Acute Gastroenteritis

by:
Brigitte Ulrike D. Tabaranza M.D.
 **Depending on the
amount of unabsorbable
dietary material consumed

• Stool 60-90% water

• Stool amount:
– 100-200g/day in healthy adults
– 10g/kg/day in infants
Stool Characteristics
• It is a change in normal bowel movements
characterized by increase in frequency, water
content or volume of stools.

• Stool weight > 200g/day

• ≥ 3 episodes/day
The Merck Manual 19th Edition
 Diarrhea
• There are number of
causes and several basic
mechanisms are
responsible:
– Increased osmotic
load
– Increased secretions
– Decreased contact
time/surface area.
The Merck Manual 19th Edition
 Diarrhea
• Osmotic Load:
• Occurs when unabsorbable, water-soluble
solutes remain in the bowel and retain water
• Increased Secretion :
• Occur when the bowels secrete more
electrolytes and water than they absorb .

• Reduced contact time/surface area :

• Rapid intestinal transit and diminished surface
area impair fluid absorption and cause diarrhea

The Merck Manual 19th Edition

Stool Characteristics in
Diarrhea
 STOOL SMALL BOWEL LARGE BOWEL
CHARACTERISTICS

APPEARNACE WATERY MUCOID AND/OR BLOODY

VOLUME LARGE SMALL

FREQUENCY INCREASED DECREASED

BLOOD POSITIVE GROSSLY BLOODY

pH < 5.5 > 5.5

WBCs <5/hpf >10/ hpf

SERUM WBCs NORMAL LEUKOCYTOSIS

STOOL SMALL BOWEL LARGE BOWEL
CHARACTERISTICS

ORGANISMS VIRAL INVASIVE

BACTERIA
Escherichia Coli
Rotavirus
Adenovirus Shigella species
Calicivirus Salmonella species
Campylobacter species
Yersinia species
Enterotoxigenic bacteria Toxic bacteria
Klebsiella
Clostridium difficile
Clostridium perfringens
Cholera species
Vibrio species

Parasites Parasites
Giardia species Entamoeba
Cryptosporidium species organisms
 Diarrhea ?
Acute Gastroenteritis?
 Acute Gastroenteritis

• It is an inflammation of the gastrointestinal

tract , involving both the stomach and the small
intestine and resulting in acute diarrhea .

World Gastroenterology Organization Global Guidelines (February 2012)

 Acute Gastroenteritis
• It can be defined as the passage of a greater
number of stools of decreased form from the
normal, and lasting less than 14 days.
• It is a group of conditions that are usually cause
by infection and produce symptoms:
– Nausea and vomiting,
– Mild to severe diarrhea and fecal urgency.
– Abdominal pain and cramps, or tenesmus
– Increase in intestinal gas-related complaints,
– loss of electrolytes
– life-threatening dehydration

The Merck Manual 19th Edition

 Acute Gastroenteritis
• About 2 billion cases of diarrheal disease every
year and 1.9million children <5yo perish, mostly in
developing countries (78%).
• Impact on the incidence:
– Poor living conditions
– Insignificant improvements in water
– Sanitation
– Personal hygiene
– Poor nutrition
– Lack of information

World Gastroenterology Organization Global Guidelines (February 2012)

 Common Organisms that Causes
Acute Gastroenteritis
Acute Gastroenteritis

**In developing countries, enteric

bacteria and parasites are more
prevalent than viruses and typically
peak during the
Bacterial: summer
Viral:
-Rotavirus
months.
Parasite:
-Campilobacter jejuni -Entamoeba histolytica
-Salmonella -Norovirus -Gardia intestinalis
-Shigella (Calicivirus) -Cryptosporidium
-E. coli --Adenovirus paryum
-Vibrio cholerae (ST 40/41) -Cyclospora
-Astrovirus cayetanensis

World Gastroenterology Organization Global Guidelines (February 2012)

 Acute Gastroenteritis
• Bacterial Agents:
• Diarrheagenic Escherichia coli
– Enterohemorrhagic E. coli (EHEC,
including E. coli O157:H7)
– Enterotoxigenic E. coli (ETEC)
– Enteropathogenic E. coli (EPEC)
– Enteroinvasive E. coli (EIEC)
– Enteroaggregative E. coli
(EAggEC)

World Gastroenterology Organization Global Guidelines (February 2012)

 Acute Gastroenteritis
• Bacterial Agents:
• Campylobacter
– prevalent in adults and is one of the most frequently
isolated bacteria from the feces of infants and
children in developing countries.
– Asymptomatic infection, but infection is associated
with watery diarrhea and on occasion dysentery
– Guillain–Barré syndrome is a rare complication
– Poultry is an important source of Campylobacter
infections

