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Official reprint from UpToDate

www.uptodate.com 2017 UpToDate

Acute viral gastroenteritis in children in resource-rich countries: Clinical features and diagnosis

Author: David O Matson, MD, PhD

Section Editors: Morven S Edwards, MD, George D Ferry, MD
Deputy Editor: Mary M Torchia, MD

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: May 2017. | This topic last updated: May 26, 2017.

INTRODUCTION The epidemiology, clinical features, and diagnosis of acute viral gastroenteritis in children in resource-rich countries
will be discussed here. The prevention and treatment of acute viral gastroenteritis in children in resource-rich countries, acute diarrhea in
children in resource-limited countries, and chronic diarrhea in children are discussed separately.

(See "Acute viral gastroenteritis in children in resource-rich countries: Management and prevention".)
(See "Approach to the child with acute diarrhea in resource-limited countries".)
(See "Overview of the causes of chronic diarrhea in children in resource-rich countries" and "Approach to the diagnosis of chronic
diarrhea in children in resource-rich countries" and "Persistent diarrhea in children in resource-limited countries".)

DEFINITION Acute gastroenteritis is a clinical syndrome often defined by increased stool frequency (eg, 3 loose or watery stools in 24
hours or a number of loose/watery bowel movements that exceeds the child's usual number of daily bowel movements by two or more),
with or without vomiting or [1-4]. It usually lasts less than one week and not longer than two weeks. Diarrhea that lasts >14 days is
"persistent" or "chronic." Diarrhea that recurs after seven days without diarrhea is "recurrent."

Acute viral gastroenteritis is caused by a viral pathogen. Acute gastroenteritis also may be caused by bacteria and parasites. (See
'Etiology' below.)

PATHOGENESIS The major clinical manifestations of viral gastroenteritis are caused by intestinal infection and destruction of
enterocytes, which results in transudation of fluid into the intestinal lumen and net loss of fluid and salt in the stool [5-9]. Intestinal injury
also decreases the ability to digest food, particularly complex carbohydrates, and to absorb digested food across the intestinal mucosa.
The pathogenesis of acute diarrhea is discussed detail separately. (See "Pathogenesis of acute diarrhea in children" and "Clinical
manifestations and diagnosis of rotavirus infection", section on 'Pathogenesis'.)

Factors associated with severe or prolonged clinical manifestations include [10-15]:

First infection with a particular pathogen

Malnutrition
Immune compromise
Lack of maternally acquired immunity (eg, antibody acquired transplacentally or in human milk)
Community change in serotype of the infecting strain
Large inoculum size
Strain with enhanced virulence

EPIDEMIOLOGY Acute viral gastroenteritis occurs throughout the year with a fall and winter predominance (table 1) [16-19].

Acute viral gastroenteritis can be transmitted by asymptomatic carriers as well as by symptomatic patients before the onset of symptoms
[4,20,21]. It is generally transmitted by the fecal-oral route. The possibility of airborne transmission of rotavirus and norovirus has been
suggested in some outbreaks [22-24]. Illness usually begins 12 hours to 5 days after exposure and generally lasts for three to seven days
[5,7,8].

ETIOLOGY The most common causes of acute viral gastroenteritis in children include (table 1):

Rotavirus Rotavirus gastroenteritis usually occurs in children between six months and two years of age [25,26]. It occurs in the fall
and winter in temperate climates and throughout the year in tropical climates (table 1). (See "Clinical manifestations and diagnosis of
rotavirus infection".)

Rotavirus has historically been the most common cause of medically attended viral gastroenteritis in children; however, in countries
that routinely immunize infants against rotavirus, rotavirus gastroenteritis has decreased substantially (figure 1) [27,28]. Laboratory
surveillance in the United States, covering the period from 2000 to 2014, observed a 58 to 90 percent reduction in rotavirus detections
in each of the seven postvaccine years [29]. (See "Rotavirus vaccines for infants", section on 'Efficacy/effectiveness'.)

Norovirus Norovirus gastroenteritis occurs in people of all ages. It occurs year-round, with a peak in the fall and winter [30].
Norovirus is highly contagious and the leading cause of outbreaks of gastroenteritis [21,31,32]. Older children and adolescents with
severe acute gastroenteritis, especially as part of a common source outbreak (food, water source, or fomite), are more likely to have
norovirus than other causes of acute gastroenteritis [21,33-37]. Norovirus also causes sporadic gastroenteritis, which occurs primarily
in young children [38]. (See "Norovirus".)

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Norovirus is, or is becoming, the leading cause of medically attended gastroenteritis in children in countries that immunize infants
against rotavirus gastroenteritis [27,28,30,39]. In laboratory surveillance from three counties in the United States (in New York, Ohio,
and Tennessee) during 2009 and 2010, norovirus was detected in 17 percent of fecal specimens from children (<5 years) hospitalized
with gastroenteritis, 23 percent of children seen in emergency departments, and 28 percent of children seen in other outpatient
settings [27].

Sapovirus Sapovirus gastroenteritis mainly affects infants and toddlers [31,40,41]. It occurs year-round. The clinical illness is milder
than that of rotavirus.

In laboratory surveillance from three counties in the United States during 2008 to 2009, sapovirus was isolated from 5.4 percent of
1281 children younger than five years with medically attended acute gastroenteritis [16]. It was detected throughout the year, with the
highest proportion from March through July.

Astrovirus Astrovirus occurs in people of all ages. It may cause outbreaks in closed populations [31]. Sporadic astrovirus
gastroenteritis occurs primarily in children younger than four years. Astrovirus gastroenteritis usually occurs in the winter months.

Astrovirus is less frequently isolated from hospitalized children than rotavirus and norovirus. In laboratory surveillance from three
counties in the United States during 2008-2009, astrovirus was isolated from 4.9 percent of 1281 children younger than five years with
medically attended acute gastroenteritis [16]. Astrovirus was predominantly detected from November through May.

Enteric adenovirus Adenovirus gastroenteritis predominantly affects children younger than four years [9,31]. It occurs throughout
the year, with a peak in the summer [16,17,31]. (See "Epidemiology and clinical manifestations of adenovirus infection", section on
'Gastrointestinal tract'.)

