1. Acute Gastroenteritis

2. Definition
• characterized by changes in the character and
frequency of stool.
• defined as the passage of a greater number of
stools of decreased form from the normal
lasting less than 14 days.
• Generally associated with other symptoms
including nausea, vomiting, abdominal pain
and cramps, increase in intestinal, fever,
passage of bloody stools, tenesmus, and fecal
urgency.

3. EPIDEMIOLOGY
According to WHO and UNICEF
• 2 billion cases of diarrheal disease worldwide every year
• 1.9 million children <5 years old die from diarrhea each year
• 78% of child deaths occur in the African and South –East Asian
regions
• Globally it is the 2nd
leading cause of death

4. EPIDEMIOLOGY
ORS, improved rates of breastfeeding,
improved nutrition, better sanitation and
hygiene have contributed to a decline in the
mortality rates in the past three decades

5. ETIOLOGY
 Bacterial agents
• Escherichia coli – most common
1. ETEC – causes traveler’s diarrhea
2. EPEC – rarely causes disease in adults but is common in children
<2 years old and persistent diarrhea
3. EIEC – causes bloody mucoid (dysentery) diarrhea, fever is
common

6. Bacterial agents
4. EHEC –produces the Shiga toxin causes bloody diarrhea, severe
hemorrhagic colitis, HUS (6-8%), cattles are the predominant
reservoir, O157:H7 from undercooked hamburger
5. EAEC – causes watery diarrhea in young children and persistent
diarrhea in children with HIV

8. Bacterial agents
 Campylobacter
– Asymptomatic infection is common
– Associated with watery diarrhea sometimes dysentery
– Develops Guillain-Barre syndrome in about 1 in 1000
patients with colitis
– Poultry is a common source
– Should ask abut recent picnic or banquets
– Common among children <2 years

10. Bacterial agents
 Shigella species
– More common in toddlers and older children
– S. sonnei is common in developed countries and
causes mild illness and may cause institutional
outbreaks
– S. flexneri is endemic and causes dysentery and
persisitent illness

11. Bacterial agents
– S. dysenteriae type 1- only one that produces the Shiga
toxin; is the epidemic serotype
– Commonly acquired from eating chicken
– Definitive dx: isolation of the organism from fecal material

13. Bacterial agents
 Vibrio cholerae
– >2000 serotypes and all are pathogenic for humans
– Serogroups O1 & O139 only two types that causes
severe cholera and outbreaks
– Severe dehydartion can lead to hypovolemic shock
and death can occur w/in 12-18h after onset

14. Bacterial agents
– Stools are watery, colorless, eith mucus – “rice watery
stools”
– Vomiting is common, fever is typically absent
– Potential for epidemic spread and should be reported
promptly

16. Bacterial agents
– Commonly from seafood, especially if raw
– Laboratory isolation of the organism requires a special
medium – taurocholate-tellurite gelatin agar or
thiosulfate-citrate-bile salts-sucrose (TCBS)

17. Bacterial agents
 Salmonella
– Infants, children and the elderly who are immune-
compromised are of greatest risk
– Animals are major reservoir
– Enteric fever – S. enterica serovar Typhi and Paratyphi A,
B, C (typhoid fever) causes prolonged fever that lasts > 3
weeks; normal bowel habits, constipation or diarrhea

18. Bacterial agents
– Nontyphoidal salmonellosis- acute onset of nausea,
vomiting and diarrhea that may be watery or dyseteric
– Fever develops in 70% of children
– Bacteremia occurs in 1-5%, mostly in infants
– Commonly acquired from mayonnais, creams or raw eggs

20. Bacterial agents
• Definitive dx: isolation of the organism from blood(40-80
%sensitive), BM or other sterile sites
• 1st
week – blood
• 2nd
week – urine
• 3rd
week - stool

21. Viral agents
Predominant cause of acute diarrhea in both
industrialized and developing countries
Rotavirus
– Leading cause of severe, dehydrating gastroenteritis
among children
– Neonatal infections are common but often asymptomatic
– Peaks between 4-23 months of age

