Question 1 of 10

    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.

    Acute Gastroenteritis results from this process: infectious.

    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.

    Entire body system
    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]
    Fever
    • […] rice, vegetables, dried fruits, meat) Yes C. perfringens 8-24 hrs Nausea, minimal vomiting, watery diarrhea Abd cramps Previously cooked or reheated meats and poultry Yes V. cholerae 11-72 hrs Explosive rice-water diarrhea Vomiting, abdominal cramps Fever[wikem.org]
    • S typhi causes enteric fever.[emedicine.medscape.com]
    • A fever is usually present.[healthhype.com]
    • Definition Acute gastroenteritis is generally defined as a decrease in the consistency of stools (loose or liquid) and/or an increase in the frequency of evacuations (typically 3 in 24 h), with or without fever or vomiting.[link.springer.com]
    • Antimotility drugs should be avoided if there is blood and/or mucus in the stools, or high fever.[patient.info]
    Malaise
    • 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.[emedicine.medscape.com]
    • Malaise, myalgias, and prostration may occur.[merckmanuals.com]
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  • neurologic
    Headache
    • You might also have stomach pain , cramping, fever, nausea, and a headache .[webmd.com]
    • Symptoms of gastroenteritis include diarrhea , abdominal pain, vomiting, headache, fever and chills.[fpnotebook.com]
    • Mild fever (about 100 F or 37.77 C), chills , headache , and muscle aches along with feeling tired may occur in some individuals with viral gastroenteritis.[medicinenet.com]
    • Symptoms of gastroenteritis include diarrhea, abdominal pain, vomiting, headache, fever and chills.[icd10data.com]
    • Patients may also have fever, headache, and myalgias.[merckmanuals.com]
    Lethargy
    • […] 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, lethargy[emedicine.medscape.com]
    • These include lethargy or severe sleepiness, no urination or wet diapers over 8 hours, severe or worsening abdominal pain, or any blood in the stool.[acep.org]
    • […] 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]
    • 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.[pedemmorsels.com]
    • Signs of hemodynamic instability, including profound lethargy, markedly delayed capillary refill and tachycardia with severe orthostatic blood pressure changes, represent a medical emergency and require immediate and aggressive intravenous therapy to[aafp.org]
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  • gastrointestinal
    Abdominal Cramps
    • cramps, myalgia Fecal-oral Contaminated food or water No Staph 1-6 hrs Nausea, severe vomiting, diarrhea, Mild abdominal cramping Previously cooked foods (mayonaise, ham, salads) Yes B. cereus 1-6 hrs Abrupt onset of nausea, vomiting, mild diarrhea Previously[wikem.org]
    • We’ve all experienced the abdominal cramps and the urge to get to a toilet – quickly![theconversation.com]
    • 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).[fpnotebook.com]
    • 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]
    Abdominal Distension
    • Abdominal distension had a positive correlation with Hyponatremia and Hypokalemia.[omicsonline.org]
    Abdominal Pain
    • In children, abdominal pain may be the only presenting feature in pneumonia.[contemporaryclinic.pharmacytimes.com]
    • pain Differential Diagnosis Diffuse Abdominal pain Abdominal aortic aneurysm Aortocaval fistula Acute gastroenteritis Aortoenteric fisulta Appendicitis (early) Bowel obstruction Large bowel obstruction Ogilvie's syndrome Small bowel obstruction Bowel[wikem.org]
    • This results in the typical symptoms of nausea, vomiting, diarrhea and abdominal pain.[healthhype.com]
    • pain [ 1-4 ].[uptodate.com]
    • Diarrhea, vomiting and abdominal pain are the main symptoms.[yogurtinnutrition.com]
    Acute Abdomen
    Diarrhea
    • Code Applicable To Diarrhea NOS Type 1 Excludes functional diarrhea ( K59.1 ) neonatal diarrhea ( P78.3 ) psychogenic diarrhea ( F45.8 ) R19.7 ) functional diarrhea ( ICD-10-CM Diagnosis Code K59.1 Functional diarrhea 2016 2017 2018 Billable/Specific[icd10data.com]
