Viral Gastroenteritis Clinical Presentation

  • Author: Michael Vincent F Tablang, MD; Chief Editor: Julian Katz, MD   more...
 
Updated: Mar 19, 2012
 

History

The clinical spectrum of acute viral gastroenteritis ranges from asymptomatic infection to severe dehydration and death. Viral gastroenteritis typically presents with short prodrome, with mild fever and vomiting, followed by 1-4 days of nonbloody, watery diarrhea. Viral gastroenteritis is usually self-limited.

  • The history should focus on severity and dehydration. The onset, frequency, quantity, and duration of diarrhea and vomiting are important factors in assessing the status. Oral intake, urine output, and weight loss are important considerations. Viruses are the suspected cause of acute gastroenteritis when vomiting is prominent, when the incubation period is longer than 14 hours, and when the entire illness is over in less than 3 days. Travel history (including cruise ships), eating history, and daycare history are important epidemiological factors.
  • A viral cause should be suspected when the warning signs of bacterial infection (ie, high fever, bloody diarrhea, severe abdominal pain, >6 stools/24 h) are absent and an alternative diagnosis is not suggested by epidemiologic clues from the history (eg, travel, sexual practices, antibiotic use).
  • Factors associated with severe and prolonged disease are immunodeficiency and immune suppression, comorbid disease, and malnutrition.
  • Death results from dehydration and acidosis.
  • Ruling out other diagnoses is important. Mucus or overt blood in the stool almost always indicates bacterial or parasitic infection.

In 1982, the Kaplan criteria were established to distinguish outbreaks due to norovirus from outbreaks of bacterial etiology. The criteria are highly specific (99%) and moderately sensitive (68%). The 4 criteria indicative of an outbreak due to norovirus are as follows:[11]

  • Vomiting in 50% of affected persons in the outbreak
  • Mean incubation period of 24-48 hours
  • Mean duration of illness of 12-60 hours
  • Lack of identification of a bacterial pathogen in stool culture
Next

Physical

The physical examination can be helpful in determining the etiology of gastroenteritis and in assessing the presence and degree of dehydration.

  • Temperature, blood pressure and pulse, and body weight can provide evidence of severity of the condition.
  • Temperature may be slightly elevated. High fever suggests bacterial infection. Tachycardia, thready pulse, and hypotension suggest severe dehydration.
  • The degree of weight loss may be related to dehydration and the duration of the diarrhea.
  • The mucous membranes and the skin should be examined carefully. Dry mouth, no tears, skin tenting, dry skin, and capillary refill are all signs of dehydration.
  • The mental status in elderly patients and infants may be abnormal, especially when blood pressure and circulation are compromised.
  • The abdominal examination may demonstrate mild tenderness. Severe abdominal pain and tenderness suggest bacterial infection or an abdominal emergency.
Previous
Next

Causes

  • Sporadic infantile viral gastroenteritis
    • Group A rotavirus causes 25-65% of severe infantile gastroenteritis worldwide.
    • Acute infections with group C are quite frequent in the United States and worldwide.
    • After rotavirus, the most important cause of acute infantile gastroenteritis probably is calicivirus infection. Seroepidemiologic studies have shown that antibodies to caliciviruses are present in 50-90% of children younger than 2 years in Kuwait, Italy, Kenya, China, London, and South Africa. Using broadly reactive reverse-transcription polymerase chain reaction for calicivirus to study stool specimens from children with acute gastroenteritis, studies have found these viruses in 7-22% of cases.
    • Astrovirus infection is associated with 2-9% of cases of infantile gastroenteritis worldwide, making it the third most frequent cause after rotavirus and calicivirus. The burden of astrovirus disease in developing countries might be especially high.
    • Researchers have recognized for a long time that certain enteric adenoviruses are an important cause of infantile gastroenteritis. Studies confirm that they cause 2-6% of cases.
  • Epidemic viral gastroenteritis
    • Most cases of epidemic viral gastroenteritis in adults and children are caused by the caliciviruses. Some examples include Norovirus (formerly called Norwalk-like viruses), genogroup I (eg, Norwalk, Southampton, Desert Shield, Cruise Ship); Norovirus (formerly Norwalk-like viruses), genogroup II (eg, Snow Mountain, Mexico, White River, Lordsdale, Bristol, Camberwell, Toronto, Hawaii, Melksham); and Sapovirus (formerly Sapporo-like viruses), which sometimes are referred to as genogroup III, although they are not like Norwalk (eg, Sapporo, Parkville, Manchester, Houston, London).
    • Modern molecular diagnostic techniques, such as broadly reactive reverse-transcription polymerase chain reaction, have linked these viruses to epidemics associated with oysters, contaminated community water supplies, restaurant food, hospital patients and staff, day care facilities, nursing homes, college dormitories, military ships, cruise ships, and vacation spots.
    • Rotavirus and astrovirus also may cause epidemics of viral gastroenteritis.
  • Sporadic adult viral gastroenteritis
    • Few studies have examined the causes of sporadic cases of adult viral gastroenteritis.
    • Seroepidemiologic evidence suggests that the etiologies are (in descending order of frequency) caliciviruses, non–group A rotavirus, astrovirus, and adenovirus.
Previous
Proceed to Differential Diagnoses
 
