Acute Gastroenteritis for Adults and Children

Discussion about Acute Gastroenteritis, causes, treatment and management of different types organism that cause AGE. Also had a brief discussion about it's difference from diarrhea. This discussion was taken from WHO 2012(which is currently the latest as of now) and Merck 2016. It also include on how to discuss it.

1. by:
Brigitte Ulrike D. Tabaranza M.D.
Acute Gastroenteritis

2. •Stool 60-90% water
•Stool amount:
–100-200g/day in healthy adults
–10g/kg/day in infants
**Depending on the
amount of unabsorbable
dietary material consumed

3. Stool Characteristics

4. The Merck Manual 19th Edition
•It is a change in normal bowel movements
characterized by increase in frequency, water
content or volume of stools.
•Stool weight > 200g/day
•≥ 3 episodes/day

5. The Merck Manual 19th Edition
•There are number of
causes and several basic
mechanisms are
responsible:
–Increased osmotic
load
–Increased secretions
–Decreased contact
time/surface area.
Diarrhea

6. The Merck Manual 19th Edition
•Osmotic Load:
•Occurs when unabsorbable, water-soluble
solutes remain in the bowel and retain water
•Increased Secretion :
•Occur when the bowels secrete more
electrolytes and water than they absorb.
•Reduced contact time/surface area :
•Rapid intestinal transit and diminished surface
area impair fluid absorption and cause diarrhea
Diarrhea

7. Stool Characteristics in
Diarrhea

8. STOOL
CHARACTERISTICS
SMALL BOWEL
APPEARNACE
WATERY
VOLUME LARGE
FREQUENCY
INCREASED
BLOOD POSITIVE
pH
< 5.5
WBCs <5/hpf
SERUM WBCs NORMAL
LARGE BOWEL
MUCOID AND/OR BLOODY
SMALL
DECREASED
GROSSLY BLOODY
> 5.5
>10/ hpf
LEUKOCYTOSIS

9. STOOL
CHARACTERISTICS
SMALL BOWEL LARGE BOWEL
ORGANISMS VIRAL INVASIVE
BACTERIA
Rotavirus
Adenovirus
Calicivirus
Escherichia Coli
Shigella species
Salmonella species
Campylobacter species
Yersinia species
Enterotoxigenic bacteria
Toxic bacteria
Klebsiella
Clostridium perfringens
Cholera species
Vibrio species
Clostridium difficile
Parasites Parasites
Giardia species
Cryptosporidium species
Entamoeba
organisms

10. Diarrhea ?
Acute Gastroenteritis?

11. Acute Gastroenteritis
World Gastroenterology Organization Global Guidelines (February 2012)
•It is an inflammation of the gastrointestinal
tract , involving both the stomach and the small
intestine and resulting in acute diarrhea .

12. Acute Gastroenteritis
•It can be defined as the passage of a greater
number of stools of decreased form from the
normal, and lasting less than 14 days.
•It is a group of conditions that are usually cause
by infection and produce symptoms:
–Nausea and vomiting,
– Mild to severe diarrhea and fecal urgency.
–Abdominal pain and cramps, or tenesmus
–Increase in intestinal gas-related complaints,
–loss of electrolytes
–life-threatening dehydration
The Merck Manual 19th Edition

13. Acute Gastroenteritis
•About 2 billion cases of diarrheal disease every
year and 1.9million children <5yo perish, mostly in
developing countries (78%).
•Impact on the incidence:
–Poor living conditions
–Insignificant improvements in water
–Sanitation
–Personal hygiene
–Poor nutrition
–Lack of information
World Gastroenterology Organization Global Guidelines (February 2012)

14. Common Organisms that Causes
Acute Gastroenteritis
Acute Gastroenteritis
Viral:
-Rotavirus
-Norovirus
(Calicivirus)
--Adenovirus
(ST 40/41)
-Astrovirus
Bacterial:
-Campilobacter jejuni
-Salmonella
-Shigella
-E. coli
-Vibrio cholerae
Parasite:
-Entamoeba histolytica
-Gardia intestinalis
-Cryptosporidium
paryum
-Cyclospora
cayetanensis
World Gastroenterology Organization Global Guidelines (February 2012)
**In developing countries, enteric
bacteria and parasites are more
prevalent than viruses and typically
peak during the summer months.

