cpg on acute gastroenteritis. acute gastroenteritis acute gastroenteritis is a disease characterized...

CPG on Acute GastroenteritisCPG on Acute Gastroenteritis

Acute GastroenteritisAcute Gastroenteritis

Acute gastroenteritis is a disease characterized by Acute gastroenteritis is a disease characterized by changes in the character and frequency of stool.changes in the character and frequency of stool.It can be defined as the passage of a greater number of It can be defined as the passage of a greater number of stools of decreased form from the normal lasting less stools of decreased form from the normal lasting less than 14 days.than 14 days.Generally associated with other signs or symptoms Generally associated with other signs or symptoms including nausea, vomiting, abdominal pain and cramps, including nausea, vomiting, abdominal pain and cramps, increase in intestinal gas-related complaints, fever, increase in intestinal gas-related complaints, fever, passage of bloody stools (dysentery), tenesmus passage of bloody stools (dysentery), tenesmus (constant sensation of urge to move bowels), and fecal (constant sensation of urge to move bowels), and fecal urgency. urgency. (1)(1)

(1) Guidelines on acute infectious diarrhea in adults. The Practice Parameters Committee of the American College of Gastroenterology. (1) Guidelines on acute infectious diarrhea in adults. The Practice Parameters Committee of the American College of Gastroenterology. American Journal of Gastroenterology. 1997 Nov;92(11):1962-75.American Journal of Gastroenterology. 1997 Nov;92(11):1962-75.


Perform initial assessment

Dehydration

Duration (>1 day)

Inflammation (indicated by fever, presenceof blood in stool, tenesmus) (2)

(2) Acute Infectious Diarrhea. Nathan M. Thielman, M.D., M.P.H., and Richard L. Guerrant, M.D. The New England (2) Acute Infectious Diarrhea. Nathan M. Thielman, M.D., M.P.H., and Richard L. Guerrant, M.D. The New England Journal of Medicine. 2004; 350:38-47.Journal of Medicine. 2004; 350:38-47.


Complete blood count can be obtained to look Complete blood count can be obtained to look for anemia, hemoconcentration, or an abnormal for anemia, hemoconcentration, or an abnormal white blood cell count. white blood cell count. (4)(4)

Measurements of serum electrolyte Measurements of serum electrolyte concentrations and blood urea nitrogen and concentrations and blood urea nitrogen and serum creatinine levels can be used to serum creatinine levels can be used to determine the extent of fluid and electrolyte determine the extent of fluid and electrolyte depletion and its effect on renal function. depletion and its effect on renal function. (4)(4)

(4) Sleisenger and Fordtran’s Gastrointestinal and Liver Disease. 8th edition. 2006. Feldman, Mark (4) Sleisenger and Fordtran’s Gastrointestinal and Liver Disease. 8th edition. 2006. Feldman, Mark

MD. Volume II. p169.MD. Volume II. p169.


Provide symptomatic treatment

RehydrationTreatment of symptoms (if necessary, loperamide if diarrhea is not inflammatory or bloody) (2)

(2) Acute Infectious Diarrhea. Nathan M. Thielman, M.D., M.P.H., and Richard L. Guerrant, M.D. The New England

Journal of Medicine. 2004; 350:38-47


Initial rehydrationInitial rehydrationThe most common risk with diarrheal illnesses is The most common risk with diarrheal illnesses is dehydration. dehydration. The critical initial treatment must include rehydration, The critical initial treatment must include rehydration, which can be accomplished with an oral glucose or which can be accomplished with an oral glucose or starch-containing electrolyte solution in the vast majority starch-containing electrolyte solution in the vast majority of cases. of cases. Although many patients with mild diarrhea can prevent Although many patients with mild diarrhea can prevent dehydration by ingesting extra fluids (such as clear juices dehydration by ingesting extra fluids (such as clear juices and soups), more severe diarrhea, postural light-and soups), more severe diarrhea, postural light-headedness, and reduced urination signify the need for headedness, and reduced urination signify the need for more rehydration fluids. more rehydration fluids. (2)(2)

(2) Acute Infectious Diarrhea. Nathan M. Thielman, M.D., M.P.H., and Richard L. Guerrant, M.D. The (2) Acute Infectious Diarrhea. Nathan M. Thielman, M.D., M.P.H., and Richard L. Guerrant, M.D. The New England Journal of Medicine. 2004; 350:38-47.New England Journal of Medicine. 2004; 350:38-47.


