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Acute diarrhea is defined as the abrupt onset of 3 or more loose stools per day. The augmented water content in the stools (above the normal value of approximately 10 mL/kg/d in the infant and young child, or 200 g/d in the teenager and adult) is due to an imbalance in the physiology of the small and large intestinal processes involved in the absorption of ions, organic substrates, and thus water. A common disorder in its acute form, diarrhea has many causes and may be mild to severe. Childhood acute diarrhea is usually caused by infection of the small and/or large intestine; however, numerous disorders may result in diarrhea, including a malabsorption syndrome and various enteropathies. Acute-onset diarrhea is usually self-limited; however, an acute infection can have a protracted course. By far, the most common complication of acute diarrhea is dehydration. Although the term "acute gastroenteritis" is commonly used synonymously with "acute diarrhea," the former term is a misnomer. The term gastroenteritis implies inflammation of both the stomach and the small intestine, whereas, in reality, gastric involvement is rarely if ever seen in acute diarrhea (including diarrhea with an infectious origin); in addition, enteritis is also not consistently present. Examples of infectious acute diarrhea syndromes that do not cause enteritis include Vibrio cholerae– induced diarrhea and Shigella -induced diarrhea. Thus, the term acute diarrhea is preferable to acute gastroenteritis. Diarrheal episodes are classically distinguished into acute and chronic (or persistent) based on their duration. Acute diarrhea is thus defined as an episode that has an acute onset and lasts no longer than 14 days; chronic or persistent diarrhea is defined as an episode that lasts longer than 14 days. The distinction, supported by the World Health Organization (WHO), has implications not only for classification and epidemiological studies but also from a practical standpoint because protracted diarrhea often has a different set of causes, poses different problems of management, and has a different prognosis.
Diarrhea is the reversal of the normal net absorptive status of water and electrolyte absorption to secretion. Such a derangement can be the result of either an osmotic force that acts in the lumen to drive water into the gut or the result of an active secretory state induced in the enterocytes. In the former case, diarrhea is osmolar in nature, as is observed after the ingestion of nonabsorbable sugars such as lactulose or lactose in lactose malabsorbers. Instead, in the typical active secretory state, enhanced anion secretion (mostly by the crypt cell compartment) is best exemplified by enterotoxin-induced diarrhea. In osmotic diarrhea, stool output is proportional to the intake of the unabsorbable substrate and is usually not massive; diarrheal stools promptly regress with discontinuation of the offending nutrient, and the stool ion gap is high, exceeding 100 mOsm/kg. In fact, the fecal osmolality in this circumstance is accounted for not only by the electrolytes but also by the unabsorbed nutrient(s) and their degradation products. The ion gap is obtained by subtracting the concentration of the electrolytes from total osmolality (assumed to be 290 mOsm/kg), according to the formula: ion gap = 290 – [(Na + K) × 2]. In secretory diarrhea, the epithelial cells’ ion transport processes are turned into a state of active secretion. The most common cause of acute-onset secretory diarrhea is a bacterial infection of the gut. Several mechanisms may be at work. After colonization, enteric pathogens may adhere to or invade the epithelium; they may produce enterotoxins (exotoxins that elicit secretion by increasing an intracellular second messenger) or cytotoxins. They may also trigger release of cytokines attracting inflammatory cells, which, in turn, contribute to the activated secretion by inducing the release of agents such as prostaglandins or platelet-activating factor. Features of secretory diarrhea include a high purging rate, a lack of response to fasting, and a normal stool ion gap (ie, 100 mOsm/kg or less), indicating that nutrient absorption is intact.
