Viral Gastroenteritis

Fourth Medical, 2007

Prof. Widad Al-Nakib, FRCPath.
Viral Gastroenteritis
(Intestinal Flu)
A syndrome caused by
infection with one of
several viruses, usually
characterized by
vomiting, watery
diarrhea, and abdominal
cramps.
Etiology and
Pathophysiology
 Viral gastroenteritis is the most
common cause of infectious
diarrhea in the USA.
 Four categories of viruses are
known to cause gastroenteritis:
rotavirus, calicivirus (including
Norwalk virus), enteric
adenovirus (serotypes 40 and
41), and astrovirus
Contd..
 The viruses cause illness by infecting
the enterocytes within the villous
epithelium of the small intestine.
 Destruction of cells in this layer
causes net transudation of fluid and
salts into the intestinal lumen.
 Malabsorption of carbohydrates,
leading to osmotic diarrhea, may
also play a role.
 Characteristics of Viruses Causing Gastroenteritis

Virus Nucleic acid Particle Serotypes

Rotaviruses dsRNA, 11 nm of diameter, 3 70 ~ G and P

segments shells, wheel-like /serotypes
structure genotypes

Adenoviruses dsDNA nm of diameter, 74 ~ Serotypes 40 and

classic icosahedral 41 (Enteric
structure adenoviruses;
(EAd

Astroviruses ssRNA nm of diameter, 5 28 ~ serotypes at 8

or 6 points of star-like least
surface structure

Caliciviruses ssRNA nm of diameter, 27-32 Many but No. of

Noroviruses uncharacteristic surface serotypes
Sapoviruses nm of diameter 33 unknown
Human Rotavirus
Caliciviruses
Noroviruses
Astroviruses
Adenovirus
Enteroviruses
Epidemiology
 Rotavirus is highly contagious, and most
infections occur by the fecal-oral route.
 Adults may be infected after close contact
with an infected infant, but the illness in
adults is generally mild.
 In temperate climates, most infections
occur in the winter months
 Rotavirus is the most common cause of
severe, dehydrating diarrhea in young
children (peak incidence, 3 to 15 mo).
Contd..
 Each year in the USA, a wave
of rotavirus illness begins in
the Southwest in November
and ends in the Northeast in
March.
 Incubation period is 1 to 3
days.
Contd..
 Norwalk virus, the prototype
calicivirus, most commonly infects
older children and adults, and
infections occur year-round.
 Norwalk virus is the principal cause of
epidemic viral gastroenteritis;
waterborne and foodborne outbreaks
are well documented. Person-to-
person transmission also occurs
because the virus is highly
contagious.
 Incubation is 1 to 3 days.
Contd..
 Adenovirus serotypes 40 and 41 are
the second most common cause of
childhood viral gastroenteritis.
 Infections occur year-round, with a
slight increase in summer.
 Children < 2 yr are primarily
affected, and transmission occurs
from person to person by the fecal-
oral route.
 Incubation period is 8 to 10 days.
Contd..
 Less is known about the epidemiology of
non-Norwalk calicivirus and astrovirus.

 Both can infect persons of all ages but

usually infect infants and young children.

 Calicivirus infections occur year-round,

whereas gastroenteritis caused by
astrovirus is most common in the winter.

 Transmission is via the fecal-oral route.

Incubation is 1 to 3 days for both viruses
Signs and Symptoms
 The majority of infections caused by viral
enteropathogens are asymptomatic.

 In symptomatic infections, watery diarrhea is the

most common symptom; stools rarely contain
mucus or blood.

 Physical findings (eg, dry mucous membranes,

tachycardia) are nonspecific and relate to the
degree of dehydration.

 Infants and young children with rotavirus

gastroenteritis may develop severe watery
diarrhea lasting 5 to 7 days and leading to isotonic
dehydration.
Contd..
 Vomiting occurs in 90% of patients,
and fever > 39° C (102.2° F) occurs
in about 30%. Norwalk virus
typically causes acute onset of
vomiting, abdominal cramps, and
diarrhea, with symptoms lasting
only 1 to 2 days.
 In children, vomiting is more
prominent than diarrhea, whereas in
adults, diarrhea usually
predominates.
Contd..
 Low-grade fever occurs in about
50% of patients. Non-Norwalk
calicivirus infections in infants and
children are usually
indistinguishable from rotaviral
illness.
 However, adults may develop
clinical findings more typical of
Norwalk virus infection. Astrovirus
causes a syndrome similar to mild
rotavirus infection.
 Viral gastroenteritis is often
diagnosed clinically.
 Bacterial stool cultures and
examinations for ova and
parasites will be negative, but
these tests are often not
necessary in patients
presenting with symptoms
typical of viral gastroenteritis
Diagnosis
 Viral gastroenteritis is often
diagnosed clinically.
 Bacterial stool cultures and
examinations for ova and
parasites will be negative, but
these tests are often not
necessary in patients
presenting with symptoms
typical of viral gastroenteritis
Contd..
 Rotavirus, Norovirus and enteric
adenovirus infections can be diagnosed
rapidly using commercially available
assays that detect viral antigen in the
stool. Tests to detect the other viral
enteropathogens are available in research
laboratories only.
 Electron microscopy,when available,is
often used to diagnose these infections.
 PCR is also now being used more and more
Prevention
 Prevention of infection is
complicated by the frequency
of asymptomatic infection and
the ease with which these
viruses are transmitted from
person to person, especially
among children in diapers.
 Breastfeeding is likely to
afford some protection from
infection
Contd..
 Caregiversshould wash their
hands thoroughly with soap
and water after changing
diapers, and diaper-changing
areas should be disinfected
with diluted household
bleach or 70% alcohol.
Contd..
 For rotavirus outbreaks in child care
facilities, all children should be
tested for excretion of the
organism. Infected and uninfected
children can then be moved to
receive care in different areas and
from different caregivers.
 Several promising rotavirus vaccine
candidates are being developed.
New Rotavirus Vaccines Licensed

 Two new vaccines have

recently been licensed
 “Rotarix” (GlaxoSmithKline),
monovalent, live, oral human
89-12 strain
 “RotaTeq” (Merck),
pentavalent, live, oral human-
bovine reassortants
Concerns Regarding the
Rotavirus Vaccines

 Concern about the emergence

of “new” serotypes and
“reassortants” strains require
constant monitoring and
surveillance.
 ‘Updating’ of the new vaccine
with the “new” strains could
be important to maintain
efficacy
Treatment
 The mainstay of therapy is
appropriate fluid resuscitation.
 Even if vomiting, most patients can
be effectively rehydrated with oral
rehydration solutions.
 Several of which are available OTC.
 Sports drinks and carbonated
beverages are not appropriate
rehydration solutions for children <
5 yr old.
 IV rehydration is necessary only for
patients with severe dehydration.