Non-Inflammatory Gastroenteritis Management

1. Introduction –WIPPPPE
- Wash hands, Introduce yourself and Gain consent (Permission) by Explaining what you are going to do “I’m going
to give you a few information about your health, is that OK with you?".
- Patient details – name & DOB/Age (Gender, Nationality, Route of Admission: OPD or ER?), Privacy, Position –
setting and relaxed.
- Explain & Ask "Do you have any pain right now?"
- If the pt is female, you have to inquire if she is married, Single or Widow? menstrual cycle (regular vs. irregular)?
- If married, ask about: pregnant or planned to be? breastfeeding? children? methods of contraception?, and
if not take any, ask about using Folic acid.
2. Presenting complaint (PC) “How are you?”, “How may I help you today?”
3. ICE
I: “Do you have any Idea about what our meeting is gonna be about today?”
C: “Do you have any concerns?”
E: “Do you have any expectations about our meeting or Dx?”
E: “How is it affecting your daily life, work (job absenteeism), and sleep?”
4. CRRAAPRIOPP
Ask - Is there someone else with similar symptoms of yours? (Food poisoning: 2 persons from same source), recent
travel?(travelers)
Clarify 1. Defintin: Gastroenteritis is an inflammation of the gastrointestinal tract, involving both the stomach and the
intestines.
2. Symptoms include: diarrhea, vomiting, fatigue, fever, lack of appetite, abdominal pain, and dehydration.
3. Duration: Symptoms typically last 1 to 2 days and up to two weeks.
4. How does someone contract the infection?
- Usually caused by viruses; however, bacteria, parasites, and fungus can also cause it
- From contaminated food and water supply “You got the infection if you touched an infected person or surface with
the virus on it and didn’t wash your hands. Or if you ate food or drink liquids with the virus in them. If people with
the virus don't wash their hands, they can spread the infection to food or liquids they touch.”
Reassure - It is a common disease, and self-limiting, can be easily managed with adequate rehydration.
- Typically, no serious consequences occur and the condition resolves itself in a few days without medical treatment, as the
symptoms (diarrhea and vomiting) is the body’s way of protection and removing the toxin.
Red-flag/ There are some red flags you need to be aware of :
Safety o Blood or mucus in stool
Netting: o Vomiting black or dark red material.
o Fever of 38.33˚C or higher + persistent.
o Confusion
o Localized and/or persistent abdominal pain.
o Symptoms persist for > 3-7 days.
o Dehydration, vomiting and Diarrhea cause your body to lose too much water and this is called dehydration. signs
include:
▪ Extreme thirst
▪ Urine that is darker in color, or less in amount
▪ Dry skin, mouth
▪ Sunken cheeks or eyes
▪ Dizziness and change in mental status
“If you experienced these symptoms you have to go to the ER for IV fluid to prevent severe dehydration“
Assess - Comorbidities: “Do you have chronic diseases like DM or HTN”
- Risky behaviors ( smoker, alcohol drinker, illicit drug user), immunodeficiency (HIV)
Advice (4x - Hydration “ you have to drink lots of water 2 to 3 L per day “
H) - Hand hygiene “you have to wash your hands to prevent transmission of the infection or acquiring the infection”
- Honey ( Not for infants)
- Healthy diet: follow BRAT Diet (bananas, rice, apple sauce, and toast)
- avoidance of dairy products and solid food (limited data)
- Rest
Prescribe 1) “Do you use any medication” (use of excess steroids) & “Are you allergic to foods or any medication like penicillin
or sulfa-containing antibiotics?”
2) Give a written prescription (verbalize that you will) :
For Adults &Children:
- The first step in treatment is rehydration, preferably oral rehydration.
“I will prescribe you Oral rehydration solution (ORS) which contains a mixture of salt (electrolytes) and glucose in
combination with water to correct the dehydration and electrolyte imbalance that happened with the diarrhea &
vomiting and also for continuation of maintenance fluid. You could either purchase it from the pharmacy or prepare
it at home.”
How to prepare ORS at home? “To prepare ORS at home, you need 1 L of water + 6 teaspoon of sugar + half
teaspoon of salt”
- Also early refeeding is helpful in reducing the illness duration, and improve nutritional outcomes
- We can give you acetaminophen to relieve the fever (if present).
Exclusive For children (in the article): (however, in osce exam say it even if the patient is adult. each has a grade)
- Probiotics: in children with acute diarrhea > reduce the severity and duration of illness (one less day of illness:
being sick for 4 days instead of 5), improve Immune system.
- Zinc supplementation: 20mg per day for 10 days in children older than two months> treating and preventing acute
diarrhea and decreasing the risk of dehydration, duration, and severity of diarrhea.
Not to be given:
- Antibiotics: usually NOT recommended because it is self-limited and caused by viruses. Additionally; the over use
of abx can lead to 1. resistance, 2.prolongation of illness, 3.harmful eradication of normal flora. “If a bacterial
infection is confirmed, Antibiotics may be needed.”
- “We can’t prescribe anti-emetics or anti-diarrheal because we need the pathogen to be excreted out from your
system and they prevent the washout of Pathogens”. But if needed (not as initial Tx): A
loperamide(anti-diarrheal)/simethicone(anti-flatulence) combination has demonstrated faster and more complete
relief of acute nonspecific watery diarrhea and gas-related discomfort compared with either medication alone.
You have to comply with the plan to prevent the discussed complications.
Referral “No need for referral, unless there’s severe dehydration which may require admission.”
Investigatio - “Investigations are not necessary for most cases as the disease is self-limiting in immunocompetent individuals”
n - Indication to order stool culture: “we may consider stool culture & then treat based on the pathogen”
- If severe dehydration, more severe illness
- persistent fever, or persistent diarrhea for more than 3 to 7 days
- Gross blood or mucus in stool
- or immune-compromised, and suspected nosocomial infections.
- signs of inflammatory disease
- “Culture may help with the antibiotic selection (if needed).”
Observation No need for observation & F/U unless if no improvement
Prevention Prevention “To prevent having another gastroenteritis:”
- Adequate hand washing, Good hygiene
- safe food preparation (Avoid takeout food from unknown venders)
- access to clean water (avoid having ice cubes in restaurants)
- Zinc in children & Honey (not in infant)
- report the source of infection to the health inspectors/public health authorities (food poisoning).
Opportunistic prevention
- Smoking cessation: “Do you smoke?”; if yes, “I will refer you to a smoking cessation clinic.”
- Vaccinations: rotavirus, typhoid fever, and cholera, flu “We recommend taking the Flu vaccine.”
- Diet and exercise are crucial, Stress management
Plan -Do you Agree on the plan?
- Depression screening
o Low mood “How is your mood for the past 2 weeks”?
o Loss of interest “Have you stopped doing something you loved doing; like a hobby?”
- To complete the visit
1. Is everything clear? Can you briefly summarize what I said?
2. Do you have any questions? If you need anything we are here for you.
3. Thank the patient and Wash hands.