Version 1.

Gastroenteritis

8/06/2012

Definition Gastroenteritis (GE) is a non-specific term for a condition comprising a combination of nausea, vomiting, diarrhoea and abdominal pain. Usually taken to mean of infectious origin. Epidemiology GE is caused by a variety of viral, bacterial, and parasitic pathogens. Very common - Worldwide, there are more than 1 billion cases, UK about 1 in 5 people/yr. Up to 20% of presentation of children<5 are for GE. Virus infections cause 30-40% of GE in industrialized countries. Up to 70% in children. Epidemics in Aus usually from Rotavirus but Norovirus can cause "winter vomiting" Risk Factors Poor personal hygiene and lack of sanitation Immunocompromise & AIDS Achlorhydria e.g. from PPIs (especially for Salmonella and Campylobacter) Poor food handling raw food (shellfish), inadequate cooking or refrigeration, reheating. Breast feeding affords some protection. Presentation

History:
Nausea, vomiting, diarrhoea and abdominal pain to varying degrees. Duration, frequency and contents of vomit/diarrhoea. Blood/mucus/bile. Bloody diarrhoea suggests invasive bacterial infection, e.g. E coli 0157, Entamoeba histolytica, or Salmonella Pyrexia in adults may suggest invasive organism, but children nearly always febrile. Variable incubation periods from a couple of hrs (preformed bacterial toxins) to 5+ days (parasites such as Giardia). Recent travel abroad. Ill contacts or fellow diners. ?Dehydrated wt loss, CRT, lethargy, sunken eyes/fontanelle, skin turgor, HR, urine Abdo r/o appendicitis. Listen for bowel sounds.

Examination:

Differential Diagnosis Urinary tract infection. Constipation with overflow. Gastritis, e.g. from alcohol abuse. Acute appendicitis. Hyperemesis gravidarum or, in late pregnancy, fulminating pre-eclampsia. Irritable bowel syndrome, inflammatory bowel disease, antibiotic-related. Intestinal obstruction, intussusception, coeliac disease Laxative abuse. Other drug/poison related. Addison's disease, DKA. Common infectious causes Campylobacter (commonest), Rotavirus (commonest in children), Non-typhoidal salmonellosis, Norovirus (increasingly important), Giardia, Cryptosporidium, E. coli O157:H7, Shigella sonnei.

Investigations Stool: Microscopy for ova or parasites, culture, antigen testing (Rotavirus) FBC and U&E Urine culture. Management

Treat/prevent dehydration: ORT, IVF if severe. Starvation for couple of days common. Breast
feeding should continue and in children diet re-introduced when vomiting subsides. Prevent spread. Hand washing. Prevent subsequent cases: Public Health Notification - dysentery and food poisoning notification is a statutory duty. Food storage/handling/cooking advice

Drugs:
ABx do not shorten most GE, but may prolong the carrier stage. Used in the severely ill, especially the immunocompromised. If GE severe and community-acquired, empirical ciprofloxacin used (azithromycin or cotrimoxazole in children). Giardiasis and amoebiasis can be treated with metronidazole. Cochrane review found little evidence of benefit from antiemetics in children. Sometimes anti-diarrhoea or anti-spasmodic drugs may be required/used in adults. Return to work/school: generally advised once diarrhoea has settled. Food handlers may require 48hrs symptom-free and a negative stool culture. Complications Dehydration esp in infants & elderly. Electrolyte (esp. Na+) derangement Haemolytic uraemic syndrome more likely in children with E. coli O157:H7. Reactive features e.g. arthritis, carditis, urticaria, erythema nodosum, conjunctivitis, and Reiter's syndrome. Salmonella can invade bones, joints, meninges, or the gallbladder. Toxic megacolon is rare. Some viruses may cause Guillain-Barre syndrome as may Campylobacter. IBS may follow gastroenteritis. Poor absorption of drugs such as anticonvulsants or oral contraceptives. Prognosis Usually there is uneventful recovery with just a period of starvation and fluids only. Risk is greatest at the extremes of life and with immune compromise. In developed countries most deaths are in the elderly pop.

Causes of Gastroenteritis
Organism
Staphylococcus (preformed toxin)

Incubation Period
18 hours

Vomiting
+++

Diarrhea

Fever

Associated Foods
Staphylococci grow in meats, dairy, and bakery products and produce enterotoxin. Reheated fried rice causes vomiting or diarrhea. Toxin in meats, stews, and gravy.

Diagnosis
Clinical. Food and stool can be tested for toxin.

Clinical Features and Treatment

Abrupt onset, intense nausea and vomiting for up to 24 hours, recovery in 2448 hours. Supportive care.

Bacillus cereus (preformed toxin) B cereus (diarrheal toxin)

18 hours

+++

Clinical. Food and stool can be tested for toxin. Clinical. Food and stool can be tested for toxin.

