Acute Gastroenteritis

-General:During the first 3 yrs of life, a child will likely experience about 1 to 3 acute diarrheal illnesses. The hallmark of G.E is vomiting and diarrhea, with different levels of dehydration due to increased loss of fluids and decreased intake. The cause of G.E may be viral or bacterial , but the most common cause is viral accounts for about 80 % of cases , caused by Rotaviruses, there is important points in the history that may help us in differentiating viral from bacterial cause of G.E. For Example:1- A history of Fever. 2- Blood or Mucus in the diarrhea. 3- Foul-odor diarrhea. 4- Diarrhea for a prolonged duration. Are suggestive of bacterial etiology although they are not a must. When a patient is presented to us with vomiting and diarrhea , there are another important historical items that should be obtained and they are :I- Weight loss. II- Dietary intake history. III- Ill contacts. VI- Travel history. And the physical exam should focus on the signs of dehydration. The lab INVx that are available include :CBC. Stool wright stain ( It detects WBCs in the stool). Stool culture. Stool Rotazyme( it detects rotaviruses in the stool). Serum electrolytes. Serum glucose.
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-Differential Diagnosis:As we said before , Acute G.E is characterized by vomiting and diarrhea , so there is wide differential diagnosis for each symptom alone , but , when these symptoms together occur , the differential diagnosis is more limited and is most often due to G.E. The differential diagnosis of vomiting may include:Meningitis. Increased ICP. Heart failure. Pneumonia. UTI. Acute surgical conditions( Appendicitis , intussusception , midgut volvulus , etc.) The differential diagnosis of diarrhea is more limited.

-Etiology :As we noted earlier there may be viral or bacterial causes of diarrhea as well as parasitic etiology although to a lesser extent.

Bacterial causes of diarrhea and there manifestations

#1- Campylobacter :- Epidemiology:Campylobacter is a major cause of diarrhea in the world . The two predominant species causing acute diarrhea in humans are:- C. Jejuni , C. coli.

Transmission:It occurs through the fecal-oral route , through contaminated food and water or by direct contact from infected humans and animals , And the main source of C.jejuni and C.coli infection in humans is poultry.
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Incidence:It mainly affects children < 5 yrs. It also affects individuals 15-29 yrs old. In temperate climates it occurs more during the warm months, and in tropical climate in the rainy season.

Clinical manifestations:The incubation period of is 1-7 days, after which begins the prodromal symptoms , and they include:1- Fever. 2- Chills. 3- Headache. 4- Myalgia. And within 24 hrs, of the onset of prodromal symptoms, the patient well start to have:Diarrhea accompanied by nausea , vomiting and crampy abdominal pain. The stool could vary from loose and watery , to grossly Bloody. The diarrhea can last in 20 % of cases up to 2 weeks, but usually Gradual resolution is to be expected. The abdominal pain affects about 90 %, of patients > 2 yrs.

Management:# Rehydration and Correction of electrolytes abnormalities are the mainstay of T.T. # The use of ABX is usually not indicated, since resolution without ABX usually occurs . But if we need to give ABX the D.O.C is erythromycin and is given only after culture has been obtained.

Complications:C.jejuni can cause :- Septicemia, Abortion and Guillain-barre syndrome.

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C.pylori ( now called H.pylori):- does not cause G.E, but it may cause PUD.

# 2-E.coli :-Epidemiology:E.coli is one of the most common causes of bacterial diarrhea in humans world wide. It is usually normal bowel flora, but some strains of it are pathogenic, and they are:EHEC ( enterohemorrhagic). ETEC ( enterotoxigenic). EIEC ( enteroinvasive). EPEC ( enteropathogenic). EAEC ( enteroaggregative).

Clinical manifestations:
The clinical manifestations, depends on the type of E.coli strain is involved , so we well talk separately on each one. @ EHEC It causes a Hemorrhagic colitis syndrome , that is characterized by the following :Bloody diarrhea. NO Fever.( VIP). Abdominal pain. The strain that causes this specific syndrome is E.coli O157:H7. This strain also produces a potent cytotoxin that is called Verotoxin 1, what is important in this toxin that it may cause Hemolytic uremic syndrome (HUS) in about 5% to 8% of cases. @ETEC

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It is manifested as Explosive diarrhea (not bloody) accompanied by:1- Nausea . 2- Vomiting. 3- Abdominal pain. 4- NO or little fever. It is responsible for the syndrome Travelers diarrhea ( Note the T in ETEC). @EIEC It causes Dysentery-like illness, it is very hard to distinguish it from shigella dysentery. It is characterized by :I- Fever. II- Abdominal pain. III- Tenesmus. VI- Watery or Bloody diarrhea. @EPEC It usually causes diarrhea in infants and children in the first 2 years of life , this can be remembered as pediatric diarrhea ( Note the P in EPEC). It is characterized by :None bloody diarrhea and contains mucus. It causes prolonged diarrhea (VIP). The strain EAEC is somewhat very similar to EPEC.

