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 Abdominal cramps after copious, watery diarrhea is consistent with

gastroenteritis.
 However, abdominal pain followed by nausea and loose stool could
represent appendicitis.
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→ Diarrhoea is present if one of the following criteria is fulfilled:

» Frequent defecation>3 times per day
» Altered stool consistency: water content>75%
» Increase in stool quantity: more than 200-250 g per day
→ Acute diarrhoea: lasting<14 days
→ Persistent diarrhoea: lasting > 14 days
→ Chronic diarrhoea: lasting > 30 days
Complaint of (C/O)
» Acute or chronic diarrhoea
Further possible symptoms
● Fever
● abdominal Pain and cramping
● Blood in stool
● Nausea and vomiting in cases of gastroenteritis
● Signs of dehydration in severe cases → Asses through level of dehydration
● Chronic cases: malnutrition and in children. failure to thrive
>>Disease courses can range from mild to severe with need of hospitalization.
Dx: Approach to diarrhoea
On Examination Management Protocols
Diarrhoea: The Features Mild Moderate Severe dehydration
excretion of more dehydration dehydration
than 250g of stool Mental status Normal/awake Restless, lethargic/unconscious
per day. Irritable
Dysentery: Eyes Normal Sunken sunken
Diarrhoea that Thirst Drinks Thirsty, Not able to
contains blood. normally drink eagerly drink/poorly
mucus. and pus. Skin pinch Goes back Goes back Goes back very
Gastroenteritis rapidly slowly slowly
(acute enteritis); Management Plan A: Plan B: Plan C:
inflammation of plan Treat Give fluid Admit the patient
the intestines according diarrhoea at and food Intravenous
manifested as WHO home Consider rehydration-give R/L
diarrhoea guidelines Give food and ORS therapy OR N/S 100ml/kg
accompanied by fluid/ORS Give Zinc Reassess patients
nausea and Follow-up supplement every 1-2 hours. After
vomiting. after 5 days if Follow-up 3 to 6 hours evaluate
Food poisoning: It not improving after 5 days the patient then
is a gastroenteritis if not choose an appropriate
that occurs improving treatment plan.
suddenly and is
often associated
with abdominal Evaluation of gastroenteritis in ER
pain and cramping. It is not usually possible. or necessary. to identify the causative: organism
It is caused by in the Emergency Room. Rather the focus should be on identifying whether
ingestion of food the organism is invasive or toxigenic.
containing
preformed toxins.
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Organism/ disease Source/transmission I.P Presentation

70%
Viral Fecal–oral, person-to- 12– Norvo & rotavirus are the most
gastroenteritis person 72 common agents; nausea,
transmission; hours vomiting, and watery diarrhea;
contaminated may have mild
food or water; abdominal cramps and
daycare; myalgias; usually
cooler months afebrile; occasionally
epidemics occur,
especially in infants and small
children
10-20%
Camphylobacter jejuni Unpasteurized milk 1-7 Fever, headache, abdominal
(camphylobacter Contaminated water days pain, myalgias for several days
enteritis/ Animal dropping followed by diarrhea with little
camphylobacteriosis) vomiting. May mimic
appendicitis. Fecal RBCs and
WBCs common.

Salmonella species Contaminated water 8 hr- Duration: 3-7 days, highly

(Salmonellosis/ Foodborne: poultry, 3 contagious
Salmonella raw eggs and milk days Fever (usually resolves within
gastroenteritis) 2 days) severe vomiting and
inflammatory (watery-bloody)
diarrhoea
E.coli Faecal-oral 2-10 Children and the elderly; fever,
(EHEC,0157:H7) Contaminated food days abdominal pain, vomiting,
Usually occurs at grossly bloody
outbreak diarrhea; may mimic
gastrointestinal bleed or
mesenteric ischemia; hemolytic
uremic syndrome
Shigella species Faeco-oral (poor 0-2 Duration: 2-7 days
(shigellosis/bacillary hygiene) days High fever
dysentery) Oral-anal sexual Tenesmus, abdominal cramps
contact Profuse inflammatory, mucoid-
Contaminated bloody diarrhoea
water/food
S. aureus Previously cooked 1–6 Nausea, severe vomiting, mild
proteinaceous foods hour diarrhea, and abdominal
(ham, shrimp, cream- s cramps; fever is rare;
filled goods, potato the source is an infected food
salad, chicken, and handler; symptoms are
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egg salads) caused by preformed

