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Acute Gastroenteritis

Acute gastroenteritis refers to an inflammation of stomach and intestines mainly caused by infection with viral or bacterial agents. Sudden onset of symptoms like abdominal pain, vomiting and diarrhea is characteristic for this condition.


Presentation

AG may run an asymptomatic, typical or severe course, depending on the overall health of the patient, the pathogenicity of the causative agent, the infectious dose and degree of dehydration.

The typical course consists of a short prodromal phase with mild fever, nausea and vomiting. Diarrhea and possibly an increase in body temperature marks the subsequent phase of disease that usually doesn't last longer than three or four days. It has been suggested that high fever is generally caused by bacteria, while mild fever indicates viral gastroenteritis. Both incubation period and duration of illness are usually shorter if the causative agent is a virus. It has to be noted though, that these parameters are little specific and sensitive [9]. AG is usually self-limiting.

Melena is not characteristic for AG, but may be observed if pathogens either penetrate deep into the intestinal wall or mechanically destroy its inner layers. This condition may be provoked by certain bacterial and parasitic species, e.g., by enterohemorrhagic Escherichia coli or Shigella spp., or may result from an exacerbation of a rather harmless infection in immunocompromised patients.

Fever
  • This disease is characterized by vomiting and/or diarrhea with blood or mucus, discomfort, fever, and nonspecific abdominal pain. Commonly involved pathogens in the developed world include: viruses, bacteria, and parasites.[ncbi.nlm.nih.gov]
  • It has been suggested that high fever is generally caused by bacteria, while mild fever indicates viral gastroenteritis. Both incubation period and duration of illness are usually shorter if the causative agent is a virus.[symptoma.com]
  • Patients with Salmonella infection frequently presented with fever, lethargy, bloody stool, and elevated serum level of C-reactive protein (CRP); norovirus and rotavirus infection frequently presented with vomiting.[ncbi.nlm.nih.gov]
  • Major clinical symptoms of HBoV mono infections included diarrhoea (100%), fever (90%), dehydration (74%), and vomiting (58%). Dehydration was observed in all of the HBoV2-4 cases and in 50% of the HBoV1 cases.[ncbi.nlm.nih.gov]
  • Clinically, fever was verified in 43% of the positive cases and 46.3% of the negative cases, and vomiting was observed in 75.8% and 70.8% cases in these groups, respectively.[ncbi.nlm.nih.gov]
Malaise
  • AG is characterized by a sudden onset of symptoms - typically fever, malaise, abdominal pain, nausea, vomiting and diarrhea - but severity may vary widely. In industrialized countries, self-limiting diarrhea is the most common manifestation of AG.[symptoma.com]
  • Abdominal pain Signs and symptoms of infection - Presence of fever, chills, myalgias, rash, rhinorrhea, sore throat, cough; these may be evidence of systemic infection or sepsis Changes in appearance and behavior - Including weight loss and increased malaise[emedicine.medscape.com]
  • This syndrome has an insidious onset of malaise, fever, abdominal pain, and bradycardia. Diarrhea and rash (rose spots) appear after 1 week of symptoms.[emedicine.medscape.com]
Vomiting
  • Although the affected children habitually have vomiting, recommendations do not focus on the correction of this symptom.[ncbi.nlm.nih.gov]
  • The use of antiemetics for vomiting in acute gastroenteritis in children is still a matter of debate.[ncbi.nlm.nih.gov]
