cpg on acute gastroenteritis

7/27/2019 CPG on Acute Gastroenteritis

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CPG on Acute Gastroenteritis


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Acute Gastroenteritis

Acute gastroenteritis is a disease characterized bychanges in the character and frequency of stool.

It can be defined as the passage of a greater number ofstools of decreased form from the normal lasting less

than 14 days.Generally associated with other signs or symptomsincluding nausea, vomiting, abdominal pain and cramps,increase in intestinal gas-related complaints, fever,passage of bloody stools (dysentery), tenesmus(constant sensation of urge to move bowels), and fecalurgency. (1)

(1) Guidelines on acute infectious diarrhea in adults. The Practice Parameters Committee of the American College of Gastroenterology.American Journal of Gastroenterology. 1997 Nov;92(11):1962-75.


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Perform initial assessment

Dehydration

Duration (>1 day)Inflammation (indicated by fever, presence

of blood in stool, tenesmus) (2)

(2) Acute Infectious Diarrhea. Nathan M. Thielman, M.D., M.P.H., and Richard L. Guerrant, M.D. The New England

Journal of Medicine. 2004; 350:38-47.


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Complete blood count can be obtained to lookfor anemia, hemoconcentration, or an abnormalwhite blood cell count. (4)

Measurements of serum electrolyteconcentrations and blood urea nitrogen andserum creatinine levels can be used todetermine the extent of fluid and electrolytedepletion and its effect on renal function. (4)

(4) Sleisenger and Fordtrans Gastrointestinal and Liver Disease. 8th edition. 2006. Feldman, Mark

MD. Volume II. p169.


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Provide symptomatic treatment

Rehydration

Treatment of symptoms (if necessary,loperamide if diarrhea is not inflammatory

or bloody) (2)

(2) Acute Infectious Diarrhea. Nathan M. Thielman, M.D., M.P.H., and Richard L. Guerrant, M.D. The New England

Journal of Medicine. 2004; 350:38-47


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Initial rehydrationThe most common risk with diarrheal illnesses isdehydration.

The critical initial treatment must include rehydration,

which can be accomplished with an oral glucose orstarch-containing electrolyte solution in the vast majorityof cases.

Although many patients with mild diarrhea can preventdehydration by ingesting extra fluids (such as clear

juices and soups), more severe diarrhea, postural light-headedness, and reduced urination signify the need formore rehydration fluids. (2)

(2) Acute Infectious Diarrhea. Nathan M. Thielman, M.D., M.P.H., and Richard L. Guerrant, M.D. TheNew England Journal of Medicine. 2004; 350:38-47.


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Prevention of Dehydration

It is recommended that continued use of the

patients preferred, usual, and appropriate diet

be encouraged to prevent or limit dehydration.

Regular diets are generally more effective than

restricted and progressive diets, and in

numerous trials have consistently produced areduction in the duration of diarrhea. (5)(5) Cincinnati Childrens Hospital Medical Center. Evidence-based clinical care guideline for acute gastroenteritis (AGE) in children aged 2 months through 5

years. Cincinnati (OH): Cincinnati Childrens Hospital Medical Center; 2006 May. 15 p. [50 references].


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The use of BRAT diet (consisting of bananas,rice, apple, and toast) with avoidance of milkproducts (since a transient lactase deficiencymay occur) is commonly recommended,although supporting data are limited. (3)

Clear liquids are not recommended as asubstitute for oral rehydration solutions (ORS) orregular diets in the prevention or therapy ofdehydration. (5)

(3) Practice Guidelines for the Management of Infectious Diarrhea. Infectious diseases Society of America. Clinical Infectious Diseases 2001;32:33150.

(5) Cincinnati Childrens Hospital Medical Center. Evidence-based clinical care guideline for acute gastroenteritis (AGE) in children aged 2 months through 5years. Cincinnati (OH): Cincinnati Childrens Hospital Medical Center; 2006 May. 15 p. [50 references].


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Oral Feeding Following Rehydration

> It is recommended that giving the patients usual dietbe started at the earliest opportunity after an adequatedegree of rehydration is achieved. (5)

On-going IV or NG Fluids following Rehydration

> It is recommended that maintenance IV fluids or NGORS be given: when unable to replace the estimated fluid deficit and keep up

with the on-going losses using oral feedings alone, and/or to severely dehydrated patient with obtunded mental status

(5) Cincinnati Childrens Hospital Medical Center. Evidence-based clinical care guideline for acute gastroenteritis (AGE) in children aged 2 monthsthrough 5 years. Cincinnati (OH): Cincinnati Childrens Hospital Medical Center; 2006 May. 15 p. [50 references].


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Stratify subsequent management according to

clinical and epidemiologic features

Epidemiologic clues:

Food, antibiotics, sexual activity, travel, day-careattendance, other illnesses outbreaks, season

Clinical clues:

Bloody diarrhea, abdominal pain, dysentery, wasting, fecal

inflammation. (2)

(2) Acute Infectious Diarrhea. Nathan M. Thielman, M.D., M.P.H., and Richard L. Guerrant, M.D. The New England Journal of Medicine. 2004;

350:38-47


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When to admit?Persistent Diarrhea (>7 days) (2)

Fever

Unstable

Severely dehydratedBloody diarrhea

Persistent Vomiting

No improvement after initial hydration or symptoms

exacerbate/ overall condition gets worse(6)

(2) Acute Infectious Diarrhea. Nathan M. Thielman, M.D., M.P.H., and Richard L. Guerrant, M.D. The New England Journal of Medicine. 2004;

350:38-47

(6) World Gastroenterology Organisation (WGO). WGO practice guideline: acute diarrhea. Munich, Germany: World GastroenterologyOrganisation (WGO); 2008 Mar.