Prevention of Dehydration Prevention of Dehydration It is recommended that continued use of the It is recommended that continued use of the patient’s preferred, usual, and appropriate diet patient’s preferred, usual, and appropriate diet be encouraged to prevent or limit dehydration. be encouraged to prevent or limit dehydration. Regular diets are generally more effective than Regular diets are generally more effective than restricted and progressive diets, and in restricted and progressive diets, and in numerous trials have consistently produced a numerous trials have consistently produced a reduction in the duration of diarrhea. reduction in the duration of diarrhea. (5)(5)

(5) Cincinnati Children’s Hospital Medical Center. Evidence-based clinical care guideline for acute gastroenteritis (AGE) in children aged 2 months through (5) Cincinnati Children’s Hospital Medical Center. Evidence-based clinical care guideline for acute gastroenteritis (AGE) in children aged 2 months through

5 years. Cincinnati (OH): Cincinnati Children’s Hospital Medical Center; 2006 May. 15 p. [50 references].5 years. Cincinnati (OH): Cincinnati Children’s Hospital Medical Center; 2006 May. 15 p. [50 references].


The use of BRAT diet (consisting of bananas, The use of BRAT diet (consisting of bananas, rice, apple, and toast) with avoidance of milk rice, apple, and toast) with avoidance of milk products (since a transient lactase deficiency products (since a transient lactase deficiency may occur) is commonly recommended, may occur) is commonly recommended, although supporting data are limited. although supporting data are limited. (3)(3)

Clear liquids are not recommended as a Clear liquids are not recommended as a substitute for oral rehydration solutions (ORS) or substitute for oral rehydration solutions (ORS) or regular diets in the prevention or therapy of regular diets in the prevention or therapy of dehydration. dehydration. (5)(5)

(3) Practice Guidelines for the Management of Infectious Diarrhea. Infectious diseases Society of America. Clinical Infectious Diseases 2001; (3) Practice Guidelines for the Management of Infectious Diarrhea. Infectious diseases Society of America. Clinical Infectious Diseases 2001; 32:331–50.32:331–50.

(5) Cincinnati Children’s Hospital Medical Center. Evidence-based clinical care guideline for acute gastroenteritis (AGE) in children aged 2 months through 5 (5) Cincinnati Children’s Hospital Medical Center. Evidence-based clinical care guideline for acute gastroenteritis (AGE) in children aged 2 months through 5 years. Cincinnati (OH): Cincinnati Children’s Hospital Medical Center; 2006 May. 15 p. [50 references].years. Cincinnati (OH): Cincinnati Children’s Hospital Medical Center; 2006 May. 15 p. [50 references].


Oral Feeding Following Rehydration Oral Feeding Following Rehydration > It is recommended that giving the patient’s usual diet > It is recommended that giving the patient’s usual diet be started at the earliest opportunity after an adequate be started at the earliest opportunity after an adequate degree of rehydration is achieved. degree of rehydration is achieved. (5)(5)

On-going IV or NG Fluids following Rehydration On-going IV or NG Fluids following Rehydration > It is recommended that maintenance IV fluids or NG > It is recommended that maintenance IV fluids or NG ORS be given: ORS be given: – • • when unable to replace the estimated fluid deficit and keep up when unable to replace the estimated fluid deficit and keep up

with the on-going losses using oral feedings alone, and/or with the on-going losses using oral feedings alone, and/or – • • to severely dehydrated patient with obtunded mental statusto severely dehydrated patient with obtunded mental status(5) Cincinnati Children’s Hospital Medical Center. Evidence-based clinical care guideline for acute gastroenteritis (AGE) in children aged 2 months (5) Cincinnati Children’s Hospital Medical Center. Evidence-based clinical care guideline for acute gastroenteritis (AGE) in children aged 2 months

through 5 years. Cincinnati (OH): Cincinnati Children’s Hospital Medical Center; 2006 May. 15 p. [50 references].through 5 years. Cincinnati (OH): Cincinnati Children’s Hospital Medical Center; 2006 May. 15 p. [50 references].


