Gastroenteritis

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Gastroenteritis
Classification and external resources
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

Look up gastroenteritis in Wiktionary, the free dictionary.

Gastroenteritis (also known as gastro, gastric flu, tummy bug in some countries, 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. 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, 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
[hide]
• 1 Classification
○ 1.1 Bacterial gastroenteritis
○ 1.2 Viral gastroenteritis
 • 2 Symptoms and signs
• 3 Diagnosis
• 4 Prevention
• 5 Management
○ 5.1 Rehydration
○ 5.2 Diet
○ 5.3 Pharmacologic therapy
○ 5.4 Alternative medications
• 6 Complications
• 7 Epidemiology
• 8 History
• 9 See also
• 10 Notes
• 11 External links

[edit] Classification

Gastroenteritis viruses: A = rotavirus, B = adenovirus, C = Norovirus and D = Astrovirus. The

virus particles are shown at the same magnification to allow size comparison.
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]
[edit] 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.
[edit] 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]

[edit] 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.
[edit] 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]
[edit] 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]
[edit] 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]
[edit] 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]
[edit] Diet
Centers for Disease Control and Prevention (CDC) recommends that breastfed infants continue
to be nursed on demand and that formula-fed infants should continue their usual formula
immediately upon rehydration with ORS in amounts sufficient to satisfy energy and nutrient
requirements and at the usual concentration. 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 (carbonated or flat), juice, gelatin desserts, 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]
[edit] 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 blood brain barrier due to its
immaturity 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]
[edit] 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]
[edit] 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. It may increase the diarrhea,[31] however, is not a reason to discontinue
breastfeeding.
[edit] 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]
[edit] 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]