eMedicine Specialties > Emergency Medicine > Gastrointestinal

Gastroenteritis: Follow-up

Author: Arthur Diskin, MD, Vice-President, Global Chief Medical Officer, Royal Caribbean Cruise Lines; Voluntary Associate Professor, University of Miami School of Medicine
Contributor Information and Disclosures

Updated: Oct 22, 2009

Follow-up

Further Inpatient Care

• Continue rehydration and management of electrolytes if ED response is inadequate.
• Manage sepsis in the toxic-appearing patient.
• Evaluate for underlying etiology if the diagnosis is uncertain.
• Manage complications.

Further Outpatient Care

• Rehydrate orally with balanced sodium and glucose solutions.
• Ensure appropriate early oral refeeding.
• Ensure appropriate deterrence and infection control procedures and activities, including notification of common source or close contact exposures, as appropriate.
• Administer antibiotic, antimotility, and antiemetic treatment only as indicated and directed.
• Wash buttocks after each diarrheal stool to avoid effects of stool enzyme on the skin.
• Instruct the patient to return upon experiencing bloody stools, worsening abdominal pain, severe vomiting, and/or concerns regarding dehydration.
• Instruct the patient to seek follow-up care if diarrhea persists longer than 10 days.

Inpatient & Outpatient Medications

• Antibiotics
• Antiemetics
• Antimotility agents

Transfer

• Transfer of the unstable patient is inappropriate under Emergency Medical Treatment and Active Labor Act (EMTALA) regulations unless benefits clearly outweigh risks.
• Unless the patient requires admission and has a complicated medical condition that would be better managed in another facility, transfer is neither necessary nor recommended.

Deterrence/Prevention

• The following are factors to consider with breastfeeding:
• Decreased incidence of rotavirus but does not eliminate this diagnosis
• Formula supplementation with nonpathogenic bacteria such as Bifidobacterium bifidum
• Take enteric precautions to avoid spread to family members, especially by washing hands before eating and after each stool or diaper change.
• Avoid shellfish served in unregulated environments, in areas with known red tides, or areas of recently reported outbreaks, including Vibrio species and Norwalk virus. Individuals with a history of any liver disease should avoid raw shellfish.
• Wash all produce prior to consumption, especially if imported.
• Avoid cross-contamination of foods during preparation (eg, cutting boards).
• Avoid raw or undercooked eggs or poultry.
• As many as 40% of travelers to high-risk areas (South and Southeast Asia, Africa, and Latin America) contract diarrhea. Dietary precautions, in addition to the above, which will reduce this risk are as follows:
• Eat steaming hot foods (cooked foods) and drink steaming hot beverages (eg, coffee, tea).
• Consume acidic foods, such as citrus.
• Consume dry foods, such as bread and nuts.
• Drink carbonated beverages.
• Avoid water, ice, raw fruits without a skin or peel, raw vegetables, unpasteurized milk and dairy products, and foods sold in the streets.
• Avoid moist foods served at room temperature, leafy green vegetables, and ripened fruit with broken skin.
• Take the above precautions when aboard the aircraft leaving the high-risk area.
• Travelers who request prophylaxis can take 2 tablets of Pepto-Bismol with each meal and at bedtime, not exceeding a daily dose of 8 tablets.
• Although prophylactic antimicrobial therapy generally should be discouraged in the young and healthy traveler, if chemoprophylaxis is requested, a daily single dose of TMP/SMZ or a fluoroquinolone can be provided.
• Travelers with certain underlying conditions should be encouraged to use prophylactic antibiotics. These include patients with AIDS, inflammatory bowel disease, systemic malignancy, insulin dependency, or achlorhydria and patients taking omeprazole or chronically using H2 antagonists. Sporadic or intermittent H2 antagonist use is not an indication for prophylaxis.
• Avoid drinking from unfamiliar fresh water sources, such as lakes and rivers.
• Norovirus
• There are very few ways to entirely eliminate norovirus. Alcohol-based hand sanitizers, used by a number of cruise lines and recommended by hospital-based practices, need a minimum of 30-60 seconds of contact time to be effective and should not be considered a substitute for aggressive handwashing and mechanical drying. In addition, sanitizing the finger tips and under the finger nails with alcohol hand gels is difficult, and this may be another factor in their relative infectiveness in comparison to handwashing with soap and water. Because norovirus is an unencapsulated virus, alcohol-containing products are less effective and require higher concentrations of alcohol. Two popular commercially available products containing 62% and 70% alcohol are not especially effective showing approximately a 2.0 log reduction.
• Alcohol-based hand gels are relatively ineffective in the disinfection and/or removal of norovirus from the hands. The recent increase in norovirus infection in acute care hospitals may be the result of the increased availability of alcohol-based hand gels, and the possible resultant reduction in the frequency of staff handwashing with soap and water and drying with a paper towel.
• During an outbreak on board a cruise ship, most surfaces that can be safely disinfected are treated with sodium hypochlorite (bleach), 1000 ppm, freshly constituted (higher concentrations quoted are not freshly constituted and may have varying efficacy). A 1-minute contact time is required, and a >4.0 log reduction is anticipated. However, this concentration is not approved for food handling surfaces and cannot be used on fabrics and many other surfaces.
• Steam cleaning to >70^o C is recommended for carpets and certain furnishings.
• Benzethonium chloride is a synthetic quaternary ammonium, surfactant, antiseptic, and anti-infective compound used as a topical antimicrobial agent and in antibacterial moist towelettes and wipes. While many of these compounds have limited efficacy for unencapsulated viruses, newer products seem more effective. However, studies show a contact time of >10 minutes may be required. Cruise lines are considering placing "quat wipes" outside of dining areas entrances.
• Accelerated and stabilized hydrogen peroxide is another product used for virucidal disinfecting. It requires a 5-minute contact time. It can be expensive, and, currently, no hand wipes are available.
• Phenolic-based products have been used with some success in the past, but concerns about toxicity and their mucosal irritation when "fogged" have meant most cruise lines have moved away from their primary use in mitigating norovirus.
• Oil of thyme, which has bactericidal and virucidal properties, is another hand wipe alternative.
• Numerous new products are always becoming available, and objective third-party evaluations are critical in the decision-making processes.
• A study by ATS labs compared Virox (accelerated hydrogen peroxide) wipes, Germstar (70% alcohol), and Benefact (oil of thyme). The lab used test methodology meant to replicate reality and used FCV as a surrogate virus. Their research found that after a 20-second contact time, no reduction occurred at all for Germstar, the Virox wipes had a complete inactivation of FCV, and Benefact had 99.9% reduction in viral titers (personal communication, Steve Williams, RN, Medical Coordinator, Carnival Cruise Lines).

