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DIARRHEADIARRHEA

Like constipation, diarrhea is a symptom of an underlying disorder, not a disease itself. It is characterized by
increased stool frequency (usually greater than three times daily), stool weight, liquidity, and decreased
consistency of stools compared with an individual’s usual pattern. Acute diarrhea is defined as diarrhea
lasting for 14 days or less. Diarrhea lasting more than 30 days is called chronic diarrhea. Illness of 15 to 30 days
is referred to as persistent diarrhea.

EPIDEMIOLOGY AND ETIOLOGY


Most cases of diarrhea in adults are mild and resolve quickly. Infants and children (especially less than 3 years)
are highly susceptible to the dehydrating effect of diarrhea, and its occurrence in this age group should be taken
seriously.

Acute Diarrhea
The terms acute diarrhea and acute gastroenteritis are not synonymous because diarrheal events do not invariably
produce enteritis or involve the stomach. Acute diarrhea has many possible causes, but infection is the most
common. Infectious diarrhea occurs because of transmission of contaminated food and water via the fecal–oral
route.

Viruses cause a large proportion of cases; common culprits include Rotavirus, Norwalk, and adenovirus. Bacterial
causes include Escherichia coli, Salmonella species, Shigella species, Vibrio cholerae, and Clostridium difficile.
The term dysentery describes some of these bacterial infections when associated with
serious occurrences of bloody diarrhea.

Acute diarrheal conditions can also result from parasites and protozoa such as Entamoeba histolytica,
Microsporidium, Giardia lamblia, and Cryptosporidium parvum. Most of these infectious agents can cause
traveler’s diarrhea, a common malady afflicting travelers worldwide. It usually occurs during or just after travel
following ingestion of fecally contaminated food or water. It has an abrupt onset but usually subsides within 2 to
3 days.

Noninfectious causes of acute diarrhea include drugs and toxins (Table 21–3), laxative abuse, food intolerance,
IBS, inflammatory bowel disease, ischemic bowel disease, lactase deficiency, Whipple disease, pernicious
anemia, diabetes mellitus, malabsorption, fecal impaction, diverticulosis, and celiac sprue.

Lactose intolerance is responsible for many cases of acute diarrhea, especially in persons of African descent,
Asians, and Native Americans. Possible food-related causes include fat substitutes, dairy products, and products
containing nonabsorbable carbohydrates.

The diarrhea of IBS is sudden, perhaps watery but likely loose, usually accompanied by urgency, bloating, and
abdominal pain often in the morning or immediately following a meal. Inflammatory bowel disease is typically
associated with the sudden onset of bloody diarrhea accompanied by urgency, crampy abdominal pain, and fever.
Patients who experience bowel ischemia may develop bloody diarrhea, particularly if they progress to shock.

Chronic Diarrhea
Most cases of chronic diarrhea result from functional or inflammatory bowel disorders, endocrine disorders,
malabsorption syndromes, and drugs (including laxative abuse). Daily watery stools may not occur with chronic
diarrhea. Diarrhea may be either intermittent or continual.

PATHOPHYSIOLOGY
Approximately 9 L (2.4 gallons) of fluid normally traverse the GI tract daily. Of this amount, 2 L represent gastric
juice, 1 L is saliva, 1 L is bile, 2 L are pancreatic juice, 1 L is intestinal secretions, and 2 L are ingested. Of the 9
L of fluid presented to the intestine, only about 150 to 200 mL remain in the stool after reabsorptive processes
occur.

Any event that increases the amount of fluid retained in the stool may result in diarrhea. Large-stool diarrhea often
signifies small intestinal involvement, whereas small-stool diarrhea usually originates in the colon. Diarrhea may
be classified according to pathophysiologic mechanisms, including osmotic, secretory, inflammatory, and altered
motility.
Osmotic diarrhea results from the intake of unabsorbable, water-soluble solutes in the intestinal lumen leading to
water retention. Common causes include lactose intolerance and ingestion of magnesium-containing antacids.

Secretory diarrhea results from increased movement (secretion) of ions into the intestinal lumen, leading to
increased intraluminal fluid. Medications, hormones, and toxins may be responsible for secretory activity.

Inflammatory (or exudative) diarrhea results from changes to the intestinal mucosa that damage absorption
processes leading to increased proteins and other products in the intestinal lumen with fluid retention. The
presence of blood or fecal leukocytes in the stool indicates an inflammatory process. The diarrhea of
inflammatory bowel disease fits this classification.

Increased motility results in decreased contact time of ingested food and drink with the intestinal mucosa, leading
to reduced reabsorption and increased fluid in the stool. Diarrhea resulting from altered motility is often
established after other mechanisms have been excluded. IBS-related diarrhea is due to altered motility.

Diarrhea may be attributed to a single or multiple overlapping mechanisms. For example, malabsorption
syndromes and traveler’s diarrhea are associated with both secretory and osmotic mechanisms.

