Scenario

Objectives
• Definitions
• Differential diagnosis
• Clinical approach(history ,physical examination, investigation)
• Management
• Indications of referral
• Prevention

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 Acute Gastroenteritis
Increased stool frequency with or without vomiting, fever, or
abdominal pain

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 Definition of acute diarrhea
The passage of :
•3 or more loose or liquid stools per 24 hours
and/or
•Stools that are more frequent than what is normal for the
individual lasting <14 days
and/or
• Stool weight greater than 200 g/day.

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 Causes of acute diarrhea in adults: infections
 Viral pathogens
• Norovirus (cause 50% of acute diarrheal illnesses in the United States)
• Rotavirus (mostly affects children ≤ 2 years old)
 Bacterial pathogens
• Salmonella, Shigella, Campylobacter, E.coli, and Clostridium difficile.
 Parasites
• Giardia lamblia and Entamoeba histolytica

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 Causes of acute diarrhea in adults: Noninfectious conditions

Gastrointestinal conditions Endocrine conditions Medications

Inflammatory bowel disease Neuroendocrine tumors Antibiotics (especially broad-
spectrum and clavulanic
acid containing)
Irritable bowel syndrome (IBS) Hyperthyrodism Laxatives

Lactose intolerance Magnesium antacids

Celiac disease Colchicine

Ischemic colitis Long-term steroid

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 Non-inflammatory vs. Inflammatory
infectious diarrhea

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 Causes(DDs) of acute diarrhea in children:
infectious
• Gastrointestinal infection
• The most common cause of acute diarrhea in children
• Viral pathogens account for most cases of gastroenteritis in children

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 Causes(DDs) of acute diarrhea in children: Non-infectious
life- Gastrointestina Extraintestina Endocrine disease Medications
threatening l conditions l infection
conditions

Intussusception Inflammatory Meningitis Hyperthyroidism Antibiotics

bowel disease (especially broad-
spectrum and
clavulanic acid
containing)

Hemolytic-uremic IBS Pneumonia Carcinoid tumors Laxatives

syndrome

Clostridium difficile Lactose intolerance Urinary tract Magnesium

infection antacids
(pseudomembrano
us colitis)
Toxic shock Celiac disease Acute otitis media Colchicine
syndrome

Appendicitis long-term steroid

(diarrhea may be use
initial symptom in
some younger
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children)
 Approach to patient with acute diarrhea

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 Case
• A 6 years old boy
• Came complaining of diarrhea for 3 days

How to approach this patient ?

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 Chief concern (CC) History
• Ask about symptom characteristics to assess severity
 Fever

 Diarrhea characteristics
• Onset
• Duration
• Frequency
• Severity
• Stool character - watery, bloody, mucus-filled

 Signs of dehydration
 Thirst
 Dizziness
 Change in mental status
 Decreased urine output
 Decreased activity

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History of present illness History
• Ask about associated symptoms
 Fever bacterial infection, but does not exclude viral infection.
 Tenesmus bacterial infection.
 Nausea and/or vomiting viral gastroenteritis or food poisoning
 Severe abdominal pain and age ≥ 50 years intra-abdominal condition which may require surgical
intervention
• Ask about stool characteristics
 Bloody stool bacterial infection with intestinal inflammation
 Rice-water stool Vibrio cholera

• Ask about timing of symptoms after suspected infectious exposure

 Onset 2-7 hours after possible exposure foodborne illness
 Onset 24-48 hours after possible exposure viral pathogen

• Ask about duration

 Diarrhea lasting > 7 days raises suspicion of parasitic infection, especially if weight loss.

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 Past medical history History
• Ask about past medical conditions that are associated with diarrhea
 Gastrointestinal conditions
 Endocrine conditions

• Some conditions raise suspicion of specific etiology

 Recent hospitalization or antibiotic use Clostridium difficile infection.

Medication history

 Ask about medications associated with diarrhea

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 Diet history History
• Fluid and food intake (including breast milk) since onset of diarrhea

• Ask about recent food consumption

 Untreated water raises suspicion of parasitic infection or cholera
 Fried rice raises suspicion of Bacillus cereus infection

• Dairy and eggs

 Raw milk raises suspicion of Salmonella , Campylobacter, Shiga toxin-producing E. coli
 Eggs raises suspicion of Salmonella infection

• Seafood (particularly raw or undercooked shellfish)

 V. cholerae, Salmonella, or norovirus infections

• Poultry
 raises suspicion of Campylobacter or Salmonella infection

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 Social history History
• Travel to a developing country raises suspicion of E. coli (most common)

• Exposure to animals (such as reptiles [may harbor Salmonella], or pets with diarrhea.

ICEE

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 Clues to the diagnosis of acute diarrhea

???
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 Clues to the diagnosis of acute diarrhea cont.

???
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 Physical exam
• Common findings on physical examination of patients with acute viral gastroenteritis
 Mild diffuse abdominal tenderness on palpation
 Fever

• Look for signs of dehydration to assess severity

• Abdominal examination (assess bowel sounds, palpate for localized pain and
rebound tenderness)

• Neck stiffness (bacterial meningitis)

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Dehydration in
adult

Copyrights apply
 Dehydration in
children

What are the most useful individual

signs for identifying dehydration in
children ?

