AUTHOR INFORMATION

Section 1 of 12

Authored by Arthur Diskin, MD, Chair, Department of Emergency Medicine, Mount Sinai Medical Center

Arthur Diskin, MD, is a member of the following medical societies: American College of Emergency Physicians

Edited by Michelle Ervin, MD, Chair, Department of Emergency Medicine, Howard University Hospital; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Eugene Hardin, MD, FACEP, FAAEM, Chair and Associate Professor, Department of Emergency Medicine, Charles R Drew University of Medicine and Science; Chair, Department of Emergency Medicine, Martin Luther King, Jr/Drew Medical Center; John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School; and Steven C Dronen, MD, FAAEM, Director of Emergency Services, Director of Chest Pain Center, Department of Emergency Medicine, Ft Sanders Sevier Medical Center

Author's Email:	Arthur Diskin, MD
Editor's Email:	Michelle Ervin, MD

eMedicine Journal, July 12 2006, VOLUME 7, Number 7

INTRODUCTION

Section 2 of 12

Background: Gastroenteritis is a nonspecific term for various pathologic states of the gastrointestinal tract. The primary manifestation is diarrhea, but it may be accompanied by nausea, vomiting, and abdominal pain. A universal definition of diarrhea does not exist, although patients seem to have no difficulty defining their own situation. Although most definitions center on the frequency, consistency, and water content of stools, the author prefers defining diarrhea as stools that take the shape of their container.

The severity of illness may vary from mild and inconvenient to severe and life threatening. Appropriate management requires extensive history and assessment and appropriate, general supportive treatment that is often etiology specific. Diarrhea associated with nausea and vomiting is referred to as gastroenteritis.

Diarrhea is one of the most common reasons patients seek medical care. In the developed world, it is the most common reason for missing work, while in the developing world, it is a leading cause of death. In developing countries, diarrhea is a seasonal scourge usually worsened by natural phenomena, as evidenced by monsoon floods in Bangladesh in 1998. An estimated 100 million cases of acute diarrhea occur every year in the United States. Of these patients, 90% do not seek medical attention, and 1-2% require admission. Diarrheal diseases can quickly reach epidemic proportions, rapidly overwhelming public health systems in even the most advanced societies.

Pathophysiology: Infectious agents usually cause acute gastroenteritis. These agents cause diarrhea by adherence, mucosal invasion, enterotoxin production, and/or cytotoxin production.

These mechanisms result in increased fluid secretion and/or decreased absorption. This produces an increased luminal fluid content that cannot be adequately reabsorbed, leading to dehydration and the loss of electrolytes and nutrients.

Diarrheal illnesses may be classified as follows:

• Osmotic, due to an increase in the osmotic load presented to the intestinal lumen, either through excessive intake or diminished absorption

• Inflammatory (or mucosal), when the mucosal lining of the intestine is inflamed

• Secretory, when increased secretory activity occurs

• Motile, caused by intestinal motility disorders

The small intestine is the prime absorptive surface. The colon then absorbs additional fluid, transforming a relatively liquid fecal stream in the cecum to well-formed solid stool in the rectosigmoid.

Disorders of the small intestine result in increased amounts of diarrheal fluid with a concomitantly greater loss of electrolytes and nutrients.

Microorganisms may produce toxins that facilitate infection. Enterotoxins are generated by bacteria (ie, enterotoxigenic Escherichia coli, Vibrio cholera) that act directly on secretory mechanisms and produce typical, copious watery (rice water) diarrhea. No mucosal invasion occurs. The small intestines are primarily affected, and elevation of the adenosine monophosphate (AMP) levels is the common mechanism.

Cytotoxin production by bacteria (ie, Shigella dysenteriae, Vibrio parahaemolyticus, Clostridium difficile, enterohemorrhagic E coli) results in mucosal cell destruction that leads to bloody stools with inflammatory cells. A resulting decreased absorptive ability occurs.

Enterocyte invasion is the preferred method by which microbes such as Shigella and Campylobacter organisms and enteroinvasive E coli cause destruction and inflammatory diarrhea. Similarly, Salmonella and Yersinia species also invade cells but do not cause cell death. Hence, dysentery does not usually occur. However, these bacteria invade the bloodstream across the lamina propria and cause enteric fever such as typhoid.

Diarrheal illness occurs when microbial virulence overwhelms normal host defenses. A large inoculum may overwhelm the host capacity to mount an effective defense. Normally, more than 100,000 E coli are required to cause disease, while only 10 Entamoeba or Giardia cysts may suffice to do the same. Some organisms (eg, V cholera, enterotoxigenic E coli) produce proteins that aid their adherence to the intestinal wall, thereby displacing the normal flora and colonizing the intestinal lumen.

In addition to the ingestion of pathogenic organisms or toxins, other intrinsic factors can lead to infection. An alteration of normal bowel flora can create a biologic void that is filled by pathogens. This occurs most commonly after antibiotic administration, but infants are also at risk prior to colonization with normal bowel flora.

The normally acidic pH of the stomach and colon is an effective antimicrobial defense. In achlorhydric states (ie, caused by antacids, histamine-2 [H2] blockers, gastric surgery, decreased colonic anaerobic flora), this defense is weakened.

Hypomotility states may result in colonization by pathogens, especially in the proximal small bowel, where motility is the major mechanism in the removal of organisms. Hypomotility may be induced by antiperistaltic agents (eg, opiates, diphenoxylate and atropine [Lomotil], loperamide) or anomalous anatomy (eg, fistulae, diverticula, antiperistaltic afferent loops) or is inherent in disorders such as diabetes mellitus or scleroderma.

The immunocompromised host is more susceptible to infection, as evidenced by the wide spectrum of diarrheal pathogens in patients with AIDS.

The exact mechanism of vomiting in acute diarrheal illness is not known, although serotonin release has been postulated as a cause, stimulating visceral afferent input to the chemoreceptor trigger zone in the lower brainstem. Preformed neurotoxins produced by Staphylococcus aureus and Bacillus cereus, when ingested, can cause severe vomiting.

Frequency:

• In the US: Frequency is difficult to determine because of underreporting, especially of mild illness, resulting in wide variations of estimated numbers of cases, hospitalizations, and deaths. As many as 90 million cases occur per year with several million physician visits and thousands of hospitalizations. According to the Centers for Disease Control and Prevention (CDC), 3.5 million cases of acute diarrhea from rotavirus alone and at least 90,000 cases of food poisoning occur yearly. Others estimate millions of cases.

  The following are examples of sporadic common source outbreaks:

  • Gastroenteritis associated with V parahaemolyticus infection from Gulf Coast oysters has been reported.

  • Salmonella gastroenteritis from reptilian pets has been reported.

  • A religious cult in Oregon intentionally contaminated salad with Salmonella typhimurium, which resulted in 751 victims who developed acute gastroenteritis.

  • In July 1998, more than 60 persons in Wyoming were infected with E coli O157:H7 from a contaminated water supply.

  • In 1993, E coli O157:H7–contaminated fast-food hamburger meat in the Pacific Northwest infected 500 persons, 4 of whom died.

  • From 1981-1994, 333 cases of Vibrio vulnificus infection associated with raw oyster consumption were reported in Florida. Two persons died from gastroenteritis, and 50 persons died from septicemia.