Drug-induced diarrhea can occur by several mechanisms. First, water can be drawn into the intestinal lumen
osmotically (eg, saline laxatives). Second, the intestinal bacterial ecosystem can be upset leading to emergence of
invasive pathologic organisms triggering secretory and inflammatory processes (eg, antibiotic use). Third, altered
motility may occur with drugs such as tegaserod maleate. Other drugs produce diarrhea through undetermined
mechanisms (eg, procainamide, colchicine). Discontinuation of the offending drug may be the only measure
needed to ameliorate diarrhea.

CLINICAL PRESENTATION AND DIAGNOSIS


Refer to the accompanying box for the clinical presentation of diarrhea.

Diagnosis
Patients with diarrhea should be questioned about the onset of symptoms, recent travel, diet, source of water, and
medication use. Other important considerations include duration and severity of the diarrhea and the presence of
abdominal pain or vomiting; blood in the stool; stool consistency, appearance, and frequency; and weight loss.
Although most cases of diarrhea are self-limited, infants, children, elderly persons, and immunocompromised
patients are at risk for increased morbidity.

Findings on physical examination can assist in determining hydration status and disease severity. The presence of
blood in the stool suggests an invasive organism, an inflammatory process, or perhaps a neoplasm. Large-volume
stools suggest a small-intestinal disorder, whereas small-volume stools suggest a colon or rectal disorder. Patients
with prolonged or severe symptoms may require colonoscopic evaluation to identify the underlying cause.

TREATMENT
Acute diarrhea is generally self limited, lasting 3 to 4 days even without treatment. Most healthy adults with
diarrhea do not develop significant dehydration or other complications and can self-medicate symptomatically if
necessary. Dehydration can occur when diarrhea is severe and oral intake is limited, particularly in the elderly
and infants. Other complications of diarrhea resulting from fluid loss include electrolyte disturbances, metabolic
acidosis, and cardiovascular collapse.

Children are more susceptible to dehydration (particularly when vomiting occurs) and may require medical
attention early in the course, especially if younger than 3 years. Physician intervention is also necessary for elderly
patients who are sensitive to fluid loss and electrolyte changes due to concurrent chronic illness.

Patients should undergo medical evaluation in the following circumstances: (a) moderate to severe abdominal
tenderness, distention, or cramping; (b) bloody stools; (c) evidence of dehydration (eg, thirst, dry mouth, fatigue,
dark-colored urine, infrequent urination, reduced urine, dry skin, reduced skin elasticity, rapid pulse, rapid
breathing, muscle cramps, muscle weakness, sunken eyes, or lightheadedness); (d) high fever (38.3 oC or 101oF or
higher); (e) evidence of weight loss greater than 5% of total body weight; and (f) diarrhea that lasts longer than
48 hours.

Desired Outcomes
The goals of treatment for diarrhea are to relieve symptoms, maintain hydration, treat the underlying cause(s), and
maintain nutrition. The primary treatment of acute diarrhea includes fluid and electrolyte replacement, dietary
modifications, and drug therapy.

Nonpharmacologic Therapy
» Fluid and Electrolytes

Fluid replacement is not a treatment to relieve diarrhea but rather an attempt to restore fluid balance. In many
parts of the world where diarrheal states are frequent and severe, fluid replacement is accomplished using oral
rehydration solution (ORS), a measured mixture of water, salts, and glucose. The solution recognized by the World
Health Organization consists of 75 mEq/L (75 mmol/L) sodium, 75 mmol/L glucose, 65 mEq/L (65 mmol/L)
chloride, 20 mEq/L (20 mmol/L) potassium, and 10 mEq/L (3.3 mmol/L) citrate, having a total osmolarity of 245
mOsm/L. A simple solution can be prepared from 1 L water mixed with eight teaspoonfuls of sugar and one
teaspoonful of table salt. Some commercial products include Pedialyte, Rehydralyte, and CeraLyte.

Consistent intake of water (perhaps by slowly sipping), along with eating as tolerated, should restore lost fluids
and salt for typical diarrhea sufferers. Patients may also replace lost fluid by drinking flat soft drinks such as
ginger ale, tea, fruit juice, broth, or soup. Although sports drinks may be used to treat dehydration, caution should
be exercised so they are not viewed as a casual panacea. Severe diarrhea may require use of parenteral
solutions, and parenteral products should be used if patients are vomiting or unconscious. 26

» Dietary Modifications

During an acute diarrheal episode, patients typically eat less as they focus on the diarrhea. Both children and adults
should attempt to maintain nutrition because food helps replete lost nutrients and fluid volume. However, food-
related fluid may not be sufficient to compensate for diarrheal losses. Some foods may be inappropriate if they
irritate the GI tract or if they are implicated as the cause of the diarrhea. Patients with chronic diarrhea may find
that increasing bulk in the diet may help (eg, rice, bananas, whole wheat, and bran).

Pharmacologic Therapy
The goal of drug therapy is to control symptoms, enabling the patient to continue with as normal a routine as
possible while avoiding complications (Table 21–4). Most infectious diarrheas are self-limited or curable with
anti-infective agents.

