Gastroenteritis resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]

Patient evaluation

Initial evaluation:

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

Management:

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

General principles for treatment

• Rehydration with a balanced sodium-glucose solution is The first step for treatment. Oral rehydration solution (ORS) has reduced infant mortality in developing countries by at least 50%. ORS has no effect on disease course however, it's valuable to treat dehydration.
• For infants and the elderly with severe travelers diarrhea (TD) and in anyone who develops profuse cholera-like watery diarrhea, balanced ORS and medical evaluation are advised.
• For most otherwise healthy adults with TD, formal ORS is not needed as they can keep up with fluid losses by taking in salty soups, fruit juices and carbohydrates to provide enough compensation.
• In severe diarrhea, a balanced ORS can usually be found at a local pharmacy with sodium of 60–75 mEq/l and glucose of 75–90 mmol/l for replacing salt and water.
• Bismuth subsalicylates (BSSs) can be administered to control rates of passage of stool and may help travelers function better during bouts of mild to moderate illness. The recommended dose of BSS for therapy of acute diarrhea is 30 ml (525 mg) of liquid formulation or two tablets (263 mg per tablet) chewed well each 30–60 min not to exceed eight doses in 24 h. The drug will cause black stools and black tongues.
• In patients receiving antibiotics for TD, adjunctive loperamide therapy can be administered to decrease duration of diarrhea and increase chance for a cure. The recommended dose of loperamide for therapy for adults with diarrhea is 4 mg initially followed by 2 mg after subsequently passed watery stools not to exceed 8 mg per day. Loperamide is not given for more than 48 h. The most valuable use of loperamide in the self-treatment of TD is as a combination drug with antibacterial drugs where the antimotility drug quickly reduces the number of diarrhea stools passed while the antibiotic cures the enteric infection.
• empiric anti-microbial therapy for routine acute diarrheal infection, except in cases of TD where the likelihood of bacterial pathogens is high enough to justify the potential side effects of antibiotics.
• Use of antibiotics for community-acquired diarrhea should be discouraged as epidemiological studies suggest that most community-acquired diarrhea is viral in origin (norovirus, rotavirus, and adenovirus) and is not shortened by the use of antibiotics.
• Antibiotics shorten the overall duration of moderate-to-severe TD to a little over 24 h and are recommended in TD. The following table summarizes the recommended antibiotics for TD.

Antibiotic treatment recommendations Antibiotic Dose Duration† Levofloxacin 500 mg PO Single dose or 3 days Ciprofloxacin 750 mg PO Single dose 500 mg PO 3 days Ofloxacin 400 mg PO Single dose b or 3 days Azithromycin‡ 1000 mg PO Single dose 500 mg PO 3 days Rifaximin¶ 200 mg PO, TID 3 days

†: If symptoms are not resolved after 24 h, complete a 3-day course of antibiotics. ‡: Preferred regimen for dysentery or febrile diarrhea. ¶: Do not use if clinical suspicion for Campylobacter , Salmonella , Shigella , or other causes of invasive diarrhea.