Introduction
Background
Gastroenteritis is a nonspecific term for various pathologic states of the gastrointestinal tract. The primary manifestation is diarrhea, but it may be accompanied by nausea, vomiting, and abdominal pain. A universal definition of diarrhea does not exist, although patients seem to have no difficulty defining their own situation. Although most definitions center on the frequency, consistency, and water content of stools, the author prefers defining diarrhea as stools that take the shape of their container.
The severity of illness may vary from mild and inconvenient to severe and life threatening. Appropriate management requires extensive history and assessment and appropriate, general supportive treatment that is often etiology specific. Diarrhea associated with nausea and vomiting is referred to as gastroenteritis.
Diarrhea is one of the most common reasons patients seek medical care. In the developed world, it is the most common reason for missing work, while in the developing world, it is a leading cause of death. In developing countries, diarrhea is a seasonal scourge usually worsened by natural phenomena, as evidenced by monsoon floods in Bangladesh in 1998. An estimated 100 million cases of acute diarrhea occur every year in the United States. Of these patients, 90% do not seek medical attention, and 1-2% require admission. Diarrheal diseases can quickly reach epidemic proportions, rapidly overwhelming public health systems in even the most advanced societies.
Pathophysiology
Infectious agents usually cause acute gastroenteritis. These agents cause diarrhea by adherence, mucosal invasion, enterotoxin production, and/or cytotoxin production.
These mechanisms result in increased fluid secretion and/or decreased absorption. This produces an increased luminal fluid content that cannot be adequately reabsorbed, leading to dehydration and the loss of electrolytes and nutrients.
Diarrheal illnesses may be classified as follows:
- Osmotic, due to an increase in the osmotic load presented to the intestinal lumen, either through excessive intake or diminished absorption
- Inflammatory (or mucosal), when the mucosal lining of the intestine is inflamed
- Secretory, when increased secretory activity occurs
- Motile, caused by intestinal motility disorders
The small intestine is the prime absorptive surface. The colon then absorbs additional fluid, transforming a relatively liquid fecal stream in the cecum to well-formed solid stool in the rectosigmoid.
Disorders of the small intestine result in increased amounts of diarrheal fluid with a concomitantly greater loss of electrolytes and nutrients.
Microorganisms may produce toxins that facilitate infection. Enterotoxins are generated by bacteria (ie, enterotoxigenic Escherichia coli, Vibrio cholera) that act directly on secretory mechanisms and produce typical, copious watery (rice water) diarrhea. No mucosal invasion occurs. The small intestines are primarily affected, and elevation of the adenosine monophosphate (AMP) levels is the common mechanism.
Cytotoxin production by bacteria (ie, Shigella dysenteriae, Vibrio parahaemolyticus, Clostridium difficile, enterohemorrhagic E coli) results in mucosal cell destruction that leads to bloody stools with inflammatory cells. A resulting decreased absorptive ability occurs.
Enterocyte invasion is the preferred method by which microbes such as Shigella and Campylobacter organisms and enteroinvasive E coli cause destruction and inflammatory diarrhea. Similarly, Salmonella and Yersinia species also invade cells but do not cause cell death. Hence, dysentery does not usually occur. However, these bacteria invade the bloodstream across the lamina propria and cause enteric fever such as typhoid.
Diarrheal illness occurs when microbial virulence overwhelms normal host defenses. A large inoculum may overwhelm the host capacity to mount an effective defense. Normally, more than 100,000 E coli are required to cause disease, while only 10 Entamoeba or Giardia cysts may suffice to do the same. Some organisms (eg, V cholera, enterotoxigenic E coli) produce proteins that aid their adherence to the intestinal wall, thereby displacing the normal flora and colonizing the intestinal lumen.
In addition to the ingestion of pathogenic organisms or toxins, other intrinsic factors can lead to infection. An alteration of normal bowel flora can create a biologic void that is filled by pathogens. This occurs most commonly after antibiotic administration, but infants are also at risk prior to colonization with normal bowel flora.
