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Diarrhea
Updated: Nov 11, 2016 | Author: Stefano Guandalini, MD; Chief Editor: Carmen Cuffari, MD more...

Diarrhea is the reversal of the normal net absorptive status of water and electrolyte
absorption to secretion. The augmented water content in the stools (above the normal
value of approximately 10 mL/kg/d in the infant and young child, or 200 g/d in the
teenager and adult) is due to an imbalance in the physiology of the small and large
intestinal processes involved in the absorption of ions, organic substrates, and thus
water.

Signs and symptoms

Acute diarrhea is defined as the abrupt onset of 3 or more loose stools per day and lasts
no longer than 14 days; chronic or persistent diarrhea is defined as an episode that lasts
longer than 14 days. The distinction has implications not only for classification and
epidemiologic studies but also from a practical standpoint, because protracted diarrhea
often has different etiologies, poses different management problems, and has a different
prognosis.

The clinical presentation and course of diarrhea therefore depend on its cause and on
the host. Consider the following to determine the source/cause of the patient’s diarrhea:

Stool characteristics (eg, consistency, color, volume, frequency)

Presence of associated enteric symptoms (eg, nausea/vomiting, fever, abdominal
pain)
Use of child daycare (common pathogens: rotavirus, astrovirus, calicivirus;
Campylobacter, Shigella, Giardia, and Cryptosporidium species [spp])
Food ingestion history (eg, raw/contaminated foods, food poisoning)
Water exposure (eg, swimming pools, marine environment)
Camping history (possible exposure to contaminated water sources)
Travel history (common pathogens affect specific regions; also consider rotavirus
and Shigella, Salmonella, and Campylobacter spp regardless of specific travel
history, as these organisms are prevalent worldwide)
Animal exposure (eg, young dogs/cats: Campylobacter spp; turtles: Salmonella spp)
Predisposing conditions (eg, hospitalization, antibiotic use, immunocompromised
state)

Signs and symptoms of diarrhea may include the following:

Dehydration: Lethargy, depressed consciousness, sunken anterior fontanel, dry

mucous membranes, sunken eyes, lack of tears, poor skin turgor, delayed capillary
refill
 Failure to thrive and malnutrition: Reduced muscle/fat mass or peripheral edema
Abdominal pain/cramping
Borborygmi
Perianal erythema

See Clinical Presentation for more detail.

Diagnosis
Fecal laboratory studies include the following:

Examination for ova and parasites

Leukocyte count
pH level: A pH level of 5.5 or less or the presence of reducing substances indicates
carbohydrate intolerance, which is usually secondary to viral illness
Examination of exudates for presence/absence of leukocytes
Cultures: Always culture for Salmonella, Shigella, and Campylobacter spp and Y
enterocolitica in the presence of clinical signs of colitis or if fecal leukocytes are
present; look for Clostridium difficile in those with diarrhea characterized by colitis
and/or bloody stools; assess for Escherichia coli, particularly O157:H7, with bloody
diarrhea and a history of eating ground beef; screen for Vibrio and Plesiomonas spp
with a history of eating raw seafood or foreign travel
Enzyme immunoassay for rotavirus or adenovirus antigens
Latex agglutination assay for rotavirus

Other laboratory studies may include the following:

Serum albumin levels: Low in protein-losing enteropathies from enteroinvasive

intestinal infections (eg, Salmonella spp, enteroinvasive E coli)
Fecal alpha1-antitrypsin levels: High in enteroinvasive intestinal infections
Anion gap to determine nature of the diarrhea (ie, osmolar vs secretory)
Intestinal biopsy: May be indicated in the presence of chronic or protracted
diarrhea, as well as in cases in which a search for a cause is believed to be
mandatory (eg, in patients with acquired immunodeficiency syndrome [AIDS] or
patients who are otherwise severely immunocompromised)

See Workup for more detail.