  • In January 1995, 322 cases of Norwalk virus (calicivirus) infection–associated acute gastroenteritis resulted from the consumption of raw oysters in Florida.

  • In October 1996, 629 children and staff members at one elementary school in Florida were infected in a point-source outbreak of a Norwalk-like agent (calicivirus).

  • In July 1995, 77 cases of cryptosporidiosis at a day camp in Florida were reported, most likely secondary to contamination involving a water hose.

  • In April 1994, 96 cases of Campylobacter infection were reported in Florida. The common source was ingested, contaminated commercial ice cubes.

  • In 1996, Norwalk virus–associated gastroenteritis resulted from the ingestion of raw oysters in Louisiana.

  • From May 1996 to June 1996, E coli O157:H7 infections secondary to consumption of mesclun lettuce from a single producer were reported in multiple states (first identified in Connecticut and Illinois).

  • In August and September of 1999, E coli O157:H7 infections secondary to contaminated well water at the Washington County Fair (New York) were reported.

  • Norwalk virus is the leading cause of viral gastroenteritis in the United States.

  • From January 1, 2002, to December 2, 2002, norovirus was attributed to 9 of the 21 outbreaks of acute gastroenteritis on cruise ships reported to the CDC’s Vessel Sanitation Program in this period. Noroviruses cause approximately 23 million cases of acute gastroenteritis each year and are the leading cause of gastroenteritis outbreaks.

  • Norovirus outbreaks have been reported in various locations, including casinos, airplanes, schools, hospitals, nursing homes, and cruise ships.

  • In 2005, E coli O157:H7 infections secondary to contaminated animals were reported at Florida fairs.

• Internationally: Three to five billion cases of acute diarrhea occur yearly, and it is the leading cause of death in many underdeveloped countries. Approximately 30-50% of visitors to developing countries develop, and perhaps return with, diarrhea. In 2001 and 2002, outbreaks of gastroenteritis caused by norovirus were reported in diverse locations such as the American Midwest; Boston; northern Europe; St. Petersburg, Russia; Canada; and Alaska.

Mortality/Morbidity:

• Estimates for mortality and morbidity widely vary. In the United States, 210,000 pediatric hospitalizations occur yearly, with as many as 10,000 deaths.

• Internationally, the mortality rate is 5-10 million deaths each year.

Age:

• Pediatric gastroenteritis is discussed in Pediatrics, Gastroenteritis.

• Gastroenteritis may occur at any age. Morbidity and mortality are much higher in the very young and the very old.

CLINICAL

Section 3 of 12

History: A well-taken history, considering important epidemiologic factors, can help to identify not only the cause of diarrhea but also the patient at risk for complications. History in infectious cases and food poisoning varies depending upon the agent with variation in the onset; the frequency and nature of the stools; and the presence or absence of blood and mucus, vomiting, cramps, and fever. The history should also identify risk factors for unusual causes of acute gastroenteritis and possible reasons to suspect noninfectious etiologies. Indications of dehydration or sepsis should also be sought.

• Duration of illness

• Duration and rapidity of symptom onset are important in determining the incubation period and possible infecting organism and in directing further care.

• Diarrhea that lasts longer than a month requires consideration of a different spectrum of etiologic factors than diarrhea that lasts less than 1-2 weeks.

• Fever: The presence of fever (with or without chills) generally suggests that an invasive organism is the cause of diarrhea, although many extraintestinal illnesses can present with both fever and diarrhea, especially in children.

• Vomiting

• Vomiting, a symptom common to a host of illnesses, implies proximal bowel involvement, especially with preformed neurotoxin, as elaborated by S aureus and B cereus.

• Vomiting is a leading symptom of intestinal obstruction, usually coupled with distention; however, distention may not be significant if the obstructing lesion is very proximal. Vomiting without diarrhea must always prompt a search for noninfectious causes and cannot be referred to as gastroenteritis.

• Pain

• The location and character of pain may be indicative of the area of infection because colonic involvement is usually associated with tenesmus and pain in either of the lower quadrants or the lower back, whereas jejunoileal infection may result in periumbilical pain.

• Cramps may be caused by an electrolyte imbalance.

• Pain, especially in patients older than 50 years, should raise the suspicion of an ischemic process.

• Stools

• Ask about frequency, nature (amount, color, watery, semisolid, odor), and presence of blood and/or mucus.

• Large volumes of stool are usually associated with enteric infection, whereas colonic infection results in many small stools.

• The presence of blood indicates colonic ulceration (bacterial infection, inflammatory disease, ischemia).

• White bulky feces that float (high fat content) are due to a small bowel pathology that leads to malabsorption.

• Copious (rice water) diarrhea is a hallmark of cholera.

• Extraintestinal causes

• A history of other nonintestinal illnesses that can lead to diarrhea may be obtained. Vomiting and/or diarrhea may be a manifestation of that illness or a result of its treatment. Obtaining a history of recent surgery or radiation, food or drug allergies, and endocrine or gastrointestinal disorders is extremely important. The patient should always be questioned regarding prior episodes.

• Malaria, Whipple disease, irritable bowel, incomplete bowel obstruction, inflammatory disease, nutritional disease, and carcinoid and malabsorption syndromes can result in diarrhea.

• Drugs such as colchicine, quinidine, antimicrobials, cancer chemotherapeutic agents, and magnesium-containing antacids frequently cause diarrhea.

• Dehydration

• Orthostasis, lightheadedness, diminished urine formation, and a change in mentation herald marked dehydration and electrolyte loss, requiring aggressive treatment.

• These symptoms are particularly important in elderly patients, a group that is most at risk from diarrhea.

• Epidemiologic factors

• A number of historical questions may provide clues to the etiology of the illness, including foreign travel, recent camping, recent antibiotic use, daycare attendance, and/or ingestion of raw, possibly spoiled, or new marine products, as well as similar illnesses in family, friends, or contacts.

• An epidemiologic factor may be travel to developing countries where bacterial or parasitic agents can cause infection or to campgrounds in developed regions, where agents such as Giardia lamblia, Aeromonas, and Cryptosporidium can contaminate untreated water.

• Enterotoxigenic E coli is the most frequent cause of traveler’s diarrhea. Symptoms usually begin within days of arrival in the region and can last from 5 days to 2 weeks.

• Vibrio species are more common in Asia, although epidemics have occurred in Central America within the last 10 years.

• As many as 12% of diarrheal illness cases may be caused by rotavirus in travelers to Asia, Africa, and South America.

• Men who are homosexual are more prone to infection by usual pathogens via the fecal-oral route (ie, Shigella, Campylobacter jejuni, Salmonella, protozoalike Entamoeba). Anal receptive intercourse may result in the direct inoculation of Neisseria gonorrhoeae, Chlamydia trachomatis, Treponema pallidum, and herpes simplex virus. Severely immunocompromised states (CD4 cell count <200) increase the risk of infection by agents such as Mycobacterium avium complex, microsporidia, cytomegalovirus (CMV), and Isospora belli.

• Recent use of antimicrobial drugs increases the risk of C difficile infection.

• A common source outbreak from contaminated water and food may cause gastroenteritis either by infection (C jejuni, G lamblia) or by ingestion of a preformed toxin (E coli O157:H7, scombroid, ciguatera).

• Infections via the fecal-oral route are prevalent in children who attend daycare centers. Rotavirus has an infection rate of nearly 100% in exposed children younger than 2 years. Other family members are also at risk for infection.

Physical: A thorough physical examination is essential to assess the general state of hydration and nutrition and to exclude extraintestinal causes of diarrhea. Often, the cause of diarrhea cannot be determined based on the physical findings present, which may be scarce.

• The most important element of the physical examination is the assessment of the patient's hydration status. (Dehydration in children, for example, is classified according to the degree of hydration/percentage deficit as <3%, none; 3-6%, mild; 6-9%, moderate; and >10%, severe.) Additionally, signs of bacteremia or sepsis should be sought. Patients with chronic diarrhea may need an evaluation of their nutritional status.

• A rectal examination should be performed, involving checking for blood and mucus. Rectal examination may reveal abscesses, fistulae, and fissures, which may indicate inflammatory bowel disease. A partially obstructing tumor or a fecal impaction may be discovered as a cause of diarrhea. Finally, the stool can be examined for the presence of blood and pus.

• Hydration and nutritional status

• Diminished skin turgor, weight loss, resting hypotension and tachycardia, dry mucus membranes, decreased frequency of urination, changes in mental status, and orthostasis can be used to gauge dehydration.

• In children, the absence of tears, poor capillary refill, sunken eyes, depressed fontanelles, increased axillary skin folds, and dry diapers all may reflect a dehydrated state.

• Muscle wasting and signs of neural dysfunction due to nutritional depletion may be observed in patients with chronic diarrhea.

• Abdominal examination

• A careful abdominal examination is necessary to exclude causes of diarrhea that may require surgical intervention, such as pelvic abscesses close to the rectosigmoid that are causing tenesmus.

• The examiner should look for signs of an acute abdomen, listening for bowel sounds, determining the location of any tenderness, and palpating for masses or organomegaly.

• Appendicitis in children may manifest as diarrhea.

Causes:

• Viral (50-70%)

• The Norwalk virus (This is the leading cause of viral gastroenteritis in the United States. Norwalk virus belongs to the species of noroviruses [formerly known as Norwalk-like viruses]. Noroviruses, along with the sapoviruses (formerly known as Sapporo-like viruses), are members of the Caliciviridae family of viruses.)

• Caliciviruses (Various caliciviruses, other than Norwalk virus, are likely responsible for many outbreaks of previously unidentified viral gastroenteritis.)

• Rotavirus (This is the leading cause of gastroenteritis in children, but rotavirus can also be found in adults. Rotavirus may cause severe dehydration.)

• Adenovirus

• Parvovirus

• Astrovirus

• Coronavirus

• Pestivirus

• Torovirus

• Bacterial (15-20%)

• Shigella

• Salmonella

• C jejuni

• Yersinia enterocolitica

• E coli - Enterohemorrhagic 0157:H7, enterotoxigenic, enteroadherent, enteroinvasive

• V cholera

• Aeromonas

• B cereus

• C difficile

• Clostridium perfringens

• Listeria

• M avium-intracellulare (MAI), immunocompromised

• Providencia

• V parahaemolyticus

• V vulnificus

• Parasitic (10-15%)

• Giardia

• Amebiasis

• Cryptosporidium

• Cyclospora

• Food-borne toxigenic diarrhea

• Preformed toxin - S aureus, B cereus

• Postcolonization - V cholera, C perfringens, enterotoxigenic E coli, Aeromonas

• Shellfish poisoning and poisoning from other marine animals

• Paralytic shellfish poisoning (PSP) - Saxitoxin

• Neurologic shellfish poisoning (NSP) - Brevetoxin

• Diarrheal shellfish poisoning (DSP) - Okadaic acid

• Amnesic shellfish poisoning - Domoic acid

• Ciguatera (ciguatoxins)

• Scombroid (conversion of histidine to histamine)

• Drug-associated diarrhea

• Antibiotics, due to alteration of normal flora

• Laxatives, including magnesium-containing antacids

• Colchicine

• Quinidine

• Cholinergics

• Sorbitol

• Pseudomembranous colitis

• Overgrowth of C difficile

• Positive C difficile assay findings

• Other causes

• Unknown agents, especially in developing countries

• Ischemic colitis

• Ulcerative colitis

• Crohn disease

• Carcinoid tumor or vasoactive intestinal peptide tumor (VIPoma)

• AIDS

• Dumping or short bowel syndrome

• Radiation or chemotherapy

DIFFERENTIALS

Section 4 of 12

Appendicitis, Acute
CBRNE - Botulism
Giardiasis
Hemolytic Uremic Syndrome
Inflammatory Bowel Disease
Obstruction, Large Bowel
Obstruction, Small Bowel
Pediatrics, Dehydration
Pediatrics, Gastroenteritis
Salmonella Infection
Shock, Hypovolemic

Other Problems to be Considered:

Various infectious etiologies
Pseudomembranous colitis
Food-borne toxigenic diarrhea
Toxins
Hormonal (vasoactive intestinal peptides)
Drugs (ie, sorbitol, cholinergics, caffeine)
Surgery
Radiation colitis
Carcinoid
Pediatrics - Adrenogenital/cystic fibrosis

WORKUP

Section 5 of 12

Lab Studies:

• Determination of laboratory tests: The patient's evaluation should be based on the clinical assessment and the need to do the following:

• Further evaluate the seriousness of the condition (degree of dehydration and electrolyte derangement).

• Determine a specific etiologic agent.

• Evaluate the patient for noninfectious etiologies.

• Patients who require further workup include those who appear seriously ill or dehydrated; those who have high fevers, bloody stools, severe abdominal pain, or persistent diarrhea; and those who are immunocompromised or whose condition is suspected of having an epidemic diarrheal etiology.

• History, epidemiologic considerations, and the physical examination should be the primary guides in determining whether any further diagnostic evaluation is necessary, followed by microscopic examination of the stool.

• Stool studies and culture

• The presence of blood or leukocytes in stool is a strong indicator of inflammatory diarrhea.

• Stool studies can be performed efficiently and inexpensively by using a Wright stain or methylene blue and directly observing for leukocytes and performing an occult blood test.

• Fecal leukocytes are present in 80-90% of all patients with Salmonella or Shigella infections but are less common with other infecting organisms such as Campylobacter and Yersinia. They may also be present in ulcerative colitis and Crohn disease but are usually absent in viral infections, Giardia infection, enterogenic E coli infection, and toxigenic bacterial food poisoning.

• A stool culture is not necessary or cost-effective in all cases of diarrhea unless a bacterial cause is suspected.

• Fever, bloody stools, leukocytes in stool, pain resembling that associated with appendicitis (Yersinia), and diarrheal illness associated with partially cooked hamburger (cytotoxigenic E coli O157:H7) are all indications for culture.

• Frequently, stool cultures are obtained inappropriately in the United States. The ED physician should consider whether obtaining a culture would change the therapy.

• Specific indications for stool cultures include bloody stools, stools that test positive for occult blood or leukocytes, prolonged course of diarrhea that has not been treated with antibiotics, immunocompromised host, or for epidemiologic purposes, such as cases involving food handlers.

• Routine stool cultures identify only Campylobacter, Shigella, Salmonella, Aeromonas, and Yersinia species.

• Testing for other pathogens, such as Vibrio species, enterohemorrhagic E coli O157:H7, and other shigatoxin-producing bacteria require special media. The laboratory should be informed regarding appropriate media for suspected organisms (eg, MacConkey sorbitol agar for E coli O157:H7). Additionally, the laboratory may need to perform specialized testing to specifically identify the organism.

