Approach to patient with Diarrhea and Vomiting

Acute Gastroenteritis / Food Poisoning MOHW August 2020

Definition
Acute Gastroenteritis is an acute inflammatory disease of mucous membrane of the
whole gastrointestinal tract

Food poisoning – Acute Gastroenteritis caused by preformed noninvasive bacterial

enterotoxin by eating poorly cooked / preserved food or contaminated drinking water.
Overview
 Majority due to noninvasive bacterial enterotoxin or of Viral origin
 Majority recovers with supportive treatment at home.
 Optimal Fluid, electrolyte and symptomatic management remains the cornerstone.
 Majority do NOT require Antibiotics including Metronidazole

Diagnosis: presents with Diarrhea + /- Vomiting +/- Abdominal colicky pain +/- Fever

Notification: ALL TO BE NOTIFIED

Assess Severity of Dehydration and High Risk Patient

 Frequency of Diarrhea & Vomiting
 Dehydration* –Mild- Moderate-Severe
 Blood Pressure
 Temperature
 Urine output-decreased
 Mental state - Confusion
 Assess associated Comorbidity / High Risk patients
IHD/CRF/CCF/Immunosuppressed/Elderly patient
 Recent Travel to /Foreign workers from tropical Countries

Dehydration Mild Moderate Severe /High Risk

Admission

Vomiting
<3 /day <5/day >5/day
/Diarrhea
Blood Normal Normal Low BP <100/80
Pressure
 1st Casualty Supportive RX Supportive RX
Admit
attendance Discharge Observe +/- Admit
2nd casualty
Admit - -
attendance
1. FBC
Investigation

Usually NO 2. S.electrolyte
specific test 3. S.urea/Creatinine
-

required 4. +/- Stool M/E Parasites

5. +/- Stool Culture

Viral or Bacterial enterotoxin Bacterial /parasitic origin

Origin
Most Common
Assess Possible Causative factor

NO Blood   Spiky Fever >38 0c

Cl. Features No Mucus   Bloody Diarrhea
+/- low Grade fever   +/- Mucus ++/ Tenesmus
Viruses Bacterial
 Norovirus  E.coli
 Rota Virus  Shigella-Bacillary Dysentry
 Adeno virus  Salmonella-Typoid/enteric fever
Organism
 Compylo bacter
s
Noninvasive Bacterial Toxin  Clostridum Dificile
 E.coli Parasitic
 Salmonella  Giardia
 Entamoeba
1. Optimal of oral Fluid replacement- Water/soup
2. Vomiting -Few
a. NO ORS if patient is vomiting
Mild / Viral/ enterotoxin related

b. Pt age < 18 yrs – IV vogalen or Supp/Tab- Vogalen

c. Pt age > 18 yrs -IM Metoclopopamide ( Primperan)
1 amp stat followed by oral anti emetic
d. No Place for odansetrone in AGE at casualty Level
Treatment

3. Abdominal cramps/colic
Inj /Oral – antispasmodic – Dicyclomine /Buscopan
4. Diarrhea-
a. Emphasise to focus on Fluid replacement and not on diarrheal
count.
b. Fever- Paracetamol tab/sup if can tolerate-may need
Iv Paracetamol may be considered if vomiting
5. Oral Feeding- resume early if can tolerate
6. NO Antibiotic including metronidazole usually needed
 1. Optimal IV- D/S Fluid + electrolyte management
a. Normal requirement of average 6o Kg patient requires 2500-
3000 ml /day

Moderate
b. Optimal fluid= Basic + estimated Loss due to vomiting+
diarrhea)
c. Dextrose /Saline 1-2 liters + 1-2g KCl over 1 hour may be
required in mod /severe cases
2. Oral Feeding- resume early if can tolerate
3. NO Antibiotics including metronidazole usually needed
1. As Above for Moderate case Plus
High Risk
Severe /

2. Cautious IV Fluid in CCF/CRF/IHD

3. Empirical Antibiotic or as per stool culture report
Bacterial strain specific
Antibiotic Choice

Empirical Antibiotics

Antibiotics

a. Blood Pressure
monitoring
Treatment

b. Intake /Output daily-1-2 m//kg/hr

c. Bowel sound- for paralytic ileus
d. FBC
e. S electrolyte + S.Crearinine

1. Dehydration Assessment –Skin Turgor, Dry mouth/tongue, Sunken eyes, rapid

Pulse & Respiration, Low BP, Decrease urine output, Confusion
Special Note

2. HBP Drug continuation in admitted Moderate and Severe AGE patient

The course of AGE may be unpredictable in moderate to severe cases –
antihypertensive drugs should be omitted temporarily under supervision
3. All patients must have a S.Crearinine before discharging patient
4. Antibiotic Induced Diarrhea- R/o Clostridium difficile to be excluded