Acute Diarrhea

From Anvita Health Wiki

Contents 1 Introduction 2 Etiology 3 Clinical-manifestations 4 Laboratory 5 Differential-diagnosis 6 Management 7 More General Terms 8 Additional Terms 9 References

Introduction

• Most episodes of acute diarrhea are mild & self-limited. <10% come to a physician's attention. Of those that do, the majority require only oral rehydration.

Etiology

• infectious

• viral (most cases are viral)

• rotavirus
• calcivirus
• adenovirues 40, 41
• astrovirus

• bacterial

• Campylobacter jejuni*
• Salmonella:* contaminated beef, poultry, milk, eggs
• Shigella*
• enterohemorrhagic E. coli*
• Staphylococcus
• Clostridium difficile*
• Vibrio parahaemolyticus
• Yersinia enterocolitica
• Vibrio cholerae
• Clostridium perfringens
• Bacillus cereus
• enterotoxigenic E. coli
• Aeromonas hydrophilia
• Plesiomonas shigelloides
• Mycobacterium avium-intracellulare
• enteroaggregative E. coli [6]

• 1/3 coinfected with rotavirus

• protozoa

• Giardia lamblia
• Entamoeba histolytica*
• Cryptosporidium

• young children
• immunocompromised

• non- infectious

• pharmacologic causes (see pharmaceutical agents associated with diarrhea)
• dietary items

• lactose, caffeine, sorbitol, diet colas, mannitol fructose sucrose

• inflammatory bowel disease*
• toxins

• heavy metals, insecticides, mushrooms

• intestinal ischemia*
• bile acid diarrhea &/or malabsorption

• * causes of bloody diarrhea or inflammatory diarrhea

Clinical-manifestations

• frequent, small volume stools with urgency & tenesmus suggest the distal colon as the site of pathology
• bulky & large stools suggests small-bowel disease
• steatorrhea suggests small bowel disease or pancreatic insufficiency
• fever & bloody stools suggest invasive bacterial diarrhea caused by Shigella or Vibrio parahaemolyticus
• grossly bloody diarrhea without fever suggests enterotoxic E. coli
• fever with non-bloody diarrhea suggests Salmonella
• diarrhea within 6 hours of ingestion suggests preformed toxin - Stapholococcus, Bacillus cereus
• diarrhea 8-14 hours after ingestions suggests Clostridium perfringens
• viral diarrhea & most other food-borne diarrhea occurs > 14 hours after ingestion [4]

Laboratory

• indications for laboratory testing

• symptomatic patients with fever
• abdominal pain
• tenesmus
• dehydration
• diarrhea of longer than 3 days duration

• general laboratory investigation

• stool examination for WBC & RBC

• fecal leukocytes indicate inflammatory diarrhea
• fecal leukocytes negative with: Salmonella

• stool culture
• stool for ova & parasites

• interference by

• tetracycline, sulfonamides, castor oil, Mg(OH)2, barium, hypertonic saline, soap, tap water, bismuth, kaolin, antiprotozoal agents

• fecal electrolytes (Na+, K+, Cl-)
• fecal osmolality

• 400 mOsm in osmotic diarrhea,
• 290 in secretory diarrhea

• fecal osmolal gap

• osmolality - (Na+ + K+) x 2
• > 100 in osmotic diarrhea
• < 50 in secretory diarrhea

• blood cultures

• laboratory tests as indicated by presentation

• string test or ELISA for Giardia lamblia

• day care centers & travelers

• modified acid-fast stain (Cryptosporidium)

• day care centers, travelers, immunosuppressed

• E. coli serotype 0157

• day care centers, nursing homes & travelers

• Clostridium difficile enterotoxin

• day care centers, nursing homes or history of antibiotics

• Vibrio cholera - travelers (alert laboratory)
• HIV testing
• Mycobacterium avium-intracellulare
• amoeba titers
• food poisoning: culture food, vomitus, feces
• thiosulfate citrate bile salts: Vibrio parahaemolyticus
• culture for Yersinia enterocolitica

• unexplained fever (alert laboratory)

Differential-diagnosis

• Yersinia enterocolitica can mimic

• appendicitis
• Crohn's disease [4]

Management

• general

• fluid replacement

• oral - Pedialyte, Enfalyte, Oralyte
• intravenous

• lactated Ringers or normal saline
• KCl or potassium phosphate added

• diet without influence/impact [5]
• kaopectate improves stool form
• anti-motility agents

