Gastroenteritis: Management Strategies

Gastroenteritis: An overview

Gastroenteritis is defined as the inflammation of the mucosal lining of the gastrointestinal tract, and is characterized by diarrhea or vomiting. It is a very common gastrointestinal presentation to the emergency room as well as the out-patient clinics, and majority of gastroenteritis cases are infectious.¹Chow CM, Leung AK, Hon KL. Acute gastroenteritis: from guidelines to real life. Clin Exp Gastroenterol. 2010;3:97-112.   ²Malik OAA. Role of antimicrobials in the treatment of adult patients presenting to the emergency department with acute gastroenteritis – A mini review. Pak J Med Sci. 2017;33(2):488-492.    ³Fletcher SM, McLaws M-L, Ellis JT. Prevalence of Gastrointestinal Pathogens In Developed and Developing Countries: Systematic Review and Meta- Analysis. J Public Health Res. 2013;2(1):42-53.   1-3 Gastrointestinal disorders contribute remarkably to the burden of illness from infectious diseases worldwide. Notwithstanding a robust association between gastrointestinal disorders and factors such as poor hygiene, inadequate access to safe drinking water and other risk factors, both developed and developing countries alike are affected by gastrointestinal disorders.³Fletcher SM, McLaws M-L, Ellis JT. Prevalence of Gastrointestinal Pathogens In Developed and Developing Countries: Systematic Review and Meta- Analysis. J Public Health Res. 2013;2(1):42-53.

Acute gastroenteritis, characterized by diarrhea or vomiting (or both) of more than seven days duration, remains one of the most common diseases of humankind, and its associated morbidity and mortality are greatest among those at the extremes of age, children and the elderly.⁴Elliott EJ. Acute gastroenteritis in children. BMJ. 2007;334(7583):35-40.   ⁵ Fatima S, Irfana N, Mushtaq SM, et al. A Cross-Sectional Study to Assess Prevalence and Management of Acute Gastroenteritis in Pediatric Inpatients of A Large Teaching Hospital. IOSR Journal of Pharmacy. 2014; 4(12): 12-26.   ⁶Glass RI, Bresee J, Jiang B, et al. Gastroenteritis viruses: an overview. Novartis Found Symp. 2001;238:5-19; discussion 19-25.    According to the World Health Organization (WHO), it is a leading cause of mortality worldwide, accounting for millions of deaths each year in young children, mostly in developing countries.²Malik OAA. Role of antimicrobials in the treatment of adult patients presenting to the emergency department with acute gastroenteritis – A mini review. Pak J Med Sci. 2017;33(2):488-492.   ⁷Viral Gastroenteritis. Available at: http://emedicine.medscape.com/ article/176515-overview. Accessed on: 29-05-2017.    In the developed countries, gastroenteritis is a major cause for morbidity across all age groups, and is a common reason for presentation to general practice or emergency departments and for hospitalization.⁴Elliott EJ. Acute gastroenteritis in children. BMJ. 2007;334(7583):35-40.   ⁶Glass RI, Bresee J, Jiang B, et al. Gastroenteritis viruses: an overview. Novartis Found Symp. 2001;238:5-19; discussion 19-25.   ⁷Viral Gastroenteritis. Available at: http://emedicine.medscape.com/ article/176515-overview. Accessed on: 29-05-2017.    Altogether, acute gastroenteritis causes remarkable mortality in developing countries and considerable economic burden to developed countries.¹Chow CM, Leung AK, Hon KL. Acute gastroenteritis: from guidelines to real life. Clin Exp Gastroenterol. 2010;3:97-112.   

