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Diarrhea, Acute

Diarrhea, Acute is a topic covered in the 5-Minute Clinical Consult.

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Basics

Description

  • An abnormal increase in stool water content, volume, or frequency (≥3 in 24 hours) for <14 days duration
  • Acute viral diarrhea (50–70%)
    • Most common cause of infectious diarrhea; noninflammatory (watery)
    • Frequently presents with associated nausea and/or vomiting
    • Symptoms usually develop after an incubation period of ~1 day and last for 1 to 3 days; typically self-limited
  • Bacterial diarrhea (15–20%)
    • Most common infectious cause of inflammatory (bloody) diarrhea
    • Incubation period variable; diarrhea caused by preformed enterotoxin presents within 1 to 6 hours of contaminated food ingestion, whereas bacterial infection typically presents within 1 to 3 days.
    • Symptoms usually resolve in 1 to 7 days; antibiotic use attenuates length and/or severity of disease.
    • Suspect when concurrent illness in others who have shared potentially contaminated food.
    • Suspect Clostridium difficile in patients with recent antibiotic use or hospitalization.
  • Protozoal infections (10–15%)
    • Typically cause noninflammatory (watery) diarrhea
    • Long incubation period and prolonged disease course, symptoms develop approximately 7 days after exposure and commonly last >7 days
    • Suspect when outbreaks of watery diarrhea in areas with contaminated water or food supply.
  • Traveler’s diarrhea (TD) typically begins 3 to 7 days after arrival in foreign location and resolves within 5 days; rapid onset, generally self-limited

Epidemiology

  • In developing countries, acute diarrhea is more common in children; no age predilection in developed countries
  • Acute diarrhea accounts for >128,000 U.S. hospital admissions and ~1.5 million annual deaths worldwide (1).

Prevalence
  • Second leading cause of death in children <5 years and seventh leading cause of death among all ages worldwide
  • Affects 11% of the general population
  • Rotavirus and adenovirus most common in children <2 years, bacteria are more common in children >2 years
  • In developing world, acute diarrhea is largely due to contaminated food and water (1).

Etiology and Pathophysiology

  • Bacterial
    • Escherichia coli
    • Salmonella, Shigella, Campylobacter jejuni
    • Vibrio parahaemolyticus, Vibrio cholerae
    • Yersinia enterocolitica
    • C. difficile
    • Staphylococcus aureus
    • Bacillus cereus
    • Clostridium perfringens
    • Listeria monocytogenes
  • Viral
    • Rotavirus and norovirus (most common)
    • Adenovirus
    • Astrovirus
    • Cytomegalovirus (in immunocompromised)
  • Protozoal
    • Giardia lamblia
    • Entamoeba histolytica
    • Cryptosporidium
    • Isospora belli
    • Cyclospora, Microspora
  • Pathophysiology (1)
    • Noninflammatory: most commonly viral; increased intestinal secretions without disruption of intestinal mucosa; watery
    • Inflammatory: generally invasive or toxin-producing bacteria; disrupts mucosal integrity with subsequent tissue invasion/damage; bloody stools
  • Viral diarrhea: changes in small intestine cell morphology including villous shortening, increased number of crypt cells, and increased cellularity of the lamina propria
  • Bacterial diarrhea: Bacterial invasion of colonic wall leads to mucosal hyperemia, edema, and leukocytic infiltration.

Risk Factors

  • Travel to developing countries
  • Failure to observe food/water precautions
  • Immunocompromised host
  • Antibiotic use
  • Proton pump inhibitor (PPI) use
  • Daycare exposure
  • Fecal-oral sexual contact
  • Nursing home residence
  • Pregnancy (12-fold increase for listeriosis) (1)

General Prevention

  • Frequent hand washing and alcohol-based hand sanitizers; hand washing promotion may reduce incidence of diarrhea by approximately 30%.
  • Proper food and water precautions, particularly during foreign travel—“boil it, peel it, cook it, or forget it”
  • Avoid undercooked meat, raw fish, unpasteurized milk.
  • Rotavirus vaccine (for infants)
  • Typhoid fever and cholera vaccine (for travel to endemic areas)

Traveler’s Diarrhea (TD) Prophylaxis

  • Pretravel counseling on high-risk food/beverage
  • Consider daily prophylaxis with bismuth subsalicylate (BSS) in all travelers (can reduce the risk of TD by up to 60%).
  • Antibiotic prophylaxis should not be routinely used. Consider rifaximin use in patients at high risk of health-related complications of TD; fluoroquinolones no longer recommended for TD prophylaxis (2)
  • Probiotics, prebiotics, and synbiotics have unclear benefit as prophylaxis.

Commonly Associated Conditions

  • Inflammatory bowel disease (IBD)
  • Immunocompromised (HIV, malignancy, chemotherapy)

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Citation

Stephens, Mark B., et al., editors. "Diarrhea, Acute." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2019. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116184/all/Diarrhea__Acute.
Diarrhea, Acute. In: Stephens MB, Golding J, Baldor RA, et al, eds. 5-Minute Clinical Consult. 27th ed. Wolters Kluwer; 2019. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116184/all/Diarrhea__Acute. Accessed April 20, 2019.
Diarrhea, Acute. (2019). In Stephens, M. B., Golding, J., Baldor, R. A., & Domino, F. J. (Eds.), 5-Minute Clinical Consult. Available from https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116184/all/Diarrhea__Acute
Diarrhea, Acute [Internet]. In: Stephens MB, Golding J, Baldor RA, Domino FJ, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2019. [cited 2019 April 20]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116184/all/Diarrhea__Acute.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Diarrhea, Acute ID - 116184 ED - Stephens,Mark B, ED - Golding,Jeremy, ED - Baldor,Robert A, ED - Domino,Frank J, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116184/all/Diarrhea__Acute PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -