Sandbox:GE

Patient Evaluation

Initial Management

Shown below is an algorithm depicting the initial management of acute diarrhea is based on the 2001 IDSA practice guidelines for the management of infectious diarrhea.

Characterize the symptoms: ❑ Onset ❑ Duration ❑ Pattern (continuous or intermittent) ❑ Stool characteristic (watery, bloody, mucous or greasy) ❑ Frequency of bowel movements ❑ Dysenteric symptoms (fever, tenesmus, blood and/or pus in stool) Associated symptoms: ❑ Abdominal pain ❑ Nausea and vomiting ❑ Weight loss Epidemiological factors: ❑ Travel ❑ Food (raw meat, eggs, shellfish, unpasteurized cheese or milk) ❑ Outbreaks ❑ Sexual history ❑ Day care attendance ❑ Previous evaluations ❑ Medications, radiation therapy or surgery ❑ Underlying medical condition (cancer, diabetes, hyperthyroidism or AIDS)

Examine the patient: ❑ Temperature ❑ Pulse ❑ Blood pressure ❑ Respiratory rate ❑ Signs of volume depletion (decreased skin turgor, dry mucosa) ❑ Abdominal tenderness ❑ Level of consciousness

Assessment of volume status General condition Normal Irritable/less active* Lethargic/comatose§ Eyes Normal Sunken - Mucosa Normal Dry - Thirst Normal Thirsty Unable to drink§ Radial pulse Normal Low volume* Absent/ uncountable§ Skin turgor Normal Reduced - † Some dehydration = At least two signs, including at least one key sign (*) are present. ‡ Severe dehydration = Signs of “some dehydration” plus at least one key sign (§) are present.

No dehydration

Some dehydration

Severe dehydration

Start altered diet ❑ Stop lactose products ❑ Avoid alcohol and high osmolar supplements ❑ Drink 8-10 large glasses of clear fluids (Fruit juices, soft drinks etc) ❑ Eat frequent small meals (Rice, potato, banana, pastas etc) Can start oral rehydration therapy (ORT) for replacement of stool losses

❑ Start ORT at a volume of 50-100 mL/kg ❑ Start altered diet ❑ Reassess status every 4 hr

❑ Start IV fluids: Ringer lactate at 30ml/kg in the first 1/2hr and 70ml/kg for the next 2 1/2 hr, if unavailable use normal saline ❑ CBC ❑ Electrolytes ❑ Assess status every 15 mins until strong pulse felt and then every 1 hr

Patient stable and able to drink ❑ Start ORT at a volume of 100 mL/kg over 4 hour ❑ Calculate the continuing stool and emesis losses every hour for additional maintenance ORT therapy ❑ Reassess status every 4 hr

Hemodynamic stabilized Proceed to Diagnosis and Management

Diagnostic and Management approach

Passage of ≥3 unformed stools in 24 h + an enteric symptom (nausea, vomiting, abdominal pain/cramps, tenesmus, fecal urgency, moderate to severe flatulence)

Watery diarrhea ± Vomiting

Dysenteric diarrhea (passage of grossly bloody stools)

Mild Illness†

Moderate to Severe†

No or low-grade fever(≤100°F)

Severe illness† with fever≥(101°F) in a single case (not outbreak)

Hydration only May use loperamide 4 mg initially to control stooling

Travel associated

Non travel associated

Non travel associated

Travel associated

Antibiotic therapy

No or low-grade fever (≤100°F)

Fever (≥101°F)

Empiric treatment Azithromycin 1 g in single dose OR 500 mg once daily for 3 days

<72 h duration

≥72 h duration

Loperamide therapy for 48 h

Microbiologic assessment and appropriate treatment

Persistent diarrhea (14–30 days) should be worked up by culture and/or culture independent microbiologic assessment, then treatment with anti microbial agent directed to cause

†Illness severity:

• Severe: Total disability due to diarrhea;
• Moderate: Able to function but with forced change in activities due to illness;
• Mild: No change in activities

Classification

Gastroenteritis

Viral

Bacterial

Parasites

Common

Less Common

Common

Less Common

Helminthic

Protozoal

❑ Rotaviruses ❑ Noroviruses ❑ Enteric Adenoviruses ❑ Astroviruses

❑ Kobuviruses ❑ Enteroviruses ❑ Orthoreoviruses ❑ Toroviruses ❑ Coronaviruses (including SARS) ❑ Parvoviruses

Gram Positive

Gram Negative

Gram Positive

Gram Negative

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Prevention

❑ E.Coli species
❑ Salmonella species
❑ Shigella
❑ Campilobacter
❑ Vibrio species|D04=❑ Bacillus cereus
❑ Bacteroids fragilis
❑ Aeromonas
❑ Staphylococcus aureus