Professional Documents
Culture Documents
July 2004
Volume 6, Number 7
Authors Michael D. Burg, MD, FACEP Residency Program Director, Department of Emergency Medicine, Onze Lieve Vrouwe Gasthuis (Hospital), Amsterdam, The Netherlands. Hoori Hovanessian, MD, FACEP Assistant Clinical Professor, Department of Emergency Medicine, UCSFFresno, University Medical Center, Fresno, CA; Presbyterian Intercommunity Hospital, Whittier, CA. Peer Reviewers Andy Jagoda, MD, FACEP Vice-Chair of Academic Affairs, Department of Emergency Medicine; Residency Program Director; Director, International Studies Program, Mount Sinai School of Medicine, New York, NY. Earl J. Reisdorff, MD, FACEP Director of Medical Education, Ingham Regional Medical Center; Associate Professor, Michigan State University Emergency Medicine Residency, Lansing MI. CME Objectives Upon completing this article, you should be able to: 1. construct a broad differential diagnosis for diarrheal illness in adults and children; 2. describe aspects of a targeted history and physical examination for patients with diarrhea, including indications for diagnostic testing; 3. identify ED patients at high risk for serious or life-threatening diarrheal illnesses; and 4. describe treatment strategies for ED patients with diarrhea.
IARRHEA is a common condition that can stem from many causes. Fortunately, the care of the ED patient with diarrhea is usually straightforwarda targeted history and physical examination, followed by symptomatic remedies. However, the temptation to dismiss a case as just diarrhea can be quite dangerous, as serious disease processes can present with diarrhea as the chief complaint. Some patients require more systematic investigation or even hospitalization. Clinical judgment based on the current evidence can help guide a cost-effective work-up of patients with diarrhea that will identify patients with more severe etiologies or at risk for complications.
Date of original release: July 1, 2004. Date of most recent review: June 15, 2004. See Physician CME Information on back page.
New Mexico Health Sciences Center School of Medicine, Albuquerque, NM. Francis M. Fesmire, MD, FACEP, Director, Heart-Stroke Center, Erlanger Medical Center; Assistant Professor of Medicine, UT College of Medicine, Chattanooga, TN. Valerio Gai, MD, Professor and Chair, Department of Emergency Medicine, University of Turin, Italy. Michael J. Gerardi, MD, FAAP, FACEP, Clinical Assistant Professor, Medicine, University of Medicine and Dentistry of New Jersey; Director, Pediatric Emergency Medicine, Childrens Medical Center,
Atlantic Health System; Department of Emergency Medicine, Morristown Memorial Hospital. Michael A. Gibbs, MD, FACEP, Chief, Department of Emergency Medicine, Maine Medical Center, Portland, ME. Gregory L. Henry, MD, FACEP, CEO, Medical Practice Risk Assessment, Inc., Ann Arbor, MI; Clinical Professor, Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI; Past President, ACEP. Francis P. Kohrs, MD, MSPH, Lifelong Medical Care, Berkeley, CA. Keith A. Marill, MD, Emergency
Attending, Massachusetts General Hospital; Faculty, Harvard Affiliated Emergency Medicine Residency, Boston, MA. Michael S. Radeos, MD, MPH, Attending Physician, Department of Emergency Medicine, Lincoln Medical and Mental Health Center, Bronx, NY; Assistant Professor in Emergency Medicine, Weill College of Medicine, Cornell University, New York, NY. Steven G. Rothrock, MD, FACEP, FAAP, Associate Professor of Emergency Medicine, University of Florida; Orlando Regional Medical Center; Medical Director of Orange County Emergency Medical Service, Orlando, FL. Alfred Sacchetti, MD, FACEP,
Research Director, Our Lady of Lourdes Medical Center, Camden, NJ; Assistant Clinical Professor of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA. Corey M. Slovis, MD, FACP, FACEP, Professor of Emergency Medicine and Chairman, Department of Emergency Medicine, Vanderbilt University Medical Center; Medical Director, Metro Nashville EMS, Nashville, TN. Charles Stewart, MD, FACEP, Colorado Springs, CO. Thomas E. Terndrup, MD, Professor and Chair, Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, AL.
Editorial Board
William J. Brady, MD, Associate Professor and Vice Chair, Department of Emergency Medicine, University of Virginia, Charlottesville, VA. Judith C. Brillman, MD, Professor, Department of Emergency Medicine, The University of
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Evaluating the patient: The presence of a dry axilla supports the diagnosis of hypovolemia, and moist mucous membranes and a tongue without furrows argue against it. In adults, the capillary refill time and poor skin turgor have no proven diagnostic value.3 Acute body weight changes provide the best measures of dehydration in children. Mucous membrane hydration, capillary refill time, absence of tears, and alterations in mental status are the next best associated measures.4 Important features of the history include how the illness began; stool characteristics (frequency and quantity); travel history; occupation; day care center attendance or nursing home residence; whether the patient has ingested raw or undercooked meat, raw seafood, or raw milk; whether the patients contacts are ill; the patients sexual contacts, medications, and other medical conditions, if any.2,5 Red-flag findings include severe dehydration, bloody or febrile diarrhea, or illness in infants, elderly, or immunocompromised patients.5 Serial evaluations over several hours can improve the diagnostic accuracy in patients in whom the etiology is unclear.1 Laboratory testing: Routine testing for specific pathogens is not recommended.4 Reserve laboratory testing and stool cultures for select circumstances. Criteria vary but often include bloody diarrhea, weight loss, diarrhea leading to dehydration, fever, neurologic involvement, sudden onset of severe abdominal pain, persistent (> 7 days) diarrhea, or possible community-acquired diarrhea, travelers diarrhea, or nosocomial diarrhea.2,5 Maintain a lower threshold for ordering if the patient is pediatric, elderly, or immunocompromised.2 Rehydration: Initiate rehydration (oral whenever possible).5 In children, clear liquids are not recommended as a substitute for oral rehydration solutions or regular diets to prevent or treat dehydration.4 Diet: Refeeding of the usual diet at the earliest opportunity should be encouraged to prevent or limit dehydration. Very frequent (e.g., every 10-60 minutes), small feedings may be better tolerated if vomiting is present. The BRAT diet (bananas, rice, applesauce, and toast) affords no advantage unless these foods are part of the regular diet.4 Medications: Antibiotic therapy can reduce illness duration by one or two days in most cases. Criteria for empiric antibiotic therapy vary, but consideration of risks must be weighed against any potential benefits. In children, antimicrobial therapies are recommended only when special risks or evidence of serious bacterial infection is present.4 Institute selective therapy for travelers diarrhea, shigellosis, and Campylobacter infection.5 Avoid administering antimotility agents with bloody diarrhea or proven infection with Shiga toxinproducing Escherichia coli.5 Anti-diarrheal agents and antiemetics are not recommended for use in children with acute gastroenteritis.4
Epidemiology
Virtually every human being experiences diarrhea at some point. Causes may range from the mild to the life-threatening, although the clinical course is generally brief and selflimited in developed nations. However, worldwide, diarrheal illnesses are the second most common cause of death and the leading cause of death in children.21 Diarrhea is a common cause of morbidity even in the United States. The number of hospital admissions due to gastroenteritis in the United States is estimated to be 450,000 per year.20 Additionally, the U.S. prevalence of chronic diarrhea approaches 5%.22
Pathophysiology
Diarrhea is broadly categorized as one of two typeseither secretory or osmotic. The poorly named secretory diarrhea actually occurs due to abnormal electrolyte transport across the intestinal epithelial cells. Increased secretion and/or decreased absorption result. The diarrhea is not related to the intestinal contents and therefore typically does not stop with fasting. Infection (e.g., cholera) is the most common cause of secretory diarrhea. The fluid losses can be enormous. Osmotic diarrhea results from the presence of nonabsorbable solute that exerts an osmotic pressure effect across the intestinal mucosa, resulting in excessive water output. Because the diarrhea is caused by the solute, it tends to stop during fasting. Sorbitol, a poorly absorbed sugar, is capable of causing osmotic diarrhea.20 Another way that diarrhea is commonly classified is as infectious vs. noninfectious or inflammatory vs. noninflammatory. Symptoms such as fever, bloody diarrhea, and severe cramping suggest an invasive bacterial pathogen such as Shigella, Salmonella, Yersinia, or Campylobacter. The presence of nausea and vomiting strongly suggests a viral agent, and prior antibiotic use suggests possible Clostridium difficile enteritis. Absence of these factors suggests a noninfectious cause. Inflammatory diarrhea can be bloody and associated with fever and abdominal cramps. The causes can be infectious or non-infectious. Non-inflammatory diarrhea tends to be watery and can be associated with nausea, vomiting, and abdominal cramps.