  • This case report describes an unusual presentation of nausea, vomiting and diarrhea, which was misdiagnosed as acute gastroenteritis in a 6-year-old girl.[ncbi.nlm.nih.gov]
  • This disease is characterized by vomiting and/or diarrhea with blood or mucus, discomfort, fever, and nonspecific abdominal pain. Commonly involved pathogens in the developed world include: viruses, bacteria, and parasites.[ncbi.nlm.nih.gov]
  • This article discusses the classic presentation of gastroenteritis in children, which includes a short history of vomiting followed by diarrhoea.[ncbi.nlm.nih.gov]
Diarrhea
  • The common causes of diarrhea are infections with viruses and bacteria, diarrhea due to a systemic infection other than gastrointestinal, diarrhea associated with antibiotic administration, and feeding related diarrhea.[ncbi.nlm.nih.gov]
  • G9 was significantly associated with mucus diarrhea, than G1 or G3 which were associated with watery diarrhea (P 0.025). Also, G9 was significantly associated with loose stool for 5 days (P 0.006) and 54.4% of G9 patients had severe dehydration.[ncbi.nlm.nih.gov]
  • Clostridium difficile was identified only in patients with acute gastroenteritis (p 0.01), while STEC was detected exclusively in patients with hemorragic diarrhea (p 0.01).[ncbi.nlm.nih.gov]
  • Sudden onset of symptoms like abdominal pain, vomiting and diarrhea is characteristic for this condition.[symptoma.com]
  • This case report describes an unusual presentation of nausea, vomiting and diarrhea, which was misdiagnosed as acute gastroenteritis in a 6-year-old girl.[ncbi.nlm.nih.gov]
Nausea
  • In this condition, elevated ketone bodies and stimuli initiated by gut mucosa damage produced by the enteral pathogen likely underlay nausea and vomiting.[ncbi.nlm.nih.gov]
  • There were no significant differences in abdominal pain, nausea, vomiting, or school absenteeism between both groups at time of consultation.[ncbi.nlm.nih.gov]
  • This case report describes an unusual presentation of nausea, vomiting and diarrhea, which was misdiagnosed as acute gastroenteritis in a 6-year-old girl.[ncbi.nlm.nih.gov]
  • “Notably, when looking at results by initial severity of nausea, we see a treatment effect even in patients with very severe nausea at baseline, suggesting that the drug works regardless of the initial severity of gastroenteritis,” Terry F.[healio.com]
  • This results in the typical symptoms of nausea, vomiting, diarrhea and abdominal pain.[healthhype.com]
Abdominal Pain
  • There were no significant differences in abdominal pain, nausea, vomiting, or school absenteeism between both groups at time of consultation.[ncbi.nlm.nih.gov]
  • This disease is characterized by vomiting and/or diarrhea with blood or mucus, discomfort, fever, and nonspecific abdominal pain. Commonly involved pathogens in the developed world include: viruses, bacteria, and parasites.[ncbi.nlm.nih.gov]
  • A 12-year-old boy was brought to the hospital with a 3-week history of watery diarrhea mixed with mucus and colicky abdominal pain. Stool culture identified Edwardsiella tarda O4: H4, and no other pathogenic bacteria were detected.[ncbi.nlm.nih.gov]
  • Up to 50% of cases are preceded by an upper tract respiratory infection caused by group-A beta-hemolytic streptococcus and present with the common tetrad of abdominal pain, arthritis, purpuric rash, and renal involvement.[ncbi.nlm.nih.gov]
  • Mid-abdominal pain could be a sign of intestinal obstruction or mesenteric ischemia. Lower abdominal pain could be appendicitis or sigmoid diverticulitis, or it could have a gynecologic or urologic cause.[contemporaryclinic.pharmacytimes.com]
