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{{Infobox Disease
| Name = Gastroenteritis
| Image =
| Caption =
| DiseasesDB = 30726
| ICD10 = {{ICD10|A|09||a|00}}, {{ICD10|J|10|8|j|09}}, {{ICD10|K|52||k|50}}
| ICD9 = {{ICD9|009.0}}, {{ICD9|009.1}}, {{ICD9|558}}
| ICDO =
| OMIM =
| MedlinePlus =
| eMedicineSubj = emerg
| eMedicineTopic = 213
| MeshID = D005759
}}
{{wiktionarypar|gastroenteritis}}
'''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 (medicine)|acute]] [[diarrhea]]. The inflammation is caused most often by [[infection]] with certain [[virus]]es, less often by [[bacteria]] or their [[toxin]]s, [[parasites]], or [[adverse reaction]] to something in the diet or medication. Worldwide, inadequate treatment of gastroenteritis kills 5 to 8 million people per year,<ref name=Harrison>Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL. [[Harrison's Principles of Internal Medicine]]. New York: McGraw-Hill, 2005. ISBN 0-07-139140-1.</ref> and is a leading cause of death among [[infant]]s and [[child]]ren under 5.<ref name="pmid14627948">{{cite journal
| author = King CK, Glass R, Bresee JS, Duggan C
| title = Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy
| journal = MMWR Recomm Rep
| volume = 52
| issue = RR-16
| pages = 1–16
| year = 2003
| pmid = 14627948
| doi =
| url = http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm
| issn =
}}</ref>

At least 50% of cases of gastroenteritis as [[foodborne illness]] are due to [[norovirus]].<ref name="cdcfactsheet">{{cite web |url=http://www.cdc.gov/ncidod/dvrd/revb/gastro/norovirus-factsheet.htm |title=Norovirus: Technical Fact Sheet |publisher=National Center for Infectious Diseases, CDC}}</ref> Another 20% of cases, and the majority of severe cases in children, are due to [[rotavirus]]. Other significant viral agents include [[adenovirus]]<ref name=Murray/> and [[astrovirus]].

Different species of bacteria can cause gastroenteritis, including ''[[Salmonella]]'', ''[[Shigella]]'', ''[[Staphylococcus]]'', ''[[Campylobacter jejuni]]'', ''[[Clostridium]]'', ''[[Escherichia coli]]'', ''[[Yersinia]]'', and others. Some sources of the infection are improperly prepared food, reheated meat dishes, seafood, dairy, and bakery products. Each organism causes slightly different symptoms but all result in diarrhea. [[Colitis]], inflammation of the large intestine, may also be present.

Risk factors include consumption of improperly prepared foods or contaminated water and travel or residence in areas of poor sanitation. It is also common for river swimmers to become infected during times of rain as a result of contaminated runoff water. <ref name="Surfing Sicknesses">[http://surf.transworld.net/2009/01/27/seven-surf-sicknesses/ Seven Surfing Sicknesses], .</ref> The incidence is 1 in 1,000 people.

Gastroenteritis can be classified as either viral or bacterial.