In laboratory surveillance from three counties in the United States during 2008-2009, enteric adenovirus was isolated from 11.8
percent of 1281 children younger than five years with medically attended acute gastroenteritis [16]. Enteric adenovirus was detected
throughout the year, with the highest proportion in June.

Other viruses Viruses that typically have extraintestinal manifestations (eg, coxsackievirus, echovirus, poliovirus, SARS
coronavirus, influenza virus type B) also may cause mild gastroenteritis.

Mixed viral infections Mixed viral infections are common, but the clinical significance of coinfection with multiple viruses is unclear.
In a 2014 literature review of studies using polymerase chain reaction (PCR) to detect viral gastroenteritis pathogens, the prevalence
of mixed infections in children with symptoms of gastroenteritis ranged from 5.7 to 17 percent [42]. Detection of more than one virus
did not appear to influence clinical presentation or severity.

CLINICAL PRESENTATION Most viral enteric infections are asymptomatic, but asymptomatic patients may transmit infection. (See
'Epidemiology' above.)

Virtually every child has more than one symptomatic episode of acute gastroenteritis before two years of age [4,20]. Among symptomatic
children, the clinical manifestations include diarrhea, vomiting, fever, anorexia, headache, abdominal cramps, and myalgia. The
constellation of findings varies by age, with young infants having less specific signs, from day to day and from person to person. Children
may have only diarrhea or vomiting at first, but with progression can become sufficiently ill to require hospitalization. Other symptoms may
develop as the disease evolves; approximately 10 percent of children hospitalized for rotavirus infection have only fever and/or vomiting at
the time of admission [43]. Vomiting is the prominent feature in most cases of norovirus gastroenteritis [44,45].

Illness generally begins 12 hours to 5 days after exposure and lasts for three to seven days [5,7,8]. Vomiting usually lasts for one to two
days and diarrhea for five to seven days [2,17,46]. Stools are typically loose or watery; they may be normal in color or relatively pale
colored. They may be odorless or have a characteristic odor [47]. Gross blood or mucus in the stool are uncommon in viral gastroenteritis
and should prompt consideration of a nonviral etiology. (See 'Bacterial or parasitic gastroenteritis' below.)

The clinical features of medically attended viral gastroenteritis in immune competent children were described in a review of 135 cases of
polymerase chain reaction (PCR)-confirmed gastroenteritis from a tertiary care children's hospital between 2006 and 2009 (during which
there was an outbreak of norovirus) [17]:

Diarrhea was present in 90 percent; the median duration of diarrhea was six days (interquartile range 3 to 14); the median maximum
number of stools per day was six (interquartile range 4 to 10)

Vomiting was present in 56 percent of patients; the median duration of vomiting was four days (interquartile range two to six); the
median maximum number of episodes of emesis per day was three (interquartile range two to five)

Fever (>38.3C [101F]) was present in 42 percent

Abdominal cramping was reported in 12 percent; abdominal distension in 16 percent, and abdominal tenderness in 16 percent

COMPLICATIONS Complications of acute viral gastroenteritis include [25]:

Hypovolemia/dehydration; severe dehydration that is not promptly addressed with rehydration may lead to shock, multiorgan
dysfunction, and death, particularly in immunocompromised patients. (See "Clinical assessment and diagnosis of hypovolemia
(dehydration) in children" and "Hypovolemic shock in children: Initial evaluation and management", section on 'Etiology'.)

Acute viral gastroenteritis that requires medical attention for dehydration occurs predominantly in young children, particularly those

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younger than two years. Young children are more susceptible to dehydration than older children because they have a higher body
surface-to-volume ratio, a higher metabolic rate, lower fluid reserves, and depend upon others to provide fluids [3].

Electrolyte abnormalities and acid base disturbance (hypernatremia, hyponatremia, hypokalemia, metabolic acidosis); hypokalemia
may cause ileus, which can impair fluid and electrolyte absorption. (See "Acid-base and electrolyte abnormalities with diarrhea" and
"Hypokalemia in children", section on 'Muscular weakness'.)

Carbohydrate intolerance, particularly lactose intolerance (due to damage to and loss of mature enterocytes containing lactase) is
uncommon. The diagnosis of lactose intolerance is supported by reducing substances in the stool and/or stool pH <6. Lactose
intolerance can be recognized at disease onset and when patients develop an exacerbation of diarrhea after introduction of lactose-
containing foods and beverages (including infant formulas). (See "Lactose intolerance: Clinical manifestations, diagnosis, and
management", section on 'Secondary lactose malabsorption'.)

Irritant diaper dermatitis. (See "Diaper dermatitis", section on 'Risk factors'.)

EVALUATION

Setting of evaluation The evaluation of children with acute gastroenteritis may begin with a telephone call to assess whether the child
needs to be seen in the office or the emergency department. The child's fluid status and the possibility of severe illness or condition other
than acute gastroenteritis that requires specific therapy are the focus of this conversation.

Indications for a medical visit include [1-3,48]:

Age <6 months or weight <8 kg (17 pounds 10 ounces)

Temperature 38C (100.4F) for infants <3 months or 39C (102.2F) for children 3 to 36 months
Visible blood in stool or melena
Frequent and substantial volumes of diarrhea
Diarrhea for >7 days or persistent vomiting
Caregiver's report of symptoms of moderate to severe dehydration (table 2)
Multisystem compromise, cardiovascular instability (these children should be referred directly to the emergency department)
Inability of the caregiver to administer or failure of the child to tolerate or respond to oral rehydration therapy at home
Underlying immunodeficiency or condition complicating the treatment or course of illness (eg, malnutrition, diabetes mellitus or other
metabolic disease)
Social circumstances that make telephone assessment unreliable

History and examination The history (table 3) and examination (table 4) of children with symptoms and signs of gastroenteritis focus
upon:

Determining the severity of illness; gastroenteritis severity is reflected by the degree of dehydration (table 2) [1,3].

Weight loss, prolonged capillary refill time, loss of skin turgor, and increased and deep respiratory pattern are the best individual signs
of hypovolemia and associated acidosis; other important signs include elevated temperature and pulse, diminished systolic and/or
diastolic blood pressure, sunken fontanelle (in children whose fontanelle remains open), and dry mucus membranes (table 2). (See
"Clinical assessment and diagnosis of hypovolemia (dehydration) in children", section on 'Clinical assessment'.)

