Acute diarrhea

Definitions

Diarrhea: 3 or more stools per day; assumes shape of container

Hyperacute: 1-6 hours

Acute: less than 2 weeks in duration

Gastroenteritis: diarrhea with nausea and or vomiting

Dysentery: Diarrhea with blood/mucus/pus

Invasive=Infectious

==

Diagnosis

Emergent Causes

1) Appendicitis

2) Mesenteric ischemia

3) Ectopic

4) CO poisoning

5) SAH

6) Diverticultis

Questions

Ingestions

Abd pain

Blood/Consistency

Frequency/Quantity/Odor

Tenesmus (infxs - shigella)

HIV/Immunocomp/Sexual hx

Recent Abx (<30 dys), PPI

Recent travel

Timing: Chronic (>1mo) vs. acute (<2wk)

Chemo

*guiac, fecal leuks, stool Cx, CBC, chem 7 --> unhelpful in adults (Rosen)

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

W/U

Toxigenic:�Nothing

Invasive:

Stool Cx

-Additional Cx:�E.Coli 0157:H7

C. dif toxin

Sool O&P

-only if suspect parasitic, recent travel, failed abx, chronic diarrhea, immunocompromised

Send stool WBCs only if diagnosis is uncertain; Sensitivity: 60-85% (ie unclear if invasive or toxigenic)

Treatment

Toxigenic

Rehydrate with fluids containing sugar, salt, fluids po, IV�NS

Avoid high osmolality (gatorade!), caffeine, lactose-containing (lactase removed during infection)

Eat! - BRAT�diet (small amounts banana, rice, apple sauce, toast) - will speed up recovery

Analgesia as needed

Anti-diarrheals

Kaolin-pectin agents

Bismuth

Antimotility (avoid alone in invasive illness)

Infectious

Above plus:

Ciprofloxacin 500mg po bid or

Levofloxacin 500mg po qd or

Bactrim DS 1tab po bid (+/-)

3-7d treatment

Empiric Abx

1) Toxic appearance

2) Vital abnl

3) Fever >39

4) Bloody diarrhea

5) Severe dehydration

Loperimide Contraindications

1) Pediatric

2) IBD

3) C. Diff

4) Dysentery

(always give with abx)

WHO Oral Rehydration

1 cup orange juice

4 tsp sugar

1tsp baking powder

3/4 tsp salt

in 1 liter of H2O

Other

*Octreotide can be used in AIDS-associated diarrhea unresponsive to loperimide

*Consider Pepto-Bismol for traveler's diarrhea (contraindicated in HIV-->encephalopathy)

Source

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

Definitions

Diarrhea: 3 or more stools per day; assumes shape of container

Hyperacute: 1-6 hours

Acute: less than 2 weeks in duration

Gastroenteritis: diarrhea with nausea and or vomiting

Dysentery: Diarrhea with blood/mucus/pus

Invasive=Infectious

Diagnosis

Emergent Causes

1) Appendicitis

2) Mesenteric ischemia

3) Ectopic

4) CO poisoning

5) SAH

6) Diverticultis

Questions

Ingestions

Abd pain

Blood/Consistency

Frequency/Quantity/Odor

Tenesmus (infxs - shigella)

HIV/Immunocomp/Sexual hx

Recent Abx (<30 dys), PPI

Recent travel

Timing: Chronic (>1mo) vs. acute (<2wk)

Chemo

• guiac, fecal leuks, stool Cx, CBC, chem 7 --> unhelpful in adults (Rosen)

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

W/U

Toxigenic: Nothing

Invasive:

    Stool Cx

         -Additional Cx: E.Coli 0157:H7

    C. dif toxin

    Sool O&P

         -only if suspect parasitic, recent travel, failed abx, chronic diarrhea, immunocompromised

Send stool WBCs only if diagnosis is uncertain; Sensitivity: 60-85% (ie unclear if invasive or toxigenic)

Treatment

Toxigenic

Rehydrate with fluids containing sugar, salt, fluids po, IV NS

Avoid high osmolality (gatorade!), caffeine, lactose-containing (lactase removed during infection)

Eat! - BRAT diet (small amounts banana, rice, apple sauce, toast) - will speed up recovery

Analgesia as needed

Anti-diarrheals

    Kaolin-pectin agents

    Bismuth

Antimotility (avoid alone in invasive illness)

Infectious

Above plus:

Ciprofloxacin 500mg po bid or

Levofloxacin 500mg po qd or

Bactrim DS 1tab po bid (+/-)

3-7d treatment

Empiric Abx1) Toxic appearance

2) Vital abnl

3) Fever >39

4) Bloody diarrhea

5) Severe dehydration

Loperimide Contraindications

1) Pediatric

2) IBD

3) C. Diff

4) Dysentery

(always give with abx)

WHO Oral Rehydration

1 cup orange juice

4 tsp sugar

1tsp baking powder

3/4 tsp salt

in 1 liter of H2O

Other

• Octreotide can be used in AIDS-associated diarrhea unresponsive to loperimide

• Consider Pepto-Bismol for traveler's diarrhea (contraindicated in HIV-->encephalopathy)

Source

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