Acute gastroenteritis presentation 2018

Acute gastroenteritis in adult and children

1. Acute Gastroenteritis Presented by Abdulaziz Bagasi – R2 Family Medicine NGH Supervised by Dr.Nisreen Asraf 22 nd November 2018 1

2. Objectives Definitions Differential diagnosis Clinical approach(history ,physical examination, investigation) Management Indications of referral Prevention MCQs 2

3. Acute Gastroenteritis I ncreased stool frequency with or without vomiting, fever, or abdominal pain 3

4. Definition of acute diarrhea The passage of : • 3 or more loose or liquid stools per 24 hours and/or • Stools that are more frequent than what is normal for the individual lasting <14 days and/or • Stool weight greater than 200 g/day. 4

5. Causes of acute diarrhea in adults : infections Viral pathogens   N orovirus ( cause 50% of acute diarrheal illnesses in the United States) Rotavirus   (mostly affects children ≤ 2 years old ) B acterial pathogens    Salmonella ,  Shigella ,  Campylobacter ,   E. coli , and  Clostridium difficile . Parasites     Giardia lamblia  and  Entamoeba histolytica 5

6. Causes of acute diarrhea in adults : Noninfectious conditions Medications Endocrine conditions Gastrointestinal conditions Antibiotics (especially broad-spectrum and clavulanic acid containing) Neuroendocrine tumors Inflammatory bowel disease Laxatives Hyperthyrodism Irritable bowel syndrome (IBS) Magnesium antacids Lactose intolerance Colchicine Celiac disease Long-term steroid Ischemic colitis 6

7. Non-inflammatory vs. Inflammatory infectious diarrhea 7

8. Causes(DDs) of acute diarrhea in children : infectious Gastrointestinal infection T he most common cause of acute diarrhea in children Viral pathogens account for most cases of gastroenteritis in children 8

9. Causes(DDs) of acute diarrhea in children : Non-infectious Medications Endocrine disease Extraintestinal infection Gastrointestinal conditions life-threatening conditions Antibiotics (especially broad-spectrum and clavulanic acid containing) Hyperthyroidism Meningitis Inflammatory bowel disease Intussusception Laxatives Carcinoid tumors Pneumonia IBS Hemolytic-uremic syndrome Magnesium antacids Urinary tract infection Lactose intolerance Clostridium difficile (pseudomembranous colitis) Colchicine Acute otitis media Celiac disease Toxic shock syndrome long-term steroid use Appendicitis (diarrhea may be initial symptom in some younger children) 9

10. Approach to patient with acute diarrhea 10

11. Case A 6 years old boy Came complaining of diarrhea for 3 days How to approach this patient ? 11

12. History Ask about symptom characteristics to assess severity Fever D iarrhea characteristics O nset D uration Frequency S everity S tool character - watery, bloody, mucus-filled Signs of dehydration T hirst D izziness C hange in mental status D ecreased urine output Decreased activity Chief concern (CC) 12

13. History A sk about associated symptoms Fever Tenesmus Nausea and/or vomiting Severe abdominal pain and age ≥ 50 years A sk about stool characteristics Bloody stool bacterial infection with intestinal inflammation Rice-water stool   Vibrio cholera   A sk about timing of symptoms after suspected infectious exposure O nset 2-7 hours after possible exposure  foodborne illness O nset 24-48 hours after possible exposure viral pathogen A sk about duration D iarrhea lasting > 7 days raises suspicion of parasitic infection, especially if weight loss. History of present illness 13 bacterial infection, but does not exclude viral infection. bacterial infection. viral gastroenteritis or food poisoning  intra-abdominal condition which may require surgical intervention

14. History A sk about past medical conditions that are associated with diarrhea Gastrointestinal conditions Endocrine conditions S ome conditions raise suspicion of specific etiology R ecent hospitalization or antibiotic use Clostridium difficile infection. Ask about medications associated with diarrhea Past medical history Medication history 14