 
Contributor Information and Disclosures
Author

Michael Vincent F Tablang, MD  Resident Physician, Department of Internal Medicine, University of Connecticut Health Center

Michael Vincent F Tablang, MD is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Michael J Grupka, MD  Physician, Atlanta Center for Gastroenterology

Disclosure: Nothing to disclose.

George Y Wu, MD, PhD  Professor, Department of Medicine, Director, Hepatology Section, Herman Lopata Chair in Hepatitis Research, University of Connecticut School of Medicine

George Y Wu, MD, PhD is a member of the following medical societies: American Association for the Study of Liver Diseases, American Gastroenterological Association, American Medical Association, American Society for Clinical Investigation, and Association of American Physicians

Disclosure: Springer Consulting fee Consulting; Gilead Consulting fee Review panel membership; Vertex Honoraria Speaking and teaching; Bristol-Myers Squibb Honoraria Speaking and teaching; Springer Royalty Review panel membership; Merck Honoraria Speaking and teaching

Specialty Editor Board

John Gunn Lee, MD  Director of Pancreaticobiliary Service, Associate Professor, Department of Internal Medicine, Division of Gastroenterology, University of California at Irvine School of Medicine

John Gunn Lee, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Noel Williams, MD  Professor Emeritus, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Professor, Department of Internal Medicine, Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada

Noel Williams, MD is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Alex J Mechaber, MD, FACP  Senior Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine

Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine

Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD  Clinical Professor of Medicine, Drexel University College of Medicine

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

References

  1. Ramani S, Kang G. Viruses causing childhood diarrhoea in the developing world. Curr Opin Infect Dis. Oct 2009;22(5):477-82. [Medline].

  2. Scarcella C, Carasi S, Cadoria F, et al. An outbreak of viral gastroenteritis linked to municipal water supply, Lombardy, Italy, June 2009. Euro Surveill. Jul 23 2009;14(29):epub ahead of print. [Medline].

  3. Lorrot M, Vasseur M. How do the rotavirus NSP4 and bacterial enterotoxins lead differently to diarrhea?. Virol J. Mar 21 2007;4:31. [Medline].

  4. Estes MK, Prasad BV, Atmar RL. Noroviruses everywhere: has something changed?. Curr Opin Infect Dis. Oct 2006;19(5):467-74. [Medline].

  5. Desai R, Yen C, Wikswo M, Gregoricus NA, Provo JE, Parashar UD, et al. Transmission of norovirus among NBA players and staff, winter 2010-2011. Clin Infect Dis. Dec 2011;53(11):1115-7. [Medline].

  6. CDC research shows outbreaks linked to imported foods increasing. Available at http://www.cdc.gov/media/releases/2012/p0314_foodborne.html. Accessed March 14, 2012.

  7. Tate JE, Panozzo CA, Payne DC, et al. Decline and change in seasonality of US rotavirus activity after the introduction of rotavirus vaccine. Pediatrics. Aug 2009;124(2):465-71. [Medline].

  8. Smith MJ, Clark HF, Lawley D, et al. The clinical and molecular epidemiology of community- and healthcare-acquired rotavirus gastroenteritis. Pediatr Infect Dis J. Jan 2008;27(1):54-8. [Medline].

