Acute Gastroenteritis: An

Approach

Dr ranjith
 Approach
 Considerations
 History

 Rule out acute/surgical abdomen

 Hydration status
History ?
 Record duration of symptoms
 Frequency and description of stools and vomit
stools- watery /mucous/blood stained(diff b/w
SI/LI)
 abdomen pain
 Tenesmes
 Fever
 Food and fluid ingestion
 Drug intake
 Travel h/o
 Approach

 Physical examination
 Temperature, heart rate, blood pressure,
pain
 Abdominal examination
 Palpation
 Masses
 Tenderness
 Auscultation for bowel sounds
 Assess the degree of dehydration
 Dehydration

 Mild (3-5%)
 thirst

 Decreased urine output

 Dry mouth

 MODERATE(5-10%)
 Sunken frontanale in infants
 Sunken eyes
 Tachypnoea due to metabolic acidosis
 tachycardia
 SEVERE(<10%)
 Decreased skin turgor on pinching the skin
 Drowsiness
 irritable
 etiology
 Bacterial
shigella species
salmonella species
campylobacter
aeromonas species
bacillis species

c.difficile ,c.perfringes
entero haemorrhagic E.COLI
Enterotoxigenic E.coli

vibrio species
staph aureus
y. enterocolitica
 etiology

 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
 Etiology

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

 History
 Stool examination
 Mucus
 Blood

 Leukocytes

 Stool culture

 U&E,abg,cbc
 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
TREATMENT

Most cases are self limiting

Ensure adequate fluid replacement

ADMISSION ?
If patient looks toxic
Moderate to severe dehydration
High fever
 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
Who requires antibiotics ?

 Suspected bacterial infection

(abdominal pain,tenesmus,high
fever,mucus and /or bloody stools)
Role of antibiotics

 adjunct, to shorten the clinical course,

eradicate causative organisms, reduce
transmission, and prevent invasive
complications.
 empiric therapy may be appropriate in
the presence of a severe illness with
bloody diarrhea and stool leucocytes,
particularly in infancy and the
immunocompromised.
 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
 Antimicrobial therapy

 Aeromonas
 TMP/SMZ
 Dysentery-like illness, prolonged diarrhea
 Campylobacter
 Erythromycin, azithromycin
 Clostridium dificile
 Metronidazole, vancomycin
 E. coli
 TMP/SMZ
 Travellers diarrhoea
prophylatic-TMP 200 mg BD 5days
ciprofloxacin 500mg BD 2days
Pseudomembrane colitis

 antibiotic-associated colitis
 Vancomycin, metronidazole, bacitracin,
and cholestyramine are useful in
treatment of antibiotic-associated colitis.
Consequences of treatment of
gastrointestinal infections
 . Enteric bacterial pathogens are the common
cause of gastroenteritis in developing countries.

 Appropriate uses of antibiotics in selected

cases of diarrhoea will decrease symptoms or
reduce faecal shedding of the organism and
prevent spread of infection.

 Antimicrobial agents improve the diarrhoea

associated with cholera, shigellosis, enteric
fever, enterotoxigenic Escherichia coli,
giardiasis, amoebiasis, and probably Vibrio
parahaemolyticus, and enteropathogenic E.
coli.
 Most of the diarrhoeal diseases are self-limited

 Treatment of gastrointestinal infections with

antimicrobials will change intestinal microflora,
promote the emergence of resistant strains and
overgrowth of potential pathogenic bacteria and
fungi. Risks and benefits should be considered
before prescribing antimicrobial agents

 However, empiric therapy may be appropriate

in the presence of a severe illness with bloody
diarrhea and stool leucocytes, particularly in
infancy and the immunocompromised
 Therapy

 Antidiarrheal medication
 Alters intestinal motility
 Alters adsorption
 Alters intestinal flora
 Alters fluid/electrolyte secretion
 Antidiarrheal medication generally not
recommended
 Minimal benefit
 Potential for side effects
Role of antidiarrhoeals ?

 usage of probiotics and racecadotril as

their role in the management of acute
diarrhea is yet to be established.
 Loperamide is considered in severe
cases of viral AGE
Role of probiotics?

 Several placebo-controlled trials showed

a reduction in the severity and duration
of acute diarrhea in children with use of
Lactobacillus .
 Studies of probiotics for the prevention of
traveler's diarrhea yielded conflicting
results, and their routine use cannot be
recommended in this setting.
 complications

 Acute kidney injury

 shock

Common complications that can occur with

various organisms are as follows:

Aeromonas caviae - Intussusception,

gram-negative sepsis, and HUS

Bacillus species - Fulminant liver failure (very

rare) and rhabdomyolysis (very rare )
 C difficile - Chronic diarrhea, toxic
megacolon, and ileus
 Enterohemorrhagic E coli - Hemorrhagic
colitis
 Enterohemorrhagic E coli O157:H7 - HUS
 Listeria species - Bacteremia and meningitis
 Salmonella species - Enteric fever,
bacteremia, meningitis, osteomyelitis,
myocarditis, and Reiter syndrome
 Shigella species - Seizures, HUS,
perforation, and Reiter syndrome
 Vibrio species - Rapid dehydration
 Yersinia enterocolitica - Appendicitis,
perforation, intussusception, peritonitis, toxic
megacolon, cholangitis, bacteremia, and
Reiter syndrome
Consultations
 Certain organisms cause abdominal pain and bloody
stools. Symptoms resembling appendicitis,
hemorrhagic colitis, intussusception, or toxic
megacolon may be appreciated. In such cases, obtain
a consultation with a surgeon.

 Consider consultation with an infectious disease

specialist, especially for any patient who is
immunocompromised due to human
immunodeficiency virus (HIV) infection,
chemotherapy, or immunosuppressive drugs,
because atypical organisms are more likely and
complications can be more serious and can fulminate.
 Prevention

 Contact precautions
 Education
 Mode of acquisition
 Methods to decrease transmission
 Exclusion from day care until diarrhea
subsides
 Surveillance
 Salmonella typhi vaccine
Any questions?