Gastroenteritis
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2008-07-15T15:22:23Z
Ettrig
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{{Mergefrom|Traveler's diarrhea|talk:Traveler's diarrhea|date=February 2008}}
{{Infobox_Disease
| Name = Gastroenteritis
| Image =
| Caption =
| DiseasesDB = 30726
| ICD10 = {{ICD10|A|09||a|00}}, {{ICD10|J|10|8|j|09}}, {{ICD10|K|52||k|50}}
| ICD9 = {{ICD9|009.0}}, {{ICD9|009.1}}, {{ICD9|558}}
| ICDO =
| OMIM =
| MedlinePlus =
| eMedicineSubj = emerg
| eMedicineTopic = 213
| MeshID = D005759
}}
{{wiktionarypar|gastroenteritis}}
'''Gastroenteritis''' (also known as '''gastro''', '''gastric flu''', and '''stomach flu''' although unrelated to [[influenza]]) is [[inflammation]] of the [[gastrointestinal tract]], involving both the [[stomach]] and the [[small intestine]] (see also [[gastritis]] and [[enteritis]]) and resulting in [[acute (medicine)|acute]] [[diarrhea]]. The inflammation is caused most often by [[infection]] with certain [[virus]]es, less often by [[bacteria]] or their [[toxin]]s, [[parasites]], or [[adverse reaction]] to something in the diet or medication. Worldwide, inadequate treatment of gastroenteritis kills 5 to 8 million people per year,<ref name=Harrison>Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL. [[Harrison's Principles of Internal Medicine]]. New York: McGraw-Hill, 2005. ISBN 0-07-139140-1.</ref> and is a leading cause of death among [[infant]]s and [[child]]ren under 5.<ref name="pmid14627948">{{cite journal
| author = King CK, Glass R, Bresee JS, Duggan C
| title = Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy
| journal = MMWR Recomm Rep
| volume = 52
| issue = RR-16
| pages = 1–16
| year = 2003
| pmid = 14627948
| doi =
| url = http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm
| issn =
}}</ref>
At least 50% of cases of gastroenteritis as [[foodborne illness]] are due to [[norovirus]].<ref name="cdcfactsheet">{{cite web |url=http://www.cdc.gov/ncidod/dvrd/revb/gastro/norovirus-factsheet.htm |title=Norovirus: Technical Fact Sheet |publisher=National Center for Infectious Diseases, CDC}}</ref> Another 20% of cases, and the majority of severe cases in children, are due to [[rotavirus]]. Other significant viral agents include [[adenovirus]]<ref name=Murray>Murray PR, Pfaller MA, Rosenthal KS. [[Medical Microbiology]]. Mosby, 2005. ISBN 0323033032.</ref> and [[astrovirus]].
Many different bacteria can cause gastroenteritis, including ''[[Salmonella]]'', ''[[Shigella]]'', ''[[Staphylococcus]]'', ''[[Campylobacter jejuni]]'', ''[[Clostridium]]'', ''[[Escherichia coli]]'', ''[[Yersinia]]'', and others. Some sources of the infection are improperly prepared food, reheated meat dishes, seafood, dairy, and bakery products. Each organism causes slightly different symptoms but all result in diarrhea. [[Colitis]], inflammation of the large intestine, may also be present.
Risk factors are consumption of improperly prepared foods or contaminated water and travel or residence in areas of poor sanitation. The incidence is 1 in 1,000 people.
==Epidemiology==
Globally, gastroenteritis caused 4.6 million deaths in children in 1980 alone, most of these in the [[third world|developing world]],<ref name="Mandell"/> where the lack of adequate [[safe water]] and [[sewage treatment]] capacity contribute to the spread of infectious gastroenteritis. ''[[Harrison's Principles of Internal Medicine]]'' estimates the current total figure to be 2.4 to 2.9 million per year.<ref name="Harrison"/> The global death rate has now come down significantly to approximately 1.5 million deaths annually, largely due to global introduction of proper [[oral rehydration therapy]].<ref>Victora et al. 2000</ref>
The incidence in the [[developed nation|developed countries]] is as high as 1-2.5 cases per child per year and a major cause of hospitalisation in this age group.
