HOLY ANGEL UNIVERSITY COLLEGE OF NURSING ANGELES CITY

A Case Study of a patient with ACUTE GASTROENTERITIS (AGE)

In partial fulfillment of the course requirements in NCM RLE Prepared by: Group 2-A CON II-202 Asuncion, Mark Jason C. Aquino, Romulo C. Fernandez, Krista Manelle P. Icban, Trixia Jennica Q. Manalang, Ma.Filipinas M. Pangilinan, Jacquelyn L.

Submitted to: Ms. Doreen M. Dimalanta, RN Clinical Instructor

December 3, 2009

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I.

INTRODUCTION Gastroenteritis (also known as gastro, gastric flu, tummy bug in some countries, and

stomach flu, although unrelated to influenza) is inflammation of the gastrointestinal tract, involving both the stomach and the small intestine (see also gastritis and enteritis) and resulting in acute diarrhea. The inflammation is caused most often by an infection from certain viruses or less often by bacteria, their toxins, parasites, or an adverse reaction to something in the diet or medication. Worldwide, inadequate treatment of gastroenteritis kills 5 to 8 million people per year,[1] and is a leading cause of death among infants and children under 5. At least 50% of cases of gastroenteritis due to foodborne illness are caused by norovirus..Another 20% of cases, and the majority of severe cases in children, are due to rotavirus. Other significant viral agents include adenovirus and astrovirus. According to the website Science Daily (May 11, 2009) Zinc supplementation can be ineffective in the treatment of diarrhea. A randomized controlled trial published in the open access journal BMC Medicine has shown that supplementation with either zinc or zinc and copper is no more effective than placebo. Archana Patel, from the Lata Medical Research Foundation, India, led a team of researchers who studied the effects of the different supplements on a group of 808 children in Nagpur, also in India. She said, "The expected beneficial effects of zinc supplementation for acute diarrhea were not observed. Therapeutic zinc or zinc and copper supplementation may not have a universal beneficial impact on the duration of acute diarrhea in children". The authors found that neither duration of diarrhea, total stool weight, use of oral rehydration salts nor use of intravenous fluids were affected by supplementation. The authors said, "There could be many reasons for the lack of effect observed in our study. Although our study controlled for baseline serum zinc concentrations, these are not always a reliable measure of body zinc status. As such, baseline zinc deficiency in our subjects may have affected our results. Different diarrhea etiologies and the impact of interactions

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of zinc with multi-vitamins shown in previous studies may also explain the difference between our study and others that have shown a positive effect." The authors have called for a re-examination of all available trial data, including this one, to dissect out the potential contributors to heterogeneity of results before zinc can be universally recommended for treatment of acute childhood diarrhea. Caring for a patient is our primary goal as health care providers and as far as nursing management is concern. The case was chosen because we all know that acute gastroenteritis is a very common disease but we still forget to put in mind that if this will not be treated promptly it will eventually lead to complications like hypovolemic shock and death. Though it is simple, we still forget some things regarding this disease and thru this, we are able to freshen our minds regarding the disease condition. Another reason is that AGE is a very common disease nowadays and one way of preventing it, is to know what are the causative factors responsible in acquiring such. In opting such case, this can help us to be skillful in providing health teachings about what should be done and avoided as to prevent acquiring such diseases. And also for those people who by now are at risk, it is better to be informed early in order to alleviate the risk of acquiring such. This case can also be helpful for hospital nurses to do the proper intervention if they have encountered patient with the same ailment and to provide the necessary health teachings.

OBJECTIVE: After 2 days of nurse-patient interaction, student nurses shall have: Render services of nursing interventions for the clients care. Provide and disseminate important information as teachings to the client and the significant others to boost the knowing and understanding of the nature of the said health condition.

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II. NURSING HISTORY A. Demographic/ Personal Data Gastroboy, son of Mommy Gastro and Daddy Gastro, is a 27-month old male, Roman Catholic and currently living in a certain barangay in San Fernando, Pampanga. He was born on August 3, 2007 in Bulaon via caesarian section and is a full-blooded Filipino. He is the youngest among 3 siblings.

