Evaluation of diarrhea in children

Author
Gary R Fleisher, MD
Section Editors
Stephen J Teach, MD, MPH
Teresa K Duryea, MD
Deputy Editor
James F Wiley, II, MD, MPH

Disclosures
Last literature review version 19.3: Fri Sep 30 00:00:00 GMT 2011 | This topic last
updated: Mon Nov 07 00:00:00 GMT 2011(More)

INTRODUCTION — Diarrhea refers to the passage of loose or watery stools. The World
Health Organization (WHO) defines a case as the passage of three or more loose or watery
stools per day [1]. Nevertheless, absolute limits of normalcy are difficult to define; any
deviation from the child's usual pattern should arouse some concern (particularly with ill
appearance, the passage of blood or mucus, or dehydration) regardless of the actual
number of stools or their water content.

CAUSES — Acute infectious gastroenteritis due to viruses accounts for most bouts of
diarrhea in developed countries, resulting in more than 1.5 million outpatient visits and
200,000 hospitalizations in the United States annually [1]. However, watery and/or frequent
stools may be the initial manifestation of a wide spectrum of acute and chronic disorders
(table 1) [2].

Life-threatening conditions — A number of disorders causing diarrhea may be life

threatening in children (table 1 and algorithm 1) [3]. Particularly urgent are
intussusception, hemolytic uremic syndrome (HUS), pseudomembranous colitis,
appendicitis, toxic megacolon, and in very young infants, the congenital secretory diarrheas.

Intussusception — Intussusception is most common from 6 to 12 months of age, and the

vast majority of cases occur in the first two years of life. Most children with intussusception
develop the sudden onset of intermittent, severe, crampy abdominal pain, accompanied by
inconsolable crying and drawing up of the legs toward the abdomen, but some present with
bloody diarrhea. The episodes of pain usually occur at 15 to 20 minute intervals. They
become more frequent and may be followed initially by emesis of gastric contents. Bilious
emesis may develop as the obstruction progresses. Between the painful episodes, the child
may behave normally. As a result, initial symptoms can be confused with gastroenteritis. As
symptoms progress, increasing lethargy develops, which can be mistaken for meningitis.

The attacks also can be separated by periods of apathy followed by vomiting and the
passage of "currant jelly" stool (representing a mixture of blood and mucus). A sausage-
shaped abdominal mass may be felt in the right side of abdomen. The prevalence of blood
in the stool is as high as 70 percent if occult blood is included and increases with the
duration of symptoms. However, the classically described triad of pain, a palpable sausage-
shaped abdominal mass, and currant-jelly stool is seen in less than 15 percent of patients at
the time of presentation. Up to 20 percent of young infants have no obvious pain. Patients
do not pass blood or mucus or develop an abdominal mass in approximately one-third of
cases. Some infants and many older children have pain alone without other signs or
symptoms. (See "Intussusception in children".)

Hemolytic uremic syndrome — Hemolytic uremic syndrome (HUS), although uncommon,

merits consideration in any child with bloody diarrhea, particularly in the first five years of
life, because it is a potentially fatal illness. It complicates 6 to 9 percent of
enterohemorrhagic E. coli infections with the 0157:H7 strain and usually begins 5 to 10
days after the onset of diarrhea. HUS, which has a sudden onset, is characterized by the
triad of (see "Clinical manifestations and diagnosis of Shiga-like toxin associated (typical)
hemolytic uremic syndrome in children", section on 'Clinical and laboratory manifestations'):

 Microangiopathic hemolytic anemia

 Thrombocytopenia
 Acute renal failure

Children typically have a prodromal illness with abdominal pain, vomiting, and diarrhea that
precedes the development of HUS by a few days, as a result of which a patient may have no
signs of hemolysis or renal failure when seen earlier in the course. The diarrhea and
associated gastrointestinal complaints may mimic those of ulcerative colitis, other enteric
infections, and appendicitis. (See "Clinical manifestations and diagnosis of Shiga-like toxin
associated (typical) hemolytic uremic syndrome in children", section on 'Evaluation and
diagnosis'.)

