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Acute Gastroenteritis

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 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


Foreign Body





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%) •


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

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



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, • •



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 •


Dysentery-like illness, prolonge prolonged d diarrhea 

Campylobacter •

Clostridium dificile •

Erythromycin, azithromycin Metronidazole, Metronidazo le, vancomycin

E. coli •



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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