Their housing structure is made up of light wood and concrete and is in fair condition as verbalized by Mommy Gastro. The house has two rooms and their source of water (including drinking water) is through nawasa. They get their food from the market or nearby store and their method of excreta disposal is through pour flush or pail system. In terms of health seeking behaviors, they would rather prefer going first to herbolarios then to public doctors, or in hospitals due to their socio-economic status.

He was admitted in a secondary hospital in San Fernando on November 19, 2009 at 9:25 p.m. with the chief complaint of LBM and vomiting. He was confined for 2 days and was discharged on November 21, 2009. The information that was provided regarding Gastroboys personal history was provided by Mommy Gastro.

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B. SOCIO-ECONOMIC AND CULTURAL FACTORS Daddy Gastro is a construction worker for 3 years already; he works 5 days a week and earns 250php/ day. On the other hand, Mommy Gastro is a housewife and takes care of her children and husband. The head of the family earns enough for their food allowances and some other important expenses Both parents are high school graduates. The eldest son is currently a fourth year high school student while the second child is on his second year. Gastroboy is not yet attending school. Gastroboy is a Roman Catholic but Mommy Gastro verbalized that they are not a devout Catholic. They seldom go to the mass every Sunday but they still never forget to pray. Her mother verbalized that Gastroboy is fond of eating junk foods/chips and softdrinks. Their housing structure is made up of light wood and concrete and is in fair condition as verbalized by Mommy Gastro. The house has two rooms and their source of water (including drinking water) is through nawasa. They get their food from the market or nearby store and their method of excreta disposal is through pour flush or pail system. Mommy Gastro, as the decision maker in the family in terms of health, believes in herbolarios and in superstitious beliefs like the concept of usog, nuno and the like. She verbalized that in seeking health advice, she first consults in herbolarios and hilots then second to it is the public hospital when someone in their family is sick. The genogram on the last page shows the pertinent family history up to 3rd degree of relationship. Pictures were used to represent each member of the family .We can see that Gastroboys relatives have no history of disease. Only his grandfathers on Mommy Gastros side have a history of illness or disease. Mommy Gastros father has asthma; her siblings are free from any disease condition. On the other hand, Daddy Gastros family members dont have past history of disease or illness 6

3. HISTORY OF PAST ILLNESS According to Mommy Gastro, Gastroboy also had chickenpox, measles and mumps during his childhood years but she doesnt remember anymore the age when her son had it and the treatment done to resolve it. Other than that, he also experienced mild illnesses like cough & colds, and fever. Mommy Gastro uses over the counter drugs to treat these illness like Tuseran or Neozep for cough and colds, Paracetamol/ Bioflu for fever. Also, Mommy Gastro also uses nonpharmacologic treatment in treating these illnesses like for cough and colds, she encourages Gastroboy to increase his fluid intake and eat foods rich in Vitamin C like calamansi. She also makes use Lagundi and boils it to make a concoction. He also has no known allergy to any food or drug and there is no history of hospitalization.

4. HISTORY OF PRESENT ILLNESS Two (2) days prior to admission, he experienced decrease in appetite, vomiting and passage of loose watery stool. These continued until one (1) day prior to admission. Because of this, Mommy Gastro decided to bring Gastroboy in the hospital for appropriate treatment. Hence, admitted in a secondary hospital in on November 19, 2009 at 9:25p.m. with the chief complaint of LBM and vomiting. He was confined for 2 days and was discharged on November 21, 2009.

III. PHYSICAL EXAMINATION

NOVEMBER 20, 2009 (INITIAL) 7

GENERAL APPEARANCE Gastroboy was seen wearing a white shirt, with diaper and received lying on bed. He appears restless but he is cooperative when he was assessed by the student nurse. Vital Signs: taken on NOVEMBER 20, 2009 (Friday) Temperature: 36.5 C / axilla Respiratory Rate: 23 bpm Heart Rate: 107 bpm MENTAL STATUS: SKININSPECTION

Appears weak and restless, conscious with slouchy posture and slow but coordinated movement. He is lying on bed and is slightly irritable.