World Gastroenterology Organization Global Guidelines (February 2012)

 Acute Gastroenteritis
• Bacterial Agents:
• Shigella Species
– S. sonnei
– S. flexneri
– S. dysenteriae type 1 (Sd1)

• Vibrio cholerae
– V. cholerae serogroups O1 and O139
– Hypovolemic shock and death can occur within 12–18
hrs after the onset of the first symptom
– Stools are watery, colorless, and flecked with mucus;
Vomiting is common; fever is rare

World Gastroenterology Organization Global Guidelines (February 2012)

Rice Watery Stool
 Acute Gastroenteritis
• Bacterial Agents:
• Salmonella:
– Enteric Fever-- Salmonella enterica serovar Typhi and
Paratyphi A,B, or C(typhoid fever)
– In non-typhoidal salmonellosis (Salmonella
gastroenteritis)
• Fever develops in 70% of affected children.
• Bacteremia occurs in 1–5%, mostly in infants.
• Diarrhea (with or without blood) develops, and
fever lasting 3 weeks or more

World Gastroenterology Organization Global Guidelines (February 2012)

 Salmonella

• Definitive dx: isolation of the organism

from blood(40-80 %sensitive), BM or
other sterile sites
– 1st week – blood
– 2nd week – urine
– 3rd week – stool

The Merck Manual 19th Edition

Types of Bacterial Infection

World Gastroenterology Organization Global Guidelines (February 2012)

 Acute Gastroenteritis
• Viral agents:
 Rotavirus
– Leading cause of severe, dehydrating gastroenteritis
among children
 Norovirus
– Belongs to the family Caliciviridae
– Most common cause of outbreaks affecting in all age
group
 Sapovirus
– Also from the family of Caliciviridae
– Primarily affects children
– 2nd most common viral agent after rotavirus

World Gastroenterology Organization Global Guidelines (February 2012)

 Acute Gastroenteritis
• Parasitic agents:
 Giardia intestinalis
 Cryptosporidium parvum
 Entamoeba histolytica

World Gastroenterology Organization Global Guidelines (February 2012)

 PATHOGENESIS
Organism attaches to the
Releases toxins
Bacteria surface of the cell
Mechanisms:
1. Inoculum size- varies
In the villus 2.
cells, Toxin
there will be ↓
production Stimulating the
in the active absorption
 of Na
Enterotoxin production of AMP
 Cytotoxins
In the crypt cells, there will be ↑ from ATP
 Neurotoxins
in the secretion of chloride and
3.waterAdherence
4.Invasion
5.Ability to combat host defenses

Blood to appear in Stool

Bacteria Invasion and destruction Produce micro-

of mucosal cells abscessess and ulcers

World Gastroenterology Organization Global Guidelines (February 2012)

 PATHOGENESIS
First is decreased The virus enters the cell, it
absorption multiplies and destroys the cell
Decrease or diminish
Virus Second is destruction of secretion of enzyme lactase
brush borders
Rapid movement upward even
Third is increased though they are still immature
secreation

Viral Diarrhea Causing blunting and

flattening of the villi
1. Malabsorption of The crypt cells occupy
electrolytes the absorptive area of
2. Stimulation of CAMP the villi
3. Carbohydrate Decrease
Malabsorption Lactase malabsorption
absorption.

increasing the secretion

process
 Episodes of Diarrhea

Chronic
Diarrhea

Infectious
Diarrhea

MIMS Gastroenterology Philippines

Episodes of Diarrhea
Common and associated with
invasive pathogens

-Invasive and cytotoxin releasing

pathogens
-Suspect EHEC infection in the absence
of fecal leukocytes
-Not with viral agents and enterotoxins
releasing bacteria

Frequently in viral diarrhea and

illness caused by ingestion of
bacterial toxins (eg S. aureus)
World Gastroenterology Organization Global Guidelines (February 2012)
Evaluation of the Acute Diarrhea
History Physical
Examination
• Onset, stool
frequency, type and
•volume • Body weight
• Presence of blood • Temperature
• Vomiting • Pulse/heart and
• Medicines received respiratory rate
• Past medical history • Blood pressure
• Underlying •Pediatric details:
conditions Evidence of
• Epidemiological clues associated problems
•24h food recall in children

World Gastroenterology Organization Global Guidelines (February 2012)

Patient’s History and Causes
of Acute Diarrhea
Assess Dehydration
 DHAKA METHOD
ASSESSMENT PLAN A PLAN B PLAN C
1. General N Irritable/ less active* Lethargic /comatose
condition *