Acute onset, severe nausea and vomiting lasting 24 hours. Supportive care. Abdominal cramps, watery diarrhea, and nausea lasting 2448 hours. Supportive care. Abrupt onset of profuse diarrhea, abdominal cramps, nausea; vomiting occasionally. Recovery usual without treatment in 2448 hours. Supportive care; antibiotics not needed. Diplopia, dysphagia, dysphonia, respiratory embarrassment. Treatment requires clear airway, ventilation, and intravenous polyvalent antitoxin (see text). Symptoms can last for days to months. Abrupt onset of diarrhea that may be bloody; fever. Oral metronidazole first-line therapy. If no response, oral vancomycin can be given.

1016 hours

+++

Clostridium perfringens

816 hours

+++

Clostridia grow in rewarmed meat and poultry dishes and produce an enterotoxin.

Stools can be tested for enterotoxin or cultured.

Clostridium botulinum

1272 hours

Clostridia grow in anaerobic acidic environment eg, canned foods, fermented fish, foods held warm for extended periods. Associated with antimicrobial drugs; clindamycin and cephalosporins most commonly implicated. Undercooked beef, especially hamburger; unpasteurized milk and juice; raw fruits and vegetables.

Stool, serum, and food can be tested for toxin. Stool and food can be cultured.

Clostridium difficile

Usually occurs after 710 days of antibiotics. Can occur after a single dose or several weeks after completion of antibiotics. 18 days

+++

++

Stool tested for toxin.

Enterohemorrhagic Escherichia coli, including E coli O157:H7 and other Shiga-toxin producing strains (STEC)

+++

E coli O157:H7 can be cultured on special medium. Other toxins can be detected in stool.

Usually abrupt onset of diarrhoea, often bloody; abdominal pain. In adults, it is usually self-limited to 510 days. In children, it is assoc with haemolyticuraemic syndrome (HUS). Antibiotic therapy may increase risk of HUS. Watery diarrhea and abdominal cramps, usually lasting 37 days. In travelers, fluoroquinolones shorten disease.

Enterotoxigenic E coli (ETEC)

13 days

+++

Water, food contaminated with faeces.

Stool culture. Special tests required to identify toxin-producing strains. Stool culture on special medium.

Vibrio parahaemolyticus

248 hours

Undercooked or raw seafood.

Abrupt onset of watery diarrhea, abdominal cramps, nausea and vomiting. Recovery is usually complete in 25 days.

Organism
Vibrio cholerae

Incubation Period
2472 hours

Vomiting
+

Diarrhea
+++

Fever

Associated Foods
Contaminated water, fish, shellfish, street vendor food.

Diagnosis
Stool culture on special medium.

Clinical Features and Treatment

Abrupt onset of liquid diarrhea in endemic area. Needs prompt intravenous or oral replacement of fluids and electrolytes. Tetracyclines shorten excretion of vibrios. Fever, diarrhea that can be bloody, cramps. Usually self-limited in 210 days. Early treatment (erythromycin) shortens course. May be associated with GuillainBarr syndrome. Abrupt onset of diarrhea, often with blood cramps, tenesmus, and lethargy. Therapy depends on sensitivity testing, but the fluoroquinolones are most active. Often mild and self-limited, resolving in 47 days. Gradual or abrupt onset of diarrhea and low-grade fever. No antimicrobials unless high risk (see text) or systemic dissemination is suspected, in which case give a fluoroquinolone. Prolonged carriage can occur. Severe abdominal pain, (appendicitis-like symptoms) diarrhea, fever. Polyarthritis, erythema nodosum in children. If severe, give tetracycline or fluoroquinolone. Without treatment, self-limited in 13 weeks. Acute onset, vomiting, watery diarrhea that lasts 48 days. Supportive care.

Campylobacter jejuni

25 days

+++

Raw or undercooked poultry, unpasteurized milk, water.

Stool culture on special medium.

Shigella species (mild cases)

2472 hours

Food or water contaminated with human feces. Person to person spread.

Routine stool culture.

Salmonella species

13 days

++

Eggs, poultry, unpasteurized milk, cheese, juices, raw fruits and vegetables.

Routine stool culture.

Yersinia enterocolitica

2448 hours

Undercooked pork, contaminated water, unpasteurized milk, tofu.

Stool culture on special medium.

Rotavirus

13 days

++

+++

Fecally contaminated foods touched by infected food handlers. Shell fish and fecally contaminated foods touched by infected food handlers.

Immunoassay on stool.

Noroviruses and other caliciviruses

1248 hours

++

+++

Clinical diagnosis with negative stool cultures. PCR available on stool.

Nausea, vomiting (more common in children) diarrhea (more common in adults), fever, myalgias, abdominal cramps. Lasts 1260 hours. Supportive care.