• Dark (almost black)
color, sticky
consistency, and
odorless nature.
• Normal passage of
meconium should
include at least one
stool in the first 48
hours after birth
and end with the
onset of transitional
stools by day 4.
• Change from meconium
to the normal yellow,
seedy stools that
characterize infants
feeding on milk only
• Here, the dark color of
meconium is still visible,
but lighter, yelowish
curds can also be seen.
• Exclusively breastfed
infants should have
transitional stools by
day4 if feeding is
• Normal appearance of
stool in an infant who is
exclusively breastfed
• Typically described as
“bright yellow and
• Note that a significant
amount of liquid stool
absorbed into the
diaper with only some
solid material on top.

• This is the stool of a 2
weeks old infant who
was fed extensively on
hydrolyzed formula.
• The stool is normal, but
has less of bright yellow,
seedy consistency of a
breast-fed infant stool.
• Not a normal stool
• It is a very viscous
congealed mass of
meconium that may
either be spontaneously
passed or may create an
obstruction and be the
cause of delayed
• Typically, after the
infant passed the plug,
the subsequent stool is
Normal phenomena
• The number ,color &
consistency of stools
varies with age & diet :
– Meconium
– Transitional stools
– Milk stools
• Color of stools
• Presence of solid

• Diarrhea : excessive loss of fluids &
electrolytes in stool
• More than 10ml(5g)/kg /day
• Defined based on:
– consistency of the stool (loose or watery) &
– frequency (usually at least three stools in a 24
hour period)

Definitions (con’t)
• Pseudodiarrhea & hyperdefecation
– Increase in number of bowel movement
• Encopresis
– the voluntary or involuntary passage of feces into
inappropriate places at least once a month for 3
consecutive months once a chronologic or
developmental age of 4 yr has been reached.
• Dysentery : small volume , frequent, bloody,
tenesmus , urgency

• A total of 8 to 9 L of fluid enters the healthy intestines on a daily basis.
• Only 1 to 2 L are derived from food and liquid intake; the rest is from
salivary, gastric, pancreatic, biliary, and intestinal secretions.
• Each day, about 90% of this fluid is absorbed in the small intestine, ~1 L
enters the colon, and about 100 mL is excreted in stool.
• Normal stool output is approximately 100
to 200 g/day.
• Diarrhea is defined as stool output
greater than 200 g/day in children older
than 2 years of age and greater than 10
mL/kg/day in children younger than 2
years of age.
• It is also described more practically as an
increase in liquidity and frequency of
bowel movements.
• Duration:
• acute (≤2 weeks) or chronic (>2 weeks), or by
• Mechanism:
• osmotic or secretory.
• It can also be categorized by the presence or
absence of malabsorption

• Both secretory and osmotic
diarrhea are caused by defective
or impaired mucosal absorption.
Osmotic Diarrhea
• Excess amounts of non-absorbed substances, such as lactose,
lactulose, fructose, or sorbitol, remain in the intestinal lumen,
causing luminal water retention.
• After these luminal substances enter the colon, they are processed by
colonic flora, producing large amounts of organic acids, increased
flatulence, and faster transit.

• The fecal osmolar gap [290 mOsm/L − {2 ×
(measured stool sodium + measured stool
potassium)}] is usually greater than 50 mOsm/L in
the setting of osmotic diarrhea.
• When an abnormal gap is found, reducing
substances, stool pH, and fecal fat should be
• Osmotic diarrhea improves with fasting.
• Examples of osmotic diarrhea include lactase
deficiency, celiac disease, and short bowel

Secretory diarrhea
• Abnormal ion transport in epithelial cells, leading to decreased absorption
of electrolytes and increased secretion of fluid.
• The fecal osmolar gap is less than 50 mOsm/L, and the diarrhea persists
despite fasting.
• Examples include congenital chloride and sodium diarrhea, cholera, and
neuroendocrine tumors.

• Another important underlying mechanism of
diarrhea is dysmotility.
• For example, pseudo-obstruction may result in
bacterial stasis, overgrowth and resultant
diarrhea, while hyperthyroidism may be
associated with diarrhea because of rapid
intestinal transit.

Stool Character
• The character of the stool can help to
determine the origin of diarrhea.
• Disease of small intestine origin:
– Watery, voluminous, non-bloody stool with few or
no white blood cells (WBCs) and low pH (<5.5)
• Colonic origin:
– Low-volume, mucusy, often bloody diarrhea with
a large number of WBCs and higher pH

• The most common electrolyte
abnormalities related to diarrhea
include hypokalemic metabolic
acidosis caused by bicarbonate and
potassium losses in stool.

Bloody Diarrhea
• A concerning symptom.
• The most common cause is infection, especially in
a setting of fever and acute onset.
• If bloody diarrhea is progressive and persistent,
chronic inflammatory causes should be
• The age of the patient is also important.
• In infants, milk protein–induced enterocolitis is a
common cause of bloody stools.

