DIARRHEA

Diarrhea is a common symptom that can range in severity from an acute, self-limited annoyance to a severe, life-threatening illness. Patients may use the term "diarrhea" to refer to increased frequency of bowel movements, increased stool liquidity, a sense of fecal urgency, or fecal incontinence

Definition
• In the normal state, approximately 10 L of fluid enter the duodenum daily, of which all but 1.5 L are absorbed by the small intestine. The colon absorbs most of the remaining fluid, with only 100 mL lost in the stool. From a medical standpoint, diarrhea is defined as a stool weight of more than 250 g/24 h

• The causes of diarrhea are myriad. In clinical practice, it is helpful to distinguish acute from chronic diarrhea, as the evaluation and treatment are entirely different

Causes of acute infectious diarrhea
• 1. 2. 3. Noninflammatory Diarrhea Viral - Norwalk virus, Norwalk-like virus, Rotavirus Protozoal - Giardia lamblia, Cryptosporidium Bacterial - Preformed enterotoxin production Staphylococcus aureus, Bacillus cereus, Clostridium perfringens Enterotoxin production; Enterotoxigenic E coli (ETEC), Vibrio cholerae

Inflammatory Diarrhea
• Viral – Cytomegalovirus • Protozoal - Entamoeba histolytica • Bacterial - Cytotoxin productio; Enterohemorrhagic E coli, Vibrio parahaemolyticus, Clostridium difficile. Mucosal invasion; Shigella, Campylobacter jejuni Salmonella, Enteroinvasive E coli ,Aeromonas Plesiomonas,Yersinia enterocolitica,Chlamydia Neisseria gonorrhoeae, Listeria monocytogenes

lactulose. Disaccharidase deficiency: lactose intolerance 3. laxatives) CLUES: .Causes of chronic diarrhea • Osmotic diarrhea Stool volume decreases with fasting. increased stool osmotic gap 1. Factitious diarrhea: magnesium (antacids. Medications: antacids. sorbitol 2.

little change with fasting. Medications . cascara. Zollinger-Ellison syndrome (gastrin) 2.Secretory diarrhea • Large volume ( >1 L/d). postcholecystectomy) 5. normal stool osmotic gap 1. Bile salt malabsorption (ileal resection. Factitious diarrhea (laxative abuse): phenolphthalein. medullary carcinoma of thyroid (calcitonin). Hormonally mediated: VIPoma. Crohn's ileitis. senna 3. carcinoid. Villous adenoma 4.

Ulcerative colitis 2. Microscopic colitis 4. adenocarcinoma (with obstruction and pseudodiarrhea) 5. Crohn's disease 3. Malignancy: lymphoma.Inflammatory conditions • Fever. Radiation enteritis . hematochezia. abdominal pain 1.

retroperitoneal fibrosis 3. Kaposi's sarcoma.Malabsorption syndromes • Weight loss. infectious (TB. tropical sprue. small intestinal diverticula . sarcoidosis. Lymphatic obstruction: lymphoma. abnormal laboratory values. fecal fat > 7-10 g/24 h. carcinoid. Whipple's disease. Bacterial overgrowth: motility disorders (diabetes. small bowel resection (short bowel syndrome) 2. fistulas. Pancreatic disease: chronic pancreatitis. scleroderma). Crohn's disease. pancreatic carcinoma 4. eosinophilic gastroenteritis. MAI). vagotomy.

Irritable bowel syndrome . hyperthyroidism 3. Postsurgical: vagotomy. partial gastrectomy. diabetes mellitus. Systemic disorders: scleroderma.Motility disorders • Systemic disease or prior abdominal surgery 1. blind loop with bacterial overgrowth 2.

Cyclospora • AIDS-related: • Viral: Cytomegalovirus. HIV infection (?) • Bacterial: Clostridium difficile.Chronic infections • Parasites: Giardia lamblia. Entamoeba histolytica. Isospora belli . Mycobacterium avium complex • Protozoal: Microsporida (Enterocytozoon bieneusi ). Cryptosporidium.

bacterial toxins (either ingested preformed in food or produced in the gut).ACUTE DIARRHEA • Diarrhea that is acute in onset and persists for less than 3 weeks is most commonly caused by infectious agents. or drugs .