  9. Centers for Disease Control and Prevention (CDC). Deaths from gastroenteritis double. Available at http://www.cdc.gov/media/releases/2012/p0314_gastroenteritis.html.

  10. Notes from the field: outbreaks of rotavirus gastroenteritis among elderly adults in two retirement communities--Illinois, 2011. MMWR Morb Mortal Wkly Rep. Oct 28 2011;60(42):1456. [Medline].

  11. Turcios RM, Widdowson MA, Sulka AC, et al. Reevaluation of epidemiological criteria for identifying outbreaks of acute gastroenteritis due to norovirus: United States, 1998-2000. Clin Infect Dis. Apr 1 2006;42(7):964-9. [Medline].

  12. Lee N, Chan MC, Wong B, et al. Fecal viral concentration and diarrhea in norovirus gastroenteritis. Emerg Infect Dis. Sep 2007;13(9):1399-401. [Medline].

  13. Vandenplas Y, Salvatore S, Vieira M, et al. Probiotics in infectious diarrhoea in children: are they indicated?. Eur J Pediatr. Dec 2007;166(12):1211-8. [Medline].

  14. Sartor RB. Therapeutic manipulation of the enteric microflora in inflammatory bowel diseases: antibiotics, probiotics, and prebiotics. Gastroenterology. May 2004;126(6):1620-33. [Medline].

  15. US Food and Drug Administration. FDA Approves New Vaccine to Prevent Gastroenteritis Caused by Rotavirus. Available at http://www.fda.gov/bbs/topics/NEWS/2008/NEW01814.html.

  16. Glass RI, Parashar UD. The promise of new rotavirus vaccines. N Engl J Med. Jan 5 2006;354(1):75-7. [Medline].

  17. [Best Evidence] Ruiz-Palacios GM, Perez-Schael I, Velazquez FR, et al. Safety and efficacy of an attenuated vaccine against severe rotavirus gastroenteritis. N Engl J Med. Jan 5 2006;354(1):11-22. [Medline].

  18. American Academy of Pediatrics. Red Book® Online Table - NEWStatus of Licensure and Recommendations for New Vaccines*. Available at http://aapredbook.aappublications.org/news/vaccstatus.shtml.

  19. American Academy of Pediatrics. Practice parameter: the management of acute gastroenteritis in young children. American Academy of Pediatrics, Provisional Committee on Quality Improvement, Subcommittee on Acute Gastroenteritis. Pediatrics. Mar 1996;97(3):424-35. [Medline].

  20. Ball JM, Graham DY, Opekun AR, et al. Recombinant Norwalk virus-like particles given orally to volunteers: phase I study. Gastroenterology. Jul 1999;117(1):40-8. [Medline].

  21. Belhorn T. Rotavirus diarrhea. Curr Probl Pediatr. Aug 1999;29(7):198-207. [Medline].

  22. Bon F, Fascia P, Dauvergne M, et al. Prevalence of group A rotavirus, human calicivirus, astrovirus, and adenovirus type 40 and 41 infections among children with acute gastroenteritis in Dijon, France. J Clin Microbiol. Sep 1999;37(9):3055-8. [Medline].

  23. Burkhart DM. Management of acute gastroenteritis in children. Am Fam Physician. Dec 1999;60(9):2555-63, 2565-6. [Medline].

  24. Caeiro JP, Mathewson JJ, Smith MA, et al. Etiology of outpatient pediatric nondysenteric diarrhea: a multicenter study in the United States. Pediatr Infect Dis J. Feb 1999;18(2):94-7. [Medline].

  25. Centers for Disease Control and Prevention. Advisory Committee Recommends New Vaccine to Prevent Rotavirus. [Full Text].

  26. Centers for Disease Control and Prevention. Outbreak of Gastroenteritis Associated with Noroviruses on Cruise Ships --- United States, 2002. MMWR Morb Mortal Wkly Rep. Dec 13 2002;51(49):1112-1115. [Full Text].

  27. Centers for Disease Control and Prevention. Withdrawal of rotavirus vaccine recommendation. JAMA. Dec 8 1999;282(22):2113-4. [Medline].