The normally acidic pH of the stomach and colon is an effective antimicrobial defense. In achlorhydric states (ie, caused by antacids, histamine-2 [H2] blockers, gastric surgery, decreased colonic anaerobic flora), this defense is weakened.
Hypomotility states may result in colonization by pathogens, especially in the proximal small bowel, where motility is the major mechanism in the removal of organisms. Hypomotility may be induced by antiperistaltic agents (eg, opiates, diphenoxylate and atropine [Lomotil], loperamide) or anomalous anatomy (eg, fistulae, diverticula, antiperistaltic afferent loops) or is inherent in disorders such as diabetes mellitus or scleroderma.
The immunocompromised host is more susceptible to infection, as evidenced by the wide spectrum of diarrheal pathogens in patients with AIDS.
The exact mechanism of vomiting in acute diarrheal illness is not known, although serotonin release has been postulated as a cause, stimulating visceral afferent input to the chemoreceptor trigger zone in the lower brainstem. Preformed neurotoxins produced by Staphylococcus aureus and Bacillus cereus, when ingested, can cause severe vomiting.
Frequency
United States
Frequency is difficult to determine because of underreporting, especially of mild illness, resulting in wide variations of estimated numbers of cases, hospitalizations, and deaths. As many as 90 million cases occur per year with several million healthcare visits and thousands of hospitalizations. According to the Centers for Disease Control and Prevention (CDC), 3.5 million cases of acute diarrhea from rotavirus alone and at least 90,000 cases of food poisoning occur yearly. It is estimated that the norovirus is responsible for more than 70% of GI illnesses in the USA, probably more than 23 million cases a year and up to 93% of outbreaks. In Great Britain, it has been known as winter vomiting disease. Whether the increased incidence is real or simply a result of increased awareness, surveillance, and reporting is unclear.
The following are examples of sporadic common source outbreaks:
- Gastroenteritis associated with V parahaemolyticus infection from Gulf Coast oysters has been reported.
- Salmonella gastroenteritis from reptilian pets has been reported.
- A religious cult in Oregon intentionally contaminated salad with Salmonella typhimurium, which resulted in 751 victims who developed acute gastroenteritis.
- In July 1998, more than 60 persons in Wyoming were infected with E coli O157:H7 from a contaminated water supply.
- In 1993, E coli O157:H7–contaminated fast-food hamburger meat in the Pacific Northwest infected 500 persons, 4 of whom died.
- From 1981-1994, 333 cases of Vibrio vulnificus infection associated with raw oyster consumption were reported in Florida. Two persons died from gastroenteritis, and 50 persons died from septicemia.
- In January 1995, 322 cases of Norwalk virus (calicivirus) infection–associated acute gastroenteritis resulted from the consumption of raw oysters in Florida.
- In October 1996, 629 children and staff members at one elementary school in Florida were infected in a point-source outbreak of a Norwalk-like agent (calicivirus).
- In July 1995, 77 cases of cryptosporidiosis at a day camp in Florida were reported, most likely secondary to contamination involving a water hose.
- In April 1994, 96 cases of Campylobacter infection were reported in Florida. The common source was ingested, contaminated commercial ice cubes.
- In 1996, Norwalk virus–associated gastroenteritis resulted from the ingestion of raw oysters in Louisiana.
- From May 1996 to June 1996, E coli O157:H7 infections secondary to consumption of mesclun lettuce from a single producer were reported in multiple states (first identified in Connecticut and Illinois).
- In August and September of 1999, E coli O157:H7 infections secondary to contaminated well water at the Washington County Fair (New York) were reported.
- Norwalk virus is the leading cause of viral gastroenteritis in the United States.
- From January 1, 2002, to December 2, 2002, norovirus was attributed to 9 of the 21 outbreaks of acute gastroenteritis on cruise ships reported to the CDC's Vessel Sanitation Program in this period. Noroviruses cause approximately 23 million cases of acute gastroenteritis each year and are the leading cause of gastroenteritis outbreaks.
