Guide to Assessment and Management of Acute

Gastroenteritis in Primary Care

PATIENT WITH DIARRHOEA +/- VOMITING (PROBABLE GASTROENTERITIS)

HISTORY

CLINICAL HISTORY EXPOSURE HISTORY TRANSMISSION RISK

How sick is the patient? Where did it come from? Could this Where might it spread to? Could this
Symptoms of dehydration be part of an outbreak? be the start of an outbreak?
Duration/frequency of diarrhoea Suspicious food or water consumption Occupation, especially food handler,
Blood or pus in stool (food poisoning) health care worker
Abdominal pain Recent antibiotics Childcare, school, institution
Fever Recent overseas travel attendance
Viral symptoms Pet or farm animal contact Immunosuppressed contact at home
(headache, myalgia, arthralgias) Childcare, school, nursing home, Poor personal hygiene
Review of systems, particularly in children institution attendance e.g. age, infirmity.
Health care worker
Is the patient at greater risk of Known contacts or outbreak
complications? (home, wedding etc.)
Immunosuppression
Medication
Bowel disease or past bowel surgery

EXAMINATION

Temperature, heart rate, BP, weight

Assessment of severity of dehydration (see an appropriate table)
GIT examination
Other systems, particularly in children (need to exclude pneumonia, meningitis, UTI, surgical conditions etc)
Consider Haemolytic-Uraemic Syndrome in the child with bloody diarrhoea, pallor and poor urine output

INVESTIGATION

STOOL CULTURE IF SPECIAL REQUESTS

Positive Clinical Features Laboratories test for a limited range of pathogens on routine
Systemically unwell specimens. Specific request with additional clinical details
Fever over 38.5 and/or direct liaison with the laboratory may be required for
Duration > 3-4 days more comprehensive testing e.g.
Severe diarrhoea leading to dehydration Possible outbreak (Rotavirus or Norovirus)
Blood or pus in stool Duration > 7-10 days (ova, cysts and parasites [OCP] for
Immunocompromised Giardia and Cryptosporidium)
Positive Exposure History e.g. recent overseas travel Suspicion of VTEC (culture for E. coli 0157 )
High Transmission Risk e.g. child care attendance Recent broad spectrum antibiotics or hospitalisation
(C. difficile toxin)
HIV or immunosuppressed (discuss with lab)

MANAGEMENT

CLINICAL MANAGEMENT PUBLIC HEALTH MANAGEMENT BY GPs

Correct dehydration by fluid replacement refer to hospital Hand washing & hygiene advice
where appropriate Exclusion, particularly food handlers & carers
Continue feeding as tolerated Notification by phone in cases of concern
Limited role for anti-diarrhoeals (never in children) Education and health promotion
Antibiotics should not be routinely prescribed
This resource is an evidence-based, best practice guide to assessment and management of gastroenteritis in primary care. It should be used in
conjunction with recognised clinical practice guidelines and adapted to the individual clinical situation.

EXPLANATORY NOTES

CLINICAL HISTORY
Acute infectious gastroenteritis is characterised by sudden others. Routine stool testing varies between laboratories
onset of diarrhoea, and may be accompanied by nausea, and special requests are required for many organisms.
vomiting, fever, abdominal discomfort and/or bloating. The Therefore, when requesting stool examination, relevant
presence of blood or pus in the stool suggests bacterial history (clinical and exposure) and the specific
invasion of the bowel wall, and is frequently accompanied by investigations should be written on the request form.
abdominal pain and fever. Myalgia and arthralgia suggests a Only one stool specimen should be requested for routine
viral cause. People with a history of immunosuppressive examination and viral testing, but multiple stools at
disease, or on immunosuppressive drugs e.g. steroids, are at different times are necessary for suspected parasitic
greater risk of gastroenteritis. infection.

EXPOSURE (EPIDEMIOLOGICAL) HISTORY CLINICAL MANAGEMENT BY GPs

The patient presenting with gastroenteritis might be part of Acute gastroenteritis is usually mild and self-limiting.
an otherwise unknown cluster of cases in a family, institution Rehydration and maintenance with appropriate fluids is
or community, i.e. an outbreak. The question Could this be necessary for all patients. Continuation, or early
part of an outbreak? should always be considered. An resumption, of usual feeding in children with acute
exposure history is therefore essential in trying to determine gastroenteritis can reduce the severity and duration of the
a possible source of the gastroenteritis. illness. Hospital admission should be considered in all
children under 6 months and those at high risk of
TRANSMISSION (PUBLIC HEALTH) RISK dehydration (poor oral intake and prolonged vomiting
Infectious gastroenteritis is a communicable disease and the and/or diarrhoea). There is absolutely no role for anti-
potential for transmission to others should always be diarrhoeal and anti-emetic drugs in children and a very
assessed i.e. Could this be part of an outbreak?. Food limited role in adults. Anti-diarrhoeals are absolutely
handlers with gastroenteritis pose a particular risk to the contraindicated in all patients with bloody diarrhoea.
public. Settings at high risk of transmission include child care Antibiotics may be appropriate in patients with features
centres, schools, and other institutions. suggestive of invasive disease, e.g. bloody diarrhoea, but
such patients are likely to be managed in hospital.
EXAMINATION
The most common serious complication of acute PUBLIC HEALTH MANAGEMENT BY GPs
gastroenteritis is dehydration, and this should be assessed General enteric precautions consist of personal hygiene
using appropriate criteria. In children, acute gastroenteritis with hand washing and disposal or decontamination of
should be regarded as a diagnosis of exclusion, as vomiting soiled items and surfaces. Parents and patients should be
and diarrhoea may be non-specific symptoms of serious educated on good hygiene and food safety practices.
illnesses like meningitis, pneumonia and surgical conditions. Patients with acute gastroenteritis should be excluded
Consider an alternative diagnosis particularly when there is from school or work until resolution of symptoms and
high fever, pallor, jaundice, abdominal pain with tenderness, ideally for 48 hours afterwards. This is essential for those at
severe abdominal pain, guarding and/or bile-stained high risk of transmission, including food handlers, health
vomiting. care workers and carers. It is a statuary obligation for GPs
to notify all cases of acute gastroenteritis and/or suspected
INVESTIGATION food poisoning to the local Department of Public Health in
Most episodes of gastroenteritis are short lived and the Republic. In Northern Ireland, food poisoning is
investigation is usually not clinically necessary. However, stool notifiable, as is gastroenteritis in children under two years
samples should be requested when the patient is clinically of age. To enable prompt public health action, initial
unwell or immunosuppressed, there is a positive exposure notification should be by telephone in those cases of
history or they are at high risk of transmitting the infection to particular concern e.g. possible outbreak or case of VTEC.