Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Gi infections


Published on

Published in: Health & Medicine, Technology
  • I can advise you this service - ⇒ ⇐ Bought essay here. No problem.
    Are you sure you want to  Yes  No
    Your message goes here
  • Don't forget another good way of simplifying your writing is using external resources (such as ⇒ ⇐ ). This will definitely make your life more easier
    Are you sure you want to  Yes  No
    Your message goes here
  • People used to laugh at me behind my back before I was in shape or successful. Once I lost a lot of weight, I was so excited that I opened my own gym, and began helping others. I began to get quite a large following of students, and finally, I didn't catch someone laughing at me behind my back any longer. CLICK HERE NOW ➤➤
    Are you sure you want to  Yes  No
    Your message goes here
    Are you sure you want to  Yes  No
    Your message goes here
  • Sex in your area is here: ♥♥♥ ♥♥♥
    Are you sure you want to  Yes  No
    Your message goes here

Gi infections

  1. 1. Gastro-intestinal Infections Dr Kamran Afzal Classified Microbiologist
  2. 2. Diarrhea <ul><li>Symptoms Increase in stool frequency/ volume and/or decrease in consistency </li></ul><ul><li>Signs Stool water excretion more than 150-300 ml above normal </li></ul>
  3. 3. Classification Of Diarrheas <ul><li>Duration </li></ul><ul><ul><li>acute </li></ul></ul><ul><ul><li>chronic </li></ul></ul><ul><li>Affected organ </li></ul><ul><ul><li>small intestine </li></ul></ul><ul><ul><li>large intestine </li></ul></ul><ul><li>Clinical description </li></ul><ul><ul><li>volume </li></ul></ul><ul><ul><li>frequency </li></ul></ul><ul><ul><li>consistency </li></ul></ul><ul><ul><li>presence of blood </li></ul></ul><ul><li>Patho-physiologic </li></ul><ul><ul><li>inflammatory </li></ul></ul><ul><ul><li>(infectious) </li></ul></ul><ul><ul><li>non-inflammatory </li></ul></ul><ul><ul><li>(non-infectious) </li></ul></ul>
  4. 4. 1. Non-inflammatory vs inflammatory <ul><li>Noninflammatory diarrhea </li></ul><ul><ul><li>Pathogens act primarily on small intestine to induce fluid secretions </li></ul></ul><ul><ul><li>Voluminous watery diarrhea, dehydration, nausea, vomiting, abdominal cramps, low grade fever </li></ul></ul><ul><ul><li>No blood, pus, tenesmus, or fever </li></ul></ul><ul><ul><li>No fecal leukocytes, and rarely occult blood </li></ul></ul><ul><li>Inflammatory diarrhea </li></ul><ul><ul><li>Induce inflammation by invasion or cytotoxins </li></ul></ul><ul><ul><li>Stools of small volume, fever, blood and mucus, tenesmus, abdominal cramping </li></ul></ul><ul><ul><li>Dehydration unusual </li></ul></ul><ul><ul><li>Fecal leukocytes, occult blood </li></ul></ul>
  5. 5. Infectious Diarrhea - Possible Pathogens <ul><li>Bacteria </li></ul><ul><li>Invasive and Cytotoxin-producing Microorganisms Salmonella spp </li></ul><ul><li>Shigella spp </li></ul><ul><li>Campylobacter spp </li></ul><ul><li>Vibrio cholerae </li></ul><ul><li>Escherichia coli (EPEC, EHEC, ETEC, EIEC) </li></ul><ul><li>Clostridium difficile </li></ul><ul><li>Aeromonas hydrophila </li></ul><ul><li>Yersinia enterocolitica </li></ul><ul><li>Vibrio parahaemolyticus </li></ul><ul><li>Listeria monocytogenes </li></ul>
  6. 6. <ul><li>Bacteria (Food Poisoning-Enterotoxigenic) Staphylococcus aureus </li></ul><ul><li>Clostridium perfringens </li></ul><ul><li>Bacillus cereus </li></ul>
