Professional Documents
Culture Documents
I. DEFINITION
What is diarrhea?
Diarrhea is an increase in the frequency of bowel movements or a decrease in the form of stool
(greater looseness of stool). Although changes in frequency of bowel movements and looseness of
stools can vary independently of each other, changes often occur in both.
Diarrhea needs to be distinguished from four other conditions. Although these conditions may
accompany diarrhea, they often have different causes and different treatments than diarrhea. These
1. incontinence of stool, which is the inability to control (delay) bowel movements until an
appropriate time, for example, until one can get to the toilet
2. rectal urgency, which is a sudden urge to have a bowel movement that is so strong that if a
3. incomplete evacuation, which is a sensation that another bowel movement is necessary soon
after a bowel movement, yet there is difficulty passing further stool the second time
II. SIMPTONS
Diarrhea can be defined in absolute or relative terms based on either the frequency of bowel
Thus, since among healthy individuals the maximum number of daily bowel movements is
approximately three, diarrhea can be defined as any number of stools greater than three. Relative
diarrhea is having more bowel movements than usual. Thus, if an individual who usually has one
bowel movement each day begins to have two bowel movements each day, then diarrhea is present-
even though there are not more than three bowel movements a day, that is, there is not absolute
diarrhea.
Consistency of stools. Absolute diarrhea is more difficult to define on the basis of the consistency of
stool because the consistency of stool can vary considerably in healthy individuals depending on
their diets. Thus, individuals who eat large amounts of vegetables will have looser stools than
individuals who eat few vegetables. Stools that are liquid or watery are always abnormal and
considered diarrheal. Relative diarrhea is easier to define based on the consistency of stool. Thus, an
individual who develops looser stools than usual has diarrhea--even though the stools may be within
III. CAUSES
With diarrhea, stools usually are looser whether or not the frequency of bowel movements is
increased. This looseness of stool--which can vary all the way from slightly soft to watery--is caused
by increased water in the stool. During normal digestion, food is kept liquid by the secretion of large
amounts of water by the stomach, upper small intestine, pancreas, and gallbladder. Food that is not
digested reaches the lower small intestine and colon in liquid form. The lower small intestine and
particularly the colon absorb the water, turning the undigested food into a more-or-less solid stool
with form. Increased amounts of water in stool can occur if the stomach and/or small intestine
secretes too much fluid, the distal small intestine and colon do not absorb enough water, or the
undigested, liquid food passes too quickly through the small intestine and colon for enough water to
be removed. Of course, more than one of these abnormal processes may occur at the same time.
For example, some viruses, bacteria and parasites cause increased secretion of fluid, either by
invading and inflaming the lining of the small intestine (inflammation stimulates the lining to secrete
fluid) or by producing toxins (chemicals) that also stimulate the lining to secrete fluid but without
causing inflammation. Inflammation of the small intestine and/or colon from bacteria or from
ileitis/colitis can increase the rapidity with which food passes through the intestines, reducing the
time that is available for absorbing water. Conditions of the colon such as collagenous colitis can
Chronic diarrhea can be defined in several ways but almost always lasts more than three
weeks.
It is important to distinguish between acute and chronic diarrhea because they usually have different
The most common cause of acute diarrhea is infection--viral, bacterial, and parasitic. Bacteria also
can cause acute food poisoning. A third important cause of acute diarrhea is starting a new
medication.