Copyrights apply
• The most useful individual signs for identifying dehydration in
children are
 Prolonged capillary refill time
 Abnormal skin turgor
 Abnormal respiratory pattern

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 Back to the case
• A 6 years old boy
• Came complaining of diarrhea for 3 days
• fever 38
• Mild diffused abdominal pain
• Vomiting 2 times daily of food contents , no blood
• It was sudden in onset and occurred about 4 times per day
• The diarrhea was watery in nature, yellowish to brown in color with no blood
or mucus
• His mother said was appeared lethargic and less active than usual
• No recent history of taking outside food or travelling
• Other systemic review unremarkable
• Past medical/surgical history : negative
•23 Immunization up to his age
 Back to the case
On examination
• Awake ,alert, not ill looking
• Vital signs : fever and tachycardia , no hypotension
• Mild to mederate dehydrated : tongue and mucous
membranes were dry , reduced skin turgor, Capillary refill time
was less than 2 s ,no sunken eyes
• The abdomen appeared normal, on palpation his abdomen
was soft and non tender with no organomegaly.

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 What investigation will you order?

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 Investigation
• Testing usually not needed, particularly if symptoms are mild
with no red flags and usually of viral etiology.

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 Indications of acute diarrhea testing
1) Severe illness
 Profuse watery diarrhea with signs of dehydration
 Passage of >6 unformed stools per 24 hours
 Severe abdominal pain

2) Other signs or symptoms concerning for inflammatory diarrhea

 Bloody diarrhea
 Passage of many small volume stools containing blood and mucus
 Temperature ≥38.5ºC (101.3ºF)

3) High-risk host features

 Age ≥70 years
 Comorbidities, such as cardiac disease, which may be exacerbated by hypovolemia or rapid infusion of fluid
 Immunocompromising condition (HIV infection)

4)Inflammatory bowel disease

5) Pregnancy

6) Symptoms persisting for

more than one week

7)
27 Suspected infectious
outbreak (e.g handlers large
 Investigation : stool analysis
• Stool studies (such as culture, PCR, or immunoassays):
 Occult blood (increase suspicion for inflammatory bacterial diarrhea)
 Consider testing for fecal lactoferrin or fecal leukocytes to assess for
inflammation.
o Lactoferrin is marker for leukocytes released by damaged cells which increases in bacterial
infections
o Lactoferrin testing is the preferred method (over testing for leukocytes)
o sensitivity > 90% and specificity > 70%

 Consider microbiological stool investigation (depend on the lab and the

pathogen suspected).
 Parasitic infections: consider stool ova and parasite test
 PCR can detect evidence of multiple pathogens and can distinguish
between them.
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 Investigation :Other tests
• Blood tests
 CBC
 Electrolytes
 Blood cultures
• Urinalysis

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 Back to the case
• CBC and electrolytes are normal
• Stool studies : negative
• Urine analysis : negative

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 What imaging will you order?

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 Indications for imaging
• Abdominal imaging is not typically needed.
• For patients who have significant peritoneal signs or ileus
• Most typically CT to rule out other DD

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 So our diagnosis is acute viral gastroenteritis
with mild to moderate dehydration

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 Management

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 Management
1. Rehydration therapy
2. Diet
3. Antidiarrheal medications
4. Antimicrobial medications
5. Probiotics

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 1.Rehydration therapy

• The most critical therapy in diarrheal illness.

• Preferably by the oral route, with solutions that contain water,
salt, and sugar.
• Consumption of fruit juices, sports drinks, soups, and saltine
crackers

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Dehydration in
adult

Copyrights apply
 Rehydration in children
• Acute GE (no or minimal signs of dehydration) managed at
home after educating parents about fluid management, proper
nutrition and how to identify signs of dehydration.

• If dehydration is present
 Oral rehydration solution(e.g: Pedialyte) with mild to moderate
dehydration
 IV rehydration with severe dehydration

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 Rehydration in children: Composed of two steps
1. The first is to emergently correct severe dehydration with IV
isotonic fluids
• Severe dehydration (more than 10%) :
 Rapid infusion of 20 mL/kg of isotonic saline.
 Then reassess during and after the saline bolus
 And similar isotonic fluid infusions should be repeated as needed until
adequate perfusion is restored.
• Mederate dehydration (6-9%) :
 Bolus of 10 mL/kg is given over 30 to 60 minutes
 Then reassess to decide on administration of a repeat IV bolus or change
to oral therapy.

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 Rehydration in children: Composed of two steps
2. The second step is to finish repletion of fluids and electrolytes
either with IV fluids or ORT (the preferred method unless can not
tolerating orally )

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 ORS preparation at home
• From Rehydration Project by UNICEF
 1 L clean drinking water (or water that has been boiled and then
cooled)
 one-half teaspoon salt
 6 teaspoons sugar
 consider adding one-half cup orange juice or some mashed banana
to provide potassium and improve taste

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 Q2
A 22-year-old healthy male sees you for “diarrhea.” He reports frequent
loose stools without bleeding. You determine that he likely has a
virally mediated process and recommend supportive care. Which of the
following dietary measures should you recommend?

a. The patient should fast until the diarrhea resolves.

b.The patient should not eat solids, but should drink an oral rehydrating
solution.
c. The patient should drink milk.
d. The patient should drink fruit juice.
e. The patient can eat rice and potatoes.

