eMedicine Specialties > Emergency Medicine > Gastrointestinal

Gastroenteritis

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

Updated: Oct 22, 2009

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 60^o 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
• 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%)
  • Giardia
  • Amebiasis
  • Cryptosporidium
  • Cyclospora
• 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
  • Paralytic shellfish poisoning (PSP) - Saxitoxin
  • Neurologic shellfish poisoning (NSP) - Brevetoxin
  • Diarrheal shellfish poisoning (DSP) - Okadaic acid
  • Amnesic shellfish poisoning - Domoic acid
  • Ciguatera (ciguatoxins)
  • Scombroid (conversion of histidine to histamine)
• 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

Differential Diagnoses

Other Problems to Be Considered

Various infectious etiologies
Pseudomembranous colitis
Food-borne toxigenic diarrhea
Toxins
Hormonal (vasoactive intestinal peptides)
Drugs (ie, sorbitol, cholinergics, caffeine)
Surgery
Radiation colitis
Carcinoid
Pediatrics - Adrenogenital/cystic fibrosis

Workup

Laboratory Studies

• Determination of laboratory tests: The patient's evaluation should be based on the clinical assessment and the need to do the following:
  • Further evaluate the seriousness of the condition (degree of dehydration and electrolyte derangement).
  • Determine a specific etiologic agent.
  • Evaluate the patient for noninfectious etiologies.
  • Patients who require further workup include those who appear seriously ill or dehydrated; those who have high fevers, bloody stools, severe abdominal pain, or persistent diarrhea; and those who are immunocompromised or whose condition is suspected of having an epidemic diarrheal etiology.
  • History, epidemiologic considerations, and the physical examination should be the primary guides in determining whether any further diagnostic evaluation is necessary, followed by microscopic examination of the stool.
• Stool studies and culture
  • The presence of blood or leukocytes in stool is a strong indicator of inflammatory diarrhea.
  • Stool studies can be performed efficiently and inexpensively by using a Wright stain or methylene blue and directly observing for leukocytes and performing an occult blood test.
  • Fecal leukocytes are present in 80-90% of all patients with Salmonella or Shigella infections but are less common with other infecting organisms such as Campylobacter and Yersinia. They may also be present in ulcerative colitis and Crohn disease but are usually absent in viral infections, Giardia infection, enterogenic E coli infection, and toxigenic bacterial food poisoning.
  • A stool culture is not necessary or cost-effective in all cases of diarrhea unless a bacterial cause is suspected.
  • A lower threshold for performing stool cultures and examination for ova and parasites is indicated in immunocompromised and immunosuppressed patients.
  • Fever, bloody stools, leukocytes in stool, pain resembling that associated with appendicitis (Yersinia), and diarrheal illness associated with partially cooked hamburger (cytotoxigenic E coli O157:H7) are all indications for culture.
  • Frequently, stool cultures are obtained inappropriately in the United States. Consider whether obtaining a culture would change the therapy.
  • Specific indications for stool cultures include bloody stools, stools that test positive for occult blood or leukocytes, prolonged course of diarrhea that has not been treated with antibiotics, immunocompromised host, or for epidemiologic purposes, such as cases involving food handlers.
  • Routine stool cultures identify only Campylobacter, Shigella, Salmonella, Aeromonas, and Yersinia species.
  • Testing for other pathogens, such as Vibrio species, enterohemorrhagic E coli O157:H7, and other Shigatoxin-producing bacteria require special media. The laboratory should be informed regarding appropriate media for suspected organisms (eg, MacConkey sorbitol agar for E coli O157:H7). Additionally, the laboratory may need to perform specialized testing to specifically identify the organism.

The MacConkey medium is commonly used and differentiates lactose fermenters, which produce acid, decrease the pH, and cause the neutral red indicator to give the colonies a pink-to-red color.

Hektoen enteric agar with Escherichia coli colonies. Different growth media are necessary for identifying different enteric pathogens, suppressing the growth of nonpathogens, and allowing for chemical reactions to assist in identification. The appearance results from the organism's ability to ferment lactose placed in the medium. This results in the production of acid, which lowers the pH and causes a change in the pH indicator placed in the medium. Salmonella and Shigella organisms do not ferment lactose.

