GASTROENTERITIS

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GASTROENTERITIS

• Dr. Bikha Ram Devrajani
• MBBS(SINDH),FCPS(PAK),FACP(USA),FRCP(LONDON)
• Professor Medicine
• Liaquat University of Medical Health Sciences
• Jamshoro

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Gastroenteritis

• Gastroenteritis is a nonspecific term for a
  variety of pathologic states of the
  gastrointestinal tract.
• The primary manifestation is diarrhea, but it may
  be accompanied by nausea, vomiting, and abdominal
  pain.
• A universal definition of diarrhea does not
  exist, although patients seem to have no
  difficulty defining their own situation.

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Gastroenteritis

• Although most definitions center around the
  frequency, consistency, and water content of
  stools, the author prefers the definition that
  diarrheal stools take the shape of their
  container.

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Gastroenteritis

• Severity of illness may vary from mild and
  inconvenient to severe and life threatening.
• Appropriate management requires extensive history
  and assessment and appropriate general supportive
  and, often, etiology-specific treatment.
• Diarrhea associated with nausea and vomiting is
  referred to as gastroenteritis.

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Diarrhea is..

• A symptom characterized by an abnormal increase
  in stool frequency or liquidity
• Acute diarrhea is usually self limiting and lasts
  48-72 hours, sometimes up to 7 days
• Chronic diarrhea lasts more than 4 weeks, should
  seek medical care

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Global Problem

• 4.6 million children less than 5 years of age die
  of diarrheal diseases.
• Diarrhea accounts for 19 of all deaths among
  children ages 0-4.
• Eighty-five percent of diarrheal deaths occur in
  the first year of life.

World Health Organization. 1997. WHO Fact
Sheet Reducing Mortality from Major Childhood
Killer Diseases. Fact Sheet Number 180.
http//www.who.int/chd/pub/imci/fs_180.html Center
s for Disease Control and Prevention. 1992.
Diarrhea The Management of Acute Diarrhea in
Children Oral Rehydratioin, Maintenance, and
Nutritional Therapy. http//www.rehydrate.org/html
Graph. http//www.who.int/chd/images/deaths.gif
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OUTBREAKS

• July 1998 E coli 0157H7 infection outbreak from
  contaminated water supply in Wyoming, more than
  60 infected
• July 1995 77 cases of cryptosporidiosis at a day
  camp in Florida, most likely secondary to water
  hose contamination
• August-September 1999 E coli 0157H7 infections
  secondary to contaminated well water in
  Washington County Fair (New York)

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OUTBREAKS

• Three to five billion cases of acute diarrhea
  occur yearly, and it is the leading cause of
  death in many underdeveloped countries.
• Approximately 30-50 of visitors to developing
  countries will develop, and perhaps return with,
  diarrhea.

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Age

• Gastroenteritis may occur at any age.
• Morbidity and mortality are much higher in the
  very young and the very old.

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Transmission

• Diarrheal agents are mostly spread via the
  fecal-oral route.
• physical contact with infected feces
• eating or drinking contaminated food or water
• person to person relay

World Health Organization. 1998. The
Epidemiology and Etiology of Diarrhea.
http//www.who.int/chd/pub/cdd/meded/1med.html
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Socioeconomic factors

• Poverty
• Overcrowding
• Poor sanitation
• Contamination of water
• Inadequate food hygiene

UNICEF. 1998. The State of the Worlds
Children, 1998. Oxford and New York Oxford
University Press.
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Risk Factors

• Household crowding
• Low maternal education
• Low birth weight

Claeson, M., Merson, M. 1990. Global progress
in the control of diarrheal diseases. Pediatric
Infectious Diseases Journal, 9 345-355.
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Behavioral Factors

• Failure to breast-feed exclusively for the first
  4-6 months of life
• Failure to continue breast-feeding until one year
  of age
• Using infant bottles

• Storing food at room temperature
• Contaminated drinking water
• Failure to wash hands
• Failure to dispose of feces hygienically

Claeson, M., Merson, M. 1990. Global progress
in the control of diarrheal diseases. Pediatric
Infectious Diseases Journal, 9 345-355.
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Host Factors

• Immunosuppression
• Measles
• Malnutrition

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Prevention Strategies

• Breast Feeding
• Improved weaning practices
• Proper use of water
• Hand washing
• Disposing feces properly
• Effectiveness of measles vaccination

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Diarrhea

• The passing of 3 or more watery or loose stools
  in a 24-hour period.