Pseudomembranous colitis — This rare but serious disorder results from an overgrowth
of toxin-producing clostridial organisms in the bowel. The typical presentation is acute
watery diarrhea with lower abdominal pain, low-grade fever, and leukocytosis, starting
during or shortly after antibiotic administration. The course can be fulminant, progressing
from diarrhea to toxic megacolon and shock [4]. Community-associated infection with a
highly toxigenic strain of Clostridium difficile has been reported in otherwise healthy children
who had minimal or no exposure to antibiotics. (See "Clostridium difficile infection in
children: Clinical features" and "Clostridium difficile infection in children: Microbiology,
pathogenesis, and epidemiology", section on 'Hypervirulent strain (BI/NAP1/027)'.)

Appendicitis — Appendicitis typically begins with diffuse abdominal pain followed by

vomiting, often in association with constipation. The three most predictive clinical features
are (see "Acute appendicitis in children: Clinical manifestations and diagnosis", section on
'Classic signs'):

 Pain in the right lower quadrant

 Abdominal wall rigidity
 Migration of periumbilical pain to the right lower quadrant

Less commonly, appendicitis may cause diarrhea. In a retrospective series of 63 children

less than three years of age with appendicitis, 33 percent had diarrhea as an initial
symptom. The presumed mechanism for the diarrhea is irritation of the colon by the
inflamed appendix. The stools are usually of low volume and with mucus. (See "Acute
appendicitis in children: Clinical manifestations and diagnosis", section on 'History'.)
The diagnosis of appendicitis as the cause of diarrhea may be delayed because the classic
constellation of findings is absent. This is particularly true in very young children or among
patients of any age who have a perforated appendix and a long duration of illness. However,
abdominal tenderness will be greater than would be expected with gastroenteritis.
(See "Acute appendicitis in children: Clinical manifestations and diagnosis", section on
'Physical findings'.)

Toxic megacolon — Toxic megacolon can occur as a complication of Shigella infection,

pseudomembranous colitis, Hirschsprung disease, or inflammatory bowel disease. These
conditions are reviewed elsewhere. (See "Treatment of ulcerative colitis in children and
adolescents" and "Congenital aganglionic megacolon (Hirschsprung disease)" and "Clinical
manifestations and diagnosis of Shigella infection", section on 'Toxic megacolon'.)

Congenital secretory diarrheas — Congenital secretory diarrheas are characterized by

profuse watery diarrhea beginning at or shortly after birth and are rare. They are caused by
a variety of inherited disorders that disrupt nutrient digestion, absorption, or transport,
enterocyte development and function, or enteroendocrine function (table 2). (See "Overview
of the causes of chronic diarrhea in children", section on 'Congenital secretory and osmotic
diarrheas'.)

Common conditions — The common causes of diarrhea are infections with viruses and
bacteria, diarrhea due to a systemic infection other than gastrointestinal, diarrhea
associated with antibiotic administration, and feeding related diarrhea [3].

 By far, the single most common diarrheal disorder seen in the emergency
department and in general practice is viral gastroenteritis. In one series of children
two months to two years of age, a viral etiology was identified in 60 percent of all
cases of diarrhea and in 85 percent of moderately severe and severe episodes [5].
(See "Epidemiology, pathogenesis, clinical presentation and diagnosis of viral
gastroenteritis in children".)
 Extraintestinal infections (such as otitis media, urinary tract infections, and
pneumonia) can cause acute diarrhea that is usually mild and self-limited.
(See "Acute otitis media in children: Epidemiology, microbiology, clinical
manifestations, and complications", section on 'Symptoms and signs'.)
 Antibiotic associated diarrhea (AAD) occurs commonly with many antibiotics,
including amoxicillin which is frequently prescribed in pediatrics. In one prospective
series, 18 percent of children less than two years of age developed diarrhea
associated with antibiotic use [6]. The pathophysiology of AAD is poorly understood,
but is likely related to disruption in fecal flora [7].
 Overfeeding (particularly with hyperosmolar fluids) may cause diarrhea as the result
of increased osmotic load. Diarrhea may also occur when intake of solid foods is
limited (sometimes referred to as "starvation stools"). (See "Malnutrition in
developing countries: Clinical assessment", section on 'Diarrhea and dehydration'.)
 Lactase deficiency, when it occurs in younger children, this is usually a transient
problem, caused by mucosal injury from an enteric infection [8]. In older children
and adolescents, this may be a primary lactase deficiency (also known as adult-type
 hypolactasia or lactase nonpersistence), that affects up to 70 percent of normal
adults. (See "Lactose intolerance".)

