Acute diarrhea

Background

• 85% of diarrhea is infectious in etiology
• Almost all true diarrheal emergencies are of noninfectious origin
• Definitions
  • Diarrhea: Increased frequency of defection, usually >3 bowel movements per day
  • Hyperacute: 1-6 hr
  • Acute: less than 3 wks in duration
  • Gastroenteritis: Diarrhea with nausea and/or vomiting
  • Dysentery: Diarrhea with blood/mucus/pus
  • Invasive = Infectious

Diagnosis

DDX Emergent

1. Appendicitis
2. Mesenteric ischemia
3. Ectopic
4. CO poisoning
5. SAH
6. Diverticultis

History

1. Possible food poisoning?
2. Does it resolve (osmotic) or persist (secretory) w/ fasting?
3. Are the stools of smaller volume (large intestine) or larger volume (small intestine)
4. Fever or abdominal pain? (diverticulitis, gastroenteritis, IBD)
5. Bloody or melenic?
6. Tenesmus? (shigella)
7. Malodorous? (giardia)
8. Recent travel?
9. Recent Abx?
10. HIV/immunocomp/sexual hx
11. Heat intolerance and anxiety? (thyrotoxicosis)
12. Paresthesias or reverse temperature sensation? (ciguatera)

Physical Exam

1. Thyroid masses
2. Oral ulcers, erythema nodosum, episcleritis, anal fissure (IBD)
3. Reactive arthritis (Arthritis, conjunctivitis, urethritis)
   1. Suggests infx w/ salmonella, shigella, campylobacter, or yersinia
4. Rectal exam for fecal impaction
5. Guaiac
6. Abdominal pain out of proportion to exam (mesenteric ischemia)

Work-Up

Only indicated for:

• Profuse watery diarrhea w/ signs of hypovolemia
• Severe abdominal pain
• Fever >38.5 (101.3) (suggests infection w/ invasive bacteria)
• Symptoms >2-3d
• Blood or pus in stool (E. coli 0157:H7)
• Recent hospitalization or abx use
• Elderly or immunocompromised
• Systemic illness w/ diarrhea (esp if pregnant (listeria))

1. Fecal leukocytes
   1. Used to differentiate invasive from noninvasive infectious diarrheas
   2. Sn 50-80%, Sp 83% for presence of bacterial pathogen
   3. If pt has +leukocytes but negative infection consider IBD
2. Stool culture
   1. Plays minor role in ED evaluation
   2. Yield is only 1.5-5.5%
   3. Consider in pts w/:
      1. Immunosuppression
      2. Severe, inflammatory diarrhea (including bloody diarrhea)
      3. Underlying IBD (need to distinguish between flare and superimposed infection)
3. O&P
   1. Indicated if parasitic cause is suspected:
      1. Diarrhea >7d
      2. Untreated water
      3. AIDS
      4. Bloody diarrhea w/ few or no fecal leukocytes (intestinal amebiasis)
4. C. diff toxin
   1. 10% false negative rate
   2. Takes 24hr to run
5. Chemistry
   1. Warranted in severely dehydrated pts
6. Abd x-ray
   1. Consider if h/o abdominal sx (r/o obstruction)
7. CXR
   1. Consider if diarrhea + cough (Legionella)
8. CT
   1. Consider if suspect mesenteric ischemia