Management
Acute-onset diarrhea is usually self-limited; however, an acute infection can have a
protracted course. Management is generally supportive: In most cases, the best option
for treatment of acute-onset diarrhea is the early use of oral rehydration therapy (ORT). [1]

Pharmacotherapy
Vaccines (eg, rotavirus) can help increase resistance to infection. Antimicrobial and
antiparasitic agents may be used to treat diarrhea caused by specific organisms and/or
clinical circumstances. Such medications include the following:

Cefixime
Ceftriaxone
Cefotaxime
Erythromycin
Furazolidone
Iodoquinol
Metronidazole
Paromomycin
Quinacrine
Sulfamethoxazole and trimethoprim
Vancomycin
Tetracycline
Nitazoxanide
Rifaximin

Practice
See Essentials
Treatment and Medication for more detail.

Acute diarrhea is defined as the abrupt onset of 3 or more loose stools per day. The
augmented water content in the stools (above the normal value of approximately 10
mL/kg/d in the infant and young child, or 200 g/d in the teenager and adult) is due to an
imbalance in the physiology of the small and large intestinal processes involved in the
absorption of ions, organic substrates, and thus water. A common disorder in its acute
form, diarrhea has many causes and may be mild to severe.

Childhood acute diarrhea is usually caused by infection of the small and/or large
intestine; however, numerous disorders may result in diarrhea, including a malabsorption
syndrome and various enteropathies. Acute-onset diarrhea is usually self-limited;
however, an acute infection can have a protracted course. By far, the most common
complication of acute diarrhea is dehydration.

Although the term "acute gastroenteritis" is commonly used synonymously with "acute
diarrhea," the former term is a misnomer. The term gastroenteritis implies inflammation of
both the stomach and the small intestine, whereas, in reality, gastric involvement is rarely
if ever seen in acute diarrhea (including diarrhea with an infectious origin); in addition,
enteritis is also not consistently present. Examples of infectious acute diarrhea
syndromes that do not cause enteritis include Vibrio cholerae– induced diarrhea and
Shigella -induced diarrhea. Thus, the term acute diarrhea is preferable to acute
gastroenteritis.
Diarrheal episodes are classically distinguished into acute and chronic (or persistent)
based on their duration. Acute diarrhea is thus defined as an episode that has an acute
onset and lasts no longer than 14 days; chronic or persistent diarrhea is defined as an
episode that lasts longer than 14 days. The distinction, supported by the World Health
Organization (WHO), has implications not only for classification and epidemiological
studies but also from a practical standpoint because protracted diarrhea often has a
different set of causes, poses different problems of management, and has a different
Background
prognosis.

Diarrhea is the reversal of the normal net absorptive status of water and electrolyte
absorption to secretion. Such a derangement can be the result of either an osmotic force
that acts in the lumen to drive water into the gut or the result of an active secre​tory state
induced in the enterocytes. In the former case, diarrhea is osmolar in nature, as is
observed after the ingestion of nonabsorbable sugars such as lactulose or lactose in
lactose malabsorbers. Instead, in the typical active secretory state, enhanced anion
secretion (mostly by the crypt cell compartment) is best exemplified by enterotoxin-​‐
induced diarrhea.

In osmotic diarrhea, stool output is proportional to the intake of the unabsorbable

substrate and is usually not massive; diarrheal stools promptly regress with
discontinuation of the offending nutrient, and the stool ion gap is high, exceeding 100
mOsm/kg. In fact, the fecal osmolality in this circumstance is accounted for not only by
the electrolytes but also by the unabsorbed nutrient(s) and their degradation products.
The ion gap is obtained by subtracting the concentration of the elec​trolytes from total
osmolality (assumed to be 290 mOsm/kg), according to the formula: ion gap = 290 – [(Na
+ K) × 2].

In secretory diarrhea, the epithelial cells’ ion transport processes are turned into a state
of active secretion. The most common cause of acute-onset secretory diarrhea is a
bacterial infection of the gut. Several mechanisms may be at work. After colonization,
enteric pathogens may adhere to or invade the epithelium; they may produce
enterotoxins (exotoxins that elicit secretion by increasing an intracellular second
messenger) or cytotoxins. They may also trigger release of cytokines attracting
inflammatory cells, which, in turn, contribute to the acti​vated secretion by inducing the
release of agents such as prostaglandins or platelet-activating factor. Features of
secretory diarrhea include a high purg​ing rate, a lack of response to fasting, and a normal
Pathophysiology
stool ion gap (ie, 100 mOsm/kg or less), indicating that nutrient absorption is intact.

