Acute diarrhea
Definitions
Diarrhea: 3 or more stools per day; assumes shape of container
Hyperacute: 1-6 hours
Acute: less than 2 weeks in duration
Gastroenteritis: diarrhea with nausea and or vomiting
Dysentery: Diarrhea with blood/mucus/pus
Invasive=Infectious
Diagnosis
Emergent Causes
1) Appendicitis
2) Mesenteric ischemia
3) Ectopic
4) CO poisoning
5) SAH
6) Diverticultis
Questions
Ingestions
Abd pain
Blood/Consistency
Frequency/Quantity/Odor
Tenesmus (infxs - shigella)
HIV/Immunocomp/Sexual hx
Recent Abx (<30 dys), PPI
Recent travel
Timing: Chronic (>1mo) vs. acute (<2wk)
Chemo
- guiac, fecal leuks, stool Cx, CBC, chem 7 --> unhelpful in adults (Rosen)
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
W/U
Toxigenic: Nothing
Invasive:
Stool Cx
-Additional Cx: E.Coli 0157:H7
C. dif toxin
Sool O&P
-only if suspect parasitic, recent travel, failed abx, chronic diarrhea, immunocompromised
Send stool WBCs only if diagnosis is uncertain; Sensitivity: 60-85% (ie unclear if invasive or toxigenic)
Treatment
Toxigenic
Rehydrate with fluids containing sugar, salt, fluids po, IV NS
Avoid high osmolality (gatorade!), caffeine, lactose-containing (lactase removed during infection)
Eat! - BRAT diet (small amounts banana, rice, apple sauce, toast) - will speed up recovery
Analgesia as needed
Anti-diarrheals
Kaolin-pectin agents
Bismuth
Antimotility (avoid alone in invasive illness)
Infectious
Above plus:
Ciprofloxacin 500mg po bid or
Levofloxacin 500mg po qd or
Bactrim DS 1tab po bid (+/-)
3-7d treatment
Empiric Abx1) Toxic appearance
2) Vital abnl
3) Fever >39
4) Bloody diarrhea
5) Severe dehydration
Loperimide Contraindications
1) Pediatric
2) IBD
3) C. Diff
4) Dysentery
(always give with abx)
WHO Oral Rehydration
1 cup orange juice
4 tsp sugar
1tsp baking powder
3/4 tsp salt
in 1 liter of H2O
Other
- Octreotide can be used in AIDS-associated diarrhea unresponsive to loperimide
- Consider Pepto-Bismol for traveler's diarrhea (contraindicated in HIV-->encephalopathy)
Source
3/12/06 DONALDSON (adapted from Rosen); 09 Birnbaumer