Under a gastroenteritis we understand an inflammation of the mucosal lining of the stomach, small and large intestine. Most cases are infectious, although gastroenteritis even after taking medication and chemical toxins (z. B. metals, vegetable substances) may occur. Transmission is by food, water or from person to person. In the US, an estimated 1 of 6 people ill from food poisoning each year. Symptoms include anorexia, nausea, vomiting, diarrhea and abdominal pain. The diagnosis is made clinically or by a stool culture, and PCR and immunoassays are increasingly used for diagnosis. Treatment is symptomatic, parasitic and some bacterial infections require specific therapy.

Under a gastroenteritis we understand an inflammation of the mucosal lining of the stomach, small and large intestine. Most cases are infectious, although gastroenteritis even after taking medication and chemical toxins (z. B. metals, vegetable substances) may occur. Transmission is by food, water or from person to person. In the US, an estimated 1 of 6 people ill from food poisoning each year. Symptoms include anorexia, nausea, vomiting, diarrhea and abdominal pain. The diagnosis is made clinically or by a stool culture, and PCR and immunoassays are increasingly used for diagnosis. Treatment is symptomatic, parasitic and some bacterial infections require specific therapy.

(Food allergies and mushroom poisoning.) Under an gastroenteritis we mean inflammation of the mucosal lining of the stomach, small and large intestine. Most cases are infectious, although gastroenteritis even after taking medication and chemical toxins (z. B. metals, vegetable substances) may occur. Transmission is by food, water or from person to person. In the US, an estimated 1 of 6 people ill from food poisoning each year. Symptoms include anorexia, nausea, vomiting, diarrhea and abdominal pain. The diagnosis is made clinically or by a stool culture, and PCR and immunoassays are increasingly used for diagnosis. Treatment is symptomatic, parasitic and some bacterial infections require specific therapy. Gastroenteritis is usually unpleasant, but it is self-limited. The electrolyte and fluid loss is merely inconvenient for an otherwise healthy patients, but it can be extremely serious in the very young (dehydration in children), in elderly, debilitated or patients with severe comorbidities as well. Worldwide an estimated 1.5 million children die each year from infectious gastroenteritis; although this number is high, it is still only one-half to one-quarter of the earlier mortality. Improvements in sanitation in many parts of the world and the appropriate use of oral rehydration therapy in infants with diarrhea are probably responsible for this decline. The etiology of infectious gastroenteritis can be caused by viruses, bacteria or parasites. Many specific pathogens are discussed in § INF (s. Ch. 167). Viruses The following viruses are most frequently involved: Rotavirus Norovirus Viruses are the most common cause of gastroenteritis in the US. They infect the enterocytes in the villous epithelium of the small intestine. The result is a transudation of fluid and salts in the intestinal lumen, sometimes the malabsorption of carbohydrates worsens symptoms by an osmotic diarrhea. There is a watery diarrhea. An inflammatory diarrhea (dysentery) with white and red blood cells or the addition of whole blood in the stool is rare. Four categories of viruses cause the majority of gastroenteritis: rotavirus and calicivirus (mainly norovirus [formerly Norwalk virus]) are responsible for the majority of viral gastroenteritis, followed by astrovirus and enteric adenovirus. Rotavirus is the most common cause of sporadic severe dehydrating diarrhea in young children (frequency maximum 3-15 months of life). Rotavirus is highly contagious, the most common transmission route is fecal-oral route. Adults can become infected through close contact with an infectious child. The illness is mild in adults in general. The incubation period is 1-3 days. In temperate climates, most infections in the winter occur. Begins each year in the United States a wave of rotavirus disease in November in the southwest and ends in March in the Northeast. Noroviruses infect mostly older children and adults. Infections occur throughout the year, but 80% occur in the months of November to April. Noroviruses are the leading cause of sporadic viral gastroenteritis in adults and epidemic viral gastroenteritis