Diarrhea, acute

BASICS

DESCRIPTION:

Diarrhea of abrupt onset in a healthy individual is most often related to an infectious process. A variety of symptoms are often observed, including frequent passage of loose or watery stools, fever, chills, anorexia, vomiting and malaise.
  •Acute viral diarrhea - the most common form, usually occurs for 1-3 days, and is self-limited. It causes changes in the small intestine cell morphology such as villous shortening and an increase in the number of crypt cells.
  •Bacterial diarrhea - may be suspected if there is a history of a similar and simultaneous illness in individuals who have shared contaminated food with the patient. Diarrhea developing within 12 hours of the meal is most likely due to ingestion of a preformed toxin.
  •Protozoal infections - such as Giardia lamblia cause prolonged, watery diarrhea that often afflicts travelers returning from endemic areas where the water supply has been contaminated.
  •Traveler's diarrhea - typically begins three to seven days after arrival in a foreign location and is generally quite acuteRead more...

System(s) affected: Gastrointestinal, Endocrine/Metabolic
Genetics: N/A
Incidence/Prevalence in USA: N/A
Predominant age: All ages
Predominant sex: N/A

SIGNS AND SYMPTOMS:

  •Loose liquid stools +/- blood or mucus
  •Fever
  •Abdominal pain and distension
  •Headache
  •Anorexia
  •Malaise
  •Vomiting
  •Myalgia
  •With Giardia - cramping, pale-greasy stools, fatigue, weight loss, chronicity

CAUSES:

  •Bacterial
      •E. coli
      •Salmonella
      •Shigella
      •Campylobacter jejuni
      •Vibrio parahaemolyticus
      •Vibrio cholerae
      •Yersinia enterocolitica
  •Viral
      •Rotavirus
      •Norwalk virus
  •Parasitic
      •Giardia lamblia
      •Cryptosporidium
      •Entamoeba histolytica

RISK FACTORS:

  •Individual from an industrialized country visiting a developing country
  •Immunocompromised host

DIAGNOSIS

DIFFERENTIAL DIAGNOSIS:

  •Ulcerative colitis
  •Crohn's disease
  •Drugs (cholinergic agents, magnesium-containing antacids)
  •Pseudomembranous colitis secondary to antibiotic use
  •Diverticulitis
  •Spastic (irritable) colon
  •Fecal impaction
  •Malabsorption
  •Zollinger-Ellison syndrome
  •Ischemic bowel
  •Gastrinoma

LABORATORY:

  •CBC - increased WBC with a left shift may indicate an infectious process; decreased hemoglobin/hematocrit may indicate anemia from blood loss
  •Serum electrolytes - increased sodium from dehydration, decreased potassium from diarrhea
  •BUN, creatinine - elevated in dehydration
  •pH - hyperchloremic acidosis
  •Stool sample - occult blood (present in IBD, bowel ischemia, bacterial infections), fecal leukocytes (present in diarrhea caused by Salmonella, Campylobacter, Yersinia), bacterial culture and sensitivity (for Salmonella, Yersinia, Shigella, Campylobacter), ova and parasites, C. difficile toxin, Ziehl-Neelsen stain (for Cryptosporidium)

Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS:

  •Viral diarrhea - changes in small intestine cell morphology that include villous shortening, increased number of crypt cells and increased cellularity of the lamina propria
  •Bacterial diarrhea - bacterial invasion of colonic wall leads to mucosal hyperemia, edema and leukocytic infiltration

SPECIAL TESTS:

N/A

IMAGING:

Abdominal x-rays (flat plate and upright) are indicated in patients with abdominal pain or evidence of obstruction to rule out toxic megacolon and bowel ischemia

DIAGNOSTIC PROCEDURES:

Sigmoidoscopy indicated in patients with bloody diarrhea or suspected pseudomembranous or ulcerative colitis

TREATMENT

APPROPRIATE HEALTH CARE:

Outpatient except for complicating emergencies (dehydration)

GENERAL MEASURES:

  •Replacement of lost fluid and electrolytes
  •Clear liquids such as tea, broth, carbonated beverages (without caffeine) and rehydration fluids (e.g., Gatorade) to replace lost fluid
  •Packets of rehydration salts (one packet to be diluted in one quart of water); drink until thirst is quenched; will help in replacing lost electrolytes. Treatment of choice for pediatric patients.

