GASTROENTERITIS
Definition:
Inflammation of the lining of the stomach and intestines,
predominantly manifested by upper GI tract symptoms
(anorexia, nausea, vomiting), diarrhea, and abdominal
discomfort.
Etiology and Epidemiology
Gastroenteritis may be of nonspecific, uncertain, or
unknown etiology or of bacterial, viral, parasitic, or toxic
etiology
Campylobacter infection is the most common bacterial
cause of diarrheal illness in the USA
Person-to-person transmission is especially common with
gastroenteritis caused by Shigella, Escherichia coli,
Giardia, Norwalk virus, and rotavirus.
Pathophysiology
Certain bacterial species elaborate enterotoxins, which
impair intestinal absorption and can provoke secretion of
electrolytes and water e.g. the enterotoxin of Vibrio
cholerae and E. coli enterotoxin
Some Shigella, Salmonella, and E. coli species penetrate
the mucosa of the small intestine or colon and produce
microscopic ulceration, bleeding, exudation of protein-rich
fluid, and secretion of electrolytes and water.
Gastroenteritis may follow ingestion of chemical toxins
contained in plants (e.g. mushrooms, potatoes, garden
flora), seafood (fish, clams, mussels), or contaminated
food.
Symptoms and Signs
Onset is often sudden and sometimes dramatic, with
anorexia, nausea, vomiting, borborygmi, abdominal
cramps, and diarrhea (with or without blood and mucus).
Associated malaise, muscular aches, and prostration may
occur
If vomiting causes excessive fluid loss, metabolic alkalosis
with hypochloremia occurs; if diarrhea is more prominent,
acidosis is more likely
Excessive vomiting or diarrhea may cause hypokalemia
Severe dehydration and acid-base imbalance can produce
headache and muscular and nervous irritability.
Persistent vomiting and diarrhea may result in severe
dehydration and shock, with vascular collapse and oliguric
renal failure.
Diagnosis
A history of ingestion of potentially contaminated food,
untreated surface water, or a known GI irritant; recent
travel; and contact with similarly ill persons may be
important.
Stool examination for fecal WBCs and culture are
indicated
Diagnosis may also require culture of vomitus, food, and
blood.
Eosinophilia may indicate parasitic infection
General Principles of Treatment
Supportive treatment is most important.
Bed rest with convenient access to a toilet or bedpan is
desirable
When nausea or vomiting is mild or has ended, oral
glucose-electrolyte solutions, strained broth, or salted
bouillon may prevent dehydration or treat mild
dehydration.
Even if vomiting, the patient should take frequent but
small sips of such fluids because the vomiting may resolve
with volume replacement
If vomiting is protracted or if severe dehydration is
prominent, IV replacement of appropriate electrolytes is
necessary
If vomiting is severe and a surgical condition has been
excluded, an antiemetic (e.g. dimenhydrinate 50 mg IM q
4 h, chlorpromazine >= 25 to 100 mg/day IM) or
prochlorperazine 10 mg po tid (suppository 25 mg bid)
may be beneficial.
Meperidine 50 mg IM q 3 or 4 h may be given for severe
abdominal cramps.
When the patient can tolerate fluids without vomiting,
bland food (cereal, gelatin, bananas, and toast) may be
added to the diet gradually.
If after 12 to 24 h, moderate diarrhea persists without
severe systemic symptoms or blood in the stool,
diphenoxylate 2.5 to 5 mg tid or qid in tablet or liquid
form, loperamide 2 mg po qid, or bismuth subsalicylate
524 mg (two tablets or 30 mL) po six to eight times/day
may be given.
Antibiotics appropriate to sensitivity testing should be
given when systemic infection is evident.
However, antibiotics do not help patients with simple
gastroenteritis, nor do they help asymptomatic carriers to
"clear" rapidly.
