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Gastroenteritis
Classification and external resources

Gastroenteritis viruses: A = rotavirus, B = adenovirus, C = Norovirus and D = Astrovirus. The virus particles are shown at the same magnification to allow size comparison.
ICD-10 A02.0, A08., A09., J10.8, J11.8, K52.
ICD-9 009.0, 009.1, 558
DiseasesDB 30726
eMedicine emerg/213
MeSH D005759

Gastroenteritis (also known as gastro, gastric flu, and stomach flu, although unrelated to influenza) is inflammation of the gastrointestinal tract, involving both the stomach and the small intestine (see also gastritis and enteritis) and resulting in acute diarrhea. It can be transferred by contact with contaminated food and water. The inflammation is caused most often by an infection from certain viruses or less often by bacteria, their toxins, parasites, or an adverse reaction to something in the diet or medication. Worldwide, inadequate treatment of gastroenteritis kills 5 to 8 million people per year,[1] and is a leading cause of death among infants and children under 5.[2]

At least 50% of cases of gastroenteritis due to foodborne illness are caused by norovirus.[3] Another 20% of cases, and the majority of severe cases in children, are due to rotavirus. Other significant viral agents include adenovirus[4] and astrovirus.

Different species of bacteria can cause gastroenteritis, including Salmonella, Shigella, Staphylococcus, Campylobacter jejuni, Clostridium, Escherichia coli, Yersinia, Vibrio cholerae, and others. Some sources of the infection are improperly prepared food, reheated meat dishes, seafood, dairy, and bakery products. Each organism causes slightly different symptoms but all result in diarrhea. Colitis, inflammation of the large intestine, may also be present.

Risk factors include consumption of improperly prepared foods or contaminated water and travel or residence in areas of poor sanitation. It is also common for river swimmers to become infected during times of rain as a result of contaminated runoff water.[5]

Contents

Classification

Infectious gastroenteritis is caused by a wide variety of bacteria and viruses.

It is important to consider infectious gastroenteritis as a diagnosis per exclusionem. A few loose stools and vomiting may be the result of systemic infection such as pneumonia, septicemia, urinary tract infection and even meningitis. Surgical conditions such as appendicitis, intussusception and, rarely, even Hirschsprung's disease may mislead the clinician. Endocrine disorders (e.g. thyrotoxicosis and Addison's disease) are disorders that can cause diarrhea. Also, pancreatic insufficiency, short bowel syndrome, Whipple's disease, coeliac disease, and laxative abuse should be excluded as possibilities.[6]

Bacterial gastroenteritis

For a list of bacteria causing gastroenteritis, see above. Pseudomembranous colitis is an important cause of diarrhea in patients often recently treated with antibiotics.

If gastroenteritis in a child is severe enough to require admission to a hospital, then it is important to distinguish between bacterial and viral infections. Bacteria, Shigella and Campylobacter, for example, and parasites like Giardia can be treated with antibiotics

Traveler's diarrhea is usually a type of bacterial gastroenteritis.

Viral gastroenteritis

Viruses causing gastroenteritis include rotavirus, norovirus, adenovirus and astrovirus. Viruses do not respond to antibiotics and infected children usually make a full recovery after a few days.[7] Children admitted to hospital with gastroenteritis routinely are tested for rotavirus A to gather surveillance data relevant to the epidemiological effects of rotavirus vaccination programs.[8][9] These children are routinely tested also for norovirus, which is extraordinarily infectious and requires special isolation procedures to avoid transmission to other patients. Other methods, electron microscopy and polyacrylamide gel electrophoresis, are used in research laboratories.[10][11]

Symptoms and signs

Gastroenteritis often involves stomach pain or spasms, diarrhea and/or vomiting, with noninflammatory infection of the upper small bowel, or inflammatory infections of the colon.[1][6][12][13]

The condition is usually of acute onset, normally lasting 1–6 days, and is self-limiting.

  • Nausea and vomiting
  • Diarrhea
  • Loss of appetite
  • Fever
  • Headaches
  • Abnormal flatulence
  • Abdominal pain
  • Abdominal cramps
  • Bloody stools (dysentery - suggesting infection by amoeba, Campylobacter, Salmonella, Shigella or some pathogenic strains of Escherichia coli[4])
  • Fainting and Weakness

The main contributing factors include poor feeding in infants. Diarrhea is common, and may be followed by vomiting. Viral diarrhea usually causes frequent watery stools, whereas blood stained diarrhea may be indicative of bacterial colitis. In some cases, even when the stomach is empty, bile can be vomited up.