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Differential Diagnosis
The differential diagnosis of diarrhea with abdominal pain is vast. While patients who present with vomiting, diarrhea, and abdominal cramps and who have benign abdominal examinations may seem like clear-cut cases of gastroenteritisand most patients will respond well given rehydration and antiemeticsit is important to be aware that the differential diagnosis includes more severe etiologies that require different management approaches. (See Table 1.)
Entamoeba histolytica, and Cryptosporidium.2 Signs and symptoms such as bloody diarrhea, weight loss, diarrhea leading to dehydration, fever, prolonged diarrhea (3 or more unformed stools per day, persisting several days), neurologic involvement (such as paresthesias, motor weakness, cranial nerve palsies), and/or severe abdominal pain may suggest infectious causes and drive the need for laboratory testing, especially in young, elderly, or immunocompromised patients.2
Vascular
Ischemic bowel disease Diarrhea, severe abdominal pain, older patient, history of peripheral vascular disease
Malabsorption
e.g., celiac disease or lactose intolerance Diarrhea, gas, bloating, and stomach pains that seems to be triggered by certain foods
Medications
Recent new medicine, especially antibiotics, high blood pressure medications, cancer drugs/radiation therapy, some herbal medicines
Toxins
Radiation enteritis Tenesmus, bleeding, and diarrhea stemming from malabsorption; can persist for two or three months after treatment cessation Arsenic, mushroom poisoning, pesticides, etc. Varies; usually diarrhea is one of several symptoms
Inflammatory
Inflammatory bowel disease (includes Crohns disease and ulcerative colitis) Frequent bowel movements mixed with blood or mucus Appendicitis Vomiting that follows abdominal pain, small amounts of
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Eliciting a family history of inflammatory bowel disease or other risk factors for it will allow rapid evaluation of this condition by referral to a gastroenterologist.24 The diagnosis rests on the clinical history, stool studies to exclude infection, and colonoscopy to determine the presence and extent of disease.
Staphylococcus aureus
Symptoms: severe nausea, abdominal cramps, vomiting, and diarrhea occur 1-6 hours after eating; recovery within 2-3 dayslonger if severe dehydration occurs.
Clostridium perfringens
Symptoms: diarrhea and gas pains may appear 8-24 hours after eating; usually last about one day, but less severe symptoms may persist for 1-2 weeks.
Vibrio parahaemolyticus
Symptoms: Diarrhea, abdominal cramps, nausea, vomiting, headache, fever, and chills; onset four hours to four days after eating; lasts about 2.5 days.
Cyclospora cayetanensis
Symptoms: Nausea, vomiting, loss of appetite, and diarrhea; onset within two days; lasts one week to two months.
Listeria monocytogenes
Symptoms: fever, chills, headache, backache, sometimes abdominal pain and diarrhea; onset from 7-30 days after eating, but most symptoms are reported 48-72 hours after consumption of contaminated food; primarily affects pregnant women and their fetuses, newborns, the elderly, people with cancer, and those with impaired immune systems; can cause fetal and infant death.
Cryptosporidium parvum
Symptoms: Profuse watery diarrhea, abdominal pain, appetite loss, vomiting, and low-grade fever, onset within 1-12 days.
Giardia lamblia
Symptoms: Sudden onset of explosive watery stools, abdominal cramps, anorexia, nausea, and vomiting; onset within 1-3 days.
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hypovolemia, sepsis, cardiac arrhythmias, congestive heart failure, and those using vasoconstrictive medications or drugs (e.g., digitalis, pseudoephedrine, cocaine, amphetamines).29 Ischemia may progress to infarct unless detected and treated early.
uncomplicated gastroenteritis generally resolves with fluids, a period of observation can help identify patients with appendicitis if the diagnosis is unclear.
Miscellaneous Causes
Many other entities should be considered in the differential diagnosis of diarrhea, including melena, laxative abuse, partial bowel obstruction, various malabsorption syndromes (e.g., Whipples disease, small bowel bacterial overgrowth, celiac sprue), food allergy, rectosigmoid abscess, colon cancer, diverticulitis, hyperthyroidism, and pernicious anemia. Many medications (as well as herbal remedies) can cause diarrhea. In pediatric patients, ageappropriate problems such as intussusception and Meckels diverticulum should be considered in the differential diagnosis of diarrhea. Uncommon causes of diarrhea include mushroom poisoning, ciguatera fish poisoning, arsenic ingestion, and exposure to pesticides, sodium fluoride, thallium, or zinc. In most of these cases, diarrhea is part of a symptom complex, and other suggestive elements of the history are present.
Radiation Enteritis
Radiation therapy is used to treat a number of urologic, gynecologic, and colorectal cancers. During the radiation treatment period, most patients experience tenesmus, bleeding, and diarrhea.30 Malabsorption from mucosal damage and bacterial overgrowth are two factors that contribute to these symptoms.26 Symptoms can start within hours of initial treatment and usually resolve two or three months after treatment cessation,30 although some patients may develop chronic problems necessitating surgery. The rectum is the most commonly inflamed site given its proximity to the irradiated tissue; the terminal ileum can also be irradiated in patients undergoing treatment for pelvic malignancies. Treatment of acute radiation enteritis involves temporary discontinuation of radiation therapy, selective intravenous fluid administration, and antimotility medications. Sucralfate may ameliorate the symptoms of radiation enteritis. In one double-blind placebo-controlled trial of patients with prostate or bladder cancer randomized to receive either oral sucralfate or placebo, those patients receiving sucralfate had improvement in the frequency and consistency of bowel movements, and fewer patients required treatment with anti-diarrheal preparations.31
Prehospital Care
Initial prehospital assessment should focus on the patients vital signs and mental status. Transport hemodynamically stable patients without further intervention. Follow local EMS protocols for hypotension/shock for patients who are hemodynamically unstable; usually, this includes establishing at least one large-bore intravenous line and infusing crystalloid solution and expediting the transport of unstable patients for further evaluation and care. While gastrointestinal infections may be caused by a variety of agents, including bacteria, viruses, and protozoa, only a few agents have been documented in person-toperson transmission. Generally, adherence to either standard or contact precautions will minimize the risk of transmitting enteric pathogens.36
Appendicitis
Patients with appendicitis can have vomiting as well as loose stools. Rectal irritation by an inflamed pelvic appendix can produce small amounts of watery diarrhea, as compared to the voluminous amounts produced as a consequence of gastroenteritis.32 In Rothrock et als study of 181 children younger than 13 years who were ultimately found to have appendicitis, 27% were initially misdiagnosed. Patients in this group were more likely to be younger, have vomiting before pain, and have diarrhea (in addition to constipation, dysuria, and upper respiratory tract symptoms).33 A retrospective case series review of 63 children younger than 3 years ultimately diagnosed with appendicitis found that 57% were initially misdiagnosed; diarrhea was commonly reported.34 A retrospective review of 87 patients with appendicitis revealed that six patients (7%) required more than one ED visit before their diagnosis was established. The initial diagnosis in two of these patients was gastroenteritis. These six patients were more likely to have a normal appetite, to have diarrhea, and to be afebrile.35 While most patients with appendicitis present with right lower quadrant abdominal pain, 15% of appendices are in atypical locations, causing pain in locations other than the right lower quadrant.32 Gastroenteritis can present with fevers higher (>103F) than those seen with appendicitis, and in general, vomiting and diarrhea precede abdominal pain, whereas vomiting follows abdominal pain in appendicitis. Because appendicitis will steadily worsen, while
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Shigella, Salmonella, or Campylobacter species), enteric viruses, or toxin-induced damage due to Clostridium difficile or Entamoeba histolytica.37 Character and location of any abdominal pain: Pain is common in patients with mesenteric ischemia, inflammatory bowel disease, and irritable bowel syndrome.22 Duration of symptoms: Symptom duration can help narrow the differential diagnosis. Viral gastroenteritis usually lasts 12-60 hours.2 Thus, it is less likely that diarrhea lasting more than a couple of days or so is viral. Diarrhea lasting greater than two weeks often has a different etiology (see Table 3) than diarrhea that has been present for less than two weeks.37 Weight loss: Determine whether the patient has lost weight. Patients with diarrhea may have weight loss because of both increased output and reduced intake. Substantial weight loss is more likely due to ischemia, neoplasm, or malabsorptive syndromes.22 Weight loss may be an indicator of dehydration in children. Indicators of dehydration: Asking about urine output, dizziness, thirst, and syncopeas well as asking family members or prehospital personnel about altered mental statusis useful in assessing the patients volume status. Epidemiological risk factors: Further questions should focus on the patients recent diet, and specifically whether there has been any ingestion of seafood, raw or undercooked meat, eggs, or milk products. In addition, ask about recent foreign travel or local outings involving lake or stream swimming or visits to a farm, ill contacts, group living arrangements (e.g., nursing home, college dormitory) or day care atten-
dance, and occupational hazards such as food handling or working with animals.
