Diarrhea

Diarrhea - Acute

 

Definition  

More than 200 grams or 200 millimeters of stool per 24 hours while consuming a typical Western diet . As dietary fiber intake increases in the Western diet, 250 grams or 250 millimeters of daily stool has become the more appropriate normal value.

 

Medical History  

* Gastroenteritis [Gastroenteritis - Acute]

* Lactose intolerance

* Dietary intake finding

* Dietary fructose intolerance

* Food allergy

* Laxative use

* Theophylline use

* Colchicine use

* Methotrexate use

* Antibiotic use

* Antiarrhythmic, Group IV use

* Thyroid Supplement use

* Electrolyte/Mineral Supplement Combination use

* Alcohol Abuse

* Foreign travel history finding

* Zollinger-Ellison syndrome

* Past medical history of Radiation therapy procedure or service

* Inflammatory bowel disease

* Hyperthyroidism

* Addison's disease

* AIDS

* Diabetes mellitus type 1

* Pancreatic insufficiency

* Crohn's disease

* Mesenteric lymphadenitis

* Whipple's disease

* Celiac disease

* Past medical history of Forceps delivery

* Malignant lymphoma

 

Findings  

* Abnormal weight loss

* Flushing

* Lymphadenopathy - Acute

* Palpitations - Acute

* Rectal mass

* Abdominal tenderness

* Anal reflex absent

* Condition of perineum around anus

* Defecation urgency

* Fever with chills

* Hematochezia

* Incontinence of feces

* Integrity of anal sphincter - finding

* Liquid stool

* Mucus in stool

* Perineal descent

* Perineal fistula

* Pus in stool

* Small stool

* Steatorrhea

* Stool finding

 

Tests  

 

Suspected infectious gastroenteritis  

* Fecal leukocytes: A positive fecal leukocyte test confirms an inflammatory etiology in patients with fever, tenesmus, or bloody stools and is predictive of finding an identifiable bacterial pathogen on culture .

 

Suspected gastrointestinal bleeding  

* Screening for occult blood in feces: A positive fecal occult blood test may reflect gastrointestinal bleeding and colonoscopy or upper endoscopy may be indicated .

 

Suspected gastrointestinal bleeding in Henoch-Schönlein purpura  

* Screening for occult blood in feces

 

Suspected anemia  

* Hematocrit determination: Very mild anemias are associated with few or no clinical signs or symptoms; therefore, a mild anemia usually is first detected from a screening measurement of Hgb or HCT.

 

Diarrheal disorder  

* White blood cell count with differential: Depending on the underlying etiology of the diarrhea, leukocytosis, leukopenia, and/or eosinophilia may be seen.

* Fiberoptic colonoscopy with biopsy: A colonoscopy should be performed in patients with acute bloody diarrhea or suspected pseudomembranous colitis.

* Stool fat, quantitative measurement: A 72-hour fecal fat test may discriminate between pancreatic and mucosal dysfunction.

* Xylose measurement

* CT of abdomen: CT scans can help diagnose chronic pancreatitis, pancreatic masses, occult tumors, and bowel wall thickening seen in inflammatory bowel disease.

* Eosinophil count, stool: Stool smears positive for eosinophils are indicative of parasitic infections.

* Esophagogastroduodenoscopy: Esophagogastroduodenoscopy (EGD) is useful for the visualization of the esophagus, stomach, and duodenum.

* Small bowel series: Barium studies of the small bowel are useful for the detection of structural abnormalities.

 

Suspected dehydration or electrolyte abnormalities  

* Electrolytes measurement, serum

 

Clostridium difficile infection  

* Clostridium difficile detection

 

Suspected or known diarrheal disorder  

* Stool culture: The most common enteric pathogens identified in patients with acute infectious diarrhea include Shigella, Salmonella, Campylobacter, Aeromonas, Yersinia, noncholera Vibrios, and Clostridium difficile.

 

Chronic diarrhea with suspected intestinal parasitic infection  

* Microbial ova-parasite examination, fecal: The finding of ova or parasites in stool in association with patient history and comorbidities may confirm the etiology of chronic organic diarrhea .

 

Suspected giardiasis  

* Giardia lamblia antigen assay: A positive Giardia lamblia antigen test is diagnostic of G lamblia infection, and appears to be highly sensitive and specific for disease detection .

 

Suspected and known sepsis  

* Blood culture: In patients with suspected sepsis, at least 2 sets of blood cultures should be obtained, preferably from peripheral venipuncture before antimicrobial therapy is initiated, if obtaining such cultures does not cause a significant delay in antibiotic administration .

 

Suspected hyperthyroidism  

* Thyroid stimulating hormone measurement: Overt hyperthyroidism is defined as a serum TSH less than 0.1 milliunits/L (mU/L) in the presence of an elevated serum free thyroxine (FT4), thyroxine (T4), or serum free triiodothyronine (FT3). Subclinical hyperthyroidism is defined as a TSH below the statistically defined lower limit of the reference range in the presence of a normal FT4 and FT3.

 

Suspected hyperthyroidism in patients with atrial fibrillation  

* Thyroid stimulating hormone measurement: A TSH level ?0.1 milliunits/L (mU/L) is associated with an increased risk of atrial fibrillation .

 

Suspected and known celiac disease  

* Endomysial antibody measurement: Endomysial antibodies (EMA) assays are highly sensitive and specific for celiac disease diagnosis ; moreover, positivity rates are correlated with the degree of villous atrophy found at biopsy .

