The term gastroenteritis (GE) refers to infections of the gastrointestinal tract (GI tract) caused by bacterial, viral, or parasitic pathogens. Many of these infections are foodborne diseases (the pathogen is ingested through food).
The most common manifestations are diarrhea and vomiting, which can also be associated with systemic features such as abdominal pain and fever. The term gastroenteritis covers most of the infectious cases of diarrhea.
Etiology and pathogenesis of gastroenteritis in children
Features of the structure of the gastrointestinal tract in children
In childhood, the digestive tract has the following features:
- the mucous membrane is dry, fine structure, it can be easily injured;
- the submucosa consists of loose fibrous connective tissue and is well supplied with blood;
- elastic and muscle tissues are undeveloped to the end;
- the stomach glands produce small amounts of digestive juices and enzymes.
In this regard, if a child eats food that does not correspond to his age, the digestion process becomes difficult, the protective function decreases, and as a result, inflammation may develop.
Therefore, the child's digestive tract requires careful and attentive care.
Predisposing factors
The main predisposing factors areenvironmental pollution and increased exposure to enteropathogens... Additional conditions include: small age, immunodeficiency, measles, indigestion, artificial feeding (absolute or predominant), poor hygiene.
Other internal factors can lead to infection.
- Change in normal intestinal flora can create a biological void that will be filled with pathogens. This occurs most often after an antibiotic has been given, but babies are also at risk before colonizing with normal gut flora.
- Usually acidic stomach pH and the colon is an effective antimicrobial defense. With the use of antacids H2-blockers, proton pump inhibitors, and a decrease in the anaerobic flora in the large intestine, this protection is weakened.
- Intestinal hypomobility can lead to colonization by pathogens, especially in the proximal small intestine, where motility is the main mechanism for removing organisms. Hypomobility often accompanies diabetes mellitus.
The main causes of gastroenteritis in children of different ages
In about 70% of cases, HP is caused by viruses, of which rotavirus is the most common culprit. Rotavirus infection is associated with about half of the hospitalizations of children with acute EH. The peak incidence is observed in babies from six months to two years.
Bacteria are responsible for about 15% of episodes of HE; Bacterial HE is usually more common in the first few months of life and then in school-aged children. The most common bacterial causes are salmonella spp., Campylobacter jejuni, Escherichia coli, shigella spp. Giardia lamblia is the most common HP causing parasite and is associated with more persistent diarrhea. Other parasitic protozoa associated with GE are cryptosporidium spp. and Entamoeba histolytica.
The essence of the pathological process
The small intestine is the main absorbing surface of the digestive tract. The colon then absorbs additional fluid, converting the relatively liquid fecal flow in the cecum into well-formed, hard stools in the rectosigmoid (sigmoid to rectal transition).
Infectious agents are a common cause of acute EH. These agents cause diarrhea by activating several mechanisms, including mucosal adhesion, penetration, and toxin production.
Lesions in the small intestine result in an increase in luminal fluid that cannot be adequately reabsorbed. As a result, dehydration develops, and electrolytes and nutrients are lost.
Microorganisms can produce toxins that increase infection. Enterotoxins produced by some bacteria (eg enterotoxigenic E. coli, Vibrio cholera) act directly on the secretory mechanisms and cause the typical profuse watery (rice water-like) diarrhea. Penetration into the mucous membrane does not occur.
The production of toxins by other bacteria (for example, Shigella dysenteriae, Vibrio parahaemolyticus, Clostridium difficile, enterohemorrhagic Escherichia coli) leads to the destruction of mucosal cells, resulting in bloody stools, and a decrease in absorption capacity.
Penetration into enterocytes (intestinal epithelial cells) is the mode of action of Shigella and Campylobacter and enteroinvasive Escherichia coli, which leads to cell destruction and inflammatory diarrhea. Likewise, Salmonella and Yersinia species enter cells without causing cell death. These bacteria enter the bloodstream through the intestinal mucosa, leading to systemic toxicity.