1. Viral gastroenteritis
Viral gastroenteritis (viral infection of the stomach and the small intestine) is the most common
cause of acute diarrhea worldwide. Symptoms of viral gastroenteritis (nausea, vomiting, abdominal
cramps, and diarrhea) typically last only 48-72 hrs. Unlike bacterial enterocolitis (bacterial infection
of the small intestine and colon), patients with viral gastroenteritis usually do not have blood or pus
Viral gastroenteritis can occur in a sporadic form (in a single individual) or in an epidemic form
(among groups of individuals). Sporadic diarrhea probably is caused by several different viruses and
is believed to be spread by person-to-person contact. The most common cause of epidemic diarrhea
(for example, on cruise ships) is infection with a family of viruses known as caliciviruses of which the
genus norovirus is the most common (for example, "Norwalk agent"). The caliciviruses are
2. Food poisoning
Food poisoning is a brief illness that is caused by toxins produced by bacteria. The toxins cause
abdominal pain (cramps) and vomiting and also cause the small intestine to secrete large amounts of
water that leads to diarrhea. The symptoms of food poisoning usually last less than 24 hours. With
some bacteria, the toxins are produced in the food before it is eaten, while with other bacteria, the
Symptoms usually appear within several hours when food poisoning is caused by toxins that are
formed in the food before it is eaten. It takes longer for symptoms to develop when the toxins are
formed in the intestine (because it takes time for the bacteria to produce the toxins). Therefore, in
Staphylococcus aureus is an example of a bacterium that produces toxins in food before it is eaten.
Typically, food contaminated with Staphylococcus (such as salad, meat or sandwiches with
multiply in the food and produce toxins. Clostridium perfringens is an example of a bacterium that
multiplies in food (usually canned food), and produces toxins in the small intestine after the
There are many strains of E. coli bacteria. Most of the E. coli bacteria are normal inhabitants of the
small intestine and colon and are non-pathogenic, meaning they do not cause disease in the
intestines. Nevertheless, these non-pathogenic E. coli can cause diseases if they spread outside of
the intestines, for example, into the urinary tract (where they cause bladder or kidney infections) or
Certain strains of E. coli, however, are pathogenic (meaning they can cause disease in the small
intestine and colon). These pathogenic strains of E. coli cause diarrhea either by producing toxins
(called enterotoxigenic E. coli or ETEC) or by invading and inflaming the lining of the small intestine
and the colon and causing enterocolitis (called enteropathogenic E. coli or EPEC). Traveler's diarrhea
Tourists visiting foreign countries with warm climates and poor sanitation (Mexico, parts of Africa,
etc.) can acquire ETEC by eating contaminated foods such as fruits, vegetables, seafood, raw meat,
water, and ice cubes. Toxins produced by ETEC cause the sudden onset of diarrhea, abdominal
cramps, nausea, and sometimes vomiting. These symptoms usually occur 3-7 days after arrival in the
foreign country and generally subside within 3 days. Occasionally, other bacteria or parasites can
cause diarrhea in travelers (for example, Shigella, Giardia, Campylobacter). Diarrhea caused by these
4. Bacterial enterocolitis
Disease-causing bacteria usually invade the small intestines and colon and cause enterocolitis
(inflammation of the small intestine and colon). Bacterial enterocolitis is characterized by signs of
inflammation (blood or pus in the stool, fever) and abdominal pain and diarrhea. Campylobacter
jejuni is the most common bacterium that causes acute enterocolitis in the U.S. Other bacteria that
cause enterocolitis include Shigella, Salmonella, and EPEC. These bacteria usually are acquired by
drinking contaminated water or eating contaminated foods such as vegetables, poultry, and dairy
products.
Enterocolitis caused by the bacterium Clostridium difficile is unusual because it often is caused by
antibiotic treatment. Clostridium difficile is also the most common nosocomial infection (infection
acquired while in the hospital) to cause diarrhea. Unfortunately, infection also is increasing among
E. coli O157:H7 is a strain of E. coli that produces a toxin that causes hemorrhagic enterocolitis
(enterocolitis with bleeding). There was a famous outbreak of hemorrhagic enterocolitis in the U.S.
traced to contaminated ground beef in hamburgers (hence it is also called hamburger colitis).
Approximately 5% of patients infected with E. coli O157:H7, particularly children, can develop
hemolytic uremic syndrome (HUS), a syndrome that can lead to kidney failure . Some evidence
suggests that prolonged use of anti-diarrhea agents or use of antibiotics may increase the chance of
developing HUS.
