Acute and Chronic Diarrhea
Diarrhea: defined as passage of abnormally loose or fluid stools more frequently than normal. Normal bowel habits vary greatly from person to person, but recent onset of 3 or more liquid or loose stools per day is considered abnormal.
Acute Diarrhea: passage of stools for less than 4 weeks. Infectious agents, toxins, and drugs are major causes of acute diarrhea
Chronic Diarrhea: loose stools for more than 4 weeks, can be with or without increased frequency
History:
Need to ask nature of onset (sudden or gradual), duration, pattern (during fasting, day or night), stool characteristics, stool volume, relieving factors, fecal incontinence, fever, weight loss, pain, exposures, travel history, dietary history, antibiotic use, contact with diarrhea, immunopression, family history and risk factors for HIV infection.
Types of diarrhea:
Acute Diarrhea with blood
Bacillary dysentery (shigellosis) causes by Shigella dysenteriae
-children mostly affected. Person to person contact or ingestion of contaminated food. Severe cases: bloody diarrhea with fevers, dehydration, rash. Treatment: ampillicin in severe disease
Enterohaemmorrhagic Ecoli
-produces vero cell cytotoxin. Most common Ecoli O157:h7
-inflammatory, hemorrhagic colitis, can be complicated by HUS syndrome.
-occur in summer mostly, contaminated food. First watery diarrhea, then blood in 2-3 days with vomiting, abdominal pain, decreased platelets, renal failure. No antibiotics indicated.
Camplyobacter Enterocolitis: C jejuni, C.Coli
-contact with animals, poultry. Self limiting disease, usually lasts 5-7 days.
-fever, abdominal pain, watery diarrhea followed by blood
Yersinia enterocolitis: yersinia enterocolitica
Salmonella entercolitis: salmonella typhimurium
-among wild and domesticated animals, *associated with malaria and HIV
-nausea vomiting, headache, fever, malaise, diarrhea (watery then bloody), severe abdominal pain.
-*patients with schistosomiasis are prone to salmonella bacteremia
-when severe, Typhoid: systemic illness
-treatment: supportive, if severe: ciprofloxacin, amoxicillin, chloramphenicol
Amoebic dysentery: entamoeba histolytica, parasite
-fecal oral transmission. Can be asymptomatic to fulminant colitis with perforation in severe infection. Abdominal pain, increasingly bloody diarrhea.
-treatment: metronidazole x 5 days, then diloxanide furoate x 10 days
-extraintestinal manifestations: liver abscess.
Trichuriasis (whipworm): trichuris trichuria
-colonize the colon after ingestion of fecally contaminated soil. Can have vomiting, abdominal distention, blood diarrhea, weight loss. Treatment: albendazole
Acute Diarrhea without blood
Rotavirus: mostly affects children
Cholera: vibrio cholerae
-causes severe dehydration from voluminous diarrhea, described as rice stool, vomiting, can lead to electrolyte imbalance. Treatment: supportive
Clostridium perfringens: more common in Uganda
-2 types of disease simple diarrhea or nectroic enterocolitis
Giardia: giardia intestinalis
-infection follow ingestion of cysts in fecally contaminated water. Watery diarrhea is most common symptoms, usually resolves in 2-4 weeks, accompanied with abdominal pain, weight loss
Cryptosporidiosis: protozoan cryptosporidium parvum
-most common in HIV patients, transmission through contaminated water
-also can be persistent chronic diarrhea, more severe in HIV patients. Treatment: supportive
Cyclospora: protozoa cyclospora cayetanensis
-transmission via water or food. Watery diarrhea, fever, fatigue.
-Treatment: cotrimoxazole for 7 days
Strongyloidiasis: nematode strongloides stercoralis
-more common in south east asia and south america.
Types of Chronic Diarrhea
Infections:
-Giardia, E. histolytica, parasites, cryptosporidium
-Clues as to etiology:
o Giardia: ingestion of water from streams
o Undercooked beaf: Ecoli O157:H7
o Undercooked chicken: campylobacter, salmonella
o Shellfish: norovirus, vibrio
-HIV related diarrhea
-Tuberculosis of ileocecal area
-intestinal works/flukes: common in Asia
Medications
Can cause increased secretion, increased gut motility, change in bacterial flora in the gut and inflammation.
Common medications: antibiotics, lactulose, NSAIDs, HIV medications
Malabsorption
Impaired absorption of nutrients and fat. Intraluminal mucosal or obstructive malabsorption may cause steatorrhea. Symptoms include voluminous pale, greasy, foul-smelling stools, flatulence, abdominal distention, low albumin, anorexia, weight loss, nutritional deficits, glossitis, anemia. Diarrhea improves with fasting.