  7. 7. <ul><li>Protozoa Giardia lamblia Entamoeba histolytica Balantidium coli Isospora belli Cryptosporidium Microsporidium Cyclospora </li></ul><ul><li>Viruses </li></ul><ul><li>Rota virus </li></ul><ul><li>Enteric Adeno virus </li></ul><ul><li>Norwalk virus </li></ul><ul><li>Calici virus </li></ul><ul><li>Astro virus </li></ul>
  8. 8. Infectious doses of enteric pathogens <ul><li>Shigella 10 1-2 </li></ul><ul><li>Giardia lamblia 10 1-2 </li></ul><ul><li>Entamoeba histolytica 10 1-2 </li></ul><ul><li>Campylobacter jejuni 10 2-6 </li></ul><ul><li>Salmonella 10 5 </li></ul><ul><li>E. coli 10 8 </li></ul><ul><li>Vibrio cholerae 10 8 </li></ul>
  9. 9. Fecal leukocytes <ul><li>Shigellosis </li></ul><ul><li>Enteroinvasive E. coli </li></ul><ul><li>Clostridium difficile </li></ul><ul><li>Salmonella enteritidis </li></ul><ul><li>Vibrio parahemolyticus </li></ul><ul><li>Ulcerative colitis </li></ul><ul><li>Ischemic colitis </li></ul>
  10. 10. Pathophysiology <ul><li>Toxin production </li></ul><ul><li>Entero-adherence </li></ul><ul><li>Mucosal invasion </li></ul><ul><li>Antibiotic associated colitis </li></ul>
  11. 11. a. Toxin production <ul><li>Neurotoxins (preformed toxin) </li></ul><ul><ul><li>Bacillus cereus , Clostridium perfringens , Staphylococcus aureus </li></ul></ul><ul><li>Enterotoxin </li></ul><ul><ul><li>Intracellular mediators </li></ul></ul><ul><ul><ul><li>Increased cyclic AMP, GMP or Calcium </li></ul></ul></ul><ul><ul><li>Vibrio cholerae, Aeromonas species, ETEC </li></ul></ul><ul><li>Cytotoxin </li></ul><ul><ul><li>Destruction of the mucosal cells </li></ul></ul><ul><ul><li>Clostridium difficile, E. coli 0157:H7, Shigellae </li></ul></ul>
  12. 12. b. Entero-adherence <ul><li>Pili or fimbirae bind to specific receptors </li></ul><ul><ul><li>Enteroadherent and enteropathogenic E. coli </li></ul></ul><ul><ul><li>Giardiasis ( Giardia lamblia ) </li></ul></ul><ul><ul><li>Helminths </li></ul></ul><ul><ul><li>Cryptosporidiosis ( Cryptosporidium parvum) </li></ul></ul><ul><ul><li>Cyclospora species (?) </li></ul></ul>
  13. 13. c. Mucosal invasion <ul><li>Minimal invasion </li></ul><ul><ul><li>Norwalk virus, Rotavirus, other viruses </li></ul></ul><ul><li>Variable invasion </li></ul><ul><ul><li>Aeromonas sp., Campylobacter sp., Salmonella sp., Vibrio parahemolyticus </li></ul></ul><ul><li>Severe invasion </li></ul><ul><ul><li>Intense inflammatory response </li></ul></ul><ul><ul><li>Entamoeba histolytica , enteroinvasive E. coli , Salmonella and Shigella species </li></ul></ul>
  14. 14. d. Antibiotic Associated Colitis <ul><li>Antibiotic exposure </li></ul><ul><li>Intestinal endogenous flora </li></ul><ul><li>Exposure to C. difficile in environment </li></ul><ul><li>Colonic colonization - C. difficile </li></ul><ul><li>Elaboration of toxin(s) </li></ul><ul><li>Diarrhea and colitis </li></ul>
  15. 15. Features Of Food Poisoning Agents ++ + +++ 8-72 hrs 8-24 hrs Cl. perfringens ++ +++ + 2-10 hrs 1-6 hrs Bacillus cereus ++ +++ + 12-24 hrs 1-8 hrs Staph aureus Enterotoxin Vomiting Diarrhea Duration Incubation period Organism
  16. 16. Salmonella gastroenteritis <ul><li>S. typhi is confined to humans so spread is purely faecal-oral </li></ul><ul><li>Non-typhoidal strains such as ( S. enterica ) serovars S. typhimurium, S. enteritidis, etc </li></ul><ul><li>Found in GI tracts of mammals, birds, reptiles </li></ul><ul><li>Acquired from ingestion of contaminated poultry, eggs, meat and exposure to pet reptiles </li></ul><ul><li>Fever, abdominal cramping, nausea, vomiting, diarrhea with fecal leukocytes </li></ul><ul><li>Untreated diarrhea lasts 4-10 days </li></ul>
