Acute Gastroenteritis: An Approach Paolo Aquino, M.D., M.P.H.
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Transcript of Acute Gastroenteritis: An Approach Paolo Aquino, M.D., M.P.H.
Acute Gastroenteritis: Acute Gastroenteritis: An ApproachAn Approach
Paolo Aquino, M.D., M.P.H.Paolo Aquino, M.D., M.P.H.
OutlineOutline
ApproachApproach EtiologyEtiology DiagnosisDiagnosis TreatmentTreatment PreventionPrevention
ApproachApproach
ConsiderationsConsiderations
• Rule out acute/surgical abdomenRule out acute/surgical abdomen
• Hydration statusHydration status
Acute AbdomenAcute AbdomenIntraluminal Intraluminal ObstructionObstruction
Extraluminal Extraluminal ObstructionObstruction
GastrointestinGastrointestinalal
DiseaseDisease
Paralytic Paralytic IleusIleus
Blunt Blunt TraumaTrauma
MiscellaneousMiscellaneous
Foreign BodyForeign Body
BezoarBezoar
FecalithFecalith
GallstoneGallstone
ParasitesParasites
Cystic fibrosisCystic fibrosis
TumorTumor
FecalomaFecaloma
HerniaHernia
IntussusceptioIntussusceptionn
VolvulusVolvulus
DuplicationDuplication
StenosisStenosis
TumorTumor
Mesenteric Mesenteric cystcyst
SMA syndromeSMA syndrome
Pyloric stenosisPyloric stenosis
AppendicitisAppendicitis
Crohn diseaseCrohn disease
Ulcerative Ulcerative colitiscolitis
VasculitisVasculitis
Peptic ulcer Peptic ulcer diseasedisease
Meckel’sMeckel’s
AGEAGE
SepsisSepsis
PneumoniaPneumonia
PyelonephritisPyelonephritis
PeritonitisPeritonitis
PancreatitisPancreatitis
CholecystitisCholecystitis
Renal stonesRenal stones
GallstonesGallstones
PIDPID
LymphadenitisLymphadenitis
AccidentAccident
Battered child Battered child syndromesyndrome
Lead poisoningLead poisoning
Sickle cell Sickle cell diseasedisease
Familial Familial Mediterranean Mediterranean feverfever
PorphyriaPorphyria
DKADKA
Addisonian Addisonian crisiscrisis
Testicular Testicular torsiontorsion
Ovarian TorsionOvarian Torsion
ApproachApproach
HistoryHistory• SymptomsSymptoms
Nausea, emesis, retchingNausea, emesis, retching Abdominal painAbdominal pain Bowel movementsBowel movements TimingTiming
• AgeAge• OnsetOnset• Relation to feedsRelation to feeds
• Focus of infection, other affected Focus of infection, other affected individualsindividuals
ApproachApproach
Physical examinationPhysical examination• Temperature, heart rate, blood Temperature, heart rate, blood
pressure, painpressure, pain• Abdominal examinationAbdominal examination
Auscultation before palpationAuscultation before palpation PalpationPalpation
• MassesMasses• TendernessTenderness
Auscultation for bowel soundsAuscultation for bowel sounds
ApproachApproach
ObjectivesObjectives• Assess the degree of dehydrationAssess the degree of dehydration• Prevent spread of the enteropathogenPrevent spread of the enteropathogen• Selectively determine etiology and Selectively determine etiology and
provide specific therapyprovide specific therapy
DehydrationDehydration
Mild (3-5%)Mild (3-5%)• Normal or increased pulseNormal or increased pulse• Decreased urine outputDecreased urine output• ThirstyThirsty• Normal physical examNormal physical exam
DehydrationDehydration
Moderate (7-10%)Moderate (7-10%)• TachycardiaTachycardia• Little/no urine outputLittle/no urine output• Irritable/lethargicIrritable/lethargic• Sunken eyes/fontanelleSunken eyes/fontanelle• Decreased tearsDecreased tears• Dry mucous membranesDry mucous membranes• Skin- tenting, delayed cap refill, cool, Skin- tenting, delayed cap refill, cool,
palepale
DehydrationDehydration
Severe (10-15%)Severe (10-15%)• Rapid, weak pulseRapid, weak pulse• Decreased blood pressureDecreased blood pressure• No urine outputNo urine output• Very sunken eyes/fontanelleVery sunken eyes/fontanelle• No tearsNo tears• Parched mucous membranesParched mucous membranes• Skin- tenting, delayed cap refill, cold, Skin- tenting, delayed cap refill, cold,
mottledmottled
DehydrationDehydration
TreatmentTreatment• Calculate deficitsCalculate deficits
Water: % dehydration x weightWater: % dehydration x weight Sodium: water deficit x 80 mEq/LSodium: water deficit x 80 mEq/L Potassium: water deficit x 30 mEq/LPotassium: water deficit x 30 mEq/L
• Treat mild-moderate dehydration with Treat mild-moderate dehydration with oral rehydration solutionsoral rehydration solutions
• May treat severe dehydration with May treat severe dehydration with intravenous fluidsintravenous fluids