Stratify subsequent management according to clinical and epidemiologic featuresEpidemiologic clues:

Food, antibiotics, sexual activity, travel, day-care attendance, other illnesses outbreaks, season

Clinical clues:Bloody diarrhea, abdominal pain, dysentery, wasting, fecal

inflammation. (2)

(2) Acute Infectious Diarrhea. Nathan M. Thielman, M.D., M.P.H., and Richard L. Guerrant, M.D. The New England Journal of Medicine. 2004; (2) Acute Infectious Diarrhea. Nathan M. Thielman, M.D., M.P.H., and Richard L. Guerrant, M.D. The New England Journal of Medicine. 2004; 350:38-47350:38-47


When to admit?When to admit?Persistent Diarrhea (>7 days) Persistent Diarrhea (>7 days) (2)(2)

FeverFeverUnstableUnstableSeverely dehydratedSeverely dehydratedBloody diarrheaBloody diarrheaPersistent VomitingPersistent VomitingNo improvement after initial hydration or symptoms No improvement after initial hydration or symptoms exacerbate/ overall condition gets worse exacerbate/ overall condition gets worse (6)(6)

(2) Acute Infectious Diarrhea. Nathan M. Thielman, M.D., M.P.H., and Richard L. Guerrant, M.D. The New England Journal of Medicine. 2004; (2) Acute Infectious Diarrhea. Nathan M. Thielman, M.D., M.P.H., and Richard L. Guerrant, M.D. The New England Journal of Medicine. 2004; 350:38-47350:38-47

(6) World Gastroenterology Organisation (WGO). WGO practice guideline: acute diarrhea. Munich, Germany: World Gastroenterology (6) World Gastroenterology Organisation (WGO). WGO practice guideline: acute diarrhea. Munich, Germany: World Gastroenterology Organisation (WGO); 2008 Mar.Organisation (WGO); 2008 Mar.

(2) Acute Infectious Diarrhea. Nathan M. Thielman, M.D., M.P.H., and Richard L. Guerrant, M.D. The New England Journal of Medicine. 2004; 350:38-47(2) Acute Infectious Diarrhea. Nathan M. Thielman, M.D., M.P.H., and Richard L. Guerrant, M.D. The New England Journal of Medicine. 2004; 350:38-47

Immunocompromised patientsImmunocompromised patients

If symptoms recur or are uncontrolled despite hydration If symptoms recur or are uncontrolled despite hydration and antimicrobial treatment....and antimicrobial treatment....

If evidence of colitis is present,If evidence of colitis is present,

Do:Do:– Proctosigmoidoscopy with biopsy of lesions with Proctosigmoidoscopy with biopsy of lesions with

attention to CMV, mycobacteria, Adenovirus, Fungi, attention to CMV, mycobacteria, Adenovirus, Fungi, Herpes simplexHerpes simplex

(1) Guidelines on acute infectious diarrhea in adults. The Practice Parameters Committee of the American College of Gastroenterology. American (1) Guidelines on acute infectious diarrhea in adults. The Practice Parameters Committee of the American College of Gastroenterology. American Journal of Gastroenterology. 1997 Nov;92(11):1962-75.Journal of Gastroenterology. 1997 Nov;92(11):1962-75.

Immunocompromised patientsImmunocompromised patients

If symptoms recur or are uncontrolled despite If symptoms recur or are uncontrolled despite hydration and antimicrobial treatment....hydration and antimicrobial treatment....

