal pain, or fever where
causes other than AGE have been excluded

Does patient meet high-risk criteria?

(Age < 3 months or > 65 years [relative], immunocompromised,
severe illness, or suspected bacteremia)

YES NO

• For bloody stools or fever and watery diarrhea for > 72 hours,
• Order CBC, electrolyte panel, lactate, blood cultures, stool
consider sending stool studies (Class II)
culture/Shiga toxin, consider Clostridium difficile and parasite
• Give antispasmodics (except for patients with grossly bloody
testing (Class II)
stools) (Class I)
• Give crystalloid IV fluids, electrolyte repletion, antiemetics,
• Give oral antiemetics (Class I)
antispasmodics (Class I)
• Give fluids and salty snacks (Class II)
• Give azithromycin 500 mg PO/IV (Class I)
• Consider piperacillin/tazobactam 4.5 g IV, or
azithromycin 500 mg IV + metronidazole 500 mg IV if penicillin
allergic, ICU-bound, or immunosuppressed (Class I) Traveler's diarrhea?

NO YES

Is there clinical improvement • Give azithromycin 1 g PO x 1

Admit to hospital NO in the ED (euvolemic, or
tolerating oral fluids, • Give ciprofloxacin 750
reassuring repeat mg PO x 1 if allergy or
abdominal examination)? contraindication
(Class I)
YES

• Discharge to home with supportive medications, hydration, diet

discussion, and return precautions/follow-up plan
• Provide work excuse note and emphasize no return to work for
food handlers or childcare workers until infection clears

Abbreviations: AGE, acute gastroenteritis; CBC, complete blood cell (count); ED, emergency department; ICU, intensive care unit; IV, intravenous; PO, by
mouth. www.ebmedicine.net

Class of Evidence Definitions

Each action in the clinical pathways section of Emergency Medicine Practice receives a score based on the following definitions.
Class I Class II Class III Indeterminate
• Always acceptable, safe • Safe, acceptable • May be acceptable • Continuing area of research
• Definitely useful • Probably useful • Possibly useful • No recommendations until further
• Proven in both efficacy and effectiveness • Considered optional or alternative treat- research
Level of Evidence: ments
Level of Evidence: • Generally higher levels of evidence Level of Evidence:
• One or more large prospective studies • Nonrandomized or retrospective studies: Level of Evidence: • Evidence not available
are present (with rare exceptions) historic, cohort, or case control studies • Generally lower or intermediate levels of • Higher studies in progress
• High-quality meta-analyses • Less robust randomized controlled trials evidence • Results inconsistent, contradictory
• Study results consistently positive and • Results consistently positive • Case series, animal studies, • Results not compelling
compelling consensus panels
• Occasionally positive results

This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual
needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright © 2020 EB Medicine. www.ebmedicine.net. No part of this publication may be reproduced in any format without written consent of EB Medicine.

Copyright © 2020 EB Medicine. All rights reserved. 8 Reprints: www.ebmedicine.net/empissues

