Diarrhea

Diarrhea is loose, watery stools. A person with diarrhea typically passes stool more than three times a day. People
with diarrhea may pass more than a quart of stool a day. Acute diarrhea is a common problem that usually lasts 1
or 2 days and goes away on its own without special treatment. Prolonged diarrhea persisting for more than 2 days
may be a sign of a more serious problem and poses the risk of dehydration. Chronic diarrhea may be a feature of a
chronic disease.

Diarrhea can cause dehydration, which means the body lacks enough fluid to function properly. Dehydration is
particularly dangerous in children and older people, and it must be treated promptly to avoid serious health
problems. See Dehydration.

People of all ages can get diarrhea and the average adult has a bout of acute diarrhea about four times a year. In
the United States, each child will have had seven to 15 episodes of diarrhea by age 5.

What causes diarrhea?

Acute diarrhea is usually related to a bacterial, viral, or parasitic infection. Chronic diarrhea is usually related to
functional disorders such as irritable bowel syndrome or inflammatory bowel disease.
A few of the more common causes of diarrhea include the following:
 Bacterial infections. Several types of bacteria consumed through contaminated food or water can cause
diarrhea. Common culprits include Campylobacter, Salmonella, Shigella, and Escherichia coli (E. coli).
 Viral infections. Many viruses cause diarrhea, including rotavirus, Norwalk virus, cytomegalovirus, herpes
simplex virus, and viral hepatitis.

 Food intolerances. Some people are unable to digest food components such as artificial sweeteners and
lactose—the sugar found in milk.

 Parasites. Parasites can enter the body through food or water and settle in the digestive system. Parasites
that cause diarrhea include Giardia lamblia, Entamoeba histolytica, andCryptosporidium.

 Reaction to medicines. Antibiotics, blood pressure medications, cancer drugs, and antacids containing
magnesium can all cause diarrhea.

 Intestinal diseases. Inflammatory bowel disease, colitis, Crohn’s disease, and celiac disease often lead to
diarrhea.

 Functional bowel disorders. Diarrhea can be a symptom of irritable bowel syndrome.

Some people develop diarrhea after stomach surgery or removal of the gallbladder. The reason may be a change in
how quickly food moves through the digestive system after stomach surgery or an increase in bile in the colon after
gallbladder surgery.

People who visit foreign countries are at risk for traveler’s diarrhea, which is caused by eating food or drinking
water contaminated with bacteria, viruses, or parasites. Traveler’s diarrhea can be a problem for people visiting
developing countries. Visitors to the United States, Canada, most European countries, Japan, Australia, and New
Zealand do not face much risk for traveler’s diarrhea. See Preventing Traveler’s Diarrhea.

In many cases, the cause of diarrhea cannot be found. As long as diarrhea goes away on its own, an extensive
search for the cause is not usually necessary.

What are the symptoms of diarrhea?

Diarrhea may be accompanied by cramping, abdominal pain, bloating, nausea, or an urgent need to use the
bathroom. Depending on the cause, a person may have a fever or bloody stools.
Diarrhea in Children
Children can have acute and chronic forms of diarrhea. Causes include bacteria, viruses, parasites, medications,
functional bowel disorders, and food sensitivities. Infection with the rotavirus is the most common cause of acute
childhood diarrhea. Rotavirus diarrhea usually resolves in 3 to 9 days. Children who are 6 to 32 weeks old can be
vaccinated against the virus with a vaccine called Rotateq.

If your child has diarrhea, do not hesitate to call the doctor for advice. Diarrhea is especially dangerous in
newborns and infants, leading to dehydration in just a day or two. A child can die from dehydration within a few
days. The main treatment for diarrhea in children is rehydration to replace lost fluid quickly. See Dehydration.

Take your child to the doctor if there is no improvement after 24 hours or if any of the following symptoms appear:

 stools containing blood or pus

 black stools

 a temperature above 102 degrees

 signs of dehydration

Medications to treat diarrhea in adults can be dangerous for children and should only be given with a doctor’s
guidance.

Dehydration
Diarrhea can cause dehydration, which means the body has lost too much fluid and too many electrolytes and can’t
function properly. Dehydration is particularly dangerous in children and in older adults and must be treated
promptly to avoid serious health problems.

Signs of dehydration include

 thirst
 less frequent urination

 dry skin

 fatigue

 light-headedness

 dark-colored urine

Signs of dehydration in children include

 dry mouth and tongue

 no tears when crying

 no wet diapers for 3 hours or more

 sunken abdomen, eyes, or cheeks

 high fever

 listlessness or irritability
  skin that does not flatten when pinched and released

If you suspect that you or your child is dehydrated, call the doctor immediately. Severe dehydration may require
hospitalization.

Preventing Dehydration
The fluid and electrolytes lost during diarrhea need to be replaced promptly because the body cannot function
without them. Electrolytes are the salts and minerals that affect the amount of water in your body, muscle activity,
and other important functions.

Although water is extremely important in preventing dehydration, it does not contain electrolytes. Broth and soups
that contain sodium, and fruit juices, soft fruits, or vegetables that contain potassium, help restore electrolyte
levels. Over-the-counter rehydration solutions such as Pedialyte, Ceralyte, and Infalyte are also good electrolyte
sources and are especially recommended for use in children.

When should a doctor be consulted?

Diarrhea is not usually harmful, but it can become dangerous or signal a more serious problem. You should see the
doctor if you experience any of the following:
 diarrhea for more than 3 days
 severe pain in the abdomen or rectum

 a fever of 102 degrees or higher

 blood in your stool or black, tarry stools

 signs of dehydration

How is the cause of diarrhea diagnosed?

Diagnostic tests to find the cause of diarrhea may include the following:

 Medical history and physical examination. The doctor will ask you about your eating habits and
medication use and will examine you for signs of illness.
 Stool culture. A sample of stool is analyzed in a laboratory to check for bacteria, parasites, or other signs
of disease and infection.

 Blood tests. Blood tests can be helpful in ruling out certain diseases.

 Fasting tests. To find out if a food intolerance or allergy is causing the diarrhea, the doctor may ask you to
avoid lactose, carbohydrates, wheat, or other foods to see whether the diarrhea responds to a change in
diet.

 Sigmoidoscopy. For this test, the doctor uses a special instrument to look at the inside of the rectum and
lower part of the colon.

 Colonoscopy. This test is similar to a sigmoidoscopy, but it allows the doctor to view the entire colon.

 Imaging tests. These tests can rule out structural abnormalities as the cause of diarrhea.

