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Gastroenteritis

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Last Updated: August 1, 2005

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Author Information
Introduction
Clinical
Differentials
Workup
Treatment
Medication
Follow-up
Miscellaneous
Pictures
Bibliography

Synonyms and related keywords: enterogastritis, stomach flu, intestinal

flu, dysentery, infectious diarrhea, diarrhea, traveler's diarrhea, food
poisoning, food-borne toxigenic diarrhea, shellfish poisoning, saxitoxin,
brevetoxin, okadaic acid, domoic acid, ciguatera, ciguatoxins, scombroid,
Click for related
drug-associated diarrhea, ischemic colitis, ulcerative colitis, Crohn disease, images.
short bowel syndrome, amebiasis, rotavirus, calicivirus, norovirus, Norwalklike virus, Norwalk virus, adenovirus, parvovirus, astrovirus, coronavirus,
Related Articles
pestivirus, torovirus, Shigella dysenteriae, S dysenteriae, Salmonella,
Campylobacter jejuni, C jejuni, Yersinia enterocolitica, Y enterocolitica,
Appendicitis,
Escherichia coli, E coli, Vibrio cholera, V cholera, Aeromonas, Bacillus
Acute
cereus, B cereus, Clostridium difficile, C difficile, Clostridium perfringens,
Listeria, Mycobacterium avium-intracellulare, MAI, Providencia, Vibrio
CBRNE parahaemolyticus, Vibrio vulnificus, Giardia lamblia, Cryptosporidium,
Botulism
Cyclospora, Staphylococcus aureus, S aureus, dehydration, loss of
electrolytes, disorders of small intestine, enterotoxins, rice water diarrhea, Giardiasis
typhoid, malaria, Whipple disease, irritable bowel, incomplete bowel
obstruction, carcinoid syndrome, malabsorption syndrome, colchicine,
Hemolytic Uremic
quinidine, cancer chemotherapeutic agents, magnesium-containing antacids, Syndrome
protozoalike Entamoeba, Mycobacterium avium complex, microsporidia,
cytomegalovirus, CMV, Isospora belli, E coli O157:H7, dehydration,
Inflammatory
Giardia, amebiasis, enterotoxigenic E coli, paralytic shellfish poisoning,
Bowel Disease
neurologic shellfish poisoning, diarrheal shellfish poisoning, amnesic
shellfish poisoning, cholinergics, sorbitol, carcinoid tumor, vasoactive

intestinal peptide tumor, VIPoma, Dumping syndrome

AUTHOR INFORMATION

Section 1 of 11

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up

Miscellaneous Pictures Bibliography

Author: Arthur Diskin, MD, Chair, Department of Emergency Medicine,

Mount Sinai Medical Center
Arthur Diskin, MD, is a member of the following medical societies:
American College of Emergency Physicians
Editor(s): Michelle Ervin, MD, Chair, Department of Emergency Medicine,
Howard University Hospital; Francisco Talavera, PharmD, PhD, Senior
Pharmacy Editor, eMedicine; Eugene Hardin, MD, FACEP, FAAEM,
Chair and Associate Professor, Department of Emergency Medicine, Charles
R Drew University of Medicine and Science; Chair, Department of
Emergency Medicine, Martin Luther King, Jr/Drew Medical Center; John
Halamka, MD, Chief Information Officer, CareGroup Healthcare System,
Assistant Professor of Medicine, Department of Emergency Medicine, Beth
Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard
Medical School; and Steven Dronen, MD, FAAEM, Director of
Emergency Services, Associate Professor, Department of Emergency
Medicine, Fort Sanders Sevier Medical Center

Obstruction, Large
Bowel
Obstruction, Small
Bowel
Pediatrics,
Dehydration
Pediatrics,
Gastroenteritis
Salmonella
Infection
Shock,
Hypovolemic

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INTRODUCTION

Patient Education
Section 2 of 11

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up

Miscellaneous Pictures Bibliography

Background: Gastroenteritis is a nonspecific term for various 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. Although most definitions
center on the frequency, consistency, and water content of stools, the author
prefers defining diarrhea as stools that take the shape of their container.
The 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 treatment that is often
etiology specific. Diarrhea associated with nausea and vomiting is referred
to as gastroenteritis.