2. Eyes N Sunken Sunken

3. Mucosa N Dry Dru
4. Thirst N Thirsty Unable to drink*

5. Radial pulse N Low volume* Absent

6. Skin turgor N Reduced* Reduced
Diagnosis No signs of Some dehydration Severe dehydration
dehydration At least 2 signs; Some signs of
including one key dehydration plus at
sign (*) are present least one key sign
present

World Gastroenterology Organization Global Guidelines (February 2012)

1. Two of the ff. signs:
 Drowsy, lethargic
 Sunken eyes
 Not able to drink, drinking poorly
 Skin pinch goes back very slowly
SEVERE DEHYDRATION
2. Two of the ff signs:
 Restless, irritable
 Sunken eyes
 Thirsty, drinks eagerly Skin pinch goes back very
slowly
 Skin pinch goes back slowly
 LABORATORY EVALUATION
• Stool examination (Fecalysis)

• CBC

• Serum electrolyte concentrations (Na, K, Cl)

• BUN, Creatinine

• Other labs:
– ABG

– RBS
 TREATMENT
PLAN A PLAN B PLAN C
TREATMENT Prevent Rehydrate with Rehydrate with
dehydration ORS solution I.V. fluids and
ORS
Reassess
Reassess frequently Reassess more
periodically frequently

World Gastroenterology Organization Global Guidelines (February 2012)

 TREATMENT
 PLAN A
-Home therapy to prevent dehydration and malnutrition
 Rule 1: give more fluids than usual
• <2 y.o : 50-100 ml after each loose stool
• 2-10 : 100-200ml
• Older children and adults : as much as the want
 Rule 2: give Zinc (10-20mg) daily for 10-14 days
 Rule 3: Continue to feed the child to prevent
malnutrition
 Rule 4: take the child to a health worker when signs of
dehydration develop

World Gastroenterology Organization Global Guidelines (February 2012)

 TREATMENT
 PLAN B

 Oral rehydration therapy (ORS)

 Give also supplemental Zinc

 Monitoring of the patient’s conditon

 If at any time the patient develops signs of severe

dehydration, shift to plan C

World Gastroenterology Organization Global Guidelines (February 2012)

 TREATMENT
 PLAN C
• Intravenous rehydration
- Give 100ml/kg PLR:
Age First give 30ml/kg in: Then give 70ml/kg in:

Infants <12 months 1 hour 5 hours

Older 30 minutes 2.5 hours

• Reassess patient every 1-2 hours

• After 3 or 6 hrs evaluate patient then choose
appropriated treatment plan

World Gastroenterology Organization Global Guidelines (February 2012)

 Oral Rehydration Therapy
 Oral rehydration therapy (ORT) is the administration of
appropriate solutions by mouth to prevent or correct diarrheal
dehydration.
 The new lower-osmolarity ORS recommended by (WHO and
UNICEF) has reduced concentrations of sodium and glucose
 is associated with:

less vomiting
less stool output
lesser chance of hypernatremia
reduced need for intravenous infusions in comparison
with standard ORS.

World Gastroenterology Organization Global Guidelines (February 2012)

 Oral Rehydration Therapy
• ORT consists of:
• Rehydration
• Maintenance fluid therapy
• According to the 2012 WGO guidelines ORT is
contraindicated as initial therapy in:
 cases of severe dehydration,
 children with paralytic ileus,
 frequent and persistent vomiting
 Painful oral conditions such as moderate to severe
thrush

World Gastroenterology Organization Global Guidelines (February 2012)

 Oral Rehydration Therapy
 However, nasogastric (NGT) administration of ORS
solution is potentially lifesaving when intravenous
rehydration is not possible.
 Rice-based ORS is superior to standard ORS in cholera
 Home-made oral fluid
It is not superior recipeORS in the
to standard
treatment
 The of children
ingredients with acute
to be mixed are: noncholera
diarrhea, especially when food is given
 One level teaspoon of salt.
shortly after rehydration
 4 level tablespoon of sugar.
 One liter (five cupfuls) of clean drinking water, or water
that has been boiled and then cooled.
World Gastroenterology Organization Global Guidelines (February 2012)
Oral Rehydration Therapy

World Gastroenterology Organization Global Guidelines (February 2012)

