Acute Diarrhea

By
Shahira Aly El-Etreby
Prof. of Internal Medicine
Hepatology & Gastroenterology unit
Faculty of Medicine
Mansoura University
ILOS:
Background

Definition

Classification of diarrhea

Assessment of severity

Causes of acute diarrhea

Approach of Acute diarrhea

Treatment
Fluid loads through the intestine
 Each day approximately 9 to 10 L of fluid pass into the jejunum.

This consists of approximately 2 L of ingested food and drink,

1.5 L of saliva, 2.5 L of gastric juice, 1.5 L of bile, and 2.5 L of

pancreatic juice. The jejunum absorbs most of this load as

nutrients are taken up, and the ileum absorbs most of the rest.

The colon absorbs more than 90% of the fluid load reaching it,

leaving only 1% of the original fluid entering the jejunum

excreted in stool. Substantial fluid malabsorption in the small

bowel can overwhelm colonic absorptive capacity and may

result in diarrhea. Less severe disruption of colonic absorption

can lead to diarrhea because of the lack of any more distal

absorbing segment. A reduction of absorptive efficiency of only

1% for the total intestine can result in diarrhea.

Definition
 Diarrhea is defined as an increase in the frequency
or fluidity of stools or both.

Criteria for diagnosis of Diarrhea

 Dysentery

 Definition ……Diarrhea + blood & mucus in stool + tenesmus.

Etiology

▪ Amoebic dysentery ▪ Cancer rectum ▪ Protozoa: malaria, giardia

▪ Bacillary dysentery ▪ Crohn's proctitis ▪ Poisoning: mercury
Ulcerative Colitis
▪ Bilharzial dysentery ▪ Uremic dysentery
▪ Diverticulitis
Tenesmus
Definition

Painful straining, sense of incomplete evacuation.

 Etiology

▪ IBD, IBS , Infective colitis.

▪ Rectal prolapse, Rectal carcinoma.
Classification of diarrhea

• Acute diarrhea < 2 weeks.

• Persistent diarrhea 2-4 weeks.

• Chronic diarrhea ≥ 4 weeks.

Severity
 The severity of acute diarrhea can be defined as:

o Mild, where no change in daily activities is noted.

o Moderate, where a change in daily activities is required
but the patient is able to function.
o Severe, where the patient is disabled by the symptoms.
Etiology:

1. Infectious agents.
2. Bacterial toxins (Preformed or Produced in the gut).
3. Medications.
Etiology:
1. Non-inflammatory: Watery, non-bloody. Usually mild and self-limited.
2. Inflammatory: Blood or pus, fever.

ETEC=Enterotoxigenic E.coli, EHEC=Enterohemorrhagic E. coli, and EIEC=Enteroinvasive

E.coli. C. difficile=Clostridiodes difficile (previously named Clostridium difficile).
Clinical findings:
1. Community outbreaks suggest a viral etiology or a common food source.

2. Similar recent illnesses in family members suggest an infectious origin.

3. Among patients with COVID-19 infection, watery diarrhea (usually mild)

occurs in one-third and may be the presenting symptom in 3–16%.

4. Ingestion of improperly stored or prepared food suggests “food

poisoning” due to bacterial toxins that are either present in the ingested
food (preformed) or produced within the GI tract after ingestion.

5. Day care attendance or exposure to unpurified water (camping,

swimming) may result in infection with Giardia.
Clinical findings:
6. Recent travel abroad suggests “traveler’s diarrhea”.

7. Antibiotic administration within the preceding several weeks suggests C.

difficile colitis.

8. Risk factors for sexually transmitted diseases should be determined.

9. Persons engaging in anal intercourse or oral-anal sexual activities are at

risk for a variety of infections that cause proctitis, including gonorrhea.

10.Pregnant women have an increased risk of developing listeriosis.

 Pseudomembranous colitis

Definition: Severe, acute, exudative colitis.

usually due to infection by Clostridium difficile.
Clostridium difficile: Gram +ve, anaerobic, spore-forming & toxin-producing bacillus.

Frequently seen with use of: quinolones, cephalosporines, clindamycin,

broad spectrum penicillin.
C/P: Profuse diarrhea, fever, anorexia, nausea, vomiting and malaise.

Investigations:
leukocytosis, anemia, high ESR & CRP, C. difficile toxin in stool.
Colonoscopy: Pseudomembranes, raised yellow or off-white plaques scattered over
the rectal mucosa.