Medications
Obtaining a history of medication usespecifically including prescription, over-the-counter, and herbal preparationsis important, since many can cause diarrhea. Some of the more common offenders include laxatives, antibiotics, colchicine, and magnesium- or calcium-containing antacids. If there is a history of antibiotic use within the past three months, C. difficile-induced diarrhea is an important consideration.38 Diabetics using a relatively new class of hypoglycemic medications known as alpha-glucosidase inhibitors (e.g., acarbose, miglitol) may develop abdominal pain, bloating, and diarrhea. Artificial sweeteners containing sorbitol or mannitol are poorly absorbed and may cause diarrhea. Patients on enteral tube feedings may also develop diarrhea.28 The elderly are more likely to be on multiple medications and may be more susceptible to adverse effects.
Review Of Systems
A brief review of systems is additionally helpful. A patient who is currently menstruating may have guaiacpositive stools secondary to stool sample contamination from menstrual blood. The patients pregnancy status is important for antibiotic selection, use of medications for symptomatic treatment of the diarrhea, and decisions about managing her hemodynamic status. Ask the patient about the ability to get to the bathroom on time. Some individuals complain of diarrhea when the real problem is fecal incontinence.
Bacteria
Campylobacter, Clostridium difficile, Escherichia coli, Listeria monocytogenes, Salmonella enteritidis, Shigella
Viral infections
HIV
Social History
The patients occupational history may be relevant if they work as a veterinarian, food handler, or day care center or nursing home employee. The patients sexual preference and whether they engage in receptive anal intercourse should be ascertained as this may expand the differential diagnosis to include AIDS-associated diarrhea as well as proctitis secondary to sexually transmitted diseases. Inquire about alcohol and drug use. Patients who abuse alcohol may present with various abdominal complaints, including diarrhea and melena. Opioid withdrawal frequently involves nausea, vomiting, and diarrhea. Patients with eating disorders or those attempting to lose weight should be questioned about laxative abuse.
Medications
Antibiotics, high blood pressure medications, cancer drugs/ radiation therapy
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Secondary Survey
A secondary survey allows for further assessment of the patients volume status as well as the presence or absence of systemic toxicity. Is the patient febrile? Is postural hypotension present? Are the mucus membranes dry? For infants, is the anterior fontanelle sunken? Is the pediatric patient producing any tears when crying? Note the patients skin turgor, jugular venous pressure, capillary refill, and the presence or absence of sunken eyes. Also, evaluate the patients mental status. Is the patient awake, alert, and able to answer questions? Is the patient lethargic or completely unresponsive? Other features of diagnostic significance include the presence of flushing or rashes on the skin, mouth ulcers, thyroid masses, wheezing, arthritis, heart murmurs, hepatomegaly or abdominal masses, ascites, and edema.16 The abdominal examination should include auscultation of bowel sounds as well as the presence or absence of tenderness or peritoneal signs. A rectal examination can determine whether the stools are grossly bloody, melanotic, or guaiac-positive. Given the fact that melanotic stools are usually liquid, the patient may refer to this type of stool simply as diarrhea. Thus, a rectal examination may play an important role in assessing the nature of the stools. Selected female patients may require a pelvic examination depending on the degree and location of their abdominal pain.
Diagnostic Studies
Blood Tests
Routine CBC counts or chemistry panels are unnecessary in most patients since diarrhea is a self-limited problem in most cases. A chemistry panel may reveal an electrolyte imbalance or the degree of dehydration in systemically ill patients, or in those with severe or persistent diarrhea. In patients with bloody diarrhea, obtain a CBC and platelet count to exclude hemolytic uremic syndrome. (Hemolytic uremic syndrome is discussed in further detail in the section on pediatric patients later in this article.) Eosinophilia on the leukocyte differential can point to food allergy, collagenvascular diseases, neoplasm, parasitic infections, or eosinophilic gastroenteritis or colitis.22 Such diagnostic testing should be reserved for select cases in which clinical or epidemiologic factors or disease severity suggest their need.5 Unfortunately, the literature does not provide clearcut indications for such testing.
more timely results and are therefore more useful in the ED setting than stool cultures in identifying causes of inflammatory diarrhea. A selective approach to fecal leukocyte/ lactoferrin testing in patients with diarrhea is recommended, yet the precise approach remains a matter of dispute. Community-acquired or travelers diarrhea, nosocomial diarrhea, and diarrhea persisting more than seven days have been suggested by the Infectious Diseases Society of America as indications for testing.5 The utility of these tests lies in helping to determine whether antibiotic treatment is indicated.37 Occult blood, fecal leukocytes, and fecal lactoferrin are often found in the stools of patients with inflammatory diarrhea. The most common pathogens in patients with a positive test result include Shigella, Salmonella, Campylobacter, Aeromonas, Yersinia, non-cholera Vibrio species,40,41 and Clostridium difficile.42 Fecal leukocytes are generally seen in the stool of patients with shigellosis, salmonellosis, Campylobacter, enteroinvasive E. coli, enterohemorrhagic E. coli, or staphylococcal enterocolitis.43 Other conditions in which fecal leukocytes may be seen include Entamoeba histolytica enteritis, Crohns disease, ulcerative colitis, and pseudomembraneous colitis.44 Lactoferrin is a protein found in leukocytes. The fecal lactoferrin assay can measure levels of lactoferrin released from damaged or deteriorated leukocytes in stool specimens.43 Although more research is needed, some studies indicate that fecal lactoferrin is more sensitive than fecal leukocytes or occult blood as a screening tool for detecting invasive pathogens45,46 as well as for detecting other causes of inflammatory diarrhea such as ulcerative colitis and Crohns disease.47,48 The test is slightly costlier than fecal leukocyte testing, but it is quicker and easier to perform and is not limited by the need for a fresh stool specimen.49 Guaiac-positive stools, as well as the findings of fecal leukocytes and fecal lactoferrin, are all predictive of finding an identifiable bacterial pathogen on stool culture.37 In one prospective study of 873 patients, stool cultures were ordered in 549 episodes (62.6%), most frequently for patients with fever, more than 10 stools per day, or visibly bloody stools. Enteropathogens were identified in 168 episodes (30.6%).39 In another well-designed study of 1040 patients, the absence of occult blood in the stool was a reliable indicator for a lack of enteroinvasive bacteria.40
Stool Culture
While readily obtainable tests such as heme- or leukocytepositive stools can provide the ED practitioner with valuable information, stool cultures may be advisable under certain circumstances. The use of antibiotics in certain cases of bacterial diarrhea can produce undesirable outcomes, so determining the causative agent via stool cultures can be helpful. For instance, treatment of salmonellosis can prolong the carrier state and lead to a higher clinical relapse rate.28 The likelihood of hemolytic uremic syndrome in patients infected with E. coli 0157:H7 is increased with the use of antibiotics.50 Empiric antibiotic use may increase the risk