How is diarrhea treated?

In most cases of diarrhea, replacing lost fluid to prevent dehydration is the only treatment necessary. Medicines
that stop diarrhea may be helpful, but they are not recommended for people whose diarrhea is caused by a
bacterial infection or parasite. If you stop the diarrhea before having purged the bacteria or parasite, you will trap
the organism in the intestines and prolong the problem. Rather, doctors usually prescribe antibiotics as a first-line
treatment. Viral infections are either treated with medication or left to run their course, depending on the severity
and type of virus.

Tips About Food

Until diarrhea subsides, try to avoid caffeine, milk products, and foods that are greasy, high in fiber, or very sweet.
These foods tend to aggravate diarrhea.
As you improve, you can add soft, bland foods to your diet, including bananas, plain rice, boiled potatoes, toast,
crackers, cooked carrots, and baked chicken without the skin or fat. For children, the pediatrician may also
recommend a bland diet. Once the diarrhea has stopped, the pediatrician will likely encourage children to return to
a normal

Preventing Traveler’s Diarrhea

Traveler’s diarrhea happens when you consume food or water contaminated with bacteria, viruses, or parasites.
You can take the following precautions to prevent traveler’s diarrhea when you travel outside of the United States:
 Do not drink tap water or use it to brush your teeth.
 Do not drink unpasteurized milk or dairy products.

 Do not use ice made from tap water.

 Avoid all raw fruits and vegetables, including lettuce and fruit salads, unless they can be peeled and you
peel them yourself.

 Do not eat raw or rare meat and fish.

 Do not eat meat or shellfish that is not hot when served.

 Do not eat food from street vendors.

You can safely drink bottled water—if you are the one to break the seal—along with carbonated soft drinks, and
hot drinks such as coffee or tea.

Depending on where you are going and how long you will stay, your doctor may recommend that you take
antibiotics before leaving to protect you from possible infection.

Hope through Research

The Division of Digestive Diseases and Nutrition at the National Institute of Diabetes and Digestive and Kidney
Diseases supports basic and clinical research into gastrointestinal conditions, including diarrhea. Among other
areas, researchers are studying how the processes of absorption and secretion in the digestive tract affect the
content and consistency of stool, the relationship between diarrhea and Helicobactor pylori, motility in chronic
diarrhea, and chemical compounds that may be useful in treating diarrhea.

Points to Remember
 Diarrhea is a common problem that usually resolves on its own.
 Diarrhea is dangerous if a person becomes dehydrated.

 Causes include viral, bacterial, parasitic infections, food intolerance, reactions to medicine, intestinal
diseases, and functional bowel disorders.

 Treatment involves replacing lost fluid and electrolytes. Depending on the cause of the problem, a person
might also need medication to stop the diarrhea or treat an infection. Children may need an oral
rehydration solution to replace lost fluid and electrolytes.
  Call the doctor if the person with diarrhea has severe pain in the abdomen or rectum, a fever of 102
degrees or higher, blood in the stool, signs of dehydration, or diarrhea for more than 3 days.

Diarrhea
In medicine, diarrhea (from the Greek, "diarrhoia" meaning "a flowing through"[1]), also
spelled diarrhoea (see spelling differences), is the condition of having frequent loose or liquid bowel
movements. Acute diarrhea is a common cause of death in developing countries and the second most
common cause of infant deaths worldwide. The loss of fluids through diarrhea can cause
severe dehydration which is one cause of death in diarrhea sufferers. A study with partial results released
in October 2009 suggests diarrhea is now estimated to cause 3 times more deaths than previously
thought, at 1.1 million annually for people aged 5 and over, up from 300,000 assumed in a 2002 study.
[2]
According to UNICEF, diarrhea kills some 1.5 million children under the age of 5 annually. [3] Also,
according to WHO statistics, some 50 million children have been saved thanks to the low cost treatment
of oral rehydration salts in the past 25 years.

Types of diarrhea

Secretory diarrhea

Secretory diarrhea means that there is an increase in the active secretion, or there is an inhibition of
absorption. There is little to no structural damage. The most common cause of this type of diarrhea is
a cholera toxin that stimulates the secretion of anions, especially chloride ions. Therefore, to maintain a
charge balance in the lumen, sodium is carried with it, along with water. In this type of diarrhoea intestinal
fluid secretion is isotonic with plasma even during fasting .[4]

Osmotic diarrhea

Osmotic diarrhea occurs when too much water is drawn into the bowels. This can be the result of
maldigestion (e.g., pancreatic disease or Coeliac disease), in which the nutrients are left in the lumen to
pull in water. Osmotic diarrhea can also be caused by osmotic laxatives (which work to
alleviate constipation by drawing water into the bowels). In healthy individuals, too
much magnesium or vitamin C or undigested lactose can produce osmotic diarrhea and distention of the
bowel. A person who has lactose intolerance can have difficulty absorbing lactose after an extraordinarily
high intake of dairy products. In persons who have fructose malabsorption, excess fructose intake can
also cause diarrhea. High-fructose foods that also have a high glucose content are more absorbable and
less likely to cause diarrhea. Sugar alcohols such as sorbitol (often found in sugar-free foods) are difficult
for the body to absorb and, in large amounts, may lead to osmotic diarrhea. [4]

Exudative diarrhea

Exudative diarrhea occurs with the presence of blood and pus in the stool. This occurs with inflammatory
bowel diseases, such as Crohn's disease or ulcerative colitis, and other severe infections.[4]

Motility-related diarrhea
Motility-related diarrhea is caused by the rapid movement of food through the intestines (hypermotility). If
the food moves too quickly through the GI tract, there is not enough time for sufficient nutrients and water
to be absorbed. This can be due to a vagotomy or diabetic neuropathy, or a complication
of menstruation[citation needed]. Hyperthyroidism can produce hypermotility and lead to pseudodiarrhea and
occasionally real diarrhea. Diarrhea can be treated with antimotility agents (such as loperamide).
Hypermotility can be observed in patients who have had portions of their bowel removed, allowing less
total time for absorption of nutrients.

Inflammatory diarrhea

Inflammatory diarrhea occurs when there is damage to the mucosal lining or brush border, which leads to
a passive loss of protein-rich fluids, and a decreased ability to absorb these lost fluids. Features of all
three of the other types of diarrhea can be found in this type of diarrhea. It can be caused by bacterial
infections, viral infections, parasitic infections, or autoimmune problems such as inflammatory bowel
diseases. It can also be caused by tuberculosis, colon cancer, and enteritis.