enterotoxins
Vibrio cholerae Faeco-oral 0-2 Low-grade fever
(cholera) Contaminated water days Vomiting
Undercooked seafood Profuse rice water stools
Yersinia enterocolitica Contaminated 4-6 Children and young adults.
(Yersiniosis) water/food days Anorexia,
Unpasteurized milk low-grade fever, right lower
Raw/undercooked quadrant
pork abdominal pain, and vomiting
may
precede diarrhea and mimic
appendicitis
Clostridium Undercooked food 6-24 Duration:<24 hrs
perfringens Reheated/poorly hr Initial symptoms: profuse
Refrigerated meat vomiting, later: diarrhoea
(watery),Upper abdominal pain
Bacillus cereus (aka Reheated rice 1-6hr Initial symptoms: profuse
Chinese restaurant sauces vomiting, later:
syndrome) diarrhoea(watery)
Upper abdominal pain

Escherichia coli Recent travel 3-4 Fever

(ETEC) days Watery diarrhoea
MCC organism of Abdominal cramping
travellers’ diarrhoea Nausea and possibly vomiting
<10
Giardia lamblia Contaminated food or 1–4 causes bloating, crampy
water; fecal–oral, week abdominal pain, excessive
person s flatus, and malabsorptive
to-person transmission diarrhea; vomiting is rare; a
common cause of chronic
diarrhea
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Dx: Approach to diarrhoea

On Examination Management Protocols
1) Stool analysis: Emergency Management
● Stool D/R: Finding I. Maintain double large bore IV line
leukocytes in the 2. Correction of electrolyte imbalances
stool sample is 3. Check Vitals 2 Hourly
diagnostic for an 4. Assess Fluid Deficit/ Degree of Dehydration
invasive diarrhoea. Degree of Fluid Signs/Symptoms
● Patients with a Dehydration Deficit
history of antibiotic Mild (Also 3-5% - Restlessness
usc within the classified as No - Excessive Thirst
preceding 2 weeks dehydration) - Oliguria
should have a stool - Fever +
sample sent for a Moderate (Also 5-10% - Tachycardia
C. difficile toxin classified as - Oliguria
assay. Some - Irritable
● Stool Culture and dehydration) - Sunken eyes and fontanel
sensitivity (toxin - Decreased tears
detection in stool - Dry mucus membrane
cultures) - Mile tenting of skin
● Stool microscopy - Delay in CFT
in certain cases (e.g - Cool & pale
ova and parasites) Severe 10-15% - lethargic
2) Blood Test: - Rapid & weak pulse
● CBC(elevated - Decreased BP
WBC count) - No urine output
● Urea, creatine and - Very sunken eyes & fontanel
electrolytes - No tears
(Deranged) - Tenting of skin
● ABGs (Metabolic - CFT - very delayed
acidosis) - Cold & mottled skin
3) Abdominal X-ray: - Parched mucus membranes
Colonic dilation Phase 1 : (Shock Therapy)
Restoration of volume - 1 to 2 hrs
20ml / Kg N. Saline or R.L. rapid IV
Phase 2:
Replacement of ½ the calculated fluid loss
(Deficit + Maintenance) in first 8 hrs
Phase 3:
- Replacement of ½ the calculated fluid loss
(Deficit + Maintenance) in next 16 hrs
- Replacement of K+ (after voiding with a max. of 40mEq/L)
Half the potassium deficit is replaced in 1st day
���� ����ℎ� − �ℎ���� �� ����ℎ�
Dehydration(%) = �100
���� ����ℎ�
Fluid deficit in ml = % dehydration x weight in kg x 10
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Dx: Approach to diarrhoea