Age, living conditions, hygiene and cultural habits are important factors. [[Etiology|Aetiological]] agents vary depending on the climate. Furthermore, most cases of gastroenteritis are seen during the winter in temperate climates and during summer in the tropics.<ref name="Mandell"/>
==History==
Before the 20th century, the term "gastroenteritis" was not commonly used. What would now be diagnosed as gastroenteritis may have instead been diagnosed ''more specifically'' as [[typhoid fever]] or "cholera morbus", among others, or ''less specifically'' as "griping of the guts", "surfeit", "flux", "colic", "bowel complaint", or any one of a number of other archaic names for acute diarrhea.<ref name="archaic">[http://www.antiquusmorbus.com/English/English.htm Rudy's List of Archaic Medical Terms]</ref> Historians, genealogists, and other researchers should keep in mind that gastroenteritis was not considered a discrete diagnosis until fairly recently.
== Symptoms and signs ==
It often involves stomach pain or spasms (sometimes to the point of being crippling), [[diarrhea]] and/or [[vomiting]], with noninflammatory infection of the upper [[small bowel]], or inflammatory infections of the [[Colon (anatomy)|colon]].<ref name="SleisengerFordtran">
[http://www.elsevier-international.com/catalogue/title.cfm?ISBN=0721689736 Sleisenger & Fordtran's Gastrointestinal and Liver Disease] 7th edition,<!-- 2-Volume Set,--> by Mark Feldman<!--, MD, Chair of Internal Medicine, Presbyterian Hospital of Dallas, Clinical Professor of Internal Medicine, University of Texas Southwestern Medical School of Dallas, Dallas, TX-->; Lawrence S. Friedman<!--, MD, Professor of Medicine, Gastroinstestinal Unit, Massachusetts General Hospital, Boston, MA-->; and Marvin H. Sleisenger<!--, MD, Distinguished Physician, Department of Veterans Affairs Medical Center, San Francisco, CA-->, ISBN 0-7216-8973-6, Hardback,<!-- 2688 Pages, 850 Illustrations,--> Saunders, Published July 2002</ref><ref name="Mandell">
[http://www.ppidonline.com/ Mandell's Principles and Practices of Infection Diseases] 6th Edition (2004) by Gerald L. Mandell MD, MACP, John E. Bennett MD, Raphael Dolin MD, ISBN 0-443-06643-4 · Hardback · 4016 Pages Churchill Livingstone </ref><ref name="Harrison"> [http://books.mcgraw-hill.com/medical/harrisons/ Harrison's Principles of Internal Medicine] 16th Edition, The [[McGraw-Hill]] Companies, ISBN 0-07-140235-7</ref><ref name="Oxford">[http://www.oup.com/us/catalog/general/subject/Medicine/PrimaryCare/?ci=0192629220&view=usa The Oxford Textbook of Medicine]{{Dead link|url=http://www.oup.com/us/catalog/general/subject/Medicine/PrimaryCare/?ci=0192629220&view=usa|date=December 2007|date=January 2008}} Edited by David A. Warrell, Timothy M. Cox and John D. Firth with Edward J. Benz, Fourth Edition (2003), [[Oxford University Press]], ISBN 0-19-262922-0</ref>
It usually is of [[acute (medical)|acute]] onset, normally lasting fewer than 10 days and [[self-limiting]].
* [[Nausea]] and [[vomiting]]
* [[Diarrhea]]
* Loss of appetite
* Abdominal pain
* Abdominal cramps
* Bloody stools ([[dysentery]] - suggesting infection by amoeba, ''Campylobacter'', ''Salmonella'', ''Shigella'' or some pathogenic strains of ''Escherichia coli''<ref name=Murray>Murray PR, Pfaller MA, Rosenthal KS. [[Medical Microbiology]]. Mosby, 2005. ISBN 0323033032.</ref>)
* Fainting and Weakness
The main contributing factors include poor feeding in infants. Diarrhea is common, and may be (but not always) followed by vomiting. Viral diarrhea usually causes frequent watery stools, whereas blood stained diarrhea may be indicative of bacterial [[colitis]]. In some cases, even when the stomach is empty, [[bile]] can be vomited up.
A child with gastroenteritis may be [[lethargic]], suffer lack of sleep, or run a low fever and have signs of [[dehydration]], which include dry mucous membranes, [[tachycardia]], reduced skin [[turgor]], skin color discoloration, sunken [[fontanelles]] and sunken eyeballs and darkened eye circles, glassy eyes,poor [[perfusion]] and ultimately [[Shock (medical)|shock]].
Symptoms occur for up to 6 days on average. Given appropriate treatment, bowel movements will return to normal within a week after that.
===Signs and Tests===
* Stool culture positive for the organism that causes the infection
* White blood cells in the stool
* Examination of food for toxin and bacteria
This disease may also alter the results of the following tests:
* Stool [[gram stain]]
* [[Stool test|Fecal smear]]
== Differential diagnosis ==
[[Image:Gastroenteritis viruses.jpg|right|thumb|350px|Gastroenteritis viruses: A = rotavirus, B = adenovirus, C = Norovirus and D = Astrovirus. The virus particles are shown at the same magnification to allow size comparison.]]
