Transcript CPG on Acute Gastroenteritis

CPG on Acute Gastroenteritis
Acute Gastroenteritis
Acute gastroenteritis is a disease characterized by
changes in the character and frequency of stool.
It can be defined as the passage of a greater number of
stools of decreased form from the normal lasting less
than 14 days.
Generally associated with other signs or symptoms
including nausea, vomiting, abdominal pain and cramps,
increase in intestinal gas-related complaints, fever,
passage of bloody stools (dysentery), tenesmus
(constant sensation of urge to move bowels), and fecal
urgency. (1)
(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.
Acute Gastroenteritis
Perform initial assessment
Dehydration
Duration (>1 day)
Inflammation (indicated by fever, presence
of 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
Journal of Medicine. 2004; 350:38-47.
Acute Gastroenteritis
Complete blood count can be obtained to look
for anemia, hemoconcentration, or an abnormal
white blood cell count. (4)
Measurements of serum electrolyte
concentrations and blood urea nitrogen and
serum creatinine levels can be used to
determine the extent of fluid and electrolyte
depletion and its effect on renal function. (4)
(4) Sleisenger and Fordtran’s Gastrointestinal and Liver Disease. 8th edition. 2006. Feldman, Mark
MD. Volume II. p169.
Acute Gastroenteritis
Provide symptomatic treatment
Rehydration
Treatment 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
Acute Gastroenteritis
Initial rehydration
The most common risk with diarrheal illnesses is
dehydration.
The critical initial treatment must include rehydration,
which can be accomplished with an oral glucose or
starch-containing electrolyte solution in the vast majority
of cases.
Although many patients with mild diarrhea can prevent
dehydration by ingesting extra fluids (such as clear
juices and soups), more severe diarrhea, postural lightheadedness, and reduced urination signify the need for
more rehydration fluids. (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.
Acute Gastroenteritis
Prevention of Dehydration
It is recommended that continued use of the
patient’s preferred, usual, and appropriate diet
be encouraged to prevent or limit dehydration.
Regular diets are generally more effective than
restricted and progressive diets, and in
numerous trials have consistently produced a
reduction in the duration of diarrhea. (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].
Acute Gastroenteritis
The use of BRAT diet (consisting of bananas,
rice, apple, and toast) with avoidance of milk
products (since a transient lactase deficiency
may occur) is commonly recommended,
although supporting data are limited. (3)
Clear liquids are not recommended as a
substitute for oral rehydration solutions (ORS) or
regular diets in the prevention or therapy of
dehydration. (5)
(3) Practice Guidelines for the Management of Infectious Diarrhea. Infectious diseases Society of America. Clinical Infectious Diseases 2001;
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
years. Cincinnati (OH): Cincinnati Children’s Hospital Medical Center; 2006 May. 15 p. [50 references].
Acute Gastroenteritis
Oral Feeding Following Rehydration
> It is recommended that giving the patient’s usual diet
be started at the earliest opportunity after an adequate
degree of rehydration is achieved. (5)
On-going IV or NG Fluids following Rehydration
> It is recommended that maintenance IV fluids or NG
ORS be given:
– • when unable to replace the estimated fluid deficit and keep up
with the on-going losses using oral feedings alone, and/or
– • to 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
through 5 years. Cincinnati (OH): Cincinnati Children’s Hospital Medical Center; 2006 May. 15 p. [50 references].
Acute Gastroenteritis
Stratify subsequent management according to
clinical and epidemiologic features
Epidemiologic 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;
350:38-47
Acute Gastroenteritis
When to admit?
Persistent Diarrhea (>7 days) (2)
Fever
Unstable
Severely dehydrated
Bloody diarrhea
Persistent Vomiting
No improvement after initial hydration or symptoms
exacerbate/ overall condition gets worse (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;
350:38-47
(6) World Gastroenterology Organisation (WGO). WGO practice guideline: acute diarrhea. Munich, Germany: World Gastroenterology
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 patients
If symptoms recur or are uncontrolled despite hydration
and antimicrobial treatment....
If evidence of colitis is present,
Do:
– Proctosigmoidoscopy with biopsy of lesions with
attention to CMV, mycobacteria, Adenovirus, Fungi,
Herpes simplex
(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.