Abdominal Cramps
  • Symptoms of AG, which is a common disease worldwide, include diarrhoea, vomiting, nausea, abdominal cramps or pain, fever, and blood or mucus in the stool.[swissinfo.ch]
  • In 2001, the Vessel Sanitation Program and the cruise industry expanded the diarrheal illness case definition to include acute gastroenteritis (diarrhea, or vomiting that is associated with loose stools, bloody stools, abdominal cramps, headache, muscle[cdc.gov]
  • We’ve all experienced the abdominal cramps and the urge to get to a toilet – quickly![theconversation.com]
  • Overview Viral gastroenteritis is an intestinal infection marked by watery diarrhea, abdominal cramps, nausea or vomiting, and sometimes fever.[mayoclinic.org]
  • Symptoms may include nausea, vomiting, diarrhea, and abdominal cramps (dull or sharp pains). Gastroenteritis may be caused by infection with bacteria, parasites, or viruses.[fpnotebook.com]
Skin Lesion
  • Here we document a rare case of anaphylactoid purpura which manifested with skin lesions in the form of palpable purpura following about of acute gastroenteritis with severe dehydration; it was treated with a short regimen of steroid therapy, which resulted[ncbi.nlm.nih.gov]
Palpable Purpura
  • Here we document a rare case of anaphylactoid purpura which manifested with skin lesions in the form of palpable purpura following about of acute gastroenteritis with severe dehydration; it was treated with a short regimen of steroid therapy, which resulted[ncbi.nlm.nih.gov]
Purpura
  • Here we document a rare case of anaphylactoid purpura which manifested with skin lesions in the form of palpable purpura following about of acute gastroenteritis with severe dehydration; it was treated with a short regimen of steroid therapy, which resulted[ncbi.nlm.nih.gov]
Myalgia
  • […] chloride ions into the intestinal lumen, leading to secretory diarrhea Signs and symptoms These include the following: Diarrhea Vomiting Increase or decrease in urinary frequency Abdominal pain Signs and symptoms of infection - Presence of fever, chills, myalgias[emedicine.medscape.com]
Lethargy
  • Patients with Salmonella infection frequently presented with fever, lethargy, bloody stool, and elevated serum level of C-reactive protein (CRP); norovirus and rotavirus infection frequently presented with vomiting.[ncbi.nlm.nih.gov]
  • Give them appropriate anticipatory guidance regarding the need to monitor for urine output (at least one urination in 8hrs) and signs of true lethargy – for which they should return to the ED. Fluids can be given via NasoGastric Tube also![pedemmorsels.com]
  • […] pain Diarrhea Nausea and vomiting Other symptoms may include: Chills, clammy skin, or sweating Fever Joint stiffness or muscle pain Poor feeding Weight loss The health care provider will look for signs of dehydration , including: Dry or sticky mouth Lethargy[medlineplus.gov]
  • Parents should be told to return if their child develops intractable vomiting, signs of more severe dehydration such as irritablity or lethargy, sunken eyes, reduced skin pinch, decreased tears, or refusal to drink fluids.[emedicine.medscape.com]
  • Children with gastroenteritis or stomach flu usually have diarrhea, but may have other symptoms, for example: Diarrhea Refusing to eat or drink or are very thirsty Either increased or low or no urine output Weight loss Lethargy Bloody diarrhea Pinched[medicinenet.com]
Apathy
  • Moderate dehydration: apathy, tiredness, dizziness, muscle cramps, dry tongue, sunken eyes, reduced skin elasticity, postural hypotension (systolic blood pressure 90 mm Hg), tachycardia, oliguria.[patient.info]

