INTRODUCTION

Gastroenteritis (also known as gastric flu or stomach flu, although unrelated to

influenza) is inflammation of the gastrointestinal tract, involving both the stomach and the small
intestine and resulting in acute diarrhea. It can be transferred by contact with contaminated food
and water. The inflammation is caused most often by an infection from certain viruses or less
often by bacteria, their toxins, parasites, or an adverse reaction to something in the diet or
medication. Current death rates have come down significantly to approximately 1.5 million
deaths annually in the year 2000, largely due to the global introduction of oral rehydration
therapy and is a leading cause of death among infants and children under 5.

At least 50% of cases of gastroenteritis due to foodborne illness are caused by 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.

Different species of bacteria can cause gastroenteritis, including Salmonella, Shigella,

Staphylococcus, Campylobacter jejuni, Clostridium, Escherichia coli, Yersinia, Vibrio cholerae,
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

• consumption of improperly prepared foods

• contaminated water
• travel or residence in areas of poor sanitation

Classification
Infectious gastroenteritis is caused by a wide variety of bacteria and viruses.

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. 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.
Bacterial gastroenteritis

For a list of bacteria causing gastroenteritis, see above. Pseudomembranous colitis is an

important cause of diarrhea in patients often recently treated with antibiotics.

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

Traveler's diarrhea is usually a type of bacterial gastroenteritis.

Viral gastroenteritis

Viruses causing gastroenteritis include rotavirus, norovirus, adenovirus and astrovirus. Viruses
do not respond to antibiotics and infected children usually make a full recovery after a few days.
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. 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.

Symptoms and signs

Gastroenteritis often involves stomach pain or spasms, diarrhea and/or vomiting, with
noninflammatory infection of the upper small bowel, or inflammatory infections of the colon.

The condition is usually of acute onset, normally lasting 1–6 days, and is self-limiting.

• Nausea and vomiting

• Diarrhea
• Loss of appetite
• Fever
• Headaches
• Abnormal flatulence
• Abdominal pain
• Abdominal cramps
• Bloody stools (dysentery - suggesting infection by amoeba, Campylobacter, Salmonella,
Shigella or some pathogenic strains of Escherichia coli[)
• Fainting and Weakness
• Heartburn

The main contributing factors include poor feeding in infants. Diarrhea is common, and may be
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.

Diagnosis
Gastroenteritis is diagnosed based on symptoms, a complete medical history and a physical
examination. An accurate medical history may provide valuable information on the existence or
inexistence of similar symptoms in other members of the patient's family or friends. The
duration, frequency, and description of the patient's bowel movements and if they experience
vomiting are also relevant and these question are usually asked by a physician during the
examination.

No specific diagnostic tests are required in most patients with simple gastroenteritis. If symptoms
including fever, bloody stool and diarrhea persist for two weeks or more, examination of stool
for Clostridium difficile may be advisable along with cultures for bacteria including Salmonella,
Shigella, Campylobacter and enterotoxic Escherichia coli. Microscopy for parasites, ova and
cysts may also be helpful.

A complete medical history may be helpful in diagnosing gastroenteritis. A complete and

accurate medical history of the patient includes information on travel history, exposure to
poisons or other irritants, diet change, food preparation habits or storage and medications.
Patients who travel may be exposed to E. Coli infections or parasite infections contacted from
beverages or food. Swimming in contaminated water or drinking from suspicious fresh water
such as mountain streams or wells may indicate infection from Giardia - an organism found in
water that causes diarrhea.

Food poisoning must be considered in cases when the patient was exposed to undercooked or
improperly stored food. Depending on the type of bacteria that is causing the condition, the
reactions appear in 2 to 72 hours. Detecting the specific infectious agent is required in order to
establish a proper diagnosis and an effective treatment plan.

The doctor may want to find whether the patient has been using broad-spectrum or multiple
antibiotics in their recent past. If so, they could be the cause of an irritation of the gastrointestinal
tract.

During the physical examination, the doctor will look for other possible causes of the infection.
Conditions such as appendicitis, gallbladder disease, pancreatitis or diverticulitis may cause
similar symptoms but a physical examination will reveal a specific tenderness in the abdomen
which is not present in gastroenteritis.

Diagnosing gastroenteritis is mainly an exclusion procedure. Therefore in rare cases when the
symptoms are not enough to diagnose gastroenteritis, several tests may be performed in order to
rule out other gastrointestinal disorders. These include rectal examinations, complete blood
count, electrolytes and kidney function tests. However, when the symptoms are conclusive, no
tests apart from the stool tests are required to correctly diagnose gastroenteritis especially if the
patient has traveled to at-risk areas.

Prevention

Percentage of rotavirus tests with positive results, by surveillance week, United States, July
2000--June 2009.