• Studies of selected centers have shown that only 2% of stool culture results are positive as routinely obtained. The cost per positive stool culture result has been estimated to be at least $900-1200.

• Similarly, if parasitic illness is in the differential or if the patient has recently traveled to an endemic region or has chronic diarrhea, the stool should be examined for parasites or their ova with the caveat that several samples may be required to make the diagnosis. Ova and parasite studies are indicated for patients who are immunocompromised, who have a persistent or prolonged course, or whose conditions are unresponsive to antibiotics.

• Travel to endemic regions followed by chronic diarrhea without signs of acute bacterial diarrhea should prompt a search for a parasitic etiology.

• Entamoeba histolytica can result in bloody stools, but a smear reveals a lack of leukocytes due to exotoxin produced by the parasite that lyses the cells.

• Routine laboratory tests

• Routine laboratory tests (CBC, electrolytes, renal function) may not be helpful or indicated in making a diagnosis. These tests may be useful as indicators of severity of disease, especially in elderly or very young patients, although that determination is best made clinically.

• Electrolytes and BUN tests are indicated in patients with severe diarrhea or dehydration to rule out hyponatremia or hypernatremia. Decreased serum bicarbonate suggests severe dehydration, especially in children. Acidosis secondary to bicarbonate loss in the stools and/or from hypovolemia-induced lactic acidosis may be present. Hypokalemia may also occur.

• A CBC may be indicated with a prolonged course, severe diarrhea, or toxicity. The WBC count is usually increased in Salmonella infections but normal or low with significant left shift in Shigella infections. The WBC count is otherwise variable. Eosinophilia may be present in parasitic infections.

• Enzyme-linked immunosorbent assay

• Commercially available immunofluorescent antibody and enzyme immunoassays are also available for Giardia and Cryptosporidium organisms. C difficile toxin assays can be performed when antibiotic-associated diarrhea is suspected.

• Rotavirus: Enzyme-linked immunosorbent assay (ELISA) is available in less than 2 hours but is not sensitive enough in adults.

• Giardia: ELISA is more than 90% sensitive in susceptible populations (eg, people who camp or travel to endemic areas). Consider ELISA prior to ova and parasite examination or string test.

Imaging Studies:

• An acute abdominal series is indicated only when bowel obstruction, toxic megacolon, or perforation is suspected.

Procedures:

• Sigmoidoscopy may be indicated if pseudomembranous colitis or inflammatory bowel disease is suspected. Sigmoidoscopy is useful in obtaining tissue for culture in patients with AIDS who have undiagnosed diarrhea or wasting syndrome.

TREATMENT

Section 6 of 12

Prehospital Care:

• Prehospital care is directed toward early and aggressive fluid therapy in patients who are unstable.

Emergency Department Care:

• Goals of ED therapy

• Rehydrate orally or intravenously as needed.

• Treat symptoms (eg, fever, pain) as indicated.

• Identify complications.

• Prevent the spread of infections.

• Identify public health concerns and treat certain specific cases with specific or empiric antibiotic therapy.

• Rehydration

• Administration of 1-2 L dextrose 5% in 0.5 isotonic sodium chloride solution with 50 mEq NaHCO₃ and 10-20 mEq KCl over 30-45 minutes may be necessary in patients who are severely dehydrated.

• Clinical assessment and serum electrolyte concentrations should guide therapy.

• To give fluids more rapidly, KCl may be given orally or in the second or third liter bag or as a supplemental IV of 20 mEq KCl in 100 mL of isotonic sodium chloride solution over 1 hour.

• Rehydrate patients until mental status and signs of perfusion and pulse are normal (caution in elderly patients with congestive heart failure [CHF]).

• For pediatric patients, administer 20 mL/kg of isotonic sodium chloride solution initially for resuscitation. Repeat as necessary and add KCl as indicated.

• Indications for IV rehydration include severe intractable vomiting, altered consciousness, severe dehydration, ileus, excessive choleralike stools, and time or environment not conducive to oral rehydration therapy (ORT).

• Solutions for oral rehydration
  • The World Health Organization solution is 90 mEq/L Na⁺, 20 mEq/L K⁺, 80 mEq/L Cl^-, 20 g/L glucose; osmolarity is 310; CHO:Na = 1.2:1; administer 250 mL (approximately 8 oz) every 15 minutes until fluid balance is clinically restored, then 1.5 L of oral fluid per liter of stool.

  • Other products include Naturalyte, Cera Lyte, Rehydralyte, and Pedialyte.

  • Oral rehydration may not decrease the duration or volume of diarrhea.

  • Small amounts of oral fluids may be given repeatedly while the patient is still vomiting.

  • Oral rehydration has been largely responsible for the tremendous decrease in the death rate in underdeveloped countries from infectious diarrhea, including cholera.

  • The glucose/sodium transport mechanism remains intact despite enterotoxigenic illness. Coupled transport is one of several mechanisms of sodium and water absorption in the bowel. It is the direct entry of sodium and water across the cell at the intestinal brush border membrane via the linking (coupling) of 1 organic molecule, such as glucose, to 1 sodium molecule. This is the principle upon which ORT is based. Optimally, therefore, the ratio of carbohydrate to sodium should approach 1:1. Glucose is necessary to stimulate the absorption of water and electrolytes by the small intestines.

• The solution must be iso-osmolar or hypo-osmolar to avoid an increased osmotic load in the small intestines contributing to an osmotic diarrheal effect, pulling fluid into the lumen.

• Studies have shown oral and IV rehydration to be equivalent therapies in patients who can tolerate the oral fluid.

• Although standard glucose-electrolyte solutions achieve and maintain rehydration, they may not reduce stool volume or duration of diarrheal illness, affecting compliance.

• Newer solutions with complex carbohydrates and short chain polypeptides of cereals and legumes are now available to provide additional organic cotransport molecules with no increase in osmolarity. These appear to offer the advantage of decreased stool volumes and shortened duration of illness.

• Early age-appropriate refeeding in children (and adults) is important to initiate as soon as rehydration is complete.
  • Early refeeding with complex carbohydrates provides additional cotransport molecules without osmotic penalty and stimulates mucosal repair.

  • Consider rice, wheat, bread, potatoes, and lean meats, especially chicken.

  • Milk can be safely given early. Despite the potential for lactose intolerance, clinical evidence of lactase deficiency is uncommon, and most children can tolerate nonhuman milk without difficulty during acute diarrheal illnesses.

  • What has been learned from studies of early pediatric refeeding probably can be generalized to the adult population. Initiate early feeding with the above dietary recommendations once rehydration has been accomplished and vomiting is controlled.

• Empiric therapy for infectious diarrhea is sometimes indicated. Food-borne toxigenic diarrhea usually requires only supportive treatment, not antibiotics.
  • The duration of traveler’s diarrhea (E coli, Shigella) can be shortened by half or more with trimethoprim-sulfamethoxazole (TMP/SMZ) or ciprofloxacin administered for 3 days. Single doses have been used effectively. The duration of treatment may be extended by 2-3 days for moderate-to-severe cases.

  • Generally, fluoroquinolones are the drugs of choice for acute infectious gastroenteritis when used empirically. They do not appear to increase carrier states; however, they are contraindicated in pregnant women and in children.

