FCH 260.

1: Clinical Internship in Family Medicine

Acute Gastroenteritis Trans 04

19 August 2020
Louella Patricia D. Carpio, MD, DFM

Topic Outline
I. Epidemiology o With adequate urine output
II. Overview
III. Diagnosis and Evaluation III. DIAGNOSIS AND EVALUATION
A. When is diagnosis suspected? A. When is diagnosis suspected?
B. Pre-treatment clinical evaluation ● If a patient presents with the passage of 3 or more loose,
C. Clinical use of Diagnostic Tests watery or bloody stools within 24 hours that may be
D. Clinical parameters of dehydration accompanies by any of the following:
E. Laboratory tests to assess complications o Nausea
F. Admission criteria o Vomiting
o Abdominal pain
IV. Management o Fever
A. Management of Dehydration ● Case Question: Does Junior have AGE? Yes
B. Homemade ORS
C. Treatment Plans B. What pre-treatment clinical evaluations are
D. Indications of Empiric Antibiotic treatment recommended for immunocompetent patients
E. Recommended antimicrobials presenting with acute infectious diarrhea?
F. Medications ● Extensive clinical history
G. Role of Probiotics o Consumption of raw, ill-prepared, or rotten food
H. Recommended diet o Intake of contaminated water
o History of travel
V. Prevention • Complete physical examination
A. Interventions o Done to assess disease severity, degree of
B. Food and Water-Borne Disease Prevention and dehydration, presence of complications
Control Program
VI. Summary C. What is the clinical use of diagnostic tests in children
and adults with acute infectious diarrhea?
VII. Question and Answers ● Diagnostic tests should be requested based on patient’s
clinical status
This trans is based on Dr. Carpio’s lecture on Approach to ● Routine stool examination is not indicated n acute watery
Acute Gastroenteritis diarrhea, except in cases where parasitism is suspected or
in the presence of bloody diarrhea
I. EPIDEMIOLOGY ● Stool cultures are indicated only for severe cases, high risk
● Acute Watery Diarrhea was the 6th leading cause of of transmission of enteric pathogens (food handlers); high
Morbidity in the Philippines last 2018 risk of complications; and for epidemiological purposes
● In developing countries, a large proportion of childhood (when there is suspicion of an outbreak that is enteric in
morbidity and mortality is caused by 5 conditions: origin)
o Acute Respiratory Infections o Done within 3 days of the infection
o Diarrhea o Done before initiation of antibiotic treatment
o Measles ● There is insufficient evidence to support the use of
o Malaria biomarkers (CRP, calprotectin, ESR, procalcitonin) in
o Malnutrition distinguishing the cause of acute infectious diarrhea
● Rapid diagnostic tests may be used during outbreaks of
II. OVERVIEW cholera and shigella but confirmation with stool culture is still
● Acute gastroenteritis is a disease characterized by changes recommended
in the character and frequency of stool ● Clinical correlation is necessary in interpreting tests done
● It can be defined as the passage of a greater number of using molecular diagnostics
stools of decreased form from the normal lasting less than ● Case Question: Will you order a routine stool examination?
14 days No
● Generally associated with other signs and symptoms
including nausea, vomiting, abdominal pain and cramps, D. What are the clinical parameters that would indicate the
increase in intestinal gas-related complaints, fever, passage presence of dehydration in children with acute
of bloody stools (dysentery), tenesmus (constant sensation infectious diarrhea?
of urge to move bowels), and fecal urgency ● Abnormal vital signs (tachycardia, tachypnea)
● Depressed level of consciousness
Case ● Depressed fontanels
● Junior, a 5-year-old boy, previously healthy, was brough to ● Sunken eyes
the Ambulatory Care Unit for the following ● Decreased or absent tears
o Loose water stools withing the day occurring 6 times ● Poor skin turgor
already ● Prolonged capillary refill time
o With low grade fever and vomiting ● Abnormal respiratory pattern
o Able to sip fluids ● Decreased urine output

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FCH 260.1: Clinical Internship in Family Medicine

