Viral Gastroenteritis

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Background

Acute gastroenteritis is a common cause of morbidity and mortality worldwide. Conservative estimates put diarrhea in the top 5 causes of deaths worldwide, with most occurring in young children in nonindustrialized countries. In industrialized countries, diarrheal diseases are a significant cause for morbidity across all age groups. Etiologies include bacteria, viruses, parasites, toxins, and drugs. Viruses are responsible for a significant percentage of cases affecting patients of all ages. Viral gastroenteritis ranges from a self-limited watery diarrheal illness (usually < 1 wk) associated with symptoms of nausea, vomiting, anorexia, malaise, or fever, to severe dehydration resulting in hospitalization or even death.

The clinician encounters acute viral gastroenteritis in 3 settings. The first is sporadic gastroenteritis in infants, which most frequently is caused by rotavirus.[1] The second is epidemic gastroenteritis, which occurs either in semiclosed communities (eg, families, institutions, ships, vacation spots) or as a result of classic food-borne or water-borne pathogens.[2] Most of these infections are caused by caliciviruses. The third is sporadic acute gastroenteritis of adults, which most likely is caused by caliciviruses, rotaviruses, astroviruses, or adenoviruses.

For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education article Gastroenteritis.

Pathophysiology

Viral spread from person to person occurs by fecal-oral transmission of contaminated food and water. Some viruses, like noroviruses, may be transmitted by an airborne route. Clinical manifestations are related to intestinal infection, but the exact mechanism of the induction of diarrhea is not clear.

The most extensive studies have been done with rotavirus. Rotaviruses attach and enter mature enterocytes at the tips of small intestinal villi. They cause structural changes to the small bowel mucosa, including villus shortening and mononuclear inflammatory infiltrate in the lamina propria.

The current knowledge on the mechanisms leading to diarrheal disease by rotavirus is as follows:[3]

Morphologic abnormalities can be minimal, and studies demonstrate that rotavirus can be released from infected epithelial cells without destroying them. Viral attachment and entry into the epithelial cell without cell death may be enough to initiate diarrhea. The epithelial cell synthesizes and secretes numerous cytokines and chemokines, which can direct the host immune response and potentially regulate cell morphology and function. Studies also suggest that one of the nonstructural viral proteins may act as an enterotoxin, promoting active chloride secretion mediated through increases in intracellular calcium concentration. Toxin-mediated diarrhea would explain the observation that villus injury is not necessarily linked to diarrhea.

Epidemiology

Frequency

United States

Each year, more than 3.5 million infants develop acute viral gastroenteritis, resulting in more than 500,000 office visits, 55,000 hospitalizations, and 30 deaths. Statistics on sporadic cases of adult viral gastroenteritis are not known; however, food- and water-borne epidemics of viral gastroenteritis are monitored by the US Centers for Disease Control and Prevention (CDC) surveillance programs. The CDC estimates that viruses cause 9.2 million cases of food-related illness each year (out of a total of 13.8 million cases from all causes).

Noroviruses cause approximately 23 million cases of acute gastroenteritis each year and are the leading cause of outbreaks of gastroenteritis. They are responsible for 68-80% of all outbreaks in industrialized countries. The genus Norovirus, formerly called the Norwalk-like virus, is a member of the family Caliciviridae.

Noroviruses are now recognized to be a common cause of gastroenteritis in new settings, including nursing homes and other health care settings, cruise ships, in other travelers, and in immunocompromised patients.[4] In 2010-2011, norovirus was transmitted among players and staff of the National Basketball Association.[5]

In March 2012, the CDC reported a rise in foodborne disease outbreaks caused by imported food in 2009 and 2011. Nearly 50% of the outbreaks implicated food that was imported from regions not previously associated with outbreaks (mostly fish and peppers). Approximately 45% percent of the imported foods causing outbreaks came from Asia.[6]