Etiology of gastroenteritis

Acute gastroenteritis is a clinical syndrome produced by a wide variety of viral, bacterial, and parasitic enteropathogens. Viruses are the most important etiology and are accountable for approximately 70% of the cases of acute gastroenteritis in children (Table 1).¹Chow CM, Leung AK, Hon KL. Acute gastroenteritis: from guidelines to real life. Clin Exp Gastroenterol. 2010;3:97-112.    ⁴Elliott EJ. Acute gastroenteritis in children. BMJ. 2007;334(7583):35-40.   ⁶Glass RI, Bresee J, Jiang B, et al. Gastroenteritis viruses: an overview. Novartis Found Symp. 2001;238:5-19; discussion 19-25.   ⁸Shek KC, Ng P, Hung CY, et al. A review on the management of acute gastroenteritis in children. Hong Kong J Emerg Med. 2004; 11(3): 152-60.    Worldwide, rotavirus is the most common intestinal virus causing acute gastroenteritis and accounts for almost 30% to 72% of all the hospitalizations and 4% to 24% of acute gastroenteritis at the community level.¹Chow CM, Leung AK, Hon KL. Acute gastroenteritis: from guidelines to real life. Clin Exp Gastroenterol. 2010;3:97-112.    Moreover, rotaviruses are the most common cause of severe watery diarrhea in young children, and are accountable for 40% of cases of dehydrating diarrhea. Other viruses, such as calicivirus, adenovirus and astrovirus also play a role in the etiology of gastroenteritis. Globally, these viruses are accountable for diarrhea episodes in hospitalized children, with detection rates varying from 3.2%–29.3%, 1%–31%, and 1.8%–16%, respectively. Rates of virus infection are comparable in both developed and developing countries.¹Chow CM, Leung AK, Hon KL. Acute gastroenteritis: from guidelines to real life. Clin Exp Gastroenterol. 2010;3:97-112.   ⁹Revelas A. Acute gastroenteritis among children in the developing world. South Afr J Epidemiol Infect. 2012; 27(4): 156-62.

Bacterial pathogens account for 10% to 20% of all the acute gastroenteritis cases. In developing countries, as a group, bacterial enteropathogens are responsible for the majority of diarrheal diseases. Among them, diarrheogenic Escherichia coli (enteropathogenic, enterotoxigenic, enteroaggregative, enteroinvasive and enterohemorrhagic) is the most important group, followed by Campylobacter, Aeromonas, Shigella, and Salmonella spp. Vibrio cholerae remains a major cause of diarrhea, particularly in endemic areas and conditions. Improvement in sanitation, although may not decrease the disease prevalence of viral infection, but can be effective in prevention of parasites and bacterial infections.¹Chow CM, Leung AK, Hon KL. Acute gastroenteritis: from guidelines to real life. Clin Exp Gastroenterol. 2010;3:97-112.   ⁹Revelas A. Acute gastroenteritis among children in the developing world. South Afr J Epidemiol Infect. 2012; 27(4): 156-62.    ¹⁰Zollner-Schwetz I, Krause R. Therapy of acute gastroenteritis: role of antibiotics. Clin Microbiol Infect. 2015 Aug;21(8):744-9.    ¹¹O’Ryan M, Vidal R, del Canto F, Carlos Salazar J, Montero D. Vaccines for viral and bacterial pathogens causing acute gastroenteritis: Part II: Vaccines for Shigella, Salmonella, enterotoxigenic E. coli (ETEC) enterohemorragic E. coli (EHEC) and Campylobacter jejuni. Hum Vaccin Immunother. 2015;11(3):601-619.   

Prevalence estimates

Acute gastroenteritis is widely prevalent worldwide, with millions of cases being registered annually. Acute gastroenteritis is a major killer of the very young worldwide; current estimates suggest that acute gastroenteritis affects 3 to 5 billion children below 5 years of age each year, and accounts for 1.5 to 2.5 million deaths per year. In developed countries, acute gastroenteritis accounts for around 300 deaths per year. It causes more than 1.5 million visits to primary care providers each year and accounts for about 10% (220,000) of hospital admissions for children under the age of 5 years. Moreover, it incurs a heavy financial burden on the health care system.¹Chow CM, Leung AK, Hon KL. Acute gastroenteritis: from guidelines to real life. Clin Exp Gastroenterol. 2010;3:97-112.   ⁴Elliott EJ. Acute gastroenteritis in children. BMJ. 2007;334(7583):35-40.   ¹²Rose MA. Mucosal Immunity and acute viral gastroenteritis: The example rotavirus. Hum Vaccin Immunother. 2014;10(7):2112-2114.

