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Classification

of

diarrhea:I.Acutediarrhea

Threeormoreloose,waterystoolswithin24hours

II.BloodyDiarrhea/Dysentery

Bloody

diarrhea,

visible

blood

and

mucus

present

III.Chronic/Persistentdiarrhea

Episodesofdiarrhealastingmorethan14days

DIARRHEA

I.

Acutediarrhea

A.Usuallyaselflimitedinfectiousillness.

B.Particularfeaturesmaysuggestaspecificcause

1.Vomitingismorecommoninviralgastroenteritisoringestion of

apre

formed

bacterialtoxin(foodpoisoning)

2.Profusewaterydiarrheaissuggestiveofrotavirus(theNorwalk

agent),

cholera,

or

occasionally

Giardia.

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C.Deathfromacutediarrheaisduetodehydrationandelectrolyte

shifts.

1.Patients

at

risk

for

death

from

acute

diarrhea

are

those

at

extremes

ofage(especially

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F.Severityofacutediarrheaislargelydeterminedbyvolumestatus.

1.Assessmentofvolumestatusdiffersbetweenadultsandchildren

a)Adults

(1)Restingtachycardia,posturalhypotension,jugularvenous

distension,drymucousmembranes

b)

Children(1)Urineoutput,drymouth/eyes,sunkenfontanelle,skinturgor,

irritableorlethargic,drinkingpoorly

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G.TreatmentofAcuteDiarrheahas3phases

1.Rehydration

2.Replacementofongoinglosses

3.Nutritionalsupport

4.Additionalaspectsoftreatment

a)Hospitalize

if

severely

dehydrated,

malnourished,

age

viral

enteritis?)

g)Antibioticsusuallynotindicated

(1)Giveantibioticsfor:dysentery(seebelow),suspicionofcholera,

entericfever,giardiasis.

(2)Seeantimicrobialtablebelow

h)Antidiarrheal drugsandantiemetics aretypicallycontraindicated

inacute

diarrhea.

i)Protectyourselfandothersbywashingyourhandsbetween

patientsandtrimmingyour

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5.Howtouseoralreplacementsolution(ORS)

a)

Key

ingredients

are

sodium

and

glucose/rice,

in

an

iso

osmotic

orhypoosmotic solution.

b)TeachafamilymembertoprepareandgiveORS.

c)Givetoinfantsandyoungchildrenusingacleanspoonorcup,

notafeeding

bottle.

(1)Forbabiesaspoonorsyringewithoutaneedlecanbeusedto

putthesolutionintothemouth.

d)Children

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H.Preventionofacutediarrhea

1.Breastfeeding

2.Rotavirusvaccine

3.Accesstocleanwater

4.Handwashing

5.Use

of

latrines

II.BloodyDiarrhea

A.

Differential

diagnosis:1.Shigella,enterohemorrhagicEcoli(EHEC)

a)Oftenwithfever

2.Entericfever(Salmonellatyphi)

a)Systemic

illness

,ileal inflammation

(see

abdominal

pain

talk)

3.Amebiasis

a)Nofever(unlessinliver)

4.Noninfectiouscauses

a)Ischemic

colitis,

inflammatory

bowel

disease

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B.Infectiousdysenteryisusuallyaselflimiteddiseasethatdoesnot

requireantibiotictherapy.

1.Antibioticsarerecommendedfor

a)Entericfever(Salmonellatyphi)

b)Ameobiasis

c)Extremesofage

d)Immunocompromised ormalnourishedpatients

e)Toxicpatients,suspicionofsepsis

2.Antibioticscanprecipitatehemolyticuremic syndromeinchildren

withEcoliO157:H7infection,especiallyinindustrializedcountries.

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1. Persistentdiarrhea

in

children

A.Amonginfantsindevelopingcountries,upto20%ofacute

diarrheal illnessesbecomechronic.

B.Commonpathogensareenteropathic Ecoli(EPEC),giardia.

C.A

vicious

cycle

of

diarrhea

and

malabsorption can

lead

to

death.

D.Evaluation:checkstoolovaandparasiteexam;considerHIV

testing

E.Treatmentislargelynutritional

1.Isoosmolar carbohydrateporridgemadefromlocalingredients(yams,bananas,rice)anddeliveredthroughafeedingtubeif

needed

2.

Multivitamins

and

zinc3.Antibiotics

III.Chronic/Persistant Diarrhea

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2.Persistentdiarrheainadults

A.A

leading

presentation

of

HIV

infection

in

some

regions

B.Causesinclude:

1.Campylobacterileitis:chronicdiarrhea,rightlowerquadrant

tenderness

2.TB

enteritis:

doughy

abdomen,

high

ESR

3.Parasites:giardia,amoeba,cryptosporidium(detectedonacid

faststainofstool),isospora belli (detectedonroutineovaand

parasiteexam),cyclospora

4.Tropical

sprue:

fat

in

the

stool

5.Chronicpancreatitis:fatinthestool,pancreaticcalcificationson

abdominalXRayorUS

6.

Inflammatory

bowel

disease7.Malignancy

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Labtestsindiarrhealsyndromes

A.Stoolforovaandparasites:Especiallyinsevereorpersistent

diarrhea

B.Fecalleukocytes:Suggestscolitis,invasiveorganism

C.CBC:WontalteracuteRx,unlesstherearesignsofsevere

anemiaD.Stoolculture:Usuallynotavailableorrequired

E.StoolSudanstain(fecalfat):Inchronicdiarrheawithweightloss

F.XRay:ifconcernfortoxicmegacolon