If evidence of colitis is NOT present,If evidence of colitis is NOT present,

Do:Do:

-Gastroduodenoscopy with biopsy, Smears and -Gastroduodenoscopy with biopsy, Smears and culture for special parasites plus culture for special parasites plus proctosigmoidoscopyproctosigmoidoscopy

(1) Guidelines on acute infectious diarrhea in adults. The Practice Parameters Committee of the American College of Gastroenterology. American (1) Guidelines on acute infectious diarrhea in adults. The Practice Parameters Committee of the American College of Gastroenterology. American Journal of Gastroenterology. 1997 Nov;92(11):1962-75.Journal of Gastroenterology. 1997 Nov;92(11):1962-75.


When to discharge?When to discharge?– Stable Vital signsStable Vital signs– Maintains a sufficient fluid intakeMaintains a sufficient fluid intake– Able to eat meals adequatelyAble to eat meals adequately– Able to take medications (if still indicated) Able to take medications (if still indicated) (6)(6)

(6) World Gastroenterology Organisation (WGO). WGO practice guideline: acute diarrhea. Munich, Germany: World Gastroenterology (6) World Gastroenterology Organisation (WGO). WGO practice guideline: acute diarrhea. Munich, Germany: World Gastroenterology Organisation (WGO); 2008 Mar.Organisation (WGO); 2008 Mar.

Patient EducationPatient Education

Many diarrheal diseases can be prevented by Many diarrheal diseases can be prevented by following simple rules of personal hygiene and following simple rules of personal hygiene and safe food preparation. safe food preparation. Hand-washing with soap is an effective step in Hand-washing with soap is an effective step in preventing spread of illness and should be preventing spread of illness and should be emphasized for caregivers of persons with emphasized for caregivers of persons with diarrheal illnesses. diarrheal illnesses. As noted above, human feces must always be As noted above, human feces must always be considered potentially hazardous, whether or not considered potentially hazardous, whether or not diarrhea or potential pathogens have been diarrhea or potential pathogens have been identified. identified. (3)(3)

(3) Practice Guidelines for the Management of Infectious Diarrhea. Infectious diseases Society of America. Clinical Infectious Diseases 2001; 32:331–50.(3) Practice Guidelines for the Management of Infectious Diarrhea. Infectious diseases Society of America. Clinical Infectious Diseases 2001; 32:331–50.

Patient EducationPatient Education

Consequently, microbial studies should not be Consequently, microbial studies should not be needed to justify careful attention to hygiene. needed to justify careful attention to hygiene.

Select populations may require additional Select populations may require additional education about food safety, and health care education about food safety, and health care providers can play an important role in providing providers can play an important role in providing this information. this information. (3)(3)

(3) Practice Guidelines for the Management of Infectious Diarrhea. Infectious diseases Society of America. Clinical (3) Practice Guidelines for the Management of Infectious Diarrhea. Infectious diseases Society of America. Clinical Infectious Diseases 2001; 32:331–50.Infectious Diseases 2001; 32:331–50.

THANK YOU!THANK YOU!

Clinical Pathway for Acute Gastroenteritis with Severe Clinical Pathway for Acute Gastroenteritis with Severe dehydrationdehydration

1st 30 minutes1st 30 minutes 2nd 30 minutes to 2 hrs2nd 30 minutes to 2 hrs 2 hrs to 24 hours2 hrs to 24 hours

AA

SS

SS

EE

SS

SS

MM

EE

NN

TT

AGE documented based on history and AGE documented based on history and physical examinationphysical examination

Assess patient as stable or unstableAssess patient as stable or unstable

HistoryHistory

Onset frequency, quantity Character - Onset frequency, quantity Character - bile/blood/mucusbile/blood/mucusFeverFeverVomiting Vomiting

Past medical history, underlying medical Past medical history, underlying medical conditions conditions

Epidemiological clues (food, antibiotics, sexual Epidemiological clues (food, antibiotics, sexual activity, travel, outbreaks, season)activity, travel, outbreaks, season)

Signs of dehydration in adultsSigns of dehydration in adults

Decreased sensorium (severe dehydration)Decreased sensorium (severe dehydration)