Dark complexion Skin is dry Absence of lesions With poor skin turgor Absence of edema and nodules upon palpation

PALPATION

HEADINSPECTION

Round

PALPATION 8

HAIR

No lesions and nodules palpated

INSPECTION Evenly distributed hair strands No sign of hair loss No dandruff or flakes seen

NAILS INSPECTION With pale nail beds on the upper and lower extremities, smooth texture, convex curvature With long and dirty nails With capillary refill less than 2 seconds

SKULL AND FACE INSPECTION EYES INSPECTION Eyelashes and eyebrows are evenly distributed With sunken eyeballs Eyelashes slightly curled outward Pink palpebral conjunctiva Cornea is shiny and transparent Pupils are black in color, equal in size and converges when seeing near objects Pupils are equally round and reactive to light and accommodation Sclerae are white in color 9 No lesions noted upon inspection Scalp is smooth PALPATION

PALPATION EARS INSPECTION NOSE INSPECTION Both nostrils are patent No noted nasal discharges Nasal septum is in midline Auricles are symmetrical in size and are in line with the outer canthus Pinna recoils after being folded With minimal presence of cerumen on both ears No edema and no tenderness of the lacrimal sacs and nasolacrimal duct

MOUTH INSPECTION NECK INSPECTION No distended jugular veins No masses noted Gums are pink in color and no noted sores or lesions upon inspection Presence of dental caries on lower and upper incisor Uvula is positioned in the midline of the soft palate Inner and outer lips are pale in color and dry

PALPATION Carotid pulse palpated No pain upon swallowing

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LUNGS/CHEST INSPECTION Chest wall symmetrically expands and relaxes No deformities in chest noted Absence of rales or crackles upon auscultation Normal respiratory rate and rhythm

AUSCULTATION

HEARTAUSCULTATION

Absence of murmurs and heaves Normal heart rate and heart beat

ABDOMEN INSPECTION Uniform in color, not distended, symmetric contour Normal abdominal bowel sounds Soft and tender PERCUSSION PALPATION

EXTREMITIES INSPECTION Extremities are symmetrical Peripheral pulses are equal and non-palpable PALPATION DEVELOPMENTAL STAGE Cognitive development : pre operational stage

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Gastroboy likes to talk to others even though he cannot speak straight. He tends to repeat every syllable he said before finally saying the word. He can now speak having at least 3-4 words per sentence. According to his mother, whenever Gastroboy plays, he did it with an imaginary friend. Development Task: Autonomy vs. Shame & Doubt During the assessment, we observed that whenever Gastroboys mother would attend to his needs, he refuses. Instead he will do it on his own. Like for example, when his mother is feeding him, he refuses to eat the food given by his mother. Instead hell get the spoon and feed on his own. Whenever his mother tries to assist him, he refuses and get mad. Another is, when someone tries to ask him, he always responds negatively. Lets say for instance, you asked him if he wants to eat, hell say No.

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IV. DIAGNOSTIC AND LABORATORY PROCEDURES Diagnostic/ Laboratory Procedure HemoglobinIndication/Purposes

Measur es Gastroboys amount of DR: hemoglobin November 20, molecule in 2009 volume of blood This test is important to know Gastroboys oxygen carrying capacity of the blood Signifies percentage of Gastroboys white blood occupied by red blood cells Aids in diagnosing if Gastroboy has an abnormal state of hydration Indicates whether Gastroboy has a presence of bacterial infection DO: November 19, 2009 DR: November 20, 2009

Date ordered/Date released DO: November 19, 2009

Result 121g/l Normal

Normal Values M (140180g/L) F ( 120140g/L) C (110130g/L)

Hematocrit

0.39g/l Normal

M 0.42-0.52 F 0.37-0.47 C - .34-.40

Leukocytes (WBC)

DO: November 19, 2009 DR: November 20, 2009

4.2 thousand/ mm3 Decreased

5-10 thousand/mm3

Analysis & Interpretatio n Gastroboys hemoglobin level is within the normal range for children. This means that the Gatroboy has no anemia. Thereby, has good oxygen carrying capacity in the blood. Gastroboys hematocrit level is within the normal range for children. It indicates that Gastroboy has no anemia as well as abnormal hydration. Gastroboys leukocytes are decreased. It indicates that Gastroboy has an increased risk of 13

Lymphocyte s

To check if Gastroboy has a viral infection

DO: November 19, 2009 DR: November 20, 2009 DO: November 19, 2009 DR: November 20, 2009

0.45 Increased

0.20-0.40

Neutrophils

Indicates whether Gastroboy has a bacterial infection

0.55 Normal

0.40-0.60

infection. Gastroboys lymphocytes are increased. Thus, it indicates viral infection. Gastroboys neutrophil level is within normal range. This indicates that Gastroboy has no bacterial infection.