Evaluating other causes of diarrhea and/or vomiting that require definitive therapy and can be confused with acute gastroenteritis in
the first day or two of symptoms (eg, meningitis, acute abdominal processes, diabetic ketoacidosis, toxic ingestions) [2,3,25,49-51].
(See 'Differential diagnosis' below and "Approach to diarrhea in children in resource-rich countries" and "Approach to the infant or child
with nausea and vomiting".)

Laboratory evaluation Most immune competent children older than one year of age with typical findings of acute gastroenteritis do not
require laboratory evaluation. The results of laboratory tests are unlikely to change management, which focuses on fluid repletion and
maintenance (even for bacterial and parasitic gastroenteritis); however, a complete blood count (eg, for evidence of anemia or hemolysis;
elevated band count that may suggest bacterial infection), serum electrolytes (for sodium, potassium, and anion gap), and stool studies
(eg, fecal leukocytes, pH, reducing substances) may be helpful in supporting or excluding the diagnosis and in determining severity. (See
"Acute viral gastroenteritis in children in resource-rich countries: Management and prevention", section on 'Management'.)

Laboratory evaluation also may be warranted in children who require intravenous hydration or who have an atypical presentation (table 5)
or if conditions other than acute viral gastroenteritis cannot be excluded clinically. The evaluation depends upon the clinical scenario and
diagnostic considerations.

As examples:

Serum electrolytes Measurement of serum electrolytes is suggested for children who require intravenous hydration; the serum
sodium concentration determines fluid management. (See "Clinical assessment and diagnosis of hypovolemia (dehydration) in
children", section on 'Laboratory testing' and "Treatment of hypovolemia (dehydration) in children", section on 'Intravenous rehydration
therapy'.)

Measurement of serum electrolytes is also suggested for children with symptoms or signs suggestive of hypernatremia (eg, jittery
movement, increased muscle tone, hyperreflexia, thirst out of proportion to degree of dehydration, doughy feel to skin, convulsions,

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drowsiness, coma) or hypokalemia (eg, decreased/absent bowel sounds) [2,49,50]. (See "Hypernatremia in children" and
"Hypokalemia in children".)

Electrolyte abnormalities and acid-base disorders in patients with diarrhea are discussed separately. (See "Acid-base and electrolyte
abnormalities with diarrhea".)

Complete blood count (CBC) A CBC may be helpful if hemolytic uremic syndrome is suspected (the demonstration of anemia or
evidence of hemolysis supports the diagnosis). (See "Overview of hemolytic uremic syndrome in children", section on 'Diagnosis'.)

The CBC may show signs of hemoconcentration (eg, increased hemoglobin or hematocrit) in children with volume depletion.

The white blood cell count does not reliably distinguish between viral and bacterial gastroenteritis, but an elevated band count may
suggest bacterial infection. Peripheral eosinophilia may suggest parasitic infection.

Fecal leukocytes Microscopic examination of a fecal smear stained with Wright stain or methylene blue for fecal leukocytes may be
warranted if bacterial gastroenteritis or inflammatory bowel disease is suspected [52]. Gross mucus suggests a high number of fecal
leukocytes on a fecal smear [53,54].

Bacterial gastroenteritis may be suspected during a known outbreak or if the child has exposures associated with food poisoning
(eg, consumption of undercooked meats, eggs, shellfish, unpasteurized milk (table 6)). (See "Differential diagnosis of microbial
foodborne disease".)

Inflammatory bowel disease may be suspected in children with persistent or recurrent episodes of diarrhea, poor growth, and/or
extraintestinal manifestations. (See "Clinical presentation and diagnosis of inflammatory bowel disease in children", section on
'Clinical manifestations'.)

Fecal leukocytes indicate inflammation in the bowel wall, which is more characteristic of bacterial than viral gastroenteritis; however,
fecal leukocytes do not distinguish between infectious and non-infectious inflammatory processes. Most bacteria cause a
polymorphonuclear inflammation, although Salmonella typhi and Entamoeba histolytica frequently cause a mononuclear reaction
(table 7); eosinophils may suggest ulcerative colitis [55,56], Cystoisospora belli (formerly known as Isospora belli), and possibly, other
parasitic infections, particularly in immunocompromised patients and patients with a history of travel to areas with inadequate sewage
handling [57].

Inflammatory markers Inflammatory markers in the serum (C-reactive protein, procalcitonin) or stool (fecal lactoferrin, fecal
calprotectin) may suggest inflammatory rather than viral causes of diarrhea, but inflammatory markers generally are not recommended
because they are unlikely to change the management of young children with acute gastroenteritis [1,58]. Stool lactoferrin may be
falsely positive in breastfed infants [51].

Stool studies Stool culture, stool examination for ova and parasites, and/or stool studies for Clostridium difficile (particularly in
children with recent exposure to antibiotics) may be indicated in children with persistent diarrhea, immunocompromised hosts, children
in whom infectious gastroenteritis must be excluded to verify another diagnosis (eg, inflammatory bowel disease), or in the setting of
an outbreak. (See "Clostridium difficile infection in children: Clinical features and diagnosis", section on 'Diagnostic testing' and
"Clinical presentation and diagnosis of inflammatory bowel disease in children", section on 'Stool testing for enteric pathogens'.)

Urinalysis and urine culture Urinalysis and urine culture are suggested if urinary tract infection is suspected (eg, suprapubic or
flank tenderness, dysuria, urgency, frequency) or if the child has a history of previous urinary tract infection (See "Urinary tract
infections in infants and children older than one month: Clinical features and diagnosis", section on 'Clinical presentation'.)

DIAGNOSIS

Clinical diagnosis The diagnosis of acute viral gastroenteritis is made clinically; laboratory studies are not routinely necessary. Clinical
features suggestive of viral gastroenteritis include:

Diarrhea (eg, 3 loose or watery stools in 24 hours or a number of loose/watery bowel movements that exceeds the child's usual
number of daily bowel movements by two or more), with or without vomiting, fever, or abdominal pain
Absence of gross blood and mucus in the stool
Absence of atypical features: findings more characteristic of bacterial or parasitic gastroenteritis, extraintestinal infections, or
noninfectious conditions associated with diarrhea and vomiting (table 5) (see 'Differential diagnosis' below)

In children with atypical features, other causes of acute gastroenteritis, extraintestinal infections, and noninfectious causes of diarrhea
and/or vomiting must be considered and may require exclusion (by history, examination, or targeted laboratory or imaging studies) before
making the diagnosis of acute viral gastroenteritis. (See 'Differential diagnosis' below and "Approach to diarrhea in children in resource-rich
countries" and "Approach to the infant or child with nausea and vomiting".)