in all age groups. Large, water-borne or food outbreaks occur. A transfer from person to person also happens because the virus is highly contagious. Most Gastroenteritisepidemien on cruise ships and in nursing homes are due to this virus. The incubation period is 24-48 hours. The Astro virus can infect people of all ages, but most infants and young children. The infection in the winter months occurs most frequently. Transmission is fecal-oral route. The incubation period is 3-4 days. Adenoviruses are the fourth leading cause of viral gastroenteritis in childhood. The infections occur throughout the year, with a slight increase in the summer. Children <2 years are primarily affected. Transmission is fecal-oral route. The incubation period is 3-10 days. In immunocompromised patients, other viruses can (. Eg cytomegalovirus, enterovirus) gastroenteritis hervorrufen.Bakterien These bacteria are most frequently involved: Salmonella Campylobacter Shigella Escherichia coli (especially serotype O157: H7) Clostridium difficile Bacterial gastroenteritis is less common as a viral. Bacteria cause gastroenteritis via several mechanisms. Some species (Vibrio cholerae, enterotoxic strains of E. coli) adhere to the intestinal mucosa without penetrating into it, and produce endotoxins. These toxins impair the gut absorption and cause the release of electrolytes and water by stimulating adenylate cyclase, leading to aqueous diarrhea. C. difficile produces a similar toxin (Clostridium difficile-induced diarrhea). Some bacteria (Staphylococcus aureus, Bacillus cereus, Clostridium perfringens, Clostridium perfringens food poisoning by) produce an exotoxin which is incorporated contaminated food. This exotoxin can cause gastroenteritis without bacterial infection. Most of these toxins produce acute nausea, vomiting and diarrhea within 12 hours after ingestion of the contaminated diet. The symptoms can be within 36 hours after. Other bacteria (eg. B. Shigella, Salmonella, Campylobacter, some E. coli subtypes, 173 Gram-negative rods) penetrate the mucosa of the small or large intestine and produce microscopic ulceration, bleeding, exudation of protein-rich fluid and a release of electrolyte and water. This invasive process and its consequences occur regardless of whether the pathogen produces an enterotoxin or not. The resulting diarrhea contains white and red blood cells and sometimes whole blood. Salmonella and Campylobacter are the most common bacterial causes of diarrheal illness in the United States. Both infections are usually acquired by incompletely cooked or roasted poultry; non-pasteurized milk is also a possible source. Campylobacter is occasionally transmitted from dogs and cats with diarrhea. Salmonella can be transmitted by eating undercooked eggs and by contact with reptiles, birds or amphibians. A species of Shigella are the third most common bacterial cause of diarrheal illness in the United States and are generally transmitted by direct human contact, although transmitted by food epidemics occur. Shigella dysenteriae type 1 (does not occur in the US), the Shiga toxin that causes a hemolytic uremic syndrome produced (thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS)). Several different subtypes of E. coli cause diarrhea. The epidemiology and clinical manifestations may vary greatly depending on the subtype: 1. enterohaemorrhagic E. coli is the clinically significant subtype in the United States. He produces the Shiga toxin that causes bloody diarrhea one. E. coli O157: H7 is the most common strain of this subtype in the US (infection by Escherichia coli O157: H7 and other enterohemorrhagic E. coli (EHEC)). Undercooked beef, unpasteurized milk and juice and contaminated water are possible sources of infection. A transmission from humans to humans often occurs in day care centers. Outbreaks associated with water contact in leisure time (eg. As pools, lakes, water parks) have also been reported. Hemolytic uremic syndrome is a serious complication that occurs in 2-7% of cases, most often in young and old people. 2. enterotoxigenic E. coli produce two toxins (one similar to the cholera toxin) which cause watery diarrhea. This subtype is the most common cause of travelers' diarrhea in persons traveling to developing countries. 3. enteric pathogens E. coli cause watery diarrhea. Once a common cause of outbreaks of diarrhea in kindergartens, this subtype is rare today. 