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acute diarrhea

Diarrhea of 1-14 days duration. Most episodes of acute diarrhea are mild & self-limited. <10% come to a physician's attention. Of those that do, the majority require only oral rehydration. Etiology: 1) infectious diarrhea a) viral (most cases are viral) - rotavirus - Caliciviridae - Norwalk virus - norovirus - adenovirues 40, 41 - astrovirus - cytomegalovirus (CMV) in immunocompromised patients - CMV seropositive organ transplant donor or recipient places recipient at risk for CMV [4] b) bacterial - Campylobacter jejuni* - most common cause from undercooke poultry [13] - Salmonella:* contaminated beef, poultry, milk, eggs - Shigella* - enterohemorrhagic E. coli* - Staphylococcus - Clostridium difficile* - may occur in outpatient setting [10] - Vibrio parahaemolyticus - Yersinia enterocolitica - Vibrio cholerae - Clostridium perfringens - Bacillus cereus - enterotoxigenic E. coli - Aeromonas hydrophilia - Plesiomonas shigelloides - Mycobacterium avium-intracellulare - enteroaggregative E. coli [6] - 1/3 coinfected with rotavirus - Listeria monocytogenes (encephalitis, immunosuppression, dairy) c) protozoa - Giardia lamblia - Entamoeba histolytica* - Cryptosporidium (see Cryptosporidiosis) - young children - immunocompromised - public swimming pools, water playgrounds [4] 2) non-infectious a) pharmacologic causes (see pharmaceutical agents associated with diarrhea) b) dietary items - lactose, caffeine, sorbitol, diet colas, mannitol, fructose, sucrose c) inflammatory bowel disease* d) toxins - heavy metals, insecticides, mushrooms e) intestinal ischemia* f) bile acid diarrhea &/or malabsorption * causes of bloody diarrhea or inflammatory diarrhea Clinical manifestations: 1) frequent, small volume stools with urgency & tenesmus suggest the distal colon as the site of pathology 2) bulky & large stools suggests small-bowel disease 3) steatorrhea suggests small bowel disease or pancreatic insufficiency 4) fever & bloody stools suggest invasive bacterial diarrhea caused by Shigella or Vibrio parahaemolyticus 5) grossly bloody diarrhea without fever suggests enterotoxic E. coli 6) fever with non-bloody diarrhea suggests Salmonella or Campylobacter 7) diarrhea within 6 hours of ingestion suggests preformed toxin - Staphylococcus aureus, Bacillus cereus 8) diarrhea 8-14 hours after ingestions suggests Clostridium perfringens 9) viral diarrhea & most other food-borne diarrhea due to ingestion of viable organisms occurs > 14 hours after ingestion [4] 10) most episodes are brief, with resolution within 1 week - diarrhea lasting > 7 days suggests parasitic or non-infectious origin (see chronic diarrhea) [4] * Red flags - severe abdominal pain - bloody stools (hematochezia, BRBPR) - fever - recent hospitalization or antimicrobial use - elderly - immunosuppression - inflammatory bowel disease - pregnancy Laboratory: 1) indications for laboratory testing a) symptomatic patients with fever b) abdominal pain c) tenesmus d) dehydration e) bloody diarrhea or mucoid stools [4] f) diarrhea of longer than 3 days duration (> 7 days) [12] g) recent antibiotic use h) inflammatory bowel disease i) patient populations at risk - elderly patients - hospitalized patients - pregnant women - immunocompromised patients j) food handlers k) high risk of spreading disease or during outbreaks [12] 2) general laboratory investigation a) stool examination for WBC & RBC - fecal leukocytes indicate inflammatory diarrhea - fecal leukocytes negative with: Salmonella - fecal leukocytes probably unnecessary [12] b) stool culture - moderate to severe watery diarrhea > 3 days duration [12] - do not obtain stool culture in patients hospitalized > 3 days [4] - do not conduct antibiotic sensitivity testing in acute diarrhea [12] c) stool for ova & parasites - diarrhea lasting >= 7 days - not recommended for patients with onset of diarrhea > 3 days into hospital stay [4] - interference by - tetracycline, sulfonamides, castor oil, Mg(OH)2, barium, hypertonic saline, soap, tap water, bismuth, kaolin, antiprotozoal agents d) fecal electrolytes (Na+, K+, Cl-) e) fecal osmolality - 400 mOsm in osmotic diarrhea, - 290 in secretory diarrhea f) fecal osmolal gap - osmolality - (Na+ + K+) x 2 - > 100 in osmotic diarrhea - < 50 in secretory diarrhea