SURGICAL MEASURES:

N/A

ACTIVITY:

Bedrest

DIET:

  •During periods of active diarrhea, avoid coffee, alcohol, dairy products, most fruits, vegetables, red meats, and heavily seasoned foods
  •After 12 hours with no diarrhea, begin by eating clear soup, salted crackers, dry toast or bread, and sherbet
  •As stooling rate decreases, slowly add to diet, rice, baked potato, and chicken soup with rice or noodles
  •As stool begins to retain shape, add to diet baked fish, poultry, applesauce, and bananas

PATIENT EDUCATION:

See guidelines in Prevention/Avoidance

MEDICATIONS

DRUG(S) OF CHOICE:

  •Loperamide, 4 mg followed by 2 mg capsule after each unformed stool, or bismuth subsalicylate, 30 mL every half hour until 8 doses, may be helpful in mild diarrhea
  •If diarrhea persists and a bacterial or parasitic organism is identified, antibiotic therapy should be started:
      •Giardia: metronidazole 250 mg tid for 5-10 days
      •E. histolytica: metronidazole 500-750 mg tid for 10 days
      •Shigella: trimethoprim-sulfamethoxazole 160 mg and 800 mg, respectively, bid for five days, or ciprofloxacin (Cipro) 500 mg bid for 10 days
      •Campylobacter: erythromycin 250 mg qid for 5 days or ciprofloxacin (Cipro) 500 mg bid for 7 days
      •C. difficile: metronidazole 250 mg tid for 10-14 days
      •Traveler's diarrhea: trimethoprim-sulfamethoxazole one double strength tablet bid for 3 days or ciprofloxacin (Cipro) 500 mg bid for 3 days

Contraindications:
  •Antibiotics are contraindicated in Salmonella infections unless caused by S. typhosa or the patient is septic
  •Avoid alcoholic beverages with metronidazole due to possibility of disulfiram reaction
Precautions:
  •Antiperistaltic agents (e.g., loperamide) should be used with caution in patients suspected of having infectious diarrhea or antibiotic associated colitis
  •Doxycycline, sulfamethoxazole-trimethoprim, ciprofloxacin - may cause photosensitivity. Use sunscreen.
Significant possible interactions:
  •Salicylate absorption from bismuth subsalicylate can cause toxicity in patients already taking aspirin containing compounds and may alter anticoagulation control in patients taking coumadin
  •Ciprofloxacin and erythromycin increase theophylline levels

ALTERNATIVE DRUGS:

  •Doxycycline 100 mg bid for 3 days
  •Diphenoxylate-atropine in nonpregnant adults
  •Tinidazole or secnidazole for E. histolytica
  •Vancomycin for C. difficile infections
  •Alosetron in IBS

FOLLOW UP

PATIENT MONITORING:

If diarrhea continues for three to five days with or without blood or mucus then consult physician

PREVENTION/AVOIDANCE:

  •Frequent oversights during foreign travel include brushing teeth with contaminated water, ingesting ice cubes, or eating cold salads or meats
  •Avoid uncooked or undercooked seafood or meat, buffet meals left out for several hours, or food served by street vendors

POSSIBLE COMPLICATIONS:

  •Dehydration
  •Sepsis
  •Shock
  •Anemia

EXPECTED COURSE AND PROGNOSIS:

A common problem that is rarely life-threatening if attention is given to maintaining adequate hydration

MISCELLANEOUS

ASSOCIATED CONDITIONS:

  •Diabetes mellitus
  •Ileal resection
  •Gastrectomy
  •Hyperthyroidism

AGE-RELATED FACTORS:

Pediatric:
  •Rotavirus is a common cause of viral diarrhea in the winter months and is accompanied with vomiting
  •Other etiologies include overfeeding, medications, cystic fibrosis and malabsorption
Geriatric: Watery diarrhea in elderly patient with chronic constipation may be caused by fecal impaction or obstructing neoplasm
Others: N/A

PREGNANCY:

Avoid dehydration since this may lead to preterm labor

SYNONYMS:

N/A

SEE ALSO:

  • Cholera
  • Botulism
  • Food poisoning, bacterial

OTHER NOTES:

N/A

ABBREVIATIONS:

IBD = inflammatory bowel disease

REFERENCES

  •Hirschhorn N, Greenough WB: Progress in oral rehydration therapy. Scientific American 1991;264:5
  •Dupont HL, Edelman R: Infectious diarrhea: From E. coli to Vibrio. Patient Care, May 30,1991