Esophagus,
Stomach, and
Intestine Center
Gastroenteritis
Overview
Gastroenteritis
Causes
Gastroenteritis
Symptoms
Gastroenteritis
Treatment
Abdominal Pain

Diarrhea is one of the most common reasons patients seek medical care. In
the developed world, it is the most common reason for missing work, while
in the developing world, it is a leading cause of death. In developing
countries, diarrhea is a seasonal scourge usually worsened by natural
phenomena, as evidenced by monsoon floods in Bangladesh in 1998. An
estimated 100 million cases of acute diarrhea occur every year in the United
States. Of these patients, 90% do not seek medical attention, and 1-2%
require admission. Diarrheal diseases can quickly reach epidemic
proportions, rapidly overwhelming public health systems in even the most
advanced societies.
Pathophysiology: Infectious agents usually cause acute gastroenteritis.
These agents cause diarrhea by adherence, mucosal invasion, enterotoxin
production, and/or cytotoxin production.
These mechanisms result in increased fluid secretion and/or decreased
absorption. This produces an increased luminal fluid content that cannot be
adequately reabsorbed, leading to dehydration and the loss of electrolytes
and nutrients.
Diarrheal illnesses may be classified as follows:

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

The small intestine is the prime absorptive surface. The colon then absorbs
additional fluid, transforming a relatively liquid fecal stream in the cecum to
well-formed solid stool in the rectosigmoid.
Disorders of the small intestine result in increased amounts of diarrheal fluid
with a concomitantly greater loss of electrolytes and nutrients.
Microorganisms may produce toxins that facilitate infection. Enterotoxins
are generated by bacteria (ie, enterotoxigenic Escherichia coli, Vibrio
cholera) that act directly on secretory mechanisms and produce typical,
copious watery (rice water) diarrhea. No mucosal invasion occurs. The small
intestines are primarily affected, and elevation of the adenosine

in Adults
Overview
Diarrhea
Overview
Vomiting and
Nausea
Overview

monophosphate (AMP) levels is the common mechanism.

Cytotoxin production by bacteria (ie, Shigella dysenteriae, Vibrio
parahaemolyticus, Clostridium difficile, enterohemorrhagic E coli) results in
mucosal cell destruction that leads to bloody stools with inflammatory cells.
A resulting decreased absorptive ability occurs.
Enterocyte invasion is the preferred method by which microbes such as
Shigella and Campylobacter organisms and enteroinvasive E coli cause
destruction and inflammatory diarrhea. Similarly, Salmonella and Yersinia
species also invade cells but do not cause cell death. Hence, dysentery does
not usually occur. However, these bacteria invade the bloodstream across the
lamina propria and cause enteric fever such as typhoid.
Diarrheal illness occurs when microbial virulence overwhelms normal host
defenses. A large inoculum may overwhelm the host capacity to mount an
effective defense. Normally, more than 100,000 E coli are required to cause
disease, while only 10 Entamoeba or Giardia cysts may suffice to do the
same. Some organisms (eg, V cholera, enterotoxigenic E coli) produce
proteins that aid their adherence to the intestinal wall, thereby displacing the
normal flora and colonizing the intestinal lumen.
In addition to the ingestion of pathogenic organisms or toxins, other intrinsic
factors can lead to infection. An alteration of normal bowel flora can create a
biologic void that is filled by pathogens. This occurs most commonly after
antibiotic administration, but infants are also at risk prior to colonization
with normal bowel flora.
The normally acidic pH of the stomach and colon is an effective
antimicrobial defense. In achlorhydric states (ie, caused by antacids,
histamine-2 [H2] blockers, gastric surgery, decreased colonic anaerobic
flora), this defense is weakened.
Hypomotility states may result in colonization by pathogens, especially in
the proximal small bowel, where motility is the major mechanism in the
removal of organisms. Hypomotility may be induced by antiperistaltic
agents (eg, opiates, diphenoxylate and atropine [Lomotil], loperamide) or
anomalous anatomy (eg, fistulae, diverticula, antiperistaltic afferent loops)
or is inherent in disorders such as diabetes mellitus or scleroderma.
The immunocompromised host is more susceptible to infection, as
evidenced by the wide spectrum of diarrheal pathogens in patients with
AIDS.
The exact mechanism of vomiting in acute diarrheal illness is not known,

