Diarrhea: cause, Symptoms & Treatment -medical Health care
•Diarrhea?
Diarrhea can range in severity from an acute self-limited episode to a severe, life-threatening illness. To properly evaluate the complaint, the clinician must determine the patient’s normal bowel pattern and the nature of the cur-rent symptoms.
Approximately 10 L of fluid enter the duodenum daily, of which all but 1.5 L are absorbed by the small intes-tine. The colon absorbs most of the remaining fluid, with
less than 200 mL lost in the stool. Although diarrhea sometimes is defined as a stool weight of more than 200–300 g/24 h,
quantification of stool weight is necessary.
•Type of Diarrhea ?
1. Acute Diarrhea
» Diarrhea of less than 2 weeks’ duration is most commonly caused by noninvasive pathogens and their enterotoxins.
Acute noninflammatory diarrhea
» Watery, nonbloody.
» Usually mild, self-limited.
» Caused by a virus or bacteria.
» Diagnostic evaluation is limited to patients with diarrhea that is severe or persists beyond 7 days.
Acute inflammatory diarrhea
» Blood or pus, fever.
» Caused by toxin-producing bacterium.
•Causes of acute infectious diarrhea.
1)Noninflammatory Diarrhea-
a)Viral
Noroviruses, astrovirus,
adenovirus,
Rotavirus, sapovirus.
b)ProtozoalGiardia lamblia
Cryptosporidium
Cyclospora
c)Bacterial
1. Preformed enterotoxin
production
Staphylococcus aureus
Bacillus cereus
Clostridium perfringens
2. Enterotoxin production
Enterotoxigenic
E coli (ETEC)
Vibrio cholera, Vibrio
vulnificus
2) Inflammatory Diarrhea-
a)Viral
Cytomegalovirus
b)Protozoal
Entamoeba histolytica.
c)Bacterial
1. Cytotoxin production
Enterohemorrhagic E coli
(EHEC).
2. Mucosal invasion
Shigella
Campylobacter jejuni
Salmonella
Enteroinvasive E coli (EIEC)
Aeromonas
Plesiomonas
Yersinia enterocolitica
Chlamydia
Neisseria gonorrhoeae.
•Treatments:
A. Diet:
Most mild diarrhea will not lead to
dehydration provided the patient takes
adequate oral fluids carbohydrates & Patients find it more comfortable to rest the bowel by avoiding high-fiber foods, fats,milk products, caf-feine, and alcohol. Frequent feedings of tea, “flat” carbonated
beverages, and soft, easily digested foods
(eg, soups, crackers, bananas, applesauce, rice, toast) are encouraged.
B. Rehydration:
In more severe diarrhea, dehydration can occur quickly, especially in children and frail older adults. Oral rehydra-tion with fluids containing glucose, Na+, K+, Cl–, and bicar-bonate or citrate is preferred when feasible. A convenient mixture is ½ tsp salt (3.5 g), 1 tsp baking soda (2.5 g NaHCO3), 8 tsp sugar (40 g), and 8 oz orange juice (1.5 g KCl), diluted to 1 L with water.Alternatively, oral electro-lyte solutions (eg, Pedialyte, Gatorade) are readily available. Fluids should be given at rates of 50–200 mL/kg/24
h depending on the hydration status. Intravenous fluids (lac-tated Ringer
injection) are preferred in patients with severe dehydration.
C. Antidiarrheal Agents:
Antidiarrheal agents may be used safely in patients with mild to moderate diarrheal illnesses to improve patient comfort. Opioid agents help decrease the stool number
and liquidity and control fecal urgency.
However, they should not be used inpatients with bloody diarrhea, high
fever, or systemic toxicity and should be discontinued in patients whose diarrhea is worsening despite therapy. With these provisos, such drugs provide excellent
symptomaticrelief. Loperamide is preferred, in a dosage of 4 mg orally initially, followed by 2 mg after each loose stool (maximum: 8 mg/24 h).
» When to Admit:
• Severe dehydration for intravenous fluids, especially if vomiting or unable to maintain sufficient oral fluid intake.
• Bloody diarrhea that is severe or worsening in order to distinguish infectious versus noninfectious cause.
• Severe abdominal pain, worrisome for toxic colitis, inflammatory bowel disease, intestinal ischemia, or surgical abdomen.
