Rosen & Barkin's 5-Minute Emergency Medicine Consult (291 page)

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  2008;6:174–179.
  
• Malfertheiner P, Megraud F, O’Morain C, et al. Current concepts in the management of
  Helicobacter pylori
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  Gut
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• Oishi Y, Kiyohara Y, Kubo M, et al. The serum pepsinogen test as a predictor of gastric cancer: The Hisayama study.
  Am J Epidemiol.
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• Ricci C, Vakil N, Rugge M, et al. Serological markers for gastric atrophy in asymptomatic patients infected with
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See Also (Topic, Algorithm, Electronic Media Element)

• GI Bleeding
  
• Gastroesophageal Reflux Disease
  
• Peptic Ulcer Disease
  

CODES

• 535.00 Acute gastritis, without mention of hemorrhage
  
• 535.30 Alcoholic gastritis, without mention of hemorrhage
  
• 535.50 Unspecified gastritis and gastroduodenitis, without mention of hemorrhage
  

BASICS

Inflammation of stomach and intestines associated with diarrhea and vomiting; often the result of infectious or toxin exposure.

• Viruses:
  
  • 50–70% of all cases with Norovirus cases on the rise in travelers returning from Mexico and India.
    
• Invasive bacteria:
  
  • Campylobacter
    : Contaminated food or water, wilderness water, birds, and animals:
    
    • Most common cause
      
    • Gross or occult blood is found in 60–90%.
      
  • Salmonella
    : Contaminated water, eggs, poultry, or dairy products:
    
    • Typhoid fever (Salmonella typhi)
      characterized by unremitting fever, abdominal pain, rose spots, splenomegaly, and bradycardia
      
    • Immunocompromised susceptible
      
  • Shigella
    : Fecal–oral route
    
  • Vibrio parahaemolyticus
    : Raw and undercooked seafood
    
  • Yersinia
    : Contaminated food (pork), water, and milk:
    
    • May present as mesenteric adenitis or mimic appendicitis
      
  • Specific food-borne disease (food poisoning):
    
    • Staphylococcus aureus
      :
      
      • Most common toxin-related disease
        
      • Symptoms within 1–6 hr after ingesting food
        
    • Bacillus cereus
      :
      
      • Classic source is fried rice left on steam tables.
        
      • Symptoms within 1–36 hr
        
  • Cholera: Profuse watery stools with mucous (rice-water stools)
    
  • Ciguatera:
    
    • Fish intoxication
      
    • Onset 5 min–30 hr (average 6 hr) after ingestion
      
    • Paresthesias, hypotension, peripheral muscle weakness
      
    • Amitriptyline may be therapeutic.
      
  • Scombroid:
    
    • Caused by blood fish: Tuna, albacore, mackerel, and mahi-mahi
      
    • Flushing, headache, erythema, dizziness, blurred vision, and generalized burning sensation
      
    • Symptoms last <6 hr.
      
    • Treatment includes antihistamines.
      
• Protozoa:
  
  • Giardia lamblia:
    
    • High-risk groups: Travelers, day care children, homosexual men, and campers who drink untreated mountain water
      

• Toxins:
  
  • Zinc, copper, cadmium
    
  • Organic chemicals: Polyvinyl chlorides
    
  • Pesticides: Organophosphates
    
  • Radioactive substances
    
  • Alkyl mercury
    
• Altered host response to food substance (tyramine, monosodium glutamate, tryptamine)
  

• Focus evaluation on state of hydration
  
• Most of viral origin and self-limited
  
• Rotavirus accounts for up to 50%
  
• Shigella
  infections associated with seizures
  

DIAGNOSIS

• Nausea, vomiting, diarrhea
  
• Bloody/mucous diarrhea
  
• Abdominal cramps or pain
  
• Fever
  
• Malaise, myalgias, headache, anorexia
  
• Hypotension, lethargy, and dehydration (severe cases)
  

• Dry mucous membranes
  
• Tachycardia
  
• Abdominal tenderness
  
• Perianal inflammation, fissure, fistula
  

• Digital rectal exam to determine presence of gross or occult blood
  
• Fecal leukocyte determination:
  
  • Present with invasive bacteria
    
  • Absent in protozoal infections, viral, toxin-induced food poisoning
    

• CBC indications:
  
  • Significant blood loss
    
  • Systemic toxicity
    
• Electrolytes, glucose, BUN, creatinine—indications:
  
  • Lethargy, significant dehydration, toxicity, or altered mental status
    
  • Diuretic use, persistent diarrhea, chronic liver or renal disease
    
• Stool culture indications:
  
  • Presence of fecal leukocytes
    
  • Historical markers (immunocompromised, travel, homosexual)
    
  • Public health (food handler, day/health care worker)
    
• Blood culture indications:
  
  • Suspected bacteremia or systemic infections
    
  • Ill patients requiring admission
    
  • Immunocompromised
    
  • Elderly patients and infants
    

Abdominal radiographs have no value unless obstruction or toxic megacolon suspected.

• Lab studies not required in most cases
  
• Rotazyme assay detects rotavirus:
  
  • Rarely indicated in managing outpatients
    
  • Helpful to cohort and avoid cross-contamination among inpatients
    
• Stool culture indication:
  
  • Fecal leukocytes
    
  • Toxic
    
  • Infants
    
  • Immunocompromised
    

• Gastritis/peptic ulcer disease
  
• Milk and food allergies
  
• Appendicitis
  
• Irritable bowel syndrome
  
• Ulcerative colitis/Crohn's disease
  
• Malrotation with midgut volvulus
  
• Meckel diverticulum
  
• Drugs and toxins:
  
  • Mannitol
    
  • Sorbitol
    
  • Phenolphthalein
    
  • Magnesium-containing antacids
    
  • Quinidine
    
  • Colchicine
    
  • Mushrooms
    
  • Mercury poisoning
    

TREATMENT

• Difficult IV access with severe dehydration.
  
• Avoid exposure to contaminated clothes or body substances.
  

• Management of ABCs
  
• IV fluid with 0.9% NS resuscitation for severely dehydrated