5. Parasites
Parasitic infections are not common causes of diarrhea in the U. S. Infection with Giardia lamblia
occurs among individuals who hike in the mountains or travel abroad and is transmitted by
contaminated drinking water. Infection with Giardia usually is not associated with inflammation;
there is no blood or pus in the stool and little fever. Infection with amoeba (amoebic dysentery)
usually occurs during travel abroad to undeveloped countries and is associated with signs of
can survive chlorination. Cyclospora is a diarrhea-producing parasite that has been associated with
6. Drugs
Drug-induced diarrhea is very common because many drugs cause diarrhea. The clue to drug-
induced diarrhea is that the diarrhea begins soon after treatment with the drug is begun. The
medications that most frequently cause diarrhea are antacids and nutritional supplements that
contain magnesium.
chemotherapy medications,
antibiotics,
misoprostol (Cytotec),
olsalazine (Dipentum),
colchicine (Colchicine),
Irritable bowel syndrome. The irritable bowel syndrome (IBS) is a functional cause of diarrhea or
constipation. Inflammation does not typically exist in the affected bowel. (Nevertheless, recent
information suggests that there MAY be a component of inflammation in IBS.) It may be caused by
several different underlying problems, but it is believed that the most common cause is rapid
Infectious diseases. There are a few infectious diseases that can cause chronic diarrhea, for example,
Giardia lamblia . Patients with AIDS often have chronic infections of their intestines that cause
diarrhea.
Bacterial overgrowth of the small intestine. Because of small intestinal problems, normal colonic
bacteria may spread from the colon and into the small intestine. When they do, they are in a position
to digest food that the small intestine has not had time to digest and absorb. The mechanism that
Post-infectious. Following acute viral, bacterial or parasitic infections, some individuals develop
chronic diarrhea. The cause of this type of diarrhea is not clear, but some of the individuals have
bacterial overgrowth of the small intestine. This condition also is referred to as post-infectious IBS.
Inflammatory bowel disease (IBD). Crohn's disease and ulcerative colitis, diseases causing
inflammation of the small intestine and/or colon, commonly cause chronic diarrhea.
Colon cancer. Colon cancer can cause either diarrhea or constipation. If the cancer blocks the
passage of stool, it usually causes constipation. Sometimes, however, there is secretion of water
behind the blockage, and liquid stool from behind the blockage leaks around the cancer and results
in diarrhea. Cancer, particularly in the distal part of the colon, can lead to thin stools. Cancer in the
Severe constipation. By blocking the colon, hardened stool can lead to the same problems as colon
and absorb sugars. The most well-recognized malabsorption of sugar occurs with lactase deficiency
(also known as lactose or milk intolerance) in which milk products containing the milk sugar, lactose,
lead to diarrhea. The lactose is not broken up in the intestine because of the absence of an intestinal
enzyme, lactase, that normally breaks up lactose. Without being broken up, lactose cannot be
absorbed into the body. The undigested lactose reaches the colon and pulls water (by osmosis) into
the colon. This leads to diarrhea. Although lactose is the most common form of sugar malabsorption,
other sugars in the diet also may cause diarrhea, including fructose and sorbitol.
Fat malabsorption. Malabsorption of fat is the inability to digest or absorb fat. Fat malabsorption may
occur because of reduced pancreatic secretions that are necessary for normal digestion of fat (for
example, due to pancreatitis or pancreatic cancer) or by diseases of the lining of the small intestine
that prevent the absorption of digested fat (for example, celiac disease). Undigested fat enters the
last part of the small intestine and colon where bacteria turn it into substances (chemicals) that
cause water to be secreted by the small intestine and colon. Passage through the small intestine and
Endocrine diseases. Several endocrine diseases (imbalances of hormones) may cause diarrhea, for
Laxative abuse. The abuse of laxatives by individuals who want attention or to lose weight is an
Dehydration occurs when there is excessive loss of fluids and minerals (electrolytes) from the
Dehydration is common among adult patients with acute diarrhea who have large amounts of
stool, particularly when the intake of fluids is limited by lethargy or is associated with nausea and
vomiting.
It also is common in infants and young children who develop viral gastroenteritis or bacterial
infection.