Workup

Information regarding symptom onset, frequency and quantity of vomiting, diarrhea and micturition as well as possible loss of body weight should be obtained during the initial interview. Reduced ingestion of water, decrease of urine output and body weight indicate an advanced state of dehydration.

Laboratory analyses of blood samples may confirm a suspected dehydration if such diagnosis cannot be made during clinical examination. In any case, such tests are very helpful to assess water and electrolyte imbalances and to recognize acidosis. In cases of severe dehydration, kidney function should be monitored by repeated measurements of urea and creatinine.

Especially in cases of prolonged gastroenteritis, i.e., if diarrhea does persist for more than four days, detection of blood in stool samples may serve as an additional hint at bacterial or parasitic genesis. Such analysis may be followed by bacterial culture, molecular biological exams or immunoassays to identify the etiologic agent of the disease. The latter may also be carried out to specify the causative pathogen in case of viral infection, if this information is of interest due to clinical or epidemiological reasons. Serological tests may yield positive findings after more than 24 hours of illness and for up to two weeks after infection.

Colitis
  • Local rectal application of tacrolimus in distal colitis, pouchitis and perianal Crohn's disease has previously been reported to be both effective and safe.[ncbi.nlm.nih.gov]
  • K52.8 Other specified noninfective gastroenteritis and colitis K52.81 Eosinophilic gastritis or gastroenteritis K52.82 Eosinophilic colitis K52.83 Microscopic colitis K52.838 Other microscopic colitis K52.89 Other specified noninfective gastroenteritis[icd10data.com]
  • For 2.0% (95% CI 1.4–2.9) of patients, Sentinella-physicians reported sequelae, like dehydration, diverticulitis, or colitis. No deaths due to AG were reported.[link.springer.com]
  • Association of proton-pump inhibitors with outcomes in Clostridium difficile colitis. Am J Health Syst Pharm . 2007 Nov 15. 64(22):2359-63. [Medline] . Wei L, Ratnayake L, Phillips G, et al.[emedicine.medscape.com]
  • Toxic megacolon caused by fulminant colitis is rare.[patient.info]

Treatment

Treatment is supportive and mainly aims at compensating for fluid and electrolyte loss and avoiding severe dehydration. Thirst, skin turgor, mucous membranes, blood pressure and urine output are suitable parameters to continuously evaluate the current state of hydration.

Mild cases of dehydration may be treated with oral rehydration therapy. The latter may even be indicated before unequivocal symptoms of fluid loss manifest. In contrast, oral rehydration is generally not sufficient to revoke severe lack of fluids. Here, intravenous administration of saline solutions, possibly supplemented with lacking electrolytes, is required.

Antiemetics and antidiarrheal compounds are generally not applied, particularly not in young children.

Patients may, however, benefit from administration of probiotics. Both duration of diarrhea and hospitalization have been shown to be shortened if patients receive probiotics, although their precise mechanisms of action are not yet completely understood [10]. They have been suggested to suppress proliferation of pathogenic microorganisms and to modulate immune function. Of note, probiotics may have a beneficial but only limited effect in AG patients.

Prognosis

Prognosis is usually excellent if an appropriate state of hydration is kept. Rapid dehydration and difficult rehydration may be an issue in children, old people and those that are immunodeficient or suffer from other comorbidities. Intravenous rehydration is often required in these cases. Prognosis worsens significantly with the inability to compensate for fluid loss sustained through vomitus and diarrhea.

Etiology

The vast majority of AG cases is caused by distinct species of viruses. Rotavirus, for instance, accounts for hundreds of millions of annual cases in children aged less than five years [1]. There are few children in the world who are older than three years and who have not suffered from an infection with rotavirus. Over the course of the last decades, a plethora of other viral agents has also been related to AG. The most common are:

  • Caliciviridae. This family comprises the genera norovirus and sapovirus. The former includes several species sometimes referred to as Norwalk and Norwalk-like viruses.
  • Enteric adenoviruses 40 and 41
  • Astrovirus
  • Coronavirus and torovirus, both pertaining to the family of Coronaviridae

Data regarding the relative share of each of the aforementioned species in overall viral AG prevalence vary largely [4] [5]. Also, infections with more than one pathogen are very common.

It has been estimated that one out of five cases is caused by bacteria. Most commonly, Enterobacteriaceae account for them. In detail, the following species have been related with AG:

  • Escherichia coli
  • Salmonella spp.
  • Shigella spp.
  • Yersina spp.
  • Campylobacter spp.
  • Vibrio cholerae

With regards to parasites, acute inflammation of the gastrointestinal tract is often mediated by protozoa. These species have to be mentioned in this context:

There are significant differences between industrialized nations and developing countries regarding the likelihood of gastroenteritis being triggered by any of the above mentioned species. Bacterial and parasitic AG, for instance, are much more common in the developing world. This fact results from an overall improved sanitary status in developed countries and points out that disease incidence - at least regarding those pathogens - may be diminished by taking the appropriate hygiene measures.

Epidemiology

It has been estimated that more than 130 million children aged less than five years are affected by viral gastroenteritis every year [1]. Although viral infection accounts for the majority of cases, the overall number of AG will surely surpass this number if bacterial and parasitic forms as well as patients pertaining to other age groups are considered, too. Annually, almost one million children die from AG. These values result in a worldwide mortality of 0.7% for pediatric AG patients. However, there are large geographical differences and mortality in industrialized countries is generally about 1 per 100,000 children. Mortality may be significantly reduced by making immunization against rotavirus part of the routine pediatric care [6] [7].

