ACUTE GASTROENTERITIS I.

Definition a medical condition characterized by inflammation ("-itis") of the gastrointestinal tract that involves both the stomach ("gastro"-) and the small intestine ("entero"-), resulting in some combination of diarrhea, vomiting, and abdominal pain and cramping also been referred to as gastro, stomach bug, and stomach virus although unrelated to influenza, it has also been called stomach flu and gastric flu II. Incidence Statistics in the United States: accounts for > 1.5 million outpatient visits/year accounts for 200,000 hospitalizations/year accounts for 300 deaths/year Statistics Worldwide: diarrheal disease is leading cause of pediatric morbidity and mortality 1.5 (35) billion episodes annually in children < 5yo 1.52.5million deaths annually in children <5yo III. Risk Factors Drinking well water Improperly stored food Eating undercooked food, especially seafood Travel to high risk areas Any condition that causes a weakening of the immune system such as: o Diabetes o Organ transplant o Chemotherapy: The administration of medicines that kill cancer cells. o AIDS Living around poor sanitation* Living in close quarters: o Army barracks o Dormitories o Nursing homes IV. Manifestations Common gastroenteritis symptoms Low grade fever to 100 F (37.7 C) Nausea with or without vomiting Mild-to-moderate diarrhea Crampy painful abdominal bloating (The cramps may come in cycles, increasing in severity until a loose bowel movement occurs and the pain resolves somewhat.) More serious symptoms of gastroenteritis Blood in vomit or stool Vomiting more than 48 hours Fever higher than 101 F (40 C) Swollen abdomen or abdominal pain Dehydration - weakness, lightheadedness, decreased urination, dry skin, dry mouth and lack of sweat and tears are characteristic signs and symptoms. V. COMPLICATIONS 1. Dehydration and electrolyte disturbance These occur if losses of fluid and electrolytes in the stool are not replaced. Dehydration and electrolyte imbalance from severe diarrheal disease can progress to acidosis and circulatory failure, with hypoperfusion of vital organs, renal failure, and eventual death. Water and electrolyte depletion is variable, depending on the duration of symptoms and the causative pathogen. 2. Hemolytic Uremic Syndrome (HUS) HUS is rare, but is one of the more serious complications of acute infectious gastroenteritis. HUS is characterized by acute renal failure, hemolytic anaemia, and thrombocytopenia. It occurs mostly in young children and the elderly. 3. Reactive complications These include arthritis, carditis, urticaria, erythema nodosum, conjunctivitis, and Reiter's syndrome (the combination of urethritis, arthritis, and uveitis). They are associated with Salmonella, Campylobacter, Yersinia enterocolitica and Shigella infections. There are usually no reactive complications associated with viral or parasitic gastroenteritis. 4. Systemic invasion by Salmonella