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(2) Acute Infectious Diarrhea. Nathan M. Thielman, M.D., M.P.H., and Richard L. Guerrant, M.D. The New England Journal of Medicine. 2004; 350:38-47


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(2) Acute Infectious Diarrhea. Nathan M. Thielman, M.D., M.P.H., and Richard L. Guerrant, M.D. The New England Journal of Medicine. 2004; 350:38-47


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Immunocompromised patients

If symptoms recur or are uncontrolled despite hydration

and antimicrobial treatment....

If evidence of colitis is present,

Do: Proctosigmoidoscopy with biopsy of lesions with

attention to CMV, mycobacteria, Adenovirus, Fungi,

Herpes simplex

(1) Guidelines on acute infectious diarrhea in adults. The Practice Parameters Committee of the American College of Gastroenterology. American

Journal of Gastroenterology. 1997 Nov;92(11):1962-75.


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Immunocompromised patients

If symptoms recur or are uncontrolled despite

hydration and antimicrobial treatment....

If evidence of colitis is NOT present,

Do:

-Gastroduodenoscopy with biopsy, Smears and

culture for special parasites plus

proctosigmoidoscopy

(1) Guidelines on acute infectious diarrhea in adults. The Practice Parameters Committee of the American College of Gastroenterology. American

Journal of Gastroenterology. 1997 Nov;92(11):1962-75.


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When to discharge?

Stable Vital signs

Maintains a sufficient fluid intake

Able to eat meals adequately

Able to take medications (if still indicated) (6)

(6) World Gastroenterology Organisation (WGO). WGO practice guideline: acute diarrhea. Munich, Germany: World Gastroenterology

Organisation (WGO); 2008 Mar.


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Patient Education

Many diarrheal diseases can be prevented byfollowing simple rules of personal hygiene andsafe food preparation.

Hand-washing with soap is an effective step in

preventing spread of illness and should beemphasized for caregivers of persons withdiarrheal illnesses.

As noted above, human feces must always be

considered potentially hazardous, whether or notdiarrhea or potential pathogens have beenidentified. (3)

(3) Practice Guidelines for the Management of Infectious Diarrhea. Infectious diseases Society of America. Clinical Infectious Diseases 2001; 32:33150.


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Patient Education

Consequently, microbial studies should not beneeded to justify careful attention to hygiene.

Select populations may require additionaleducation about food safety, and health careproviders can play an important role in providingthis information. (3)

(3) Practice Guidelines for the Management of Infectious Diarrhea. Infectious diseases Society of America. ClinicalInfectious Diseases 2001; 32:33150.


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THANK YOU!


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Clinical Pathway for Acute Gastroenteritis with Severe

dehydration

1st 30 minutes 2nd 30 minutes to 2 hrs 2 hrs to 24 hours

A

S

S

E

S

S

M

E

N

T

AGE documented based on history and

physical examination

Assess patient as stable or unstable

History

Onset frequency, quantity Character -

bile/blood/mucusFeverVomiting

Past medical history, underlying medical

conditions

Epidemiological clues (food, antibiotics, sexual

activity, travel, outbreaks, season)

Signs of dehydration in adults

Decreased sensorium (severe dehydration)

Tachycardia

Postural hypotension

Supine hypotension and absence of palpable

pulse

Dry tongue

Sunken eyeballs Skin pinch/turgor

Decrease urine output

Response to treatment

assessed

Presence of urine output

Stable vital signs

Response to treatment

assessed

Presence of urine

output

Stable vital signs


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Clinical Pathway for Acute Gastroenteritis with

Severe dehydration

1st 30 minutes 2nd 30 minutes to 2

hrs

2 hrs to 24 hours

D

I

A

G

N

O

S

T

I

C

S

Serum electrolytes

BUN, creatinine

CBC

FecalysisStool for c. difficile toxin (if with

recent/chronic antibiotic use)

ABG (if with decreased sensorium/

tachypneic/ dyspneic)

RBS (if with decreased sensorium

Follow up result of

tests

Serum electrolytes

and BUN, creatinine

monitored at

appropriate intervals

(every 24 hours)


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Severe dehydration

1st 30 minutes 2nd 30 minutes to 2

hrs

2 hrs to 24 hours

T

R

E

A

T

M

E

N

T

IV Line or Central vein catheter for

rapid fluid delivery

Oxygen by nasal cannula (if

tachpneic/ dyspneic)

Elevate patients feet and legs (if

with hypotension

IV Hydration

correct fluid and

electrolyte

disturbances

Adjust IV fluids

accordinglycorrect

fluid and electrolyte

disturbances start

oral hydration (if

tolerated) of

preferred diet


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Severe dehydration


M

E

D

I

C

A

T

I

O

N

S

IV Hydration Metoclopramide for recurrent

or persistent vomiting

Treatment of symptoms (if

necessary loperamide ifdiarrhea is not inflammatory

or bloody)

Continue medications

Consider antimicrobial

treatment for specific

pathogens


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Severe dehydration


T

E

A

C

H

I

N

G

Relatives are Informed

on the condition of the

patient

Relatives are Informed on need

to have continued fluid

replacement

Request for renal, pulmonary and

cardiac support (if needed)

Relatives are

Updated on the

patients condition

cpg on acute gastroenteritis

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