Gastroenteritis in Emergency Medicine Treatment & Management

  • Author: Arthur Diskin, MD; Chief Editor: Steven C Dronen, MD, FAAEM   more...
 
Updated: Jan 3, 2012
 

Prehospital Care

  • Prehospital care is directed toward early and aggressive fluid therapy in patients who are unstable.
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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 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. Ensure normal renal function prior to KCl administration.
    • Rehydrate patients until mental status and signs of perfusion and pulse are normal (caution in elderly patients with congestive heart failure [CHF]), such as a urine output of 1-2 mL/kg/h.
    • 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 oral rehydration 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 acute 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 also 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. Loperamide (Imodium) 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.
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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.
  • If a surgical abdomen is suspected or if the patient is post gastric bypass bariatric surgery, a consultation to a surgeon may be appropriate.
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Contributor Information and Disclosures
Author

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

Specialty Editor Board

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.

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

Disclosure: Medscape Salary Employment

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.

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  Chair, Department of Emergency Medicine, LeConte 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.

References

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  2. Centers for Disease Control and Prevention. Vessel Sanitation Program: Cruise Ship Inspection. Available at http://wwwn.cdc.gov/InspectionQueryTool/Forms/InspectionSearch.aspx.

  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.

  4. Rasko DA, Webster DR, Sahl JW, et al. Origins of the E. coli strain causing an outbreak of hemolytic-uremic syndrome in Germany. N Engl J Med. Aug 25 2011;365(8):709-17. [Medline]. [Full Text].

  5. Farthing M, Lindberg G, Dite P, et al. World Gastroenterology Organisation practice guideline: Acute diarrhea. World Gastroenterology Organisation. Available at http://www.worldgastroenterology.org/acute-diarrhea-in-adults.html. Accessed September 2011.

  6. Belliot G, Lavaux A, Souihel D, Agnello D, Pothier P. Use of murine norovirus as a surrogate to evaluate resistance of human norovirus to disinfectants. Appl Environ Microbiol. May 2008;74(10):3315-8. [Medline]. [Full Text].

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

  8. DuPont HL, Jiang ZD, Okhuysen PC, Ericsson CD, de la Cabada FJ, Ke S, et al. A randomized, double-blind, placebo-controlled trial of rifaximin to prevent travelers' diarrhea. Ann Intern Med. May 17 2005;142(10):805-12. [Medline].

  9. Caeiro JP, DuPont HL. Management of travellers' diarrhoea. Drugs. Jul 1998;56(1):73-81. [Medline].

  10. Centers for Disease Control and Prevention. Outbreaks of gastroenteritis associated with noroviruses on cruise ships--United States, 2002. MMWR Morb Mortal Wkly Rep. Dec 13 2002;51(49):1112-5. [Medline]. [Full Text].

  11. Heymann DL. Control of communicable diseases manual. 19th ed. Washington, DC: American Public Health Association; 2008:258-260, 534-539.

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  18. 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.

  19. Hom J. Do probiotics reduce the duration and symptoms of acute infectious diarrhea?. Ann Emerg Med. November 2011;58:445-446.

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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.
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.
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).
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.
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).
 
 
 
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