Treatment: Vancomycin + metronidazole

Who should undergo medical evaluation for acute
diarrhea?

 Most cases of acute diarrhea are self-limited and require no

medical evaluation.

 Nearly half of the cases last for less than 1 day.

Investigations: when to evaluate??
1. Severe illness:
A: Abdominal pain (severe).
B: Bloody diarrhea.
C: Count of WBCs ≥ 15,000 / µl.
D: Dehydration.
E: Excessive motions (> 6 stools / 24 hours).
F: Fever (Temperature > 38.5 °C).
G. Severe diarrhea of >48 hours' duration
2. Immunocompromised patient: AIDS, post-transplantation.
3. Elderly patient (> 70 years).
4. Mild illness: If it persists > 7 days or worsens.
Investigations…what you evaluate??

1.Stool analysis: Fecal leukocytes, protozoa.

2.PCR [nucleic acid amplification test (NAAT)]

3. If positive, obtain stool culture for confirmation, and antibiotic

sensitivity.
4. C. difficile assay if recent hospitalization or antibiotics.

NAAT: Nucleic acid amplification (e.g., PCR assays) that screen for a panel of
pathogens, including viruses, protozoa, and bacteria, within 1–5 hours. If the
PCR assay detects a bacterial pathogen, stool culture is recommended for
confirmation and antibiotic sensitivity testing.
Treatment:
1. Diet: Bowel rest (Avoid high-fiber foods, fats, milk products, and
caffeine). Drink tea, applesauce, and “flat” carbonated beverages. Eat
soft, easily digested foods (e.g., soups, crackers, bananas, rice, toast).

2. Rehydration:
a. Oral rehydration is preferred whenever possible.
b. Intravenous fluids (lactated Ringer injection) in severe dehydration.

3. Anti-diarrheal agents: Loperamide is preferred (4 mg orally, then 2 mg

after each loose stool (maximum: 8 mg/24 hours). It should not be used
in bloody diarrhea, or systemic toxicity. Anticholinergic agents (e.g.,
diphenoxylate with atropine) are contraindicated in acute diarrhea
because of the rare precipitation of toxic megacolon.
Treatment:

4. Antibiotic therapy:

Empirical: The oral drugs of choice are fluoroquinolones, e.g.,

ciprofloxacin 500 mg twice daily for 1–5 days

Specific: e.g., vancomycin and metronidazole in Clostridioides

difficile infection and Ampicillin / Amoxicillin in pregnant with
listeria.
Take home messages
Diarrhea is defined as an increase in the frequency or fluidity of stools or both.
3 Classification of diarrhea according to
 Duration: Acute versus chronic (4 weeks or longer).

Most cases of acute diarrhea are self-limited and require no medical evaluation. Nearly
half of the cases last for less than 1 day.

Evaluation should be reserved for patients with evidence of systemic toxicity

(dehydration, bloody diarrhea, fever, severe abdominal pain), diarrhea of >48 hours'
duration, and elderly or immunocompromised patients.

Most common cause of acute diarrhea is infectious diarrhea , the mainstay of treatment
is hydration either oral rehydration solution or IV fluids according to severity. May be
there is need to use of antibiotics.
Review Questions
Acute diarrhea is defined as passage of more than 3 stools per
for duration less than:

A. 2 weeks.
B. 3 weeks.
C. 2-4weeks.
D. 4 week.
E. 5 days.
Review Questions
A 30 year old male presents with acute, profuse, watery
diarrhea with some blood after returning from a work trip in
Tanzania . He had been taking oral hydration salts. Which
one of the following is the most appropriate treatment?

A. Ciprofloxacin.
B. Loperamide.
C. Metronidazle.
D. Prednisolone.
E. Vancomycin.
Review Questions
A 19 year old student presents with 15 week history of diarrhea.
He has lost 2 kg of his weight. A smear of a duodenal biopsy
reveals many trophozoites. What is the best treatment
option?

A. Ciprofloxacin
B. Gluten free diet
C. Metronidazole.
D. Prednisolone.
E. Quinine .
Review Questions
An 80 years female presents with confusion associated with a
chest infection. She received standard treatment, and four
days later she developed green, bloody diarrhea. Which of
the following organisms is most likely to be responsible for
her diarrhea:

A. Campylobacter jejuni.
B. Clostridium defficile.
C. Escherichia coli.
D. Methicllin resistant staphylococcus aureus.
E. Vancomycin resistant enterococuss.