• Signs of severe infection or sepsis (temperature higher than 39.5°C,leukocytosis, rash).
• Severe or worsening diarrhea in patients who are older than 70 years or immunocompromised.
• Signs of hemolytic-uremic syndrome (acute kidney injury, thrombocytopenia, hemolytic anemia).
2. Chronic Diarrhea
» Diarrhea present for longer than 4 weeks.
» Before embarking on extensive workup,common causes should be excluded, including chronic infections, and irritable bowel syndrome.
•Causes of chronic diarrhea.
1)Osmotic diarrhea:
1. Medications: antacids, lactulose, sorbitol.
2 Disaccharidase deficiency: lactose intolerance.
3. Factitious diarrhea: magnesium (antacids, laxatives).
2)Secretorydiarrhea:
Large volume (> 1 L/day)
1. Hormonally mediated: VIPoma,carcinoid, medullary carcinoma of thyroid (calcitonin),syndrome (gastrin)
2. Factitious diarrhea (laxative abuse); phenolphthalein,
cascara, senna
3. Villous adenoma
4. Bile salt malabsorption (idiopathic, ileal resection;
Crohn ileitis; postcholecystectomy)
5. Medications.
3)Inflammatory conditions:
Fever, hematochezia, abdominal pain
1. Ulcerative colitis
2. Crohn disease
3. Microscopic colitis
4. Malignancy: lymphoma, adenocarcinoma
(with obstruction and pseudodiarrhea)
5. Radiation enteritis.
4)Medications:
Weight loss, abnormal laboratory values; fecal fat > 10 g/24h.
1. Small bowel mucosal disorders: celiac disease,small bowel resection
(short bowel syndrome),Crohn disease.
2. Lymphatic obstruction: lymphoma,carcinoid, infectious (tuberculo-sis),Kaposi sarcoma, sarcoidosis, retroperitoneal fibrosis.
3. Pancreatic disease: chronic pancreatitis, pancreatic carcinoma.
4. Bacterial overgrowth: motility disorders (diabetes, vagotomy),,
scleroderma fistulas, small intestinal diverticula.
4)Motility disorders:
Systemic disease or prior abdominal surgery
1. Postsurgical: vagotomy, partial gastrectomy, blind loop with bacterial overgrowth.
2. Systemic disorders:
scleroderma,DM,hyperthyroidism.
3.Irritable bowel syndrome.
5)Chronicinfections:
1. Parasites: Giardia lamblia, Entamoeba histolytica, Strongyloidiasis
stercoralis, Capillaria philippinensis
2. AIDS-related: Viral: Cytomegalovirus, HIV infection .Bacterial:
Clostridium difficile, Mycobacterium avium complex.
» Treatment:
A number of antidiarrheal agents may be used in certain patients with chronic diarrheal conditions and are listed below. Opioids are safe in most patients with chronic, sta-ble symptoms.
Loperamide: 4 mg orally initially, then 2 mg after each loose stool (maximum: 16
mg/day).
Dephenoxylate with atropine: One tablet orally three or four times daily as needed.
Codeine and deodorized tincture of opium: Because of potential habituation, these drugs are avoided except in cases of chronic, intractable diarrhea.
Codenine may be given in a dosage of 15–60 mg orally every 4 hours; tincture of opium, 0.3–1.2 mL orally every 6 hours as needed.
Clonidine: Alpha-2-adrenergic agonists inhibit intesti-nal electrolyte secretion. Clonidine, 0.1–0.3 mg orally twice
daily, or a clonidine patch, 0.1–0.2 mg/day, may help in some patients with secretory diarrheas, diabetic diarrhea, or cryptosporidiosis.
Octreotide: This somatostatin analog stimulates intes-tinal fluid and electrolyte absorption and inhibits intestinal
fluid secretion and the release of gastrointestinal peptides. It is given for secretory diarrheas due to neuroendocrine tumors (VIPomas, carcinoid). Effective doses range from 50 mcg to 250 mcg subcutaneously three times daily.