Etiologic diagnosis Microbiologic testing usually is not necessary in immunocompetent hosts with routine gastroenteritis; however,
microbiologic testing, including virologic assays, bacterial stool cultures, testing for C. difficile toxin, and/or stool examination for ova and
parasites, may be indicated in the following circumstances or patients [1,2,49]:

During outbreaks of gastroenteritis, particularly in an institution with a closed population (hospital, childcare center, school)

For cohorting and isolation of hospitalized patients (see "Acute viral gastroenteritis in children in resource-rich countries: Management
and prevention", section on 'Prevention')

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Patients with underlying conditions (eg, immune compromise, cancer, inflammatory bowel disease)

Patients with prolonged diarrhea (ie, >7 days)

Uncertain diagnosis (eg, acute viral gastroenteritis versus inflammatory bowel disease)

Clinical features and the pattern of illness may suggest a particular virus (table 1), but confirmation requires microbiologic testing [17]. Viral
gastroenteritis pathogens are excreted in the stool. They can be detected one to two days before symptom onset through a week or two
after symptom resolution. Diagnosis of most of the common causes of acute viral gastroenteritis in children is discussed separately:

Norovirus (see "Norovirus", section on 'Diagnosis')

Rotavirus (see "Clinical manifestations and diagnosis of rotavirus infection", section on 'Diagnosis')

Adenoviruses 40 and 41 (see "Diagnosis, treatment, and prevention of adenovirus infection", section on 'Diarrhea in young children')

Commercial tests for the diagnosis of astrovirus are not available in the United States [59]. Many other countries use enzyme
immunoassays. Reverse transcriptase polymerase chain reaction (RT-PCR) is the most sensitive of the methods of detection used by
research and reference laboratories; other methods include electron microscopy, enzyme immunoassay, and latex agglutination

Molecular methods such as multiplex real-time PCR are now licensed in the United States and are replacing traditional tests to detect fecal
viral pathogens [42]. The major advantages of molecular diagnostic methods are increased sensitivity for common viruses such as
rotavirus and adenovirus and the ability to detect uncultivable viruses such as norovirus, sapovirus, and astrovirus. Interpretation of assay
results may be complicated by the frequent detection of viruses in fecal samples from asymptomatic children and the detection of multiple
viruses in a single sample [60,61]. When multiple pathogens are detected, the clinician should recognize that disease outbreaks in closed
settings and individual cases in regions with poor water and sewage handling may be caused by multiple pathogens, with a clinical
presentation of features of each pathogen, such as profuse and watery diarrhea, with blood apparent, in a patient simultaneously ill from
rotavirus and hemorrhagic E. coli infection.

DIFFERENTIAL DIAGNOSIS

Bacterial or parasitic gastroenteritis Nonvirus enteritis pathogens (eg, bacteria and parasites) account for approximately 30 percent
of cases of acute gastroenteritis in children; the proportion is lower in resource-rich countries and higher in resource-poor countries [25].
Clinical features that favor bacterial or parasitic gastroenteritis over viral gastroenteritis include:

Age >2 years Bacterial and parasitic agents generally cause gastroenteritis in children at an older age (eg, two to four years),
whereas viral pathogens tend to cause serious gastroenteritis in those younger than two years.

Gross blood or mucus in the stool Gross blood or mucus in the stool is more suggestive of bacterial than viral gastroenteritis, but
may occur in viral gastroenteritis [17]; occult blood (detected only by stool guaiac test) does not help to distinguish viral from bacterial
gastroenteritis.

High fever (ie, >40C [104F]), tenesmus, central nervous system symptoms (eg, seizures), severe abdominal pain, and smaller
volume stools are more characteristic of bacterial pathogens [1,25,49,58], but seizures have been reported in rotavirus and norovirus
gastroenteritis [62,63].

Exposures (eg, international travel, exposure to poultry or other farm animals, consumption of processed meat).

An elevated band count (if complete blood count is performed) is suggestive of bacterial gastroenteritis.

Bacterial causes of acute gastroenteritis in children include:

Some Escherichia coli spp (see "Microbiology, pathogenesis, epidemiology, and prevention of enterohemorrhagic Escherichia coli
(EHEC)" and "Clinical manifestations, diagnosis and treatment of enterohemorrhagic Escherichia coli (EHEC) infection" and "Clinical
manifestations and diagnosis of Shiga toxin-producing Escherichia coli (STEC) hemolytic uremic syndrome (HUS) in children")

Salmonella strains (see "Nontyphoidal Salmonella: Microbiology and epidemiology" and "Epidemiology, microbiology, clinical
manifestations, and diagnosis of typhoid fever" and "Nontyphoidal Salmonella: Gastrointestinal infection and carriage")

Shigella species (see "Shigella infection: Clinical manifestations and diagnosis")

C. difficile (see "Clostridium difficile infection in children: Microbiology, pathogenesis, and epidemiology" and "Clostridium difficile
infection in children: Clinical features and diagnosis")

Campylobacter jejuni (see "Microbiology, pathogenesis, and epidemiology of Campylobacter infection" and "Clinical manifestations,
diagnosis, and treatment of Campylobacter infection")

C. upsaliensis (see "Infection with less common Campylobacter species and related bacteria", section on 'Campylobacter upsaliensis')

Mycobacteria, such as Mycobacterium avium complex, particularly in immunocompromised patients (see "Disseminated
nontuberculous mycobacterial (NTM) infections and NTM bacteremia in children", section on 'Clinical features')

Parasitic causes of acute gastroenteritis in children include:

Giardia (see "Epidemiology, clinical manifestations, and diagnosis of giardiasis")

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Cryptosporidium (see "Epidemiology, clinical manifestations, and diagnosis of cryptosporidiosis")

Cystoisospora belli (formerly known as Isospora belli) (see "Epidemiology, clinical manifestations, and diagnosis of Cystoisospora
infections")

Microsporidia and Cyclospora (see "Microsporidiosis" and "Cyclospora infection")

Extraintestinal infections Extraintestinal infections that may present with diarrhea and/or vomiting are listed below [25,50]. These
infections can usually be differentiated from acute gastroenteritis by their extraintestinal manifestations and/or specific laboratory tests (eg,
chemistry, cell count, and culture of cerebrospinal fluid; urinalysis and urine culture; etc).