- Norovirus outbreaks have been reported in various locations, including casinos, airplanes, schools, hospitals, nursing homes, and cruise ships.
- In 2005, E coli O157:H7 infections secondary to contaminated animals were reported at Florida fairs.
- Between January 1996 and November 2000, 348 outbreaks of norovirus (also known as Norwalk virus or Norwalk-like virus) were reported to the CDC.
- Amongst all cruise ship voyages under the auspices of the CDC's Vessel Sanitation Program (VSP), 15 reported outbreaks occurred in 2008 and an additional 9 have been reported through May 2009.1 The CDC posts outbreaks as occurring on voyages from 3-21 days, on ships carrying 100 or more passengers in which 3% or more of passengers or crew reported symptoms of diarrheal disease to the ships medical staff during the voyage, and are gastrointestinal illness outbreaks of public health significance.
- The CDC also has a very active Vessel Sanitation Program (VSP), which inspects cruise ships and issues scores, with a score of 85 or less being unsatisfactory.2 These inspections cover issues of food safety, potable and recreational water treatment, outbreak prevention and reporting policies, and pest management programs, amongst other issues.
- While cruise ship outbreaks get the most publicity, outbreaks have also occurred at casinos, nursing homes, hospitals, amusement parks, camps, military facilities, and schools.
- As of April 2009, 714 cases of Salmonella Typhimurium had been reported in 46 states due to contaminated peanut products, such as peanut butter and peanut butter containing products, precipitating a major recall of affected products.3
International
Three to five billion cases of acute diarrhea occur yearly, and it is the leading cause of death in many underdeveloped countries. Approximately 30-50% of visitors to developing countries develop, and perhaps return with, diarrhea. In 2001 and 2002, outbreaks of gastroenteritis caused by norovirus were reported in diverse locations such as the American Midwest; Boston; Northern Europe; St. Petersburg, Russia; Canada; and Alaska.
Mortality/Morbidity
- Estimates for mortality and morbidity widely vary. In the United States, 210,000 pediatric hospitalizations occur yearly, with as many as 10,000 deaths.
- Internationally, the mortality rate is 5-10 million deaths each year.
Age
- Pediatric gastroenteritis is discussed in Pediatrics, Gastroenteritis.
- Gastroenteritis may occur at any age. Morbidity and mortality are much higher in the very young and the very old.
Clinical
History
A well-taken history, considering important epidemiologic factors, can help to identify not only the cause of diarrhea but also the patient at risk for complications. History in infectious cases and food poisoning varies depending upon the agent with variation in the onset; the frequency and nature of the stools; and the presence or absence of blood and mucus, vomiting, cramps, and fever. The history should also identify risk factors for unusual causes of acute gastroenteritis and possible reasons to suspect noninfectious etiologies. Indications of dehydration or sepsis should also be sought. As an example, norovirus is usually diagnosed by history. The incubation period for the norovirus is between 12 and 48 hours. Some of the early symptoms include nausea, a sudden onset of vomiting, moderate diarrhea, headache, fever (~50%), chills, and myalgia and will last 12-60 hours. The clinical factors suggestive of norovirus include the patient's presentation and the sudden onset of symptoms, with uncontrolled vomiting being a classic sign. Usually, more vomiting than diarrhea occurs. The natural course of this illness usually provides resolution within 36 hours.
- Duration of illness
- Duration and rapidity of symptom onset are important in determining the incubation period and possible infecting organism and in directing further care.
- Diarrhea that lasts longer than a month requires consideration of a different spectrum of etiologic factors than diarrhea that lasts less than 1-2 weeks.
- Fever: The presence of fever (with or without chills) generally suggests that an invasive organism is the cause of diarrhea, although many extraintestinal illnesses can present with both fever and diarrhea, especially in children.
- Vomiting
- Vomiting, a symptom common to a host of illnesses, implies proximal bowel involvement, especially with preformed neurotoxin, as elaborated by S aureus and B cereus.