Patients with mild dehydration may experience only thirst and dry mouth.
Moderate to severe dehydration may cause orthostatic hypotension with syncope (fainting upon
standing due to a reduced volume of blood, which causes a drop in blood pressure upon standing), a
diminished urine output, severe weakness, shock, kidney failure, confusion, acidosis (too much acid
Electrolytes (minerals) also are lost with water when diarrhea is prolonged or severe, and
mineral or electrolyte deficiencies may occur. The most common deficiencies occur with sodium
Finally, there may be irritation of the anus due to the frequent passage of watery stool containing
irritating substances.
IV. INTERVENTION
Most episodes of diarrhea are mild and of short duration and do not need to be brought to the
Diarrhea in persons with serious underlying illness for whom dehydration may have more serious
consequences, for example, persons with diabetes, heart disease, and AIDS
Severe diarrhea that shows no improvement after 48 hours.
Acute diarrhea in pregnant women because of concern for the health of the fetus
Diarrhea that occurs during or immediately after completing a course of antibiotics because the
diarrhea may represent antibiotic-associated infection with C. difficile that requires treatment .
Diarrhea after returning from developing countries or from camping in the mountains because there
Diarrhea that develops in patients with chronic intestinal diseases such as colitis, or Crohn's disease
because the diarrhea may represent worsening of the underlying disease or a complication of the
Acute diarrhea in an infant or young child in order to ensure the appropriate use of oral liquids (type,
amount, and rate), to prevent or treat dehydration, and to prevent complications of inappropriate
Chronic diarrhea
Measurement of blood pressure in the upright and supine (lying) positions can demonstrate
orthostatic hypotension and confirm the presence of dehydration. If moderate or severe dehydration
that intestinal inflammation is present and prompting further testing, particularly bacterial cultures
If antibiotics have been taken within the previous two weeks, stool should be tested for the toxin of
C. difficile.
Testing stool or blood for viruses is performed only rarely, since there is no specific treatment for the
If there has been recent travel to undeveloped countries or the mountains, stool may be examined
There are also immunologic tests that can be done on samples of stool to diagnose infection with
Giardia.
Chronic diarrhea. With chronic diarrhea, the focus usually shifts from dehydration and infection
(with the exception of Giardia, which occasionally causes chronic infections) to the diagnosis of non-
infectious causes of diarrhea. (See the prior discussion of common causes of chronic diarrhea.)
This may require X-rays of the intestines (upper gastrointestinal series or barium enema), or
Fat malabsorption can be diagnosed by measuring the fat in a 72 hour collection of stool.
Sugar malabsorption can be diagnosed by eliminating the offending sugar from the diet or by
performing a hydrogen breath test. Hydrogen breath testing also can be used to diagnose bacterial
An under-active pituitary or adrenal gland and an overactive thyroid gland can be diagnosed by
V. SUGGESTIONS
Oral rehydration solutions (ORS) are liquids that contain a carbohydrate (glucose or rice syrup) and
electrolyte (sodium, potassium, chloride, and citrate or bicarbonate). Originally, the World Health
Organization (WHO) developed the WHO-ORS to rapidly rehydrate victims of the severe diarrheal
illness, cholera. The WHO-ORS solution contains glucose and electrolytes. The glucose in the solution
is important because it forces the small intestine to quickly absorb the fluid and the electrolytes. The
purpose of the electrolytes in the solution is the prevention and treatment of electrolyte
deficiencies.
In the United States, convenient, premixed commercial ORS products that are similar to the WHO-
ORS are available for rehydration and prevention of dehydration. Examples of these products are
Most of the commercially available ORS products in the U.S. contain glucose. Infalyte is the only one
that contains rice carbohydrate instead of glucose. Most doctors believe that there are no important
Infants and young children. Most acute diarrhea in infants and young children is due to viral
gastroenteritis and is usually short-lived. Antibiotics are not routinely prescribed for viral
gastroenteritis. However, fever, vomiting, and loose stools can be symptoms of other childhood
infections such as otitis media (infection of the middle ear), pneumonia, bladder infection, sepsis
(bacterial infection in the blood) and meningitis. These illnesses may require early antibiotic
treatment.