Etiology & Pathogenesis
• The most common cause of acute
diarrhea is infection.
• In young children, this is most often
viral, with the most common agents
being rotavirus, adenovirus,
astrovirus, and norovirus.
• Rotavirus is a leading cause of death
in children younger than 5 years of
age worldwide
• In immunocompromised hosts,
viruses, including cytomegalovirus,
Epstein-Barr virus, and BK virus,
should be considered.
• It is estimated that 70% of infectious diarrhea is
foodborne, and thus a detailed history of exposures
is very important.
• Exposure to untreated water may cause giardiasis.

• Use of public swimming pools poses a risk of
Shigella, Giardia, Cryptosporidium, and
Entamoeba infection, with the last three being
chlorine resistant.

• Home pets can transmit infections.
• For example, turtles carry Salmonella spp.

• History of foreign travel may narrow
exposures based on the specific destination.
• The most common etiology of traveler’s
diarrhea remains enterotoxigenic Escherichia

• Cryptosporidium and Giardia spp. are
responsible for most parasitic infections in
developed countries.
• Clostridium difficile infection, previously thought to
affect only hospitalized patients or those taking
antibiotics, is now responsible for 40% of community-
acquired diarrhea.
• A recent increase in C. difficile infections has been
observed, some attributable to the resistant strain, BI/
• An overgrowth of toxin-producing Clostridium organ-
isms causes pseudomembranous colitis, which may be
a potentially life-threatening condition.
• Vibrio cholerae remains a cause of illness and death in
war zones and developing countries.
• The mechanism of infectious diarrhea is
primarily secretory.
• It can quickly lead to electrolyte abnormalities
and acidosis.
• Infection may result in villous atrophy, which
can add an osmotic component.
• Mucosal healing after infection may lead to
transient postinfectious diarrhea.
Other causes of Acute Diarrhea
• Particularly concerning in
afebrile children
• Intussusception, a telescoping
of two segments of bowel that
occurs mostly in children
between 6 months and 2 years
of age, may present with bloody
– The typical presentation is colicky
abdominal pain, vomiting, and an
abdominal mass.
– “Currant jelly” stools do not occur
in all patients with intussusception
but are pathognomonic for the
• Hemolytic- uremic syndrome (HUS) is an
uncommon but potentially fatal illness that
may present with acute bloody diarrhea.
–HUS begins as a mild gastroenteritis that evolves
into hematochezia, microangiopathic hemolytic
anemia, thrombocytopenia, and acute renal
• Less commonly, appendicitis may present with
abdominal pain and diarrhea as a result of
colonic irritation from the inflamed appendix

• Other acute causes of diarrhea include
– inflammatory bowel disease,
– overfeeding (caused by increased osmotic loads),
– antibiotic-associated diarrhea (likely caused by
changes in bowel flora),
– extra-intestinal infections (otitis media, urinary
tract infection, pneumonia), and
– toxic ingestions.

Clinical Presentation
• In any patient presenting with acute diarrhea,
a thorough history and physical examination
should guide the immediate and subsequent
evaluation and therapy.
• It is important to quantify the duration and
frequency of stooling in addition to emesis,
liquid intake, and urine output to assess for
hydration status.

• A travel history
should be
• Recent antibiotic
use may suggest
nous colitis with
C. difficile.

History Taking
• The presence of
abdominal pain may
occur in infectious
enteritis; however,
• it may also be indicative
(colicky, episodic) or
(periumbilical, right
lower quadrant).
• Bloody diarrhea is usually typical in bacterial
enteritis but may be seen in viral illness, HUS,
or colitis.
• Associated vomiting suggests viral

• In infectious diarrhea, there is usually a 1- to 8-
day incubation period with a sudden onset of
• There may be associated fever, vomiting, crampy
abdominal pain, bloody stools, tenesmus, loss of
appetite, and dehydration.
• The immune state of the child should be
determined because an immunocompromised
child may present with more unusual organisms.

Physical Examination
• Begins with the general appearance of the
– does the child look malnourished or has he or she
lost weight?
• Vital signs then help to guide evaluation and
• Fever usually indicates infection.
• Pulse and blood pressure changes may
indicate dehydration, shock, or sepsis.
• A careful abdominal examination should look
for bowel sounds (to evaluate for obstruction)
and masses (to evaluate for intussusception).
• A stool sample should be guaiac tested for
microscopic blood.

Evaluation & Management
• Patients should be assessed for hydration
status and electrolyte abnormalities, with
correction as indicated.
• Acute viral gastroenteritis often requires
aggressive rehydration with intravenous fluids
or oral rehydration solutions.
• Stool should be sent for viral polymerase chain
reaction, culture, and C. difficile toxin assay.
• Most gastrointestinal (GI) infections, except for C.
difficile, do not require treatment.
• Antibiotics tend to prolong diarrhea and result in
a carrier state.
• There are special circumstances, such as
Salmonella enteritis in young infants and
immunocompromised patients, for which
antibiotic therapy is indicated.

• Most infections resolve in 14 days
in healthy children.
• Antidiarrheal agents are typically
not effective and should be
avoided in children.
• Serious complications, such as
sepsis, HUS, pancreatitis, urinary
tract infection, and perforation,
are uncommon.


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