able, is recommended in patents at risk (eg, those
with recent consumption of raw shellfish). Fecal
leukocyte testing is of extremely limited value and
should not be used in the evaluation of infectious
diarrhea in immunocompetent patients.1 Testing for
fecal leukocytes has a sensitivity for invasive bacte-
rial infection of only 42%, as compared to 79% for
fecal occult blood testing.18
Testing for Shiga Toxin-Producing Escherichia coli
Infection
Testing for STEC can guide treatment, as antibiotics
are contraindicated in STEC infection due to in-
creased risk of developing hemolytic uremic syn-
drome.22 With the exception of large-scale outbreaks
from contaminated food sources, which are com-
monly due to STEC infection, there are no classic
or definitive clinical features to indicate testing for
Shiga toxin. The laboratory standard assay for Shiga
toxin utilizes the cytotoxicity of the toxin on Vero
cells, which are derived from African green monkey
kidney.23 Over the last 40 years since this discovery
was made, a number of alternative assays have been
developed with faster turnaround times, lower cost,
and equal specificity. However, the sensitivities of
these assays vary from 77% for immunoassays to
96% for RT-PCR-based techniques.24 We recommend
testing for STEC in cases where an outbreak is sus-
pected or when treatment with antibiotics is being
considered. Due to the relative rarity of STEC infec-
tion, we do not withhold empiric antibiotics while
Shiga toxin testing is pending unless a known STEC
outbreak is occurring in the community. If toxin test-
ing is positive, the patient can be contacted and told
to stop antibiotics and be evaluated for hemolytic
uremic syndrome.
Testing for Giardia
Giardia testing should be considered if the patient
has had recent exposure to untreated fresh water;
childcare environments; or anal-genital, oral-anal,
or digital-anal contact. There are a number of com-
mercial antigen detection assays for Giardia, includ-
ing direct immunofluorescence assays (DFA) and
enzyme-linked immunosorbent assays (ELISA), as
well as a number of nucleic acid amplification assays
(NAAT). The NAAT assays are more sensitive for
the detection of active Giardia infection, though they
generally become negative shortly following initia-
tion of treatment, as Giardia DNA is rapidly cleared
in the absence of viable organisms. Also, it is impor-
tant to use caution in the interpretation of Giardia
testing, as the vast majority of people infected with
Giardia are asymptomatic, and a positive result may
reflect a Giardia carrier who is actually symptomatic
from another pathogen.25
March 2020 • www.ebmedicine.net
Testing for Immunocompromised Patients
Immunocompromised patients, particularly those
with HIV and a CD4 count of < 100 cells/mcL, are
at high risk for Cryptosporidium infection. Atypical
presentations are possible, including those with
hepatic and biliary involvement. As with most
other stool studies discussed here, there are a va-
riety of methods for detection of Cryptosporidium,
including microscopy, enzyme immunoassay, and
PCR-based techniques.
Testing for other parasitic infections, such as
Entamoeba histolytica, Cyclospora, and Microsporidium
are not generally indicated in the ED due to the low
incidence, morbidity, and mortality in the United
States.26,27 However, in patients with immunosup-
pression, or in returning travelers from low-resource
nations, testing should be discussed with infectious
disease specialists.
Testing for Clostridium difficile Infection
C difficile testing should be performed in all patients
with suspected AGE who are aged > 2 years who
have a history of recent antibiotic use or recent
hospitalization,1 because C difficile infection requires
different treatment from conventional bacterial AGE.
Patients of advanced age are also at increased risk
for C difficile colitis. However, with increases in com-
munity-acquired C difficile infection in the United
States, the at-risk population is increasing, and the
disease is being found in patients with no clear risk
factors.28 Of the hospital-based stool testing routine-
ly available, testing for C difficile infection is gener-
ally the most rapid to result. The 2018 IDSA clinical
practice guidelines for C difficile infection in adults
and children state that any patients aged > 2 years
with “unexplained and new-onset” diarrhea are the
target population for C difficile infection testing.29 For
these reasons, we maintain a low threshold to send
stool testing for C difficile infection when bacterial
etiology is suspected. Initial testing for C difficile in-
fection involves simultaneous immunoassay of liquid
stool for C difficile toxin A (enterotoxin)/toxin B (cyto-
toxin) and glutamate dehydrogenase (GDH). If the
toxin and GDH assay are positive, active infection
is likely and treatment should be initiated. If both
assays are negative, infection is unlikely. If the results
of the toxin assay are discordant with the GDH assay,
confirmatory testing with NAAT is indicated.29
Additional Stool Testing Assays
Molecular assays such as RT-PCR or enzyme im-
munosorbent assays from stool samples exist for
the viral pathogens norovirus, adenovirus, and
rotavirus, and their sensitivity in ED patients with
AGE is greater than serologic testing.5 However, it
is difficult to justify the expense of this testing, as
treatment is supportive and positive testing does
not change management. Exceptions may include
9 Copyright © 2020 EB Medicine. All rights reserved.
large-scale outbreaks or testing to ensure disease
resolution in patients with a high risk of transmis-
sion, such as healthcare or food service workers, but
would likely lie outside the realm and responsibility
of the ED.
Blood Cultures and Serologic Testing
Blood cultures are recommended for infants aged
< 3 months and patients of any age with signs of
sepsis, immunocompromise, or evidence of he-
molytic uremic syndrome.1 Blood cultures should
be considered in patients with fever of suspected
gastrointestinal etiology, recent travel to typhoid-en-
demic areas, or febrile illness of unknown etiology.1
This latter group is extremely heterogeneous with
regard to clinical presentation, and we would urge
caution in the reflexive obtaining of blood cultures
in the more well-appearing patients in this group,
particularly those who are appropriate for discharge
and outpatient follow-up.
Serologic testing is not recommended for
gastrointestinal pathogens due to the poor test
characteristics.1 In ED patients, serology testing for
norovirus was less sensitive than RT-PCR of stool
samples.5 Furthermore, this testing is often difficult
to obtain from the ED.21 Nonetheless, there may be
some value in patients with suspected postinfectious
complications, such as hemolytic uremic syndrome,
where no stool Shiga testing was performed at the
time of active infection.
Imaging
There is extremely limited utility in standard ra-
diographs for patients with AGE, with the possible
exception of suspected bowel perforation, where a
rapid diagnosis of intraperitoneal free air may expe-
dite treatment, such as IV antibiotics and surgical in-
tervention. There is some value in advanced imaging
to evaluate for complications of AGE such as aortitis,
mycotic aneurysms, toxic megacolon, abscess, or
perforation.1 For these reasons, we generally reserve
testing for patients with severe presentations or
those with immunosuppression. Additionally, IV
contrast-enhanced computed tomography or ultra-
sound may evaluate for AGE mimics, such as acute
appendicitis, if sufficient clinical concern exists.
Treatment
Initial Hydration
Oral rehydration is optimal, if tolerated. Reduced os-
molarity (245 mOsm/kg) oral rehydration solution
(ORS) is recommended as first-line treatment for
patients of all ages with mild to moderate disease.1
Although it is not appropriate for patients who have
significant nausea and vomiting, ORS packets recon-
stituted in water can be ideal for patients tolerating
oral fluids who are discharged home. ORS packets
Copyright © 2020 EB Medicine. All rights reserved. 10
are readily available in the United States from large
commercial pharmacy chains and online retailers, al-
though there is some variability in the exact compo-
sition, including the addition of artificial flavors and
colors. Commercial preparations (such as Pedialyte®,
Hydralyte®, etc) are extremely close in composi-
tion and osmolarity, but can be expensive. Sports
rehydration drinks appear to be a safe alternative
in patients with viral AGE, although hypokalemia
may persist.30 Due to the high sugar content of some
of these products, a 50% dilution with water may
be better tolerated. Coconut water is another valid
rehydration option, as it contains electrolytes.
A recent large study of children aged 6 months
to 60 months with AGE and minimal dehydration
demonstrated decreased treatment failure and need
for IV hydration with half-strength apple juice as
compared to an apple-flavored electrolyte mainte-
nance solution.31 There have also been a number of
small studies of rice-based ORS in pediatric patients
with AGE, with supportive results.32,33
IV hydration is indicated for patients with
severe dehydration, hypovolemic or septic shock,
or where oral rehydration has failed. Either lactated
Ringer’s solution or normal saline (0.9% sodium
chloride) are appropriate; there are few data to
suggest superiority of one solution over the other.34
However, recent publications comparing balanced
crystalloids to normal saline in critically ill patients
of diverse etiologies have demonstrated decreased
mortality and renal dysfunction with administra-
tion of balanced solutions such as lactated Ringer’s
as compared to normal saline.35 Once dehydration
is corrected, as demonstrated by normalization of
vital signs and urine production, patients should be
transitioned to a maintenance regimen. For infants
who are breastfeeding, this should be continued.1
Patients should be monitored closely for hypo-
glycemia and repleted orally or intravenously, as
clinically indicated. There is a theoretical advantage
in using dextrose-containing fluids as the initial IV
resuscitation fluid, to increase serum ketone clear-
ance; however, this has not been shown to decrease
the need for hospitalization in children with AGE.36
Electrolyte repletion should be provided to patients
with laboratory-shown deficits, particularly with re-
gard to potassium and magnesium. Hyponatremia is
often secondary to hypovolemia, and volume status
should be corrected before specific sodium repletion.
Symptom Control
Antinausea/Antiemetic Agents
Good-quality evidence, primarily from pediatric
studies, supports the use of oral or orally disinte-
grating tablets of ondansetron for AGE in the ED. A
2016 study of 356 children admitted to the ED with
AGE following failed oral rehydration administra-
tion demonstrated a 17% absolute reduction in the
need for IV rehydration after administration of
Reprints: www.ebmedicine.net/empissues
0.15 mg/kg of liquid ondansetron, as compared to
placebo (number needed to treat, 5.9).37 These data
are consistent with findings presented by multiple
other groups.38-40 Treatment with oral ondansetron
does not appear to reduce the rate of hospitalization
and return visits to the ED, which are relatively low
overall.40 In the only dose-response study available
in this population, there appeared to be no benefit to
higher doses of oral ondansetron when given within
the range of 0.13 to 0.26 mg/kg.41 IV ondansetron
(0.15 mg/kg, max 4 mg) appears to have efficacy