  • Erythromycin or azithromycin is effective in Campylobacter infections, although erythromycin is not well tolerated in the patient who is vomiting.

  • Metronidazole (oral or parenteral) is effective in mild-to-moderate cases of C difficile diarrhea (in addition to discontinuance of the causative agent). Patients who are severely ill may require orally administered vancomycin, which may require delivery via nasogastric tube or colonoscope.

  • Mild cases of suspected Yersinia infection should be treated with TMP/SMZ or a fluoroquinolone, while patients who are more ill and require admission benefit from IV ceftriaxone.

  • Intestinal salmonellosis in an immunocompetent host does not require antimicrobials because they may prolong fecal shedding of organisms.

  • Metronidazole is effective against parasitic infestations with Giardia or Entamoeba.

• Antiemetics may be useful in the treatment of nausea and vomiting in adults. They are usually not recommended in children.

• Antidiarrheals (antimotility agents)
  • These agents have traditionally been discouraged because of concerns with causing bacteremia; however, they appear to have a role in the symptomatic treatment of mild-to-moderate diarrhea, especially with nonbloody and traveler's diarrhea.

  • The most common agents include bismuth subsalicylate (Pepto-Bismol). For patients older than 14 years, give 2 tablets or 20 mL PO q30min as needed to a maximum of 8 doses and loperamide (Imodium), which is useful as an adjunct to rehydration for symptomatic relief. The American Academy of Pediatrics (AAP) does not recommend this for children.

  • Octreotide (Sandostatin), an analog of somatostatin, may be used subcutaneously and intravenously to control severe secretory diarrhea. It has been approved for this purpose in the treatment of carcinoid tumors and VIPomas. Octreotide is under investigation for other uses, including secretory diarrhea associated with AIDS, short bowel syndrome, dumping syndrome, radiation, and chemotherapy.

Consultations:

• A consultation to an infectious diseases specialist may be necessary for patients with chronic diarrhea, patients whose conditions have parasitic etiologies, patients infected with C difficile when vancomycin use is contemplated, patients who relapse, and patients with AIDS who have diarrhea.

• A consultation to a gastroenterologist may also be indicated in the above circumstances and when pseudomembranous colitis, ulcerative colitis, or Crohn disease are in the differential diagnosis.

MEDICATION

Section 7 of 12

The goals of pharmacotherapy are to reduce morbidity, to prevent complications, and to possibly decrease the duration of illness.

In February 2006, the United States Food and Drug Administration (FDA) approved an oral vaccine for rotavirus (RotaTeq). It is currently the only vaccine approved in the United States for prevention of rotavirus gastroenteritis as of the date of this publication. RotaTeq is administered in a 3-dose series starting between age 6-12 weeks and completing before age 32 weeks. It is currently under review by the American Academy of Pediatrics (AAP) and the Advisory Committee on Immunization Practices (ACIP) to determine if it will be part of the regularly scheduled pediatric vaccine recommendations.

Drug Category: Antibiotics -- Therapy must cover all likely pathogens in the context of the clinical setting.

Drug Name	Ciprofloxacin (Cipro) -- Fluoroquinolones are the agents of choice for the empiric treatment of invasive and traveler's diarrhea syndromes in adult patients. They are also the agents of choice when treatment is indicated and the organism involved is known to be Campylobacter, E coli (non-0157:H7), nontyphoid Salmonella (although antibiotic treatment may prolong bacterial shedding), Shigella, or Yersinia.
Adult Dose	500 mg PO bid for 3-5 d; studies have shown that a single dose of 500 mg or 1000 mg may be equally effective
Pediatric Dose	<18 years: Not recommended >18 years: Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; ciprofloxacin reduces therapeutic effects of phenytoin; probenecid may increase ciprofloxacin serum concentrations May increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy

Drug Name	Trimethoprim-sulfamethoxazole (Bactrim) -- Excellent second choice for empiric therapy, although it is not effective against Campylobacter organisms. Increasing resistance. First drug of choice for patients younger than 18 years. Specifically recommended for 5 d for shigellosis.
Adult Dose	1 DS tab (or 4 tsp of the pediatric susp) PO bid for 3-5 d
Pediatric Dose	Dose is adjusted based on the trimethoprim component; 8-10 mg/kg/d PO in divided doses or 40 mg of trimethoprim per tsp (5 mL) PO
Contraindications	Documented hypersensitivity; megaloblastic anemia due to folate deficiency
Interactions	May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly patients; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Discontinue at first appearance of skin rash or sign of adverse reaction; obtain CBC frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, give 5-15 mg/d leucovorin); caution in folate deficiency (eg, chronic alcoholism, elderly patients, those receiving anticonvulsant therapy, those with malabsorption syndrome); hemolysis may occur in G-6-PD deficiency; patients with AIDS may not tolerate or respond to TMP-SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); give fluids to prevent crystalluria and stone formation; refer to PDR and product information

Drug Name	Rifaximin (Xifaxan, RedActiv, Flonorm) -- Nonabsorbed ( <0.4%), broad-spectrum antibiotic specific for enteric pathogens of the gastrointestinal tract (ie, gram-positive, gram-negative, aerobic, and anaerobic). Rifampin structural analog. Binds to beta-subunit of bacterial DNA-dependent RNA polymerase, thereby inhibiting RNA synthesis. Indicated for E coli (enterotoxigenic and enteroaggregative strains) associated with travelers’ diarrhea.
Adult Dose	200 mg PO tid
Pediatric Dose	<12 years: Not established >12 years: Administer as in adults
Contraindications	Documented hypersensitivity to rifaximin or rifamycin antimicrobial agents (eg, rifampin)
Interactions	Induces CYP450 3A4 in vitro; limited data exist; no significant interactions shown in single-dose studies with midazolam and oral contraceptives
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	May promote intestinal bacterial overgrowth and cause superinfection; discontinue if diarrhea persists more than 24-48 h or worsens; seek immediate medical care if fever and/or bloody stools emerge (tabs not effective); not effective for travelers’ diarrhea due to suspected pathogens other than E coli; postmarketing reports include allergic dermatitis, rash, angioneurotic edema, urticaria, and pruritus

Drug Category: Antiemetics -- All these drugs are indicated in the control of nausea and vomiting. All have been associated with extrapyramidal adverse effects, especially in patients who are acutely ill, dehydrated, or children. They should be used with caution and only in the lowest effective dose. A weak association with Reye syndrome exists, and all may mask the vomiting associated with underlying CNS lesions.

