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Diarrhea, Acute

- Serum electrolytes - BUN and creatinine may elevate with volume depletion. - Nonanion gap metabolic acidosis - Stool sample - Occult blood present in inflammatory bowel disease, bowel ischemia, and certain bacterial infections - Fecal leukocytes - Stool ova and parasites - Stool culture - For bloody diarrhea, consider Salmonella, Shigella, Campylobacter, E. coli 0157:H7, Y. enterocolitica, E. histolytica.

- C. difficile toxin (especially with recent hospitalization or antibiotic use) (8)[B] - Giardia ELISA >90% sensitive in at-risk population - Abdominal radiographs (flat plate and upright) if severe abdominal pain or concern for obstruction - Abdominal CT scan is preferred to evaluate intra-abdominal and intestinal disease.

- Consider empiric antibiotics (fluoroquinolones or macrolides) in patients with signs and symptoms of systemic infection and severe cases of traveler's diarrhea (10). - Fever - Bloody diarrhea - Presence of fecal leukocytes - Immunocompromised host - Signs of volume depletion - Symptoms >1 week

- Tailor antibiotics to stool culture results (11) - Giardia: metronidazole, tinidazole - E. histolytica: metronidazole - Shigella: ciprofloxacin or azithromycin - Campylobacter: azithromycin or erythromycin - C. difficile: metronidazole, PO vancomycin, or fidaxomicin - Traveler's diarrhea: patients without fever or dysentery: rifaximin 200 mg PO TID or ciprofloxacin 500 mg PO BID. Patients with fever or dysentery: azithromycin 500 mg PO 1 on day 1 followed by 250 mg PO for 4 days

- Significant medication interactions - Salicylate absorption from bismuth subsalicylate can cause toxicity in patients already taking aspirin-containing compounds and may alter anticoagulation control in patients taking warfarin. - Avoid alcoholic beverages with metronidazole due to the possibility of a disulfiram reaction.

para>Watery diarrhea with chronic constipation may be caused by fecal impaction or obstructing neoplasm.

DIFFERENTIAL DIAGNOSIS

  • Inflammatory bowel disease
  • Malabsorption
  • Medications (cholinergic agents, magnesium-containing antacids, chemotherapy, antibiotics)
  • C. difficile colitis secondary to antibiotic use
  • Diverticulitis; ischemic colitis
  • Spastic (irritable) colon
  • Fecal impaction
  • Endocrinopathies: thyroid disease
  • Neoplasia

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

  • CBCLeukocytosis, anemia from blood loss, eosinophilia (parasite infection)
  • Serum electrolytes
  • BUN and creatinine may elevate with volume depletion.
  • Nonanion gap metabolic acidosis
  • Stool sampleOccult blood present in inflammatory bowel disease, bowel ischemia, and certain bacterial infectionsFecal leukocytesStool ova and parasitesStool cultureFor bloody diarrhea, consider Salmonella, Shigella, Campylobacter, E. coli 0157:H7, Y. enterocolitica, E. histolytica.C. difficile toxin (especially with recent hospitalization or antibiotic use) (8)[B]Giardia ELISA >90% sensitive in at-risk populationAbdominal radiographs (flat plate and upright) if severe abdominal pain or concern for obstructionAbdominal CT scan is preferred to evaluate intra-abdominal and intestinal disease.

Diagnostic Procedures/Other

  • Consider sigmoidoscopy or colonoscopy in patients with persistent diarrhea, when there is no clear diagnosis after routine blood and stool tests, and if empiric or supportive therapy is ineffective.
  • Consider colonoscopy in immunocompromised patients to evaluate for CMV colitis.
  • Colonoscopy helps to distinguish infectious diarrhea from inflammatory bowel disease.