United States
In the United States, one estimate before the introduction of specific antirotavirus
immunization in 2006 assumed a cumulative incidence of 1 hospitalization for diarrhea
per 23-27 children by age 5 years, with more than 50,000 hospitalizations. By these
estimates, rotavirus was associated with 4-5% of all childhood hospitalizations and a cost
of nearly $ 1 billion. [2] Furthermore, acute diarrhea is responsible for 20% of physician
referrals in children younger than 2 years and for 10% in children younger than 3 years.

The impact of vaccination on rotavirus morbidity has been remarkable, with significant
reduction of diarrhea-associated hospitalizations and visits to emergency departments in
children in the years 2007-2008 compared with the prevaccine period. [3]

International
In developing countries, an average of 3 episodes per child per year in children younger
than 5 years is reported; however, some areas report 6-8 episodes per year per child. In
these settings, malnutrition is an important additional risk factor for diarrhea, and
recurrent episodes of diarrhea lead to growth faltering and substantially increased
mortality. [4] Childhood mortality associated with diarrhea has constantly but slowly
declined during the past 2 decades, mostly because of the widespread use of oral
rehydration solutions; however, it appears to have plateaued over the past several years.

Because the single most common cause of infectious diarrhea worldwide is rotavirus,
and because a vaccine has been in use for over 3 years now, a reduction in the overall
frequency of diarrheal episodes is hoped for in the near future.

A study by Lübbert et al found the incidence of Clostridium difficile infection in Germany

in 2012 to be 83 cases per 100,000 population. The chance of recurrence increased with
each relapse; an initial recurrence of the infection was found in 18.2% of patients with
index events, with 28.4% of these patients having a second recurrence and 30.2% of
Frequency patients having a third recurrence. [5]
second-recurrence

Mortality from acute diarrhea is overall globally declining but remains high. Most
estimates have diarrhea as the second cause of childhood mortality, with 18% of the 10.6
million yearly deaths in children younger than age 5 years.

Despite a progressive reduction in global diarrheal disease mortality over the past 2
decades, diarrhea morbidity in published reports from 1990-2000 slightly increased
worldwide compared with previous reports. In the United States, an average of 369
diarrhea-associated deaths/year occurred among children aged 1-59 months during
1992-1998 and 2005-2006. [6] The vast majority of diarrhea-associated infant deaths
were reported in 2005-2007, with 86% of deaths occurring among low-birthweight (<
2500 g) infants. [7]

Furthermore, in countries in which the toll of diarrhea is highest, poverty also adds an
enormous additional burden, and long-term consequences of the vicious cycle of enteric
infections, diarrhea, and malnutrition are devastating. [4]

Sex
Most cases of infectious diarrhea are not sex specific. Females have a higher incidence
of Campylobacter species infections and hemolytic uremic syndrome (HUS).

Age
Viral diarrhea is most common in young children. Rotavirus and adenovirus are
particularly prevalent in children younger than 2 years. Astrovirus and norovirus usually
infect children younger than 5 years. Yersinia enterocolitis typically infects children
younger than 1 year, and the Aeromonas organism is a significant cause of diarrhea in
young children.

Very young children are particularly susceptible to secondary dehydration and secondary
nutrient malabsorption. Age and nutritional status appear to be the most important host
factors in determining the severity and the duration of diarrhea. In fact, the younger the
child, the higher is the risk for severe, life-threatening dehydration as a result of the high
body-water turnover and limited renal compensatory capacity of very young children.
Whether younger age also means a risk of run​ning a prolonged course is an unsettled
issue. In developing countries, persis​tent postenteritis diarrhea has a strong inverse
correlation with age.

Mortality/Morbidity Clinical Presentation

SECTIONS
Diarrhea

Overview

• Practice Essentials

Background

Pathophysiology

Frequency

Mortality/Morbidity

Presentation

DDx

Workup
Treatment

Medication

Follow-up

Tables

References

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