Other conditions — Cryptosporidium is an intracellular protozoan parasite that is

associated with sporadic outbreaks of self-limited diarrhea in immunocompetent hosts,
sometimes in relationship to contaminated drinking water; chronic life-threatening illness in
immunocompromised patients, especially those with human immunodeficiency virus; and
diarrhea and malnutrition in young children in developing countries. (See "Epidemiology,
clinical manifestations, and diagnosis of cryptosporidiosis", section on 'Epidemiology'.)

Toxic ingestions (such as contaminated food and organophosphates) can cause diarrhea.
(See "Food poisoning in children" and "Organophosphate and carbamate poisoning".)

A number of uncommon conditions (table 1) can cause diarrhea that is usually chronic.
These include primary immunodeficiencies, diarrhea related to HIV infection, food allergies,
celiac disease, inflammatory bowel disease, cystic fibrosis, acrodermatitis enteropathica,
secretory tumors, endocrine disorders (particularly hyperthyroidism), and neonatal drug
withdrawal. (See "Overview of the causes of chronic diarrhea in children" and "Clinical
manifestations of food allergy: An overview" and "Zinc deficiency and supplementation in
children and adolescents", section on 'Zinc malabsorption' and "Clinical characteristics of
carcinoid tumors" and "Neonatal opioid withdrawal".)

ACUTE DIARRHEA

History — There are a number of historical factors to consider. Among the first is the
immune status of the child, as immunocompromise increases the risk for infections with
unusual organisms, the prevalence of which varies with the degree of immunosuppression
and the nature of the underlying condition.

Another feature of the illness to identify is whether the diarrhea is acute or chronic. An
acute diarrheal illness is typically defined as a duration of five days or less. Symptoms that
have persisted for longer suggest other diagnoses, such as those discussed below.
(See 'Chronic diarrhea' below.)

Institutionalized children and those recently returning from developing countries are more
likely to have bacterial or parasitic pathogens. (See "Travelers' diarrhea".)

A history of recent antibiotic use suggests the possibility of pseudomembranous colitis.

(See "Clostridium difficile infection in children: Clinical features", section on 'Clinical
manifestations'.)

Two features of the diarrheal illness, either alone or in combination, that are particularly
helpful in sorting through the differential diagnosis are the presence of fever and bloody or
mucousy diarrhea. (See 'Algorithmic approach to the patient' below.)

Physical examination — The patient who requires volume resuscitation must be quickly
identified. Clinical evidence of dehydration such as decreased urine output, tachycardia, and
dry mucus membranes are already apparent at a deficit of 5 percent of body weight. The
most useful signs for predicting a volume deficit of 5 percent or more include delayed
capillary refill time greater than two seconds, reduced skin turgor, and deep respirations
with or without an increase in respiratory rate, particularly if a combination of these findings
is present. (See "Clinical assessment and diagnosis of hypovolemia (dehydration) in
children", section on 'Degree of dehydration'.)

In addition to identifying volume depletion, a thorough examination must be performed

because systemic, non-enteric infections, particularly otitis media, may cause diarrhea. A
palpable mass or peritonitis suggests appendicitis, intussusception or, less commonly, toxic
megacolon. Generalized toxicity and/or shock may occur with hemolytic uremic syndrome or
with sepsis, such as from Salmonella or staphylococcal toxic shock syndrome [9].
(See "Clinical manifestations and diagnosis of Shiga-like toxin associated (typical) hemolytic
uremic syndrome in children", section on 'Clinical and laboratory manifestations'.)

Laboratory testing and imaging — Information gathered from the history and physical
examination will suggest useful laboratory tests and imaging studies:

 Diarrhea usually results in isotonic volume depletion. Although clinically significant

electrolyte disturbances do not occur frequently, children who are ill-appearing or
who have significant dehydration requiring intravenous rehydration should have
serum electrolytes measured. (See "Clinical assessment and diagnosis of
hypovolemia (dehydration) in children".)
 A stool culture should be performed in febrile children with frankly bloody or
mucousy diarrhea. A bacterial pathogen will be identified in 15 to 20 percent of cases
[10-12]. Routine cultures of stool are not recommended for nonbloody diarrhea of
brief duration in otherwise healthy children. Stool for Clostridium difficile should be
sent in patients with bloody diarrhea who have been on antibiotics. Stool for ova and
parasites is indicated for children who have traveled to or reside in an endemic area.
 Viral antigen tests of stool (especially for rotavirus during times of high prevalence)
may be helpful in distinguishing acute viral gastroenteritis from a bacterial process,
but they are generally not necessary for most patients.
 Infants and young children with urinary tract infections may have diarrhea. Thus, a
urine culture should be obtained in young children at risk for urinary tract infection
when diarrhea occurs in a febrile child and no other source of infection is identified.
(See "Clinical features and diagnosis of urinary tract infections in children", section
on 'Decision to obtain'.)

Imaging studies such as abdominal ultrasound, abdominal computed tomography, and air
contrast enema may also be helpful in children with diarrhea and findings suggestive of
intussusception, and less commonly, appendicitis as follows:

 Abdominal ultrasound is a noninvasive technique to identify an intussusception. It is

also useful in the initial evaluation of appendicitis, particularly in girls where there
may be a possibility of ovarian torsion. (See "Intussusception in children", section on
'Ultrasonography' and "Acute appendicitis in children: Diagnostic imaging", section
on 'Ultrasonography'.)
  Contrast enema confirms the ultrasound diagnosis and in most cases provides
treatment of ileocolic intussusception. (See "Intussusception in children", section on
'Nonoperative reduction'.)
 Abdominal computed tomography can provide important diagnostic information in
patients who may have a significant intraabdominal process, including appendicitis.
(See "Acute appendicitis in children: Diagnostic imaging", section on 'Computed
tomography'.)

Algorithmic approach to the patient — An algorithmic approach provides clinical

guidance to the diagnostic approach of diarrhea in children (algorithm 1 and algorithm
2 and algorithm 3) [3].

Immunocompromised patients are at risk for unusual infections and require a rigorous
approach in accordance with protocols specific to the underlying disorder. First, the
physician should determine whether the child appears seriously ill (algorithm 1)or has signs
of a surgical abdominal process. A palpable mass or peritonitis suggests appendicitis,
intussusception, or, less commonly, toxic megacolon. Generalized toxicity and/or shock may
occur with hemolytic uremic syndrome and with sepsis, such as from Salmonella [9] or
staphylococcal toxic shock syndrome. Seizures may be seen with shigellosis, occasionally
before the onset of diarrhea. Profuse diarrhea in associate with excessive salivation,
lacrimation, and urination suggests organophosphate ingestion. Immunocompromised
patients (algorithm 2)are at risk for unusual infections and require a rigorous approach in
accordance with protocols specific to the underlying disorder.

Next, the physician focuses on those with acute diarrhea (algorithm 2), as these patients
are more likely to require a diagnostic or therapeutic intervention. Fever and bloody or
mucousy diarrhea, either alone or in combination, are particularly helpful in sorting through
the differential diagnosis (algorithm 2):

 Blood is seen in the stool of up to 10 percent of children with diarrhea. In most

cases, the blood appears in small quantities as drops on the surface of the stool and
should not be construed as ominous.
 A small percentage of children with diarrhea, however, have more profuse rectal
bleeding. Particularly in these patients, one must exclude life-threatening disorders
such as intussusception, HUS, and pseudomembranous colitis. (See "Diagnostic
approach to lower gastrointestinal bleeding in children", section on 'Causes of
bleeding'.)
 Mucousy diarrhea, with or without blood, suggests bacterial enteritis [11,12].