- Vomiting is a leading symptom of intestinal obstruction, usually coupled with distention; however, distention may not be significant if the obstructing lesion is very proximal. Vomiting without diarrhea must always prompt a search for noninfectious causes and cannot be referred to as gastroenteritis.
- Pain
- The location and character of pain may be indicative of the area of infection because colonic involvement is usually associated with tenesmus and pain in either of the lower quadrants or the lower back, whereas jejunoileal infection may result in periumbilical pain.
- Cramps may be caused by an electrolyte imbalance.
- Pain, especially in patients older than 50 years, should raise the suspicion of an ischemic process.
- Stools
- Ask about frequency, nature (amount, color, watery, semisolid, odor), and presence of blood and/or mucus.
- Large volumes of stool are usually associated with enteric infection, whereas colonic infection results in many small stools.
- The presence of blood indicates colonic ulceration (bacterial infection, inflammatory disease, ischemia).
- White bulky feces that float (high fat content) are due to a small bowel pathology that leads to malabsorption.
- Copious (rice water) diarrhea is a hallmark of cholera.
- Extraintestinal causes
- A history of other nonintestinal illnesses that can lead to diarrhea may be obtained. Vomiting and/or diarrhea may be a manifestation of that illness or a result of its treatment. Obtaining a history of recent surgery or radiation, food or drug allergies, and endocrine or gastrointestinal disorders is extremely important. The patient should always be questioned regarding prior episodes.
- Malaria, Whipple disease, irritable bowel, incomplete bowel obstruction, inflammatory disease, nutritional disease, and carcinoid and malabsorption syndromes can result in diarrhea.
- Drugs such as colchicine, quinidine, antimicrobials, cancer chemotherapeutic agents, and magnesium-containing antacids frequently cause diarrhea.
- Dehydration
- Orthostasis, lightheadedness, diminished urine formation, and a change in mentation herald marked dehydration and electrolyte loss, requiring aggressive treatment.
- These symptoms are particularly important in elderly patients, a group that is most at risk from diarrhea.
- Epidemiologic factors
- A number of historical questions may provide clues to the etiology of the illness, including foreign travel, recent camping, recent antibiotic use, daycare attendance, and/or ingestion of raw, possibly spoiled, or new marine products, as well as similar illnesses in family, friends, or contacts.
- An epidemiologic factor may be travel to developing countries where bacterial or parasitic agents can cause infection or to campgrounds in developed regions, where agents such as Giardia lamblia, Aeromonas, and Cryptosporidium can contaminate untreated water.
- Enterotoxigenic E coli is the most frequent cause of traveler's diarrhea. Symptoms usually begin within days of arrival in the region and can last from 5 days to 2 weeks.
- Vibrio species are more common in Asia, although epidemics have occurred in Central America within the last 10 years.
- As many as 12% of diarrheal illness cases may be caused by rotavirus in travelers to Asia, Africa, and South America.
- Men who are homosexual are more prone to infection by usual pathogens via the fecal-oral route (ie, Shigella, Campylobacter jejuni, Salmonella, protozoalike Entamoeba). Anal receptive intercourse may result in the direct inoculation of Neisseria gonorrhoeae, Chlamydia trachomatis, Treponema pallidum, and herpes simplex virus. Severely immunocompromised states (CD4 cell count <200) increase the risk of infection by agents such as Mycobacterium avium complex, microsporidia, cytomegalovirus (CMV), and Isospora belli.
- Recent use of antimicrobial drugs increases the risk of C difficile infection.
- A common source outbreak from contaminated water and food may cause gastroenteritis either by infection (C jejuni, G lamblia) or by ingestion of a preformed toxin (E coli O157:H7, scombroid, ciguatera).
- Infections via the fecal-oral route are prevalent in children who attend daycare centers. Rotavirus has an infection rate of nearly 100% in exposed children younger than 2 years. Other family members are also at risk for infection.
Physical
A thorough physical examination is essential to assess the general state of hydration and nutrition and to exclude extraintestinal causes of diarrhea. Often, the cause of diarrhea cannot be determined based on the physical findings present, which may be scarce.