TachycardiaTachycardia

Postural hypotension Postural hypotension

Supine hypotension and absence of palpable Supine hypotension and absence of palpable pulse pulse

Dry tongue Dry tongue

Sunken eyeballs Skin pinch/turgorSunken eyeballs Skin pinch/turgor

Decrease urine outputDecrease urine output

Response to treatment Response to treatment assessedassessed

Presence of urine outputPresence of urine output

Stable vital signs Stable vital signs

Response to treatment Response to treatment assessedassessed

Presence of urine Presence of urine outputoutput

Stable vital signsStable vital signs

Clinical Pathway for Acute Gastroenteritis with Clinical Pathway for Acute Gastroenteritis with Severe dehydrationSevere dehydration

1st 30 minutes1st 30 minutes 2nd 30 minutes to 2 2nd 30 minutes to 2 hrshrs

2 hrs to 24 hours2 hrs to 24 hours

DD

II

AA

GG

NN

OO

SS

TT

II

CC

SS

Serum electrolytes Serum electrolytes

BUN, creatinine BUN, creatinine

CBCCBC

FecalysisFecalysis

Stool for c. difficile toxin (if with Stool for c. difficile toxin (if with recent/chronic antibiotic use)recent/chronic antibiotic use)

ABG (if with decreased sensorium/ ABG (if with decreased sensorium/ tachypneic/ dyspneic)tachypneic/ dyspneic)

RBS (if with decreased sensorium RBS (if with decreased sensorium

Follow up result of Follow up result of tests tests

Serum electrolytes Serum electrolytes and BUN, creatinine and BUN, creatinine monitored at monitored at appropriate intervals appropriate intervals (every 24 hours) (every 24 hours)


1st 30 minutes1st 30 minutes 2nd 30 minutes to 2 2nd 30 minutes to 2 hrshrs

2 hrs to 24 hours2 hrs to 24 hours

TT

RR

EE

AA

TT

MM

EE

NN

TT

IV Line or Central vein catheter for IV Line or Central vein catheter for rapid fluid deliveryrapid fluid delivery

Oxygen by nasal cannula (if Oxygen by nasal cannula (if tachpneic/ dyspneic)tachpneic/ dyspneic)

Elevate patient’s feet and legs (if Elevate patient’s feet and legs (if with hypotension with hypotension

IV HydrationIV Hydration

correct fluid and correct fluid and electrolyte electrolyte disturbancesdisturbances

Adjust IV fluids Adjust IV fluids accordinglycorrect accordinglycorrect fluid and electrolyte fluid and electrolyte disturbances start disturbances start oral hydration (if oral hydration (if tolerated) of tolerated) of preferred dietpreferred diet



MM

EE

DD

II

CC

AA

TT

II

OO

NN

SS

IV HydrationIV Hydration Metoclopramide for recurrent Metoclopramide for recurrent or persistent vomitingor persistent vomiting

Treatment of symptoms (if Treatment of symptoms (if necessary loperamide if necessary loperamide if diarrhea is not inflammatory diarrhea is not inflammatory or bloody) or bloody)

Continue medicationsContinue medications

Consider antimicrobial Consider antimicrobial treatment for specific treatment for specific pathogenspathogens



TT

EE

AA

CC

HH

II

NN

GG

Relatives are Relatives are Informed Informed on the condition of the on the condition of the patient patient

Relatives are Relatives are Informed on need Informed on need to have continued fluid to have continued fluid replacement replacement

Request for renal, pulmonary and Request for renal, pulmonary and cardiac support (if needed) cardiac support (if needed)

Relatives are Relatives are Updated on the Updated on the patient’s condition patient’s condition

cpg on acute gastroenteritis. acute gastroenteritis acute gastroenteritis is a disease characterized...

Documents

acute gastroenteritis

acute gastroenteritis

acute infectious diarrhea

cincinnati oh

rehydration fluids

duration of diarrhea

severe diarrhea

clinical infectious