It is important to consider infectious gastroenteritis as a [[diagnosis per exclusionem]]. A few loose stools and vomiting may be the result of systemic [[infection]] such as [[pneumonia]], [[septicemia]], [[urinary tract infection]] and even [[meningitis]]. Surgical conditions such as [[appendicitis]], [[intussusception]] and, rarely, even [[Hirschsprung's disease]] may mislead the clinician.
Non-infectious causes to consider are poisoning with heavy metals (e.g. [[arsenic]], [[cadmium]]), seafood (e.g. [[ciguatera]], [[scombroid]], toxic encephalopathic shellfish poisoning) or mushrooms (e.g. [[Amanita phalloides]]). Secretory tumours (e.g. [[carcinoid]], medullary tumour of the thyroid, [[Vipoma|vasoactive intestinal peptide-secreting adenomas]]) and endocrine disorders (e.g. [[thyrotoxicosis]] and [[Addison's disease]]) are disorders that can cause diarrhea. Also, pancreatic insufficiency, [[short bowel syndrome]], [[Whipple's disease]], [[coeliac disease]], and [[laxative abuse]] should be excluded as possibilities.<ref name="Oxford"/> Infectious gastroenteritis is caused by a wide variety of [[bacteria]] and [[virus]]es. For a list of bacteria causing gastroenteritis, see above. [[Pseudomembranous colitis]] is an important cause of diarrhea in patents often recently treated with antibiotics. Viruses causing gastroenteritis include [[rotavirus]], [[norovirus]], [[adenovirus]] and [[astrovirus]].
If gastroenteritis in a child is severe enough to require admission to a hospital, then it is important to distinguish between bacterial and viral infections. Bacteria, ''[[Shigella]]'' and ''[[Campylobacter]]'', for example, and [[parasite]]s like ''[[Giardia]]'' can be treated with [[antibiotic]]s, but viruses do not respond to antibiotics and infected children usually make a full recovery after a few days.<ref name="pmid1649479">{{cite journal |author=Haffejee IE |title=The pathophysiology, clinical features and management of rotavirus diarrhoea |journal=Q. J. Med. |volume=79 |issue=288 |pages=289–99 |year=1991 |pmid=1649479 |doi=}}</ref> Children admitted to hospital with gastroenteritis routinely are tested for rotavirus A to gather surveillance data relevant to the epidemiological effects of rotavirus vaccination programs.<ref name="pmid17901797">{{cite journal |author=Patel MM, Tate JE, Selvarangan R, ''et al'' |title=Routine laboratory testing data for surveillance of rotavirus hospitalizations to evaluate the impact of vaccination |journal=Pediatr. Infect. Dis. J. |volume=26 |issue=10 |pages=914–9 |year=2007 |pmid=17901797 |doi=10.1097/INF.0b013e31812e52fd |doi_brokendate=2008-06-21}}</ref><ref name="pmid16650331">{{cite journal |author= |title=The paediatric burden of rotavirus disease in Europe |journal=Epidemiol. Infect. |volume=134 |issue=5 |pages=908–16 |year=2006 |pmid=16650331 |doi=10.1017/S0950268806006091}}</ref> These children are routinely tested also for [[norovirus]], which is extraordinarily infectious and requires special isolation procedures to avoid transmission to other patients. Other methods, [[electron microscopy]] and [[polyacrylamide gel electrophoresis]], are used in research laboratories.<ref name="pmid3132369">{{cite journal |author=Beards GM |title=Laboratory diagnosis of viral gastroenteritis |journal=Eur. J. Clin. Microbiol. Infect. Dis. |volume=7 |issue=1 |pages=11–3 |year=1988 |pmid=3132369 |doi=10.1007/BF01962164}}</ref><ref name="pmid1321223">{{cite journal |author=Steel HM, Garnham S, Beards GM, Brown DW |title=Investigation of an outbreak of rotavirus infection in geriatric patients by serotyping and polyacrylamide gel electrophoresis (PAGE) |journal=J. Med. Virol. |volume=37 |issue=2 |pages=132–6 |year=1992 |pmid=1321223 |doi=10.1002/jmv.1890370211}}</ref>
== Treatment ==
The objective of treatment is to replace lost [[fluid]]s and [[electrolyte]]s. The person's usual foods and drinks should not be withheld, but consumed as the person is able to tolerate them.{{Fact|date=January 2008}}
=== Rehydration ===
Regardless of cause, the principal treatment of gastroenteritis (and of all other diarrheal illnesses) in both children and adults is [[rehydration]], i.e. replenishment of water lost in the stools. Depending on the degree of [[dehydration]], this can be done by giving the person [[oral rehydration therapy]] (ORT) or through [[vein|intravenous]] delivery. ORT can begin before dehydration occurs, and continue until the person's urine and stool output return to normal.
