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GASTROENTERITIS Dr. Bikha Ram Devrajani Professor Medicine

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

2 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.

3 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.

4 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.


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

7 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 WHO Fact Sheet: Reducing Mortality from Major Childhood Killer Diseases. Fact Sheet Number 180. Centers for Disease Control and Prevention Diarrhea: The Management of Acute Diarrhea in Children: Oral Rehydratioin, Maintenance, and Nutritional Therapy. Graph.

8 OUTBREAKS July 1998: E coli 0157:H7 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 0157:H7 infections secondary to contaminated well water in Washington County Fair (New York)

9 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.

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

11 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 The Epidemiology and Etiology of Diarrhea.

12 Socioeconomic factors
Poverty Overcrowding Poor sanitation Contamination of water Inadequate food hygiene UNICEF The State of the World’s Children, Oxford and New York: Oxford University Press.

13 Risk Factors Household crowding Low maternal education
Low birth weight Claeson, M., & Merson, M Global progress in the control of diarrheal diseases. Pediatric Infectious Diseases Journal, 9:

14 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 Global progress in the control of diarrheal diseases. Pediatric Infectious Diseases Journal, 9:

15 Host Factors Immunosuppression Measles Malnutrition

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

17 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 The Epidemiology and Etiology of Diarrhea. World Health Organization WHO Fact Sheet: Reducing Mortality from Major Childhood Killer Diseases. Fact Sheet Number 180.

18 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

19 Etiological Agents Bacterial, Viral, and Parasitic Agents Protozoans
Rotavirus Enterotoxigenic E. Coli Shigellae Salmonellae Vibrio Cholerae Campylobacter jejuni Cryptosporidium Protozoans Giardia Entamoeba Rotavirus Giardia E.Coli World Health Organization

20 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

21 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

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

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

24 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)

25 Etiology of diarrhea Drug-associated diarrhea Pseudomembranous colitis
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

26 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

27 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

28 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

29 Traveler’s 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

30 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

31 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

32 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

33 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





38 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

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

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

41 Oral Rehydration Therapy

42 Fluid and Electrolyte Replacement
Not more than mEq/L of Na for rehydration Not more than mEq of Na for maintenance Carb to Na ratio should be 2:1 Important in children and infants All patients should rehydrate and maintain during diarrheal episode

43 Loperamide Good for treatment of traveler’s 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 <6 years old use electrolyte tx instead

44 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

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

46 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)

47 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

48 Bismuth Subsalicylate BSS
Used for non-specific diarrhea, indigestion, tx and prevention of traveler’s 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 <2 years old

49 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

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

51 Things to Remember Always remember to rehydrate
Special populations (elderly, <3 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

52 New Developments “Super-ORS” Rotavirus vaccine

53 Controversies Underuse of ORT and overuse of drugs “Boil the water”

54 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









63 First steps for managing an outbreak of acute diarrhoea

Is this the beginning of an outbreak?

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

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.

1. Inform and ask for help 2. Protect the community 3. Treat the patients




71 diarrhea








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

80 3. TREAT THE PATIENTS 80% of the cases can be treated with Oral Rehydration Salt (ORS)



83 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.





88 Thank you

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