The frequency is seasonal. The highest incidence of rotavirus cases occurs during the months from November to April. Cruise ship outbreaks of noroviruses are more common during the summer months. However, a CDC study by Tate et al demonstrated a decline in the seasonality of rotavirus following the 2006 introduction of the rotavirus vaccine.[7]

The investigators evaluated data for July 2000 through June 2008 to assess national, regional, and local trends in rotavirus testing and detection and found not only was the onset of the 2007-2008 rotavirus season delayed 15 weeks and the peak delayed 8 weeks relative to the prevaccine rotavirus season from 2000 to 2006, but the 2007-2008 season also lasted a little over half (14 wk) of the median prevaccine seasons (26 weeks).[7] Moreover, there was a 67% decline in the number and a 69% decline in the proportion of 2007-2008 rotavirus-positive test results compared with the median in 2000-2006.

Rotavirus is the most common etiologic agent of health care–acquired diarrhea in pediatric patients. Community- and health care–acquired infections have similar temporal distributions; they are caused by the same viral subtypes; and they affect children of the same age groups. All of the health care–acquired infections with known viral subtypes occurred while the same subtype was still active in the community, suggesting that health care–acquired infections arise from repeated introduction of the community-acquired rotavirus into the hospital setting.[8]

International

Acute viral gastroenteritis is a leading cause of infant mortality throughout the world. By age 3 years, virtually all children become infected with the most common agents. Rotavirus causes 2 million hospitalizations and 600,000-875,000 deaths per year.

Noroviruses were attributed to 9 out of the 21 outbreaks of acute gastroenteritis on cruise ships reported to the CDC's Vessel Sanitation Program from January 1, 2002, to December 2, 2002. The occurrence of noroviruses on cruise ships has led to the use of the term "the cruise ship virus" as another name for these viruses. Some illnesses previously attributed to sea sickness are now recognized to be caused by norovirus infections.[4]

Mortality/Morbidity

Severe cases are seen in the elderly, infant, and immunosuppressed populations, including transplant patients.

Rotavirus infantile gastroenteritis is an important cause of infant mortality in the developing world.

In the United States, elderly persons have the highest risk of death from gastroenteritis.

Caliciviruses may kill more people in the United States than do rotaviruses.

Noroviruses are the most common cause of gastroenteritis in nursing homes, and several such outbreaks have resulted in deaths due to aspiration or exacerbation of another chronic disease. Norovirus infections in hospitalized patients are more severe than those seen in otherwise healthy persons.[4]

The CDC reported enteritis deaths more than doubled in the United States, an increase to 17,000 in 2007 from about 7,000 in 1999. Adults over 65 years old accounted for 83% of deaths. Clostridium difficile (C difficile) and norovirus were the most common infectious causes of gastroenteritis-associated deaths. Norovirus was associated with about 800 deaths annually, though there were 50% more deaths in years when epidemics were caused by new strains of the virus.[9]

Age

History

The clinical spectrum of acute viral gastroenteritis ranges from asymptomatic infection to severe dehydration and death. Viral gastroenteritis typically presents with short prodrome, with mild fever and vomiting, followed by 1-4 days of nonbloody, watery diarrhea. Viral gastroenteritis is usually self-limited.

In 1982, the Kaplan criteria were established to distinguish outbreaks due to norovirus from outbreaks of bacterial etiology. The criteria are highly specific (99%) and moderately sensitive (68%). The 4 criteria indicative of an outbreak due to norovirus are as follows:[11]

Physical

The physical examination can be helpful in determining the etiology of gastroenteritis and in assessing the presence and degree of dehydration.

Causes

Laboratory Studies

Medical Care

In 1996, the American Academy of Pediatrics formulated and published practice guidelines for the management of acute gastroenteritis in children. Use the following parameters to assess the degree of dehydration: blood pressure, pulse, heart rate, skin turgor, fontanelle, mucous membranes, eyes, extremities, mental status, urine output, and thirst.