Febrile with non-bloody diarrhea — The presence of fever in an immunocompetent child

with diarrhea is the hallmark of infection. Most febrile children with nonbloody diarrhea have
viral enteritis. (See "Epidemiology, pathogenesis, clinical presentation and diagnosis of viral
gastroenteritis in children".)

Afebrile with non-bloody diarrhea — Many afebrile children with nonbloody diarrhea will
also have viral enteritis. For those taking antibiotics, such as amoxicillin, the diarrhea may
be related to the medication [6,7]. Overfeeding may cause diarrhea during the first 6 to 12
months of life. The tip-off to this diagnosis is the history of excessive fluid intake in an
overweight child [13].

Febrile with bloody diarrhea — Febrile children with bloody and/or mucousy diarrhea
typically have infectious bacterial enteritis. (See "Epidemiology and causes of acute diarrhea
in developed countries", section on 'Bloody diarrhea'.)

Possible exceptions include the following:

 Pseudomembranous colitis is an important consideration in children with bloody

diarrhea who have also received antibiotic therapy, especially if systemic toxicity,
abdominal distension, and gross blood in the stools are present. (See "Clostridium
difficile infection in children: Clinical features", section on 'Clinical manifestations'.)
 Amebiasis merits consideration in children or immigrants from endemic areas (eg,
India, Africa, Mexico, Central and South America) and, less commonly, among
travelers to these regions. (See "Intestinal Entamoeba histolytica amebiasis", section
on 'Epidemiology'.)
 An occasional child with inflammatory bowel disease may present with an initial
episode of acute, bloody diarrhea. In most of these cases, the physician can elicit a
preceding history of weight loss or recurrent abdominal pain. (See "Diagnosis of
inflammatory bowel disease in children and adolescents", section on 'Symptoms
suggesting colitis'.)

Afebrile with bloody diarrhea — Afebrile children with bloody diarrhea represent the
most worrisome category because most patients with intussusception, hemolytic-uremic
syndrome (HUS), and pseudomembranous colitis have this symptom constellation:

 Intussusception should be considered carefully in any child less than one year of age
with grossly bloody diarrhea that does not appear to have an infectious cause. A
history of severe, colicky abdominal pain in a lethargic child warrants an abdominal
ultrasound or contrast enema. (See "Intussusception in children", section on 'Clinical
manifestations'.)
 Bloody diarrhea with pallor, purpura, elevated serum blood urea nitrogen or
creatinine, and hematuria point to HUS. (See "Clinical manifestations and diagnosis
of Shiga-like toxin associated (typical) hemolytic uremic syndrome in children",
section on 'Clinical and laboratory manifestations'.)
 Prior antibiotic therapy raises the possibility of pseudomembranous colitis.
(See "Clostridium difficile infection in children: Clinical features", section on 'Clinical
manifestations'.)

The most common diagnosis, infectious bacterial enteritis, should be made only after
exclusion of the more serious disorders by history, physical examination, and occasionally,
laboratory or imaging studies.

Therapeutic interventions — Children with life-threatening causes for diarrhea warrant

specific therapy dictated by the underlying condition. (See 'Life-threatening
conditions' above.)
Parenteral fluid resuscitation with an isotonic solution (eg, normal saline) should be initiated
promptly in children with moderate to severe dehydration or circulatory compromise and
may be particularly important in preventing oliguric renal failure in those with patients with
hemolytic uremic syndrome. Patients with toxic megacolon and intussusception may also
have significant ongoing third space losses that must be replaced. (See "Treatment of
Shiga-like toxin associated (typical) hemolytic uremic syndrome in children", section on
'Fluid' and "Treatment of hypovolemia (dehydration) in children".)

Most children with diarrhea will not require intravenous hydration. Treatment with oral
rehydration solutions should be encouraged as the first line therapy for both rehydration
and maintenance therapy in patients who have mild to moderate dehydration and can drink.
(See "Oral rehydration therapy".)

