Approach

A detailed history and a thorough physical exam are required to assess for other causes of vomiting and/or diarrhea and to assess the level of dehydration.[40] However, clinical differentiation of viral gastroenteritis from bacterial gastroenteritis can be difficult.

History

The duration of the illness; the number of episodes, quantity, and character of vomiting (such as the presence of bile) and diarrhea (such as the presence of blood and mucus); and the apparent volume of fluid intake and output should be determined. Stools are typically loose or watery; mucus and blood are uncommon.[9] Extraintestinal manifestations may include headache, myalgia, or respiratory symptoms.[9]

The child's weight before onset of the illness; associated symptoms such as fever, abdominal cramps, and tenesmus; overall activity level; consumption of contaminated foods or fluid; exposure to people with gastroenteritis; outbreak of gastroenteritis in the community; concurrent illness in family members; daycare attendance; past medical history; recent travel to a diarrhea-endemic area; recent infection; recent use of antibiotics; duration of breast-feeding; and immunization status should be noted.[9][41][42][43]

Physical exam

The general condition of the patient and the severity of dehydration should be assessed. This is based on mental status; pulse rate; capillary refill; skin turgor; and the state of mucous membranes, eyes, and fontanelles.[40]

  • Signs of mild dehydration include: alert state; slightly decreased urine output; slightly increased thirst; slightly dry mucous membrane; slightly elevated heart rate; normal capillary refill; normal skin turgor; normal eyes; and normal anterior fontanelle.

  • Signs of moderate dehydration include: alert state, fatigued, or irritable; decreased urine output; moderately increased thirst; dry mucous membranes; elevated heart rate; prolonged capillary refill; decreased skin turgor; sunken eyes; and sunken anterior fontanelle.

  • Signs of severe dehydration include: apathetic or lethargic state; markedly decreased or absent urine output; greatly increased thirst; very dry mucous membranes; greatly elevated heart rate; prolonged or minimal capillary refill; decreased skin turgor; very sunken eyes; very sunken anterior fontanelle; cold extremities; hypotension; and coma.

Although loss in body weight is a useful indicator of dehydration, it should always be corroborated by changes in clinical signs, because weight measurement is susceptible to many potential errors (such as use of different scales or unstandardized measurement techniques). Weight may change significantly depending on whether the child has recently eaten, voided, or defecated.[43]

In viral gastroenteritis, the fever is usually low grade, the abdomen is soft and nondistended, and the bowel sounds are active. If the findings differ from this, alternative causes of vomiting and/or diarrhea should be considered and sought.

Investigations

Viral gastroenteritis is usually a clinical diagnosis and no investigations are needed.[9] Measurements of serum electrolytes, blood urea nitrogen, and creatinine should be considered in a subset of patients with severe dehydration receiving intravenous therapy.[42][44]

Stool diagnostic studies for viral pathogens are not necessary, except for epidemiologic purposes. Stool cultures should be considered in children with bloody diarrhea, because this is more typical of bacterial gastroenteritis.[9]

Complete blood count and appropriate cultures should be considered if other sources of infection need to be excluded.[9]

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