Probiotics are nonpathogenic live microorganisms that provide beneficial effects on the health of the host. In recent years, probiotics have entered mainstream medical practice, as a decrease in the severity and duration of infectious gastroenteritis has been shown in some strains.[13]

Deterrence/Prevention

Author

Michael Vincent F Tablang, MD, Resident Physician, Department of Internal Medicine, University of Connecticut Health Center

Disclosure: Nothing to disclose.

Coauthor(s)

George Y Wu, MD, PhD, Professor, Department of Medicine, Director, Hepatology Section, Herman Lopata Chair in Hepatitis Research, University of Connecticut School of Medicine

Disclosure: Springer Consulting fee Consulting; Gilead Consulting fee Review panel membership; Vertex Honoraria Speaking and teaching; Bristol-Myers Squibb Honoraria Speaking and teaching; Springer Royalty Review panel membership; Merck Honoraria Speaking and teaching

Michael J Grupka, MD, Physician, Atlanta Center for Gastroenterology

Disclosure: Nothing to disclose.

Specialty Editors

John Gunn Lee, MD, Director of Pancreaticobiliary Service, Associate Professor, Department of Internal Medicine, Division of Gastroenterology, University of California at Irvine School of Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Noel Williams, MD, Professor Emeritus, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Professor, Department of Internal Medicine, Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada

Disclosure: Nothing to disclose.

Alex J Mechaber, MD, FACP, Senior Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine

Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine

Disclosure: Nothing to disclose.