Antibiotics should not be used for children with acute bloody diarrhea unless a specific
pathogen has been isolated. Antibiotic therapy may be a risk factor for the development of
hemolytic uremic syndrome in patients with bloody diarrhea due to E. Coli O157:H7, which
may be indistinguishable from bloody diarrhea seen with other non E Coli bacterial etiologies
[14]. (See "Clinical manifestations, diagnosis and treatment of enterohemorrhagic
Escherichia coli (EHEC)", section on 'Treatment'.)

Probiotics refer to products derived from food sources, especially cultured milk products.
The list of such microorganisms continues to grow and includes a variety of different strains
of bacteria. Probiotics appear to have only a modest effect on recovery from infectious
diarrhea. Systematic reviews also suggest that probiotics (including various bacterial species
and the yeast S. boulardii) are effective in reducing the incidence of diarrhea in patients
who are taking antibiotics. However, discordant data have been published and there is little
detailed information regarding the optimal dose or timing of supplementation or the effects
on subgroups of patients. The use of probiotics for these indications is discussed in more
detail separately. (See "Probiotics for gastrointestinal diseases", section on 'Antibiotic-
associated diarrhea' and "Probiotics for gastrointestinal diseases", section on 'Infectious
diarrhea'.)

Disposition — The majority of children with infectious diarrhea have mild to moderate
dehydration and can be managed as outpatients after receiving appropriate assessment and
oral rehydration therapy.

Hospital admission is warranted in children with any one of the following findings:

 Diagnosis of or strong clinical suspicion for a life-threatening cause of diarrhea, such

as HUS or other systemic illnesses (see 'Life-threatening conditions' above)
 Severe dehydration or significant electrolyte abnormalities upon presentation
(see "Clinical assessment and diagnosis of hypovolemia (dehydration) in children",
section on 'Degree of dehydration')
 Lack of improvement with rehydration
 Continued copious diarrhea that is likely to lead to recurrent dehydration if
intravenous replacement of ongoing losses does not occur
 Inability to drink
Persistent symptoms — The child who returns with the persistence of an acute diarrheal
illness, initially presumed to be viral in origin and with no evidence of malnutrition or
dehydration, often can be managed without an extensive evaluation. Common causes, in
addition to persistent viral infection, are:

 Bacterial infections
 Parasitic infections
 Starvation stools in the child who inadvertently has been continued on a clear liquid
diet for several days
 Secondary lactase deficiency following viral enteritis

A stool culture should be obtained, and testing for clostridial toxin is indicated in children
who have had recent antibiotic therapy. Gradual refeeding is recommended if the child has
remained on a clear liquid diet.

CHRONIC DIARRHEA — A brief initial evaluation of the child with chronic diarrhea in the
acute setting (eg, emergency department) is described below (algorithm 3 and table 1). A
more comprehensive diagnostic approach to chronic diarrheal diseases in developed
countries is discussed in detail separately. (See "Overview of the causes of chronic diarrhea
in children" and "Approach to the diagnosis of chronic diarrhea in children in developed
countries".)

In the developing world, chronic diarrhea typically is associated with serial enteric infections
and malnutrition. This common pathophysiology calls for a distinct algorithmic approach to
diagnosis and treatment, which is discussed separately. (See "Persistent diarrhea in children
in developing countries".)

History — The following historical features may indicate serious underlying disease:

 A history of delayed passage of meconium, constipation since birth, and abdominal

distension are compatible with Hirschsprung disease.
 Malabsorptive stools and respiratory infections suggest cystic fibrosis.
 Failure to thrive, thrush, and pneumonia occur in association with human
immunodeficiency virus (HIV) infection.
 A prolonged history of diarrhea (>1 month) points to inflammatory bowel disease,
particularly if the diarrhea is bloody, or to irritable bowel syndrome, malabsorption
(eg, cystic fibrosis), immunodeficiency, secretory disorders, or anatomic
abnormalities (eg, Hirschsprung disease). (See "Epidemiology and environmental
factors in inflammatory bowel disease in children and adolescents".)
 In those children with diarrhea of intermediate duration (one to four weeks), the
physician should consider an appendiceal abscess (particularly with the finding of
abdominal tenderness or a history of abdominal pain), bacterial enteritis, and
parasitic infestations.