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 2.Diet
• After dehydration resume feeding as soon as possible because
it reduces illness duration
• Limited or no evidence to support although they are
recommended :
 Avoiding solid food or dairy
 BRAT diet

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 Anti-diarrhea medications are they
recommended or not in acute
GE ?

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 3.Anti-diarrhea medications(in adult)
• May reduce stool volume and frequency.
• Specific symptomatic therapies for adults with acute viral
gastroenteritis with moderate to severe non-bloody diarrhea
or signs of dehydration ,and no fever
• Contraindicated if :
 bloody stool
 fever
 abdominal pain
• Due to concern about prolonging duration of inflammatory
infectious diarrhea.
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 3.Anti-diarrhea medications (in children)
• In general, antidiarrheal medications should not be used in
children with acute gastroenteritis because they delay the
elimination of infectious agents from the intestines.
• May be considered after patient is adequately hydrated
(Weak recommendation)

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 3.Anti-diarrhea medications
• Loperamide(anti-motility) (Imodium) monotherapy
 Initial dose ≤ 4 mg, with additional doses ≤ 2 mg after each unformed
stool up to 8 mg/day (max 16 mg/day) for 2 days.
• Loperamide-simethicone combination
 Such as chewable tablet containing loperamide 2 mg plus
simethicone 125 mg.
 Recommended over monotherapy for faster and more complete
relief of acute nonspecific diarrhea and gas-related discomfort
• Racecadotril (anti-secretory)
 may reduce acute diarrhea in adults by about 1 day or about 1 unformed stool
49 per day
 4.Antimicrobial medications

• Antimicrobial use not recommended in most patients

• Empiric antibiotic therapy not recommended unless high
likelihood of traveler's diarrhea

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 4.Antimicrobial medications

• Inappropriate use may lead to

 Antimicrobial resistance
 Prolonged duration (such as with Clostridium difficile infection)
 Prolonged carrier state (such as with Salmonella infection)
 Harmful eradication of normal flora

• Treating Shiga toxin-producing E.coli (STEC) O157 with

antimicrobials may increase risk of hemolytic-uremic syndrome
(HUS)

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 4.Antimicrobial medications

• Consider antimicrobial therapy if

Symptoms severe (such as passage ≥ 6 stools daily or duration without
improvement > 72 hours) or do not improve after rehydration
therapy or antidiarrheal medication
AND
 Bacterial or parasitic pathogen strongly suspected such as with
 Fever or bloody stool
 Suspected hospital-associated or antibiotic therapy-associated
diarrhea
Suspected traveler's diarrhea (characterized by ≥ 3 loose stools over 24-hour
period shortly after or during travel)

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 5. probiotics

• Defined by WHO: live microorganisms that, when administered in

adequate amounts, confer a health benefit on the host.
• Example : Lactobacillus casei .

 Probiotics may reduce duration of acute infectious diarrhea (level 2

[mid-level] evidence)
 When used with an oral rehydration solution, probiotics can help reduce
the duration of diarrhea in children with gastroenteritis
 Probiotics associated with reduced duration of diarrhea and stool
frequency on day 2 of treatment in children < 5 years old with acute
diarrhea (level 2 [mid-level] evidence)
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 Probiotics in private pharmacy

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 Do you recommend Zinc supplements in
treatment of acute gastroenteritis?

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 Zinc supplementation
• The effect on adults
 Has not been studied, and its use is not the standard of care.

• The effect on children

 Reduces the severity and duration of acute diarrhea in children from
populations in which zinc deficiency is common

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 Red
Flags Indication of referral of GE (in adult)
• Signs of severe dehydration
• Persistent vomiting
• Abnormal electrolytes or renal function
• Excessive bloody stool or rectal bleeding
• Severe abdominal pain
• Prolonged symptoms (more than one week)
• Age 65 or older with signs of hypovolemia
• Comorbidities (eg, diabetes mellitus, immunocompromised)
• Pregnancy
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 Indication of referral of GE (in children)
• Diarrhea lasting more than one week
• Severe dehydration
• Hypernatremia
• Clinical features suggesting extraintestinal involvement
or another etiology (eg, hemolytic uremia syndrome)
• Immune compromise

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 Prevention
• Non-vaccine prevention methods
 Good hygiene practices such as hand washing
 Safe practices in food preparation
 Access to clean water
 Probiotics

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 Probiotics in prevention
• Probiotics shown to reduce rate of antibiotic-associated diarrhea (level 1 [likely
reliable] evidence)

• Some probiotics appear effective in prevention of traveler's diarrhea (level 2

[mid- level] evidence)

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 Prevention
• Prophylactic vaccines are available for
 Rotavirus (more common in children)
 Typhoid fever
 Cholera

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Copyrights apply
 Evaluation of acute diarrhea

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 MCQ

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 Any Questions?

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