TREATMENT

GENERAL MEASURES

  • Oral rehydration and electrolyte management are key elements in successful treatment (9)[A].
  • Diet, as tolerated-"if the gut works, use it"
  • IV fluids if patient cannot tolerate oral rehydration or presents with severe dehydration

MEDICATION

First Line

  • Consider empiric antibiotics (fluoroquinolones or macrolides) in patients with signs and symptoms of systemic infection and severe cases of traveler's diarrhea (10).FeverBloody diarrheaPresence of fecal leukocytesImmunocompromised hostSigns of volume depletionSymptoms >1 week
  • Tailor antibiotics to stool culture results (11)Giardia: metronidazole, tinidazoleE. histolytica: metronidazoleShigella: ciprofloxacin or azithromycinCampylobacter: azithromycin or erythromycinC. difficile: metronidazole, PO vancomycin, or fidaxomicinTraveler's diarrhea: patients without fever or dysentery: rifaximin 200 mg PO TID or ciprofloxacin 500 mg PO BID. Patients with fever or dysentery: azithromycin 500 mg PO 1 on day 1 followed by 250 mg PO for 4 days
  • General considerationsAntibiotics are not recommended in Salmonella infections unless caused by Salmonella typhosa, or if the patient is febrile or immunocompromised.Avoid antibiotics in patients with E. coli 0157:H7 due to risk for hemolytic-uremic syndrome.Antibiotics are not indicated for foodborne toxigenic diarrhea.Avoid antimotility agents (e.g., loperamide) when possible in patients suspected of having infectious diarrhea (especially, E. coli 0157:H7) or antibiotic-associated colitis.Antimotility agents, when used in combination with antibiotics, may speed recovery from traveler's diarrhea (12)[A].
  • Significant medication interactionsSalicylate absorption from bismuth subsalicylate can cause toxicity in patients already taking aspirin-containing compounds and may alter anticoagulation control in patients taking warfarin.Avoid alcoholic beverages with metronidazole due to the possibility of a disulfiram reaction.

COMPLEMENTARY & ALTERNATIVE MEDICINE

  • Probiotic use above 1010/g may help in patients with antibiotic-associated diarrhea (3)[A].
  • The use of probiotics is controversial in the treatment of acute diarrhea. Probiotics should be avoided in immunocompromised patients (3,13)[A].
  • Probiotics shorten the duration of symptoms in pediatric (14).
  • Zinc supplementation can decrease diarrhea-related morbidity and mortality (15)[A].

INPATIENT CONSIDERATIONS

Admission Criteria/Initial Stabilization

Outpatient management, except for patients who are severely ill with signs of volume depletion

ONGOING CARE

DIET

  • Early refeeding is encouraged. Regular diets are as effective as restricted diets.
  • The traditional bananas, rice, applesauce, toast (BRAT) diet has little evidence-based support, despite heavy clinical use, and may result in suboptimal nutrition.
  • During periods of active diarrhea, coffee, alcohol, dairy products, fruits, vegetables, red meats, and heavily seasoned foods may exacerbate symptoms.

PATIENT EDUCATION

See guidelines in "General Prevention" section.

PROGNOSIS

Acute diarrhea is rarely life-threatening if adequate hydration is maintained.

COMPLICATIONS

  • Volume depletion, shock
  • Sepsis
  • Anemia
  • Hemolytic uremic syndrome with E. coli 0157:H7
  • Guillain-Barr © syndrome with C. jejuni
  • Reactive arthritis with Salmonella, Shigella, and Yersinia
  • Functional bowel disorders (e.g., postinfectious irritable bowel syndrome [PI-IBS]) (16)

