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Gastroenteritis

Gastroenteritis (also known as gastro, gastric flu, 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 infection with certain viruses, less often by bacteria
or their toxins, parasites, or adverse reaction to something in the diet or medication.
Worldwide, inadequate treatment of gastroenteritis kills 5 to 8 million people per year,
and is a leading cause of death among infants and children under 5.

At least 50% of cases of gastroenteritis as foodborne illness are due to norovirus. Another
20% of cases, and the majority of severe cases in children, are due to rotavirus. Other
significant viral agents include adenovirus 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. The
incidence is 1 in 1,000 people.

Gastroenteritis can be classified as either viral or bacterial.

Symptoms and signs

Gastroenteritis often involves stomach pain or spasms (sometimes to the point of being
crippled), diarrhea and/or vomiting, with noninflammatory infection of the upper small
bowel, or inflammatory infections of the colon.

It usually is of acute onset, normally lasting 1-6 days (fewer than 10 days) and self-
limiting.

• Nausea and vomiting


• Diarrhea
• Loss of appetite
• Abdominal pain
• Abdominal cramps
• Bloody stools (dysentery - suggesting infection by amoeba, Campylobacter,
Salmonella, Shigella or some pathogenic strains of Escherichia coli)
• Fainting and Weakness

The main contributing factors include poor feeding in infants. Diarrhea is common, and
may be (but not always) 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.
Symptoms occur for up to 6 days on average. Given appropriate treatment, bowel
movements will return to normal within a week after that.

Laboratory tests

• Examination of stool for toxins, (e.g. Clostridium difficile toxin)


• Stool cultures for the organisms that causes the disease, (e.g. Salmonella,
Shigella, Campylobacter and enterotoxic Escherichia coli)
• Microscopy for parasites and their ova and cysts
• EIA for 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.

Noninfectious

Non-infectious causes to consider are poisoning with heavy metals (e.g. arsenic,
cadmium), seafood (e.g. ciguatera, scombroid, toxic encephalopathic shellfish poisoning)
or mushrooms (e.g. Amanita phalloides). Secretory tumours (e.g. carcinoid, medullary
tumour of the thyroid, vasoactive intestinal peptide-secreting adenomas) and 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.

Infectious

Infectious gastroenteritis is caused by a wide variety of bacteria and viruses. For a list of
bacteria causing gastroenteritis, see above. Pseudomembranous colitis is an important
cause of diarrhea in patients often recently treated with antibiotics. Viruses causing
gastroenteritis include rotavirus, norovirus, adenovirus and astrovirus.

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,
but viruses do not respond to antibiotics and infected children usually make a full
recovery after a few days. 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. 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.

Management
Rehydration

The principal treatment of gastroenteritis in both children and adults is rehydration, i.e.
replenishment of water lost in the stools. Depending on the degree of dehydration, this
can be done by giving the person oral rehydration therapy (ORT) or through intravenous
delivery.
People taking diuretics ("water pills") need to be cautious with diarrhea and may need to
stop taking the medication during an acute episode, as directed by the health care
provider.

Dietary therapy

Centers for Disease Control and Prevention recommendations for infants and children
include: Breastfed infants should continue to be nursed on demand. Formula-fed infants
should continue their usual formula immediately upon rehydration in amounts sufficient
to satisfy energy and nutrient requirements, and at the usual concentration. Lactose-free
or lactose-reduced formulas usually are unnecessary. 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, substantial amounts of soft drinks (carbonated or flat), juice, gelatin desserts,
and other highly sugared liquids should be avoided. Fatty foods should not be avoided,
because maintaining adequate calories without fat is difficult, and fat might have an
added benefit of reducing intestinal motility. The practice of withholding food for more
than 24 hours is inappropriate.

The BRAT diet (Bananas, Rice, Applesauce, Toast and Tea) was recommended in the
past; however, it is no longer recommended, as it contains insufficient nutrients.

Probiotics

Some Probiotics have been shown to be beneficial in preventing and treating various
forms of gastroenteritis. Fermented milk products ( such as yogurt ) also reduce the
duration of symptoms.

Zinc

The World Health Organization recommends that infants and children receive a dietary
supplement of zinc for up to 2 weeks after onset of gastroenteritis.

Pharmacologic therapy

Viral gastroenteritis is usually an acute and self-limited disease which does not require
pharmacologic therapy.

Antibiotics

Antibiotics may however sometimes be used if symptoms are severe and a bacterial cause
is either isolated or suspected.[citation needed] If antibiotics are decided on a fluoroquinolone is
often used.[6] Pseudomembranous colitis is treated by discontinuing the causative agent
and starting with metronidazole or vancomycin.

Antibiotics usually are not given for gastroenteritis, although they may be given due to
some bacteria.

Antiemetic drugs

If vomiting is severe, antiemetic drugs may be helpful. Ondansetron has some clinical
utility in this condition with a single dose associated with reduced use of intravenous
fluids, fewer hospitalizations, and decreasing nausea and vomiting. Metoclopramide
however has not been found to be helpful.

Complications
The most serious complication is dehydration, usually due to severe diarrhea but
sometimes made worse due to improper treatment such as withholding fluids until
diarrhea stops. Severe dehydration can be lethal and requires prompt medical care. The
most common complication,[citation needed] especially in infants, is malabsorption of certain
sugars in the diet, and consequent food intolerances. This complication may persist for
weeks, during which time it causes mild diarrhea to return when the patient resumes their
normal diet. Malabsorption of lactose, the principal sugar in milk, is the most common.
Its consequent milk intolerance is caused by lactase deficiency, and the diarrhea is caused
by bacterial fermentation of excess lactose in the gut. However, this is not reason to
discontinue breastfeeding. In children with viral gastroenteritis (usually rotavirus), the
viral infection also can cause a high fever, which in turn can cause febrile convulsion.
Gastroenteritis sometimes is followed by pneumonia.

Epidemiology

Globally, gastroenteritis caused 4.6 million deaths in children in 1980 alone, most of
these in the third world, where the lack of adequate safe water and sewage treatment
capacity contribute to the spread of infectious gastroenteritis. Harrison's Principles of
Internal Medicine estimates the current total figure to be 2.4 to 2.9 million per year. The
global death rate has now come down significantly to approximately 1.5 million deaths
annually, largely due to global introduction of proper oral rehydration therapy.

The incidence in the developed countries is as high as 1-2.5 cases per child per year[citation
needed]
and a major cause of hospitalisation 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.