Laboratory Studies

General laboratory evaluation

In most cases that fit the clinical features of viral gastroenteritis, laboratory tests are not indicated.

If bacterial or protozoal infection is suspected, stool studies for occult blood, white blood cell (WBC) count, microscopy for protozoa, C difficile toxin, Giardia lamblia by enzyme immunoassay (EIA), or bacterial culture may be indicated.

Consider investigating patients with low-grade fever, nausea, vomiting, abdominal pain, and extreme dehydration by evaluating serum electrolytes, urea, creatinine, amylase, complete blood cell (CBC) count, and abdominal imaging studies.

Blood cultures should be obtained in patients with high fevers or who appear systemically ill.

Stool cultures are not performed for most patients who do not have severe illness or high-risk comorbidities, because most infectious cases of acute diarrhea are self-limited and of viral etiology, and the rate of positive stool cultures in all-comers with acute diarrhea is generally low.^[25] When stool cultures are obtained in patients with acute diarrhea, it is to identify a potential bacterial pathogen and determine the potential for complications and treatment decisions.

Polymerase chain reaction (PCR) for enteropathogen detection in stool of patients with diarrhea is available. Cost effectiveness in specific communities remains to be determined.^[26]

Japanese researchers have developed a multiplex real-time PCR assay to detect human enteric viruses other than norovirus ("non-NoV" gastroenteritis viruses) conducted separately from norovirus testing that have the potential to deal with two types of epidemiologic investigations: regular surveillance of infectious gastroenteritis and urgent testing when gastroenteritis outbreaks occur.^[27]

In a systematic literature review, Lee et al used pooled data to calculate median incubation periods for astrovirus (4.5 days), norovirus genogroups I and II (1.2 days), sapovirus (1.7 days), and rotavirus (2.0 days).^[28]

Diagnosis of rotavirus infection

Rapid antigen testing of the stool, either by EIA (>98% sensitivity and specificity) or latex agglutination tests (less sensitive and specific as compared to EIA), is used to aid in the diagnosis of rotavirus infection.

Expect antirotavirus antibodies (ie, immunoglobulin M, immunoglobulin A) to be excreted in the stool after the first day of illness. Antibody tests can remain positive for 10 days after primary infection and longer after reinfection; therefore, they can be used as an adjunct to diagnosis.

Diagnosis of calicivirus infection

In epidemics, save stool and emesis specimens for evaluation by public health officials. Polymerase chain reaction is valuable in both the outbreak setting and the sporadic case setting.

Researchers have cloned several of the caliciviruses and placed the genome in a baculovirus that produces unlimited amounts of recombinant calicivirus capsid protein. Enzyme immunoassays for serum antibody and stool antigen have been developed using this antigen source.

A modification to PCR has allowed many of the various strains of caliciviruses to be recognized with just a few primers (broadly reactive reverse-transcription polymerase chain reaction). These primers are directed at a region of the genome that is common to many of the strains of calicivirus. This has been an important tool for identifying caliciviruses as the most common cause of epidemic viral gastroenteritis.

Fecal viral concentration of norovirus correlates with duration of illness. As in most viral infections, active viral replication determines clinical disease. High fecal viral concentrations suggest the need for both aggressive fluid replacement and stringent infection control measures.^[29]