22. Viral agents
 Norovirus
– Belongs to the family Caliciviridae
– Most common cause of outbreaks affecting in all age
group
 Sapovirus
– Also from the family of Caliciviridae
– Primarily affects children
– 2nd
most common viral agent after rotavirus

23. Parasitic agents
 Cryptosporidium parvum, Giardia intestinalis,
Entamoeba histolytica
 Usually causes traveler’s diarrhea
 Relatively small portion of cases

24. PATHOGENESIS
 Pathogens have a variety of tactics to overcome host
defenses
 Mechanisms:
1. Inoculum size- varies
 Shigella, EHEC, G. lamblia, Entamoeba as few as 10 -100
bacteria or cysts
 Vibrio cholerae - 105
– 108
organisms
 Salmonella – varies on the specie, host and food
vehicle

25. PATHOGENESIS
2. Adherence
 Adheres to the GI mucosa
 Specific cell surface proteins involved in attachment of
the bacteria to intestinal cells
 Ex. V. cholerae adheres to the brush border of the SI
enterocytes via specific surface adhesins
 ETEC produces an adherence protein called
colonization factor antigen

26. PATHOGENSIS
 EPEC and EHEC produce virulence that allow these
organisms to attach to and efface the brush border of
the intestinal epithelium
3. Toxin production
 Enterotoxin – ex. Cholera toxin, Heat labile
enterotoxin, heat stable
 Cytotoxins – ex. Shigella dysenteriae type 1
 Neurotoxins – ex. Bacillus cereus toxins

28. PATHOGENESIS
4. Invasion
5. Host defenses – ability to combat pathogens
 Normal flora
 Gastric acidity
 Intestinal motility
 Immunity
 Genetic determinants

29. CLASSIFICATION
 Classified accordingly as:
 Acute diarrhea - >3 loose watery stools in the previous 24
hours
 Dysentery – presence of visible blood in stools
 Persistent diarrhea – acutely starting episode of diarrhea
lasting more than 14 days

30. CLINICAL MANIFESTATIONS

31. CLINICAL MANIFESTATIONS
Loose watery stools
Fever
Bloody stools
Nausea and Vomiting
Abdominal pain

38. Clinical evaluation
• Assess the degree of dehydration, presence of
acidosis and provide rapid rehydration
• Obtain appropriate contact, travel or
exposure history
• Clinically determine the probable etiology for
prompt antibiotic institution if indicated

39. HISTORY
 Initial evaluation should include the ff:
Onset, frequency, type, volume
+/- blood
Vomiting
Medicines taken
Comorbidities
Epidemiologic clues
24h food recall

41. PHYSICAL EXAM
Body weight
Temperature
PR and RR
BP
Complete PE and assess the level of dehydaration

43. DHAKA METHOD
ASSESSMENT PLAN A PLAN B PLAN C
1. General
condition
N Irritable/ less
active*
Lethargic /comatose
*
2. Eyes N Sunken Sunken
3. Mucosa N Dry Dru
4. Thirst N Thirsty Unable to drink*
5. Radial pulse N Low volume* Absent
6. Skin turgor N Reduced* Reduced
Diagnosis No signs of
dehydration
Some dehydration
At least 2 signs;
including one key
sign (*) are present
Severe dehydration
Some signs of
dehydration plus at
least one key sign
present

44. LABORATORY EVALUATION
• Stool examination
• Stool cultures are indicated in cases of dysentery or
where the diagnosis of AGE is unclear
• CBC to look for anemia, hemoconcentration, or an
abnormal white blood cell count.