g) blood cultures h) rapid molecular diagnostic testing indicated in immunocompromised patients [4] 3) laboratory tests as indicated by presentation a) string test or ELISA for Giardia lamblia - day care centers & travelers b) modified acid-fast stain (Cryptosporidium) - day care centers, travelers, immunosuppressed c) E. coli serotype 0157 - day care centers, nursing homes & travelers d) testing for C-difficle colitis if antibiotic exposure in past 1-10 weeks - C-difficile DNA - Clostridium difficile enterotoxin - day care centers, nursing homes or history of antibiotics - hospitalized patients with diarrhea who test negative for C difficile colitis should be treated with antidiarrheal agents without further testing or treatment for C difficile [4] e) Vibrio cholera - travelers (alert laboratory) f) HIV testing g) Mycobacterium avium-intracellulare h) amoeba titers i) food poisoning: culture food, vomitus, feces j) thiosulfate citrate bile salts: Vibrio parahaemolyticus k) culture for Yersinia enterocolitica - unexplained fever (alert laboratory) Special laboratory: - gastrointestinal endoscopy not recommended [12] Differential diagnosis: - Yersinia enterocolitica can mimic a) appendicitis b) Crohn's disease [4] Management: 1) general a) fluid replacement to maintain hydration (primary goal) - oral (most patients) - Pedialyte, Enfalyte, Oralyte - water, juice, sports drinks, soups, salty crackers [12] - intravenous - lactated Ringers or normal saline - KCl or potassium phosphate added b) diet without influence/impact [5] c) kaopectate improves stool form d) anti-motility agents - loperamide (Imodium) 4 gm PO, then 2 g orally after each formed stool - up to 5 doses/day - diphenoxylate with atropine (Lomotil) 2.5-5 g PO - up to 5 times per day - codeine - paregoric - tincture of opium - anti-motility agents contraindicated with fever or bloody diarrhea or inflammatory diarrhea* e) bismuth subsalicylate (Pepto-Bismol) anti-secretory agent 2) do NOT give empiric antibiotic therapy for acute diarrhea - most community-acquired acute diarrhea is viral in origin [12] 3) infectious diarrhea (non-viral), antimicrobial agents: a) indications: - diarrhea lasting > 7 days, or fever, abdominal pain, hematochezia (dysentery) - exception: E. coli O157:H7 (no antibiotics) - require antimicrobial treatment [4] - empiric azithromycin after stool examination & cultures obtained b) Campylobacter jejuni - erythromycin 250 mg PO QID for 7 days - ciprofloxacin (Cipro) 500 mg PO BID for 7-10 days c) Clostridium difficile - vancomycin 125-250 mg PO QID for 5-10 days - 1st line vs metronidazole - severe or persistent diarrhea & offending antibiotic cannot be stopped - metronidazole (Flagyl) - formerly 250 mg PO QID for 10 days, now relegated to intravenous adjunct to vancomycin - avoid during pregnancy d) Escherichia coli (traveler's diarrhea) - azithromycin [4] - Bactrim, Septra DS PO BID for 5 days - ciprofloxacin (Cipro) 500 mg PO BID for 5 days e) Entamoeba histolytica - metronidazole (Flagyl) 750 mg PO TID for 10 days followed by: - iodoquinol 650 mg PO TID for 20 days to eliminate cyst phase - avoid if patient is allergic to iodine - tinidazole 2 g PO [4] (may be best agent), nitazoxanide (Alinia) f) Giardia lamblia - quinacrine (Atrabine) 100 mg PO TID for 5 days - furazolidone (Furoxone) 100 mg PO QD for 7 days - metronidazole (Flagyl) 250 mg PO TID for 7 days - tinidazole 2 g PO [4] (may be best agent), nitazoxanide (Alinia) g) Salmonella - treat only if immunocompromised, bacteremic or < 1 year of age - ciprofloxacin (Cipro) 500 mg PO BID for 7 days - Bactrim DS PO BID for 5 days - adjust dosage for child < 1 year of age h) Shigella - Bactrim, Septra DS PO BID for 5 days - ciprofloxacin (Cipro) 500 mg PO BID for 7 days - norfloxacin (Noroxin) 800 mg PO once i) Listeria monocytogenes - see Listeria monocytogenes 4) probiotics - do not treat acute diarrhea with probiotics & prebiotics except for postantibiotic diarrhea [12] - may be useful for shortening the duration of acute infectious diarrhea (1 day shorter) [11] 5) antibiotic-associated diarrhea (including C difficile) - probiotics may be useful for prevention [7] * toxic megacolon is complication Prophylaxis: 1) vaccines - typhoid, cholera, Shigella, rotavirus 2) travelers - boil, cook, or peel food 3) handwashing