and long-term consequences of the vicious cycle of enteric infections. Females have a higher incidence of Campylobacter species infections and hemolytic uremic syndrome (HUS). an average of 3 episodes per child per year in children younger than 5 years is reported.6 million yearly deaths in children younger than age 5 years. The impact of vaccination on rotavirus morbidity has been remarkable. Despite a progressive reduction in global diarrheal disease mortality over the past 2 decades. acute diarrhea is responsible for 20% of physician referrals in children younger than 2 years and for 10% in children younger than 3 years. in countries in which the toll of diarrhea is highest. life-threatening dehydration as a result of the high body-water turnover and limited renal compensatory capacity of very young children. The vast majority of diarrheaassociated infant deaths were reported in 2005-2007. however. persistent postenteritis diarrhea has a strong inverse correlation with age. one estimate before the introduction of specific antirotavirus immunization in 2006 assumed a cumulative incidence of 1 hospitalization for diarrhea per 23-27 children by age 5 years. Age and nutritional status appear to be the most important host factors in determining the severity and the duration of diarrhea. Sex Most cases of infectious diarrhea are not sex specific. poverty also adds an enormous additional burden. and malnutrition are devastating.  Furthermore. Rotavirus and adenovirus are particularly prevalent in children younger than 2 years. Because the single most common cause of infectious diarrhea worldwide is rotavirus. diarrhea.Frequency United States In the United States. with 86% of deaths occurring among lowbirthweight (< 2500 g) infants. the younger the child. Mortality/Morbidity Mortality from acute diarrhea is overall globally declining but remains high. with 18% of the 10. rotavirus was associated with 45% of all childhood hospitalizations and a cost of nearly $ 1 billion. By these estimates. however. and the Aeromonas organism is a significant cause of diarrhea in young children. the higher is the risk for severe. In the United States. . Very young children are particularly susceptible to secondary dehydration and secondary nutrient malabsorption. In these settings. an average of 369 diarrhea-associated deaths/year occurred among children aged 1-59 months during 1992-1998 and 2005-2006. with more than 50. Yersinia enterocolitis typically infects children younger than 1 year.000 hospitalizations. In developing countries. and recurrent episodes of diarrhea lead to growth faltering and substantially increased mortality. Age Viral diarrhea is most common in young children. some areas report 6-8 episodes per year per child. Furthermore. and because a vaccine has been in use for over 3 years now. a reduction in the overall frequency of diarrheal episodes is hoped for in the near future. International In developing countries. Most estimates have diarrhea as the second cause of childhood mortality.  Childhood mortality associated with diarrhea has constantly but slowly declined during the past 2 decades. Whether younger age also means a risk of running a prolonged course is an unsettled issue. with significant reduction of diarrhea-associated hospitalizations and visits to emergency departments in children in the years 2007-2008 compared with the prevaccine period. it appears to have plateaued over the past several years. In fact. diarrhea morbidity in published reports from 1990-2000 slightly increased worldwide compared with previous reports. Astrovirus and norovirus usually infect children younger than 5 years. malnutrition is an important additional risk factor for diarrhea. mostly because of the widespread use of oral rehydration solutions.
color. for example. For example. diarrhea is defined as daily stools with a weight greater than 200 g. In practice.21 episodes per personyear. Close to 90% of episodes were acute (ie. and frequency can be helpful in determining whether the source is from the small or large bowel. with an overall incidence of 2. dehydration. Diarrhea implies an increase in stool volume and diminished stool consistency. with a median duration of 2 d and a median of 6 stools per day). Flatulence associated with foul-smelling stools that float suggests fat malabsorption.5 Negative Commonly >10/high power field Possible leukocytosis. lasting < 14 d.5 Possibly positive < 5/high power field Normal Viral Large Bowel Mucoid and/or bloody Small Highly increased Commonly grossly bloody >5. enterohemorrhagic) Shigella species Salmonella species Campylobacter species Yersinia species Aeromonas species Plesiomonas species Toxic bacteria Clostridium difficile Rotavirus Adenovirus Calicivirus Astrovirus Norovirus Enterotoxigenic bacteria E coli Klebsiella Clostridium perfringens Cholera species Vibrio species . self-limited condition. subsiding within a few days. o In children younger than 2 years. o In children older than 2 years. volume. diarrhea is defined as daily stools with a volume greater than 10 mL/kg. bandemia Invasive bacteria Escherichia Coli (enteroinvasive. which can be observed with infection with Giardia lamblia. breastfed children may normally have 5-6 stools per day. and a greater number of work days lost than nonrotavirus gastroenteritis. Stool Characteristics and Determining Their Source (Open Table in a new window) Stool Characteristics Appearance Volume Frequency Blood pH Reducing substances WBCs Serum WBCs Organisms Small Bowel Watery Large Increased Possibly positive but never gross blood Possibly < 5. The clinical presentation and course of illness depend on the etiology of the diarrhea and on the host. Knowledge of the characteristics of consistency. Table 1. A prospective study conducted in the United States in 604 children aged 3-36 months in community settings before the introduction of rotavirus vaccine found that the highest incidence of acute diarrhea was in January and August. Table 1 outlines these characteristics and demonstrates that an index of suspicion can be easily generated for a specific set of organisms. o Individual stool patterns widely vary. rotavirus is more commonly associated with vomiting.History Acute diarrhea in developed countries is almost invariably a benign. this typically means loose-to-watery stools passed 3 or more times per day.
