ACUTE GASTROENTERITIS
BACKGROUND
A change in stool consistency to watery or loose, with >3 episodes or >200g stool in 24 hours.
Acute: <14 days
Persistent: 14-30 days
Chronic: >30 days
ETIOLOGY
Infectious: 85-90% of cases
o Viral: 60%
Norovirus
Rotavirus most common pathogen in children
o Bacterial: 20-25%
E coli, Campylobacter, Salmonella, and Shigella most commonly
identified pathogens
o Parasitic: 6%
Non-infectious: 10-15% of cases
o Toxins, medication side effects, osmotic food and drink, underlying GI pathology
(inflammatory bowel disease, malignancy, etc)
ED EVALUATION AND MANAGEMENT
Resuscitate if necessary
Patients may be fluid depleted and require volume resuscitation
Give IV fluids if clinically dehydrated
Antibiotics with gram negative and anaerobic coverage should be given as quickly as
possible if patient is hemodynamically unstable.
o Consider addition of PO vancomycin for coverage of c difficile
Obtain relevant history
Ask food intake history to identify any suspect foods.
Classification: Confidential
o Consumption of raw or undercooked meats, unpasteurized dairy, or osmotic
supplements may yield clues as to the causative organism.
o Onset of symptoms within 6 hours of inoculation suggests ingestion of pre-
formed toxins, usually staphylococcus or bacillus species . However, often
difficult to know at what time inoculation occurred.
Determine nature of symptoms
o Small bowel (more likely viral): watery, large volume stools. Often associated
with abdominal cramping, bloating, and gas. Less commonly febrile.
o Large bowel (more likely bacterial): frequent small volume stools. Stools may be
bloody or mucoid. Often associated with painful bowel movements. Fever
common .
Exposure to poultry, livestock, turtles suggests Salmonella infection
Travel to developing nations should raise concern for bacterial or parasitic infection,
check CDC travel advisories for specific endemic infections
Recent antibiotic use or hospitalization increases risk of c difficile infection (Shane 2017)
Determine whether high-risk features are present :
Severe abdominal pain
Bloody or mucoid diarrhea
Extremes of age (e.g. >70 years old or <3 months old)
Known HIV or other immunocompromise
Known inflammatory bowel disease
Co-morbidities exacerbated by hypovolemia
Pregnancy
LABORATORY TESTING
Complete blood count
o Marked elevation in WBC count common in c difficile infection
o Thrombocytopenia should raise concern for hemolytic uremic syndrome (HUS)
Basic metabolic panel
o Patients may be hypokalemic. Replete as needed
Classification: Confidential
o Assess creatinine level. Acute kidney injury may be present if patient
hypovolemic
Hepatic panel
Lactate
o Only warranted if patient unwell appearing. May indicate hypoperfusion in
volume depletion
Fecal leukocytes
o Low utility in the ED
o Will be elevated in any inflammatory condition. Could result from viral, bacterial,
or autoimmune process such as ulcerative colitis or Crohns disease.
o Will be low in malignancy, mesenteric ischemia
o Classically low in amebiasis, but can be variable
Stool culture
o Common assays will reliably identify campylobacter, salmonella, shigella
Stool ova/parasites
o Useful in cases of chronic diarrhea, when patient is immunocompromised, or in
patient from developing nation
o Will identify e. histolitica, cryptosporidium, giardia, cyclospora
Specific assays:
o Many available: examples include c diff, e. coli 0157:H7, giardia (protozoa),
amebiasis
Urinalysis, Urine culture
o Warranted if dysuria present, or if patient is infant or elderly to rule out UTI as
cause of diarrhea
CT abdomen pelvis
o Warranted if abdomen tender to palpation raising concern for acute abdomen, or if
history concerning for mesenteric ischemia or other acute intraabdominal
pathology
Isolation
Not routinely needed, but contact isolation required if c difficile is suspected
Classification: Confidential
Good hand hygiene is the most effective way to prevent spread of pathogens
Use standard barrier precautions
Bloody diarrhea
The majority of diarrhea is non-bloody. The presence of blood raises concern for shiga-toxin
producing e coli(O157:H7) or for non-infectious causes of diarrhea such as ischemia or
inflammatory bowel disease.
Traditional teaching is to avoid antibiotics in this case. Administration of antibiotics
could cause widespread release of shiga-toxin as bacteria lyse, inducing Hemolytic
Uremic Syndrome .
This risk may be overstated in adults, but remains of concern in children .
Shigella, campylobacter, and salmonella may also commonly cause bloody diarrhea.