15. History Fluid and food intake (including breast milk ) since onset of diarrhea A sk about recent food consumption Untreated water raises suspicion of parasitic infection or cholera F ried rice raises suspicion of Bacillus cereus infection D airy and eggs R aw milk raises suspicion of Salmonella , Campylobacter, Shiga toxin-producing E. coli E ggs raises suspicion of Salmonella infection S eafood (particularly raw or undercooked shellfish) V . cholerae , Salmonella, or norovirus infections Poultry raises suspicion of Campylobacter or Salmonella infection Diet history 15

16. History T ravel to a developing country raises suspicion of  E. coli  (most common)  E xposure to animals (such as reptiles [may harbor  Salmonella ], or pets with diarrhea. Social history ICEE 16

17. Clues to the diagnosis of acute diarrhea ??? 17

18. Clues to the diagnosis of acute diarrhea cont. 18 ???

19. Physical exam Common findings on physical examination of patients with acute viral gastroenteritis M ild diffuse abdominal tenderness on palpation Fever Look for signs of dehydration to assess severity A bdominal examination (assess bowel sounds, palpate for localized pain and rebound tenderness) N eck stiffness (bacterial meningitis) 19

20. Dehydration in adult

21. Dehydration in children What are the most useful individual signs for identifying dehydration in children ?

22. The most useful individual signs for identifying dehydration in children are Prolonged capillary refill time A bnormal skin turgor A bnormal respiratory pattern 22

23. Back to the case A 6 years old boy Came complaining of diarrhea for 3 days fever 38 Mild diffused abdominal pain Vomiting 2 times daily of food contents , no blood It was sudden in onset and occurred about 4 times per day The diarrhea was watery in nature, yellowish to brown in color with no blood or mucus His mother said was appeared lethargic and less active than usual No recent history of taking outside food or travelling Other systemic review unremarkable Past medical/surgical history : negative Immunization up to his age 23

24. Back to the case On examination Awake ,alert, not ill looking Vital signs : fever and tachycardia , no hypotension Mild to mederate dehydrated : tongue and mucous membranes were dry , reduced skin turgor , Capillary refill time was less than 2 s ,no sunken eyes The abdomen appeared normal, o n palpation his abdomen was soft and non tender with no organomegaly . 24

25. What investigation will you order? 25

26. Investigation T esting usually not needed , particularly if symptoms are mild with no red flags and usually of viral etiology. 26

27. Indications of acute diarrhea testing 1) Severe illness Profuse watery diarrhea with signs of dehydration Passage of >6 unformed stools per 24 hours Severe abdominal pain 2) Other signs or symptoms concerning for inflammatory diarrhea Bloody diarrhea Passage of many small volume stools containing blood and mucus Temperature ≥38.5ºC (101.3ºF ) 3) High-risk host features Age ≥70 years Comorbidities , such as cardiac disease, which may be exacerbated by hypovolemia or rapid infusion of fluid Immunocompromising condition (HIV infection) 4) Inflammatory bowel disease 5) Pregnancy 6) Symptoms persisting for more than one week 7) Suspected infectious outbreak ( e.g handlers large quantities of food) 27

28. Investigation : stool analysis S tool studies (such as culture, PCR, or immunoassays ): Occult blood ( increase suspicion for inflammatory bacterial diarrhea) C onsider testing for fecal lactoferrin or fecal leukocytes to assess for inflammation. L actoferrin is marker for leukocytes released by damaged cells which increases in bacterial infections L actoferrin testing is the preferred method (over testing for leukocytes ) sensitivity > 90% and specificity > 70% Consider microbiological stool investigation (depend on the lab and the pathogen suspected). P arasitic infections: consider stool ova and parasite test PCR can detect evidence of multiple pathogens and can distinguish between them. 28

29. Investigation :Other tests B lood tests  CBC E lectrolytes B lood cultures U rinalysis 29

30. Back to the case CBC and electrolytes are normal Stool studies : negative Urine analysis : negative 30

31. What imaging will you order? 31

32. Indications for imaging  Abdominal imaging is not typically needed. F or patients who have significant peritoneal signs or ileus M ost typically CT to rule out other DD 32