Dysentery

Generally, if there is blood visible in the stools, it is not diarrhea, but dysentery. The blood is trace of an
invasion of bowel tissue. Dysentery is a symptom of, among others, Shigella, Entamoeba histolytica,
andSalmonella.

Causes

Diarrhea commonly results from gastroenteritis caused by viral infections, parasites or bacterial toxins.
[5]
In sanitary living conditions where there is ample food and a supply of clean water, an otherwise healthy
patient usually recovers from viral infections in a few days. However, for ill or malnourished individuals,
diarrhea can lead to severe dehydration and can become life-threatening without treatment. [6]

It can also be a symptom of more serious diseases, such as dysentery, cholera, or botulism, and can also
be indicative of a chronic syndrome such as Crohn's disease or severemushroom poisoning syndromes.
Though appendicitis patients do not generally have violent diarrhea, it is a common symptom of a
ruptured appendix. It is also an effect of severeradiation sickness.

Symptomatic treatment for diarrhea involves the patient consuming adequate amounts of water to replace
that loss, preferably mixed with electrolytes to provide essential salts and some amount of nutrients. For
many people, further treatment is unnecessary. The following types of diarrhea indicate medical
supervision is required:

 Diarrhea in infants
 Moderate or severe diarrhea in young children;
 Diarrhea associated with blood

 Diarrhea that continues for more than two days;

 Diarrhea that is associated with more general illness such as non-cramping abdominal
pain, fever, weight loss, etc;

 Diarrhea in travelers, since they are more likely to have exotic infections such as parasites;

 Diarrhea in food handlers, because of the potential to infect others;

 Diarrhea in institutions such as hospitals, child care centers, or geriatric and convalescent homes.

A severity score is used to aid diagnosis in children.[7]

Infectious diarrhea
Main article: Infectious diarrhea

There are many causes of infectious diarrhea, which include viruses, bacteria and parasites.
[8]
Norovirus is the most common cause of viral diarrhea in adults, [9] but rotavirus is the most common
cause in children under five years old.[10] Adenovirus types 40 and 41),[11] and astroviruses cause a
significant number of infections.[12]

The bacterium campylobacter is a common cause of bacterial diarrhea, but infections

by salmonellae, shigellae and some strains of Escherichia coli (E.coli) are frequent.[13] In the elderly,
particularly those who have been treated with antibiotics for unrelated infections, a toxin produced
by Clostridium difficile often causes severe diarrhea.[14]

Parasites do not often cause diarrhea except for the protozoan Giardia, which can cause chronic
infections if these are not diagnosed and treated with drugs such as metronidazole,[15] and Entamoeba
histolytica.[16][17]

Malabsorption

Malabsorption is the inability to absorb food, mostly in the small bowel but also due to the pancreas.

Causes include celiac disease (intolerance to wheat, rye, and barley gluten, the protein of the
grain), lactose intolerance (intolerance to milk sugar, common in non-Europeans), fructose
malabsorption, pernicious anemia (impaired bowel function due to the inability to absorb vitamin B12),
loss of pancreatic secretions (may be due to cystic fibrosis or pancreatitis), short bowel
syndrome (surgically removed bowel), radiation fibrosis (usually following cancer treatment), and other
drugs, including agents used in chemotherapy.

Inflammatory bowel disease

The two overlapping types here are of unknown origin:

 Ulcerative colitis is marked by chronic bloody diarrhea and inflammation mostly affects the
distal colon near the rectum.
 Crohn's disease typically affects fairly well demarcated segments of bowel in the colon and often
affects the end of the small bowel.

Irritable Bowel Syndrome

Another possible cause of diarrhea is Irritable Bowel Syndrome (IBS). Symptoms defining IBS: abdominal
discomfort or pain relieved by defecation and unusual stool (diarrhea or constipation or both) or stool
frequency, for at least 3 days a week over the previous 3 months. [18] IBS symptoms can be present in
patients with a variety of conditions including food allergies, infective diarrhea, celiac, and inflammatory
bowel diseases. Treating the underlying condition (celiac disease, food allergy, bacterial dysbiosis, etc.)
usually resolves the diarrhea.[19] IBS can cause visceral hypersensitivity. While there is no direct treatment
for undifferentiated IBS, symptoms, including diarrhea, can sometimes be managed through a
combination of dietary changes, soluble fiber supplements, and/or medications.

It is important to note that IBS can often be confused with Giardiasis since false negative tests
for giardia can result in a misdiagnoses of the actual cause, a parasitic infection. [20]

Alcohol

Chronic diarrhea can be caused by chronic ethanol ingestion.[21] Consumption of alcohol affects the
body's capability to absorb water – this is often a symptom that accompanies a hangover after a binge
drinkingsession. The alcohol itself is absorbed in the intestines and as the intestinal cells absorb it, the
toxicity causes these cells to lose their ability to absorb water. This leads to an outpouring of fluid from the
intestinal lining, which is in turn poorly absorbed. The diarrhea usually lasts for several hours until the
alcohol is detoxified and removed from the digestive system. Symptoms range from person to person and
are influenced by the amount consumed as well as physiological differences.

Other important causes

 Ischemic bowel disease. This usually affects older people and can be due to blocked arteries.
 Bowel cancer: Some (but not all) bowel cancers may have associated diarrhea. Cancer of the
large intestine is most common.
 Hormone-secreting tumors: some hormones (e.g., serotonin) can cause diarrhea if excreted in
excess (usually from a tumor).
 Bile salt diarrhea: excess bile salt entering the colon rather than being absorbed at the end of
the small intestine can cause diarrhea, typically shortly after eating. Bile salt diarrhea is a bad side-
effect ofgallbladder removal. It is usually treated with cholestyramine, a bile acid sequestrant.
 Celiac Disease

 Intestinal protozoa such as Giardiasis

Treatment

In many cases of diarrhea, replacing lost fluid and salts is the only treatment needed. This is usually by
mouth – oral rehydration therapy – or, in very severe cases, intravenously.
Diet restriction, to known well-tolerated foods, and the BRAT diet and its extensions, may be used for 1-
to-3 days[22]. However, limiting milk to children has no effect on the duration of diarrhea. [23]
Medicines such loperamide (Imodium), bismuth subsalicylate (as found in Pepto Bismol and Kaopectate)
may be beneficial, however they may be contraindicated in certain situations.[24] Prescribed medications
sometimes contain pain-killers, such as morphine or codeine, to counter the cramps that can accompany
diarrhea.
Evolutionary medicine