Certain organisms (eg. o Parasites Giardia species Cryptosporidium species Parasites Entamoeba organisms Associated systemic symptoms include the following: Some enteric infections commonly have systemic symptoms. whereas others less commonly are associated with systemic features. calicivirus. Food history can be helpful. o Increase in daycare usage has raised the incidence of rotavirus and Cryptosporidium species. C difficile. and Cryptosporidium species. Entamoeba species) may be associated with a protracted course. o Organisms that cause food poisoning include the following: o . Table 2. Giardia. Organisms and Frequency of Symptoms (Open Table in a new window) Organism Rotavirus Adenovirus Norovirus Astrovirus Calicivirus Aeromonas species Campylobacter species C difficile C perfringens Enterohemorrhagic E coli Enterotoxigenic E coli Plesiomonas species Salmonella species Shigella species Vibrio species Y enterocolitica Giardia species Cryptosporidium species Entamoeba species Incubation 1-7 d 8-10 d 1-2 d 1-2 d 1-4 d None 2-4 d Variable Minimal 1-8 d 1-3 d None 0-3 d 0-2 d 0-1 d None 2 wk 5-21 d 5-7 d Duration 4-8 d 5-12 d 2d 4-8 d 4-8 d 0-2 wk 5-7 d Variable 1d 3-6 d 3-5 d 0-2 wk 2-7 d 2-5 d 5-7 d 1-46 d 1+ wk Months 1-2+ wk Vomiting Yes Delayed Yes +/Yes +/No No Mild No Yes +/Yes No Yes Yes No No No Fever Low Low No +/+/+/Yes Few No +/Low +/Yes High No Yes No Low Yes Abdominal Pain No No No No No No Yes Few Yes Yes Yes +/Yes Yes Yes Yes Yes Yes No Daycare considerations are as follows: Certain organisms are spread quickly in daycare. It also outlines incubation periods and usual duration of symptoms of common organisms. o Ingestion of raw or contaminated food is a common cause of infectious diarrhea. Shigella. These organisms include rotavirus. Giardia. astrovirus. o Table 2 outlines the frequency of some of these symptoms with particular organisms. and Campylobacter.
o Exposure to young dogs or cats is associated with Campylobacterorganisms. Dairy food -Campylobacter and Salmonella species Eggs -Salmonella species Meats -C perfringens and Aeromonas. o Rotavirus and Shigella. Aeromonas organisms are associated with exposure to the marine environment. Giardia. o Water is a major reservoir for many organisms that cause diarrhea. and severity. andSalmonella species Ground beef . .Hospitalization o Giardia species -Agammaglobulinemia.Enterotoxigenic E coli andAeromonas. Campylobacter. Plesiomonas. Salmonella. andYersinia species New Guinea -Clostridium species Animal exposure can contribute to diarrhea. Cryptosporidium. exposure to contaminated water should raise index of suspicion for these parasites. chronic pancreatitis. and Vibriospecies Oysters . A history of camping suggests exposure to water sources contaminated withGiardia organisms. o Risk of contracting diarrhea while traveling is. o Swimming pools have been associated with outbreaks of infection withShigella species. and Campylobacter organisms are prevalent worldwide and need to be considered regardless of specific travel history.Hospitalization. including the following: o C difficile . highest for persons traveling to Africa.Immunocompromised or immunosuppressed state Physical The following may be observed: o o Dehydration Dehydration is the principal cause of morbidity and mortality. antibiotic administration o Plesiomonas species . malnutrition.Calicivirus and Plesiomonas and Vibrio species Vegetables -Aeromonas species and C perfringens Water exposure can contribute to diarrhea.Astrovirus and Aeromonas.Intestinal dysmotility. V cholerae Travel to Japan -Vibrio parahaemolyticus Travel to Mexico -Aeromonas. Y enterocolitica Seafood . cystic fibrosis o Cryptosporidia species . V cholerae. achlorhydria.Liver diseases or malignancy o Salmonella species . and Entamoeba organisms are resistant to water chlorination. Certain medical conditions predispose patients to infection. o Other organisms that are prevalent in particular parts of the world include the following: Nonspecific foreign travel history . Plesiomonas. enterotoxigenic E coli Travel to Asia -V cholerae Travel to Australia -Yersinia species Travel to Canada -Yersinia species Travel to Europe -Yersinia species Travel to India -Entamoeba species. Assess every patient with diarrhea for signs. o Enterotoxigenic E coli is the leading cause of traveler's diarrhea. Plesiomonas. o Travel to Central and South America and Eastern European countries is also associated with a relatively high risk of contracting diarrhea. Vibrio cholerae Travel to South America and Central America -Entamoebaspecies. hemolytic anemia (especially sickle cell disease). symptoms. therefore. and Shigellaspecies Underdeveloped tropical visit -C perfringens Travel to Africa -Entamoeba species. o Exposure to turtles is associated with Salmonella organisms. o Giardia. immunosuppression.malaria o Rotavirus . Entamoeba.Enterohemorrhagic E coli Poultry -Campylobacter species Pork -C perfringens. by far. achlorhydria. Salmonella. Travel history may indicate a cause for diarrhea.