Example of Salmonella on Hektoen enteric agar. The medium also contains ferric ammonium citrate, which indicates the production of hydrogen sulfide by the appearance of a black precipitate.

• Studies of selected centers have shown that only 2% of stool culture results are positive as routinely obtained. The cost per positive stool culture result has been estimated to be at least $900-1200.
• Similarly, if parasitic illness is in the differential or if the patient has recently traveled to an endemic region or has chronic diarrhea, the stool should be examined for parasites or their ova with the caveat that several samples may be required to make the diagnosis. Ova and parasite studies are indicated for patients who are immunocompromised, who have a persistent or prolonged course, or whose conditions are unresponsive to antibiotics.
• Travel to endemic regions followed by chronic diarrhea without signs of acute bacterial diarrhea should prompt a search for a parasitic etiology.
• Entamoeba histolytica can result in bloody stools, but a smear reveals a lack of leukocytes due to exotoxin produced by the parasite that lyses the cells.
• Stool can be sent to reference labs for examination for norovirus by PCR. This is usually reserved for epidemiological purposes. Rapid assays are becoming available with varying sensitivities and questionable clinical applicability.
• Routine laboratory tests
  • Routine laboratory tests (CBC, electrolytes, renal function) may not be helpful or indicated in making a diagnosis. These tests may be useful as indicators of severity of disease, especially in elderly or very young patients, although that determination is best made clinically.
  • Electrolytes and BUN tests are indicated in patients with severe diarrhea or dehydration to rule out hyponatremia or hypernatremia. Decreased serum bicarbonate suggests severe dehydration, especially in children. Acidosis secondary to bicarbonate loss in the stools and/or from hypovolemia-induced lactic acidosis may be present. Hypokalemia may also occur.
  • A CBC may be indicated with a prolonged course, severe diarrhea, or toxicity. The WBC count is usually increased in Salmonella infections but normal or low with significant left shift in Shigella infections. The WBC count is otherwise variable. Eosinophilia may be present in parasitic infections.
• Enzyme-linked immunosorbent assay
  • Commercially available immunofluorescent antibody and enzyme immunoassays are also available for Giardia and Cryptosporidium organisms. C difficile toxin assays can be performed when antibiotic-associated diarrhea is suspected.
  • Rotavirus: Enzyme-linked immunosorbent assay (ELISA) is available in less than 2 hours but is not sensitive enough in adults.
  • Giardia: ELISA is more than 90% sensitive in susceptible populations (eg, people who camp or travel to endemic areas). Consider ELISA prior to ova and parasite examination or string test.

Imaging Studies

• An acute abdominal series is indicated only when bowel obstruction, toxic megacolon, or perforation is suspected.

Procedures

• Sigmoidoscopy may be indicated if pseudomembranous colitis or inflammatory bowel disease is suspected. Sigmoidoscopy is useful in obtaining tissue for culture in patients with AIDS who have undiagnosed diarrhea or wasting syndrome.

Treatment

Prehospital Care

• Prehospital care is directed toward early and aggressive fluid therapy in patients who are unstable.