● Q: The most common complication of Diarrhea is: ● Breastfeeding should be continued in addition to hydration
Dehydration therapy for breastfed infants
● Case Question: What is the degree of dehydration of ● Carbonated, sweetened, caffeinated and sports beverages
Junior? A: Some are not recommended for fluid replacement
SEE APPENDIX FOR TABLE AND ALGORITHM
Table 1. Assess, Classify and Treat Algorithm for Diarrhea in Children
E. What laboratory tests should be done to assess for the
presence of complications for acute infectious diarrhea?
● Complete Blood Count
● Urinalysis
● Serum electrolytes (Na, K, Cl)
● BUN and creatinine
● Serum bicarbonate or total CO2 (if available)
● ABG (optional)
● Complications such as AKI and electrolyte imbalances can
occur with acute infectious diarrhea

F. What are the criteria for admission among children

presenting with acute infectious diarrhea?
● Clinical History
o Unable to tolerate fluids SEE APPENDIX FOR ALGORITHM
o Suspected electrolyte abnormalities
o Conditions for safe follow-up and home B. Homemade ORS
management are met ● 4-5 teaspoons of sugar
● Physical Findings ● 1 teaspoon salt
o Altered consciousness ● 1 liter of clean drinking water
o Abdominal distention
o Respiratory distress C. What are the different treatment plans based on the
o Hypothermia degree of dehydration?
● Co-existing medical condition Treatment Plan A: Treat Diarrhea at Home
o Pneumonia
o Meningitis
o Sepsis
o Moderate to severe malnutrition
o Suspected medical condition
● Case Question: Will you advise admission for Junior?
Cannot tell
o With some signs of dehydration = observe for a few
hours
o Do rehydration and reassess after 4 hours
▪ Improved – send home
▪ Not improved – check for other causes or refer to
pedia ER

IV. MANAGEMENT
A. How will you manage dehydration among children?
● No signs of dehydration
o Reduced osmolarity oral rehydration solution (ORS) is
recommended to replace ongoing losses
o If commercial ORS is not available, homemade ORS may
be given
● Mild to Moderate dehydration
o Reduced osmolarity ORS is recommended to replace
ongoing losses
o If oral rehydration is not feasible, administration of ORS
via nasogastric tube is preferred
over IV hydration
● Severe dehydration
o Rapid intravenous rehydration is recommended with plain
lactated ringer’s solution or 0.9% Sodium Chloride
● Monitoring
o Check the child from time to time during rehydration to
ensure that ORS is being taken satisfactorily and that
signs of dehydration are not worsening
o Evaluate the child’s hydration status at least hourly

