Gastroenteritis is a condition that causes irritation and inflammation of the stomach and intestines (the

gastrointestinal tract). The most common symptoms are

diarrhea,
nausea, and
crampy abdominal pain,
vomiting.
Many people also refer to gastroenteritis as "stomach flu." This can sometimes be confusing
because influenza (flu) symptoms include
headache,
muscle aches and pains, and
respiratory symptoms, but influenza does not involve the gastrointestinal tract.
The term stomach flu presumes a viral infection, even though there may be other causes of infection.
Viral infections are the most common cause of gastroenteritis but bacteria, parasites, and foodborne
illnesses (such as shellfish) can also be the offending agents. Many people !ho e"perience vomiting and
diarrhea that develops from these types of infections or irritations thin# they have "food poisoning," !hen
they actually may have a foodborne illness.
Travelers to foreign countries may e"perience "traveler$s diarrhea" from contaminated food and unclean
!ater.
The severity of infectious gastroenteritis depends on the immune system$s ability to resist the
infection. %lectrolytes (these include essential elements of sodium and potassium) may be lost as the
affected individual vomits and e"periences diarrhea.
Most people recover easily from a short episode of vomiting and diarrhea by drin#ing fluids and gradually
progressing to a normal diet. &ut for others, such as infants and the elderly, the loss of bodily fluid !ith
gastroenteritis can causedehydration, !hich is a lifethreatening illness unless the condition is treated and
fluids are restored.
The most recent data from the '(', sho!s that deaths from gastroenteritis have increased dramatically.
)n *++,, -,,+++ people died from gastroenteritis, over!helmingly, these people !ere older and the most
common infections !ereClostridium difficile and norovirus.
Gastroenteritis has many causes. Viruses and bacteria are the most common.
Viruses and bacteria are very contagious and can spread through the consumption contaminated food or
!ater. )n up to .+/ of diarrheal outbrea#s, no specific agent is found. The infection can spread from
person to person because of improper hand!ashing follo!ing a bo!el movement or handling a soiled
diaper.
Gastroenteritis caused by viruses may last one to t!o days. 0o!ever, some bacterial cases can continue
for a longer period of time.
Viruses
Norovirus 1ifty to seventy percent of cases of gastroenteritis in adults are caused
bynoroviruses (genus Norovirus, familyCaliciviridae). This virus is highly contagious and spreads rapidly.
2orovirus is the most common cause of gastroenteritis in the 3nited 4tates.
2oroviruses can be transmitted by
o consuming contaminated food and li5uids,
o touching ob6ects contaminated !ith norovirus and then placing the hands or fingers in
the mouth,
o direct contact !ith an infected individual (for e"ample, e"posure to norovirus !hen
caring for or sharing foods, drin#s, eating utensils !ith an affected individual, and
o e"posure to infected individuals and ob6ects in daycare centers and nursing homes.
2orovirus is often in the ne!s !hen cruise ship passengers contract the virus causing
gastroenteritis.
Rotavirus 7ccording to the '(', "8otavirus !as also the leading cause of severe diarrhea in 3.4.
infants and young children before rotavirus vaccine !as introduced for *++9. :rior to that, almost all
children in the 3nited 4tates !ere infected !ith rotavirus before their .th birthday. %ach year in the 3nited
4tates in the prevaccine period, rotavirus !as responsible for more than ;++,+++ doctor visits< more than
*++,+++ emergency room visits< ..,+++ to ,+,+++ hospitalizations< and *+ to 9+ deaths in children
younger than . years of age."
=ther viruses that cause gastrointestinal symptoms include>
Adenoviruses This virus most commonly causes respiratory illness< ho!ever, other illnesses may be
caused by adenoviruses such as gastroenteritis, bladder infections, and rash illnesses.
Parvoviruses - The human bocavirus (0&oV), !hich can cause gastroenteritis belongs to the family
:arvoviridae.
Astroviruses 7strovirus infection is the third most fre5uent cause of gastroenteritis in infants.
