Acute diarrhoea: a guide to assessment and management

KEY POINTS

Acute diarrhoea is mostly due to infectious gastroenteritis though in many episodes the cause is not identified The most common bacterial causes identified in the United Kingdom are various strains of Escherichia coli followed closely by Campylobacter spp

Salmonella spp and Clostridium difficile are less common while Giardia and Shigella are the least common of the major infectious causes in the UK though they are more important in other countries

Viral gastroenteritis is as frequent as bacterial gastroenteritis

Small round structured viruses (norovirus) or "winter vomiting disease" and rotavirus are the most common viral causes

Acute diarrhoea usually settles rapidly

Rehydration and supportive measures may be necessary but treatment with antibiotics is rarely needed

CLINICAL TIPS

Most episodes of acute diarrhoea settle within a few days Symptoms continuing for more than five days or those episodes associated with a cluster of episodes warrant stool cultures to identify notifiable infections

When associated with vomiting, infectious diarrhoea can cause severe dehydration and syncope You need to admit patients with syncope, tachycardia (heart rate >100 beats per minute), hypotension (systolic BP <100 mm Hg), and/or marked oliguria to hospital for intravenous rehydration

You need to check both stool and blood cultures in such patients since patients with septicaemia due to Salmonellaneed treatment with intravenous antibiotics

Acute diarrhoea: a guide to assessment and management

KEY POINTS

Acute diarrhoea is mostly due to infectious gastroenteritis though in many episodes the cause is not identified The most common bacterial causes identified in the United Kingdom are various strains of Escherichia coli followed closely by Campylobacter spp

Salmonella spp and Clostridium difficile are less common while Giardia and Shigella are the least common of the major infectious causes in the UK though they are more important in other countries

Viral gastroenteritis is as frequent as bacterial gastroenteritis

Small round structured viruses (norovirus) or "winter vomiting disease" and rotavirus are the most common viral causes

Acute diarrhoea usually settles rapidly

Rehydration and supportive measures may be necessary but treatment with antibiotics is rarely needed

CLINICAL TIPS

Most episodes of acute diarrhoea settle within a few days Symptoms continuing for more than five days or those episodes associated with a cluster of episodes warrant stool cultures to identify notifiable infections

When associated with vomiting, infectious diarrhoea can cause severe dehydration and syncope You need to admit patients with syncope, tachycardia (heart rate >100 beats per minute), hypotension (systolic BP <100 mm Hg), and/or marked oliguria to hospital for intravenous rehydration

You need to check both stool and blood cultures in such patients since patients with septicaemia due to Salmonellaneed treatment with intravenous antibiotics

Clinical features
Recovery from infectious diarrhoea is usually slower in patients whose initial illness was more severe.

Campylobacter jejuni enteritis

The onset of Campylobacter jejuni enteritis is usually acute. Patients present with abdominal cramping and pass loose watery stools with considerable urgency. About one in three patients in our Nottingham series3 experienced fever, one in three rectal bleeding, and one in five reported weight loss of more than 6 kg. Septicaemia is almost never seen with Campylobacter infection except in immunocompromised patients, for example, those with HIV infection. Although many recover within a week, around half are off work for more than seven days. The main risk factors are4 5:

Travel abroad Consumption of poultry

Contact with puppies Diabetes mellitus Treatment with inhibitors of gastric acid secretion.

Shigella and Salmonella

Shigella and Salmonella infections can cause similar symptoms. Salmonella typhi has a febrile prodrome consisting of 7-14 days with fever, headache, and nausea and vomiting. Diarrhoea appears late in the illness. Salmonella typhi may be associated with septicaemia leading to osteomyelitis, mycotic aneurysms, or liver abscesses. Salmonella enteritidis is associated with a less severe illness.

Shigella flexneri
Patients with Shigella flexneri present with bloody diarrhoea. Complications include haemolytic uraemic syndrome which can occur in up to 15% of untreated episodes though the incidence is much lower in those treated with antibiotics at 0.3%.6 It is now rare in industrialised countries.