  28. Clark B, McKendrick M. A review of viral gastroenteritis. Curr Opin Infect Dis. Oct 2004;17(5):461-9. [Medline].

  29. DuPont HL. Guidelines on acute infectious diarrhea in adults. The Practice Parameters Committee of the American College of Gastroenterology. Am J Gastroenterol. Nov 1997;92(11):1962-75. [Medline].

  30. Estes MK, Morris AP. A viral enterotoxin. A new mechanism of virus-induced pathogenesis. Adv Exp Med Biol. 1999;473:73-82. [Medline].

  31. Fankhauser RL, Noel JS, Monroe SS, et al. Molecular epidemiology of "Norwalk-like viruses" in outbreaks of gastroenteritis in the United States. J Infect Dis. Dec 1998;178(6):1571-8. [Medline].

  32. Flem E, Vainio K, Dollner H, et al. Rotavirus gastroenteritis in Norway: Analysis of prospective surveillance and hospital registry data. Scand J Infect Dis. 2009;41(10):753-9. [Medline].

  33. Ford T. Emerging issues in water and health research. J Water Health. 2006;4 Suppl 1:59-65. [Medline].

  34. Gaggero A, O'Ryan M, Noel JS, et al. Prevalence of astrovirus infection among Chilean children with acute gastroenteritis. J Clin Microbiol. Dec 1998;36(12):3691-3. [Medline].

  35. Glass RI, Parashar UD. The promise of new rotavirus vaccines. N Engl J Med. Jan 5 2006;354(1):75-7. [Medline].

  36. Green J, Gallimore CI, Norcott JP, et al. Broadly reactive reverse transcriptase polymerase chain reaction for the diagnosis of SRSV-associated gastroenteritis. J Med Virol. Dec 1995;47(4):392-8. [Medline].

  37. ICTVdb. The Universal Virus Database of the International Committee on Taxonomy of Viruses Web site. Available at: http://ictvdb.bio2.columbia.edu/Ictv/index.htm. Accessed on December 27, 2002.

  38. Johnsen CK, Midgley S, Bottiger B. Genetic diversity of sapovirus infections in Danish children 2005-2007. J Clin Virol. Nov 2009;46(3):265-9. [Medline].

  39. Maldonado Y, Cantwell M, Old M, et al. Population-based prevalence of symptomatic and asymptomatic astrovirus infection in rural Mayan infants. J Infect Dis. Aug 1998;178(2):334-9. [Medline].

  40. Mead PS, Slutsker L, Dietz V, et al. Food-related illness and death in the United States. Emerg Infect Dis. Sep-Oct 1999;5(5):607-25. [Medline].

  41. Pang XL, Joensuu J, Vesikari T. Human calicivirus-associated sporadic gastroenteritis in Finnish children less than two years of age followed prospectively during a rotavirus vaccine trial. Pediatr Infect Dis J. May 1999;18(5):420-6. [Medline].

  42. Pang XL, Koskenniemi E, Joensuu J, et al. Effect of rhesus rotavirus vaccine on enteric adenovirus--associated diarrhea in children. J Pediatr Gastroenterol Nutr. Sep 1999;29(3):366-9. [Medline].

  43. Pang XL, Vesikari T. Human astrovirus-associated gastroenteritis in children under 2 years of age followed prospectively during a rotavirus vaccine trial. Acta Paediatr. May 1999;88(5):532-6. [Medline].

  44. [Best Evidence] Ruiz-Palacios GM, Perez-Schael I, Velazquez FR, et al. Safety and efficacy of an attenuated vaccine against severe rotavirus gastroenteritis. N Engl J Med. Jan 5 2006;354(1):11-22. [Medline].

  45. Saps M, Pensabene L, Turco R, et al. Rotavirus gastroenteritis: precursor of functional gastrointestinal disorders?. J Pediatr Gastroenterol Nutr. Nov 2009;49(5):580-3. [Medline].

  46. Shornikova AV, Isolauri E, Burkanova L, et al. A trial in the Karelian Republic of oral rehydration and Lactobacillus GG for treatment of acute diarrhoea. Acta Paediatr. May 1997;86(5):460-5. [Medline].

  47. [Best Evidence] Vesikari T, Matson DO, Dennehy P, et al. Safety and efficacy of a pentavalent human-bovine (WC3) reassortant rotavirus vaccine. N Engl J Med. Jan 5 2006;354(1):23-33. [Medline]. [Full Text].

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.