• Recent ingestion of improperly stored or prepared food implicates food poisoning. Exposure to unpurified water (camping. swimming) may result in infection with Giardia or Cryptosporidium . especially if other people were similarly affected.

social conditions. or sanitation standards and facilities—diarrhea is likely to develop within 2–10 days .TRAVELER'S DIARRHEA • Whenever a person travels from one country to another—particularly if the change involves a marked difference in climate.

dehydration. often accompanied by abdominal cramps. and aside from weakness.• There may be up to ten or even more loose stools per day. and rarely fever. occasionally vomiting. nausea. and in 2% symptoms persist for longer than a month . and occasionally acidosis. although 10% remain symptomatic for a week or longer. The illness usually subsides spontaneously within 1–5 days. The stools do not usually contain mucus or blood. there are no systemic manifestations of infection.

and change in bowel flora . Shigella species.• Bacteria cause 80% of cases of traveler's diarrhea. and Campylobacter jejuni being the most common pathogens. noncholera vibrios. Entamoeba histolytica. Salmonella. with enterotoxigenic E coli. Less common causative agents include Aeromonas. Contributory causes may at times include unusual food and drink. occasional viral infections (adenoviruses or rotaviruses). change in living habits. and Giardia lamblia.

and symptomatic therapy with opiates or diphenoxylate with atropine is all that is required provided the patient is not systemically ill (fever ł 39 °C) and does not have dysentery (bloody stools). Packages of oral rehydration salts to treat dehydration are available over the counter in the USA and in many foreign countries . in which case antimotility agents should be avoided. the affliction is short-lived.• For most individuals.

where infectious diarrheal illnesses are endemic. diabetes. Prophylaxis is recommended for those with significant underlying disease (inflammatory bowel disease.• Avoidance of fresh foods and water sources that are likely to be contaminated is recommended for travelers to developing countries. heart disease in the elderly . AIDS.

ciprofloxacin 500 mg. For stays of more than 3 weeks. Numerous antimicrobial regimens for oncedaily prophylaxis also are effective. For prophylaxis. prophylaxis is not recommended because of the cost and increased toxicity. which may be needed for malaria prophylaxis. daily for 5 days . ofloxacin 300 mg. bismuth subsalicylate is effective but turns the tongue and the stools blue and can interfere with doxycycline absorption.• Prophylaxis is started upon entry into the destination country and is continued for 1 or 2 days after leaving. or trimethoprim-sulfamethoxazole 160/800 mg. such as norfloxacin 400 mg.

but resistance is common in many areas. Trimethoprim-sulfamethoxazole 160/800 mg twice daily can be used as an alternative (especially in children).• Because not all travelers will have diarrhea and because most episodes are brief and self-limited. or norfloxacin 400 mg twice daily. also is efficacious when given orally in a dose of 100 mg three times .to 5-day supply of antimicrobials to be taken if significant diarrhea occurs during the trip. Commonly used regimens include ciprofloxacin 500 mg twice daily. an alternative approach that is currently recommended is to provide the traveler with a 3. ofloxacin 300 mg twice daily. Aztreonam. a poorly absorbed monobactam with activity against most bacterial enteropathogens.

Giardia) that disrupt the normal absorption and secretory process in the small intestine. nonbloody diarrhea associated with periumbilical cramps. or vomiting (singly or in any combination) suggests small bowel enteritis caused by either a toxinproducing bacterium (enterotoxigenic E coli [ETEC]. Staphylococcus aureus. . bloating.Noninflammatory Diarrhea • Watery. C perfringens) or other agents (viruses. Bacillus cereus. nausea.

. Though typically mild. cholera). fecal leukocytes are not present.• Prominent vomiting suggests viral enteritis or S aureus food poisoning. Because tissue invasion does not occur. the diarrhea (which originates in the small intestine) may be voluminous (ranging from 10 to 200 mL/kg/24 h) and result in dehydration with hypokalemia and metabolic acidosis due to loss of HCO3– in the stool (eg.

