What are the management options for viral gastroenteritis?

Management of Viral Gastroenteritis

The cornerstone of viral gastroenteritis management is adequate hydration with oral rehydration solutions, while antimotility agents should be avoided in most cases, particularly in children. 1

Hydration and Rehydration

Oral Rehydration

• Oral rehydration solution (ORS) is the primary treatment for viral gastroenteritis 1
• For patients with vomiting, administer small, frequent volumes of ORS 1
• ORS has been proven as effective as intravenous fluid therapy (IVF) for children with mild-to-moderate dehydration 2
  • ORS can be initiated more quickly (19.9 minutes vs. 41.2 minutes for IVF) 2
  • Similar improvement rates at 2 hours (78.8% ORS vs 80% IVF) 2
  • Lower hospitalization rates with ORS (30.6% vs 48.7% with IVF) 2

Intravenous Rehydration

• Reserve for cases with:
  • Severe dehydration
  • Inability to tolerate oral intake
  • Failure of oral rehydration therapy 1
• Once the patient stabilizes, transition to oral rehydration 3

Nutritional Management

• Continue normal feeding during illness to maintain gut integrity 1
• Resume age-appropriate usual diet during or immediately after rehydration 1
• Recommended diet: easily digestible foods (bananas, rice, applesauce, toast) 1
• Avoid foods high in simple sugars and fats 1
• For infants, breast milk may have a protective effect against viral enteric infection 3
• Most infants can be "fed through" an episode of viral gastroenteritis 3

Pharmacological Management

Antimotility Agents

• Contraindicated in children <18 years with acute diarrhea 1
• May prolong viral shedding 1
• In adults, loperamide may be considered only after adequate hydration is achieved 1
• Avoid loperamide in cases with fever or inflammatory diarrhea due to risk of toxic megacolon 1
• Caution with loperamide in elderly patients taking drugs that can prolong QT interval 4
• Monitor patients with hepatic impairment for CNS toxicity when using loperamide 4

Antiemetic Therapy

• Ondansetron may be considered when vomiting is severe and preventing adequate oral rehydration 1
• Particularly useful in children >4 years 1
• Can increase success rate of oral rehydration therapy and minimize need for IV therapy and hospitalization 5

Symptomatic Relief

• Bismuth subsalicylate may reduce duration of Norwalk infection (from 27 to 20 hours) 3

Special Populations

Children

• Higher risk of dehydration; respond well to oral rehydration therapy 3
• May develop mild lactose intolerance after rotavirus infection (typically 10-14 days) 3

Elderly

• At higher risk for dehydration and electrolyte imbalances 1
• May experience prolonged constitutional symptoms 1
• Require closer monitoring for complications 1
• Use caution with antimotility agents in those taking QT-prolonging medications 4

Immunocompromised Individuals

• May experience prolonged viral shedding and illness duration 1
• At risk for more severe disease, particularly with cytomegalovirus or adenovirus 1
• Require more aggressive supportive care and monitoring 1

Infection Control Measures

Personal Hygiene

• Vigorous handwashing with soap for at least 10 seconds after each contact with ill persons 3, 1
• Special handwashing products not indicated; regular soap is effective 3

Environmental Control

• Clean soiled surfaces promptly with appropriate disinfectants 1
• Use detergents for laundering fecally contaminated linens and clothing 3
• Handle soiled linens with minimum agitation to prevent microbial contamination 3

Isolation Measures

• Isolate affected individuals for at least 2 days after symptom resolution 1
• For nosocomial rotavirus, isolation should continue until the stool is negative by antigen detection (may be ≥1 week) 3
• Food handlers should not prepare food for at least 2 days after resolution of illness 1

Common Pitfalls to Avoid

• Using antimotility agents too early or in contraindicated populations 1
• Inadequate hydration, which can increase cramping and prolong recovery 1
• Ignoring warning signs such as severe abdominal pain, bloody diarrhea, high fever, or signs of severe dehydration 1
• Using antibiotics, which are ineffective against viral infections and may disrupt gut flora 1

Monitoring and Follow-up

• Monitor for signs of dehydration: decreased urine output, dry mucous membranes, sunken eyes, decreased skin turgor
• Assess electrolyte balance, particularly in severe cases requiring IV fluids
• For most patients, viral gastroenteritis is self-limited, lasting 12-60 hours for Norwalk-like viruses and up to 7 days for rotavirus 1, 6