What are the management and treatment recommendations for patients with gastroenteritis?

Management and Treatment of Gastroenteritis

The cornerstone of gastroenteritis management is appropriate rehydration therapy, with oral rehydration solution (ORS) being the first-line treatment for mild to moderate dehydration in both children and adults. 1

Rehydration Therapy

Assessment of Dehydration

• Evaluate hydration status through clinical signs: skin turgor, mental status, mucous membrane moisture, capillary refill, and vital signs 1
• Categorize dehydration as:
  • Mild (3-5%): increased thirst, slightly dry mucous membranes
  • Moderate (6-9%): loss of skin turgor, dry mucous membranes
  • Severe (≥10%): lethargy, altered consciousness, prolonged skin tenting, cool extremities, decreased perfusion 1

Oral Rehydration

• For mild to moderate dehydration, use ORS until clinical dehydration is corrected 1
• Continue ORS to replace ongoing losses until diarrhea and vomiting resolve 1
• Nasogastric administration of ORS may be considered for patients who cannot tolerate oral intake or refuse to drink adequately 1
• Low-osmolarity ORS formulations (e.g., Pedialyte, CeraLyte) are preferred over sports drinks or juices 1

Intravenous Rehydration

• Reserve for patients with:
  • Severe dehydration
  • Shock
  • Altered mental status
  • Failure of oral rehydration therapy
  • Ileus 1
• Use isotonic fluids such as lactated Ringer's or normal saline 1
• Continue IV rehydration until pulse, perfusion, and mental status normalize 1
• Transition to ORS to replace remaining deficit once patient improves 1

Nutritional Management

• Continue breastfeeding in infants throughout the diarrheal episode 1
• Resume age-appropriate diet during or immediately after rehydration 1
• Early refeeding is recommended rather than fasting or restrictive diets 1
• The BRAT diet (bananas, rice, applesauce, toast) has limited supporting evidence 1

Pharmacological Management

Antimotility Agents

• Loperamide should not be given to children <18 years with acute diarrhea 1
• May be given to immunocompetent adults with acute watery diarrhea once adequately hydrated 1
• Contraindicated in all ages with inflammatory diarrhea, fever, or suspected toxic megacolon 1
• Potential adverse effects include constipation, dizziness, and rarely cardiac events (QT prolongation) 2

Antiemetics

• Ondansetron may be given to children >4 years and adolescents to facilitate oral rehydration when vomiting is significant 1
• May increase stool volume as a side effect 1
• Should not substitute for appropriate fluid and electrolyte therapy 1

Probiotics

• May reduce symptom severity and duration in both adults and children 1
• Consider in immunocompetent patients with infectious or antibiotic-associated diarrhea 1

Zinc Supplementation

• Reduces diarrhea duration in children 6 months to 5 years of age in areas with high zinc deficiency prevalence or in children with signs of malnutrition 1

Infection Control Measures

• Practice proper hand hygiene:
  • After using toilet or changing diapers
  • Before and after food preparation
  • Before eating
  • After handling soiled items 1
• Use gloves and gowns when caring for people with diarrhea 1
• Clean and disinfect contaminated surfaces promptly 1
• Separate ill persons from well persons until at least 2 days after symptom resolution 1

Common Pitfalls to Avoid

• Delaying rehydration therapy while awaiting diagnostic testing 3, 4
• Using inappropriate fluids like apple juice or sports drinks as primary rehydration solutions for moderate to severe dehydration 1
• Administering antimotility drugs to children or in cases of bloody diarrhea 1
• Unnecessarily restricting diet during or after rehydration 1
• Neglecting infection control measures, which can lead to outbreaks 1

Remember that most cases of gastroenteritis are self-limiting, but proper rehydration is essential to prevent complications related to dehydration, which is the primary cause of morbidity and mortality in gastroenteritis 3, 4.