15. Acute Gastroenteritis
•Bacterial Agents:
•Diarrheagenic Escherichia coli
–Enterohemorrhagic E. coli (EHEC,
including E. coli O157:H7)
–Enterotoxigenic E. coli (ETEC)
–Enteropathogenic E. coli (EPEC)
–Enteroinvasive E. coli (EIEC)
–Enteroaggregative E. coli
(EAggEC)
World Gastroenterology Organization Global Guidelines (February 2012)

16. Acute Gastroenteritis
•Bacterial Agents:
•Campylobacter
–prevalent in adults and is one of the most frequently
isolated bacteria from the feces of infants and
children in developing countries.
–Asymptomatic infection, but infection is associated
with watery diarrhea and on occasion dysentery
–Guillain–Barré syndrome is a rare complication
–Poultry is an important source of Campylobacter
infections
World Gastroenterology Organization Global Guidelines (February 2012)

17. Acute Gastroenteritis
•Bacterial Agents:
•Shigella Species
–S. sonnei
–S. flexneri
–S. dysenteriae type 1 (Sd1)
•Vibrio cholerae
–V. cholerae serogroups O1 and O139
–Hypovolemic shock and death can occur within 12–18
hrs after the onset of the first symptom
–Stools are watery, colorless, and flecked with mucus;
Vomiting is common; fever is rare
World Gastroenterology Organization Global Guidelines (February 2012)

18. Rice Watery Stool

19. Acute Gastroenteritis
•Bacterial Agents:
•Salmonella:
–Enteric Fever-- Salmonella enterica serovar Typhi and
Paratyphi A,B, or C(typhoid fever)
–In non-typhoidal salmonellosis (Salmonella
gastroenteritis)
•Fever develops in 70% of affected children.
•Bacteremia occurs in 1–5%, mostly in infants.
•Diarrhea (with or without blood) develops, and
fever lasting 3 weeks or more
World Gastroenterology Organization Global Guidelines (February 2012)

20. Salmonella
•Definitive dx: isolation of the organism
from blood(40-80 %sensitive), BM or
other sterile sites
–1
st
week – blood
–2
nd
week – urine
–3
rd
week – stool
The Merck Manual 19th Edition

21. Types of Bacterial Infection
World Gastroenterology Organization Global Guidelines (February 2012)

22. Acute Gastroenteritis
•Viral agents:
Rotavirus
–Leading cause of severe, dehydrating gastroenteritis
among children
Norovirus
–Belongs to the family Caliciviridae
–Most common cause of outbreaks affecting in all age
group
Sapovirus
–Also from the family of Caliciviridae
–Primarily affects children
–2
nd
most common viral agent after rotavirus
World Gastroenterology Organization Global Guidelines (February 2012)

23. Acute Gastroenteritis
•Parasitic agents:
Giardia intestinalis
Cryptosporidium parvum
Entamoeba histolytica
World Gastroenterology Organization Global Guidelines (February 2012)

24. PATHOGENESIS
World Gastroenterology Organization Global Guidelines (February 2012)
Bacteria
Releases toxins
Invasion and destruction
of mucosal cells
Stimulating the
production of AMP
from ATP
Organism attaches to the
surface of the cell
In the villus cells, there will be ↓
in the active absorption of Na
In the crypt cells, there will be ↑
in the secretion of chloride and
water
Bacteria Produce micro-
abscessess and ulcers
Blood to appear in Stool
Mechanisms:
1. Inoculum size- varies
2. Toxin production
Enterotoxin
Cytotoxins
Neurotoxins
3. Adherence
4.Invasion
5.Ability to combat host defenses

25. PATHOGENESIS
Virus
First is decreased
absorption
Second is destruction of
brush borders
1.Malabsorption of
electrolytes
2.Stimulation of CAMP
3.Carbohydrate
Malabsorption
Viral Diarrhea
The virus enters the cell, it
multiplies and destroys the cell
Decrease or diminish
secretion of enzyme lactase
Third is increased
secreation
Causing blunting and
flattening of the villi
Lactase malabsorption
Rapid movement upward even
though they are still immature
The crypt cells occupy
the absorptive area of
the villi
Decrease
absorption.
increasing the secretion
process

26. Episodes of Diarrhea
MIMS Gastroenterology Philippines
2009
Infectious
Diarrhea
Chronic
Diarrhea

27. Episodes of Diarrhea
World Gastroenterology Organization Global Guidelines (February 2012)
Common and associated with
invasive pathogens
-Invasive and cytotoxin releasing
pathogens
-Suspect EHEC infection in the absence
of fecal leukocytes
-Not with viral agents and enterotoxins
releasing bacteria
Frequently in viral diarrhea and
illness caused by ingestion of
bacterial toxins (eg S. aureus)

29. Evaluation of the Acute Diarrhea
World Gastroenterology Organization Global Guidelines (February 2012)
• Onset, stool
frequency, type and
•volume
• Presence of blood
• Vomiting
• Medicines received
• Past medical history
• Underlying
conditions
• Epidemiological clues
•24h food recall
• Body weight
• Temperature
• Pulse/heart and
respiratory rate
• Blood pressure
•Pediatric details:
Evidence of
associated problems
in children
History Physical
Examination

