Best Approaches to Acute Gastroenteritis

Sara Marlow, MSN, RN, PHN, FNP-C
Monday February 01, 2016
Medications
Many medications can cause gastroenteritis, so a careful review of all medications and supplements that a patient has been taking is important. Examples of medications that frequently cause gastroenteritis are chemotherapeutics, antibiotics, laxatives, sorbitol, nonsteroidal anti-inflammatory drugs, cardiac antidysrhythmics, and colchicine.2

Allergies
Some patients experience GI intolerances with many medications, which may be listed in their medical record. Asking about allergies can lead clinicians to consider possible noninfectious causes of gastroenteritis and aid them in selecting an appropriate antibiotic if one is warranted.

Past Medical History
Patients who are immunocompromised or very young or very old are at higher risk for complications and death from severe dehydration. Knowing a patient’s health history is important in determining whether more aggressive action or investigation is needed and how vigilant the follow-up should be. The medical history can also tell the clinician if this is likely a chronic problem, an acute problem, or an infectious or noninfectious problem.

Social History
Because many pathogens have stereotypic scenarios, the patient’s social history provides key clues into the type of pathogen involved. The patient should be asked about recent travel, contact with children or daycare centers, occupation, recent meals, onset of symptoms related to meals, and whether anyone they know has experienced these symptoms.

Other Diagnostics
Vital signs should be reviewed to determine severity of illness and stability. What does the patient look like? Common causes of gastroenteritis, such as norovirus, typically do not cause patients to look toxic. Therefore, a toxic- looking patient warrants investigation and prompt treatment or referral.

The heart and lungs should be auscultated to check for abnormal breathing, irregular heartbeat, tachycardia, bradycardia, and murmurs. A detailed abdominal exam should include close attention to bowel sounds, abdominal distention, masses/bulges, pain, tenderness, guarding, radiating pain, or rebound tenderness.2 The skin and oral mucosa should be examined for signs of dehydration, as well as skin color and texture. Tenting, cracked lips, peeling lips, scaly skin, lack of tears, sunken fontanels, sluggish capillary refill, and sunken eyes are signs of dehydration.

Stool cultures are generally reserved for patients with a suspected nosocomial infection and those who are immunosuppressed, have blood or mucus in the stool, show signs of severe dehydration or inflammatory disease, or have symptoms lasting more than 3 to 7 days.9

Treatment
In acute viral gastroenteritis, the focus is on treating symptoms and preventing dehydration. Resting; eating a soft, bland diet; and drinking fluids with a proper balance of electrolytes can help patients recover. Children and adults can drink water, Pedialyte, and oral rehydration solutions.

Bacterial and parasitic infections are treated with appropriate medication, rest, hydration, and a gastroenteritis diet. Treating bacterial gastroenteritis with empiric antibiotics is controversial. Overuse of antibiotics can lead to resistance and may cause secondary infections such as a C. difficile and yeast infections, prolong the carrier state, induce Shiga toxins, and increase costs. Antibiotics have been shown to be effective for shigellosis, campylobacteriosis, C. difficile infection, traveler’s diarrhea, and protozoal infections. If the patient presents with symptoms suggestive of Shiga toxin–producing E. coli, then antibiotics should not be used because of the risk for hemoly tic-uremic syndrome.9

Gastroenteritis Diet
Diet is a large portion of acute gastroenteritis treatment. The goal is to aid in patient comfort while maintaining hydration and nutrition. Foods to avoid with all age groups include caffeine; fatty foods; spicy foods; sharp foods such as seeds, nuts, and chips; sugary foods and desserts; carbonated drinks; fruit juices; and alcohol.14 Recommended foods for older children and adults include soft, bland, easy-to-digest foods such as bananas, brown rice, broths, potatoes, plain natural applesauce, oral rehydration solutions, and whole grain bread. Infants should be given breast milk or infant formula.14 The key to nutrition and hydration is frequent sips of liquids and small volumes of food at a time. Too much liquid or food at once can cause discomfort and worsen symptoms.

Prevention
The best way to prevent the spread of infection is proper hand hygiene. Patients should be educated on when and how to wash their hands with soap and water, as well as when alcohol-based rubs are appropriate. Other actions that patients can take to reduce their risk for contracting and spreading gastroenteritis include:
  • Be up-to-date on immunizations, including flu and rotavirus vaccinations.
  • Avoid eating communal foods and at buffets.
  • Handle food properly.15
  • Avoid undercooked meats.
  • Drink bottled water, and avoid raw and peeled fruit and vegetables when traveling.
  • Avoid close contact and sharing personal items with others.
  • Disinfect surfaces at home with ½ cup of bleach to 1 gallon of water. Apply the solution to surfaces and let it dry for 5 minutes. Rinse thoroughly and allow it to air-dry.16
  • Frequently wash bedding, pillows, and blankets.