4. Enteroinvasive E. coli lead to bloody and not bloody diarrhea, v. a. In the developing countries. In the US, they rarely occur. In the past infections occurred with C. difficile on almost exclusively in hospitalized patients receiving antibiotics. With the emergence of hypervirulent NAP1 strain in the United States in the late 2000s many community-associated cases now occur. A number of other bacteria cause gastroenteritis, but most are rare in the United States. Yersinia enterocolitica (plague and other yersinia infections), a gastroenteritis or a syndrome similar to trigger appendicitis. It is transmitted by undercooked or roasted pork, unpasteurized milk or contaminated water. Several Vibrio species (eg. B. V. parahaemolyticus, Vibrio -cholerae non-infections) lead to diarrhea after ingestion of insufficiently cooked seafood. V. cholerae (cholera) occasionally causes severe dehydrating diarrhea in the developing world and is a particular problem of natural disasters or in refugee camps. Listeria causes a foodborne gastroenteritis (listeriosis). Aeromonas is acquired while swimming in or drinking contaminated fresh or brackish water. Plesiomonas shigelloides can cause diarrhea in patients who have eaten raw shells or reisen.Parasiten in tropical regions of the Third World following parasites are most frequently involved: Giardia Cryptosporidium Certain intestinal parasites, particularly Giardia intestinalis (lamblia, Giardiasis), adhere or invade the intestinal mucosa and cause nausea, vomiting, diarrhea, and general malaise. A giardiasis occurs in all regions of the United States and around the world. The infection can become chronic and can cause malabsorption syndrome. It is (often in kindergartens) usually acquired via human-to-human contact or through contaminated water. Cryptosporidium parvum (cryptosporidiosis) gives aqueous diarrhea, sometimes accompanied by abdominal cramps, nausea and vomiting. In healthy people, the disease is self-limiting and lasts about 2 weeks. In immunocompromised patients, the disease can be serious and cause substantial electrolyte and fluid losses. Cryptosporidium is usually acquired through contaminated water. It is not easy to kill by chlorine and is in the US, the most common cause of diseases by recreational activities on the water, which account for around three quarters of the outbreaks. Other parasites that cause similar symptoms as with a cryptosporidiosis are Cyclospora cayetanensis and, in immunocompromised patients, Cystoisospora (Isospora) belli and a whole collection of pathogens that as microsporidia (z. B. Enterocytozoon bieneusi, Encephalitozoon intestinalis), respectively. Entamoeba histolytica (amebiasis, amebiasis) is a common cause of subacute bloody diarrhea in the developing world, is in the US but rare. Symptoms and complaints character and severity of symptoms vary. Usually the onset is sudden, with anorexia, nausea, vomiting, abdominal cramps and diarrhea (with or without blood and mucus). Malaise, muscle pain and fatigue may also occur. The abdomen may be distended and sensitive to pain, in severe cases there may be a muscular guarding. inflated by air bowel loops can be palpable. There are striking bowel sounds (Borborygmi) during auscultation, even without diarrhea (an important differential diagnostic criterion for paralytic ileus, absent in the bowel sounds, or may be reduced). Permanent vomiting and diarrhea lead to intravascular volume depletion with hypotension and tachycardia. In severe cases, a shock with circulatory collapse and oliguric renal failure occurs. If vomiting is the main cause of fluid loss, metabolic alkalosis can occur with a hypochloraemia. If the diarrhea is important, acidosis is more likely. Both vomiting as diarrhea produce hypokalemia. At the same time hyponatremia may develop, v. a. when hypotonic fluids are used as a fluid replacement. In viral infections aqueous diarrhea are the most common symptom, the chair often contains mucus or blood. A rotavirus gastroenteritis in infants and young children may take 5-7 days. Vomiting occurs in 90% of patients and fever> 39 ° C at about 30%. Noroviruses typically cause acute onset of vomiting, abdominal pain and diarrhea, the symptoms last only 1-2 days. In children, vomiting faces the diarrhea in the foreground, while in adults usually outweigh the diarrhea. Furthermore, the patients suffer from fever, headache and muscle pain. The main characteristic of a Adenovirusgastroenteritis is a 1-2 week