33. So our diagnosis is acute viral gastroenteritis with mild to moderate dehydration 33

34. Q1 You are seeing a 6-year-old boy with nausea and vomiting. His symptoms began acutely last evening, starting with malaise, headache, low grade fever, body aches, and diarrhea. On examination, he has dry mucous membranes, but no orthostatic symptoms. He has diffuse mild abdominal pain without rebound or involuntary guarding. Which of the following is the best treatment for his condition ? a. Nothing by mouth until his symptoms improve b. Oral rehydration with clear liquids, advancing the diet as tolerated c. IV rehydration, advancing to oral as tolerated d. Antiemetics , given intravenously or intramuscularly e. Trimethoprim/ sulfamethoxazole therapy 34

35. Management 35

36. 36

37. Management Rehydration therapy Diet Antidiarrheal medications Antimicrobial medications Probiotics 37

38. 1.Rehydration therapy The most critical therapy in diarrheal illness. Preferably by the oral route, with solutions that contain water, salt, and sugar. C onsumption of fruit juices, sports drinks, soups, and saltine crackers  38

39. Dehydration in adult

40. Rehydration in children A cute GE (no or minimal signs of dehydration) managed at home after educating parents about fluid management, proper nutrition and how to identify signs of dehydration. I f dehydration is present O ral rehydration solution( e.g :  Pedialyte ) with mild to moderate dehydration IV rehydration with severe dehydration 40

41. Rehydration in children: Composed of two steps The first is to emergently correct severe dehydration with IV isotonic fluids Severe dehydration (more than 10%) : R apid infusion of 20 mL/kg of isotonic saline . Then reassess during and after the saline bolus And similar isotonic fluid infusions should be repeated as needed until adequate perfusion is restored. Mederate dehydration (6-9%) : B olus of 10 mL/kg is given over 30 to 60 minutes Then reassess to decide on administration of a repeat IV bolus or change to oral therapy. 41

42. Rehydration in children: Composed of two steps 2. The second step is to finish repletion of fluids and electrolytes either with IV fluids or ORT (the preferred method unless can not tolerating orally ) 42

43. ORS preparation at home F rom   Rehydration Project by UNICEF 1 L clean drinking water (or water that has been boiled and then cooled) o ne-half teaspoon salt 6 teaspoons sugar c onsider adding one-half cup orange juice or some mashed banana to provide potassium and improve taste 43

44. Q2 A 22-year-old healthy male sees you for “diarrhea.” He reports frequent loose stools without bleeding. You determine that he likely has a virally mediated process and recommend supportive care. Which of the following dietary measures should you recommend ? a. The patient should fast until the diarrhea resolves. b. The patient should not eat solids, but should drink an oral rehydrating solution. c. The patient should drink milk. d. The patient should drink fruit juice. e. The patient can eat rice and potatoes. 44

45. 2.Diet A fter dehydration resume feeding as soon as possible because it reduces illness duration L imited or no evidence to support although they are recommended : A voiding solid food or dairy BRAT diet 45

46. Anti-diarrhea medications are they recommended or not in acute GE ? 46

47. 3.Anti-diarrhea medications(in adult)   May reduce stool volume and frequency. Specific symptomatic therapies for adults with acute viral gastroenteritis with moderate to severe non-bloody diarrhea or signs of dehydration ,and no fever C ontraindicated if : bloody stool fever abdominal pain D ue to concern about prolonging duration of inflammatory infectious diarrhea. 47

48. 3.Anti-diarrhea medications (in children) In general, antidiarrheal medications should not be used in children with acute gastroenteritis because they delay the elimination of infectious agents from the intestines.   May be considered after patient is adequately hydrated (Weak recommendation) 48

49. 3.Anti-diarrhea medications Loperamide (anti-motility) (Imodium) monotherapy Initial dose ≤ 4 mg, with additional doses ≤ 2 mg after each unformed stool up to 8 mg/day (max 16 mg/day) for 2 days. Loperamide-simethicone combination Such as chewable tablet containing loperamide 2 mg plus simethicone 125 mg. Recommended over monotherapy for faster and more complete relief of acute nonspecific diarrhea and gas-related discomfort Racecadotril (anti-secretory) may reduce acute diarrhea in adults by about 1 day or about 1 unformed stool per day  49

50. 4.Antimicrobial medications Antimicrobial use not recommended in most patients Empiric antibiotic therapy not recommended unless high likelihood of traveler's diarrhea  50