Of note, developing countries have a higher rate of hospital admissions as compared to developed countries. In particular, it is estimated that every child encounters at least one episode of rotavirus gastroenteritis by the age of 5 years. Alarmingly, these infections cause more than 500000 deaths annually among children up to 5 years of age worldwide and most of these deaths occur in the developing countries.¹Chow CM, Leung AK, Hon KL. Acute gastroenteritis: from guidelines to real life. Clin Exp Gastroenterol. 2010;3:97-112.   ¹³Moradi-Lakeh M, Shakerian S, Yaghoubi M, et al. Rotavirus Infection in Children with Acute Gastroenteritis in Iran: A Systematic Review and Metaanalysis. Int J Prev Med. 2014;5(10):1213-1223.

Symptoms & signs of gastroenteritis

Acute gastroenteritis, also known as acute diarrhea, is consistently characterized by diarrhea that is often accompanied by abdominal pain, nausea, vomiting, and fever. The WHO defines acute diarrhea as the passage of three or more loose or liquid stools per day, for three or more days and for less than 14 days.⁴Elliott EJ. Acute gastroenteritis in children. BMJ. 2007;334(7583):35-40.    ¹³Moradi-Lakeh M, Shakerian S, Yaghoubi M, et al. Rotavirus Infection in Children with Acute Gastroenteritis in Iran: A Systematic Review and Metaanalysis. Int J Prev Med. 2014;5(10):1213-1223.     ¹⁴Florez ID, Al-Khalifah R, Sierra JM, et al. The effectiveness and safety of treatments used for acute diarrhea and acute gastroenteritis in children: protocol for a systematic review and network meta-analysis. Syst Rev. 2016;5:14.

Onset is usually sudden, and is accompanied with anorexia, nausea, vomiting, abdominal cramps, and diarrhea (with or without blood and mucus). Malaise, myalgias, and prostration may also occur. An important feature of acute gastroenteritis is the presence of hyperactive bowel sounds (borborygmi) on auscultation even without diarrhea. In severe cases, shock, with vascular collapse and oliguric renal failure, may occur.¹⁵Overview of Gastroenteritis. Available at: http://www.msdmanuals.com/ professional/gastrointestinal-disorders/gastroenteritis/overview-ofgastroenteritis. Accessed on: 30-05-2017.

The most common symptoms associated with rotavirus infection include watery diarrhea and vomiting, which sometimes aggravate resulting in severe dehydration requiring hospitalization. In children, vomiting is more prominent than diarrhea, while in adults, diarrhea usually predominates. Further, patients may also experience fever, headache, and myalgias.¹³Moradi-Lakeh M, Shakerian S, Yaghoubi M, et al. Rotavirus Infection in Children with Acute Gastroenteritis in Iran: A Systematic Review and Metaanalysis. Int J Prev Med. 2014;5(10):1213-1223.    ¹⁵Overview of Gastroenteritis. Available at: http://www.msdmanuals.com/ professional/gastrointestinal-disorders/gastroenteritis/overview-ofgastroenteritis. Accessed on: 30-05-2017.

Bacterial gastroenteritis (Shigella, Salmonella) is more likely to result in high fever and may be associated with blood and white blood cells in the stool. E. coli infection may cause hemorrhagic colitis (with severe bloody diarrhea), which may be complicated by hemolytic uremic syndrome, an endemic condition across the world, characterized by acute onset of microangiopathic hemolytic anemia, thrombocytopenia, acute renal impairment, and multisystem involvement.⁴Elliott EJ. Acute gastroenteritis in children. BMJ. 2007;334(7583):35-40.

