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Diarrhea, Adult, Emergency Medicine

Basics

Description

- Salmonella: - Contaminated water, eggs, poultry, or dairy products - Typhoid fever (Salmonella typhi) characterized by unremitting fever, abdominal pain, rose spots, splenomegaly, and bradycardia

- Bacterial toxin: - Escherichia coli: - Major cause of travelers diarrhea - Ingestion of food or water contaminated by feces

- Bacillus cereus: - Classic source-fried rice left on steam tables - Symptoms within 1-36 hr

- Aeromonas hydrophila: - Aquatic sources primarily - Affects children <3 yr of age - Fecal leukocytes absent

- Cholera: - Caused by enterotoxin produced by Vibrio cholerae - Profuse watery stools with mucus (classic appearance of rice-water stools)

- Protozoa: - Giardia lamblia: - Most common cause of parasite gastroenteritis in North America - High-risk groups: Travelers, children in day care centers, institutionalized people, homosexual men, and campers who drink untreated mountain water

- Cryptosporidium parvum: - Commonly carried in patients with AIDS

- Stool culture-indications: - Presence of fecal leukocytes - Historical markers: Immunocompromised, travel, homosexual - Public health: Food handler, day care or health care worker, institutionalized

- Bismuth subsalicylate (Pepto-Bismol): - Antisecretory agent - Effective clinical relief without adverse effects

Bowel movements characterized as frequent (>3/day), loose, and watery owing to an infectious or toxin exposure

Etiology

  • Viruses:
  • Invasive bacteria:Campylobacter:Contaminated food or water, wilderness water, birds, and animalsMost common bacterial diarrheaGross or occult blood is found in 60-90%.Salmonella:Contaminated water, eggs, poultry, or dairy productsTyphoid fever (Salmonella typhi) characterized by unremitting fever, abdominal pain, rose spots, splenomegaly, and bradycardiaShigella:Vibrio parahaemolyticus:Raw and undercooked seafoodYersinia:Contaminated food (pork), water, and milkMay present as mesenteric adenitis or mimic appendicitis
  • Bacterial toxin:Escherichia coli:Major cause of travelers diarrheaIngestion of food or water contaminated by fecesStaphylococcus aureus:Most common toxin-related diseaseSymptoms 1-6 hr after ingesting foodBacillus cereus:Classic source-fried rice left on steam tablesSymptoms within 1-36 hrClostridium difficile:Antibiotic-associated enteritis linked to pseudomembranous colitisIncubation period within 10 days of exposure or initiation of antibioticsAeromonas hydrophila:Aquatic sources primarilyAffects children <3 yr of ageFecal leukocytes absentCholera:Caused by enterotoxin produced by Vibrio choleraeProfuse watery stools with mucus (classic appearance of rice-water stools)
  • Protozoa:Giardia lamblia:Most common cause of parasite gastroenteritis in North AmericaHigh-risk groups: Travelers, children in day care centers, institutionalized people, homosexual men, and campers who drink untreated mountain waterCryptosporidium parvum:Commonly carried in patients with AIDSEntamoeba histolytica (entamebiasis):5-10% extraintestinal manifestations (hepatic amebic abscess)
  • Most are viral in origin and self-limited.
  • Rotavirus accounts for 50%.
  • Shigella: Infections associated with seizures
  • Focus evaluation on state of hydration.

Diagnosis

Signs and Symptoms

History

  • Loose, watery bowel movements
  • Bloody stools with mucus
  • Abdominal pain and cramps, tenesmus, flatulence
  • Fever, headache, myalgias
  • Nausea, vomiting
  • Dehydration, lethargy, and stupor

Physical Exam

  • Dry mucous membranes
  • Abdominal tenderness
  • Perianal inflammation, fissure, fistula

Essential Workup

  • Digital rectal exam to determine presence of gross or occult blood
  • Fecal leukocyte determination:Present with invasive bacteriaAbsent in protozoal infections, viral, toxin-induced food poisoning

Diagnosis Tests & Interpretation

Lab

  • CBC-indications:Significant blood lossSystemic toxicity
  • Electrolytes, glucose, BUN, creatinine-indications:Lethargy, significant dehydration, toxicity, or altered mental statusDiuretic use, persistent diarrhea, chronic liver, or renal disease
  • Stool culture-indications:Presence of fecal leukocytesHistorical markers: Immunocompromised, travel, homosexualPublic health: Food handler, day care or health care worker, institutionalized
  • Blood cultures-indications:Suspected bacteremia or systemic infectionsIll patients requiring admissionImmunocompromisedElderly patients and infants

Imaging

Abdominal radiographs:

  • No value unless obstruction or toxic megacolon suspected

Differential Diagnosis

  • Ulcerative colitis
  • Crohns disease
  • Mesenteric ischemia
  • Diverticulitis, anal fissures, hemorrhoids
  • Irritable bowel syndrome
  • Milk and food allergies
  • Malrotation with midgut volvulus
  • Meckel diverticulum
  • Intussusception
  • Appendicitis
  • Drugs and toxins:MannitolSorbitolPhenolphthaleinMagnesium-containing antacidsQuinidineColchicineMushroomsMercury poisoning

Treatment

Pre-Hospital

  • Difficult IV access with severe dehydration
  • Avoid exposure to contaminated clothes or body substances.