According to two researchers into evolutionary medicine, Nesse and Williams,[25] diarrhea functions as an
evolved expulsion defense mechanism. As a result, if it is stopped, there might be a delay in illness
recovery. They cite in support of this argument research carried out by DuPont and Hornick that was
published in the Journal of the American Medical Association (JAMA)[26] showed that treating Shigella with
the anti-diarrhea drug (Lomotil) caused people to stay feverish twice as long as those not so treated. The
researchers indeed themselves observed that: "Lomotil may be contraindicated in shigellosis. Diarrhea
may represent a defense mechanism".
What is diarrhea?
Diarrhea is an increase in the frequency of bowel movements or a decrease in the form of stool (greater
looseness of stool). Although changes in frequency of bowel movements and looseness of stools can vary
independently of each other, changes often occur in both.
Diarrhea needs to be distinguished from four other conditions. Although these conditions may accompany
diarrhea, they often have different causes and different treatments than diarrhea. These other conditions
are:
1. incontinence of stool, which is the inability to control (delay) bowel movements until an
appropriate time, for example, until one can get to the toilet
2. rectal urgency, which is a sudden urge to have a bowel movement that is so strong that if a toilet
is not immediately available there will be incontinence

3. incomplete evacuation, which is a sensation that another bowel movement is necessary soon
after a bowel movement, yet there is difficulty passing further stool the second time

4. bowel movements immediately after eating a meal

How is diarrhea defined?

Diarrhea can be defined in absolute or relative terms based on either the frequency of bowel movements
or the consistency (looseness) of stools.
 Frequency of bowel movements.Absolute diarrhea is having more bowel movements than normal.
Thus, since among healthy individuals the maximum number of daily bowel movements is approximately
three, diarrhea can be defined as any number of stools greater than three. Relative diarrhea is having
more bowel movements than usual. Thus, if an individual who usually has one bowel movement each day
begins to have two bowel movements each day, then diarrhea is present-even though there are not more
than three bowel movements a day, that is, there is not absolute diarrhea.
Consistency of stools. Absolute diarrhea is more difficult to define on the basis of the consistency of
stool because the consistency of stool can vary considerably in healthy individuals depending on their
diets. Thus, individuals who eat large amounts of vegetables will have looser stools than individuals who
eat few vegetables. Stools that are liquid or watery are always abnormal and considered diarrheal.
Relative diarrhea is easier to define based on the consistency of stool. Thus, an individual who develops
looser stools than usual has diarrhea--even though the stools may be within the range of normal with
respect to consistency.

Why does diarrhea develop?

With diarrhea, stools usually are looser whether or not the frequency of bowel movements is increased.
This looseness of stool--which can vary all the way from slightly soft to watery--is caused by increased
water in the stool. During normal digestion, food is kept liquid by the secretion of large amounts of water
by the stomach, upper small intestine, pancreas, and gallbladder. Food that is not digested reaches the
lower small intestine and colon in liquid form. The lower small intestine and particularly the colon absorb
the water, turning the undigested food into a more-or-less solid stool with form. Increased amounts of
water in stool can occur if the stomach and/or small intestine secretes too much fluid, the distal small
intestine and colon do not absorb enough water, or the undigested, liquid food passes too quickly through
the small intestine and colon for enough water to be removed. Of course, more than one of these
abnormal processes may occur at the same time.

For example, some viruses, bacteria and parasites cause increased secretion of fluid, either by invading
and inflaming the lining of the small intestine (inflammation stimulates the lining to secrete fluid) or by
producing toxins (chemicals) that also stimulate the lining to secrete fluid but without causing
inflammation. Inflammation of the small intestine and/or colon from bacteria or from ileitis/colitis can
increase the rapidity with which food passes through the intestines, reducing the time that is available for
absorbing water. Conditions of the colon such as collagenous colitis can block the ability of the colon to
absorb water.

Diarrhea generally is divided into two types, acute and chronic.

 Acute diarrhea lasts from a few days up to a week.

 Chronic diarrhea can be defined in several ways but almost always lasts more than three
weeks.
It is important to distinguish between acute and chronic diarrhea because they usually have different
causes, require different diagnostic tests, and require different treatment

What are common causes of acute diarrhea?

The most common cause of acute diarrhea is infection--viral, bacterial, and parasitic. Bacteria also can
cause acute food poisoning. A third important cause of acute diarrhea is starting a new medication.

Viral gastroenteritis
Viral gastroenteritis (viral infection of the stomach and the small intestine) is the most common cause of
acute diarrhea worldwide. Symptoms of viral gastroenteritis (nausea,vomiting, abdominal cramps, and
diarrhea) typically last only 48-72 hrs. Unlike bacterial enterocolitis (bacterial infection of the small
intestine and colon), patients with viral gastroenteritis usually do not have blood or pus in their stools and
have little if any fever.

Viral gastroenteritis can occur in a sporadic form (in a single individual) or in an epidemic form (among
groups of individuals). Sporadic diarrhea probably is caused by several different viruses and is believed to
be spread by person-to-person contact. The most common cause of epidemic diarrhea (for example, on
cruise ships) is infection with a family of viruses known as caliciviruses of which the genus norovirus is the
most common (for example, "Norwalk agent"). The caliciviruses are transmitted by food that is
contaminated by sick food-handlers or by person-to-person contact.

Food poisoning

Food poisoning is a brief illness that is caused by toxins produced by bacteria. The toxins
cause abdominal pain (cramps) and vomiting and also cause the small intestine to secrete large amounts
of water that leads to diarrhea. The symptoms of food poisoning usually last less than 24 hours. With
some bacteria, the toxins are produced in the food before it is eaten, while with other bacteria, the toxins
are produced in the intestine after the food is eaten.

Symptoms usually appear within several hours when food poisoning is caused by toxins that are formed
in the food before it is eaten. It takes longer for symptoms to develop when the toxins are formed in the
intestine (because it takes time for the bacteria to produce the toxins). Therefore, in the latter case,
symptoms usually appear after 7-15 hours.

Staphylococcus aureus is an example of a bacterium that produces toxins in food before it is eaten.
Typically, food contaminated with Staphylococcus (such as salad, meat or sandwiches with mayonnaise)
is left un-refrigerated at room temperature overnight. TheStaphylococcal bacteria multiply in the food and
produce toxins. Clostridium perfringensis an example of a bacterium that multiplies in food (usually
canned food), and produces toxins in the small intestine after the contaminated food is eaten.

