CPG on Acute Gastroenteritis

1
CPG on Acute Gastroenteritis
2
Acute Gastroenteritis

• Acute gastroenteritis is a disease characterized
  by changes in the character and frequency of
  stool.
• It can be defined as the passage of a greater
  number of stools of decreased form from the
  normal lasting less than 14 days.
• Generally associated with other signs or symptoms
  including nausea, vomiting, abdominal pain and
  cramps, increase in intestinal gas-related
  complaints, fever, passage of bloody stools
  (dysentery), tenesmus (constant sensation of urge
  to move bowels), and fecal urgency. (1)
• (1) Guidelines on acute infectious diarrhea in
  adults. The Practice Parameters Committee of the
  American College of Gastroenterology. American
  Journal of Gastroenterology. 1997
  Nov92(11)1962-75.

3
Acute Gastroenteritis

• Perform initial assessment
• Dehydration
• Duration (gt1 day)
• Inflammation (indicated by fever, presence
• of blood in stool, tenesmus) (2)
• (2) Acute Infectious Diarrhea. Nathan M.
  Thielman, M.D., M.P.H., and Richard L. Guerrant,
  M.D. The New England Journal of Medicine. 2004
  35038-47.

4
Acute Gastroenteritis

• Complete blood count can be obtained to look for
  anemia, hemoconcentration, or an abnormal white
  blood cell count. (4)
• Measurements of serum electrolyte concentrations
  and blood urea nitrogen and serum creatinine
  levels can be used to determine the extent of
  fluid and electrolyte depletion and its effect on
  renal function. (4)
• (4) Sleisenger and Fordtrans Gastrointestinal
  and Liver Disease. 8th edition. 2006. Feldman,
  Mark MD. Volume II. p169.

5
Acute Gastroenteritis

• Provide symptomatic treatment
• Rehydration
• Treatment of symptoms (if necessary, loperamide
  if diarrhea is not inflammatory or bloody) (2)
• (2) Acute Infectious Diarrhea. Nathan M.
  Thielman, M.D., M.P.H., and Richard L. Guerrant,
  M.D. The New England Journal of Medicine. 2004
  35038-47

6
Acute Gastroenteritis

• Initial rehydration
• The most common risk with diarrheal illnesses is
  dehydration.
• The critical initial treatment must include
  rehydration, which can be accomplished with an
  oral glucose or starch-containing electrolyte
  solution in the vast majority of cases.
• Although many patients with mild diarrhea can
  prevent dehydration by ingesting extra fluids
  (such as clear juices and soups), more severe
  diarrhea, postural light-headedness, and reduced
  urination signify the need for more rehydration
  fluids. (2)
• (2) Acute Infectious Diarrhea. Nathan M.
  Thielman, M.D., M.P.H., and Richard L. Guerrant,
  M.D. The New England Journal of Medicine. 2004
  35038-47.

7
Acute Gastroenteritis

• Prevention of Dehydration
• It is recommended that continued use of the
  patients preferred, usual, and appropriate diet
  be encouraged to prevent or limit dehydration.
• Regular diets are generally more effective than
  restricted and progressive diets, and in numerous
  trials have consistently produced a reduction in
  the duration of diarrhea. (5)
• (5) Cincinnati Childrens Hospital Medical
  Center. Evidence-based clinical care guideline
  for acute gastroenteritis (AGE) in children aged
  2 months through 5 years. Cincinnati (OH)
  Cincinnati Childrens Hospital Medical Center
  2006 May. 15 p. 50 references.

8
Acute Gastroenteritis

• The use of BRAT diet (consisting of bananas,
  rice, apple, and toast) with avoidance of milk
  products (since a transient lactase deficiency
  may occur) is commonly recommended, although
  supporting data are limited. (3)
• Clear liquids are not recommended as a substitute
  for oral rehydration solutions (ORS) or regular
  diets in the prevention or therapy of
  dehydration. (5)
• (3) Practice Guidelines for the Management of
  Infectious Diarrhea. Infectious diseases Society
  of America. Clinical Infectious Diseases 2001
  3233150.
• (5) Cincinnati Childrens Hospital Medical
  Center. Evidence-based clinical care guideline
  for acute gastroenteritis (AGE) in children aged
  2 months through 5 years. Cincinnati (OH)
  Cincinnati Childrens Hospital Medical Center
  2006 May. 15 p. 50 references.

