Acute diarrhea laboratory findings: Difference between revisions

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{{Acute diarrhea}}
{{Acute diarrhea}}
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==Overview==
==Overview==
An elevated/reduced concentration of serum/blood/urinary/CSF/other [lab test] is diagnostic of [disease name].


OR
Laboratory investigations performed in the evaluation of patients with acute diarrhea include spot [[Stool examination|stool analysis]], detection of [[occult blood]], [[white blood cells]], [[stool culture]], quantitative [[Stool examination|stool analysis]], fecal weight, stool osmotic gap, [[Fecal pH test|fecal pH]], [[Fecal fat|fecal fat concentration]] and analysis for [[Laxative|laxative abuse]]. According to the ACG guidelines, [[stool culture]] is done only in cases where the patient is at high risk of spreading the disease to others. [[Stool examination|Stool diagnostic studies]] are performed when symptoms last for >7 days, patient has [[dysentery]] or moderate-to-severe diarrhea and to determine [[etiology]] to enable directed [[pathogen]]-specific therapy. [[Antibiotic sensitivity|Antibiotic sensitivity testing]] for management of acute diarrhea is not advised.


Laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].
==Laboratory Findings==
Laboratory investigations performed in the workup of patients with acute diarrhea include [[complete blood count]], [[glucose]] levels, [[white blood cells]] ([[WBC]]) detection, urine analysis, [[calcium]] levels, [[Thyroid stimulating hormone]] ([[TSH]]) levels, complete metabolic panel and [[stool examination]].
* [[Stool examination]] includes the following:
** [[Stool culture]]
** Stool [[electrolyte]]s
** Stool osmolality
** Ova and parasites
** [[Lactoferrin|Fecal lactoferrin]]
** [[White blood cells|Fecal leukocytes]]
** Test for ''[[C. difficile]]''
* According to the ACG guidelines, the following points should be kept in mind in the diagnostic evaluation of acute diarrhea patients:
** [[Stool culture]] is done only in cases where the patient is at high risk of spreading the disease to others.
** Stool diagnostic studies are performed in the following cases:
*** Symptoms lasting >7 days
*** [[Dysentery]]
*** Moderate-to-severe diarrhea
*** Determination of [[etiology]] to enable directed [[pathogen]]-specific therapy
** [[Antibiotic sensitivity|Antibiotic sensitivity testing]] for management of acute diarrhea is not advised.
===Laboratory Evaluation of Acute Diarrhea===
 
====Spot Stool Analysis====
* [[Human feces|Stool]] spot analysis is preferred over 24 hour [[Human feces|stool]] collection as it is less cumbersome.


OR
=====Occult Blood=====
* A positive test result suggests the presence of [[inflammatory bowel disease]] and acute causes of [[Dysentery|bloody diarrhea]].<ref name="pmid24319453">{{cite journal| author=Viana Freitas BR, Kibune Nagasako C, Pavan CR, Silva Lorena SL, Guerrazzi F, Saddy Rodrigues Coy C et al.| title=Immunochemical fecal occult blood test for detection of advanced colonic adenomas and colorectal cancer: comparison with colonoscopy results. | journal=Gastroenterol Res Pract | year= 2013 | volume= 2013 | issue=  | pages= 384561 | pmid=24319453 | doi=10.1155/2013/384561 | pmc=PMC3844264 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24319453  }} </ref>
* [[Fecal occult blood]] positivity may also be associated with diarrhea due to idiopathic secretory diarrhea, [[Laxative|laxative abuse]], and [[microscopic colitis]].<ref name="pmid8602182">{{cite journal| author=Fine KD| title=The prevalence of occult gastrointestinal bleeding in celiac sprue. | journal=N Engl J Med | year= 1996 | volume= 334 | issue= 18 | pages= 1163-7 | pmid=8602182 | doi=10.1056/NEJM199605023341804 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8602182  }} </ref>


