Acute diarrhea

Definitions

1. Diarrhea: 3 or more stools per day; assumes shape of container
2. Hyperacute: 1-6 hours
3. Acute: less than 2 weeks in duration
4. Gastroenteritis: diarrhea with nausea and or vomiting
5. Dysentery: Diarrhea with blood/mucus/pus
6. Invasive=Infectious

Diagnosis

Emergent Causes

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

Questions

1. Ingestions
2. Abd pain
3. Blood/Consistency
4. Frequency/Quantity/Odor
5. Tenesmus (infxs - shigella)
6. HIV/Immunocomp/Sexual hx
7. Recent Abx (<30 dys), PPI
8. Recent travel
9. Timing: Chronic (>1mo) vs. acute (<2wk)
10. Chemo

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

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)

Treatment

Toxigenic

1. Rehydrate with fluids containing sugar, salt, fluids po, IV NS
2. Avoid high osmolality (gatorade!), caffeine, lactose-containing (lactase removed during infection)
3. Eat! - BRAT diet (small amounts banana, rice, apple sauce, toast) - will speed up recovery
4. Analgesia as needed
5. Anti-diarrheals
6. Kaolin-pectin agents
7. Bismuth
8. Antimotility (avoid alone in invasive illness)

Infectious

Above plus:

1. Antibiotics
   1. Ciprofloxacin 500mg po bid or
   2. Levofloxacin 500mg po qd or
   3. Bactrim DS 1tab po bid (+/-)
2. 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. 1 cup orange juice
2. 4 tsp sugar
3. 1 tsp baking powder
4. 3/4 tsp salt
5. 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