and/or protein malabsorption. dry mucous membranes. Borborygmi: Significant increases in peristaltic activity can cause an audible and/or palpable increase in bowel activity. and delayed capillary refill are obvious and important signs of dehydration. Table 3. Dehydration Severity. and Symptoms (Open Table in a new window) Hydration 0-5% Dehydration 5-10% Dehydration 10% or More (Mild) (Moderate) (Severe) General Eyes Tears Mouth Thirst Skin Well Normal Present Moist Drinks normally Pinch retracts immediately Restless Sunken Absent Dry Thirsty Pinch retracts slowly Lethargic Very sunken Absent Very dry Drinks poorly Pinch stays folded o o o o o o o o Failure to thrive and malnutrition Reduced muscle and fat mass or peripheral edema may be clues to the presence of carbohydrate. one should not dismiss other causes that can lead to the same presentation. rebound tenderness. particularly in young children. or guarding. Pain usually does not increase with palpation. lack of tears. sunken eyes.o Lethargy. poor skin turgor. fat. Perianal erythema Frequent stools can cause perianal skin breakdown. Secondary bile acid malabsorption can result in a severe diaper dermatitis that is often characterized as a "burn." Causes Although infectious agents are by far the most common cause for sporadic or endemic episodes of acute diarrhea. be alert for possible complications or for another noninfectious diagnosis. sunken anterior fontanel. Abdominal pain Nonspecific nonfocal abdominal pain and cramping are common with some organisms. Giardia organisms can cause intermittent diarrhea and fat malabsorption. Secondary carbohydrate malabsorption often results in acidic stools. Causes of diarrhea with acute onset include the following: Infections Enteric infections (including food poisoning Extraintestinal infections o Drug-induced Antibiotic-associated Laxatives Antacids that contain magnesium Opiate withdrawal Other drugs o Food allergies or intolerances Cow's milk protein allergy Soy protein allergy Multiple food allergies Olestra o . With focal abdominal pain worsened by palpation. Table 3 below details dehydration severity and symptoms. Signs. depressed consciousness.
4-9% of cases Enteric-type adenovirus . hyacinths.6-8% of cases Salmonella .Unknown Aeromonas hydrophila . copper. mistletoe.0-1% of cases V cholerae . daffodils. azalea.10-20% of cases Calicivirus . zinc) o Ingestion of plants (eg. theophylline) Disorders of digestive/absorptive processes Glucose-galactose malabsorption Sucrase-isomaltase deficiency Late-onset (adult-type) hypolactasia.3-5% of cases Shigella . theobromine.1-3% of cases G lamblia .0-2% of cases Vibrio parahaemolyticus .25-40% of cases Norovirus .1-2% of cases C difficile . Amanitaspecies mushrooms Infectious causes of acute diarrhea in developed countries o Viruses Rotavirus . resulting in lactose intolerance o Chemotherapy or radiation-induced enteritis o Surgical conditions Acute appendicitis Intussusception o Vitamin deficiencies Niacin deficiency Folate deficiency o Vitamin toxicity Vitamin C Niacin.2-4% of cases o Bacteria Campylobacter jejuni . vitamin B3 o Ingestion of heavy metals or toxins (eg. tin.0-2% of cases o Parasites Cryptosporidium .Methylxanthines (caffeine.0-3% of cases Y enterocolitica .1-20% of cases Astrovirus .1-3% of cases o .3-7% of cases E Coli .
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