Abdominal spasm – an important manifestation in gastroenteritis

Abdominal spasms, also referred as colic, are involuntary contractions of the muscles of the abdomen characterized by pain that increases and decreases abruptly in its intensity with varying period of absence intermittently. The spasm usually occurs due to an obstruction in any hollow viscus, and is the result of attempt to relieve it by smooth muscle contractions.¹⁶Stern LZ, Bernick C. Muscle Cramps. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 53. Available at: http://www.ncbi.nlm.nih.gov/books/NBK376/. Accessed on: 30-05-2017.   ¹⁷Sherman R. Abdominal Pain. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 86. Available at: http://www. ncbi.nlm.nih.gov/books/NBK412/. Accessed on: 30-05-2017.    Most abdominal spasm/pain arise from an abdominal pathology; while a few causes may be of extra-abdominal origin.¹⁸Tsalkidis A, Gardikis S, Cassimos D, Kambouri K, Tsalkidou E, Deftereos S, Chatzimichael A. Acute abdomen in children due to extra-abdominal causes. Pediatr Int. 2008 Jun;50(3):315-8.   Abdominal spasm shows a gender predilection; women are more commonly affected compared to men (12-55% versus 7-38%, respectively). Abdominal pain can range from mild, self limiting to severe life-threatening conditions, particularly in case of the elderly patients who are at 6-8 times greater risk than the younger individuals. The cause of abdominal spasm can be surgical or non surgical depending upon the underlying etiology.¹⁹Quigley EM, Locke GR, Mueller-Lissner S, Paulo LG, Tytgat GN, Helfrich I, Schaefer E. Prevalence and management of abdominal cramping and pain: a multinational survey. Aliment Pharmacol Ther. 2006 Jul 15;24(2):411-9.    ²⁰Abdullah M, Firmansyah MA. Diagnostic approach and management of acute abdominal pain. Acta Med Indones. 2012 Oct;44(4):344-50.    ²¹Comroe BI. Non-surgical causes of acute abdominal pain. Ann Surg. 1935;101(1):438-444.

Etiological basis of abdominal spasms

Abdominal spasm may have multiple etiologies, it can arise from gastrointestinal tract or from the adjoining sites including pancreas, hepatobiliary, and genitourinary tract.²²Mendelson R. Imaging for chronic abdominal pain in adults. Aust Prescr. 2015;38(2):49-54.    The common causes of abdominal spasm are gall stones, renal stones, urinary tract infection (UTI), dysmenorrhea, and various digestive system diseases including gastroenteritis, diarrhea, constipation, ulcerative colitis, tumors, stomach ulcers, irritable bowel syndrome, pancreatitis, appendicitis, Crohn’s disease, diverticulitis and cholecystitis (Table 2).²⁰Abdullah M, Firmansyah MA. Diagnostic approach and management of acute abdominal pain. Acta Med Indones. 2012 Oct;44(4):344-50.    ²¹Comroe BI. Non-surgical causes of acute abdominal pain. Ann Surg. 1935;101(1):438-444.

Management of gastroenteritis

Prevention of dehydration is the hallmark of gastroenteritis treatment. Most patients with gastroenteritis with minimal or no dehydration can be managed at home, and should be encouraged to continue usual diet and drink adequate fluids.²³Churgay CA, Aftab Z. Gastroenteritis in Children: Part II. Prevention and Management. Am Fam Physician. 2012 Jun 1;85(11):1066-1070.

The American Academy of Pediatrics (AAP), Centers for Disease Control and Prevention (CDC), European Society for Pediatric Gastroenterology and Nutrition, and the WHO all strongly encourage the use of oral rehydration therapy as the first-line therapy for the treatment of acute gastroenteritis, except in cases of severe dehydration. A large slew of studies have substantiated the effectiveness of oral rehydration therapy in treating acute gastroenteritis, with mild to moderated dehydration.¹Chow CM, Leung AK, Hon KL. Acute gastroenteritis: from guidelines to real life. Clin Exp Gastroenterol. 2010;3:97-112.