Bacteria
&acteria may cause gastroenteritis directly by infecting the lining of the stomach and intestine. 4ome
bacteria such as Staphylococcus aureus produce a to"in that is the cause of the symptoms. 4taph is a
common type of food poisoning.
Escherichia coli infection can cause significant complications. E. coli =-.,>0,(one type of the bacteria)
can cause complications in appro"imately -+/ of affected individuals (for e"ample, #idney failure in
children ?hemolyticuremic syndrome or 034), bloody diarrhea, and thrombotic thrombocytopenic purpura
(TT:) in the elderly.
Salmonella, Shigella and Campylobacter
Salmonella, Shigella and Campylobacter are also common causes of illness.
Salmonella is contracted by ingesting the bacteria in contaminated food or !ater, and by
handling poultry or reptiles such as turtles that carry the germs.
Campylobacter occurs by the consumption of ra! or undercoo#ed poultry meat and cross
contamination !ith other foods. )nfants may ac5uire the infection by contact !ith poultry pac#ages in
shopping carts. 'ampylobacter is also associated !ith unpasteurized mil# or contaminated !ater. The
infection can be spread to humans by contact !ith infected stool of an ill pet (for e"ample, cats or
dogs). )t is generally not passed from human to human.
Shigella bacteria generally spreads from an infected person to another person.Shigella are
present in diarrheal stools of infected individuals !hile they are ill, and for up to one to t!o !ee#s after
contracting the infection. Shigellainfection also may be contracted by eating contaminated food,
drin#ing contaminated !ater, or s!imming or playing in contaminated !ater (for e"ample, !ading
pools, shallo! play fountains). 4higella can also spread among men !ho have se" !ith men.
Clostridium difficile
Clostridium difficile (C difficile) bacteria may overgro! in the large intestine after a person has been
on antibiotics for an infection. The most common antibiotics that pose a potential ris# for C
difficile include>
clindamycin (for e"ample, 'leocin),
fluoro5uinolones (for e"ample, levoflo"acin ?@eva5uinA, ciproflo"acin ?'ipro, 'irpo B8, :ro5uin
B8A),
penicillins, and
cephalosporins.
=ther ris# factors for C difficile infection are hospitalization, individuals 9. years of age or older, and
e"isting chronic medical conditions.
The '(' lists C. Difficile as one of the most common causes of death due to gastroenteritis and suggest
that ne! strains of the bacteria have become more aggressive and dangerious.
Parasites and Protozoans
These tiny organisms are less fre5uently responsible for intestinal irritation. 7 person may become
infected by one of these by drin#ing contaminated !ater. 4!imming pools are common places to come in
contact !ith these parasites. 'ommon parasites include
Giardia is the most fre5uent cause of !aterborne diarrhea, causing giardiasis. =ften, people
become infected after s!allo!ing !ater that has been contaminated by animal feces (poop). This may
occur by drin#ing infected !ater from river or la#es but giardia may also be found in s!imming pools,
!ells and cisterns.
Cryptosporidium ('rypto) is a parasite that lives in the intestine of affected individuals or animals.
The infected individual or animal sheds theCryptosporidium parasite in the stool. 'rypto may also be
found in food, !ater, soil, or contaminated surfaces (s!allo!ing contaminated !ater, beverages,
uncoo#ed food, un!ashed fruits and vegetables, touching contaminated surfaces such as bathroom
fi"tures, toys, diaper pails, changing tables, changing diapers, caring for an infected individual or
handling an infected co! or calf). Those at ris# for serious disease are individuals !ith !ea#ened
immune systems.
Other Common Causes of Gastroenteritis
Gastroenteritis that is not contagious to others can be caused by chemical to"ins, most often found in
seafood, food allergies, heavy metals, antibiotics, and other medications.
Gastroenteritis Symptoms
&y definition, gastroenteritis affects both the stomach and the intestines, resulting in vomiting and
diarrhea.
