Acute Gastroenteritis- Author: Dr. Brian Geyer
Introduction:
Do both vomiting and diarrhea have to be present? No 1996 AAP guidelines, 2016 ACG guidelines, and 2017 IDSA guidelines all note diarrhea illness but may be vomiting predominant. Studies use more vague definitions like: > 1 episode of vomiting and/or > 3 episodes of diarrhea in 24 hours without known chronic cause like inflammatory bowel disease. Diarrhea is at least 3 unformed stools per day. Acute episode 29 days Patients in the ED may present with only some of these symptoms depending their time in course of illness.Literature Review:
There is abundant literature on pediatric AGE but sparse research on AGE in adults. Therefore, many recommendations are extrapolated from the pediatric literature.Causes:
70% of US cases are estimated to be caused by viruses, norovirus being most common. o 26% norovirus o 18% rotavirus Among bacterial causes: o 5.3% Salmonella, most common o 5.3% Clostridium o 3% Campylobacter o 3% parasitic infections Large portion, 51%, have no cause identified. (In ED patients) Interestingly, 79% of cases never have a cause identified (not ED specific) In ED patients, only 25% ever have a cause identified, this increases to 49% when a stool sample is obtained. (not ED specific) Food poisoning is responsible for 5% of AGE but results in 30% of deaths. Most commonly: Salmonella, Clostridium perfringens, and Campylobacter Majority of foodborne illness is still viral, mostly norovirus E Coli is normal in the gut, but two most common causes are: Shiga toxin Ecoli (STEC) AKA enterohemorrhagic Ecoli (EHEC) - causes Hemolytic Uremic Syndrome in 5-10% Entertoxigenic Ecoli (ETEC) - causes traveler's diarrhea Both cause self-limited illness.Alternate Diagnoses:
Appendicitis: In the peds literature, misdiagnosis of appendicitis as AGE leads to 47% absolute increased risk of perforation. Suggestive findings include: Migration of pain to RLQ RLQ tenderness on exam (initial or repeat) Absence of diarrhea Pain not improved with episodes of diarrhea Negative factors include multiple ill family members, recent international travel, presence of diarrhea (as defined above). Ciguatera Fish Poisoning Toxin produced by algae consumed by reef fish like grouper, red snapper, sea bass and Spanish mackerel. Symptoms begin 6-24 hours post ingestion. Fish tastes normal. Patients may develop neurological symptoms like paresthesias, generalized pruritis, and reversal of hot/cold sensation. Symptoms resolve spontaneously, and treatment with mannitol is controversial. Scombroid Poisoning Ingesting fish in the Scombroidae family - mackerel, bonito, albacore, and skipjack - that have been stored improperly Bacteria produce histidine decarboxylase which converts histidine to histamine Causes abdominal cramps and diarrhea, and may cause metallic bitter or peppery taste in mouth, and facial flushing within 20-30 min of ingestion Can be confused with allergic reaction Symptoms resolve in 6-8 hours Notification of health dept may prevent others from being infected. Page 5 Table 1- Distinguishing Factors in the Differential Diagnosis of AGEHistory:
Table 2, page 6 has key questions to ask. Onset, timing, number of stools, presence of blood, fever, quality of abdominal pain and location, recent antibiotics, etc. Extremes of age, immunosuppression, and pregnancy should be identified. Mortality is highest in the patients >65 yo.Physical Exam:
We talked about RLQ abd pain, but what about bloody stool? An observational study of 889 adults and 151 pediatric with AGE showed that a negative fecal occult test showed accurately excluded invasive bacterial etiology with a NPV 87% in adults and 96% in children. But PPV was only 24%.Laboratory Testing and Imaging:
Dehydration is the biggest contributor to mortality, especially in the very young and elderly. Lab evaluation for dehydration is recommended in these populations. No consistent association between lab abnormalities and bacterial etiology. WBC and differential does not differentiate bacterial vs viral, but may help in identifying severity of illness. Hemoglobin and platelets are helpful if HUS is suspected. Stool Cultures: 2017 IDSA guidelines recommends them in patients with fever, bloody or mucoid stools, severe abdominal cramping or tenderness, or signs of sepsis, noting these patients are at higher risk of bacterial infection. Specifically, Salmonella, shigella, Campylobacter, and Yersinia 2016 ACG guidelines recommend them for patients with watery diarrhea and moderate to severe illness with fever for at least 72 hours. Consider them for immunocompromised patients and those with recent abx use or hospitalization. C Difficile testing is recommended for all patients with AGE who are age >2 with a history of recent abx use or recent hospitalization Blood cultures are recommended for patients 1-2 weeks, or immunocompromised patients.Diet:
No specific recommendations. Just prove patient is tolerating adequate oral fluids first.Special Populations:
Immunocompromised (HIV/AIDS, etc) and patients 65 yo are at increased risk Extend work up Treat with abx more liberally because of higher risk of cryptosporidium, Cyclospora, cystoisospora, microsporidia, and MAC. IDSA recommend abx therapy in immunocompromised patients and avoidance of probiotics due to lack of evidence. Loperamide is safe in these patients with acute watery diarrhea Patients on PPI and H2 blockers Increasing evidence that these meds increase susceptibility to viral and bacterial pathogens. Suspension of these meds in patients with AGE is reasonable. No formal guidelines on this. Post infectious irritable bowel syndrome results in persistent abdominal pain and diarrhea after an episode of AGE Management is supportiveDisposition:
OK for discharge if vitals are better after fixing dehydration and tolerating oral hydration. Remember to treat electrolyte abnormalities. Higher risk patients (65 yo, immunocompromised) should be considered for admission until they demonstrate clinical improvement.
Episode 32 - Assisting With Air Travel Medical Emergencies: Responsibilities and Pitfalls (Ethics CME)
EXTRA Supplement Podcast - Concussion in the Emergency Department: A Review of Current Guidelines - Trauma EXTRA Supplement (Trauma CME)
Episode 31 - Emergency Department Management of Patients Taking Direct Oral Anticoagulant Agents (Pharmacology CME)
Episode 30 - Emergency Department Management of Patients With Complications of Bariatric Surgery
Episode 29 - Assessing Abdominal Pain in Adults: A Rational, Cost-Effective, and Evidence-Based Strategy
Episode 28 - Depressed and Suicidal Patients in the Emergency Department: An Evidence-Based Approach
Episode 27 - Emergency Department Diagnosis and Treatment of Sexually Transmitted Diseases (Pharmacology CME and Infectious Disease CME)
Episode 26 – Blunt Cardiac Injury: Emergency Department Diagnosis and Management (Trauma CME)
Episode 25 - Evaluation and Management of Life-Threatening Headaches in the Emergency Department
Episode 24 - First Trimester Pregnancy Emergencies: Recognition and Management
Episode 23 - Influenza Diagnosis and Management in the Emergency Department
Episode 22 - Electrical Injuries in the Emergency Department An Evidence-Based Review
Episode 21- Updates and Controversies in the Early Management of Sepsis and Septic Shock
Episode 20 - Emergency Department Management of North American Snake Envenomations
Episode 19 - Cannabinoids: Emerging Evidence in Use and Abuse
Episode 18 – Emergency Department Management of Dyspnea in the Dying Patient
Episode 17 - Managing Shoulder Injuries in the Emergency Department Fracture, Dislocation, and Overuse
Episode 16 - Recognizing and Managing Emerging Infectious Diseases in the Emergency Department
Episode 15 - Jaundice in the Emergency Department: Meeting the Challenges of Diagnosis and Treatment
Episode 14 - Emergency Department Management of Smoke Inhalation Injury in Adults
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