REFERENCES

11 World Health Organization. The top 10 causes of death in the world, 2000 and 2012 fact sheet. http://www.who.int/mediacentre/factsheets/fs310/en/22 Barr W, Smith A. Acute diarrhea. Am Fam Physician. 2014;89(3):180-189.33 Janarthanan S, Ditah I, Adler DG, et al. Clostridium difficile-associated diarrhea and proton pump inhibitor therapy: a meta-analysis. Am J Gastroenterol. 2012;107(7):1001-1010.44 Soares-Weiser K, Maclehose H, Bergman H, et al. Vaccines for preventing rotavirus diarrhoea: vaccines in use. Cochrane Database Syst Rev. 2012;(11):CD008521.55 Anwar E, Goldberg E, Fraser A, et al. Vaccines for preventing typhoid fever. Cochrane Database Syst Rev. 2014;(1):CD001261.66 Sinclair D, Abba K, Zaman K, et al. Oral vaccines for preventing cholera. Cochrane Database Syst Rev. 2011;(3):CD008603.77 Ritchie ML, Romanuk TN. A meta-analysis of probiotic efficacy for gastrointestinal diseases. PLoS One. 2012;7(4):e34938.88 Pawlowski SW, Warren CA, Guerrant R. Diagnosis and treatment of acute or persistent diarrhea. Gastroenterology. 2009;136(6):1874-1886.99 DuPont HL. Clinical practice. Bacterial diarrhea. N Engl J Med. 2009;361(16):1560-1569.1010 Dryden MS, Gabb RJ, Wright SK. Empirical treatment of severe acute community-acquired gastroenteritis with ciprofloxacin. Clin Infect Dis. 1996;22(6):1019-1025.1111 DuPont HL. Acute infectious diarrhea in immunocompetent adults. N Engl J Med. 2014;370(16):1532-1540.1212 Riddle MS, Arnold S, Tribble DR. Effect of adjunctive loperamide in combination with antibiotics on treatment outcomes in traveler's diarrhea: a systematic review and meta-analysis. Clin Infect Dis. 2008;47(8):1007-1014.1313 Goldenberg JZ, Ma SS, Saxton JD, et al. Probiotics for the prevention of Clostridium difficile-associated diarrhea in adults and children. Cochrane Database Syst Rev. 2013;(5):CD006095.1414 Corr Șa NB, Penna FJ, Lima FM, et al. Treatment of acute diarrhea with Saccharomyces boulardii in infants. J Pediatr Gastroenterol Nutr. 2011;53(5):497-501.1515 Walker CL, Black RE. Zinc for the treatment of diarrhoea: effect on diarrhoea morbidity, mortality and incidence of future episodes. Int J Epidemiol. 2010;39(Suppl 1):i63-i69.1616 Schwille-Kiuntke J, Mazurak N, Enck P. Systematic review with meta-analysis: post-infectious irritable bowel syndrome after travellers' diarrhoea. Aliment Pharmacol Ther. 2015;41(11):1029-1037.

ADDITIONAL READING

  • Chen CC, Kong MS, Lai MW, et al. Probiotics have clinical, microbiologic, and immunologic efficacy in acute infectious diarrhea. Pediatr Infect Dis J. 2010;29(2):135-138.
  • DuPont HL. Systematic review: the epidemiology and clinical features of travellers' diarrhoea. Aliment Pharmacol Ther. 2009;30(3):187-196.
  • Johnston BC, Ma SS, Goldenberg JZ, et al. Probiotics for the prevention of Clostridium difficile-associated diarrhea: a systematic review and meta-analysis. Ann Intern Med. 2012;157(12):878-888.
  • Koo HL DuPont HL. Rifaximin: a unique gastrointestinal-selective antibiotic for enteric diseases. Curr Opin Gastroenterol. 2010;26(1):17-25.
  • McFarland LV. Evidence-based review of probiotics for antibiotic-associated diarrhea and Clostridium difficile infections. Anaerobe. 2009;15(6):274-280.

SEE ALSO

Botulism; Cholera; Food Poisoning, Bacterial

CODES

ICD10

  • R19.7 Diarrhea, unspecified
  • A09 Infectious gastroenteritis and colitis, unspecified
  • A08.4 Viral intestinal infection, unspecified
  • A04.9 Bacterial intestinal infection, unspecified
  • K52.2 Allergic and dietetic gastroenteritis and colitis
  • A05.9 Bacterial foodborne intoxication, unspecified
  • A04.4 Other intestinal Escherichia coli infections

ICD9

  • 787.91 Diarrhea
  • 009.2 Infectious diarrhea
  • 008.69 Enteritis due to other viral enteritis
  • 008.5 Bacterial enteritis, unspecified
  • 005.9 Food poisoning, unspecified

SNOMED

  • 409966000 Acute diarrhea (disorder)
  • 236076004 Infective diarrhea (disorder)
  • 111843007 Viral gastroenteritis (disorder)
  • 75375008 Bacterial enteritis (disorder)
  • 11840006 Travelers diarrhea (disorder)
  • 5891000119102 Clostridium difficile diarrhea (disorder)
  • 75258004 food poisoning (disorder)

CLINICAL PEARLS

  • Viruses are the most common causes of acute diarrheal illness in the United States.
  • Oral rehydration is the most important step in treating acute diarrhea.
  • Routine stool culture is not recommended, unless the patient presents with bloody diarrhea, fever >38.5 °C, severe dehydration, signs of inflammatory disease, persistent symptoms >3 to 7 days, or immunosuppression.
  • Start empiric antibiotics in patients who are severely ill or immunocompromised.