Acute diarrhea resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mugilan Poongkunran M.B.B.S [2]

Overview

Acute diarrhea is the alteration of the volume, water content and frequency (≥ 3 episodes per day) of bowel movements for a duration of less than 14 days. When the diarrhea lasts more than 14 days it is referred to as persistent diarrhea; and when it lasts more than 30 days it is considered as chronic.[1]

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Common Causes

Inflammatory Causes

Noninflammatory Causes

Management

Initial Management

Shown below is an algorithm depicting the initial management of acute diarrhea is based on the 2001 IDSA practice guidelines for the management of infectious diarrhea.[1]

 
 
 
 
Characterize the symptoms:

❑ Onset
❑ Duration
❑ Pattern (continuous or intermittent)
❑ Stool characteristic (watery, bloody, mucous or greasy)
❑ Frequency of bowel movements
❑ Dysenteric symptoms (fever, tenesmus, blood and/or pus in stool)


Associated symptoms:
Abdominal pain
Nausea and vomiting
❑ Weight loss


Epidemiological factors:
❑ Travel
❑ Food (raw meat, eggs, shellfish, unpasteurized cheese or milk)
❑ Outbreaks
❑ Sexual history
❑ Day care attendance
❑ Previous evaluations
❑ Medications, radiation therapy or surgery
❑ Underlying medical condition (cancer, diabetes, hyperthyroidism or AIDS)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:

Temperature
Pulse
Blood pressure
❑ Respiratory rate
❑ Signs of volume depletion (decreased skin turgor, dry mucosa)
❑ Abdominal tenderness

❑ Level of consciousness
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assessment of volume status
General conditionNormalIrritable/less active*Lethargic/comatose§
EyesNormalSunken -
MucosaNormalDry -
ThirstNormalThirstyUnable to drink§
Radial pulseNormalLow volume*Absent/ uncountable§
Skin turgorNormalReduced -

† Some dehydration = At least two signs, including at least one key sign (*) are present.

‡ Severe dehydration = Signs of “some dehydration” plus at least one key sign (§) are present.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No dehydration
 
Some dehydration
 
Severe dehydration
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Start altered diet

❑ Stop lactose products
❑ Avoid alcohol and high osmolar supplements
❑ Drink 8-10 large glasses of clear fluids (Fruit juices, soft drinks etc)
❑ Eat frequent small meals (Rice, potato, banana, pastas etc)


Can start oral rehydration therapy (ORT) for replacement of stool losses
 
❑ Start ORT at a volume of 50-100 mL/kg
❑ Start altered diet
❑ Reassess status every 4 hr
 
❑ Start IV fluids: Ringer lactate at 30ml/kg in the first 1/2hr and 70ml/kg for the next 2 1/2 hr, if unavailable use normal saline
CBC
Electrolytes
❑ Assess status every 15 mins until strong pulse felt and then every 1 hr
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patient stable and able to drink
❑ Start ORT at a volume of 100 mL/kg over 4 hour
❑ Calculate the continuing stool and emesis losses every hour for additional maintenance ORT therapy
❑ Reassess status every 4 hr
 


Additional Management

Shown below is an algorithm depicting additional management of acute diarrhea based on the 2001 IDSA practice guidelines for the management of infectious diarrhea.[1]

 
 
 
 
 
 
Determine if the patient has any of the following:
❑ Diarrhea for more than 1 day
❑ Inflammation signs (fever, abdominal pain and/or bloody stools
❑ Recent antibitics use
❑ Recent attendance of day care
❑ Hospitalization
❑ Severe dehydration
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed for selective fecal testing
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Traveler's diarrhea
 
Community acquired diarrhea
 
Nosocomial diarrhea
(3 days following hospitalization)
 
 
Persistent diarrhea for more than 7 days
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Empiric treatment with quinolone or TMX/SMZ
 
 
 
 
 
 
 
 
 
 
 
HIV negative
 
HIV positive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
PANEL A:
❑ Order cultures for:
Salmonella
Shigella
Campylobacter
E. coli O157:H7

