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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

Acute Gastroenteritis: An Approach

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

outline
Outline
  • Approach
  • Etiology
  • Diagnosis
  • Treatment
  • Prevention
approach
Considerations

Rule out acute/surgical abdomen

Hydration status

Approach
approach1
Approach
  • History
    • Symptoms
      • Nausea, emesis, retching
      • Abdominal pain
      • Bowel movements
      • Timing
        • Age
        • Onset
        • Relation to feeds
    • Focus of infection, other affected individuals
approach2
Approach
  • Physical examination
    • Temperature, heart rate, blood pressure, pain
    • Abdominal examination
      • Auscultation before palpation
      • Palpation
        • Masses
        • Tenderness
      • Auscultation for bowel sounds
approach3
Approach
  • Objectives
    • Assess the degree of dehydration
    • Prevent spread of the enteropathogen
    • Selectively determine etiology and provide specific therapy
dehydration
Dehydration
  • Mild (3-5%)
    • Normal or increased pulse
    • Decreased urine output
    • Thirsty
    • Normal physical exam
dehydration1
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
dehydration2
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
dehydration3
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
Etiology
  • Enteropathogens
    • Non-inflammatory vs. inflammatory diarrhea
      • Non-inflammatory
        • Enterotoxin production
        • Destruction of villi
        • Adherence to GI tract
      • Inflammatory
        • Intestinal invasion
        • Cytotoxins
etiology1
Etiology
  • Chronic diarrhea
    • Giardia lamblia
    • Cryptosporidium parvum
    • Escherichia coli: enteroaggregative, enteropathogenic
    • Immunocompromised host
    • Non-infectious causes: anatomic, malabsorption, endocrinopathies, neoplasia
etiology2
Etiology
  • Bacterial
    • Inflammatory diarrhea
      • Aeromonas
      • Campylobacter jejuni
      • Clostridium dificile
      • E. coli: enteroinvasive, O157:H7
      • Plesiomonas shigelloides
      • Salmonella
      • Shigella
      • Vibrio parahaemolyticus
      • Yersinia enterocolitica
etiology3
Etiology
  • Bacterial
    • Non-inflammatory
      • E. coli: enteropathogenic, enterotoxigenic
      • Vibrio cholerae
  • Viral
    • Rotavirus
    • Enteric adenovirus
    • Astroviruus
    • Calcivirus
    • Norwalk
    • CMV
    • HSV
etiology4
Etiology
  • Parasites
    • Giardia lamblida
    • Entamoeba histolytica
    • Strongyloides stercoralis
    • Balantidium coli
    • Cryptosporidium parvum
    • Cyclospora cayetanensis
    • Isospora belli
diagnosis
Diagnosis
  • History
  • Stool examination
    • Mucus
    • Blood
    • Leukocytes
    • Stool culture
diagnosis1
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
antimicrobial therapy
Antimicrobial therapy
  • Aeromonas
    • TMP/SMZ
    • Dysentery-like illness, prolonged diarrhea
  • Campylobacter
    • Erythromycin, azithromycin
  • Clostridium dificile
    • Metronidazole, vancomycin
  • E. coli
    • TMP/SMZ
antimicrobial therapy1
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
therapy
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
prevention
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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