What is the management approach for gastroenteritis in adults?

Management Approach for Gastroenteritis in Adults

The management of gastroenteritis in adults should follow a stepwise approach based on severity, with uncomplicated cases managed with oral hydration, dietary modification, and loperamide, while complicated cases require hospitalization and aggressive treatment with IV fluids, antibiotics, and possibly octreotide. 1

Classification and Initial Assessment

Uncomplicated Gastroenteritis

• Mild to moderate symptoms
• No signs of dehydration or systemic illness
• No fever, vomiting, or severe cramping

Complicated Gastroenteritis

• Moderate to severe cramping
• Nausea and vomiting
• Diminished performance status
• Fever, sepsis, neutropenia
• Bleeding or dehydration
• Severe diarrhea

Management Algorithm

1. Uncomplicated Gastroenteritis

Hydration

• Oral rehydration therapy (ORT) is the cornerstone of treatment 1, 2
• Commercial oral rehydration solutions (ORS) or sports drinks like Gatorade can be effective 2
• For each loose stool, replace fluid losses with ORT

Dietary Modifications

• Continue regular feeding rather than fasting 1
• Avoid foods high in simple sugars and fats
• Resume age-appropriate diet during or immediately after rehydration

Medications

• Loperamide: Start with 4 mg initially, followed by 2 mg after every loose stool (maximum 16 mg/day) 1
• Avoid antimotility agents if bloody diarrhea, high fever, or suspected inflammatory diarrhea is present 1

Skin Care

• Use skin barriers to prevent irritation from fecal material 1

2. Complicated Gastroenteritis

Hospitalization Criteria

• Sepsis, neutropenia, bleeding, dehydration
• Severe diarrhea
• Inability to maintain oral hydration

Fluid Resuscitation

• IV fluids for severe dehydration 1
• Rate of fluid administration must exceed continued fluid losses
• For potentially septic patients with tachycardia, give initial fluid bolus of 20 mL/kg 1

Laboratory Evaluation

• Complete blood count
• Electrolyte profile
• Stool work-up for:
  • Blood
  • Clostridium difficile
  • Salmonella
  • Escherichia coli
  • Campylobacter
  • Other infectious colitis pathogens 1

Medications

• Loperamide: Same dosing as for uncomplicated cases 1
• Consider antibiotics:
  • Fluoroquinolones for bacterial gastroenteritis
  • Metronidazole for C. difficile or anaerobic infections 1
• Consider octreotide:
  • Starting dose: 100-150 μg subcutaneously three times daily
  • For severe dehydration: 25-50 μg/h IV
  • Can escalate up to 500 μg subcutaneously three times daily until diarrhea is controlled 1

Special Considerations

Neutropenic Enterocolitis

• Medical management includes:
  • Broad-spectrum antibiotics (covering gram-negative, gram-positive, and anaerobic organisms)
  • Granulocyte colony-stimulating factors (G-CSFs)
  • Nasogastric decompression
  • IV fluids
  • Bowel rest
  • Serial abdominal examinations 1
• Antibiotic options:
  • Monotherapy: piperacillin-tazobactam or imipenem-cilastatin
  • Combination therapy: cefepime or ceftazidime with metronidazole 1
• Avoid anticholinergic, antidiarrheal, and opioid agents as they may aggravate ileus 1
• Consider surgical intervention for:
  • Persistent gastrointestinal bleeding after correction of coagulopathy
  • Free intraperitoneal perforation
  • Abscess formation
  • Clinical deterioration despite aggressive supportive measures 1

Prevention of Complications

• Monitor hydration status through:
  • Changes in weight
  • Laboratory results
  • Urine output
  • Complaints of thirst 3
• Evaluate for signs of dehydration:
  • General appearance
  • Eyes and mucous membranes
  • Tears
  • Capillary refill time
  • Vital signs (especially heart rate and blood pressure) 3

Evidence-Based Insights

• Recent research shows that sports drinks like Gatorade can be as effective as medical ORS solutions for mild viral gastroenteritis, though persistent hypokalemia was observed more frequently with Gatorade 2
• Antimicrobial therapy is indicated for C. difficile infections, travel-related diarrhea, severe bacterial infections, and parasitic infections 3
• The widespread use of ORS solutions has revolutionized the management and outcomes of acute gastroenteritis in both children and adults 4
• Lower osmolarity ORS formulations have enhanced efficacy compared to original WHO formulations 4

Common Pitfalls to Avoid

• Delaying oral rehydration therapy
• Withholding food during episodes of diarrhea
• Overuse of antimotility agents in cases of bloody diarrhea or suspected infectious colitis
• Failure to recognize and aggressively treat complicated cases
• Not monitoring electrolyte abnormalities, particularly hypokalemia and hyponatremia