  17. 17. Shigellosis <ul><li>Four species: </li></ul><ul><ul><li>S. dysenteriae, S. flexneri, S. boydi, S. sonnei </li></ul></ul><ul><li>Highly infectious: infectious dose < 200 </li></ul><ul><li>Incubation period 1-7 days </li></ul><ul><li>Symptoms can develop 12 hours after ingestion </li></ul><ul><li>Presents as fever, abdominal pain, tenesmus, bloody diarrhea </li></ul><ul><li>Anti-motility drugs have been associated with toxic megacolon </li></ul><ul><li>Self-limited but treatment recommended to prevent secondary spread to contacts </li></ul>
  18. 18. E. coli gastroenteritis <ul><li>Enterohemorrhagic ( E coli 0157:H7) </li></ul><ul><ul><li>Most common strain in developed countries </li></ul></ul><ul><ul><li>Usually transmitted by beef, but many other foods </li></ul></ul><ul><ul><li>Low infectious dose (as few as 100 bacteria) </li></ul></ul><ul><ul><li>Shiga-toxin </li></ul></ul><ul><ul><li>Crampy abdominal pain </li></ul></ul><ul><ul><li>Copious bloody diarrhea sometimes with the hemolytic-uremic syndrome </li></ul></ul>
  19. 19. <ul><li>Enterotoxigenic </li></ul><ul><ul><li>Most common cause of travelers diarrhea </li></ul></ul><ul><ul><li>Acquired by ingestion of fecally contaminated food or water </li></ul></ul><ul><ul><li>Occurs 3-14 days after ingestion </li></ul></ul><ul><ul><li>Causes watery diarrhea, abdominal cramps occasionally nausea and vomiting </li></ul></ul><ul><ul><li>Self-limiting lasts 1-5 days </li></ul></ul>
  20. 20. <ul><li>Enteropathogenic </li></ul><ul><ul><li>Diarrhea in infants common in developing countries </li></ul></ul><ul><li>Enteroinvasive </li></ul><ul><ul><li>Dysentery with blood and mucus </li></ul></ul><ul><li>Enteroaggregative </li></ul><ul><ul><li>Dysentery with blood and mucus </li></ul></ul>
  21. 21. Transmission of E. coli O157 <ul><li>Raw milk </li></ul><ul><li>“ Pasteurised milk” </li></ul><ul><li>Yoghurt </li></ul><ul><li>Cheese </li></ul><ul><li>Cream </li></ul><ul><li>Vegetables </li></ul><ul><li>Salad vegetables </li></ul><ul><li>Mayonnaise </li></ul><ul><li>Apple cider (USA) </li></ul><ul><li>Fruit </li></ul>
  22. 22. Vibrio cholerae <ul><li>01 serotype: (Cholera) watery diarrhea, dehydration; associated with residence in endemic areas, Toxin causes host cells to secrete Cl – , HCO – , and water </li></ul><ul><li>Non-01-serotypes: (Noncholera vibrios) diarrhea, fever, nausea, vomiting, blood in stool; often associated with traveler’s diarrhea </li></ul><ul><ul><li>V. parahaemolyticus </li></ul></ul><ul><ul><li>V. vulnificus </li></ul></ul>
  23. 23. Staphylococcal food poisoning <ul><li>Common food borne illness </li></ul><ul><li>Infections originate from asymptomatic carriers of Staphylococcus aureus </li></ul><ul><li>Can contaminate processed meats, salad, ice-cream </li></ul><ul><li>Preformed toxin (enterotoxin) in food rather than from direct effect of organism </li></ul><ul><li>Incubation period about 4 hours </li></ul><ul><li>Symptoms last < 24 hours </li></ul><ul><ul><li>No new toxin produced by ingested bacteria </li></ul></ul><ul><li>Severe nausea and vomiting along with abdominal pain and diarrhea </li></ul><ul><li>No fever </li></ul>
  24. 24. Traveler’s diarrhea <ul><li>Bacterial </li></ul><ul><ul><li>Enterotoxigenic E. coli (ETEC) </li></ul></ul><ul><ul><li>Shigella </li></ul></ul><ul><ul><li>Salmonella </li></ul></ul><ul><ul><li>Campylobacter </li></ul></ul><ul><li>Protozoa </li></ul><ul><ul><li>Giardia, Entamoeba, Cryptosporidium </li></ul></ul><ul><li>Virus </li></ul><ul><ul><li>Norwalk, rotavirus, enterovirus </li></ul></ul>