although serotonin release has been postulated as a cause, stimulating

visceral afferent input to the chemoreceptor trigger zone in the lower
brainstem. Preformed neurotoxins produced by Staphylococcus aureus and
Bacillus cereus, when ingested, can cause severe vomiting.
Frequency:

In the US: Frequency is difficult to determine because of

underreporting, especially of mild illness, resulting in wide variations
of estimated numbers of cases, hospitalizations, and deaths. As many
as 90 million cases occur per year with several million physician
visits and thousands of hospitalizations. According to the Centers for
Disease Control and Prevention (CDC), 3.5 million cases of acute
diarrhea from rotavirus alone and at least 90,000 cases of food
poisoning occur yearly. Others estimate millions of cases.
The following are examples of sporadic common source outbreaks:
o Gastroenteritis associated with V parahaemolyticus infection
from Gulf Coast oysters has been reported.
o Salmonella gastroenteritis from reptilian pets has been
reported.
o A religious cult in Oregon intentionally contaminated salad
with Salmonella typhimurium, which resulted in 751 victims
who developed acute gastroenteritis.
o In July 1998, more than 60 persons in Wyoming were
infected with E coli 0157:H7 from a contaminated water
supply.
o In 1993, E coli 0157:H7contaminated fast-food hamburger
meat in the Pacific Northwest infected 500 persons, 4 of
whom died.
o From 1981-1994, 333 cases of Vibrio vulnificus infection
associated with raw oyster consumption were reported in
Florida. Two persons died from gastroenteritis, and 50
persons died from septicemia.
o In January 1995, 322 cases of Norwalk virus (calicivirus)
infectionassociated acute gastroenteritis resulted from the
consumption of raw oysters in Florida.

o In October 1996, 629 children and staff members at one

elementary school in Florida were infected in a point-source
outbreak of a Norwalk-like agent (calicivirus).
o In July 1995, 77 cases of cryptosporidiosis at a day camp in
Florida were reported, most likely secondary to
contamination involving a water hose.
o In April 1994, 96 cases of Campylobacter infection were
reported in Florida. The common source was ingested,
contaminated commercial ice cubes.
o In 1996, Norwalk virusassociated gastroenteritis resulted
from the ingestion of raw oysters in Louisiana.
o From May 1996 to June 1996, E coli 0157:H7 infections
secondary to consumption of mesclun lettuce from a single
producer were reported in multiple states (first identified in
Connecticut and Illinois).
o In August and September of 1999, E coli 0157:H7 infections
secondary to contaminated well water at the Washington
County Fair (New York) were reported.
o Norwalk virus is the leading cause of viral gastroenteritis in
the United States.
o From January 1, 2002, to December 2, 2002, norovirus was
attributed to 9 of the 21 outbreaks of acute gastroenteritis on
cruise ships reported to the CDC's Vessel Sanitation Program
in this period. Noroviruses cause approximately 23 million
cases of acute gastroenteritis each year and are the leading
cause of gastroenteritis outbreaks.
o Norovirus outbreaks have been reported in various locations,
including casinos, airplanes, schools, hospitals, nursing
homes, and cruise ships.
o In 2005, E coli 0157:H7 infections secondary to contaminated
animals were reported at Florida fairs.

Internationally: 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

develop, and perhaps return with, diarrhea. In 2001 and 2002,

outbreaks of gastroenteritis caused by norovirus were reported in
diverse locations such as the American Midwest; Boston; northern
Europe; St. Petersburg, Russia; Canada; and Alaska.
Mortality/Morbidity:

Estimates for mortality and morbidity widely vary. In the United

States, 210,000 pediatric hospitalizations occur yearly, with as many
as 10,000 deaths.