Infants with acute diarrhea also can quickly become severely dehydrated and therefore need early
rehydration. For these reasons, sick infants with diarrhea should be evaluated by their pediatricians
to identify and treat underlying infections as well as to provide instructions on the proper use of oral
rehydration products.
Infants with moderate to severe dehydration usually are treated with intravenous fluids in the
hospital. The pediatrician may decide to treat infants who are mildly dehydrated due to viral
Infants that are breast-fed or formula-fed should continue to receive breast milk during the
rehydration phase of their illness if not prevented by vomiting. During, and for a short time after
recovering from viral gastroenteritis, babies can be lactose intolerant due to a temporary deficiency
of the enzyme, lactase (necessary to digest the lactose in milk) in the small intestine. Patients with
lactose intolerance can develop worsening diarrhea and cramps when dairy products are introduced.
Therefore, after rehydration with ORS, an undiluted lactose-free formula and diluted juices are
Older children and adults. During mild cases of diarrhea, diluted fruit juices, soft drinks containing
sugar, sports drinks such as Gatorade, and water can be used to prevent dehydration. Caffeine and
lactose containing dairy products should be temporarily avoided since they can aggravate diarrhea,
the latter primarily in individuals with transient lactose intolerance. If there is no nausea and
vomiting, solid foods should be continued. Foods that usually are well tolerated during a diarrheal
ORS can be used for moderately severe diarrhea that is accompanied by dehydration in children
older than 10 years of age and in adults. These solutions are given at 50 ml/kg over 4-6 hours for
mild dehydration or 100 ml/kg over 6 hours for moderate dehydration. After rehydration, the ORS
solution can be used to maintain hydration at 100 ml to 200 ml/kg over 24 hours until the diarrhea
stops. Directions on the solution label usually state the amounts that are appropriate. After
rehydration, older children and adults should resume solid food as soon as any nausea and vomiting
subside. Solid food should begin with rice, cereal, bananas, potatoes, and lactose free and low fat
Absorbents. Absorbents are compounds that absorb water. Absorbents that are taken orally bind
water in the small intestine and colon and make diarrheal stools less watery. They also may bind toxic
chemicals produced by bacteria that cause the small intestine to secrete fluid; however, the
The two main absorbents are attapulgite and polycarbophil, and they are both available without
o Donnagel,
o Rheaban,
o Parepectolin, and
o Diasorb.
o Equalactin,
o Konsyl Fiber,
o Mitrolan, and
o Polycarb.
Equalactin is the antidiarrheal product containing attapulgite; however the laxative, Konsyl, also
contains attapulgite. Attapulgite and polycarbophil remain in the intestine and, therefore, have no
side effects outside of the gastrointestinal tract. They may occasionally cause constipation and
bloating. One concern is that absorbents also can bind medications and interfere with their
absorption into the body. For this reason, it often is recommended that medications and absorbents
be taken several hours apart so that they are physically separated within the intestine.
Anti-motility medications. Anti-motility medications are drugs that relax the muscles of the small
intestine and/or the colon. Relaxation results in slower flow of intestinal contents. Slower flow allows
more time for water to be absorbed from the intestine and colon and reduces the water content of
stool. Cramps, due to spasm of the intestinal muscles, also are relieved by the muscular relaxation.
The two main anti-motility medications are loperamide (Imodium), which is available without a
prescription, and diphenoxylate (Lomotil), which requires a prescription. Both medications are
related to opiates (for example, codeine ) but neither has the pain-relieving effects of opiates.
Diphenoxylate is a man-made medication that at high doses can be addictive because of its opiate-
like, euphoric (mood-elevating) effects. In order to prevent abuse of diphenoxylate and addiction, a
second medication, atropine, is added to loperamide in Lomotil. If too much Lomotil is ingested,
Loperamide and diphenoxylate are safe and well-tolerated. There are some precautions, however,
Anti-motility medications should not be used without a doctor's guidance to treat diarrhea caused by
moderate or severe ulcerative colitis, C. difficile colitis, and intestinal infections by bacteria that
invade the intestine (for example, Shigella). Their use can lead to more serious inflammation and
Anti-motility medications should not be used in children younger than two years of age.