Treatment & Management

Chiejina M, Samant H. Diarrhea, viral. 2018 Jan. [QxMD MEDLINE Link]. [Full Text].
Ramani S, Kang G. Viruses causing childhood diarrhoea in the developing world. Curr Opin Infect Dis. 2009 Oct. 22(5):477-82. [QxMD MEDLINE Link].
Scarcella C, Carasi S, Cadoria F, et al. An outbreak of viral gastroenteritis linked to municipal water supply, Lombardy, Italy, June 2009. Euro Surveill. 2009 Jul 23. 14(29):epub ahead of print. [QxMD MEDLINE Link].
Lorrot M, Vasseur M. How do the rotavirus NSP4 and bacterial enterotoxins lead differently to diarrhea?. Virol J. 2007 Mar 21. 4:31. [QxMD MEDLINE Link].
Olortegui MP, Rouhani S, Yori PP, et al, for the MAL-ED Network. Astrovirus infection and diarrhea in 8 countries. Pediatrics. 2018 Jan. 141 (1):[QxMD MEDLINE Link].
Chhabra P, Payne DC, Szilagyi PG, et al. Etiology of viral gastroenteritis in children J Infect Dis</i>. 2013 Sep 1. 208(5):790-800. [QxMD MEDLINE Link].
Glass RI, Kilgore PE, Holman RC, et al. The epidemiology of rotavirus diarrhea in the United States: surveillance and estimates of disease burden. J Infect Dis. 1996 Sep. 174 Suppl 1:S5-11. [QxMD MEDLINE Link].
Fischer TK, Viboud C, Parashar U, et al. Hospitalizations and deaths from diarrhea and rotavirus among children J Infect Dis</i>. 2007 Apr 15. 195 (8):1117-25. [QxMD MEDLINE Link].
Tate JE, Panozzo CA, Payne DC, et al. Decline and change in seasonality of US rotavirus activity after the introduction of rotavirus vaccine. Pediatrics. 2009 Aug. 124(2):465-71. [QxMD MEDLINE Link].
Centers for Disease Control and Prevention. Norovirus worldwide: global trends. Available at https://www.cdc.gov/norovirus/worldwide.html. Updated: June 24, 2016; Accessed: January 9, 2018.
Smith MJ, Clark HF, Lawley D, et al. The clinical and molecular epidemiology of community- and healthcare-acquired rotavirus gastroenteritis. Pediatr Infect Dis J. 2008 Jan. 27(1):54-8. [QxMD MEDLINE Link].
Centers for Disease Control and Prevention. Norovirus: US trends and outbreaks. Available at https://www.cdc.gov/norovirus/trends-outbreaks.html. Reviewed: June 24, 2016; Accessed: January 9, 2018.
Centers for Disease Control and Prevention. Estimates of foodborne illness in the United States. Burden of foodborne illness: findings. Available at https://www.cdc.gov/foodborneburden/2011-foodborne-estimates.html. Updated July 15, 2016; Accessed: January 9, 2018.
Estes MK, Prasad BV, Atmar RL. Noroviruses everywhere: has something changed?. Curr Opin Infect Dis. 2006 Oct. 19(5):467-74. [QxMD MEDLINE Link].
Desai R, Yen C, Wikswo M, Gregoricus NA, Provo JE, Parashar UD, et al. Transmission of norovirus among NBA players and staff, winter 2010-2011. Clin Infect Dis. 2011 Dec. 53(11):1115-7. [QxMD MEDLINE Link].
CDC research shows outbreaks linked to imported foods increasing. Available at http://www.cdc.gov/media/releases/2012/p0314_foodborne.html. Accessed: March 14, 2012.
Wikswo ME, Kambhampati A, Shioda K, Walsh KA, Bowen A, Hall AJ, et al. Outbreaks of acute gastroenteritis transmitted by person-to-person contact, environmental contamination, and unknown modes of transmission--United States, 2009-2013. MMWR Surveill Summ. 2015 Dec 11. 64 (12):1-16. [QxMD MEDLINE Link]. [Full Text].
Barreira DMPG, Fumian TM, Tonini MAL, et al. Detection and molecular characterization of the novel recombinant norovirus GII.P16-GII.4 Sydney in southeastern Brazil in 2016. PLoS One. 2017. 12 (12):e0189504. [QxMD MEDLINE Link]. [Full Text].
Notes from the field: outbreaks of rotavirus gastroenteritis among elderly adults in two retirement communities--Illinois, 2011. MMWR Morb Mortal Wkly Rep. 2011 Oct 28. 60(42):1456. [QxMD MEDLINE Link].
Centers for Disease Control and Prevention (CDC). Deaths from gastroenteritis double. Available at http://www.cdc.gov/media/releases/2012/p0314_gastroenteritis.html.
Lindesmith LC, Brewer-Jensen PD, Mallory ML, et al. Antigenic characterization of a novel recombinant GII.P16-GII.4 Sydney norovirus strain with minor sequence variation leading to antibody escape. J Infect Dis. 2017 Dec 22. [QxMD MEDLINE Link].