Internationally, the mortality rate is 5-10 million deaths each year.

Age:

Pediatric gastroenteritis is discussed in Pediatrics, Gastroenteritis.

Gastroenteritis may occur at any age. Morbidity and mortality are

much higher in the very young and the very old.

CLINICAL

Section 3 of 11

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up

Miscellaneous Pictures Bibliography

History: A well-taken history, considering important epidemiologic factors,

can help to identify not only the cause of diarrhea but also the patient at risk
for complications. History in infectious cases and food poisoning varies
depending upon the agent with variation in the onset; the frequency and
nature of the stools; and the presence or absence of blood and mucus,
vomiting, cramps, and fever. The history should also identify risk factors for
unusual causes of acute gastroenteritis and possible reasons to suspect
noninfectious etiologies. Indications of dehydration or sepsis should also be
sought.

Duration of illness
o Duration and rapidity of symptom onset are important in
determining the incubation period and possible infecting
organism and in directing further care.

o Diarrhea that lasts longer than a month requires consideration

of a different spectrum of etiologic factors than diarrhea that
lasts less than 1-2 weeks.

Fever: The presence of fever (with or without chills) generally

suggests that an invasive organism is the cause of diarrhea, although
many extraintestinal illnesses can present with both fever and
diarrhea, especially in children.

Vomiting
o Vomiting, a symptom common to a host of illnesses, implies
proximal bowel involvement, especially with preformed
neurotoxin, as elaborated by S aureus and B cereus.
o Vomiting is a leading symptom of intestinal obstruction,
usually coupled with distention; however, distention may not
be significant if the obstructing lesion is very proximal.
Vomiting without diarrhea must always prompt a search for
noninfectious causes and cannot be referred to as
gastroenteritis.

Pain
o The location and character of pain may be indicative of the
area of infection because colonic involvement is usually
associated with tenesmus and pain in either of the lower
quadrants or the lower back, whereas jejunoileal infection
may result in periumbilical pain.
o Cramps may be caused by an electrolyte imbalance.
o Pain, especially in patients older than 50 years, should raise
the suspicion of an ischemic process.

Stools
o Ask about frequency, nature (amount, color, watery,
semisolid, odor), and presence of blood and/or mucus.
o Large volumes of stool are usually associated with enteric
infection, whereas colonic infection results in many small
stools.

o The presence of blood indicates colonic ulceration (bacterial

infection, inflammatory disease, ischemia).
o White bulky feces that float (high fat content) are due to a
small bowel pathology that leads to malabsorption.
o Copious (rice water) diarrhea is a hallmark of cholera.

Extraintestinal causes
o A history of other nonintestinal illnesses that can lead to
diarrhea may be obtained. Vomiting and/or diarrhea may be a
manifestation of that illness or a result of its treatment.
Obtaining a history of recent surgery or radiation, food or
drug allergies, and endocrine or gastrointestinal disorders is
extremely important. The patient should always be questioned
regarding prior episodes.
o Malaria, Whipple disease, irritable bowel, incomplete bowel
obstruction, inflammatory disease, nutritional disease, and
carcinoid and malabsorption syndromes can result in
diarrhea.
o Drugs such as colchicine, quinidine, antimicrobials, cancer
chemotherapeutic agents, and magnesium-containing antacids
frequently cause diarrhea.

Dehydration
o Orthostasis, lightheadedness, diminished urine formation, and
a change in mentation herald marked dehydration and
electrolyte loss, requiring aggressive treatment.
o These symptoms are particularly important in elderly
patients, a group that is most at risk from diarrhea.