Patients with bloody diarrhea will likely benefit from antibiotic therapy, but treatment
should be delayed until stool is tested for shiga-toxin
If non-infectious etiology is suspected, CT abdomen pelvis likely warranted to assess
underlying pathology.
C difficile
Suspect in patients with:
o Profuse diarrhea, significant abdominal pain, fever
o Recent abx exposure
o Recent hospitalization
o History of c difficile infection
TREATMENT:
o Nonsevere, first time infection:
Vancomycin 125 mg PO 4 times per day or fidaxomicin 200 mg twice
daily for 10 days
If oral Vancomycin and fidaxomicin unavailable, metronidazole 500 mg
PO TID for 10 days is acceptable alternative
o Severe or fulminant infection:
Vancomycin 500 mg PO QID
PLUS Metronidazole 500mg IV every 8 hours
Classification: Confidential
If Ileus present, ADD Vancomycin 500 mg in 100 mL normal saline per
rectum every 6 hours as a retention enema (McDonald 2018)
Pregnancy
Pregnant women are ten times more likely to be infected with Listeria than the general
population, and may present as diarrheal illness
Maternal Listeria infection can result in fetal infection, so testing for Listeria and/or
empiric treatment with ampicillin or penicillin should be considered in the pregnant
patient presenting with diarrhea .
Cholera
Rare in developed countries, but endemic in developing countries – particularly Africa
and Southeast Asia.
Exposure usually from:
o Developed countries: undercooked shellfish
o Developing countries: unclean water and poor sanitation
Classically presents with profuse “rice-water” diarrhea and severe dehydration
Treatment centers on oral rehydration therapy (N’cho 2019).
Patients with severe disease benefit from doxycycline (azithromycin for pregnant women
and children)
Typhoid
Specific strain of Salmonella leading to typhoid fever
Endemic to much of the developing world
May present with concurrent fever and relative bradycardia, elevated transaminases,
characteristic red macular rash on trunk
Asymptomatic carriers may develop, so major public health concern
Typically treated with ciprofloxacin
o Other options are azithromycin or cephalosporins (Appiah 2019)
Norovirus
Classically causes nausea, vomiting, and diarrhea for 48-72 hours with rapid resolution of
symptoms
May be identified using GI pathogen panel PCR testing
Classification: Confidential
Usually self-limiting for an individual patient, but is extremely contagious and thus a
public health concern.
Norovirus requires special disinfection
o Clorox wipes and alcohol-based hand sanitizers ineffective Shane 2017).
DISPOSITION
Indications for Hospitalization
Toxic appearance / severe dehydration requiring IV rehydration
Marked electrolyte derangements
Inability to tolerate PO fluids
Severe symptoms in any high risk patient group .
Low risk patient
If the patient has no high risk features and no hemodynamic instability, discharge home with oral
hydration and return precautions. Oral hydration is preferred over enteral. No antibiotic treatment
is recommended.
If patient has bloody diarrhea (after first ruling out e coli O157:H7), severe symptoms (fever, >6
episodes per day), dehydration, or foreign travel, empiric antibiotic treatment may be warranted.
Outpatient antibiotic regimens:
Azithro 1g once or 500mg PO daily for 3 days
Ciprofloxacin – 750mg PO daily or 500mg PO twice daily for 3-5 days
Levofloxacin – 500mg PO daily for 3-5 days
Symptomatic Treatment:
Loperamide – may be considered in nonbloody diarrhea
Bismuth subsalicylate – less efficacious than loperamide
Probiotics – may shorten length of symptoms and frequency of bowel movements.
Appears lactobacilli most effective
Diet
No proven benefit to any specific diet during diarrheal illness
Generally recommended to consume simple starches such as pasta, bread, or fruit, and to
avoid foods heavy in fats or lactose
Classification: Confidential
Oral rehydration with diluted sports drinks or specifically designed formulas is beneficial
REFERENCES
1. Rcem learnings
2. Lazarciuc N. Diarrhea. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th
ed. Philadelphia, Elsevier. 2018; 28:249-256.e2
3. Healy J, Bruce B (2019). Salmonellosis (Nontyphoidal). Centers for Disease Control
Yellow Book. Chapter 4(78). Available
online: https://wwwnc.cdc.gov/travel/yellowbook/2020/travel-related-infectious-
diseases/salmonellosis-nontyphoidal
4. Connor B (2019). Traveller’s Diarrhea. Centers for Disease Control Yellow Book.
Chapter 2(15). Available
online: https://wwwnc.cdc.gov/travel/yellowbook/2020/preparing-international-travelers/
travelers-diarrhea
Classification: Confidential
