1. Data Gathering
It means getting the history of food consumption, recent travel, presence of fever, tenesmus, bloody diarrhea, frequency of diarrhea and different aspects of epidemiology.
2. Duration
It means onset less than two weeks before the visit.
3. Date (Time of Consumed Food)
Less than six hours: consider toxin of Staphylococcus aurous and Bacillus cereus; onset between 8 - 14 hours: enterotoxin of Clostridium perfringens and B. cereus; onset between 16 - 48 hours: norovirus, Campylobacter, Escherichia coli, Salmonella, Shigella, and Vibrio parahaemolyticus.
4. Intravenous Hydration
IV therapy is indicated in unstable patients, presence of protracted vomiting, ileus, patients with obtundated mental status, signs and symptoms of shock or intussusception, or stool output of more than 10 cc/kg/h, and carbohydrate intolerance.
5. Associated Signs and Symptoms
Signs and symptoms such as fever, anemia and hemolysis (Yersinia, Campylobacter), hemolytic uremic syndromes (HUS: Enterohemorrhagic E. coli, EHEC 0159-H7 & 0104-H4, S. dysentery), erythema nodosum (Salmonella, Campylobacter, Yersinia) (9, 10), IgA nephropathy (Campylobacter), glomerulonephritis (Yersinia, Campylobacter, Shigella, Salmonella), reactive arthritis (Salmonella, Shigella, Campylobacter, Yersinia, C. difficile, Cryptosporidium) (11), rashes (enteroviruses, adenovirus, Yersinia, Salmonella, Listeria), loss of consciousness (Ekiri syndrome, Salmonella, Encephalopathy, shock) seizures (Salmonella, Shigella, Campylobacter, rotavirus (12), Rhinovirus (13), Listeria), Guillan-Barre syndrome (Campylobacter) could be associated with the disease.
6. Red Flags
Red flags are signs and symptoms of severe dehydration, shock, loss of consciousness, acute abdomen, toxic megacolon, presence of protracted vomiting, and oliguria.
7. Repeated RE-evaluation
Repeated re-evaluation is very important. These points should be considered: 1) Probable complications and/or differential diagnoses such as: toxic megacolon, hemolytic uremic syndrome (HUS), appendicitis, gastrointestinal obstruction, and intussusceptions. 2) Re-evaluation of the hydration level and electrolyte imbalance (monitoring the mental status, quality of pulse, heart rate, mucosa and skin dryness, breathing, capillary filling, thirsty, skin fold, and urine output).
8. Host Factors
Previous history or signs and symptoms of prematurity, failure to thrive, immune deficiency, and underlying diseases should be gained.
9. Exudative or Nonexudative Diarrhea and Electrolyte Correction
9.1. Probable Causes of Exudative Diarrhea
-Infectious: Shigella spp., Salmonella spp., Campylobacter spp., Bacillus anthracis, EHEC, C. difficile, Entamoeba histolytica, urosepsis (especially in infants), typhlitis.
-Noninfectious: intussusception, appendicitis, HUS, Kawasaki disease, milk allergy, Hirschsprung, bowel ischemia (9, 14).
9.2. Probable Causes of NonExudative Diarrhea
-Secretory; bacterial: V. cholera, Salmonella spp., Enterotoxicogenic (ETEC), Shigella spp.; viral: rotavirus, enterovirus, adenovirus, astrovirus, calicivirus, avian flu.
-Toxin; Food poisoning: S. aureus, C. perfringens, E. coli, V. cholera, V. parahaemolyticus, Chinese restaurant food.
-Heavy metal poisoning: arsenic, lead, iron.
9.3. Electrolyte Correction
The electrolyte imbalance should be corrected properly.
10. Antibiotic-Associated Diarrhea, Treatment and Other Therapies
10.1. Antibiotic-Associated Diarrhea
It can occur with C. difficile or Non-C. difficile (klebsiella oxytoca: cytotoxic hemolytic colitis) (9).
10.2. Antibiotic Therapy and Other Supplements
In a few cases of bacterial or protozoan gastroenteritis, antibiotics are needed. These included Shigella spp., S. typhi, V. cholera, some ETEC and Shiga toxin-producing E. coli and selected cases of non-typhi Salmonella, E. histolytica, Giardia and Cryptosporidium. Zinc sulfate, vitamin A and probiotics can be beneficial especially in resource-limited countries. Breastfeeding, continuous and proper nutrition, and age-appropriate calorie-protein intake during the episode will reduce further severe episodes.
