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07-SEPTEMBER-2008 03:17:44 - Gastroenteritis It has been suggested that Traveler's diarrhea be merged into this article or section. Discuss Gastroenteritis Classification and external resources ICD-10 A09., J10.8, 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, 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,1 and is a leading cause of death among infants and children under 5.2 At least 50% of cases of gastroenteritis as foodborne illness are due to norovirus.3 Another 20% of cases, and the majority of severe cases in children, are due to rotavirus. Other significant viral agents include adenovirus4 and astrovirus. Many different 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 are consumption of improperly prepared foods or contaminated water and travel or residence in areas of poor sanitation. The incidence is 1 in 1,000 people. Contents 1 Epidemiology 2 History 3 Symptoms and signs 3.1 Signs and Tests 4 Differential diagnosis 5 Treatment 5.1 Rehydration 5.2 Dietary therapy 5.3 Probiotics 5.4 Zinc 5.5 Drug therapy 5.5.1 Antibiotics 5.5.2 Antidiarrheal agents 5.5.3 Antiemetic drugs 6 Complications 7 See also 8 References 9 External links Epidemiology Globally, gastroenteritis caused 4.6 million deaths in children in 1980 alone, most of these in the third world,5 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.1 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.6 The incidence in the developed countries is as high as 1-2.5 cases per child per yearcitation 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.5 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.7 Historians, genealogists, and other researchers should keep in mind that gastroenteritis was not considered a discrete diagnosis until fairly recently. Symptoms and signs Gastroenteritis often involves stomach pain or spasms sometimes to the point of being crippling, diarrhea and/or vomiting, with noninflammatory infection of the upper small bowel, or inflammatory infections of the colon.8519 It usually is of acute onset, normally lasting 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 coli4 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. Signs and Tests Stool culture positive for the organism that causes the infection White blood cells in the stool Examination of food for toxin and bacteria This disease may also alter the results of the following tests: Stool gram stain Fecal smear Differential diagnosis Gastroenteritis viruses: A = rotavirus, B = adenovirus, C = Norovirus and D = Astrovirus. The virus particles are shown at the same magnification to allow size comparison. Gastroenteritis viruses: A = rotavirus, B = adenovirus, C = Norovirus and D = Astrovirus. The virus particles are shown at the same magnification to allow size comparison. 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. 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.9 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.10 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.1112 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.1314 Treatment 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. Rehydration Regardless of cause, the principal treatment of gastroenteritis and of all other diarrheal illnesses 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. ORT can begin before dehydration occurs, and continue until the person's urine and stool output return to normal. 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 Prevention16 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. Probiotics Probiotics have been showncitation needed to be beneficial in preventing and treating various forms of gastroenteritis. 