Gastroenteritis

Gastroenteritis is an acute illness that usually lasts between 1-2 days. However, symptoms may take 1-3 days to develop depending on the causative agent and may range from slight discomfort to severe dehydration, which can be fatal, especially in children. The typical symptoms of the infection, irrespective of the cause, include:

• Diarrhea
• Vomiting
• Nausea
• Abdominal cramps
• Abdominal pain
• Headache
• Body ache
• Chills
• Bloating
• Loss of appetite

Gastroenteritis caused by bacteria may also include bloody diarrhea, known as dysentery, which occurs due to damage to the intestinal wall by the bacteria.

Signs of Dehydration

• Decreased urine output
• Dark-colored urine
• Dry skin
• Thirst
• Dizziness

Signs of Dehydration in Infants and Toddlers

Vomiting is more commonly seen in young children and infants, which can lead to severe dehydration. It is very important to notice the signs of dehydration, which include:

• Thirst
• Dry diapers
• Less urination
• Lack of urination
• Dry mouth
• Lack of tears
• Drowsiness
• Lack of energy
• Sunken fontanel (the soft spot on the top of an infant’s head)
• Sunken eyes and cheeks
• Fever

1. Infectious gastroenteritis

Infections causing gastroenteritis can be viral, bacterial, or parasitic in origin.

Viruses: The most common viruses responsible for gastroenteritis include:

• Norovirus: The most common cause, responsible for the majority of viral gastroenteritis cases. It is often associated with outbreaks in closed communities such as nursing homes, schools, military populations, athletic teams, and cruise ships.
• Rotavirus: Primarily causes severe vomiting in young children and infants, often requiring hospitalization.
• Less common viruses include astrovirus and adenovirus.

How does viral gastroenteritis spread?

Viral gastroenteritis is highly infectious. Viruses are present in the vomit and stool of infected individuals and can survive outside the human body for extended periods. It can spread through:

• Direct contact with vomit or stool of an infected person
• Shaking hands with an infected person
• Touching contaminated surfaces and objects such as handrails, elevator buttons, utensils, and doors
• Sharing food and beverages with an infected person

Bacteria: While less common, several species of bacteria can also cause gastroenteritis, including:

• Campylobacter: Spreads through contaminated milk and poultry products.
• Staphylococcus: Commonly found in undercooked meats, eggs, and dairy products.
• E. coli: Primarily present in undercooked beef and unwashed fruits and vegetables.
• Shigella: Grows in raw food and contaminated water, such as swimming pools.

How does bacterial gastroenteritis spread?

Improper storage and unhygienic handling of food can allow bacteria to grow. Bacterial gastroenteritis spreads rapidly through:

• Eating contaminated food and beverages
• Handling stool of an infected person

Parasites: Parasites are organisms that require a host to grow and multiply, typically residing in the intestines of the host. The parasites that can cause gastroenteritis include:

• Entamoeba histolytica
• Giardia lamblia
• Cryptosporidium

How does parasitic gastroenteritis spread?

Parasites are usually present in the bowel of infected humans and animals and can spread through:

• Swimming in a contaminated pool and accidentally swallowing water or through contact with infected animals
• Handling infected animals
• Changing the nappy of an infected baby without washing hands afterward

2. Chemicals

Gastroenteritis can also result from foods contaminated with chemicals such as lead, mercury, cadmium, and arsenic, or from directly consuming heavy metals or chemicals.

3. Medications

Gastroenteritis can be a side effect of certain medications, including:

• Antacids containing magnesium as a major ingredient
• Antibiotics
• Chemotherapy drugs
• Colchicine
• Digoxin
• Laxatives

Confirming the drug as a cause of gastroenteritis can be challenging. To identify this, doctors typically discontinue the therapy and observe clinical changes.

