Background

Although often considered a benign disease, acute gastroenteritis remains a

major cause of morbidity and mortality in children around the world,
accounting for 1.34 million deaths annually in children younger than 5 years,
or roughly 15% of all child deaths. [1] As the disease severity depends on the
degree of fluid loss, accurately assessing dehydration status remains a crucial
step in preventing mortality. Luckily, most cases of dehydration in children can
be accurately diagnosed by a careful clinical examination and treated with
simple, cost-effective measures. Although dehydration technically refers to
pure water loss and can be associated with euvolemic or even hypervolemic
states in certain pediatric disorders, the term is used throughout this article in
its more general sense to mean overall fluid or volume loss due to diarrhea.
Pathophysiology
Adequate fluid balance in humans depends on the secretion and reabsorption
of fluid and electrolytes in the intestinal tract; diarrhea occurs when intestinal
fluid output overwhelms the absorptive capacity of the gastrointestinal tract.
The 2 primary mechanisms responsible for acute gastroenteritis are (1)
damage to the villous brush border of the intestine, causing malabsorption of
intestinal contents and leading to an osmotic diarrhea, and (2) the release of
toxins that bind to specific enterocyte receptors and cause the release of
chloride ions into the intestinal lumen, leading to secretory diarrhea. [2]
Even in severe diarrhea, however, various sodium-coupled solute co-transport
mechanisms remain intact, allowing for the efficient reabsorption of salt and
water. By providing a 1:1 proportion of sodium to glucose, classic oral
rehydration solution (ORS) takes advantage of a specific sodium-glucose
transporter (SGLT-1) to increase the reabsorption of sodium, which leads to
the passive reabsorption of water. Rice and cereal-based ORS may also take
advantage of sodium-amino acid transporters to increase reabsorption of fluid
and electrolytes. [2]
Epidemiology
Frequency
United States
Children in the United States experience, on average, 1.3-2.3 episodes of
diarrhea each year. Overall, acute gastroenteritis accounts for than 1.5 million
outpatient visits, 220,000 hospitalizations, and direct costs of more than $2
billion each year in the United States alone. [3]
A study by Hullegie et al investigated the effects of first-year daycare
attendance on acute gastroenteritis incidence and primary care contact rate
up to age 6 years. The study found that first-year daycare attendance
advances the timing of acute gastroenteritis infections, resulting in increased
acute gastroenteritis disease burden in the first year and relative protection
thereafter. The study also added that protection against acute gastroenteritis
infection persists at least up to age 6 years. [4]
International
Worldwide, children younger than 5 years have an estimated 1.7 billion episodes of
diarrhea each year, leading to 124 million clinic visits, 9 million hospitalizations, and
1.34 million deaths, with more than 98% of these deaths occurring in the developing
world. [1, 5, 6, 7]
Although the prevalence of acute gastroenteritis in children has changed little over the
past 4 decades, mortality has declined sharply, from 4.6 million in the 1970s to 3 million
in the 1980s and 2.5 million in the 1990s. [8] One of the most important reasons for this
decline has been the increasing international support for the use of oral rehydration
solution (ORS) as the treatment of choice for acute diarrhea, with the proportion of
diarrheal episodes treated with ORS rising from 15% in 1984 to 40% in 1993.  [8]
History
The history and physical examination serve 2 vital functions: (1) differentiating
gastroenteritis from other causes of vomiting and diarrhea in children and (2)
estimating the degree of dehydration. In some cases, the history and physical
examination can also aid in determining the type of pathogen responsible for
the gastroenteritis, although only rarely will this affect management.
Diarrhea
Determine the duration of diarrhea, the frequency and amount of stools, the time since
the last episode of diarrhea, and the quality of stools. Frequent, watery stools are more
consistent with viral gastroenteritis, while stools with blood or mucous are indicative of a
bacterial pathogen. Similarly, a long duration of diarrhea (>14 days) is more consistent
with a parasitic or noninfectious cause of diarrhea.
Vomiting
Determine the duration of vomiting, the amount and quality of vomitus (eg, food
contents, blood, bile), and time since the last episode of vomiting. When symptoms of
vomiting predominate, one should consider other diseases such as gastroesophageal
reflux disease (GERD), diabetic ketoacidosis, pyloric stenosis, acute abdomen, or
urinary tract infection.
Urination
Determine if there is an increase or decrease in the frequency of urination as measured
by the number of wet diapers, time since last urination, color and concentration of urine,
and presence of dysuria. Urine output may be difficult to determine with frequent watery
stools.
Abdominal pain
Determine the location, quality, radiation, severity, and timing of pain, based on a report
from the parents and/or child. In general, pain that precedes vomiting and diarrhea is
more likely to be due to abdominal pathology other than gastroenteritis.
Signs of infection
Determine the presence of fever, chills, myalgias, rash, rhinorrhea, sore throat, cough,
known immunocompromised status. These may indicate evidence of systemic infection
or sepsis.
Appearance and behavior
Elements include weight loss, quality of feeding, amount and frequency of feeding, level
of thirst, level of alertness, increased malaise, lethargy, or irritability, quality of crying,
and presence or absence of tears with crying.
Antibiotics
A history of recent antibiotic use increases the likelihood of Clostridium difficile infection.
Travel
History of travel to endemic areas may make prompt consideration of organisms that
are relatively rare in the United States, such as parasitic diseases or cholera.
