Author:
Isam F.Nasr
Description
Inflammation of stomach and intestines associated with diarrhea and vomiting; often the result of infectious or toxin exposure
Etiology
Infectious
- Viruses:
- 50-70% of all cases with Norovirus cases on the rise in travelers returning from Mexico and India
- Invasive bacteria:
- Campylobacter: Contaminated food or water, wilderness water, birds, and animals:
- Most common cause
- Gross or occult blood is found in 60-90%
- Salmonella: Contaminated water, eggs, poultry, or dairy products:
- Shigella: Fecal-oral route
- Vibrio parahaemolyticus: Raw and undercooked seafood
- Yersinia: Contaminated food (pork), water, and milk:
- Specific food-borne disease (food poisoning):
- Staphylococcus aureus:
- Most common toxin-related disease
- Symptoms within 1-6 hr after ingesting food
- Bacillus cereus:
- Classic source is fried rice left on steam tables
- Symptoms within 1-36 hr
- Cholera: Profuse watery stools with mucous (rice-water stools)
- Ciguatera:
- Fish intoxication
- Onset 5 min-30 hr (average 6 hr) after ingestion
- Paresthesias, hypotension, peripheral muscle weakness
- Scombroid:
- Caused by blood fish: Tuna, albacore, mackerel, and mahi-mahi
- Flushing, headache, erythema, dizziness, blurred vision, and generalized burning sensation
- Symptoms last <6 hr
- Treatment includes antihistamines
- Protozoa:
- Giardia lamblia:
- High-risk groups: Travelers, day care children, homosexual men, and campers who drink untreated mountain water
Noninfectious Causes
- Toxins:
- Zinc, copper, cadmium
- Organic chemicals: Polyvinyl chlorides
- Pesticides: Organophosphates
- Radioactive substances
- Alkyl mercury
- Altered host response to food substance (tyramine, monosodium glutamate, tryptamine)
Pediatric Considerations |
- Focus evaluation on state of hydration
- Most of viral origin and self-limited
- Rotavirus accounts for up to 50%
- Shigella infections associated with seizures
|
Signs and Symptoms
History
- Nausea, vomiting, diarrhea
- Bloody/mucous diarrhea
- Abdominal cramps or pain
- Fever
- Malaise, myalgias, headache, anorexia
- Hypotension, lethargy, and dehydration (severe cases)
Physical Exam
- Dry mucous membranes
- Tachycardia
- Abdominal tenderness
- Perianal inflammation, fissure, fistula
Essential Workup
- Digital rectal exam to determine presence of gross or occult blood
- Fecal leukocyte determination:
- Present with invasive bacteria
- Absent in protozoal infections, viral, toxin-induced food poisoning
Diagnostic Tests & Interpretation
Lab
- CBC indications:
- Significant blood loss
- Systemic toxicity
- Electrolytes, glucose, BUN, creatinine - indications:
- Stool culture indications:
- Presence of fecal leukocytes
- Historical markers (immunocompromised, travel, homosexual)
- Public health (food hand ler, day/health care worker)
- Blood culture indications:
- Suspected bacteremia or systemic infections
- Ill patients requiring admission
- Immunocompromised
- Elderly patients and infants
Imaging
Abdominal radiographs have no value unless obstruction or toxic megacolon suspected
Pediatric Considerations |
- Lab studies not required in most cases
- Rotazyme assay detects rotavirus:
- Rarely indicated in managing outpatients
- Helpful to cohort and avoid cross-contamination among inpatients
- Stool culture indication:
- Fecal leukocytes
- Toxic
- Infants
- Immunocompromised
|
Differential Diagnosis
- Gastritis/peptic ulcer disease
- Milk and food allergies
- Appendicitis
- Irritable bowel syndrome