Diarrhea occurs when microbial virulence (the ability of a pathogen to infect) interferes with the body's normal defenses. Large inoculum (volume) can inhibit the host's ability to provide effective defense. Typically, more than 100,000 Escherichia coli are required for the onset of the disease, while intestinal amoeba, lamblia or norovirus particles are only 10. Some organisms (eg V cholera, enterotoxigenic Escherichia coli) produce proteins that help these bacteria adhere to the intestinal wall. thereby displacing the normal flora and colonizing the intestinal lumen.
Classification of gastroenteritis in children and adults
HE is classified based on the cause of the disease:
1) Infectious:
- viral;
- bacterial;
- parasitic.
2) Non-infectious
- eosinophilic (allergic reaction);
- alimentary (due to the use of products that irritate the gastrointestinal mucosa).
Classic symptoms of gastroenteritis
The symptoms of gastroenteritis are quite acute and painful. Children with viral EH usually have watery diarrhea without blood with or without vomiting, low-grade fever, and weight loss. Bacterial gastroenteritis in a child is usually characterized by bloody diarrhea, mucus in the stool, and high fever.
Clinical manifestations of gastroenteritis of various etiologies
| Cause | Incubation period | Manifestations | Duration of illness | Associated Products |
| Bacterial gastroenteritis | ||||
| Bacillus anthrax | 2 - 7 days | Nausea, vomiting, malaise, bloody diarrhea, acute pain in the abdomen | 1 week | Insufficiently cooked contaminated meat |
| Bacillus cereus | 1 - 6 h | Severe nausea and vomiting come on suddenly. Possible diarrhea | Day | Improperly chilled boiled or fried rice, meat |
| Brucella | 7 - 21 days | Fever, chills, sweating, lethargy, pain in the head, muscles and joints, diarrhea, bloody stools in the acute stage | A week | Raw milk, goat cheese made from unprocessed milk, contaminated meat |
| Campylobacter | 2 - 5 days | Diarrhea, seizures, fever, and vomiting; diarrhea is bloody | 2 - 10 days | Raw and undercooked poultry, unprocessed milk, contaminated water |
| Clostridium in a baby | 3 - 30 days | Lethargy, poor appetite, constipation, hypotension, poor vomiting and sucking reflex | Variable | Honey, homemade canned fruits and vegetables, corn syrup |
| Clostridium in children from a year | 12 - 72 h | Vomiting, diarrhea, blurred vision, difficulty swallowing, muscle weakness | Food canned at home with little acid, inadequately canned commercial food, home-salted fish, foil-baked potatoes, food that has been warm for long periods (e.g. in a warm oven) | |
| Escherichia coli | 1 - 8 days | Severe, often bloody diarrhea, abdominal pain, and vomiting The temperature is normal or slightly elevated. More common in children under 4 years of age | 5 - 10 days | Water or food contaminated with human feces |
| Listeria | 9-48 h | Fever, muscle aches, nausea, or diarrhea Pregnant women may have mild flu illness, and infection can lead to early labor or stillbirth. | variable | Fresh soft cheeses, unpasteurized or illiterately processed milk. |
| Salmonella | 1 - 3 days | Diarrhea, fever, abdominal cramps, vomiting. S. typhi and S. paratyphi cause insidious onset typhoid fever, characterized by fever, headache, constipation, malaise, chills, and myalgia; diarrhea is rare and vomiting is usually not severe | 4 - 7 days | Contaminated eggs, poultry, unprocessed milk or juice, cheese, contaminated raw fruits and vegetables. S. typhi epidemics are often associated with faecal contamination of water supplies or street food |
| Shigillosis | 24 - 48 h | Abdominal cramps, high fever, diarrhea. Possible blood and mucus in the stool | Food or water contaminated with human feces. Ready-to-eat food that has been touched by infected employees (raw vegetables, salads, sandwiches) | |
| Staphylococcus aureus | 1 - 6 h | Nausea and vomiting come on suddenly. Abdominal cramps Possible diarrhea and fever | 24 - 48 h | Uncooled or illiterately chilled meat, potato and egg salads, cream pastries |
| Vibrio cholerae | 24 - 72 h | Profuse watery diarrhea and vomiting, causing great dehydration. | 3 - 7 days | Contaminated water, fish, shellfish, street food |