Epidemiologic factors
o A number of historical questions may provide clues to the
etiology of the illness, including foreign travel, recent
camping, recent antibiotic use, daycare attendance, and/or
ingestion of raw, possibly spoiled, or new marine products, as
well as similar illnesses in family, friends, or contacts.

o An epidemiologic factor may be travel to developing

countries where bacterial or parasitic agents can cause
infection or to campgrounds in developed regions, where
agents such as Giardia lamblia, Aeromonas, and
Cryptosporidium can contaminate untreated water.
o Enterotoxigenic E coli is the most frequent cause of traveler's
diarrhea. Symptoms usually begin within days of arrival in
the region and can last from 5 days to 2 weeks.
o Vibrio species are more common in Asia, although epidemics
have occurred in Central America within the last 10 years.
o As many as 12% of diarrheal illness cases may be caused by
rotavirus in travelers to Asia, Africa, and South America.
o Men who are homosexual are more prone to infection by
usual pathogens via the fecal-oral route (ie, Shigella,
Campylobacter jejuni, Salmonella, protozoalike Entamoeba).
Anal receptive intercourse may result in the direct inoculation
of Neisseria gonorrhoeae, Chlamydia trachomatis,
Treponema pallidum, and herpes simplex virus. Severely
immunocompromised states (CD4 cell count <200) increase
the risk of infection by agents such as Mycobacterium avium
complex, microsporidia, cytomegalovirus (CMV), and
Isospora belli.
o Recent use of antimicrobial drugs increases the risk of C
difficile infection.
o A common source outbreak from contaminated water and
food may cause gastroenteritis either by infection (C jejuni, G
lamblia) or by ingestion of a preformed toxin (E coli
O157:H7, scombroid, ciguatera).
o Infections via the fecal-oral route are prevalent in children
who attend daycare centers. Rotavirus has an infection rate of
nearly 100% in exposed children younger than 2 years. Other
family members are also at risk for infection.
Physical: A thorough physical examination is essential to assess the general
state of hydration and nutrition and to exclude extraintestinal causes of
diarrhea. Often, the cause of diarrhea cannot be determined based on the
physical findings present, which may be scarce.

The most important element of the physical examination is the

assessment of the patient's hydration status. (Dehydration in children,
for example, is classified according to the degree of
hydration/percentage deficit as <3%, none; 3-6%, mild; 6-9%,
moderate; and >10%, severe.) Additionally, signs of bacteremia or
sepsis should be sought. Patients with chronic diarrhea may need an
evaluation of their nutritional status.

A rectal examination should be performed, involving checking for

blood and mucus. Rectal examination may reveal abscesses, fistulae,
and fissures, which may indicate inflammatory bowel disease. A
partially obstructing tumor or a fecal impaction may be discovered as
a cause of diarrhea. Finally, the stool can be examined for the
presence of blood and pus.

Hydration and nutritional status

o Diminished skin turgor, weight loss, resting hypotension and
tachycardia, dry mucus membranes, decreased frequency of
urination, changes in mental status, and orthostasis can be
used to gauge dehydration.
o In children, the absence of tears, poor capillary refill, sunken
eyes, depressed fontanelles, increased axillary skin folds, and
dry diapers all may reflect a dehydrated state.
o Muscle wasting and signs of neural dysfunction due to
nutritional depletion may be observed in patients with chronic
diarrhea.

Abdominal examination
o A careful abdominal examination is necessary to exclude
causes of diarrhea that may require surgical intervention, such
as pelvic abscesses close to the rectosigmoid that are causing
tenesmus.
o The examiner should look for signs of an acute abdomen,
listening for bowel sounds, determining the location of any
tenderness, and palpating for masses or organomegaly.
o Appendicitis in children may manifest as diarrhea.

