Diarrhea: Identifying Serious Illness And Providing Relief

Table of Contents

 

1. Abstract
2. Critical Appraisal Of The Literature
3. Etiology, Epidemiology, And Pathophysiology
   1. Etiology
   2. Epidemiology
   3. Pathophysiology
4. Differential Diagnosis
   1. Infectious Enteritis
   2. Irritable Bowel Syndrome
   3. Inflammatory Bowel Disease
   4. Ischemic Bowel Disease
   5. Radiation Enteritis
   6. Appendicitis
   7. Miscellaneous Causes
5. Prehospital Care
6. Emergency Department Evaluation
   1. History
      1. History Of Present Illness
      2. Past Medical History
      3. Medications
      4. Review Of Systems
      5. Social History
   2. Physical Examination
      1. Primary Survey
      2. Secondary Survey
7. Diagnostic Studies
   1. Blood Tests
   2. Fecal Leukocyte/Lactoferrin Testing
   3. Stool Culture
      1. Stool Testing For Parasites
   4. Endoscopy/Computed Tomography
8. Treatment
   1. Rehydration
   2. Symptomatic Therapy
   3. Empiric Antibiotic Therapy
   4. Traveler's Diarrhea
      1. Prevention Of Traveler's Diarrhea
9. Special Circumstances
   1. Immunocompromized Patients
   2. Elderly Patients
   3. Pediatric Patients
   4. Pregnant Patients
10. Controversies/Cutting Edge
    1. Probiotics
    2. Zinc
11. Disposition
    1. Preventive Measures
12. Summary
13. Key Points In The Managemnt of Patients With Diarrhea
14. Sample Discharge Instructions For Patients With Diarrhea
    1. Adults
    2. Children
    3. Medications
15. Cost And Time Effective Strategies For Patients with Diarrhea
16. Clinical Pathway: Approach To Patients With Diarrhea
17. Tables
    1. Typical Characteristics Of Different Etiologies Of Diarrhea
    2. Agents Causing Infectious Diarrhea And Their Associated Symptoms
    3. Common Causes Of Diarrhea Persisting Longer Than Two Weeks
    4. Empiric Antibiotic Therapy Regimens For Suspected Infectious Diarrhea
    5. Diarrheal Syndromes In Patients With HIV AIDS
18. References

Abstract

Diarrhea is a common condition that can stem from many causes. Fortunately, the care of the ED patient with diarrhea is usually straightforward— a 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.

Critical Appraisal Of The Literature

Given that diarrhea is such a ubiquitous part of the human condition, it's not surprising that the literature on the subject is truly voluminous. Thousands of studies address the epidemiology, etiology, pathophysiology, evaluation, treatment, differential diagnosis, and other features of patients with diarrhea. Thankfully, a number of well-done reviews, meta-analyses, and position statements from expert medical organizations condense the findings, making the job of the practicing emergency physician caring for patients with diarrhea much easier.^1-19

In general, the preponderance of evidence tends to support the following practices in patients with diarrhea:

• 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 patient's contacts are ill; the patient's 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, traveler's 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 traveler's 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

Etiology, Epidemiology, And Pathophysiology

Etiology

Diarrhea is a change in normal bowel movements characterized by an increase in the water content, volume, or frequency of stools. Fluid secretion into the gut and increased gut motility together produce both the increased stooling frequency and the increased stool liquidity.^16,20 The passage of more than 200 grams of stool per day is considered to be diarrhea; two to three bowel movements per day is the upper limit of normal.

An episode of diarrhea lasting 14 days or less is generally defined as "acute diarrhea," while "persistent diarrhea" refers to episodes lasting longer than 14 days. "Chronic" diarrhea is generally defined as diarrhea that lasts more than 30 days.

Tables

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.

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