Meningitis Characteristic features of meningitis include fever, altered level of consciousness, and meningeal signs. (See "Bacterial
meningitis in children older than one month: Clinical features and diagnosis", section on 'Clinical features' and "Viral meningitis:
Clinical features and diagnosis in children".)

Bacterial sepsis Clinical features of sepsis include alterations in vital signs and white blood cell count indicating a systemic
inflammatory response syndrome (SIRS) in the presence of clinical or laboratory findings of infection. (See "Systemic inflammatory
response syndrome (SIRS) and sepsis in children: Definitions, epidemiology, clinical manifestations, and diagnosis".)

Pneumonia Clinical features of pneumonia include fever and symptoms or signs of respiratory distress (eg, tachypnea, nasal flaring,
grunting, retractions, crackles, decreased breath sounds). (See "Community-acquired pneumonia in children: Clinical features and
diagnosis", section on 'Clinical presentation'.)

Urinary tract infection (UTI) Clinical features of UTI include suprapubic or flank tenderness, dysuria, urgency, frequency). (See
"Urinary tract infections in infants and children older than one month: Clinical features and diagnosis", section on 'Clinical
presentation'.)

Otitis media Symptoms and signs of otitis media include ear pain, bulging of the tympanic membrane, and hearing loss. (See "Acute
otitis media in children: Epidemiology, microbiology, clinical manifestations, and complications", section on 'Clinical manifestations' and
"Acute otitis media in children: Diagnosis", section on 'Clinical diagnosis'.)

Noninfectious conditions A number of noninfectious conditions can present with symptoms the mimic those of infectious
gastroenteritis (table 8). The approach to distinguishing these conditions from acute viral gastroenteritis is discussed separately. (See
"Approach to diarrhea in children in resource-rich countries" and "Approach to the infant or child with nausea and vomiting".)

INDICATIONS FOR REFERRAL Urgent referral for diagnostic evaluation and therapy may be warranted in children with:

Diarrhea lasting more than seven days (see "Overview of the causes of chronic diarrhea in children in resource-rich countries" and
"Approach to the diagnosis of chronic diarrhea in children in resource-rich countries")

Severe dehydration (table 2) associated with cardiovascular instability

Hypernatremia (see "Hypernatremia in children")

Clinical features suggesting extraintestinal involvement or another etiology (eg, hemolytic uremia syndrome) (see 'Differential
diagnosis' above)

Immune compromise

SOCIETY GUIDELINE LINKS Links to society and government-sponsored guidelines from selected countries and regions around the
world are provided separately. (See "Society guideline links: Acute diarrhea in children".)

INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The
Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key
questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer
short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These
articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with
some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You
can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Viral gastroenteritis (The Basics)" and "Patient education: Diarrhea in children (The Basics)" and
"Patient education: Rotavirus infection (The Basics)")

Beyond the Basics topic (see "Patient education: Acute diarrhea in children (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Acute gastroenteritis is a clinical syndrome often defined by increased stool frequency (eg, 3 loose or watery stools in 24 hours or a
number of loose/watery bowel movements that exceeds the child's usual number of daily bowel movements by two or more) with or
without vomiting or fever. Acute viral gastroenteritis is caused by a viral pathogen. (See 'Definition' above.)

Acute viral gastroenteritis occurs throughout the year with a fall and winter predominance (table 1). It can be transmitted by

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asymptomatic carriers as well as by symptomatic patients before the onset of symptoms. It is generally transmitted by the fecal-oral
route. (See 'Epidemiology' above.)

The most common causes of acute viral gastroenteritis in children include rotavirus, norovirus, sapovirus, astrovirus, and enteric
adenoviruses (table 1). Mixed viral infections are common, but the clinical significance of coinfection with multiple viruses is unclear.
(See 'Etiology' above.)

Among symptomatic patients, the clinical manifestations include diarrhea, vomiting, fever, anorexia, headache, abdominal cramps, and
myalgia. The constellation of symptoms varies from day to day and from person to person. (See 'Clinical presentation' above.)

Acute viral gastroenteritis may be complicated by dehydration, electrolyte and acid-base disturbances, carbohydrate intolerance, and
irritant diaper dermatitis. Acute viral gastroenteritis that requires medical attention for dehydration occurs predominantly in young
children, particularly those younger than two years. (See 'Complications' above.)

The history (table 3) and examination (table 4) of children with symptoms and signs of gastroenteritis focus upon determining the
severity of illness (table 2) and evaluating other causes of diarrhea and/or vomiting that require definitive therapy (eg, meningitis, acute
abdominal processes, diabetes mellitus, and toxic ingestions) and can be confused with acute gastroenteritis in the first day or two of
symptoms. (See 'History and examination' above.)

Laboratory evaluation is not usually necessary but may be warranted in children who require intravenous hydration for severe
dehydration or have an atypical presentation (table 5) or if conditions other than acute viral gastroenteritis cannot be excluded
clinically. (See 'Laboratory evaluation' above.)

The diagnosis of acute viral gastroenteritis is made by the characteristic history of diarrhea that does not contain gross blood or
mucus; with or without vomiting, fever, or abdominal pain; and the absence of findings more characteristic of bacterial or parasitic
gastroenteritis, extraintestinal infections, or noninfectious conditions associated with diarrhea and vomiting (table 5). (See 'Diagnosis'
above.)

The differential diagnosis of acute viral gastroenteritis includes bacterial and parasitic gastroenteritis, extraintestinal infections, and
noninfectious conditions. These conditions generally are associated with features that are atypical for acute viral gastroenteritis (table
5). (See 'Differential diagnosis' above.)