• Age: Infants and young children are more prone to gastroenteritis due to their low immunity. Episodes of high temperature are common in children during their early years as their immunity develops.
• Malnutrition: Individuals with certain nutritional deficiencies, such as Vitamin A or zinc deficiency, are at a higher risk of gastroenteritis.
• Poor hygiene: People living in unsanitary conditions with inadequate sanitation are more likely to contract bacteria and parasites that cause gastroenteritis.
• Weak immune system: Individuals with weakened immunity, including those undergoing chemotherapy or infected with HIV, are more susceptible to bacterial and viral infections that can lead to gastroenteritis.
• Poverty: Individuals living in poverty, particularly in crowded areas with limited access to a balanced diet, face a higher risk of gastroenteritis infections.
• Season: Viral infections such as rotavirus and norovirus are more prevalent during the winter months.
• Traveling: Frequent travelers, especially to areas where gastroenteritis is endemic, are at an increased risk of infection.

Gastroenteritis is diagnosed by observing the symptoms of the patients. Laboratory examination is necessary to determine the cause, which helps in initiating the right treatment plan.

Medical history and physical examination

In most cases, the doctor will ask about your medical history to rule out the possibility of other diseases that may present with the same set of symptoms. However, if the patient has consistent fever, bloody stool, and severe dehydration, tests are required.

A. Stool tests

The examination of the stool sample is done to diagnose bacteria and parasites in the stool. The test does not diagnose specific viral causes of gastroenteritis. Patients with bloody stool, high fever, severe abdominal pain, and chronic dehydration are usually recommended for stool tests due to their high specificity for bacterial gastroenteritis.

• Examining the stool for blood: Blood in the stool can be a sign of infectious gastroenteritis. The stool sample is checked for the presence of hidden blood.
• Stool culture: The culturing of the stool is done to identify the disease-causing bacteria. For a stool culture, loose and fresh stool samples are taken. Sometimes, more than one stool sample is collected for the culture. The identification of the virus through stool culture can also be done; however, it takes longer.
• Testing the stool for parasites and ova: The presence of parasites and ova (the egg stage of the parasite) can also be detected in a stool sample. The identification is done by examining the stool smear under the microscope.

B. Blood tests

The complete blood count (CBC) is performed to check for infection. The infection can cause mild leukocytosis (high white blood cell count). In cases of severe dehydration, electrolyte levels are also measured through blood tests. Sometimes, serum inflammatory markers are also examined through blood tests.

C. Urine test

Dehydration can be due to acute kidney injury. Blood urea nitrogen and creatinine tests are also recommended to rule out the possibility of kidney disease.

D. Imaging tests

Imaging tests are rarely done for gastroenteritis. In some cases, imaging studies such as CT scans, ultrasound, and X-rays are performed to assess the condition of the intestine. CT scans may show thickened walls of the colon or other inflammatory changes of the bowel. Imaging studies are mostly done to rule out other major causes of the symptoms.

Vaccination

Immunization for rotavirus is recommended for young children and infants to prevent the risk of gastroenteritis, hospitalization, and death from rotavirus infection. There are currently two vaccines available that are administered in two or three doses, depending on the type of vaccine. The first dose should be given before the child is 15 weeks of age. Children should receive all doses of the rotavirus vaccine before they turn 8 months old.

Hand Washing

Most viral gastroenteritis can be prevented by washing hands with soap and water for at least 10 seconds after:

• Using the toilet
• Preparing or handling food
• Eating
• Handling vomit from an infected patient
• Changing a child's diaper

Hand washing facilities should be available for staff, residents, children, and visitors in childcare centers and hospitals. There is also evidence that alcohol-based hand sanitizers, in addition to handwashing, reduce the chances of gastroenteritis in offices and daycares. A reduction in school absenteeism has also been observed. Learn the right way to wash your hands!

Education

People, especially children, should be educated about the importance of hand washing and maintaining good hygiene as the most effective way to prevent gastroenteritis. Signs reminding individuals to wash their hands should be placed in toilets and eating areas.

Hygiene Measures

Infectious gastroenteritis spreads through contaminated surfaces. Practicing good hygiene is the best way to prevent infection. The following measures can be taken to ensure cleanliness:

• Keep nails short and avoid wearing false fingernails, nail extenders, nail polish, and jewelry, as they restrict adequate cleaning of hands.
• Clean surfaces or objects that have been exposed to vomit or feces.
• Wear disposable gloves and masks while handling feces or vomit of infected individuals.
• Use disposable paper towels to dry hands; cloth towels should be avoided as bacteria can survive on them.
• Keep kitchen tops, toys, toilet seats, and nappy change tables clean to avoid the growth of bacteria and viruses.

