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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 (norwalk virus) 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 |
|Bloody diarrhea (dysentery)||Watery diarrhea||• Bacillus cereus |
|•Bacteroides fragilis |
Salmonella(non-typhoidal) sp.†||•Escherichia coli |
(ETEC, EPEC, EAEC)
§ EHEC, EIEC, EPEC and EAEC may cause bloody diarrhea, but they are classically associated with watery diarrhea.
† Both Salmonella and Yersinia can cause watery and or bloody diarrhea.
‡ Entamoeba histolytica may cause dysentery.
* Mycobacterium sp is Gram Postive Acid fast.
|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||+||+||-||+||+||-||Most common cause of diarrhea among children.
Mostly in day cares and in winter.
|Norovirus||Any age||-||10 -103||24-48 h||+||+||+||+||+||-||Most common cause of adult gastroenteritis.
Common infection on cruise ships.
|Adenovirus||<2 y||-||105 -106||8-10 d||+||+||+||+||+||-||Associated with multiorgan involvement.
|Astrovirus||<5 y||-||72-96 h||+||+||+||+||+||Seafood||Mostly during winter|
|Bacterial||Escherichia coli||ETEC||Any age||+||108 -1010||24 h||-||+||+||+||+||-||Causes traveler's diarrhea.
Contains heat-labile toxins (LT) and heat-stable toxins (ST).
|EPEC||<1 y||-||10†||6-12 h||-||+||+||+||+||Raw beef and chicken||Mostly affects pediatric population.|
|EIEC||Any ages||-||10†||24 h||+||+||+||+||+||Hamburger meat and unpasteurized milk||Similar to shigellosis, can cause bloody diarrhea.|
|Any ages||-||10||3-4 d||-||+||+||+||+||Undercooked or raw hamburger (ground beef)||Can cause HUS/TTP.
Prescribing antibiotics may worsen the condition.
|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.||Causes Pseudo-Appendicitis (due to mesenteric adenitis / granulomatous microabscesses).|
|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.
Also causes gas gangrene.
|Vibrio cholerae||Any ages||-||106-1010||24-48 h||-||+||+||+||+||Seafoods, including molluscan shellfish (oysters, mussels, and clams), crab, lobster, shrimp, squid, and finfish.||Endemic to developing countries.
Typical rice-water stools.
|Parasites||Protozoa||Giardia lamblia||2-5 y||+||1 cyst||1-2 we||-||-||+||+||+||Contaminated water (chlorination does not kill the cysts)||May cause malabsorption syndrome leading to severe weight loss.|
|Entamoeba histolytica||4-11 y||+||<10 cysts||2-4 we||-||+||+||+||+||Contaminated water and raw foods||May cause intestinal amoebiasis and amoebic liver abscess with characteristic ''Anchovy paste'' abscess.|
|Cryptosporidium parvum||Any ages||-||10-100 oocysts||7-10 d||+||+||+||+||+||Juices and milk||Most common cause of diarrhea in AIDS patients( especially with CD4 < 180).|
|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.
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