Causes:

Viral (50-70%)
o The Norwalk virus (This 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.)
o Caliciviruses (Various caliciviruses, other than Norwalk
virus, are likely responsible for many outbreaks of previously
unidentified viral gastroenteritis.)
o Rotavirus (This is the leading cause of gastroenteritis in
children, but rotavirus can also be found in adults. Rotavirus
may cause severe dehydration.)
o Adenovirus
o Parvovirus
o Astrovirus
o Coronavirus
o Pestivirus
o Torovirus

Bacterial (15-20%)
o Shigella
o Salmonella
o C jejuni
o Yersinia enterocolitica
o E coli - Enterohemorrhagic 0157:H7, enterotoxigenic,
enteroadherent, enteroinvasive

o V cholera
o Aeromonas
o B cereus
o C difficile
o Clostridium perfringens
o Listeria
o M avium-intracellulare (MAI), immunocompromised
o Providencia
o V parahaemolyticus
o V vulnificus

Parasitic (10-15%)
o Giardia
o Amebiasis
o Cryptosporidium
o Cyclospora

Food-borne toxigenic diarrhea

o Preformed toxin - S aureus, B cereus
o Postcolonization - V cholera, C perfringens, enterotoxigenic
E coli, Aeromonas

Shellfish poisoning and poisoning from other marine animals

o Paralytic shellfish poisoning (PSP) - Saxitoxin
o Neurologic shellfish poisoning (NSP) - Brevetoxin

o Diarrheal shellfish poisoning (DSP) - Okadaic acid

o Amnesic shellfish poisoning - Domoic acid
o Ciguatera (ciguatoxins)
o Scombroid (conversion of histidine to histamine)

Drug-associated diarrhea
o Antibiotics, due to alteration of normal flora
o Laxatives, including magnesium-containing antacids
o Colchicine
o Quinidine
o Cholinergics
o Sorbitol

Pseudomembranous colitis
o Overgrowth of C difficile
o Positive C difficile assay findings

Other causes
o Unknown agents, especially in developing countries
o Ischemic colitis
o Ulcerative colitis
o Crohn disease
o Carcinoid tumor or vasoactive intestinal peptide tumor
(VIPoma)
o AIDS

o Dumping or short bowel syndrome

o Radiation or chemotherapy

DIFFERENTIALS

Section 4 of 11

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up

Miscellaneous Pictures Bibliography

Appendicitis, Acute
CBRNE - Botulism
Giardiasis
Hemolytic Uremic Syndrome
Inflammatory Bowel Disease
Obstruction, Large Bowel
Obstruction, Small Bowel
Pediatrics, Dehydration
Pediatrics, Gastroenteritis
Salmonella Infection
Shock, Hypovolemic
Other Problems to be Considered:
Various infectious etiologies
Pseudomembranous colitis
Food-borne toxigenic diarrhea
Toxins
Hormonal (vasoactive intestinal peptides)
Drugs (ie, sorbitol, cholinergics, caffeine)
Surgery
Radiation colitis
Carcinoid
Pediatrics - Adrenogenital/cystic fibrosis

WORKUP

Section 5 of 11

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

Lab Studies:

Determination of laboratory tests: The patient's evaluation should be based on the clinical
assessment and the need to do the following:
o Further evaluate the seriousness of the condition (degree of dehydration and
electrolyte derangement).
o Determine a specific etiologic agent.
o Evaluate the patient for noninfectious etiologies.
o Patients who require further workup include those who appear seriously ill or
dehydrated; those who have high fevers, bloody stools, severe abdominal pain, or
persistent diarrhea; and those who are immunocompromised or whose condition is
suspected of having an epidemic diarrheal etiology.
o History, epidemiologic considerations, and the physical examination should be the
primary guides in determining whether any further diagnostic evaluation is
necessary, followed by microscopic examination of the stool.

Stool studies and culture

o The presence of blood or leukocytes in stool is a strong indicator of inflammatory
diarrhea.
o Stool studies can be performed efficiently and inexpensively by using a Wright
stain or methylene blue and directly observing for leukocytes and performing an
occult blood test.
o Fecal leukocytes are present in 80-90% of all patients with Salmonella or Shigella
infections but are less common with other infecting organisms such as
Campylobacter and Yersinia. They may also be present in ulcerative colitis and
Crohn disease but are usually absent in viral infections, Giardia infection,
enterogenic E coli infection, and toxigenic bacterial food poisoning.
o A stool culture is not necessary or cost-effective in all cases of diarrhea unless a

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