Traveler's diarrhea

There are many strains of E. coli bacteria. Most of the E. coli bacteria are normal inhabitants of the small
intestine and colon and are non-pathogenic, meaning they do not cause disease in the intestines.
Nevertheless, these non-pathogenic E. coli can cause diseases if they spread outside of the intestines,
for example, into the urinary tract (where they cause bladder or kidney infections) or into the blood stream
(sepsis).

Certain strains of E. coli, however, are pathogenic (meaning they can cause disease in the small intestine
and colon). These pathogenic strains of E. coli cause diarrhea either by producing toxins
(called enterotoxigenic E. coli or ETEC) or by invading and inflaming the lining of the small intestine and
the colon and causing enterocolitis (called enteropathogenic E. coli or EPEC). Traveler's diarrhea usually
is caused by an ETEC strain of E. coli that produces a diarrhea-inducing toxin.

Tourists visiting foreign countries with warm climates and poor sanitation (Mexico, parts of Africa, etc.) can
acquire ETEC by eating contaminated foods such as fruits, vegetables, seafood, raw meat, water, and ice
cubes. Toxins produced by ETEC cause the sudden onset of diarrhea, abdominal cramps, nausea, and
sometimes vomiting. These symptoms usually occur 3-7 days after arrival in the foreign country and
generally subside within 3 days. Occasionally, other bacteria or parasites can cause diarrhea in travelers
 (for example, Shigella, Giardia, Campylobacter). Diarrhea caused by these other organisms usually lasts
longer than 3 days.

Bacterial enterocolitis

Disease-causing bacteria usually invade the small intestines and colon and cause enterocolitis
(inflammation of the small intestine and colon). Bacterial enterocolitis is characterized by signs of
inflammation (blood or pus in the stool, fever) and abdominal pain and diarrhea. Campylobacter jejuni is
the most common bacterium that causes acute enterocolitis in the U.S. Other bacteria that cause
enterocolitis include Shigella,Salmonella, and EPEC. These bacteria usually are acquired by drinking
contaminated water or eating contaminated foods such as vegetables, poultry, and dairy products.

Enterocolitis caused by the bacterium Clostridium difficile is unusual because it often is caused by
antibiotic treatment. Clostridium difficile is also the most common nosocomial infection (infection acquired
while in the hospital) to cause diarrhea. Unfortunately, infection also is increasing among individuals who
have neither taken antibiotics or been in the hospital.

E. coli O157:H7 is a strain of E. coli that produces a toxin that causes hemorrhagic enterocolitis
(enterocolitis with bleeding). There was a famous outbreak of hemorrhagic enterocolitis in the U.S. traced
to contaminated ground beef in hamburgers (hence it is also called hamburger colitis). Approximately 5%
of patients infected with E. coli O157:H7, particularly children, can develop hemolytic uremic
syndrome (HUS), a syndrome that can lead to kidney failure . Some evidence suggests that prolonged
use of anti-diarrhea agents or use of antibiotics may increase the chance of developing HUS.

Parasites

Parasitic infections are not common causes of diarrhea in the U. S. Infection with Giardia lamblia occurs
among individuals who hike in the mountains or travel abroad and is transmitted by contaminated drinking
water. Infection with Giardia usually is not associated with inflammation; there is no blood or pus in the
stool and little fever. Infection with amoeba (amoebic dysentery) usually occurs during travel abroad to
undeveloped countries and is associated with signs of inflammation--blood or pus in the stool and fever.

Cryptosporidium is a diarrhea-producing parasite that is spread by contaminated water because it can

survive chlorination. Cyclospora is a diarrhea-producing parasite that has been associated with
contaminated raspberries from Guatemala.

Drugs

Drug-induced diarrhea is very common because many drugs cause diarrhea. The clue to drug-induced
diarrhea is that the diarrhea begins soon after treatment with the drug is begun. The medications that
most frequently cause diarrhea are antacids and nutritional supplements that contain magnesium. Other
classes of medication that cause diarrhea include:

 nonsteroidal anti-inflammatory drugs (NSAIDs),

 chemotherapy medications,
 antibiotics,
 medications to control irregular heartbeats (antiarrhythmics), and
 medications for high blood pressure.

A few examples of specific medications that commonly cause diarrhea are:

 misoprostol (Cytotec),
 quinidine (Quinaglute, Quinidex),
 olsalazine (Dipentum),
 colchicine (Colchicine),
 metoclopramide (Reglan), and
 cisapride (Propulsid, Motilium).
What are common causes of chronic diarrhea?
Irritable bowel syndrome. The irritable bowel syndrome (IBS) is a functional cause of diarrhea
or constipation. Inflammation does not typically exist in the affected bowel. (Nevertheless, recent
information suggests that there MAY be a component of inflammation in IBS.) It may be caused by
several different underlying problems, but it is believed that the most common cause is rapid passage of
the intestinal contents through the colon.
Infectious diseases. There are a few infectious diseases that can cause chronic diarrhea, for
example, Giardia lamblia . Patients with AIDS often have chronic infections of their intestines that cause
diarrhea.
Bacterial overgrowth of the small intestine.Because of small intestinal problems, normal colonic
bacteria may spread from the colon and into the small intestine. When they do, they are in a position to
digest food that the small intestine has not had time to digest and absorb. The mechanism that leads to
the development of diarrhea in bacterial overgrowth is not known.
Post-infectious. Following acute viral, bacterial or parasitic infections, some individuals develop chronic
diarrhea. The cause of this type of diarrhea is not clear, but some of the individuals have bacterial
overgrowth of the small intestine. This condition also is referred to as post-infectious IBS.
Inflammatory bowel disease (IBD). Crohn's disease and ulcerative colitis, diseases causing
inflammation of the small intestine and/or colon, commonly cause chronic diarrhea.
Colon cancer. Colon cancer can cause either diarrhea or constipation. If the cancerblocks the passage of
stool, it usually causes constipation. Sometimes, however, there is secretion of water behind the
blockage, and liquid stool from behind the blockage leaks around the cancer and results in diarrhea.
Cancer, particularly in the distal part of the colon, can lead to thin stools. Cancer in the rectum can lead to
a sense of incomplete evacuation.
Severe constipation. By blocking the colon, hardened stool can lead to the same problems as colon
cancer, as discussed previously.
Carbohydrate (sugar) malabsorption. Carbohydrate or sugar malabsorption is an inability to digest and
absorb sugars. The most well-recognized malabsorption of sugar occurs with lactase deficiency (also
known as lactose or milk intolerance) in which milk products containing the milk sugar, lactose, lead to
diarrhea. The lactose is not broken up in the intestine because of the absence of an intestinal enzyme,
lactase, that normally breaks up lactose. Without being broken up, lactose cannot be absorbed into the
body. The undigested lactose reaches the colon and pulls water (by osmosis) into the colon. This leads to
diarrhea. Although lactose is the most common form of sugar malabsorption, other sugars in the diet also
may cause diarrhea, including fructose and sorbitol.
Fat malabsorption. Malabsorption of fat is the inability to digest or absorb fat. Fat malabsorption may
occur because of reduced pancreatic secretions that are necessary for normal digestion of fat (for
example, due to pancreatitis or pancreatic cancer) or by diseases of the lining of the small intestine that
prevent the absorption of digested fat (for example, celiac disease). Undigested fat enters the last part of
the small intestine and colon where bacteria turn it into substances (chemicals) that cause water to be
secreted by the small intestine and colon. Passage through the small intestine and colon also may be
more rapid when there is malabsorption of fat.
Endocrine diseases. Several endocrine diseases (imbalances of hormones) may cause diarrhea, for
example, an over-active thyroid gland (hyperthyroidism) and an under-active pituitary or adrenal gland
(Addison's disease).
 Laxative abuse. The abuse of laxatives by individuals who want attention or to lose weight is an
occasional cause of chronic diarrhea.
What are the complications of diarrhea?
Dehydration occurs when there is excessive loss of fluids and minerals (electrolytes) from the body due to
diarrhea, with or without vomiting.
 Dehydration is common among adult patients with acute diarrhea who have large amounts of
stool, particularly when the intake of fluids is limited by lethargy or is associated with nausea and
vomiting.
 It also is common in infants and young children who develop viral gastroenteritis or bacterial
infection.
 Patients with mild dehydration may experience only thirst and dry mouth.
 Moderate to severe dehydration may cause orthostatic hypotension with syncope (fainting upon
standing due to a reduced volume of blood, which causes a drop in blood pressure upon standing), a
diminished urine output, severe weakness, shock, kidney failure,confusion, acidosis (too much acid in
the blood), and coma.
Electrolytes (minerals) also are lost with water when diarrhea is prolonged or severe, and mineral or
electrolyte deficiencies may occur. The most common deficiencies occur with sodium and potassium.
Abnormalities of chloride and bicarbonate also may develop.
Finally, there may be irritation of the anus due to the frequent passage of watery stool containing irritating
substances.
When should the doctor be called for diarrhea?
Most episodes of diarrhea are mild and of short duration and do not need to be brought to the attention of
a doctor. The doctor should be consulted when there is:

 High fever (temperature greater than 101 F)

 Moderate or severe abdominal pain or tenderness
 Bloody diarrhea that suggests severe intestinal inflammation
 Diarrhea in persons with serious underlying illness for whom dehydration may have more serious
consequences, for example, persons with diabetes, heart disease, and AIDS
 Severe diarrhea that shows no improvement after 48 hours.
 Moderate or severe dehydration
 Prolonged vomiting that prevents intake of fluids orally
 Acute diarrhea in pregnant womenbecause of concern for the health of the fetus
 Diarrhea that occurs during or immediately after completing a course of antibiotics because the
diarrhea may represent antibiotic-associated infection with C. difficilethat requires treatment
 Diarrhea after returning from developing countries or from camping in the mountains because
there may be infection with Giardia (for which there is treatment)
 Diarrhea that develops in patients with chronic intestinal diseases such as colitis, or Crohn's
disease because the diarrhea may represent worsening of the underlying disease or a complication of
the disease, both requiring treatment
 Acute diarrhea in an infant or young child in order to ensure the appropriate use of oral liquids
(type, amount, and rate), to prevent or treat dehydration, and to prevent complications of inappropriate
use of liquids such as seizures and abnormal blood electrolytes
 Chronic diarrhea

What tests are useful in the evaluation of diarrhea?

Acute diarrhea. Acute diarrhea usually requires few tests.
 Measurement of blood pressure in the upright and supine (lying) positions can demonstrate
orthostatic hypotension and confirm the presence of dehydration. If moderate or severe dehydration or
electrolyte deficiencies are likely, blood electrolytes can be measured.
 Examination of a small amount of stool under the microscope may reveal white blood cells
indicating that intestinal inflammation is present and prompting further testing, particularly bacterial
cultures of stool and examination of stool for parasites.

 If antibiotics have been taken within the previous two weeks, stool should be tested for the toxin
of C. difficile.

 Testing stool or blood for viruses is performed only rarely, since there is no specific treatment for
the viruses that cause gastroenteritis.

 If there has been recent travel to undeveloped countries or the mountains, stool may be
examined under the microscope for Giardia and other parasites.

 There are also immunologic tests that can be done on samples of stool to diagnose infection with
Giardia.

Chronic diarrhea. With chronic diarrhea, the focus usually shifts from dehydration and infection (with the
exception of Giardia, which occasionally causes chronic infections) to the diagnosis of non-infectious
causes of diarrhea. (See the prior discussion of common causes of chronic diarrhea.)
 This may require X-rays of the intestines (upper gastrointestinal series or barium enema), or
endoscopy (esophagogastroduodenoscopy or EGD, or colonoscopy) with biopsies.
 Fat malabsorption can be diagnosed by measuring the fat in a 72 hour collection of stool.
 Sugar malabsorption can be diagnosed by eliminating the offending sugar from the diet or by
performing a hydrogen breath test. Hydrogen breath testing also can be used to diagnose bacterial
overgrowth of the small intestine.
 An under-active pituitary or adrenal gland and an overactive thyroid gland can be diagnosed by
measuring blood levels of cortisol and thyroid hormone, respectively.
 Celiac disease can be diagnosed with blood tests and a biopsy of the small intestine.
How can dehydration be prevented and treated?
Oral rehydration solutions (ORS) are liquids that contain a carbohydrate (glucose or rice syrup) and
electrolyte (sodium, potassium, chloride, and citrate or bicarbonate). Originally, the World Health
Organization (WHO) developed the WHO-ORS to rapidly rehydrate victims of the severe diarrheal
illness, cholera. The WHO-ORS solution contains glucose and electrolytes. The glucose in the solution is
important because it forces the small intestine to quickly absorb the fluid and the electrolytes. The
purpose of the electrolytes in the solution is the prevention and treatment of electrolyte deficiencies.
In the United States, convenient, premixed commercial ORS products that are similar to the WHO-ORS
are available for rehydration and prevention of dehydration. Examples of these products are Pedialyte,
Rehydralyte, Infalyte, and Resol.

