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Acute Gastroenteritis:

An Approach
Paolo Aquino, M.D., M.P.H.

Outline

Approach
Etiology
Diagnosis
Treatment
Prevention

Approach

Considerations
Rule out acute/surgical abdomen
Hydration status

Acute Abdomen
Intraluminal
Obstruction

Extraluminal
Obstruction

Gastrointestin
al
Disease

Paralytic
Ileus

Blunt
Trauma

Miscellaneous

Foreign Body
Bezoar
Fecalith
Gallstone
Parasites
Cystic fibrosis
Tumor
Fecaloma

Hernia
Intussusceptio
n
Volvulus
Duplication
Stenosis
Tumor
Mesenteric cyst
SMA syndrome
Pyloric stenosis

Appendicitis
Crohn disease
Ulcerative
colitis
Vasculitis
Peptic ulcer
disease
Meckels
AGE

Sepsis
Pneumonia
Pyelonephritis
Peritonitis
Pancreatitis
Cholecystitis
Renal stones
Gallstones
PID
Lymphadenitis

Accident
Battered child
syndrome

Lead poisoning
Sickle cell
disease
Familial
Mediterranean
fever
Porphyria
DKA
Addisonian
crisis
Testicular
torsion
Ovarian Torsion

Approach

History
Symptoms
Nausea, emesis, retching
Abdominal pain
Bowel movements
Timing

Age
Onset
Relation to feeds

Focus of infection, other affected individuals

Approach

Physical examination
Temperature, heart rate, blood pressure,
pain
Abdominal examination
Auscultation before palpation
Palpation

Masses
Tenderness

Auscultation for bowel sounds

Approach

Objectives
Assess the degree of dehydration
Prevent spread of the enteropathogen
Selectively determine etiology and
provide specific therapy

Dehydration

Mild (3-5%)
Normal or increased pulse
Decreased urine output
Thirsty
Normal physical exam

Dehydration

Moderate (7-10%)
Tachycardia
Little/no urine output
Irritable/lethargic
Sunken eyes/fontanelle
Decreased tears
Dry mucous membranes
Skin- tenting, delayed cap refill, cool,
pale

Dehydration

Severe (10-15%)
Rapid, weak pulse
Decreased blood pressure
No urine output
Very sunken eyes/fontanelle
No tears
Parched mucous membranes
Skin- tenting, delayed cap refill, cold,
mottled

Dehydration

Treatment
Calculate deficits
Water: % dehydration x weight
Sodium: water deficit x 80 mEq/L
Potassium: water deficit x 30 mEq/L

Treat mild-moderate dehydration with oral


rehydration solutions
May treat severe dehydration with
intravenous fluids
Hyponatremic v. isotonic v. hypernatremic

Etiology

Enteropathogens
Non-inflammatory vs. inflammatory
diarrhea

Non-inflammatory

Enterotoxin production
Destruction of villi
Adherence to GI tract

Inflammatory
Intestinal invasion
Cytotoxins

Etiology

Chronic diarrhea
Giardia lamblia
Cryptosporidium parvum
Escherichia coli: enteroaggregative,
enteropathogenic
Immunocompromised host
Non-infectious causes: anatomic,
malabsorption, endocrinopathies,
neoplasia

Etiology

Bacterial
Inflammatory diarrhea

Aeromonas
Campylobacter jejuni
Clostridium dificile
E. coli: enteroinvasive, O157:H7
Plesiomonas shigelloides
Salmonella
Shigella
Vibrio parahaemolyticus
Yersinia enterocolitica

Etiology

Bacterial

Non-inflammatory

E. coli: enteropathogenic, enterotoxigenic


Vibrio cholerae

Viral

Rotavirus
Enteric adenovirus
Astroviruus
Calcivirus
Norwalk
CMV
HSV

Etiology

Parasites
Giardia lamblida
Entamoeba histolytica
Strongyloides stercoralis
Balantidium coli
Cryptosporidium parvum
Cyclospora cayetanensis
Isospora belli

Diagnosis

History
Stool examination
Mucus
Blood
Leukocytes
Stool culture

Diagnosis

Examination for ova and parasites


Recent travel to an endemic area
Stool cultures negative for other
enteropathogens
Diarrhea persists for more than 1 week
Part of an outbreak
Immunocompromised
May require examination of more than
one specimen

Antimicrobial therapy

Aeromonas
TMP/SMZ
Dysentery-like illness, prolonged diarrhea

Campylobacter
Erythromycin, azithromycin

Clostridium dificile
Metronidazole, vancomycin

E. coli
TMP/SMZ

Antimicrobial therapy

Salmonella

Cefotaxime, ceftriaxone, ampicillin, TMP/SMZ


Infants < 3 months
Typhoid fever
Bacteremia
Dissemination with localized suppuration

Shigella
Ampicillin, ciprofloxacin, ofloxacin, ceftriaxone

Vibrio cholerae
Doxycycline, tetracycline

Therapy

Antidiarrheal medication
Alter intestinal motility
Alter adsorption
Alter intestinal flora
Alter fluid/electrolyte secretion

Antidiarrheal medication generally


not recommended
Minimal benefit
Potential for side effects

Prevention

Contact precautions
Education
Mode of acquisition
Methods to decrease transmission

Exclusion from day care until


diarrhea subsides
Surveillance
Salmonella typhi vaccine

Any questions?