E coli
The most common infections are those associated with traveller's diarrhoea. These are the enterotoxigenic strains of E coli and cause a short lived, watery diarrhoea. Enterohaemorrhagic E coli (EHEC) strains account for around 1% of E coli infections. They produce a shiga toxin (verocytotoxin), a toxin which damages endothelial cells and is the cause of haemolytic-uraemic syndrome.7 Such patients usually present with severe abdominal pain and diarrhoea which is bloody in about one third of patients.8 The annual incidence in the community is around 3/1000 patients.2

C difficile
Most patients will have a history of prior antibiotic use. The most common patient group is debilitated elderly hospitalised patients. Such patients often relapse after treatment. It is increasingly seen in the community - this now accounts for one third of all episodes of pseudomembranous colitis.9 Recent outbreaks have been reported of a hypervirulent strain which produces more toxin and is associated with a worse prognosis.10 11 Mortality in the elderly is high and relapse common and in one series in whom 47% were nursing home residents the mortality was 29%.12

G intestinalis
This is ubiquitous in surface ground water throughout the world so it is seen in backpackers and mountaineers and in places where the drinking water is not adequately treated or becomes contaminated. Onset may be insidious with mainly upper gastrointestinal symptoms of nausea, bloating, postprandial distension, and heartburn. Diarrhoea may be associated with frequent bulky stools which float and are difficult to flush suggesting fat malabsorption. Weight loss is common though rarely severe. These symptoms may persist for many months if the diagnosis is missed.

Cryptosporidium parvum
This is ubiquitous in the soil of dairy farms. Patients infected with it present with diarrhoea of short duration (one to eight days). It is most common in young children.13 Immunocompromised patients such as those with HIV infection have a more prolonged debilitating illness which responds poorly to treatment with antibiotics.

Rotavirus
Rotavirus gastroenteritis is characterised by a short incubation period of about 48 hours. Patients have acute severe diarrhoea and vomiting lasting 3-8 days often associated with a fever. By age 5 most children will have been infected with it and since immunity is long lasting it is rare in older individuals. Since it is associated with severe dehydration it is the most common cause of admission to hospital with diarrhoea, with about 18 000 admissions to hospital per year in England and Wales. A vaccine was shown to be effective but it was withdrawn after one year because of an increase in episodes of intussusception in those vaccinated.

Norovirus
This is being recognised more frequently. Spread is via contaminated food, particularly shell fish. It is a cause of outbreaks of diarrhoea in institutions such as care homes and hospitals. Effective control often necessitates shutting down wards to new admissions. It is highly infectious being spread by food handlers and by aerosol from projectile vomiting. It has a short incubation period (12-48 hours), causing diarrhoea and vomiting that is short lived. It shows marked

seasonal periodicity being previously called "winter vomiting disease." Immunity is short lived.
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Acute diarrhoea: a guide to assessment and management

ASSESSMENT You should focus on the following questions in the history:

Have other people exposed to the same food also experienced symptoms? This is something which strongly suggests a common infectious agent

Is there a possible source of food contamination, such as eating out? Has the patient had diarrhoea before? Are there any features that suggest hypovolaemia such as oliguria, confusion, light headedness on standing?

Diagnostic clinical features

Severe abdominal pain, fever, and the presence of rectal bleeding is suggestive of Campylobacter jejuni or more rarely E coliO157. A history of travel should make you consider the possibility of Shigella flexneri, Salmonella typhi, or G intestinalis. Prominent vomiting suggests norovirus or rotavirus particularly if the patient is under 5 years old.

Examination and immediate resuscitation

You should examine the patient for signs of dehydration and hypovolaemia. Patients who are profoundly dehydrated will have a haggard appearance with reduced skin turgor and sunken eye sockets, and will have difficulty standing upright. They may also be confused. This will be associated with:

Tachycardia - heart rate more than 100 beats per minute Hypotension - systolic blood pressure less than 100 mm Hg often with a postural drop.

You need to give such patients a fluid challenge immediately. If they do not respond to adequate fluid replacement, it may be necessary to insert a central line to guide fluid replacement.

Acute diarrhoea: a guide to assessment and management Investigations

You should check:

Full blood count and urea and electrolytes

Stool cultures.