Isolation

As gastroenteritis is highly contagious, isolating the patient prevents the spread of the infection. Children who have experienced diarrhea should not return to childcare until 24 hours after symptoms have resolved. Anyone with diarrhea should not swim for at least 2 weeks after complete recovery.

Dietary Modifications

As contaminated food and beverages are the most important sources of infection, some dietary modifications can help prevent the infection:

• Cook foods thoroughly.
• Avoid consuming uncooked and unpasteurized milk.
• Drink only bottled water while traveling.
• Avoid food buffets, uncooked foods, peeled fruits and vegetables, and ice in drinks.
• Studies suggest that daily administration of probiotics, especially in children, reduces the occurrence of acute gastroenteritis.
• The intake of zinc supplements also has a preventive effect on diarrhea associated with gastroenteritis.

Breastfeeding

Antibodies in human milk enhance the infant’s immunity and play a major role in the prevention of certain diseases. Exclusive breastfeeding for the initial four months of life lowers the risk of acute gastroenteritis and decreases the rate of hospitalization due to diarrhea.

The treatment of gastroenteritis is based upon the cause and symptoms. The most important goal of the therapy is to maintain hydration and electrolyte balance that is disturbed due to vomiting and persistent diarrhea. In some cases, such as severe dehydration, uncontrolled vomiting, severe electrolyte disturbances, significant renal failure, continuous abdominal pain, and pregnancy, hospital admission is required. The treatment protocols may include:

• Fluid therapy
• Most cases of mild dehydration can easily be managed at home through fluid therapy.
• It is advised to drink plenty of fluids to compensate for water loss and prevent dehydration.
• Oral rehydration solutions are preferred over other clear fluids for managing diarrhea.
• Fluids high in sugar (such as cola, apple juice, and sports drinks) should be avoided as they may aggravate dehydration and diarrhea.
• Patients with severe dehydration and persistent vomiting may require hospital admission for continuous monitoring of electrolyte levels.
• Enteral (oral or nasogastric) and intravenous fluids (saline solution and lactate Ringer’s solution) are given to patients facing difficulty in taking fluids due to nausea and vomiting to correct electrolyte levels.

• Zinc supplementation
• Zinc is a metal found in a variety of foods such as meat, fish, almonds, and cereals. Diarrhea, the most common symptom of gastroenteritis, is associated with severe zinc deficiency. Zinc supplementation is a very safe and effective way to reduce complications due to gastroenteritis in children. WHO recommends the intake of 10 to 20 mg of zinc for 10 to 14 days for the management of diarrhea in children. It is given in the form of zinc sulfate, zinc acetate, or zinc gluconate.

• Probiotics
• Probiotics are effective in the treatment of diarrhea, especially for diseases with an infectious origin. The use of probiotics is associated with a reduction in the duration of diarrhea if started immediately after the onset of symptoms.

• Antibiotics
• Antibiotics are mostly used to treat gastroenteritis caused by bacteria. Some commonly used antibiotics in gastroenteritis include metronidazole, ceftriaxone, and azithromycin.

• Antiemetics
• Antiemetic medications are used to control nausea and vomiting. The commonly used antiemetic medications are ondansetron and metoclopramide.

• Antidiarrheal medications
• Antidiarrheal medications are used only in those patients who are unable to maintain a well-hydrated status. Medications such as diphenoxylate and atropine are used.

Keep a watch on fluid intake

It is advised to have plenty of fluids such as fresh fruit juices, coconut water, and clear soups. In cases of severe vomiting, take small sips of fluids at regular intervals. Mothers of infected infants should ensure that their babies are receiving enough breast milk.

Have ice chips

If you are having difficulty digesting fluids, try sucking on ice chips. This can aid in rehydration. Ice chips should not be given to small children.