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of C. difficile colitis. Determination of antimicrobial susceptibility is also important given the emergence of resistance to some commonly used antibiotics. Finally, negative stool culture results may be important prerequisites for the diagnosis of certain ailments such as inflammatory bowel disease. Stool cultures can also play a role in identifying agents that have significant public health consequences. An outbreak of illness due to Salmonella enteritidis serves to illustrate this point. The state public health laboratory in Minnesota received a higher-than-expected number of reports of Salmonella isolates from local clinical laboratories in 1994. These reports ultimately led to the detection of a nationwide outbreak of Salmonella enteritidis infection due to contaminated ice cream that had been widely distributed (with patients afflicted in 41 states). An estimated 220,000 people were affected by this outbreak.51 Elimination of the contaminated product from the market potentially prevented the spread of this infection to thousands of others. These preventive measures were possible because stool cultures were obtained on the first patients who presented to their physicians with diarrhea. While these examples provide compelling evidence for obtaining stool cultures on patients with diarrhea, the yield on routinely obtained stool cultures is low. In six studies conducted between 1980 and 1997, stool cultures were positive in 1.5%-5.6% of cases.5 This translates to a cost of $952-$1200 for each positive culture obtained. Interestingly, in the study with a positive culture yield of 5.6%, 63% of the patients had grossly bloody stools, while 91% presented with a history of bloody diarrhea.52 Therefore, experts recommend restricting the use of stool cultures. In patients in whom vomiting is a prominent feature of their disease, viral agents are the likely etiology and stool cultures will have a low yield. Proposed criteria that suggest a higher yield from stool cultures include history of bloody stools (grossly bloody or heme-positive stools) or stools containing leukocytes or lactoferrin; immunocompromised patients; fever higher than 38.5C (101.3F); systemic illness or an illness that is clinically severe or persistent; and patients with severe abdominal pain.2,28,53 Selective cultures can be considered in specific circumstances such as bloody diarrhea in afebrile patients with a history of ingestion of unpasteurized juice or milk or undercooked beef (suggests enterohemorrhagic E. coli); patients who have consumed shellfish within 72 hours of the onset of illness (suggests Vibrio parahemolyticus); and
patients who have been on antibiotics within the past three months (suggests C. difficile). Ideally, stool samples should be sent for culture within two hours after passage to allow for detection of certain pathogens that perish quickly. If the patient is unable to provide a stool sample, a rectal swab can be brought to the lab in transport media and then cultured.28 Routine stool cultures in most laboratories will identify Shigella, Campylobacter, and Salmonella.2 (In patients who develop diarrhea after three days of hospitalization, C. difficile testing will have a higher yield (15%-20%), whereas standard stool cultures will have poor yields.28)
Endoscopy/Computed Tomography
Lower gastrointestinal endoscopy should be considered in patients with rectal bleeding, severe abdominal pain, fever, as well as negative stool tests for pathogens or otherwise unexplained chronic diarrhea lasting longer than three weeks.20 Biopsy and evaluation of the colonic mucosa is crucial to exclude the presence of C. difficile pseudomembraneous colitis, inflammatory bowel disease, ischemic colitis, microscopic or collagenous colitis (types of inflammatory bowel disease), and malignancy.20 In one study, 809 HIV-negative patients with chronic non-bloody diarrhea underwent colonoscopy. Fifteen percent of these patients had an inflammatory cause of diarrhea, including microscopic colitis and, to a lesser extent, Crohns disease and ulcerative colitis.55
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In patients with unexplained diarrhea and a negative colonoscopic examination, upper gastrointestinal tract infections (Giardia, bacterial overgrowth syndrome) and small bowel and pancreatic diseases resulting in malabsorption should be considered. Biopsies obtained by upper endoscopy can determine etiologies such as celiac sprue (which causes the malabsorption of gluten), Whipples disease (a malabsorption illness caused by Tropheryma whippelii), or other malabsorptive syndromes. CT scanning of the abdomen and pelvis may provide further information about small bowel and colonic disease or extrinsic disease processes such as pancreatic tumors that can cause diarrhea.56 Although these are not primary diagnostic considerations, a working knowledge of these options is important to facilitate the work-up of patients who present to the ED with persistent diarrhea and a negative initial evaluation.
Treatment
Treatment decisions are influenced by several factors, including the patients hydration status, the need for symptomatic relief, and the likelihood of the presence of a bacterial pathogen.
Rehydration
Rehydration can be accomplished by oral or intravenous fluid administration. In patients with moderate-to-severe dehydration, as well as those in whom vomiting disallows adequate oral fluid intake, intravenous hydration speeds up the recovery process. In many cases, rehydration can be achieved with oral rehydration solutions. Fluids used for rehydration should contain sodium, potassium, and glucose.28 Various commercial types of oral rehydration solutions (such as Pedialyte, Lytren, and Rehydrolyte) are available. Various home preparations have been proposed, although they are not recommended in children. Additionally, sports drinks, which are designed to replenish fluids and electrolytes lost by sweating, are inadequate to replace diarrheal sodium losses. These solutions can be effective if they are supplemented with another source of salt such as pretzels or crackers.16,22 The use of the BRAT diet (bananas, rice, applesauce, toast) is commonly recommended, although evidence-based data supporting its use are sparse. One evidence-based clinical practice guideline suggests that continued use of the patients preferred, usual, and age-appropriate diet should be encouraged, and that the BRAT diet offers no advantage unless those foods are part of the usual diet.4
enteric pathogens, prolonged fever, and toxic megacolon,28,53 although some argue that antimotility agents may be used in patients with nondysenteric forms of diarrhea caused by enteroinvasive pathogens as long as antibiotics are also prescribed. Agents available for diarrhea relief include loperamide, diphenoxylate, and bismuth subsalicylate. Loperamide is a commonly recommended antimotility agent because of its safety and efficacy profile. It slows intraluminal flow of liquid by inhibiting peristalsis, which allows for increased intestinal absorption of fluid and electrolytes, which in turn results in substantial stool volume reduction. When used with antibiotics in patients with travelers diarrhea or bacillary dysentery, loperamide can reduce the duration of diarrhea by one day.53 It is an opiate that does not penetrate the nervous system; thus, there are no CNS side-effects or potential for addiction. Diphenoxylate is less costly than loperamide; however, it is chemically related to meperidine, can penetrate the CNS, and may be habit-forming. Bismuth subsalicylate helps alleviate symptoms of dyspepsia, nausea, and diarrhea. It exerts its anti-diarrheal effects via an antisecretory mechanism, binding of bacterial toxins, and by its inherent antimicrobial activity. It helps alleviate nausea and vomiting by a topical effect on the gastric mucosa and is preferred when vomiting is a prominent complaint. It has been used effectively in children with diarrhea as well as in patients with travelers diarrhea.57
Symptomatic Therapy
Symptomatic therapy may be used in selected patients with diarrhea. Patients who are afebrile and have non-bloody diarrhea as well as most patients with chronic diarrhea associated with inflammatory bowel disease may benefit from the use of antimotility agents.28 Antimotility agents should generally be avoided in patients with high fever, sepsis, immunocompromise, bloody diarrhea, or suspected inflammatory diarrhea because of delayed clearance of
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YES
NO
Diagnostic evaluation as indicated
The evidence for recommendations is graded using the following scale. For complete definitions, see back page. Class I: Definitely recommended. Definitive, excellent evidence provides support. Class II: Acceptable and useful. Good evidence provides support. Class III: May be acceptable, possibly useful. Fair-to-good evidence provides support. Indeterminate: Continuing area of research.
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patients individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.
