Transcript Acute Gastroenteritis: An Approach

Acute Gastroenteritis:
An Approach
Paolo Aquino, M.D., M.P.H.
Outline
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Approach
Etiology
Diagnosis
Treatment
Prevention
Approach
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Considerations
• Rule out acute/surgical abdomen
• Hydration status
Acute Abdomen
Intraluminal
Obstruction
Extraluminal
Obstruction
Gastrointestin
al
Disease
Paralytic
Ileus
Blunt
Trauma
Miscellaneous
Foreign Body
Bezoar
Fecalith
Gallstone
Parasites
Cystic fibrosis
Tumor
Fecaloma
Hernia
Intussusceptio
n
Volvulus
Duplication
Stenosis
Tumor
Mesenteric cyst
SMA syndrome
Pyloric stenosis
Appendicitis
Crohn disease
Ulcerative
colitis
Vasculitis
Peptic ulcer
disease
Meckel’s
AGE
Sepsis
Pneumonia
Pyelonephritis
Peritonitis
Pancreatitis
Cholecystitis
Renal stones
Gallstones
PID
Lymphadenitis
Accident
Battered child
syndrome
Lead poisoning
Sickle cell
disease
Familial
Mediterranean
fever
Porphyria
DKA
Addisonian
crisis
Testicular
torsion
Ovarian Torsion
Approach
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History
• Symptoms
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Nausea, emesis, retching
Abdominal pain
Bowel movements
Timing
• Age
• Onset
• Relation to feeds
• Focus of infection, other affected
individuals
Approach
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Physical examination
• Temperature, heart rate, blood
pressure, pain
• Abdominal examination
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Auscultation before palpation
Palpation
• Masses
• Tenderness
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Auscultation for bowel sounds
Approach
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Objectives
• Assess the degree of dehydration
• Prevent spread of the enteropathogen
• Selectively determine etiology and
provide specific therapy
Dehydration
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Mild (3-5%)
• Normal or increased pulse
• Decreased urine output
• Thirsty
• Normal physical exam
Dehydration
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Moderate (7-10%)
• Tachycardia
• Little/no urine output
• Irritable/lethargic
• Sunken eyes/fontanelle
• Decreased tears
• Dry mucous membranes
• Skin- tenting, delayed cap refill, cool,
pale
Dehydration
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Severe (10-15%)
• Rapid, weak pulse
• Decreased blood pressure
• No urine output
• Very sunken eyes/fontanelle
• No tears
• Parched mucous membranes
• Skin- tenting, delayed cap refill, cold,
mottled
Dehydration
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Treatment
• Calculate deficits
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Water: % dehydration x weight
Sodium: water deficit x 80 mEq/L
Potassium: water deficit x 30 mEq/L
• Treat mild-moderate dehydration with
oral rehydration solutions
• May treat severe dehydration with
intravenous fluids
• Hyponatremic v. isotonic v.
hypernatremic
Etiology
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Enteropathogens
• Non-inflammatory vs. inflammatory
diarrhea
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Non-inflammatory
• Enterotoxin production
• Destruction of villi
• Adherence to GI tract
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Inflammatory
• Intestinal invasion
• Cytotoxins
Etiology
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Chronic diarrhea
• Giardia lamblia
• Cryptosporidium parvum
• Escherichia coli: enteroaggregative,
enteropathogenic
• Immunocompromised host
• Non-infectious causes: anatomic,
malabsorption, endocrinopathies,
neoplasia
Etiology
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Bacterial
• Inflammatory diarrhea
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Aeromonas
Campylobacter jejuni
Clostridium dificile
E. coli: enteroinvasive, O157:H7
Plesiomonas shigelloides
Salmonella
Shigella
Vibrio parahaemolyticus
Yersinia enterocolitica
Etiology
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Bacterial
• Non-inflammatory
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Viral
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E. coli: enteropathogenic, enterotoxigenic
Vibrio cholerae
Rotavirus
Enteric adenovirus
Astroviruus
Calcivirus
Norwalk
CMV
HSV
Etiology
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Parasites
• Giardia lamblida
• Entamoeba histolytica
• Strongyloides stercoralis
• Balantidium coli
• Cryptosporidium parvum
• Cyclospora cayetanensis
• Isospora belli
Diagnosis
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History
Stool examination
• Mucus
• Blood
• Leukocytes
• Stool culture
Diagnosis
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Examination for ova and parasites
• Recent travel to an endemic area
• Stool cultures negative for other
enteropathogens
• Diarrhea persists for more than 1 week
• Part of an outbreak
• Immunocompromised
• May require examination of more than
one specimen
Antimicrobial therapy
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Aeromonas
• TMP/SMZ
• Dysentery-like illness, prolonged
diarrhea
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Campylobacter
• Erythromycin, azithromycin
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Clostridium dificile
• Metronidazole, vancomycin
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E. coli
• TMP/SMZ
Antimicrobial therapy
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Salmonella
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Cefotaxime, ceftriaxone, ampicillin, TMP/SMZ
Infants < 3 months
Typhoid fever
Bacteremia
Dissemination with localized suppuration
Shigella
• Ampicillin, ciprofloxacin, ofloxacin, ceftriaxone
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Vibrio cholerae
• Doxycycline, tetracycline
Therapy
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Antidiarrheal medication
• Alter
• Alter
• Alter
• Alter
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intestinal motility
adsorption
intestinal flora
fluid/electrolyte secretion
Antidiarrheal medication generally
not recommended
• Minimal benefit
• Potential for side effects
Prevention
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Contact precautions
Education
• Mode of acquisition
• Methods to decrease transmission
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Exclusion from day care until
diarrhea subsides
Surveillance
Salmonella typhi vaccine
Any questions?