- Ulcerative colitis/Crohn disease
- Malrotation with midgut volvulus
- Meckel diverticulum
- Drugs and toxins:
- Mannitol
- Sorbitol
- Phenolphthalein
- Magnesium-containing antacids
- Quinidine
- Colchicine
- Mushrooms
- Mercury poisoning
Prehospital
- Difficult IV access with severe dehydration
- Avoid exposure to contaminated clothes or body substances
Initial Stabilization/Therapy
- Management of ABCs
- IV fluid with 0.9% NS resuscitation for severely dehydrated
ED Treatment/Procedures
- Oral fluids for mild dehydration (Gatorade/Pedialyte)
- IV fluids for:
- Hypotension, nausea and vomiting, obtundation, metabolic acidosis, significant hypernatremia, or hyponatremia
- 0.9% NS bolus (adults: 500 mL-1 L, peds: 20 mL/kg) for resuscitation, then 0.9% NS or D5 0.45% peds: NS (peds: D5 0.25% NS) to maintain adequate urine output
- Bismuth subsalicylate (Pepto-Bismol):
- Antisecretory agent
- Effective clinical relief without adverse effects
- Kaolin-pectin (Kaopectate):
- Reduces fluidity of stools
- Does not influence course of disease
- Antimotility drugs (diphenoxylate [Lomotil], loperamide [Imodium], paregoric, and codeine):
- Appropriate in noninfectious diarrhea
- Initial use of sparse amounts to control symptoms in infectious diarrhea
- Avoid prolonged use in infectious diarrhea - may increase duration of fever, diarrhea, and bacteremia and may precipitate toxic megacolon
- Antibiotics for infectious pathogens:
- Antiemetics for nausea/vomiting:
Medication
- Ampicillin: 500 mg (peds: 20 mg/kg/24 hr) PO or IV q6h
- TMP-SMX; Bactrim DS: 1 tab (peds: 8-10 mg TMP/40-50 mg SMX/kg/24 hr) PO b.i.d
- Ceftriaxone: 1 g (peds: 50-75 mg/kg/12 hr) IM or IV q12h
- Ciprofloxacin (quinolone): 500 mg PO or 400 mg IV b.i.d (>18 yr)
- Doxycycline: 100 mg PO or 400 mg IV b.i.d
- Metronidazole: 250 mg (peds: 35 mg/kg/24 hr) PO t.i.d (>8 yr)
- Ondansetron 4 mg (peds: 0.1 mg/kg) IV
- Prochlorperazine (Compazine): 5-10 mg IV q3-4h; 10 mg PO q8h; 25 mg per rectum (PR) q12h
- Promethazine (Phenergan): 25 mg IM/IV q4h; 25 mg PO/PR (peds: 0.25-1 mg/kg PO/PR/IM)
- Tetracycline: 500 mg PO or IV q.i.d
- Vancomycin 125-500 mg (peds: 40 mg/kg/24 hr) PO q6h
Disposition
Admission Criteria
- Hypotension unresponsive to IV fluids
- Significant bleeding
- Signs of sepsis/toxicity
- Intractable vomiting or abdominal pain
- Severe electrolyte imbalance
- Metabolic acidosis
- Altered mental status
- Children with >10-15% dehydration
Discharge Criteria
- Mild cases requiring oral hydration
- Dehydration responsive to IV fluids
Issues for Referral
Cases of prolonged symptoms may be referred to a gastroenterologist for further workup
Follow-up Recommendations
Most cases are self-limiting; therefore, follow-up is optional
- BreseeJS, MarcusR, VeneziaRA, et al. The etiology of severe acute gastroenteritis among adults visiting emergency departments in the United States . J infect Dis. 2012;205:1374-1381.
- Centers for Disease Control and Prevention (CDC). Vital signs: Incidence and trends of infection with pathogens transmitted commonly through food—foodborne diseases active surveillance network, 10 U.S. sites, 1996-2010 . MMWR Morb Mortal Wkly Rep. 2011;60:749-755.
- DuPontHL. Clinical practice. Bacterial diarrhea . N Engl J Med. 2009;361(16):1560-1569.
- ShaneAL, ModyRK, CrumpJA, et al. 2017 Infectious Disease Society of America clinical practice guidelines for the diagnosis and management of infectious diarrhea . Clin Infect Dis. 2017;65(12):e45-e80.
See Also (Topic, Algorithm, Electronic Media Element)