Acute Gastroenteritis: Acute Gastroenteritis: An ApproachAn Approach

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

OutlineOutline

ApproachApproach EtiologyEtiology DiagnosisDiagnosis TreatmentTreatment PreventionPrevention

ApproachApproach

ConsiderationsConsiderations

• Rule out acute/surgical abdomenRule out acute/surgical abdomen

• Hydration statusHydration status

Acute AbdomenAcute AbdomenIntraluminal Intraluminal ObstructionObstruction

Extraluminal Extraluminal ObstructionObstruction

GastrointestinGastrointestinalal

DiseaseDisease

Paralytic Paralytic IleusIleus

Blunt Blunt TraumaTrauma

MiscellaneousMiscellaneous

Foreign BodyForeign Body

BezoarBezoar

FecalithFecalith

GallstoneGallstone

ParasitesParasites

Cystic fibrosisCystic fibrosis

TumorTumor

FecalomaFecaloma

HerniaHernia

IntussusceptioIntussusceptionn

VolvulusVolvulus

DuplicationDuplication

StenosisStenosis

TumorTumor

Mesenteric Mesenteric cystcyst

SMA syndromeSMA syndrome

Pyloric stenosisPyloric stenosis

AppendicitisAppendicitis

Crohn diseaseCrohn disease

Ulcerative Ulcerative colitiscolitis

VasculitisVasculitis

Peptic ulcer Peptic ulcer diseasedisease

Meckel’sMeckel’s

AGEAGE

SepsisSepsis

PneumoniaPneumonia

PyelonephritisPyelonephritis

PeritonitisPeritonitis

PancreatitisPancreatitis

CholecystitisCholecystitis

Renal stonesRenal stones

GallstonesGallstones

PIDPID

LymphadenitisLymphadenitis

AccidentAccident

Battered child Battered child syndromesyndrome

Lead poisoningLead poisoning

Sickle cell Sickle cell diseasedisease

Familial Familial Mediterranean Mediterranean feverfever

PorphyriaPorphyria

DKADKA

Addisonian Addisonian crisiscrisis

Testicular Testicular torsiontorsion

Ovarian TorsionOvarian Torsion

ApproachApproach

HistoryHistory• SymptomsSymptoms

Nausea, emesis, retchingNausea, emesis, retching Abdominal painAbdominal pain Bowel movementsBowel movements TimingTiming

• AgeAge• OnsetOnset• Relation to feedsRelation to feeds

• Focus of infection, other affected Focus of infection, other affected individualsindividuals

ApproachApproach

Physical examinationPhysical examination• Temperature, heart rate, blood Temperature, heart rate, blood

pressure, painpressure, pain• Abdominal examinationAbdominal examination

Auscultation before palpationAuscultation before palpation PalpationPalpation

• MassesMasses• TendernessTenderness

Auscultation for bowel soundsAuscultation for bowel sounds

ApproachApproach

ObjectivesObjectives• Assess the degree of dehydrationAssess the degree of dehydration• Prevent spread of the enteropathogenPrevent spread of the enteropathogen• Selectively determine etiology and Selectively determine etiology and

provide specific therapyprovide specific therapy

DehydrationDehydration

Mild (3-5%)Mild (3-5%)• Normal or increased pulseNormal or increased pulse• Decreased urine outputDecreased urine output• ThirstyThirsty• Normal physical examNormal physical exam

DehydrationDehydration

Moderate (7-10%)Moderate (7-10%)• TachycardiaTachycardia• Little/no urine outputLittle/no urine output• Irritable/lethargicIrritable/lethargic• Sunken eyes/fontanelleSunken eyes/fontanelle• Decreased tearsDecreased tears• Dry mucous membranesDry mucous membranes• Skin- tenting, delayed cap refill, cool, Skin- tenting, delayed cap refill, cool,

palepale

DehydrationDehydration

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

mottledmottled

DehydrationDehydration

TreatmentTreatment• Calculate deficitsCalculate deficits

Water: % dehydration x weightWater: % dehydration x weight Sodium: water deficit x 80 mEq/LSodium: water deficit x 80 mEq/L Potassium: water deficit x 30 mEq/LPotassium: water deficit x 30 mEq/L

• Treat mild-moderate dehydration with Treat mild-moderate dehydration with oral rehydration solutionsoral rehydration solutions

• May treat severe dehydration with May treat severe dehydration with intravenous fluidsintravenous fluids

• Hyponatremic v. isotonic v. Hyponatremic v. isotonic v. hypernatremichypernatremic

EtiologyEtiology

EnteropathogensEnteropathogens• Non-inflammatory vs. inflammatory Non-inflammatory vs. inflammatory

diarrheadiarrhea Non-inflammatoryNon-inflammatory

• Enterotoxin productionEnterotoxin production• Destruction of villiDestruction of villi• Adherence to GI tractAdherence to GI tract

