Difference between revisions of "Acute diarrhea"

(Text replacement - "infx" to "infection")
(Text replacement - " w/ " to " with ")
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**Viruses cause vast majority of infectious diarrhea
 
**Viruses cause vast majority of infectious diarrhea
 
**Bacterial causes are responsible for most cases of severe diarrhea
 
**Bacterial causes are responsible for most cases of severe diarrhea
***Foreign travel assoc w/ 80% probability of bacterial diarrhea (see [[Traveler's Diarrhea]])
+
***Foreign travel assoc with 80% probability of bacterial diarrhea (see [[Traveler's Diarrhea]])
  
 
===Definitions===
 
===Definitions===
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*Possible food poisoning?
 
*Possible food poisoning?
 
**Symptoms occur within 6hr
 
**Symptoms occur within 6hr
*Does it resolve (osmotic) or persist (secretory) w/ fasting?
+
*Does it resolve (osmotic) or persist (secretory) with fasting?
 
*Are the stools of smaller volume (large intestine) or larger volume (small intestine)
 
*Are the stools of smaller volume (large intestine) or larger volume (small intestine)
 
*Fever or abdominal pain? (diverticulitis, gastroenteritis, IBD)
 
*Fever or abdominal pain? (diverticulitis, gastroenteritis, IBD)
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*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 infection 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
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===Indications for Workup===
 
===Indications for Workup===
 
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 abx 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===
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**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====
 
====[[C. diff]] toxin====
 
*10% false negative rate
 
*10% false negative rate

Revision as of 21:21, 12 July 2016

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 wks in duration
  • Gastroenteritis: Diarrhea with nausea and/or vomiting
  • Dysentery: Diarrhea with blood/mucus/pus
  • Invasive = Infectious

Clinical Features

History

  • Possible food poisoning?
    • Symptoms occur within 6hr
  • Does it resolve (osmotic) or persist (secretory) with fasting?
  • Are the stools of smaller volume (large intestine) or larger volume (small intestine)
  • Fever or abdominal pain? (diverticulitis, gastroenteritis, IBD)
  • Bloody or melenic?
  • Tenesmus? (shigella)
  • Malodorous? (giardia)
  • Recent travel? (Traveler's Diarrhea)
  • Recent Abx? (C. diff)
  • HIV/immunocomp/sexual hx
  • Heat intolerance and anxiety? (thyrotoxicosis)
  • Paresthesias or reverse temperature sensation? (Ciguatera)

Physical Exam

  • Thyroid masses
  • Oral ulcers, erythema nodosum, episcleritis, anal fissure (IBD)
  • Reactive arthritis (Arthritis, conjunctivitis, urethritis)
    • Suggests infection with salmonella, shigella, campylobacter, or yersinia
  • Rectal exam for fecal impaction
  • Guaiac
  • Abdominal pain out of proportion to exam (mesenteric ischemia)

Differential Diagnosis

Acute diarrhea

Infectious

Noninfectious

Watery Diarrhea

Traveler's Diarrhea

Diagnosis

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, N/V
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 abx 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 w/:
    • 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:
    • Diarrhea >7d
    • Untreated water
    • AIDS
    • Bloody diarrhea with few or no fecal leukocytes (intestinal amebiasis)

C. diff toxin

  • 10% false negative rate
  • Takes 24hr to run

Chemistry

  • Warranted in severely dehydrated patients

Abdominal X-ray

  • Consider if h/o abdominal symptoms (r/o obstruction)

Chest Xray

CT

Supportive Therapies

Oral rehydration

  • 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 (incr gastric motility), raw fruit (incr 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

Diphenoxylate and atropine

  • Dose: 4mg QID x2d
  • 2nd line agent (may cause cholinergic side effects

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

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 ouptatient
  • 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