gastroenteritis%20-%20viral
GASTROENTERITIS - VIRAL
Treatment Guideline Chart
Acute gastroenteritis is a diarrheal disease of rapid onset.
Viruses are one of the common causes of acute gastroenteritis.
Rotavirus, norovirus/"Norwalk-like" virus, sapovirus, enteric adenovirus serotypes 40 and 41, astrovirus, calicivirus and enterovirus are the established viral agents causing gastroenteritis.
Rotavirus is the most common pathogen causing diarrhea in patients 3-24 months old.
Patients <3 months old are protected by maternal rotavirus antibodies that are passed transplacentally and possibly by breastfeeding.
Transmission is through fecal-oral route.

Gastroenteritis%20-%20viral Treatment

Principles of Therapy

  • Viral gastroenteritis is generally a self-limiting illness
  • Treatment is based on the degree of dehydration
  • Oral replacement therapy (ORT) encompasses 2 phases of treatment: 
    • Rehydration phase: Electrolytes and water are administered as oral rehydration solution (ORS) to replenish fluid losses
      • Should be performed rapidly within 3-4 hours
    • Maintenance phase: Restoration of ongoing fluid and electrolyte losses, and adequate dietary intake
  • Age-appropriate diet (including solids) for rapid realimentation is recommended once adequate degree of hydration is attained
  • Breastfeeding should be continued especially for breastfed patients
  • Changes in formula milk are not necessary

Pharmacotherapy

  • No specific antiviral therapy is available
  • Based on several controlled studies, antidiarrheal medications have shown no benefit in patients with viral gastroenteritis
  • Antiemetic agents (eg Ondansetron) may be used in children >4 years of age to decrease vomiting or help avoid the need for intravenous fluid, but may increase episodes of diarrhea
  • Zinc supplementation given during an episode of diarrhea may decrease the duration and severity of diarrheal illness and reduce the incidence of diarrhea in the next 2-3 months
    • For patients up to 6 months old, may give 10 mg/day PO x 10-14 days
    • Patients ≥6 months old, may give 20 mg/day PO x 10-14 days
  • Probiotics have been shown to reduce the intensity and duration of acute infectious diarrhea in children
    • May be used in rotavirus gastroenteritis
    • Examples include Lactobacillus spp, Saccharomyces boulardii, Bifidobacterium spp
  • Racecadotril, an antisecretory agent, may be used as an adjunctive therapy in acute diarrhea
    • Studies showed decreased diarrhea duration and reduced stool output following administration of Racecadotril in children with acute diarrhea
  • Smectite, an adsorbent, may have a role in the treatment of acute viral gastroenteritis in children but further studies are recommended 
  • Bovine colostrum contains antimicrobial peptides (lactoferrin, lactoperoxidase), immune-regulating and inflammatory cytokines, and growth factors that may help provide passive immunity by enhancing different immune functions (eg phagocytosis, antigen presentation, antimicrobial activity via antigen chelation, inflammation control) in the gastrointestinal tract
    • Studies showed that bovine colostrum improved clinical symptoms (eg reduced stool frequency, reduced occurrence and duration of diarrhea) in children with infectious diarrhea
    • Clinical benefit in the prevention and management of infectious diarrhea is currently undergoing clinical trials
  • Human milk, gelatin tannate and other probiotics are being studied to conclude their use in the management of gastroenteritis

Non-Pharmacological Therapy

Dietary Therapy

  • Depends on age and diet history
  • Breastfed patients should continue nursing on demand while formula-fed patients must continue their usual full-strength milk
    • Based on several trials, feedings with diluted formula are associated with protracted symptoms and delayed nutritional recovery
  • Lactose-free formulas are recommended in patients with documented and persistent lactose intolerance
  • Intake of patient’s usual diet is recommended
  • Recommended foods include complex carbohydrates, lean meats, yogurt, fruits and vegetables
    • Highly specific diets [eg BRAT (banana, rice, applesauce and toast) diet] have been commonly recommended, however these may provide insufficient nutrition for patient’s nourishment and recovering gut
  • Foods high in simple sugars should be avoided

Indications for Hospital Admission

  • Severely dehydrated
  • Difficulties in ORT administration (eg continuous vomiting, refusal or inadequate intake of ORS)
  • Failure of ORS treatment including worsening diarrhea or dehydration despite adequate volumes
  • Presence of coexisting illnesses
  • Family incapable of providing adequate care at home
  • Concerns that might prevent return for evaluation or follow-up
  • Presence of the following factors: Young age, changes in sensorium, advancing course of symptoms, need for close monitoring due to ambiguous diagnosis
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