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47. Poulton J, Tarlow MJ. Diagnosis of rotavirus gastroenteritis by smell. Arch Dis Child 1987; 62:851.
48. Ho MS, Glass RI, Pinsky PF, et al. Diarrheal deaths in American children. Are they preventable? JAMA 1988; 260:3281.
49. Granado-Villar D, Cunill-De Sautu B, Granados A. Acute gastroenteritis. Pediatr Rev 2012; 33:487.
50. World Gastroenterology Organisation Global Guidelines. Acute diarrhea in adults and children: A global perspective. February 2012.
www.worldgastroenterology.org/acute-diarrhea-in-adults.html (Accessed on July 29, 2015).
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32:331.
52. DeWitt TG, Humphrey KF, McCarthy P. Clinical predictors of acute bacterial diarrhea in young children. Pediatrics 1985; 76:551.
53. Muz O, Coello-Ramrez P, Serafin F, et al. [Acute infectious gastroenteritis. Etiology and its correlation with clinical manifestations
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54. Coello-Ramrez P, Movrn-Meleg JC, Daz-Bensussen S. [Analysis of fecal mucus in children with prolonged and acute diarrhea]. Bol
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55. Smyth CM, Akasheh N, Woods S, et al. Activated eosinophils in association with enteric nerves in inflammatory bowel disease. PLoS
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56. Sadi G, Yang Q, Dufault B, et al. Prevalence of Peripheral Eosinophilia at Diagnosis in Children With Inflammatory Bowel Disease. J
Pediatr Gastroenterol Nutr 2016; 62:573.
57. Kim MJ, Kim WH, Jung HC, et al. Isospora belli Infection with Chronic Diarrhea in an Alcoholic Patient. Korean J Parasitol 2013;
51:207.
58. Wiegering V, Kaiser J, Tappe D, et al. Gastroenteritis in childhood: a retrospective study of 650 hospitalized pediatric patients. Int J
Infect Dis 2011; 15:e401.
59. American Academy of Pediatrics. Astrovirus infections. In: Red Book: 2015 Report of the Committee on Infectious Diseases, 30th ed,
Kimberlin DW, Brady MT, Jackson MA, Long SS (Eds), American Academy of Pediatrics, Elk Grove Village, IL 2015. p.252.
60. Nicholson MR, Van Horn GT, Tang YW, et al. Using Multiplex Molecular Testing to Determine the Etiology of Acute Gastroenteritis in
Children. J Pediatr 2016; 176:50.
61. Hanson KE, Couturier MR. Multiplexed Molecular Diagnostics for Respiratory, Gastrointestinal, and Central Nervous System
Infections. Clin Infect Dis 2016; 63:1361.
62. Johansen K, Hedlund KO, Zweygberg-Wirgart B, Bennet R. Complications attributable to rotavirus-induced diarrhoea in a Swedish
paediatric population: report from an 11-year surveillance. Scand J Infect Dis 2008; 40:958.
63. Ueda H, Tajiri H, Kimura S, et al. Clinical characteristics of seizures associated with viral gastroenteritis in children. Epilepsy Res
2015; 109:146.

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GRAPHICS

Epidemiologic and clinical features of common causes of acute viral gastroenteritis in children

Common
modes of
Predominant Incubation Lactose Other
Virus transmission Age Duration
season period intolerance features
in order of
frequency

Rotavirus Fall/winter 1 to 3 days Fecal-oral 6 to 24 months 5 to 7 days Yes Causes severe

Respiratory? childhood
diarrhea
Endemic;
season
broadened by
mass
immunization

Norovirus All year (winter) 12 to 48 hours Fecal-oral All ages 1 to 4 days No Vomiting is
Water prominent
Shellfish symptom

Other foods Causes most

outbreaks of
Respiratory?
nonbacterial
gastroenteritis
Endemic and
epidemic

Sapovirus All year 1 to 2 days Fecal-oral Infants and 3 to 4 days Endemic and
toddlers epidemic

Astrovirus Winter 4 to 5 days Fecal-oral All ages 5 to 6 days Yes Endemic and
Water epidemic

Enteric Summer 3 to 10 days Fecal-oral Children 6 to 9 days Yes Endemic

adenovirus
(types 40 and
41)

Data from:
1. Dennehy PH. Viral gastroenteritis in children. Pediatr Infect Dis J 2011; 30:63.
2. Lee RM, Lessler J, Lee RA, et al. Incubation periods of viral gastroenteritis: A systematic review. BMC Infect Dis 2013; 13:446.
3. Public Health Agency of Canada. Adenovirus (serotypes 40 & 41). Available at: www.phac-aspc.gc.ca/lab-bio/res/psds-ftss/adenovirus-eng.php
(Accessed on August 5, 2015).

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Rotavirus season duration and peak activity by reporting years*, National Respiratory and Enteric Virus
Surveillance System (NREVSS), United States, 2000-2014

* Prevaccine: 2000 to 2006; postvaccine: 2007 to 2014.

10% is the threshold proportion of positive test results that is used to determine the onset and offset of a rotavirus season.

Reproduced from: Aliabadi N, Tate JE, Haynes AK, Parashar UD. Sustained decrease in laboratory detection of rotavirus after implementation of routine
vaccination - United States, 2000-2014. MMWR Morb Mortal Wkly Rep 2015; 64:337.

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Physical findings of volume depletion in infants and children

Mild Moderate Severe

Finding
(3 to 5%) (6 to 9%) (10%)

Pulse Full, normal rate Rapid Rapid and weak OR absent

Systolic pressure Normal Normal to low Low

Respirations Normal Deep, rate may be increased Deep, tachypnea OR decreased to

absent

Buccal mucosa Tacky or slightly dry Dry Parched

Anterior fontanelle Normal Sunken Markedly sunken

Eyes Normal Sunken Markedly sunken

Skin turgor Normal Reduced Tenting

Skin Normal Cool Cool, mottled, acrocyanosis

Urine output Normal or mildly reduced Markedly reduced Anuria

Systemic signs Increased thirst Listlessness, irritability Grunting, lethargy, coma

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Important aspects of the history for a child with acute gastroenteritis

Historical feature Potential significance

Duration of illness Symptoms >7 days may indicate underlying gastrointestinal or

metabolic disease, or systemic disease (eg, IBD, celiac disease,
immunodeficiency)

