Gastroenteritis

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Resident
Survival
Guide

For Gastroentritis patient information click here

Gastroenteritis Microchapters

Patient Information

Overview

Classification

Differential Diagnosis

Prevention

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]

Overview

Acute gastroenteritis and diarrhea are among the leading causes of seeking medical care. Approximately, 48 million cases occur annually that cost about $150 million for the U.S. health care system. [1][2] Gastroenteritis is defined as inflammation of the stomach or intestinal mucosa. It typically presents with acute diarrhea, fever, nausea and vomiting, anorexia and crampy abdominal pain and is defined as passage of loose stool for at least 3 times per day for less than 14 days. It may be caused by viruses, bacteria or parasites. Most cases of acute gastroenteritis are caused by viruses and among them, Norovirus is the most common etiology for adults.[3][4][5] Other common viral causes include, Rotavirus, Adenovirus and Astrovirus. Common bacterial causes of gastroenteritis include, Escherichia coli sp, Salmonella sp, Yersinia enterocolitica and Vibrio sp that can cause watery diarrhea and Shigella sp and Campylobacter sp that can cause dysenteric diarrhea. Parasites are other causes of gastroenteritis especially in developing countries which Giardia lamblia and Entamoeba histolytica are the most frequent causes. First step in management of this patients is to evaluate the hydration status and vital signs. Once the patient is stabilized, health care provider must proceed to diagnostic evaluation. There are some principles to decrease the risk of acquiring infection which include, using safe water and foods, avoid unsafe foods during traveling and hand washing.

Classification

Abbreviations: ETEC: Enterotoxigenic Escherichia coli, EPEC: Enteropathogenic Escherichia coli, EHEC: Enterohemorrhagic Escherichia coli, EAEC: Enteroaggregative Escherichia coli, EIEC: Enteroinvasive Escherichia coli, SARS: severe acute respiratory syndrome

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Gastroenteritis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Viral
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Bacterial
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Parasites
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Common
 
Less Common
 
 
 
 
 
 
 
Common
 
 
 
 
 
 
 
 
 
 
 
 
Less Common
 
 
 
 
Helminthic
 
Protozoal
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Rotavirus
Norovirus
•Enteric Adenovirus
Astroviruses
 
•Kobuviruses
Enterovirus
Orthoreovirus
•Torovirus
Coronavirus
(including SARS)
Parvovirus
 
 
 
Gram Positive
 
 
 
 
 
Gram Negative
 
 
 
 
 
Gram Positive
 
 
 
Gram Negative
 
Trichinella spiralis
Trichuris trichiura
Strongyloides stercoralis
Taenia solium
Taenia saginata
Diphyllobothrium latum
Schistosoma mansoni
 
Giardia lamblia
Entamoeba histolytica
Cryptosporidium parvum
Cyclospora cayetanensis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Clostridium perfringens
Clostridium difficile
 
 
Dysenteric diarreha
 
 
 
Watery diarrhea
 
 
Bacillus cereus
Listeria monocytogenes
 
 
 
Bacteroides fragilis
Aeromonas hydrophila
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Shigella sp., •Campylobacter sp.
 
 
 
Escherichia coli
(ETEC, EPEC, EHEC, EAEC, EIEC)
Salmonella sp.
Yersinia enterocolitica
Vibrio sp.
 



§ EHEC, EIEC, EPEC and EAEC may cause bloody diarrhea, but they are classically associated with watery diarrhea.
† Either Salmonella and Yersinia can cause dysentery.
Entamoeba histolytica may cause dysentery

