It’s summertime and many people are grilling outdoors. I find that with BBQ season upon us I have been treating a growing number of patients for acute onset gastrointestinal illness. These patients present complaining of acute crampy abdominal pain, nausea and associated diarrhea. Most deny emesis and the majority are able to maintain adequate oral intake.
When you perform an initial work-up for acute gastrointestinal illness with associated diarrhea, consider the following factors when making your diagnosis: dehydration status, duration of symptoms, and fever or hematochezia as a manifestation of an inflammatory response. In addition, a history of recent travel should be ruled out.
Consider hypovolemia if the patient presents with six or more unformed watery stools in 24 hours, a change in vitals signs such as tachycardia or orthostatic hypotension, and pale skin or decrease in skin turgor.
Acute diarrhea is defined as unformed stools for 14 days or less. Viral infections are the most frequent cause of acute diarrhea in developed countries. The most common non-inflammatory causes of diarrhea are Norwalk virus, rotavirus, Clostridium perfringes, Staphylococcus aureus, Bacillus cereus, Giardia, antibiotics, and irritable bowel syndrome. Inflammatory causes include Campylobacter, Shigella, Salmonella, enterohemorrhagic Escherichia coli and Clostridium difficile.
Consider more severe illness in patients with diarrhea or systemic symptoms that have not improved after 48 to 72 hours. A body temperature greater than 101.3°F and stools containing blood or mucus are also suggestive of severe illness. If gastrointestinal illness has not improved or resolved within 72 hours, testing for fecal leukocytes and stool cultures should be ordered.
Antibiotics are not indicated in most cases. However, if stools are bloody, occur more than eight times per day, are associated with fever, have lasted longer than seven days, and/or are accompanied by signs of dehydration, empiric treatment following cultures is indicated. Due to high rates of antibiotic resistance, treatment with fluoroquinolones for three to five days should only be used if enterohemorrhagic Escherichia coli or Campylobacter are not suspected.
Symptomatic treatment is indicated for patients with acute diarrhea without fever or bloody stools. For these patients, recommend an anti-motility agent and a bland diet. Probiotics can also be beneficial for reintroducing microorganisms that promote gastrointestinal health. Although few studies have validated the use of probiotics, in my experience, patients are generally compliant with this intervention and often report improvement in overall gastrointestinal health.
Leigh Montejo, MSN, FNP-BC, is a National Public Health Service Corp scholar completing her service commitment as a Family Nurse Practitioner at Tampa Family Health Centers Inc. in Florida. Her areas of interest include adolescent health, health promotion and improving access to healthcare in underserved populations.