» Adsorbents and Bulk Agents

Attapulgite adsorbs excess fluid in the stool with few adverse effects. Formulations of attapulgite are available in
Canada but not within the United States. Calcium polycarbophil is a hydrophilic polyacrylic resin (widely
available in the United States) that also works as an adsorbent, binding about 60 times its weight in water and
leading to formation of a gel that enhances stool formation. Neither attapulgite nor polycarbophil is systemically
absorbed. Calcium polycarbophil is effective in reducing fluid in the stool. However, caution must be exercised
because it
can also adsorb nutrients and other medications, thereby reducing their benefits. Its administration should be
separated from other oral medications by 2 to 3 hours. Psyllium and methylcellulose products may also be used
to reduce fluid in the stool and relieve chronic diarrhea.

» Antiperistaltic (Antimotility) Agents

Antiperistaltic drugs prolong intestinal transit time, thereby reducing the amount of fluid lost in the stool. The two
drugs in this category are loperamide HCl (available over-the-counter as Imodium A–D and generically) and
diphenoxylate HCl with atropine sulfate (available by prescription as Lomotil and generically). The atropine is
included only as an abuse deterrent; when taken in large doses, the unpleasant anticholinergic effects of
atropine negate the euphoric effect of diphenoxylate. Both loperamide and diphenoxylate are effective in relieving
symptoms of acute noninfectious diarrhea and are safe for most patients experiencing chronic diarrhea. These
products should be discontinued in patients whose diarrhea worsens despite therapy.

» Antisecretory Agents
Bismuth subsalicylate (BSS) is thought to have antisecretory and antimicrobial effects and is used to treat acute
diarrhea. Although it passes largely unchanged through the GI tract, the salicylate portion is absorbed in the
stomach and small intestine. For this reason, BSS should not be given to people who are allergic to salicylates,
including aspirin. Caution should be exercised with regard to the total dose given to patients taking salicylates
for other reasons to avoid salicylism. Patients taking BSS should be informed that their stool will turn black.

Octreotide is an antisecretory agent used for severe secretory diarrhea associated with cancer chemotherapy,
human immunodeficiency virus, diabetes, gastric resection, and GI tumors. It is administered as a subcutaneous
or IV bolus injection in an initial dose of 50 mcg three times daily to assess the patient’s tolerance to GI adverse
effects. Possible adverse effects include nausea, bloating, pain at the injection site, and gallstones (with
prolonged therapy).

» Probiotics

Probiotics are dietary supplements containing bacteria (Lactobacillus species, Bifidobacterium species, and
others) that may promote health by enhancing the normal microflora of the GI tract while resisting colonization
by potential pathogens. Probiotics can stimulate the immune response and suppress the inflammatory response.
Probiotics can be taken in tablets, gummies, capsules, powders, and liquids. The type of product is not as important
as the viability and number of organisms present.

Yogurt may provide relief from diarrhea due to lactose intolerance. The Lactobacillus acidophilus in yogurt,
cottage cheese, and acidophilus milk improve digestion of lactose and may prevent or relieve diarrhea related to
lactose deficiency and milk intake. Although lactase is not a probiotic, lactase tablets may also be used to prevent
diarrhea in susceptible patients.

» Antiinfectives

Empiric antibiotic therapy is an appropriate approach to traveler’s diarrhea. Eradication of the causal microbe
depends on the etiologic agent and its antibiotic sensitivity. Most cases of traveler’s diarrhea and other community-
acquired infections result from enterotoxigenic (ETEC) or enteropathogenic E. Coli (EPEC). Routine stool
cultures do not identify these strains; primary empiric antibiotic choices include fluoroquinolones such
as ciprofloxacin or levofloxacin. Azithromycin may be a feasible option when fluoroquinolone resistance is
encountered. Rifaximin can also treat traveler’s diarrhea effectively.

Although most cases of infectious diarrhea resolve with therapy, routine antibiotic use may contribute to
antimicrobial resistance. Empiric treatment should be considered for other acute infectious diarrhea including
those caused by nonhospitalacquired invasive organisms such as Campylobacter, Salmonella, and Shigella
organisms producing moderate to severe fever, tenesmus, and bloody stools.

Shiga toxin-producing E. coli (STEC) O157 should not be treated with antibiotics or antimotility agents. 27 There
is no evidence that antibiotic treatment is helpful, and antibiotic use with E. coli 0157 infection may increase the
risk of a form of kidney failure called hemolytic-uremic syndrome (HUS).

OUTCOME EVALUATION
 Monitor the patient with diarrhea from the point of first contact until symptoms resolve, keeping in mind
that most episodes are self-limiting.
 Question the patient to determine whether symptom resolution occurs within 48 to 72 hours in acute
diarrhea.
 Monitor for the maintenance of hydration, particularly when symptoms continue for more than 48 hours.
Ask about increased thirst, decreased urination, dark-colored urine, dry mucous membranes, and rapid
heartbeat, which suggest dehydration especially when nausea and vomiting are present.
 Monitor for symptom control in patients with chronic diarrhea.
 When antibiotics are used, monitor for completion of the course of therapy.

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