Further, probiotics—used as an adjunct to oral rehydration therapy—are shown to be effective in decreasing the duration of diarrhea, particularly in rotavirus gastroenteritis. Probiotics are useful in modulating the immune response against foreign antigens in children with gastroenteritis. The self-limited nature of vomiting and its tendency to ameliorate with the correction of dehydration precludes the use of pharmacotherapy; however, pharmacotherapy may be needed for symptomatic treatment. Indeed, the complaint of abdominal pain and spasm may warrant treatment even before rehydration therapy is considered.⁴Elliott EJ. Acute gastroenteritis in children. BMJ. 2007;334(7583):35-40.   ²³Churgay CA, Aftab Z. Gastroenteritis in Children: Part II. Prevention and Management. Am Fam Physician. 2012 Jun 1;85(11):1066-1070.

Management of spasmodic pain in acute gastroenteritis

Abdominal pain and spasms are frequently encountered in gastrointestinal disorders; however, there is unmet need with respect to recognition and treatment. Pain management merits multifaceted consideration with well-defined role of pharmacologic therapy including antispasmodic agents after accounting for risk-benefit ratio. Antispasmodics are considered important for treatment of mild-to moderate pain.²⁴Makharia GK. Understanding and treating abdominal pain and spasms in organic gastrointestinal diseases: inflammatory bowel disease and biliary diseases. J Clin Gastroenterol. 2011 Aug;45 Suppl:S89-93.    Antispasmodic agent such as drotaverine, has suitable relaxing effect on intestinal smooth muscle that aids in relieving pain and is devoid of anticholinergic side-effects. Drotaverine thus renders effective analgesia in colicky pain.²⁵Golzari SE, Soleimanpour H, Rahmani F, et al. Therapeutic Approaches for Renal Colic in the Emergency Department: A Review Article. Anesth Pain Med. 2014;4(1):e16222.     ²⁶Talley NJ. Evaluation of drug treatment in irritable bowel syndrome. Br J Clin Pharmacol. 2003;56(4):362-369.

Conversely, anticholinergics used in pain management have several limitations. They are required to be administered 30-45 minutes before meal in order to alleviate pain. In clinical experience, the individual response to this therapy is variable and unimpressive. In addition, side-effects like dry mouth, urinary retention, blurred vision, insomnia, restlessness and constipation further support its limited prescription for management of gastrointestinal symptoms.²⁷Bannwarth B. Gastrointestinal safety of paracetamol: is there any cause for concern? Expert Opin Drug Saf. 2004 Jul;3(4):269-72.

Paracetamol is usually regarded as a safe analgesicantipyretic agent, and is believed to be virtually without any gastrointestinal side-effects.²⁷Davis MP. Drug Management of Visceral Pain: Concepts from Basic Research. Pain Research and Treatment. 2012; (2012), Article ID 265605, 18 pages.    It is frequently used in pain management; it has been shown that it may help in alleviating visceral pain.²⁹Bolaji OO, Onyeji CO, Ogundaini AO, et al. Pharmacokinetics and bioavailability of drotaverine in humans. Eur J Drug Metab Pharmacokinet. 1996 Jul-Sep;21(3):217-21.    It thus seems appropriate to include antispasmodics and analgesics in the treatment regimen; while antispasmodics are established in relieving spasmodic pain in gastrointestinal disorders, paracetamol may have a certain degree of role as it is useful in visceral pain relief. In addition, antipyretic action of paracetamol may also help in treatment of fever in gastroenteritis.

Drotaverine – a drug of choice for spasm in acute gastroenteritis

Drotaverine, a benzylisoquinoline derivative, is an effective spasmolytic agent. It is a more potent spasmolytic agent than papaverine and it is used in the symptomatic treatment of various conditions, such as gastrointestinal diseases, biliary dyskinesia and vasomotor diseases associated with smooth muscle spasm.³⁰Blasko G. Pharmacology, mechanism of action and clinical significance of a convenient antispasmodic agent: drotaverine. J Am Med Assoc Ind. 1998;1:63-9.

