LET’S DISCUSS GASTROENTERITIS, ITS SYMPTOMS, CAUSES, TREATMENT, TRANSMISSION AND ITS PREVENTION!!

Written by Bukola. Published: 04/03/23

DEFINITIONS:

Gastroenteritis is characterized by the sudden onset of diarrhoea, with or without vomiting. Similarly, it can be defined as acute diarrhoea disease of rapid onset, with or without nausea, vomiting, fever, or abdominal pain.

Food poisoning is defined as 'an illness caused by the consumption of food or water contaminated with bacteria and/or their toxins, or with parasites, viruses, or chemicals'.

Acute diarrhoea is usually defined as three or more episodes of liquid or semi-liquid stool in a 24-hour period, lasting for less than 14 days, where the stool takes the shape of the sample pot.

Prolonged diarrhoea is acute-onset diarrhoea that has persisted for over 14 days

Dysentery is an acute infectious gastroenteritis characterized by diarrhoea with blood and mucus, often with fever and abdominal pain.

[National Collaborating Centre for Women's and Children's Health; 2009, Hartman, 2019; Steffen, 2015; PHE, 2020a; PHE, 2015; PHE, 2019].

HOW LONG SHOULD DIARRHOEA AND VOMITING LAST FOR IN ADULT/CHILDREN?

Diarrhoea usually stops within 5 to 7 days

Vomiting usually stops in 1 or 2 days

SYMPTOMS OF GASTROENTERITIS INCLUDES

Sudden-onset diarrhoea (change of stool consistency to loose or watery stools, usually at least three times in 24 hours); blood or mucus in the stool; faecal urgency.

Nausea or sudden onset of vomiting.

Fever or general malaise.

Abdominal pain or cramps.

Associated headache, myalgia, bloating, flatulence, weight loss, and malabsorption, depending on the underlying cause of infection.

SYMPTOMS FOR DEHYDRATION IN ADULTS INCLUDES

a). MILD SYMPTOMS INCLUDE:

Lassitude.

Anorexia and nausea.

Light-headedness.

Signs include:

Possible postural hypotension.

b). MODERATE SYMPTOMS INCLUDE:

Apathy/tiredness.

Dizziness.

Nausea.

Headache.

Muscle cramps.

Signs include:

Pinched face.

Dry tongue or sunken eyes.

Reduced skin elasticity.

Postural hypotension.

Tachycardia.

Oliguria.

c). SEVERE SYMPTOMS INCLUDE:

Profound apathy and weakness.

Confusion, leading to coma.

Signs include:

Marked peripheral vasoconstriction.

Hypotension.

Tachycardia.

Uraemia, oliguria, or anuria.

Shock.

[Farthing, 1996]

ORGANISMS THAT CAUSES GASTROENTERITIS

Most infectious diarrhoea is a self-limiting illness, caused by viruses (rather than bacteria or parasites), with nearly half of episodes lasting less than 1 day.

VIRUSES

1). NOROVIRUSES (formerly known as 'Norwalk-like viruses')

Norovirus is the commonest cause of gastroenteritis in England and Wales, with an increased prevalence during colder months.

Infection can occur in people of all ages because immunity is not long lasting.

Symptoms begin 24–48 hours after infection and last for 12–60 hours. Sudden-onset nausea is followed by projectile vomiting and watery diarrhoea. There may be associated fever, headache, abdominal pain, and myalgia. Most people make a full recovery within 1–2 days.

Transmission is person-to-person, usually by the faecal-oral route. It can also be transmitted by consumption of contaminated food (such as oysters) or water, or contact with contaminated surfaces (such as toilets, soft furnishings, or floors), and outbreaks are common in semi-closed environments such as schools, hospitals, care homes, and cruise ships.

2). ROTAVIRUS

This is the most common cause of viral gastroenteritis in children, however, there has been a reduction in disease prevalence since the introduction of the rotavirus vaccine, as part of the UK national childhood immunization programme.