Common astroenteritis symptoms
@o! grade fever to -++ 1 (C,., ')
2ausea !ith or !ithout vomiting
Mildtomoderate diarrhea
'rampy painful abdominal bloating (The cramps may come in cycles, increasing in severity until
a loose bo!el movement occurs and the pain resolves some!hat.)
!ore serious symptoms of astroenteritis
&lood in vomit or stool (blood in vomit or stool is never normal and the affected individual should
call or a visit a health care professional.)
Vomiting more than ;D hours
1ever higher than -+- 1 (;+ ')
4!ollen abdomen or abdominal pain
(ehydration !ea#ness, lightheadedness, decreased urination, dry s#in, dry mouth and lac# of
s!eat and tears are characteristic signs and symptoms.
"hen to See# !edica$ Care
Most often gastroenteritis is selflimiting, but it can cause significant problems !ith dehydration. 4hould
that be a concern, contacting a primary care professional is reasonable.
Vomiting blood or having bloody or blac# bo!el movements are not normal, and emergency care should
be sought. 4ome medications such as iron or bismuth subsalicylate (:epto&ismol) can turn stool blac# in
color.
1ever, increasing severity of abdominal pain, and persistent symptoms should not be ignored and see#ing
medical care should be considered.
Gastroenteritis %ianosis
Gastroenteritis is often selflimiting, and the care is supportive designed to control symptoms and prevent
dehydration. Tests may not be needed.
)f the symptoms persist for a prolonged period of time, the health care professional may consider blood
and stool tests to determine the cause of the vomiting and diarrhea.
Patient &istory and Physica$ '(amination
Ta#ing a thorough history and physical e"amination is very helpful in accessing the diagnosis.
Euestions as#ed by the health care professional may include>
-. 0ave any other family members or friends had similar e"posure or symptomsF
*. Ghat is the duration, fre5uency, and description of the patient$s bo!el movements, and is
vomiting presentF
C. 'an the patient tolerate any fluids by mouthF
These 5uestions help determine the potential ris# of dehydration and may also include as#ing 5uestions
about the amount and fre5uency of urination, !eight loss, lightheadedness, andfainting (syncope).
=ther information in the medical history that may be helpful in the diagnosis of gastroenteritis include>
)rave$ history* Travel may suggest E. coli bacterial infection or a parasite infection ac5uired
from something the patient ate or dran#. 2orovirus infections tend to occur !hen many people are
confined to a close space (for e"ample, cruise ship).
'(posure to poisons or other irritants* 4!imming in contaminated !ater or drin#ing from
suspicious fresh !ater such as mountain streams or !ells may indicate infection !ith Giardia an
organism found in !ater.
%iet chane, food preparation ha+its, and storae* Ghen the disease occurs follo!ing
e"posure to undercoo#ed or improperly stored or prepared food (for e"ample foods at picnics and
&&Es that should be refrigerated to avoid contamination), food poisoning must be considered. )n
general, symptoms caused by bacteria or their to"ins !ill become apparent after the follo!ing amount
of time>
o Staphylococcus aureus in * to 9 hours
o Clostridium D to -+ hours
o Salmonella in -* to ,* hours
!edications* )f the patient has used antibiotics recently, they may have antibioticassociated
irritation of the gastrointestinal tract, caused byclostridium difficile infection.
:hysical e"amination !ill e"plore the reasons for symptoms that may not be related to infection. )f there
are specific tender areas in the abdomen, the health care practitioner may !ant to determine if the patient
has appendicitis, gallbladder disease, pancreatitis, diverticulitis, or other conditions that may be the cause
of the patient$s symptoms.
=ther noninfectious gastrointestinal diseases such as 'rohn$s disease, ulcerative colitis, or microscopic
colitis also must be considered. The health care practitioner !ill feel the abdomen for masses. 7 rectal
e"amination may be considered, in !hich the physician inspects the anus for any abnormalities and then
inserts a finger in the rectum to feel for any masses. 4tool obtained during this test may be tested for the
presence of blood.