Pogan R, Schneider C, Reimer R, Hansman G, Uetrecht C. Norovirus-like VP1 particles exhibit isolate dependent stability profiles. J Phys Condens Matter. 2018 Feb 14. 30(6):064006. [QxMD MEDLINE Link]. [Full Text].
Turcios RM, Widdowson MA, Sulka AC, et al. Reevaluation of epidemiological criteria for identifying outbreaks of acute gastroenteritis due to norovirus: United States, 1998-2000. Clin Infect Dis. 2006 Apr 1. 42(7):964-9. [QxMD MEDLINE Link].
[Guideline] DuPont HL. Guidelines on acute infectious diarrhea in adults. The Practice Parameters Committee of the American College of Gastroenterology. Am J Gastroenterol. 1997 Nov. 92 (11):1962-75. [QxMD MEDLINE Link].
[Guideline] Guerrant RL, Van Gilder T, Steiner TS, Thielman NM, Slutsker L, Tauxe RV, et al. Practice guidelines for the management of infectious diarrhea. Clin Infect Dis. 2001 Feb 1. 32 (3):331-51. [QxMD MEDLINE Link].
Schierenberg A, Nipshagen MD, Broekhuizen BD, van de Pol AC, Bruijning-Verhagen PC, Kusters JG, et al. Design of the PROUD study: PCR faeces testing in outpatients with diarrhoea. BMC Infect Dis. 2016 Jan 30. 16:39. [QxMD MEDLINE Link].
Kowada K, Takeuchi K, Hirano E, Toho M, Sada K. Development of a multiplex real-time PCR assay for detection of human enteric viruses other than norovirus using samples collected from gastroenteritis patients in Fukui Prefecture, Japan. J Med Virol. 2018 Jan. 90 (1):67-75. [QxMD MEDLINE Link].
Lee RM, Lessler J, Lee RA, et al. Incubation periods of viral gastroenteritis: a systematic review. BMC Infect Dis. 2013 Sep 25. 13:446. [QxMD MEDLINE Link]. [Full Text].
Lee N, Chan MC, Wong B, et al. Fecal viral concentration and diarrhea in norovirus gastroenteritis. Emerg Infect Dis. 2007 Sep. 13(9):1399-401. [QxMD MEDLINE Link].
[Guideline] American Academy of Pediatrics. Practice parameter: the management of acute gastroenteritis in young children. American Academy of Pediatrics, Provisional Committee on Quality Improvement, Subcommittee on Acute Gastroenteritis. Pediatrics. 1996 Mar. 97(3):424-35. [QxMD MEDLINE Link]. [Full Text].
[Guideline] American Academy of Pediatrics Provisional Committee on Quality Improvement. Practice parameter: the management of acute gastroenteritis in young children. American Academy of Pediatrics, Provisional Committee on Quality Improvement, Subcommittee on Acute Gastroenteritis. Pediatrics. 1996 Mar. 97 (3):424-35. [QxMD MEDLINE Link]. [Full Text].
[Guideline] King CK, Glass R, Bresee JS, Duggan C, Centers for Disease Control and Prevention. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21. 52 (RR-16):1-16. [QxMD MEDLINE Link]. [Full Text].
Vandenplas Y, Salvatore S, Vieira M, et al. Probiotics in infectious diarrhoea in children: are they indicated?. Eur J Pediatr. 2007 Dec. 166(12):1211-8. [QxMD MEDLINE Link].
Sartor RB. Therapeutic manipulation of the enteric microflora in inflammatory bowel diseases: antibiotics, probiotics, and prebiotics. Gastroenterology. 2004 May. 126(6):1620-33. [QxMD MEDLINE Link].
Centers for Disease Control and Prevention. Vaccines and preventable diseases. Rotavirus vaccination: information for health care professionals). Available at https://www.cdc.gov/vaccines/vpd/rotavirus/hcp/index.html. Updated: November 22, 2016; Accessed: January 8, 2018.
Glass RI, Parashar UD. The promise of new rotavirus vaccines. N Engl J Med. 2006 Jan 5. 354(1):75-7. [QxMD MEDLINE Link].
Centers for Disease Control and Prevention. Vaccines & immunizations. Rotavirus vaccine (RotaShield) and intussusception (archived document). Available at https://www.cdc.gov/vaccines/vpd-vac/rotavirus/vac-rotashield-historical.htm. Reviewed: April 22, 2011; Accessed: January 8, 2018.
Marsh ZA, Grytdal SP, Beggs JC, et al. The unwelcome houseguest: secondary household transmission of norovirus. Epidemiol Infect. 2017 Dec 12. 1-9. [QxMD MEDLINE Link].
US Food and Drug Administration. FDA Approves New Vaccine to Prevent Gastroenteritis Caused by Rotavirus. Available at http://www.fda.gov/bbs/topics/NEWS/2008/NEW01814.html.