Frequency, volume, and character of stools (eg, blood mucus)
Frequent, watery, large volume without blood or mucus favors viral
gastroenteritis
Small volume, gross blood, or mucus favors bacterial gastroenteritis
Blood or mucus also may occur with intussusception, appendicitis,
toxic megacolon

Frequency, volume, and character of emesis (eg, blood, bile, projectile)
Prolonged vomiting increases risk of dehydration and concern for
underlying systemic or metabolic disorder
Bilious or projectile vomiting may indicate intestinal obstruction (eg,
intussusception, pyloric stenosis)
Hematemesis may suggest esophageal injury or varices (with
underlying liver disease)

Weight before illness Used to assess degree of dehydration and response to fluid repletion

Urine output Decreased: suggests dehydration

Increased: may indicate diabetes ketoacidosis

Associated symptoms: fever, headache, localized abdominal pain, urinary May suggest alternate etiology (eg, urinary tract infection,
complaints, and others appendicitis, and others)

Recent intake of food and fluids Used to assess degree of dehydration and other causes of diarrhea
(eg, starvation stools, food poisoning, food allergy/intolerance,
overfeeding [particularly with hyperosmolar fluids])

Underlying medical problems May increase risk of complications

Recent medications (particularly antibiotics) and medications in the home May be associated with vomiting or diarrhea
Clinical manifestations of certain ingestions may mimic findings of
acute gastroenteritis (eg, tachypnea and acidosis in salicylate
ingestion)

Immunization history (particularly rotavirus) Rotavirus immunization decreases likelihood of rotavirus

gastroenteritis (even after one dose)
Incomplete pneumococcal or Haemophilus influenzae type b
immunization may increase likelihood of extraintestinal infection with
these organisms (eg, otitis media, pneumonia, meningitis)

Contacts with acute diarrhea or vomiting Supports infectious gastroenteritis, may suggest a common source
outbreak
Symptoms may suggest etiology (eg, prominence of vomiting suggests
norovirus)

Exposures: Increases risk of bacterial or parasitic gastroenteritis

Known source of enteric infection (eg, contaminated food or water)
Unsafe foods (eg, raw/undercooked meats, eggs, shellfish,
unpasteurized milk or juice)
Swimming in or drinking untreated fresh surface water
Farm, petting zoo, reptiles, pets with diarrhea
International travel

IBD: inflammatory bowel disease.

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Important aspects of the examination of a child with acute gastroenteritis

Clinical finding Potential significance

Growth parameters

Body weight Used to determine degree of dehydration and response to fluid

repletion

Growth retardation Chronic underlying condition (eg, gastrointestinal disease, immune

deficiency)

Vital signs

Fever: Temperature elevation tends to be higher in extraintestinal infection or

38C (100.4F) in patient <3 months bacterial gastroenteritis (particularly if >40C [104F])
39C (102.2F) in patient 3 months

Rapid, weak, or absent pulse Dehydration

Decreased blood pressure Dehydration, shock, sepsis

Hypotension disproportionate to apparent illness Adrenal crisis

HEENT

Sunken anterior fontanelle, sunken eyes Moderate to severe dehydration

Bulging anterior fontanelle Increased intracranial pressure

Scleral icterus HUS, viral hepatitis

Bulging tympanic membrane Acute otitis media

Tacky, dry, or parched mucous membranes Dehydration

Neck

Neck stiffness, nuchal rigidity, other meningeal signs Meningitis

Chest

Deep respirations Moderate to severe dehydration, acidosis

Tachypnea, crackles, decreased breath sounds Pneumonia

Abdomen

Severe, localized pain, rebound tenderness, marked abdominal Acute abdomen (eg, appendicitis, bowel obstruction, toxic megacolon)
distension

Hypoactive/absent bowel sounds Hypokalemia

Flank pain or suprapubic tenderness UTI

Abdominal mass "Olive" at lateral edge of rectus abdominus in RUQ: pyloric stenosis
"Sausage-shaped" right-sided mass: intussusception

Skin

Cool, mottled, poor capillary refill, decreased turgor Moderate to severe dehydration, sepsis

Nonblanching lesions (petechiae, purpura, bruises) HUS, trauma (intracranial, intraabdominal)

Jaundice HUS, viral hepatitis

Neurologic

Altered consciousness or focal neurologic abnormalities Toxic ingestion, diabetic ketoacidosis, CNS mass, or inborn error of
metabolism

RR: respiratory rate; CNS: central nervous system; HEENT: head, eyes, ears, nose, throat; UTI: urinary tract infections; HUS: hemolytic uremic syndrome.

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Clinical features atypical for acute viral gastroenteritis in children

Clinical feature Potential significance

Historical features

Fever: Extraintestinal infection (eg, UTI, otitis media, pneumonia, etc) or

38C (100.4F) in infants <3 months bacterial gastroenteritis (particularly if >40C [104F])
39C (102.2F) in infants and children 3 months

Gross blood or mucus in stool Bacterial gastroenteritis, inflammatory bowel disease

Bilious vomiting Intestinal obstruction

Projectile vomiting Pyloric stenosis, intestinal obstruction

Persistent diarrhea (>7 days) Underlying gastrointestinal, metabolic, or CNS disease

Persistent, recurrent, or isolated vomiting CNS disease, metabolic disease

Increased urine output Diabetic ketoacidosis

Altered consciousness, seizures, focal neurologic abnormalities Increased ICP (CNS mass, hydrocephalus, idiopathic intracranial
hypertension)

History of trauma Intracranial or intraabdominal injury (eg, duodenal hematoma)

Weight loss and multisystem involvement Parasitic gastroenteritis; underlying gastrointestinal or metabolic
disorder

Recent antibiotic exposure Antibiotic-associated diarrhea, including Clostridium difficile colitis

International travel Bacterial or parasitic gastroenteritis, measles

Exposures: unsafe foods (eg, raw/undercooked meats, eggs, shellfish, Bacterial or parasitic gastroenteritis
unpasteurized milk or juice), farm animals, petting zoo, reptiles, pets
with diarrhea, untreated surface water

Examination

Moderate to severe dehydration in a child >2 years May indicate underlying condition predisposing to dehydration

Bulging fontanelle Hydrocephalus, meningitis

Bulging tympanic membrane Acute otitis media

Hypotension disproportionate to apparent illness and/or hyponatremia Adrenal crisis

with hyperkalemia

Tachypnea, retractions, crackles, decreased breath sounds Pneumonia or other respiratory tract infection