- The most important element of the physical examination is the assessment of the patient's hydration status. (Dehydration in children, for example, is classified according to the degree of hydration/percentage deficit as <3%, none; 3-6%, mild; 6-9%, moderate; and >10%, severe.) Additionally, signs of bacteremia or sepsis should be sought. Patients with chronic diarrhea may need an evaluation of their nutritional status.
- A rectal examination should be performed, involving checking for blood and mucus. Rectal examination may reveal abscesses, fistulae, and fissures, which may indicate inflammatory bowel disease. A partially obstructing tumor or a fecal impaction may be discovered as a cause of diarrhea. Finally, the stool can be examined for the presence of blood and pus.
- Hydration and nutritional status
- Diminished skin turgor, weight loss, resting hypotension and tachycardia, dry mucus membranes, decreased frequency of urination, changes in mental status, and orthostasis can be used to gauge dehydration.
- In children, the absence of tears, poor capillary refill, sunken eyes, depressed fontanelles, increased axillary skin folds, and dry diapers all may reflect a dehydrated state.
- Muscle wasting and signs of neural dysfunction due to nutritional depletion may be observed in patients with chronic diarrhea.
- Abdominal examination
- A careful abdominal examination is necessary to exclude causes of diarrhea that may require surgical intervention, such as pelvic abscesses close to the rectosigmoid that are causing tenesmus.
- The examiner should look for signs of an acute abdomen, listening for bowel sounds, determining the location of any tenderness, and palpating for masses or organomegaly.
- Appendicitis in children may manifest as diarrhea.
Causes
- Viral (50-70%)
- Norovirus
- This is the leading cause of viral gastroenteritis in the United States. Noroviruses (formerly known as Norwalk virus in the United States and as small round structured virus [SRSV] in the United Kingdom), along with the sapoviruses (formerly known as Sapporo-like viruses), are members of the Caliciviridae family of viruses. The norovirus is a small, 26-40 nm, nonenveloped, single-stranded RNA virus classified as a Calicivirus. Sapoviruses, a cause of gastroenteritis, predominantly in children, are also in the Caliciviridae family. Five norovirus genogroups have been identified: GI, GII, GIII, GIV, and GV; 27 clusters (genotypes) have also been identified. In 2006, the land-based experience was slightly busier than usual. The dominating strain was GII-4 (Bristol).
- It is a highly infectious virus—with as few as 10-100 particles necessary for transmission—and is quite resistant to quaternary ammonia compounds, alcohol, detergent-based compounds, freezing, and heat (to 60o C). It is a very difficult virus to culture and measure; thus, studies on norovirus are limited, with researchers using a "surrogate," nonenveloped virus, Feline Calicivirus (FCV), to assess the efficacy of disinfectants and other mitigation strategies. Recently, some researchers have questioned the use of FCV as a surrogate since FCV is a respiratory virus and norovirus is a GI virus and likely is more resilient than FCV due to the need for norovirus to survive in the hostile environment of the gut. Therefore, the results of testing performed to validate the efficacy of disinfectants and hand sanitizers possibly overestimate the actual effectiveness of these products on human norovirus.
- Various modes of transmission exist including fecal-oral transmission (predominant), person to person, fecal contamination of food and/or water, fomite transmission, and airborne spread when in close proximity of someone vomiting, as the virus is easily aerosolized.
- Between January 1996 and November 2000, 348 outbreaks of norovirus were reported to the CDC. Out of these, 54% patients were contaminated by food, 17% by person to person, 4% by water, and 25% by unidentified sources. Most of the food sources responsible were identified as oysters, salads, salad dressing, sandwiches, deli meats, cake and frosting, raspberries, drinking water, and ice. Shellfish have been implicated in some outbreaks, but it is not a frequent source on cruise ships, where the predominant mode of infection is believed to be fecal-oral and person to person from individuals who come onto the ships ill and do not report the illness or quarantine themselves in their cabins. The same study reveals that 39% contracted the disease in restaurants, 30% in nursing homes, 12% at school, 10% on vacation, and 9% remain unidentified.