Physical
Elements of the physical examination are as follows:
 General - Weight, ill appearance, level of alertness, lethargy,
irritability
 HEENT (head, ears, eyes, nose, and throat) - Presence or absence
of tears, dry or moist mucous membranes, and whether the eyes
appear sunken
 Cardiovascular - Heart rate and quality of pulses
 Respiratory - Rate and quality of respirations (deep, acidotic
breathing suggests severe dehydration).
 Abdomen - Abdominal tenderness, guarding and rebound, and
bowel sounds; abdominal tenderness on examination, with or
without guarding, should prompt consideration of diseases other
than gastroenteritis
 Back - Flank/costovertebral angle tenderness increase the
likelihood of pyelonephritis
 Rectal - Quality and color of stool, presence of gross blood or mucous
 Extremities - Capillary refill time, warm or cool extremities
 Skin - Abdominal rash may indicate typhoid fever (infection with Salmonella
typhi), while jaundice might make viral or toxic hepatitis more likely; slow return of
abdominal skin pinch suggests decreased skin turgor and dehydration, while a
doughy feel to the skin may indicate hypernatremia
  Causes
 Identifying the specific etiologic agent responsible for the acute
gastroenteritis rarely changes management. However, it may be helpful
to differentiate between viral, bacterial, parasitic, and noninfectious
causes of diarrhea.
 By far, viruses remain the most common cause of acute gastroenteritis
in children, both in the developed and developing world. Rotavirus
represents the most important viral pathogen worldwide, responsible for
37% of diarrhea-related deaths in children younger than 5
years. [9] Rotavirus infection follows seasonal variation, with an increased
incidence in winter and decreased incidence in summer months.
In the United States, routine rotavirus vaccination has led to a 60-75%
reduction in pediatric rotavirus hospitalization since 2006. [10, 11] A 2014
retrospective analysis reported that implementation of rotavirus vaccines has
reduced the diarrhea-related healthcare use in US children by as much as
94% in 2009–2010. [12, 13] With the continued decline of rotavirus-associated
gastroenteritis, noroviruses (Norwalk-like viruses) have become the leading
cause of medically attended acute gastroenteritis in children younger than 5
years in the United States, accounting for 14,000 hospitalizations, 281,000
emergency department visits, 627,000 outpatient visits, and more than $273
million in treatment costs each year. [14] Caliciviruses, astroviruses, and enteric
adenoviruses make up the remainder of cases of viral gastroenteritis. Viral
gastroenteritis typically presents with low-grade fever and vomiting followed
by copious watery diarrhea(upto10-20bowelmovementsper day),with
symptomspersisting for 3-8 days. [3]
In developed countries, bacterial pathogens account for a small portion, perhaps 2-10%,
of all cases of pediatric gastroenteritis. In the United States, the most important
pathogens, in order of prevalence, are Campylobacter, Salmonella, Shigella, and
Enterohemorrhagic Escherichia coli (EHEC) species. [3] Relative to viral gastroenteritis,
bacterial disease is more likely to be associated with high fevers, shaking chills, bloody
bowel movements (dysentery), abdominal cramping, and fecal leukocytes.
In developing countries, Enterotoxigenic Ecoli (ETEC) remains the most important
bacterial cause of acute gastroenteritis in children, followed
by Campylobacter, Salmonella, and Shigella, while also causing the majority of
traveler’s diarrhea in all age groups. [15] Unlike other bacterial causes of gastroenteritis,
ETEC is unlikely to cause dysentery.
C difficile has emerged as an important cause of antibiotic-associated diarrhea in
children. Any antibiotic can trigger infection with C difficile, although penicillins,
cephalosporins, and clindamycin are the most likely causes.  [3] Since 50% of neonates
and young infants are colonized with C difficile, symptomatic disease is unlikely in
children younger than 12 months. [3]
Parasites remain yet another source of gastroenteritis in young children,
with Giardia and Cryptosporidium the most common causes in the United States.
Parasitic gastroenteritis generally presents with watery stools but can be differentiated
from viral gastroenteritis by a protracted course or history of travel to endemic areas.  [3]
Laboratory Studies
The vast majority of children presenting with acute gastroenteritis do not
require serum or urine tests, as they are unlikely to be helpful in determining
the degree of dehydration. In a meta-analysis of 6 studies, only serum
bicarbonate (greater or less than 17) had statistically significant positive and
negative likelihood ratios for detecting moderate dehydration. [16]
Clinically significant electrolyte abnormalities are rare in children with
moderate dehydration. Any child being treated with intravenous fluids for
severe dehydration, however, should have baseline electrolytes, bicarbonate,
and urea/creatinine values tested. Laboratory tests are also indicated in
patients with moderate dehydration whose history and physical examination
are inconsistent with straightforward gastroenteritis.
Fecal leukocytes and stool culture may be helpful in children presenting with
dysentery. Children older than 12 months with a recent history of antibiotic
use should have stool tested for C difficile toxins. Those with a history of
prolonged watery diarrhea (>14 days) or travel to an endemic area should
have stool sent for ova and parasite tests.
Any child with evidence of systemic infection should have a complete workup,
including CBC count and blood cultures. If indicated, urine cultures, chest
radiography, and/or lumbar puncture should be performed.
Imaging Studies
Abdominal films are not indicated in the management of acute gastroenteritis.
If the clinician suspects a diagnosis other than acute gastroenteritis based on
history and physical examination findings, appropriate imaging modalities
should be pursued.