Drug Name	Prochlorperazine (Compazine) -- Antidopaminergic drug that blocks the postsynaptic mesolimbic dopamine receptors. Has an anticholinergic effect and can depress the reticular activating system, possibly responsible for relieving nausea and vomiting.
Adult Dose	5-10 mg PO/IM tid/qid; not to exceed 40 mg/d 2.5-10 mg IV q3-4h prn; not to exceed 10 mg/dose or 40 mg/d 25 mg PR bid
Pediatric Dose	2.5 mg PO/PR q8h or 5 mg q12h prn; not to exceed 15 mg/d IV dosing is not recommended for children 0.1-0.15 mg/kg/dose IM and change to PO as soon as possible
Contraindications	Documented hypersensitivity; bone marrow suppression; narrow-angle glaucoma; severe liver or cardiac disease
Interactions	Coadministration with other CNS depressants or anticonvulsants may cause additive effects; with epinephrine, may cause hypotension
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Drug-induced Parkinson syndrome or pseudoparkinsonism occurs frequently; akathisia is the most common extrapyramidal reaction in elderly patients; lowers seizure threshold; caution with history of seizures; refer to PDR and product information

Drug Name	Promethazine (Phenergan) -- Antidopaminergic agent effective in the treatment of emesis. Blocks postsynaptic mesolimbic dopaminergic receptors in the brain and reduces stimuli to the brainstem reticular system.
Adult Dose	12.5-25 mg PO/IV/IM/PR q4h prn
Pediatric Dose	<2 years: Contraindicated >2 years: 0.25-1 mg/kg PO/IV/IM/PR 4-6 times/d prn
Contraindications	Documented hypersensitivity; children younger than 2 y (incidences of death due to respiratory depression)
Interactions	May have additive effects when used concurrently with other CNS depressants or anticonvulsants; coadministration with epinephrine may cause hypotension
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Caution in cardiovascular disease, impaired liver function, seizures, sleep apnea, and asthma; refer to PDR and product information

Drug Name	Trimethobenzamide (Tigan) -- Has central effects in which it inhibits the medullary receptor trigger zone.
Adult Dose	250 mg PO tid/qid Alternatively, 200 mg IM/PR tid/qid
Pediatric Dose	<14 kg: 100 mg PO tid/qid 14-40 kg: 100-200 mg PO tid/qid >40 kg: Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	May inhibit effects of anticoagulants
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Not for use in patients with acute vomiting; refer to PDR and product information

Drug Name	Ondansetron (Zofran) -- Selective 5-HT3 receptor antagonist that blocks serotonin both peripherally and centrally. Indicated for nausea and vomiting due to radiation and/or chemotherapy and for postoperative nausea and vomiting. Cost considerations.
Adult Dose	Nausea and vomiting secondary to gastroenteritis: 4-8 mg PO q8h; 4 mg IV
Pediatric Dose	Nausea and vomiting secondary to gastroenteritis: 4 mg PO q8h; 0.1-0.15 mg/kg IV
Contraindications	Documented hypersensitivity
Interactions	None reported
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Adjust dose and use caution if liver function significantly impaired

Drug Category: Antidiarrheal agents -- These agents are used to decrease the frequency of diarrheal stools and possibly the duration. They should be used with caution in children and in patients with dysentery, as some reports of prolonged illness and development of toxic megacolon exist.

Drug Name	Loperamide (Imodium) -- Antimotility DOC. Generally safe and indicated in the early treatment of travelers' diarrhea.
Adult Dose	4 mg PO once, followed by 2 mg after each loose stool; do not exceed 16 mg/d
Pediatric Dose	Initial doses: 2-6 years: 1 mg PO tid 6-8 years: 2 mg PO bid 8-12 years: 2 mg PO tid Maintenance: 0.1 mg/kg PO after each loose stool; not to exceed initial dose Chronic diarrhea: 0.08-0.24 mg/kg/d PO divided bid/tid; not to exceed 2 mg/dose
Contraindications	Documented hypersensitivity; diarrhea resulting from infections; pseudomembranous colitis
Interactions	Phenothiazines, tricyclic antidepressants, and CNS depressants may increase loperamide toxicity
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Discontinue use if no clinical improvement in 48 h; because loperamide is primarily metabolized in the liver, monitor for CNS toxicity in patients with hepatic insufficiency; do not use medication if high fever or blood in stool coincides with diarrhea; refer to PDR and product information

Drug Name	Diphenoxylate HCl 2.5 mg/atropine sulfate 0.025 mg (Lomotil) -- Antidiarrheal agent chemically related to narcotic analgesic meperidine. A subtherapeutic dose of anticholinergic atropine sulfate is added to discourage overdosage, in which case diphenoxylate may clinically mimic the effects of codeine. Each tab of Lomotil or 5 cc of elixir contains 2.5 mg diphenoxylate hydrochloride and 0.025 mg atropine sulfate. Almost always the preferred antimotility agent.
Adult Dose	2 tab PO qid until the diarrhea is controlled
Pediatric Dose	<2 years: Not recommended 2-5 years: 2 mg of diphenoxylate PO tid 5-8 years: 2 mg of diphenoxylate PO qid 8-12 years: 2 mg of diphenoxylate PO 5 times/d
Contraindications	Documented hypersensitivity; narrow-angle glaucoma; hepatic insufficiency
Interactions	May delay metabolism of drugs in liver; CNS depressants, MAOIs, and antimuscarinic agents may increase the toxicity of this drug combination
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	In young children, dehydration may influence variability of response and predispose patient to delayed diphenoxylate intoxication; exercise caution in patients with ulcerative colitis A decrease in intestinal motility may be detrimental to patients with diarrhea resulting from Shigella, Salmonella, and toxigenic strains of E coli; refer to PDR and product information

Drug Category: Vaccines -- Elicit active immunization to increase resistance to infection. Vaccines consist of microorganisms or cellular components, which act as antigens. Administration of the vaccine stimulates the production of antibodies with specific protective properties.

Drug Name	Rotavirus vaccine (RotaTeq) -- Orally administered live-virus vaccine. Pentavalent vaccine that contains 5 live reassortant rotaviruses. Indicated to prevent rotavirus gastroenteritis, a major cause of severe diarrhea in infants. Administered as a 3-dose regimen against G1, G2, G3, and G4 serotypes, the 4 most common rotavirus group A serotypes. Also contains attachment protein P1A (genotype P[8]). Clinical trials demonstrated prevention of 74% of all rotavirus gastroenteritis cases, nearly all severe rotavirus gastroenteritis cases, and nearly all hospitalizations due to rotavirus.
Adult Dose	Not indicated
Pediatric Dose	<6 weeks: Not established 6-12 weeks: 2 mL PO as a single dose, followed by 2 additional doses at 4- to 10-wk intervals; do not administer after age 32 wk >32 weeks: Not established
Contraindications	Documented hypersensitivity
Interactions	Immunosuppressive therapies (eg, irradiation, antimetabolites, alkylating agents, cytotoxic drugs, high-dose corticosteroids) may decrease immune response
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Common adverse effects include diarrhea, vomiting, otitis media, inflamed nasal passages, and bronchospasm; refrigerate and protect from light; handle and discard empty tube according to biological waste procedures; previously marketed rotavirus vaccine (RotaShield) was associated with intussusception, but RotaTeq did not show an increased risk compared with placebo in clinical trials (monitor for signs of intestinal blockage); do not mix with other vaccines or solutions

FOLLOW-UP

Section 8 of 12

Further Inpatient Care:

• Continue rehydration and management of electrolytes if ED response is inadequate.

• Manage sepsis in the toxic-appearing patient.

• Evaluate for underlying etiology if the diagnosis is uncertain.

• Manage complications.

Further Outpatient Care:

• Rehydrate orally with balanced sodium and glucose solutions.

• Ensure appropriate early oral refeeding.

• Ensure appropriate deterrence and infection control procedures and activities, including notification of common source or close contact exposures, as appropriate.

• Administer antibiotic, antimotility, and antiemetic treatment only as indicated and directed.

• Wash buttocks after each diarrheal stool to avoid effects of stool enzyme on the skin.

