What is the treatment for gastroenteritis?

Treatment of Gastroenteritis

The cornerstone treatment for gastroenteritis is oral rehydration therapy (ORT) with continued feeding, while addressing underlying causes and maintaining nutritional status to prevent dehydration and malnutrition. 1

Assessment of Dehydration

• Evaluate hydration status through:
  • Changes in weight
  • Physical examination findings (using the four-item Clinical Dehydration Scale) 2
  • General appearance, eyes, mucous membranes, tears
  • Capillary refill time, urine output
  • Vital signs, especially heart rate and blood pressure 1

Treatment Algorithm

1. Rehydration

For Mild to Moderate Dehydration:

• First-line: Oral rehydration therapy (ORT)
  • Administer 10 ml/kg of ORS for each liquid stool and 2 ml/kg for each episode of vomiting 1
  • For children, half-strength apple juice followed by preferred liquids can be as effective as commercial ORS 2
  • Continue breastfeeding during episodes of diarrhea 1

For Severe Dehydration:

• Intravenous rehydration until pulse, perfusion, and mental status normalize 1
• Once stabilized, transition to oral rehydration 2

2. Nutritional Management

• Resume age-appropriate diet during or immediately after rehydration
• Offer food every 3-4 hours
• Avoid foods high in simple sugars and fats 1
• For formula-fed infants:
  • Consider lactose-free formulas if lactose malabsorption is suspected
  • Full-strength formulas can be safely introduced immediately after rehydration 1
• Increased caloric intake may be needed (120-150 kcal/kg/day) 1

3. Pharmacological Management

Antiemetics:

• Ondansetron may be used to prevent vomiting and improve tolerance of ORT 2
  • Particularly useful when vomiting hinders ORT 3
  • Has been shown to reduce gastroenteritis-related vomiting and facilitate ORT without significant adverse events 3

Antimotility Agents:

• Loperamide may be used in adults with non-bloody diarrhea after adequate hydration
• Do not use in children under 18 years with acute diarrhea 1
• Contraindicated in cases of bloody diarrhea, fever, or suspected inflammatory diarrhea 1

Antibiotics:

• Only indicated for specific bacterial pathogens:
  • Shigella: Azithromycin (first-line) or TMP-SMX (if susceptible)
  • Campylobacter: Azithromycin or Erythromycin
  • Enterotoxigenic E. coli: TMP-SMX (if susceptible) or Azithromycin
  • Bacterial gastroenteritis: Third-generation cephalosporin or Azithromycin 1

Probiotics:

• May improve intestinal microbial balance, reducing duration and severity of diarrhea
• Those with documented efficacy include Lactobacillus rhamnosus GG, Lactobacillus reuteri, and Saccharomyces boulardii 4

Prevention Measures

• Hand washing with soap and water:
  • After using toilet
  • After changing diapers
  • Before preparing food 1
• Contact precautions with gloves and gowns for C. difficile
• Rotavirus vaccination to reduce incidence of rotavirus gastroenteritis 1, 2

Special Considerations

• For neonates unable to feed orally: Consider nasogastric tube feeding 1
• For severe cases: Management includes fluid resuscitation, broad-spectrum antibiotics, bowel decompression, and surgical intervention if perforation occurs 1

Important Caveats

• ORT has a slightly higher failure rate compared to IV therapy (for every 25 children treated with ORT, one may fail and require IV therapy) 5
• Despite this, ORT remains first-line due to:
  • Lower risk of complications (IV therapy carries risk of phlebitis)
  • Shorter hospital stays reported for ORT groups
  • Cost-effectiveness and practicality 5
• Avoid unnecessary diagnostic testing when viral gastroenteritis is the likely diagnosis in children with mild illness 2
• The "do the least" approach (oral rehydration, early refeeding, no unnecessary drugs) remains the evidence-based standard for most cases 4