NURSING RESPONSIBILITIES Hematology (CBC) Before: Check the doctors order for CBC. Explain the test by using direct, simple language and avoid jargon. Tell the patient that fasting is not required. Explain that some brief discomfort may accompany the needle puncture or the application of a tourniquet. Always observe standard precautions.

During: Do not take the blood sample from a hand or arm receiving IV fluid. The tourniquet should be less than a minute. Collect 5-7ml of venous blood in purple/violet cap. 14

After:

List on the laboratory slip any drugs that may affect test results.

After taking blood sample apply a pressure or a pressure dressing to the venipuncture site for 2 minutes. If any hematoma develops at the venipuncture site, apply warm soaks. Label the sample. Document properly. Send the sample in the laboratory immediately.

V. PATIENT AND HIS ILLNESS 1. ANATOMY AND PHYSIOLOGY The digestive system is made up of the digestive tracta series of hollow organs joined in a long, twisting tube from the mouth to the anusand other organs that help the body break down and absorb food. Organs that make up the digestive tract are the mouth, esophagus, stomach, small intestine, large intestinealso called the colonrectum, and anus. Inside these hollow organs is a lining called the mucosa. In the mouth, stomach, and small intestine, the mucosa contains tiny glands that produce juices to help digest food. The digestive tract also contains a layer of smooth muscle that helps break down food and move it along the tract. Two solid digestive organs, the liver and the pancreas, produce digestive juices that reach the intestine through small tubes called ducts. The gallbladder stores the livers digestive juices until they are needed in the intestine. Parts of the nervous and circulatory systems also play major roles in the digestive system.

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WHY IS DIGESTION IMPORTANT? When you eat foodssuch as bread, meat, and vegetablesthey are not in a form that the body can use as nourishment. Food and drink must be changed into smaller molecules of nutrients before they can be absorbed into the blood and carried to cells throughout the body. Digestion is the process by which food and drink are broken down into their smallest parts so the body can use them to build and nourish cells and to provide energy. HOW IS FOOD DIGESTED? Digestion involves mixing food with digestive juices, moving it through the digestive tract, and breaking down large molecules of food into smaller molecules. Digestion begins in the mouth, when you chew and swallow, and is completed in the small intestine. MOVEMENT OF FOOD THROUGH THE SYSTEM The large, hollow organs of the digestive tract contain a layer of muscle that enables their walls to move. The movement of organ walls can propel food and liquid through the system and also can mix the contents within each organ. Food moves from one organ to the next through muscle action called peristalsis. Peristalsis looks like an ocean wave traveling through the muscle. The muscle of the organ contracts to create a narrowing and then propels the narrowed portion slowly down the length of the organ. These waves of narrowing push the food and fluid in front of them through each hollow organ. The first major muscle movement occurs when food or liquid is swallowed. Although you are able to start swallowing by choice, once the swallow begins, it becomes involuntary and proceeds under the control of the nerves. Swallowed food is pushed into the esophagus, which connects the throat above with the stomach below. At the junction of the esophagus and stomach, there is a ringlike muscle, called the lower esophageal sphincter, closing the passage between the two organs. As food approaches the closed sphincter, the sphincter relaxes and allows the food to pass through to the stomach.