• Instruct the patient to return upon experiencing bloody stools, worsening abdominal pain, severe vomiting, and/or concerns regarding dehydration.

• Instruct the patient to seek follow-up care if diarrhea persists longer than 10 days.

In/Out Patient Meds:

• Antibiotics

• Antiemetics

• Antimotility agents

Transfer:

• Transfer of the unstable patient is inappropriate under Emergency Medical Treatment and Active Labor Act (EMTALA) regulations unless benefits clearly outweigh risks.

• Unless the patient requires admission and has a complicated medical condition that would be better managed in another facility, transfer is neither necessary nor recommended.

Deterrence/Prevention:

• The following are factors to consider with breastfeeding:

• Decreased incidence of rotavirus but does not eliminate this diagnosis

• Formula supplementation with nonpathogenic bacteria such as Bifidobacterium bifidum

• Take enteric precautions to avoid spread to family members, especially by washing hands before eating and after each stool or diaper change.

• Avoid shellfish served in unregulated environments, in areas with known red tides, or areas of recently reported outbreaks, including Vibrio species and Norwalk virus. Individuals with a history of any liver disease should avoid raw shellfish.

• Wash all produce prior to consumption, especially if imported.

• Avoid cross-contamination of foods during preparation (eg, cutting boards).

• Avoid raw or undercooked eggs or poultry.

• As many as 40% of travelers to high-risk areas (South and Southeast Asia, Africa, and Latin America) contract diarrhea. Dietary precautions, in addition to the above, which will reduce this risk are as follows:

• Eat steaming hot foods (cooked foods) and drink steaming hot beverages (eg, coffee, tea).

• Consume acidic foods, such as citrus.

• Consume dry foods, such as bread and nuts.

• Drink carbonated beverages.

• Avoid water, ice, raw fruits without a skin or peel, raw vegetables, unpasteurized milk and dairy products, and foods sold in the streets.

• Avoid moist foods served at room temperature, leafy green vegetables, and ripened fruit with broken skin.

• Take the above precautions when aboard the aircraft leaving the high-risk area.

• Travelers who request prophylaxis can take 2 tablets of Pepto-Bismol with each meal and at bedtime, not exceeding a daily dose of 8 tablets.

• Although prophylactic antimicrobial therapy generally should be discouraged in the young and healthy traveler, if chemoprophylaxis is requested, a daily single dose of TMP/SMZ or a fluoroquinolone can be provided.

• Travelers with certain underlying conditions should be encouraged to use prophylactic antibiotics. These include patients with AIDS, inflammatory bowel disease, systemic malignancy, insulin dependency, or achlorhydria and patients taking omeprazole or chronically using H2 antagonists. Sporadic or intermittent H2 antagonist use is not an indication for prophylaxis.

• Avoid drinking from unfamiliar fresh water sources, such as lakes and rivers.

Complications:

• Dehydration

• Malabsorption

• Transient lactose intolerance

• Chronic diarrhea

• Systemic infection (meningitis, arthritis, pneumonia) especially with Salmonella infections

• Sepsis (Salmonella, Yersinia, Campylobacter organisms)

• Hemolytic-uremic syndrome (much more common in children, especially with E coli 0157:H7)

• Toxic megacolon

• Reactive arthritides (Salmonella, Shigella, Yersinia, Campylobacter, Giardia organisms)

• Persistent diarrhea

• Thrombotic thrombocytopenic purpura or TTP (E coli 0157:H7)

• Guillain-Barré syndrome (Campylobacter organisms)

Prognosis:

• Most cases of gastroenteritis are self-limited with an excellent prognosis.

Patient Education:

• Patients should be educated on the importance and proper methods of oral rehydration and early appropriate feeding.

• All patients, especially the parents of infants and young children, must be extensively educated about the signs and symptoms of dehydration.

• Patients with food-borne exposures should be educated on deterrence.

• Immunocompromised patients and individuals with liver disease should be educated not to consume raw shellfish, especially oysters.

• Travelers to underdeveloped areas should be made aware of proper avoidance measures, appropriate treatment, and current endemic illnesses.

• For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education articles, Gastroenteritis, Abdominal Pain in Adults, Diarrhea, and Vomiting and Nausea.

MISCELLANEOUS

Section 9 of 12

Medical/Legal Pitfalls:

• Failure to recognize dehydration or sepsis

• Failure to recognize immunocompromised patients and their potential, unusual etiologies or propensity to develop complications

• Failure to recognize hemolytic-uremic syndrome in the patient with E coli infection

• Failure to recognize pseudomembranous colitis (C difficile)

• Failure to recognize toxic megacolon

• Failure to diagnose appendicitis in the patient who presents with vomiting and diarrhea

• Failure to diagnose noninfectious etiology, such as ischemic bowel, bowel obstruction, or other etiologies for abdominal symptomatology

• Diagnosing gastroenteritis in a patient who is only vomiting when the vomiting is due to a nongastrointestinal and possibly life-threatening etiology

• Complications resulting from the inappropriate use of antimotility and antiemetic medications

Special Concerns:

• Pseudomembranous colitis (C difficile)

• This condition occurs mostly in patients who are hospitalized or live in a nursing home and who have recently been on antibiotics and is due to infection with toxin-producing strains of C difficile. Toxins A and B damage the mucosa of the colon.

• Symptoms may range from mild to severe bloody diarrhea and colitis, with pseudomembranous colitis being the most severe form.

• Complications include dehydration, toxic megacolon, and perforation.

• Stop any antibiotics.

• Treat with intravenous fluids and vancomycin or metronidazole.

• Condition is suspect with prior or current antibiotic therapy.

• Diagnosis via assay or sigmoidoscopy.

• Gastroenteritis in the elderly patient: Diagnosing complications, such as dehydration (may have chronic poor skin turgor and dry mucus membranes) is more difficult. Elderly patients may be unable to take needed medications. Electrolyte disorders and hypovolemia may have much more serious implications, and life-threatening abdominal emergencies, such as appendicitis, are easier to overlook. Fever may not be manifested, and pain sensation may be blunted.

• Travelers' diarrhea

• Condition is usually self-limited (3-5 d).

• Onset is within 1 week of arrival.

• Fever, vomiting, and bloody stools are uncommon.

• Early treatment may decrease duration.

• Loperamide is often useful.

• If a lack of response to antibiotics is present, check for parasites.

• Consider C difficile in patients taking prophylactic antibiotics.

• The use of probiotics, such as Lactobacillus GG, has had mixed results in treatment and prevention.

• Rifaximin at 200 mg PO tid may be used for the treatment or prevention of travelers’ diarrhea.

• Food-borne toxigenic diarrhea

• Condition is usually self-limited and of short duration.

• Stool analysis and culture are not helpful.

• Perform supportive treatment only.

• Antibiotics rarely are useful or indicated.

• Diarrhea in patients with AIDS

• The condition usually becomes more severe as the immune system deteriorates.

• Patient may require antimotility agents only.

• Consider drug-related and herb-related causes.

• Start with empiric treatment with a quinolone and culture the stool.

• Pursue diagnostic testing more aggressively because patients with AIDS are more likely to have an identifiable etiology.

• Consider nonopportunistic bacterial and protozoal infections first, then etiologies such as CMV and Mycobacterium infections.

• Treatment must include nutritional and psychosocial support.

