Acute Gastroenteritis

Gastroenteritis is a common pediatric condition that is the second most common reason
for unscheduled visits to the pediatrician after respiratory infections. Approximately 1 in 50
children in developing nations is hospitalized for acute gastroenteritis during childhood.
Estimated incidence in children less than 5 years old is between 1.3-2.3 episodes per child per
year. There are over 1 billion cases of gastroenteritis worldwide. Hospitalizations for viral
gastroenteritis peak in the winter with 70-90% of virally associated gastroenteritis occurring
during that season. Gastroenteritis refers to infections of the gastrointestinal tract that may be
caused by viral, bacterial or parasitic pathogens and are commonly foodborne illnesses. The
enteric pathogens generally produce symptoms of diarrhea, vomiting, associated abdominal pain
and fever. After the reintroduction of rotavirus immunization in 2006, Norovirus has surpassed
Rotavirus as the leading cause of diarrhea in developed countries. Rotavirus accounts for the
majority of cases of severe gastroenteritis in developing countries. Transmission is mainly
through fecal-oral route, contamination of food and water and occasionally through airborne
infection.
Viruses cause gastroenteritis by inducing villus shortening and cell destruction upon
entering the enterocytes of the small intestine, which generates an inflammatory reaction
producing cytokines and chemokines leading to malabsorption. Villus cells are also replaced by
immature crypt-like cells that secrete water and electrolytes. As an example, rotavirus functions
by inducing the release of calcium from ER stores and causes through its NSP4 toxin, which
causes disruption of tight junctions, alters cell cytoskeleton and increasing electrolyte excretion
resulting in the passive loss of water. Viral causes include calciviruses, rotavirus, astroviruses
and adenoviruses.
Bacteria can produce gastroenteritis through elaboration of enterotoxin, adherence and
translocation of bacteria, or through inflammatory means via invasion or production of
cytotoxins. Inflammatory diarrhea results from infection with bacteria such as Shigella, EHEC
and EIEC E. coli, Campylobacter jejuni, and Clostridium difficle. Non-invasive bacteria causing
gastroenteritis include ETEC, Vibrio Cholera, Bacillus Cereus and Stap. Aureus. Vibrio cholera
functions by producing cholera toxin, which activates adenylate cyclase producing cAMP and
causes the cell to secrete electrolytes, which lead to the passive loss of water. As an example of
an inflammatory mechanism, Shigella enters the epithelial cells of the colon and replicates and
invades neighboring cells via actin fibers and produces an intense inflammatory response.
Examples of parasites that cause gastroenteritis include Entamoeba histolytica, cyclospora, and
cryptosporidium.
Diagnosis is largely made clinically through careful history taking, assessment of risk
factors, inquiring about stool consistency and presence or absence of mucus or blood and
assessment of hydration status during physical examination as well identifying any potential
extraintestinal manifestations. Stool cultures are not routinely needed but should be obtained in
patients with persistent diarrhea, patients that are immunocompromised, and patients suspected
to be part of an outbreak. Viral assays exist for identification of a number of virally caused
gastroenteritis.
Risk factors include environmental contamination, young age, immunodeficiency,
measles, daycare attendance, lack of breastfeeding, travel to endemic areas and malnutrition. The
most immediate complication that must be addressed is dehydration and electrolyte imbalances,
which is treated through oral rehydration therapy. Patients may also receive anti-emetics and in

certain cases may require antibiotics, but generally treatment focuses on supportive care. In
severe infections, additional complications may result depending on the specific causative agent
such as Guillain-bare syndrome with campylobacter and Hemolytic Uremic syndrome with
shigella and E. coli 0157: H7.