-Bile salt deficiency: decrease synthesis: liver disease (cirrhosis)
-Pancreatic insufficiency: most commonly from chronic pancreatitis
-Tropical sprue
-Mucosal abnormalities
-Celiac sprue: intestinal reaction to gliadin in gluten. Loss of villi and absorptive area. Can present with iron deficiency anemia, rash
-Tropical sprue: treat with antibiotics, b12/folate replacement
-Whipple’s disease: infection with T. whipplei
-Lactulose intolerance
-symptoms: bloating, flatulence, epigastric discomfort with eating
-treat: lactose free diet, lactase enzyme replacement
Inflammatory: presents with fever, bloody stool, abdominal pain (acute or chronic)
-Inflammatory bowel disease: crohn’s disease or ulcerative colitis
-Ischemic colitis, diverticulitis, colon cancer, lymphoma
Secretory: no change in diarrhea with fasting, nocturnal diarrhea is frequently described
-Hormonal diarrhea: gastrin (Zollinger-Ellison), thyroxine, serotonin (carcinoid)
-Neoplasm: carcinoma, lymphoma, villous adenoma
Motility
-Irritable bowel syndrome: recurrent abdominal pain > 3 months with constipation and/or diarrhea symptoms
-Hyperthyroidism
Diagnosis and treatment:
Diagnosis based mostly on history
Acute Diarrhea:
Asses for severe dehydration, fever, duration < 5 days, stool with mucus or pus, blood in stool, abdominal pain
If no to above: then observe, conservative management, oral hydration
If yes to any of above:
-begin IVF for dehydration
-then check stool for fecal leukocytes and culture
-if infectious etiology: treat according to symptoms and guide therapy through stool culture, for severe illness can give empiric antibiotics, quinolones such as cipro
-avoid anti-diarrheal medication for bloody diarrhea, risk of toxic megacolon
Chronic Diarrhea:
Asses for any culprit medications and lactulose intolerance. For chronic diarrhea, all patients should have rapid test for HIV and stool culture/fecal leukocytes sent. Discontinue any possible culprit medications that may be causing diarrhea.
-negative fecal leukocytes->secretory diarrhea
-positive fecal leukocytes->inflammatory diarrhea (inflammatory bowel disease)
-if diarrhea decreases with fasting->malabsorptive process
Acute and Chronic Diarrhea Clinical Cases
Case 1
30 yo M with IDS (CD4 250) presents to clinic with productive cough and low grade fevers. ROS: + 2 month history of watery diarrhea, fatigue, malaise, anorexia, dyspnea and nausea.
Meds: ARVs
NKDA
FH: Non-Contributory
SH: Married. Works as a fisherman. No tobacco/alcohol/drug use.
On evaluation, T 38.3, HR 110, BP 98/50, RR 22 with 95% oxygenation at room air. Exam notable for mild respiratory distress, dry mucus membranes, oral thrush, normal cardiac exam, diffuse bilateral crepitations, diffuse abdominal tenderness, no distension/organomegaly, no rash, no LE edema.
CXR: bilateral patchy opacities
Laboratory Studies: pending
1. What additional history would you like to know?
a. Any sick contacts at home, any recent changes in ARVs, any blood in the watery bowel movements, # of BMs per day, any lightheadedness or dizziness. Any ingestion of stream water, exposure to raw meat or chicken, any recent travel to Asia.
2. What is your differential diagnosis for the patients diarrhea?
a. The differential for chronic diarrhea in a patient with IDS is broad. Includes Infectious etiologies such as Giardia, E. Coli, Campylobacter, and crypto. But can also include non-infectious etiologies such as medication effect, secretory diarrheas, and even inflammatory etiologies
3. What further investigations would you like to do?
a. Stool culture and fecal leukocytes, as well as reviewing medication list. An FBP might also be of benefit if the patient has had any blood.
Case 2
25yo American female presents to a NYC Emergency room with 2-week history of intermittent diarrhea. Pt recently returned from Mwanza, Tanzania one week prior.
On evaluation, T 36.7 110/60 P 72. Exam notable for mild abdominal tenderness and distension. No rebound/guarding/organomegaly.
AXR: normal gas pattern
1. What additional history would you like to know?
a. Need to ask nature of onset (sudden or gradual, stool characteristics, stool volume, relieving factors, fecal incontinence, fever, weight loss, pain, exposures while in Mwanza, dietary history, antibiotic use, contact with diarrhea, immunopression, family history and risk factors for HIV infection.
2. What is your differential diagnosis?
a. Is broad given recent travel history and includes most of the organisms listed above in the acute diarrhea section; presence of blood would be very important.
3. What further investigations would you like to do?
a. At this time, would check stool for occult blood, send fecal leukocytes, and stool culture.
Case 3
50yF with history of cholelithiasis presents with 2 month history of intermittent loose stools. She occasionally has abdominal pain and describes her stools has being greasy and foul-smelling. She is embarrassed to tell you but her daughter states her stool floats and they are worse with eating. No associated fevers, nausea/vomiting, hematochezia/melena.
On evaluation, Afebrile, BP 140/80, HR 90. Exam notable for pallor, dry mucus membranes, pedal edema, mild abdominal distension. No abdominal tenderness/guarding/rebound/organomegaly. Lungs clear and cardiac exam unremarkable.
1. What type of diarrhea is she having?
a. This type of diarrhea is classified as steatorrhea.
- What is your differential diagnosis?
- Bile Salt Deficiency, lactose intolerance, celiac sprue, whipple’s disease, etc.
3. How do you diagnose this class of diarrhea? Any further investigations would you like to do?
a. A trial of fasting should decrease the diarrhea. Also, fecal fat can be quantified.