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The stomach has three mechanical tasks. First, it stores the swallowed food and liquid. To do this, the muscle of the upper part of the stomach relaxes to accept large volumes of swallowed material. The second job is to mix up the food, liquid, and digestive juice produced by the stomach. The lower part of the stomach mixes these materials by its muscle action. The third task of the stomach is to empty its contents slowly into the small intestine. Several factors affect emptying of the stomach, including the kind of food and the degree of muscle action of the emptying stomach and the small intestine. Carbohydrates, for example, spend the least amount of time in the stomach, while protein stays in the stomach longer, and fats the longest. As the food dissolves into the juices from the pancreas, liver, and intestine, the contents of the intestine are mixed and pushed forward to allow further digestion. Finally, the digested nutrients are absorbed through the intestinal walls and transported throughout the body. The waste products of this process include undigested parts of the food, known as fiber, and older cells that have been shed from the mucosa. These materials are pushed into the colon, where they remain until the feces are expelled by a bowel movement. PRODUCTION OF DIGESTIVE JUICES The digestive glands that act first are in the mouththe salivary glands. Saliva produced by these glands contains an enzyme that begins to digest the starch from food into smaller molecules. An enzyme is a substance that speeds up chemical reactions in the body. The next set of digestive glands is in the stomach lining. They produce stomach acid and an enzyme that digests protein. A thick mucus layer coats the mucosa and helps keep the acidic digestive juice from dissolving the tissue of the stomach itself. In most people, the stomach mucosa is able to resist the juice, although food and other tissues of the body cannot. After the stomach empties the food and juice mixture into the small intestine, the juices of two other digestive organs mix with the food. One of these organs, the pancreas, produces a juice that contains a wide array of enzymes to break down the carbohydrate, fat, and protein in food. Other enzymes that are active in the process come from glands in the wall of the intestine.

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The second organ, the liver, produces yet another digestive juicebile. Bile is stored between meals in the gallbladder. At mealtime, it is squeezed out of the gallbladder, through the bile ducts, and into the intestine to mix with the fat in food. The bile acids dissolve fat into the watery contents of the intestine, much like detergents that dissolve grease from a frying pan. After fat is dissolved, it is digested by enzymes from the pancreas and the lining of the intestine. ABSORPTION AND TRANSPORT OF NUTRIENTS Most digested molecules of food, as well as water and minerals, are absorbed through the small intestine. The mucosa of the small intestine contains many folds that are covered with tiny fingerlike projections called villi. In turn, the villi are covered with microscopic projections called microvilli.These structures create a vast surface area through which nutrients can be absorbed. Specialized cells allow absorbed materials to cross the mucosa into the blood, where they are carried off in the bloodstream to other parts of the body for storage or further chemical change. This part of the process varies with different types of nutrients. Carbohydrates. The Dietary Guidelines for Americans 2005 recommend that 45 to 65 percent of total daily calories be from carbohydrates. Foods rich in carbohydrates include bread, potatoes, dried peas and beans, rice, pasta, fruits, and vegetables. Many of these foods contain both starch and fiber. The digestible carbohydratesstarch and sugarare broken into simpler molecules by enzymes in the saliva, in juice produced by the pancreas, and in the lining of the small intestine. Starch is digested in two steps. First, an enzyme in the saliva and pancreatic juice breaks the starch into molecules called maltose. Then an enzyme in the lining of the small intestine splits the maltose into glucose molecules that can be absorbed into the blood. Glucose is carried through the bloodstream to the liver, where it is stored or used to provide energy for the work of the body. Sugars are digested in one step. An enzyme in the lining of the small intestine digests sucrose, also known as table sugar, into glucose and fructose, which are absorbed through the intestine into the blood. Milk contains another type of sugar, lactose, which is changed into absorbable molecules by another enzyme in the intestinal lining.