Add these foods to your diet

• B.R.A.T: Bananas, rice, applesauce, and toast. These food items should be included in the diet as they help to make the stool smooth and compensate for nutrient loss due to vomiting and diarrhea.
• Foods such as chicken, lean meats, whole grains, and potatoes can help reduce the symptoms of gastroenteritis.
• It is also advised to consume smaller, easy-to-digest meals at regular intervals.

Avoid certain foods

Certain food items should be avoided as they can upset the stomach and cause indigestion, which may aggravate diarrhea and vomiting. These include:

• Greasy and spicy foods containing chili, black pepper, and garlic.
• Drinks with caffeine, such as coffee, tea, and some soft drinks.
• Fatty junk foods such as fried foods, pizza, and fast foods.
• Foods and drinks containing large amounts of simple sugars, such as sweetened beverages and packaged fruit juices.
• Milk and milk products containing lactose, which can cause some individuals to develop lactose intolerance.

Take proper rest

Individuals with gastroenteritis should take proper rest even after completing therapy. This will promote complete recovery and healing of the digestive system.

Try a heating pad

Some patients with gastroenteritis may experience severe abdominal pain. Such patients can use a heating pad to relieve cramps.

Say no to alcohol

Alcohol can cause inflammation in the stomach and increase the secretion of gastric acid. Therefore, alcohol should be avoided as it can heighten feelings of nausea.

In most cases, gastroenteritis resolves through fluid therapy and medications. However, persistent diarrhea and vomiting can lead to:

• Dehydration
• Metabolic acidosis
• Electrolyte imbalance
• Hypernatraemia (high levels of sodium)
• Hyponatraemia (low levels of sodium)
• Hypokalaemia (low levels of potassium)
• Development of intolerance to food such as lactose, glucose, cow’s milk, and soy protein
• Increased susceptibility to infection

Dehydration can lead to more serious problems, such as:

• Heat stroke: Lack of fluids could lead to heat stroke, which is more common in physically active patients.
• Kidney disorders: Prolonged dehydration can develop or trigger kidney stones, urinary tract infections (UTIs), or even kidney failure.
• Seizures: Electrolyte imbalance can lead to seizures over time.
• Hypovolemic shock: This can occur due to low blood volume and a drop in blood pressure.

Home Remedies

• Tea: Caffeine-free teas are beneficial for nausea and vomiting. Peppermint and lemon can be added to improve the taste.
• Ginger (Adrak): It possesses anti-inflammatory, antiviral, and antibacterial properties, easing nausea. It can be taken raw or boiled in water or tea.
• Apple Cider Vinegar: It soothes an irritated stomach, reducing nausea, vomiting, and abdominal cramps. Add 1 teaspoon of apple cider vinegar to a glass of warm water and drink 30 minutes before meals.
• Yogurt: It contains beneficial bacteria that help maintain gut health and reduce watery diarrhea. It should be included in every meal for patients suffering from gastroenteritis.
• Cinnamon (Dalchini): It has antibacterial and antiviral properties that can combat gastroenteritis, as well as reduce stomach pain and bloating.
• Turmeric (Haldi): Curcumin in turmeric possesses anti-inflammatory properties. It can be consumed by adding it to a glass of warm water or milk.
• Basil (Tulsi): It has antispasmodic properties that help reduce spasms in gastroenteritis and gastroprotective properties that aid in relieving symptoms.
• Peppermint: It soothes the stomach, helping with bloating and gas. The most effective way to use it is as tea.
• Triphala: Known to improve digestive health and aid in nutrient absorption.
• Coriander (Dhania): It has healing properties and is known to alleviate symptoms of upset stomach and diarrhea.
• Asafoetida (Hing): Known for strengthening the digestive system, it has antiviral and antibacterial properties. It can be added to meals or consumed with lukewarm water.
• Licorice (Mulethi): It promotes healing of an inflamed stomach and treats indigestion.
• Rice Water: Used especially in infants to reduce diarrhea.
• Chamomile Tea: Acts as a digestive relaxant and can help treat gastrointestinal disturbances, such as diarrhea and vomiting, commonly observed in gastroenteritis.

Acupressure

Patients suffering from excessive nausea and vomiting can also try acupuncture finger pressure techniques, which may help stimulate trigger points to reduce nausea and vomiting.