equivalent to IV metoclopramide (0.3 mg/kg, max
10 mg) in pediatric patients with vomiting second-
ary to AGE.42
In a single study comparing IV dexamethasone to
IV ondansetron and to placebo for the management
of pediatric patients with viral gastritis, IV dexa-
methasone (0.15 mg/kg, max 15 mg) conferred no
additional benefit when compared to placebo, and it
was inferior to IV ondansetron (0.15 mg/kg, no max
dose provided).43 Oral dimenhydrinate (marketed as
Dramamine® or Gravol®) also appears to have limited
to no benefit in the management of vomiting second-
ary to AGE in pediatric patients.44,45 In a study of 84
adult patients in the ED presenting with nausea and
vomiting secondary to acute gastritis/gastroenteritis,
prochlorperazine (10 mg IV) was superior to pro-
methazine (25 mg IV) for symptom relief, with fewer
treatment failures and less sedation.46
Although the studies noted provide some
guidance for dosing, a recent Cochrane review of
studies comparing first-line monotherapy found no
significant evidence to recommend one agent over
another.47 In the absence of significant differences
in efficacy, they suggested that the initial choice
of medication be guided by physician preference,
adverse-effect profile, and cost.
Additional Antinausea/Antiemetic Agent Therapies
A 2016 study of 84 ED patients with nausea demon-
strated decreased nausea after inhaling the vapors
from an isopropyl alcohol pad held 2.5 cm from
the nose, twice, 2 minutes apart, versus placebo.48
Although these were not specifically AGE patients,
the study population had high rates of associated
abdominal pain (35.1%), vomiting (32.4%), or diar-
rhea (16.2%), which suggest the results may have
generalizability to AGE patients. The same group
also recently published a study of patients who were
classified as having AGE (55.2%) or “food poison-
ing” (8.6%), reporting that isopropyl alcohol aro-
matherapy is superior to 4 mg oral ondansetron for
relief of nausea in the ED at 30 minutes, although at
longer time points, the effect seems to wane.49
Although frequently used by patients, no stud-
ies evaluating the efficacy of ginger and ginger
derivatives in patients with AGE were identified.
While there are data supporting its use in pregnant
March 2020 • www.ebmedicine.net
and postoperative patients,50,51 there are conflicting
data in chemotherapy-induced nausea and vomit-
ing.52,53 In all studies reviewed, ginger appeared to
be safe and well tolerated. The recommended dosing
is 250 mg orally, 4 times/day.
Antimotility Agents
Antimotility agents may be given to adult immu-
nocompetent patients with watery diarrhea, but
they are not a substitute for aggressive rehydration.
The 2016 ACG guideline for management of acute
diarrhea recommends providing loperamide as an
adjunct to antibiotic therapy at a dosage of 4 mg
orally initially, followed by 2 mg orally after each
loose stool (max dose, 16 mg/24 hours).4 How-
ever, the risks of loperamide therapy outweigh the
benefits in all patients aged < 3 years, as well as
those between the ages of 3 and 12 years who have
moderate dehydration, severe disease, or bloody
diarrhea.54 Although there are no studies comparing
loperamide to dicyclomine for patients with AGE,
dicyclomine is available in an intramuscular prepa-
ration that may be better tolerated in patients who
are actively vomiting. Importantly, there is very little
literature about the use of dicyclomine in patients
with AGE, and most of the evidence is extrapolated
from low-quality studies of patients with irritable
bowel syndrome or inflammatory bowel disease.
Antimotility agents such as loperamide are
contraindicated in confirmed or suspected STEC
infection due to the increased risk of developing
hemolytic uremic syndrome. In a retrospective
study of 118 pediatric patients with STEC infection,
24% of whom went on to develop hemolytic uremic
syndrome, use of antidiarrheal agents was signifi-
cantly associated with increased risk of developing
hemolytic uremic syndrome.55 A prospective cohort
study of 71 children with STEC infection found an
increased rate of hemolytic uremic syndrome among
children receiving antimotility agents, although this
was not statistically significant and the study was
not powered to detect this outcome.56
Probiotics
Probiotics are recommended to reduce symptom du-
ration and severity in immunocompetent adults and
children.1 In a study of 111 pediatric patients with
acute infectious gastroenteritis, administration of a
probiotic Streptococcus, Lactobacillus, and Bifidobacte-
rium preparation shortened the course of diarrhea by
1 day and reduced overall cost of treatment by 25%
by reducing the need for additional evaluation and
medications.57 Although the World Health Organiza-
tion recommends zinc supplementation for children
with diarrhea, in the United States, oral zinc supple-
mentation is recommended only to reduce the dura-
tion of diarrhea for severely malnourished children
aged 6 months to 5 years.1
11 Copyright © 2020 EB Medicine. All rights reserved.
Antibiotic Use in Acute Gastroenteritis
Empiric treatment with antibiotics is not indicated
for the vast majority of patients with community-ac-
quired AGE who have watery diarrhea, who are im-
munocompetent, afebrile, and have had symptoms
for < 72 hours.1,4 The vast majority of these cases are
of viral etiology, and the remainder will generally
clear spontaneously with a normal host response
and adequate supportive care. Treatment should
be reserved for patients with severe or disabling
symptoms who also have fever and/or grossly
bloody stools, with an extended duration of illness.
Consider treatment in patients who are at high risk
for development of severe disease, such as those at
the extremes of age and the immunosuppressed.
Patients with traveler’s diarrhea, particularly those
with moderate to severe disease, should also receive
antibiotic therapy due to the high likelihood of
bacterial etiology and the significant body of litera-
ture demonstrating shorter duration of illness with
treatment.58 Recommended treatment regimens are
summarized in Table 4.
In patients with uncomplicated traveler’s diar-
rhea, it is reasonable to prescribe azithromycin (1 g
orally in 1 dose, or 500 mg orally daily for 3 days)
or ciprofloxacin (750 mg orally in 1 dose or 500 mg
Table 4. Antibiotics for Suspected Bacterial Acute Gastroenteritis
Specific Factors Causative Agent
Traveler’s diarrhea Campylobacter, Salmonella, ETEC,
Yersinia
Suspected bacterial AGE and severe disease Campylobacter, Salmonella, ETEC,
or high-risk host factors (eg, extremes of Yersinia
age, immunosuppression)
Recent antibiotic use, healthcare exposure Clostridium difficile
Positive (or suspected positive) Shiga toxin STEC
stool assay
Recent shellfish ingestion Vibrio parahaemolyticus
Recent travel to low-resource, cholera- Vibrio cholerae
endemic nation
Abbreviations: AGE, acute gastroenteritis; BID, 2 times per day; ETEC, enterotoxigenic Escherichia coli; IV, intravenous; PO, by mouth; QID, 4 times per
day; STEC, Shiga toxin-producing Escherichia coli; TID, 3 times per day.
Copyright © 2020 EB Medicine. All rights reserved. 12
orally 2 times/day for 3 days) for patients returning
from Latin America,59 the Caribbean, and Africa,
where ETEC predominates. For patients returning
from South Asia and Southeast Asia where fluoro-
quinolone-resistant strains of Campylobacter are more
common, use azithromycin (1 g orally in 1 dose, or
500 mg orally daily for 3 days).7
The 2016 ACG clinical guideline recommends
empiric treatment with azithromycin 1 g orally
in 1 dose, or 500 mg orally daily for 3 days for
patients with diarrhea and either fever or severe
illness or disability due to diarrhea, as well as pa-
tients with watery diarrhea with moderate to se-
vere illness and fever ≥ 38.3°C (101°F) for at least
72 hours.4 The 3-day course should be prescribed
to patients who do not show resolution of symp-
toms after the 1-day course.
IDSA guidelines recommend empiric treatment
of suspected bacterial pathogens while culture
data are pending for infants aged < 3 months,
ill or immunocompromised patients with severe
illness and/or documented fever, bloody stools,
abdominal cramping, and tenesmus. They suggest
treatment is also indicated for recent international
travelers with temperature ≥ 38.5°C (101.3°F) and/
or signs of sepsis.1
Recommended Treatment/Alternative if
Allergy or Contraindications
• Azithromycin 1 g PO, 1 dose
or
• Ciprofloxacin 750 mg PO, 1 dose
• Azithromycin 500 mg PO/IV daily for 3 days
or
• Ciprofloxacin 500 mg PO (400 mg IV) BID for 3 days
• Vancomycin 125 mg PO QID for 10 days
or
• Fidaxomicin 200 mg PO BID for 10 days
• If unavailable, metronidazole 500 mg PO TID for 10
days
• Antibiotics not indicated; may increase risk for
hemolytic uremic syndrome
• Doxycycline 300 mg PO, 1 dose
or
• Azithromycin 500 mg PO/IV daily for 3 days
or
• Ciprofloxacin 750 mg PO daily for 3 days
• Doxycycline 300 mg PO, 1 dose
or
• Azithromycin 1 g PO, 1 dose (for pregnant patients)
or
• Ciprofloxacin 1 g PO, 1 dose
www.ebmedicine.net
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 Patients who are being admitted due to the se-
verity of presentation should be treated empirically
while stool studies are pending. For adult patients,
give either a fluoroquinolone or azithromycin, de-
pending on local susceptibility patterns and travel
history (ciprofloxacin 400 mg IV, 2 times/day for 3
days; ciprofloxacin 500 mg orally, 2 times/day for 3
days; or azithromycin, 500 mg IV daily for 3 days).
For pediatric patients, a third-generation cephalo-
sporin or azithromycin is recommended.
There are very limited data from the ED to sup-
port the use of one antibiotic agent over another;
however, there is a significant body of literature
from other settings that may be helpful once the
decision to treat has been made. In a 1992 Swedish
study of 598 patients with acute diarrhea, of whom
70% had traveled internationally in the previous 6
weeks, treatment with oral fluoroquinolone (nor-
floxacin 400 mg orally, 2 times/day), compared
with placebo, was associated with reduced time
to overall clinical cure (3 vs 4 days) as well as
more rapid resolution of diarrhea.9 Campylobacter
and Salmonella species were the most commonly
isolated organisms. Importantly, fluoroquinolone
resistance was seen in only 6% of Campylobacter
isolates. Nonetheless, these are relatively old data,
and we adhere to the current recommendations to
use azithromycin as first-line therapy.
A 2010 Cochrane review of 16 clinical trials of
antibiotic treatment for Shigella infection demon-
strated decreased duration of illness with antibiotic
treatment. There was significant variability in the
antibiotic regimens utilized, including fluoroquino-
lones, macrolides, trimethoprim-sulfamethoxazole,
and beta-lactams, with no clear indication of superi-
ority of one regimen over another.60 Similar results
were presented in a 2007 meta-analysis of random-
ized controlled trials comparing antibiotic treatment
to placebo in Campylobacter gastroenteritis.61 Patients
treated with antibiotics (either fluoroquinolone or
macrolide) had resolution of diarrhea 1.3 days faster
than those treated with placebo, although no regi-
men was clearly superior.61
STEC or E coli O157 infections should not be
treated with antibiotics due to a lack of data to sup-
port efficacy while possibly increasing the risk of
hemolytic uremic syndrome. Additionally, there is
no indication for treatment or prophylaxis of asymp-
tomatic close contacts of treated patients, although
infection prevention and control techniques should