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Fiber is indigestible and moves through the digestive tract without being broken down by enzymes. Many foods contain both soluble and insoluble fiber. Soluble fiber dissolves easily in water and takes on a soft, gel-like texture in the intestines. Insoluble fiber, on the other hand, passes essentially unchanged through the intestines. Protein. Foods such as meat, eggs, and beans consist of giant molecules of protein that must be digested by enzymes before they can be used to build and repair body tissues. An enzyme in the juice of the stomach starts the digestion of swallowed protein. Then in the small intestine, several enzymes from the pancreatic juice and the lining of the intestine complete the breakdown of huge protein molecules into small molecules called amino acids. These small molecules can be absorbed through the small intestine into the blood and then be carried to all parts of the body to build the walls and other parts of cells. Fats. Fat molecules are a rich source of energy for the body. The first step in digestion of a fat such as butter is to dissolve it into the watery content of the intestine. The bile acids produced by the liver dissolve fat into tiny droplets and allow pancreatic and intestinal enzymes to break the large fat molecules into smaller ones. Some of these small molecules are fatty acids and cholesterol. The bile acids combine with the fatty acids and cholesterol and help these molecules move into the cells of the mucosa. In these cells the small molecules are formed back into large ones, most of which pass into vessels called lymphatic near the intestine. These small vessels carry the reformed fat to the veins of the chest, and the blood carries the fat to storage depots in different parts of the body. Vitamins. Another vital part of food that is absorbed through the small intestine are vitamins. The two types of vitamins are classified by the fluid in which they can be dissolved: water-soluble vitamins (all the B vitamins and vitamin C) and fat-soluble vitamins (vitamins A, D, E, and K). Fat-soluble vitamins are stored in the liver and fatty tissue of the body, whereas water-soluble vitamins are not easily stored and excess amounts are flushed out in the urine. Water and salt. Most of the material absorbed through the small intestine is water in which salt is dissolved. The salt and water come from the food and liquid you swallow and the juices secreted by the many digestive glands.

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HOW IS THE DIGESTIVE PROCESS CONTROLLED? Hormone Regulators The major hormones that control the functions of the digestive system are produced and released by cells in the mucosa of the stomach and small intestine. These hormones are released into the blood of the digestive tract, travel back to the heart and through the arteries, and return to the digestive system where they stimulate digestive juices and cause organ movement. The main hormones that control digestion are gastrin, secretin, and cholecystokinin (CCK):

Gastrin causes the stomach to produce an acid for dissolving and digesting some foods. Gastrin is also necessary for normal cell growth in the lining of the stomach, small intestine, and colon.

Secretin causes the pancreas to send out a digestive juice that is rich in bicarbonate. The bicarbonate helps neutralize the acidic stomach contents as they enter the small intestine. Secretin also stimulates the stomach to produce pepsin, an enzyme that digests protein, and stimulates the liver to produce bile.

CCK causes the pancreas to produce the enzymes of pancreatic juice, and causes the gallbladder to empty. It also promotes normal cell growth of the pancreas.

Additional hormones in the digestive system regulate appetite:

Ghrelin is produced in the stomach and upper intestine in the absence of food in the digestive system and stimulates appetite. Peptide YY is produced in the digestive tract in response to a meal in the system and inhibits appetite. Both of these hormones work on the brain to help regulate the intake of food for energy.

Researchers are studying other hormones that may play a part in inhibiting appetite, including glucagon-like peptide-1 (GPL-1), oxyntomodulin (+ ), and pancreatic polypeptide.

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Nerve Regulators Two types of nerves help control the action of the digestive system. Extrinsic, or outside, nerves come to the digestive organs from the brain or the spinal cord. They release two chemicals, acetylcholine and adrenaline. Acetylcholine causes the muscle layer of the digestive organs to squeeze with more force and increase the push of food and juice through the digestive tract. It also causes the stomach and pancreas to produce more digestive juice. Adrenaline has the opposite effect. It relaxes the muscle of the stomach and intestine and decreases the flow of blood to these organs, slowing or stopping digestion. The intrinsic, or inside, nerves make up a very dense network embedded in the walls of the esophagus, stomach, small intestine, and colon. The intrinsic nerves are triggered to act when the walls of the hollow organs are stretched by food. They release many different substances that speed up or delay the movement of food and the production of juices by the digestive organs. Together, nerves, hormones, the blood, and the organs of the digestive system conduct the complex tasks of digesting and absorbing nutrients from the foods and liquids you consume each day.