    • Diarrhea that recurs after seven days without diarrhea is "recurrent."[uptodate.com]
    • Viral (norovirus, adenovirus, rotavirus) 11-72 hrs Nausea, vomiting, watery diarrhea Mild abdominal cramps, myalgia Fecal-oral Contaminated food or water No Staph 1-6 hrs Nausea, severe vomiting, diarrhea, Mild abdominal cramping Previously cooked foods[wikem.org]
    Dyspepsia
    Epigastric Pain
    Flatulence
    • Less frequently reported signs and symptoms included flatulence, fever, dehydration and headache.[link.springer.com]
    Hyperactive Bowel Sounds
    • Hyperactive bowel sounds are present on auscultation even without diarrhea (an important differential feature from paralytic ileus, in which bowel sounds are absent or decreased).[merckmanuals.com]
    Loss of Appetite
    • While it’s unclear how H. pylori spreads, it can result in stomach inflammation, loss of appetite, nausea, bloating, and abdominal pain.[healthline.com]
    • In addition to the classic symptoms above, food poisoning and gastroenteritis can also bring about: Loss of appetite Fever - high temperature and 'chills' The type of gastrointestinal symptoms are a clue to the type of infection - viral infection generally[medicalnewstoday.com]
    • Loss of appetite was reported for 63.5% (95% CI 58.4–68.4), abdominal pain or cramps for 61.1% (95% CI 57.0–65.1), nausea for 60.4% (95% CI 56.6–64.1) and vomiting for 57.5% (95% CI 54.3–60.7) of patients.[link.springer.com]
    Nausea
    • […] onset of nausea, vomiting, mild diarrhea Previously cooked foods (rice, vegetables, dried fruits, meat) Yes C. perfringens 8-24 hrs Nausea, minimal vomiting, watery diarrhea Abd cramps Previously cooked or reheated meats and poultry Yes V. cholerae 11[wikem.org]
    • Gastroenteritis symptoms may include diarrhea in addition to nausea or vomiting.[healthline.com]
    • This results in the typical symptoms of nausea, vomiting, diarrhea and abdominal pain.[healthhype.com]
    • If you have diarrhea and are unable to drink or keep down fluids because of nausea or vomiting, you may need fluids through a vein, which is done in the hospital.[medicardphils.com]
    • Foods to try include: Cereals, bread, potatoes, lean meats Plain yogurt, bananas, fresh apples Vegetables If you have diarrhea and are unable to drink or keep down fluids because of nausea or vomiting, you may need fluids through a vein (IV).[medlineplus.gov]
    Severe Abdominal Pain
    • The symptoms of acute gastroenteritis are very intense with extreme nausea, violent vomiting and explosive diarrhea accompanied by severe abdominal pain being a typical presentation of infectious gastroenteritis.[healthhype.com]
    • Only 10% of gastroenteritis will have bloody diarrhea, so this finding should prompt further work-up. 1 In addition, any child with severe abdominal pain (or any pain in the right lower quadrant) or altered mental status deserves further work-up.[acep.org]
    Upper Abdominal Pain
    Vomiting
    • Vomiting caused by acute gastroenteritis is very common in children and adolescents.[cochrane.org]
    • Viral (norovirus, adenovirus, rotavirus) 11-72 hrs Nausea, vomiting, watery diarrhea Mild abdominal cramps, myalgia Fecal-oral Contaminated food or water No Staph 1-6 hrs Nausea, severe vomiting, diarrhea, Mild abdominal cramping Previously cooked foods[wikem.org]
    • In addition, "not all that vomits is gastroenteritis."[acep.org]
    • Do not try to force down large amounts of fluid at one time, which can cause vomiting.[medicardphils.com]
    • Norovirus can cause acute onset of vomiting, especially in children.[medicalnewstoday.com]
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  • musculoskeletal
    Myalgia
    • Viral AGE usually lasts Do not diagnosis isolated vomiting as AGE Causes Noninvasive AGE Species Onset Symptoms Transmisison Preformed Toxin Viral (norovirus, adenovirus, rotavirus) 11-72 hrs Nausea, vomiting, watery diarrhea Mild abdominal cramps, myalgia[wikem.org]
    • […] 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]
    • Malaise, myalgias, and prostration may occur.[merckmanuals.com]
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  • cardiovascular
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  • 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.

