acute diarrhea
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Introduction
Diarrhea of 1-14 days duration.
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 diarrhea
- viral (most cases are viral)
- rotavirus
- Caliciviridae
- adenovirues 40, 41
- astrovirus
- cytomegalovirus (CMV) in immunocompromised patients
- CMV seropositive organ transplant donor or recipient places recipient at risk for CMV[4]
- bacterial
- Campylobacter jejuni*
- most common cause from undercooke poultry[13]
- Salmonella:* contaminated beef, poultry, milk, eggs
- Shigella*
- enterohemorrhagic E. coli*
- Staphylococcus
- Clostridium difficile*
- may occur in outpatient setting[10]
- 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
- Listeria monocytogenes (encephalitis, immunosuppression, dairy)
- Campylobacter jejuni*
- protozoa
- Giardia lamblia
- Entamoeba histolytica*
- Cryptosporidium (see Cryptosporidiosis)
- young children
- immunocompromised
- public swimming pools, water playgrounds[4]
- viral (most cases are viral)
- non-infectious
- pharmacologic causes (see pharmaceutical agents associated with diarrhea)
- dietary items
- inflammatory bowel disease*
- toxins
- 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 or Campylobacter
- diarrhea within 6 hours of ingestion suggests preformed toxin
- diarrhea 8-14 hours after ingestions suggests Clostridium perfringens
- viral diarrhea & most other food-borne diarrhea due to ingestion of viable organisms occurs > 14 hours after ingestion[4]
- most episodes are brief, with resolution within 1 week
- diarrhea lasting > 7 days suggests parasitic or non-infectious origin (see chronic diarrhea)[4]
- severe abdominal pain
- bloody stools (hematochezia, BRBPR)
- fever
- recent hospitalization or antimicrobial use
- elderly
- immunosuppression
- inflammatory bowel disease
- pregnancy
Laboratory
- indications for laboratory testing
- symptomatic patients with fever
- abdominal pain
- tenesmus
- dehydration
- bloody diarrhea or mucoid stools[4]
- diarrhea of longer than 3 days duration (> 7 days)[12]
- recent antibiotic use
- inflammatory bowel disease
- patient populations at risk
- elderly patients
- hospitalized patients
- pregnant women
- immunocompromised patients
- food handlers
- high risk of spreading disease or during outbreaks[12]
- general laboratory investigation
- stool examination for WBC & RBC
- fecal leukocytes indicate inflammatory diarrhea
- fecal leukocytes negative with: Salmonella
- fecal leukocytes probably unnecessary[12]
- stool culture
- moderate to severe watery diarrhea > 3 days duration[12]
- do not obtain stool culture in patients hospitalized > 3 days[4]
- do not conduct antibiotic sensitivity testing in acute diarrhea[12]
- stool for ova & parasites
- diarrhea lasting >= 7 days
- not recommended for patients with onset of diarrhea > 3 days into hospital stay[4]
- 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
- rapid molecular diagnostic testing indicated in immunocompromised patients[4]
- stool examination for WBC & RBC
- 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
- hospitalized patients with diarrhea who test negative for C difficile colitis should be treated with antidiarrheal agents without further testing or treatment for C difficile[4]
- 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)
- string test or ELISA for Giardia lamblia
Diagnostic procedures
- gastrointestinal endoscopy not recommended[12]
Differential diagnosis
Management
- general
- fluid replacement to maintain hydration (primary goal)
- oral (most patients)
- Pedialyte, Enfalyte, Oralyte
- water, juice, sports drinks, soups, salty crackers[12]
- intravenous
- lactated Ringers or normal saline
- KCl or potassium phosphate added
- oral (most patients)
- 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*
- loperamide (Imodium) 4 gm PO, then 2 g orally after each formed stool
- bismuth subsalicylate (Pepto-Bismol) anti-secretory agent
- fluid replacement to maintain hydration (primary goal)
- do NOT give empiric antibiotic therapy for acute diarrhea
- infectious diarrhea (non-viral), antimicrobial agents:
- indications:
- diarrhea lasting > 7 days, or fever, abdominal pain, hematochezia (dysentery)