Emergency Department Care

• Goals of ED therapy
  • Rehydrate orally or intravenously as needed.
  • Treat symptoms (eg, fever, pain) as indicated.
  • Identify complications.
  • Prevent the spread of infections.
  • Identify public health concerns and treat certain specific cases with specific or empiric antibiotic therapy.
• Rehydration
  • Administration of 1-2 L dextrose 5% in 0.5 isotonic sodium chloride solution with 50 mEq NaHCO₃ and 10-20 mEq KCl over 30-45 minutes may be necessary in patients who are severely dehydrated.
  • Clinical assessment and serum electrolyte concentrations should guide therapy.
  • To give fluids more rapidly, KCl may be given orally or in the second or third liter bag or as a supplemental IV of 20 mEq KCl in 100 mL of isotonic sodium chloride solution over 1 hour.
  • Rehydrate patients until mental status and signs of perfusion and pulse are normal (caution in elderly patients with congestive heart failure [CHF]).
  • For pediatric patients, administer 20 mL/kg of isotonic sodium chloride solution initially for resuscitation. Repeat as necessary and add KCl as indicated.
  • Indications for IV rehydration include severe intractable vomiting, altered consciousness, severe dehydration, ileus, excessive choleralike stools, and time or environment not conducive to oral rehydration therapy (ORT).
  • Solutions for oral rehydration
    • The World Health Organization solution is 90 mEq/L Na⁺, 20 mEq/L K⁺, 80 mEq/L Cl^-, 20 g/L glucose; osmolarity is 310; CHO:Na = 1.2:1; administer 250 mL (approximately 8 oz) every 15 minutes until fluid balance is clinically restored, then 1.5 L of oral fluid per liter of stool.
    • Other products include Naturalyte, Cera Lyte, Rehydralyte, and Pedialyte.
    • Oral rehydration may not decrease the duration or volume of diarrhea.
    • Small amounts of oral fluids may be given repeatedly while the patient is still vomiting.
    • Oral rehydration has been largely responsible for the tremendous decrease in the death rate in underdeveloped countries from infectious diarrhea, including cholera.
    • The glucose/sodium transport mechanism remains intact despite enterotoxigenic illness. Coupled transport is one of several mechanisms of sodium and water absorption in the bowel. It is the direct entry of sodium and water across the cell at the intestinal brush border membrane via the linking (coupling) of 1 organic molecule, such as glucose, to 1 sodium molecule. This is the principle upon which ORT is based. Optimally, therefore, the ratio of carbohydrate to sodium should approach 1:1. Glucose is necessary to stimulate the absorption of water and electrolytes by the small intestines.
  • The solution must be iso-osmolar or hypo-osmolar to avoid an increased osmotic load in the small intestines contributing to an osmotic diarrheal effect, pulling fluid into the lumen.
  • Studies have shown oral and IV rehydration to be equivalent therapies in patients who can tolerate the oral fluid.
  • Although standard glucose-electrolyte solutions achieve and maintain rehydration, they may not reduce stool volume or duration of diarrheal illness, affecting compliance.
  • Newer solutions with complex carbohydrates and short chain polypeptides of cereals and legumes are now available to provide additional organic cotransport molecules with no increase in osmolarity. These appear to offer the advantage of decreased stool volumes and shortened duration of illness.
  • Early age-appropriate refeeding in children (and adults) is important to initiate as soon as rehydration is complete.
    • Early refeeding with complex carbohydrates provides additional cotransport molecules without osmotic penalty and stimulates mucosal repair.
    • Consider rice, wheat, bread, potatoes, and lean meats, especially chicken.
    • Milk can be safely given early. Despite the potential for lactose intolerance, clinical evidence of lactase deficiency is uncommon, and most children can tolerate nonhuman milk without difficulty during acute diarrheal illnesses.
    • What has been learned from studies of early pediatric refeeding probably can be generalized to the adult population. Initiate early feeding with the above dietary recommendations once rehydration has been accomplished and vomiting is controlled.
• Empiric therapy for infectious diarrhea is sometimes indicated. Food-borne toxigenic diarrhea usually requires only supportive treatment, not antibiotics.
  • The duration of traveler's diarrhea (E coli, Shigella) can be shortened by half or more with trimethoprim-sulfamethoxazole (TMP/SMZ) or ciprofloxacin administered for 3 days. Single doses have been used effectively. The duration of treatment may be extended by 2-3 days for moderate-to-severe cases.
  • Generally, fluoroquinolones are the drugs of choice for acute infectious gastroenteritis when used empirically. They do not appear to increase carrier states; however, they are contraindicated in pregnant women and in children.
  • Erythromycin or azithromycin is effective in Campylobacter infections, although erythromycin is not well tolerated in the patient who is vomiting.
  • Metronidazole (oral or parenteral) is effective in mild-to-moderate cases of C difficile diarrhea (in addition to discontinuance of the causative agent). Patients who are severely ill may require orally administered vancomycin, which may require delivery via nasogastric tube or colonoscope.
  • Mild cases of suspected Yersinia infection should be treated with TMP/SMZ or a fluoroquinolone, while patients who are more ill and require admission benefit from IV ceftriaxone.
  • Intestinal salmonellosis in an immunocompetent host does not require antimicrobials because they may prolong fecal shedding of organisms.
  • Metronidazole is effective against parasitic infestations with Giardia or Entamoeba.
• Antiemetics may be useful in the treatment of nausea and vomiting in adults. They are usually not recommended in children.
• Antidiarrheals (antimotility agents)
  • These agents have traditionally been discouraged because of concerns with causing bacteremia; however, they appear to have a role in the symptomatic treatment of mild-to-moderate diarrhea, especially with nonbloody and traveler's diarrhea.
  • The most common agents include bismuth subsalicylate (Pepto-Bismol). For patients older than 14 years, give 2 tablets or 20 mL PO q30min as needed to a maximum of 8 doses and loperamide (Imodium), which is useful as an adjunct to rehydration for symptomatic relief. The American Academy of Pediatrics (AAP) does not recommend this for children.
  • Octreotide (Sandostatin), an analog of somatostatin, may be used subcutaneously and intravenously to control severe secretory diarrhea. It has been approved for this purpose in the treatment of carcinoid tumors and VIPomas. Octreotide is under investigation for other uses, including secretory diarrhea associated with AIDS, short bowel syndrome, dumping syndrome, radiation, and chemotherapy.