== Symptoms and signs ==
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 (anatomy)|colon]].<ref name="SleisengerFordtran">
[http://www.elsevier-international.com/catalogue/title.cfm?ISBN=0721689736 Sleisenger & Fordtran's Gastrointestinal and Liver Disease] 7th edition,<!-- 2-Volume Set,--> by Mark Feldman<!--, MD, Chair of Internal Medicine, Presbyterian Hospital of Dallas, Clinical Professor of Internal Medicine, University of Texas Southwestern Medical School of Dallas, Dallas, TX-->; Lawrence S. Friedman<!--, MD, Professor of Medicine, Gastroinstestinal Unit, Massachusetts General Hospital, Boston, MA-->; and Marvin H. Sleisenger<!--, MD, Distinguished Physician, Department of Veterans Affairs Medical Center, San Francisco, CA-->, ISBN 0-7216-8973-6, Hardback,<!-- 2688 Pages, 850 Illustrations,--> Saunders, Published July 2002</ref><ref name="Mandell">
[http://www.ppidonline.com/ Mandell's Principles and Practices of Infection Diseases] 6th Edition (2004) by Gerald L. Mandell MD, MACP, John E. Bennett MD, Raphael Dolin MD, ISBN 0-443-06643-4 · Hardback · 4016 Pages Churchill Livingstone </ref><ref name="Harrison"> [http://books.mcgraw-hill.com/medical/harrisons/ Harrison's Principles of Internal Medicine] 16th Edition, The [[McGraw-Hill]] Companies, ISBN 0-07-140235-7</ref><ref name="Oxford">''[http://www.oup.com/us/catalog/general/subject/Medicine/PrimaryCare/?view=usa&ci=9780198529989 The Oxford Textbook of Medicine]''. Edited by David A. Warrell, Timothy M. Cox and John D. Firth with Edward J. Benz, Fourth Edition (2003), [[Oxford University Press]], ISBN 0-19-262922-0</ref>

It usually is of [[acute (medical)|acute]] onset, normally lasting 1-6 days (fewer than 10 days) and [[self-limiting (biology)|self-limiting]].

* [[Nausea]] and [[vomiting]]
* [[Diarrhea]]
* Loss of appetite
* Abdominal pain
* Abdominal cramps
* Bloody stools ([[dysentery]] - suggesting infection by amoeba, ''Campylobacter'', ''Salmonella'', ''Shigella'' or some pathogenic strains of ''Escherichia coli''<ref name=Murray>Murray PR, Pfaller MA, Rosenthal KS. [[Medical Microbiology]]. Mosby, 2005. ISBN 0323033032.</ref>)
* Fainting and Weakness
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 (medical)|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===
* Examination of stool for toxins, (e.g. [[Clostridium difficile|Clostridium difficile toxin]])
* Stool cultures for the organisms that causes the disease, (e.g. [[Salmonella]], [[Shigella]], [[Campylobacter]] and enterotoxic Escherichia coli)
* Microscopy for parasites and their ova and cysts
*[[EIA]] for viruses

== Differential diagnosis ==
[[Image:Gastroenteritis viruses.jpg|right|thumb|350px|Gastroenteritis viruses: A = rotavirus, B = adenovirus, C = Norovirus and D = Astrovirus. The virus particles are shown at the same magnification to allow size comparison.]]

It is important to consider infectious gastroenteritis as a [[diagnosis per exclusionem]]. A few loose stools and vomiting may be the result of systemic [[infection]] such as [[pneumonia]], [[septicemia]], [[urinary tract infection]] and even [[meningitis]]. Surgical conditions such as [[appendicitis]], [[intussusception]] and, rarely, even [[Hirschsprung's disease]] may mislead the clinician.

===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, [[Vipoma|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.<ref name="Oxford"/>

===Infectious===
Infectious gastroenteritis is caused by a wide variety of [[bacteria]] and [[virus]]es. 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]].