The health care practitioner may perform other laboratory tests, including complete blood
count ('&'), electrolytes, and #idney function tests. 4tool samples may be collected and tested for blood
or different types of infection.
Gastroenteritis !edica$ )reatment
3pon see#ing medical attention, if the patient cannot ta#e fluids by mouth because of vomiting, the health
care practitioner may insert an )V to replace fluids bac# into the body (rehydration).
)n infants, depending upon the level of dehydration, intravenous fluids may be delayed in order to
attempt oral rehydration therapy. 1re5uent feedings, as small as a -H9 ounce (. cc) at a time, may be
used to restore hydration.
Gastroenteritis !edications
7ntibiotics are usually not prescribed until a bacteria or parasite has been identified as the cause of the
infection. 7ntibiotics may be given for certain bacteria, specifically Campylobacter,Shigella, and Vibrio
cholerae, if properly identified through laboratory tests. =ther!ise, using any antibiotic or the !rong
antibiotic can !orsen some infections or ma#e them last longer.
7ntibiotics are not used to treat virus infections.
4ome infections, such as salmonella, are not treated !ith antibiotics. Gith supportive care comprising of
fluids and rest, the body is able to fight and resolve the infection !ithout antibiotics.
1or adults, the health care practitioner may prescribe medications to stop the vomiting (antiemetics) such
as promethazine(:henergan, 7nergan), prochlorperazine('ompazine), or ondansetron (Iofran).
4ometimes these medications are prescribed as a suppository. (octors usually do not recommend
antiemetics for infants, but depending upon the situation, older children may be prescribed an antiemetic
(antinausea) medication in a lo!er dosage.
7ntidiarrhea medications are not usually recommended if the infection is associated !ith a to"in that
causes the diarrhea. The most common antidiarrheal agents for people older than C years of age include
overthecounter (=T') medications such as dipheno"ylateatropine (@omotil, @ofene, @ono")
or loperamidehydrochloride ()modium).
Gastroenteritis Prevention
Gith most infections, the #ey is to bloc# the spread of the organism.
7l!ays !ash your hands.
%at properly prepared and stored food.
&leach soiled laundry.
Vaccinations for Vibrio cholerae, androtavirus have been developed. 8otavirus vaccination is
recommended for infants in the 3.4. Vaccines for V. cholerae may be administered to individuals
traveling to atris# areas.
ymptoms of Salmonella ,nfection
The symptoms of Salmonella infections depend on the overall health of the infected person (for e"ample,
normal or !ith a suppressed immune system) and the particular serovar infecting the patient. )n general,
normal people contract 4. spp (for e"ample, serovars S. enteritidis, S. cholerasuis) that usually cause a
selflimitingdiarrhea, nausea, and vomiting termed salmonellosis or S. gastroenteritis. 1ever may be
present but usually lasts only one to three days, !ith all the symptoms resolving in about three to seven
days. This gastroenteritis is not al!ays traced to the bacterial source and is sometimes simply termed
"food poisoning," a term used to describe similar symptoms caused by several different bacterial,
parasitic, and viral organisms (for e"ample, E. coli,Giardia, and rotavirus). Those !ith a suppressed
immune system, the elderly, and neonates may develop more severe symptoms (for e"ample, bacteremia
or sepsis).
1ever and the above mentioned symptoms lasting over seven to -+ days suggest infection !ith the more
virulent serovars, S. typhi or S. paratyphi. S. typhi causes typhoid fever, !hich includes symptoms of a
high fever (-+; 1),abdominal pains, s!eating, and confusion. 7bout .+/ of patients develop a slo!
heartbeat (bradycardia), and about C+/ get slightly raised red or rosecolored spots on the chest and
abdomen. S. paratyphi causes paratyphoid fever, a disease similar to but !ith less severe symptoms than
typhoid fever. 4ome untreated patients that become infected !ith S. typhi orS. paratyphi and are
other!ise healthy !ill resolve the infection in about one month, but others can suffer complications (for
e"ample, becoming a carrier of the organism, developing organ infections, sepsis, and potentially death).