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10
Discharge (Class I)
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Adults
Signs of dehydration You are very thirsty You feel weak or dizzy You faint or feel like you might faint Your skin is dry or very loose Your urine is dark How to avoid or treat dehydration For the first 1-2 days: Drink lots of fluids, such as caffeine-free sodas, sports drinks, and flavored mineral water, or an oral rehydration solution that you can buy at the supermarket or pharmacy. Nibble on salted crackers or pretzels (you need the salt) and drink some orange juice or eat some bananas (for the potassium, needed for the heart and muscles. You are probably drinking enough if you are not thirsty and your urine is pale yellow. After the first 1-2 days: Try plain potatoes, noodles, rice, boiled cereals, bread, and other similar items. Go back to your regular diet if the diarrhea is gone. Do Not: Dont drink milk or eat dairy products (cheese, ice cream) for 2-3 days Dont drink caffeine (tea, cola, coffee) Dont drink alcohol Dont drink fruit juices like prune, apple, or grape juice (these can cause diarrhea)
at the pharmacy or supermarket. Let your child eat a regular diet as soon as possible. If your child is vomiting, try having him or her drink very small amounts of liquid until the vomiting stops. Do Not: Dont use water or sports drinks for your dehydrated child (use an oral rehydration solution instead) Dont withhold dairy products (milk, cheese, ice cream) from your child Dont have your child drink fruit juices like prune, apple, or grape juice (these can cause diarrhea)
Medications
Use all medications exactly as your doctor advises. You have been prescribed: ______________________________ ______________________________ ______________________________ You may also use: ______________________________ ______________________________ ______________________________
Children
Signs of dehydration Your child is very thirsty Your child is very weak, sleepy, or cranky Your childs skin feels cool, doughy, or loose Your child cries but does not make tears Your child does not make as much urine as usual How to avoid or treat dehydration Use an oral rehydration solution that you can buy
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choices.5 Empiric therapy with metronidazole (or other anti-Giardia agent) can also be considered in patients with diarrhea lasting 2-4 weeks, without systemic symptoms or dysentery.16 In suspected cases of C. difficile-associated diarrhea, the offending antibiotic should be stopped if possible and treatment with oral metronidazole begun. Metronidazole should be stopped if the assay for C. difficile toxin is negative.14 When empiric antibiotic therapy is not employed judiciously, it can be ineffective or even harmful. If vomiting is a prominent symptom of the illness, a viral source is more likely. Antibiotics should also not be used if the diarrhea is thought to be due to Shiga toxin-producing E. coli. This decision will involve physician judgment since no diagnostic test will yield an immediate result to help the clinician. Keep in mind that Shiga toxin-producing E. coli (E. coli 0157:H7 being the most common type) causes bloody diarrhea. E. coli 0157:H7 outbreaks have been associated with undercooked ground beef as well as with fresh produce such as unpasteurized apple cider, cabbage, and alfalfa sprouts.2
diarrhea include quinolones, TMP-SMX, as well as nonabsorbable or poorly absorbed antibiotics such as rifaximin and aztreonam.59,60 A comparison of two different doses of TMP-SMX with or without loperamide vs. loperamide alone in American adults with acute diarrhea in Mexico revealed that combination therapy with TMP-SMX and loperamide was the most efficacious regimen.61 Several studies have also provided data regarding the efficacy and safety of rifaximin for the treatment of travelers diarrhea. Adults with acute travelers diarrhea who took rifaximin vs. placebo for three days had earlier resolution of symptoms (average, slightly more than one day).62 A randomized, controlled trial comparing rifaximin with TMP-SMX revealed an 11% clinical failure rate with rifaximin vs. a 29% clinical failure rate with TMP-SMX.63 In another comparison of rifaximin with ciprofloxacin, no significant differences were noted between the two treatment groups.59 There is an increasing emergence of fluoroquinoloneresistant Campylobacter, with the rate of resistance exceeding 80% in Southern Asia.53 For patients with travel histories to this part of the world, erythromycin or azithromycin are alternatives.53
Travelers Diarrhea
Antibiotics commonly used in the treatment of travelers
Treatment:
A fluoroquinolone in adults Trimethoprim-sulfamethoxazole in children Treatment period: 1-5 days
Special Circumstances
Immunocompromized Patients
Patients with HIV/AIDS are especially prone to diarrheal illnesses. About half of North American AIDS patients will develop diarrhea at some point in their illness. The incidence of diarrhea in AIDS patients throughout the develop-
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ing world approaches 100%.65 While HIV/AIDS patients are at risk for all of the diarrheal ailments that afflict the immunocompetent population, they can develop enteric infections from a variety of unusual viral, parasitic, protozoal, and bacterial organisms. Malignancies affecting the gastrointestinal tract, such as lymphoma and Kaposis sarcoma, may produce diarrhea, as can many antiretroviral medications.65,66 Finally, many AIDS patients receive multiple or sustained courses of antibiotics, predisposing them to C. difficile-associated diarrhea.66 Therefore, it is important to maintain a broad differential diagnosis, consider a more aggressive diagnostic strategy, involve consultants early when appropriate, and consider hospitalization to improve diagnostic certainty through a combination of testing, observation, and consultant involvement. (See also the January 2002 issue of Emergency Medicine Practice, HIV-Related Illnesses: The Challenge Of ED Management.) Because certain symptoms may suggest particular organisms (see Table 5), the approach to the HIV/AIDS patient with diarrhea begins with the history. Definitive diagnosis, however, is likely to result from either microbiological studies or endoscopy.65,66 Begin by assessing the patients immune status. Ask about specific exposures (sexual practices, travel history, and medications including recent antibiotics). Inquire also about the stool characteristics (bloody, mucoid, watery) and all associated symptoms (e.g., fever, vomiting, abdominal pain or cramping, tenesmus, bloating, weight loss).65,66 What may seem like an acute bout of diarrhea may actually represent the beginning of chronic symptoms. Routine laboratory tests should be ordered based on the clinical situation.65 Many authorities recommend that in AIDS patients, a stool culture should be done, along with C. difficile toxin and ova and parasite testing.66 If these studies are negative, referral to a gastroenterologist for endoscopic investigations could be the next step in the patients evaluation.65,66 In the AIDS patient with chronic diarrhea and a negative microbiological work-up for infectious agents, authorities are divided on the best approach. Some advocate symptomatic care, some a course of empiric antibiotics, and still others suggest endoscopy with gastrointestinal mucosal biopsy; symptoms and
disease stage guide these decisions.17 Endoscopy often produces a definitive diagnosis in AIDS patients with chronic diarrhea and negative stool studies.67 ED treatment options include rehydration, antimotility agents, and empiric antibiotics, as discussed earlier in this article. Consultation or referral to the patients primary care provider or infectious disease specialist regarding antibiotic therapy or changes in antiretroviral therapy are advisable.
Elderly Patients
Diarrheal illnesses are important causes of death and disability in the elderly. Not only are more serious etiologies more common in the elderly, the physiological stresses of diarrheal illness are more challenging for this population. Age-related declines in immune system functioning, physiologic changes of aging, medications (e.g., those that inhibit gastric acid secretion, antibiotics, vasoconstrictors, and others), and environmental factors (e.g., group living in nursing homes) all contribute to the elderly patients susceptibility to develop diarrhea.68 Furthermore, elderly patients with diarrhea are often profoundly dehydrated due to fluid losses associated with their illness, fever, an age-related disordered thirst mechanism, co-existing illnesses (e.g., diabetes mellitus), medications (e.g., diuretics) and limited access to fluids due to infirmity. Prompt, adequate rehydration is essential; however, intravenous rehydration of the elderly individual may be complicated by the presence of cardiovascular disease or renal dysfunction, thus limiting rapid, largevolume fluid administration.68 Ischemic colitis, diverticulitis, bacterial overgrowth, and colonic malignancies are all more common in the elderly and may present with loose stool.7,68,69 Infections notably, C. difficile, E. coli 0157:H7 and Salmonella species are more common in the elderly.68,70 Infectious diarrhea in the elderly is associated with a higher mortality rate.68 If medications are indicated for an elderly patient with diarrhea, be aware of drug interactions and side-effects, particularly if the patient is already on multiple medications. Antacids may reduce the potency of fluoroquinolones. Additionally, fluoroquinolones can increase theophylline and warfarin levels and can either increase or decrease phenytoin levels. Metronidazole can cause nausea and vomiting, exacerbating the situation for a patient who initially presented with a gastrointestinal complaint. Drinking alcohol while taking metronidazole must be strictly avoided since a disulfiram-like reaction can ensue. Also, warfarin, phenytoin, and phenobarbital metabolism may all increase in the patient on metronidazole, potentiating their effect.68 Be particularly cautious when evaluating elderly patients with diarrhea combined with abdominal pain. Elderly patients with abdominal pain tend to have more serious, often surgical, illnesses that present atypically or go unrecognized longer.69 (See also the premier issue of Emergency Medicine Practice, Assessing Abdominal Pain In Adults: A Rational, Cost-Effective, And EvidenceBased Strategy.) Specific surgical diagnoses to consider
Profuse watery diarrhea, weight loss, electrolyte disturbance (especially in advanced disease)
Possible agent: Cryptosporidia
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in the elderly patient with diarrhea include bowel obstruction, appendicitis, mesenteric ischemia, neoplasm, and diverticulitis.69
Pediatric Patients
Diarrhea is very common in children, especially among those who attend day care. While most children in developed nations have mild, self-limited disease, pediatric patients are susceptible to more adverse outcomes especially dehydrationthan their healthy adult counterparts.21 In the United States, about 9% of all hospitalizations of children younger than 5 years are because of diarrhea.71 While pediatric patients are susceptible to more adverse outcomes from diarrheal illnesses, the approach is generally the same. As with adults, infectious causes predominate, although children have more of a predisposition to rotavirus. Another common non-infectious cause in children is the excessive consumption of sugary, clear liquids, which can cause copious, watery stools. The wary practitioner should also keep more serious diagnoses such as intussusception and Meckels diverticulum in mind. In most cases, prevention of dehydration is the primary consideration. Oral rehydration methods are preferred. After rehydration, recommend prompt resumption of a
regular diet, supplemented with oral rehydration solution as tolerated. In vomiting children, frequent, small-volume oral intake is recommended.4 In children, as a general rule, pharmacologic agents should not be used to treat acute diarrhea.21 While some well-designed studies have shown statistically significant results for certain agents, the results were not clinically significant, and published evidence-based guidelines do not support their use in children.4,21 Antibiotic use may be considered in patients in high-risk categories or with serious bacterial infections.4 Hemolytic uremic syndrome is a complication of E. coli 0157:H7 infection that occurs primarily in children. While rare, it is the most common cause of acute kidney failure in infants and children. Early symptoms include vomiting and diarrhea (sometimes bloody), fever, and irritability or lethargy. Later, urine output, decreased consciousness, pallor, bruising, petechiae, or jaundice may occur. An enlarged liver or spleen may be present. Laboratory studies will show evidence of hemolytic anemia and acute renal failure. Administration of packed red blood cells may be necessary, and severe cases may require dialysis. Nevertheless, most children receiving treatment recover completely with no long-term consequences.