| Yersinia enterocolytica and Y. pseudotuberculosis | 24 - 48 h | Appendicitis-like manifestations (diarrhea and vomiting, fever, abdominal pain) occur mainly in older children Possibly scarlet-like rash with Y. pseudotuberculosis | 1 - 3 weeks | Undercooked pork, unprocessed milk, contaminated water |
| Viral gastroenteritis
| ||||
| Hepatitis A | 28 days. on average (15-50 days) | Diarrhea, dark urine, jaundice, and flu-like symptoms such as fever, nausea, and pain in the abdomen and head. | Variable, 2 weeks - 3 months | Crustaceans harvested from polluted waters, raw food, polluted drinking water. |
| Caliciviruses (including noroviruses and sapoviruses) | 12 - 48 h | Nausea, vomiting, abdominal cramps, diarrhea, high fever, headache and muscle pain. Diarrhea occurs in adults and vomiting occurs in children Possibly prolonged asymptomatic course | 12 - 60 h | Shellfish, fecal contaminated food, ready-to-eat food that has been touched by contaminated food workers. |
| Rotavirus (groups A-C) | 1 - 3 days | Vomiting, watery diarrhea, low-grade fever Lactase deficiency may occur temporarily | 4 - 8 days | |
| Other viral agents | 10 - 70 h | Nausea, vomiting, diarrhea, malaise, pain in the abdomen and head, high fever. | 2 - 9 days | |
| Parasitic gastroenteritis
| ||||
| Angiostrongylosis | 7 - 30 days | Severe headaches, nausea, vomiting, neck stiffness, paresthesia, hyperesthesia (sensory disturbances), seizures and other neurological disorders | From several weeks to several masses. | Raw or undercooked intermediate hosts (eg snails or slugs), infected transport hosts (eg crabs, freshwater shrimp), fresh food contaminated with intermediate or transport hosts. |
| Cryptosporodium | 2 - 10 days | Diarrhea (usually watery), stomach cramps, indigestion, mild fever. | Possible relief and relapse within weeks or months | Any raw food or food contaminated with contaminated food after cooking; drinking water. |
| Cyclosporosis | 1-14 days | Diarrhea (usually watery), loss of appetite, significant weight loss, stomach cramps, nausea, vomiting, fatigue. | Various types of fresh food. | |
| Amoebiasis | 2-3 days up to 1-4 weeks | Diarrhea (often bloody), frequent bowel movements, lower abdominal pain | ||
| Giardiasis | 1 - 2 weeks | Diarrhea, stomach cramps, gas, weight loss | From several days. up to weeks | |
| Toxoplasmosis | 5 - 23 days | Usually asymptomatic, 20% develop cervical lymphadenopathy and / or influenza illness. In immunocompromised patients: CNS disorders, myocarditis or pneumonitis are common. | A few months. | Accidental ingestion of contaminated substances (such as soil contaminated with cat feces, fruits and vegetables), raw or partially cooked meat (especially pork, lamb, or venison) |
| Congenital toxoplasmosis | Treatment of the mother can reduce the severity and / or frequency of congenital infections. Most infected babies have minor manifestations at birth; later they usually show signs of congenital toxoplasmosis (mental retardation, severe visual impairment, cerebral palsy, seizures) when the disease is not treated | Transmitted from the mother (who acquired an acute infection during pregnancy) to the child | ||
| Trichinosis | 1-2 days for initial symptoms; others begin to appear after 2-8 weeks. after infection | Nausea, diarrhea, vomiting, fatigue, fever, abdominal discomfort with muscle soreness, weakness, and sometimes cardiac and neurologic complications | Raw or undercooked contaminated meat | |
DE degrees and their characteristics
| First (easy) | Infrequent diarrhea, vomiting, body temperature within the normal range, no symptoms of dehydration |
| Average | Vomiting and diarrhea up to 10 times a day, signs of mild dehydration, fever up to 38.5 0С. |
| Heavy | Severe dehydration, significant fever, impaired consciousness. |
Complications
The main complication of gastroenteritis is dehydration and hypovolemic shock (a condition caused by a critical decrease in blood volume, its thickening). Attacks can occur at high temperatures, especially with shigellosis. Intestinal abscesses can form with shigellosis and salmonellosis, especially typhoid fever, leading to intestinal perforation, a life-threatening complication.
Severe vomiting associated with gastroenteritis can cause rupture of the esophagus or aspiration pneumonia (occurs when vomit enters the lungs). Mortality due to diarrhea reflects an underlying problem of fluid and electrolyte homeostasis, resulting in dehydration, electrolyte imbalance, vascular instability and shock.
Dehydration assessment
The most important complication of EH is dehydration. The risk of dehydration is higher in young children.
Dehydration most often develops in:
- children under 6 months of age;
- children with anatomical abnormalities in the intestine (for example, short bowel syndrome).
Weight loss provides the best estimate of the degree of dehydration.
You should also pay attention to the following warning signs:
- dry, chapped lips;
- dark urine;
- little or no urine for eight hours;
- cold or dry skin;
- sunken eyes or sunken fontanelle (in babies);
- excessive sleepiness;
- low energy level;
- crying without tears;
- excessive fussiness;
- rapid breathing.
In the most severe cases, the child may become delirious or unconscious.
When dehydration develops, an ambulance should be called immediately.
Diagnostic approaches
It should be noted that HE is a diagnosis of exclusion, as vomiting and diarrhea can be nonspecific symptoms in young children, and it is important to rule out other causes of these manifestations, namely:
- acute appendicitis;
- intestinal intussusception;
- inflammatory bowel disease;
- systemic infections (urinary tract infections, pneumonia, meningitis);
- metabolic conditions (for example, diabetes mellitus).
Based on the medical history, epidemiological criteria and physical examination, the physician determines the need for further diagnostic evaluation followed by microscopic examination of the stool.
Diagnostic tests are usually not needed because most forms of gastroenteritis do not last long. However, if symptoms are severe or last more than 48 hours, stool samples can be tested in a laboratory for white blood cells and bacteria, viruses, or parasites. Blood tests may be done to look for complications.
Treatment
The main groups of drugs
The goals of pharmacotherapy are to reduce morbidity, prevent complications, and provide prophylaxis.
Antibacterial drugs
Since most cases of acute gastroenteritis are associated with viruses, antibiotics are usually not given.
For patients with detected Clostridium difficile and giardiasis, Metronidazole is the drug of first choice. For resistant infections, vancomycin is prescribed.
Nitazoxanide will be effective for cryptosporodiosis and other intestinal parasites.
Antidiarrheal drugs
Antidiarrheal medicines are generally not recommended because of the risk of side effects. Loperamide causes intestinal obstruction, drowsiness, and nausea in children under 3 years of age. Bismuth subsalicylate has shown limited efficacy in the treatment of acute gastroenteritis in children. The use of racecadotril, which reduces the secretion of water and electrolytes in the intestine without affecting intestinal motility, has been studied under steady-state conditions with promising effects.
Antiemetic drugs
It is necessary to stop vomiting in a child to prevent dehydration. Ondansetron has been shown to be effective as an antiemetic, however it has a number of side effects. Older antiemetics (such as Promethazine) were found to be less effective in reducing vomiting.
