Gastroenteritis is inflammation of the lining of the stomach and small and large intestines. Most cases are infectious, although gastroenteritis may occur after ingestion of drugs and chemical toxins (eg, metals, plant substances). Acquisition may be foodborne, waterborne, person-to-person spread, or occasionally through zoonotic spread. In the US, an estimated 1 in 6 people contracts foodborne illness each year. Symptoms include anorexia, nausea, vomiting, diarrhea, and abdominal discomfort. Diagnosis is clinical or by stool culture, although polymerase chain reaction testing and immunoassays are increasingly used. Treatment is symptomatic, although some parasitic and some bacterial infections require specific anti-infective therapy. Show
Most episodes of gastroenteritis are self-limited but cause uncomfortable symptoms. Electrolyte and fluid loss is usually little more than an inconvenience to an otherwise healthy adult but can be grave for people who are very young ( see Dehydration in Children Dehydration in Children Dehydration is significant depletion of body water and, to varying degrees, electrolytes. Symptoms and signs include thirst, lethargy, dry mucosa, decreased urine output, and, as the degree... read more ), who are older, or who are immunocompromised or have serious concomitant illnesses. In the US, about 48 million people contract a foodborne illness each year (1 General references Gastroenteritis is inflammation of the lining of the stomach and small and large intestines. Most cases are infectious, although gastroenteritis may occur after ingestion of drugs and chemical... read more ). Worldwide, an estimated 1.6 million people die each year of infectious gastroenteritis (2 General references Gastroenteritis is inflammation of the lining of the stomach and small and large intestines. Most cases are infectious, although gastroenteritis may occur after ingestion of drugs and chemical... read more ); although high, this number represents a significant decrease from previous mortality. Improvements in water sanitation in many parts of the world and the appropriate use of oral rehydration therapy Oral Rehydration Oral fluid therapy is effective, safe, convenient, and inexpensive compared with IV therapy. Oral fluid therapy is recommended by the American Academy of Pediatrics and the World Health Organization... read more for infants with diarrhea are likely responsible for this decrease.
Infectious gastroenteritis may be caused by viruses, bacteria, or parasites. Many specific organisms are discussed further in the Infectious Diseases section. Viruses are the most common cause of gastroenteritis in the US, and most viral gastroenteritis is caused by Most other viral gastroenteritis infections are caused by astrovirus or enteric adenovirus. Astrovirus can infect people of all ages but usually infects infants and young children. In temperate climates, infection is most common in winter months, and in tropical regions, infection is more common in summer months. Transmission is by the fecal-oral route. Incubation is 3 to 4 days. The bacteria most commonly implicated are Bacterial gastroenteritis is less common than viral. Bacteria cause gastroenteritis by several mechanisms. Mucosal invasion occurs with other bacteria (eg, Shigella Shigellosis Shigellosis is an acute infection of the intestine caused by the gram-negative Shigella species. Symptoms include fever, nausea, vomiting, tenesmus, and diarrhea that is usually bloody... read more , Salmonella Overview of Salmonella Infections The genus Salmonella is divided into 2 species, S. enterica and S. bongori, which include > 2500 known serotypes. Some of these serotypes are named. In such cases, common... read more , Campylobacter Campylobacter and Related Infections Campylobacter infections typically cause self-limited diarrhea but occasionally cause bacteremia, with consequent endocarditis, osteomyelitis, or septic arthritis. Diagnosis is by culture... read more , C. difficile Overview of Clostridial Infections Clostridia are spore-forming, gram-positive, anaerobic bacilli present widely in dust, soil, and vegetation and as normal flora in mammalian gastrointestinal tracts. Pathogenic species produce... read more , some E. coli Escherichia coli Infections The gram-negative bacterium Escherichia coli is the most numerous aerobic commensal inhabitant of the large intestine. Certain strains cause diarrhea, and all can cause infection when... read more subtypes) that invade the mucosa of the small bowel or colon and cause ulceration, bleeding, exudation of protein-rich fluid, and secretion of electrolytes and water. The invasive process and its results can occur whether or not the organism produces an enterotoxin. The resulting diarrhea has evidence of this invasion and inflammation with leukocytes and RBCs present on microscopy and sometimes with gross blood. Pearls & Pitfalls