Consultations

• A consultation to an infectious diseases specialist may be necessary for patients with chronic diarrhea, patients whose conditions have parasitic etiologies, patients infected with C difficile when vancomycin use is contemplated, patients who relapse, and patients with AIDS who have diarrhea.
• A consultation to a gastroenterologist may also be indicated in the above circumstances and when pseudomembranous colitis, ulcerative colitis, or Crohn disease are in the differential diagnosis.

Medication

The goals of pharmacotherapy are to reduce morbidity, to prevent complications, and to possibly decrease the duration of illness.

In February 2006, the United States Food and Drug Administration (FDA) approved an oral vaccine for rotavirus (RotaTeq). It is currently the only vaccine approved in the United States for prevention of rotavirus gastroenteritis as of the date of this publication. RotaTeq is administered in a 3-dose series starting between age 6-12 weeks and completed before age 32 weeks.

Antibiotics

Therapy must cover all likely pathogens in the context of the clinical setting.

Ciprofloxacin (Cipro)

Fluoroquinolones are the agents of choice for the empiric treatment of invasive and traveler's diarrhea syndromes in adult patients. They are also the agents of choice when treatment is indicated and the organism involved is known to be Campylobacter, E coli (non-O157:H7), nontyphoid Salmonella (although antibiotic treatment may prolong bacterial shedding), Shigella, or Yersinia.

Dosing

Adult

500 mg PO bid for 3-5 d; studies have shown that a single dose of 500 mg or 1000 mg may be equally effective

Pediatric

<18 years: Not recommended
>18 years: Administer as in adults

Interactions

Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; ciprofloxacin reduces therapeutic effects of phenytoin; probenecid may increase ciprofloxacin serum concentrations
May increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy

Trimethoprim-sulfamethoxazole (Bactrim)

Excellent second choice for empiric therapy, although it is not effective against Campylobacter organisms. Increasing resistance. First drug of choice for patients younger than 18 years. Specifically recommended for 5 d for shigellosis.

Dosing

Adult

1 DS tab (or 4 tsp of the pediatric susp) PO bid for 3-5 d

Pediatric

Dose is adjusted based on the trimethoprim component; 8-10 mg/kg/d PO in divided doses or 40 mg of trimethoprim per tsp (5 mL) PO

Interactions

May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly patients; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine

Contraindications

Documented hypersensitivity; megaloblastic anemia due to folate deficiency

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Discontinue at first appearance of skin rash or sign of adverse reaction; obtain CBC frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, give 5-15 mg/d leucovorin); caution in folate deficiency (eg, chronic alcoholism, elderly patients, those receiving anticonvulsant therapy, those with malabsorption syndrome); hemolysis may occur in G-6-PD deficiency; patients with AIDS may not tolerate or respond to TMP-SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); give fluids to prevent crystalluria and stone formation; refer to PDR and product information

Rifaximin (Xifaxan, RedActiv, Flonorm)

Nonabsorbed (<0.4%), broad-spectrum antibiotic specific for enteric pathogens of the gastrointestinal tract (ie, gram-positive, gram-negative, aerobic, and anaerobic). Rifampin structural analog. Binds to beta-subunit of bacterial DNA-dependent RNA polymerase, thereby inhibiting RNA synthesis. Indicated for E coli (enterotoxigenic and enteroaggregative strains) associated with travelers' diarrhea.