Most cases are transmitted by person-to-person spread by the faecal-oral route, or more rarely by contact with contaminated surfaces. Most cases in the UK occur in winter and spring.

Symptoms include watery diarrhoea and vomiting with or without fever and abdominal pain. Vomiting usually settles within 1–3 days, and diarrhoea within 5–7 days, but can persist for 2 weeks.

Infection in adults is uncommon because immunity is long lasting.

3) ADENOVIRUSES

These commonly cause respiratory tract infections, but can also cause gastroenteritis, particularly in children.

BACTERIA

1). CAMPYLOBACTER JEJUNI AND CAMPYLOBACTER COLI

These are the most commonly reported bacterial causes of infectious intestinal disease in England and Wales, and one of the commonest causes of travellers' diarrhoea in the UK.

Infection may be asymptomatic in 25–50% of people or cause diarrhoea (which may be bloody), nausea, vomiting, abdominal cramps, and fever.

Most cases are self-limiting within 2–3 days and usually resolve within 1 week.

It is usually associated with the consumption of contaminated food and drink, such as undercooked meat (especially poultry), unpasteurised milk, or untreated water, but the source of infection is often not found.

2). ESCHERICHIA COLI (INCLUDING SHIGA TOXIN-PRODUCING E. COLI [STEC] OR VEROCYTOTOXIN-PRODUCING E. COLI [VTEC])

1. coli O157 is the most common serogroup of STEC causing infections in the UK.

In England and Wales, rates of infection are highest in children under 5 years of age, with the peak incidence in children aged 1–4 years.

Infection with E. coli O157:H7 may be asymptomatic, or cause diarrhoea (which may be bloody), fever, abdominal cramps, and vomiting. Illness is usually self-limiting and resolves within 10 days.

1. coli is transmitted through contaminated food, particularly meat, salad products, water, and unpasteurised milk. It can also be transmitted person-to-person by direct contact (faecal-oral route), particularly in households, schools and childcare settings, and care homes; by contact with infected animals (especially cattle, sheep, goats, and other ruminants); or environmental exposure to contaminated water.

3). SALMONELLOSIS (EXCLUDING SALMONELLA TYPHI AND SALMONELLA PARATYPHI CAUSING ENTERIC FEVER).

The majority of cases are sporadic, but outbreaks may occur in the general population and in institutions.

Ingestion of contaminated food is the most common source, such as red and white meats, raw eggs, milk, and dairy products. Person-to-person spread and contact with infected animals can also occur.

Typical features are watery and sometimes bloody diarrhoea, abdominal pain, headache, nausea, vomiting, and fever. The illness usually lasts for 4–7 days, and people usually recover spontaneously.

4). SHIGELLA DYSENTERIAE, SHIGELLA FLEXNERI, SHIGELLA BOYDII, AND SHIGELLA SONNEI

Shigellosis is most commonly transmitted person-to-person by the faecal-oral route, particularly in households, nurseries, and schools. More rarely, it can be transmitted through contaminated food, or sexually transmitted (particularly in men who have sex with men).

Shigellosis occurs most commonly in children less than 5 years of age, but infection can occur in all ages. Infections peak in late summer in the UK.

Typically, 1–3 days after infection, there is diarrhoea (may have blood and mucus), fever, and abdominal cramps, with or without nausea and vomiting, headache, and malaise. Shigellosis usually resolves in 5–7 days.

5) YERSINIA ENTEROCOLITICA

This is a rare infection and occurs most commonly in children.

Common symptoms are watery diarrhoea (which is often bloody), fever, and abdominal pain. In older children and adults, right-sided abdominal pain and fever may occur.

Symptoms typically develop 4–7 days after exposure and may last 2 days to 6 weeks.

1. enterocolitica is transmitted by direct contact with infected animals and person-to-person (faecal-oral route), and through contaminated food (especially raw pork and pork products) and water.