Campylobacter or Yersinia infection. salmonellosis.Inflammatory Diarrhea • The presence of fever and bloody diarrhea (dysentery) indicates colonic tissue damage caused by invasion (shigellosis. urgency. and tenesmus. amebiasis) or a toxin (C difficile. the diarrhea is small in volume (< 1 L/d) and associated with left lower quadrant cramps. Because these organisms involve predominantly the colon. . E coli O157:H7).

• Fecal leukocytes are present in infections with invasive organisms. often severe hemorrhagic colitis. noninvasive organisms that may be acquired from contaminated meat or unpasteurized juice and has resulted in several outbreaks of an acute. E coli O157:H7 is a toxigenic. In immunocompromised and HIV-infected patients. cytomegalovirus may result in intestinal ulceration with watery or bloody diarrhea .

respiratory symptoms followed by abdominal tenderness. diarrhea. and a rash is due to infection with Salmonella typhi or Salmonella paratyphi. prostration. which causes bacteremia and multiorgan dysfunction . confusion.Enteric Fever • A severe systemic illness manifested initially by prolonged high fevers.

or diarrhea not subsiding after 4–5 days. patients with symptoms of dehydration must be evaluated (excessive thirst. Similarly.Evaluation • In over 90% of patients with acute diarrhea. lethargy) . bloody diarrhea. decreased urination. weakness.5 °C). dry mouth. the illness is mild and self-limited and responds within 5 days to simple rehydration therapy or antidiarrheal agents • Patients with signs of inflammatory diarrhea manifested by any of the following require prompt medical attention: high fever (> 38. abdominal pain.

mental status.• Physical examination should note the patient's general appearance. or marked abdominal pain. volume status. Hospitalization is required in patients with severe dehydration. and the presence of abdominal tenderness or peritonitis • Peritoneal findings may be present in C difficile and enterohemorrhagic E coli. Stool specimens should be sent in all cases for examination for fecal leukocytes and bacterial cultures . toxicity.

Neisseria gonorrhoeae. In patients with diarrhea that persists for more than 10 days.• The rate of positive bacterial cultures in patients with dysentery is 60–75%. A wet mount examination of the stool for amebiasis should also be performed in patients with dysentery who have a history of recent travel to endemic areas or those who are homosexuals. a stool sample should be sent for C difficile toxin. Rectal swabs may be sent for Chlamydia. If E coli O157:H7 is suspected. and herpes simplex virus in sexually active patients with severe proctitis . three stool examinations for ova and parasites also should be performed. the laboratory must be alerted to do specific serotyping. In patients with a history of antibiotic exposure.

and alcohol. Frequent feedings of fruit drinks. easily digested foods (eg. milk products. crackers) are encouraged . fats. tea. and soft.Treatment • Diet :The overwhelming majority of adults have mild diarrhea that will not lead to dehydration provided the patient takes adequate oral fluids containing carbohydrates and electrolytes. Patients will find it more comfortable to rest the bowel by avoiding high-fiber foods. "flat" carbonated beverages. soups. caffeine.

dehydration can occur quickly. Oral rehydration with fluids containing glucose. safe. and highly effective in almost all awake patients . especially in children.Rehydration • In more severe diarrhea. K+. Na+. Cl–. and bicarbonate or citrate is preferred in most cases to intravenous fluids because it is inexpensive.

oral electrolyte solutions (eg. Alternatively.5 g KCl).• An easy mixture is ˝ tsp salt (3. 8 tsp sugar (40 g). 1 tsp baking soda (2. Intravenous fluids (lactated Ringer's solution) are preferred acutely in patients with severe dehydration. . Fluids should be given at rates of 50–200 mL/kg/24 h depending on the hydration status. diluted to 1 L with water.5 g). and 8 oz orange juice (1. Pedialyte) are readily available.5 g NaHCO3).

Antidiarrheal Agents • Loperamide is the preferred drug in a dosage of 4 mg initially. followed by 2 mg after each loose stool (maximum:16 mg/24 h • Bismuth subsalicylate (Pepto-Bismol). reduces symptoms in patients with traveler's diarrhea by virtue of its antiinflammatory and antibacterial properties • Anticholinergic agents are contraindicated in acute diarrhea . two tablets or 30 mL four times daily.