  25. 25. Helicobacter pylori <ul><li>70-90% of population in developing countries </li></ul><ul><li>Associated with gastritis, duodenal ulcer, gastric ulcer and gastric adenocarcinoma </li></ul><ul><li>Fecal-oral transmission </li></ul>
  26. 26. Intestinal tuberculosis <ul><li>Primary – ingestion of organism in unsensitised host </li></ul><ul><li>Can cause severe ulcero-inflammatory disease with perforation </li></ul><ul><li>Secondary – swallowing of infected sputum </li></ul><ul><li>Most common in terminal ileum and jejunum </li></ul><ul><li>Complications – obstruction, fistula </li></ul>
  27. 27. Clostridium difficile <ul><li>1970s: Found to be the cause of enterocolitis related to the antibiotic clindamycin </li></ul><ul><li>Pseudomembranous colitis with yellow-white plaques; can progress to toxic megacolon </li></ul><ul><li>At least two toxins (A and B) cause necrosis of epithelium </li></ul><ul><li>Nosocomial transmission </li></ul><ul><li>Widespread contamination of hospital environments </li></ul>
  28. 28. Endoscopic view of multiple scattered, yellowish plaques consistent with pseudomembranous colitis
  29. 29. Abdominal radiograph demonstrating markedly dilated colon, wall edema, and loss of haustrations in a patient with Clostridium difficile- associated pseudomembranous colitis complicated by toxic megacolon
  30. 30. Entamoeba histolytica (amebiasis) <ul><li>Affects 10% of world’s population </li></ul><ul><li>Order of involvement: caecum, ascending colon, rectum, sigmoid </li></ul><ul><li>Flask-shaped ulcers </li></ul><ul><li>Liver abscesses in up to 10% </li></ul>
  31. 31. Giardia lamblia (giardiasis) <ul><li>Waterborne </li></ul><ul><li>Can cause diarrhea by several mechanisms </li></ul><ul><li>Weight loss, cramps, steatorrhea, flatulence, vomiting, belching, fever </li></ul>
  32. 32. Rotavirus diarrhea <ul><li>Usually sporadic but can cause epidemics in institutions, including nursing homes </li></ul><ul><li>Cytopathic effect on mature enterocytes, replaced by immature cells with loss of absorptive function </li></ul><ul><ul><li>Usually infants and young children </li></ul></ul><ul><li>Fecal-oral transmission </li></ul>
  33. 33. Norovirus diarrhea <ul><li>Typically epidemic, often traced to a common source </li></ul><ul><li>Throughout the year </li></ul><ul><li>Often traced to contaminated food or water </li></ul><ul><ul><li>Usually adults and school-aged children </li></ul></ul>
  34. 34. HIV associated diarrhea <ul><li>Diarrhoea is a big problem </li></ul><ul><li>Opportunistic infection </li></ul><ul><ul><li>Candida, cryptosporidia, cytomegalovirus, Mycobacterium avium-intracellulare, strongyloides, leishmaniasis </li></ul></ul><ul><li>HIV itself causes enteropathy </li></ul>
  35. 35. Dysentery <ul><li>Bacillary </li></ul><ul><li>High frequency </li></ul><ul><li>Blood and mucus </li></ul><ul><li>Not sticky </li></ul><ul><li>Alkaline </li></ul><ul><li>Pus cells > RBCs </li></ul><ul><li>Macrophages </li></ul><ul><li>Amoebic </li></ul><ul><li>Low frequency </li></ul><ul><li>Blood and mucus, mixed with stools </li></ul><ul><li>Sticky </li></ul><ul><li>Acidic </li></ul><ul><li>RBCs > Pus cells </li></ul><ul><li>Trophozoites of E. histolytica </li></ul>