Treatment

1. Oral rehydration
   1. Fluids should contain sugar, salt, and water
2. Food
   1. Eat: BRAT diet
   2. Avoid: Caffeine (incr gastric motility), raw fruit (incr osmotic diarrhea), lactose
3. Antimotility agents
   1. May mask amount of fluid lost (fluid may pool in the intestine); encourage rehydration
   2. Agents:
      1. Loperamide
         1. Most effective agent
         2. Dose: 4mg; then 2mg after each unformed stool for no more than 2d (max 16mg/d)
         3. Give w/ abx in pts w/ invasive infection
         4. Avoid in pts w/:
            1. Bloody diarrhea
            2. C. diff
            3. High fever
      2. Bismuth subsalicylate
         1. Consider when loperamide is contraindicated (high fever, dysentery)
         2. Dose: 30 mL or 2tab q30 min for 8doses; repeat on day 2
         3. Caution: may cause bismuth encephalopathy in HIV pts
      3. Diphenoxylate and atropine 4mg QID x2d
         1. 2nd line agent (may cause cholinergic side effects)
4. Abx
   1. Contraindications:
      1. Suspected or proven EHEC (e.g. O157:H7)
         1. Suspect if bloody diarrhea, abdominal pain, but little or no fever
      2. Suspected or proven salmonella typhi in healthy host w/ mild-moderate symptoms
   2. Indications:
      1. Suspected bacterial diarrhea
         1. Fever
         2. Bloody diarrhea (except for EHEC)
         3. Occult blood or +fecal leukocytes
      2. Moderate to severe travelers' diarrhea (>4 stools/d, fever, blood, or mucus in stool)
      3. >8 stools/d
      4. Volume depletion
      5. >1wk duration
      6. Immunocompromised
      7. Toxic appearance
   3. Ciprofloxacin
      1. First-line choice for empiric therapy
      2. 500mg BID x 3-5d
   4. Azithromycin
      1. Use if fluoroquinolone resistance is expected (e.g. Campylobacter from SE Asia)
      2. 500mg QD x3d

Toxigenic v. Infectious

Characteristic	Toxic	Infectious/Invasive
Incubation	2-12h	1-3d
Onset	abrupt	gradual
Duration	<10-24h	1-7days
Fever	No	Yes
Abdominal Pain	Minimal	Yes, tenesmus
Systemic	No	Yes, myalgias, N/V
Physical findings	Nontoxic	Toxic
Abdominal Tenderness	No	Yes
Stool Blood, WBCs	No	Yes

DDX

Noninfectious

• GI bleed
• Adrenal insufficiency
• Thyroid storm
• Toxicologic exposures
• Mesenteric ischemia
• Antibiotic or drug-associated

Infectious

Viruses cause the vast majority of infectious diarrhea bacterial causes are responsible for most cases of severe diarrhea. A history of foreign travel is associated with an 80% probability of bacterial diarrhea

The presence of severe abdominal pain, fever, or bloody stool mandates microbiologic workup to rule out bacterial or amoebic infection.

If the stool demonstrates fecal leukocytes, there is an increased chance of finding an invasive pathogen. Bloody stool without white blood cells is a common feature of Shiga toxin–producing E. coli or E coli O157:H7 and colitis that is due to E. histolytica.1,6

Patients with severe pain, fever, and bloody stool should undergo stool studies for specific pathogens, including culture for Salmonella, Shigella, Campylobacter, and E coli O157:H7; assay for Shiga toxin; and microscopy or antigen assay for E. histolytica.6

Exposure of a traveler or hiker to untreated water and illnesses that persist for more than 7 days should prompt evaluations for protozoal pathogens. Indeed, one of the major clinical features of protozoal diarrheas is prolonged course. Patients who have persistent diarrhea should have stools tested for E. histolytica antigen, G. intestinalis antigen, and Cryptosporidium parvum antigen by enzyme immunoassay.1,6

When deciding whether to admit a patient with diarrhea, conservatism should be the rule with the young and the elderly

Work Up

1. Toxigenic:Nothing
2. Invasive:
   1. Stool Cx
      1. Additional Cx: E.Coli 0157:H7
3. C. dif toxin
4. Sool O&P
   1. 1. only if suspect parasitic, recent travel, failed abx, chronic diarrhea, immunocompromised
5. Send stool WBCs only if diagnosis is uncertain; Sensitivity: 60-85% (ie unclear if invasive or toxigenic)

Source

3/12/06 DONALDSON (adapted from Rosen); 09 Birnbaumer