Dosing

Adult

200 mg PO tid

Pediatric

<12 years: Not established
>12 years: Administer as in adults

Interactions

Induces CYP450 3A4 in vitro; limited data exist; no significant interactions shown in single-dose studies with midazolam and oral contraceptives

Contraindications

Documented hypersensitivity to rifaximin or rifamycin antimicrobial agents (eg, rifampin)

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

May promote intestinal bacterial overgrowth and cause superinfection; discontinue if diarrhea persists more than 24-48 h or worsens; seek immediate medical care if fever and/or bloody stools emerge (tabs not effective); not effective for travelers' diarrhea due to suspected pathogens other than E coli; postmarketing reports include allergic dermatitis, rash, angioneurotic edema, urticaria, and pruritus

Antiemetics

All these drugs are indicated in the control of nausea and vomiting. All have been associated with extrapyramidal adverse effects, especially in patients who are acutely ill, dehydrated, or children. They should be used with caution and only in the lowest effective dose. A weak association with Reye syndrome exists, and all may mask the vomiting associated with underlying CNS lesions.

Prochlorperazine (Compazine)

Antidopaminergic drug that blocks the postsynaptic mesolimbic dopamine receptors. Has an anticholinergic effect and can depress the reticular activating system, possibly responsible for relieving nausea and vomiting.

Dosing

Adult

5-10 mg PO/IM tid/qid; not to exceed 40 mg/d
2.5-10 mg IV q3-4h prn; not to exceed 10 mg/dose or 40 mg/d
25 mg PR bid

Pediatric

2.5 mg PO/PR q8h or 5 mg q12h prn; not to exceed 15 mg/d
IV dosing is not recommended for children
0.1-0.15 mg/kg/dose IM and change to PO as soon as possible

Interactions

Coadministration with other CNS depressants or anticonvulsants may cause additive effects; with epinephrine, may cause hypotension

Contraindications

Documented hypersensitivity; bone marrow suppression; narrow-angle glaucoma; severe liver or cardiac disease

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Drug-induced Parkinson syndrome or pseudoparkinsonism occurs frequently; akathisia is the most common extrapyramidal reaction in elderly patients; lowers seizure threshold; caution with history of seizures; refer to PDR and product information

Promethazine (Phenergan)

Antidopaminergic agent effective in the treatment of emesis. Blocks postsynaptic mesolimbic dopaminergic receptors in the brain and reduces stimuli to the brainstem reticular system.

Dosing

Adult

12.5-25 mg PO/IV/IM/PR q4h prn

Pediatric

<2 years: Contraindicated
>2 years: 0.25-1 mg/kg PO/IV/IM/PR 4-6 times/d prn

Interactions

May have additive effects when used concurrently with other CNS depressants or anticonvulsants; coadministration with epinephrine may cause hypotension

Contraindications

Documented hypersensitivity; children younger than 2 y (incidences of death due to respiratory depression)

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in cardiovascular disease, impaired liver function, seizures, sleep apnea, and asthma; not for use in children <2 years as it may cause respiratory depression; refer to PDR and product information

Trimethobenzamide (Tigan)

Has central effects in which it inhibits the medullary receptor trigger zone.

Dosing

Adult

250 mg PO tid/qid
Alternatively, 200 mg IM tid/qid

Pediatric

<14 kg: 100 mg PO tid/qid
14-40 kg: 100-200 mg PO tid/qid
>40 kg: Administer as in adults

Interactions

May inhibit effects of anticoagulants

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Not for use in patients with acute vomiting; refer to PDR and product information

Ondansetron (Zofran)

Selective 5-HT3 receptor antagonist that blocks serotonin both peripherally and centrally. Indicated for nausea and vomiting due to radiation and/or chemotherapy and for postoperative nausea and vomiting. Cost considerations.