30. Patient’s History and Causes
of Acute Diarrhea

31. Assess Dehydration

33. DHAKA METHOD
ASSESSMENT PLAN A PLAN B PLAN C
1.General
condition
N Irritable/ less active*Lethargic /comatose
*
2. Eyes N Sunken Sunken
3. Mucosa N Dry Dru
4. Thirst N Thirsty Unable to drink*
5. Radial pulse N Low volume* Absent
6. Skin turgor N Reduced* Reduced
Diagnosis No signs of
dehydration
Some dehydration
At least 2 signs;
including one key
sign (*) are present
Severe dehydration
Some signs of
dehydration plus at
least one key sign
present
World Gastroenterology Organization Global Guidelines (February 2012)

34. 1.Two of the ff. signs:
Drowsy, lethargic
 Sunken eyes
Not able to drink, drinking poorly
 Skin pinch goes back very slowly
SEVERE DEHYDRATION
2. Two of the ff signs:
 Restless, irritable
 Sunken eyes
Thirsty, drinks eagerly Skin pinch goes back very
slowly
Skin pinch goes back slowly
SOME DEHYDRATION

35. LABORATORY EVALUATION
•Stool examination (Fecalysis)
•CBC
•Serum electrolyte concentrations (Na, K, Cl)
•BUN, Creatinine
•Other labs:
–ABG
–RBS

36. TREATMENT
PLAN A PLAN B PLAN C
TREATMENT Prevent
dehydration
Reassess
periodically
Rehydrate with
ORS solution
Reassess
frequently
Rehydrate with
I.V. fluids and
ORS
Reassess more
frequently
World Gastroenterology Organization Global Guidelines (February 2012)

37. TREATMENT
PLAN A
-Home therapy to prevent dehydration and malnutrition
Rule 1: give more fluids than usual
•<2 y.o : 50-100 ml after each loose stool
•2-10 : 100-200ml
•Older children and adults : as much as the want
Rule 2: give Zinc (10-20mg) daily for 10-14 days
Rule 3: Continue to feed the child to prevent
malnutrition
Rule 4: take the child to a health worker when signs of
dehydration develop
World Gastroenterology Organization Global Guidelines (February 2012)

38. TREATMENT
PLAN B
Oral rehydration therapy (ORS)
Give also supplemental Zinc
Monitoring of the patient’s conditon
If at any time the patient develops signs of severe
dehydration, shift to plan C
World Gastroenterology Organization Global Guidelines (February 2012)

39. TREATMENT
PLAN C
•Intravenous rehydration
- Give 100ml/kg PLR:

•Reassess patient every 1-2 hours
•After 3 or 6 hrs evaluate patient then choose
appropriated treatment plan
World Gastroenterology Organization Global Guidelines (February 2012)
Age First give 30ml/kg in:Then give 70ml/kg in:
Infants <12 months 1 hour 5 hours
Older 30 minutes 2.5 hours

40. Oral Rehydration Therapy
Oral rehydration therapy (ORT) is the administration of
appropriate solutions by mouth to prevent or correct diarrheal
dehydration.
The new lower-osmolarity ORS recommended by (WHO and
UNICEF) has reduced concentrations of sodium and glucose
is associated with:
less vomiting
less stool output
lesser chance of hypernatremia
reduced need for intravenous infusions in comparison
with standard ORS.
World Gastroenterology Organization Global Guidelines (February 2012)

41. Oral Rehydration Therapy
•ORT consists of:
• Rehydration
• Maintenance fluid therapy
•According to the 2012 WGO guidelines ORT is
contraindicated as initial therapy in:
cases of severe dehydration,
children with paralytic ileus,
frequent and persistent vomiting
Painful oral conditions such as moderate to severe
thrush
World Gastroenterology Organization Global Guidelines (February 2012)

42. Oral Rehydration Therapy
However, nasogastric (NGT) administration of ORS
solution is potentially lifesaving when intravenous
rehydration is not possible.
Rice-based ORS is superior to standard ORS in cholera
Home-made oral fluid recipe
The ingredients to be mixed are:
One level teaspoon of salt.
4 level tablespoon of sugar.
One liter (five cupfuls) of clean drinking water, or water
that has been boiled and then cooled.
World Gastroenterology Organization Global Guidelines (February 2012)
It is not superior to standard ORS in the
treatment of children with acute noncholera
diarrhea, especially when food is given
shortly after rehydration

43. Oral Rehydration Therapy
World Gastroenterology Organization Global Guidelines (February 2012)

44. Treatment of ORS based on
Degree of Dehydration

45. SUPPORTIVE TREATMENT
Zinc supplement
Recommendation :
20mg OD for 10 days
Infants: 10mg/day OD for 10 days
Multivitamins and minerals
Diet:
normal feeding should be continued for those with no
signs of dehydration
food should be started immediately after correction of
some and severe dehydration
World Gastroenterology Organization Global Guidelines (February 2012)