DEFINITION OF THE DISEASE Gastroenteritis is a condition that causes irritation and inflammation of the stomach and intestines (the gastrointestinal tract). An infection may be caused by bacteria or parasites in spoiled food or unclean water. Some foods may irritate your stomach and cause gastroenteritis. Lactose intolerance to dairy products is one example. Many people who experience the vomiting and diarrhea that develop from these types of infections or irritations think they have " food poisoning," which they may, or call it "stomach flu," although influenza has nothing to do with it. Travelers to foreign countries may experience "traveler's diarrhea" from contaminated food and unclean water. 21

The severity of infectious gastroenteritis depends on your immune systems ability to resist the infection. Electrolytes (these include essential elements of sodium and potassium) may be lost as you vomit and experience diarrhea. Most people recover easily from a short bout with vomiting and diarrhea by drinking fluids and easing back into a normal diet. But for others, such as babies and the elderly, loss of bodily fluid with gastroenteritis can cause dehydration, which is a life-threatening illness unless the condition is treated and fluids restored. GASTROENTERITIS CAUSES Gastroenteritis has many causes. Viruses and bacteria are the most common. The infectious agents can come from outside your body or internally from some abnormal condition. For example, both normal and disease-causing intestinal bacteria may grow when antacids or other medication alter the stomach acidity. Viruses and bacteria are very contagious and can spread through contaminated food or water. In up to 50% of diarrheal outbreaks, no specific agent is found. Improper handwashing following a bowel movement or handling a diaper can spread the disease from person to person. Gastroenteritis caused by viruses may last 1-2 days. On the other hand, bacterial cases can last a week or more. Bacteria: These are the most common bacterial causes: Escherichia coli - Travelers diarrhea, food poisoning, dysentery, colitis, or uremic syndrome Salmonella - Typhoid fever; handling poultry or reptiles such as turtles that carry the germs Campylobacter - Undercooked meat, unpasteurized milk Shigella - Dysentery

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Viruses: Viral outbreaks (30-40% of cases in children) can spread rapidly through close contact among children in day care and schools. Poor handwashing habits can spread viruses. Common viral causes include the following: Adenoviruses Rotaviruses Caliciviruses Astroviruses Norovirus (formerly called Norwalk-like virus or NLV) and Norwalk virus Norovirus was attributed to 9 out of the 21 outbreaks of acute gastroenteritis on cruise ships reported to the CDCs Vessel Sanitation Program from January 1, 2002, to December 2, 2002. Noroviruses cause about 23 million cases of acute gastroenteritis each year and are the leading cause of outbreaks. Parasites and protozoans: These tiny organisms are less frequently responsible for intestinal irritation. You may pick up one of these by drinking contaminated water. Swimming pools are common places to come in contact with these parasites. Common parasites include these: Giardia - The most frequent cause of waterborne diarrhea causing giardiasis Cryptosporidium Affects mostly people with weakened immune systems, causes watery diarrhea OTHER COMMON CAUSES: Chemical toxins most often found in seafood, food allergies, heavy metals, antibiotics, and other medications also may be responsible for bouts of gastroenteritis that are not infectious to others. Medications like:

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>Aspirin >Nonsteroidal anti-inflammatory medicines (such as Motrin or Advil) >Antibiotics Caffeine Steroids - Excessive use or a sudden change in frequency or dosage Laxatives Inability to tolerate the sugar lactose in milk and milk products such as cheese and ice cream Exposure to heavy metals sometimes present in drinking water Arsenic Lead Mercury GASTROENTERITIS SYMPTOMS Gastroenteritis may affect both the stomach and the intestines, resulting in one or more of the following symptoms: Common symptoms Low grade fever (99F) Nausea with or without vomiting Mild-to-moderate diarrhea: May range from 2-4 loose stools per day for adolescents and adults to stools that run out of the diaper in infants. Crampy painful bloating

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Vomiting: May or may not accompany diarrhea. If you do vomit, your dehydration rate will increase. Either together or alone, diarrhea and vomiting result not only in loss of significant amounts of fluid, leading to dehydration and possibly shock, but also loss of potassium, sodium, and bicarbonate. More serious symptoms Blood in vomit or stool Vomiting more than 48 hours Fever higher than 101F Swollen abdomen or abdominal pain coming from the right lower side Dehydration - Little to no urination, extreme thirst, lack of tears, and dry mouth (dry diapers in infants) EXAMS AND TESTS