Dosing

Adult

Nausea and vomiting secondary to gastroenteritis: 4-8 mg PO q8h; 4 mg IV

Pediatric

Nausea and vomiting secondary to gastroenteritis: 4 mg PO q8h; 0.1-0.15 mg/kg IV

Interactions

None reported

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose and use caution if liver function significantly impaired

Antidiarrheal agents

These agents are used to decrease the frequency of diarrheal stools and possibly the duration. They should be used with caution in children and in patients with dysentery, as some reports of prolonged illness and development of toxic megacolon exist.

Loperamide (Imodium)

Antimotility DOC. Generally safe and indicated in the early treatment of travelers' diarrhea.

Dosing

Adult

4 mg PO once, followed by 2 mg after each loose stool; do not exceed 16 mg/d

Pediatric

Initial doses:
2-6 years: 1 mg PO tid
6-8 years: 2 mg PO bid
8-12 years: 2 mg PO tid
Maintenance: 0.1 mg/kg PO after each loose stool; not to exceed initial dose
Chronic diarrhea: 0.08-0.24 mg/kg/d PO divided bid/tid; not to exceed 2 mg/dose

Interactions

Phenothiazines, tricyclic antidepressants, and CNS depressants may increase loperamide toxicity

Contraindications

Documented hypersensitivity; diarrhea resulting from infections; pseudomembranous colitis

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Discontinue use if no clinical improvement in 48 h; because loperamide is primarily metabolized in the liver, monitor for CNS toxicity in patients with hepatic insufficiency; do not use medication if high fever or blood in stool coincides with diarrhea; refer to PDR and product information

Diphenoxylate HCl 2.5 mg/atropine sulfate 0.025 mg (Lomotil)

Antidiarrheal agent chemically related to narcotic analgesic meperidine. A subtherapeutic dose of anticholinergic atropine sulfate is added to discourage overdosage, in which case diphenoxylate may clinically mimic the effects of codeine.
Each tab of Lomotil or 5 cc of elixir contains 2.5 mg diphenoxylate hydrochloride and 0.025 mg atropine sulfate.
Almost always the preferred antimotility agent.

Dosing

Adult

2 tab PO qid until the diarrhea is controlled

Pediatric

<2 years: Not recommended
2-5 years: 2 mg of diphenoxylate PO tid
5-8 years: 2 mg of diphenoxylate PO qid
8-12 years: 2 mg of diphenoxylate PO 5 times/d

Interactions

May delay metabolism of drugs in liver; CNS depressants, MAOIs, and antimuscarinic agents may increase the toxicity of this drug combination

Contraindications

Documented hypersensitivity; narrow-angle glaucoma; hepatic insufficiency

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

In young children, dehydration may influence variability of response and predispose patient to delayed diphenoxylate intoxication; exercise caution in patients with ulcerative colitis
A decrease in intestinal motility may be detrimental to patients with diarrhea resulting from Shigella, Salmonella, and toxigenic strains of E coli; refer to PDR and product information

Vaccines

Elicit active immunization to increase resistance to infection. Vaccines consist of microorganisms or cellular components, which act as antigens. Administration of the vaccine stimulates the production of antibodies with specific protective properties.

Rotavirus vaccine (RotaTeq, Rotarix)

Currently, 2 orally administered live-virus vaccines are marketed in the United States. Each is indicated to prevent rotavirus gastroenteritis, a major cause of severe diarrhea in infants.
RotaTeq is a pentavalent vaccine that contains 5 live reassortant rotaviruses and is administered as a 3-dose regimen against G1, G2, G3, and G4 serotypes, the 4 most common rotavirus group A serotypes. It also contains attachment protein P1A (genotype P[8]).
Rotarix protects against rotavirus gastroenteritis caused by G1, G3, G4, and G9 strains and is administered as a 2-dose series in infants aged 6-24 wk.
Clinical trials found that the vaccines prevented 74-78% of all rotavirus gastroenteritis cases, nearly all severe rotavirus gastroenteritis cases, and nearly all hospitalizations due to rotavirus.