AG may affect people of all races and both genders. Most patients are children and the age peak corresponds to infants aged less than two years, but the disease may be diagnosed in patients of any age.

Seasonal dependency has been shown for AG incidence. More cases are registered during the cold season than during warm summer months.

Sex distribution
Age distribution

Pathophysiology

Fecal-oral transmission and contaminated water and food are the main sources of infection, although droplet infection has been described for some agents related to AG.

With regards to viral AG, pathogens infect enterocytes, replicate inside these cells and subsequently mediate cell lysis. This process leads to epithelium atrophy. Repair mechanisms set in, but only immature cells can repopulate the damaged intestinal parts. Thus, impaired intestinal function may persist even after the causative pathogens have been eliminated. Of note, release of viruses from host cells has been described to occur without lysis. While this has consequences for potential histopathological analysis in as much as only few epithelial lesions will be visible, enterocytic function is still disturbed and AG symptoms will set in nevertheless. Similarly, release of toxins may alter intestinal function without any obvious damage to villi or crypts.

Diarrhea may result from maldigestion and reduced absorption of osmotically active compounds or from active secretion of electrolytes and water into the intestinal lumen [8]. Presumably, both processes contribute to diarrhea in most cases of AG: An inflamed intestinal wall will be restricted in function, show a decreased permeability for certain molecules that consequently draw water into the lumen, and stimulation of the enteric nervous system augments active water and electrolyte secretion. These conditions may be provoked by all kinds of pathogens by means of cell lysis as described above, release of toxins, invasion of the intestinal wall and initiation of an immune response, or mechanical damage alone.

Prevention

Appropriate hygiene measures may largely contribute to reduce the risk of contracting gastroenteritis:

  • Regular hand washing, especially after close contact to children and before eating
  • Education of children to adopt this behavior themselves
  • Avoidance of ingestion of water or food of unknown sources unless it has been boiled, cooked or peeled, respectively (water spring, unpasteurized milk, ice cream, fruits, etc.)
  • The latter particularly applies while traveling

Vaccines are available for certain types of AG [7].

Summary

Acute gastroenteritis (AG) is a very common disease associated with inflammation of the stomach and intestines that can be triggered by all kinds of pathogens, i.e., by viruses, bacteria and parasites, and by consciously or unconsciously ingested toxins. By far most cases are caused by viral infection, especially with rotavirus. With regards to bacteria, those species pertaining to the family of Enterobacteriaceae are most frequently associated with AG.

Patients of all ages may present with AG, but the majority of affected individuals are children. In pediatric patients, sporadic infection with rotavirus triggers AG. Similar cases may be observed in adults, but the relevant pathogen spectrum is wider and additionally comprises enteric adenovirus, astrovirus and calicivirus [1]. The latter is actually the most frequently isolated pathogen in this regards. Calicivirus may also account for epidemics of AG. Such cases usually occur due to contamination of water or food and simultaneous ingestion of the pathogen by many people [2].

AG is characterized by a sudden onset of symptoms - typically fever, malaise, abdominal pain, nausea, vomiting and diarrhea - but severity may vary widely. In industrialized countries, self-limiting diarrhea is the most common manifestation of AG. Here, symptoms subside within a few days. However, diarrhea may provoke severe dehydration and become life-threatening in risk groups like children, old people and those suffering from comorbidities. And although morbidity is high, mortality is still rather low in these geographical regions. In contrast, AG is one of the leading causes of death in developing countries [3]. Highest mortality rates are encountered in pediatric patients. They result from the inability to compensate for severe loss of fluids and dehydration.

In case of infectious AG, pathogens are excreted with stools and may take a number of different routes towards new hosts. Direct contact and fecal-oral transmission is one of the main forms of spread of disease and particularly occurs among children in all parts of the world. Ingestion of contaminated water or food is the other way of contracting AG and does not require direct contact to an infected person. This may largely be prevented by application of appropriate hygienic measures in the food industry and, on a personal level, by avoiding consumption of unboiled water or food of unknown quality. The incubation period usually lasts a few days.