Differential Diagnosis

Organism Age predilection Travel History Incubation Size (cell) Incubation Time History and Symptoms Diarrhea type∞ Food source Specific consideration
Fever N/V Cramping Abd Pain Small Bowel Large Bowel Inflammatory Non-inflammatory
Viral Rotavirus <2 y - <102 <48 h + + - + + - Mostly in day cares, most common in winter.
Norovirus Any age - 10 -103 24-48 h + + + + + - Most common cause of gastroenteritis, abdominal tenderness,
Adenovirus <2 y - 105 -106 8-10 d + + + + + - No seasonality
Astrovirus <5 y - 72-96 h + + + + + Seafood Mostly during winter
Bacterial Escherichia coli ETEC Any age + 108 -1010 24 h - + + + + - Causes travelers diarrhea, contains heat-labile toxins (LT) and heat-stable toxins (ST)
EPEC <1 y - 10 6-12 h - + + + + Raw beef and chicken -
EIEC Any ages - 10 24 h + + + + + Hamburger meat and unpasteurized milk Similar to shigellosis, can cause bloody diarrhea
EHEC Any ages - 10 3-4 d - + + + + Undercooked or raw hamburger (ground beef)  Known as E. coli O157:H7, can cause HUS/TTP.
EAEC Any ages + 1010 8-18 h - - + + + - May cause prolonged or persistent diarrhea in children
Salmonella sp. Any ages + 1 6 to 72 h + + + + + Meats, poultry, eggs, milk and dairy products, fish, shrimp, spices, yeast, coconut, sauces, freshly prepared salad. Can cause salmonellosis or typhoid fever.
Shigella sp. Any ages - 10 - 200 8-48 h + + + + + Raw foods, for example, lettuce, salads (potato, tuna, shrimp, macaroni, and chicken) Some strains produce enterotoxin and Shiga toxin similar to those produced by E. coli O157:H7
Campylobacter sp. <5 y, 15-29 y - 104 2-5 d + + + + + Undercooked poultry products, unpasteurized milk and cheeses made from unpasteurized milk, vegetables, seafood and contaminated water. May cause bacteremia, Guillain-Barré syndrome (GBS), hemolytic uremic syndrome (HUS) and recurrent colitis
Yersinia enterocolitica <10 y - 104 -106 1-11 d + + + + + Meats (pork, beef, lamb, etc.), oysters, fish, crabs, and raw milk. May cause reactive arthritis; glomerulonephritis; endocarditis; erythema nodosum.

can mimic appendicitis and mesenteric lymphadenitis.

Clostridium perfringens Any ages > 106 16 h - - + + + Meats (especially beef and poultry), meat-containing products (e.g., gravies and stews), and Mexican foods. Can survive high heat,
Vibrio cholerae Any ages - 106-1010 24-48 h - + + + + Seafoods, including molluscan shellfish (oysters, mussels, and clams), crab, lobster, shrimp, squid, and finfish. Hypotension, tachycardia, decreased skin turgor. Rice-water stools
Parasites Protozoa Giardia lamblia 2-5 y + 1 cyst 1-2 we - - + + + Contaminated water May cause malabsorption syndrome and severe weight loss
Entamoeba histolytica 4-11 y + <10 cysts 2-4 we - + + + + Contaminated water and raw foods May cause intestinal amebiasis and amebic liver abscess
Cryptosporidium parvum Any ages - 10-100 oocysts 7-10 d + + + + + Juices and milk May cause copious diarrhea and dehydration in patients with AIDS especially with 180 > CD4
Cyclospora cayetanensis Any ages + 10-100 oocysts 7-10 d - + + + + Fresh produce, such as raspberries, basil, and several varieties of lettuce. More common in rainy areas
Helminths Trichinella spp Any ages - Two viable larvae (male and female) 1-4 we - + + + + Undercooked meats More common in hunters or people who eat traditionally uncooked meats
Taenia spp Any ages - 1 larva or egg 2-4 m - + + + + Undercooked beef and pork Neurocysticercosis: Cysts located in the brain may be asymptomatic or seizures, increased intracranial pressure, headache.
Diphyllobothrium latum Any ages - 1 larva 15 d - - - + + Raw or undercooked fish. May cause vitamin B12 deficiency



Small bowel diarrhea: watery, voluminous with less than 5 WBC/high power field

Large bowel diarrhea: Mucousy and/or bloody with less volume and more than 10 WBC/high power field
† It could be as high as 1000 based on patient's immunity system.