9
Acute Gastroenteritis

• Oral Feeding Following Rehydration
• gt It is recommended that giving the patients
  usual diet be started at the earliest opportunity
  after an adequate degree of rehydration is
  achieved. (5)
• On-going IV or NG Fluids following Rehydration
• gt It is recommended that maintenance IV fluids or
  NG ORS be given
• when unable to replace the estimated fluid
  deficit and keep up with the on-going losses
  using oral feedings alone, and/or
• to severely dehydrated patient with obtunded
  mental status
• (5) Cincinnati Childrens Hospital Medical
  Center. Evidence-based clinical care guideline
  for acute gastroenteritis (AGE) in children aged
  2 months through 5 years. Cincinnati (OH)
  Cincinnati Childrens Hospital Medical Center
  2006 May. 15 p. 50 references.

10
Acute Gastroenteritis

• Stratify subsequent management according to
  clinical and epidemiologic features
• Epidemiologic clues
• Food, antibiotics, sexual activity, travel,
  day-care attendance, other illnesses outbreaks,
  season
• Clinical clues
• Bloody diarrhea, abdominal pain, dysentery,
  wasting, fecal inflammation. (2)
• (2) Acute Infectious Diarrhea. Nathan M.
  Thielman, M.D., M.P.H., and Richard L. Guerrant,
  M.D. The New England Journal of Medicine. 2004
  35038-47

11
Acute Gastroenteritis

• When to admit?
• Persistent Diarrhea (gt7 days) (2)
• Fever
• Unstable
• Severely dehydrated
• Bloody diarrhea
• Persistent Vomiting
• No improvement after initial hydration or
  symptoms exacerbate/ overall condition gets worse
  (6)
• (2) Acute Infectious Diarrhea. Nathan M.
  Thielman, M.D., M.P.H., and Richard L. Guerrant,
  M.D. The New England Journal of Medicine. 2004
  35038-47
• (6) World Gastroenterology Organisation (WGO).
  WGO practice guideline acute diarrhea. Munich,
  Germany World Gastroenterology Organisation
  (WGO) 2008 Mar.

12
(2) Acute Infectious Diarrhea. Nathan M.
Thielman, M.D., M.P.H., and Richard L. Guerrant,
M.D. The New England Journal of Medicine. 2004
35038-47
13
(2) Acute Infectious Diarrhea. Nathan M.
Thielman, M.D., M.P.H., and Richard L. Guerrant,
M.D. The New England Journal of Medicine. 2004
35038-47
14
Immunocompromised patients

• If symptoms recur or are uncontrolled despite
  hydration and antimicrobial treatment....
• If evidence of colitis is present,
• Do
• Proctosigmoidoscopy with biopsy of lesions with
  attention to CMV, mycobacteria, Adenovirus,
  Fungi, Herpes simplex
• (1) Guidelines on acute infectious diarrhea in
  adults. The Practice Parameters Committee of the
  American College of Gastroenterology. American
  Journal of Gastroenterology. 1997
  Nov92(11)1962-75.

15
Immunocompromised patients

• If symptoms recur or are uncontrolled despite
  hydration and antimicrobial treatment....
• If evidence of colitis is NOT present,
• Do
• -Gastroduodenoscopy with biopsy, Smears and
  culture for special parasites plus
  proctosigmoidoscopy
• (1) Guidelines on acute infectious diarrhea in
  adults. The Practice Parameters Committee of the
  American College of Gastroenterology. American
  Journal of Gastroenterology. 1997
  Nov92(11)1962-75.