lasting diarrhea. Affected infants and children may exhibit excessive vomiting that typically first appears 1-2 days after the onset of diarrhea. Low elevated temperatures occur in 50% of patients. Astro viruses cause a syndrome as a mild rotavirus infection. Bacteria that cause invasive disease (eg. As Shigella, Salmonella), leading to more frequent fever, exhaustion and bloody diarrhea. Infection with E. coli O157: H7 usually begins with aqueous diarrhea for 1-2 days, followed by bloody diarrhea. Fever is absent or is low. The spectrum of C. difficile infection ranges from mild abdominal cramps, and diarrhea with mucus to severe hemorrhagic colitis and shock. Bacteria that produce an enterotoxin (z. B. S. aureus, B. Cereus, C. Perfringens) usually cause diarrhea aqueous. Parasitic infections typically cause subacute or chronic diarrhea, most make a non-bloody diarrhea, an exception is E. histolytica, which causes amebic dysentery. Fatigue and weight loss are often a result of prolonged diarrhea. Diagnosis Clinical evaluation stool examination in selected cases Other gastrointestinal diseases can cause similar symptoms (eg. As appendicitis, cholecystitis, ulcerative colitis) and must be excluded. Findings that raise the suspicion of a gastroenteritis, are intensive aqueous diarrhea, intake of potentially contaminated food (especially during a known outbreak), untreated surface water or a well-known, the GIT irritating substance recently past travel or contact with certain animals or from similar symptoms ill patients. An E. coli -O157: H7-induced diarrhea typically manifests as bleeding and not as infectious process, as gastrointestinal bleeding with little or no bowel movements. A hemolytic uremic syndrome may follow, as evidenced by renal failure and hemolytic anemia (thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS)). When oral antibiotics were administered recently (within 3 months), the suspected infection with C. difficile must address (Clostridium difficile-induced diarrhea). But about a quarter of patients with community-associated C. difficile infection has no antibiotics used in prehistoric times. Stool tests, if the rectal examination shows occult blood or when aqueous diarrhea persist> 48 hours, a stool test (leukocytes, eggs and parasites in the stool) and a culture are indexed. In the diagnosis of giardiasis or cryptosporidiosis the detection of stool antigen enzyme immunoassay has the higher sensitivity. Rotavirus and enteric adenovirus infections can be detected in the chair, are diagnosed using commercially available rapid tests, the viral antigen. This diagnosis is often performed to document an outbreak. The Norovirus can be detected by PCR in reference laboratories; this test is occasionally indexed to determine the cause of the persistent diarrhea in an immunocompromised patient. All patients with bloody diarrhea should be based on E. coli O157: H7 are examined, as well as other patients during an outbreak that do not have bloody diarrhea. Most specific cultures must be requested because these organisms can not be detected with standard stool culture media. Alternatively, a faster enzyme assay for the detection of Shiga toxin can be made, a positive test has an infection with E. coli O157: H7 towards or to a different serotype of enterohemorrhagic E. coli. (Note: Shigella species in the United States do not produce Shiga toxin). However, a rapid enzyme test is not as sensitive as a culture. In some centers, the polymerase chain reaction is used (PCR) to detect Shiga toxin. In patients with bloody diarrhea sigmoidoscopy with biopsy and creating cultures is performed. The appearance of the colonic mucosa can at diagnosis amoebic dysentery, shigellosis and E. coli O157: H7 infection be helpful, although ulcerative colitis may have similar symptoms. In patients with recent use of antibiotics in the history or other risk factors for C. difficile infection (. For example, inflammatory bowel disease, use of proton pump inhibitors) should be performed on C. difficile toxin a stool examination; the test should be performed in patients with severe disease, even if these risk factors are not present, because about 25% of C. difficile infections in people occur without proven risk factors. Originally enzyme immunoassays were used for toxins A and B for the diagnosis of C. difficile infection. However Nukleinsäureamplifikationtests for one of the C. difficile toxin genes or their