A child with gastroenteritis may be lethargic, suffer lack of sleep, run a low fever, have signs of dehydration (which include dry mucous membranes), tachycardia, reduced skin turgor, skin color discoloration, sunken fontanelles, sunken eyeballs, darkened eye circles, glassy eyes, poor perfusion and ultimately shock.

Diagnosis

No specific diagnostic tests are required in most patients with simple gastroenteritis. If symptoms including fever, bloody stool and diarrhea persist for two weeks or more, examination of stool for Clostridium difficile may be advisable along with cultures for bacteria including Salmonella, Shigella, Campylobacter and Enterotoxic Escherichia coli. Microscopy for parasites, ova and cysts may also be helpful.[citation needed]

Prevention

Percentage of rotavirus tests with positive results, by surveillance week, United States, July 2000--June 2009.

A rotavirus vaccine has between 2000 and 2009 decreased the number of cases of diarrhea due to rotavirus in the United States.[14]

Management

The objective of treatment is to replace lost fluids and electrolytes. Oral rehydration is the preferred treatment of fluid and electrolyte losses caused by diarrhea in children with mild to moderate dehydration.[15]

Rehydration

The primary treatment of gastroenteritis in both children and adults is rehydration, i.e., replenishment of water and electrolytes lost in the stools. This is preferably achieved by giving the person oral rehydration therapy (ORT) although intravenous delivery may be required if a decreased level of consciousness or an ileus is present.[16][17] Complex-carbohydrate-based Oral Rehydration Salts (ORS) such as those made from wheat or rice have been found to be superior to simple sugar-based ORS.[18]

Sugary drinks such as soft drinks and fruit juice are not recommended for gastroenteritis in children under 5 years of age as they may make the diarrhea worse.[19] Plain water may be used if specific ORS are unavailable or not palatable.[19]

Diet

It is recommended that breastfed infants continue to be nursed on demand and that formula-fed infants should continue their usual formula immediately after rehydration with oral rehydration solutions. Lactose-free or lactose-reduced formulas usually are not necessary.[20] Children receiving semisolid or solid foods should continue to receive their usual diet during episodes of diarrhea. Foods high in simple sugars should be avoided because the osmotic load might worsen diarrhea; therefore, soft drinks, juice, and other high simple sugar foods should be avoided.[20] The practice of withholding food is not recommended and immediate normal feeding is encouraged.[21] The BRAT diet (bananas, rice, applesauce, toast and tea) is no longer recommended, as it contains insufficient nutrients and has no benefit over normal feeding.[22]

Pharmacologic therapy

Gastroenteritis is usually an acute and self-limited disease that does not require pharmacological therapy.[19] Metoclopramide and ondansetron however may be helpful in children.[23]

Antibiotics

Antibiotics are usually not useful for gastroenteritis, although they are sometimes used if symptoms are severe or a susceptible bacterial cause is isolated or suspected.[citation needed] If antibiotics are decided on, a fluoroquinolone or macrolide is often used.[12]

Pseudomembranous colitis, usually caused by antibiotics use, is managed by discontinuing the causative agent and treating with either metronidazole or vancomycin.[1][6][12][13]

Antimotility agents

Antimotility drugs have a theoretical risk of causing complications, clinical experience however has shown this to be unlikely.[6][12] They are thus discouraged in people with bloody diarrhea or diarrhea complicated by a fever.[1]

Loperamide, an opioid analogue, is commonly used for the symptomatic treatment of diarrhea.[12] Loperamide is not recommended in children as it may cross the immature blood brain barrier and cause toxicity.

Bismuth subsalicylate (BSS), an insoluble complex of trivalent bismuth and salicylate, can be used in mild-moderate cases.[6][12]

Antiemetic drugs

Antiemetic drugs may be helpful for vomiting in children. Ondansetron has some utility with a single dose associated with less need for intravenous fluids, fewer hospitalizations, and decreased vomiting.[24][25] Metoclopramide also might be helpful.[26]

Alternative medications

Probiotics

Some probiotics have been shown to be beneficial in preventing and treating various forms of gastroenteritis.[22] Fermented milk products (such as yogurt) also reduce the duration of symptoms.[27]

Zinc

The World Health Organization recommends that infants and children receive a dietary supplement of zinc for up to two weeks after onset of gastroenteritis.[28] A 2009 trial however did not find any benefit from supplementation.[29]

Complications

Dehydration is a common complication of diarrhea. It can be made worse with the withholding fluids or the administration of juice / soft drinks.[30] Malabsorption of lactose, the principal sugar in milk, may occur. Though it may increase the diarrhea,[31] however, one should not discontinue breastfeeding.