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.17 Drug therapy Antibiotics This article may require cleanup to meet 's quality standards. Please improve this article if you can. January 2008 When the symptoms are severe one usually starts empirical antimicrobial therapy,citation needed i.e. a fluoroquinolone antibiotic.8 Pseudomembranous colitis is treated by discontinuing the causative agent and starting with metronidazole or vancomycin.8519 Antibiotics usually are not given for gastroenteritis, although they may be given due to some bacteria.18 Antidiarrheal agents This article may require cleanup to meet 's quality standards. Please improve this article if you can. January 2008 Loperamide is an opioid analogue commonly used for symptomatic treatment of diarrhea. It slows down gut motility, but does not cross the mature blood-brain barrier8 to cause the central nervous effect of other opioids. In too high doses, loperamide may cause constipation and significant slowing down of passage of feces, but an appropriate single dose will not slow down the duration of the disease.19 Although antimotility drugs have the risk of exacerbating the condition, this fear is not supported by clinical experience.89 Nevertheless, others discourage the use of antiperistaltic agents and opiates in febrile dysentery, since they may mask, or exacerbate the symptoms.1 All these sources agree that in severe colitis antimotility drugs should not be used. Loperamide prevents the body from flushing toxins from the gut, and should not be used when an active fever is present or there is a suspicion that the diarrhea is associated with organisms that can penetrate the intestinal walls, such as E. coli O157:H7 or Salmonella. Loperamide is also not recommended in children, especially in children younger than 2 years of age, as it may cause systemic toxicity due to an immature blood brain barrier, and oral rehydration therapy remains the main stay treatment for children. Bismuth subsalicylate BSS, an insoluble complex of trivalent bismuth and salicylate, is another drug that can be used in mild-moderate cases.89 Combining an antimicrobial drug and an antimotility drug, seems to be effective more rapidly.89 Antiemetic drugs If vomiting is severe, antiemetic drugs may be helpful. However, these drugs are not recommended for treatment of acute gastroenteritis in children.20 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, 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.21 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. Rare complications of gastroenteritis caused by bacteria include sepsis treated with antibiotics, anemia, renal kidney failure, arthritis, and new onset of irritable bowel syndrome.citation needed See also Diarrhea 1984 Rajneeshee bioterror attack Food poisoning Eosinophilic gastroenteritis Hemorrhagic gastroenteritis Cholera Dysentery Infectious diarrhea Traveler's diarrhea Wilderness diarrhea Pseudomembranous colitis Rotavirus References ^ a b c d e Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL. Harrison's Principles of Internal Medicine. New York: McGraw-Hill, 2005. ISBN 0-07-139140-1. ^ King CK, Glass R, Bresee JS, Duggan C 2003. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep 52 RR-16: 1-16. PMID 14627948. ^ Norovirus: Technical Fact Sheet. National Center for Infectious Diseases, CDC. ^ a b Murray PR, Pfaller MA, Rosenthal KS. Medical Microbiology. Mosby, 2005. ISBN 0323033032. ^ a b c d Mandell's Principles and Practices of Infection Diseases 6th ion 2004 by Gerald L. Mandell MD, MACP, John E. Bennett MD, Raphael Dolin MD, ISBN 0-443-06643-4 · Hardback · 4016 Pages Churchill Livingstone ^ Victora CG, Bryce J, Fontaine O, Monasch R 2000. Reducing deaths from diarrhoea through oral rehydration therapy. Bull. World Health Organ. 78 10: 1246-55. PMID 11100619. ^ Rudy's List of Archaic Medical Terms ^ a b c d e f g Sleisenger Fordtran's Gastrointestinal and Liver Disease 7th ion, by Mark Feldman; Lawrence S. Friedman; and Marvin H. Sleisenger, ISBN 0-7216-8973-6, Hardback, Saunders, Published July 2002 ^ a b c d e f The Oxford Textbook of Medicinedead link ed by David A. Warrell, Timothy M. Cox and John D. Firth with Edward J. Benz, Fourth ion 2003, Oxford University Press, ISBN 0-19-262922-0 ^ Haffejee IE 1991. The pathophysiology, clinical features and management of rotavirus diarrhoea. Q. J. Med. 79 288: 289-99. PMID 1649479. ^ Patel MM, Tate JE, Selvarangan R, et al 2007. Routine laboratory testing data for surveillance of rotavirus hospitalizations to evaluate the impact of vaccination. Pediatr. Infect. Dis. J. 26 10: 914-9. doi:10.1097/INF.0b013e31812e52fd inactive 2008-06-21. PMID 17901797. ^ The paediatric burden of rotavirus disease in Europe 2006. Epidemiol. Infect. 134 5: 908-16. doi:10.1017/S0950268806006091. PMID 16650331. ^ Beards GM 1988. Laboratory diagnosis of viral gastroenteritis. Eur. J. Clin. Microbiol. Infect. Dis. 7 1: 11-3. doi:10.1007/BF01962164. PMID 3132369. ^ Steel HM, Garnham S, Beards GM, Brown DW 1992. Investigation of an outbreak of rotavirus infection in geriatric patients by serotyping and polyacrylamide gel electrophoresis PAGE. J. Med. Virol. 