Diarrhea
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| Diarrhea Classification and external resources | |
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| ICD-10 | A09., K59.1 |
| ICD-9 | 787.91 |
| DiseasesDB | 3742 |
| eMedicine | ped/583 |
| MeSH | D003967 |
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Overview
Diarrhea, also spelled diarrhoea refers to frequent loose or liquid bowel movements.
Although for many people diarrhea is merely unpleasant, diarrhea that is both acute and severe is a common cause of death in developing countries and a major cause of infant death worldwide. It is often due to gastroenteritis.
Causes
The principal cause of diarrhea stems from ingestion of unsafe drinking water (typically from admixture of raw sewage to water supplies); the occurrence is predominantly in lesser developed countries.
Causes of diarrhea can be infection, allergy, food intolerance, foodborne illness and/or extreme excesses of Vitamin C and/or magnesium and may be accompanied by abdominal pain, nausea and vomiting. Temporary diarrhea can also result from the ingestion of laxative medications or large quantities of certain foods like prunes with laxative properties. There are other conditions which involve some but not all of the symptoms of diarrhea, and so the formal medical definition of diarrhea involves defecation of more than 200 grams per day (although formal weighing of stools to determine a diagnosis is rarely actually carried out).
Diarrhea occurs when insufficient fluid is absorbed by the colon. As part of normal digestion, food is mixed with large amounts of water. The water is supplied, as needed, by the stomach and small intestine. The colon recovers this water, leaving the remaining material as a semisolid stool. If the colon is damaged or inflamed, however, absorption is inhibited, and watery stools result.
Diarrhea is most commonly caused by viral infections or bacterial toxins. In sanitary living conditions and with ample food and water available, an otherwise healthy patient typically recovers from the common viral infections in a few days and at most a week. However, for ill or malnourished individuals diarrhea can lead to severe dehydration and can become life-threatening without treatment.
Diarrhea can also be a symptom of more serious diseases, such as dysentery, Montezuma's Revenge, cholera, or botulism, and can also be indicative of a chronic syndrome such as Crohn's disease. Though appendicitis patients do not generally have diarrhea, it is a common symptom of a ruptured appendix. It is also an effect of severe radiation sickness.
Diarrhea can also be caused by dairy intake in those who are lactose intolerant.
Symptomatic treatment for diarrhea involves the patient consuming adequate amounts of water to replace that loss, preferably mixed with electrolytes to provide essential salts and some amount of nutrients. For many people, further treatment is unnecessary. The following types of diarrhea indicate medical supervision is required:
- Diarrhea in infants;
- Moderate or severe diarrhea in young children;
- Diarrhea associated with blood;
- Diarrhea that continues for more than two weeks;
- Diarrhea that is associated with more general illness such as non-cramping abdominal pain, fever, weight loss, etc;
- Diarrhea in travelers, since they are more likely to have exotic infections such as parasites;
- Diarrhea in food handlers, because of the potential to infect others;
- Diarrhea in institutions such as hospitals, child care centers, or geriatric and convalescent homes.
A severity score is used to aid diagnosis.[1]
Complete List of Differential Diagnoses
In alphabetical order. [1] [1]
Acute Diarrhea
- Addison's Disease
- Adrenal insufficiency
- Appendicitis
- Bacterial:
- C-cell carcinoma
- Chronic inflammatory bowel disease (first manifestation)
- Colon cancer
- Drugs:
- Food:
- Food allergy
- Graft-host reaction after allogenic bone marrow transplantation
- Heavy metal intoxication
- HIV
- Hyperthyroidism
- Irritable Bowel Syndrome (IBS)
- Ischemic-hemorrhagic colitis
- Lactose intolerance
- Neoplasia
- Other hormone-producing tumor
- Parasites:
- Runner's diarrhea
- Traveler's diarrhea
- Most commonly seen germs:
- Typhoid Fever
- Viral:
Chronic Diarrhea
- Achylia
- Addison's Disease
- Amebiasis
- Amyloidosis
- Anxiety
- Autonomous neuropathy
- Bacterial gastroenteritis
- Bacterial toxins
- Behcet syndrome
- Bile acid malabsorption
- Biliary fistula
- Carcinoid syndrome
- Carcinoma of the pancreas
- Celiac Sprue
- Chologenic diarrhea
- Collagenous colitis
- Colitis after radiation therapy
- Colon cancer
- Crohn's Disease
- Cryptosporidiosis
- Diabetes Mellitus