• Three types acute watery
• persistent
• dysentery
• World Health Organization. 1998. The
  Epidemiology and Etiology of Diarrhea.
  http//www.who.int/chd/pub/cdd/meded/1med.html
• World Health Organization. 1997. WHO Fact
  Sheet Reducing Mortality from Major Childhood
  Killer Diseases. Fact Sheet Number 180.
  http//www.who.int/chd/pub/imci/fs_180.htm

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Diarrheal illnesses also may be classified

• Osmotic, due to an increase in the osmotic load
  presented to the intestinal lumen, either through
  excessive intake or diminished absorption
• Inflammatory (or mucosal), when the mucosal
  lining of the intestine is inflamed.
• Secretory, when increased secretory activity
  occurs
• Motile, caused by intestinal motility disorders

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Etiological Agents

• Bacterial, Viral, and Parasitic Agents
• Rotavirus
• Enterotoxigenic E. Coli
• Shigellae
• Salmonellae
• Vibrio Cholerae
• Campylobacter jejuni
• Cryptosporidium

• Protozoans
• Giardia
• Entamoeba

Rotavirus
Giardia
E.Coli
World Health Organization. 1997.
http//www.who.int/chd/pub/imci/fs_180.html
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Etiology of diarrhea

• Diarrhea is a symptom of an underlying pathology
  or infection
• Viral gastroenteritis
• Bacterial gastroenteritis
• Protozoal diarrhea
• Antibiotic associated diarrhea
• AIDS associated diarrhea
• Food-induced diarrhea

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Etiology of diarrhea

• Viral (50-70)
• The Norwalk virus is the leading cause of viral
  gastroenteritis in the United States. Norwalk
  virus belongs to the species of Noroviruses
  (formerly known as Norwalk-like viruses).
  Noroviruses, along with the Sapoviruses (formerly
  known as Sapporo-like viruses) are members of the
  Caliciviridae family of viruses.
• Caliciviruses Various caliciviruses, other than
  Norwalk, are likely responsible for many out
  breaks of previously unidentified viral
  gastroenteritis.
• Rotavirus A leading cause of gastroenteritis in
  children, but can also be found in adults. May
  cause severe dehydration.
• Adenovirus
• Parvovirus
• Astrovirus
• Coronavirus
• Pestivirus
• Torovirus

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Etiology of diarrhea

• Bacterial (15-20)
• Shigella
• Salmonella
• C jejuni
• Yersinia enterocolitica
• E coli - Enterohemorrhagic 0157H7,
  enterotoxigenic, enteroadherent, enteroinvasive
• V cholera
• Aeromonas
• B cereus
• C difficile
• Clostridium perfringens
• Listeria
• Mycobacterium avium-intracellulare (MAI),
  immunocompromised
• Providencia
• Vibrio parahaemolyticus
• Vibrio vulnificus

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Etiology of diarrhea

• Parasitic (10-15)
• Giardia
• Amebiasis
• Cryptosporidium
• Cyclospora
• Food-borne toxigenic diarrhea
• Preformed toxin - S aureus, B cereus
• Postcolonization - V cholera, C perfringens,
  enterotoxigenic E coli, Aeromonas

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Etiology of diarrhea

• Shellfish poisoning and poisoning from other
  marine animals
• Paralytic shellfish poisoning (PSP) - Saxitoxin
• Neurologic shellfish poisoning (NSP) - Brevotoxin
  
• Diarrheal shellfish poisoning (DSP) - Okadaic
  acid
• Amnesic shellfish poisoning - Domoic acid
• Ciguatera (ciguatoxins)
• Scombroid (conversion of histidine to histamine)

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Etiology of diarrhea

• Drug-associated diarrhea
• Antibiotics due to alteration of normal flora
• Laxatives, including magnesium-containing
  antacids
• Colchicine
• Quinidine
• Cholinergics
• Sorbitol
• Pseudomembranous colitis
• Overgrowth of C difficile
• Positive C difficile assay