Physical examination — The child's overall state of nutrition may indicate the severity and
or duration of symptoms. Physical findings associated with inflammatory bowel disease such
as weight loss, arthritis or aphthous ulcers may point to that diagnosis.
Laboratory testing — A stool culture diagnoses serious infections of the gastrointestinal
tract and provides a head start on the evaluation for the physician who subsequently sees
the child. Parasitic infections merit consideration as well, particularly in individuals with a
history of recent immigration, travel to an underdeveloped country, or backcountry
camping.

Algorithmic approach to the patient — A child with chronic diarrhea who presents in an
acute care setting is infrequently seriously ill. The evaluation usually requires a period of
observation and ancillary studies rather than urgent diagnostic and therapeutic intervention.
Urgent conditions are suggested by a history of bloody diarrhea or the physical finding of
abdominal tenderness (algorithm 3).

Appendicitis and bacterial enteritis are urgent conditions that must be identified. Other less
urgent diagnoses include Hirschsprung disease or cystic fibrosis. (See "Congenital
aganglionic megacolon (Hirschsprung disease)" and "Cystic fibrosis: Overview of
gastrointestinal disease" and "Overview of the causes of chronic diarrhea in
children" and "Approach to the diagnosis of chronic diarrhea in children in developed
countries".)

Disposition — The child with chronic diarrhea who is well-appearing and tolerates oral
fluids can be managed as an outpatient. The key factor in successfully diagnosing the
etiology of the diarrhea is good follow-up with a primary care provider.

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education

materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are
written in plain language, at the 5th to 6th grade reading level, and they answer the four or
five key questions a patient might have about a given condition. These articles are best for
patients who want a general overview and who prefer short, easy-to-read materials. Beyond
the Basics patient education pieces are longer, more sophisticated, and more detailed.
These articles are written at the 10th to 12th grade reading level and are best for patients
who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to
print or e-mail these topics to your patients. (You can also locate patient education articles
on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)

 Basics topics (see "Patient information: Diarrhea in children (The Basics)")

 Beyond the Basics topics (see "Patient information: Acute diarrhea in children")

SUMMARY

 The approach to the evaluation of acute diarrhea is summarized in the algorithms

(algorithm 1 and algorithm 2). The table summarizes the causes of diarrhea,
highlighting the most common and the most life threatening pediatric causes (table
1).
 Two features of acute diarrheal illness, either alone or in combination, that are
particularly helpful in sorting through the differential diagnosis are the presence of
 fever and bloody or mucousy diarrhea. (See 'History' above and 'Algorithmic
approach to the patient' above.)
 The patient with acute diarrhea who requires volume resuscitation must be quickly
identified. Clinical evidence of dehydration such as decreased urine output,
tachycardia, and dry mucus membranes are already apparent at a deficit of 5
percent of body weight. The most useful signs for predicting a volume deficit of 5
percent or more include delayed capillary refill time greater than two seconds,
reduced skin turgor, and deep respirations with or without an increase in respiratory
rate, particularly if a combination of these findings is present. (See 'Physical
examination' above.)
 In addition to identifying volume depletion, a thorough examination must be
performed because systemic, non-enteric infections, particularly otitis media, may
cause acute diarrhea. A palpable mass or peritonitis suggests appendicitis,
intussusception or, less commonly, toxic megacolon. Generalized toxicity and/or
shock may occur with hemolytic uremic syndrome or with sepsis, such as from
Salmonella or staphylococcal toxic shock syndrome. (See 'Physical
examination' above.)
 Ancillary studies in children with acute diarrhea are based upon a careful history and
physical examination. (See 'Laboratory testing and imaging' above.)
 A brief initial evaluation of the child with chronic diarrhea in the acute setting (eg,
emergency department) is described above (algorithm 3 and table 1). (See 'Chronic
diarrhea' above.)
 A more comprehensive diagnostic approach to chronic diarrheal diseases in
developed and developing countries is discussed in greater detail separately.
(See "Overview of the causes of chronic diarrhea in children" and "Approach to the
diagnosis of chronic diarrhea in children in developed countries" and "Persistent
diarrhea in children in developing countries".)

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