regulator have shown a higher sensitivity and are now the diagnosis of choice dar.Allgemeine tests serum electrolytes, urea and creatinine should be collected to assess the Hydrierungszustands and acid-base status in critically ill patients become. A total blood count is non-specific, but eosinophilia may indicate a parasitic infection. Kidney function tests and blood counts should be about a week after the onset of symptoms in patients with E. coli O157: H7 can be made to recognize the early symptoms of a hemolytic-uremic syndrome. Oral therapy or i.v. Rehydration antidiarrhoischer test substances, if no suspicion of C. difficile, or E. coli O157: H7 infection is antibiotic only in selected cases, a supportive therapy is sufficient for the majority of patients. Bed rest with convenient access to a toilet or bedpan is desirable. An oral glucose electrolyte solution, broth or bouillon may prevent dehydration or treat mild. Even with vomiting, the patient should take frequent sips of liquid: vomiting may decrease in volume replacement. In patients with E. coli O157: H7 infection can reduce the severity of kidney damage rehydration with isotonic infusions, a hemolytic uremic syndrome should evolve. Children become dehydrated quickly and should therefore be treated with appropriate solutions (several are commercially available, oral rehydration). Carbonated drinks and sports drinks lack the proper ratio of glucose to sodium, which is why they are not suitable for children <5 years. If the child is breastfed, breastfeeding should continue. If vomiting lasts longer or if severe dehydration is present, is an i.v. Volume and electrolyte substitution is necessary (intravenous fluid replacement). Once the patient can take fluids without vomiting and appetite returns, you can slowly start again with the food intake. Light food is recommended (eg. As cereal, gelatin, bananas, toast). Some patients suffer temporarily lactose intolerant. Antidiarrheal agents (indicated by hämnegativen chair) in patients> 2 years with watery diarrhea suitable. On the other hand, anti-diarrheal agents can deterioration in patients with C. difficile, or E. coli O157: H7 cause infection and no patient should be administered with recently successful antibiotic therapy or hämpositivem chair in which the diagnosis is still pending. Effective anti-diarrheal agents are loperamide 4 mg p.o. initially, followed by 2 mg p.o. for each subsequent episode of diarrhea (maximum of 6 doses / day or 16 mg / day), diphenoxylate 2.5-5 mg 3 to 4 times daily, as tablets, or in liquid form. Children are given loperamide. The dose for children of 13-20 kg is 1 mg po 3 times a day, for children from 20 to 30 kg 2 mg po 2 times a day and for children> 30 kg to 12 years, 2 mg po 3 times a day. Adults and children ? 12 years of age can 4 mg p.o. after the first soft stool and then received 2 mg after each subsequent soft stool, wherein 16 mg should not be exceeded in a 24-hour period. In severe vomiting and the exclusion of a surgically to be rehabilitated cause antiemetics can be favorable. Effective medicines in adults are prochlorperazine 5-10 mg iv 3 to 4 times daily or 25 mg twice daily rectally 2 and promethazine 12.5-25 mg i.m. 3 to 4 times a day or 25-50 mg rectally 4 times daily. These drugs are avoided in children usually because their value has not been adequately demonstrated and there is a high incidence of dystonic reactions. Ondansetron is safe and effective for the relief of nausea and vomiting in children and adults, including those with gastroenteritis, and is available as standard tablet, orally disintegrating tablet or intravenous preparation. The dose for children ? 2 years is 0.15 mg / kg p.o. or iv 3 times daily with a maximum single dose of 8 mg. The dose for adults is 4 or 8 mg p.o. or iv 3 times a day. Although probiotics appear to reduce the duration of diarrhea, there is insufficient evidence that they affect important clinical parameters (eg. As reducing the need for iv hydration and / or hospitalization), so their routine use in the treatment or prevention of a infectious diarrhea can not be supported. Antimicrobial drugs An empirical use of antibiotics is not recommended in general, except in certain cases of travelers’ diarrhea or strongly suspected to Shigella or Campylobacter infection (eg. As contact with a known case). Otherwise you should not use antibiotics, until the results of stool cultures are present; This applies v. a. for