51. 4.Antimicrobial medications I nappropriate use may lead to A ntimicrobial resistance P rolonged duration (such as with  Clostridium difficile   infection ) P rolonged carrier state (such as with  Salmonella  infection) H armful eradication of normal flora T reating Shiga toxin-producing  E.coli  (STEC) O157 with antimicrobials may increase risk of hemolytic-uremic syndrome (HUS)  51

52. 4.Antimicrobial medications C onsider antimicrobial therapy if Symptoms severe (such as passage ≥ 6 stools daily or duration without improvement > 72 hours) or do not improve after rehydration therapy or antidiarrheal medication  AND B acterial or parasitic pathogen strongly suspected such as with F ever or bloody stool Suspected hospital-associated or antibiotic therapy-associated diarrhea S uspected  traveler's diarrhea (characterized by ≥ 3 loose stools over 24-hour period shortly after or during travel ) 52

53. 5. probiotics   D efined by WHO: live microorganisms that, when administered in adequate amounts, confer a health benefit on the host. Example : Lactobacillus casei   . Probiotics may reduce duration of acute infectious diarrhea (level 2 [mid-level] evidence ) When used with an oral rehydration solution, probiotics can help reduce the duration of diarrhea in children with gastroenteritis P robiotics associated with reduced duration of diarrhea and stool frequency on day 2 of treatment in children < 5 years old with acute diarrhea (level 2 [mid-level] evidence) 53

54. Probiotics in private pharmacy 54

55. Do you recommend Z inc supplements in treatment of acute gastroenteritis? 55

56. Zinc supplementation The effect on adults H as not been studied, and its use is not the standard of care . The effect on children R educes the severity and duration of acute diarrhea in children from populations in which zinc deficiency is common 56

57. Indication of referral of GE (in adult) Signs of severe dehydration Persistent vomiting Abnormal electrolytes or renal function Excessive bloody stool or rectal bleeding Severe abdominal pain Prolonged symptoms (more than one week) Age 65 or older with signs of hypovolemia Comorbidities ( eg , diabetes mellitus, immunocompromised) Pregnancy Red Flags 57

58. Indication of referral of GE (in children) Diarrhea lasting more than one week Severe dehydration Hypernatremia Clinical features suggesting extraintestinal involvement or another etiology ( eg , hemolytic uremia syndrome) Immune compromise 58

59. Prevention Non-vaccine prevention methods G ood hygiene practices such as hand washing S afe practices in food preparation A ccess to clean water P robiotics 59

60. Probiotics in prevention P robiotics shown to reduce rate of antibiotic-associated diarrhea  (level 1 [likely reliable] evidence ) S ome probiotics appear effective in prevention of traveler's diarrhea   (level 2 [mid-level] evidence ) 60

61. P revention P rophylactic vaccines are available for Rotavirus (more common in children) T yphoid fever Cholera 61

62. Evaluation of acute diarrhea 63

63. MCQ 64

64. Q3 A 30-year-old man returned from a vacation in Mexico 1 day ago. He spent the last 3 days of his trip with loose, more frequent bowel movements that are continuing without resolution. He has not had bloody stool or fever. His examination is normal, except for mildly diffuse lower abdominal pain. Which of the following is the best empiric treatment option for his condition ? a. Erythromycin b. Ciprofloxacin c. Metronidazole d. Doxycycline e. Vancomycin 65

65. Q4 You are seeing a 6-month-old boy whose mother reports that he has had diarrhea for almost 2 weeks. He has had four to six bowel movements a day, with a loose to liquid consistency. His mother stays at home with him and the child is not in day care. His symptoms began after his young cousins visited for Christmas. Which of the following is the most likely cause of his diarrhea ? a. Rotavirus b. Norwalk virus c. Giardiasis d. Salmonella e. Enterotoxigenic Escherichia coli 66

66. Q5 You are performing a physical examination on a student traveling to Mexico with her college Spanish class. She is concerned about traveler’s diarrhea, and asks about antibiotic prophylaxis. Which of the following best represents the current guideline from the Centers for Disease Control and Prevention (CDC) for prevention of traveler’s diarrhea ? a. The CDC does not have an antibiotic guideline regarding antibiotic prophylaxis for traveler’s diarrhea. b. The traveler should take trimethoprim- sulfamethoxazole . c. The traveler should take doxycycline. d. The traveler should take ciprofloxacin. e. The traveler should take metronidazole 67

