Acute diarrhea: Difference between revisions

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{{Adult top}} [[diarrhea (peds)]]
==Background==
==Background==
*Almost all true diarrheal emergencies are of noninfectious origin
*Almost all true diarrheal emergencies are of noninfectious origin
*85% of diarrhea is infectious in etiology
*85% of diarrhea is infectious in etiology
**Viruses cause vast majority of infectious diarrhea
**[[Viruses]] cause vast majority of infectious diarrhea
**Bacterial causes are responsible for most cases of severe diarrhea
**[[Bacteria]]l causes are responsible for most cases of severe diarrhea
***Foreign travel assoc w/ 80% probability of bacterial diarrhea (see [[Traveler's Diarrhea]])
***Foreign travel associated with 80% probability of bacterial diarrhea (see [[Traveler's Diarrhea]])
*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==
===Definitions===
=== History ===
*[[Diarrhea]]: Increased frequency of defection, usually >3 bowel movements per day
#Possible food poisoning?
*Hyperacute: 1-6 hr
##Symptoms occur within 6hr
*Acute: less than 3 weeks in duration
#Does it resolve (osmotic) or persist (secretory) w/ fasting?
*[[Gastroenteritis]]: Diarrhea with nausea and/or vomiting
#Are the stools of smaller volume (large intestine) or larger volume (small intestine)
*Dysentery: Diarrhea with blood/mucus/pus
#Fever or abdominal pain? (diverticulitis, gastroenteritis, IBD)
*Invasive = Infectious
#Bloody or melenic?
 
#Tenesmus? ([[shigella]])
==Clinical Features==
#Malodorous? ([[giardia]])
===History===
#Recent travel? ([[Traveler's Diarrhea]])
*Possible food poisoning?
#Recent Abx? ([[C. diff]])
**Symptoms occur within 6hr
#HIV/immunocomp/sexual hx
*Does it resolve (osmotic) or persist (secretory) with fasting?
#Heat intolerance and anxiety? ([[thyrotoxicosis]])
*Are the stools of smaller volume (large intestine) or larger volume (small intestine)
#Paresthesias or reverse temperature sensation? ([[Ciguatera]])
*[[Fever]] or [[abdominal pain]]? ([[diverticulitis]], [[gastroenteritis]], [[IBD]])
*[[GI bleeding|Bloody or melenic]]?
*Tenesmus? ([[shigella]])
*Malodorous? ([[giardia]])
*Recent travel? ([[Traveler's Diarrhea]])
*Recent antibiotics? ([[C. diff]])
*[[HIV]]/immunocompromised/high risk behaviors?
*Heat intolerance and anxiety? ([[thyrotoxicosis]])
*[[Paresthesias]] or reverse temperature sensation? ([[Ciguatera]])


===Physical Exam===
===Physical Exam===
#Thyroid masses
*[[Thyroid]] masses
#Oral ulcers, erythema nodosum, episcleritis, anal fissure (IBD)
*Oral ulcers, erythema nodosum, episcleritis, [[anal fissure]] ([[IBD]])
#Reactive arthritis (Arthritis, conjunctivitis, urethritis)
*[[Reactive arthritis]] ([[Arthritis]], [[conjunctivitis]], urethritis)
##Suggests infx w/ salmonella, shigella, campylobacter, or yersinia
**Suggests infection with [[salmonella]], [[shigella]], [[campylobacter]], or [[yersinia]]
#Rectal exam for fecal impaction
*Rectal exam for [[fecal impaction]]
#Guaiac
*Guaiac
#Abdominal pain out of proportion to exam (mesenteric ischemia)
*[[Abdominal pain]] out of proportion to exam ([[mesenteric ischemia]])
 
==Differential Diagnosis==
{{Diarrhea DDX}}


== Toxigenic v. Infectious ==
==Evaluation==
[[File:Causes_of_Diarrhea.jpg|thumb]]
===Toxigenic v. Infectious===


{| class="wikitable"
{| class="wikitable"
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| Systemic
| Systemic
| No
| No
| Yes, myalgias, N/V
| Yes, myalgias, nausea and vomiting
|-
|-
| Physical findings
| Physical findings
Line 83: Line 90:
|}
|}