If gastroenteritis in a child is severe enough to require admission to a hospital, then it is important to distinguish between bacterial and viral infections. Bacteria, ''[[Shigella]]'' and ''[[Campylobacter]]'', for example, and [[parasite]]s like ''[[Giardia]]'' can be treated with [[antibiotic]]s, but viruses do not respond to antibiotics and infected children usually make a full recovery after a few days.<ref name="pmid1649479">{{cite journal |author=Haffejee IE |title=The pathophysiology, clinical features and management of rotavirus diarrhoea |journal=Q. J. Med. |volume=79 |issue=288 |pages=289–99 |year=1991 |pmid=1649479 |doi=}}</ref> Children admitted to hospital with gastroenteritis routinely are tested for rotavirus A to gather surveillance data relevant to the epidemiological effects of rotavirus vaccination programs.<ref name="pmid17901797">{{cite journal |author=Patel MM, Tate JE, Selvarangan R, ''et al'' |title=Routine laboratory testing data for surveillance of rotavirus hospitalizations to evaluate the impact of vaccination |journal=Pediatr. Infect. Dis. J. |volume=26 |issue=10 |pages=914–9 |year=2007 |pmid=17901797 |doi=10.1097/INF.0b013e31812e52fd |doi_brokendate=2008-06-21}}</ref><ref name="pmid16650331">{{cite journal |author= |title=The paediatric burden of rotavirus disease in Europe |journal=Epidemiol. Infect. |volume=134 |issue=5 |pages=908–16 |year=2006 |pmid=16650331 |doi=10.1017/S0950268806006091}}</ref> These children are routinely tested also for [[norovirus]], which is extraordinarily infectious and requires special isolation procedures to avoid transmission to other patients. Other methods, [[electron microscopy]] and [[polyacrylamide gel electrophoresis]], are used in research laboratories.<ref name="pmid3132369">{{cite journal |author=Beards GM |title=Laboratory diagnosis of viral gastroenteritis |journal=Eur. J. Clin. Microbiol. Infect. Dis. |volume=7 |issue=1 |pages=11–3 |year=1988 |pmid=3132369 |doi=10.1007/BF01962164}}</ref><ref name="pmid1321223">{{cite journal |author=Steel HM, Garnham S, Beards GM, Brown DW |title=Investigation of an outbreak of rotavirus infection in geriatric patients by serotyping and polyacrylamide gel electrophoresis (PAGE) |journal=J. Med. Virol. |volume=37 |issue=2 |pages=132–6 |year=1992 |pmid=1321223 |doi=10.1002/jmv.1890370211}}</ref>

== Management ==
The objective of treatment is to replace lost [[fluid]]s and [[electrolyte]]s. [[Oral rehydration therapy|Oral rehydration]] is the preferred treatment of [[fluid]] and [[electrolyte]] losses caused by [[diarrhea]] in children with mild to moderate dehydration <ref>{{cite journal |author= |title=Practice parameter: the management of acute gastroenteritis in young children. American Academy of Pediatrics, Provisional Committee on Quality Improvement, Subcommittee on Acute Gastroenteritis |journal=Pediatrics |volume=97 |issue=3 |pages=424–35 |year=1996 |pmid=8604285 |doi= |url=}}</ref>.

=== 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 [[vein|intravenous]] delivery.<ref>{{cite web |url=http://www.bestbets.org/bets/bet.php?id=1039 |title=BestBets: Fluid Treatment of Gastroenteritis in Adults |format= |work= |accessdate=}}</ref>

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]]<ref>[http://www.cdc.gov/mmwR/preview/mmwrhtml/rr5216a1.htm Managing Acute Gastroenteritis Among Children: Oral Rehydration, Maintenance, and Nutritional Therapy<!-- Bot generated title -->]</ref> 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 sugar]]s should be avoided because the [[osmosis|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 [[calorie]]s 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.<ref>{{cite web |url=http://www.bestbets.org/bets/bet.php?id=390 |title=BestBets: Gradual introduction of feeding is no better than immediate normal feeding in children with gastro-enteritis |format= |work= |accessdate=December 6,2008}}</ref>

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. <ref name=MMWR2003>{{cite journal |author=King CK, Glass R, Bresee JS, Duggan C |title=Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy |journal=MMWR Recomm Rep |volume=52 |issue=RR-16 |pages=1–16 |year=2003 |month=November |pmid=14627948 |doi= |url=http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm}}</ref>

===Probiotics===
Some [[Probiotics]] have been shown to be beneficial in preventing and treating various forms of gastroenteritis.<ref name=MMWR2003/> Fermented milk products ( such as [[yogurt]] ) also reduce the duration of symptoms.<ref>{{cite web |url=http://www.bestbets.org/bets/bet.php?id=1000 |title=Does yogurt decrease acute diarrhoeal symptoms in children with acute gastroenteritis |format= |work= |accessdate=}}</ref>

===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.<ref>[http://rehydrate.org/zinc/index.html Rehydrate.org: Zinc Supplementation]</ref>

===Pharmacologic therapy===
Viral gastroenteritis is usually an acute and self-limited disease which does not require pharmacologic therapy.<ref>{{cite web |url=http://www.merck.com/mmhe/sec09/ch122/ch122a.html+Merck+Manual |title=Merck - Error Page |format= |work= |accessdate=}}</ref>

==== Antibiotics ====
Antibiotics may however sometimes be used if symptoms are severe and a bacterial cause is either isolated or suspected.{{Fact|date=January 2008}} If antibiotics are decided on a [[fluoroquinolone]] is often used.<ref name="SleisengerFordtran"/> [[Pseudomembranous colitis]] is treated by '''discontinuing''' the causative agent and starting with [[metronidazole]] or [[vancomycin]].<ref name="SleisengerFordtran"/><ref name="Mandell"/><ref name="Harrison"/><ref name="Oxford"/>

Antibiotics usually are not given for gastroenteritis, although they may be given due to some bacteria.

==== Antidiarrheal agents ====
{{Cleanup|date=January 2008}}
[[Loperamide]] is an [[opioid]] analogue commonly used for symptomatic treatment of diarrhea. It slows down [[peristalsis|gut motility]], but does not cross the mature [[blood-brain barrier]]<ref name="SleisengerFordtran"/> to cause the central nervous effect of other opioids. In excessive doses, loperamide may cause constipation and significantly slow down of passage of feces, but an appropriate single dose will not<!-- What? it's not effective in a single dose, or is the "not" a mistake?--> slow down the duration of the disease.<ref>{{cite journal |author=Wingate D, Phillips SF, Lewis SJ, ''et al'' |title=Guidelines for adults on self-medication for the treatment of acute diarrhoea |journal=Aliment. Pharmacol. Ther. |volume=15 |issue=6 |pages=773–82 |year=2001 |pmid=11380315 |doi=10.1046/j.1365-2036.2001.00993.x |url=http://www.blackwell-synergy.com/openurl?genre=article&sid=nlm:pubmed&issn=0269-2813&date=2001&volume=15&issue=6&spage=773}}</ref> Although antimotility drugs have the risk of exacerbating the condition, clinical experience shows this is unlikely.<ref name="SleisengerFordtran"/><ref name="Oxford"/> Nevertheless, others discourage the use of antiperistaltic agents and opiates in febrile [[dysentery]], since they may mask, or exacerbate the symptoms.<ref name="Harrison"/> All these sources agree that in severe [[colitis]] antimotility drugs should not be used.

Loperamide prevents the body from flushing toxins from the gut, and should not be used when an active fever is present or there is a suspicion that the diarrhea is associated with organisms that can penetrate the intestinal walls, such as [[E. coli O157:H7]] or ''[[Salmonella]]''.

Loperamide is also not recommended in children, especially in children younger than 2 years of age, as it may cause systemic toxicity due to an immature blood brain barrier, and oral rehydration therapy remains the main stay treatment for children.

[[Bismuth subsalicylate]] (BSS), an insoluble complex of trivalent bismuth and salicylate, is another drug that can be used in mild-moderate cases.<ref name="SleisengerFordtran"/><ref name="Oxford"/>

Combining an antimicrobial drug and an antimotility drug seems to be more rapidly effective<!-- more effective than what? and -->.<ref name="SleisengerFordtran"/><ref name="Oxford"/>

====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.<ref>{{cite journal |author=DeCamp LR, Byerley JS, Doshi N, Steiner MJ |title=Use of antiemetic agents in acute gastroenteritis: a systematic review and meta-analysis |journal=Arch Pediatr Adolesc Med |volume=162 |issue=9 |pages=858–65 |year=2008 |month=September |pmid=18762604 |doi=10.1001/archpedi.162.9.858 |url=}}</ref><ref name="pmid17279195">{{cite journal| author = Mehta S, Goldman RD| title = Ondansetron for acute gastroenteritis in children| journal = Can Fam Physician| volume = 52| issue = 11| pages = 1397–8| year = 2006| pmid = 17279195| doi = | url = http://www.cfp.ca/cgi/pmidlookup?view=long&pmid=17279195| issn = }}</ref> [[Metoclopramide]] however has not been found to be helpful.<ref>{{cite web |url=http://www.bestbets.org/bets/bet.php?id=902 |title=BestBets: Are antiemetics helpful in young children suffering from acute viral gastroenteritis? |format= |work= |accessdate=}}</ref>