References

  1. Ramani S, Kang G. Viruses causing childhood diarrhoea in the developing world. Curr Opin Infect Dis. Oct 2009;22(5):477-82. [View Abstract]
  2. Scarcella C, Carasi S, Cadoria F, et al. An outbreak of viral gastroenteritis linked to municipal water supply, Lombardy, Italy, June 2009. Euro Surveill. Jul 23 2009;14(29):epub ahead of print. [View Abstract]
  3. Lorrot M, Vasseur M. How do the rotavirus NSP4 and bacterial enterotoxins lead differently to diarrhea?. Virol J. Mar 21 2007;4:31. [View Abstract]
  4. Estes MK, Prasad BV, Atmar RL. Noroviruses everywhere: has something changed?. Curr Opin Infect Dis. Oct 2006;19(5):467-74. [View Abstract]
  5. Desai R, Yen C, Wikswo M, Gregoricus NA, Provo JE, Parashar UD, et al. Transmission of norovirus among NBA players and staff, winter 2010-2011. Clin Infect Dis. Dec 2011;53(11):1115-7. [View Abstract]
  6. CDC research shows outbreaks linked to imported foods increasing. Available at http://www.cdc.gov/media/releases/2012/p0314_foodborne.html. Accessed March 14, 2012.
  7. Tate JE, Panozzo CA, Payne DC, et al. Decline and change in seasonality of US rotavirus activity after the introduction of rotavirus vaccine. Pediatrics. Aug 2009;124(2):465-71. [View Abstract]
  8. Smith MJ, Clark HF, Lawley D, et al. The clinical and molecular epidemiology of community- and healthcare-acquired rotavirus gastroenteritis. Pediatr Infect Dis J. Jan 2008;27(1):54-8. [View Abstract]
  9. Centers for Disease Control and Prevention (CDC). Deaths from gastroenteritis double. Available at http://www.cdc.gov/media/releases/2012/p0314_gastroenteritis.html
  10. Notes from the field: outbreaks of rotavirus gastroenteritis among elderly adults in two retirement communities--Illinois, 2011. MMWR Morb Mortal Wkly Rep. Oct 28 2011;60(42):1456. [View Abstract]
  11. Turcios RM, Widdowson MA, Sulka AC, et al. Reevaluation of epidemiological criteria for identifying outbreaks of acute gastroenteritis due to norovirus: United States, 1998-2000. Clin Infect Dis. Apr 1 2006;42(7):964-9. [View Abstract]
  12. Lee N, Chan MC, Wong B, et al. Fecal viral concentration and diarrhea in norovirus gastroenteritis. Emerg Infect Dis. Sep 2007;13(9):1399-401. [View Abstract]
  13. Vandenplas Y, Salvatore S, Vieira M, et al. Probiotics in infectious diarrhoea in children: are they indicated?. Eur J Pediatr. Dec 2007;166(12):1211-8. [View Abstract]
  14. Sartor RB. Therapeutic manipulation of the enteric microflora in inflammatory bowel diseases: antibiotics, probiotics, and prebiotics. Gastroenterology. May 2004;126(6):1620-33. [View Abstract]
  15. US Food and Drug Administration. FDA Approves New Vaccine to Prevent Gastroenteritis Caused by Rotavirus. Available at http://www.fda.gov/bbs/topics/NEWS/2008/NEW01814.html
  16. Glass RI, Parashar UD. The promise of new rotavirus vaccines. N Engl J Med. Jan 5 2006;354(1):75-7. [View Abstract]
  17. [Best Evidence] Ruiz-Palacios GM, Perez-Schael I, Velazquez FR, et al. Safety and efficacy of an attenuated vaccine against severe rotavirus gastroenteritis. N Engl J Med. Jan 5 2006;354(1):11-22. [View Abstract]
  18. American Academy of Pediatrics. Red Book® Online Table - NEWStatus of Licensure and Recommendations for New Vaccines*. Available at http://aapredbook.aappublications.org/news/vaccstatus.shtml
  19. American Academy of Pediatrics. Practice parameter: the management of acute gastroenteritis in young children. American Academy of Pediatrics, Provisional Committee on Quality Improvement, Subcommittee on Acute Gastroenteritis. Pediatrics. Mar 1996;97(3):424-35. [View Abstract]
  20. Ball JM, Graham DY, Opekun AR, et al. Recombinant Norwalk virus-like particles given orally to volunteers: phase I study. Gastroenterology. Jul 1999;117(1):40-8. [View Abstract]
  21. Belhorn T. Rotavirus diarrhea. Curr Probl Pediatr. Aug 1999;29(7):198-207. [View Abstract]
  22. Bon F, Fascia P, Dauvergne M, et al. Prevalence of group A rotavirus, human calicivirus, astrovirus, and adenovirus type 40 and 41 infections among children with acute gastroenteritis in Dijon, France. J Clin Microbiol. Sep 1999;37(9):3055-8. [View Abstract]
  23. Burkhart DM. Management of acute gastroenteritis in children. Am Fam Physician. Dec 1999;60(9):2555-63, 2565-6. [View Abstract]
