Diagnosis and Management of Acute Gastroenteritis in Adults in the Urgent Care Setting

Table of Contents

 

About This Issue

The predominant symptoms of acute gastroenteritis are diarrhea with or without nausea and vomiting. While viruses and bacterial pathogens are the most common causes of acute gastroenteritis, targeted questions as part of a detailed history will help narrow down the broad differential diagnosis. First-line treatment includes rehydration and antiemetic therapy. Disease severity, patient factors, and red flag symptoms may prompt an escalation of supportive care. In this issue, you will learn:

How patient history and disease severity can help determine the etiology of acute diarrheal illness

What are the standard approaches to supportive care and empiric antimicrobial treatment

What concerning symptoms and special populations require referral to the emergency department for further evaluation and management

CODING & CHARTING: Documentation supports the level of care provided and appropriate billing for patients presenting with acute gastroenteritis in the urgent care setting. Learn more in our monthly coding column.

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Etiology and Pathophysiology
6. Differential Diagnosis
7. Urgent Care Evaluation
   1. History
   2. Physical Examination
8. Diagnostic Studies
   1. Stool Studies
   2. Blood Tests
   3. Endoscopy
   4. Imaging
9. Treatment
   1. Rehydration
      1. Oral Rehydration Solution
      2. Intravenous Fluids
   2. Food Intake
   3. Antiemetic Therapy
   4. Antimicrobials
   5. Antisecretory Agents
   6. Antimotility Agents
10. Special Populations
    1. Older Patients
    2. Immunocompromised Patients
    3. Patients With Inflammatory Bowel Disease
    4. Pregnant Patients
    5. Travelers' Diarrhea
       1. Prevention
       2. Functional Definitions
       3. Antibiotic Therapy
       4. Antimicrobial Resistance
11. Controversies and Cutting Edge
    1. Probiotics as Treatment for Acute Gastroenteritis
    2. Proton Pump Inhibitors
12. Disposition
13. Summary
14. Critical Appraisal of the Literature
15. Risk Management Pitfalls
16. Time- and Cost-Effective Strategies
17. 5 Things That Will Change Your Practice
18. Case Conclusions
19. Coding & Charting: What You Need to Know
    1. Problems Addressed
    2. Complexity of Data
    3. Risk of Patient Management
20. Coding Challenge: Acute Gastroenteritis in Urgent Care
21. Clinical Pathway for Managing Patients Presenting with Acute Diarrhea in Urgent Care
22. References

Abstract

Acute gastroenteritis is a common condition frequently encountered in the urgent care setting. Although most cases are mild and self-limited, an important subgroup of patients will manifest severe disease that necessitates comprehensive diagnostic testing, empiric therapy, and escalation of care. This review provides evidence-based recommendations for the diagnosis, treatment, and disposition of adult patients with acute gastroenteritis. Guidance on management among special patient populations, including immunocompromised patients or patients with recent international travel, are discussed. Emerging issues in the field, such as evolving patterns of antimicrobial resistance and the impact of proton pump inhibitors on acute gastroenteritis, are also reviewed.

Case Presentations

A 32-year-old healthy woman presents to urgent care with a complaint of nonbloody diarrhea…

• She reports that she returned from a trip to Central America 3 days ago. The diarrhea began 1 day after she returned.
• The patient denies any fevers or abdominal pain and can tolerate oral hydration. She does report increased flatulence and multiple episodes of loose stools per day.
• She asks you if she needs antibiotics...

A 15-year-old healthy boy presents to urgent care with 2 to 3 days of fevers, decreased appetite and oral intake, and generalized weakness…

• He reports that he has diarrhea, which was initially watery and nonbloody, but has become mucous-like and bloody in the last 24 hours. He also reports a constant urge to defecate. He is able to maintain adequate hydration.
• He asks you if there is anything that can be done for his symptoms...

A 54-year-old man with a history of liver transplant presents to urgent care with nonbloody diarrhea for 1 week...

• He was initially able to adequately hydrate but reports feeling increasingly weak and has decreased urine output.
• He is concerned about the ongoing diarrhea and dehydration.
• You wonder if his symptoms could indicate a serious condition, given his transplant history...

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Clinical Pathway for Managing Patients Presenting with Acute Diarrhea in Urgent Care

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

2. * Moon RC, Bleak TC, Rosenthal NA, et al. Epidemiology and economic burden of acute infectious gastroenteritis among adults treated in outpatient settings in US health systems. Am J Gastroenterol. 2023;118(6):1069-1079. (Retrospective epidemiological study; 248,896 patients) DOI: 10.14309/ajg.0000000000002186

3. * Riddle MS, DuPont HL, Connor BA. ACG clinical guideline: diagnosis, treatment, and prevention of acute diarrheal infections in adults. Am J Gastroenterol. 2016;111(5):602-622. (Clinical practice guidelines) DOI: 10.1038/ajg.2016.126

4. * Shane AL, Mody RK, Crump JA, et al. 2017 Infectious Diseases Society of America clinical practice guidelines for the diagnosis and management of infectious diarrhea. Clin Infect Dis. 2017;65(12):e45-e80. (Clinical practice guidelines) DOI: 10.1093/cid/cix669

27. * McAuliffe GN, Anderson TP, Stevens M, et al. Systematic application of multiplex PCR enhances the detection of bacteria, parasites, and viruses in stool samples. J Infect. 2013;67(2):122-129. (Prospective comparative study; 1516 patients) DOI: 10.1016/j.jinf.2013.04.009

34. * Krones E, Hogenauer C. Diarrhea in the immunocompromised patient. Gastroenterol Clin North Am. 2012;41(3):677-701. (Review) DOI: 10.1016/j.gtc.2012.06.009

50. * Hartling L, Bellemare S, Wiebe N, et al. Oral versus intravenous rehydration for treating dehydration due to gastroenteritis in children. Cochrane Database Syst Rev. 2006;2006(3):CD004390. (Cochrane review; 17 studies, 1811 patients) DOI: 10.1002/14651858.CD004390.pub2

88. * Riddle MS, Connor BA, Beeching NJ, et al. Guidelines for the prevention and treatment of travelers’ diarrhea: a graded expert panel report. J Travel Med. 2017;24(suppl_1):S57-S74. (Expert guidance) DOI: 10.1093/jtm/tax026

91. * De Bruyn G, Hahn S, Borwick A. Antibiotic treatment for travellers’ diarrhoea. Cochrane Database Syst Rev. 2000;2000(3):CD002242. (Cochrane review; 20 studies) DOI: 10.1002/14651858.CD002242

98. * Kuschner RA, Trofa AF, Thomas RJ, et al. Use of azithromycin for the treatment of Campylobacter enteritis in travelers to Thailand, an area where ciprofloxacin resistance is prevalent. Clin Infect Dis. 1995;21(3):536-541. (Randomized controlled trial; 42 patients) DOI: 10.1093/clinids/21.3.536

101. *Tribble DR, Sanders JW, Pang LW, et al. Traveler’s diarrhea in Thailand: randomized, double-blind trial comparing single-dose and 3-day azithromycin-based regimens with a 3-day levofloxacin regimen. Clin Infect Dis. 2007;44(3):338-346. (Randomized controlled trial; 156 patients) DOI: 10.1086/510589

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Keywords: gastroenteritis, acute diarrhea, norovirus, traveler’s diarrhea, dehydration, gastrointestinal disorders, diarrhea with nausea and vomiting, dehydration, oral rehydration, rotovirus, bacterial infection