Complications

• Dehydration
• Malabsorption
• Transient lactose intolerance
• Chronic diarrhea
• Systemic infection (meningitis, arthritis, pneumonia) especially with Salmonella infections
• Sepsis (Salmonella, Yersinia, Campylobacter organisms)
• Hemolytic-uremic syndrome (much more common in children, especially with E coli O157:H7)
• Toxic megacolon
• Reactive arthritides (Salmonella, Shigella, Yersinia, Campylobacter, Giardia organisms)
• Persistent diarrhea
• Thrombotic thrombocytopenic purpura or TTP (E coli O157:H7)
• Guillain-Barré syndrome (Campylobacter organisms)

Prognosis

• Most cases of gastroenteritis are self-limited with an excellent prognosis.

Patient Education

• Patients should be educated on the importance and proper methods of oral rehydration and early appropriate feeding.
• All patients, especially the parents of infants and young children, must be extensively educated about the signs and symptoms of dehydration.
• Patients with food-borne exposures should be educated on deterrence.
• Immunocompromised patients and individuals with liver disease should be educated not to consume raw shellfish, especially oysters.
• Travelers to underdeveloped areas should be made aware of proper avoidance measures, appropriate treatment, and current endemic illnesses.
• For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education articles, Gastroenteritis, Abdominal Pain in Adults, Diarrhea, and Vomiting and Nausea.

Miscellaneous

Medicolegal Pitfalls

• Failure to recognize dehydration or sepsis
• Failure to recognize immunocompromised patients and their potential, unusual etiologies or propensity to develop complications
• Failure to recognize hemolytic-uremic syndrome in the patient with E coli infection
• Failure to recognize pseudomembranous colitis (C difficile)
• Failure to recognize toxic megacolon
• Failure to diagnose appendicitis in the patient who presents with vomiting and diarrhea
• Failure to diagnose noninfectious etiology, such as ischemic bowel, bowel obstruction, or other etiologies for abdominal symptomatology
• Diagnosing gastroenteritis in a patient who is only vomiting when the vomiting is due to a nongastrointestinal and possibly life-threatening etiology
• Complications resulting from the inappropriate use of antimotility and antiemetic medications

Special Concerns

• Pseudomembranous colitis (C difficile)
  • This condition occurs mostly in patients who are hospitalized or live in a nursing home and who have recently been on antibiotics and is due to infection with toxin-producing strains of C difficile. Toxins A and B damage the mucosa of the colon.
  • Symptoms may range from mild to severe bloody diarrhea and colitis, with pseudomembranous colitis being the most severe form.
  • Complications include dehydration, toxic megacolon, and perforation.
  • Stop any antibiotics.
  • Treat with intravenous fluids and vancomycin or metronidazole.
  • Condition is suspect with prior or current antibiotic therapy.
  • Diagnosis via assay or sigmoidoscopy.
• Gastroenteritis in the elderly patient: Diagnosing complications, such as dehydration (may have chronic poor skin turgor and dry mucus membranes) is more difficult. Elderly patients may be unable to take needed medications. Electrolyte disorders and hypovolemia may have much more serious implications, and life-threatening abdominal emergencies, such as appendicitis, are easier to overlook. Fever may not be manifested, and pain sensation may be blunted.
• Travelers' diarrhea
  • Condition is usually self-limited (3-5 d).
  • Onset is within 1 week of arrival.
  • Fever, vomiting, and bloody stools are uncommon.
  • Early treatment may decrease duration.
  • Loperamide is often useful.
  • If a lack of response to antibiotics is present, check for parasites.
  • Consider C difficile in patients taking prophylactic antibiotics.
  • The use of probiotics, such as Lactobacillus GG, has had mixed results in treatment and prevention.
  • Rifaximin at 200 mg PO tid may be used for the treatment or prevention of travelers' diarrhea.⁵
• Food-borne toxigenic diarrhea
  • Condition is usually self-limited and of short duration.
  • Stool analysis and culture are not helpful.
  • Perform supportive treatment only.
  • Antibiotics rarely are useful or indicated.
• Diarrhea in patients with AIDS
  • The condition usually becomes more severe as the immune system deteriorates.
  • Patient may require antimotility agents only.
  • Consider drug-related and herb-related causes.
  • Start with empiric treatment with a quinolone and culture the stool.
  • Pursue diagnostic testing more aggressively because patients with AIDS are more likely to have an identifiable etiology.
  • Consider nonopportunistic bacterial and protozoal infections first, then etiologies such as CMV and Mycobacterium infections.
  • Treatment must include nutritional and psychosocial support.

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