- exception: E. coli O157:H7 (no antibiotics)
- require antimicrobial treatment[4]
- empiric azithromycin after stool examination & cultures obtained
- Campylobacter jejuni
- erythromycin 250 mg PO QID for 7 days
- ciprofloxacin (Cipro) 500 mg PO BID for 7-10 days
- Clostridium difficile
- vancomycin 125-250 mg PO QID for 5-10 days
- 1st line vs metronidazole
- severe or persistent diarrhea & offending antibiotic cannot be stopped
- metronidazole (Flagyl)
- formerly 250 mg PO QID for 10 days, now relegated to intravenous adjunct to vancomycin
- avoid during pregnancy
- vancomycin 125-250 mg PO QID for 5-10 days
- Escherichia coli (traveler's diarrhea)
- azithromycin[4]
- 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
- tinidazole 2 g PO[4] (may be best agent), nitazoxanide (Alinia)
- 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
- tinidazole 2 g PO[4] (may be best agent), nitazoxanide (Alinia)
- 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
- Listeria monocytogenes
- indications:
- probiotics
- do not treat acute diarrhea with probiotics & prebiotics except for postantibiotic diarrhea[12]
- may be useful for shortening the duration of acute infectious diarrhea (1 day shorter)[11]
- antibiotic-associated diarrhea (including C difficile)
- probiotics may be useful for prevention[7]
* toxic megacolon is complication
More general terms
More specific terms
Additional terms
- bloody (inflammatory) versus non-bloody (non-inflammatory) diarrhea
- infectious diarrhea; infectious colitis
- pharmaceutical agents associated with diarrhea
References
- ↑ Harrison's Principles of Internal Medicine, 13th ed. Companion Handbook, Isselbacher et al (eds), McGraw-Hill Inc. NY, 1995, pg 829-39
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 302-304
- ↑ Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 290-98
- ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 4.13 4.14 Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2006, 2012, 2015, 2018, 2021.
Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - ↑ 5.0 5.1 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: https://www.ncbi.nlm.nih.gov/pubmed/15356807
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: https://www.ncbi.nlm.nih.gov/pubmed/15356808 - ↑ 6.0 6.1 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: https://www.ncbi.nlm.nih.gov/pubmed/15644823
- ↑ 7.0 7.1 The NNT: Co-Administration of Probiotics with Prescribed Antibiotics for Preventing C. Difficile Diarrhea. http://www.thennt.com/nnt/probiotics-for-preventing-c-difficile-diarrhea/
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: https://www.ncbi.nlm.nih.gov/pubmed/16635227
Johnston BC, Ma SS, Goldenberg JZ et al Probiotics for the prevention of Clostridium difficile-associated diarrhea: a systematic review and meta-analysis. Ann Intern Med. 2012 Dec 18;157(12):878-88. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23362517 - ↑ Prescriber's Letter 14(4): 2007 Oral rehydration therapy Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=230413&pb=PRL (subscription needed) http://www.prescribersletter.com
- ↑ Baldi F, Bianco MA, Nardone G, Pilotto A, Zamparo E. Focus on acute diarrhoeal disease. World J Gastroenterol. 2009 Jul 21;15(27):3341-8 PMID: https://www.ncbi.nlm.nih.gov/pubmed/19610134
- ↑ 10.0 10.1 Hensgens MP et al. Diarrhoea in general practice: When should a Clostridium difficile infection be considered? Results of a nested case control study. Clin Microbiol Infect 2014 Jul 7 PMID: https://www.ncbi.nlm.nih.gov/pubmed/25040463
- ↑ 11.0 11.1 The NNT: Probiotics for Acute Infectious Diarrhea. http://www.thennt.com/nnt/probiotics-for-acute-infectious-diarrhea/
Allen SJ, Martinez EG, Gregorio GV, Dans LF. Probiotics for treating acute infectious diarrhoea. Cochrane Database Syst Rev. 2010 Nov 10;(11):CD003048 PMID: https://www.ncbi.nlm.nih.gov/pubmed/21069673 - ↑ 12.0 12.1 12.2 12.3 12.4 12.5 12.6 12.7 12.8 12.9 Riddle MS, DuPont HL, Connor BA. ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults. Am J Gastroenterol. 2016 May;111(5):602-22. PMID: https://www.ncbi.nlm.nih.gov/pubmed/27068718
- ↑ 13.0 13.1 NEJM Knowledge+ Gastroenterology