Rosen & Barkin's 5-Minute Emergency Medicine Consult (292 page)

• Oral fluids for mild dehydration (Gatorade/Pedialyte)
  
• IV fluids for:
  
  • Hypotension, nausea and vomiting, obtundation, metabolic acidosis, significant hypernatremia, or hyponatremia
    
  • 0.9% NS bolus (adults: 500 mL–1 L, peds: 20 mL/kg) for resuscitation, then 0.9% NS or D
    ₅
    0.45% peds: NS (peds: D
    ₅
    0.25% NS) to maintain adequate urine output
    
• Bismuth subsalicylate (Pepto-Bismol):
  
  • Antisecretory agent
    
  • Effective clinical relief without adverse effects
    
• Kaolin–pectin (Kaopectate):
  
  • Reduces fluidity of stools
    
  • Does not influence course of disease
    
• Antimotility drugs (diphenoxylate [Lomotil], loperamide [Imodium], paregoric, and codeine):
  
  • Appropriate in noninfectious diarrhea
    
  • Initial use of sparse amounts to control symptoms in infectious diarrhea
    
  • Avoid prolonged use in infectious diarrhea—may increase duration of fever, diarrhea, and bacteremia and may precipitate toxic megacolon.
    
• Antibiotics for infectious pathogens:
  
  • Campylobacter
    : Quinolones or erythromycin
    
  • Salmonella
    : Quinolones or trimethoprim–sulfamethoxazole (TMP–SMX)
    
  • Typhoid fever: Ceftriaxone
    
  • Shigella
    : Quinolone, TMP–SMX, or ampicillin
    
  • V. parahaemolyticus:
    Tetracycline or doxycycline
    
  • Clostridium difficile:
    Metronidazole or vancomycin
    
  • Escherichia coli:
    Quinolones or TMP–SMX
    
  • Giardia lamblia:
    Metronidazole
    
• Antiemetics for nausea/vomiting:
  
  • Ondansetron
    
  • Prochlorperazine
    
  • Promethazine
    

• Ampicillin: 500 mg (peds: 20 mg/kg/24 h) PO or IV q6h
  
• TMP–SMX; Bactrim DS: 1 tab (peds: 8–10 mg TMP/40–50 mg SMX/kg/24 h) PO BID
  
• Ceftriaxone: 1 g (peds: 50–75 mg/kg/12 h) IM or IV q12h
  
• Ciprofloxacin (quinolone): 500 mg PO or 400 mg IV BID (>18 yr)
  
• Doxycycline: 100 mg PO or 400 mg IV BID
  
• Metronidazole: 250 mg (peds: 35 mg/kg/24 h) PO TID (>8 yr)
  
• Ondansetron 4 mg (peds: 0.1 mg/kg) IV
  
• Prochlorperazine (Compazine): 5–10 mg IV q3–4h; 10 mg PO q8h; 25 mg per rectum (PR) q12h
  
• Promethazine (Phenergan): 25 mg IM/IV q4h; 25 mg PO/PR (peds: 0.25–1 mg/kg PO/PR/IM)
  
• Tetracycline: 500 mg PO or IV QID
  
• Vancomycin 125–500 mg (peds: 40 mg/kg/24 h) PO q6h
  

FOLLOW-UP

• Hypotension unresponsive to IV fluids
  
• Significant bleeding
  
• Signs of sepsis/toxicity
  
• Intractable vomiting or abdominal pain
  
• Severe electrolyte imbalance
  
• Metabolic acidosis
  
• Altered mental status
  
• Children with >10–15% dehydration
  

• Mild cases requiring oral hydration
  
• Dehydration responsive to IV fluids
  

Cases of prolonged symptoms may be referred to a gastroenterologist for further workup.

Most cases are self-limiting; therefore, follow-up is optional.

• Viruses account for over 50% of cases
  
• Avoid antimotility drugs in cases due to infectious pathogens.
  
• TMP–SMX (Bactrim DS), ciprofloxacin, doxycycline, and tetracycline are contraindicated in pregnancy. Metronidazole may be used during the 3rd trimester.
  

• Bresee JS, Marcus R, Venezia RA, et al. The etiology of severe acute gastroenteritis among adults visiting emergency departments in the United States.
  J infect Dis.
  2012;205:1374–1381.
  
• Centers for Disease Control and Prevention (CDC). Vital signs: Incidence and trends of infection with pathogens transmitted commonly through food–foodborne diseases active surveillance network, 10 U.S. sites, 1996–2010.
  MMWR Morb Mortal Wkly Rep.
  2011;60:749–755.
  
• DuPont HL. Clinical practice. Bacterial diarrhea.
  N Engl J Med
  . 2009;361(16):1560–1569.
  
• Hill DR, Ericsson CD, Pearson RD, et al. The practice of travel medicine: Guidelines by the Infectious Diseases Society of America.
  Clin Infect Dis
  . 2006;43:1499–1539.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Diarrhea, Adult
  
• Diarrhea, Pediatric
  

CODES

• 008.63 Enteritis due to norwalk virus
  
• 009.0 Infectious colitis, enteritis, and gastroenteritis
  
• 558.9 Other and unspecified noninfectious gastroenteritis and colitis
  

BASICS

• Spectrum of pathology in which gastric reflux causes symptoms and damage to esophageal mucosa
  
• Reflux esophagitis vs. nonerosive reflux disease
  
• 40% of general population experience symptoms monthly
  

• Incompetent reflux barrier allowing increase in frequency and duration of gastric contents into esophagus
  
• Lower esophageal sphincter (LES):
  
  • Main antireflux barrier
    
  • Crural diaphragm attachment (diaphragmatic sphincter)
    
  • Contributes to pressure barrier at gastroesophageal junction
    
  • Esophageal acid clearance via peristalsis and esophageal mucosal resistance are additional barriers.
    
  • Most healthy individuals have brief episodes of reflux without symptoms.
    
• Transient lower esophageal sphincter relaxations (TLESRs):
  
  • Occur with higher frequency in gastroesophageal reflux disease (GERD) patients
    
  • Exposed esophageal mucosa becomes acidified and with time necroses
    
• Decreased LES tone:
  
  • Smoking
    
  • Foods: Alcohol, chocolate, onion, coffee, tea
    
  • Drugs: Calcium channel blockers, morphine, meperidine, barbiturates, theophylline, nitrates
    
• Delayed gastric emptying, increased body mass, and gastric distention contribute to reflux
  
• Hiatal hernias associated with GERD:
  
  • Significance varies in any given individual
    
  • Most persons with hiatal hernias do not have clinically evident reflux disease
    
• Acid secretion is same in those with or without GERD
  
• Associated medical conditions: Pregnancy, chronic hiccups, cerebral palsy, Down syndrome, autoimmune diseases, diabetes mellitus (DM), hypothyroidism
  

DIAGNOSIS

• Esophageal manifestations
  
  • Heartburn (or pyrosis)
    
  • Regurgitation
    
  • Dysphagia
    
• Extraesophageal manifestations
  
  • Bronchospasm
    
  • Laryngitis
    
  • Chronic cough
    

• Typical signs and symptoms:
  
  • Heartburn (pyrosis):
    
    • Retrosternal burning pain
      
    • Radiates from epigastrium through chest to neck and throat
      
  • Dysphagia:
    
    • Dysphagia suggests esophageal spasm or stricture.
      
  • Odynophagia:
    
    • Odynophagia suggests ulcerative esophagitis.
      
  • Regurgitation
    
  • Water brash
    
  • Belching
    
  • Esophageal strictures, bleeding
    
  • Barrett esophagus (esophageal carcinoma)
    
  • Early satiety, nausea, anorexia, weight loss
    
  • Symptoms worse with recumbence or bending over
    
  • Symptoms usually relieved with antacids, although temporarily
    
• Atypical signs and symptoms:
  
  • Noncardiac chest pain
    
  • Asthma
    
  • Persistent cough, hiccups
    
  • Hoarseness
    
  • Pharyngeal/laryngeal ulcers and carcinoma
    
  • Frequent throat clearing
    
  • Recurrent pneumonitis
    
  • Nocturnal choking
    
  • Upper GI tract bleeding