❑ Test for shiga toxin (if bloody stools)

❑ Test for clostridium toxin (if antibiotics or chemotherapy taken recently)
 
PANEL B:
❑ Test for clostridium toxin
❑ Do tests in panel A in case of nosocomial outbreaks and in the presence of bloody stools
 
PANEL C:
❑ Test for parasites:
Giardia
Cryptosporidum
Cyclospora
Isospora belli

❑ Inflammatory screen:

Fecal lactoferrin test, or
Microscopy for leukocytes
 
❑ Order panel A
❑ Order panel C
❑ Test for microsporidia
❑ Test for mycobaterium avium complex
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
In case of no resolution of symptoms:
❑ Order Panel A
 
❑ Quinolone if suspected shigellosis
❑ Macrolide for suspected resistant campylobacter
No antimicrobial and no antimotility if suspected STEC
 
Treat clostridium difficile
 
Treat according the test results
 
Treat according to the test results
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Order additional diagnostic tests if needed (CBC, blood cultures, electrolytes, urinanalysis)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Consider non infectious and extraintestinal causes of diarrhea if no pathogen is identified by the diagnostic workup:
IBS, IBD, laxative abuse, partial obstruction, rectosigmoid abscess Whipple's disease, pernicious anemia, diabetes, malabsorption, scleroderma, celiac sprue
 
 
 
 
 
 
 
 


Diagnostic Clues

Diagnostic Clue Possible Pathogen
Fever and inflammation in community acquired diarrhea Shigella
Right side abdominal pain with afebrile bloody/non bloody diarrhea Shiga toxin producing E. coli (STEC) O157
Seafood or sea coast exposure Vibrio species
Persistent abdominal pain and fever Yersina entercolitica
Post diarrhea hemolytic uremic syndrome (HUS) STEC O157

Specific Antibiotics

Shigella TMP-SMZ, 160 and 800 mg, respectively (pediatric dose, 5 and 25 mg/kg, respectively) BID for 3 days, or

Fluoroquinolone (300 mg ofloxacin, 400 mg norfloxacin, or 500 mg ciprofloxacin) BID for 3 days, or
Ciprofloxacin 750 mg OD for 3 days,[3] or
Azithromycin 500 mg OD for 3 days,[3] or
Nalidixic acid 1 g/day (55 mg/kg/d for pediatric) for 5 days[1]

Salmonella (typhoid fever) Levofloxacin or any fluoroquinolone 500 mg OD for 7 days, or
Azithromycin 500 mg OD for 7 days[3]
Salmonella (not typhi) Antibiotics are not recommended routinely[1]
Levofloxacin or any fluoroquinolone 500 mg OD for 7-10 days, or
Azithromycin 500 mg OD for 7 days, or
Levofloxacin or Azithromycin should be given for 14 days in immunocompromised patients[3]
Campylobacter Erythromycin 500 mg BID for 5 days, or
Erythromycin 500 mg QID for 3 days, or
Azithromycin 500 mg OD for 3 days
E coli
Enterotoxigenic
Enteropathogenic
Enteroinvasive
TMP-SMZ, 160 and 800 mg, respectively, or
Fluoroquinolone (300 mg ofloxacin, 400 mg norfloxacin, or 500 mg ciprofloxacin) BID for 3 days[1]
Ciprofloxacin 750 mg OD for 1-3 days, or
Azithromycin 1000 mg single dose, or
Rifaximin 500 mg OD for 3 days[3]
STEC Avoid antibiotics[1]
Yersinia Antibiotics are not recommended routinely[1]
Vibrio cholera Doxycycline 300 mg single dose,[3] or
Tetracycline 500 mg QID for 3 days,[3] or
Erythromycin 250 mg TID for 3 days,[3] or
Azithromycin 500 mg OD for 3 days,[3] or
TMP-SMZ, 160 and 800 mg, respectively, or
Single dose fluoroquinolone[1]
Giardia Metronidazole 250-750 mg TID for 7 to 10 days[1]
Entamoeba histolytica Metronidazole 750 mg TID for 5 to 10 days, PLUS
Diiodohydroxyquin 650 mg TID for 20 days, or
Paromomycin 500 mg TID for 7 days[1]