Salmonella. 500 mg twice daily) for 5–7 days. Yersinia. 250–500 mg four times daily . Alternative agents are trimethoprim-sulfamethoxazole.Antibiotic Therapy • Empiric treatment-fluoroquinolones (eg. ciprofloxacin. and Aeromonas. including Shigella. These agents provide good antibiotic coverage against most invasive bacterial pathogens. Campylobacter. or erythromycin. 160/800 mg twice daily.

Campylobacter. C difficile infection.Antibiotics are not generally recommended in patients with nontyphoid Salmonella. or Yersinia infection except in severe or prolonged disease because they have not been shown to hasten recovery or reduce the period of fecal bacterial excretion. cholera. and the sexually transmitted infections (gonorrhea. and herpes simplex infection) . syphilis. The infectious diarrheas for which treatment is clearly recommended are shigellosis. "traveler's" diarrhea. extraintestinal salmonellosis. chlamydiosis. giardiasis. amebiasis.• Specific antimicrobial treatment.

CHRONIC DIARRHEA • Etiology The causes of chronic diarrhea may be grouped into six major pathophysiologic categories .

the major osmoles are Na+. Cl–. Under normal circumstances.Osmotic Diarrheas • As stool leaves the colon. The stool osmolality may be estimated by multiplying the stool (Na+ + K+) × 2 (multiplied by 2 to account for the anions) . and HCO3–. approximately 290 mosm/kg. K+. fecal osmolality is equal to the serum osmolality. ie.

• The osmotic gap is the difference between the measured osmolality of the stool (or serum) and the estimated stool osmolality and is normally less than 50 mosm/kg • An increased osmotic gap implies that the diarrhea is caused by ingestion or malabsorption of an osmotically active substance .

and flatulence due to increased colonic gas production. . Osmotic diarrheas resolve during fasting. Osmotic diarrheas caused by malabsorbed carbohydrates are characterized by abdominal distention. bloating. and malabsorption syndromes (see below). laxative abuse.• The most common causes of osmotic diarrhea are disaccharidase deficiency (lactase deficiency).

intestinal resections. lymphatic obstruction. small intestinal bacterial overgrowth. and pancreatic insufficiency • In patients with suspected malabsorption.Malabsorptive Conditions • The major causes of malabsorption are small mucosal intestinal diseases. quantification of fecal fat should be performed .

and laxative abuse .Secretory Conditions • Increased intestinal secretion or decreased absorption results in a watery diarrhea that may be large in volume (1–10 L/d) but with a normal osmotic gap • here is little change in stool output during the fasting state. significant dehydration and electrolyte imbalance may develop. Major causes include endocrine tumors (stimulating intestinal or pancreatic secretion). bile salt malabsorption (stimulating colonic secretion). In serious conditions.

Crohn's disease.Inflammatory Conditions • Diarrhea is present in most patients with inflammatory bowel disease (ulcerative colitis. A variety of other symptoms may be present. weight loss. including abdominal pain. fever. microscopic colitis). and hematochezia .

Motility Disorders • Abnormal intestinal motility secondary to systemic disorders or surgery may result in diarrhea due to rapid transit or to stasis of intestinal contents with bacterial overgrowth resulting in malabsorption .

Chronic Infections • Chronic parasitic infections may cause diarrhea through a number of mechanisms. Although the list of parasitic organisms is a long one. E histolytica. and the intestinal nematodes • Immunocompromised patients. are susceptible to a number of infectious agents that can cause acute or chronic diarrhea Chronic diarrhea in AIDS is commonly caused by Microsporida. . agents most commonly associated with diarrhea include the protozoans Giardia. especially those with AIDS. Cryptosporidium. Isospora belli. Cyclospora. cytomegalovirus. and Mycobacterium avium complex. Cyclospora.

Factitial Diarrhea • Approximately 15% of patients with chronic diarrhea have factitial diarrhea caused by surreptitious laxative abuse or factitious dilution of stool .