[Test] is usually normal among patients with [disease name].
=====White Blood Cells=====
* Wright's staining and microscopy is the standard method for the detection of [[White blood cells|white blood cells (WBCs)]] present in [[Human feces|stool]].
* [[Neutrophil|Neutrophils]] in the [[Human feces|stool]] present in patients having acute infectious diarrhea may be detected by [[Latex fixation test|latex agglutination test]].<ref name="pmid12818275">{{cite journal| author=Kane SV, Sandborn WJ, Rufo PA, Zholudev A, Boone J, Lyerly D et al.| title=Fecal lactoferrin is a sensitive and specific marker in identifying intestinal inflammation. | journal=Am J Gastroenterol | year= 2003 | volume= 98 | issue= 6 | pages= 1309-14 | pmid=12818275 | doi=10.1111/j.1572-0241.2003.07458.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12818275  }} </ref>
=====Stool Culture=====
* In [[Immunocompetence|immunocompetent]] patients with acute diarrhea, [[stool culture]] is not routinely performed.
* If the patient has a history of swimming in streams or ponds and consuming untreated water from wells, stool culture may be performed to evaluate the patient for [[Aeromonas]] or [[Plesiomonas shigelloides|Plesiomonas]] species.
* In [[Immunodeficiency|immunocompromised]] patients, [[stool culture]] is included as a part of routine investigations to rule out [[infection]] due to [[bacteria]] such as [[Salmonella]], [[Campylobacter]], [[protozoa]] and [[Fungus|fungi]].<ref name="pmid17277989">{{cite journal| author=Friedman M, Ramsay DB, Borum ML| title=An unusual case report of small bowel Candida overgrowth as a cause of diarrhea and review of the literature. | journal=Dig Dis Sci | year= 2007 | volume= 52 | issue= 3 | pages= 679-80 | pmid=17277989 | doi=10.1007/s10620-006-9604-4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17277989  }} </ref>


OR
* [[Protozoa]] may detected by the use of [[Feces|fecal]] [[Enzyme linked immunosorbent assay (ELISA)|enzyme-linked immunosorbent assay]] ([[ELISA]]).<ref name="pmid8863034">{{cite journal| author=Koontz F, Weinstock JV| title=The approach to stool examination for parasites. | journal=Gastroenterol Clin North Am | year= 1996 | volume= 25 | issue= 3 | pages= 435-49 | pmid=8863034 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8863034  }} </ref>


Some patients with [disease name] may have elevated/reduced concentration of [test], which is usually suggestive of [progression/complication].
====Quantitative Stool Analysis====
* A 48 or 72-hour quantitative [[Human feces|stool]] collection may sometimes may be useful in the evaluation of acute diarrhea in patients.
* Full analysis includes measurement of:
** Stool weight
** Stool fat content
** Stool osmolality
** Stool electrolyte concentrations
** [[Magnesium|Magnesium levels]]
** Stool pH
** [[Occult blood|Stool occult blood]]
** [[Chymotrypsin|Fecal chymotrypsin]]
** [[Fecal elastase|Fecal elastase activity]]
** Prior to collection period, patient should eat a regular diet containing adequate amounts of calories and fat. All medications, especially antidiarrheal medications should be avoided.


OR
=====Fecal Weight=====
* Stool weight is also a useful index in the diagnosis of acute diarrhea.
* Stool weight of >200g/day is considered diarrheal.
* Low stool weight with increased frequency of stools may be indicative of [[incontinence]] or pain.
* Cessation of diarrhea with fasting is indicative of osmotic diarrhea caused by nonabsorbable substances or secretory diarrhea due to [[Laxative|laxatives]].<ref name="pmid6051321">{{cite journal| author=Fordtran JS| title=Speculations on the pathogenesis of diarrhea. | journal=Fed Proc | year= 1967 | volume= 26 | issue= 5 | pages= 1405-14 | pmid=6051321 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6051321  }} </ref>


There are no diagnostic laboratory findings associated with [disease name].
=====Stool Osmotic Gap=====
* The stool osmotic gap is calculated from [[Electrolyte|electrolyte concentrations]] in [[Human feces|stool]] water by the following formula : 290 - 2([Na+] + [K+]).
* The [[Osmolarity|osmolality]] of stool present in the [[Intestine|distal intestine]] is preferred over [[Feces|fecal]] fluid, as measured osmolality of [[Feces|fecal]] fluid increases with [[Fermentation|bacterial fermentation]] of [[Carbohydrate|carbohydrates]] to osmotically active [[Organic acid|organic acids]].
* Stool osmotic gap in cases of osmotic diarrhea is characterized by osmotic gaps >125 mOsm/kg and in secretory diarrheas, osmotic gap is <50 mOsm/kg.
* In mixed cases, the osmotic gap lies between 50-125mOsm/kg.<ref name="pmid1634072">{{cite journal| author=Eherer AJ, Fordtran JS| title=Fecal osmotic gap and pH in experimental diarrhea of various causes. | journal=Gastroenterology | year= 1992 | volume= 103 | issue= 2 | pages= 545-51 | pmid=1634072 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1634072  }} </ref>