==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''',{{Fact|date=January 2009}} especially in infants, is [[malabsorption]] of certain sugars in the diet, and consequent [[food intolerance]]s. 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]].<ref name="pmid6436397">{{cite journal
|author=Arya SC
|title=Rotaviral infection and intestinal lactase level
|journal=J. Infect. Dis.
|volume=150
|issue=5
|pages=791
|year=1984
|pmid=6436397
|doi=
}}</ref> 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]],<ref name="Mandell"/> 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.<ref name="Harrison"/> 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]].<ref>{{cite journal |author=Victora CG, Bryce J, Fontaine O, Monasch R |title=Reducing deaths from diarrhoea through oral rehydration therapy |journal=Bull. World Health Organ. |volume=78 |issue=10 |pages=1246–55 |year=2000 |pmid=11100619 |doi= |url=}}
</ref>

The incidence in the [[developed nation|developed countries]] is as high as 1-2.5 cases per child per year{{Fact|date=August 2008}} and a major cause of hospitalisation in this age group.

Age, living conditions, hygiene and cultural habits are important factors. [[Etiology|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.<ref name="Mandell"/>

==History==
Before the 20th century, the term "gastroenteritis" was not commonly used. What would now be diagnosed as gastroenteritis may have instead been diagnosed ''more specifically'' as [[typhoid fever]] or "cholera morbus", among others, or ''less specifically'' as "griping of the guts", "surfeit", "flux", "colic", "bowel complaint", or any one of a number of other archaic names for acute diarrhea.<ref name="archaic">[http://www.antiquusmorbus.com/English/English.htm Rudy's List of Archaic Medical Terms]</ref> Historians, genealogists, and other researchers should keep in mind that gastroenteritis was not considered a discrete diagnosis until fairly recently.

U.S. President [[Zachary Taylor]] died of gastroenteritis on July 9, 1850.

==See also==
<div class="references-medium" style="-moz-column-count:3; column-count:3;">
*[[Diarrhea]]
*[[1984 Rajneeshee bioterror attack]]
*[[Food poisoning]]
*[[Eosinophilic gastroenteritis]]
*[[Hemorrhagic gastroenteritis]]
*[[Cholera]]
*[[Dysentery]]
*[[Infectious diarrhea]]
*[[Traveler's diarrhea]]
*[[Wilderness diarrhea]]
*[[Pseudomembranous colitis]]
*[[Rotavirus]]
*[[Cryptosporidium]]
</div>

==References==
{{reflist|2}}

==External links==
* {{Cite web|url=http://www.nhsdirect.nhs.uk/articles/article.aspx?articleId=172|title=NHS Direct: Gastroenteritis|accessdate=2007-04-12}}
* {{Cite web|url=http://www.emedicinehealth.com/gastroenteritis/article_em.htm|title=eMedicine Health:Gastroenteritis|accessdate=2007-04-12}}
* {{Cite web|url=http://www.who.int/topics/diarrhoea/en/|title=The World Health Organisation: Diarrhoea|accessdate=2007-04-12}}
* [http://www.mayoclinic.com/health/first-aid-gastroenteritis/FA00030 Gastroenteritis: First aid from the Mayo Clinic]
* {{Cite web
|url=http://coldflu.about.com/od/flumisconceptions/f/stomachflu.htm
|title=About.com: Seasonal Flu vs. Stomach Flu
|accessdate=2007-04-12}}