Since 2000, the implementation of a rotavirus vaccine has decreased the number of cases of
diarrhea due to rotavirus in the United States

Gastroenteritis may be prevented through immunization. The U.S. Food and Drug
Administration approved in 2006 a rotavirus called Rotateq that may be given to infants aged 6
to 32 weeks to prevent getting infected with viral gastroenteritis. The vaccines may however
have side effects that are similar to the mild flu symptoms.

Different types of vaccinations are available for Salmonella typhi and Vibrio cholera and which
may be administered to people who intend traveling in at-risk areas. However, the vaccines that
are currently available are effective only on rotavirual gastroenteritis.

Doctors recommend that food be properly cooked and stored to prevent gastroenteritis. Avoid
suspect food or drink. Thoroughly wash both hands before eating and after using the bathroom or
changing diapers. Viral gastroenteritis is a highly contagious disease and thus avoiding crowded
spaces such as markets, theaters or shopping centers may also help in preventing infection for
those who have weak resistance. Bleaching soiled laundry and household surfaces may help
prevent spreading bacteria.

Management
Gastroenteritis is usually an acute and self-limited disease that does not require pharmacological
therapy. The objective of treatment is to replace lost fluids and electrolytes. Oral rehydration is
the preferred method of replacing these losses in children with mild to moderate dehydration.
Metoclopramide and ondansetron however may be helpful in children.

Rehydration

The primary treatment of gastroenteritis in both children and adults is rehydration, i.e.,
replenishment of water and electrolytes lost in the stools. This is preferably achieved by giving
the person oral rehydration therapy (ORT) although intravenous delivery may be required if a
decreased level of consciousness or an ileus is present. Complex-carbohydrate-based oral
rehydration therapy such as those made from wheat or rice may be superior to simple sugar-
based ORS.

Sugary drinks such as soft drinks and fruit juice are not recommended for gastroenteritis in
children under 5 years of age as they may make the diarrhea worse. Plain water may be used if
specific ORS are unavailable or not palatable.

Diet

It is recommended that breastfed infants continue to be nursed on demand and that formula-fed
infants should continue their usual formula immediately after rehydration with oral rehydration
solutions. Lactose-free or lactose-reduced formulas usually are not necessary. 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, juice, and other high simple sugar foods should be
avoided. The practice of withholding food is not recommended and immediate normal feeding is
encouraged. The BRAT diet (bananas, rice, applesauce, toast and tea) is no longer recommended,
as it contains insufficient nutrients and has no benefit over normal feeding.

Medications

Antiemetics

Antiemetic drugs may be helpful for vomiting in children. Ondansetron has some utility with a
single dose associated with less need for intravenous fluids, fewer hospitalizations, and
decreased vomiting. Metoclopramide also might be helpful. However there was an increased
number of children who returned and were subsequently admitted in those treated with
ondansetron. The intravenous preparation of ondansetron may be given orally.

Antibiotics

Antibiotics are not usually used for gastroenteritis, although they are sometimes used if
symptoms are severe (such as dysentry) or a susceptible bacterial cause is isolated or suspected.
If antibiotics are decided on, a fluoroquinolone or macrolide is often used. Pseudomembranous
colitis, usually caused by antibiotics use, is managed by discontinuing the causative agent and
treating with either metronidazole or vancomycin.

Antimotility agents

Antimotility drugs have a theoretical risk of causing complications; clinical experience, however,
has shown this to be unlikely. They are thus discouraged in people with bloody diarrhea or
diarrhea complicated by a fever. Loperamide, an opioid analogue, is commonly used for the
symptomatic treatment of diarrhea. Loperamide is not recommended in children as it may cross
the immature blood brain barrier and cause toxicity. Bismuth subsalicylate (BSS), an insoluble
complex of trivalent bismuth and salicylate, can be used in mild-moderate cases.
Antispasmotics

Butylscopolamine (Buscopan) is useful in treating crampy abdominal pain.

Alternative medicine

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 two weeks after onset of gastroenteritis. A 2009 trial however did
not find any benefit from supplementation.

Complications
Dehydration is a common complication of diarrhea. It can be made worse with the withholding
fluids or the administration of juice / soft drinks. Malabsorption of lactose, the principal sugar in
milk, may occur. Though it may increase the diarrhea, however, mothers should continue
breastfeeding.

Epidemiology
Every year worldwide rotavirus in children under 5, causes 111 million cases of gastroenteritis
and nearly half a million deaths. 82% of these deaths occur in the world's poorest nations.

In 1980 gastroenteritis from all causes caused 4.6 million deaths in children with most of these
occurring in the third world. Lack of adequate safe water and sewage treatment has contributed
to the spread of infectious gastroenteritis. Current death rates have come down significantly to
approximately 1.5 million deaths annually in the year 2000, largely due to the global introduction
of oral rehydration therapy.

The incidence in the developed world is as high as 1-2.5 cases per child per year and is a major
cause of hospitalization 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.