Drotaverine is a preferred drug in treatment of abdominal spasms owing to its characteristic properties. Drotaverine has significant inhibitory effect on phosphodiesterase (PDE) enzyme. Drotaverine is a selective inhibitor for phosphodiesterase IV (PDE IV), an enzyme responsible for breakdown and inactivation of cAMP and cGMP, which regulates the contractile activity of smooth muscles; thereby drotaverine controls the contractile activity of abdominal muscles to provide relief in abdominal spasms.³¹Romics I, Molnar DL, Timberg G, Mrklic B, Jelakovic B, Koszegi G, Blasko G. The effect of drotaverine hydrochloride in acute colicky pain caused by renal and ureteric stones. BJU Int. 2003 Jul;92(1):92-6.    ³²Rai RR, Dwivedi M, Kumar N. Efficacy and Safety of Drotaverine Hydrochloride in Irritable Bowel Syndrome: A Randomized Double-Blind Placebo-Controlled Study. Saudi Journal of Gastroenterology : Official Journal of the Saudi Gastroenterology Association. 2014;20(6):378-382.

Additionally, few studies have also delineated that PDE IV inhibitors may also exert an anti-inflammatory activity that can be utilized in cases of spastic and inflammatory conditions. Good tolerability of drotaverine have been established in various toxicological studies due to its wide therapeutic index and LD50 values > 1000 mg/kg on oral administration, unlike other anticholinergic antispasmodics, which are associated with a range of adverse effects. It does not have morphine-like effect and therefore does not induce addictive potential (Table 3). The drug also demonstrates its suitability for both oral and parenteral administration with excellent absorption from the small intestine (90%).³¹Romics I, Molnar DL, Timberg G, Mrklic B, Jelakovic B, Koszegi G, Blasko G. The effect of drotaverine hydrochloride in acute colicky pain caused by renal and ureteric stones. BJU Int. 2003 Jul;92(1):92-6.    ³²Rai RR, Dwivedi M, Kumar N. Efficacy and Safety of Drotaverine Hydrochloride in Irritable Bowel Syndrome: A Randomized Double-Blind Placebo-Controlled Study. Saudi Journal of Gastroenterology : Official Journal of the Saudi Gastroenterology Association. 2014;20(6):378-382.

The anti-spasmodic and pain-relieving effect of drotaverine does not mask the symptoms of acute abdomen, and it does not interfere with diagnostic precision while providing optimum pain control; this may have relevant application in practice. Due to its strong antispasmodic effect, drotaverine is extensively employed in biliary, intestinal and renal colic, dysmenorrheal and prior to various instrumental investigative procedures. Drotaverine has also found an important place in emergency medicine. Its versatile pharmacokinetic properties such as rapid absorption, early onset of action, rapid response to IV dosing and wide therapeutic window favorably contribute to its utility in emergency conditions.²⁵Golzari SE, Soleimanpour H, Rahmani F, et al. Therapeutic Approaches for Renal Colic in the Emergency Department: A Review Article. Anesth Pain Med. 2014;4(1):e16222.     ³¹Romics I, Molnar DL, Timberg G, Mrklic B, Jelakovic B, Koszegi G, Blasko G. The effect of drotaverine hydrochloride in acute colicky pain caused by renal and ureteric stones. BJU Int. 2003 Jul;92(1):92-6.    ³²Rai RR, Dwivedi M, Kumar N. Efficacy and Safety of Drotaverine Hydrochloride in Irritable Bowel Syndrome: A Randomized Double-Blind Placebo-Controlled Study. Saudi Journal of Gastroenterology : Official Journal of the Saudi Gastroenterology Association. 2014;20(6):378-382.

Various studies have been conducted highlighting the role of drotaverine in management of different types of spasmodic pain. One such study²⁵Golzari SE, Soleimanpour H, Rahmani F, et al. Therapeutic Approaches for Renal Colic in the Emergency Department: A Review Article. Anesth Pain Med. 2014;4(1):e16222.    was performed by Rai and colleagues on 180 patients with irritable bowel syndrome, randomized to drotaverine and placebo treatment groups. It was observed that abdominal pain frequency decreased considerably in 22 (25.9%), 51 (60%), and 66 (77.7%) patients in the drotaverine group, at the end of 2nd, 3rd, and 4th week, respectively, as compared with 8 (9.4%), 18 (21.2%), and 26 (30.6%) in the placebo group (Figure 1). Moreover, compared to placebo, drotaverine HCl was shown to provide considerable amelioration in global relief in abdominal pain as perceived by the patient (85.9% versus 39.5%) and the clinician (82.4% versus 36.5%).

