Gastroenteritis
18 years old male admitted to hospital for vomiting and diarrhea for the past 2 days.
Vital signs:
Temperature: 37 (taken at axillary)
HR: 86 bpm
Respiratory rate: 24/min
Blood pressure: 110/ 56 mmHg (taken by brachiocephalic during supine position)
History:
The initial evaluation of patients who present to medical care with acute diarrhea and
vomiting should include a careful history to determine the duration of symptoms, the
frequency and characteristics of the stool and vomit, and associated symptoms. For it’s
important to classify it:
Mild-moderate:
o Abdominal pain with normal abdominal examination
o Mild diarrhea, nausea and or vomiting
Severe:
o Gastroenteritis features: -Bloody stools
-Severe diarrhea, nausea and/or vomiting
-Severe abdominal cramping and or tenderness
o Systematic features: -fever (> or equal to 38.3) or sepsis
-Clinical signs of significant dehydration
-End Organ damage
▶️The patient was apparently well until 2 days ago when he started to have fever.
▶️characteristic of fever: sudden onset, low grade and intermittent.
▶️Any medications taken for fever?
Paracetamol
▶️did it resolve?
Yes
▶️any associated symptoms?
Soon after the fever resolved, he had vomiting with diarrhea
Details about vomiting should be asked.
▶️when did it start and how many episodes of vomiting?
3 episodes for the past 2 days
▶️Can you describe its content and characteristics?
Vomitus contained food particles, no blood or bile content and was projectile.
▶️Is it related to eating?
Yes, soon after taking meals.
▶️was any medication taken to stop the vomiting?
Yes, motilium 10mg PO twice
Details about diarrhea should be asked.
▶️when did it start and how many episodes of diarrhea?
6 episodes for the past 2 days.
▶️Can you describe it? Is it watery or loose? Is there any blood or mucous? Is the amount
small or large?
It’s important to differentiate between bloody and non-bloody diarrhea.
It was watery and yellow. No blood or mucous content and was small amount each time
pass motion.
Any other complaint?
▶️patient complained of lethargy and weakness.
As by patient, he was able to replace some of his water losses by drinking water.
Review of systems:
Skin: No rashes
Neurology: normal motor and sensory functions. No seizures.
Respiratory: chest discomfort but no cough, no shortness of breath.
GI: no abdominal pain or distention, no anal redness. Tolerated drinking water.
Urinary: urine output normal, and the color is normal, no dark color nor blood
In cases if vomiting and diarrhea, it is very important to ask about the type of food
eaten recently and the place. Ask about other people who ate the same food and if
they experienced similar symptoms.
Ask about Travel history
Ask about recent antibiotic use
patient Had outside food the day before onset of symptoms but none of his family
members had similar symptoms. No travel history nor recent antibiotics use.
Routine questions:
▶️Ask about past medical history: none
▶️past surgical history? None
▶️smoker non smoker? Non smoker
▶️alcoholic or non-alcoholic? Non alcoholic
▶️family history? None
On physical exam:
Assess for clinical signs and symptoms of dehydration, including thirst, weight loss, dry
mucous membranes, sunken-appearing eyes, decreased skin turgor, increased capillary
refill time, hypotension and postural hypotension, tachycardia, weak and thready
peripheral pulses, flat neck veins .. etc
-Patient was conscious, cooperative, oriented to person, time and place
-didn’t look in pain or distress
-He had no signs of dehydration
-Conjunctiva was not pallor and no icterus
-no rash on skin and the color tone is pink
-no hepatosplenomegaly
In summary, on examination patient was well hydrated and doesn’t show any significant
sign and symptoms.
Furthermore, capillary refill time was not prolonged and he was not anemic.
On systemic examination, the abdomen appeared normal, there was no organomegaly and
bowel sounds were present.
As Differential Diagnosis:
-acute gastroenteritis/ food poisoning
-Giardiasis
Diagnostic confirmation: Diagnostic studies are only recommended for the following:
Patients with severe gastroenteritis or risk factors
And/ or if the results may alter the management
Labs: BMP and serum electrolytes may show AKI or electrolytes abnormalities
CBC: search for leukocytosis with left shift: may indicate an inflammatory bacterial
infection
Hb: 12.4
Wbc: 8000/uL
Neutrophils: 60%
Eosinophils: 2.5%
Creatinine and electrolytes were normal
The following studies were not performed for this patient:
Stool analysis: may show leukocytosis, occult blood and/ or lactoferrin. This helps me
differentiates between secretory, invasive and inflammatory diarrhea
Further studies: in select cases. Microbiological studies should be reserved for patients
with fever, mucoid or bloody stools, signs of sepsis, immunosuppressed, or severe
abdominal cramping and in cases where identifying the agent may modify treatment.
o C. difficile toxin: Obtain for patients with risk factors such as antibiotics use
o Blood cultures
o Stool microscopy to identify ova and parasites
o Endoscopy may show signs of inflammation
Management:
Infectious gastroenteritis is usually self-limiting. Supportive therapy may suffice for most
patients.
Diet and fluids:
o Bland diet: e.g., broths, saltine crackers, broiled food, baked food
o Oral rehydration therapy or intravenous fluid therapy: i.e., fluid replacement or
fluid resuscitation
o Oral or parenteral electrolyte repletion
Pharmacotherapy (not routinely recommended):
o Oral or parenteral antiemetics as needed: e.g., ondansetron (off label) or
promethazine )
o Consider antimotility drugs (e.g., loperamide ) for immunocompetent adult
patients with acute watery diarrhea.
Antibiotic therapy:
Antibiotic therapy is not routinely indicated in bacterial gastroenteritis. When indications
for empiric antibiotics exist, they should be started after appropriate cultures have been
collected. Empiric antibiotics for bacterial gastroenteritis.
Indications include:
o Suspected Shigella infection
o Suspected enteric fever
o High-grade fever or sepsis
o High-risk groups
Recommended regimens (adult patients)
o Azithromycin: can be given as a single 1 g dose (for patients without dysentery) or
as 500 mg once daily for three days
o Ciprofloxacin: a single 750 mg dose or 500 mg twice daily for three to five days
-Trimethoprim/sulfamethoxazole is not recommended because of high resistance rates.
Targeted therapy: Once a pathogen has been identified, modify therapy
accordingly. E.g., treatment for C. difficile infection
Patient was only treated supportively.
Bayan Abouali
Lebanese University
[email protected]