&o- %o Salmonella spp Cause %isease.s/0
The ma6ority of Salmonella spp are ingested !ith food or !ater. )n people !ith normal gastrointestinal
tracts and immune systems, researchers have estimated that about - million to - billion 4. spp need to be
ingested to cause infection, because normal human stomach acid can #ill large numbers of these
bacteria. )f some bacteria reach the intestine, the organisms can attach to intestinal cells !here 4. spp
to"ins (cytoto"in and enteroto"in) can damage and #ill cells. The intestinal cell damage results in the
inability of the body to normally retain and adsorb fluids, so diarrhea results. )n some people, the diarrhea
can cause serious dehydration. 0o!ever, the ma6ority of 4. spp infections are then eventually eliminated
by the person$s immune defenses. 4ome 4. spp are not eliminated< these bacteria survive the initial
immune response by living inside cells (macrophages) of the immune system. The bacteria can
sometimes spread to the blood (bacteremia). 4ome 4. spp (for e"ample,S. typhi) can also enter the
gallbladder and remain there. The patient can recover from the disease but still sheds bacteria through
the gallbladder secretions (bile) into the feces. This person thus becomes a carrier of 4. spp and
potentially can infect many others, especially if the person lives in unsanitary conditions or !or#s in the
foodprocessing industry.
Ris# 1actors for Salmonella ,nfection
The greatest ris# factor for getting a Salmonellainfection is ingesting the bacteria in contaminated food or
!ater. 7nother high ris# factor for people in industrialized countries is eating and drin#ing !hen visiting in
a developing country !here sources of food and drin# may be contaminated. 0o!ever, even
industrialized countries li#e the 3.4. can have outbrea#s ofSalmonella infection if a food or !ater source
is not properly sanitized or screened for contamination. 7n e"ample !as a recent (*++D*++J) outbrea#
of Salmonella infections that !ere traced to a peanut processing plant that sold processed peanut
material (paste) that !as subse5uently put into many food products (candy, coo#ies, ice cream, cereals,
dog food). This contaminated paste caused about 9++,++ cases of salmonella in ;9 states< more than
-*. products !ere eventually recalled and the company plant closed.
%ating ra! meat or ra! eggs or eating un!ashed vegetables or fruits also increases the ris#
of Salmonella infection. )n *++D, ra! tomatoes !ere lin#ed to over
-9+ Salmonellainfections. Salmonella can be cultivated from animals, birds, and reptiles< outbrea#s have
been lin#ed to e"posure to turtles, sna#es, and house pets. 7ny dusty, dirty material may
carry Salmonella as !ell as mycotic (fungal) diseases as most animal, reptile, and bird feces may contain
these infectious agents. 'onse5uently, eating !ell cleaned and thoroughly coo#ed foods decreases the
ris# of e"posure to Salmonella and other infectious agents.
%ianosis of Salmonella ,nfection
Many cases are first suspected !hen a physician or public health official recognizes a group of patients
that ate food from a similar source have developed fever and diarrhea. The definitive diagnosis of
all Salmonella infections is based on culture of the organisms from the patient and occasionally from a
source (for e"ample, food , !ater). )n most cases, the feces of the patient is cultured on agar media that is
selective for Salmonella spp. 3nfortunately, these culture results can ta#e three to seven days to obtain.
7lthough rapid tests such as polymerase chain reaction (:'8) that detect the genetic material of the
bacteria have been attempted, :'8 does not seem sensitive enough to detect the organisms in feces
(about ;,/ sensitive). )nvestigators suggest that the sensitivity of :'8 is good !hen performed on a
blood sample rather than feces (D;/J./ after five days of infection), but this test is not !idely available.