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Pregnant Patients
Constipation is usually more of a problem than diarrhea during pregnancy; however, when diarrhea does occur, treatment principles are similar. Preventing dehydration in pregnant patients is a top priority, as it is dangerous for both mother and fetus. Replete disordered electrolytes as needed and provide symptomatic relief. Antibiotic and other medication use in the pregnant patient with diarrhea should be guided by an assessment of the individual patients riskbenefit ratio based on symptom severity and pregnancy risk category of the medication. Loperamide is the safest antimotility agent since it acts peripherally (unlike diphenoxlylate) and does not contain salicylates (unlike bismuth subsalicylate).72 Of the antibiotics generally used for diarrhea treatment, none are considered relatively safe in pregnancy except metronidazole (a Category B drug) after the first trimester if the benefits outweigh the risks. The quinolones and TMP-SMX are either to be avoided or used with caution depending on stage of pregnancy. If doubts exist about antibiotic use in the pregnant patient, the best approach is to coordinate treatment with the patients obstetrician-gynecologist or consult a medical reference that lists teratogenic agents.
than those in the placebo group.77 It should be noted that the studies referenced above were conducted primarily in the developing world, where zinc deficiency in children is prevalent. In the United States, zinc administration to children with diarrheal illnesses is not a part of standard therapy.
Disposition
For patients with diarrheal illness, disposition decisions rely heavily on physician judgment. Clinically stable patients with benign physical examinations and diagnoses that present low risk for complicationsthe most common scenariocan be safely discharged with good follow-up instructions. Ill patients who fail to respond adequately to simple ED measures like rehydration and symptom relief may either be held in the ED or admitted to an observation area or to the hospital, depending on local resources and hospital policies. A brief hospital admission can provide dramatic improvement, especially for patients at the extremes of age or with serious co-morbidities. Patients who represent diagnostic dilemmas or who present atypically could require either a period of observation or immediate further investigation depending on the level of concern. Given the incredibly broad differential diagnosis of diarrheal illness, no definitive rules are available to guide decision-making. Again, maintain a heightened level of alertness when evaluating the very old and the very young, those with multiple or serious co-morbidities, and the immunocompromised. Patients with chronic diarrhea deserve special mention because they often need extensive evaluation to determine the cause of their symptoms. This diagnostic evaluation usually exceeds the scope of most ED capabilities. Coordination of care with a gastroenterologist is advised in these cases. The role of the emergency physician is to exclude serious illness, ensure patient stability, begin an investigation to exclude infectious causes of diarrhea, and provide timely referral for further evaluation.
Controversies/Cutting Edge
Probiotics
Probiotics are microorganisms that some have used in a variety of settings and clinical circumstances to colonize the intestine to prevent or treat diarrhea. One recent meta-analysis of probiotic use in children hospitalized with acute gastroenteritis found that probiotics are a useful adjuvant along with rehydration therapy in acute gastroenteritis.73 Another meta-analysis of oral Lactobacillus (the most-studied probiotic) treatment of children with acute infectious diarrhea found that diarrhea duration was reduced an average of 0.7 days, and stool frequency decreased by an average of 1.6 per day.74 A third recent meta-analysis of probiotics for antibiotic-associated diarrhea found that diarrhea occurred in 23% of patients not receiving a probiotic agent and in 13% of patients receiving a probiotic.75 This meta-analysis involved children and adults. While probiotics are not standard therapy for adults or children with diarrhea in the United States, they are available over-the-counter in a variety of retail outlets, and patients may ask about their utility in diarrheal illnesses.
Zinc
In 2000, a pooled analysis of randomized, controlled trials of zinc therapy in children under 5 years of age with diarrhea concluded that zinc supplementation reduces the duration and severity of acute and persistent diarrhea.76 A more recent randomized, controlled clinical trial studied the effects of zinc administration in children with diarrhea. This study was done in Nepalese children 6-35 months of age with acute diarrhea. Findings were that zinc supplementation substantially reduced diarrhea duration and that those in the zinc group were more likely to vomit
Preventive Measures
Emergency physicians should also teach patients and their families about simple preventive measures to reduce disease transmission, especially when a patient is being discharged with a transmissible diarrheal illness. Norwalklike viruses, in particular, are infectious in very low concentrations and are easily spread from person to person by droplets, or even by contaminated objects. Asymptomatic carriers can also transmit these viruses. In addition, infectious agents are easily spread among the institutionalized elderly due to poor personal hygiene (secondary to
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immobility, incontinence, and reduced mental alertness), and close living quarters. Hand-washing with soap is a simple, effective measure that can be used by caregivers of patients with diarrhea. This is especially important for caretakers of immunocompromised patients (those receiving cancer chemotherapy, immunosuppressive agents, long-term steroids, or those with HIV) as well as food handlers.
Summary
A simple approach focused on obtaining a thorough history and performing a focused physical examination is generally sufficient for most ED patients presenting with diarrhea. Selective laboratory testing can be helpful but should not be the cornerstone of patient evaluation. Symptomatic treatment is simple and well-supported in the literature. Differentiating between those patients requiring symptomatic treatment prior to discharge, those needing hospitalization and more systematic investigation, and those with more serious disease processes masquerading as simple diarrhea remains the most essential element of the ED encounter. It is easy to confuse the common (gastroenteritis) with the rare (poisonings), the serious (appendicitis), and the deadly (gastrointestinal hemorrhage). If there is a doubt about the diagnosis, ED observation and repeated examinations can be helpful. Patients warranting a greater level of concern are the very young, the elderly, immunocompromised individuals, those with major comorbidities, and those with unusual or atypical presentations such as severe abdominal pain. v
References
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report. To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study, will be included in bold type following the reference, where available. In addition, the most informative references cited in the paper, as determined by the authors, will be noted by an asterisk (*) next to the number of the reference.
1. No authors listed. Clinical policy: critical issues for the initial evaluation and management of patients presenting with a chief complaint of nontraumatic acute abdominal pain. Ann Emerg Med 2000 Oct;36(4):406-415. (Clinical policy) No authors listed; American Medical Association; Centers for Disease Control and Prevention; Center for Food Safety and Applied Nutrition, Food and Drug Administration; Food Safety and Inspection Service, U.S. Department of Agriculture. Diagnosis and management of foodborne illnesses: a primer for physicians. MMWR Recomm Rep 2001 Jan 26;50(RR-2):1-69. (Review) McGee S, Abernethy WB 3rd, Simel DL. The rational clinical examination. Is this patient hypovolemic? JAMA 1999 Mar 17;281(11):1022-1029. (Meta-analysis) Cincinnati Childrens Hospital Medical Center. Evidence based clinical practice guideline for children with acute gastroenteritis (AGE). Cincinnati (OH): Cincinnati Childrens Hospital Medical Center; 2001 Apr. (Practice guideline; 118 references)
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4.*
