Gastroenteritis

Question 1

Acute gastroenteritis

Answer 1

• Diarrheal disease (3+ watery stool per day) of rapid onset that lasts less than 2 weels and may be accompanited by nausea, vomiting, fever, or abdominal pain.
  
  • Both vomiting and diarrhea are present, but either can occur alone
  • Inflammation of the stomach and intestines usually due to bacterial toxins or viral infection
  • Most cases are viral, with norovirus being the most common

Question 2

Physical exam findings gastroenteritis

Answer 2

• Mid diffuse abdominal tenderness on palpation
• Fever
• Hypovolemia (rare)- dry mucous memnbrains, tacycarida, altered mental status, hypotension

Question 3

Laboratory studies gastroenteritis

Answer 3

• Generally not necessary to do stool studies - only do them if patient presents with alarm featues (blood stool, weight loss, symptoms for more than a week).
  
  • Presence of fecal leukocytes, occult blood, lactoferrin or + stool sulture indicate nonviral cause
• Measure serum electrolytes if their are signs of volume depletion - look for hypokalemia or renal dysfunction

Question 4

Diagnosis gastroenteritis

Answer 4

• Diagnosis is made by a characterisitc history of diarrheal disease or rapid onset that lasts less than one week and may be accompanied ny nausea, vomiting, fever, or abdominal pain and physical exam showing mild, diffuse abdominal tenderness.

Question 5

Differential Diagnosis Gastroenteritis

Answer 5

• Other causes of acute diarrhea
  
  • Giardia - diarrhea that lasts over a week in patients with history of travel, hiking or oral-anal sexual activity
  • C. difficle - recent antiboitc use or hospitialization
  • Foodborne illnesses
• Causes of chronic diarrhea that may be masked as acute
  
  • Colorectal cancer
  • IBS
  • IBD
  • Malabsorption syndromes
  • Post cholecystecomy related disorders
  • Medication indues
  • Laxative abuse
  • chronic infections

Question 6

Treatment Gastroenteritis

Answer 6

• Acute viral gastroenteritis is generally self-limited and is treated with supportive measures

1. Fluid meaintenance and repletion
   
   • No signs of volume depletion - sports drink and broths
   • Mild to moderate hypovolemia - ora rehydration solutions (superior to sports drinks in maintaining electrolyte balance).
   • Secere hypovolemia - IV fluids
2. Diet
   
   • Patients should be encouraged to eat as tolerated
   • Smallar more bland meals are likely to be better tolerated
3. Pharmacotherapy
   
   • Generally medications are not requried. However, when they are used, the goal os to reduce fluid losses and allow for rehydration
   • Antimotility agents (loperamide) - give to pateints <65 with moderate to severe diarrhea or signs of volume depletion
   • Antiemetics - give to patients who can’t handle oral rehydration due to excessive vomiting

Question 7

Prevention of Gastroenteritis

Answer 7

• Hand hygiene
• Avoidance of calss contract with people who have GI symptoms
• Safe food handling - most foodborne cases of gastroenteritis are due to norovirus. Contamination occurs either at the environmental source or by food handlers

Question 8

Travelers Diarrhea

Answer 8

• Diarrhea that develops in individuals from resource rich settings during or within 10 days of returning from travel to resource limited countries or regions.

Question 9

Clinical Manifestation travelers diarrhea

Answer 9

• E. Coli (most common) - malaise, anorexia, and abdominal cramps followed by sudden onset of watery diarrhea. Nausea and vomiting may also occur. Typically no blood or pus is seen. Patients may have low grade fever.
• Campylobacter, jejuni and shigella species - same syptoms as seen with E. Coli, but may progress to symptoms of colitis (fever, tenesmus, uregency, cramping, and bloody diarrhea).
• Gairdiases - Bleching and other upper GI symptoms
• Cholera, cryptosprodiasis, and cyclospora cayetanesis - profuse watery diarrhea

Question 10

Diagnosis of travelers diarrhea

Answer 10

• Daignosis is made in an individual who develops unformed stools during or shortly after returning from travel to resource-limited settings.
• Generally, it is not necessary to determine the microbiological agent. However, certain features may warrent a work up:
  
  • Fever to symptoms of colitis - stool culture for campylobacter and shigella
  • Main upper GI symptoms (bloating, gas, nausa)- stool examination for Giardia
  • Travelers who took antibiotics - C. diff
  • Patients who appear systemically ill - Salmonella

Question 11

Approach to nausea and vomiting

(acute)

Answer 11

• Acute disorders

1. Acute gastroenteritis - characterized by diarrhea and/or vomiting
2. Postoperative nausea and vomiting - ~1/3 or patients experience nausaea, vomiting, or both after receivng general anesthesia
3. Vestibular neuritis - disorder characterized by rapid onset of secere vertigo with nausae, vomiting, and gait instability
4. Patients receiving chemotherapy - nausea and vomiting are common side effects
5. Drugs - several medications cause N/V

Question 12

Approach to nausea and vomiting

(chronic)

Answer 12

• Pregnancy
• Chronic nausea and vomiting syndrome - requries presence of the following for at least 3 months: 1. bothersome nausea, occuring at least once a day oer week and/or one or more vomiitng episodes per week; 2. not self-induced, 3. No evidence of organic systemic, or metabolic disease that explains symptoms.
• Gastroparesis
• GERD
• Gastric outlet obstruction
• Eosinophilic gastroenteritis - food-related reactions resulting in inflitration of eosinophils in the GI tract
• Cyclic vomiting syndrome - repeated epsiodes of N/V that lasts for hours-days and is sperated by a symptoms free period of variable length
• Chroninc idiopathic intestinal pseudo-obstruction
• Rumination syndrome - behaviour consistent of daily, effecortless regurgitation of undgested food within minuets of starting or completing a meal.