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Acute gastroenteritis and diarrhea are among the leading causes of seeking medical care. Approximately, 48 million cases occur annually that cost about $150 million for the U.S. health care system.  Gastroenteritis is defined as inflammation of the stomach or intestinal mucosa. It typically presents with acute diarrhea, fever, nausea and vomiting, anorexia and crampy abdominal pain and is defined as passage of loose stool for at least 3 times per day for less than 14 days. It may be caused by viruses, bacteria or parasites. Most cases of acute gastroenteritis are caused by viruses and among them, Norovirus is the most common etiology for adults. Other common viral causes include, Rotavirus, Adenovirus and Astrovirus. Common bacterial causes of gastroenteritis include, Escherichia coli sp, Salmonella sp, Yersinia enterocolitica and Vibrio sp that can cause watery diarrhea and Shigella sp and Campylobacter sp that can cause dysenteric diarrhea. Parasites are other causes of gastroenteritis especially in developing countries which Giardia lamblia and Entamoeba histolytica are the most frequent causes. First step in management of this patients is to evaluate the hydration status and vital signs. Once the patient is stabilized, health care provider must proceed to diagnostic evaluation. There are some principles to decrease the risk of acquiring infection which include, using safe water and foods, avoid unsafe foods during traveling and hand washing.
ETEC: Enterotoxigenic Escherichia coli, EPEC: Enteropathogenic Escherichia coli, EHEC: Enterohemorrhagic Escherichia coli, EAEC: Enteroaggregative Escherichia coli, EIEC: Enteroinvasive Escherichia coli, SARS: severe acute respiratory syndrome
|Common||Less Common||Common||Less Common||Helminthic||Protozoal|
|Gram Positive||Gram Negative||Gram Positive||Gram Negative||•Trichinella spiralis|
|•Giardia lamblia |
|Dysenteric diarreha||Watery diarrhea||• Bacillus cereus |
|•Bacteroides fragilis |
|•Shigella sp., •Campylobacter sp.||•Escherichia coli |
(ETEC, EPEC, EHEC, EAEC, EIEC)
§ EHEC, EIEC, EPEC and EAEC may cause bloody diarrhea, but they are classically associated with watery diarrhea.
† Either Salmonella and Yersinia can cause dysentery.
‡ Entamoeba histolytica may cause dysentery
|Organism||Age predilection||Travel History||Incubation Size (cell)||Incubation Time||History and Symptoms||Diarrhea type∞||Food source||Specific consideration|
|Fever||N/V||Cramping Abd Pain||Small Bowel||Large Bowel||Inflammatory||Non-inflammatory|
|Viral||Rotavirus||<2 y||-||<102||<48 h||+||+||-||+||+||-||Mostly in day cares, most common in winter.|
|Norovirus||Any age||-||10 -103||24-48 h||+||+||+||+||+||-||Most common cause of gastroenteritis, abdominal tenderness,|
|Adenovirus||<2 y||-||105 -106||8-10 d||+||+||+||+||+||-||No seasonality|
|Astrovirus||<5 y||-||72-96 h||+||+||+||+||+||Seafood||Mostly during winter|
|Bacterial||Escherichia coli||ETEC||Any age||+||108 -1010||24 h||-||+||+||+||+||-||Causes travelers diarrhea, contains heat-labile toxins (LT) and heat-stable toxins (ST)|
|EPEC||<1 y||-||10†||6-12 h||-||+||+||+||+||Raw beef and chicken||-|
|EIEC||Any ages||-||10†||24 h||+||+||+||+||+||Hamburger meat and unpasteurized milk||Similar to shigellosis, can cause bloody diarrhea|
|EHEC||Any ages||-||10||3-4 d||-||+||+||+||+||Undercooked or raw hamburger (ground beef)||Known as E. coli O157:H7, can cause HUS/TTP.|
|EAEC||Any ages||+||1010||8-18 h||-||-||+||+||+||-||May cause prolonged or persistent diarrhea in children|
|Salmonella sp.||Any ages||+||1||6 to 72 h||+||+||+||+||+||Meats, poultry, eggs, milk and dairy products, fish, shrimp, spices, yeast, coconut, sauces, freshly prepared salad.||Can cause salmonellosis or typhoid fever.|
|Shigella sp.||Any ages||-||10 - 200||8-48 h||+||+||+||+||+||Raw foods, for example, lettuce, salads (potato, tuna, shrimp, macaroni, and chicken)||Some strains produce enterotoxin and Shiga toxin similar to those produced by E. coli O157:H7|
|Campylobacter sp.||<5 y, 15-29 y||-||104||2-5 d||+||+||+||+||+||Undercooked poultry products, unpasteurized milk and cheeses made from unpasteurized milk, vegetables, seafood and contaminated water.||May cause bacteremia, Guillain-Barré syndrome (GBS), hemolytic uremic syndrome (HUS) and recurrent colitis|
|Yersinia enterocolitica||<10 y||-||104 -106||1-11 d||+||+||+||+||+||Meats (pork, beef, lamb, etc.), oysters, fish, crabs, and raw milk.||May cause reactive arthritis; glomerulonephritis; endocarditis; erythema nodosum.|
|Clostridium perfringens||Any ages||> 106||16 h||-||-||+||+||+||Meats (especially beef and poultry), meat-containing products (e.g., gravies and stews), and Mexican foods.||Can survive high heat,|
