Difference between revisions of "Acute diarrhea"

 
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*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]])
  
== Toxigenic v. Infectious ==
+
==Differential Diagnosis==
 +
{{Diarrhea DDX}}
 +
 
 +
==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
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|}
 
|}
  
[[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==
 
==Supportive Therapies==
===Oral rehydration===
+
===[[Oral rehydration therapy]]===
#Fluids should contain sugar, salt, and water
+
*Fluids should contain sugar, salt, and water
 
===Probiotics===
 
===Probiotics===
#Lactobacilli and bifidobacterium
+
*Lactobacilli and bifidobacterium
#25% decrease in average duration of diarrhea (good evidence)
+
*25% decrease in average duration of diarrhea (good evidence)
 
===Diet Modification===
 
===Diet Modification===
#Eat: BRAT(Bananas, Rice, Applesauce and Toast) diet (no evidence)
+
*Eat: BRAT(Bananas, Rice, Applesauce and Toast) diet (no evidence)
#Avoid: Caffeine (incr gastric motility), raw fruit (incr osmotic diarrhea), lactose
+
*Avoid: [[Caffeine]] (increased gastric motility), raw fruit (increased osmotic diarrhea), lactose
  
===Bismuth subsalicylate===
+
===[[Bismuth subsalicylate]]===
 
*Consider when loperamide is contraindicated (high fever, dysentery)
 
*Consider when loperamide is contraindicated (high fever, dysentery)
 
*Dose: 30 mL or 2tab q30 min for 8doses; repeat on day 2
 
*Dose: 30 mL or 2tab q30 min for 8doses; repeat on day 2
*Caution: may cause bismuth encephalopathy in HIV patients
+
*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 and atropine===
+
===[[Diphenoxylate/atropine]]===
 
*Dose: 4mg QID x2d
 
*Dose: 4mg QID x2d
*2nd line agent (may cause cholinergic side effects
+
*2nd line agent (may cause cholinergic side effects)
 
+
*Contraindicated in pseudomembranous colitis, obstructive jaundice, and children <6y
 
 
  
 
==[[Antibiotics]] for Infectious Diarrhea==
 
==[[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)]]''<ref name="practical guide"> Aranda-Michel J et al. Acute diarrhea: A practical review. AmJMed. 1999;106:670-676.</ref>
+
*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>
 
*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>
 
*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>
  
 
===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>===
 
===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>===
#Suspected bacterial diarrhea  
+
*Suspected bacterial diarrhea  
#Bloody diarrhea (except for EHEC) with fever and systemic illness
+
*Bloody diarrhea (except for EHEC) with fever and systemic illness
#Occult blood or +fecal leukocytes
+
*Occult blood or +fecal leukocytes
#Moderate to severe travelers' diarrhea (>4 stools/d, fever, blood, or mucus in stool)
+
*Moderate to severe travelers' diarrhea (>4 stools/d, fever, blood, or mucus in stool)
#>8 stools/d
+
*>8 stools/d
#Volume depletion
+
*Volume depletion
#>1wk duration
+
*>1wk duration
#Immunocompromised
+
*Immunocompromised
#Toxic appearance
+
*Toxic appearance
  
 
===Empiric Therapy===
 
===Empiric Therapy===
Line 175: Line 186:
 
{{Travelers Diarrhea Pediatric Antibiotics}}
 
{{Travelers Diarrhea Pediatric Antibiotics}}
  
===[[Clostridium difficile]]===
+
===Culture Specific Antibiotics===
{{Severe Cdiff Antibiotics}}
+
{| {{table}}
 
+
| align="center" style="background:#f0f0f0;"|'''Agent'''
===[[Campylobacter jejuni]]===
+
| align="center" style="background:#f0f0f0;"|'''Treatment'''
{{Campylobacter antibiotics}}
+
|-
 
+
| [[Clostridium difficile]]||{{Severe Cdiff Antibiotics}}
===[[Amebiasis|Entamoeba Histolytica]]===
+
|-
{{Entamoeba diarrhea antibiotics}}
+
| [[Campylobacter jejuni]]||{{Campylobacter antibiotics}}
 
+
|-
===[[Giardia lamblia]]===
+
| [[Entamoeba histolytica]]||{{Entamoeba diarrhea antibiotics}}
{{Giardia antibiotics}}
+
|-
 
+
| [[Giardia lamblia]]||{{Giardia antibiotics}}
===[[Microsporidium]]===
+
|-
{{Microsporidium antibiotics}}
+
| [[Microsporidium]]||{{Microsporidium antibiotics}}
 
+
|-
===[[Cryptosporidium]]===
+
| [[Cryptosporidium]]||{{Cryptosporidium diarrhea antibiotics}}
{{Cryptosporidium diarrhea antibiotics}}
+
|-
 
+
| [[Salmonella]] (non typhoid)||{{Salmonella diarrhea antibiotics}}
===[[Salmonella]]===
+
|-
{{Salmonella diarrhea antibiotics}}
+
| [[Shigella]]||{{Shigella diarrhea antibiotics}}
 
+
|-
===[[Shigella]]===
+
| [[Cholera|Vibrio Cholerae]]||{{Vibrio cholerae antibiotics}}
{{Shigella diarrhea antibiotics}}
+
|-
 
+
| [[Yersinia enterocolitica]]||{{Yersiniae enterocolitica antibiotics}}
===[[Cholera|Vibrio Cholerae]]===
+
|}
{{Vibrio cholerae antibiotics}}
 
 
 
===[[Amebiasis|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==
Line 218: Line 227:
 
[[Category:GI]]
 
[[Category:GI]]
 
[[Category:ID]]
 
[[Category:ID]]
 +
[[Category:Symptoms]]

Latest revision as of 18:26, 29 September 2019

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
  • Vancomycin 125-250mg PO q6hr x10d (IV form is not effective)
  • Add Metronidazole 500mg IV q6hr if ileus or patient cannot tolerate PO
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