Most unimportant, acute diarrhea should improve within 72 hours. If symptoms do not improve or if
they worsen, a doctor should be consulted before continuing treatment with anti-motility
medications.
Bismuth compounds. Many bismuth-containing preparations are available around the world.
Bismuth subsalicylate (Pepto-Bismol) is available in the United States. It contains two potentially
active ingredients, bismuth and salicylate (aspirin). It is not clear how effective bismuth compounds
are, except in traveler's diarrhea and the treatment of H. pylori infection of the stomach where they
have been shown to be effective. It also is not clear how bismuth subsalicylate might work. It is
thought to have some antibiotic-like properties that affect bacteria that cause diarrhea. The salicylate
is anti-inflammatory and could reduce secretion of water by reducing inflammation. Bismuth also
Pepto-Bismol is well-tolerated. Minor side effects include darkening of the stool and tongue. There
Since it contains aspirin, patients who are allergic to aspirin should not take Pepto-Bismol.
Pepto-Bismol should not be used with other aspirin-containing medications since too much aspirin
may be ingested and lead to aspirin toxicity, the most common manifestation of which is ringing in
the ears.
The aspirin in Pepto-Bismol can accentuate the effects of anticoagulants, particularly warfarin
(Coumadin), and lead to excessive bleeding. It also may cause abnormal bleeding in people who have
a tendency to bleed because of genetic disorders or underlying diseases, for example, cirrhosis, that
The aspirin in Pepto-Bismol can aggravate stomach and duodenal ulcer disease.
Pepto-Bismol and aspirin-containing products should not be given to children and teenagers with
chickenpox, influenza, and other viral infections because they may cause Reye's syndrome. Reye's
syndrome is a serious illness affecting primarily the liver and brain that can lead to liver failure and
Pepto-Bismol should not be given to infants and children younger than two years of age.
Most episodes of diarrhea are acute and of short duration and do not require antibiotics. Antibiotics
are not even necessary for the most common bacterial infections that cause diarrhea. Antibiotics,
however, often are used when (1) patients have more severe and persistent diarrhea, (2) patients
have additional debilitating diseases such as heart failure, lung disease, and AIDS, (3) stool
examination and testing discloses parasites, more serious bacterial infections (for example, Shigella),
Diarrhea At A Glance
Diarrhea is an increase in the frequency of bowel movements, an increase in the looseness of stool
or both.
Diarrhea is caused by increased secretion of fluid into the intestine, reduced absorption of fluid from
Diarrhea can be defined absolutely or relatively. Absolute diarrhea is defined as more than five bowel
movements a day or liquid stools. Relative diarrhea is defined as an increase in the number of bowel
movements per day or an increase in the looseness of stools compared with an individual's usual
bowel habit.
Diarrhea may be either acute or chronic, and each has different causes and treatments.
the anus.
Dehydration can be treated with oral rehydration solutions and, if necessary, with intravenous fluids.
Tests that are useful in the evaluation of acute diarrhea include examination of stool for white blood
cells and parasites, cultures of stool for bacteria, testing of stool for the toxin of C. difficile and blood
Tests that are useful in the evaluation of chronic diarrhea include examination of stool for parasites,
upper gastrointestinal X-rays (UGI series), barium enema, esophago-gastro-duodenoscopy (EGD) with
biopsies, colonoscopy with biopsies, hydrogen breath testing, and measurement of fat in the stool.
Diarrhea may be treated with absorbents, anti-motility medications, and bismuth compounds.
Antibiotics should not be used in treating diarrhea unless there is a culture-proven bacterial infection
that requires antibiotics, severe diarrhea that is likely to be infectious in origin, or when an individual
A Grouping Task
By :
BANDAR LAMPUNG
2011