37 2: 132-6. doi:10.1002/jmv.1890370211. PMID 1321223. ^ Practice parameter: the management of acute gastroenteritis in young children. American Academy of Pediatrics, Provisional Committee on Quality Improvement, Subcommittee on Acute Gastroenteritis 1996. Pediatrics 97 3: 424-35. PMID 8604285. ^ Managing Acute Gastroenteritis Among Children: Oral Rehydration, Maintenance, and Nutritional Therapy ^ Rehydrate.org: Zinc Supplementation ^ Merck Manual ^ Wingate D, Phillips SF, Lewis SJ, et al 2001. Guidelines for adults on self-medication for the treatment of acute diarrhoea. Aliment. Pharmacol. Ther. 15 6: 773-82. doi:10.1046/j.1365-2036.2001.00993.x. PMID 11380315. ^ Mehta S, Goldman RD 2006. Ondansetron for acute gastroenteritis in children. Can Fam Physician 52 11: 1397-8. PMID 17279195. ^ Arya SC 1984. Rotaviral infection and intestinal lactase level. J. Infect. Dis. 150 5: 791. PMID 6436397. External links NHS Direct: Gastroenteritis. Retrieved on 2007-04-12. eMedicine Health:Gastroenteritis. Retrieved on 2007-04-12. The World Health Organisation: Diarrhoea. Retrieved on 2007-04-12. Gastroenteritis: First aid from the Mayo Clinic About.com: Seasonal Flu vs. Stomach Flu. Retrieved on 2007-04-12. v d e Digestive system - Digestive disease - Gastroenterology primarily K20-K93, 530-579 Upper GI tract Esophagus Esophagitis Candidal - Boerhaave syndrome - UES Zenker's diverticulum - LES Barrett's esophagus, Mallory-Weiss syndrome - Esophageal motility disorder Nutcracker esophagus, Achalasia, Diffuse esophageal spasm, GERD - Esophageal stricture - Megaesophagus Stomach Gastritis Atrophic, Ménétrier's disease, Gastroenteritis - Peptic gastric ulcer/Dieulafoy's lesion - Dyspepsia - Pyloric stenosis - Achlorhydria - Gastroparesis - Gastroptosis - Portal hypertensive gastropathy - Gastric antral vascular ectasia - Gastric dumping syndrome - Gastric volvulus Intestinal/ enteropathy Small intestine/ duodenum/jejunum/ileum Enteritis Duodenitis, Jejunitis, Ileitis Peptic duodenal ulcer Malabsorption: Coeliac - Tropical sprue - Blind loop syndrome - Whipple's - Short bowel syndrome - Steatorrhea Large intestine appendix/colon Appendicitis - Colitis Pseudomembranous, Ulcerative, Ischemic Functional colonic disease IBS, Intestinal pseudoobstruction/Ogilvie syndrome Megacolon/Toxic megacolon - Diverticulitis/Diverticulosis Large and/or small Enterocolitis Necrotizing - IBD Crohn's disease vascular: Abdominal angina - Mesenteric ischemia - Angiodysplasia Bowel obstruction: Ileus - Intussusception - Volvulus - Fecal impaction Constipation - Diarrhea Rectum/anus Proctitis Radiation proctitis - Proctalgia fugax - Rectal prolapse - Anal fissure/Anal fistula - Anal abscess Accessory Liver Hepatitis Viral hepatitis, Autoimmune hepatitis, Alcoholic hepatitis - Cirrhosis PBC - Fatty liver NASH - vascular Hepatic veno-occlusive disease, Portal hypertension, Nutmeg liver - Alcoholic liver disease - Liver failure Hepatic encephalopathy, Acute liver failure - Liver abscess - Hepatorenal syndrome - Peliosis hepatis Gallbladder Cholecystitis - Gallstones/Cholecystolithiasis - Cholesterolosis - Rokitansky-Aschoff sinuses - Postcholecystectomy syndrome Bile duct/ other biliary tree Cholangitis PSC, Ascending - Cholestasis/Mirizzi's syndrome - Biliary fistula - Haemobilia - Gallstones/Cholelithiasis common bile duct Choledocholithiasis, Biliary dyskinesia Pancreatic Pancreatitis Acute, Chronic, Herary - Pancreatic pseudocyst - Exocrine pancreatic insufficiency - Pancreatic fistula Hernia Diaphragmatic: Congenital diaphragmatic - Hiatus Abdominal hernia: Inguinal Indirect, Direct - Umbilical - Incisional - Femoral Obturator hernia - Spigelian hernia Peritoneal Peritonitis Spontaneous bacterial peritonitis - Hemoperitoneum - Pneumoperitoneum GI bleeding Upper Hematemesis, Melena - Lower Hematochezia See also congenital, neoplasia v d e Infectious diseases - Virus diseases A80-B34, 042-079 CNS Encephalitis/ meningitis DNA virus: Progressive multifocal leukoencephalopathy RNA virus: Subacute sclerosing panencephalitis - Lymphocytic choriomeningitis - Tick-borne meningoencephalitis unknown: Encephalitis lethargica Eye DNA virus: Cytomegalovirus retinitis Other