- The incubation period for the norovirus is between 12 and 48 hours. Some of the early symptoms include nausea, a sudden onset of vomiting, moderate diarrhea, headache, fever (~50%), chills, and myalgia and will last 12-60 hours. The clinical factors suggestive of norovirus include the patient's presentation and the sudden onset of symptoms, with uncontrolled vomiting being a classic sign. Usually, more vomiting than diarrhea occurs. The virus is noninvasive of the colon; therefore, WBCs are not seen in the stool, and hematochezia is rare.
- The natural course of this illness usually provides resolution within 36 hours. Unless the patient is very young, very old, debilitated with severe underlying disease, or immunocompromised, they usually do very well with this self-limited illness responding to oral rehydration and a rapid return to normal diet once the vomiting has ceased. The only therapy is oral and/or intravenous hydration with occasional need for antiemetics. The usual cautions concerning the use of antiemetics in very young patients apply. Although viral shedding has been reported for up to 2 weeks, the polymerase chain reaction (PCR) testing used to determine this may just be detecting inactivated RNA.
- There are many norovirus strains with no cross-immunity, so repeat infections are possible throughout one's lifetime.
- Caliciviruses (Various caliciviruses, other than norovirus, are likely responsible for many outbreaks of previously unidentified viral gastroenteritis.)
- Rotavirus (This is the leading cause of gastroenteritis in children, but rotavirus can also be found in adults. Rotavirus may cause severe dehydration.)
- Adenovirus
- Parvovirus
- Astrovirus
- Coronavirus
- Pestivirus
- Torovirus
- Norovirus
- Bacterial (15-20%)
- Shigella
- Salmonella
- C jejuni
- Yersinia enterocolitica
- E coli - Enterohemorrhagic O157:H7, enterotoxigenic, enteroadherent, enteroinvasive
- V cholera
- Aeromonas
- B cereus
- C difficile
- Clostridium perfringens
- Listeria
- M avium-intracellulare (MAI), immunocompromised
- Providencia
- V parahaemolyticus
- V vulnificus
- Parasitic (10-15%)
- Food-borne toxigenic diarrhea
- Preformed toxin -S aureus, B cereus
- Postcolonization -V cholera, C perfringens, enterotoxigenic E coli, Aeromonas
- Shellfish poisoning and poisoning from other marine animals
- Drug-associated diarrhea
- Antibiotics, due to alteration of normal flora
- Laxatives, including magnesium-containing antacids
- Colchicine
- Quinidine
- Cholinergics
- Sorbitol
- Pseudomembranous colitis
- Overgrowth of C difficile
- Positive C difficile assay findings
- Other causes
- Unknown agents, especially in developing countries
- Ischemic colitis
- Ulcerative colitis
- Crohn disease
- Carcinoid tumor or vasoactive intestinal peptide tumor (VIPoma)
- AIDS
- Dumping or short bowel syndrome
- Radiation or chemotherapy
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| References |
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References
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Further Reading
Keywords
gastroenteritis symptoms, gastroenteritis causes, gastroenteritis treatment, enterogastritis, stomach flu, intestinal flu, dysentery, infectious diarrhea, diarrhea, traveler's diarrhea, food poisoning, food-borne toxigenic diarrhea, shellfish poisoning, amebiasis, rotavirus, norovirus, Norwalk-like virus, Norwalk virus, Shigella dysenteriae, Salmonella, Campylobacter jejuni, C jejuni, Yersinia enterocolitica, Y enterocolitica, Escherichia coli, E coli, Vibrio cholera, V cholera, Clostridium difficile, C difficile, Clostridium perfringens, Listeria, Mycobacterium avium-intracellulare, MAI, Vibrio parahaemolyticus, Vibrio vulnificus, Giardia lamblia, Cryptosporidium, Cyclospora, Staphylococcus aureus, S aureus, dehydration, enterotoxins, rice water diarrhea, E coli O157:H7
