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Gastroenteritis (also known as gastro, gastric flu, and stomach flu, although unrelated
to influenza) is inflammation of the gastrointestinal tract, involving both the stomach and
the small intestine (see also gastritis and enteritis) and resulting in acute diarrhea. The
inflammation is caused most often by infection with certain viruses, less often by bacteria
or their toxins, parasites, or adverse reaction to something in the diet or medication.
Worldwide, inadequate treatment of gastroenteritis kills 5 to 8 million people per year,
and is a leading cause of death among infants and children under 5.
At least 50% of cases of gastroenteritis as foodborne illness are due to norovirus. Another
20% of cases, and the majority of severe cases in children, are due to rotavirus. Other
significant viral agents include adenovirus and astrovirus.
Gastroenteritis often involves stomach pain or spasms (sometimes to the point of being
crippled), diarrhea and/or vomiting, with noninflammatory infection of the upper small
bowel, or inflammatory infections of the colon.
It usually is of acute onset, normally lasting 1-6 days (fewer than 10 days) and self-
limiting.
The main contributing factors include poor feeding in infants. Diarrhea is common, and
may be (but not always) followed by vomiting. Viral diarrhea usually causes frequent
watery stools, whereas blood stained diarrhea may be indicative of bacterial colitis. In
some cases, even when the stomach is empty, bile can be vomited up.
A child with gastroenteritis may be lethargic, suffer lack of sleep, run a low fever, have
signs of dehydration (which include dry mucous membranes), tachycardia, reduced skin
turgor, skin color discoloration, sunken fontanelles, sunken eyeballs, darkened eye
circles, glassy eyes, poor perfusion and ultimately shock.
Symptoms occur for up to 6 days on average. Given appropriate treatment, bowel
movements will return to normal within a week after that.
Laboratory tests
Noninfectious
Non-infectious causes to consider are poisoning with heavy metals (e.g. arsenic,
cadmium), seafood (e.g. ciguatera, scombroid, toxic encephalopathic shellfish poisoning)
or mushrooms (e.g. Amanita phalloides). Secretory tumours (e.g. carcinoid, medullary
tumour of the thyroid, vasoactive intestinal peptide-secreting adenomas) and endocrine
disorders (e.g. thyrotoxicosis and Addison's disease) are disorders that can cause
diarrhea. Also, pancreatic insufficiency, short bowel syndrome, Whipple's disease, coeliac
disease, and laxative abuse should be excluded as possibilities.
Infectious
Infectious gastroenteritis is caused by a wide variety of bacteria and viruses. For a list of
bacteria causing gastroenteritis, see above. Pseudomembranous colitis is an important
cause of diarrhea in patients often recently treated with antibiotics. Viruses causing
gastroenteritis include rotavirus, norovirus, adenovirus and astrovirus.
Management
Rehydration
The principal treatment of gastroenteritis in both children and adults is rehydration, i.e.
replenishment of water lost in the stools. Depending on the degree of dehydration, this
can be done by giving the person oral rehydration therapy (ORT) or through intravenous
delivery.
People taking diuretics ("water pills") need to be cautious with diarrhea and may need to
stop taking the medication during an acute episode, as directed by the health care
provider.
Dietary therapy
Centers for Disease Control and Prevention recommendations for infants and children
include: Breastfed infants should continue to be nursed on demand. Formula-fed infants
should continue their usual formula immediately upon rehydration in amounts sufficient
to satisfy energy and nutrient requirements, and at the usual concentration. Lactose-free
or lactose-reduced formulas usually are unnecessary. Children receiving semisolid or
solid foods should continue to receive their usual diet during episodes of diarrhea. Foods
high in simple sugars should be avoided because the osmotic load might worsen diarrhea;
therefore, substantial amounts of soft drinks (carbonated or flat), juice, gelatin desserts,
and other highly sugared liquids should be avoided. Fatty foods should not be avoided,
because maintaining adequate calories without fat is difficult, and fat might have an
added benefit of reducing intestinal motility. The practice of withholding food for more
than 24 hours is inappropriate.
The BRAT diet (Bananas, Rice, Applesauce, Toast and Tea) was recommended in the
past; however, it is no longer recommended, as it contains insufficient nutrients.
Probiotics
Some Probiotics have been shown to be beneficial in preventing and treating various
forms of gastroenteritis. Fermented milk products ( such as yogurt ) also reduce the
duration of symptoms.
Zinc
The World Health Organization recommends that infants and children receive a dietary
supplement of zinc for up to 2 weeks after onset of gastroenteritis.
Pharmacologic therapy
Viral gastroenteritis is usually an acute and self-limited disease which does not require
pharmacologic therapy.
Antibiotics
Antibiotics may however sometimes be used if symptoms are severe and a bacterial cause
is either isolated or suspected.[citation needed] If antibiotics are decided on a fluoroquinolone is
often used.[6] Pseudomembranous colitis is treated by discontinuing the causative agent
and starting with metronidazole or vancomycin.
Antibiotics usually are not given for gastroenteritis, although they may be given due to
some bacteria.
Antiemetic drugs
If vomiting is severe, antiemetic drugs may be helpful. Ondansetron has some clinical
utility in this condition with a single dose associated with reduced use of intravenous
fluids, fewer hospitalizations, and decreasing nausea and vomiting. Metoclopramide
however has not been found to be helpful.
Complications
The most serious complication is dehydration, usually due to severe diarrhea but
sometimes made worse due to improper treatment such as withholding fluids until
diarrhea stops. Severe dehydration can be lethal and requires prompt medical care. The
most common complication,[citation needed] especially in infants, is malabsorption of certain
sugars in the diet, and consequent food intolerances. This complication may persist for
weeks, during which time it causes mild diarrhea to return when the patient resumes their
normal diet. Malabsorption of lactose, the principal sugar in milk, is the most common.
Its consequent milk intolerance is caused by lactase deficiency, and the diarrhea is caused
by bacterial fermentation of excess lactose in the gut. However, this is not reason to
discontinue breastfeeding. In children with viral gastroenteritis (usually rotavirus), the
viral infection also can cause a high fever, which in turn can cause febrile convulsion.
Gastroenteritis sometimes is followed by pneumonia.
Epidemiology
Globally, gastroenteritis caused 4.6 million deaths in children in 1980 alone, most of
these in the third world, where the lack of adequate safe water and sewage treatment
capacity contribute to the spread of infectious gastroenteritis. Harrison's Principles of
Internal Medicine estimates the current total figure to be 2.4 to 2.9 million per year. The
global death rate has now come down significantly to approximately 1.5 million deaths
annually, largely due to global introduction of proper oral rehydration therapy.
The incidence in the developed countries is as high as 1-2.5 cases per child per year[citation
needed]
and a major cause of hospitalisation in this age group.
Age, living conditions, hygiene and cultural habits are important factors. Aetiological
agents vary depending on the climate. Furthermore, most cases of gastroenteritis are seen
during the winter in temperate climates and during summer in the tropics.