Marked abdominal distention, peritoneal signs, absent bowel sounds or Acute abdomen (eg, appendicitis, intestinal obstruction)
increased high-pitched bowel sounds ("borborygmi")

Focal abdominal tenderness RLQ: appendicitis, Crohn disease

RUQ: gallbladder disease, pancreatitis
Suprapubic or flank: UTI
Epigastric: pancreatitis, peptic ulcer disease/gastritis

Abdominal mass "Olive" at lateral edge of rectus abdominus in RUQ: pyloric stenosis
"Sausage-shaped" right-sided mass: intussusception

Petechiae, purpura, bruising Hemolytic uremic syndrome, trauma, extraintestinal infection (eg,
RMSF, meningococcemia)

Jaundice Viral hepatitis, HUS

Signs of trauma Intracranial or intraabdominal injury (eg, duodenal hematoma)

Increased muscle tone, hyperreflexia Hyperkalemia

Laboratory findings (if performed)

Abnormal CBC Anemia, thrombocytopenia, hemolysis: HUS

Elevated band count: bacterial gastroenteritis
Elevated eosinophil count: parasitic gastroenteritis

Elevated serum C-reactive protein, procalcitonin Bacterial gastroenteritis, inflammatory bowel disease

Fecal leukocytes, fecal lactoferrin, fecal calprotectin Bacterial gastroenteritis, inflammatory bowel disease

Eosinophils on fecal smear Amoeba or other intestinal parasite

Persistent watery diarrhea Microsporidia, Cyclospora, and other intestinal parasites

UTI: urinary tract infection; CNS: central nervous system; ICP: intracranial pressure; RLQ: right lower quadrant; RUQ: right upper quadrant; RMSF: Rocky
Mountain spotted fever; HUS: hemolytic uremic syndrome; CBC: complete blood count.

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Differential diagnosis of foodborne disease by item consumed

Item Commonly associated microbes*

Raw seafood Norwalk-like virus, Vibrio spp, hepatitis A

Raw eggs Salmonella spp

Undercooked meat or poultry Salmonella spp, Campylobacter spp, STEC, Clostridium perfringens

Unpasteurized milk or juice Salmonella spp, Campylobacter spp, STEC, Yersinia enterocolitica

Unpasteurized soft cheeses Salmonella spp, Campylobacter spp, STEC, Y. enterocolitica, Listeria monocytogenes

Homemade canned goods Clostridium botulinum

Raw hot dogs, deli meat L. monocytogenes

STEC: shiga toxin-producing Escherichia coli.

* This association lists the commonly associated organisms and is not fully comprehensive.

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Value of fecal leukocyte examination in distinguishing viral gastroenteritis from other causes of acute
gastroenteritis

Cause Type Frequency, percent

Viruses PMN, if any 0 to 10

Vibrio cholerae, EHEC, ETEC, EPEC, Giardia lamblia PMN, if any 0 to 10

Shigella, Salmonella (not typhi), Campylobacter jejuni, Clostridium difficile PMN 90 to 100

Yersinia enterocolitica, Vibrio parahaemolyticus PMN Variable

Salmonella typhi MN 100

Amoebic dysentery MN 100

Ulcerative colitis EO 100

PMN: polymorphonuclear leukocytes; EHEC: enterohemorrhagic Escherichia coli; ETEC: enterotoxigenic E. coli; EPEC: enteropathogenic E. coli; MN:
mononuclear leukocytes; EO: eosinophilic leukocytes.

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Etiology of diarrhea in children by age

Cause Infants and young children Older children and adolescents

Gastrointestinal infections Viruses * Viruses *

Bacteria * Bacteria *
Parasites Parasites

Non-gastrointestional infections (parenteral Otitis media * Systemic infections

diarrhea) Urinary tract infections * Staphylococcal toxic shock syndrome
Other systemic infections

Dietary disturbances Functional diarrhea/Overfeeding* Starvation stools *

Food allergy *
Starvation stools *

Anatomic abnormalities Intussusception Appendicitis

Hirschsprung disease ( toxic megacolon ) Partial obstruction
Partial bowel obstruction Blind loop syndrome
Blind loop syndrome (also in patients with
dysmotility)
Intestinal lymphangiectasis
Short gut syndrome

Inflammatory bowel disease Early onset inflammatory bowel disease (rare, Ulcerative colitis ( toxic megacolon )
monogenic) Crohn's disease ( toxic megacolon )

Malabsorption or increased secretion Cystic fibrosis Celiac disease

Celiac disease
Disaccharidase deficiency (eg, lactase deficiency
due to infectious diarrhea)*
Acrodermatitis enteropathica
Congenital secretory diarrhea
Disaccharidase deficiency (primary or
secondary)*
Acrodermatitis enteropathica
Neuroendocrine secretory tumors

Immunodeficiency Severe combined immunodeficiencies and other HIV

genetic disorders
HIV

Endocrinopathy Congenital adrenal hyperplasia Hyperthyroidism

Hypoparathyroidism

Miscellaneous Antibiotic-associated diarrhea* Antibiotic-associated diarrhea*

Pseudomembranous colitis Pseudomembranous colitis

Toxins Toxins

Hemolytic uremic syndrome Irritable bowel syndrome *

Neonatal drug withdrawal Psychogenic disturbances *

HIV: human immunodeficiency virus infection.

* Common cause.
Life-threatening cause.
Potential toxins include foodborne toxin disease, poisonous plants or mushrooms, and organophosphates or carbamates.

Courtesy of Gary R Fleisher, MD.

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Contributor Disclosures
David O Matson, MD, PhD Patent Holder (maintained by Baylor College of Medicine) [Gastroenteritis (Diagnostic kit for antigen detection
of calciviruses)]. Morven S Edwards, MD Grant/Research/Clinical Trial Support: Pfizer Inc. [Group B Streptococcus]. George D Ferry,
MD Grant/Research/Clinical Trial Support: Eli Lilly and Company [Pediatric type 2 diabetes (Dulaglutide)]. Mary M Torchia, MD Nothing to
disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a
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content is required of all authors and must conform to UpToDate standards of evidence.

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