- Diabetic enteropathy
- Diverticular disease
- Drugs:
- Antacids
- Antipholgistics
- Anthraquinones
- Castor oil
- Lactulose
- Mannitol
- Prostaglandins
- Sorbitol
- Dumping syndrome
- Enteropathogenic viruses
- Excess coffee, tea, coke
- Exudative diarrhea
- Fecal impaction
- Food allergy
- Gastric surgery/Billroth operation
- Gastrinoma
- Gastrocolic fistula
- Giardia
- Hyperthyroidism
- HIV
- Idiopathic lymphangiectasis
- Inflammatory Bowel Disease
- Intestinal atrophy (post-radiation therapy)
- Irritable Bowel Syndrome (IBS)
- Irritable colon
- Lymphocytic colitis
- Lymphomas
- Malabsorption
- Maldigestion
- Medullary thyroid carcinoma
- Mesenteric ischemia
- Motility disorders of gastrointestinal (GI) tract
- Neuroendocrine tumors
- Nontropical sprue
- Obstructive jaundice
- Parasites:
- Pellagra
- Polyarteritis
- Polyposis
- Postileal resection
- Postvagotomy
- Proctitis
- Prostaglandins
- Radiation proctitis
- Rectal surgery
- Scleroderma
- Short bowel syndrome
- Tuberculosis
- Ulcerative colitis
- Unabsorbed dietary fat
- Vegetative lability
- Verner-Morrison Syndrome
- Villous adenoma
- Villous carcinoma
- Whipple's Disease
- Zollinger-Ellison Syndrome
Types of diarrhea
There are at least four types of diarrhea: secretory diarrhea, osmotic diarrhea, motility-related diarrhea, and inflammatory diarrhea.
Secretory diarrhea
Secretory diarrhea means that there is an increase in the active secretion, or there is an inhibition of absorption. There is little to no structural damage. The most common cause of this type of diarrhea is a cholera toxin that stimulates the secretion of anions, especially chloride ions. Therefore, to maintain a charge balance in the lumen, sodium is carried with it, along with water.
Osmotic diarrhea
Osmotic diarrhea occurs when there is a loss of water due to a heavy osmotic load. This can occur when there is maldigestion (e.g., pancreatic disease or Coeliac disease), where the nutrients are left in the lumen, which pulls water into the lumen.
Motility-related diarrhea
Motility-related diarrhea occurs when the motility of the gastrointestinal tract is abnormally high. If the food moves too quickly, there is not enough time for sufficient nutrients and water to be absorbed. This can be due to a vagotomy or diabetic neuropathy, or a complication of menstruation.
Inflammatory diarrhea
Inflammatory diarrhea occurs when there is damage to the mucosal lining or brush border, which leads to a passive loss of protein-rich fluids, and a decreased ability to absorb these lost fluids. Features of all three of the other types of diarrhea can be found in this type of diarrhea. It can be caused by bacterial infections, viral infections, parasitic infections, or autoimmune problems such as inflammatory bowel disease.
Infectious diarrhea
Infectious diarrhea is diarrhea cased by a microbe such as a bacterium, parasite, or virus.
Malabsorption
These tend to be more severe medical illnesses. Malabsorption is the inability to absorb food, mostly in the small bowel but also due to the pancreas.
Causes include celiac disease (intolerance to gluten, a wheat product), lactose intolerance (Intolerance to milk sugar, common in non-Europeans), fructose malabsorption, pernicious anemia (impaired bowel function due to the inability to absorb vitamin B12), loss of pancreatic secretions (may be due to cystic fibrosis or pancreatitis), short bowel syndrome (surgically removed bowel), radiation fibrosis (usually following cancer treatment), and other drugs such as chemotherapy.
Inflammatory bowel disease
The two overlapping types here are of unknown origin:
- Ulcerative colitis is marked by chronic bloody diarrhea and inflammation mostly affects the distal colon near the rectum.
- Crohn's disease typically affects fairly well demarcated segments of bowel in the colon and often affects the end of the small bowel.
Irritable Bowel Syndrome
Another possible cause of diarrhea is Irritable Bowel Syndrome (IBS). Symptoms defining IBS: abdominal discomfort or pain relieved by defecation and unusual stool (diarrhea or constipation or both) or stool frequency, for at least 3 days a week over the previous 3 months.[1] IBS symptoms can be present in patients with a variety of conditions including food allergies, infective diarrhea, celiac, and inflammatory bowel diseases. Treating the underlying condition (celiac disease, food allergy, bacterial dysbiosis, etc.) usually resolves the diarrhea.[1] IBS can cause visceral hypersensitivity. While there is no direct treatment for undifferentiated IBS, symptoms, including diarrhea, can sometimes be managed through a combination of dietary changes, soluble fiber supplements, and/or medications.
