What are the management recommendations for acute gastroenteritis?

Management of Acute Gastroenteritis

Oral rehydration therapy with oral rehydration solution (ORS) is the first-line treatment for mild to moderate dehydration in acute gastroenteritis, with early refeeding and selective use of ondansetron in children >4 years with significant vomiting. 1

Hydration Assessment and Rehydration Strategy

Initial Assessment

• Assess dehydration severity clinically by examining skin turgor, mental status, mucous membrane moisture, capillary refill, and vital signs 1
• Categorize as mild (3-5%), moderate (6-9%), or severe (≥10%) dehydration based on these clinical signs 1
• The four-item Clinical Dehydration Scale can be used to determine severity based on physical examination findings 2

Rehydration Approach by Severity

For Mild to Moderate Dehydration:

• Use oral rehydration solution (ORS) as first-line therapy until clinical dehydration is corrected 1
• Low-osmolarity ORS formulations are preferred over sports drinks or juices 1
• Continue ORS to replace ongoing losses until diarrhea and vomiting resolve 1
• Oral rehydration is as effective as intravenous rehydration for preventing hospitalization 2, 3
• Nasogastric administration of ORS may be considered for patients who cannot tolerate oral intake or refuse to drink adequately 1

For Severe Dehydration:

• Reserve intravenous rehydration for patients with severe dehydration, shock, altered mental status, failure of oral rehydration therapy, or 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

Resume normal feeding immediately after rehydration without dietary restrictions:

• 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 and dairy avoidance have limited supporting data 4
• Avoid foods high in simple sugars (soft drinks, undiluted apple juice) as they can exacerbate diarrhea through osmotic effects 1

Pharmacological Management

Antiemetics

Ondansetron may be given to children >4 years and adolescents with significant vomiting to facilitate oral rehydration 4, 1

• Ondansetron reduces immediate need for hospitalization or intravenous rehydration 4
• May increase stool volume as a side effect 4
• No recommendation can be made for routine use in children <4 years or adults 4

Antimotility Agents

Loperamide should NOT be given to children <18 years with acute diarrhea 4, 1

• Deaths have been reported in 0.54% of children given loperamide, all occurring in children <3 years old 4
• Loperamide may be given to immunocompetent adults with acute watery diarrhea once adequately hydrated 4, 1
• Avoid loperamide at any age in suspected or proven inflammatory diarrhea, diarrhea with fever, or bloody diarrhea due to risk of toxic megacolon 4

Other Agents

• Antimotility, adsorbents, antisecretory drugs, or toxin binders should not be used as they do not demonstrate effectiveness in reducing diarrhea volume or duration 1
• Probiotics may reduce symptom severity and duration in both adults and children 1
• Zinc supplementation reduces diarrhea duration in children 6 months to 5 years in areas with high zinc deficiency prevalence or in malnourished children 1

Antimicrobial Therapy

Antimicrobial agents have limited usefulness since viral agents are the predominant cause 1

• Consider antimicrobial therapy only in specific cases: bloody diarrhea, recent antibiotic use, exposure to certain pathogens, recent foreign travel, or immunodeficiency 1
• Microbial studies are not routinely needed when viral gastroenteritis is the likely diagnosis in children with mild illness 4

Infection Control

Implement strict infection control measures to prevent transmission:

• Practice proper hand hygiene after using toilet or changing diapers, before and after food preparation, before eating, and 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

Critical Pitfalls to Avoid

• Do not delay rehydration therapy while awaiting diagnostic testing—initiate rehydration promptly 1
• Do not use inappropriate fluids like apple juice or sports drinks as primary rehydration solutions for moderate to severe dehydration 1
• Do not administer antimotility drugs to children or in cases of bloody diarrhea 4, 1
• Do not unnecessarily restrict diet during or after rehydration 1
• Do not use ancillary treatments as substitutes for fluid and electrolyte therapy—they can only be considered once the patient is adequately hydrated 4
• Ondansetron may mask signs and symptoms of bowel obstruction in patients following abdominal surgery or those with chemotherapy-induced nausea and vomiting 5