&lood cultures are sometimes done in patients suspected of having typhoid and paratyphoid fevers< they
are positive in about .+/,+/ of patients. 'ulture results, !hen positive, help the physician to
differentiate Salmonella infections from other infections that may have similar initial symptoms (for
e"ample, shigellosis, brucellosis, amebic dysentery, botulism). =ften rectal or fecal e"ams are done to
determine if the patient has blood in the feces. Many physicians !ill empirically treat patients
!ithantibiotics if they sho! blood in the feces because some physicians consider the infection more li#ely
to be caused by an aggressive bacterial agent. )f the patient$s infection is severe, other ancillary tests may
be done ('T scan, ultrasound, '&' count, liver function tests, biopsy) to help determine the e"tent of the
infection.
Comp$ications of Salmonella ,nfection
The ma6ority of patients !ith salmonellosis have no complications. 0o!ever, patients that are immune
compromised may develop some complications similar to those for typhoid fever. 'omplications that may
occur !ith typhoid fever (and less fre5uently for paratyphoid fever) are numerous and occur in about C+/
of untreated or undertreated infections. The patient may e"hibit one or more complications, !ith a
mortality rate (death) of about -/*/. The follo!ing is a partial list of some of the most serious
complications of typhoid fever>meningitis, psychosis, hydrocephalus, sepsis, intestinal
perforation, myocarditis, abscesses,aortic aneurysm, nephritis, and a persistent carrier state. There are
many other problems that can occur !ith most organ systems in the body. %arly diagnosis and
appropriate antibiotic therapy greatly reduce the complication rate.
"hat is the pronosis .outcome/ for patients infected -ith Salmonella0
The prognosis for salmonellosis is very good since it is a selflimiting disease in about D+/ of patients.
%ven immunosuppressed patients can do !ell if the disease is diagnosed and treated promptly.
'omplications occur if patients become dehydrated or if the disease is caused by aggressive or drug
resistant serovars.
:atients diagnosed !ith paratyphoid fever usually do !ell and develop fe!er complications than patients
!ith typhoid fever. )f patients !ith paratyphoid or typhoid fever are diagnosed early and appropriate
antibiotics are given, fe! or no complications develop and the patients recover. 3ntreated cases of
typhoid result in about C+/ of patients developing complications that can be severe and result in
permanent disability or death. :atients infected !ith S. typhi serovars that are resistant to multiple drugs
have a !orse prognosis and can develop more complications.
Prevention of Salmonella ,nfections
1or all Salmonella diseases, the #ey to prevention is proper hygiene and enforcement of public health
rules and regulations. :roper hygiene starts !ith hand !ashing !ith soap and !ater before eating and
especially after handling any ra! foods such as eggs, meat, or produce. 7voiding direct contact !ith
carriers ofSalmonella (for e"ample, turtles, sna#es, pigs, typhoid patients) reduces the chance of
infection. :ublic health practices such as chlorination of drin#ing !ater, enforcing restaurant cleanliness
and employee hand !ashing, and not allo!ing human carriers ofSalmonella to !or# in the foodhandling
industry further reduce the chance ofSalmonella e"posure. :erhaps the most famous failure of public
health measures !as in -J+, !hen a coo# named Mary Mallon (Typhoid Mary) !as suspected of
infecting hundreds of individuals !ith a S. typhi serovar.
'urrently, there is no vaccine available to prevent salmonellosis, and the '(' does not recommend the
general population be vaccinated against S. typhi serovars. 0o!ever, the '(' does recommend that
individuals going to developing countries !here typhoid fever is endemic (some regions in 7frica, 7sia,
and @atin 7merica) be vaccinated !ith a typhoid vaccine. There are t!o types of vaccines currently
available to individuals. Ty*-a is an oral vaccine that re5uires four doses administered t!o !ee#s before
travel, !hile Vi':4 vaccine is in6ected once and re5uires only one dose administered one !ee# before
travel. The Ty*-a immunization re5uires a booster every five years !ith the minimum vaccination age of 9
years, !hile Vi':4 re5uires a booster every t!o years !ith a minimum vaccination age of * years. Gor#
is in progress to develop additional vaccines for all Salmonella infections.