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
Acute Abdomen
Intraluminal
Obstruction
Extraluminal
Obstruction
Gastrointestin
al
Disease
Paralytic
Ileus
Blunt
Trauma
Miscellaneous
Foreign Body
Bezoar
Fecalith
Gallstone
Parasites
Cystic fibrosis
Tumor
Fecaloma
Hernia
Intussusceptio
n
Volvulus
Duplication
Stenosis
Tumor
Mesenteric cyst
SMA syndrome
Pyloric stenosis
Appendicitis
Crohn disease
Ulcerative
colitis
Vasculitis
Peptic ulcer
disease
Meckels
AGE
Sepsis
Pneumonia
Pyelonephritis
Peritonitis
Pancreatitis
Cholecystitis
Renal stones
Gallstones
PID
Lymphadenitis
Accident
Battered child
syndrome
Lead poisoning
Sickle cell
disease
Familial
Mediterranean
fever
Porphyria
DKA
Addisonian
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/fontanelle
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/fontanelle
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 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
Non-infectious causes: anatomic,
malabsorption, endocrinopathies,
neoplasia
Etiology
Bacterial
Inflammatory 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 stercoralis
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
Antimicrobial therapy
Aeromonas
TMP/SMZ
Dysentery-like illness, prolonged
diarrhea
Campylobacter
Erythromycin, azithromycin
Clostridium dificile
Metronidazole, vancomycin
E. coli
TMP/SMZ
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
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
Contact precautions
Education
Mode of acquisition
Methods to decrease transmission
Exclusion from day care until
diarrhea subsides
Surveillance
Salmonella typhi vaccine

Any questions?