Most patients will recover before you know the results of stool cultures. Stool cultures may be useful to public health doctors, allowing them to document the progress of epidemics or identify sources of infection. If the infection is prolonged or severe, where patients fail to settle spontaneously, stool or blood cultures may improve management of such patients by identifying antibiotic sensitivities. If you suspect C difficile, you should send at least two stools for toxin assay, since false negatives are common. 14 A high white blood count (>20 x 109/l) is one of the adverse prognostic factors in C difficile colitis. Others include serum albumen <25 g/l and prehospital nasogastric feeding.12 Flexible sigmoidoscopy may be a more reliable way of rapid diagnosis than stool cultures and is recommended if the patient has severe symptoms or suspicion of C difficile infection is high but stool toxin tests are negative. In infections with C difficile, it will show pseudo-membranous colitis with multiple patchy white lesions which bleed on gentle scraping.9 You can perform a flexible sigmoidoscopy at the bedside in a sick patient, where you can take biopsies. These may help to exclude inflammatory bowel disease (Crohn's or ulcerative colitis), rarer forms of colitis like microscopic colitis in the elderly, or cytomegalovirus colitis in an immune suppressed patient. Taking the sigmoidoscope to the patient also reduces the risk of spreading the infection round the hospital. Although in most episodes the diarrhoea will be improving by the time the results of cultures are known, it is important to send stool cultures when food poisoning is likely since this is a notifiable condition. Identification of the infectious agent may lead to the identification of a source of infection in a food handler or the closing down of restaurants with unhygienic facilities.

Stool microscopy
You should send stools for microscopy if you suspect giardiasis or cryptosporidiosis and in all patients with known immune deficiency such as HIV. The sensitivity of stool microscopy for identifying the cysts of G intestinalis is around 75% for the examination of the first stool, and 85% after examination of the second stool. If you think the likelihood of a diagnosis of G intestinalis is high, it may be preferable to request an endoscopy with duodenal biopsy. Examination of at least two duodenal biopsies has been shown to have a detection rate of close to 100%. 15 Giardia antigens are excreted in stool where they can be detected using an ELISA test which gives good results. This does not require the experienced technicians who are needed to identify cysts by microscopy. 16

Blood cultures
Most patients will recover before you know the results of blood cultures. Blood culture can be useful in salmonella infection in which the bacteria often appear in the blood before the stool so blood culture may often be positive before the stool culture. You should take blood cultures from severely ill patients who may be hypovolaemic and/or septicaemic, particularly those with a fever and those you suspect of salmonella infection.

Acute diarrhoea: a guide to assessment and management Management

Fluids
If a patient has signs of dehydration or hypovolaemia, you should give them a fluid challenge as soon as you assess them. In all other patients, you should replace lost fluids by giving intravenous normal saline with potassium chloride since sodium will be the main electrolyte lost.

Antibiotics
Most infections are self limiting, and antibiotics may actually prolong the illness in patients infected with salmonella, possibly by suppressing the normal protective gut microbiota. C difficile Infection with C difficile is a notable exception. You should treat this with metronidazole 400 mg eight hourly for 10 days or vancomycin 250 to 500 mg eight hourly. Both have a similar efficacy but vancomycin is potentially more toxic. Relapse occurs in about 20-30% of patients.12 A new high toxin producing strain called North America PFGE type 1, (NAP-1 or ribotype 027) has appeared which is more likely to cause relapses.10 Antibiotic resistance is also increasing. You can use nitazoxanide, bacitracin, teicoplanin, and fusidic acid as second line drugs.17 Salmonella Salmonella resistance to antibiotics is increasing through the transfer of antibiotic resistance genes between organisms causing resistance to the newer cephalosporins such as ceftazidime or cefotaxime. You can use ciprofloxacin 500 mg orally 12 hourly or cefotaxime 1 g intravenously 12 hourly depending on what the organism is sensitive to. Intravenous antibiotics are indicated for those who are severely ill or vomiting. Shigella You can use ciprofloxacin 500 mg bd or ampicillin 500 mg tds orally.

Probiotics
Probiotics are dietary supplements containing potentially beneficial bacteria or yeasts. Probiotics have been shown to reduce the duration of acute diarrhoea. The best evidence is in children with a smaller effect in adults. A recent meta-analysis suggested that they reduce the duration of diarrhoea by approximately one day. 18 Sacchromyces boulardii is a yeast that has been shown to reduce the risk of antibiotic-associated diarrhoea with a number needed to treat (the number of patients who need to be treated to prevent one adverse outcome) of 10. In patients with a history of previous relapse, it reduces the rate of relapse in patients with C difficile from 65% to 35%.19

Frequent bowel movement

Rapid flushing of gut contents with frequent bowel movement is likely to be protective. Children whose normal bowel habit is frequent (one to two times a day) recover from E coli O157 more quickly than those whose normal pattern is less frequent. 20 You should therefore regard acute diarrhoea as a protective mechanism in both children and adults and, if possible, avoid using opiates to suppress the diarrhoea, or use them with caution.