Immunocompromised patients
If symptoms recur or are uncontrolled despite
hydration and antimicrobial treatment....
If evidence of colitis is NOT present,
Do:
-Gastroduodenoscopy with biopsy, Smears and
culture for special parasites plus
proctosigmoidoscopy
(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.
Acute Gastroenteritis
When to discharge?
– Stable Vital signs
– Maintains a sufficient fluid intake
– Able to eat meals adequately
– Able to take medications (if still indicated) (6)
(6) World Gastroenterology Organisation (WGO). WGO practice guideline: acute diarrhea. Munich, Germany: World Gastroenterology
Organisation (WGO); 2008 Mar.
Patient Education
Many diarrheal diseases can be prevented by
following simple rules of personal hygiene and
safe food preparation.
Hand-washing with soap is an effective step in
preventing spread of illness and should be
emphasized for caregivers of persons with
diarrheal illnesses.
As noted above, human feces must always be
considered potentially hazardous, whether or not
diarrhea or potential pathogens have been
identified. (3)
(3) Practice Guidelines for the Management of Infectious Diarrhea. Infectious diseases Society of America. Clinical Infectious Diseases 2001; 32:331–50.
Patient Education
Consequently, microbial studies should not be
needed to justify careful attention to hygiene.
Select populations may require additional
education about food safety, and health care
providers can play an important role in providing
this information. (3)
(3) Practice Guidelines for the Management of Infectious Diarrhea. Infectious diseases Society of America. Clinical
Infectious Diseases 2001; 32:331–50.
THANK YOU!
Clinical Pathway for Acute Gastroenteritis with Severe
dehydration
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1st 30 minutes
2nd 30 minutes to 2 hrs
2 hrs to 24 hours
AGE documented based on history and
physical examination
Assess patient as stable or unstable
Response to treatment
assessed
Presence of urine output
Stable vital signs
Response to treatment
assessed
Presence of urine
output
History
Onset frequency, quantity Character bile/blood/mucusFeverVomiting
Past medical history, underlying medical
conditions
Epidemiological clues (food, antibiotics, sexual
activity, travel, outbreaks, season)
Signs of dehydration in adults
Decreased sensorium (severe dehydration)
Tachycardia
Postural hypotension
Supine hypotension and absence of palpable
pulse
Dry tongue
Sunken eyeballs Skin pinch/turgor
Decrease urine output
Stable vital signs
Clinical Pathway for Acute Gastroenteritis with
Severe dehydration
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1st 30 minutes
2nd 30 minutes to 2
hrs
2 hrs to 24 hours
Serum electrolytes
BUN, creatinine
CBC
Fecalysis
Stool for c. difficile toxin (if with
recent/chronic antibiotic use)
ABG (if with decreased sensorium/
tachypneic/ dyspneic)
RBS (if with decreased sensorium
Follow up result of
tests
Serum electrolytes
and BUN, creatinine
monitored at
appropriate intervals
(every 24 hours)
Clinical Pathway for Acute Gastroenteritis with
Severe dehydration
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1st 30 minutes
2nd 30 minutes to 2
hrs
2 hrs to 24 hours
IV Line or Central vein catheter for
rapid fluid delivery
Oxygen by nasal cannula (if
tachpneic/ dyspneic)
Elevate patient’s feet and legs (if
with hypotension
IV Hydration
correct fluid and
electrolyte
disturbances
Adjust IV fluids
accordinglycorrect
fluid and electrolyte
disturbances start
oral hydration (if
tolerated) of
preferred diet
Clinical Pathway for Acute Gastroenteritis with
Severe dehydration
1st 30 minutes
M IV Hydration
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2nd 30 minutes to 2 hrs
2 hrs to 24 hours
Metoclopramide for recurrent
or persistent vomiting
Treatment of symptoms (if
necessary loperamide if
diarrhea is not inflammatory
or bloody)
Continue medications
Consider antimicrobial
treatment for specific
pathogens
Clinical Pathway for Acute Gastroenteritis with
Severe dehydration
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1st 30 minutes
2nd 30 minutes to 2 hrs
2 hrs to 24 hours
Relatives are Informed
on the condition of the
patient
Relatives are Informed on need
to have continued fluid
replacement
Request for renal, pulmonary and
cardiac support (if needed)
Relatives are
Updated on the
patient’s condition