Guerrant RL, Van Gilder T, Steiner TS, et al; Infectious Diseases Society of America. Practice guidelines for the management of infectious diarrhea. Clin Infect Dis 2001 Feb 1;32(3):331-351. (Practice guideline) 6. No authors listed. Practice parameters for the treatment of sigmoid diverticulitis. The Standards Task Force. The American Society of Colon and Rectal Surgeons. Dis Colon Rectum 2000 Mar;43(3):289. (Practice guideline) 7. Wong WD, Wexner SD, Lowry A, et al. Practice parameters for the treatment of sigmoid diverticulitissupporting documentation. The Standards Task Force. The American Society of Colon and Rectal Surgeons. Dis Colon Rectum 2000 Mar;43(3):290-297. (Practice guideline) 8. No authors listed. American Gastroenterological Association Medical Position Statement: guidelines on intestinal ischemia. Gastroenterology 2000 May;118(5):951-953. (Practice guideline) 9. Brandt LJ, Boley SJ. AGA technical review on intestinal ischemia. American Gastrointestinal Association. Gastroenterology 2000 May;118(5):954-968. (Review) 10. Hanauer SB, Sandborn W; Practice Parameters Committee of the American College of Gastroenterology. Management of Crohns disease in adults. Am J Gastroenterol 2001 Mar;96(3):635-643. (Practice guideline) 11. No authors listed; American Gastroenterology Association. American Gastroenterological Association medical position statement: irritable bowel syndrome. Gastroenterology 2002 Dec;123(6):2105-2107. (Practice guideline) 12. No authors listed. Norwalk-like viruses: public health consequences and outbreak management. MMWR Recomm Rep 2001 Jun 1:50(RR09);1-18. (Review) 13. Sampson HA, Sicherer SH, Birnbaum AH. AGA technical review on the evaluation of food allergy in gastrointestinal disorders. American Gastroenterological Association. Gastroenterology 2001 Mar;120(4):10261040. (Review) 14. Fekety R. Guidelines for the diagnosis and management of Clostridium difficile-associated diarrhea and colitis. American College of Gastroenterology, Practice Parameters Committee. Am J Gastroenterol 1997 May;92(5):739-750. (Practice guideline) 15. Andersson RE. Meta-analysis of the clinical and laboratory diagnosis of appendicitis. Br J Surg 2004 Jan;91(1):28-37. (Meta-analysis; 24 studies) 16. Fine KD, Schiller LR. AGA technical review on the evaluation and management of chronic diarrhea. Gastroenterology 1999 Jun;116(6):14641486. (Review) 17. No authors listed. American Gastroenterological Association medical position statement: guidelines for the management of malnutrition and cachexia, chronic diarrhea, and hepatobiliary disease in patients with human immunodeficiency virus infection. Gastroenterology 1996 Dec;111(6):1722-1723. (Practice guideline) 18. American College of Radiology, Expert Panel on Gastrointestinal Imaging. Imaging recommendations for patients with Crohns disease. Reston, VA: American College of Radiology; 2001. (Review) 19. Eisen GM, Dominitz JA, Faigel DO, et al; American Society for Gastrointestinal Endoscopy. Use of endoscopy in diarrheal illnesses. Gastrointest Endosc 2001 Dec;54(6):821-823. (Practice guideline) 20. Schiller LR, Sellin JH. Diarrhea. In: Feldman M, Friedman LS, Sleisenger MH, eds. Sleisenger and Fordtrans Gastrointestinal and Liver Disease. 7th ed. Philadelphia: WB Saunders; 2002:131-153. (Textbook chapter) 21.* No authors listed. Practice parameter: the management of acute gastroenteritis in young children. American Academy of Pediatrics, Provisional Committee on Quality Improvement, Subcommittee on Acute Gastroenteritis. Pediatrics 1996 Mar;97(3):424-435. (Practice guideline) 22. No authors listed. American Gastroenterological Association medical position statement: guidelines for the evaluation and management of chronic diarrhea. Gastroenterology 1999 Jun;116(6):1461-1463. (Practice guideline) 23. Hasler WL. The irritable bowel syndrome. Med Clin North Am 2002 Nov;86(6):1525-1551. (Review) 24. Andres PG, Friedman LS. Epidemiology and the natural course of inflammatory bowel disease. Gastroenterol Clin North Am 1999 Jun;28(2):255-281, vii. (Review) 25. Burns BJ, Brandt LJ. Intestinal ischemia. Gastroenterol Clin North Am 2003 Dec;32(4):1127-1143. (Review) 26. Tabrez S, Roberts IM. Malabsorption and malnutrition. Prim Care 2001 Sep;28(3):505-522, v. (Review) 27. Brandt LJ, Boley SJ. Intestinal ischemia. In: Feldman M, Friedman LS, Sleisenger MH, eds. Sleisenger and Fordtrans Gastrointestinal and Liver
5.*
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Disease. 7th ed. Philadelphia: WB Saunders; 2002:2321-2340. (Textbook chapter) 28.* Gore JI, Surawicz C. Severe acute diarrhea. Gastroenterol Clin North Am 2003 Dec;32(4):1249-1267. (Review) 29. Osorio J, Farreras N, Ortiz De Zarate L, et al. Cocaine-induced mesenteric ischaemia. Dig Surg 2000;17(6):648-651. (Case report) 30. Saclarides TJ. Radiation injuries of the gastrointestinal tract. Surg Clin North Am 1997 Feb;77(1):261-268. (Review) 31. Henriksson R, Franzen L, Littbrand B. Effects of sucralfate on acute and late bowel discomfort following radiotherapy of pelvic cancer. J Clin Oncol 1992 Jun;10(6):969-975. (Randomized, controlled trial; 70 patients) 32. Irish MS, Pearl RH, Caty MG, et al. The approach to common abdominal diagnosis in infants and children. Pediatr Clin North Am 1998 Aug;45(4):729-772. (Review) 33. Rothrock SG, Skeoch G, Rush JJ, et al. Clinical features of misdiagnosed appendicitis in children. Ann Emerg Med 1991 Jan;20(1):45-50. (Retrospective; 181 patients) 34. Horwitz JR, Gursoy M, Jaksic T, et al. Importance of diarrhea as a presenting symptom of appendicitis in very young children. Am J Surg 1997 Feb;173(2):80-82. (Retrospective; 63 patients) 35. Reynolds SL. Missed appendicitis in a pediatric emergency department. Pediatr Emerg Care 1993 Feb;9(1):1-3. (Retrospective; 87 patients) 36. Bolyard EA, Tablan OC, Williams WW, et al. Guideline for infection control in healthcare personnel, 1998. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1998 Jun;19(6):407-463. (Practice guideline) 37.* DuPont HL. Guidelines on acute infectious diarrhea in adults. The Practice Parameters Committee of the American College of Gastroenterology. Am J Gastroenterol 1997 Nov;92(11):1962-1975. (Practice guideline) 38. Brar HS, Surawicz CM. Pseudomembranous colitis: an update. Can J Gastroenterol 2000 Jan;14(1):51-56. (Review) 39. Talan D, Moran GJ, Newdow M, et al; EMERGEncy ID NET Study Group. Etiology of bloody diarrhea among patients presenting to United States emergency departments: prevalence of Escherichia coli 0157:H7 and other enteropathogens. Clin Infect Dis 2001 Feb 15;32(4):573-580. (Prospective; 873 patients) 40. McNeely WS, Dupont HL, Mathewson JJ, et al. Occult blood versus fecal leukocytes in the diagnosis of bacterial diarrhea: a study of U.S. travelers to Mexico and Mexican children. Am J Trop Med Hyg 1996 Oct;55(4):430-433. (Comparative; 1040 patients) 41. Harris JC, Dupont HL, Hornick RB. Fecal leukocytes in diarrheal illness. Ann Intern Med 1972 May;76(5):697-703. (169 patients with diarrhea) 42. Manabe YC, Vinetz JM, Moore RD, et al. Clostridium difficile colitis: an efficient clinical approach to diagnosis. Ann Intern Med 1995 Dec 1;123(11):835-840. (Prospective; 268 inpatients) 43. Turgeon DK, Fritsche TR. Laboratory approaches to infectious diarrhea. Gastroenterol Clin North Am 2001 Sep;30(3):693-707. (Review) 44. Lieberman JM. Rotavirus and other viral causes of gastroenteritis. Pediatr Ann 1994 Oct;23(10):529-532, 534-535. (Review) 45. Huicho L, Garaycochea V, Uchima N, et al. Fecal lactoferrin, fecal leukocytes and occult blood in the diagnostic approach to childhood invasive diarrhea. Pediatr Infect Dis J 1997 Jul;16(7):644-647. (Prospective; 125 patients with diarrhea) 46. Choi SW, Park CH, Silva TM, et al. To culture or not to culture: fecal lactoferrin screening for inflammatory bacterial diarrhea. J Clin Microbiol 1996 Apr;34(4):928-932. (Retrospective, cost-benefit analysis; 55 patients) 47. Fine KD, Ogunji F, George J, et al. Utility of a rapid fecal latex agglutination test detecting the neutrophil protein, lactoferrin, for diagnosing inflammatory causes of chronic diarrhea. Am J Gastroenterol 1998 Aug;93(8):1300-1305. (Non-random sample; 103 patients) 48. Kane SV, Sandborn WJ, Rufo PA, et al. Fecal lactoferrin is a sensitive and specific marker in identifying intestinal inflammation. Am J Gastroenterol 2003 Jun;98(6):1309-1314. (Prospective, comparative; 215 patients) 49. Hamer DH, Gorbach SL. Infectious diarrhea and bacterial food poisoning. In: Feldman M, Friedman LS, Sleisenger MH, eds. Sleisenger and Fordtrans Gastrointestinal and Liver Disease. 7th ed. Philadelphia: WB Saunders; 2002:1864-1913. (Textbook chapter) 50. Wong CS, Jelacic S, Habeeb RL, et al. The risk of the hemolytic-uremic syndrome after antibiotic treatment of Escherichia coli 0157:H7 infections. N Engl J Med 2000 Jun 29;342(26):1930-1936. (Prospective cohort; 71 patients) 51. Hennessy TW, Hedberg CW, Slutsker L, et al. A national outbreak of Salmonella enteritidis infections from ice cream. The Investigation Team.