RNA virus: Rabies - Myelitis: Poliomyelitis Post-polio syndrome - Tropical spastic paraparesis Skin and mucous membrane lesions DNA virus, Herpesviridae: Herpes simplex - Chickenpox - Herpes zoster - KSHV DNA virus, other: Poxviridae Smallpox, Monkeypox, Cowpox, Vaccinia, Molluscum contagiosum - exanthem Roseola, Fifth disease - HPV Wart RNA virus: exanthem Measles, Rubella - picornavirus Hand, foot and mouth disease, Foot-and-mouth disease Digestive system Hepatitis DNA virus: B RNA virus: A - D - C - E - G Gastroenteritis DNA virus: Adenovirus RNA virus: Rotavirus - Norovirus - Astrovirus - Coronavirus Respiratory system RNA virus, IV: Acute viral nasopharyngitis - Severe acute respiratory syndrome RNA virus, V: Influenza/Avian influenza - Human parainfluenza viruses - RSV - hMPV Other/varied: Infectious mononucleosis - Viral pneumonia Sexually transmitted DNA virus: HPV Genital warts, Cervical cancer RNA virus, retrovirus: HIV AIDS, AIDS dementia complex - Adult T-cell leukemia Oncovirus DNA virus: Hepatitis B - HPV - Kaposi's sarcoma-associated herpesvirus RNA virus: Hepatitis C - HTLV Systemic DNA virus: Cytomegalovirus RNA virus: Mumps - Bornholm disease - Coxsackie B v d e Inflammation Acute Plasma derived mediators Bradykinin - complement C3, C5a, MAC - coagulation Factor XII, Plasmin, Thrombin Cell derived mediators preformed: Lysosome granules - vasoactive amines Histamine, Serotonin synthesized on demand: cytokines IFN-γ, IL-8, TNF-α, IL-1 - eicosanoids Leukotriene B4, Prostaglandins - Nitric oxide - Kinins Chronic Macrophage - Epithelioid cell - Giant cell - Granuloma Processes Traditional: Rubor - Calor - Tumor - Dolor pain - Functio laesa Modern: Acute-phase reaction/Fever - Vasodilation - Increased vascular permeability - Exudate - Leukocyte extravasation - Chemotaxis Specific types Cardiovascular Endocarditis - Myocarditis - Pericarditis - Vasculitis Arteritis, Phlebitis Digestive mouth Stomatitis, Gingivitis, Gingivostomatitis, Glossitis, Tonsillitis, Sialadenitis/Parotitis - tract Esophagitis, Gastritis, Gastroenteritis, Enteritis, Colitis, Enterocolitis, Duodenitis, Ileitis, Caecitis, Appendicitis, Proctitis - accessory Hepatitis, Cholangitis, Cholecystitis, Pancreatitis - Peritonitis Musculoskeletal Arthritis - Dermatomyositis - soft tissue Myositis, Synovitis/Tenosynovitis, Bursitis, Enthesitis, Fasciitis, Capsulitis, Epicondylitis, Tendinitis, Panniculitis - Osteochondritis Osteitis, Chondritis Integumentary Dermatitis Folliculitis - Hidradenitis - Mastitis Nervous Encephalitis - Meningitis - Myelitis - Neuritis - Otitis - eye Dacryoadenitis, Scleritis, Keratitis, Choroiditis, Retinitis, Chorioretinitis, Blepharitis, Conjunctivitis, Iritis, Uveitis Respiratory upper Sinusitis, Rhinitis, Pharyngitis, Laryngitis - lower Tracheitis, Bronchitis, Bronchiolitis, Pneumonitis, Pleuritis Reproductive female: Oophoritis - Salpingitis - Endometritis - Parametritis - Cervicitis - Vaginitis - Vulvitis male: Orchitis - Epididymitis - Prostatitis - Balanitis - Balanoposthitis pregnancy/newborn: Chorioamnionitis - Omphalitis Urinary Nephritis Glomerulonephritis, Pyelonephritis - Ureteritis - Cystitis - Urethritis Retrieved from http://en..org/wiki/Gastroenteritis Categories: Pediatrics | Gastroenterology | Foodborne illnesses | Infectious diseases | Inflammations | Abdominal pain | Conditions diagnosed by stool testHidden categories: All articles with dead external links | Articles with dead external links since January 2008 | Pages with DOIs broken since 2008 | Articles to be merged since February 2008 | All articles with statements | Articles with statements since August 2008 | Articles with statements since April 2008 | Cleanup from January 2008 | All pages needing cleanup | Articles with statements since January 2008 Views Article Discussion this page History Personal tools Log in / create account Navigation Main page Contents Featured content Current events Random article Search Go Search Interaction Community portal Recent changes Contact Donate to Help Toolbox What links here Related changes Upload file Special pages Printable version Permanent link Cite this page Languages ÄŒesky Deutsch Español Français Italiano Nederlands Português РуÑ?Ñ?кий Simple English Suomi Svenska ä¸æ–‡ This page was last modified on 27 August 2008, at 17:59
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