{{Gastroenterology}}
{{Viral diseases}}
{{Inflammation}}

[[Category:Pediatrics]]
[[Category:Gastroenterology]]
[[Category:Foodborne illnesses]]
[[Category:Infectious diseases]]
[[Category:Inflammations]]
[[Category:Abdominal pain]]
[[Category:Conditions diagnosed by stool test]]
[[Category: Global health]]

[[bg:Гастроентерит]]
[[cs:Gastroenteritida]]
[[de:Gastroenteritis]]
[[es:Gastroenteritis]]
[[fr:Gastro-entérite]]
[[id:Gastroenteritis]]
[[it:Gastroenterite]]
[[nl:Gastroenteritis]]
[[ja:嘔吐下痢症]]
[[pt:Gastroenterite]]
[[ru:Гастроэнтерит]]
[[simple:Stomach flu]]
[[fi:Oksennustauti]]
[[sv:Mag-tarmkatarr]]
[[zh:腸胃炎]]

Revision as of 19:03, 1 February 2009

Gastroenteritis
SpecialtyGastroenterology Edit this on Wikidata
Look up gastroenteritis in Wiktionary, the free dictionary.

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,[1] and is a leading cause of death among infants and children under 5.[2]

At least 50% of cases of gastroenteritis as foodborne illness are due to norovirus.[3] Another 20% of cases, and the majority of severe cases in children, are due to rotavirus. Other significant viral agents include adenovirus[4] and astrovirus.

Different species of bacteria can cause gastroenteritis, including Salmonella, Shigella, Staphylococcus, Campylobacter jejuni, Clostridium, Escherichia coli, Yersinia, and others. Some sources of the infection are improperly prepared food, reheated meat dishes, seafood, dairy, and bakery products. Each organism causes slightly different symptoms but all result in diarrhea. Colitis, inflammation of the large intestine, may also be present.

Risk factors include consumption of improperly prepared foods or contaminated water and travel or residence in areas of poor sanitation. It is also common for river swimmers to become infected during times of rain as a result of contaminated runoff water. [5] The incidence is 1 in 1,000 people.

Gastroenteritis can be classified as either viral or bacterial.

Symptoms and signs

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.[6][7][1][8]

It usually is of acute onset, normally lasting 1-6 days (fewer than 10 days) and self-limiting.

  • Nausea and vomiting
  • Diarrhea
  • Loss of appetite
  • Abdominal pain
  • Abdominal cramps
  • Bloody stools (dysentery - suggesting infection by amoeba, Campylobacter, Salmonella, Shigella or some pathogenic strains of Escherichia coli[4])
  • Fainting and Weakness

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

Differential diagnosis

Gastroenteritis viruses: A = rotavirus, B = adenovirus, C = Norovirus and D = Astrovirus. The virus particles are shown at the same magnification to allow size comparison.

It is important to consider infectious gastroenteritis as a diagnosis per exclusionem. A few loose stools and vomiting may be the result of systemic infection such as pneumonia, septicemia, urinary tract infection and even meningitis. Surgical conditions such as appendicitis, intussusception and, rarely, even Hirschsprung's disease may mislead the clinician.

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.[8]

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.

If gastroenteritis in a child is severe enough to require admission to a hospital, then it is important to distinguish between bacterial and viral infections. Bacteria, Shigella and Campylobacter, for example, and parasites like Giardia can be treated with antibiotics, but viruses do not respond to antibiotics and infected children usually make a full recovery after a few days.[9] Children admitted to hospital with gastroenteritis routinely are tested for rotavirus A to gather surveillance data relevant to the epidemiological effects of rotavirus vaccination programs.[10][11] These children are routinely tested also for norovirus, which is extraordinarily infectious and requires special isolation procedures to avoid transmission to other patients. Other methods, electron microscopy and polyacrylamide gel electrophoresis, are used in research laboratories.[12][13]

Management

The objective of treatment is to replace lost fluids and electrolytes. Oral rehydration is the preferred treatment of fluid and electrolyte losses caused by diarrhea in children with mild to moderate dehydration [14].