Management Protocols

SHIGELLA INFECTIONS
Mild case
 Oral Fluids (ORS) (IV Fluids if patient is vomiting or is severely dehydrated)
 (Antidiarrheals must not be given)
Severe cases, in addition to fluids
 Tab. Ciprofloxacin 500 mg (Novidat)
1+0+1 BD PO for 3-5 days (DOC) OR
 Tab. Cotrimoxazole 160/800 mg (Septran DS)
1+0+1 BD PO for 5 days OR
 Tab. Amoxicillin 500 mg (Amoxil)
1+0+1 BD PO for 5 days OR
Tab Azithromycin 500mg
1+0+0 OD PO for 3 days
CAMPYLOBACTER ENTERITIS
Mild case
 Oral fluids (IV fluids if patient is vomiting or is severely dehydrated)
If there is fever or severe diarrhea, in addition to fluids
 Tab Azithromycin (Azomax) 500 mg
1+0+0 OD PO for 5 Days OR
 Tab. Cotrimoxazole 160/800 mg (Septran DS)
1+0+1 BD PO for 5-7 days
YERSINIA ENTEROCOLITIS
Mild case
 Oral fluids (IV fluids if patient is vomiting or is severely dehydrated)
If there is fever or severe diarrhea, in addition to fluids
 Tab. Amoxicillin 500 mg (Amoxil)
1+1+1+1 QID PO for 5 days
TRAVELER'S DIARRHEA
 Tab. Ciprofloxacin 500 mg (Novidat)
1+0+1 BD PO for 3-5 days
 Tab. Cotrimoxazole 160/800 mg (Septran DS)
1+0+1 BD PO for 5-7 days
ENTEROHEMORRHAGIC E. COLI
Antimicrobials are not recommended. Just symptomatic management is recommended.
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Dx: Approach to diarrhoea

Management Protocols
PSEUDOMEMBRANOUS ENTEROCOLITIS
 Tab Metronidazole (flagyl) 400 mg
1+1+1 TDS PO for 10-14 days
Severe or non responder Add
 Inj vancomycin (vancocin) 500 mg
1/4th of injection PO qid for 10-14 days
GIARDIA LAMBLIA
 Tab Metronidazole (flagyl) 400 mg
1+1+1 TDS PO for 5 days OR
 Tab Tinidazole (Prevent) 1g
2+0+0 OD PO for 3 Days OR
 Tab. Nitazoxanide 500 mg (Izato)
1+0+1 BD PO for 3-5 days
AMEBIASIS
 Tab Metronidazole (flagyl) 400 mg
2+2+2 PO for 5-7 days OR
 Tab Tinidazole (Prevent) 1g
2+0+0 PO for 3 Days OR
 Tab Diloxanide Furoate 500mg +Metronidazole 400mg (Entamizole)
1+1+1 TDS PO for 8 days
Primary or spontaneous peritonitis
 Inj ceftriaxone (rocephin) 1 g
IV bid for 10-14 days
Secondary peritonitis
 Inj gentamicin (genticyn) 80 mg
1+1+1 TDS IV
 Inj Metronidazole (Flagyl) 500 mg
1+1+1 TDS IV
OR
 Inj imipenem (tienam) 500- 1000 mg
IV infusion 8 hourly
CHOLERA
 Inj R/L 1000 ml (fluid of choice)
IV continuous (according to fluid deficit plus maintenance fluid)
Note: Continuous fluid is recommended until signs of fluid overload initiate
Upto 50L fluid may be required in 2-5 days.
Antibiotics only help reducing the severity and duration
 Inj. Ciprofloxacin 1g (Novidat) or Inj Doxycycline 300mg
IV Stat (Single Dose)
 Tab. Tetracycline 250 mg
1+1+1+1 QID PO for 5-7 days
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Dx: Approach to diarrhoea

