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Acute Gastroenteritis

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Content

 

 Acute Gastroenteritis:  An Approach Paolo Aquino, M.D., M.P.H.

 

Outline 









Approach Etiology Diagnosis Treatment Prevention

 

 Approach 

Considerations •

Rule out acute/surgical abdomen



Hydration status

 

Abdomen  Acute Abdomen Intraluminal Obstruction

Extraluminal Obstruction

Gastrointestin al Disease

Paralytic Ileus

Blunt Trauma

Miscellaneous

Foreign Body

Hernia

Appendicitis

Sepsis

Accident

Lead poisoning

Bezoar Fecalith Gallstone Parasites Cystic fibrosis Tumor Fecaloma

Intussusceptio n Volvulus Duplication Stenosis Tumor Mesenteric cyst SMA syndrome Pyloric stenosis

Crohn disease Ulcerative colitis Vasculitis Peptic ulcer disease Meckel’s  AGE

Pneumonia Pyelonephritis Peritonitis Pancreatitis Cholecystitis Renal stones Gallstones

Battered syndromechild

Sickle diseasecell Familial Mediterranean fever Porphyria DKA Addisonian

PID Lymphadenitis

crisis Testicular torsion Ovarian Torsion

 

 Approach 

History •

Symptoms 







Nausea, emesis, retching Abdominal pain Bowel movements Timing •

Age • Onset • Relation to feeds



Focus of infection, other affected individuals

 

 Approach 

Physical examination •

Temperature, heart rate, blood

pressure, pain • Abdominal examination 



Auscultation before palpation Palpation Masses • Tenderness •



Auscultation for bowel sounds

 

 Approach 

Objectives •

Assess the degree of dehydration

• •

Prevent spread of the enteropathogen Selectively determine etiology and provide specific therapy

 

Dehydration 

Mild (3-5%) •

Normal or increased pulse

Decreased urine output Thirsty • Normal physical exam • •

 

Dehydration 

Moderate (7-10%) •

Tachycardia

Little/no urine output Irritable/lethargic • Sunken eyes/fontane eyes/fontanelle lle • •

Decreased tears Dry mucous membranes • Skin- tenting, delayed cap refill, cool, • •

pale

 

Dehydration 

Severe (10-15%) •

Rapid, weak pulse

Decreased blood pressure No urine output • Very sunken eyes/fontane eyes/fontanelle lle • •

No tears Parched mucous membranes • Skin- tenting, delayed cap refill, cold, • •

mottled

 

Dehydration 

Treatment •

Calculate deficits   



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

Treat mild-moderate dehydration with

oral rehydration solutions • May treat severe dehydration with intravenous fluids • Hyponatremic v. isotonic v. hypernatremic

 

Etiology 

Enteropathogens •

Non-inflammatory Non-inflammato ry vs. inflammatory diarrhea Non-inflammatory 







Enterotoxin production Destruction of villi



Adherence to GI tract

Inflammatory •

Intestinal invasion • Cytotoxins

 

Etiology 

Chronic diarrhea •

Giardia lamblia

• •

Cryptosporidium parvum Escherichia coli : enteroaggregative, enteropathogenic

• •

Immunocompromised host Immunocompromised Non-infectious Non-infecti ous causes: anatomic, malabsorption, malabsorp tion, endocrino endocrinopathies, pathies, neoplasia

 

Etiology 

Bacterial •

Inflammatory Inflammator y diarrhea 

















 Aeromonas Campylobacter jejuni Clostridium dificile E. coli : enteroinvasive, O157:H7 Plesiomonas shigelloides Salmonella Shigella Vibrio parahaemolyticus Yersinia enterocolitica

 

Etiology 

Bacterial •

Non-inflammatory  



E. coli : enteropathogenic, enterotoxigenic Vibrio cholerae

Viral • • • • • • •

Rotavirus Enteric adenovirus Astroviruus Calcivirus Norwalk CMV HSV

 

Etiology 

Parasites •

Giardia lamblida

Entamoeba histolytica Strongyloides stercora stercoralis lis • Balantidium coli • •

Cryptosporidium parvum Cyclospora cayetanensis • Isospora belli • •

 

Diagnosis 



History Stool examination Mucus Blood • Leukocytes • •



Stool culture

 

Diagnosis 

Examination for ova and parasites •

Recent travel to an endemic area

Stool cultures negative for other enteropathogens • Diarrhea persists for more than 1 week •

Part of an outbreak Immunocompromised • May require examination of more than • •

one specimen

 

therapy  Antimicrobial therapy 

 Aeromonas •

TMP/SMZ



Dysentery-like illness, prolonge prolonged d diarrhea 

Campylobacter •



Clostridium dificile •



Erythromycin, azithromycin Metronidazole, Metronidazo le, vancomycin

E. coli •

TMP/SMZ

 

therapy  Antimicrobial therapy 

Salmonella • • • • •



Typhoid fever Bacteremia Dissemination Disseminat ion with localized suppuration

Shigella •



Cefotaxime, ceftriaxone, ceftriaxone, ampicillin, TMP/SMZ Infants < 3 months

Ampicillin, ciprofloxacin, ofloxacin, ceftriaxone

Vibrio cholerae •

Doxycycline,, tetracycline Doxycycline

 

Therapy 

Antidiarrheal medication •

Alter intestinal motility



Alter adsorption adsorp tionflora Alter intestinal • Alter fluid/electrolyte secretion •



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

 

Prevention 



Contact precautions Education • •







Mode of acquisition Methods to decrease transmission

Exclusion from day care until diarrhea subsides Surveillance Salmonella typhi  vaccine  vaccine

 

 Any questions?

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