TEST QUESTIONS

Section 10 of 12

CME Question 1: Which of the following is not characteristic of toxigenic (noninvasive) diarrhea?

A: Minimal or absent systemic symptoms
B: Gradual onset over 1-2 days
C: Absence of blood and mucus
D: Short self-limited duration of illness
E: Absence of WBCs in stool on methylene blue or Wright stain

The correct answer is B: Toxigenic diarrhea secondary to organisms such as Staphylococcus aureus, Bacillus cereus, and Clostridium perfringens usually presents with sudden onset of symptoms within hours of ingesting suspect food products. The illness is usually self-limited and rarely requires significant treatment. Patients rarely are febrile, and the stool is characteristically watery with an absence of blood, mucus, or WBCs.

CME Question 2: Which of the following is not true regarding Escherichia coli O157:H7 gastroenteritis?

A: Approximately 5% of cases develop hemolytic-uremic syndrome (HUS).
B: Antibiotic therapy must be instituted early in the course of the disease.
C: It is classified as an enterohemorrhagic E coli.
D: The toxin that is tested for is shigatoxin.
E: Associated diarrhea is usually bloody and is associated with severe cramping.

The correct answer is B: Antibiotic therapy in the management of enterohemorrhagic E coli infections is controversial. Most authorities recommend against antibiotic use because it may cause increased toxin release and may increase the incidence of HUS.

Pearl Question 1 (T/F): Campylobacter, Shigella, Salmonella, and Vibrio are the organisms most commonly tested for as part of routine cultures by most institutions (additional specific requests may be required for the laboratory to test for other infectious etiologies, using special techniques and media).

The correct answer is False: Campylobacter, Shigella, and Salmonella are the organisms routinely set up for culture. Vibrio species are not.

Pearl Question 2 (T/F): Campylobacter jejuni is known for causing appendicitislike syndromes.

The correct answer is True: Yersinia species may also mimic the presentation.

Pearl Question 3 (T/F): A 62-year-old man with a history of cirrhosis and mild congestive heart failure (CHF) returns from a trip to New Orleans with hemorrhagic bullae on his legs and diarrhea. The man most likely has contracted cholera.

The correct answer is False: Vibrio infection (septicemia) secondary to consuming contaminated raw oysters is most likely the cause.

Pearl Question 4 (T/F): The 2 most important features of oral rehydration solutions are that they must be hypotonic or isotonic and that they should have an equal ratio of sodium to glucose to maintain coupled transport.

The correct answer is True: Coupled transport is one of several mechanisms of sodium and water absorption in the bowel. It is the direct entry of sodium and water across the cell at the intestinal brush border membrane via the linking (coupling) of one organic molecule, such as glucose, to one sodium molecule. This is the principle upon which oral rehydration therapy is based.

PICTURES

Section 11 of 12

Caption: Picture 1. Hektoen enteric agar with Escherichia coli colonies. Different growth media are necessary for identifying different enteric pathogens, suppressing the growth of nonpathogens, and allowing for chemical reactions to assist in identification. The appearance results from the organism's ability to ferment lactose placed in the medium. This results in the production of acid, which lowers the pH and causes a change in the pH indicator placed in the medium. Salmonella and Shigella organisms do not ferment lactose.
	View Full Size Image
	eMedicine Zoom View (Interactive!)
Picture Type: Photo
Caption: Picture 2. Example of Salmonella on Hektoen enteric agar. The medium also contains ferric ammonium citrate, which indicates the production of hydrogen sulfide by the appearance of a black precipitate.
	View Full Size Image
	eMedicine Zoom View (Interactive!)
Picture Type: Photo
Caption: Picture 3. The MacConkey medium is commonly used and differentiates lactose fermenters, which produce acid, decrease the pH, and cause the neutral red indicator to give the colonies a pink-to-red color.
	View Full Size Image
	eMedicine Zoom View (Interactive!)
Picture Type: Photo
Caption: Picture 4. The Christensen method is used to determine if an organism produces the enzyme urease (Yersinia) or not (Salmonella, Shigella, Vibrio). Hydrolysis of urea produces ammonia and carbon dioxide, alkalinizing the medium and turning the phenol red from light orange to magenta (pink).
	View Full Size Image
	eMedicine Zoom View (Interactive!)
Picture Type: Photo
Caption: Picture 5. Often, a combination of methods may be used for identification. The tube on the left is triple sugar iron (TSI) agar. The alkaline slant and acid butt (K/A) indicates an organism that ferments glucose only (not lactose or sucrose). The middle tube is indole positive, as indicated by the pink ring, and indicates the organism’s ability to split tryptophan to form indole. The tube on the right is urease negative. Taken together, these tests indicate the organism is likely Shigella.
	View Full Size Image
	eMedicine Zoom View (Interactive!)
Picture Type: Photo
Caption: Picture 6. Gram stain may be helpful in identifying an etiologic agent. This stain shows gram-negative bacilli, which could be Salmonella or Shigella with 2 polymorphonucleocyte cells (PMNs).
	View Full Size Image
	eMedicine Zoom View (Interactive!)
Picture Type: Photo

BIBLIOGRAPHY

Section 12 of 12

• Caeiro JP, DuPont HL: Management of travellers' diarrhoea. Drugs 1998 Jul; 56(1): 73-81[Medline].
• CDC: Outbreaks of gastroenteritis associated with noroviruses on cruise ships--United States, 2002. MMWR Morb Mortal Wkly Rep 2002 Dec 13; 51(49): 1112-5[Medline][Full Text].
• DuPont HL: Guidelines on acute infectious diarrhea in adults. The Practice Parameters Committee of the American College of Gastroenterology. Am J Gastroenterol 1997 Nov; 92(11): 1962-75[Medline].
• DuPont HL, Jiang ZD, Okhuysen PC, et al: A randomized, double-blind, placebo-controlled trial of rifaximin to prevent travelers' diarrhea. Ann Intern Med 2005 May 17; 142(10): 805-12[Medline].
• Gonenne J, Pardi DS: Clostridium difficile: an update. Compr Ther 2004 Fall-Winter; 30(3): 134-40[Medline].
• Guerrant RL, Van Gilder T, Steiner TS, et al: Practice guidelines for the management of infectious diarrhea. Clin Infect Dis 2001 Feb 1; 32(3): 331-51[Medline].
• Musher DM, Musher BL: Contagious acute gastrointestinal infections. N Engl J Med 2004 Dec 2; 351(23): 2417-27[Medline].
• Seamens CM, Schwartz G: Food-borne illness: differential diagnosis and targeted management. Emerg Med Rep 1998; 19: 120-131.
• Teitelbaum JE: Probiotics and the treatment of infectious diarrhea. Pediatr Infect Dis J 2005 Mar; 24(3): 267-8[Medline].
• Thielman NM, Guerrant RL: Clinical practice. Acute infectious diarrhea. N Engl J Med 2004 Jan 1; 350(1): 38-47[Medline].
• Widdowson MA, Glass R, Monroe S, et al: Probable transmission of norovirus on an airplane. JAMA 2005 Apr 20; 293(15): 1859-60[Medline].

eMedicine Journals > Emergency Medicine > Gastrointestinal > Gastroenteritis

Please email us with any comments you have on our new chapter format.

Author Information | Introduction | Clinical | Differentials | Workup | Treatment | Medication | Follow-up | Miscellaneous | Test Questions | Pictures | Bibliography