Epidemiology

Disability-adjusted life year for diarrhea per 100,000 inhabitants.
     no data      ≤50      50-100      100-200      200-300      300-400      400-500      500-750      750-1000      1000-1250      1250-2500      2500-5000      ≥5000

Every year worldwide rotavirus in children under 5 causes 111 million cases of gastroenteritis and nearly half a million deaths. 82% of these deaths occur in the world's poorest nations.[32]

In 1980 gastroenteritis from all causes caused 4.6 million deaths in children with most of these occurring in the third world.[13] lack of adequate safe water and sewage treatment has contributed to the spread of infectious gastroenteritis. Current death rates have come down significantly to approximately 1.5 million deaths annually in the year 2000, largely due to the global introduction of oral rehydration therapy.[33]

The incidence in the developed world is as high as 1-2.5 cases per child per year[citation needed] and is a major cause of hospitalization in this age group.

Age, living conditions, hygiene and cultural habits are important factors. Aetiological agents vary depending on the climate. Furthermore, most cases of gastroenteritis are seen during the winter in temperate climates and during summer in the tropics.[13]

History

Before the 20th century, the term "gastroenteritis" was not commonly used. What would now be diagnosed as gastroenteritis may have instead been diagnosed more specifically as typhoid fever or "cholera morbus", among others, or less specifically as "griping of the guts", "surfeit", "flux", "colic", "bowel complaint", or any one of a number of other archaic names for acute diarrhea.[34] Historians, genealogists, and other researchers should keep in mind that gastroenteritis was not considered a discrete diagnosis until fairly recently.

U.S. President Zachary Taylor died of gastroenteritis on July 9, 1850.[35]