Several other bacteria cause gastroenteritis, but most are uncommon in the US. Yersinia enterocolitica Plague and Other Yersinia Infections Plague is caused by the gram-negative bacterium Yersinia pestis. Symptoms are either severe pneumonia or large, tender lymphadenopathy with high fever, often progressing to septicemia... read more
The parasites most commonly implicated in developed countries are Certain intestinal parasites, notably Giardia intestinalis (G. lamblia), adhere to the intestinal mucosa, causing nausea, vomiting, diarrhea, and general malaise. Giardiasis occurs in every region of the US and throughout the world. The infection can become chronic and cause a malabsorption syndrome Overview of Malabsorption Malabsorption is inadequate assimilation of dietary substances due to defects in digestion, absorption, or transport. Malabsorption can affect macronutrients (eg, proteins, carbohydrates, fats)... read more that can be misdiagnosed as irritable bowel syndrome Irritable Bowel Syndrome (IBS) Irritable bowel syndrome is characterized by recurrent abdominal discomfort or pain with at least two of the following characteristics: relation to defecation, association with a change in frequency... read more . It is usually acquired via person-to-person transmission (often in day care centers) or from ingestion of cysts in contaminated water or food. Cryptosporidium parvum causes watery diarrhea and can sometimes be accompanied by abdominal cramps, nausea, and vomiting. In healthy people, the illness is self-limited, lasting about 2 weeks. In immunocompromised patients, illness may be severe and prolonged, causing substantial electrolyte and fluid loss. Cryptosporidium is usually acquired through contaminated water. It is not easily killed by chlorine and is the most common cause of recreational waterborne illness in the US, accounting for about three fourths of outbreaks. Symptoms and Signs of GastroenteritisThe character and severity of symptoms of gastroenteritis vary. Generally, onset is sudden, with anorexia, nausea, vomiting, abdominal cramps, and diarrhea (with or without blood and mucus). Malaise and myalgias may occur. The abdomen may be distended and mildly tender; in severe cases, muscle guarding may be present. Gas-distended intestinal loops may be palpable. Hyperactive bowel sounds are present on auscultation even without diarrhea (an important differential feature from paralytic ileus, in which bowel sounds are absent or decreased). Persistent vomiting and diarrhea can result in intravascular fluid depletion with hypotension and tachycardia. Hypovolemic shock Hypovolemic shock Shock is a state of organ hypoperfusion with resultant cellular dysfunction and death. Mechanisms may involve decreased circulating volume, decreased cardiac output, and vasodilation, sometimes... read more with vascular collapse and oliguric renal failure may occur in severe cases. Viral gastroenteritisThe hallmark of adenovirus gastroenteritis is diarrhea lasting 1 to 2 weeks. Affected infants and children may have mild vomiting that typically starts 1 to 2 days after the onset of diarrhea. Low-grade fever occurs in about 50% of patients. Respiratory symptoms may be present. Symptoms are generally mild but can last longer than with other viral causes of gastroenteritis. Astrovirus causes a syndrome similar to mild rotavirus infection. Bacterial gastroenteritisBacteria that cause invasive disease (eg, Shigella Shigellosis Shigellosis is an acute infection of the intestine caused by the gram-negative Shigella species. Symptoms include fever, nausea, vomiting, tenesmus, and diarrhea that is usually bloody... read more , Salmonella Overview of Salmonella Infections The genus Salmonella is divided into 2 species, S. enterica and S. bongori, which include > 2500 known serotypes. Some of these serotypes are named. In such cases, common... read more ) are more likely to result in fever, prostration, and bloody diarrhea. Parasitic gastroenteritis
Other gastrointestinal disorders that cause similar symptoms (eg, appendicitis
Appendicitis Appendicitis is acute inflammation of the vermiform appendix, typically resulting in abdominal pain, anorexia, and abdominal tenderness. Diagnosis is clinical, often supplemented by CT or ultrasonography... read more
Findings suggestive of gastroenteritis include copious, watery diarrhea; ingestion of potentially contaminated food (particularly during a known outbreak), untreated surface water, or a known gastrointestinal irritant; recent travel; or contact with infected people or certain animals.