• Hyponatremic v. isotonic v. Hyponatremic v. isotonic v. hypernatremichypernatremic
EtiologyEtiology
EnteropathogensEnteropathogens• Non-inflammatory vs. inflammatory Non-inflammatory vs. inflammatory
diarrheadiarrhea Non-inflammatoryNon-inflammatory
• Enterotoxin productionEnterotoxin production• Destruction of villiDestruction of villi• Adherence to GI tractAdherence to GI tract
InflammatoryInflammatory• Intestinal invasionIntestinal invasion• CytotoxinsCytotoxins
EtiologyEtiology
Chronic diarrheaChronic diarrhea• Giardia lambliaGiardia lamblia• Cryptosporidium parvumCryptosporidium parvum• Escherichia coliEscherichia coli: enteroaggregative, : enteroaggregative,
enteropathogenicenteropathogenic• Immunocompromised hostImmunocompromised host• Non-infectious causes: anatomic, Non-infectious causes: anatomic,
malabsorption, endocrinopathies, malabsorption, endocrinopathies, neoplasianeoplasia
EtiologyEtiology
BacterialBacterial• Inflammatory diarrheaInflammatory diarrhea
AeromonasAeromonas Campylobacter jejuniCampylobacter jejuni Clostridium dificileClostridium dificile E. coliE. coli: enteroinvasive, O157:H7: enteroinvasive, O157:H7 Plesiomonas shigelloidesPlesiomonas shigelloides SalmonellaSalmonella ShigellaShigella Vibrio parahaemolyticusVibrio parahaemolyticus Yersinia enterocoliticaYersinia enterocolitica
EtiologyEtiology BacterialBacterial
• Non-inflammatoryNon-inflammatory E. coliE. coli: enteropathogenic, enterotoxigenic: enteropathogenic, enterotoxigenic Vibrio choleraeVibrio cholerae
ViralViral• RotavirusRotavirus• Enteric adenovirusEnteric adenovirus• AstroviruusAstroviruus• CalcivirusCalcivirus• NorwalkNorwalk• CMVCMV• HSVHSV
EtiologyEtiology
ParasitesParasites• Giardia lamblidaGiardia lamblida• Entamoeba histolyticaEntamoeba histolytica• Strongyloides stercoralisStrongyloides stercoralis• Balantidium coliBalantidium coli• Cryptosporidium parvumCryptosporidium parvum• Cyclospora cayetanensisCyclospora cayetanensis• Isospora belliIsospora belli
DiagnosisDiagnosis
HistoryHistory Stool examinationStool examination
• MucusMucus• BloodBlood• LeukocytesLeukocytes• Stool cultureStool culture
DiagnosisDiagnosis
Examination for ova and parasitesExamination for ova and parasites• Recent travel to an endemic areaRecent travel to an endemic area• Stool cultures negative for other Stool cultures negative for other
enteropathogensenteropathogens• Diarrhea persists for more than 1 weekDiarrhea persists for more than 1 week• Part of an outbreakPart of an outbreak• ImmunocompromisedImmunocompromised• May require examination of more than May require examination of more than
one specimenone specimen
Antimicrobial therapyAntimicrobial therapy
AeromonasAeromonas• TMP/SMZTMP/SMZ• Dysentery-like illness, prolonged diarrheaDysentery-like illness, prolonged diarrhea
CampylobacterCampylobacter• Erythromycin, azithromycinErythromycin, azithromycin
Clostridium dificileClostridium dificile• Metronidazole, vancomycinMetronidazole, vancomycin
E. coliE. coli• TMP/SMZTMP/SMZ
Antimicrobial therapyAntimicrobial therapy
SalmonellaSalmonella• Cefotaxime, ceftriaxone, ampicillin, TMP/SMZCefotaxime, ceftriaxone, ampicillin, TMP/SMZ• Infants < 3 monthsInfants < 3 months• Typhoid feverTyphoid fever• BacteremiaBacteremia• Dissemination with localized suppurationDissemination with localized suppuration
ShigellaShigella• Ampicillin, ciprofloxacin, ofloxacin, ceftriaxoneAmpicillin, ciprofloxacin, ofloxacin, ceftriaxone
Vibrio choleraeVibrio cholerae• Doxycycline, tetracyclineDoxycycline, tetracycline
TherapyTherapy
Antidiarrheal medicationAntidiarrheal medication• Alter intestinal motilityAlter intestinal motility• Alter adsorptionAlter adsorption• Alter intestinal floraAlter intestinal flora• Alter fluid/electrolyte secretionAlter fluid/electrolyte secretion
Antidiarrheal medication generally Antidiarrheal medication generally not recommendednot recommended• Minimal benefitMinimal benefit• Potential for side effectsPotential for side effects
PreventionPrevention
Contact precautionsContact precautions Education Education
• Mode of acquisitionMode of acquisition• Methods to decrease transmissionMethods to decrease transmission
Exclusion from day care until Exclusion from day care until diarrhea subsidesdiarrhea subsides
SurveillanceSurveillance Salmonella typhiSalmonella typhi vaccine vaccine
Any questions?Any questions?