Dosing

Adult

Not indicated

Pediatric

<6 weeks: Not established
RotaTeq
6-12 weeks: 2 mL PO as a single dose, followed by 2 additional doses at 4- to 10-wk intervals; do not administer after age 32 wk
Rotarix
6 weeks: 1 mL PO as a single dose; administer a second dose after an interval of at least 4 wk and before age 24 wk

Interactions

Immunosuppressive therapies (eg, irradiation, antimetabolites, alkylating agents, cytotoxic drugs, high-dose corticosteroids) may decrease immune response

Contraindications

Documented hypersensitivity; uncorrected congenital GI malformation that would predispose to intussusception

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Common adverse effects include diarrhea, vomiting, otitis media, inflamed nasal passages, and bronchospasm; refrigerate and protect from light; handle and discard empty tube according to biological waste procedures; previously marketed rotavirus vaccine (RotaShield) was associated with intussusception; however, RotaTeq did not show an increased risk compared with placebo in clinical trials (monitor for signs of intestinal blockage), and Rotarix did not show an increase in intussusception in 31,673 infants compared with 31,552 infants who received placebo; do not mix in same syringe with other vaccines or solutions

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.

Multimedia

Media file 1: Hektoen enteric agar with Escherichia coli colonies. Different growth media are necessary for identifying different enteric pathogens, suppressing the growth of nonpathogens, and allowing for chemical reactions to assist in identification. The appearance results from the organism's ability to ferment lactose placed in the medium. This results in the production of acid, which lowers the pH and causes a change in the pH indicator placed in the medium. Salmonella and Shigella organisms do not ferment lactose.

Media file 2: Example of Salmonella on Hektoen enteric agar. The medium also contains ferric ammonium citrate, which indicates the production of hydrogen sulfide by the appearance of a black precipitate.

Media file 3: The MacConkey medium is commonly used and differentiates lactose fermenters, which produce acid, decrease the pH, and cause the neutral red indicator to give the colonies a pink-to-red color.

Media file 4: The Christensen method is used to determine if an organism produces the enzyme urease (Yersinia) or not (Salmonella, Shigella, Vibrio). Hydrolysis of urea produces ammonia and carbon dioxide, alkalinizing the medium and turning the phenol red from light orange to magenta (pink).

Media file 5: Often, a combination of methods may be used for identification. The tube on the left is triple sugar iron (TSI) agar. The alkaline slant and acid butt (K/A) indicates an organism that ferments glucose only (not lactose or sucrose). The middle tube is indole positive, as indicated by the pink ring, and indicates the organism's ability to split tryptophan to form indole. The tube on the right is urease negative. Taken together, these tests indicate the organism is likely Shigella.

Media file 6: Gram stain may be helpful in identifying an etiologic agent. This stain shows gram-negative bacilli, which could be Salmonella or Shigella with 2 polymorphonucleocyte cells (PMNs).

References

1. Centers for Disease Control and Prevention. Vessel Sanitation Program: Cruise Ship Outbreak Updates. Available at http://www.cdc.gov/nceh/vsp/surv/GIlist.htm.

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3. Centers for Disease Control and Prevention. Investigation Update: Outbreak of Salmonella Typhimurium Infections, 2008–2009. Available at http://www.cdc.gov/salmonella/typhimurium/update.html.

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12. Health Protection Agency Centre for Infections. Guidance for the Management of Norovirus Infection in Cruise Ships - Norovirus Working Group. Available at http://www.hpa.org.uk/publications/2007/cruiseliners/cruiseliners.pdf.

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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

Contributor Information and Disclosures

Author

Arthur Diskin, MD, Vice-President, Global Chief Medical Officer, Royal Caribbean Cruise Lines; Voluntary Associate Professor, University of Miami School of Medicine
Arthur Diskin, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Royal Caribbean Cruise Lines Salary Employment

Medical Editor

Michelle Ervin, MD, Chair, Department of Emergency Medicine, Howard University Hospital
Michelle Ervin, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, National Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eugene Hardin, MD, FAAEM, FACEP, Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Steven C Dronen, MD, FAAEM, Director of Emergency Services, Director of Chest Pain Center, Department of Emergency Medicine, Ft Sanders Sevier Medical Center
Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

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