Multiplex polymerase chain reaction platforms that can identify causative organisms in each of these categories are being used more often. However, this testing is expensive, and because the categories are often distinguishable clinically or the disease courses are self-limiting, it is usually more cost-effective to test for specific microorganisms depending on the type and duration of diarrhea. In addition, polymerase chain reaction testing does not allow for antibiotic susceptibility testing. Acute watery diarrhea is probably viral and testing is not indicated unless the diarrhea persists. Although rotavirus and enteric adenovirus infections can be diagnosed using commercially available rapid assays that detect viral antigen in the stool, these assays are rarely indicated. Acute inflammatory diarrhea without gross blood can be recognized by the presence of leukocytes on stool examination. Patients should have stool culture for typical enteric pathogens (eg, Salmonella Overview of Salmonella Infections The genus Salmonella is divided into 2 species, S. enterica and S. bongori, which include > 2500 known serotypes. Some of these serotypes are named. In such cases, common... read more , Shigella Shigellosis Shigellosis is an acute infection of the intestine caused by the gram-negative Shigella species. Symptoms include fever, nausea, vomiting, tenesmus, and diarrhea that is usually bloody... read more , Campylobacter Campylobacter and Related Infections Campylobacter infections typically cause self-limited diarrhea but occasionally cause bacteremia, with consequent endocarditis, osteomyelitis, or septic arthritis. Diagnosis is by culture... read more , E. coli Escherichia coli Infections The gram-negative bacterium Escherichia coli is the most numerous aerobic commensal inhabitant of the large intestine. Certain strains cause diarrhea, and all can cause infection when... read more ). Acute inflammatory diarrhea with gross blood should also prompt testing specifically for E. coli O157:H7, as should nonbloody diarrhea during a known outbreak. Specific cultures must be requested because this organism is not detected on standard stool culture media. Alternatively, a rapid enzyme assay for the detection of Shiga toxin in stool can be done; a positive test indicates infection with E. coli O157:H7 or one of the other serotypes of enterohemorrhagic E. coli. (NOTE: Shigella species in the US do not produce Shiga toxin.) However, a rapid enzyme assay is not as sensitive as culture. Polymerase chain reaction testing is used to detect Shiga toxin in some centers.
Supportive treatment is all that is needed for most patients. Bed rest with convenient access to a toilet or bedpan is desirable. Oral glucose-electrolyte solutions, broth, or bouillon may prevent dehydration or treat mild dehydration. Even if vomiting, the patient should take frequent small sips of such fluids; vomiting may abate with volume replacement. For patients with E. coli O157:H7 infection, rehydration with isotonic IV fluids may attenuate the severity of any renal injury should hemolytic-uremic syndrome develop. Children may become dehydrated more quickly and should be given an appropriate rehydration solution (several are available commercially— see Oral Rehydration Oral Rehydration Oral fluid therapy is effective, safe, convenient, and inexpensive compared with IV therapy. Oral fluid therapy is recommended by the American Academy of Pediatrics and the World Health Organization... read more ). Carbonated beverages and sports drinks lack the correct ratio of glucose to sodium and thus are not appropriate, particularly for children < 5 years. If the child is breastfed, breastfeeding should continue. If vomiting is protracted or if severe dehydration is prominent, IV replacement of volume and electrolytes is necessary ( see Intravenous Fluid Resuscitation Intravenous Fluid Resuscitation Almost all circulatory shock states require large-volume IV fluid replacement, as does severe intravascular volume depletion (eg, due to diarrhea or heatstroke). Intravascular volume deficiency... read more ). When the patient can tolerate fluids without vomiting and the appetite has begun to return, food may be gradually restarted. Although commonly recommended, there is no demonstrated benefit to restricting the diet to bland food (eg, cereal, gelatin, bananas, toast). Some patients have temporary lactose intolerance. Antidiarrheal agents are not recommended in pediatric cases and therefore should be avoided in children < 18 years of age with acute diarrhea (see also the Infectious Diseases Society of America's 2017 clinical practice guidelines for the diagnosis and management of infectious diarrhea). Use of antidiarrheal agents is contraindicated in children < 2 years of age. These agents are generally safe for adult patients with watery diarrhea (as shown by heme-negative stool). However, antidiarrheals may cause deterioration of patients with C. difficile or E. coli O157:H7 infection and thus should not be given to any patient with recent antibiotic use, heme-positive or bloody stool, or diarrhea with fever, pending specific diagnosis. Effective antidiarrheals include loperamide 4 mg orally initially, followed by 2 mg orally for each subsequent episode of diarrhea (maximum of 8 2-mg doses/day or 16 mg/day), or diphenoxylate 2.5 to 5 mg 3 times a day or 4 times a day in tablet or liquid form. If vomiting is severe and a surgical condition (eg, small-bowel obstruction) has been excluded, an antiemetic may be beneficial. Drugs useful in adults include ondansetron, prochlorperazine, and promethazine. Ondansetron is safe and effective in decreasing nausea and vomiting in children and in adults, including those with gastroenteritis. Ondansetron can be given to adults and children orally or IV. The oral and IV dosage for adults is 4 or 8 mg 3 or 4 times a day. The IV dose for children is 0.15 or 0.3 mg/kg (maximum 16 mg). The oral dose for children is weight-based and is 2 mg for children 8 to 15 kg, 4 mg for children > 15 to 30 kg, and 8 mg for children > 30 kg. A single dose of ondansetron is usually adequate for children, but if needed the dose may be repeated every 8 hours for 2 more doses. The prochlorperazine dosage is 5 to 10 mg IV 3 times a day or 4 times a day, or 25 mg rectally 2 times a day. The promethazine dosage is 12.5 to 25 mg IM 3 times a day or 4 times a day, or 25 to 50 mg rectally 4 times a day. These drugs are usually avoided in children because of lack of demonstrated efficacy and the high incidence of dystonic reactions. Children who are still vomiting after 24 hours require reevaluation.