PARASITES

1). CRYPTOSPORIDIOSIS

Cryptosporidium is one of the most common protozoal causes of gastroenteritis in the UK, and about 20% of cases are associated with recent foreign travel.

Infection is transmitted by animal-to-human or human-to-human contact, by occupational or recreational exposure to contaminated land or water, or by consuming contaminated water or food.

It typically causes profuse watery diarrhoea associated with abdominal cramps or pain, nausea, vomiting, fever, and loss of appetite. Symptoms usually last for 1–2 weeks, and recurrence of symptoms is reported in around one-third of cases.

2). ENTAMOEBA HISTOLYTICA (AMOEBIASIS)

Transmission occurs through the ingestion of contaminated food or water. Person-to-person transmission may also occur between household and sexual contacts via the faecal-oral route.

Most cases in the UK are imported by travellers to endemic areas.

90% of cases are asymptomatic. Diarrhoea with or without dysentery occurs in intestinal disease.

Symptoms are often mild diarrhoea and abdominal pain, but severe disease (amoebic dysentery) can occur, causing fever, severe abdominal pain, and blood and mucus in the faeces.

3). GIARDIA INTESTINALIS OR GIARDIA LAMBLIA

Giardiasis can be transmitted by person-to-person spread by the faecal-oral route; by contact with the faeces of infected animals; by consumption of contaminated food or drink; waterborne including swimming in contaminated water; or by sexual transmission, particularly among men who have sex with men. Many cases are associated with recent foreign travel, particularly from South Asia, and it is the most commonly identified pathogen in returning travellers with prolonged diarrhoea.

Symptoms include diarrhoea, malaise, abdominal pain, loss of appetite, flatulence, bloating, and rarely nausea. Malabsorption, weight loss, and faltering growth may occur in children.

FOOD POISONING may be primarily caused by enterotoxins produced by the microorganism (rather than the microorganism itself), and diarrhoea and vomiting usually have a rapid onset and last for less than 24 hours. Cases are often under-reported and under-detected, and are most commonly caused by:

1). CLOSTRIDIUM PERFRINGENS — usually caused by inadequate storage and insufficient reheating of contaminated meat dishes or cooked meats or meat products, for example in institutional catering settings.

2). BACILLUS CEREUS — caused by contaminated cooked foods subjected to inadequate post-cooking temperature control that has allowed bacterial growth (such as reheated rice, pasta, meat or vegetable dishes, and dairy products).

3). STAPHYLOCOCCUS AUREUS — usually found in cooked meats and cream products.

In 40–70% of cases of travellers’ diarrhoea, no specific causative agent is identified.

The risk of developing travellers' diarrhoea depends on the destination, duration of exposure, as well as host factors.

[Barrett, 2016; PHE, 2020a; PHE, 2015; PHE, 2020a; PHE, 2020a; Barrett, 2016; Steffen, 2015].

OTHER CAUSES OF DIARRHOEA INCLUDES

Medicines – check the leaflet to see if it's a side effect

A food intolerance or food allergy

Iirritable bowel syndrome (IBS)

Inflammatory bowel disease

Coeliac disease

Diverticular disease

VOMITING CAN ALSO BE CAUSED BY:

Pregnancy

Migraine

Labyrinthitis

Medicines – check the leaflet to see if it's a side effect

Reflux – where a baby brings feeds back up ("spitting up")

Other infections – such as a urinary tract infection (UTI)

COMPLICATIONS OF GASTROENTERITIS

The risk of complications from gastroenteritis is greatest in infants and young children, pregnant women, the elderly, and people with co-morbid conditions including the immunocompromised. Possible complications include:

1). DEHYDRATION, ELECTROLYTE DISTURBANCE, AND ACUTE KIDNEY INJURY (AKI)

Dehydration from excess fluid loss, electrolyte disturbance, and AKI may follow severe infection, if fluid input does not equal or exceed fluid output. Rarely, severe dehydration can cause hypovolaemic shock, coma, and death.