Other important causes
- Ischemic bowel disease. This usually affects older people and can be due to blocked arteries.
- Bowel cancer: Some (but not all) bowel cancers may have associated diarrhea. Cancer of the large intestine is most common.
- Hormone-secreting tumors: some hormones (e.g. serotonin) can cause diarrhea if excreted in excess (usually from a tumor).
- Bile salt diarrhea: excess bile salt entering the colon rather than being absorbed at the end of the small intestine can cause diarrhea, typically shortly after eating. Bile salt diarrhea is a possible side-effect of gallbladder removal. It is usually treated with cholestyramine, a bile acid sequestrant.
Alcohol
Chronic diarrhea can be caused by chronic ethanol ingestion.[1] Consumption of alcohol affects the body's capability to absorb water - this is often a symptom that accompanies a hangover after a heavy drinking session. The alcohol itself is absorbed in the intestines and as the intestinal cells absorb it, the toxicity causes these cells to lose their ability to absorb water. This leads to an outpouring of fluid from the intestinal lining, which is in turn poorly absorbed. The diarrhea usually lasts for several hours until the alcohol is detoxified and removed from the digestive system. Symptoms range from person to person and are influenced by both the amount consumed as well as physiological differences. Alcohol-induced diarrhea is often accompanied by "the follow through" where a feeling that the patient is going to break wind (flatulence) instead becomes an uncontrolled episode of diarrhea.
Risk Factors
- Antibiotic use
- High-risk sexual behavior (STDs)
- Immunosuppression
- Recent travel to endemic area
History and Symptoms
- History should include:
- Appearance of bowel movements
- Travel history
- Associated symptoms
- Immune status
- Woodland exposure
Physical Examination
- Pulses
- Blood pressure
- Orthostatics
- Skin examination
- Signs of dehydration
- Back, genital and rectal examinations
- Complete abdominal examination
Laboratory Findings
- Complete blood count (CBC)
- Glucose
- White blood cells (WBC)
- Urinalysis
- Calcium
- Thyroid stimulating hormone (TSH)
- Liver function tests (LFTs)
- Blood urea nitrogen (BUN) / creatinine
- Hepatitis serologies
- Stool examinations:
- Stool cultures
- Stool electrolytes
- Stool osmolality
- Ova and parasites
- Fecal lactoferrin
- Fecal leukocytes
- Test for C. difficile
MRI and CT
- Abdominal CT scan may be necessary
Other Diagnostic Studies
- Breath hydrogen test
- Endoscopy
- Barium enema
- Colonoscopy
- Sigmoidoscopy
- HIV testing for those patients suspected of having HIV
Treatment
- Fluid resuscitation (oral, if not IV)
- Patients should be advised to do the following until symptoms subside:
- Hydrate with liquids that are caffeine free and contain glucose
- Avoid lactose
- Chew gum that is free of sorbitol
- Eat raw fruit
- For patients with lactose intolerance, a lactose-free diet is advised
- For patients with malabsorption diseases, a gluten free diet is advised
- Consultation with oncology, surgery and/or gastroenterology may be required for intestinal neoplasm
- Control blood sugar (diabetic neuropathy)
Pharmacotherapy
Acute Pharmacotherapies
- Antibiotics (malabsorption diseases)
- Anticholinergics (IBS)
- Antimolality agents
- Antibiotic therapy (severe disease)
- Metoclopramide (diabetic neuropathy)
- Nonspecific antidiarrheal agents
Chronic Pharmacotherapies
- Prophylactic therapy with 5-aminosalicylic agents for patients with inflammatory bowel disease
Surgery and Device Based Therapy
- Bowel resection may be necessary for those patients with inflammatory bowel disease
See also
Footnotes
External links
- Reducing deaths from diarrhoea through oral rehydration therapy. 1: Bull. World Health Organ. 2000;78(10):1246-55.
- Travelers' Diarrhea
- Rehydration Project
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Acknowledgement and Attribution Regarding Sources of Content
Some of the initial content on this page may be incorporated in part from copyleft sources in the public domain including wikis such as Wikipedia and AskDrWiki. Drug information for patients came from the The National Library of Medicine. Infectious disease information may have come from the Centers for Disease Control (CDC). Differential Diagnoses are drawn from clinicians as well as an amalgamation of 3 sources: 1.The Disease Database; 2. Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:3; 3. Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:7 .