Patient Information

Acute gastroenteritis (AG) is the medical term for what is commonly called the "stomach but". This disease is characterized by sudden onset of symptoms that indicate an inflammation of stomach and intestines.

Although AG may be diagnosed in patients of any age, most patients are young children.

Causes

Most cases of AG are caused by viruses. Distinct species have been associated with this condition and the most frequently detected strains are rotavirus, norovirus, adenovirus and astrovirus. Bacteria, particularly those pertaining to the family of Enterobacteriaceae, and parasites may also cause infectious AG. All these pathogens may be transmitted via fecal-oral transmission or by consumption of contaminated water and food.

Less frequently, AG is triggered by conscious or unconscious ingestion of toxins.

Symptoms

After a short prodromal phase of mild fever, nausea and vomiting, diarrhea sets in. Severity of symptoms may differ according to the overall health of the patient, the pathogenicity of the causative agent and the infectious dose. The disease is usually self-limiting after a few days.

Children, old people, immunodeficient individuals and those suffering from other diseases are at higher risks of dehydration while being affected by AG. Severe dehydration may lead to death.

Diagnosis

Diagnosis of AG is based on the patient's medical history and clinical examination. Additional diagnostic measures are rarely required but may be carried out in more severe cases to assess water and electrolyte imbalances. Also, if diarrhea persists for more than four days, stool samples may be obtained for further analysis as to the cause of the disease.

Treatment

In most cases, no specific treatment is necessary.

It is of utmost importance that AG patients remain hydrated. Oral rehydration therapy is required in mild cases of dehydration while intravenous administration of saline solutions and possibly electrolytes is necessary to treat more severely dehydrated patients.

Antiemetics and antidiarrheal are not routinely administered. This particularly applies to pediatric patients.

References

Article

  1. Wilhelmi I, Roman E, Sanchez-Fauquier A. Viruses causing gastroenteritis. Clin Microbiol Infect. 2003; 9(4):247-262.
  2. Mellou K, Sideroglou T, Potamiti-Komi M, et al. Epidemiological investigation of two parallel gastroenteritis outbreaks in school settings. BMC Public Health. 2013; 13:241.
  3. Ramani S, Kang G. Viruses causing childhood diarrhoea in the developing world. Curr Opin Infect Dis. 2009; 22(5):477-482.
  4. Chhabra P, Payne DC, Szilagyi PG, et al. Etiology of viral gastroenteritis in children
  5. Shoja Z, Jalilvand S, Mollaei-Kandelous Y, Validi M. Epidemiology of viral gastroenteritis in Iran. Pediatr Infect Dis J. 2014; 33(2):218-220.
  6. Amador JJ, Vicari A, Turcios-Ruiz RM, et al. Outbreak of rotavirus gastroenteritis with high mortality, Nicaragua, 2005. Rev Panam Salud Publica. 2008; 23(4):277-284.
  7. Bayard V, DeAntonio R, Contreras R, et al. Impact of rotavirus vaccination on childhood gastroenteritis-related mortality and hospital discharges in Panama. Int J Infect Dis. 2012; 16(2):e94-98.
  8. Lorrot M, Vasseur M. How do the rotavirus NSP4 and bacterial enterotoxins lead differently to diarrhea? Virol J. 2007; 4:31.
  9. Chemaly RF, Yen-Lieberman B, Schindler SA, Goldfarb J, Hall GS, Procop GW. Rotaviral and bacterial gastroenteritis in children during winter: an evaluation of physician ordering patterns. J Clin Virol. 2003; 28(1):44-50.
  10. Vandenplas Y, Salvatore S, Vieira M, Devreker T, Hauser B. Probiotics in infectious diarrhoea in children: are they indicated? Eur J Pediatr. 2007; 166(12):1211-1218.

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Last updated: 2018-06-22 01:38