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.[15]

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[16] 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.[17]

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. [18]

Probiotics

Some Probiotics have been shown to be beneficial in preventing and treating various forms of gastroenteritis.[18] Fermented milk products ( such as yogurt ) also reduce the duration of symptoms.[19]

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.[20]

Pharmacologic therapy

Viral gastroenteritis is usually an acute and self-limited disease which does not require pharmacologic therapy.[21]

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.[6][7][1][8]

Antibiotics usually are not given for gastroenteritis, although they may be given due to some bacteria.

Antidiarrheal agents

Loperamide is an opioid analogue commonly used for symptomatic treatment of diarrhea. It slows down gut motility, but does not cross the mature blood-brain barrier[6] to cause the central nervous effect of other opioids. In excessive doses, loperamide may cause constipation and significantly slow down of passage of feces, but an appropriate single dose will not slow down the duration of the disease.[22] Although antimotility drugs have the risk of exacerbating the condition, clinical experience shows this is unlikely.[6][8] Nevertheless, others discourage the use of antiperistaltic agents and opiates in febrile dysentery, since they may mask, or exacerbate the symptoms.[1] All these sources agree that in severe colitis antimotility drugs should not be used.

Loperamide prevents the body from flushing toxins from the gut, and should not be used when an active fever is present or there is a suspicion that the diarrhea is associated with organisms that can penetrate the intestinal walls, such as E. coli O157:H7 or Salmonella.

Loperamide is also not recommended in children, especially in children younger than 2 years of age, as it may cause systemic toxicity due to an immature blood brain barrier, and oral rehydration therapy remains the main stay treatment for children.

Bismuth subsalicylate (BSS), an insoluble complex of trivalent bismuth and salicylate, is another drug that can be used in mild-moderate cases.[6][8]

Combining an antimicrobial drug and an antimotility drug seems to be more rapidly effective.[6][8]

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.[23][24] Metoclopramide however has not been found to be helpful.[25]

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.[26] 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,[7] 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.[1] 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.[27]

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.[7]

History

Before the 20th century, the term "gastroenteritis" was not commonly used. What would now be diagnosed as gastroenteritis may have instead been diagnosed more specifically as typhoid fever or "cholera morbus", among others, or less specifically as "griping of the guts", "surfeit", "flux", "colic", "bowel complaint", or any one of a number of other archaic names for acute diarrhea.[28] Historians, genealogists, and other researchers should keep in mind that gastroenteritis was not considered a discrete diagnosis until fairly recently.

U.S. President Zachary Taylor died of gastroenteritis on July 9, 1850.