[[Media:Causes_of_Diarrhea.jpg]]
===Indications for Workup===
 
== Differential Diagnosis  ==
{{Template:Diarrhea DDX}}
 
==Work-Up==
Indicated for:
Indicated for:
*Profuse watery diarrhea w/ signs of hypovolemia
*Profuse watery diarrhea with signs of [[hypovolemia]]
*Severe abdominal pain
*Severe [[abdominal pain]]
*Fever >38.5 (101.3) (suggests infection w/ invasive bacteria)
*[[Fever]] >38.5 (101.3) (suggests infection with invasive bacteria)
*Symptoms >2-3d
*Symptoms >2-3d
*Blood or pus in stool (E. coli 0157:H7)
*Blood or pus in stool ([[E. coli]] 0157:H7)
*Recent hospitalization or abx use
*Recent hospitalization or antibiotic use
*Elderly or immunocompromised  
*Elderly or immunocompromised  
*Systemic illness w/ diarrhea (esp if pregnant (listeria))
*Systemic illness with diarrhea (esp if pregnant ([[listeria]]))
 
===Stool Studies===
===Stool Studies===
====Fecal leukocytes====
====Fecal leukocytes====
#Used to differentiate invasive from noninvasive infectious diarrheas
*Used to differentiate invasive from noninvasive infectious diarrheas
#Sn 50-80%, Sp 83% for presence of bacterial pathogen
*Sn 50-80%, Sp 83% for presence of bacterial pathogen
#If pt has +leukocytes but negative infection consider IBD
*If patient has +leukocytes but negative infection consider IBD
 
====Stool culture====
====Stool culture====
#Plays minor role in ED evaluation
*Plays minor role in ED evaluation
#Yield is only 1.5-5.5%
*Yield is only 1.5-5.5%
#Consider in pts w/:
*Consider in patients with
##Immunosuppression
**Immunosuppression
##Severe, inflammatory diarrhea (including bloody diarrhea)
**Severe, inflammatory diarrhea (including bloody diarrhea)
##Underlying IBD (need to distinguish between flare and superimposed infection)
**Underlying IBD (need to distinguish between flare and superimposed infection)
 
====O&P====
====O&P====
#Indicated if parasitic cause is suspected:
*Indicated if parasitic cause is suspected:
##Diarrhea >7d
**[[Diarrhea]] >7d
##Untreated water
**Untreated water
##AIDS
**[[AIDS]]
##Bloody diarrhea w/ few or no fecal leukocytes (intestinal amebiasis)
**Bloody diarrhea with few or no fecal leukocytes (intestinal [[amebiasis]])
====C. diff toxin====
 
#10% false negative rate
====[[C. diff]] toxin====
#Takes 24hr to run
*10% false negative rate
*Turnaround time for results varies by institution
 
====Chemistry====
====Chemistry====
#Warranted in severely dehydrated pts
*Warranted in severely dehydrated patients
====Abdominal X-ray====
 
#Consider if h/o abdominal sx (r/o obstruction)
====[[CXR]]====
====Chest Xray====
*Consider if diarrhea + cough ([[Legionella]])
#Consider if diarrhea + cough (Legionella)
 
====CT====
====Imaging====
#Consider if suspect mesenteric ischemia
*Consider abdominal CT if abdominal tenderness or suspicion of surgical abdomen (e.g. [[appendicitis]], [[small bowel obstruction]], [[mesenteric ischemia]])
*[[Abdominal X-ray]] is almost never indicated given low sensitivity for pathology (e.g. [[obstruction]])
 
==Supportive Therapies==
===[[Oral rehydration therapy]]===
*Fluids should contain sugar, salt, and water
===Probiotics===
*Lactobacilli and bifidobacterium
*25% decrease in average duration of diarrhea (good evidence)
===Diet Modification===
*Eat: BRAT(Bananas, Rice, Applesauce and Toast) diet (no evidence)
*Avoid: [[Caffeine]] (increased gastric motility), raw fruit (increased osmotic diarrhea), lactose
 
===[[Bismuth subsalicylate]]===
*Consider when loperamide is contraindicated (high fever, dysentery)
*Dose: 30 mL or 2tab q30 min for 8doses; repeat on day 2
*Caution: may cause [[bismuth toxicity|bismuth encephalopathy]] in [[HIV]] patients
 