• loperamide ( Imodium) 4 gm PO, then 2 g orally after each formed stool up to 5 doses/day
• diphenoxylate with atropine ( Lomotil) 2.5-5 g PO up to 5 times per day
• codeine
• paregoric
• tincture of opium
• anti-motility agents contraindicated with fever or bloody diarrhea or inflammatory diarrhea*

• bismuth subsalicylate ( Pepto-Bismol) anti- secretory agent

• infectious diarrhea, antimicrobial agents:

• indications:

• diarrhea lasting > 7 days, or
• fever, abdominal pain, hematochezia
• exception: E. coli O157:H7 (no antibiotics)
• exceptions: Giardiasis & Entamoeba histolitica always require antimicrobial treatment [4]

• Campylobacter jejuni

• erythromycin 250 mg PO QID for 7 days
• ciprofloxacin ( Cipro) 500 mg PO BID for 7-10 days

• Clostridium difficile

• metronidazole ( Flagyl) 250 mg PO QID for 10 days avoid during pregnancy
• vancomycin 125-250 mg PO QID for 5-10 days for severe of persistent diarrhea & offending antibiotic cannot be stopped

• Escherichia coli ( traveler's diarrhea)

• Bactrim, Septra DS PO BID for 5 days
• ciprofloxacin ( Cipro) 500 mg PO BID for 5 days

• Entamoeba histolytica

• metronidazole ( Flagyl) 750 mg PO TID for 10 days followed by:
• iodoquinol 650 mg PO TID for 20 days to eliminate cyst phase (avoid if patient is allergic to iodine)

• Giardia lamblia

• quinacrine ( Atrabine) 100 mg PO TID for 5 days
• furazolidone ( Furoxone) 100 mg PO QD for 7 days
• metronidazole ( Flagyl) 250 mg PO TID for 7 days

• Salmonella

• treat only if immunocompromised, bacteremic or < 1 year of age
• ciprofloxacin ( Cipro) 500 mg PO BID for 7 days
• Bactrim DS PO BID for 5 days
• adjust dosage for child < 1 year of age

• Shigella

• Bactrim, Septra DS PO BID for 5 days
• ciprofloxacin ( Cipro) 500 mg PO BID for 7 days
• norfloxacin ( Noroxin) 800 mg PO once

• antibiotic-associated diarrhea (including C difficile)

• probiotics may be useful for prevention [7]

• * toxic megacolon is complication
• Prophylaxis:

• vaccines - typhoid, cholera, Shigella, rotavirus
• travelers - boil, cook, or peel food
• handwashing

More General Terms

• diarrhea

Additional Terms

• bloody (inflammatory) versus non-bloody (non-inflammatory) diarrhea
• infectious diarrhea
• pharmaceutical agents associated with diarrhea

References

1. Harrison's Principles of Internal Medicine, 13th ed. Companion Handbook, Isselbacher et al (eds), McGraw-Hill Inc. NY, 1995, pg 829-39
2. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 302-304
3. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 290-98
4. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, American College of Physicians, Philadelphia 1998, 2006
5. Journal Watch 24(19):153-54, 2004 Huang DB, Awasthi M, Le BM, Leve ME, DuPont MW, DuPont HL, Ericsson CD. The role of diet in the treatment of travelers' diarrhea: a pilot study. Clin Infect Dis. 2004 Aug 15;39(4):468-71. Epub 2004 Jul 30. PMID: [1]
   - Steffen R, Gyr K. Diet in the treatment of diarrhea: from tradition to evidence. Clin Infect Dis. 2004 Aug 15;39(4):472-3. Epub 2004 Jul 30. No abstract available. PMID: [2]
6. Journal Watch 25(5):43, 2005 Cohen MB, Nataro JP, Bernstein DI, Hawkins J, Roberts N, Staat MA. Prevalence of diarrheagenic Escherichia coli in acute childhood enteritis: a prospective controlled study. J Pediatr. 2005 Jan;146(1):54-61. PMID: [3]
7. McFarland LV. Meta-analysis of probiotics for the prevention of antibiotic associated diarrhea and the treatment of Clostridium difficile disease. Am J Gastroenterol 2006; 101:812 PMID: [4]
8. Prescriber's Letter 14(4): 2007 Oral rehydration therapy Detail-Document#: [5] (subscription needed) [6]
9. National Guideline Clearinghouse WGO practice guideline: acute diarrhea. World Gastroenterology Organisation (WGO). ngc-guideline: [7]

acute diarrhea