A weight greater than 1000–1500 g suggests a secretory process. A fecal fat in excess of 10 g/24 h indicates a malabsorptive process . justifying further workup.Twenty-four-hour stool collection for weight and quantitative fecal fat–A stool weight of more than 300 g/24 h confirms the presence of diarrhea.Evaluation • Stool Analysis .

Stool laxative screen–In cases of suspected laxative abuse. Stool osmolality–An osmotic gap confirms osmotic diarrhea. Bisacodyl can be detected in the urine . Phenolphthalein. and cascara are indicated by the presence of a bright-red color after alkalinization of the stool or urine. phosphate.• 2. • 3. stool magnesium. senna. and sulfate levels may be measured. A stool osmolality less than the serum osmolality implies that water or urine has been added to the specimen (factitious diarrhea).

Cryptosporidium and Cyclospora are detected with modified acidfast staining. Stool for ova and parasites–The presence of Giardia and E histolytica is detected in routine wet mounts.4. • 5. . Fecal leukocytes–The presence of leukocytes in a stool sample implies an underlying inflammatory diarrhea.

albumin. low serum calcium. Hyponatremia and non–anion gap metabolic acidosis may occur in profound secretory diarrheas. serum electrolytes. Anemia occurs in malabsorption syndromes (vitamin B12. iron) and inflammatory conditions. liver function tests. and prothrombin time should be obtained. total T4. beta-carotene. or abnormal serum alkaline phosphatase .Blood Tests • Routine laboratory tests–CBC. and inflammatory diseases. phosphorus. protein-losing enteropathies. Malabsorption of fat-soluble vitamins may result in an abnormal prothrombin time. TSH. Hypoalbuminemia is present in malabsorption. low carotene. folate. calcium.

gastrin (Zollinger-Ellison syndrome). indicative of chronic use of anthraquinone laxatives. and urinary 5-HIAA (carcinoid syndrome) levels should be obtained • Proctosigmoidoscopy With Mucosal Biopsy: Examination may be helpful in detecting inflammatory bowel disease (including microscopic colitis) and melanosis coli. calcitonin (medullary thyroid carcinoma). .Other laboratory tests • In patients with suspected secretory diarrhea. serum VIP (VIPoma). cortisol (Addison's disease).

An upper gastrointestinal series or enteroclysis study is helpful in evaluating Crohn's disease. . Colonoscopy is helpful in evaluating colonic inflammation due to inflammatory bowel disease. and M aviumintracellulare infection. Abdominal CT is helpful to detect chronic pancreatitis or pancreatic endocrine tumors. or carcinoid syndrome. lymphoma.Imaging • Calcification on a plain abdominal radiograph confirms the diagnosis of chronic pancreatitis. Upper endoscopy with small bowel biopsy is useful in suspected malabsorption due to mucosal diseases. Upper endoscopy with a duodenal aspirate and small bowel biopsy is also useful in patients with AIDS and to document Cryptosporidium. Microsporida.

Paregoric: Because of their addictive potential.Treatment • A. the dosage of paregoric is 4–8 mL after each liquid bowel movement . then 2 mg after each loose stool (maximum: 16 mg/d) • Diphenoxylate With Atropine: One tablet three or four times daily • Codeine. these drugs are generally avoided except in cases of chronic. Codeine may be given in a dosage of 15–60 mg every 4 hours as needed. intractable diarrhea. Loperamide: 4 mg initially.

Octreotide: This somatostatin analog stimulates intestinal fluid and electrolyte absorption and inhibits secretion. .• Clonidine: a2-Adrenergic agonists inhibit intestinal electrolyte secretion.1–0. Effective doses range from 50 mg to 250 mg subcutaneously three times daily. it inhibits the release of gastrointestinal peptides. Furthermore.2 mg/d for 7 days may be useful in some patients with secretory diarrheas. A dosage of 4 g one to three times daily is recommended . cryptosporidiosis. and diabetes. A clonidine patch that delivers 0. It is very useful in treating secretory diarrheas due to VIPomas and carcinoid tumors and in some cases of diarrhea associated with AIDS.

• Cholestyramine: This bile salt binding resin may be useful in patients with bile saltinduced diarrhea secondary to intestinal resection or ileal disease .

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