Bile salt binders: Cholestyramine or colestipol (2–4 g once to three times daily) or colesevelam (625 mg, 1–3 tablets once or twice daily) may be useful in patients with
bile salt-induced diarrhea, which may be idiopathic or secondary to intestinal resection or ileal disease.
 |
| Diarrhea:loose, watery and possibly more-frequent bowel movements. |
Diarrhea can range in severity from an acute self-limited episode to a severe, life-threatening illness. To properly evaluate the complaint, the clinician must determine the patient’s normal bowel pattern and the nature of the cur-rent symptoms.
Approximately 10 L of fluid enter the duodenum daily, of which all but 1.5 L are absorbed by the small intes-tine. The colon absorbs most of the remaining fluid, with
less than 200 mL lost in the stool. Although diarrhea sometimes is defined as a stool weight of more than 200–300 g/24 h,
quantification of stool weight is necessary.
•Type of Diarrhea ?
1. Acute Diarrhea
» Diarrhea of less than 2 weeks’ duration is most commonly caused by noninvasive pathogens and their enterotoxins.
Acute noninflammatory diarrhea
» Watery, nonbloody.
» Usually mild, self-limited.
» Caused by a virus or bacteria.
» Diagnostic evaluation is limited to patients with diarrhea that is severe or persists beyond 7 days.
Acute inflammatory diarrhea
» Blood or pus, fever.
» Caused by toxin-producing bacterium.
•Causes of acute infectious diarrhea.
1)Noninflammatory Diarrhea-
a)Viral
Noroviruses, astrovirus,
adenovirus,
Rotavirus, sapovirus.
b)ProtozoalGiardia lamblia
Cryptosporidium
Cyclospora
c)Bacterial
1. Preformed enterotoxin
production
Staphylococcus aureus
Bacillus cereus
Clostridium perfringens
2. Enterotoxin production
Enterotoxigenic
E coli (ETEC)
Vibrio cholera, Vibrio
vulnificus
2) Inflammatory Diarrhea-
a)Viral
Cytomegalovirus
b)Protozoal
Entamoeba histolytica.
c)Bacterial
1. Cytotoxin production
Enterohemorrhagic E coli
(EHEC).
2. Mucosal invasion
Shigella
Campylobacter jejuni
Salmonella
Enteroinvasive E coli (EIEC)
Aeromonas
Plesiomonas
Yersinia enterocolitica
Chlamydia
Neisseria gonorrhoeae.
•Treatments:
A. Diet:
Most mild diarrhea will not lead to
dehydration provided the patient takes
adequate oral fluids carbohydrates & Patients find it more comfortable to rest the bowel by avoiding high-fiber foods, fats,milk products, caf-feine, and alcohol. Frequent feedings of tea, “flat” carbonated
beverages, and soft, easily digested foods
(eg, soups, crackers, bananas, applesauce, rice, toast) are encouraged.
B. Rehydration:
In more severe diarrhea, dehydration can occur quickly, especially in children and frail older adults. Oral rehydra-tion with fluids containing glucose, Na+, K+, Cl–, and bicar-bonate or citrate is preferred when feasible. A convenient mixture is ½ tsp salt (3.5 g), 1 tsp baking soda (2.5 g NaHCO3), 8 tsp sugar (40 g), and 8 oz orange juice (1.5 g KCl), diluted to 1 L with water.Alternatively, oral electro-lyte solutions (eg, Pedialyte, Gatorade) are readily available. Fluids should be given at rates of 50–200 mL/kg/24
h depending on the hydration status. Intravenous fluids (lac-tated Ringer
injection) are preferred in patients with severe dehydration.
C. Antidiarrheal Agents:
Antidiarrheal agents may be used safely in patients with mild to moderate diarrheal illnesses to improve patient comfort. Opioid agents help decrease the stool number
and liquidity and control fecal urgency.
However, they should not be used inpatients with bloody diarrhea, high
fever, or systemic toxicity and should be discontinued in patients whose diarrhea is worsening despite therapy. With these provisos, such drugs provide excellent
symptomaticrelief. Loperamide is preferred, in a dosage of 4 mg orally initially, followed by 2 mg after each loose stool (maximum: 8 mg/24 h).
» When to Admit:
• Severe dehydration for intravenous fluids, especially if vomiting or unable to maintain sufficient oral fluid intake.
• Bloody diarrhea that is severe or worsening in order to distinguish infectious versus noninfectious cause.
• Severe abdominal pain, worrisome for toxic colitis, inflammatory bowel disease, intestinal ischemia, or surgical abdomen.