N Engl J Med 1996 May 16;334(20):1281-1286. (Epidemiologic data) Eidlitz-Marcus T, Cohen YH, Nussinovitch M, et al. Comparative efficacy of two- and five-day courses of ceftriaxone for treatment of severe shigellosis in children. J Pediatr 1993 Nov;123(5):822-824. (Prospective, randomized; 40 patients) 53.* Thielman NM, Guerrant RL. Clinical practice. Acute infectious diarrhea. N Engl J Med 2004 Jan 1;350(1):38-47. (Review) 54. Siegel DL, Edelstein PH, Nachamkin I. Inappropriate testing for diarrheal diseases in the hospital. JAMA 1990 Feb 16;263(7):979-982. (Retrospective; 281 cases) 55. Fine KD, Seidel RH, Do K. The prevalence, anatomic distribution, and diagnosis of colonic causes of chronic diarrhea. Gastrointest Endosc 2000 Mar;51(3):318-326. (Prospective; 809 patients with chronic nonbloody diarrhea) 56.* Schiller LR. Diarrhea. Med Clin North Am 2000 Sep;84(5):1259-1274, x. (Review) 57. DuPont HL, Sullivan P, Evans DG, et al. Prevention of travelers diarrhea (emporiatric enteritis). Prophylactic administration of subsalicylate bismuth). JAMA 1980 Jan 18;243(3):237-241. (Randomized, controlled trial; 128 patients) 58. Karras DJ, Ong S, Moran GJ, et al; EMERGEncy ID NET Study Group. Antibiotic use for emergency department patients with acute diarrhea: Prescribing practices, patient expectations, and patient satisfaction. Ann Emerg Med 2003 Dec;42(6):835-842. (Multicenter, prospective; 104 patients) 59.* DuPont HL, Jiang ZD, Ericsson CD, et al. Rifaximin versus ciprofloxacin for the treatment of travelers diarrhea: a randomized, double-blind clinical trial. Clin Infect Dis 2001 Dec 1;33(11):1807-1815. (Randomized, controlled trial; 187 patients) 60. Ramzan NN. Travelers diarrhea. Gastroenterol Clin North Am 2001 Sep;30(3):665-678, viii. (Review) 61. Ericsson CD, DuPont HL, Mathewson JJ, et al. Treatment of travelers diarrhea with sulfamethoxazole and trimethoprim and loperamide. JAMA 1990 Jan 12;263(2):257-261. (Randomized, controlled trial; 227 patients) 62. Steffen R, Sack DA, Riopel L, et al. Therapy of travelers diarrhea with rifaximin on various continents. Am J Gastroenterol 2003 May;98(5):1073-1078. (Multicenter, randomized, controlled trial; 380 patients) 63. DuPont HL, Ericsson CD, Mathewson JJ, et al. Rifaximin: a nonabsorbed antimicrobial in the therapy of travelers diarrhea. Digestion 1998 Nov-Dec;59(6):708-714. (Multicenter, randomized, controlled trial; 72 patients) 64. Johnson PC, Ericsson CD, DuPont HL, et al. Comparison of loperamide with bismuth subsalicylate for the treatment of acute travelers diarrhea. JAMA 1986 Feb 14;255(6):757-760. (Randomized, controlled trial; 219 patients) 65. Cohen J, West AB, Bini EJ. Infectious diarrhea in human immunodeficiency virus. Gastroenterol Clin North Am 2001 Sep;30(3):637-664. (Review) 66. Sax PE. Opportunistic infections in HIV disease: down but not out. Infect Dis Clin North Am 2001 Jun;15(2):433-455. (Review) 67. Wei SC, Hung CC, Chen MY, et al. Endoscopy in acquired immunodeficiency syndrome patients with diarrhea and negative stool studies. Gastrointest Endosc 2000 Apr;51(4 Pt 1):427-432. (Prospective; 40 patients) 68. Slotwiner-Nie PK, Brandt LJ. Infectious diarrhea in the elderly. Gastroenterol Clin North Am 2001 Sep;30(3):625-635. (Review) 69. Hendrickson M, Naparst TR. Abdominal surgical emergencies in the elderly. Emerg Med Clin North Am 2003 Nov;21(4):937-969. (Review) 70. Kyne L, Hamel MB, Polavaram R, et al. Health care costs and mortality associated with nosocomial diarrhea due to Clostridium difficile. Clin Infect Dis 2002 Feb 1;34(3):346-353. (Prospective; 271 patients) 71. Cicirello HG, Glass RI. Current concepts of the epidemiology of diarrheal diseases. Semin Pediatr Infect Dis 1994;5:163-167. (Review) 72. Wald A. Constipation, diarrhea, and symptomatic hemorrhoids during pregnancy. Gastroenterol Clin North Am 2003 Mar;32(1):309-322, vii. (Review) 73. Szajewska H, Mrukowicz JZ. Probiotics in the treatment and prevention of acute infectious diarrhea in infants and children: a systematic review of published randomized, double-blind, placebocontrolled trials. J Pediatr Gastroenterol Nutr 2001 Oct;33 Suppl 2:S17-25. (Systematic review) 74. Van Niel CW, Feudtner C, Garrison MM, et al. Lactobacillus therapy for acute infectious diarrhea in children: a meta-analysis. Pediatrics 2002 Apr;109(4):678-684. (Meta-analysis) 75. Cremonini F, Di Caro S, Nista EC, et al. Meta-analysis: the effect of probiotic administration on antibiotic-associated diarrhoea. Aliment 52.
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76.
77.
78.
79.
Pharmacol Ther 2002 Aug;16(8):1461-1467. (Meta-analysis) Bhutta ZA, Bird SM, Black RE, et al. Therapeutic effects of oral zinc in acute and persistent diarrhea in children in developing countries: pooled analysis of randomized controlled trials. Am J Clin Nutr 2000 Dec;72(6):1516-1522. (Meta-analysis) Strand TA, Chandyo RK, Bahl R, et al. Effectiveness and efficacy of zinc for the treatment of acute diarrhea in young children. Pediatrics 2002 May;109(5):898-903. (Randomized, controlled trial; 1792 children) Wong MT, Kauffman CA, Standiford HC, et al; Ramoplanin VRE2 Clinical Study Group. Effective suppression of vancomycin-resistant Enterococcus species in asymptomatic gastrointestinal carriers by a novel glycolipodepsipeptide, ramoplanin. Clin Infect Dis 2001 Nov 1;33(9):1476-1482. (Multicenter, randomized, controlled trial; 68 patients) Montecalvo MA. Ramoplanin: a novel antimicrobial agent with the potential to prevent vancomycin-resistant enterococcal infection in high-risk patients. J Antimicrob Chemother 2003 Jun;51 Suppl 3:iii31-35. (Review)
7.
Which of the following can be ruled out as a cause of diarrhea persisting longer than two weeks in otherwise healthy U.S. ED patients? a. Norwalk virus b. Food allergies c. Giardia lamblia d. Ischemic bowel disease A thorough history of medication use in patients with diarrhea should include: a. recent antibiotic use. b. hypoglycemic medications. c. herbal medications. d. vasoconstrictive medications. e. all of the above. Which of the following laboratory tests should be routine in all patients with diarrhea? a. Chemistry panels b. Stool culture c. Fecal leukocyte/lactoferrin testing d. None of the above
8.
9.
2.
10. In children with mild-to-moderate dehydration, the preferred rehydration method is: a. intravenous rehydration. b. rehydration via commercial oral rehydration solutions. c. rehydration via sports drinks. d. rehydration via consumption of clear liquids. 11. Empiric antibiotic therapy should not be employed for: a. nosocomial diarrhea. b. moderate-to-severe travelers diarrhea. c. diarrhea due to E. coli 0157:H7. d. any of the above. 12. Elderly patients: a. are more likely to have serious etiologies for diarrheal illnesses. b. are more likely to be profoundly dehydrated due to diarrheal illnesses. c. are more prone to drug interactions and side-effects. d. all of the above. 13. In children with diarrheal illnesses: a. infectious etiologies are unlikely. b. oral rehydration methods are preferred. c. loperamide is recommended. d. resumption of the childs regular diet should be delayed until most of the symptoms have passed. 14. Lactobacillus: a. is a probiotic being studied for its ability to prevent and treat diarrhea. b. is available only by prescription. c. has been shown to be ineffective in several recent meta-analyses. d. is standard therapy for adults but not children in the United States.
3.
4.
5.
6.
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15. Written discharge instructions should include key reasons to return to the ED, such as: a. profuse or bloody diarrhea. b. dehydration or inability to take and retain oral fluids. c. severe or persistent abdominal pain. d. sustained fever. e. all of the above. 16. Loperamide should not be used in: a. children less than 5 years. b. adults with travelers diarrhea. c. adults with bacillary dysentery. d. all of the above.
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