See also

References

  1. ^ a b c d Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL. Harrison's Principles of Internal Medicine. New York: McGraw-Hill, 2005. ISBN 0-07-139140-1.
  2. ^ King CK, Glass R, Bresee JS, Duggan C (November 2003). "Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy". MMWR Recomm Rep 52 (RR-16): 1–16. PMID 14627948. 
  3. ^ "Norovirus: Technical Fact Sheet". National Center for Infectious Diseases, CDC. http://www.cdc.gov/ncidod/dvrd/revb/gastro/norovirus-factsheet.htm. 
  4. ^ a b Murray PR, Pfaller MA, Rosenthal KS. Medical Microbiology. Mosby, 2005. ISBN 0323033032.
  5. ^ Seven Surfing Sicknesses.
  6. ^ a b c d e The Oxford Textbook of Medicine. Edited by David A. Warrell, Timothy M. Cox and John D. Firth with Edward J. Benz, Fourth Edition (2003), Oxford University Press, ISBN 0-19-262922-0
  7. ^ Haffejee IE (1991). "The pathophysiology, clinical features and management of rotavirus diarrhoea". Q. J. Med. 79 (288): 289–99. PMID 1649479. 
  8. ^ Patel MM, Tate JE, Selvarangan R, et al. (2007). "Routine laboratory testing data for surveillance of rotavirus hospitalizations to evaluate the impact of vaccination" (Subscription required). Pediatr. Infect. Dis. J. 26 (10): 914–9. doi:10.1097/INF.0b013e31812e52fd. PMID 17901797. 
  9. ^ Pediatric ROTavirus European CommitTee (PROTECT) (2006). "The paediatric burden of rotavirus disease in Europe". Epidemiol. Infect. 134 (5): 908–16. doi:10.1017/S0950268806006091. PMID 16650331. 
  10. ^ Beards GM (1988). "Laboratory diagnosis of viral gastroenteritis". Eur. J. Clin. Microbiol. Infect. Dis. 7 (1): 11–3. doi:10.1007/BF01962164. PMID 3132369. 
  11. ^ Steel HM, Garnham S, Beards GM, Brown DW (1992). "Investigation of an outbreak of rotavirus infection in geriatric patients by serotyping and polyacrylamide gel electrophoresis (PAGE)". J. Med. Virol. 37 (2): 132–6. doi:10.1002/jmv.1890370211. PMID 1321223. 
  12. ^ a b c d e f Sleisenger & Fordtran's Gastrointestinal and Liver Disease 7th edition, by Mark Feldman; Lawrence S. Friedman; and Marvin H. Sleisenger, ISBN 0-7216-8973-6, Hardback, Saunders, Published July 2002
  13. ^ a b c d Mandell's Principles and Practices of Infection Diseases 6th Edition (2004) by Gerald L. Mandell MD, MACP, John E. Bennett MD, Raphael Dolin MD, ISBN 0-443-06643-4 · Hardback · 4016 Pages Churchill Livingstone
  14. ^ "www.cdc.gov". http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5841a2.htm. 
  15. ^ "Practice parameter: the management of acute gastroenteritis in young children. American Academy of Pediatrics, Provisional Committee on Quality Improvement, Subcommittee on Acute Gastroenteritis". Pediatrics 97 (3): 424–35. 1996. PMID 8604285. 
  16. ^ "BestBets: Fluid Treatment of Gastroenteritis in Adults". http://www.bestbets.org/bets/bet.php?id=1039. 
  17. ^ Canavan A, Arant BS (October 2009). "Diagnosis and management of dehydration in children". Am Fam Physician 80 (7): 692–6. PMID 19817339. 
  18. ^ Gregorio GV, Gonzales ML, Dans LF, Martinez EG (2009). "Polymer-based oral rehydration solution for treating acute watery diarrhoea". Cochrane Database Syst Rev (2): CD006519. doi:10.1002/14651858.CD006519.pub2. PMID 19370638. 
  19. ^ a b c "Diarrhoea and vomiting in children under 5". http://www.nice.org.uk/Guidance/CG84#summary. 
  20. ^ a b "Managing Acute Gastroenteritis Among Children: Oral Rehydration, Maintenance, and Nutritional Therapy". http://www.cdc.gov/mmwR/preview/mmwrhtml/rr5216a1.htm. 
  21. ^ "BestBets: Gradual introduction of feeding is no better than immediate normal feeding in children with gastro-enteritis". http://www.bestbets.org/bets/bet.php?id=390. Retrieved December 6, 2008. 
  22. ^ a b King CK, Glass R, Bresee JS, Duggan C (November 2003). "Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy". MMWR Recomm Rep 52 (RR-16): 1–16. PMID 14627948. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm. 
  23. ^ Alhashimi D, Al-Hashimi H, Fedorowicz Z (2009). "Antiemetics for reducing vomiting related to acute gastroenteritis in children and adolescents". Cochrane Database Syst Rev (2): CD005506. doi:10.1002/14651858.CD005506.pub4. PMID 19370620. 
  24. ^ DeCamp LR, Byerley JS, Doshi N, Steiner MJ (September 2008). "Use of antiemetic agents in acute gastroenteritis: a systematic review and meta-analysis". Arch Pediatr Adolesc Med 162 (9): 858–65. doi:10.1001/archpedi.162.9.858. PMID 18762604. 
  25. ^ Mehta S, Goldman RD (2006). "Ondansetron for acute gastroenteritis in children". Can Fam Physician 52 (11): 1397–8. PMID 17279195. PMC 1783696. http://www.cfp.ca/cgi/pmidlookup?view=long&pmid=17279195. 
  26. ^ Alhashimi D, Al-Hashimi H, Fedorowicz Z (2009). "Antiemetics for reducing vomiting related to acute gastroenteritis in children and adolescents". Cochrane Database Syst Rev (2): CD005506. doi:10.1002/14651858.CD005506.pub4. PMID 19370620. 
  27. ^ "Does yogurt decrease acute diarrhoeal symptoms in children with acute gastroenteritis". http://www.bestbets.org/bets/bet.php?id=1000. 
  28. ^ Rehydrate.org: Zinc Supplementation
  29. ^ Patel A, Dibley MJ, Mamtani M, Badhoniya N, Kulkarni H (2009). "Zinc and copper supplementation in acute diarrhea in children: a double-blind randomized controlled trial". BMC Med 7: 22. doi:10.1186/1741-7015-7-22. PMID 19416499. 
  30. ^ "Diarrhoea and vomiting in children under 5". http://guidance.nice.org.uk/CG84. 
  31. ^ Arya SC (1984). "Rotaviral infection and intestinal lactase level". J. Infect. Dis. 150 (5): 791. PMID 6436397. 
  32. ^ Parashar UD, Hummelman EG, Bresee JS, Miller MA, Glass RI (May 2003). "Global illness and deaths caused by rotavirus disease in children". Emerging Infect. Dis. 9 (5): 565–72. PMID 12737740. 
  33. ^ Victora CG, Bryce J, Fontaine O, Monasch R (2000). "Reducing deaths from diarrhoea through oral rehydration therapy". Bull. World Health Organ. 78 (10): 1246–55. PMID 11100619. 
  34. ^ Rudy's List of Archaic Medical Terms
  35. ^ "Biography of Zachary Taylor" from The White House

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