|Vibrio cholerae||Any ages||-||106-1010||24-48 h||-||+||+||+||+||Seafoods, including molluscan shellfish (oysters, mussels, and clams), crab, lobster, shrimp, squid, and finfish.||Hypotension, tachycardia, decreased skin turgor. Rice-water stools|
|Parasites||Protozoa||Giardia lamblia||2-5 y||+||1 cyst||1-2 we||-||-||+||+||+||Contaminated water||May cause malabsorption syndrome and severe weight loss|
|Entamoeba histolytica||4-11 y||+||<10 cysts||2-4 we||-||+||+||+||+||Contaminated water and raw foods||May cause intestinal amebiasis and amebic liver abscess|
|Cryptosporidium parvum||Any ages||-||10-100 oocysts||7-10 d||+||+||+||+||+||Juices and milk||May cause copious diarrhea and dehydration in patients with AIDS especially with 180 > CD4|
|Cyclospora cayetanensis||Any ages||+||10-100 oocysts||7-10 d||-||+||+||+||+||Fresh produce, such as raspberries, basil, and several varieties of lettuce.||More common in rainy areas|
|Helminths||Trichinella spp||Any ages||-||Two viable larvae (male and female)||1-4 we||-||+||+||+||+||Undercooked meats||More common in hunters or people who eat traditionally uncooked meats|
|Taenia spp||Any ages||-||1 larva or egg||2-4 m||-||+||+||+||+||Undercooked beef and pork||Neurocysticercosis: Cysts located in the brain may be asymptomatic or seizures, increased intracranial pressure, headache.|
|Diphyllobothrium latum||Any ages||-||1 larva||15 d||-||-||-||+||+||Raw or undercooked fish.||May cause vitamin B12 deficiency|
∞Small bowel diarrhea: watery, voluminous with less than 5 WBC/high power field
Large bowel diarrhea: Mucousy and/or bloody with less volume and more than 10 WBC/high power field
† It could be as high as 1000 based on patient's immunity system.
Non travel setting
- Contaminated foods are major causes of foodborne illness in the United states.
- To prevent food preparation chain from contamination, every steps of this process including, products in the farms, packaging industries, stores, restaurants and individuals in the home who are buying and preparing food must be take in to consideration.
- Proper maintaining the filtration systems at water plants is also essential.
- Avoid consuming unpasteurized milk or soft cheeses.
- Wash your hands frequently and effectively and use alcohol-based hand sanitizers.
- Rotavirus vaccination is recommended for all infants unless there is a contraindication for it.
- A simple rule is, boil it, cook it, peel it, or forget it!
- Use bottled water or boil all drinking water while on outdoor adventures.
- Wash your hands frequently and effectively and use alcohol-based hand sanitizers especially during cruise traveling.
- Chemoprophylaxis with Bismuth subsalicylate (BSS) has been shown to reduce the frequency of traveler's diarrhea (TD) when used during period of risk for 3 weeks. The recommended dose of BSS for TD prevention is two tablets four daily doses at mealtimes and at bedtime. BSS could be used for trips up to 2 weeks.
- Offer the typhoid vaccine to travelers going to countries with high prevalence of typhoid fever.
- Scallan E, Griffin PM, Angulo FJ, Tauxe RV, Hoekstra RM (2011). "Foodborne illness acquired in the United States--unspecified agents". Emerging Infect. Dis. 17 (1): 16–22. doi:10.3201/eid1701.091101p2. PMC 3204615. PMID 21192849.
- Scallan E, Hoekstra RM, Angulo FJ, Tauxe RV, Widdowson MA, Roy SL, Jones JL, Griffin PM (2011). "Foodborne illness acquired in the United States--major pathogens". Emerging Infect. Dis. 17 (1): 7–15. doi:10.3201/eid1701.091101p1. PMC 3375761. PMID 21192848.
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- Hall AJ, Rosenthal M, Gregoricus N, Greene SA, Ferguson J, Henao OL, Vinjé J, Lopman BA, Parashar UD, Widdowson MA (2011). "Incidence of acute gastroenteritis and role of norovirus, Georgia, USA, 2004-2005". Emerging Infect. Dis. 17 (8): 1381–8. doi:10.3201/eid1708.101533. PMC 3381564. PMID 21801613.
- Wikswo ME, Hall AJ (2012). "Outbreaks of acute gastroenteritis transmitted by person-to-person contact--United States, 2009-2010". MMWR Surveill Summ. 61 (9): 1–12. PMID 23235338.
- Cortese MM, Parashar UD (2009). "Prevention of rotavirus gastroenteritis among infants and children: recommendations of the Advisory Committee on Immunization Practices (ACIP)". MMWR Recomm Rep. 58 (RR-2): 1–25. PMID 19194371.
- DuPont HL, Sullivan P, Evans DG, Pickering LK, Evans DJ, Vollet JJ, Ericsson CD, Ackerman PB, Tjoa WS (1980). "Prevention of traveler's diarrhea (emporiatric enteritis). Prophylactic administration of subsalicylate bismuth)". JAMA. 243 (3): 237–41. PMID 6985681.
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