 

Suspected bacterial overgrowth syndrome  

* Hydrogen breath test: An early hydrogen peak (30 to 75 minutes) suggests bacterial degradation of the carbohydrate marker in the small intestine from bacterial contamination.

 

Suspected lactose intolerance  

* Hydrogen breath test: A breath hydrogen concentration above 20 parts per million (ppm) within 6 hours of an oral lactose challenge is diagnostic for lactose deficiency when concordant symptoms are present . The cutoff in children is 10 ppm .

 

Differentiation of irritable bowel syndrome from organic causes of intestinal disease  

* Erythrocyte sedimentation rate measurement

 

Assessment of the severity of inflammatory bowel disease  

* C-reactive protein measurement

 

Assessment of malnutrition, protein-losing enteropathy, or severity of inflammatory bowel disease  

* Serum total protein measurement

 

Suspected diabetes mellitus-related diarrhea  

* Fasting blood glucose measurement

 

Differential Diagnosis  

* Viral gastroenteritis

* Bacterial gastroenteritis

* Intestinal malabsorption of carbohydrate

* Lactose intolerance - Chronic

* Traveler's diarrhea

* Irritable bowel syndrome with diarrhea

* Food poisoning

* Drug AND/OR toxin-induced diarrhea

* Protozoal intestinal disease

* Pseudomembranous enterocolitis

* Diverticulitis - Acute

* Inflammatory bowel disease - Chronic

* Celiac disease - Chronic

* Steatorrhea

* Disorder of endocrine system

* Diarrhea due to laxative abuse

* AIDS

* Bile acid malabsorption syndrome

* Radiation-induced disorder

* Cystic fibrosis - Chronic

* Lymphoma of intestine

 

Treatment  

 

Drug Therapy  

Clostridium difficile toxin-positive antibiotic-associated colitis  

 

METRONIDAZOLE

Adults: 500 mg IV every 6 hours OR 500 mg orally every 8 hours OR 250 mg orally every 6 hours for 10 to 14 days

Pediatrics (>28 days): 7.5 mg/kg IV or orally every 6 hours

 

VANCOMYCIN HYDROCHLORIDE  

Adults: 125 mg orally every 6 hours for 10 to 14 days OR 500 mg/L saline at 1 to 3 mL/minute via small bowel tube or pigtail catheter in the cecum (maximum 2 g/day)

 

RIFAXIMIN

Adults: 200 mg orally 3 times daily for 10 days

 

 

First relapse of C difficile toxin-positive antibiotic-associated colitis  

 

METRONIDAZOLE - RIFAMPIN  

Adults: Metronidazole 500 mg orally 3 times daily for 10 days

 

 

Campylobacter jejuni infection  

 

AZITHROMYCIN  

Adults: 500 mg orally once daily for 3 days

 

CIPROFLOXACIN  

Adults: 500 mg orally twice daily

 

 

Giardiasis  

 

TINIDAZOLE

Adult: 2 g orally once

 

NITAZOXANIDE  

Adult: 500 mg orally twice daily for 3 days

 

METRONIDAZOLE

Adult: 500 to 750 mg orally 3 times daily for 5 days

 

 

Non-typhoid salmonella gastroenteritis  

 

CIPROFLOXACIN  

Adult : 500 mg orally twice daily for 5 to 7 days

 

AZITHROMYCIN  

Adult: 1 g orally once on day 1, then 500 mg orally once daily on days 2 to 7

 

 

Shigella gastroenteritis  

 

CIPROFLOXACIN  

Adults: 500 mg orally twice daily for 3 days; treat immunocompromised patients for 7 to 10 days

 

LEVOFLOXACIN  

Adults: 500 mg orally once daily for 3 days; treat immunocompromised patients for 7 to 10 days

 

SULFAMETHOXAZOLE/TRIMETHOPRIM  

Adults: One double-strength tablet orally twice daily for 3 days; treat immunocompromised patients for 7 to 10 days

Pediatrics: 5 mg/kg trimethoprim/25 mg/kg sulfamethoxazole orally for 3 days; treat immunocompromised patients for 7 to 10 days

 

AZITHROMYCIN  

Adults: 500 mg orally once on day 1, then 250 mg orally once daily on days 2 to 5; treat immunocompromised patients for 7 to 10 days

 

 

Vibrio cholerae gastroenteritis  

 

AZITHROMYCIN  

Adults: 1 g orally once

Pediatrics: 20 mg/kg orally once (maximum 1 g)

 

CIPROFLOXACIN  

Adults: 1 g orally once

 

 

Acute traveler's diarrhea  

 

AZITHROMYCIN  

Adults: 1 g orally once

Pediatrics: 5 to 10 mg/kg orally once

 

RIFAXIMIN

Adults: 200 mg orally 3 times daily for 3 days

 

LEVOFLOXACIN  

Adults: 500 mg orally once

 

 

Chronic traveler's diarrhea  

 

LOPERAMIDE HYDROCHLORIDE  

Adults: 4 mg orally once, then 2 mg after each loose stool (maximum 16 mg/day)

 

 

Moderate or chronic diarrheal disorder  

 

LOPERAMIDE HYDROCHLORIDE  

Adults: 4 mg orally once, then 2 mg after each loose stool (maximum 16 mg/day)

 

BISMUTH SUBSALICYLATE  

Adults: 2 tablets (262 mg) orally 4 times daily as needed

 

HYOSCYAMINE  

 

 

 

Bile acid-induced diarrhea  

 

CHOLESTYRAMINE

Adults: 4 g orally every 8 hours for 10 to 14 days