Prevention

Non travel setting

  • Contaminated foods are major causes of foodborne illness in the United states.[1][2]
  • To prevent food preparation chain from contamination, every steps of this process including, products in the farms, packaging industries, stores, restaurants and individuals in the home who are buying and preparing food must be take in to consideration.
  • Proper maintaining the filtration systems at water plants is also essential.
  • Avoid consuming unpasteurized milk or soft cheeses.
  • Wash your hands frequently and effectively and use alcohol-based hand sanitizers.
  • Rotavirus vaccination is recommended for all infants unless there is a contraindication for it.[6]

Travel setting

  • A simple rule is, boil it, cook it, peel it, or forget it!
  • Use bottled water or boil all drinking water while on outdoor adventures.
  • Wash your hands frequently and effectively and use alcohol-based hand sanitizers especially during cruise traveling.
  • Chemoprophylaxis with Bismuth subsalicylate (BSS) has been shown to reduce the frequency of traveler's diarrhea (TD) when used during period of risk for 3 weeks.[7] The recommended dose of BSS for TD prevention is two tablets four daily doses at mealtimes and at bedtime. BSS could be used for trips up to 2 weeks.[8]
  • Offer the typhoid vaccine to travelers going to countries with high prevalence of typhoid fever.

References

  1. 1.0 1.1 Scallan E, Griffin PM, Angulo FJ, Tauxe RV, Hoekstra RM (2011). "Foodborne illness acquired in the United States--unspecified agents". Emerging Infect. Dis. 17 (1): 16–22. PMC 3204615Freely accessible. PMID 21192849. doi:10.3201/eid1701.091101p2. 
  2. 2.0 2.1 Scallan E, Hoekstra RM, Angulo FJ, Tauxe RV, Widdowson MA, Roy SL, Jones JL, Griffin PM (2011). "Foodborne illness acquired in the United States--major pathogens". Emerging Infect. Dis. 17 (1): 7–15. PMC 3375761Freely accessible. PMID 21192848. doi:10.3201/eid1701.091101p1. 
  3. Bresee JS, Marcus R, Venezia RA, Keene WE, Morse D, Thanassi M, Brunett P, Bulens S, Beard RS, Dauphin LA, Slutsker L, Bopp C, Eberhard M, Hall A, Vinje J, Monroe SS, Glass RI (2012). "The etiology of severe acute gastroenteritis among adults visiting emergency departments in the United States". J. Infect. Dis. 205 (9): 1374–81. PMID 22454468. doi:10.1093/infdis/jis206. 
  4. Hall AJ, Rosenthal M, Gregoricus N, Greene SA, Ferguson J, Henao OL, Vinjé J, Lopman BA, Parashar UD, Widdowson MA (2011). "Incidence of acute gastroenteritis and role of norovirus, Georgia, USA, 2004-2005". Emerging Infect. Dis. 17 (8): 1381–8. PMC 3381564Freely accessible. PMID 21801613. doi:10.3201/eid1708.101533. 
  5. Wikswo ME, Hall AJ (2012). "Outbreaks of acute gastroenteritis transmitted by person-to-person contact--United States, 2009-2010". MMWR Surveill Summ. 61 (9): 1–12. PMID 23235338. 
  6. Cortese MM, Parashar UD (2009). "Prevention of rotavirus gastroenteritis among infants and children: recommendations of the Advisory Committee on Immunization Practices (ACIP)". MMWR Recomm Rep. 58 (RR-2): 1–25. PMID 19194371. 
  7. DuPont HL, Sullivan P, Evans DG, Pickering LK, Evans DJ, Vollet JJ, Ericsson CD, Ackerman PB, Tjoa WS (1980). "Prevention of traveler's diarrhea (emporiatric enteritis). Prophylactic administration of subsalicylate bismuth)". JAMA. 243 (3): 237–41. PMID 6985681. 
  8. DuPont HL, Ericsson CD, Farthing MJ, Gorbach S, Pickering LK, Rombo L, Steffen R, Weinke T (2009). "Expert review of the evidence base for prevention of travelers' diarrhea". J Travel Med. 16 (3): 149–60. PMID 19538575. doi:10.1111/j.1708-8305.2008.00299.x. 

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