be emphasized.1
Treatment for Parasitic Infection
Some cases of giardiasis are self-limited, and treat-
ment can be withheld in well-appearing patients
with mild symptoms, particularly when microbio-
logic testing is pending. However, the vast major-
ity of patients who are located in a resource-rich
March 2020 • www.ebmedicine.net
environment and are symptomatic from laboratory-
proven Giardia infection or have an extremely high
pretest clinical probability of Giardia infection should
be treated. The preferred initial treatment is tinida-
zole due to efficacy of > 90%, low cost, and ease of
the single-dose strategy (adults: 2 g orally in a single
dose; children: 50 mg/kg orally in a single dose).25
If tinidazole is not readily available, and for chil-
dren aged < 3 years, an alternative strategy includes
metronidazole (adults: 500 mg orally 2 times/day
for 7 days; children: 15 mg/kg orally 3 times/day
for 7 days). Pregnant patients, particularly in the
first trimester, should receive paromomycin (10
mg/kg orally, 3 times/day for 5-10 days) due to the
extremely low systemic absorption.
Because most cases of Cryptosporidium are self-
limited in healthy and immunocompetent patients,
empiric treatment is generally not indicated. Treat-
ment is indicated for patients with severe disease,
prolonged symptoms (> 1-2 weeks), or immuno-
compromise. First-line therapy for adult patients is
nitazoxanide 500 mg orally 2 times/day for 3 days.
Suspected or confirmed Entamoeba histolytica,
Cyclospora, or Microsporidium treatment from the
ED is extremely rare and should be discussed with
infectious disease consultants, as patients requiring
treatment often have significant comorbidities and
treatment will require admission or close outpatient
follow-up.
Vaccination Status
Vaccines exist for rotavirus, Salmonella Typhi serovar
(typhoid fever), and V cholerae (cholera). Only the
rotavirus vaccine is routinely provided to children in
the United States. This vaccine has resulted in a 57%
decrease in rotavirus-associated ED visits, with an
80% decrease in hospitalizations for rotavirus infec-
tion between 2006 and 2017.62
Diet
There are very little data to inform the discus-
sion of dietary choices in patients recovering from
AGE. There are no specific recommendations for
diet in AGE patients in the most recent AGE clini-
cal practice guidelines, while IDSA clinical practice
guidelines state that “age-appropriate usual diet is
recommended during or immediately after the rehy-
dration process is completed.” This recommendation
is based on low-quality data.1,4 Before advancement
of the patient’s diet is considered, we recommend
demonstrated tolerance of aggressive oral hydration
with water and electrolyte solutions (ORS, Pedia-
lyte®, diluted sports drinks, or apple juice). The
“BRAT” diet (banana, rice, applesauce, and toast)
has not been studied directly in ED patients, but has
been included in research protocols for ED patients
with AGE.39 Although patients recovering from AGE
have limited capacity for digestion of fat, lactose,
13 Copyright © 2020 EB Medicine. All rights reserved.
and sucrose, the BRAT diet has been criticized for
going too far and not providing complete nutrition
to support patients recovering from AGE.63 The use
of this diet is currently controversial and is not sup-
ported by any convincing data.
Infection Precautions
Many causes of AGE are contagious, and good
hand-hygiene practices are extremely important to
reduce spread to close contacts. One notable ex-
ception would be illness arising from a preformed
toxin-mediated infection, as in S aureus or B cereus,
although this is generally impossible to determine
in the ED. Furthermore, IDSA guidelines state that
“people with diarrhea who attend or work in child-
care centers, long-term care facilities, patient care,
food service, or recreational water venues should
follow jurisdictional recommendations for reporting
and infection control.”1
Special Populations
The vast majority of AGE cases are self-limited and
do not require any therapy beyond basic supportive
care. However, immunocompromised patients (such
as those with HIV/AIDS or on immunosuppres-
sive medications) or at extremes of age (< 3 months
or > 65 years) are at higher risk for clinically severe
disease and subsequent morbidity and mortality. In
these patients, we recommend more extensive ED
workup and treatment due to the higher risk of bac-
terial and parasitic infection, particularly from Cryp-
tosporidium, Cyclospora, Cystoisospora, Microsporidia,
Mycobacterium avium-intracellulare complex, and cy-
tomegalovirus. For these patients, there should be a
low threshold for obtaining stool and blood cultures,
hematology and chemistry studies, and abdominal
imaging to evaluate for complications of AGE. IDSA
guidelines emphasize a role for empiric antibiotic
treatment in immunocompromised patients, and
avoidance of probiotics due to questionable efficacy
and possible risk of complications.1 Loperamide is
safe for immunocompromised patients with acute
watery diarrhea.
Controversies and Cutting Edge
Proton-Pump Inhibitors and H2 Blockers
Although not a new idea, there is growing evidence
that use of proton-pump inhibitors (PPIs) or hista-
mine H2-receptor antagonists (H2 blockers) is a risk
factor for AGE and infectious colitis. A prospective
study of 186 pediatric patients with a median age
of 10 months (91 with diagnosed gastroesophageal
reflux disease and 95 healthy controls) found that
taking a PPI or an H2 blocker was associated with a
27% increased rate of AGE as compared to untreated
patients (20% vs 47%) over a 4-month follow-up pe-
Copyright © 2020 EB Medicine. All rights reserved. 14
riod.64 Additionally, PPI use increases susceptibility
to Salmonella, Campylobacter jejuni, invasive strains
of E coli, V cholerae, and Listeria.65 There are also
some data to support an increased incidence and
recurrence of C difficile infection in patients taking
a PPI.66,67 Although there are no formal guidelines
at this time to suspend PPI therapy in patients with
AGE, based on these data, it is reasonable to make
this recommendation to ED patients with AGE until
their symptoms resolve.
A similar rate of AGE has been noted in patients
on H2-blocking medications, due to the common
endpoint of gastric acid suppression.64,68 Therefore,
it is reasonable to hold these medications during an
episode of AGE. However, there are fewer high-
quality studies that address this question, and many
recent reports evaluating this combine patients on
PPI with those on H2-blocking medications, making
the relative risk of H2-blocking medications on time
to resolution of AGE less clear.
Postinfectious Irritable Bowel Syndrome
Postinfectious irritable bowel syndrome (PI-IBS)
describes the phenomenon of persistent abdominal
pain and diarrhea following an episode of AGE. This
was first proposed over 5 decades ago and has since
been described in over a dozen prospective stud-
ies, many of which utilized laboratory-confirmed
Shigella, Campylobacter, Salmonella, or E coli gastro-
enteritis as inclusion criteria.69 This appears to be
a global phenomenon, with the incidence ranging
from 5% to 32%, depending on the study population
and methodology. Risk factors for the development
of PI-IBS include younger age, female sex, bloody
stools, abdominal cramps, weight loss, and pro-
longed diarrhea.70 As with irritable bowel syndrome,
PI-IBS appears to have an association with psychiat-
ric disease, particularly anxiety disorder.71 However,
increased T lymphocyte counts, expression of IL-1,
and increased small intestine permeability are also
seen in PI-IBS, suggesting a mechanism beyond
functional disorders.72-74 Management is generally
supportive, and multiple specific strategies have
been proposed, including loperamide, probiotics,
and tricyclic antidepressants, although none have
high-quality evidence to support their use.75
Disposition
Discharge from the ED requires normalization of
volume status and demonstrated ability to maintain
hydration. Patients should be clinically euvolemic,
with normal heart rate and blood pressure, moist
mucous membranes, and must be tolerating oral
fluids and medications without difficulty. Patients
for whom there is concern for sepsis/bacteremia
should not be discharged to home. Any significant
electrolyte abnormalities should be corrected, and
Reprints: www.ebmedicine.net/empissues
patients should have a clear plan for follow-up. We
find it particularly useful to discuss the expected
progression of their symptoms and the importance
of return to the ED if their trajectory appears to be
worsening or does not improve. We specifically
emphasize the importance of hydration, includ-
ing the need for increased fluid intake as diarrhea
persists, as well as observing urine output and
color as a simple method to assess fluid intake. If
a decision was made to forego advanced imaging,
carefully document serial abdominal examinations,
the decision-making process, and the communica-
tion of return precautions.
Aside from persistently abnormal vital signs or
the inability to maintain hydration status, hospital
admission should be considered for patients with or
at risk for severe disease until they have demonstrat-
ed that they are improving clinically. This includes
immunocompromised patients, those at the ex-
tremes of age (< 3 months and > 65 years), and those
with significant laboratory or imaging abnormalities.
Follow-up Recommendations
Patients being discharged from the ED should be
given a clear follow-up plan. Any patient with
persistence of symptoms should be seen within 48
hours by a healthcare professional. Furthermore,
IDSA guidelines do recommend follow-up stool
testing for certain Salmonella and Shigella subtypes
in patients who present a high risk of transmission
to others, such as childcare and commercial kitchen
workers.1 The decision to test should be made in col-
laboration with local public health authorities and
is outside of the scope of routine ED care, although
patients may present to the ED requesting this test-
ing due to lack of other follow-up options.
Summary
AGE is a common clinical diagnosis made in the ED
in patients presenting with diarrhea and vomiting,
often with associated fever and abdominal pain, that
is due to an infectious cause. An acute episode lasts
for < 14 days, and longer courses of illness are classi-
fied as persistent (14-29 days) or chronic (> 29 days),
with a shorter duration favoring viral and bacterial
causes and longer courses increasing the probability
of a parasitic infection. Many high-risk conditions
can mimic AGE, most commonly acute appendicitis,
but can also include bowel obstruction, peptic ulcer
disease with upper gastrointestinal bleed, diver-
ticulitis, mesenteric ischemia, as well as IBD, IBS,
and food allergy or intolerance. Many poisonings
can present with nausea, vomiting, and diarrhea,
including organophosphate poisoning, lithium or
colchicine toxicity, opioid withdrawal, and thyrotox-
icosis. The majority of cases of AGE seen in the ED
are self-limited and resolve with minimal workup
March 2020 • www.ebmedicine.net
and with focused supportive care. This generally
includes antiemetics, ORS (or similar product), and
antispasmodics. Patients with immunosuppression,
extremes of age, or severe presentations may require
more extensive workup, including stool cultures,
laboratory studies, imaging, and IV hydration with
empiric antibiotics.
Case Conclusions
You explained to the 42-year-old man that one of the ben-
efits of being relatively young, healthy, well-appearing,