meninges, or the gallbladder. 5. Toxic megacolon This is the result of fulminant colitis, and is rare. 6. Guillain-Barr syndrome Guillain-Barr syndrome is associated with a number of viruses as well as with several conditions not due to infection. Rarely, it is associated with Campylobacter. 7. Malnutrition Malnutrition can follow some infections, and is a common risk in developing countries. 8. Intractable diarrhoea Rarely, diarrhoea can be intractable and require long-term parenteral nutrition or even small-intestinal transplantation. 9. Irritable bowel syndrome A meta-analysis reported that the risk of developing irritable bowel syndrome was increased sevenfold after infectious gastroenteritis. 10. Acquired secondary lactose intolerance Secondary or acquired lactose intolerance can occur when the intestine is damaged by gastrointestinal illness, including gastroenteritis. 11. Reduced absorption of drugs Gastroenteritis can reduce the absorption of drugs taken for other conditions for example drugs for epilepsy, diabetes, contraception, malaria prophylaxis, and anticoagulation VI. Medical Management A. Diagnostic Tests: 1. Electrolyte testing- when a large amount of sodium, potassium, chloride and bicarbonate in diarrheal stools warranting electrolyte testing in patients who require IV fluids 2. If diarrhea is bloody, a hemoglobin/hematocrit is reasonable. 3. Inflammatory markers including ESR (electrolyte sedimentation rate) and CRP(C- Reactive protein) may be helpful if a family history of IBD (inflammatory bowel disease) is present. 4. Renal function tests and a platelet level are essential if HUS (Hemolytic uremic syndrome) is suspected. Renal function is also important in severe dehydration to assess for acute renal insufficiency or failure. 5. Optional stool studies are case specific depending on the suspected etiology and include stool culture, Giardia, Rotazyme, ova and parasites, Cryptosporidium, C.difficile, V. cholera, hemoccult for blood, and fecal smear for leukocytes 6. Abdominal radiographs - indicated in cases of suspected ileus, obstruction, or in processes other than gastroenteritis such as intussusception. Any child with hypoactive or absent bowel sounds, high pitched tinkling bowel sounds, or with peritoneal signs on exam should have plain films done to evaluate the bowel gas pattern. The appearance of air fluid levels on an upright film or a paucity of distal bowel gas is indicative of obstruction. The presence of free air underneath the diaphragm indicates bowel perforation which sometimes occurs in cases of advanced peritonitis, colitis, or appendicitis. 7. CT scan and ultrasound are not routinely used in evaluation of acute gastroenteritis unless another more serious process is suspected. B. Medications 1. Antidiarrheal agents and antiemetics, except for viral or bacterial gastroenteritis, in which impairment of GI motility is avoided 2. Anti-infective agents for bacterial gastroenteritis with systemic involvement (not generally recommended for simple gastroenteritis, because these drugs may prolong the carrier state and contribute to the emergence of drug-resistant organisms). Medications for nausea and vomiting: o Metoclopramide (Reglan) o Ondansetron (Zofran) o Prochlorperazine (Compazine, Compro) Medications to control diarrhea: o Loperamide (Imodium) o Diphenoxylate and Atropine (Lomotil) Antibiotics for bacterial gastroenteritis o Ciprofloxacin (Cipro) o Cefixime (Suprax) o Sulfamethoxazole and Trimethoprim (Bactrim, Septra, TMP-SMX) o Rifaximin (Xifaxan, RedActiv, Flonorm) o Erythromycin (E.E.S., E-Mycin, Eryc, Ery-Tab) C. Other Treatment 1. Fluid Management

This can result in endovascular infections and localized infections in bones, joints,

a. Oral rehydration therapy for older children and adults: How to prepare ORS? Content One Glass One Liter Salt One pinch One teaspoon Sugar Two teaspoon Eight teaspoon Water One glass One liter Rehydration protocols: Mild: 50cc/kg of ORS plus replacement over 4 hours** begin with 5cc aliquots q 12min with volumes increasing as tolerated Moderate: 100cc/kg of ORS plus replacement over 4 hours As for mild, but should be in supervised setting (ER, office) Severe: 20cc/kg of isotonic IV fluids over one hour Repeat as necessary Continue replacement for stools ** Ongoing losses can be matched at approximately 10cc/kg for each stool Drink clear liquids only, such as water, sports drinks (best), fruit juice and dilute tea. Drink small quantities of fluids frequently, such as 2 tablespoons of fluid every 5 minutes. The absence of food allows the intestines to rest. May be able to advance to full liquid diet once symptoms improve Effective to treat mild to moderate dehydration Avoid milk and dairy products VII. Nursing Interventions 1. Assessment of pain location and intensity. 2. Assessment of bowel sounds. 3. Observe for vomiting / diarrhea. 4. Measure I/O. 5. Administer medications as ordered. 6. Manage IVs if ordered. 7. Teach why it helps to rest the gut with NPO or restricted intake. 8. Teach why re-introduction of liquids is first, with solid foods last. 9. Assess and teach contributing factors and ways to prevent a re-occurrence (unless caused by viral or bacterial infection).

PATHOPHYSIOLOGY OF ACUTE GASTROENTERITIS Predisposing Factors Extreme ages Immune-compromised Immune deficiency disease Precipitating Factors Poor sanitation Contaminated food and water Poor food preparation Ingestion of contaminated food/water Pathogen enters GI tract Interrupted normal intestinal flora activity Pathogen release endotoxins

Stimulation of mucosal lining of intestine Increased secretion of

Pathogen release endotoxins

Invasion and destruction of mucosal lining of intestine Irritation of intestinal mucosa