46. SUPPORTIVE TREATMENT
Diet:
Breastfed infants and children should continue
receiving food
However, for non-breastfed, dehydrated children and
adults, rehydration is the first priority.
 Frequent, small meals throughout the day (6
meals/day),
Avoid fruit juices
•Probiotics are said to be beneficial
(http://www.worldgastroenterology.org/probioticsprebiotics.html)
World Gastroenterology Organization Global Guidelines (February 2012)

47. Nonspecific Antidiarrheal Agents

48. Antimicrobial Agents
ORGANISM DOC DOSAGE
Shige lla Ciprofloxacin, ampicillin, ceftriaxone,
azithromycin, or TMP-SMX
Most strains are resistant now to several
antibiotics
•Ceftriaxone 50-100 mg/kg/day IV or
IM, qd or bid for 7 days
•Ciprofloxacin
20-30 mg/kg/day PO bid for 7-10
days
•Ampicillin PO,IV 50-100 mg/kg/day
qid for 7 days
EPEC, ETEC,
EIEC
TMP-SMX or ciprofloxacin •TMP 10 mg/kg/day
and SMX 50 mg/kg/day
bid for 5 days
•Ciprofloxacin PO 20-30 mg/kg/day
qid for 5-10 days
Salm o ne lla No antibiotics for uncomplicated
gastroenteritis in normal hosts caused by
nontyphoidal species
Treatment is indicated in infants <3 mo,
and patients with malignancy, chronic GI
disease,severe colitis hemoglobinopathies,
or HIV infection, and other
immunocompromised patients
Most strains have become resistant to
multiple antibiotics
See treatment
of Shige lla

49. Antimicrobial Agents

50. Antimicrobial Agents
Treatment for amebiasis should
ideally include diloxanide furoate
following the metronidazole, to get rid
of the cysts that may remain after the
metronidazole treatment;
nitazoxanide is an alternative.

51. Approach in Adults with Acute
Diarrhea
1. Perform initial assessment.
2. Manage dehydration.
3. Prevent dehydration in patients with no signs of
dehydration, using home-based fluids or ORS solution.
• Rehydration of patients with some dehydration using
ORS
– Correct dehydration of a severely dehydrating patient
with an appropriate intravenous fluid.
• Maintain hydration using ORS solution.
-Treat symptoms if necessary
World Gastroenterology Organization Global Guidelines (February 2012)

52. Approach in Adults with Acute
Diarrhea
4. Stratify subsequent management:
• Epidemiological clues: food, antibiotics, sexual activity,
travel, day-care attendance, other illness, outbreaks,
season.
• Clinical clues: bloody diarrhea, abdominal pain,
dysentery, wasting, fecal
inflammation.
5. Obtain a fecal specimen for analysis
6. Consider antimicrobial therapy for specific pathogens.
World Gastroenterology Organization Global Guidelines (February 2012)

53. Indications for Medical Consultation or
In-patient Care are:
Caregiver’s report of signs consistent with
dehydration
Changing mental status
History of premature birth, chronic medical
conditions, or concurrent illness
Young age (< 6 months or < 8 kg weight)
Fever 38 °C for infants < 3 months old or
39 °C for children aged 3–36 months
World Gastroenterology Organization Global Guidelines (February 2012)

54. Indications for Medical Consultation or
In-patient Care are:
Visible blood in stool
High-output diarrhea, including frequent and
substantial volumes
Persistent vomiting, severe dehydration,
persistent fever
Suboptimal response to ORT
No improvement within 48 hours—symptoms
exacerbate and overall condition gets worse
No urine in the previous 12 hours
World Gastroenterology Organization Global Guidelines (February 2012)

55. When to discharge?
Stable Vital signs
Normal urine output
Maintains a sufficient fluid intake
Able to eat meals adequately
Able to take medications (if still indicated)
World Gastroenterology Organization Global Guidelines (February 2012)

56. Prevention
•Promotion of exclusive breast feeding
Promotes passive immunity
•Improved complementary feeding practices
Start giving complementary food at 6
mo. And continue BF up to 1 year or
longer
•Rotavirus immunization
•Improved case management of diarrhea
•Patient education

57. Patient Education
•Family knowledge
•Proper personal hygiene and safe food
preparation
•Human feces must always be considered
potentially hazardous, whether or not diarrhea or
potential pathogens have been identified.

58. Patient Education
•Hand-washing with soap is an effective step in
preventing spread of illness
•Select populations may require additional
education about food safety, and health care
providers can play an important role in providing
this information.

65. Thank you!