===[[Loperamide]]===
*2mg PO per dose
**Start: 4mg PO x1, then 2mg PO after each loose stool; Max: 16mg/day
*Contraindicated if suspect C. diff
 
===[[Diphenoxylate/atropine]]===
*Dose: 4mg QID x2d
*2nd line agent (may cause cholinergic side effects)
*Contraindicated in pseudomembranous colitis, obstructive jaundice, and children <6y


==Treatment==
==[[Antibiotics]] for Infectious Diarrhea==
#Oral rehydration
*Most cases of diarrhea are NOT from infectious causes. If the patient suspects that there is blood in the stool but there is no abdominal pain, and no fever, the cause is unlikely to be from a bacterial cause.  Also avoid antibiotics in E. Coli 0157:H7 (EHEC) cases due the risk of [[Hemolytic Uremic Syndrome (HUS)]]''<ref name="practical guide"> Aranda-Michel J et al. Acute diarrhea: A practical review. AmJMed. 1999;106:670-676.</ref>
##Fluids should contain sugar, salt, and water
*The majority of patients, even with bacterial positive cultures, will recover from diarrhea illness without antibiotic therapy<ref>DuPont HL et al. Practice Parameters Committee of the American College of Gastroenterology. Guidelines on acute infectious diarrhea in adults. Am J Gastroenterol. 1997;92:1962-1975.</ref>
#Probiotics
 
##Lactobacilli and bifidobacterium
===Relative Indications for Antibiotics<ref>IDSA Practice Guidelines for the Management of Infectious Diarrhea. 2001. [http://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/Diarrhea.pdf fulltext]</ref>===
##25% decrease in average duration of diarrhea (good evidence)
*Suspected bacterial diarrhea  
#Food
*Bloody diarrhea (except for EHEC) with fever and systemic illness
##Eat: BRAT diet (no evidence)
*Occult blood or +fecal leukocytes
##Avoid: Caffeine (incr gastric motility), raw fruit (incr osmotic diarrhea), lactose
*Moderate to severe travelers' diarrhea (>4 stools/d, fever, blood, or mucus in stool)
#[[Antibiotics]]
*>8 stools/d
##Contraindications:
*Volume depletion
###Suspected or proven EHEC (e.g. O157:H7)
*>1wk duration
####Suspect if bloody diarrhea, abdominal pain, but little or no fever
*Immunocompromised
##Indications:
*Toxic appearance
###Suspected bacterial diarrhea
 
####Fever
===Empiric Therapy===
####Bloody diarrhea (except for EHEC)
{{Diarrhea Empiric Therapy}}
####Occult blood or +fecal leukocytes
 
###Moderate to severe travelers' diarrhea (>4 stools/d, fever, blood, or mucus in stool)
===[[Traveler's Diarrhea]]===
###>8 stools/d
*Therapy should be based on the [[Traveler's diarrhea |geography of travel]]
###Volume depletion
'''Adult Options:'''
###>1wk duration
{{Travelers Diarrhea Antibiotics}}
###Immunocompromised
 
###Toxic appearance
'''Pediatric Options:'''
##[[Ciprofloxacin]]
{{Travelers Diarrhea Pediatric Antibiotics}}
###First-line choice for empiric therapy
 
