Acute

gastroenteritis
Haitham Al-Dhmour, MD
 Acute gastroenteritis
Diarrhea: Increase in stool frequency, fluidity
(water content), or volume, in comparison
with the previously established “normal”
pattern

• Acute diarrhea Less than 2 weeks

• With or without vomiting, fever or abdominal
pain
 Epidemiology
• Second most common cause of death in pediatric
• 1.34 million deaths annually, or roughly 15% of all child
deaths, with more than 98% of these deaths occurring
in the developing world.

• 1.7 billion case annually in <5 years

• Leading to 124 million clinic visits, 9 million
hospitalizations (10% of admissions)
• 4 episode/child – year

• Rota virus is the most common cause worldwide

 Risk factors
• AGE is associated with poverty and poor hygiene
• Contamination of water and food supply (cholera)
• Young age
• Malnutrition: Zinc and Vitamin A deficiency
• Immunodeficiency

Transmission: fecal-oral or direct contact

 Mechanisms of Diarrhea

Osmotic

Secretory

Exudative

Motility disorders
 Mechanisms of Diarrhea
Osmotic
Pathophysiology:
Digestive enzyme deficiencies
Ingestion of unabsorbable solute
Ex.:
Viral infection
Lactase deficiency
Sorbitol /MgSO4
Features:
Stop with fasting
No stool WBCs
Stool PH low, positive for reducing substances
Secretory diarrhea
• Stimulation of active chloride secretion from
the crypt cells into the lumen

• Mediated by preformed bacterial toxins, as

cholera toxin, [Link], Shigella, Salmonella, and
Campylobacter jejuni
 Mechanisms of Diarrhea
Exudative Diarrhea:

Pathophysiology:
Inflammation
Decreased colonic reabsorption
Increased motility

Ex.:
Bacterial enteritis (shigella), Parasitic (Amebic)

Features:
Blood, mucus and WBCs in stool
 Mechanisms of Diarrhea
Reduction in anatomic surface area of absorption
Short bowel syndrome
celiac disease
partial villous atrophy secondary to
postgastroenteritis malabsorption syndrome,
tropical sprue, microvillous inclusion disease
 Causes
• Viral
• Bacterial
• Parasitic
 Viral
Accounts for 70 – 80% of cases of GE
• Rota
• Norovirus
• Other viral agents (astroviruses, adenoviruses,
parvoviruses)
 Rota
• Double stranded RNA virus, 11 segemts, Reoviridae family

• Most common cause worldwide, responsible for 37% of

diarrhea-related deaths in children younger than 5 years.
• G1, G2, G3, G4 s are responsible for 90% of isolates.

• IP: 1-3 d, duration: 4-8 days

• Watery diarrhea, vomitting, fever
• Dx: Stool immunoassay
• Tx: supportive
• Prevention: Rota vaccine
 Calicivirus
• RNA virus
• Including norovirses and sapoviruses
• The leading cause of gastroenteritis in USA
• Vomiting is more prominent in children, diarrhea
in adult
• Routine RT-PCR and EM on fresh unpreserved
stool samples
• Dx: Routine RT-PCR and EM on fresh unpreserved
stool samples
• Tx: supportive
 Bacterial
Accounts for 10-20% of cases of GE
• Campylobacter jejuni
• Salmonella
• Shigella
• [Link]
• Others: Bacillus cerus,staph aureus,
clostridium perferngis, Listeria, cholera,
yersenia
 Campylobacter jejuni

• IP 2-6 days

• Reservoir: Domestic animals and poultry

• Transmission: feco-oral od direct contact with infected animal or
their products
• From mild watery diarrhea to bloody diarrhea, abdominal cramps,
fever,
• May mimic appendicitis
• Duration: 2-10 days
• Dx: routine stool culture
• Tx: supportive, in severe cases erythromycin or azithromycin
• Complications: GBS, Reactive artheritis
 Salmonella enterica
• Transmission is by ingestion of contaminated
animal food products (eggs, chicken)
• IP 1-3 days, Duration: 4-7 days
• Symptpms range from self-limited waterey
diarrhea to less commonly bloody diarrhea
• Antibiotic is not indicated
• Antibiotic used if: Age<3 months, immune
deficiency, ill looking, sickle cell anemia

• Ceftriaxone, Ampicillin, gentamycin, TMP-SMS,

 Shigella
• IP 1-2 days, duration 4-7 days
• Invades colon, causing inflammatory response
• Shiga toxin responsible for extra intestinal
manifestation
• Bloody diarrhea (initially watery), fever,
abdominal cramps
• Dx: Stool culture
• Antibiotics: ceftriaxone, Ampicillin, TMP-SMZ.
• Complications: seizures and neurological, HUS,
Rectal prolapse, sepsis
 [Link]
• EHEC
Including O157H7, (STEC)
IP 1-8 days, Duration 5-10 days
Bloody diarrhea
Dx: stool culture
Tx: supportive
Complications: HUS
 [Link]
• ETEC (Traveler diarrhea)
IP 1-3 days, Duration 3-7 days
Watery diarrhea
Dx: stool culture
Tx: supportive, if needed TMP-SMX
 Vibrio Cholera
• IP 1-3 days
• Watery diarrhea, abdominal cramps, fever
• Duration: 3-7 days
• Dx: stool culture
• Tx: oral and IVF, Doxacycline, tetracycline and
TMP-SMZ
• Complications: Severe life threatening
dehydration
 Parasitic
• Entamoeba histolytica
• Cryptosporidium
• Giardia lamblia
 Entamoeba histolytica
• IP: 2-3 days to 1-4 wk
• Diarrhea (often bloody and mucus), lower
abdominal pain
• Examination of stool for cysts and trophozoite;
may need at least 3 samples + fecal leukocytes
• [Link] stool antigen
• Complication: Liver and Lung abscesses
• Tx: Metronidazole and a luminal agent
(iodoquinol or diloxanide )
 Cryptosporidium
• IP: 2-10 days
• Watery diarrhea
• Severe in immunodeficiency
• Supportive care, If severe consider
paromomycin for 7 days For children aged 1-
11 yr, consider nitazoxanide for 3 days
 History
• Diarrhea: Duration, frequency, volume, blood, mucus,
• Vomiting: Duration, content, presence of blood, bile stained,
projectile,
• Abdominal pain
• Urination: either increased or decreased (wet diaper),
concentrated, color, dysuria
• Fever
• Rash, rhinorrhea, cough, conjunctivitis, sore throat
• Activity, feeding
• Antibiotic use
• Contact, travel history
• Seizure
• Degree of dehydration
 Physical exam
• General: ill appearance, level of alertness,
lethargy, irritability.
• Growth parameters
• HEENT
• Chest exam
• Abdominal exam: tenderness, guarding,
organomegaly
• Back: costophrenic angle tenderness
• Skin: rash, jaundice, a doughy feel to the skin may
indicate hypernatremia
 Symptom or Sign Mild Dehydration Moderate Severe Dehydration
Dehydration
Mental status Alert Restless, irritable Lethargic,
unconscious
Thirst Drinks normally Drinks eagerly Drinks poorly
Heart rate Normal Normal to increased Tachycardia

Quality of pulses Normal Normal to Weak or unpalpable

decreased
Breathing Normal Normal or fast Deep
Eyes Normal Slightly sunken Deeply sunken
Tears Present Decreased Absent
Mouth and tongue Moist Dry Parched
Skin fold Instant recoil Recoil <2 seconds Recoil >2 seconds
Capillary refill Normal Prolonged Prolonged or
minimal
Extremities Warm Cool Cold, mottled,
cyanotic
Urine output Normal Decreased Minimal
 Lab testing
• Indicated for children with moderate/ severe
dehydration, patients treated wit IVF, or
patients with history and physical exam are
inconsistent with GE
 Lab testing
Basic electrolytes, glucose
KFT
ABG
CBC, Blood culture
Urine analysis and culture
 Routine stool exam
• Look for blood, mucus

