Diarrhea

Introduction

Diarrhea is an increased frequency and decreased consistency of fecal discharge as compared with an individual’s normal bowel pattern.

• It is often a symptom of a systemic disease.
• Acute diarrhea is commonly defined as shorter than 14 days’ duration, persistent diarrhea as longer than 14 days’ duration, and chronic diarrhea as longer than 30 days’ duration.
• Most cases of acute diarrhea are caused by infections with viruses, bacteria, or protozoa, and are generally self-limited.

Diarrhea is an imbalance in absorption and secretion of water and electrolytes. It may be associated with a specific disease of the gastrointestinal (GI) tract or with a disease outside the GI tract.

CLINICAL PRESENTATION Signs and symptoms

Abrupt onset of nausea, vomiting, abdominal pain, headache, fever, chills, and malaise Bowel movements are frequent and never bloody, and diarrhea lasts 12–60 h.

• Intermittent periumbilical or lower right quadrant pain with cramps and audible bowel sounds is characteristic of small intestinal disease.
• When pain is present in large intestinal diarrhea, it is a gripping, aching sensation with tenesmus (straining, ineffective, and painful stooling). Pain localizes to the hypogastric region, right or left lower quadrant, or sacral region.
• In chronic diarrhea, a history of previous bouts, weight loss, anorexia, and chronic weakness are important findings.

Physical examination

Typically demonstrates hyperperistalsis with borborygmi and generalized or local tenderness.

Laboratory tests

Stool analysis studies include examination for microorganisms, blood, mucus, fat, osmolality, pH, electrolyte and mineral concentration, and cultures.

• Stool test kits are useful for detecting GI viruses, particularly rotavirus.
• Antibody serologic testing shows rising titers over a 3- to 6-day period, but this test is not practical and is nonspecific.
• Occasionally, total daily stool volume is also determined. Direct endoscopic visualization and biopsy of the colon may be undertaken to assess for the presence of conditions such as colitis or cancer.
• Radiographic studies are helpful in neoplastic and inflammatory conditions.

TREATMENT

Goals of Treatment: To manage the diet, prevent excessive water, electrolyte, and acid-base disturbances; provide symptomatic relief; treat curable causes of diarrhea; and manage secondary disorders causing diarrhea. Diarrhea, like a cough, may be a body defense mechanism for ridding itself of harmful substances or pathogens. The correct therapeutic response is not necessarily to stop diarrhea at all costs. If diarrhea is secondary to another illness, controlling the primary condition is necessary.

GENERAL APPROACH TO TREATMENT

• Management of the diet is a first priority for treatment of diarrhea. Most clinicians recommend stopping solid foods for 24 hours and avoiding dairy products.
• When nausea or vomiting is mild, a digestible low-residue diet is administered for 24 hours.
• If vomiting is present and is uncontrollable with antiemetics, nothing is taken by mouth. As bowel movements decrease, a bland diet is begun. Feeding should continue in children with acute bacterial diarrhea.
• Rehydration and maintenance of water and electrolytes are the primary treatment measures until the diarrheal episode ends.

PHARMACOLOGIC THERAPY

• Cap Imodium (Loperamide) is often recommended for managing acute and chronic diarrhea. Diarrhea lasting 48 hours beyond initiating loperamide warrants medical attention.
• Bismol (Bismuth subsalicylate) is often used for treatment or prevention of diarrhea (traveler’s diarrhea) and has antisecretory, anti-inflammatory, and antibacterial effects. Bismuth subsalicylate contains multiple components that might be toxic if given in excess to prevent or treat diarrhea.