Do's

  • For acute diarrhea, maintaining adequate intravascular volume and correcting fluid and electrolyte disturbances take priority over identifying the causative agent from detailed history and clinical findings, including stool characteristics.[4]
  • Assess ABCD periodically depending on the patient status and check for any warning signs during the course of management.
  • When using normal saline due to unavailability of ringer lactate in diarrhea patients, oral rehydration therapy ORT should be initiated as soon as they are able to drink, to replace bicarbonate and potassium losses.[5]
  • A nasogastric tube can be used to deliver ORT in patients who have a normal mental status but may be too weak to adequately drink the necessary volume of fluid.
  • Always check for warning signs before initiating anti-motility drugs.
  • Order a sigmoidoscopy for the evaluation of proctitis in homosexual men.[1]
  • Test for STEC O157 and for shiga toxin in the stool in the case of hemolytic uremic syndrome.[1]
  • Report to the public health authorities in case of suspected outbreaks and order routine cultures for antimicrobial resistance and serotype identification.[1]

Don'ts

  • Don't treat patients with severe diarrheal dehydration using 5% dextrose with 1/4 normal saline, as using solutions with lower amounts of sodium (such as 38.5 mmol/L in 1/4 saline with 5% dextrose ) would lead to sudden and severe hyponatremia with a high risk of death.[6]
  • ORT is contraindicated in the initial management of severe dehydration and also in patients with frequent and persistent vomiting (more than four episodes per hour), and painful oral conditions such as moderate to severe thrush.
  • Antimotolity drugs should not be used in patients with significant abdominal pain, fever and bloody diarrhea that suggests inflammatory diarrhea, especially in suspected or documented shiga toxin producing E. coli (STEC).
  • Do not initiate empirical antibiotic therapy without fecal culture results except in:
    • The initial management of traveler's diarrhea (fluoroquinolone in adults and trimethoprim sulfamethoxazole in children)
    • High suspicion of giardia in diarrhea lasting more than 10-14 days without an identifiable cause, and with history of travel or drinking unfiltered water[1]
  • Experts have different opinions regarding ordering inflammatory screen (fecal leukocytes and lactoferrin) for community and nosocomial diarrhea. Do not order inflammatory screen unless in the case of persistent or recurrent diarrhea in order to rule out IBD.[1]

References

  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 Guerrant RL, Van Gilder T, Steiner TS, Thielman NM, Slutsker L, Tauxe RV; et al. (2001). [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&i d=11170940 "Practice guidelines for the management of infectious diarrhea"] Check |url= value (help). Clin Infect Dis. 32 (3): 331–51. doi:10.1086/318514. PMID 11170940. line feed character in |url= at position 117 (help)
  2. 2.0 2.1 Musher DM, Musher BL (2004). "Contagious acute gastrointestinal infections". N Engl J Med. 351 (23): 2417–27. doi:10.1056/NEJMra041837. PMID 15575058.
  3. 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 DuPont HL (2009). "Clinical practice. Bacterial diarrhea". N Engl J Med. 361 (16): 1560–9. doi:10.1056/NEJMcp0904162. PMID 19828533.
  4. "http://www.worldgastroenterology.org/assets/export/userfiles/Acute%20Diarrhea_long_FINAL_120604.pdf" (PDF). Retrieved 2 January 2014. External link in |title= (help)
  5. "http://www.worldgastroenterology.org/assets/export/userfiles/Acute%20Diarrhea_long_FINAL_120604.pdf" (PDF). Retrieved 2 January 2014. External link in |title= (help)
  6. "http://www.worldgastroenterology.org/assets/export/userfiles/Acute%20Diarrhea_long_FINAL_120604.pdf" (PDF). Retrieved 2 January 2014. External link in |title= (help)



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