Treatment of ORS based on
Degree of Dehydration
 SUPPORTIVE TREATMENT
 Zinc supplement
 Recommendation :
 20mg OD for 10 days
 Infants: 10mg/day OD for 10 days
 Multivitamins and minerals
 Diet:
 normal feeding should be continued for those with no
signs of dehydration
 food should be started immediately after correction of
some and severe dehydration
World Gastroenterology Organization Global Guidelines (February 2012)
 SUPPORTIVE TREATMENT
 Diet:
 Breastfed infants and children should continue
receiving food
 However, for non-breastfed, dehydrated children and
adults, rehydration is the first priority.
 Frequent, small meals throughout the day (6
meals/day),
 Avoid fruit juices
• Probiotics are said to be beneficial
(http://www.worldgastroenterology.org/probioticsprebiotics.html)

World Gastroenterology Organization Global Guidelines (February 2012)

Nonspecific Antidiarrheal Agents
 Antimicrobial Agents
ORGANISM DOC DOSAGE
Shig e lla Ciprofloxacin, ampicillin, ceftriaxone, •Ceftriaxone 50-100 mg/kg/day IV or
azithromycin, or TMP-SMX IM, qd or bid for 7 days
Most strains are resistant now to several •Ciprofloxacin
antibiotics 20-30 mg/kg/day PO bid for 7-10
days
•Ampicillin PO,IV 50-100 mg/kg/day
qid for 7 days

EPEC, ETEC, TMP-SMX or ciprofloxacin •TMP 10 mg/kg/day

EIEC and SMX 50 mg/kg/day
bid for 5 days
•Ciprofloxacin PO 20-30 mg/kg/day
qid for 5-10 days

Sa lm o ne lla No antibiotics for uncomplicated See treatment

gastroenteritis in normal hosts caused by of Shig e lla
nontyphoidal species
Treatment is indicated in infants <3 mo,
and patients with malignancy, chronic GI
disease,severe colitis hemoglobinopathies,
or HIV infection, and other
immunocompromised patients
Most strains have become resistant to
multiple antibiotics
Antimicrobial Agents
Antimicrobial Agents

Treatment for amebiasis should

ideally include diloxanide furoate
following the metronidazole, to get rid
of the cysts that may remain after the
metronidazole treatment;
nitazoxanide is an alternative.
 Approach in Adults with Acute
Diarrhea
1. Perform initial assessment.
2. Manage dehydration.

3. Prevent dehydration in patients with no signs of

dehydration, using home-based fluids or ORS solution.
• Rehydration of patients with some dehydration using
ORS
– Correct dehydration of a severely dehydrating patient
with an appropriate intravenous fluid.
• Maintain hydration using ORS solution.
-Treat symptoms if necessary

World Gastroenterology Organization Global Guidelines (February 2012)

 Approach in Adults with Acute
Diarrhea
4. Stratify subsequent management:
• Epidemiological clues: food, antibiotics, sexual activity,
travel, day-care attendance, other illness, outbreaks,
season.
• Clinical clues: bloody diarrhea, abdominal pain,
dysentery, wasting, fecal
inflammation.
5. Obtain a fecal specimen for analysis
6. Consider antimicrobial therapy for specific pathogens.

World Gastroenterology Organization Global Guidelines (February 2012)

 Indications for Medical Consultation or
In-patient Care are:
Caregiver’s report of signs consistent with
dehydration
Changing mental status
History of premature birth, chronic medical
conditions, or concurrent illness
Young age (< 6 months or < 8 kg weight)
Fever 38 °C for infants < 3 months old or
39 °C for children aged 3–36 months

World Gastroenterology Organization Global Guidelines (February 2012)

 Indications for Medical Consultation or
In-patient Care are:
 Visible blood in stool
 High-output diarrhea, including frequent and
substantial volumes
 Persistent vomiting, severe dehydration,
persistent fever
 Suboptimal response to ORT
 No improvement within 48 hours—symptoms
exacerbate and overall condition gets worse
 No urine in the previous 12 hours

World Gastroenterology Organization Global Guidelines (February 2012)

 When to discharge?

Stable Vital signs

Normal urine output

Maintains a sufficient fluid intake

Able to eat meals adequately

Able to take medications (if still indicated)

World Gastroenterology Organization Global Guidelines (February 2012)

 Prevention
• Promotion of exclusive breast feeding
Promotes passive immunity
• Improved complementary feeding practices
Start giving complementary food at 6
mo. And continue BF up to 1 year or
longer
• Rotavirus immunization
• Improved case management of diarrhea
• Patient education
 Patient Education
• Family knowledge

• Proper personal hygiene and safe food

preparation
• Human feces must always be considered
potentially hazardous, whether or not diarrhea or
potential pathogens have been identified.
 Patient Education
• Hand-washing with soap is an effective step in
preventing spread of illness
• Select populations may require additional
education about food safety, and health care
providers can play an important role in providing
this information.
Thank you!