and having a history without significant risk factors is
that there is no benefit to laboratory testing, which will
only increase the time and expense of his ED visit. You
gave him ondansetron 4 mg ODT, and after 1 hour, you
gave him loperamide 4 mg PO. He was then able to drink
1 L of water without vomiting. He appeared euvolemic
and his tachycardia resolved. He reported that his abdomi-
nal discomfort had improved, and he had no tenderness on
repeat exam. He was discharged, following a discussion
of the recommended supportive care regimen, as well as
return precautions and the importance of follow-up for re-
examination and to ensure resolution of symptoms. You
called him 2 days later, and he reported that all symptoms
had resolved, and he was back to work.
The 68-year-old diabetic patient from the assisted-
living facility who had diarrhea and fever was given 40
mL/kg of IV crystalloid fluid, but did not produce any
urine in the ED. She tolerated acetaminophen 1 g PO
without vomiting, after administration of ondansetron 4
mg IV, but told you that she couldn’t drink more than a
few sips of water without feeling the need to vomit. She
had several large-volume episodes of grossly bloody diar-
rhea, which you sent for bacterial culture. Lab evaluation
demonstrated mild leukocytosis, hyponatremia, hypo-
chloremia, and an elevation of her serum creatinine to
150% of her recent baseline without any other significant
abnormalities. Her lactate was 1.9. Due to her moderate
dehydration and inability to adequately take oral fluids,
you admitted her to the hospital for continued IV hydra-
tion and antiemetic therapy. With the high pretest prob-
ability for bacterial AGE, you administered azithromycin
500 mg PO, which she tolerated. She improved in the hos-
pital and was discharged 2 days later, as her stool culture
returned positive for Salmonella enterica. The local health
department conducted an investigation and determined
that 4 other residents of her assisted-living facility also
became ill with salmonellosis, which they obtained from
the kitchen worker who was preparing food while ill.
For the 34-year-old patient with recently diagnosed
AIDS, you obtained IV access and provided crystalloid
boluses, which normalized his heart rate. He remained
nauseated following administration of ondansetron,
metoclopramide, and IV fluids. His lab studies were
unremarkable. His abdominal CT showed diffuse colonic
wall thickening with liquid stool, diffuse mild lymphade-
nopathy, and no evidence of obstruction or perforation.
15 Copyright © 2020 EB Medicine. All rights reserved.
You sent blood cultures and stool studies for bacterial
culture, C difficile toxin assay, as well as specific studies
for Giardia, Cryptosporidium, Isospora, and Cyclospora,
because of his immunosuppression. Your ID consultant
requested that you hold antibiotics until a pathogen was
confirmed, out of concern for antibiotic-associated compli-
cations. You admitted the patient to the internal medicine
service, and learned the following week that his sigmoid
biopsy returned positive for cytomegalovirus. You noted
that he had improved since the initiation of ganciclovir
and antiretroviral therapy, and discharge was planned for
the next day.
Risk Management Pitfalls for Managing Patients with Acute Gastroenteritis
in the Emergency Department (Continued on page 17)
1. “The patient said she has had fever, vomiting,
and abdominal pain for the last day, and just
had an episode of diarrhea. I was certain it
was AGE and never suspected she had pelvic
inflammatory disease.”
Many serious conditions can mimic AGE. A
careful history, including the frequency, volume
and consistency of all stool output, as well as
a comprehensive physical examination that is
appropriately documented in the medical record
are essential to avoid misdiagnosis.
2. “The patient has been having > 5 episodes of
vomiting and diarrhea every day for the last 2
days. He was tachycardic, but had a good blood
pressure. He was able to drink a cup of water,
so I thought he was good to go home. I never
thought he would return septic.”
Although tolerance of oral fluid intake is
a requirement for discharge, patients with
persistent vital sign abnormalities may have
moderate to severe dehydration. Evaluation for
common complications of dehydration such
as electrolyte abnormalities and acute kidney
injury should be conducted, and the patient
should be resuscitated with IV fluids.
3. “My patient just returned from the Democratic
Republic of the Congo, and has been having
large volumes of watery diarrhea. I decided to
treat him for traveler’s diarrhea with empiric
antibiotics and discharge him. He should be
better in a few days.”
A patient with diarrhea returning from a low-
resource country may have traveler’s diarrhea,
but consideration should be given to other more
severe causes of AGE. This is particularly true
when the patient is returning from a nation
where cholera epidemics are common.
Copyright © 2020 EB Medicine. All rights reserved. 16
Time- and Cost-Effective Strategies
• Laboratory and stool testing add additional cost
and time to the ED visit. The vast majority of pa-
tients presenting with suspected AGE will have
no significant risk factors, normal vital signs,
and a reassuring abdominal examination. There
is rarely an indication for further testing in these
patients. We suggest that this time should be
spent using oral medications with oral hydra-
tion and documenting clinical improvement and
a repeat abdominal examination.
• Overutilization of advanced imaging in patients
with suspected AGE exposes patients to ion-
4. “This healthy older woman has been having
> 5 unformed stools daily with nausea, vomit-
ing, fever, and abdominal pain that are classic
for AGE. She was pretty tender when I exam-
ined her abdomen, but she must have a very
low pain tolerance. I don’t need to image her,
I’ll just treat her pain.”
Even patients with a classic presentation
for AGE and no significant risk factors may
develop more serious complications, such as
bowel perforation. Ignoring the findings of
your abdominal examination or performing an
inadequate examination can lead to missing
these potential complications, leading to
significant morbidity and mortality.
5. “This healthy young man has had fever, vomit-
ing, and grossly bloody diarrhea for the last
day. He’s looking and feeling better after some
oral medications and oral fluids. He probably
has viral gastroenteritis, so there's no need to
do any workup.”
Patients with grossly bloody stools are a
minority of AGE patients seen in the ED,
and they are significantly more likely to have
bacterial infection. Withholding empiric
antibiotics is acceptable in patients with a
documented improvement in the ED and no
high-risk features, but at a minimum, laboratory
studies and a stool culture should be sent to
guide therapy in case the patient does not
continue to improve at home.
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 izing radiation with generally very little benefit.
Patients who are immunocompetent, nontoxic,
with nothing more than mild and diffuse ab-
dominal tenderness, and ≥ 1 episode of vomiting
and/or ≥ 3 episodes of diarrhea in a 24-hour
period rarely benefit from advanced imaging.
One exception to this would be a patient with
periumbilical pain or focal right lower quadrant
tenderness and no previous appendectomy.
At this time, there is no clinical scoring system
that has adequate sensitivity to exclude acute
appendicitis, which remains a common misdi-
agnosis for AGE, carrying significant risk for the
patient.76,77
Risk Management Pitfalls for Managing Patients with Acute Gastroenteritis
in the Emergency Department (Continued from page 16)
6. “This patient just returned from Thailand with
vomiting and watery diarrhea. I think he can
go home, but he needs antibiotics. I will give
him a week of ciprofloxacin and metronida-
zole. After all, 2 antibiotics are better than 1.”
Overtreatment can be just as bad for your
patients as undertreatment. First-line therapy
for a patient with traveler’s diarrhea should be
azithromycin 1 g orally in 1 dose or ciprofloxacin
750 mg orally in 1 dose if there is allergy or
contraindication. Extended courses of multiple
antibiotics only increase the patient’s risk for an
antibiotic-associated complication. Follow-up
is imperative, to extend the course of treatment
if symptoms persist longer than 24 hours after
initial dose.
7. “Sally must have picked up AGE from daycare.
She had a fever and 2 diarrhea-soaked diapers
in the last hour. She is feeling better now, and
her mother wants to take her home because her
husband is alone at home taking care of their
other children. I put the discharge paperwork
up after her nurse said that Sally drank some
apple juice. Her mom has 3 other children, so
I’m sure that she knows how to take care of
this kind of thing.”
It is essential to provide to discharged patients
and their families appropriate strategies to
prevent spread of infectious diarrhea. At a
minimum, this should include a discussion of
good hand-washing techniques, staying home
until the acute phase of illness has passed, and
avoidance of food preparation.
March 2020 • www.ebmedicine.net
• Patients with persistent diarrhea without a se-
vere presentation or significant risk factors gen-
erally need workup and follow-up, but might
lack a primary care provider. Many communities
have outpatient resources for management of
infectious diseases, such as a hospital infectious
disease clinic or local public health clinic. Using
case management to identify these resources in
your community can save significant time in the
ED, as these patients can be rapidly evaluated
and discharged with appropriate follow-up care.
8. “She was feeling better in the ED after medi-
cation and drank a cup of water, so I told her
she’d be fine and sent her home. I figured that
if she gets worse, she will know to come back.”
Tolerance of oral fluids is important, but so
is a detailed description of the recommended
supportive care regimen, including quantities
of fluid, expected urine output, role for
antispasmodics, and diet recommendations.
Most important are specific indications for
return and a follow-up plan.
9. “This patient with AGE told me that he has
HIV, but doesn’t know his last CD4 count or
his viral load. He thought it was normal, but
admitted that he often doesn’t fully understand
the conversations with his infectious disease
specialist. I’m sure that his HIV is well
controlled.”
Patients with HIV and a normal CD4 count can
be managed in the same manner as a patient
without HIV, but confirming this information is
essential if there is any concern, as management
of the immunosuppressed patient is entirely
different.
10. “He has had nausea, diarrhea, and abdominal
cramping for the last 3 weeks. That sounds like
a severe infection. I will treat him for bacterial
gastroenteritis with azithromycin and send
him home. No need to send any testing.”
Persistent diarrhea (> 14 days) has a differential
diagnosis beyond bacterial AGE, including
parasitic causes. Be sure to obtain a complete
history, including a travel history, and send the
appropriate laboratory and stool studies to make
the correct diagnosis.
17 Copyright © 2020 EB Medicine. All rights reserved.
 Appendix 1. Organisms Associated With Acute Gastroenteritis in the United States (Continued on page 19)
Organism Incidence, Incubation Average Duration Principle Modes of Key History (in Order of Physical Findings Potential Comments
per year Period of Illness Transmission Incidence) Complications