45. LABORATORY EVALUATION
• Serum electrolyte concentrations are used to determine
the extent of fluid and electrolyte depletion
• Blood culture for some etiologies like Salmonella

46. TREATMENT

47. TREATMENT
PLAN A PLAN B PLAN C
TREATMENT Prevent
dehydration
Reassess
periodically
Rehydrate with
ORS solution
Reassess
frequently
Rehydrate with
I.V. fluids and ORS
Reassess more
frequently

48. TREATMENT
 PLAN A
-Home therapy to prevent de hydration and
malnutrition
Rule 1: give more fluids than usual
• <2 y.o : 50-100 ml after each loose stool
• 2-10 : 100-200ml
• Older children and adults : as much as the want

49. PLAN A
Rule 2: give Zinc (10-20mg) daily for 10-14 days
Rule 3: Continue to feed the child to prevent
malnutrition
Rule 4: take the child to a health worker when signs f
dehydration develop

50. PLAN B
 Oral rehydration therapy
 Give also supplemental Zinc
 Monitoring of the patient’s conditon
 If at any time the patient develops signs of severe
dehydration, shift to plan C

51. PLAN C
• Intravenous rehydration
- Give 100ml/kg PLR:
• Reassess patient every 1-2 hours
• After 3 or 6 hrs evaluate patient then choose
appropriated treatment plan
Age First give 30ml/kg in: Then give 70ml/kg in:
Infants <12 months 1 hour 5 hours
Older 30 minutes 2.5 hours

52. Oral Rehydration Therapy
Oral rehydration therapy (ORT) is the
administration of appropriate solutions by
mouth to prevent or correct diarrheal
dehydration.
ORT is a cost-effective method of managing
acute gastroenteritis and it reduces
hospitalization requirements in both

53. Oral Rehydration Therapy
The new lower-osmolarity ORS recommended
by (WHO and UNICEF) has reduced
concentrations of sodium and glucose and is
associated with less vomiting, less stool
output, lesser chance of hypernatremia, and a
reduced need for intravenous infusions in
comparison with standard ORS.

54. Oral Rehydration Therapy
This formulation is recommended irrespective
of age and the type of diarrhea including
cholera.
According to the 2012 WGO guidelines ORT is
contraindicated as initial therapy in cases of
severe dehydration, children with paralytic
ileus, frequent and persisitent vomiting.

55. Oral Rehydration Therapy
However, nasogastric administration of ORS
solution is potentially lifesaving when
intravenous rehydration is not possible.
Rice-based ORS is superior to standard ORS
for adults and children with cholera, and can
be used to treat such patients wherever its
preparation is convenient.

56. Oral Rehydration Therapy
Constituents of the new oral rehydration solution (ORS)
Sodium 75 mmol/L
Chloride 65 mmol/L
Anhydrous glucose 75 mmol/L
Potassium 20 mmol/L
Trisodium citrate 10 mmol/L
Total osmolarity 245 mmol/L

57. In comparison

58. Oral Rehydration Therapy
Home-made oral fluid recipe
 Preparing 1 L of oral fluid using salt, sugar and
water at home.
The ingredients to be mixed are:
 One level teaspoon of salt.
 Eight level teaspoons of sugar.
 One liter (five cupfuls) of clean drinking water, or water that has been
boiled and then cooled.

59. SUPPORTIVE TREATMENT
 Zinc supplement
Recommendation : 20mg OD for 10 days
 Multivitamins and minerals
 Diet
normal feeding should be continued for those with
no signs of dehydration
food should be started immediately after correction
of some and severe dehydration

60. SUPPORTIVE TREATMENT
Breastfed infants and children should continue receiving
food
However, for non-breastfed, dehydrated children and
adults, rehydration is the first priority.
Avoid fruit juices
Probiotics are said to be beneficial

61. Nonspecific antidiarrheal agents

62. Antimicrobial agents

63. ORGANISM DOC DOSAGE
Shig e lla Ciprofloxacin, ampicillin, ceftriaxone,
azithromycin, or TMP-SMX
Most strains are resistant now to several
antibiotics
•Ceftriaxone 50-100 mg/kg/day IV
or IM, qd or bid for 7 days
•Ciprofloxacin
20-30 mg/kg/day PO bid for 7-10
days
•Ampicillin PO,IV 50-100
mg/kg/day
qid for 7 days
EPEC, ETEC,
EIEC
TMP-SMX or ciprofloxacin •TMP 10 mg/kg/day
and SMX 50 mg/kg/day
bid for 5 days
•Ciprofloxacin PO 20-30
mg/kg/day
qid for 5-10 days
Sa lm o ne lla No antibiotics for uncomplicated
gastroenteritis in normal hosts caused by
nontyphoidal species
Treatment is indicated in infants <3 mo,
and patients with malignancy, chronic GI
disease,severe colitis
hemoglobinopathies, or HIV infection,
and other immunocompromised patients
Most strains have become resistant to
multiple antibiotics
See treatment
of Shig e lla