    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.

    Complications

    Colitis
    • ICD-10-CM Codes › K00-K95 Diseases of the digestive system › K50-K52 Noninfective enteritis and colitis › K52- Other and unspecified noninfective gastroenteritis and colitis › Noninfective gastroenteritis and colitis, unspecified 2016 2017 2018 Billable[icd10data.com]
    • It produces Shiga toxin, which causes bloody diarrhea (hemorrhagic colitis).[merckmanuals.com]
    • PPI therapy has also been suggested to be an independent risk factor for the development and recurrence of C difficile colitis [9] as well as increases the risk Campylobacter gastroenteritis. [ 10 ] Epidemiology Occurrence in the United States Bacterial[emedicine.medscape.com]
    • Toxic megacolon caused by fulminant colitis is rare.[patient.info]
    • Crohn’s disease, ulcerative colitis, coeliac disease), medication intake (e.g. antibiotics) or food intolerance.[link.springer.com]
    Dehydration
    • Degree of dehydration Dehydration is a common clinical feature of AGE in children. 83% (166) of the children had moderate degree of dehydration and 34 children had severe dehydration.[omicsonline.org]
    • , medicine cup Discharge Observation of ORT in ED as clinically indicated Moderate Dehydration (4-5% Estimated Deficit) Dehydrated on PE, mild tachycardia, may have small-moderate ketonuria if POC Urine done Dehydrated on PE, tachycardia, moderate-large[chop.edu]
    • Clinical signs of dehydration in children.[aafp.org]
    Hypernatremia
    • Results: AGE constituted 18% of the total admissions. 22% had Hyponatremia, 71.5% had Isonatremia and 6.5% had Hypernatremia.[omicsonline.org]
    • Summary of results in patients with hypernatremia at baseline.[frontiersin.org]
    • […] therapy is used. 17 View/Print Table TABLE 3 Signs of Hypernatremia and Hypokalemia in Dehydration Hypernatremia Cutaneous signs Warm, “doughy” texture Possibly decreased skinfold tenting in severe dehydration, thereby giving appearance of lower level[aafp.org]
    Shock
    • Akech et al. , 2010 7 Low Randomised 1:1 in strata i.e. severe dehydration/shock and presumed septic shock.[wellcomeopenresearch.org]
    • In severe cases hypovolaemic shock and even death can occur.[patient.info]
    • . – Severely dehydrated or shocked usually need intravenous fluids and hospital admission – Drugs are usually unnecessary and may do harm SYMPTOMS Most often appear within 4 to 48 hours after contact with the virus.[medicardphils.com]
    • Intravenous fluid management should be reserved for severe dehydration, shock, and patients who cannot tolerate oral intake.[acep.org]
    • […] was “dehydrated” and got an IV) CON: Requires more parental/caregiver involvement (we American’s are generally lazy) CON: Can’t be used in the setting of an ileus CON: CANNOT rapidly rehydrate someone – not useful in Sever Dehydration (AKA compensated SHOCK[pedemmorsels.com]
    Ulcerative Colitis
    • Appearance of the colonic mucosa may help diagnose amebic dysentery, shigellosis, and E. coli O157:H7 infection, although ulcerative colitis may cause similar lesions.[merckmanuals.com]
    • Crohn’s disease, ulcerative colitis, coeliac disease), medication intake (e.g. antibiotics) or food intolerance.[link.springer.com]
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  • 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.

    Self-assessment

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    References

    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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