People taking [[diuretics]] ("water pills") need to be cautious with diarrhea and may need to stop taking the medication during an acute episode, as directed by the health care provider.
===Dietary therapy===
[[Centers for Disease Control and Prevention]]<ref>[http://www.cdc.gov/mmwR/preview/mmwrhtml/rr5216a1.htm Managing Acute Gastroenteritis Among Children: Oral Rehydration, Maintenance, and Nutritional Therapy<!-- Bot generated title -->]</ref> recommendations for infants and children include: Breastfed infants should continue to be nursed on demand. Formula-fed infants should continue their usual formula immediately upon rehydration in amounts sufficient to satisfy energy and nutrient requirements, and at the usual concentration. Lactose-free or lactose-reduced formulas usually are unnecessary. Children receiving semisolid or solid foods should continue to receive their usual diet during episodes of diarrhea. Foods high in [[simple sugar]]s should be avoided because the [[osmosis|osmotic load]] might worsen diarrhea; therefore, substantial amounts of soft drinks (carbonated or flat), juice, gelatin desserts, and other highly sugared liquids should be avoided. Fatty foods should not be avoided, because maintaining adequate [[calorie]]s without fat is difficult, and fat might have an added benefit of reducing intestinal [[motility]]. The practice of withholding food for more than 24 hours is inappropriate.
===Probiotics===
[[Probiotics]] have been shown{{Fact|date=April 2008}} to be beneficial in preventing and treating various forms of gastroenteritis.
===Zinc===
The [[World Health Organization]] recommends that infants and children receive a [[dietary supplement]] of [[zinc]] for up to 2 weeks after onset of gastroenteritis.<ref>[http://rehydrate.org/zinc/index.html Rehydrate.org: Zinc Supplementation]</ref>
=== Drug therapy ===
==== Antibiotics ====
{{Cleanup|date=January 2008}}
When the symptoms are severe one usually starts empirical antimicrobial therapy,{{Fact|date=January 2008}} i.e. a [[fluoroquinolone]] antibiotic.<ref name="SleisengerFordtran"/> [[Pseudomembranous colitis]] is treated by '''discontinuing''' the causative agent and starting with [[metronidazole]] or [[vancomycin]].<ref name="SleisengerFordtran"/><ref name="Mandell"/><ref name="Harrison"/><ref name="Oxford"/>
Antibiotics usually are not given for gastroenteritis, although they may be given due to '''some''' bacteria.<ref>[http://www.merck.com/mmhe/sec09/ch122/ch122a.html Merck Manual]</ref>
==== Antidiarrheal agents ====
{{Cleanup|date=January 2008}}
[[Loperamide]] is an [[opioid]] analogue commonly used for symptomatic treatment of diarrhea. It slows down [[peristalsis|gut motility]], but does not cross the mature [[blood-brain barrier]]<ref name="SleisengerFordtran"/> to cause the central nervous effect of other opioids. In too high doses, loperamide may cause constipation and significant slowing down of passage of feces, but an appropriate single dose will not slow down the duration of the disease.<ref> (Wingate et al, 2001)</ref> Although antimotility drugs have the risk of exacerbating the condition, this fear is not supported by clinical experience.<ref name="SleisengerFordtran"/><ref name="Oxford"/> Nevertheless, others discourage the use of antiperistaltic agents and opiates in febrile [[dysentery]], since they may mask, or exacerbate the symptoms.<ref name="Harrison"/> All these sources agree that in severe colitis antimotility drugs should not be used.
Loperamide prevents the body from flushing toxins from the gut, and should not be used when an active fever is present or there is a suspicion that the diarrhea is associated with organisms that can penetrate the intestinal walls, such as [[E. coli O157:H7]] or ''[[Salmonella]]''.
Loperamide is also not recommended in children, especially in children younger than 2 years of age, as it may cause systemic toxicity due to an immature blood brain barrier, and oral rehydration therapy remains the main stay treatment for children.