  36. 36. Diagnosis - Stool Collection and Transport <ul><li>Appropriate container </li></ul><ul><li>Proper instructions to the patient </li></ul><ul><li>Representative portion of stool </li></ul><ul><li>Fresh specimen </li></ul><ul><li>Freshly collected rectal swab </li></ul><ul><li>Transport as early as possible </li></ul><ul><li>Use transport media – buffered glycerol saline or alkaline peptone water </li></ul>
  37. 37. Diagnostic Evaluation
  38. 38. Protocol For Specimen Processing
  39. 39. Laboratory Diagnosis <ul><li>Stool Microscopy </li></ul><ul><li>Saline preparation stool/rectal swab </li></ul><ul><li>Pus cells </li></ul><ul><li>RBCs </li></ul><ul><li>Trophozoites </li></ul><ul><ul><li>Entamoeba histolytica </li></ul></ul><ul><ul><li>Giardia lamblia </li></ul></ul><ul><ul><li>Balantidium coli </li></ul></ul><ul><li>Cysts </li></ul><ul><ul><li>Entamoeba histolytica </li></ul></ul><ul><ul><li>Giardia lamblia </li></ul></ul>
  40. 40. <ul><li>Methylene Blue Preparation </li></ul><ul><li>Pus cells </li></ul><ul><li>Iodine Preparation </li></ul><ul><li>Cysts of Entamoeba, Giardia </li></ul><ul><li>Modified ZN Stain </li></ul><ul><li>Cryptosporidium, Isospora belli </li></ul><ul><li>Fluorescent Staining </li></ul><ul><li>Cryptosporidium parvum </li></ul><ul><li>Gram’s Staining </li></ul><ul><li>Food Poisoning cases </li></ul>
  41. 41. Special Cultures <ul><li>Campylobacters </li></ul><ul><li>Skirrow’s or Preston medium </li></ul><ul><li>Microaerophilic conditions </li></ul><ul><li>Temp 42 o C </li></ul><ul><li>Yersinia enterocolitica </li></ul><ul><li>Yersinia Selective Agar </li></ul><ul><li>Clostridium difficile </li></ul><ul><li>Anaerobic Blood Agar </li></ul>
  42. 42. Other Investigations <ul><li>Stool Antigen Detection By ELISA </li></ul><ul><li>Giardia, Entamoeba, Rota virus, Norwalk virus </li></ul><ul><li>Clostridium difficile Toxin Detection </li></ul><ul><li>Latex agglutination </li></ul><ul><li>ELISA, Neutralisation tests </li></ul><ul><li>Electron Microscopy </li></ul><ul><li>Enteric Adeno, Norwalk and Astro viruses </li></ul><ul><li>Procto-sigmoidoscopy </li></ul><ul><li>Pseudomembranous colitis, Amoebic colitis </li></ul>
  43. 43. Treatment <ul><li>Fluid Replacement </li></ul><ul><li>Oral </li></ul><ul><li>Intravascular </li></ul><ul><li>Antimotility Agents </li></ul><ul><li>Antisecretory Agents </li></ul><ul><li>Antibiotics </li></ul><ul><li>Extremes of age </li></ul><ul><li>Toxic patient </li></ul><ul><li>Profound deyhydration </li></ul><ul><li>Probably having bacteremia </li></ul><ul><li>Blood and mucus in stools </li></ul><ul><li>Immunocompromised </li></ul>
  44. 44. Treatment <ul><li>Antibiotics </li></ul><ul><li>Conventional Agents </li></ul><ul><li>Ampicillin </li></ul><ul><li>Co-trimoxazole </li></ul><ul><li>Tetracycline </li></ul><ul><li>Chloramphenicol </li></ul><ul><li>Metronidazole </li></ul><ul><li>Other Agents </li></ul><ul><li>Nalidixic acid </li></ul><ul><li>Norfloxacin </li></ul><ul><li>Ciprofloxacin and other FQs </li></ul><ul><li>Doxycylcline, Minocycline </li></ul><ul><li>Cephalosporins </li></ul><ul><li>Newer Macrolides </li></ul>
  45. 45. 2. Duration of diarrhea <ul><li>ACUTE (symptoms  14 days) </li></ul><ul><ul><li>sudden onset, 90% are infectious in etiology </li></ul></ul><ul><ul><li>Community-acquired: </li></ul></ul><ul><ul><ul><li>Gram-negative bacterial pathogens </li></ul></ul></ul><ul><ul><ul><li>Viral pathogens </li></ul></ul></ul><ul><ul><ul><ul><li>Norovirus </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Rotovirus </li></ul></ul></ul></ul><ul><ul><ul><li>Protozoal pathogens </li></ul></ul></ul><ul><ul><ul><ul><li>Entamoeba histolytica </li></ul></ul></ul></ul><ul><ul><li>Nosocomial (> 3 days after hospitalization) </li></ul></ul><ul><ul><ul><li>Clostridium difficile </li></ul></ul></ul><ul><ul><li>Travelers: </li></ul></ul><ul><ul><ul><li>ETEC </li></ul></ul></ul>