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. 2006 Jan 5. 354(1):11-22. [QxMD MEDLINE Link].
American Academy of Pediatrics. Red Book® Online Table - NEWStatus of Licensure and Recommendations for New Vaccines*. Available at http://aapredbook.aappublications.org/news/vaccstatus.shtml.
Ball JM, Graham DY, Opekun AR, et al. Recombinant Norwalk virus-like particles given orally to volunteers: phase I study. Gastroenterology. 1999 Jul. 117(1):40-8. [QxMD MEDLINE Link].
Belhorn T. Rotavirus diarrhea. Curr Probl Pediatr. 1999 Aug. 29(7):198-207. [QxMD MEDLINE Link].
Bon F, Fascia P, Dauvergne M, et al. Prevalence of group A rotavirus, human calicivirus, astrovirus, and adenovirus type 40 and 41 infections among children with acute gastroenteritis in Dijon, France. J Clin Microbiol. 1999 Sep. 37(9):3055-8. [QxMD MEDLINE Link].
Burkhart DM. Management of acute gastroenteritis in children. Am Fam Physician. 1999 Dec. 60(9):2555-63, 2565-6. [QxMD MEDLINE Link].
Caeiro JP, Mathewson JJ, Smith MA, et al. Etiology of outpatient pediatric nondysenteric diarrhea: a multicenter study in the United States. Pediatr Infect Dis J. 1999 Feb. 18(2):94-7. [QxMD MEDLINE Link].
Centers for Disease Control and Prevention. Advisory Committee Recommends New Vaccine to Prevent Rotavirus. [Full Text].
Centers for Disease Control and Prevention. Outbreak of Gastroenteritis Associated with Noroviruses on Cruise Ships --- United States, 2002. MMWR Morb Mortal Wkly Rep. 2002 Dec 13. 51(49):1112-1115. [Full Text].
Centers for Disease Control and Prevention. Withdrawal of rotavirus vaccine recommendation. JAMA. 1999 Dec 8. 282(22):2113-4. [QxMD MEDLINE Link].
Clark B, McKendrick M. A review of viral gastroenteritis. Curr Opin Infect Dis. 2004 Oct. 17(5):461-9. [QxMD MEDLINE Link].
Estes MK, Morris AP. A viral enterotoxin. A new mechanism of virus-induced pathogenesis. Adv Exp Med Biol. 1999. 473:73-82. [QxMD MEDLINE Link].
Fankhauser RL, Noel JS, Monroe SS, et al. Molecular epidemiology of "Norwalk-like viruses" in outbreaks of gastroenteritis in the United States. J Infect Dis. 1998 Dec. 178(6):1571-8. [QxMD MEDLINE Link].
Flem E, Vainio K, Dollner H, et al. Rotavirus gastroenteritis in Norway: Analysis of prospective surveillance and hospital registry data. Scand J Infect Dis. 2009. 41(10):753-9. [QxMD MEDLINE Link].
Ford T. Emerging issues in water and health research. J Water Health. 2006. 4 Suppl 1:59-65. [QxMD MEDLINE Link].
Gaggero A, O'Ryan M, Noel JS, et al. Prevalence of astrovirus infection among Chilean children with acute gastroenteritis. J Clin Microbiol. 1998 Dec. 36(12):3691-3. [QxMD MEDLINE Link].
Green J, Gallimore CI, Norcott JP, et al. Broadly reactive reverse transcriptase polymerase chain reaction for the diagnosis of SRSV-associated gastroenteritis. J Med Virol. 1995 Dec. 47(4):392-8. [QxMD MEDLINE Link].
ICTVdb. The Universal Virus Database of the International Committee on Taxonomy of Viruses Web site. Available at: http://ictvdb.bio2.columbia.edu/Ictv/index.htm. Accessed on December 27, 2002.
Johnsen CK, Midgley S, Bottiger B. Genetic diversity of sapovirus infections in Danish children 2005-2007. J Clin Virol. 2009 Nov. 46(3):265-9. [QxMD MEDLINE Link].
Maldonado Y, Cantwell M, Old M, et al. Population-based prevalence of symptomatic and asymptomatic astrovirus infection in rural Mayan infants. J Infect Dis. 1998 Aug. 178(2):334-9. [QxMD MEDLINE Link].
Mead PS, Slutsker L, Dietz V, et al. Food-related illness and death in the United States. Emerg Infect Dis. 1999 Sep-Oct. 5(5):607-25. [QxMD MEDLINE Link]. [Full Text].
Pang XL, Joensuu J, Vesikari T. Human calicivirus-associated sporadic gastroenteritis in Finnish children less than two years of age followed prospectively during a rotavirus vaccine trial. Pediatr Infect Dis J. 1999 May. 18(5):420-6. [QxMD MEDLINE Link].
Pang XL, Koskenniemi E, Joensuu J, et al. Effect of rhesus rotavirus vaccine on enteric adenovirus--associated diarrhea in children. J Pediatr Gastroenterol Nutr. 1999 Sep. 29(3):366-9. [QxMD MEDLINE Link].