2). HAEMORRHAGIC COLITIS

This can be a complication from Shiga toxin-producing Escherichia coli (STEC) that typically presents with acute bloody diarrhoea and severe abdominal pain in children lasting for 2 weeks.

3). HAEMOLYTIC URAEMIC SYNDROME (HUS)

This is a rare but potentially life-threatening complication of acute infectious gastroenteritis that occurs mostly in children aged less than 5 years.

About 10% of STEC 0157 cases develop HUS after an initial prodrome of gastroenteritis or haemorrhagic colitis. It may also be associated with Shigella dysenteriae and Campylobacter spp. infection.

It is characterized by AKI, thrombocytopenia, and microangiopathic haemolytic anaemia, usually 1 week after the onset of bloody diarrhoea. About 50% of those affected develop chronic renal complications. Mortality rates are between 3–5%.

4). THROMBOTIC THROMBOCYTOPAENIC PURPURA (TTP)

This primarily affects adults infected with STEC, and can present with fever, flu-like symptoms, petechial haemorrhages on the lower limbs, haematuria, anaemia, renal dysfunction, and possible neurological deficits.

5). REACTIVE ARTHRITIS INCLUDING REITER'S SYNDROME

This may be associated with Campylobacter spp., Shigella flexneri, and Yersinia enterocolitica infection. Reiter's syndrome describes a combination of urethritis, inflammatory arthritis, and uveitis.

6). AORTITIS, OSTEOMYELITIS

These may be associated with Salmonella spp. and Yersinia spp. Infection.

7). SEPSIS

Invasive infection with Salmonella spp. and Yersinia enterocolitica may lead to sepsis.

8). TOXIC MEGACOLON

This can rarely occur in people with rotavirus gastroenteritis or severe travellers' diarrhoea, for example:

Pancreatitis, sclerosing cholangitis, and liver cirrhosis

This may complicate Cryptosporidium spp. infection, particularly in the immunocompromised.

9). FALTERING GROWTH

Infection with Giardia spp. can cause weight loss due to malabsorption, and chronic infection in children can lead to faltering growth.

9). CHRONIC DIARRHOEA

Chronic intractable diarrhoea for weeks, months, or longer may occur with Giardia spp. and Cryptosporidium spp. infection and viral gastroenteritis, particularly in people who are immunocompromised.

10). IRRITABLE BOWEL SYNDROME (IBS)

Gastrointestinal infection including travellers' diarrhoea is a risk factor for the development of post-infectious IBS. It affects between 3% and over 30% of people after infectious gastroenteritis.

11). INFLAMMATORY BOWEL DISEASE (IBD)

There is an increased risk of incident IBD following non-typhoidal salmonella, Campylobacter spp., and Clostridium difficile infections.

12). ACQUIRED OR SECONDARY LACTOSE INTOLERANCE

Lactase deficiency occurs in up to 40% of people with giardiasis, and can persist for several weeks after parasite eradication.

13). GUILLAIN-BARRÉ SYNDROME

Guillain-Barré syndrome is associated with different viruses, and may be rarely associated with Campylobacter spp. Infection.

14). MENINGITIS

Infants under 3 months of age with Salmonella spp. infection are at particularly high risk.

15). INVASIVE ENTAMOEBA INFECTION

Rarely, extraintestinal disease occurs when Entamoeba histolytica invades the liver causing abscesses, which can be life threatening,

[Banyai, 2018; Guarino, 2014; Shane, 2017; PHE, 2020a; PHE, 2017; Barrett, 2016; Minetti, 2016; Schwille-Kiuntke, 2015; Riddle, 2017; Keithlin, 2015; Axelrad, 2020].

DIARRHOEA AND VOMITING CAN SPREAD EASILY

. Stay off school or work until you've not been sick or had diarrhoea for at least 2 days.

. If you also have a high temperature or do not feel well enough to do your normal activities, try to stay at home and avoid contact with other people until you feel better.