Most of the commercially available ORS products in the U.S. contain glucose. Infalyte is the only one that
contains rice carbohydrate instead of glucose. Most doctors believe that there are no important
differences in effectiveness between glucose and rice carbohydrate.

Infants and young children. Most acute diarrhea in infants and young children is due to viral
gastroenteritis and is usually short-lived. Antibiotics are not routinely prescribed for viral gastroenteritis.
 However, fever, vomiting, and loose stools can be symptoms of other childhood infections such as otitis
media (infection of the middle ear), pneumonia, bladder infection, sepsis (bacterial infection in the blood)
and meningitis. These illnesses may require early antibiotic treatment.

Infants with acute diarrhea also can quickly become severely dehydrated and therefore need early
rehydration. For these reasons, sick infants with diarrhea should be evaluated by their pediatricians to
identify and treat underlying infections as well as to provide instructions on the proper use of oral
rehydration products.

Infants with moderate to severe dehydration usually are treated with intravenous fluids in the hospital. The
pediatrician may decide to treat infants who are mildly dehydrated due to viral gastroenteritis at home with
ORS.

Infants that are breast-fed or formula-fed should continue to receive breast milk during the rehydration
phase of their illness if not prevented by vomiting. During, and for a short time after recovering from viral
gastroenteritis, babies can be lactose intolerant due to a temporary deficiency of the enzyme, lactase
(necessary to digest the lactose in milk) in the small intestine. Patients with lactose intolerance can
develop worsening diarrhea and cramps when dairy products are introduced. Therefore, after rehydration
with ORS, an undiluted lactose-free formula and diluted juices are recommended. Milk products can be
gradually increased as the baby improves.

Older children and adults. During mild cases of diarrhea, diluted fruit juices, soft drinks containing
sugar, sports drinks such as Gatorade, and water can be used to prevent dehydration. Caffeine and
lactose containing dairy products should be temporarily avoided since they can aggravate diarrhea, the
latter primarily in individuals with transient lactose intolerance. If there is no nausea and vomiting, solid
foods should be continued. Foods that usually are well tolerated during a diarrheal illness include rice,
cereal, bananas, potatoes, and lactose-free products.

ORS can be used for moderately severe diarrhea that is accompanied by dehydration in children older
than 10 years of age and in adults. These solutions are given at 50 ml/kg over 4-6 hours for mild
dehydration or 100 ml/kg over 6 hours for moderate dehydration. After rehydration, the ORS solution can
be used to maintain hydration at 100 ml to 200 ml/kg over 24 hours until the diarrhea stops. Directions on
the solution label usually state the amounts that are appropriate. After rehydration, older children and
adults should resume solid food as soon as any nausea and vomiting subside. Solid food should begin
with rice, cereal, bananas, potatoes, and lactose free and low fat products. The variety of foods can be
expanded as the diarrhea subsides.

How is diarrhea treated?

Absorbents. Absorbents are compounds that absorb water. Absorbents that are taken orally bind water
in the small intestine and colon and make diarrheal stools less watery. They also may bind toxic
chemicals produced by bacteria that cause the small intestine to secrete fluid; however, the importance of
toxin binding in reducing diarrhea is unclear.
The two main absorbents are attapulgite and polycarbophil, and they are both available without
prescriptions.

Examples of products containing attapulgiteare:

 Donnagel,
 Rheaban,
 Kaopectate Advanced Formula,
 Parepectolin, and
 Diasorb.
Examples of products containingpolycarbophil are:
 Equalactin,
 Konsyl Fiber,
 Mitrolan, and

 Polycarb.

Equalactin is the antidiarrheal product containing attapulgite; however the laxative, Konsyl, also contains
attapulgite. Attapulgite and polycarbophil remain in the intestine and, therefore, have no side effects
outside of the gastrointestinal tract. They may occasionally cause constipation and bloating. One concern
is that absorbents also can bind medications and interfere with their absorption into the body. For this
reason, it often is recommended that medications and absorbents be taken several hours apart so that
they are physically separated within the intestine.
Anti-motility medications. Anti-motility medications are drugs that relax the muscles of the small
intestine and/or the colon. Relaxation results in slower flow of intestinal contents. Slower flow allows more
time for water to be absorbed from the intestine and colon and reduces the water content of stool.
Cramps, due to spasm of the intestinal muscles, also are relieved by the muscular relaxation.

The two main anti-motility medications are loperamide (Imodium), which is available without a
prescription, and diphenoxylate (Lomotil), which requires a prescription. Both medications are related to
opiates (for example, codeine ) but neither has the pain-relieving effects of opiates.

Loperamide (Imodium), though related to opiates, does not cause addiction.

Diphenoxylate is a man-made medication that at high doses can be addictive because of its opiate-like,
euphoric (mood-elevating) effects. In order to prevent abuse of diphenoxylate and addiction, a second
medication, atropine, is added to loperamide in Lomotil. If too much Lomotil is ingested, unpleasant side
effects from too much atropine will occur.

Loperamide and diphenoxylate are safe and well-tolerated. There are some precautions, however, that
should be observed.

 Anti-motility medications should not be used without a doctor's guidance to treat diarrhea caused
by moderate or severe ulcerative colitis, C. difficile colitis, and intestinal infections by bacteria that
invade the intestine (for example, Shigella). Their use can lead to more serious inflammation and
prolong the infections.
 Diphenoxylate can cause drowsiness or dizziness, and caution should be used if driving or
performing tasks that require alertness and coordination are required.
 Anti-motility medications should not be used in children younger than two years of age.
 Most unimportant, acute diarrhea should improve within 72 hours. If symptoms do not improve or
if they worsen, a doctor should be consulted before continuing treatment with anti-motility medications.
Bismuth compounds. Many bismuth-containing preparations are available around the world. Bismuth
subsalicylate (Pepto-Bismol) is available in the United States. It contains two potentially active
ingredients, bismuth and salicylate (aspirin). It is not clear how effective bismuth compounds are, except
in traveler's diarrhea and the treatment of H. pylori infection of the stomach where they have been shown
to be effective. It also is not clear how bismuth subsalicylate might work. It is thought to have some
antibiotic-like properties that affect bacteria that cause diarrhea. The salicylate is anti-inflammatory and
could reduce secretion of water by reducing inflammation. Bismuth also might directly reduce the
secretion of water by the intestine.
 Pepto-Bismol is well-tolerated. Minor side effects include darkening of the stool and tongue. There are
several precautions that should be observed when using Pepto-Bismol.