Management Protocols
Indications for empirical antibiotic therapy for acute infectious diarrhoea
1. In general, antibiotic treatment is not recommended for most cases of acute watery diarrhoea.
2. Empirical antibiotic therapy can be considered in the following cases:
(1) If bloody or mucoid stool and fever, or Shigellosis symptoms (frequent scanty bloody
stools, fever, cramping abdominal pain, and tenesmus are present and
(2) in traveller's diarrhoea accompanied by high fever above 38.5’C or septic findings.
3. Antibiotic treatment is recommended for immune-suppressed patients with bloody diarrhoea.
4. For empirical antibiotic therapy, use fluoroquinolone antibiotics or azithromycin upon
consideration of distribution and antibiotic sensitivity of pathogens in local communities or areas
where the patient travelled.
5. Rifaximin may be used for suspected infection with non-invasive bacteria without bloody
diarrhoea.
6. The use of antibiotics is not recommended for patients with suspected STEC infections.
Antiemetic options:
 Inj Ondansetron 8mg (Onset,Dyset,Onseron)
4–8 mg IV or PO every 4–6 hours; children, 0.1 mg/kg
 Inj Prochlorperazine 12.5mg/ml (Stematil)
5–10 mg IV, or 25 mg rectally; children >10 kg, 0.1 mg/kg
rectally every 6 hours (use is contraindicated in children <10 kg)
 Inj Promethazine 25ml/ml (Phenergan)
12.5–25.0 mg IV or PV; children, 0.25–1.0 mg/kg PR every 4–6 hours; use promethazine
with caution in the elderly as it can alter mental status
 Metoclopramide 5m/ml (Metomide)
5–10 mg IV; children, 0.1–0.2 mg/kg IV every 6–8 hours
Antidiarrheals
 Tab. Diphenoxylate 2.5mg (Lomotil)
1+1+1 TDS until diarrhea is controlled.
avoid in pediatrics patients; may precipitate toxic megacolon in patients
with IBD; may cause central nervous system depression OR
 Cap. Loperamide 2mg (Imodium)
1-2 Capsules after each stool (Max Dose 8mg/day).
avoid in patients with antibiotic-associated colitis, IBD, or dysentery
 Cap. Racecadotril (Hidrasec) 100mg OR
1+1+1TDS PO until symptoms improved.
avoid in patients with antibiotic-associated colitis, IBD, or dysentery
Antimotility Agents
Can generally be used in patients that do not have fever and have nonbloody diarrhea that is not
severe
 Inj Drotaverine 40mg/2ml(Nos-spa)
Diluted in 10cc IV STAT then can be repeated every 3 hourly
Can be given IM or SC without dilution
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Dx: Approach to diarrhoea

Management Protocols
 Inj Phloroglucinol 40mg+Trimethylphloroglucinol 0.04mg (Spasfon/
Anafortan plus)
Diluted in 10cc IV STAT
 Inj Hyoscine Bromide 20mg (Buscopan)
IM,SC or diluted in 10cc IV STAT then can be repeated after every 30 mins
Upto 100mg
Adsorbent
 Dioctahedral Smectite Sachet (Smecta)
1-2 sachet diluted in glass of water PO STAT then TDS
Should not be given in less than 2 year, pregnant and malabsorption syndrome
 Syp Bismuth Subsalicylate Suspension (Bismol)
2 TSF every 30 mins until diarrhea Settle
Avoid in pediatric patients because of concern about Reye syndrome; it may
cause salicylate toxicity
 Kaolin & Pectin suspension 450ml (Keptin)
60-120ml after every stool
may cause constipation, bloating; avoid if intestinal obstruction is suspected

Sample Treatment Chart for Non-Inflammatory Diarrhea

1. Inj R/L 1000ml (according to weight and degree of dehydration)
2. Cap. Loperamide 2mg (Imodium)
2 Capsules PO STAT
1-2 Capsules after each stool (Max Dose 8mg/day).
avoid in patients with antibiotic-associated colitis, IBD, or dysentery
3. Inj Ondansetron 8 mg IV STAT
(incase of vomiting)
4. Inj No-spa diluted in 10 cc IV STAT
In case of Colicky abdominal pain
Omeprazole should not be given in Diarrhea
5. Dioctahedral Smectite Sachet (Smecta)
1-2 sachet diluted in glass of water PO STAT then TDS

Sample Treatment Chart for Inflammatory Diarrhea

1. Inj R/L 1000ml (according to weight and degree of dehydration)
2. Inj 400mg (Novidat) IV STAT then BD
If fever or Blood in Stools (Tab Novidat 500mg PO BD on discharge)
3. Inj Metronidazole 500mg (Flagyl)
IV STAT then TDS (Tab Flagyl 400mg PO TDS on Discharge)
4. Inj Ondansetron 8 mg(Onset)
IV STAT then BD(incase of vomiting)
5. Dioctahedral Smectite Sachet (Smecta)
1-2 sachet diluted in glass of water PO STAT then TDS