==Laboratory Findings==
=====Fecal pH=====
* A [[Fecal pH test|fecal pH]] of < 5.3 is indicative of [[Malabsorption|carbohydrate malabsorption]].
* A [[Fecal pH test|fecal pH]] of > 5.6 may exclude [[Malabsorption|carbohydrate malabsorption]] as the cause of acute diarrhea.<ref name="pmid1634072">{{cite journal| author=Eherer AJ, Fordtran JS| title=Fecal osmotic gap and pH in experimental diarrhea of various causes. | journal=Gastroenterology | year= 1992 | volume= 103 | issue= 2 | pages= 545-51 | pmid=1634072 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1634072  }} </ref>


*There are no diagnostic laboratory findings associated with [disease name].
=====Fecal Fat Concentration and Output=====
OR
* In normal subjects, [[fecal fat]] ouput is approximately 9% of dietary fat intake (7g/day).
*An elevated/reduced concentration of serum/blood/urinary/CSF/other [lab test] is diagnostic of [disease name].
* [[Fecal fat]] levels >7g/day are suggestive of steatorrhea.
*[Test] is usually normal among patients with [disease name].
* [[Fecal fat]] concentration of <9.5 g/100 g of stool: Small intestinal malabsorptive syndromes<ref name="pmid6735076">{{cite journal| author=Bo-Linn GW, Fordtran JS| title=Fecal fat concentration in patients with steatorrhea. | journal=Gastroenterology | year= 1984 | volume= 87 | issue= 2 | pages= 319-22 | pmid=6735076 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6735076  }} </ref>
*Laboratory findings consistent with the diagnosis of [disease name] include:
* [[Fecal fat]] concentrations of ≥9.5 g/100 g of stool: [[Pancreas|Pancreatic]] and [[Bile duct|biliary]] [[steatorrhea]]<ref name="pmid20814209">{{cite journal| author=Hammer HF| title=Pancreatic exocrine insufficiency: diagnostic evaluation and replacement therapy with pancreatic enzymes. | journal=Dig Dis | year= 2010 | volume= 28 | issue= 2 | pages= 339-43 | pmid=20814209 | doi=10.1159/000319411 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20814209  }} </ref>
**[Abnormal test 1]
**[Abnormal test 2]
**[Abnormal test 3]


*Some patients with [disease name] may have elevated/reduced concentration of [test], which is usually suggestive of [progression/complication].
=====Analysis for Laxative Abuse=====
Stool analysis for [[Laxative|laxatives]] is done in the assesment of diarrhea of unknown cause. This includes the following techniques:
* Treatment of 3ml of [[Human feces|stool]] supernatant or [[urine]] with a single drop of concentrated [[Sodium hydroxide|NaOH]] with resulting pink or red color, due to [[Alkali|alkalinization]] is the simplest test for [[Laxative|laxatives]].
* [[Stool examination|Analysis of stool]] using [[chromatography]] for [[emetine]], [[bisacodyl]] and its metabolites, [[phenolphthalein]], etc may also be performed.
* Calculation of stool osmotic gap may be helpful in pinpointing the [[laxative]] responsible for acute diarrhea:
** Stool osmotic gap <50: [[Sodium sulfate]] or [[Sodium phosphates|sodium phosphate]]<ref name="pmid8193462">{{cite journal| author=Carlson J, Fernlund P, Ivarsson SA, Jakobsson I, Neiderud J, Nilsson KO et al.| title=Munchausen syndrome by proxy: an unexpected cause of severe chronic diarrhoea in a child. | journal=Acta Paediatr | year= 1994 | volume= 83 | issue= 1 | pages= 119-21 | pmid=8193462 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8193462  }} </ref>
** Stool osmotic gap >125 mOsm/kg: [[Magnesium]] [[Laxative|laxatives]]<ref name="pmid2005938">{{cite journal| author=Fine KD, Santa Ana CA, Fordtran JS| title=Diagnosis of magnesium-induced diarrhea. | journal=N Engl J Med | year= 1991 | volume= 324 | issue= 15 | pages= 1012-7 | pmid=2005938 | doi=10.1056/NEJM199104113241502 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2005938  }} </ref>


==References==
==References==
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]

Overview

Laboratory investigations performed in the evaluation of patients with acute diarrhea include spot stool analysis, detection of occult blood, white blood cells, stool culture, quantitative stool analysis, fecal weight, stool osmotic gap, fecal pH, fecal fat concentration and analysis for laxative abuse. According to the ACG guidelines, stool culture is done only in cases where the patient is at high risk of spreading the disease to others. Stool diagnostic studies are performed when symptoms last for >7 days, patient has dysentery or moderate-to-severe diarrhea and to determine etiology to enable directed pathogen-specific therapy. Antibiotic sensitivity testing for management of acute diarrhea is not advised.