HOW TO TREAT DIARRHOEA AND VOMITING YOURSELF

You can usually treat yourself or your child at home. The most important thing is to have lots of fluids to avoid dehydration.

Do stay at home and get plenty of rest

Drink lots of fluids, such as water or squash – take small sips if you feel sick

Carry on breast or bottle feeding your baby – if they're being sick, try giving small feeds more often than usual.

Eat when you feel able to – you do not need to eat or avoid any specific foods

Take paracetamol if you're in discomfort.

Do not have fruit juice or fizzy drinks – they can make diarrhoea worse

Do not make baby formula weaker – use it at its usual strength

Do not give children under 12 medicine to stop diarrhoea

IN ADULTS AT INCREASED RISK OF DEHYDRATION (SUCH AS THE ELDERLY, IMMUNOCOMPROMISED, THOSE WITH CO-MORBID CONDITIONS OR CONCURRENT ILLNESS):

Use oral rehydration salt (ORS) solution as supplemental fluid.

IN ADULTS WITH SYMPTOMS  OF DEHYDRATION WHO CAN SAFELY BE MANAGED AT HOME:

Use ORS solution frequently and in small amounts, such as 200–400 mL to be given after every loose motion, dose according to fluid loss, to rehydrate the person.

AFTER REHYDRATION:

.Gradually reintroduce usual diet, small, light, non-fatty, non-spicy meals may be better tolerated.

. Drug treatment with antidiarrhoeal (or antimotility) drugs, antiemetics, and probiotics is not routinely recommended for use in adults in primary care.

Antidiarrhoeal drugs such as Loperamide may be useful for symptom relief in adults with mild-to-moderate diarrhoea, for example, if rapid resolution would enable the person to resume essential activities.

These are available to purchase over-the-counter, but should not be used if a person has:

a). Blood, mucus, and/or pus in the stools or high fever (suggesting possible dysentery).

b). Shigellosis or confirmed, probable, or suspected Shiga toxin-producing Escherichia coli 0157 (STEC) infection, following stool culture and sensitivity testing.

METHODS TO PREVENT TRANSMISSION OF INFECTION:

.Wash hands thoroughly with liquid soap in warm running water, and dry carefully.

. Always use a flush toilet, if possible.

.If a commode or bedpan must be used, it should be handled with gloves, the contents disposed of into the toilet, and the container then washed with hot water and detergent and allowed to dry.

.Wash hands after going to the toilet and changing nappies, and before preparing, serving, or eating food.

.Toilet seats, flush handles, wash-hand basin taps, surfaces, and toilet door handles should be cleaned at least once daily with hot water and detergent. A disinfectant and disposable cloth (or one dedicated for toilet use) should be used to clean toilets.

.Do not share towels and flannels used by the infected person.

.Wash soiled clothing and bed linen separately from other clothes and at a high temperature (for example 60°C or higher for cotton), after removal of excess faecal matter or vomitus into the toilet. Soaking in disinfectant is not necessary. The washing machine should not be more than half full to allow for adequate washing and rinsing.

Do not attend work or other institutional/social settings until at least 48 hours after the last episode of diarrhoea or vomiting.

Note: if cryptosporidiosis or giardiasis is suspected or confirmed, the person should not go swimming for 2 weeks after the last episode of diarrhoea.

SEEK URGENT MEDICAL ADVICE IF THERE ARE:

.You or your child (over 5 years) still have signs of dehydration after using oral rehydration sachets

You or your child keep being sick and cannot keep fluid down

You or your child have bloody diarrhoea or bleeding from the bottom

You or your child have diarrhoea for more than 7 days or vomiting for more than 2 days

CALL 999 OR GO TO A&E IF YOU OR YOUR CHILD:

Vomit blood or have vomit that looks like ground coffee

Have green or yellow-green vomit

Might have swallowed something poisonous

Have a stiff neck and pain when looking at bright lights

Have a sudden, severe headache or stomach ache

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