In proven bacterial gastroenteritis, antibiotics are not always required.
They do not help with Salmonella and may prolong the duration of shedding in the stool. Exceptions include immunocompromised patients, neonates, and patients with Salmonella bacteremia. Antibiotics are also ineffective against toxic gastroenteritis (eg, S. aureus, B. cereus, C. perfringens). Indiscriminate use of antibiotics fosters the emergence of drug-resistant organisms, increases the risk of side effects, and increases the potential for C. difficile
infection. However, certain infections do require antibiotics ( see Table: Selected Oral Antibiotics for Infectious
Gastroenteritis* Selected Oral Antibiotics for Infectious Gastroenteritis*
Initial management of C. difficile colitis involves stopping the causative antibiotic if possible. The drug of choice to treat C. difficile colitis is oral vancomycin, which is superior to metronidazole. Unfortunately, recurrences occur in about 20% of patients receiving vancomycin. A newer drug, fidaxomicin, may have a slightly lower relapse rate and can be considered as first-line therapy in new cases of C. difficile infection (1 Antimicrobials references Gastroenteritis is inflammation of the lining of the stomach and small and large intestines. Most cases are infectious, although gastroenteritis may occur after ingestion of drugs and chemical... read more ). Many centers are using fecal microbial transplantation for patients with multiple recurrences of C. difficile colitis. This treatment generally has been shown to be safe and effective, but there are still issues with quality control, particularly regarding infection transmission ( see Treatment Treatment Toxins produced by Clostridioides difficile strains in the gastrointestinal tract cause pseudomembranous colitis, typically after antibiotic use. Symptoms are diarrhea, sometimes bloody... read more ) (2 Antimicrobials references Gastroenteritis is inflammation of the lining of the stomach and small and large intestines. Most cases are infectious, although gastroenteritis may occur after ingestion of drugs and chemical... read more ). For cryptosporidiosis, a 3-day course of nitazoxanide may be helpful in immunocompromised patients. The dosage is 100 mg orally 2 times a day for children 1 to 3 years, 200 mg orally 2 times a day for children 4 to 11 years, and 500 mg orally 2 times a day for children ≥ 12 years and adults. Giardiasis is treated with metronidazole or nitazoxanide. 
To prevent recreational waterborne infections, people should not swim if they have diarrhea. Infants and toddlers should have frequent diaper checks and should be changed in a bathroom and not near the water. Swimmers should avoid swallowing water when they swim. Infants and other immunocompromised people are particularly predisposed to developing severe cases of salmonellosis and should not be exposed to reptiles, birds, or amphibians, which commonly carry Salmonella. Breastfeeding affords some protection to neonates and infants. Caregivers should wash their hands thoroughly with soap and water after changing diapers, and diaper-changing areas should be disinfected with a freshly prepared solution of 1:64 household bleach (¼ cup diluted in 1 gallon of water). Children with diarrhea should be excluded from child care facilities for the duration of symptoms. Children infected with enterohemorrhagic E. coli or Shigella should also have two negative stool tests before readmission to the facility. The following are English-language resources that may be useful. Please note that THE MANUAL is not responsible for the content of these resources. At which age is a toddler physiologically and psychologically prepared for toilet training?Most children are ready to begin toilet training between 22 and 30 months of age. Remember that with potty training, like with all other development, every child is different. Wait to start potty training until your child is ready both physically and emotionally.
Which condition is commonly seen in preschoolers?1. Common Cold. It's not surprising that the common cold is one of the most common childhood illnesses. Colds are caused by viruses that spread easily in environments where people have close contact with one another.
Which similarities in growth and development would the nurse expect between preschoolers and toddlers quizlet?What would the nurse describe as a similarity between the growth and development of preschoolers and that of toddlers? Toddlers and preschoolers gain 5 to 7 pounds (2.26 to 3.17 kg) each year. Preschoolers need at least 1800 calories in a day. On the other hand, toddlers need fewer calories and more protein.
Which developmental milestone would the nurse anticipate for a 15 month old child quizlet?The nurse would anticipate that a 24-month-old toddler can use a straw to drink liquids. The 15-month-old toddler is expected to drink well from a cup. Beginning to use a fork by holding it in the fist and spilling small amounts of food when using a spoon are expectations for a 36-month-old toddler.
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Which predominant change occurs in the gastrointestinal system of the toddler
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