See also

References

  1. ^ a b c d e Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL. Harrison's Principles of Internal Medicine. New York: McGraw-Hill, 2005. ISBN 0-07-139140-1. Cite error: The named reference "Harrison" was defined multiple times with different content (see the help page).
  2. ^ King CK, Glass R, Bresee JS, Duggan C (2003). "Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy". MMWR Recomm Rep. 52 (RR-16): 1–16. PMID 14627948.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  3. ^ "Norovirus: Technical Fact Sheet". National Center for Infectious Diseases, CDC.
  4. ^ a b Murray PR, Pfaller MA, Rosenthal KS. Medical Microbiology. Mosby, 2005. ISBN 0323033032.
  5. ^ Seven Surfing Sicknesses, .
  6. ^ a b c d e f g Sleisenger & Fordtran's Gastrointestinal and Liver Disease 7th edition, by Mark Feldman; Lawrence S. Friedman; and Marvin H. Sleisenger, ISBN 0-7216-8973-6, Hardback, Saunders, Published July 2002
  7. ^ a b c d Mandell's Principles and Practices of Infection Diseases 6th Edition (2004) by Gerald L. Mandell MD, MACP, John E. Bennett MD, Raphael Dolin MD, ISBN 0-443-06643-4 · Hardback · 4016 Pages Churchill Livingstone
  8. ^ a b c d e f The Oxford Textbook of Medicine. Edited by David A. Warrell, Timothy M. Cox and John D. Firth with Edward J. Benz, Fourth Edition (2003), Oxford University Press, ISBN 0-19-262922-0
  9. ^ Haffejee IE (1991). "The pathophysiology, clinical features and management of rotavirus diarrhoea". Q. J. Med. 79 (288): 289–99. PMID 1649479.
  10. ^ Patel MM, Tate JE, Selvarangan R; et al. (2007). "Routine laboratory testing data for surveillance of rotavirus hospitalizations to evaluate the impact of vaccination". Pediatr. Infect. Dis. J. 26 (10): 914–9. doi:10.1097/INF.0b013e31812e52fd. PMID 17901797. {{cite journal}}: Explicit use of et al. in: |author= (help); Unknown parameter |doi_brokendate= ignored (|doi-broken-date= suggested) (help)CS1 maint: multiple names: authors list (link)
  11. ^ "The paediatric burden of rotavirus disease in Europe". Epidemiol. Infect. 134 (5): 908–16. 2006. doi:10.1017/S0950268806006091. PMID 16650331.
  12. ^ Beards GM (1988). "Laboratory diagnosis of viral gastroenteritis". Eur. J. Clin. Microbiol. Infect. Dis. 7 (1): 11–3. doi:10.1007/BF01962164. PMID 3132369.
  13. ^ Steel HM, Garnham S, Beards GM, Brown DW (1992). "Investigation of an outbreak of rotavirus infection in geriatric patients by serotyping and polyacrylamide gel electrophoresis (PAGE)". J. Med. Virol. 37 (2): 132–6. doi:10.1002/jmv.1890370211. PMID 1321223.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  14. ^ "Practice parameter: the management of acute gastroenteritis in young children. American Academy of Pediatrics, Provisional Committee on Quality Improvement, Subcommittee on Acute Gastroenteritis". Pediatrics. 97 (3): 424–35. 1996. PMID 8604285.
  15. ^ "BestBets: Fluid Treatment of Gastroenteritis in Adults".
  16. ^ Managing Acute Gastroenteritis Among Children: Oral Rehydration, Maintenance, and Nutritional Therapy
  17. ^ "BestBets: Gradual introduction of feeding is no better than immediate normal feeding in children with gastro-enteritis". Retrieved December 6,2008. {{cite web}}: Check date values in: |accessdate= (help)
  18. ^ a b King CK, Glass R, Bresee JS, Duggan C (2003). "Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy". MMWR Recomm Rep. 52 (RR-16): 1–16. PMID 14627948. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  19. ^ "Does yogurt decrease acute diarrhoeal symptoms in children with acute gastroenteritis".
  20. ^ Rehydrate.org: Zinc Supplementation
  21. ^ "Merck - Error Page".
  22. ^ Wingate D, Phillips SF, Lewis SJ; et al. (2001). "Guidelines for adults on self-medication for the treatment of acute diarrhoea". Aliment. Pharmacol. Ther. 15 (6): 773–82. doi:10.1046/j.1365-2036.2001.00993.x. PMID 11380315. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  23. ^ DeCamp LR, Byerley JS, Doshi N, Steiner MJ (2008). "Use of antiemetic agents in acute gastroenteritis: a systematic review and meta-analysis". Arch Pediatr Adolesc Med. 162 (9): 858–65. doi:10.1001/archpedi.162.9.858. PMID 18762604. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  24. ^ Mehta S, Goldman RD (2006). "Ondansetron for acute gastroenteritis in children". Can Fam Physician. 52 (11): 1397–8. PMID 17279195.
  25. ^ "BestBets: Are antiemetics helpful in young children suffering from acute viral gastroenteritis?".
  26. ^ Arya SC (1984). "Rotaviral infection and intestinal lactase level". J. Infect. Dis. 150 (5): 791. PMID 6436397.
  27. ^ Victora CG, Bryce J, Fontaine O, Monasch R (2000). "Reducing deaths from diarrhoea through oral rehydration therapy". Bull. World Health Organ. 78 (10): 1246–55. PMID 11100619.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  28. ^ Rudy's List of Archaic Medical Terms
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