Bacterial/Toxin Organisms

Campylobacter 1.3 million 1-7 days 2-10 days Food-borne Periumbilical abdominal Often with Cholecystitis, Early presentation is often
(contamination from cramping, diarrhea, fever periumbilical rash, pericarditis highly suggestive of
undercooked poultry), (1/3 of cases), vomiting or right lower and myocarditis, acute appendicitis
dog or cat feces (15%-25% of cases) quadrant reactive arthritis,
tenderness Guillain-Barré
syndrome
Salmonella enterica 1.2 million 1-3 days 4-7 days Person-to-person, Diarrhea (generally Nonspecific Endocarditis, Asymptomatic carriage
food-borne nonbloody), vomiting, fever, mycotic aneurysm, and excretion for an
abdominal cramping visceral abscesses, average of 5 weeks
and osteomyelitis are common following
infection
Enterotoxigenic 660,000 1-2 days 1-3 days Person-to-person, Watery diarrhea and Nonspecific Unlikely Most likely causative

Copyright © 2020 EB Medicine. All rights reserved.

Escherichia coli food-borne abdominal cramping (vast agent of traveler’s
majority), vomiting (20%) diarrhea
and fever (< 15%)
Clostridium difficile 500,000 1-10 days Variable Recent antibiotic use, Watery diarrhea, abdominal Severe cases may Toxic megacolon Severe cases require

18
person-to-person pain, low-grade fever appear toxic, with admission, antibiotics,
marked abdominal and surgical consultation
tenderness
Shigella 500,000 1-7 days 7 days Person-to-person Abdominal pain, diarrhea Nonspecific Proctitis, toxic Vomiting occurs in a
(mucoid, bloody, or watery), megacolon, bowel minority of patients
fever, vomiting, tenesmus obstruction/
perforation
Shiga toxin- 265,000 1-12 days 4-14 days Food-borne, Bloody diarrhea, abdominal Nonspecific Hemolytic uremic Fever is rare
producing contaminated water, pain syndrome
Escherichia coli unpasteurized dairy
products, animal or
human fecal-oral route
Staphylococcus 241,000 1-8 hours 24 hours Food-borne Nausea, vomiting and Nonspecific Unlikely Associated with improper
aureus toxin abdominal cramping; most storage of prepared
patients also have diarrhea foods
Yersinia 117,000 1-14 days 12-22 days Food-borne (raw or Diarrhea, abdominal pain, Often with Ileitis and colitis, Can be suggestive of
enterocolitica (typically undercooked pork) fever, pharyngitis (in up to periumbilical perforation, acute appendicitis
4-6 days) 20% of cases) or right lower intussusception,
quadrant ileus, cholangitis
tenderness
Bacillus cereus toxin 21,000 1-16 hours 6-48 hours Food-borne Usually either vomiting or Nonspecific Meningitis and Associated with improper

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diarrhea predominate, pneumonia in storage of prepared
depending on which toxin is immunosuppressed foods
present patients
www.ebmedicine.net
 Appendix 1. Organisms Associated With Acute Gastroenteritis in the United States (Continued from page 18)
Organism Incidence, Incubation Average Duration Principle Modes of Key History (in Order of Physical Findings Potential Comments
per year Period of Illness Transmission Incidence) Complications

Vibrio parahaemo- 45,000 4-96 hours 1-7 days Contaminated shellfish Diarrhea, abdominal Nonspecific Bacteremia, 80% of illnesses occur
lyticus cramping, vomiting, and particularly in between May and
fever (most cases); diarrhea patients with liver October, when waters
may be bloody in a minority disease are warmer; also
of cases causes wound infections
after exposure to
contaminated lakes and
rivers

March 2020 • www.ebmedicine.net

Vibrio cholerae United States- 1-5 days Variable, Contaminated food Profuse watery diarrhea, Often associated Dehydration- United States-acquired
acquired depending on or water; fecal/ vomiting, muscle cramps with markers associated cases are generally
cases are treatment (oral oral transmission is of severe metabolic disarray associated with
very rare. rehydration common in outbreak dehydration such consumption of shellfish
Cases in solution, as dry mucous from the Gulf of Mexico
returning intravenous membranes,
travelers are fluids, antibiotics) tachycardia,
estimated to lethargy
be < 100
Viral Organisms

19
Norovirus 19-21 million 1-2 days 12-60 hours Person-to-person/ Vomiting, watery diarrhea, Nonspecific Unlikely Common agent for
fecal-oral abdominal cramping are outbreaks in food service
very common; fever in 50% areas, healthcare
of cases facilities, schools,
prisons, and cruise ships
Rotavirus No reliable 1-2 days 1-20 days Fecal/oral, with very Watery diarrhea, vomiting, Nonspecific in mild Encephalitis, Vast majority of cases are
estimates in few viruses required respiratory symptoms (30%- cases seizures in patients aged 3-36
postvaccine for transmission 50% of cases), fever (1/3 of months
era, but likely cases)
remains in
millions

Parasitic Organisms

Giardia 15,000 1-3 weeks 2-6 weeks Fecal/oral, Diarrhea, flatulence, greasy Nonspecific; Irritable bowel Most common parasitic
contaminated drinking stool, abdominal pain may have mild syndrome cause of acute
water, food-borne abdominal gastroenteritis in the
distension United States
www.ebmedicine.net

Copyright © 2020 EB Medicine. All rights reserved.

References choice for patients with ciguatera fish poisoning? Clin Toxicol
(Phila). 2017;55(9):947-955. (Review)
17. Feng C, Teuber S, Gershwin ME. Histamine (scombroid) fish
Evidence-based medicine requires a critical ap- poisoning: a comprehensive review. Clin Rev Allergy Immu-
praisal of the literature based upon study methodol- nol. 2016;50(1):64-69. (Review)
ogy and number of subjects. Not all references are 18. McNeely WS, Dupont HL, Mathewson JJ, et al. Occult blood
versus fecal leukocytes in the diagnosis of bacterial diarrhea:
equally robust. The findings of a large, prospective,
a study of U.S. travelers to Mexico and Mexican children.
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as the type of study and the number of patients in the
(Prospective; 475 patients)
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261 patients) 5. For patients with AGE, stool cultures should
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Alvarado score and Pediatric Appendicitis core for the di-
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agnosis of acute appendicitis in children. Pediatr Emerg Care. a. For all patients, regardless of other factors
2015;31(3):164-168. (Prospective; 311 patients) b. For all patients with any recent travel
history
CME Questions c. For patients with grossly bloody stool
d. For all patients aged < 18 years

Take This Test Online! 6. For patients with AGE, empiric antibiotics are
indicated:
Current subscribers receive CME credit absolutely a. For all patients
free by completing the following test. Each issue b. For patients with > 14 days of symptoms
includes 4 AMA PRA Category 1 CreditsTM, 4 ACEP c. For all patients with positive stool cultures
Category I credits, 4 AAFP Prescribed credits, or d. For patients returning from low-resource
Take This Test Online!
4 AOA Category 2-A or 2-B credits. Online testing countries
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receive your free CME credits for this issue, scan 7. The best empiric coverage for traveler’s diar-
the QR code below with your smartphone or visit rhea is:
www.ebmedicine.net/E0320. a. Azithromycin 1 g orally, in 1 dose
b. Ciprofloxacin 500 mg orally, 2 times/day for
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c. Metronidazole 500 mg orally, 3 times/day
for 7 days
d. Empiric coverage is not indicated

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8. Patients with acute gastroenteritis should eat:
a. Nothing solid for the first 48 hours
b. Their normal diet, immediately
c. Their normal diet, after a rapid
advancement from clear liquids to salty
foods such as broth or crackers
d. The “BRAT” diet (banana, rice, applesauce,
toast)
10. Patients who develop chronic diarrhea follow-
ing an episode of AGE may be experiencing:
a. Viral AGE
b. Postinfectious irritable bowel syndrome
c. Colon cancer
d. Colchicine toxicity

9. Provide observation for AGE patients who:

a. Are aged < 3 months
b. Have AIDS
c. Have recently undergone chemotherapy
d. All of the above

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 CME Information
Date of Original Release: March 1, 2020. Date of most recent review: February 10, 2020.
Termination date: March 1, 2023.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical
Education (ACCME) to provide continuing medical education for physicians. This activity has been
9
December 201 12
Number
planned and implemented in accordance with the accreditation requirements and policies of the
and-Triggers
Volume 21,
ACCME.
The Timing- e Patient
Author P
MD, FACE ency Medicine, Beth Israel
A. Edlow, Medicine,
Jonathan of Emerg
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Dizziness
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MD, RDMS ency Medicine, Directoine-

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Associate Profes sity
Univer
Ultrasound,
of Emergency FL
Jacksonville,
Jacksonville,