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Etiology of diarrhea

• Other causes
• Unknown agents, especially in developing
  countries
• Ischemic colitis
• Ulcerative colitis
• Crohn disease
• Carcinoid tumor or vasoactive intestinal peptide
  tumor (VIPoma)
• AIDS
• Dumping or short bowel syndrome
• Radiation or chemotherapy

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Viral gastroenteritis

• 80-85 of episodes of acute diarrhea are caused
  by viruses
• Virus transmitted by contaminated food or water
• Clinical features include 12-48hr incubation
  period followed by vomiting, watery diarrhea and
  low grade fever
• Illness lasts 5-8 days, treatment is fluid and
  electrolyte therapy

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Bacterial gastroenteritis

• Common pathogens are Campylobacter, Salmonella,
  Shigella, E.coli, Staphylococcus, Clostridium
• If attack is in small intestine patients usually
  experience abrupt onset of large volume, watery
  stools, upper abdominal pain, nausea, vomiting,
  cramps, and low grade fever
• If attack is in large intestine, patients may
  experience dysentery like syndrome including
  bloody or mucousy diarrhea

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Travelers diarrhea

• A form of bacterial gastroenteritis
• Usually occurs when people travel to warmer
  climates with poor sanitation
• Most commonly caused by E.coli
• Characterized by sudden onset of loose stools,
  nausea, occasional vomiting, cramps, bloating,
  malaise and low grade fever
• Usually subsides over 3-4 days

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Protozoal diarrhea

• Giardia lamblia and entamoeba histolytica are
  protozoa associated with diarrhea
• Usually acquired traveling to mountainous or
  recreational water areas, drinking stream or pond
  water
• No nonprescription therapy for protozoal
  diarrhea, metronidazole is treatment of choice

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Antibiotic associated diarrhea

• Frequency of diarrhea is largely dependent on the
  extent to which the drug disrupts the normal
  intestinal flora
• Abx that have broad spectrum activity against
  aerobes and anaerobes can produce diarrhea
• AAD may be caused by an overgrowth of abx
  resistant bacteria, fungi, or toxin producing
  C.difficile
• Diarrhea caused by C.difficile is usually watery
  and greenish-mucoid
• There are no nonprescription treatments for
  eradicating C.difficile

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AIDS Associated Diarrhea

• Patients with AIDS or HIV are known to be
  susceptible to intestinal infections that produce
  diarrhea
• These patients should not self-manage their
  diarrhea, they should see their physician

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Food-Induced Diarrhea

• Food intolerance can provoke diarrhea
• The enzyme lactase hydrolyzes disaccharides into
  monosaccharides
• When you lack the lactase enzyme, disaccharides
  can not be hydolyzed to monosaccharides
• Disaccharides pool in lumen causing an osmotic
  imbalance which draws fluid into the lumen and
  causes diarrhea

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Signs of Dehydration

• Common dizziness, thirst, confusion, lethargy,
  fatigue
• Serious low BP, fever, vomiting, abdominal
  cramps, nausea, muscle aches, mucously stools,
  weight-loss
• Mild dehydration 3-5 weight-loss
• Severe dehydration 10 weight-loss (can be very
  serious in infants, may lead to cardiovascular
  collapse and renal failure
• Mild/moderate diarrhea are self-treatable
• Severe diarrhea non self-treatable

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Laboratory Investigations

• Stool DR, ova cyst, and C/S.
• CBC.
• Serum electrolytes.
• Blood urea.
• Other investigations depend upon the causative
  agent.

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Treatment Options

• Treatment Outcomes
• Assess and Correct electrolyte
• and fluid loss
• 2. Manage diet or disease
• 3. Provide relief
• 4. Identify cause

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Oral Rehydration Therapy
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Fluid and Electrolyte Replacement

• Not more than 75-90 mEq/L of Na for rehydration
• Not more than 40-60 mEq of Na for maintenance
• Carb to Na ratio should be 21
• Important in children and infants
• All patients should rehydrate and maintain during
  diarrheal episode

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Loperamide

• Good for treatment of travelers diarrhea and IBD
• Works by slowing intestinal motility
• Use 4mg initially, then 2mg after each loose
  stool but do not exceed 16mg/day (8 tablets)
• Do not use in children lt6 years old use
  electrolyte tx instead

