Acute Gastroenteritis

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• Acute gastroenteritis refers to a clinical syndrome of diarrhea (>3 stool
episodes in 24 hours) with or without vomiting that generally lasts for
several days
• Gastroenteritis may be accompanied by systemic findings, such as
fever(Fever, when present, is low grade), lethargy, myalgias, and
abdominal pain.
• Viral diarrheais characterized by watery stools with no blood or mucus.
• Vomiting may be present and dehydration may be prominent, especially
in infants and younger children.
• Can present from an extraintestinal infection, e.g., urinary tract infection,
pneumonia, hepatitis
Based on pathogenesis, diarrhea can be classified as invasive or inflammatory, or
it can be classified as secretory, producing either bloody stools with abdominal
cramping and fever or large quantities of watery stool without other symptoms
 ETIOLOGY AND EPIDEMIOLOGY
• Gastrointestinal infections are generally acquired via fecal-oral
transmission or through ingestion of contaminated food or water
• Viral gastroenteritis is the most common cause of diarrhea in children
globally. These illnesses may be associated with vomiting as well as
diarrhea, have incubation periods of hours to days, and are usually self-
limited illnesses lasting 3-7 days
• Rotavirusis the most frequent cause of diarrhea in young children
during the winter months, significant reductions with vaccinations
• Norovirus occurs in people of all ages, year round, and is the most
common cause of outbreaks of acute gastroenteritis because it is highly
contagious.
• the most common bacterial food-borne causes (in order of frequency)
are nontyphoidal Salmonella, Campylobacter, Shigella, Escherichia coli
O157:H7, Yersinia, Listeria monocytogenes, and Vibrio cholerae
• Food-borne diarrhea can also result from ingestion of preformed
enterotoxins produced by bacteria i.e s.aureus ,and nonbacterial toxins
such as from fish, shellfish, and mushrooms

Heavy metals that leach into canned food or drinks causing gastric irritation
and emetic syndromes may mimic symptoms of acute infectious enteritis.
• Nontyphoidal Salmonella
-produces diarrhea by invading the intestinal mucosa.
-The organisms are transmitted through contact with infected animals
(chickens, iguanas, other reptiles, turtles) or from contaminated food
products, such as dairy products, eggs, and poultry.
-A large inoculum of organisms is required for disease because Salmonella
is killed by gastric acidity.
The incubation period for gastroenteritis ranges from 6 to 72 hours but is
usually less than 24 hour
• Shigella dysenteriae may cause disease by producing Shiga toxin.
-The incubation period is 1-7 days
-Infection is spread by person to-person contact or by the ingestion of
contaminated food with 10-100 organisms(small load)
-The colon is selectively affected.
-High fever and febrile seizures may occur in addition to diarrhea
• Only certain strains of E. coli produce diarrhea.
-Strains associated with enteritis are classified by the mechanism of diarrhea:

Ø enterotoxigenic (ETEC):ETEC strains produce heat-labile (cholera-like)

enterotoxin, heat-stable enterotoxin, or both. ETEC is a frequent cause of
traveler’s diarrhea
Ø enterohemorrhagic (EHEC) Shiga toxin–producing (STEC):EHEC or STEC,
produces a Shiga-like toxin that is responsible for a hemorrhagic colitis and
most cases of diarrhea associated with hemolytic uremic syndrome (HUS),
which presents with microangiopathic hemolytic anemia, thrombocytopenia,
and renal failure
-STEC is associated with contaminated food, including unpasteurized fruit juices
and especially undercooked beef, and can present with nonbloody diarrhea that
then becomes bloody
Ø enteroinvasive (EIEC):acute inflammation similar to Shigella.
EIEC diarrhea is usually watery and is often associated with fever

Ø enteropathogenic (EPEC): causes mild watery diarrhea but can cause

severe dehydration in young children

Ø enteroaggregative (EAEC)
• Clostridium difficile causes diarrhea and/or colitis and is
usually associated with prior antibiotic exposure.
-The organism produces spores that spread from person to person
-Infection is generally hospital-acquired, but community acquisition of
infection is increasingly reported.
-Diagnosis is made by detection of toxin in the stool.
- Infants <12 months of age should not be tested for C. difficile as they
are frequently asymptomatically colonized with the organism in their stool,
possibly due to a lack of the receptor required for infection.
Of note, patients on antibiotics often experience diarrhea related to alterations in
their intestinal flora that are unrelated to C. difficile infection
• Campylobacter jejuni is spread by person-to-person contact and by
contaminated water and food, especially poultry, raw milk, and cheese.
The organism invades the mucosa of the jejunum, ileum, and colon

• Yersinia enterocolitica is transmitted by pets and contaminated food.

Infants and young children characteristically have a diarrheal disease,
whereas older children usually have acute lesions of the terminal ileum
or acute mesenteric lymphadenitis mimicking appendicitis or Crohn
disease. Postinfectious arthritis, rash, and spondylopathy may develop.
Important enteric parasites found in North America include Entamoeba
histolytica (amebiasis), Giardia lamblia,and Cryptosporidium parvum.

• Amebiasis occurs in warmer climates, whereas giardiasis is endemic

throughout the United States and is common among infants in daycare
centers.

• E. histolytica infects the colon; amebae may pass through the bowel
wall and invade the liver, lung, and brain. Diarrhea is of acute onset, is
bloody, and contains leukocytes
• G. lambliais transmitted through ingestion of cysts, either from contact with
an infected individual or from food or freshwater or well water contaminated
with infected feces. The organism adheres to the microvilli of the duodenal
and jejunal epithelium. Insidious onset of progressive anorexia, nausea,
gaseousness, abdominal distention, watery diarrhea, secondary lactose
intolerance, and weight loss is characteristic of giardiasis.