children, a higher rate of infection with E. coli O157: H7 have (antibiotics increase the risk of hemolytic uremic syndrome in patients treated with E. coli O157: H7 infected). In cases of confirmed bacterial gastroenteritis, antibiotics are not always necessary. In salmonella they do not help and even prolong the excretion in feces. Exceptions are immunocompromised patients, newborns and patients with Salmonella bacteremia. Even with toxic gastroenteritis (z. B. S. aureus, B. Cereus, C. Perfringens), antibiotics are not effective. The uncritical use of antibiotics promotes the appearance of drug-resistant pathogens. However, some diseases require the use of antibiotics (s. Selected oral antibiotics for infectious gastroenteritis *). The initial treatment of C. difficile colitis including if possible settling of the causative antibiotic. Mild cases are treated with oral metronidazole. In more severe cases, vancomycin should be given orally. Unfortunately recurrences in both regimens are common, they occur in approximately 20% of patients. A newer drug, fidaxomicin, has a slightly lower rate of recurrence, but it is expensive. Many centers use the fecal microbial transplantation in patients with multiple C. difficile colitis relapses. This treatment has been shown to be safe and effective (Clostridium difficile-induced diarrhea). When Cryptosporidiosis is effective in immunocompetent patients nitazoxanide. The dose is 100 mg p.o. po 2 times a day for children aged 1-3 years, 200 mg po 2 times a day for children aged 4-11 years and 500 mg 2 times a day for children ? 12 years and adults. Selected oral antibiotics in infectious gastroenteritis * excitation antibiotic adult dose children dose Vibrio cholerae Ciprofloxacin 1 g once NA † doxycycline 300 mg single dose of 6 mg / kg single dose TMP / SMX 1 DS tablet 2 times daily. For 3 days 4 ‡ 6 mg / kg 2 times daily. For 5 days Clostridium difficile metronidazole 250 mg 4 times daily. Or 500 mg 3 times daily. For 10 days 7.5 mg / kg 4 times daily. For 10-14 days vancomycin 125-250 mg 4 times daily. for 10 days 10 mg / kg 4 times daily. for 10-14 days fidaxomicin 200 mg 2 times daily. for 10 days NA Shigella ciprofloxacin 500 mg 2 times daily. For 5 days NA TMP / SMX 1 DS tablet 2 times daily. 4-6 mg ‡ / kg 2 times daily. For 5 days Giardia intestinalis (lamblia) Metronidazole 250 mg 3 times daily. . for 5 days 10 mg / kg, 3 times daily for 7-10 days (maximum 750 mg / day) nitazoxanide 500 mg 2 times daily for 3 days 1-3 years.. 100 mg 2 times daily for 3 days 4-11 years: 200 mg 2 times daily for 3 days ? 12 years. 500 mg of 2-ma l daily. for 3 days Entamoeba histolytica Metronidazol§ 750 mg 3 times daily. for 5-10 days 12-16 mg / kg, 3 times daily. for 10 days (a maximum of 750 mg / day) Campylobacter jejuni azithromycin 500 mg once daily . for 3 days 10 mg / kg once daily. for 3 days ciprofloxacin 500 mg once daily. for 5 days NA Antibiotics are not indicated in most cases, but can be used with supportive infusions to treat infections caused by specific pathogens. † This drug should not be given to children <8 years or pregnant women. ‡ Based on Trimethoprimkomponente. § The treatment should therapy with Jodoquinol 10-13 mg / kg three times daily for 20 days or paromomycin 500 mg po 3 times daily for 7 days followed. DS = double thickness; NA = not be applied; TMP / SMX = trimethoprim / sulfamethoxazole. Prevention There are two attenuated oral Rotavirusvakzinen available that are safe and effective against the majority of responsible for this disease strains. A Rotavirusimpfung is part of the recommended vaccination schedule for infants (see Table: Recommended vaccination schedule for the age of 0-6 years). Prevention of infection is difficult because asymptomatic infections are common and many pathogens, v. a. Viruses can be transmitted easily from person to person. Allgemein sollte man angebrachte Regelungen für die Behandlung und Zubereitung von Nahrungsmitteln einhalten. Reisende ( Reisediarrhö) sollten potenziell kontaminierte Speisen und Getränke vermeiden. Um Infektionen durch Freizeitaktivitäten im Wasser zu verhindern, sollten Betroffene nicht schwimmen, wenn sie Durchfall haben. Bei Säuglingen und Kleinkindern sollten die Windeln häufiger konntrolliert und im Badezimmer und nicht in der Nähe von Wasser gewechselt werden. Schwimmer sollten es vermeiden, Wasser zu schlucken, wenn sie sch

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