16
Acute Gastroenteritis

• When to discharge?
• Stable Vital signs
• Maintains a sufficient fluid intake
• Able to eat meals adequately
• Able to take medications (if still indicated) (6)
• (6) World Gastroenterology Organisation (WGO).
  WGO practice guideline acute diarrhea. Munich,
  Germany World Gastroenterology Organisation
  (WGO) 2008 Mar.

17
Patient Education

• Many diarrheal diseases can be prevented by
  following simple rules of personal hygiene and
  safe food preparation.
• Hand-washing with soap is an effective step in
  preventing spread of illness and should be
  emphasized for caregivers of persons with
  diarrheal illnesses.
• As noted above, human feces must always be
  considered potentially hazardous, whether or not
  diarrhea or potential pathogens have been
  identified. (3)
• (3) Practice Guidelines for the Management of
  Infectious Diarrhea. Infectious diseases Society
  of America. Clinical Infectious Diseases 2001
  3233150.

18
Patient Education

• Consequently, microbial studies should not be
  needed to justify careful attention to hygiene.
• Select populations may require additional
  education about food safety, and health care
  providers can play an important role in providing
  this information. (3)
• (3) Practice Guidelines for the Management of
  Infectious Diarrhea. Infectious diseases Society
  of America. Clinical Infectious Diseases 2001
  3233150.

19

• THANK YOU!

20
Clinical Pathway for Acute Gastroenteritis with
Severe dehydration
1st 30 minutes 2nd 30 minutes to 2 hrs 2 hrs to 24 hours
A S S E S S M E N T AGE documented based on history and physical examination Assess patient as stable or unstable History Onset frequency, quantity Character - bile/blood/mucusFeverVomiting Past medical history, underlying medical conditions Epidemiological clues (food, antibiotics, sexual activity, travel, outbreaks, season) Signs of dehydration in adults Decreased sensorium (severe dehydration) Tachycardia Postural hypotension Supine hypotension and absence of palpable pulse Dry tongue Sunken eyeballs Skin pinch/turgor Decrease urine output Response to treatment assessed Presence of urine output Stable vital signs Response to treatment assessed Presence of urine output Stable vital signs
21
Clinical Pathway for Acute Gastroenteritis with
Severe dehydration
1st 30 minutes 2nd 30 minutes to 2 hrs 2 hrs to 24 hours
D I A G N O S T I C S Serum electrolytes BUN, creatinine CBC Fecalysis Stool for c. difficile toxin (if with recent/chronic antibiotic use) ABG (if with decreased sensorium/ tachypneic/ dyspneic) RBS (if with decreased sensorium Follow up result of tests Serum electrolytes and BUN, creatinine monitored at appropriate intervals (every 24 hours)
22
Clinical Pathway for Acute Gastroenteritis with
Severe dehydration
1st 30 minutes 2nd 30 minutes to 2 hrs 2 hrs to 24 hours
T R E A T M E N T IV Line or Central vein catheter for rapid fluid delivery Oxygen by nasal cannula (if tachpneic/ dyspneic) Elevate patients feet and legs (if with hypotension IV Hydration correct fluid and electrolyte disturbances Adjust IV fluids accordinglycorrect fluid and electrolyte disturbances start oral hydration (if tolerated) of preferred diet
23
Clinical Pathway for Acute Gastroenteritis with
Severe dehydration
1st 30 minutes 2nd 30 minutes to 2 hrs 2 hrs to 24 hours
M E D I C A T I O N S IV Hydration Metoclopramide for recurrent or persistent vomiting Treatment of symptoms (if necessary loperamide if diarrhea is not inflammatory or bloody) Continue medications Consider antimicrobial treatment for specific pathogens
24
Clinical Pathway for Acute Gastroenteritis with
Severe dehydration
1st 30 minutes 2nd 30 minutes to 2 hrs 2 hrs to 24 hours
T E A C H I N G Relatives are Informed on the condition of the patient Relatives are Informed on need to have continued fluid replacement Request for renal, pulmonary and cardiac support (if needed) Relatives are Updated on the patients condition