• Cryptosporidium causes mild, watery diarrhea in immunocompetent persons

that resolves without treatment. It produces severe, prolongeddiarrhea in
persons with acquired immunodeficiency syndrome e.g AIDS
• Dysentery is enteritis involving the colon and rectum, with blood and mucus,
possibly foul-smelling stools, and fever. Shigella is the prototypical cause of
dysentery, which must be differentiated from infection with EIEC, EHEC, E.
histolytica(amebic dysentery), C. jejuni, Y. enterocolitica, and nontyphoidal
Salmonella. Gastrointestinal bleeding and blood loss may be significant.

• Common causes of bloody diarrhea:

Campylobacter
Amoeba (E. histolytica)
Shigella
E. Coli
Salmonella
 LABORATORY AND IMAGING STUDIES
• laboratory: electrolytes, BUN, creatinine, and urinalysis for specific gravity
as an indicator of hydration
• Most cost-effective, noninvasive testing is stool examination should be
examined for mucus, blood, and leukocytes
• Bacterial stool cultures are recommended for patients with fever, profuse
diarrhea, and dehydration or if HUS or pseudomembranous colitis is
suspected.
• Stool evaluation for parasitic agents should be considered for acute
dysenteric illness, especially in returning travelers, and in protracted cases
of diarrhea in which no bacterial agent is identified
• Serological tests are useful for diagnosis of extraintestinal amebiasis
• Enzyme immunoassays for viruses or PCR (rarely need to be diagnosed)
• If the stool test result is negative for blood and leukocytes and there is
no history to suggest contaminated food ingestion, a viral etiology is
most likely

• Positive blood cultures are uncommon with bacterial enteritis except

for Salmonella and E. coli enteritis in very young infants. In typhoid
fever, blood cultures are positive early in the disease, whereas stool
cultures become positive only after the secondary bacteremia.

• Persistent or chronic symptoms may require tests for malabsorption or

invasive studies, including endoscopy and small bowel biopsy
• acute enteritis may mimic other acute diseases, such as intussusception
and acute appendicitis (diagnosis by imaging)
 DIFFERENTIAL DIAGNOSIS
Diarrhea can be caused by:
• infection
• toxins
• gastrointestinal allergy (including allergy to milk or soy proteins)
• malabsorption defects, inflammatory bowel disease, celiac disease, or
any injury
to enterocytes.
• intussusception and acute appendicitis (diagnosis by imaging)
 TREATMENT
• Most infectious causes of diarrhea in children are self-limited. Antibiotics are not
generally useful and may be a risk factor in the development of HUS when E. coli
O157:H7 is presenManagement of viral and most bacterial causes of diarrhea is
primarily supportive and consists of correcting dehydration and ongoing fluid and
electrolyte deficits.

The degree of dehydration dictates the urgency of the situation and the volume of fluid needed for
rehydration. Mild to moderate dehydration can usually be treated with oral rehydration; severe
dehydration usually requires intravenous rehydration and may even require admission to an intensive
care unit.
• Hyponatremia is common; hypernatremia is less common.
• Metabolic acidosis results from losses of bicarbonate in stool, lactic acidosis results
from shock, and phosphate retention results from transient prerenal-renal
insufficiency.
• therapy for 24 hours with oral rehydration solutions alone is effective
for viral diarrhea.
• Therapy for severe fluid and electrolyte losses involves intravenous
hydration. Less severe degrees of dehydration (<10%) in the absence of
excessive vomiting or shock may be managed with oral rehydration
solutions containing glucose and electrolytes.
• Ondansetron may be administered to reduce emesis when this is
persistent.
• Antibiotic therapy may be necessary for high-risk patients or those with
severe disease or bacteremia.Antibiotic treatment of Shigella may reduce
the duration of symptoms and decrease transmission of infection

• Azithromycin is first-line oral therapy for children

• Salmonella is treated with antibiotics in children less than 3 months of
age.
Fluoroquinolone resistance in Salmonella and many other gram-negative organisms is increasing
in many parts of the world
• Treatment of C. difficile (pseudomembranous colitis) includes
discontinuation of the inciting antibiotic and oral metronidazole or
vancomycin.

• E. histolytica dysentery is treated with metronidazole followed by a

luminal agent, such as iodoquinol.

• The treatment of G. lamblia is metronidazole, tinidazole, or

nitazoxanide

Self-treatment of moderate diarrhea and fever with a fluoroquinolone is recommended in

adults. Similarly, children can receive azithromycin. Prompt medical evaluation is indicated for
disease persisting more than 3 days, bloody stools, fever above 102°F (38.9°C) or chills,
persistent vomiting, or moderate to severe dehydration
 COMPLICATIONS AND PROGNOSIS
• dehydration and hypovolemic shock.
• Seizures may occur with high fever, especially with Shigella.
• Intestinal abscesses can form with Shigella, Yersinia, and Salmonella
infections, leading to intestinal perforation, a life-threatening
complication.
• Severe vomiting associated with gastroenteritis can cause esophageal
tears or aspiration pneumonia
 PREVENTION
• The most important means of preventing childhood diarrhea is the
provision of clean, uncontaminated water and proper hygiene in
growing, collecting, and preparing foods.
• Good hygienic measures, especially appropriate handwashing
• Immunization against rotavirus infection is recommended for all
children beginning at 6 weeks of age
• The risk for traveler’s diarrhea, caused primarily by ETEC,
• may be minimized by avoiding uncooked food and untreated drinking
water
THANK YOU!