In another study,³³Narang M, Shah D, Akhtar H. Efficacy and Safety of Drotaverine Hydrochloride in Children with Recurrent Abdominal Pain: A Randomized Placebo Controlled Trial. Indian Pediatr. 2015 Oct;52(10):847-51.    Narang and colleagues tried to evaluate efficacy of drotaverine in cases of recurrent abdominal pain. The participants were 132 children (age 4-12 years) with recurrent abdominal pain. They were randomized to receive drotaverine (n=66) or placebo (n=66) orally. The primary outcome measures were number of episodes of pain during 4 weeks of use of drug/ placebo and number of pain-free days. The results revealed a considerable reduction in mean number of episodes of abdominal pain (10.3 versus 21.6) and lesser school absence (mean, 0.25 versus 0.71) in children receiving drotaverine in comparison to those who received placebo (Figure 2).

Based on the aforementioned clinical evidences, drotaverine may be regarded as a potent anti-spasmodic agent, in treatment of spastic and motility disorders of the smooth muscle, and different pathological conditions accompanied by spastic pain; it may be effective either alone or in combination with other analgesics such as aceclofenac, in managing spasmodic pain originating from various organs. Importantly, drotaverine is effectively used in combination with antibiotics for the treatment of gastroenteritis accompanied with gastrointestinal spasm.³¹Romics I, Molnar DL, Timberg G, Mrklic B, Jelakovic B, Koszegi G, Blasko G. The effect of drotaverine hydrochloride in acute colicky pain caused by renal and ureteric stones. BJU Int. 2003 Jul;92(1):92-6.    ³³Narang M, Shah D, Akhtar H. Efficacy and Safety of Drotaverine Hydrochloride in Children with Recurrent Abdominal Pain: A Randomized Placebo Controlled Trial. Indian Pediatr. 2015 Oct;52(10):847-51.    ³⁴El-Zaher AA, Mahrouse MA. A validated spectrofluorimetric method for the determination of nifuroxazide through coumarin formation using experimental design. Chemistry Central Journal. 2013;7:90.

Lactose malabsorption/intolerance in gastroenteritis

In gastroenteritis, secondary lactase deficiency can occur. This happens due to destruction of the cells in the lining of the upper gut (small intestine) which produce lactase. It is common and often occurs after viral or bacterial gastroenteritis. It can also be a complication of other bowel diseases or chemotherapy. This is a temporary condition which improves when the lining of the gut heals. It takes 6 to 8 weeks for mucosa to heal and lactase deficiency to get restored. Post gastroenteritis, many patients do not tolerate milk and dairy, hence they are advised to avoid milk and dairy as the gut may not have sufficient lactase to digest lactose. These patients often complain of bloating/distention, flatulence, loose stools and other symptoms of lactose intolerance. Hydrogen breath test remains to be positive in patients post-gastroenteritis, signifying that lactose is not digested. During this phase oral lactase supplement can be helpful for the patients, as they would neutralize the lactose content in milk and dairy. Oral lactase enzyme tablets are available in India and they can be taken with milk and dairy products.³⁵Robb TA, Davidson GP. Hydrogen breath test in gastroenteritis. Arch Dis in Child. 1982;57(7):561-562.    ³⁶Savaiano DA, et al. Improving lactose digestion and symptoms of lactose intolerance with a novel galacto-oligosaccharide (RP-G28): a randomized, double-blind clinical trial. Nutr J. 2013;12:160.    ³⁷Ianiro G, Pecere S, Giorgio V, Gasbarrini A, Cammarota G. Digestive Enzyme Supplementation in Gastrointestinal Diseases. Curr Drug Metabol. 2016;17(2):187-193.