  46. 46. <ul><li>PERSISTENT/CHRONIC (symptoms > 14 days) </li></ul><ul><ul><li>Most of the causes are non-infectious </li></ul></ul><ul><ul><li>Parasitic </li></ul></ul><ul><ul><ul><li>Giardia lamblia, Cryptosporidium parvum, Cyclospora, Isospora belli </li></ul></ul></ul><ul><ul><li>Immunocompromised host </li></ul></ul><ul><ul><ul><li>Also consider Microsporidium and CMV </li></ul></ul></ul>
  47. 47. 3. Low-versus high-volume diarrhea <ul><li>Low volume (low water): colonic </li></ul><ul><li>High volume (high water): small bowel </li></ul><ul><ul><li>OSMOTIC DIARRHEA: high-volume diarrhea in which the measured fecal osmolality is less than 2 [Na + K] </li></ul></ul><ul><ul><ul><li>Sorbitol-containing liquid medications, tube feedings, lactose intolerance </li></ul></ul></ul><ul><ul><li>SECRETORY DIARRHEA: high-volume diarrhea in which the measured fecal osmolality equals 2 [Na + K] </li></ul></ul><ul><ul><ul><li>E. Coli , rotavirus, laxative abuse </li></ul></ul></ul>
  48. 48. 4. Small- versus large-bowel diarrhea <ul><li>Small bowel </li></ul><ul><ul><li>Large volume, watery, less frequent, painless stools </li></ul></ul><ul><ul><li>Blood and WBCs are rare </li></ul></ul><ul><ul><li>Proctoscopy is normal </li></ul></ul><ul><ul><li>Pain is mid-abdominal </li></ul></ul><ul><li>Large bowel </li></ul><ul><ul><li>Small volume, often mucoid, more frequent, painful stools </li></ul></ul><ul><ul><li>Blood and WBCs are common </li></ul></ul><ul><ul><li>Proctoscopy is abnormal </li></ul></ul><ul><ul><li>Pain is lower-abdominal (left lower quadrant) </li></ul></ul>
  49. 49. Case History <ul><li>A 40-year-old woman presented with diarrhea. She had had loose stools for 2 years, progressing over the past 6 months to fifteen large-volume watery stools daily. </li></ul><ul><li>What is your differential diagnosis? </li></ul><ul><li>What diagnostic and management steps would you choose? </li></ul>
  50. 50. <ul><li>Differential Diagnosis </li></ul><ul><ul><li>Celiac disease </li></ul></ul><ul><ul><li>IBS </li></ul></ul><ul><ul><li>Lactose intolerance </li></ul></ul><ul><ul><li>Intestinal TB </li></ul></ul><ul><ul><li>Intestinal worms </li></ul></ul><ul><ul><li>Cryptosporidium parvum secondary to AIDS </li></ul></ul><ul><ul><li>HUS </li></ul></ul><ul><ul><li>Cancer colon </li></ul></ul><ul><ul><li>This case is a transition from semi-solid to watery diarrhea which is a classical hallmark of progressive ileal disease . When less than 50-60% ileum is involved, there is fat malabsorption and semisolid stools. But when more than 50% of ileum is involved, it will also lead ultimately to bile salt malabsorption </li></ul></ul>
  51. 51. <ul><li>Investigations </li></ul><ul><ul><li>Stool analysis, C/S, serum electrolytes (Na, K, Ca), electrolytes, CBP </li></ul></ul><ul><ul><li>Anti-gliadin/endomysial antibody testing to r/o celiac </li></ul></ul><ul><ul><li>ELISA </li></ul></ul><ul><ul><li>Barium swallow/enema, colonoscopy </li></ul></ul><ul><li>Treatment </li></ul><ul><ul><li>Fluid replacement </li></ul></ul><ul><ul><ul><li>Oral </li></ul></ul></ul><ul><ul><li>Antimotility agents </li></ul></ul>