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FCH 260.1: Clinical Internship in Family Medicine
Treatment Plan B: Treat for some Dehydration with ORS
Treatment Plan C: Treat for Severe Dehydration Quickly
SEE APPENDIX
D. What are the indications for empiric antibiotic treatment
in children with acute infectious diarrhea?
• Case Question: Will you prescribe an antibiotic to Junior? No
• Primary management of acute infectious diarrhea in children
is still rehydration therapy. Routine empiric antibiotic therapy
is not recommended
• Antimicrobials may be recommended for the following
conditions:
o Suspected cholera
o Bloody diarrhea (Entamoeba histolytica,
Salmonella and Shigella)
o Should be guided by fecalysis and culture
o Diarrhea associated with other acute infections
SEE APPENDIX FOR MAJOR ETIOLOGIES OF
CHILDHOOD DIARRHEA
E. What are the recommended antimicrobials for the
different etiologies
● Cholera
o Azithromycin 10 mgkg/dose OD x 3 days
o Doxycycline (if >8years old): 2mg/kg single dose
o Cotrimoxazole if sensitive
● Shigella
o Ciprofloxacin 30mg/kg/day PO into 2 doses
o Azithromycin 10 mg PO OD x 3 days
o Ceftriaxone IV 75-100mg/kg/day
● Amoebiasis
o Metronidazole 10 mg/kg/dose TID for 10-14 days
to avoid relapse
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Trans 04
F. Medications
● Case Question: will you give Loperamide to Junior? No
● Zinc medication as an adjunctive therapy for children >6
months to shorten the duration of diarrhea and reduce the
frequency of stools
● Racecadotril may be given to infants and children as
adjunctive therapy to shorten the duration of diarrhea
● Loperamide is not recommended for children with acute
infectious gastroenteritis due to serious adverse events
● Anti-emetics are not recommended due to potential adverse
events
G. What is the role of probiotics in the management of
acute infectious diarrhea in children?
● Case Question: Will probiotics work? Yes. Is Yakult
enough? No
● Probiotics are recommended as an adjunct therapy
throughout the duration of the diarrhea in children.
Probiotics have been found to reduce the symptom severity
and duration of diarrhea
● The following probiotics may be used:
o Saccharomyces boulardii
o Lactobacillus rhamnosus
o Lactobacillus reuteri
o There is insufficient evidence to recommend
Bacillus clausii
H. What is the recommended diet for children with acute
infectious diarrhea?
• Case Question: Do you recommend the BRAT diet? No
• Breastfeeding should be continued in breastfed infants
• In general, feeding should be continued. However, if feeding
is not tolerated, early refeeding ay be started as soon as the
child is able
• If diarrhea persists for >7 days or if patients are hospitalized
due to severe diarrhea, lactose free diet may be given to
children who are predominantly bottle fed to reduce
treatment failure and decrease duration of diarrhea
• No change in age appropriate diet is recommended
• Diluted lactose milk is not recommended
• Restrictive diet such as BRAT (banana, rice, apple, tea) diet
is not recommended because of the risk of malnutrition from
its inadequate nutritional value
V. PREVENTION
A. Interventions
● Interventions should be aimed at reducing subsequent
episodes of diarrhea, malnutrition, and delays I physical and
mental development
o Exclusive breastfeeding until age 6 months, and
continued breastfeeding with complementary foods until
2 years of age
o The consumption of safe food and water. If available,
water brought to a rolling boil for at least 5 minutes is
optimal for preparing food and drinks for young children
o Handwashing after defecating, disposing of a child’s
stool, and before preparing meals
o The use of latrines; these should be located more than
10 meters and downhill from drinking water sources
B. Food and Water-Borne Disease Prevention and Control
Program
• AO No. 29-A.s 1997
• Interventions:
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FCH 260.1: Clinical Internship in Family Medicine
o Institutionalization of Oral Rehydration Therapy
corners in both the hospitals and outpatient public
health facilities foor the immediate management and
treatment of diarrhea cases
o Integration of the identification and management of
diarrhea among the children in the IMCI protocol
o Design, installation and operationallization of a
FWBD surveillance and response system to detect
impending outbreaks and provide immediate
investigation and response to these cases
o Provisio of drugs.medicines and supplies
augmentation to identified local government units
(LGUs) wuth high incidence of FWBS
o Developing clinic practice guidelines on the
diagnosis, management and treatment of several
FWBD
VI. SUMMARY
• Manage child with diarrhea accordingly by identification of
dehydration status and possible etiologic agent
• Ordering of laboratories is not routine for all patients
• Antibiotic therapy and other adjunct treatments should be
used on a case to case basis
• Prevention and control of acute diarrheal diseases should
include other non-health sectors
VII. QUESTION AND ANSWERS
1. When should we suspect a parasitic etiology?
• When you see passage of worms in the stool and see
signs such as pruritus in the anal area
• Check the patient if he is malnourished and has a big
stomach and other signs that can point to a concomitant
parasitism
2. Does presence of mucus in stool warrant a fecalysis?
• No
3. How many parameters should be fulfilled to classify the
diarrhea episode according to its severity? Are there
parameters that would weigh heavier than others?
• At least 2 parameters according to the PSMID and IMCI
guidelines
• IMCI guidelines also has signs for severe disease that
would warrant admission. Signs such as poor skin turgor
would weigh heavier and should be referred.
4. Does presence of mucus in stool warrant a fecalysis?
• No
5. Why do we prefer nasogastric over IV for hydration?
• Because we prefer oral hydration over IV hydration. If the
patient can tolerate oral hydration, we choose this over IV
hydration as much as possible.
6. In Pediatrics, we were told that Pedialyte and Vivalyte
were not recommended. What are your comments
regarding this?
• It’s very important to look at the sugar contents of these
brands and check if it’s at par with the recommendations
of the WHO
• Gatorade, for example, is not recommended because of
the glucose content which could precipitate more the
diarrhea of the patient
• However, pediatric patients can be very choosy when it
comes to ORS. So sometimes, rather than not giving the
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Trans 04
ORS which does not taste good, I would rather give the
commercial ORS which has better flavor to prevent
dehydration.
• If there is really a need to give a commercially-made ORS,
the closest that can be given is Pocari Sweat.
7. How do we choose between LR and NSS for IV therapy?
Can IV therapy be initiated in the ambulatory unit or is
immediate referral to the PER necessary?
• IV therapy cannot be initiated in the ambulatory unit so
you have to refer to Pedia ER.
8. What if the parents insist that the child be given IV
fluids even if the child can tolerate feeding and has
no/some dehydration only?
• Call the attention of your resident immediately. Apply
active listening skills and get the context then explain to
them the rationale why you are not recommending IV
therapy.
9. Is it allowed to use IMCI to teach BHWs and midwives in
treating diarrhea in the community setting? Does PGH
provide such training?
• Yes, PGH trains non-physician health workers
• IMCI is taught to BHWs and midwives because IMCI is
designed for community members to manage these cases.
It is important, however, that they recognise which cases
should be referred.
• Pedia department has a program for IMCI
10. Does zinc supplementation have a use in adults?
• Yes, you can also give it to adults. There are studies that
show that it helps in faster recovery of the large intestines.
11. When is loperamide indicated? If anti-emetics are not
recommended, what are the acceptable interventions
when there is vomiting?
• Mainstay of treatment for AGE is hydration. Reassure the
parent that hydration is needed to prevent dehydration.
• If there is abdominal pain, Paracetamol can be given.
• As long as the etiology is not infectious, anti-spasmodics
can also be given (not necessarily Loperamide) especially if
there is severe abdominal cramping/pain.
12.Since virus is the most common cause of diarrhea and
RSE/SC is not routinely used, when will you prescribe
antibiotics for patients having acute watery diarrhea
caused by E.coli?
• If the acute watery diarrhea is >5 days, I recommend doing
a fecalysis just to make sure that you don’t miss out on any
pathogen. A stool culture can also be done.
• If you elicit from the history that the patient ingested
uncooked meat, I give antibiotics even without fecalysis or
stool culture. Closely monitor the patient to prevent
dehydration.
13. Can I give both zinc and Racecadotril?
• Yes, both can be given. Racecadotril is an enkephalinase
inhibitor which prevents further dehydration and can cause
formation of stool. Do not give too much Racecadotril
because it can cause constipation.
14. What are the parameters for reassessment vs.
monitoring?
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FCH 260.1: Clinical Internship in Family Medicine