• Fecal leukocytes: bacterial invasion of colonic

mucosa

• Cyst and trophozoites: G. lamblia and E.

histolytica
 Stool culture
• Bloody diarrhea (dysentery)
• Stool microscopy indicates fecal leukocytes
• Immunocompromised
 Other stool testing
Stool immunoassay for Rota and Adenovirus

Stool antigen for Amebiasis and Giardia if

suspected

C difficile toxins: if child older than 12 months

with a recent history of antibiotic
 Management
• ORS is recommend as the treatment of choice for
children with mild-to-moderate GE.

• In those presenting with severe dehydration, IV

access should be obtained and followed by an
immediate 20-mL/kg bolus of normal saline.

• Antibiotics are generally not indicated, because

most cases of GE are viral
 Indications of admission
• Severe dehydration
• Intractable vomiting or diarrhea
• Decreased oral intake or hypoactivity
• Uncertain diagnosis or if sepsis is suspected
• Younger age
• Electrolyte disturbances, or any other
complications
• Failure of ORS treatment
 ORS
• Concept: Na-glucose cotransporter

CI:
• Shock
• Ileus, intussusception
• Carbohydrate intolerance (rare)
• Severe emesis
• High stool output (>10 mL/kg/hr)
ORS
 ORS
• Minimal dehydration: 2-10 ml/kg ORS for each
diarrhea and vomiting

• Moderate dehydration: 50-100 ml/kg over 2-4

hours then continue as above

• Severe dehydration: IVF

Types of ORS
 Don’t
• Home remedies including soda, fruit juices,
and tea are not suitable for rehydration or
maintenance therapy because they have
inappropriately high osmolalities and low
sodium concentrations.

• Don’t use antidiarrheal medication

 Others
• Continue feeding: age-appropriate diet
• Probiotic
• Zinc supplements
• Antiemetics
• Antibiotics
Continue feeding: age-appropriate diet
• The mother should be encouraged to
breastfeed more frequently than usual and for
longer at each feed.

• If the child is not exclusively breastfed, then

oral intake (including clean water, soup, rice
water, or yogurt drink) should be emcouraged
 Probiotics
• They are live microorganisms in fermented foods that
potentially benefit the host by promoting a balance in the
intestinal flora.

• Possible mechanisms of action include synthesis of

antimicrobial substances, competition with pathogens for
nutrients, modification of toxins.

• Lactobacillus rhamnosus GG, Saccharomyces boulardii

• probiotics decreased the duration of diarrhea when

compared with ORS therapy alone.
 Zinc supplements

• Recommended in patients known to have zinc

deficiency or in areas where zinc deficiency
and moderate malnutrition is prevalent.

• A little data exist to support this

recommendation for children in developed
countries
 Antibiotic indication
• In cases of GE caused by Shigella, [Link],
Giardia, Cholera
• Antibiotic used in salmonella if: Age<3
months, immune deficiency, ill looking, sickle
cell anemia

• Oral metronidazole for C. difficile, oral

vancomycin for resistant cases
 Antiemetics
• Ondansetron reduced vomiting and the need
for intravenous (IV) rehydration and hospital
admission

• Other medications as metoclopramide is not

recommended routinely, due to their possible
side effects
 Prevention: Rota vaccine
• Oral live attenuated vaccine
• Rotarix ( 2 doses), RotaTeq (3 doses)
• Both active in preventing severe gastroenteritis, and both have
demonstrated reductions in diarrhea-related hospitalizations.

• Contraindications:
1. Hypersensitivity
2. Infants with severe combined immunodeficiency disease (SCID) or
immunosuppression
3. Infants aged <6 weeks and >32 weeks
4. History of uncorrected congenital malformation of the GI tract
that would predispose infant to intussusception
5. Infants with a history of intussusception