Conclusion

Acute gastroenteritis, characterized by diarrhea or vomiting (or both) of more than seven days duration, remains one of the most common diseases of humankind, and its associated morbidity and mortality are greatest among those at the extremes of age, children and the elderly. Acute gastroenteritis causes remarkable mortality in developing countries and considerable economic burden to developed countries. Acute gastroenteritis is a clinical syndrome produced by a wide variety of viral, bacterial, and parasitic enteropathogens. Viruses are the most important etiology and are accountable for approximately 70% of the cases of acute gastroenteritis in children. Acute gastroenteritis is accompanied with anorexia, nausea, vomiting, abdominal cramps, and diarrhea. Prevention of dehydration is the hallmark of gastroenteritis treatment; however, the complaint of abdominal pain and spasm may warrant treatment even before rehydration therapy is considered.

Drotaverine is a preferred drug in treatment of abdominal spasms owing to its characteristic properties. It controls the contractile activity of abdominal muscles to provide relief in abdominal spasms. Drotaverine is effectively used in combination with antibiotics for the treatment of gastroenteritis accompanied with gastrointestinal spasm. As far as lactose intolerance is concerned, there is abundance of information on usefulness of lactase supplementation in lactose intolerance.

References

1. Chow CM, Leung AK, Hon KL. Acute gastroenteritis: from guidelines to real life. Clin Exp Gastroenterol. 2010;3:97-112.
2. Malik OAA. Role of antimicrobials in the treatment of adult patients presenting to the emergency department with acute gastroenteritis – A mini review. Pak J Med Sci. 2017;33(2):488-492.
3. Fletcher SM, McLaws M-L, Ellis JT. Prevalence of Gastrointestinal Pathogens In Developed and Developing Countries: Systematic Review and Meta- Analysis. J Public Health Res. 2013;2(1):42-53.
4. Elliott EJ. Acute gastroenteritis in children. BMJ. 2007;334(7583):35-40.
5. Fatima S, Irfana N, Mushtaq SM, et al. A Cross-Sectional Study to Assess Prevalence and Management of Acute Gastroenteritis in Pediatric Inpatients of A Large Teaching Hospital. IOSR Journal of Pharmacy. 2014; 4(12): 12-26.
6. Glass RI, Bresee J, Jiang B, et al. Gastroenteritis viruses: an overview. Novartis Found Symp. 2001;238:5-19; discussion 19-25.
7. Viral Gastroenteritis. Available at: http://emedicine.medscape.com/ article/176515-overview. Accessed on: 29-05-2017.
8. Shek KC, Ng P, Hung CY, et al. A review on the management of acute gastroenteritis in children. Hong Kong J Emerg Med. 2004; 11(3): 152-60.
9. Revelas A. Acute gastroenteritis among children in the developing world. South Afr J Epidemiol Infect. 2012; 27(4): 156-62.
10. Zollner-Schwetz I, Krause R. Therapy of acute gastroenteritis: role of antibiotics. Clin Microbiol Infect. 2015 Aug;21(8):744-9.
11. O’Ryan M, Vidal R, del Canto F, Carlos Salazar J, Montero D. Vaccines for viral and bacterial pathogens causing acute gastroenteritis: Part II: Vaccines for Shigella, Salmonella, enterotoxigenic E. coli (ETEC) enterohemorragic E. coli (EHEC) and Campylobacter jejuni. Hum Vaccin Immunother. 2015;11(3):601-619.
12. Rose MA. Mucosal Immunity and acute viral gastroenteritis: The example rotavirus. Hum Vaccin Immunother. 2014;10(7):2112-2114.
13. Moradi-Lakeh M, Shakerian S, Yaghoubi M, et al. Rotavirus Infection in Children with Acute Gastroenteritis in Iran: A Systematic Review and Metaanalysis. Int J Prev Med. 2014;5(10):1213-1223.
14. Florez ID, Al-Khalifah R, Sierra JM, et al. The effectiveness and safety of treatments used for acute diarrhea and acute gastroenteritis in children: protocol for a systematic review and network meta-analysis. Syst Rev. 2016;5:14.
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