• When you monitor, it does not involve any action point

taken, but when you reassess there will be an action point
based on the monitoring that you did.
• The best way to monitor the hydration status is through
their urine output. The ideal urine output is around 0.5-
1cc/kg/hr

15. Can you comment on Erceflora?

• According to PSMID, there is no evidence as an
adjunctive therapy

16. Does it mean that BRAT diet is also not recommended

for adult patients?
• We’re not restricting the patients into one type of diet.
You can still recommend BRAT diet but do not limit the
patient’s diet into just that.

17.How do we augment/recommend the diet for the patient

during the diarrhea episodes and after when the patient
is sent home? What are the recommendations? What
food is recommended/should be avoided especially in
the community setting?
• You can tell the patients to avoid oily, spicy food, sodas,
and sugary drinks.
• Sugary drinks can precipitate osmotic diarrhea so best to
avoid that.

END OF TRANSCRIPTION

Ma’am’s References:
Harris JB et al. (2019). Approach to the child with acute
diarrhea in resource-limited countries

PSMID. (2017). The CPG on the Management of Acute

Infectious Diarrhea in Children and Adults

World Health Organization. (2014). Integrated Management of

Childhood Illness

Link to the local CPG on the Management of Acute Infectious

Diarrhea in Children and Adults from DOH:
https://www.doh.gov.ph/sites/default/files/publications/CPG%2
0AID_Full%20version.pdfa

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FCH 260.1: Clinical Internship in Family Medicine

APPENDIX

APPENDIX A. Clinical Signs of Dehydration (Pediatrics)

APPENDIX B. Treatment Algorithm for Pediatric Dehydration

Plan C

Plan B

Plan A

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APPENDIX C. Management of Dehydration Algorithm

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APPENDIX D. Clinical Signs of Dehydration (Adult)

APPENDIX E. Other Parameters for Assesing Dehydration in Adults

APPENDIX F. Treatment Plan C

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APPENDIX G. Etiologies of Childhood Diarrhea in Developing Countries

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