What is the management for stomach pain associated with gastroenteritis?

Management of Stomach Pain with Gastroenteritis

The cornerstone of managing stomach pain in gastroenteritis is adequate rehydration with oral rehydration solution (ORS) for mild-to-moderate dehydration, while symptomatic relief can be achieved with antiemetics once hydration is addressed—antimotility agents and routine antibiotics should be avoided. 1

Initial Assessment and Hydration Status

Assess dehydration severity through clinical signs including skin turgor, mental status, mucous membrane moisture, capillary refill time, and urine output to categorize as mild (3-5% body weight loss), moderate (6-9% body weight loss), or severe (≥10% body weight loss). 2 Look specifically for prolonged skin tenting (>2 seconds), cool extremities, decreased capillary refill, and signs of acidosis (rapid, deep breathing) as these predict significant dehydration more reliably than sunken fontanelle or absent tears. 1

Rehydration Strategy by Severity

Mild to Moderate Dehydration

• Administer 50-100 mL/kg of ORS over 3-4 hours for infants and children, or 2-4 L over 3-4 hours for adolescents and adults. 1, 2
• Replace ongoing losses with 60-120 mL ORS per diarrheal stool or vomiting episode (for children <10 kg) or 120-240 mL per episode (for children >10 kg). 1
• Nasogastric administration of ORS may be used in patients who cannot tolerate oral intake or are too weak to drink adequately. 1
• Continue breastfeeding throughout illness and resume age-appropriate normal diet once rehydration is complete. 1

Severe Dehydration

• Administer isotonic intravenous fluids (lactated Ringer's or normal saline) at 20 mL/kg boluses until pulse, perfusion, and mental status normalize. 1, 2
• Malnourished infants may benefit from smaller-volume, frequent boluses of 10 mL/kg due to reduced cardiac capacity. 1
• Once stabilized, transition to ORS for remaining deficit replacement. 1

Symptomatic Management of Stomach Pain

Antiemetic Therapy

Ondansetron (0.15 mg/kg per dose) should be given to children >4 years and adolescents with significant vomiting to facilitate oral rehydration tolerance. 1, 2 This reduces immediate need for hospitalization or IV rehydration, though it may increase stool volume. 1 Ondansetron is not routinely recommended for children <4 years or adults due to insufficient evidence. 1

Antimotility Agents - Critical Contraindications

Loperamide is absolutely contraindicated in children <18 years with acute diarrhea due to risk of ileus, abdominal distension, lethargy, and reported deaths (0.54% mortality, all in children <3 years). 1

For immunocompetent adults with acute watery diarrhea, loperamide may be used (4 mg initially, then 2 mg after each loose stool) only after adequate hydration and only if there is no fever or bloody diarrhea, as it must be avoided when toxic megacolon risk exists. 1, 2, 3

Other Symptomatic Agents

Bismuth subsalicylate is mildly effective but nonspecific antidiarrheal agents (kaolin-pectin, adsorbents) do not reduce diarrhea volume or duration and may increase electrolyte losses. 1 These shift focus away from appropriate fluid therapy and are not recommended. 1

Nutritional Management

Resume normal age-appropriate diet once rehydration is complete, offering food every 3-4 hours. 1 Early refeeding decreases intestinal permeability, reduces illness duration, and improves nutritional outcomes. 1

Lactose-containing formula can be tolerated in most instances and does not need routine replacement. 1 However, a lactose-free diet may reduce diarrhea duration by 18 hours and reduce treatment failure by half in children <5 years. 1 The BRAT diet has limited supporting data and instructing patients to avoid solid food for 24 hours is not useful. 1

Antibiotic Therapy - When NOT to Use

Antibiotics should NOT be routinely administered for gastroenteritis unless there is evidence of specific bacterial infection requiring treatment, intra-abdominal abscess, or signs of sepsis. 1, 4 The vast majority of gastroenteritis cases are viral (approximately 70%) and self-limited. 5

Common Pitfalls to Avoid

• Do not use popular beverages (apple juice, Gatorade, commercial soft drinks) for rehydration as they are not appropriate ORS formulations. 1
• Do not delay ORS therapy while waiting for IV access in mild-to-moderate dehydration—ORS is as effective as IV therapy and should be first-line. 1, 6
• Do not give loperamide to any child regardless of symptom severity, as risks far outweigh benefits. 1
• Do not withhold food for 24 hours—early refeeding improves outcomes. 1
• Do not use antimotility agents in patients with fever or bloody diarrhea at any age due to toxic megacolon risk. 1

Monitoring and Follow-up

Monitor for treatment failure indicators including persistent vomiting, worsening diarrhea, inability to maintain hydration, or development of severe symptoms. 1 If clinical improvement is not observed within 48 hours, patients should contact their healthcare provider. 3 Watch for postinfectious complications including irritable bowel syndrome (occurs in approximately 9% of patients) and lactose intolerance. 5