[[Bismuth subsalicylate]] (BSS), an insoluble complex of trivalent bismuth and salicylate, is another drug that can be used in mild-moderate cases.<ref name="SleisengerFordtran"/><ref name="Oxford"/>
Combining an antimicrobial drug and an antimotility drug, seems to be effective more rapidly.<ref name="SleisengerFordtran"/><ref name="Oxford"/>
====Antiemetic drugs====
If vomiting is severe, [[antiemetic]] drugs may be helpful. However, these drugs are not recommended for treatment of acute gastroenteritis in children.<ref name="pmid17279195">{{cite journal
| author = Mehta S, Goldman RD
| title = Ondansetron for acute gastroenteritis in children
| journal = Can Fam Physician
| volume = 52
| issue = 11
| pages = 1397–8
| year = 2006
| pmid = 17279195
| doi =
| url = http://www.cfp.ca/cgi/pmidlookup?view=long&pmid=17279195
| issn =
}}</ref>
==Complications==
The '''most serious complication''' is [[dehydration]], usually due to severe [[diarrhea]] but sometimes made worse due to improper treatment such as withholding fluids until diarrhea stops. Severe dehydration can be lethal and requires prompt medical care. The '''most common complication''', especially in infants, is [[malabsorption]] of certain sugars in the diet, and consequent [[food intolerance]]s. This complication may persist for weeks, during which time it causes mild [[diarrhea]] to return when the patient resumes their normal diet. Malabsorption of [[lactose]], the principal sugar in [[milk]], is the most common. Its consequent [[milk intolerance]] is caused by [[lactase]] deficiency, and the diarrhea is caused by bacterial fermentation of excess lactose in the [[gut]].<ref name="pmid6436397">{{cite journal
|author=Arya SC
|title=Rotaviral infection and intestinal lactase level
|journal=J. Infect. Dis.
|volume=150
|issue=5
|pages=791
|year=1984
|pmid=6436397
|doi=
}}</ref> However, this is not reason to discontinue [[breastfeeding]]. In children with viral gastroenteritis (usually [[rotavirus]]), the viral infection also can cause a high [[fever]], which in turn can cause [[febrile convulsion]]. Gastroenteritis sometimes is followed by [[pneumonia]].
Rare complications of gastroenteritis caused by bacteria include [[sepsis]] (treated with antibiotics), [[anemia]], [[renal failure|renal (kidney) failure]], [[arthritis]], and new onset of [[irritable bowel syndrome]].{{Fact|date=January 2008}}
==See also==
*[[Diarrhea]]
*[[1984 Rajneeshee bioterror attack]]
*[[Food poisoning]]
*[[Eosinophilic gastroenteritis]]
*[[Hemorrhagic gastroenteritis]]
*[[Cholera]]
*[[Dysentery]]
*[[Infectious diarrhea]]
*[[Traveler's diarrhea]]
*[[Wilderness diarrhea]]
*[[Pseudomembranous colitis]]
==References==
{{reflist}}
* Victora, C. G., Bryce, J., Fontaine, O., & Monasch, R. 2000, 'Reducing deaths from diarrhoea through oral rehydration therapy', ''Bulletin of The World Health Organization'', vol. 78, no. 10, pp. 1246-1255.
* Wingate D. et al. 2001. [http://www.blackwell-synergy.com/doi/full/10.1046/j.1365-2036.2001.00993.x 'Guidelines for adults on self-medication for the treatment of acute diarrhea'], ''Alimentary Pharmacology & Therapeutics'', vol. 15, no. 6, pp. 773-782.
==External links==
* {{Cite web|url=http://www.nhsdirect.nhs.uk/articles/article.aspx?articleId=172|title=NHS Direct: Gastroenteritis|accessdate=2007-04-12}}
* {{Cite web|url=http://www.emedicinehealth.com/gastroenteritis/article_em.htm|title=eMedicine Health:Gastroenteritis|accessdate=2007-04-12}}
* {{Cite web|url=http://www.who.int/topics/diarrhoea/en/|title=The World Health Organisation: Diarrhoea|accessdate=2007-04-12}}
* [http://www.mayoclinic.com/health/first-aid-gastroenteritis/FA00030 Gastroenteritis: First aid from the Mayo Clinic]
* {{Cite web
|url=http://coldflu.about.com/od/flumisconceptions/f/stomachflu.htm
|title=About.com: Seasonal Flu vs. Stomach Flu
|accessdate=2007-04-12}}
{{Gastroenterology}}
{{Viral diseases}}
[[Category:Pediatrics]]
[[Category:Gastroenterology]]
[[Category:Foodborne illnesses]]
[[Category:Infectious diseases]]
[[Category:Inflammations]]
[[Category:Abdominal pain]]
[[Category:Conditions diagnosed by stool test]]
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