Laboratory Findings

Laboratory investigations performed in the workup of patients with acute diarrhea include complete blood count, glucose levels, white blood cells (WBC) detection, urine analysis, calcium levels, Thyroid stimulating hormone (TSH) levels, complete metabolic panel and stool examination.

Laboratory Evaluation of Acute Diarrhea

Spot Stool Analysis

  • Stool spot analysis is preferred over 24 hour stool collection as it is less cumbersome.
Occult Blood
White Blood Cells
Stool Culture

Quantitative Stool Analysis

  • A 48 or 72-hour quantitative stool collection may sometimes may be useful in the evaluation of acute diarrhea in patients.
  • Full analysis includes measurement of:
Fecal Weight
  • Stool weight is also a useful index in the diagnosis of acute diarrhea.
  • Stool weight of >200g/day is considered diarrheal.
  • Low stool weight with increased frequency of stools may be indicative of incontinence or pain.
  • Cessation of diarrhea with fasting is indicative of osmotic diarrhea caused by nonabsorbable substances or secretory diarrhea due to laxatives.[6]
Stool Osmotic Gap
Fecal pH
Fecal Fat Concentration and Output
Analysis for Laxative Abuse

Stool analysis for laxatives is done in the assesment of diarrhea of unknown cause. This includes the following techniques:

References

  1. ↑ Viana Freitas BR, Kibune Nagasako C, Pavan CR, Silva Lorena SL, Guerrazzi F, Saddy Rodrigues Coy C; et al. (2013). "Immunochemical fecal occult blood test for detection of advanced colonic adenomas and colorectal cancer: comparison with colonoscopy results". Gastroenterol Res Pract. 2013: 384561. doi:10.1155/2013/384561. PMC 3844264. PMID 24319453.
  2. ↑ Fine KD (1996). "The prevalence of occult gastrointestinal bleeding in celiac sprue". N Engl J Med. 334 (18): 1163–7. doi:10.1056/NEJM199605023341804. PMID 8602182.
  3. ↑ Kane SV, Sandborn WJ, Rufo PA, Zholudev A, Boone J, Lyerly D; et al. (2003). "Fecal lactoferrin is a sensitive and specific marker in identifying intestinal inflammation". Am J Gastroenterol. 98 (6): 1309–14. doi:10.1111/j.1572-0241.2003.07458.x. PMID 12818275.
  4. ↑ Friedman M, Ramsay DB, Borum ML (2007). "An unusual case report of small bowel Candida overgrowth as a cause of diarrhea and review of the literature". Dig Dis Sci. 52 (3): 679–80. doi:10.1007/s10620-006-9604-4. PMID 17277989.
  5. ↑ Koontz F, Weinstock JV (1996). "The approach to stool examination for parasites". Gastroenterol Clin North Am. 25 (3): 435–49. PMID 8863034.
  6. ↑ Fordtran JS (1967). "Speculations on the pathogenesis of diarrhea". Fed Proc. 26 (5): 1405–14. PMID 6051321.
  7. ↑ 7.0 7.1 Eherer AJ, Fordtran JS (1992). "Fecal osmotic gap and pH in experimental diarrhea of various causes". Gastroenterology. 103 (2): 545–51. PMID 1634072.
  8. ↑ Bo-Linn GW, Fordtran JS (1984). "Fecal fat concentration in patients with steatorrhea". Gastroenterology. 87 (2): 319–22. PMID 6735076.
  9. ↑ Hammer HF (2010). "Pancreatic exocrine insufficiency: diagnostic evaluation and replacement therapy with pancreatic enzymes". Dig Dis. 28 (2): 339–43. doi:10.1159/000319411. PMID 20814209.
  10. ↑ Carlson J, Fernlund P, Ivarsson SA, Jakobsson I, Neiderud J, Nilsson KO; et al. (1994). "Munchausen syndrome by proxy: an unexpected cause of severe chronic diarrhoea in a child". Acta Paediatr. 83 (1): 119–21. PMID 8193462.
  11. ↑ Fine KD, Santa Ana CA, Fordtran JS (1991). "Diagnosis of magnesium-induced diarrhea". N Engl J Med. 324 (15): 1012–7. doi:10.1056/NEJM199104113241502. PMID 2005938.

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