Promethazine is approved only for children over 2 years of age and is usually associated with the development of neurological disorders as side effects that can interfere with the rehydration process. None of these drugs affect the cause of the disease.
Application of zinc
Zinc is an essential trace mineral that protects cells from oxidative damage. It is speculated that zinc may improve the absorption of water and electrolytes, although the exact mechanism of action is not fully understood.
Diet
With HE, the child must adhere to dietary table No. 4. The features of the diet are as follows:
- decrease in the daily volume of salt (up to 10 g);
- reducing calorie intake to 2000 kcal;
- meals in small portions 5 - 6 times a day;
- products must be boiled, steamed or served pureed.
The period of adherence to the diet is 2–4 weeks.
Diet in the acute period
In the acute stage of the disease, you should completely refuse to eat. At this time, the patient only needs fluid replacement. The liquids consumed should be warm. For this purpose, the child is offered: weakly brewed tea without sugar, diluted juice, pure water.
Diet during convalescence
A diet of applesauce, bananas, rice, and yesterday's bread is preferred in the early recovery period. If the patient is tolerating solid foods, the diet can be expanded to ensure that they are consuming enough protein and calories. It is necessary to introduce lean meat (without layers of fat) as soon as possible.
When feeding dairy products containing lactose, the patient should be closely monitored for signs of malabsorption (malabsorption).
Breast milk contains many substances that promote the growth of healthy gut flora and counteract bacteria, therefore, it is necessary to continue breastfeeding the infant throughout the illness.
Drinking regime
Replacing lost fluid is an initial emergency step in the management of acute EH.
Commercial rehydration solutions are the preferred method of fluid and electrolyte replenishment. The fluid should be quickly replaced within 3-4 hours.
| Age | Dose of rehydration solution every hour in ml |
| Up to 6 months | 30 – 90 |
| From 6 months up to 2 years | 90 — 125 |
| From 2 years | 125 — 250 |
The relevance of traditional medicine
Some folk remedies can relieve symptoms of gastroenteritis and minimize the likelihood of complications, but they do not address the underlying cause.
- Antispasmodic properties basilica eliminate stomach cramps and strengthen the stomach.
- Chamomile tea can help relax the nerves... It also has antibacterial and anti-inflammatory properties that can relieve a child of diarrhea and nausea.
- Cinnamon mixed with honeyhas been a cure for gastroenteritis for ages, but science hasn't proven its effectiveness. But honey and cinnamon together can minimize inflammation.
- Mint also has antispasmodic properties and helps to relieve gas, bloating and indigestion.
Prevention of gastroenteritis in children
Providing clean, uncontaminated water and ensuring proper hygienic conditions is the most important means of preventing childhood HP. Good hygiene, especially good hand washing with soap and water, is the best way to control the spread of most of the organisms that cause gastroenteritis from person to person. Likewise, poultry meat should be considered potentially contaminated with salmonella and must be cooked appropriately. It is possible to carry out immunization against rotavirus infection.
Tips for those planning trips with young children
When a child visits a place where the climate or sanitary conditions are different from the usual, the likelihood of gastroenteritis increases.
To reduce the risk of developing pathology, parents should pay special attention to food and drinks while traveling.
Travelers should drink bottled drinks or boiled water. They should avoid vegetables and fruits that they have not peeled themselves. Food should be eaten hot if possible. Raw or poorly cooked seafood is particularly dangerous. Pools and other recreational areas on the water can also get dirty.
Pharmaceutical prophylaxis is generally not recommended for previously healthy children or adults. However, travelers should carry azithromycin (<16 years of age) or ciprofloxacin (> 16 years of age) and initiate antimicrobial therapy if diarrhea develops.
Conclusion
Hygiene combined with healthy dietary habits will help prevent acute gastroenteritis in children. Also, the child's diet should include foods that strengthen the immune system. Strong immunity helps fight infection faster and minimizes risks.