67. Explanation Q5 The answer is a. The CDC does not recommend antibiotic chemoprophylaxis for traveler’s diarrhea because of the development of resistant organisms. Most of the times, the condition is self-limited. The CDC does recommend using common sense regarding food and water,eating nothing unless it is boiled, peeled, or cooked. 68

68. Q6 An 18-month-old child presents to the emergency center having had a brief, generalized tonic clonic seizure. He is now postictal and has a temperature of 40°C (104°F). During the lumbar puncture (which proves to be normal), he has a large, watery stool that has both blood and mucus in it. The most likely diagnosis in this patient is a. Salmonella b. Enterovirus c. Rotavirus d. Campylobacter e. Shigella 69

69. Explanation Q6 The answer is e. Clinical manifestations of shigellosis range from watery stools for several days to severe infection, with high fever , abdominal pain, and generalized seizures. In general, about 50% of these children have emesis, greater than two-thirds have fever, 10 to 35% have seizures, and 40% have blood in their stool. Often, the seizure precedes diarrhea and is the complaint that brings the family to the physician. Fever usually lasts about 72 h, and the diarrhea resolves within 1 week . Presumptive diagnosis can be made on the clinical history; confirmation is through stool culture. Supportive care, including adequate fluid and electrolyte support, is the mainstay of therapy. Antibiotic treatment is problematic; resistance to trimethoprim- sulfamethoxazole is common, necessitating therapy with third-generation cephalosporins in many cases. 70

70. Q7 A 2-year-old boy develops bloody diarrhea shortly after eating in a fast-food restaurant. A few days later, he develops pallor and lethargy; his face looks swollen and his mother reports that he has been urinating very little. Laboratory evaluation reveals low hematocrit and platelet count and positive blood and protein in the urine. Which of the following diagnoses is likely to explain these symptoms ? a. Henoch-Schonlein purpura b. IgA nephropathy c. Intussusception d. Meckel diverticulum e. Hemolytic-uremic syndrome 71

71. Explanation Q7 The answer is e. Hemolytic-uremic syndrome is characterized by an acute microangiopathic hemolytic anemia, thrombocytopenia from increased platelet utilization, and renal insufficiency from vascularendothelial injury and local fibrin deposition. Ischemic changes result in renal cortical necrosis and damage to other organs such as colon, liver, heart , brain, and adrenal. Laboratory findings associated with hemolyticuremic syndrome include low hemoglobin level, decreased platelet count, hypoalbuminemia , and evidence of hemolysis on peripheral smear ( burr cells , helmet cells, schistocytes ). Urinalysis reveals hematuria and proteinuria. A marked reduction of renal function leads to oliguria and rising levels of blood urea nitrogen (BUN) and creatinine. Gastrointestinal bleeding and obstruction , ascites, and central nervous system findings such as somnolence, convulsions , and coma can occur. In the past decade, infection by the verotoxin -producing Escherichia coli 0157:H7 has been implicated as a cause of hemolytic-uremic syndrome. This organism is epizootic in cattle. Outbreaks associated with undercooked contaminated hamburgers have been reported in several states. Roast beef, cow’s milk, and fresh apple cider have been implicated as well. The Coombs test is not positive in this type of hemolytic anemia. 72

72. Q8 An awake, alert infant with a 2-day history of diarrhea presents with a depressed fontanelle , tachycardia, sunken eyes, and the loss of skin elasticity. The appropriate percentage of dehydration is a. Less than 1% b. 1 to 5% c. 5 to 9% d. 10 to 15% e. More than 20% 73

73. Explanation Q8 The answer is c. A moribund state is characteristic of a loss of greater than 10% of body weight from dehydration. The other findings are characteristic of a loss of body weight of 5 to 9% when there is no hypernatremia. Additional findings at this level of dehydration can be restlessness, absent or reduced tears , weak radial pulses, and, possibly, orthostatic hypotension. 74

74. 75

75. Any Questions? 76