 Since it contains aspirin, patients who are allergic to aspirin should not take Pepto-Bismol.
 Pepto-Bismol should not be used with other aspirin-containing medications since too much
aspirin may be ingested and lead to aspirin toxicity, the most common manifestation of which is ringing
in the ears.
 The aspirin in Pepto-Bismol can accentuate the effects of anticoagulants,
particularly warfarin (Coumadin), and lead to excessive bleeding. It also may cause abnormal bleeding
in people who have a tendency to bleed because of genetic disorders or underlying diseases, for
example, cirrhosis, that may cause abnormal bleeding.
 The aspirin in Pepto-Bismol can aggravate stomach and duodenal ulcer disease.
 Pepto-Bismol and aspirin-containing products should not be given to children
andteenagers with chickenpox, influenza, and other viral infections because they may cause Reye's
syndrome. Reye's syndrome is a serious illness affecting primarily the liver and brain that can lead to
liver failure and coma, with a mortality rate of at least 20%.
 Pepto-Bismol should not be given to infants and children younger than two years of age.
When should antibiotics be used for diarrhea?
Most episodes of diarrhea are acute and of short duration and do not require antibiotics. Antibiotics are
not even necessary for the most common bacterial infections that cause diarrhea. Antibiotics, however,
often are used when (1) patients have more severe and persistent diarrhea, (2) patients have additional
debilitating diseases such asheart failure, lung disease, and AIDS, (3) stool examination and testing
discloses parasites, more serious bacterial infections (for example, Shigella), or C. difficile, and 4)
traveler's diarrhea.

Diarrhea At A Glance
 Diarrhea is an increase in the frequency of bowel movements, an increase in the looseness of
stool or both.
 Diarrhea is caused by increased secretion of fluid into the intestine, reduced absorption of fluid
from the intestine or rapid passage of stool through the intestine.
 Diarrhea can be defined absolutely or relatively. Absolute diarrhea is defined as more than five
bowel movements a day or liquid stools. Relative diarrhea is defined as an increase in the number of
bowel movements per day or an increase in the looseness of stools compared with an individual's
usual bowel habit.
 Diarrhea may be either acute or chronic, and each has different causes and treatments.
 Complications of diarrhea include dehydration, electrolytes (mineral) abnormalities, and irritation
of the anus.
 Dehydration can be treated with oral rehydration solutions and, if necessary, with intravenous
fluids.
 Tests that are useful in the evaluation of acute diarrhea include examination of stool for white
blood cells and parasites, cultures of stool for bacteria, testing of stool for the toxin of C. difficile and
blood tests for electrolyte abnormalities.
 Tests that are useful in the evaluation of chronic diarrhea include examination of stool for
parasites, upper gastrointestinal X-rays (UGI series), barium enema, esophago-gastro-duodenoscopy
(EGD) with biopsies, colonoscopy with biopsies, hydrogen breath testing, and measurement of fat in
the stool.
 Diarrhea may be treated with absorbents, anti-motility medications, and bismuth compounds.
 Antibiotics should not be used in treating diarrhea unless there is a culture-proven bacterial
infection that requires antibiotics, severe diarrhea that is likely to be infectious in origin, or when an
individual has serious underlying diseases

Diarrhea, the frequent passing of loose and watery stool, is actually not a disease but a
symptom of an underlying disorder; it usually clean up within a few days or as soon as the
disorder is treated. The conditions are seldom dangerous in adults. (Some types of diarrhea
are infectious.) The accompanying dehydration could be fatal in infants, small children, and
the elderly.

For occasional loose stools, no medication is required. A clear liquid diet (for example, water
or ginger ale) is the first thing to do for any diarrhea. This rests the bowel and replaces lost
fluid. When diarrhea persists, products containing bismuth subsalicylate or attapulgite are
often helpful. When these do not control the diarrhea, stronger agents containing
substances such as paregoric may be needed. Long- tem diarrhea is a signal to consult with
your physician.

Symptoms:

 Abnormally frequent bowel movement.

 Loose, watery stool.

 Abdominal cramps, which come and go in waves.

 Flatulence (excessive gas in the intestine).

 Fever.

 Nausea, vomiting.

Complications:

 Dehydrations (dry lips and tongue, inelastic skin, sunken eyes, thirst, rapid breathing
the passing of little urine, and a sunken fontanelle in infants).
 Death from dehydration.

Common Causes:

 Drinking unboiled and contaminated water.

 Food or medicine allergy.

 Food intolerance (e.g., lactose intolerance or the inability to digest milk sugar).

 Viral, bacterial, or parasitic infection of the intestine (e.g., intestinal flu, food
poisoning, amebiasis).

Chronic diarrhea can be due to:

 Irritable bowel syndrome (an intestinal disorder).

 Crohn's disease (chronic inflammation of a part of the digestive tract).
  Ulcerative colitis or the chronic inflammation and ulceration (open sores) of the lining
of the colon and rectum.

 Cancer of the colon.

 Malabsorption syndrome.

What you can do:

 Take plenty of fluids (water clear soups, etc). Avoid alcohol, coffee, tea, milk, and
fizzy beverages. When an infant has diarrhea, continue breastfeeding. When bottle-
feeding, however, dilute cows milk with twice the normal amount of water.
 Take dehydration fluids or salts to replace last electrolytes.

 Continue eating regular meals, but alter your diet to include binding foods (e.g.,
bananas, rice, toast). Avoid high fat and junk food at least until your bowel
movements returns to normal.

 Prolonged diarrhea, especially if accompanied by weight loss, should be investigated

thoroughly as soon as possible.

 Consult a doctor if the diarrhea persists for more than a week (two days, in a child)
or worsens; if there is dehydration; if there is continues abdominal cramps; or if the
stool is black, bloodstained or slimy. Infant's young children and elderly people
should be taken to a doctor immediately.

Prevention Tips:

 A big proportion of diarrhea is due to unsafe food preparation and handling practices.
The following are guidelines from the World Health Organization on safe food
preparation:

1. Choose foods processed for safety (e.g., pasteurized or fresh milk).

2. Cook food thoughroughly.

3. Eat cooked foods immediately.

4. Store cooked foods carefully; foods for infants should be preferably not being stored
at all.

5. Reheat cooked foods thoughroughly.

6. Avoid contact between uncooked and cooked foods.

7. Wash hands repeatedly.

8. Keep all kitchen surfaces meticulously clean.

9. Protect foods from insects, rodents and other animals.

10. Use safe water.