Acute Diarrhea

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Diarrheal diseases represent one of the ________leading causes of death worldwide

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five

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definition

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Acute — ≤14 days in duration
Persistent diarrhea — more than 14 days in duration
Chronic — more than 30 days in duration

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Most cases of acute diarrhea are due to _______and are _________

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infections with viruses and bacteria
self-limited.

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ETIOLOGY

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viruses, bacteria, and, less often, protozoa

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Indications for diagnostic evaluation

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Profuse watery diarrhea with signs of hypovolemia
Passage of many small volume stools containing blood and mucus
Bloody diarrhea
Temperature ≥38.5ºC (101.3ºF)
Passage of ≥6 unformed stools per 24 hours or a duration of illness >48 hours
Severe abdominal pain
Recent use of antibiotics or hospitalized patients
Diarrhea in the elderly (≥70 years of age) or the immunocompromised
Systemic illness with diarrhea, especially in pregnant women (in which case listeriosis should be suspected)

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fever

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suggests infection with invasive bacteria (eg, Salmonella, Shigella, or Campylobacter), enteric viruses, or a cytotoxic organism such as Clostridium difficile or Entamoeba histolytica

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Symptoms that begin within six hours suggest ingestion of a preformed toxin of

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Staphylococcus aureus or Bacillus cereus

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Symptoms that begin at 8 to 16 hours suggest

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infection with Clostridium perfringens

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Symptoms that begin at more than 16 hours can result from

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viral or bacterial infection (eg, contamination of food with enterotoxigenic or enterohemorrhagic E. coli).

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Syndromes that may begin with diarrhea but progress to fever and more systemic complaints such as head ache, muscle aches, stiff neck may suggest

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infection with Listeria monocytogenes, particularly in pregnant woman

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Bloody diarrhea

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3 percent
E. coli O157:H7 was present in 7.8 percent
Less common bacterial causes of visibly bloody diarrhea were Shigella, Campylobacter, and Salmonella species

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Fecal leukocytes and occult blood

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predict the presence of an inflammatory diarrhea has varied greatly, with reports of sensitivity and specificity ranging from 20 to 90 percent

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Fecal lactoferrin

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sensitivity and specificity ranging from 90 to 100 percent in distinguishing inflammatory diarrhea

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When to obtain stool cultures

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low rate of positive stool cultures in most reports (1.5 to 5.6 percent)
continue symptomatic therapy for several days before considering further evaluation in patients who do not have severe illness

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obtaining stool cultures on initial presentation in the following groups of patients:

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Immunocompromised patients, including those infected with the human immunodeficiency virus (HIV)
Patients with comorbidities that increase the risk for complications
Patients with more severe, inflammatory diarrhea (including bloody diarrhea)
Patients with underlying inflammatory bowel disease in whom the distinction between a flare and superimposed infection is critical
Some employees, such as food handlers, occasionally require negative stool cultures to return to work

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When to obtain stool for ova and parasites

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Persistent diarrhea (associated with Giardia, Cryptosporidium, and Entamoeba histolytica)
Persistent diarrhea following travel to Russia, Nepal, or mountainous regions (associated with Giardia, Cryptosporidium, and Cyclospora)
Persistent diarrhea with exposure to infants in daycare centers (associated with Giardia and Cryptosporidium)
Diarrhea in a man who has sex with men (MSM) or a patient with AIDS (associated with Giardia and Entamoeba histolytica in the former, and a variety of parasites in the latter)
A community waterborne outbreak (associated with Giardia and Cryptosporidium)
Bloody diarrhea with few or no fecal leukocytes (associated with intestinal amebiasis)

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Endoscopy

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uncommonly needed in the diagnosis
Distinguishing inflammatory bowel disease from infectious diarrhea
Diagnosing C. difficile infection and looking for pseudomembranes in patients who are toxic
In immunocompromised patients who are at risk for opportunistic infections with agents such as cytomegalovirus.
In patients in whom ischemic colitis is suspected but the diagnosis remains unclear after clinical and radiologic assessment

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TREATMENT

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Oral rehydration solutions
Empiric antibiotic therapy
Symptomatic therapy -loperamide (Imodium) - fever is absent or low grade and the stools are not bloody
Probiotics
Dietary recommendations

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Empiric antibiotic therapy

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fluoroquinolone for three to five days in the absence of suspected EHEC or fluoroquinolone-resistant campylobacter infection
We recommend azithromycin and erythromycin as alternative agents if fluoroquinolone resistance is suspected
We recommend directed antibiotic treatment when an intestinal pathogen is identified