• Signs of severe infection or sepsis (temperature higher than 39.5°C,leukocytosis, rash).
• Severe or worsening diarrhea in patients who are older than 70 years or immunocompromised.
• Signs of hemolytic-uremic syndrome (acute kidney injury, thrombocytopenia, hemolytic anemia).
2. Chronic Diarrhea
» Diarrhea present for longer than 4 weeks.
» Before embarking on extensive workup,common causes should be excluded, including chronic infections, and irritable bowel syndrome.
•Causes of chronic diarrhea.
1)Osmotic diarrhea:
1. Medications: antacids, lactulose, sorbitol.
2 Disaccharidase deficiency: lactose intolerance.
3. Factitious diarrhea: magnesium (antacids, laxatives).
2)Secretorydiarrhea:
Large volume (> 1 L/day)
1. Hormonally mediated: VIPoma,carcinoid, medullary carcinoma of thyroid (calcitonin),syndrome (gastrin)
2. Factitious diarrhea (laxative abuse); phenolphthalein,
cascara, senna
3. Villous adenoma
4. Bile salt malabsorption (idiopathic, ileal resection;
Crohn ileitis; postcholecystectomy)
5. Medications.
3)Inflammatory conditions:
Fever, hematochezia, abdominal pain
1. Ulcerative colitis
2. Crohn disease
3. Microscopic colitis
4. Malignancy: lymphoma, adenocarcinoma
(with obstruction and pseudodiarrhea)
5. Radiation enteritis.
4)Medications:
Weight loss, abnormal laboratory values; fecal fat > 10 g/24h.
1. Small bowel mucosal disorders: celiac disease,small bowel resection
(short bowel syndrome),Crohn disease.
2. Lymphatic obstruction: lymphoma,carcinoid, infectious (tuberculo-sis),Kaposi sarcoma, sarcoidosis, retroperitoneal fibrosis.
3. Pancreatic disease: chronic pancreatitis, pancreatic carcinoma.
4. Bacterial overgrowth: motility disorders (diabetes, vagotomy),,
scleroderma fistulas, small intestinal diverticula.
4)Motility disorders:
Systemic disease or prior abdominal surgery
1. Postsurgical: vagotomy, partial gastrectomy, blind loop with bacterial overgrowth.
2. Systemic disorders:
scleroderma,DM,hyperthyroidism.
3.Irritable bowel syndrome.
5)Chronicinfections:
1. Parasites: Giardia lamblia, Entamoeba histolytica, Strongyloidiasis
stercoralis, Capillaria philippinensis
2. AIDS-related: Viral: Cytomegalovirus, HIV infection .Bacterial:
Clostridium difficile, Mycobacterium avium complex.
» Treatment:
A number of antidiarrheal agents may be used in certain patients with chronic diarrheal conditions and are listed below. Opioids are safe in most patients with chronic, sta-ble symptoms.
Loperamide: 4 mg orally initially, then 2 mg after each loose stool (maximum: 16
mg/day).
Dephenoxylate with atropine: One tablet orally three or four times daily as needed.
Codeine and deodorized tincture of opium: Because of potential habituation, these drugs are avoided except in cases of chronic, intractable diarrhea.
Codenine may be given in a dosage of 15–60 mg orally every 4 hours; tincture of opium, 0.3–1.2 mL orally every 6 hours as needed.
Clonidine: Alpha-2-adrenergic agonists inhibit intesti-nal electrolyte secretion. Clonidine, 0.1–0.3 mg orally twice
daily, or a clonidine patch, 0.1–0.2 mg/day, may help in some patients with secretory diarrheas, diabetic diarrhea, or cryptosporidiosis.
Octreotide: This somatostatin analog stimulates intes-tinal fluid and electrolyte absorption and inhibits intestinal
fluid secretion and the release of gastrointestinal peptides. It is given for secretory diarrheas due to neuroendocrine tumors (VIPomas, carcinoid). Effective doses range from 50 mcg to 250 mcg subcutaneously three times daily.
Bile salt binders: Cholestyramine or colestipol (2–4 g once to three times daily) or colesevelam (625 mg, 1–3 tablets once or twice daily) may be useful in patients with
bile salt-induced diarrhea, which may be idiopathic or secondary to intestinal resection or ileal disease.
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