InflammatoryInflammatory• Intestinal invasionIntestinal invasion• CytotoxinsCytotoxins

EtiologyEtiology

Chronic diarrheaChronic diarrhea• Giardia lambliaGiardia lamblia• Cryptosporidium parvumCryptosporidium parvum• Escherichia coliEscherichia coli: enteroaggregative, : enteroaggregative,

enteropathogenicenteropathogenic• Immunocompromised hostImmunocompromised host• Non-infectious causes: anatomic, Non-infectious causes: anatomic,

malabsorption, endocrinopathies, malabsorption, endocrinopathies, neoplasianeoplasia

EtiologyEtiology

BacterialBacterial• Inflammatory diarrheaInflammatory diarrhea

AeromonasAeromonas Campylobacter jejuniCampylobacter jejuni Clostridium dificileClostridium dificile E. coliE. coli: enteroinvasive, O157:H7: enteroinvasive, O157:H7 Plesiomonas shigelloidesPlesiomonas shigelloides SalmonellaSalmonella ShigellaShigella Vibrio parahaemolyticusVibrio parahaemolyticus Yersinia enterocoliticaYersinia enterocolitica

EtiologyEtiology BacterialBacterial

• Non-inflammatoryNon-inflammatory E. coliE. coli: enteropathogenic, enterotoxigenic: enteropathogenic, enterotoxigenic Vibrio choleraeVibrio cholerae

ViralViral• RotavirusRotavirus• Enteric adenovirusEnteric adenovirus• AstroviruusAstroviruus• CalcivirusCalcivirus• NorwalkNorwalk• CMVCMV• HSVHSV

EtiologyEtiology

ParasitesParasites• Giardia lamblidaGiardia lamblida• Entamoeba histolyticaEntamoeba histolytica• Strongyloides stercoralisStrongyloides stercoralis• Balantidium coliBalantidium coli• Cryptosporidium parvumCryptosporidium parvum• Cyclospora cayetanensisCyclospora cayetanensis• Isospora belliIsospora belli

DiagnosisDiagnosis

HistoryHistory Stool examinationStool examination

• MucusMucus• BloodBlood• LeukocytesLeukocytes• Stool cultureStool culture

DiagnosisDiagnosis

Examination for ova and parasitesExamination for ova and parasites• Recent travel to an endemic areaRecent travel to an endemic area• Stool cultures negative for other Stool cultures negative for other

enteropathogensenteropathogens• Diarrhea persists for more than 1 weekDiarrhea persists for more than 1 week• Part of an outbreakPart of an outbreak• ImmunocompromisedImmunocompromised• May require examination of more than May require examination of more than

one specimenone specimen

Antimicrobial therapyAntimicrobial therapy

AeromonasAeromonas• TMP/SMZTMP/SMZ• Dysentery-like illness, prolonged diarrheaDysentery-like illness, prolonged diarrhea

CampylobacterCampylobacter• Erythromycin, azithromycinErythromycin, azithromycin

Clostridium dificileClostridium dificile• Metronidazole, vancomycinMetronidazole, vancomycin

E. coliE. coli• TMP/SMZTMP/SMZ

Antimicrobial therapyAntimicrobial therapy

SalmonellaSalmonella• Cefotaxime, ceftriaxone, ampicillin, TMP/SMZCefotaxime, ceftriaxone, ampicillin, TMP/SMZ• Infants < 3 monthsInfants < 3 months• Typhoid feverTyphoid fever• BacteremiaBacteremia• Dissemination with localized suppurationDissemination with localized suppuration

ShigellaShigella• Ampicillin, ciprofloxacin, ofloxacin, ceftriaxoneAmpicillin, ciprofloxacin, ofloxacin, ceftriaxone

Vibrio choleraeVibrio cholerae• Doxycycline, tetracyclineDoxycycline, tetracycline

TherapyTherapy

Antidiarrheal medicationAntidiarrheal medication• Alter intestinal motilityAlter intestinal motility• Alter adsorptionAlter adsorption• Alter intestinal floraAlter intestinal flora• Alter fluid/electrolyte secretionAlter fluid/electrolyte secretion

Antidiarrheal medication generally Antidiarrheal medication generally not recommendednot recommended• Minimal benefitMinimal benefit• Potential for side effectsPotential for side effects

PreventionPrevention

Contact precautionsContact precautions Education Education

• Mode of acquisitionMode of acquisition• Methods to decrease transmissionMethods to decrease transmission

Exclusion from day care until Exclusion from day care until diarrhea subsidesdiarrhea subsides

SurveillanceSurveillance Salmonella typhiSalmonella typhi vaccine vaccine

Any questions?Any questions?