Related

bloody (inflammatory) versus non-bloody (non-inflammatory) diarrhea infectious diarrhea; infectious colitis pharmaceutical agents associated with diarrhea

Specific

antibiotic-associated diarrhea (AAD)

General

diarrhea

References

  1. Harrison's Principles of Internal Medicine, 13th ed. Companion Handbook, Isselbacher et al (eds), McGraw-Hill Inc. NY, 1995, pg 829-39
  2. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 302-304
  3. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 290-98
  4. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2006, 2012, 2015, 2018, 2021. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  5. Journal Watch 24(19):153-54, 2004 Huang DB, Awasthi M, Le BM, Leve ME, DuPont MW, DuPont HL, Ericsson CD. The role of diet in the treatment of travelers' diarrhea: a pilot study. Clin Infect Dis. 2004 Aug 15;39(4):468-71. Epub 2004 Jul 30. PMID: 15356807 - Steffen R, Gyr K. Diet in the treatment of diarrhea: from tradition to evidence. Clin Infect Dis. 2004 Aug 15;39(4):472-3. Epub 2004 Jul 30. No abstract available. PMID: 15356808
  6. Journal Watch 25(5):43, 2005 Cohen MB, Nataro JP, Bernstein DI, Hawkins J, Roberts N, Staat MA. Prevalence of diarrheagenic Escherichia coli in acute childhood enteritis: a prospective controlled study. J Pediatr. 2005 Jan;146(1):54-61. PMID: 15644823
  7. The NNT: Co-Administration of Probiotics with Prescribed Antibiotics for Preventing C. Difficile Diarrhea. http://www.thennt.com/nnt/probiotics-for-preventing-c-difficile-diarrhea/ - McFarland LV. Meta-analysis of probiotics for the prevention of antibiotic associated diarrhea and the treatment of Clostridium difficile disease. Am J Gastroenterol 2006; 101:812 PMID: 16635227 - Johnston BC, Ma SS, Goldenberg JZ et al Probiotics for the prevention of Clostridium difficile-associated diarrhea: a systematic review and meta-analysis. Ann Intern Med. 2012 Dec 18;157(12):878-88. PMID: 23362517
  8. Prescriber's Letter 14(4): 2007 Oral rehydration therapy Detail-Document#: 230413 (subscription needed) http://www.prescribersletter.com
  9. Baldi F, Bianco MA, Nardone G, Pilotto A, Zamparo E. Focus on acute diarrhoeal disease. World J Gastroenterol. 2009 Jul 21;15(27):3341-8 PMID: 19610134
  10. Hensgens MP et al. Diarrhoea in general practice: When should a Clostridium difficile infection be considered? Results of a nested case control study. Clin Microbiol Infect 2014 Jul 7 PMID: 25040463
  11. The NNT: Probiotics for Acute Infectious Diarrhea. http://www.thennt.com/nnt/probiotics-for-acute-infectious-diarrhea/ - Allen SJ, Martinez EG, Gregorio GV, Dans LF. Probiotics for treating acute infectious diarrhoea. Cochrane Database Syst Rev. 2010 Nov 10;(11):CD003048 PMID: 21069673
  12. Riddle MS, DuPont HL, Connor BA. ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults. Am J Gastroenterol. 2016 May;111(5):602-22. PMID: 27068718
  13. NEJM Knowledge+ Gastroenterology