Infectious gastroenteritis: Clinical sciences

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A 77-year-old woman presents to the emergency department for evaluation of watery diarrhea for the past 4 days. The patient reports five watery unformed stools a day without blood in them. She reports associated vomiting, abdominal cramping, and poor oral intake due to nausea. The patient has a past medical history of hypertension, diabetes, and hyperlipidemia. Temperature is 37.3°C (99.1°F), blood pressure is 100/61, pulse is 127/min, respiratory rate is 18/min, and oxygen saturation is 97% on room air. The patient appears fatigued. Physical examination is notable for dry mucous membranes, decreased skin turgor, and delayed capillary refill. The abdomen is diffusely tender to palpation, soft, and nondistended. Which of the following is the most appropriate next step in management?  

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Gastroenteritis refers to inflammation of the gastrointestinal tract, typically caused by infectious pathogens. These pathogens injure the intestinal lining, leading to fluid shifts and water loss through diarrhea and vomit. The diagnosis of what’s causing gastroenteritis is made by first evaluating whether the patient’s diarrhea is watery or bloody, as well as identifying common pathogens such as bacteria, viruses, or parasites.

Now, if you suspect gastroenteritis, you should perform an ABCDE assessment to determine if your patient is unstable or stable.

If the patient is unstable, stabilize their airway, breathing, and circulation. Next, obtain IV access, start IV fluids, and begin continuous vital sign monitoring including blood pressure, heart rate, and oxygen saturation. Provide supplemental oxygen if needed, and start broad spectrum antibiotics. Okay, let’s go back to the ABCDE assessment and take a look at stable patients.

First, start by taking a focused history and physical exam. Your patient may report diarrhea, nausea, vomiting, and abdominal pain. Other common symptoms include flatulence, fecal urgency, and possibly fever.

On the other hand, physical exam findings will reveal abdominal tenderness, and may show signs of dehydration, such as dry skin and mucous membranes, decreased skin turgor, and decreased capillary refill time. At this point, you should suspect gastroenteritis.

Here’s a clinical pearl! Be sure to always clarify stool frequency and consistency whenever taking a history. Diarrhea is defined as passing of three or more unformed stools in 24 hours. If your patient is passing formed stools, or has not had multiple episodes per day, they do not have diarrhea.

Once you suspect gastroenteritis, determine if the diarrhea is watery or bloody. Let’s first talk about watery diarrhea.

If your patient has watery diarrhea, first assess the patient’s level of dehydration. Signs of mild dehydration include mild tachycardia, dry skin and mucous membranes, decreased skin turgor, and slightly delayed capillary refill time. If your patient has mild dehydration, provide supportive care, which includes oral rehydration therapy, or ORT for short. Then, assess your patient’s response to treatment in 24 to 48 hours. If the response is adequate, and your patient is able to maintain hydration with ORT, then you can diagnose acute gastroenteritis. In this case, continue current management until diarrhea resolves. If the response is inadequate, and your patient cannot maintain hydration with ORT, proceed with management for moderate to severe dehydration.

Sources

  1. "2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea" Clinical Infectious Diseases (2017)
  2. "ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults" The American Journal of Gastroenterology (2016)
  3. "Hemolytic Uremic Syndrome in a Young Female, Later Diagnosed With Crohn's Disease: 2095" The American Journal of Gastroenterology (2019)
  4. "The risk of the hemolytic-uremic syndrome after antibiotic treatment of Escherichia coli O157:H7 infections" N Engl J Med (2000)