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Acute Gastroenteritis: An Approach PowerPoint PPT Presentation


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Acute Gastroenteritis: An Approach. Paolo Aquino, M.D., M.P.H. Outline. Approach Etiology Diagnosis Treatment Prevention. Considerations Rule out acute/surgical abdomen Hydration status. Approach. Acute Abdomen. Approach. History Symptoms Nausea, emesis, retching Abdominal pain

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Acute Gastroenteritis: An Approach

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Acute gastroenteritis an approach l.jpg

Acute Gastroenteritis: An Approach

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


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Outline

  • Approach

  • Etiology

  • Diagnosis

  • Treatment

  • Prevention


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Considerations

Rule out acute/surgical abdomen

Hydration status

Approach


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Acute Abdomen


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Approach

  • History

    • Symptoms

      • Nausea, emesis, retching

      • Abdominal pain

      • Bowel movements

      • Timing

        • Age

        • Onset

        • Relation to feeds

    • Focus of infection, other affected individuals


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Approach

  • Physical examination

    • Temperature, heart rate, blood pressure, pain

    • Abdominal examination

      • Auscultation before palpation

      • Palpation

        • Masses

        • Tenderness

      • Auscultation for bowel sounds


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Approach

  • Objectives

    • Assess the degree of dehydration

    • Prevent spread of the enteropathogen

    • Selectively determine etiology and provide specific therapy


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Dehydration

  • Mild (3-5%)

    • Normal or increased pulse

    • Decreased urine output

    • Thirsty

    • Normal physical exam


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Dehydration

  • Moderate (7-10%)

    • Tachycardia

    • Little/no urine output

    • Irritable/lethargic

    • Sunken eyes/fontanelle

    • Decreased tears

    • Dry mucous membranes

    • Skin- tenting, delayed cap refill, cool, pale


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Dehydration

  • Severe (10-15%)

    • Rapid, weak pulse

    • Decreased blood pressure

    • No urine output

    • Very sunken eyes/fontanelle

    • No tears

    • Parched mucous membranes

    • Skin- tenting, delayed cap refill, cold, mottled


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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


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Etiology

  • Enteropathogens

    • Non-inflammatory vs. inflammatory diarrhea

      • Non-inflammatory

        • Enterotoxin production

        • Destruction of villi

        • Adherence to GI tract

      • Inflammatory

        • Intestinal invasion

        • Cytotoxins


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Etiology

  • Chronic diarrhea

    • Giardia lamblia

    • Cryptosporidium parvum

    • Escherichia coli: enteroaggregative, enteropathogenic

    • Immunocompromised host

    • Non-infectious causes: anatomic, malabsorption, endocrinopathies, neoplasia


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Etiology

  • Bacterial

    • Inflammatory diarrhea

      • Aeromonas

      • Campylobacter jejuni

      • Clostridium dificile

      • E. coli: enteroinvasive, O157:H7

      • Plesiomonas shigelloides

      • Salmonella

      • Shigella

      • Vibrio parahaemolyticus

      • Yersinia enterocolitica


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Etiology

  • Bacterial

    • Non-inflammatory

      • E. coli: enteropathogenic, enterotoxigenic

      • Vibrio cholerae

  • Viral

    • Rotavirus

    • Enteric adenovirus

    • Astroviruus

    • Calcivirus

    • Norwalk

    • CMV

    • HSV


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Etiology

  • Parasites

    • Giardia lamblida

    • Entamoeba histolytica

    • Strongyloides stercoralis

    • Balantidium coli

    • Cryptosporidium parvum

    • Cyclospora cayetanensis

    • Isospora belli


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Diagnosis

  • History

  • Stool examination

    • Mucus

    • Blood

    • Leukocytes

    • Stool culture


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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


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Antimicrobial therapy

  • Aeromonas

    • TMP/SMZ

    • Dysentery-like illness, prolonged diarrhea

  • Campylobacter

    • Erythromycin, azithromycin

  • Clostridium dificile

    • Metronidazole, vancomycin

  • E. coli

    • TMP/SMZ


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Antimicrobial therapy

  • Salmonella

    • Cefotaxime, ceftriaxone, ampicillin, TMP/SMZ

    • Infants < 3 months

    • Typhoid fever

    • Bacteremia

    • Dissemination with localized suppuration

  • Shigella

    • Ampicillin, ciprofloxacin, ofloxacin, ceftriaxone

  • Vibrio cholerae

    • Doxycycline, tetracycline


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Therapy

  • Antidiarrheal medication

    • Alter intestinal motility

    • Alter adsorption

    • Alter intestinal flora

    • Alter fluid/electrolyte secretion

  • Antidiarrheal medication generally not recommended

    • Minimal benefit

    • Potential for side effects


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Prevention

  • Contact precautions

  • Education

    • Mode of acquisition

    • Methods to decrease transmission

  • Exclusion from day care until diarrhea subsides

  • Surveillance

  • Salmonella typhi vaccine


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Any questions?


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