Pang XL, Vesikari T. Human astrovirus-associated gastroenteritis in children under 2 years of age followed prospectively during a rotavirus vaccine trial. Acta Paediatr. 1999 May. 88(5):532-6. [QxMD MEDLINE Link].
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. 2006 Jan 5. 354(1):11-22. [QxMD MEDLINE Link].
Saps M, Pensabene L, Turco R, et al. Rotavirus gastroenteritis: precursor of functional gastrointestinal disorders?. J Pediatr Gastroenterol Nutr. 2009 Nov. 49(5):580-3. [QxMD MEDLINE Link].
Shornikova AV, Isolauri E, Burkanova L, et al. A trial in the Karelian Republic of oral rehydration and Lactobacillus GG for treatment of acute diarrhoea. Acta Paediatr. 1997 May. 86(5):460-5. [QxMD MEDLINE Link].
Vesikari T, Matson DO, Dennehy P, et al. Safety and efficacy of a pentavalent human-bovine (WC3) reassortant rotavirus vaccine. N Engl J Med. 2006 Jan 5. 354(1):23-33. [QxMD MEDLINE Link]. [Full Text].
Wang X, Wang S, Zhang C, et al. Development of a surrogate neutralization assay for norovirus vaccine evaluation at the cellular level. Viruses. 2018 Jan 5. 10(1):785-808. [QxMD MEDLINE Link]. [Full Text].
Gaythorpe KAM, Trotter CL, Lopman B, Steele M, Conlan AJK. Norovirus transmission dynamics: a modelling review. Epidemiol Infect. 2017 Dec 22. 1-12. [QxMD MEDLINE Link].
Centers for Disease Control and Prevention. Rotavirus: rotavirus in the US. Available at https://www.cdc.gov/rotavirus/surveillance.html. Reviewed: August 12, 2016; Accessed: January 9, 2018.
Corcoran MS, van Well GT, van Loo IH. Diagnosis of viral gastroenteritis in children: interpretation of real-time PCR results and relation to clinical symptoms. Eur J Clin Microbiol Infect Dis. 2014 Oct. 33(10):1663-73. [QxMD MEDLINE Link].
Tan EM, Cawcutt KA, Zomok CD, Go RS, Sia IG. Activity of nitazoxanide against viral gastroenteritis: a systematic review. Int J Travel Med Glob Health. 2017 Aug 16. 5(4):107-12. [Full Text].
Borrows CL, Turner PC. Seasonal screening for viral gastroenteritis in young children and elderly hospitalized patients: is it worthwhile?. J Hosp Infect. 2014 Jun. 87(2):98-102. [QxMD MEDLINE Link].
McFarland LV. Meta-analysis of probiotics for the prevention of traveler's diarrhea. Travel Med Infect Dis. 2007 Mar. 5(2):97-105. [QxMD MEDLINE Link].

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Author

Brian Lin New York College of Osteopathic Medicine

Brian Lin is a member of the following medical societies: American College of Osteopathic Family Physicians, American College of Osteopathic Internists, American College of Physicians, American Medical Student Association/Foundation, Asian Pacific American Medical Student Association, Student Osteopathic Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

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

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

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

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

Disclosure: Nothing to disclose.

Chief Editor

Burt Cagir, MD, FACS Associate Regional Dean and Professor of Surgery, Geisinger Commonwealth School of Medicine; Director, General Surgery Residency Program, Executive Director, Donald Guthrie Foundation for Research and Education, Guthrie Robert Packer Hospital; Medical Director, Guthrie/RPH Skills and Simulation Lab; Associate in Surgery, Guthrie Robert Packer Hospital and Corning Hospital

Burt Cagir, MD, FACS is a member of the following medical societies: American College of Surgeons, Association of Program Directors in Surgery, Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Additional Contributors

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

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

Disclosure: Nothing to disclose.

Michael J Grupka, MD Physician, Atlanta Center for Gastroenterology

Disclosure: Nothing to disclose.

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

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

Disclosure: Nothing to disclose.