Symptoms of diarrhea and vomiting often indicate gastroenteritis. Finding the cause is another matter. If others around you have similar symptoms, you may be able to trace the illness to a food source or foreign travel. A doctor first will determine if your symptoms are acute (lasting less than 2 weeks) or chronic (longer lasting). A long-lasting illness suggests an inflammation or immune disorder, which should be checked after infection, has been ruled out. Sudden onset of illness may indicate changes in diet or medication. Rapidly developing fever, abdominal pain, bloody stool and presence of white blood cells (leukocytes) may mean an inflammation or diarrhea caused by bacteria. Watery stools without blood or leukocytes are more typical of viral- or toxin-induced diarrhea. You will be asked if other family or friends have similar exposure or symptoms. The doctor will want to know about the duration, frequency, and description of your bowel movements and whether you are vomiting. You will be asked how often and the amount you are urinating to help the doctor determine if your fluid loss is causing dehydration. Have you lost any weight?

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You will be given a physical exam to find any specific or localized tenderness in your abdomen. The doctor will want to determine if you have appendicitis, inflammation of the gallbladder or pancreas, or other noninfectious gastrointestinal disease. The doctor also will feel your abdomen for masses and possibly your rectum. The doctor may perform other lab tests, checking your electrolytes, blood, and stool. The doctor may examine a stool sample for blood, mucus, or abnormal odor. The sample may be inspected under a microscopic to look for parasites and their eggs. The doctor also will take your medical history including the following: Travel history: Travel (especially to Mexico) may suggest E coli bacteria or other Salmonella in 12-72 hours Medications: If you have used broad-spectrum or multiple antibiotics recently, you may have antibiotic-associated irritation. GASTROENTERITIS TREATMENT From the history of your gastroenteritis and the physical exam, the doctor will assess how dehydrated you are. Self-care at home by drinking fluids may help relieve your symptoms and avoid dehydration. Self-Care at Home The mainstay of home treatment of gastroenteritis is to drink fluids. Fluid intake helps correct electrolyte imbalance, which may stop vomiting. Dehydration in children: Children should be given oral rehydration solutions such as Pedialyte, Rehydrate, Resol, and Rice-Lyte. Cola, tea, fruit juice, and sports drinks will not correctly replace fluid or electrolytes lost from diarrhea or vomiting. Nor will plain water. The intestines irritated by gastroenteritis do not

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absorb plain water as well. In addition, plain water will not replace electrolytes and may dilute electrolytes to the point of seizures. After each loose stool, children younger than 2 years should be given 1-3 ounces of any of the rehydration solutions. Older children should be asked to drink 3-8 ounces. Adults should drink as much as possible. This guideline serves only to replace fluid loss due to diarrhea. Drink additional fluid equal to the amount you normally drink. In underdeveloped nations or regions without available commercial pediatric drinks, the World Health Organization has established a field recipe for fluid rehydration: Mix 2 tablespoons of sugar (or honey) with teaspoon of table salt and teaspoon of baking soda. (Baking soda may be substituted with teaspoon of table salt.) Mix in 1 liter (1 qt) of clean or previously boiled water. You will need solid foods eventually to help end the diarrhea. After 24 hours, begin to offer bland foods with the BRAT dietbananas, rice, applesauce without sugar, toast, pasta, or potatoes. Next Steps Diarrhea is one of the leading causes of infant sickness. Worldwide, diarrhea accounts for 3-5 million deaths for all age groups. In general, most adults and children recover after they are appropriately rehydrated. FOLLOW-UP After an infection or irritation of the digestive tract, you may not be able to eat a regular diet. Some people may be unable to tolerate dairy products for several weeks after the disease has gone. You should continue to advance slowly from bland nondairy soups and grain products to a solid diet.

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If your symptoms continue or worsen, call your doctor. PREVENTION With most infectious germs, the key is to block the spread of the organism. Always wash your hands. Eat properly prepared and stored food. Bleach soiled laundry. Vaccinations for Salmonella typhi, Vibrio cholerae, and rotavirus have been developed. But doctors base their use on your medical and foreign travel history. For lactose intolerance, supplementary enzymes are available over-the-counter for adolescents and adults to aid digestion of milk sugars. Soy formulas and other lactose-free products are available from most grocery stores for formula-feeding infant.

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Unsanitary Environment A. Book Based Pathophysiology Improper Hygiene Improper Food Preparation Contaminated food and water Contact with other people

Age