Management:Rehydration and correction of electrolytes abnormalities should be the focus of T.T. It is preferred to withhold the use of ABX until a culture proven etiologic indication, and the D.O.C is TMP.

#3-Staphylococcus aureus:S.aureus is a major cause of food poisoning. It occurs due to the ingestion of preformed S.aureus heat-stable enterotoxin.

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There is no incubation period and the symptoms occurs within 1-6 hrs after ingestion.

Clinical manifestations:1- Nausea. 2- Vomiting. 3- Abdominal pain. 4- Diarrhea without Fever. These symptoms last less than 12 hrs, so the onset is rapid as well as the resolution.

#4-Salmonella:Etiology:It is associated with ingestion of contaminated eggs with salmonella, in order for the disease to occur , 10,000 to 100,000 viable organisms must be ingested. There are three main species that was identified:1- S.cholerae-suis. 2- S.typhi (most virulent), also known as Typhoid.. 3- S.enteritidis.

Epidemiology & incidence:It is the most frequently reported causes of food borne out-breaks. It is most common in the first year of life, but can occur in all ages.

Clinical manifestations:It has an incubation period of 6-72 hrs. Salmonella causes several clinical syndromes:I- Acute G.E ( Most Common). II- Prolonged carrier state. III- Enteric Fever, Bacteremia Or Both. VI- Dissemination with localized suppuration ( i.e. abscesses) , osteomyelitis,or meningitis. Acute G.E that caused by salmonella is characterized by:Page 6 |

1- Diarrhea ( most prominent symptom), it can range from few stools , to profuse bloody.. 2- Abdominal cramps. 3- Fever. This symptoms usually last 3-7 days.

Management:The diagnosis is made by stool culture. ABX such as , Ampicillin, TMP, Chloramphenicol, can be used in patients with severe and progressing disease.

#5- Shigella:Etiology:There are four major subgroups of shigella:A- S.sonnei. B- S.flexneri. C- S.boydii. D- S.dysenteriae ( the cause of dysentery). The transmission occurs via person-to-person contact and by contamination of food and water. Only a small inoculum of shigella is required to cause illness ( as few as 10 organisms) , not like salmonella.

Epidemiology & incidence:It is common btw 6 mo-10 yrs. It is most common in the 2nd and 3rd yr of life. It occurs in the warm month in temperate climate , and in the rainy season in tropical climates.

Clinical manifestations:It has an incubation period of 12 hr up to several days.

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Shigella invades the colon, causing colitis. The infected person may have five clinical syndromes :1- Asymptomatic excretion. 2- Enterotoxin-like diarrhea. 3- Bacillary dysentery ( Bloody diarrhea) most common . 4- Arthritis similar to Reiter's. 5- HUS.

The clinical features of bacillary dysentery include high Fever with:A- GIT symptoms:Diarrhea that is initially watery and of large volume, then becomes of small volumes , bloody and mucoid stools. Vomiting. Severe abdominal pain. Tenesmus. B-CNS manifestations( occurs in about 40 % in children with Bacillary dysentery):Seizures. Headache. Confusion. Lethargy. Nuchal rigidity. C- Complications of dysentery:1- Sepsis. 2- DIC. 3- HUS. 4- Hemolytic anemias. 5- Post infectious arthritis.

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Management:Stool culture is the gold standard for diagnosis. Fluid and electrolytes replacement should be the focus of treatment. Empiric ABX treatment of all children strongly suspected of having shigellosis is highly encouraged , but it is preferred to wait for culture results.

#6- Vibrio cholera:It causes profuse watery diarrhea , known as rice water stools. They cause diarrhea by producing several toxins , and the most important toxin is the cholera toxin. Usually infected individuals experience :- diarrhea , abdominal cramps, nausea and to a lesser extent :- vomiting , headache , low grade fever and chills.

#7- Yersinia enterolitica:Y.enterolitica is a gram-negative bacillus , that causes G.E by ingestion of contaminated milk or food. Usually it causes Acute G.E or mesenteric adenitis. Symptoms include:1- Diarrhea with fever. 2- vomiting. 3- Abdominal pain. It is usually self limited disease and no need for ABX therapy.

Done by your collegue:Waseem zoabi.

www.SAWA2006.com

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