  24. Caeiro JP, Mathewson JJ, Smith MA, et al. Etiology of outpatient pediatric nondysenteric diarrhea: a multicenter study in the United States. Pediatr Infect Dis J. Feb 1999;18(2):94-7. [View Abstract]
  25. Centers for Disease Control and Prevention. Advisory Committee Recommends New Vaccine to Prevent Rotavirus.
  26. Centers for Disease Control and Prevention. Outbreak of Gastroenteritis Associated with Noroviruses on Cruise Ships --- United States, 2002. MMWR Morb Mortal Wkly Rep. Dec 13 2002;51(49):1112-1115.
  27. Centers for Disease Control and Prevention. Withdrawal of rotavirus vaccine recommendation. JAMA. Dec 8 1999;282(22):2113-4. [View Abstract]
  28. Clark B, McKendrick M. A review of viral gastroenteritis. Curr Opin Infect Dis. Oct 2004;17(5):461-9. [View Abstract]
  29. DuPont HL. Guidelines on acute infectious diarrhea in adults. The Practice Parameters Committee of the American College of Gastroenterology. Am J Gastroenterol. Nov 1997;92(11):1962-75. [View Abstract]
  30. Estes MK, Morris AP. A viral enterotoxin. A new mechanism of virus-induced pathogenesis. Adv Exp Med Biol. 1999;473:73-82. [View Abstract]
  31. Fankhauser RL, Noel JS, Monroe SS, et al. Molecular epidemiology of "Norwalk-like viruses" in outbreaks of gastroenteritis in the United States. J Infect Dis. Dec 1998;178(6):1571-8. [View Abstract]
  32. Flem E, Vainio K, Dollner H, et al. Rotavirus gastroenteritis in Norway: Analysis of prospective surveillance and hospital registry data. Scand J Infect Dis. 2009;41(10):753-9. [View Abstract]
  33. Ford T. Emerging issues in water and health research. J Water Health. 2006;4 Suppl 1:59-65. [View Abstract]
  34. Gaggero A, O'Ryan M, Noel JS, et al. Prevalence of astrovirus infection among Chilean children with acute gastroenteritis. J Clin Microbiol. Dec 1998;36(12):3691-3. [View Abstract]
  35. Glass RI, Parashar UD. The promise of new rotavirus vaccines. N Engl J Med. Jan 5 2006;354(1):75-7. [View Abstract]
  36. Green J, Gallimore CI, Norcott JP, et al. Broadly reactive reverse transcriptase polymerase chain reaction for the diagnosis of SRSV-associated gastroenteritis. J Med Virol. Dec 1995;47(4):392-8. [View Abstract]
  37. ICTVdb. The Universal Virus Database of the International Committee on Taxonomy of Viruses Web site. Available at: http://ictvdb.bio2.columbia.edu/Ictv/index.htm. Accessed on December 27, 2002.
  38. Johnsen CK, Midgley S, Bottiger B. Genetic diversity of sapovirus infections in Danish children 2005-2007. J Clin Virol. Nov 2009;46(3):265-9. [View Abstract]
  39. Maldonado Y, Cantwell M, Old M, et al. Population-based prevalence of symptomatic and asymptomatic astrovirus infection in rural Mayan infants. J Infect Dis. Aug 1998;178(2):334-9. [View Abstract]
  40. Mead PS, Slutsker L, Dietz V, et al. Food-related illness and death in the United States. Emerg Infect Dis. Sep-Oct 1999;5(5):607-25. [View Abstract]
  41. Pang XL, Joensuu J, Vesikari T. Human calicivirus-associated sporadic gastroenteritis in Finnish children less than two years of age followed prospectively during a rotavirus vaccine trial. Pediatr Infect Dis J. May 1999;18(5):420-6. [View Abstract]
  42. Pang XL, Koskenniemi E, Joensuu J, et al. Effect of rhesus rotavirus vaccine on enteric adenovirus--associated diarrhea in children. J Pediatr Gastroenterol Nutr. Sep 1999;29(3):366-9. [View Abstract]
  43. Pang XL, Vesikari T. Human astrovirus-associated gastroenteritis in children under 2 years of age followed prospectively during a rotavirus vaccine trial. Acta Paediatr. May 1999;88(5):532-6. [View Abstract]
  44. [Best Evidence] Ruiz-Palacios GM, Perez-Schael I, Velazquez FR, et al. Safety and efficacy of an attenuated vaccine against severe rotavirus gastroenteritis. N Engl J Med. Jan 5 2006;354(1):11-22. [View Abstract]
  45. Saps M, Pensabene L, Turco R, et al. Rotavirus gastroenteritis: precursor of functional gastrointestinal disorders?. J Pediatr Gastroenterol Nutr. Nov 2009;49(5):580-3. [View Abstract]
  46. Shornikova AV, Isolauri E, Burkanova L, et al. A trial in the Karelian Republic of oral rehydration and Lactobacillus GG for treatment of acute diarrhoea. Acta Paediatr. May 1997;86(5):460-5. [View Abstract]
  47. [Best Evidence] Vesikari T, Matson DO, Dennehy P, et al. Safety and efficacy of a pentavalent human-bovine (WC3) reassortant rotavirus vaccine. N Engl J Med. Jan 5 2006;354(1):23-33. [View Abstract]