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department. now focusing quality (vert
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for 2 Stroke
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Pharmacy

Joseph D.
Residency, AZ
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Physicians for 48 hours of ACEP Category I credit per annual subscription.
ent MPH,
Hoxhaj, MD, Jackson Assistant ncy Medicin ent of Emerge
managem Shkelzen Department
of Emerge ity, Chief, DepartmRamon Regional

AAFP Accreditation: This Enduring Material activity, Emergency Medicine Practice, has been
Medical Officer, Jefferson Univers e, San , CA
MD Chief l, Miami, FL Thomas Medicin San Ramon
Daniel J. Egan,
of
Vice Chair ial Hospita
Philadelphia,
PA Medical Center,
Professor, ncy Memor
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Eric Legom
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St.
Robert Schille ent of Family Medicin Internation
Andy Jagoda Chair, Department Medicine, of Physicians
and
& Mount Sinai Chair, Departm Senior on, MD
Medical Center; Peter Camer

reviewed and is acceptable for credit by the American Academy of Family Physicians. Term of
Sinai West Affairs for Alfred
Professor
and
e; Director, Vagelos College York, NY Academic Beth Israel Medicine and Director, The Centre,
ncy Medicin New Vice Chair, Mount Sinai Faculty, Family School of Academic
of Emerge Medicine Surgeons, Medicine, Health, Icahn Emergency
and Trauma
Emergency Emergency of
Community York, NY Melbourne,
Center for Resear ch, Icahn s Genes, MD,
PhD
ent of System , Icahn School York, NY at Mount Sinai, New Monash University,
and Nichola Health New e
Education Mount Sinai, Professor,
Departm Mount Sinai, Medicin
Australia
Medicine at Associate Icahn School Medicine at , MD, FACEP
School of Medicine,

approval begins 07/01/2019. Term of approval is for one year from this date. Physicians should
Emergency MD, MS Scott Silvers of Emergency MD
New York,
NY Sinai, New Keith A. Marill, Department Professor Andrea Duca, Physician,
e at Mount Professor, Associate of Facilities
and
Emergency
hief of Medicin Associate Medicine, Chair Clinic, Jacksonville,
FL Attending
Editor-In-C York, NY Medicine,
Harvard
le Papa Giovan
ni XXIII,
Associate MD, FACEP FACEP of Emergency Massachusetts
, Plannin g, Mayo Ospeda
Gibbs, MD, Medical School l, Boston, MA FACP, FACEP Bergamo,
Italy
Kaushal Shah, Vice Chair Michael A. Department Slovis, MD,
Professor, Peeters, MD

claim only the credit commensurate with the extent of their participation in the activity. Approved
and Chair, General Hospita Corey M. ent
Associate ent of Professor e, Carolinas MA, MD, Chair, Departm Suzanne Y.G. Physician,
for Educat
ion, Departm
Weill Cornell
ncy Medicin ity of North Pollack Jr., Professor and Medicine, Vanderbilt Emergency
Medicine,
of Emerge Charles V. e, TN Attending Almere,
Emergency NY Univers
Medical Center, of Medicine, Chapel , FAHA, FESC of Emergency l Center, Nashvill g Hospital,
New York, FACEP, FAAEM for Flevo Teachin
Medicine, & Senior Advisor University Medica
School of Carolina School Professor and The Netherl
ands
Hill, NC y Research MD of dez, MD,
FIFEM
Ron M. Walls, COO, Department

for 4 AAFP Prescribed credits.

InterdisciplinarDepartment of
Editorial Board
ncy
Godwin, MD,
FACEP
Trials, Kimmel Profess or and Brigham and Edgardo Menen e and Emergea
FACEP A. ent Clinical Sidney ne, or in Medicin
Saadia Akhtar,
MD, of Steven
and Chair,
Departm Medicine, Jefferson Emergency
Medici l Profess EM, Churruc
Department Professor e, Assistant Emergency of Thomas Harvard Medica Director of ity,
Professor, Dean Hospital, Medicine; Aires Univers
Associate Associate ncy Medicin ion, Medical College lphia, PA Women's l of Buenos
Medicine, of Emerge Educat , MA Hospita
Emerge ncy Education, ion
Dean, SimulatFlorida COM- University,
Philade School, Boston Argentina
te Medical MPH rs Buenos Aires,
for Gradua r, Emergency University
of FL Radeos, MD,Emergency Care Edito sarntikul,
MD
Program Directo cy, Mount Sinai Jacksonville, Michael S. al ol Rojana

AOA Accreditation: Emergency Medicine Practice is eligible for 4 Category 2-A or 2-B credit hours
nville, or of Critic , Dhanad Emerge ncy
Profess Physician,
Medicine ResidenYork, NY
Jackso MBA Associate l College MD, FACEP Attending
ushe, MD Weill Medica Knight IV, ngkorn
Beth Israel,
New Joseph Habbo or of Emerge
ncy Medicine, ity, New York; of William A. Medicine,
King Chulalo of
nt Profess Univers ent ncy l; Faculty
Assista and of Cornell FNCS of Emerge Memorial
Hospita University,
Brady, MD NYU/Langone , New York, Director, DepartmYork Professor Medical
William J. ncy Medicin
e
Medicine, Research Associate Neurosurgery, Chulalongkorn
of Emerge Director, l Centers Medicine,
New Medicine,
Professor Bellevue Medica Emergency Medicine and

per issue by the American Osteopathic Association.

NY
e; Medical LLC , Flushing, Advanced
Practice
Medical Thailand
MD Aware Hospital Queens Director, EM
and Medicin
Management,
UVA NY; CEO, ; Associate s, MD, MPH
Emergency Medical FACEP MD, MBA,
MPH
Provider Program University Stephen H. Thoma
Operational Henry, MD, Ali S. Raja, Emergency cience ICU, ncy
& Chair, Emergel Corp.,
Medical Center; rle County Fire Gregory L. ent of
or, Departm ity Vice Chair, Director, Neuros ati, OH Professor
Clinical Profess Executive General ati, Cincinn Hamad Medica
Director, Albematesville, VA Medicine,
Univers
Medicine,
Massachusetts or of of Cincinn Medicine,
Medical College
, Qatar;
Rescue, Charlot Emergency School; CEO, te Profess rt, MD, FCCM e;
n Medical ment, Hospital; Associa e and Radiolo
gy,
Scott D. Weinga Medicin Weill Cornell
Physician-in-C
hief,
of Michiga e Risk Assess Emergency

Needs Assessment: The need for this educational activity was determined by a survey of medical
Brown III,
MD Medicin
, Boston, MA Professor of Emergency l Hospital,
Calvin A. Compliance, Medical Practic MI Emergency Care, Stony
Brook
r of Physician Ann Arbor, Medical School Chief, EM Critical NY Hamad Genera
Care Harvard
Directo and Urgent
Inc., FACEP, Stony Brook, Doha, Qatar
Credentialing ncy , MD, FACEP Rogers, MD, Medicine,
ent of Emerge John M. Howell or of Emergency Robert L. MD
Services, Departm and Women's Profess , FACP ncy Edito rs Edin Zelihic, Emerge ncy
Research
Clinical gton FAAEM of Emerge ent of
Medicine,
Brigham George Washin Professor Head, Departm Hospital,

staff, including the editorial board of this publication; review of morbidity and mortality data from
r
, MA Medicine, DC; Directo Assistant ity of r, PharmD,
BCPS
Leopoldina
Hospital, Boston Washington,
University, Affairs, Best Practic
es, Medicine,
The Univers
Medicine, Aimee MishleMedicine Pharmacist, Medicine,
German y
of
ux, MD ic Maryland
School Emergency Schweinfurt,
Peter DeBlie Clinical Medicine, of Academ l, Falls r, PGY2 EM
of Fairfax Hospita Baltimore,
MD Program Directo
Professor
of ity School Inc, Inova
State Univers nce Officer, Church, VA
Louisiana

the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.
Chief Experie New
Medicine;
ity Medical Center,
Univers
Orleans, LA

Emergency Department
Management of Non–ST-Segm
January 2020
Volume 22, Number 1
Target Audience: This enduring material is designed for emergency medicine physicians, physician
ent Authors

Elevation Myocardial Infarction Julianna Jung, MD, MEd,

Associate Professor of Emergency
University School of Medicine,
FACEP
Medicine, Johns Hopkins
assistants, nurse practitioners, and residents.
Baltimore, MD
Abstract
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-
Sharon Bord, MD, FACEP
Assistant Professor Johns
Hopkins University School
Department of Emergency of Medicine,
Medicine, Baltimore, MD
Chest pain is the second most
common complaint in emer-
making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most
Peer Reviewers
gency departments, with 6.4
million visits annually in the Michael Gottlieb, MD
United States. A quarter of
these patients will be diagnosed Assistant Professor, Department
with acute coronary syndromes of Emergency Medicine, Director

critical presentations; and (3) describe the most common medicolegal pitfalls for each topic covered.
Emergency Ultrasound, Rush of
, but
will have nondiagnostic electrocard among those, nearly half
University Medical Center,
Chicago, IL
Bradley Shy, MD
iograms. Non–ST-segment
elevation myocardial infarction Visiting Associate Professor,
Department of Emergency
(NSTEMI) is twice as com- University of Colorado School Medicine,
mon as ST-segment elevation of Medicine, Aurora, CO; Medical
myocardial infarction (STEMI), Director, Adult Emergency