64. ORGANISM DOC DOSAGE
Cam pylo bacte r je juni Erythromycin or azithromycin •Erythromycin PO 50 mg/kg/day
divided tid for 5days
•Azithromycin PO 5-10 mg/kg/day
qid for 5 days
Entam o e ba histo lytica Metronidazole followed by
iodoquinol or paromomycin
•Metronidazole PO 30-40 mg/kg/day
tid for 7-10 days
•Iodoquinol PO 30- 40 mg/kg/day
tid for 20 days
•Paromomycin PO 25-35 mg/kg/day
tid for 7 days
Giardia lam blia Furazolidone or metronidazole
or albendazole or quinacrine
•Furazolidone PO 25 mg/kg/day qid
for 5-7 days
•Metronidazole PO 30-40 mg/kg/day
tid for 7 days
•Albendazole PO 200 mg bid for 10
days

65. Antimicrobial agents

66. Antimicrobial agents

67. Approach in adults with acute
diarrhea1. Perform initial assessment.
2. Manage dehydration.
3. Prevent dehydration in patients with no signs of dehydration, using
home-based fluids or ORSsolution.
• Rehydration of patients with some dehydration using ORS
– Correct dehydration of a severely dehydrating patient with an appropriate
intravenous fluid.
• Maintain hydration using ORS solution.

68. Approach in adults with acute
diarrhea
– Treat symptoms if necessary
4. Stratify subsequent management:
• Epidemiological clues: food, antibiotics, sexual activity, travel, day-care
attendance, other illness, outbreaks, season.
• Clinical clues: bloody diarrhea, abdominal pain, dysentery, wasting, fecal
inflammation.
5. Obtain a fecal specimen for analysis
6. Consider antimicrobial therapy for specific pathogens.

69. Indications for medical consultation or
in-patient care are:
 Caregiver’s report of signs consistent with dehydration
 Changing mental status
 History of premature birth, chronic medical conditions, or
concurrent illness
 Young age (< 6 months or < 8 kg weight)
 Fever 38 °C for infants < 3 months old or 39 °C for children aged 3–
36 months

70. Indications for medical consultation or
in-patient care are:
 Visible blood in stool
 High-output diarrhea, including frequent and substantial volumes
 Persistent vomiting, severe dehydration, persistent fever
 Suboptimal response to ORT
 No improvement within 48 hours—symptoms exacerbate and
overall condition gets worse
 No urine in the previous 12 hours

71. WHEN to discharge?

72. When to discharge?
Stable Vital signs
Normal urine output
Maintains a sufficient fluid intake
Able to eat meals adequately
Able to take medications (if still indicated)

73. Prevention
• Promotion of exclusive breast feeding
Promotes passive immunity
• Improved complementary feeding practices
 Start giving complementary food at 6 mo. And continue BF up to 1
year or longer
• Rotavirus immunization
• Improved case management of diarrhea
• Patient education

74. Patient Education
• Risk factors
– Environmental contamination
– Young age, immunodeficiency state, measles, lack of exclusive
breast-feeding
– Malnutrition
• Vitamin A deficiency
• Zinc deficiency

75. Patient Education
• Proper personal hygiene and safe food preparation.
• Hand-washing with soap is an effective step in preventing spread of illness
• Human feces must always be considered potentially hazardous, whether or not
diarrhea or potential pathogens have been identified.
• Select populations may require additional education about food safety, and health
care providers can play an important role in providing this information.

76. Thank you!