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Adverse Reactions

• Can cause occasional dizziness and constipation
• May worsen effects of invasive or inflammatory
  bacterial infection should not use for food borne
  illness
• May cause toxic megacolon in ABX induced diarrhea
  DO NOT use for ABX associated diarrhea - refer to
  physician
• In children less than 6 years old

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Absorbents

• Include attapulgite, kaolin, pectin
• Do not recommend because of decreased absorption
  of other drugs

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Polycarbophil

• Used for non-specific diarrhea
• Bulk laxative that is also effective in treating
  diarrhea (can also treat constipation)
• Can absorb up to 60X weight in water
• Use 2 (500mg) tablets 4 times daily or after each
  loose stool (up to 6g a day)

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Adverse Reactions

• Metabolically inert
• No systemic toxicity has been shown
• Side effects include dose-related epigastric pain
  and bloating
• May decrease absorption of warfarin, digoxin,
  tetracycline, and ciprofloxacin

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Bismuth Subsalicylate BSS

• Used for non-specific diarrhea, indigestion, tx
  and prevention of travelers diarrhea, as
  adjuvant to ABX for treating H.pylori peptic
  ulcer disease
• Reported to have an antisecretory mechanism to
  bind bacterial toxins, and to have
  anti-inflammatory and antibacterial properties
• Take 2 (262mg) tablets every hour up to 16
  tablets a day
• Not recommended for children lt2 years old

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Adverse Reactions

• May reach toxic levels of salicylate if patients
  are taking aspirin or other salicylate containing
  drugs
• Patients sensitive to salicylates should not use
• Blackened stool and tongue may occur - harmless

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Enzymes - lactase

• For lactose intolerance
• Take 1-3 tablets with first bite of dairy product
• Just avoid dairy products

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Things to Remember

• Always remember to rehydrate
• Special populations (elderly, lt3 years old,
  pregnant) require medical referral
• Healthy patients usually improve within 24 to 48
  hours
• If condition remains or worsens after 48 hours -
  refer to MD

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New Developments

• Super-ORS
• Rotavirus vaccine

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Controversies

• Underuse of ORT and overuse of drugs
• Boil the water

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Complications of Diarrhea

• Acute diarrhea may cause severe dehydration and
  electrolyte imbalance
• Infants, young children, and the elderly are most
  at risk for dehydration
• Children less than 2 yrs of age often have
  complications that require hospitalization

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• First steps for managing an outbreak of acute
  diarrhoea
• THIS PRESENTATION AIMS AT GUIDING YOU THROUGH THE
  VERY FIRST DAYS OF AN OUTBREAK

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WORLD HEALTH ORGANIZATION

• Is this the beginning of an outbreak?

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WORLD HEALTH ORGANIZATION

• You might be facing an outbreak very soon if
• You have seen an unusual number of acute
  diarrhoeal cases this week and the patients have
  the following points in common
• they have similar clinical symptoms (watery or
  bloody diarrhoea)
• they are living in the same area or location
• they have eaten the same food (at a burial
  ceremony for example)
• they are sharing the same water source
• there is an outbreak in the neighbouring community

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WORLD HEALTH ORGANIZATION

• or
• You have seen an adult suffering from acute
  watery diarrhoea with severe dehydration and
  vomiting
• If you have some statistical information from
  previous years or weeks verify if the actual
  increase of cases is unusual over the same
  period of time.

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• WHAT DO I HAVE TO DO WHEN I SUSPECT AN OUTBREAK?
• 1. Inform and ask for help
• 2. Protect the community
• 3. Treat the patients

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diarrhea
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MESSAGE TO THE COMMUNITY
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MESSAGE TO THE COMMUNITY
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MESSAGE TO THE COMMUNITY
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MESSAGE TO THE COMMUNITY
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MESSAGE TO THE COMMUNITY
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PROTECT YOURSELF FROM CONTAMINATION

• Wash your hands with soap before and after taking
  care of the patient
• Cut your nails

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3. TREAT THE PATIENTS

• 80 of the cases can be treated with Oral
  Rehydration Salt (ORS)

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Mortality/Morbidity

• Estimates for mortality and morbidity vary
  widely. In the United States, 210,000 pediatric
  hospitalizations occur yearly with as many as
  10,000 deaths.
• Internationally, mortality rate is 5-10 million
  deaths each year.

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• Thank you