Objectives: Upon completion of this activity, you should be able to: (1) evaluate and diagnose acute
Department, Denver Health
and lack of clarity surroundin Authority, Denver, CO and Hospital
g the best management of
condition can contribute to this
adverse outcomes. In this
current national manageme review,
nt guidelines for NSTEMI
gastroenteritis (AGE) in the ED and exclude high-risk conditions that mimic AGE; (2) identify patients
Prior to beginning this activity,
summarized as they pertain are see “Physician CME Information”
to the ED, and the evidence on the back page.
supporting them is considered base
. Issues surrounding special
patient populations are addressed,
therapeutic modalities are
discussed.
and new diagnostic and
with AGE who are likely to benefit from stool culture testing and/or empiric antibiotics; and (3) list the
Editor-In-Chief
Andy Jagoda, MD, FACEP
Professor and Chair, Department
of Emergency Medicine; Director,
Deborah Diercks, MD, MS,
FACC
FACEP,
Professor and Chair, Department
of
Eric Legome, MD
Chair, Emergency Medicine,
Sinai West & Mount Sinai St.
Mount
Robert Schiller, MD
Chair, Department of Family
Medicine,
International Editors
elements of appropriate supportive care for patients at high risk for treatment failure.
Emergency Medicine, University Luke's; Beth Israel Medical Center;
Center for Emergency Medicine of Vice Chair, Academic Affairs Senior Peter Cameron, MD

Discussion of Investigational Information: As part of the journal, faculty may be presenting inves-
Texas Southwestern Medical for Faculty, Family Medicine and
Education and Research, Center, Emergency Medicine, Mount Academic Director, The Alfred
Icahn Dallas, TX Sinai Community Health, Icahn School
School of Medicine at Mount Health System, Icahn School of Emergency and Trauma Centre,
Sinai, of Medicine at Mount Sinai, New Monash University, Melbourne,
New York, NY Daniel J. Egan, MD Medicine at Mount Sinai, New York, NY
York, NY Australia
Associate Professor, Vice Keith A. Marill, MD, MS Scott Silvers, MD, FACEP
Chair of
Associate Editor-In-Chief

Kaushal Shah, MD, FACEP
Associate Professor, Vice
Chair
for Education, Department
of
Emergency Medicine, Weill
Cornell
Education, Department of
Emergency
Medicine, Columbia University
Vagelos College of Physicians
and
Surgeons, New York, NY
Associate Professor, Department
of Emergency Medicine, Harvard
Medical School, Massachusetts
General Hospital, Boston,
MA
tigational information about pharmaceutical products that is outside Food and Drug Administration
Associate Professor of Emergency Andrea Duca, MD
Medicine, Chair of Facilities
and Attending Emergency Physician,
Planning, Mayo Clinic, Jacksonville,
FL Ospedale Papa Giovanni XXIII,
Bergamo, Italy
Corey M. Slovis, MD, FACP,
FACEP

School of Medicine, New York, Marie-Carmelle Elie, MD
NY Associate Professor, Department
Editorial Board of Emergency Medicine &
Critical
Care Medicine, University
Saadia Akhtar, MD, FACEP of Florida
College of Medicine, Gainesville,
Angela M. Mills, MD, FACEP
Professor and Chair, Department
of Emergency Medicine, Columbia
University Vagelos College
of
Physicians & Surgeons, New
Professor and Chair, Department
of Emergency Medicine, Vanderbilt
University Medical Center, Nashville,
TN
Ron M. Walls, MD
approved labeling. Information presented as part of this activity is intended solely as continuing
Suzanne Y.G. Peeters, MD
Attending Emergency Physician,
Flevo Teaching Hospital, Almere,
The Netherlands

Associate Professor, Department
Emergency Medicine, Associate
of
Dean Nicholas Genes, MD, PhD
for Graduate Medical Education,
Program Director, Emergency
Medicine Residency, Mount
Sinai
Beth Israel, New York, NY
FL
NY
Associate Professor, Department Charles V. Pollack Jr., MA,
of
Emergency Medicine, Icahn FACEP, FAAEM, FAHA, FESC
School Professor & Senior Advisor
of Medicine at Mount Sinai,
York, NY
New Interdisciplinary Research
York, Professor and COO, Department
Emergency Medicine, Brigham of
Women's Hospital, Harvard
MD,
School, Boston, MA
for
Critical Care Editors
and
medical education and is not intended to promote off-label use of any pharmaceutical product.
Edgardo Menendez, MD,
FIFEM
and Professor in Medicine and
Emergency
Medicine; Director of EM, Churruca
Medical
Hospital of Buenos Aires University,
Buenos Aires, Argentina
Dhanadol Rojanasarntikul,

Faculty Disclosure: It is the policy of EB Medicine to ensure objectivity, balance, independence,

William J. Brady, MD
Professor of Emergency Medicine
and Medicine; Medical Director,
Emergency Management,
UVA
Clinical Trials, Department
Michael A. Gibbs, MD, FACEP of
Emergency Medicine, Sidney
Professor and Chair, Department Kimmel
Medical College of Thomas
of Emergency Medicine, Carolinas Jefferson
University, Philadelphia, PA
Medical Center, University
of North
MD
William A. Knight IV, MD, Attending Physician, Emergency
FACEP,
FNCS Medicine, King Chulalongkorn
Associate Professor of Emergency
Memorial Hospital; Faculty
of
Medicine and Neurosurgery, Medicine, Chulalongkorn University,
Medical

Medical Center; Operational
Medical
Director, Albemarle County
Fire
Rescue, Charlottesville, VA
Steven A. Godwin, MD, FACEP
Calvin A. Brown III, MD
Carolina School of Medicine, Ali S. Raja, MD, MBA, MPH
Chapel Executive Vice Chair, Emergency
Hill, NC
Medicine, Massachusetts
General
Hospital; Associate Professor
Professor and Chair, Department of
Emergency Medicine and
Radiology, Scott D. Weingart, MD, FCCM
transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating
Director, EM Advanced Practice Thailand
Provider Program; Associate
Medical Stephen H. Thomas,
Director, Neuroscience ICU, MD, MPH
University
of Cincinnati, Cincinnati, OH Professor & Chair, Emergency
Medicine, Hamad Medical
Corp.,

Director of Physician Compliance,
Credentialing and Urgent Care
Services, Department of Emergency
Medicine, Brigham and Women's
Hospital, Boston, MA
in the planning or implementation of a sponsored activity are expected to disclose to the audience
of Emergency Medicine, Assistant Harvard Medical School, Boston, Weill Cornell Medical College, Qatar;
Dean, Simulation Education, MA Professor of Emergency Medicine; Emergency Physician-in-Chief
Robert L. Rogers, MD, FACEP, Chief, EM Critical Care, Stony ,
University of Florida COM- Brook Hamad General Hospital,
Jacksonville, Jacksonville, FAAEM, FACP Medicine, Stony Brook, NY Doha, Qatar
FL Assistant Professor of Emergency
Joseph Habboushe, MD Research Editors

Peter DeBlieux, MD
Professor of Clinical Medicine,
Louisiana State University
School of
Medicine; Chief Experience
MBA
Assistant Professor of Emergency
Medicine, NYU/Langone and
Bellevue Medical Centers,
New York, Alfred
NY; CEO, MD Aware LLC
any relevant financial relationships and to assist in resolving any conflict of interest that may arise
Medicine, The University Edin Zelihic, MD
of Head, Department of Emergency
Maryland School of Medicine, Aimee Mishler, PharmD,
Baltimore, MD BCPS Medicine, Leopoldina Hospital,
Emergency Medicine Pharmacist,
Schweinfurt, Germany
Sacchetti, MD, FACEP Program Director, PGY2 EM

from the relationship. In compliance with all ACCME Essentials, Standards, and Guidelines, all
Officer, Assistant Clinical Professor, Pharmacy Residency, Maricopa
University Medical Center, Medical Center, Phoenix, AZ
New Department of Emergency
Orleans, LA Medicine,
Thomas Jefferson University, Joseph D. Toscano, MD
Philadelphia, PA Chief, Department of Emergency

faculty for this CME activity were asked to complete a full disclosure statement. The information
Medicine, San Ramon Regional
Medical Center, San Ramon,
CA

received is as follows: Dr. Geyer, Dr. Halpern, Dr. Sano, Dr. Mishler, Dr. Toscano, Dr. Jagoda,
and their related parties report no relevant financial interest or other relationship with the
manufacturer(s) of any commercial product(s) discussed in this educational presentation.
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