Sara Marlow is a licensed and board-certified family nurse practitioner, public health nurse, and adjunct assistant professor of health policy. She was the spring 2015 Health Policy Fellow in Washington, DC, at the American Association of Nurse Practitioners’ government affairs office and is the current co-chair of the Health Policy and Practice Committee of the California Association for Nurse Practitioners.

References
  1. Hall AJ, Rosenthal M, Gregoricus N, et al. Incidence of Acute Gastroenteritis and Role of Norovirus, Georgia, USA, 2004-2005. Emerg Infect Dis. 2011;17(8):1080 - 6059. doi:10.3201/eid1708.101533.
  2. Graves N. Acute Gastroenteritis. Primary Care: Clinics in Office Practice. 2013;40(3):727-741. doi:10.1016/j.pop.2013.05.006.
  3. Centers for Disease Control and Prevention. Deaths from gastroenteritis double. http://www.cdc.gov/media/releases/2012/p0314_gastroenteritis.html. Published March 14, 2012. Accessed December 17, 2015.
  4. U.S. Department of Agriculture, Economic Research Service. Economic Burden of Major Foodborne Illnesses Acquired in the United States. http://www.ers.usda.gov/media/1837791/eib140.pdf. Published May 2015. Accessed December 17, 2015.
  5. Centers for Disease Control and Prevention. Burden of Norovirus Illness and Outbreaks. http://www.cdc.gov/norovirus/php/illness-outbreaks.html.  Published July 8 2014. Accessed December 18, 2015.
  6. Centers for Disease Control and Prevention. Outbreaks of Acute Gastroenteritis Transmitted by Person-to-Person Contact — United States, 2009–2010. http://www.cdc.gov/mmwr/pdf/ss/ss6109.pdf. Published December 14, 2012. Accessed December 17, 2015.
  7. Barr W, Smith A. Acute Diarrhea in Adults. American Family Physician. 2014: 89(3): 180-9. http://www.aafp.org/afp/2014/0201/p180.html#afp20140201p180-b3. Accessed December 18, 2015.
  8. Matson, D . Epidemiologic and clinical features of common causes of acute viral gastroenteritis in children. In: Torchia M, ed. UpToDate, Waltham, Mass.:UpToDate:2015. http://www.uptodate.com.samuelmerritt.idm.oclc.org/contents/image?imageKey=PEDS%2F80471&topicKey=PEDS%2F5984&rank=4~150&source=see_link&search=gastroenteritis&utdPopup=true. Published
  9. Diskin A, Gutierrez-Alvarez L. Emergent Treatment of Gastroenteritis Clinical Presentation: History, Physical, Causes. Emedicinemedscapecom. 2015. Available at: http://emedicine.medscape.com/article/775277-clinical. Accessed December 20, 2015.
  10. Centers for Disease Control and Prevention. Pinkbook | Rotavirus | Epidemiology of Vaccine Preventable Diseases. Center for Disease Control and Prevention website. http://www.cdc.gov/vaccines/pubs/pinkbook/rota.html. Published September 8 2015. Accessed December 21, 2015.
  11. Centers for Disease Control and Prevention. Burden of Norovirus Illness and Outbreaks. Center for Disease Control and Prevention website. http://www.cdc.gov/norovirus/php/illness-outbreaks.html. Published July 8 2014. Accessed December 21, 2015.
  12. The Royal Children’s Hospital Melbourne. Clinical Practice Guidelines : Gastroenteritis. 2015. Available at: http://www.rch.org.au/clinicalguide/guideline_index/Gastroenteritis/. Accessed December 21, 2015.
  13. Karnath B, Mileski W. Acute Abdominal Pain. Hospital Physician. 2015. Available at: http://www.turner-white.com/pdf/hp_nov02_pain.pdf. Published November 2002. Accessed December 21, 2015.
  14. Kerr S. Gastroenteritis Diet. Beth Israel Deaconess Medical Center. 2012. Available at: http://www.bidmc.org/YourHealth/Holistic-Health/Diet-Center.aspx?ChunkID=648850. Accessed December 21, 2015.
  15. National Institute for Health and Care Excellence. Diarrhoea and vomiting caused by gastroenteritis in under 5s: diagnosis and management | guidance | Guidance and guidelines | NICE. 2009. Available at: https://www.nice.org.uk/guidance/cg84/chapter/guidance. Accessed December 21, 2015.
  16. Tablang M, Wu G, Grupka M. Viral Gastroenteritis Workup. 2015. Available at: http://emedicine.medscape.com/article/176515-clinical. Accessed December 21, 2015.
  17. United States Department of Agriculture. Basics for Handling Food Safely. 2015. Available at: http://www.fsis.usda.gov/wps/portal/fsis/topics/food-safety-education/get-answers/food-safety-fact-sheets/safe-food-handling/basics-for-handling-food-safely. Accessed December 21, 2015.
  18. Clorox. Making sure you dilute bleach | Clorox. 2013. Available at: https://www.clorox.com/dr-laundry/making-sure-you-dilute-bleach/. Accessed December 19, 2015.


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