LAHORE GENERAL HOSPITAL

GASTROENTERITIS

Background to condition:

o        Infectious gastroenteritis causes diarrhea with or without vomiting.

o        Cramping abdominal pain.

o        Many cases can be managed effectively with oral rehydration.

o        Enteral rehydration is preferable to intravenous hydration.

o        Shocked patients require urgent resuscitation with 20 mls/kg boluses   

        of  IV Normal Saline.

Assessment:

Is the diagnosis of gastroenteritis correct?:

The following features may occur in gastroenteritis, but should prompt careful consideration of differential diagnoses & review by a senior doctor:

o         Severe abdominal pain or abdominal signs

o         Persistent diarrhea (> 10 days)

o         Blood in stool

o         Looks very unwell

o         Bilious (green) vomit

o        Vomiting without diarrhea

Consider the diagnosis carefully if there is

o        Abdominal pain

o        Isolated Vomiting

Investigations:

In most patients with gastroenteritis no investigations are required

Faecal samples may be collected for microbiological culture if the patient has significant associated abdominal pain or blood in the motions, as a bacterial cause of gastroenteritis is more likely. However these results usually don't alter treatment.

Blood tests (electrolytes, glucose) are not necessary in simple gastroenteritis but are required for:

o          Severe dehydration

o          Comorbidity of renal disease or on diuretics

o          Altered conscious state

o          Ileostomy

Acute Management:

Rehydration

Ondansetron drug dose

o     Should only be administered once in this setting.

Oral rehydration

o      Lemonade, homemade ORS and sports drinks are not appropriate fluids for rehydration

o      Suggest oral rehydration solutions (ORS) eg. Pedialyte

Trial of oral fluids in the emergency department:

o         Note: Most patients with mild/no dehydration can be discharged 

         without a trial of  fluids,  after appropriate advice and follow-up arranged.

o         In patients requiring rehydration: give frequent small amounts of ORS, 

         aiming for 10-20 ml/kg over 1 hour.

o         Significant ongoing GI losses (frequent vomiting or profuse diarrhoea) 

         minimise the chance of success at home. Consider early NGT  

         rehydration in these children.

Intravenous Rehydration

Indications:

o           Indicated for severe dehydration. (eg. ongoing profuse losses or 

          abdominal pain).

o           Also suitable for patients who already have an IV insitu.

IV Fluids see guideline:

o          Initial boluses: 20ml/kg Normal saline boluses, repeated until shock is 

          corrected. If > 40 ml/kg boluses required, involve senior staff and ICU.

o          Measure blood glucose and treat hypoglycaemia with 5ml/kg of 10%  

          dextrose.

o           Measure Na, K and glucose at the outset & at least 24 hourly from

          then on (more frequent testing is indicated for patients with co-

          morbidities or if more unwell). Venous blood gases provide rapid 

          results. It is not necessary to send an electrolyte tube to the lab 

          unless measurement of urea or creatinine is clinically indicated.

o          Consider septic work-up or surgical consult in severely unwell patients

         with gastroenteritis.

o          Ongoing fluids: 5% Dextrose + 0.9% Normal saline (Rates see table). 

          Use a fluid containing KCl (20mmol/L) if serum K < 3mmol/l or give

         oral supplements.

Table 4: Recommended starting rate for IV REHYDRATION AFTER INIITIAL BOLUSES      (0-24 hours)

After 1st 24 hours, if needed, use Standard Intravenous Fluids unless abnormal ongoing losses or electrolyte disturbance.

Monitoring of rehydration

o                                   Bare weigh patient 6 hourly in moderate and severe dehydration or iv fluids.

o                                   Careful reassessment after 4-6 hours needs to occur, then 8 hourly to guide ongoing fluid therapy. Look particularly for:

�           Wweight change

�            Clinical signs of dehydration

�            Urine output

�            Ongoing losses &

�            Signs of fluid overload, such as puffy face and extremities.

Consider transfer when:

o           Severe electrolyte abnormalities

o           Severe dehydration or shock

Discharge requirements:

Medical review before discharge required if:
- < 4% wt gain
- Signs of dehydration or otherwise unwell
- >=3 large stools during rehydration
- Abdominal pain worsening

Anti-diarrhoeals and maxalon are not recommended.Bottom of Form

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