###500mg BID x 3-5d
===Culture Specific Antibiotics===
##[[Azithromycin]]
{| {{table}}
###Use if [[fluroquinolone]] resistance is expected (e.g. Campylobacter from SE Asia)
| align="center" style="background:#f0f0f0;"|'''Agent'''
###500mg QD x3d
| align="center" style="background:#f0f0f0;"|'''Treatment'''
#Antimotility agents
|-
##May mask amount of fluid lost (fluid may pool in the intestine); encourage rehydration
| [[Clostridium difficile]]||{{Severe Cdiff Antibiotics}}
##Agents:
|-
###Loperamide
| [[Campylobacter jejuni]]||{{Campylobacter antibiotics}}
####Most effective agent
|-
####Dose: 4mg; then 2mg after each unformed stool for no more than 2d (max 16mg/d)
| [[Entamoeba histolytica]]||{{Entamoeba diarrhea antibiotics}}
####Give w/ abx in pts w/ invasive infection
|-
####Avoid in pts w/:
| [[Giardia lamblia]]||{{Giardia antibiotics}}
#####Bloody diarrhea
|-
#####[[C. diff]]
| [[Microsporidium]]||{{Microsporidium antibiotics}}
#####High fever
|-
###Bismuth subsalicylate
| [[Cryptosporidium]]||{{Cryptosporidium diarrhea antibiotics}}
####Consider when loperamide is contraindicated (high fever, dysentery)
|-
####Dose: 30 mL or 2tab q30 min for 8doses; repeat on day 2
| [[Salmonella]] (non typhoid)||{{Salmonella diarrhea antibiotics}}
####Caution: may cause bismuth encephalopathy in HIV pts
|-
###Diphenoxylate and atropine 4mg QID x2d
| [[Shigella]]||{{Shigella diarrhea antibiotics}}
####2nd line agent (may cause cholinergic side effects
|-
| [[Cholera|Vibrio Cholerae]]||{{Vibrio cholerae antibiotics}}
|-
| [[Yersinia enterocolitica]]||{{Yersiniae enterocolitica antibiotics}}
|}


==Disposition==
==Disposition==
*Conservatism should be the rule with the young and the elderly
*Hospitalization should be individualized based on the patient's ability to tolerate oral hydration, have adequate social support, and also based on complicating comorbidities.
*Majority of patients can be treated as an outpatient
*Observation or admission is required for those with severe disease, and significant dehydration with other end organ complications


==See Also==
==See Also==
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[[Category:GI]]
[[Category:GI]]
[[Category:ID]]
[[Category:ID]]
[[Category:Symptoms]]

Revision as of 22:42, 28 November 2019

This page is for adult patients. For pediatric patients, see: diarrhea (peds)

Background

  • Almost all true diarrheal emergencies are of noninfectious origin
  • 85% of diarrhea is infectious in etiology
    • Viruses cause vast majority of infectious diarrhea
    • Bacterial causes are responsible for most cases of severe diarrhea

Definitions

  • Diarrhea: Increased frequency of defection, usually >3 bowel movements per day
  • Hyperacute: 1-6 hr
  • Acute: less than 3 weeks in duration
  • Gastroenteritis: Diarrhea with nausea and/or vomiting
  • Dysentery: Diarrhea with blood/mucus/pus
  • Invasive = Infectious

Clinical Features

History

Physical Exam

Differential Diagnosis

Acute diarrhea

Infectious

Noninfectious

Watery Diarrhea

Traveler's Diarrhea

Evaluation

Causes of Diarrhea.jpg

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, nausea and vomiting
Physical findings Nontoxic Toxic
Abdominal Tenderness No Yes
Stool Blood, WBCs No Yes

Indications for Workup

Indicated for:

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

Stool Studies

Fecal leukocytes

  • Used to differentiate invasive from noninvasive infectious diarrheas
  • Sn 50-80%, Sp 83% for presence of bacterial pathogen
  • If patient has +leukocytes but negative infection consider IBD

Stool culture

  • Plays minor role in ED evaluation
  • Yield is only 1.5-5.5%
  • Consider in patients with
    • Immunosuppression
    • Severe, inflammatory diarrhea (including bloody diarrhea)
    • Underlying IBD (need to distinguish between flare and superimposed infection)

O&P

  • Indicated if parasitic cause is suspected:

C. diff toxin

  • 10% false negative rate
  • Turnaround time for results varies by institution

Chemistry

  • Warranted in severely dehydrated patients

CXR

Imaging

Supportive Therapies

Oral rehydration therapy

  • Fluids should contain sugar, salt, and water

Probiotics

  • Lactobacilli and bifidobacterium
  • 25% decrease in average duration of diarrhea (good evidence)

Diet Modification

  • Eat: BRAT(Bananas, Rice, Applesauce and Toast) diet (no evidence)
  • Avoid: Caffeine (increased gastric motility), raw fruit (increased osmotic diarrhea), lactose

Bismuth subsalicylate

  • Consider when loperamide is contraindicated (high fever, dysentery)
  • Dose: 30 mL or 2tab q30 min for 8doses; repeat on day 2
  • Caution: may cause bismuth encephalopathy in HIV patients

Loperamide

  • 2mg PO per dose
    • Start: 4mg PO x1, then 2mg PO after each loose stool; Max: 16mg/day
  • Contraindicated if suspect C. diff

Diphenoxylate/atropine

  • Dose: 4mg QID x2d
  • 2nd line agent (may cause cholinergic side effects)
  • Contraindicated in pseudomembranous colitis, obstructive jaundice, and children <6y

Antibiotics for Infectious Diarrhea

  • Most cases of diarrhea are NOT from infectious causes. If the patient suspects that there is blood in the stool but there is no abdominal pain, and no fever, the cause is unlikely to be from a bacterial cause. Also avoid antibiotics in E. Coli 0157:H7 (EHEC) cases due the risk of Hemolytic Uremic Syndrome (HUS)[2]
  • The majority of patients, even with bacterial positive cultures, will recover from diarrhea illness without antibiotic therapy[3]

Relative Indications for Antibiotics[4]

  • Suspected bacterial diarrhea
  • Bloody diarrhea (except for EHEC) with fever and systemic illness
  • Occult blood or +fecal leukocytes
  • Moderate to severe travelers' diarrhea (>4 stools/d, fever, blood, or mucus in stool)
  • >8 stools/d
  • Volume depletion
  • >1wk duration
  • Immunocompromised
  • Toxic appearance

Empiric Therapy

Traveler's Diarrhea

Adult Options:

Pediatric Options:

Avoid fluroquinolones

Culture Specific Antibiotics

Agent Treatment
Clostridium difficile
Campylobacter jejuni
Entamoeba histolytica
Giardia lamblia
Microsporidium
Cryptosporidium
Salmonella (non typhoid)
  • Treatment is not recommended routinely but should be considered if:
  • Immunocompromised
  • Age<6 mo or >50yo
  • Has any prostheses
  • Valvular heart disease
  • Severe Atherosclerosis
  • Active Malignancy
  • Uremic

Options: Immunocompromised patients should have 14 days of therapy

Shigella Treatment extended for 10 days if immunocompromised'
Vibrio Cholerae
Yersinia enterocolitica Antibiotics are not required unless patient is immunocompromised or systemically ill

Disposition

  • Hospitalization should be individualized based on the patient's ability to tolerate oral hydration, have adequate social support, and also based on complicating comorbidities.
  • Majority of patients can be treated as an outpatient
  • Observation or admission is required for those with severe disease, and significant dehydration with other end organ complications

See Also

References

  1. Marx et al. “Cholera and Gastroenteritis caused by Noncholera Vibrio Species”. Rosen’s Emergency Medicine 8th edition vol 1 pg 1245-1246.
  2. Aranda-Michel J et al. Acute diarrhea: A practical review. AmJMed. 1999;106:670-676.
  3. DuPont HL et al. Practice Parameters Committee of the American College of Gastroenterology. Guidelines on acute infectious diarrhea in adults. Am J Gastroenterol. 1997;92:1962-1975.
  4. IDSA Practice Guidelines for the Management of Infectious Diarrhea. 2001. fulltext
  5. Hoge CW. et al. Trends in antibiotic resistance among diarrheal pathogens isolated in Thailand over 15 years. Clin Infect Dis. 1998;26:341–5
  6. Steffen R, et al. Traveler’s Diarrhea: A Clinical Review. JAMA. 2015;313(1):71-80. doi:10.1001/jama.2014.17006
  7. Sanders JW. et al. An observational clinic-based study of diarrheal illness in deployed United States military personnel in Thailand: presentation and outcome of Campylobacter infection. Am J Trop Med Hyg. 2002;67:533–8
  8. Steffen R, et al. Traveler’s Diarrhea: A Clinical Review. JAMA. 2015;313(1):71-80. doi:10.1001/jama.2014.17006
  9. Steffen R, et al. Traveler’s Diarrhea: A Clinical Review. JAMA. 2015;313(1):71-80. doi:10.1001/jama.2014.17006
  10. DuPont HL. et al. Rifaximin versus ciprofloxacin for the treatment of traveler’s diarrhea: a randomized, double-blind clinical trial. Clin Infect Dis. 2001;33:1807–15
  11. Stauffer WM, Konop RJ, Kamat D. Traveling with infants and young children. Part III: travelers’ diarrhea. J Travel Med. 2002;9:141–50