Initial Stabilization/Therapy

  • ABCs
  • IV fluid with 0.9% normal saline (NS) resuscitation for severely dehydrated

Ed Treatment/Procedures

  • Oral fluids for mild dehydration (Gatorade/Pedialyte)
  • IV fluids for:Hypotension, nausea and vomiting, obtundation, metabolic acidosis, significant hypernatremia or hyponatremia0.9% NS bolus: 500 mL-1 L (peds: 20 mL/kg) for resuscitation, then 0.9% NS or D5W 0.45% NS (peds: D5W 0.25% NS) to maintain adequate urine output
  • Bismuth subsalicylate (Pepto-Bismol):Antisecretory agentEffective clinical relief without adverse effects
  • Kaolin-pectin (Kaopectate):Reduces fluidity of stoolsDoes not influence course of disease
  • Antimotility drugs: Diphenoxylate (Lomotil), loperamide (Imodium), paregoric, codeine:Appropriate in noninfectious diarrheaInitial use of sparse amounts to control symptoms in infectious diarrheaAvoid prolonged use in infectious diarrhea-may increase duration of fever, diarrhea, and bacteremia and may precipitate toxic megacolon
  • Antibiotics for infectious pathogens:Campylobacter: Quinolone or erythromycinSalmonella: Quinolone or trimethoprim-sulfamethoxazole (TMP-SMX)Typhoid fever:CeftriaxoneShigella: Quinolone, TMP-SMX, or ampicillinV. parahaemolyticus:Tetracycline or doxycyclineC. difficile: Metronidazole or vancomycinE. coli: Quinolone or TMP-SMXG. lamblia: Metronidazole or quinacrineE. histolytica (entamebiasis): Iodoquinol or metronidazole

Medication

  • Ampicillin: 500 mg (peds: 20 mg/kg/24h) PO or IV q6h
  • TMP-SMX (Bactrim DS): 1 tab (peds: 8-10 mg TMP/40-50 mg SMX/kg/24h) PO or 4-5 mg/kg TMP IV BID
  • Ceftriaxone: 1 g (peds: 50-75 mg/kg/12h) IM or IV q12h.
  • Ciprofloxacin (quinolone): 500 mg PO or 400 mg IV q12h (>18 yr)
  • Doxycycline: 100 mg PO or 100 mg IV q12h
  • Erythromycin: 500 mg (peds: 40-50 mg/kg/24h) PO QID
  • Iodoquinol: 650 mg (peds: 30-40 mg/kg/24h not to exceed 2 g daily) PO TID
  • Metronidazole: 250 mg (peds: 35 mg/kg/24h) PO TID (>8 yr)
  • Quinacrine: 100 mg (peds: 6 mg/kg/24h) PO TID
  • Tetracycline: 500 mg PO or IV q6h
  • Vancomycin: 125-500 mg (peds: 40 mg/kg/24h) PO q6h

Follow-Up

Disposition

Admission Criteria

  • Hypotension, unresponsive to IV fluids
  • Significant bleeding
  • Signs of sepsis or toxicity
  • Intractable vomiting or abdominal pain
  • Severe electrolyte imbalance or metabolic acidosis
  • Altered mental status
  • Children with >10-15% dehydration

Discharge Criteria

  • Mild cases requiring oral hydration
  • Dehydration responsive to IV fluids

Issues for Referral

Cases of prolonged diarrhea may be referred to a gastroenterologist for further workup.

Followup Recommendations

Since diarrhea is self-limiting, follow-up is optional.

Pearls and Pitfalls

  • Avoid prolonged use of antimotility drugs in infectious diarrhea.
  • TMP-SMX (Bactrim DS), ciprofloxacin, doxycycline, and tetracycline are contraindicated in pregnancy. Metronidazole may be used in the 3rd trimester.
  • Health care providers and food handlers with documented infectious diarrhea may need clearance to return to work from their local health department.
  • Infectious diarrhea with C. difficile is on the rise, especially in nursing home patients.

Additional Reading

  • Denno DM, Shaikh N, Stapp JR, et al. Diarrhea etiology in a pediatric emergency department: A case control study. Clin Infect Dis. 2012;55:897-904.
  • DuPont HL. Clinical practice. Bacterial diarrhea. N Engl J Med. 2009;361(16):1560-1569.
  • Leffler DA, Lamont JT. Treatment of Clostridium difficile-associated disease. Gastroenterology. 2009;136:1899-1912.
  • Mehal JM, Esposito DH, Holman RC, et al. Risk factors for diarrhea-associated infant mortality in the United States, 2005-2007. Pediatr Infect Dis J. 2012;31:717-721.

See Also (Topic, Algorithm, Electronic Media Element)

Gastroenteritis

Codes

ICD9

  • 008.5 Bacterial enteritis, unspecified
  • 008.8 Intestinal infection due to other organism, not elsewhere classified
  • 787.91 Diarrhea
  • 008.43 Intestinal infection due to campylobacter
  • 003.0 Salmonella gastroenteritis
  • 004.9 Shigellosis, unspecified
  • 008.00 Intestinal infection due to E. coli, unspecified

ICD10

  • A04.9 Bacterial intestinal infection, unspecified
  • A08.4 Viral intestinal infection, unspecified
  • R19.7 Diarrhea, unspecified
  • A04.5 Campylobacter enteritis
  • A02.0 Salmonella enteritis
  • A03.9 Shigellosis, unspecified
  • A04.4 Other intestinal Escherichia coli infections

SNOMED

  • 62315008 Diarrhea (finding)
  • 111843007 Viral gastroenteritis (disorder)
  • 274080003 Bacterial gastroenteritis (disorder)
  • 18081009 enteric campylobacteriosis (disorder)
  • 111817006 Infection by Shigella (disorder)
  • 111839008 Intestinal infection due to E. coli (disorder)
  • 302229004 Salmonella food poisoning
  • 42338000 Salmonella gastroenteritis (disorder)