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Diarrhea
Authors

Valerie Nemeth; Nicholas Pfleghaar1.

Affiliations
1 Firelands Regional Medical Center

Last Update: November 21, 2022.

Continuing Education Activity

Diarrhea is a common condition that varies in severity and etiology. Its evaluation varies depending on duration,
severity, and the presence of certain concurrent symptoms. Treatment also varies, though rehydration therapy is an
important aspect of managing any patient with diarrhea. This activity reviews the evaluation and treatment of diarrhea
and stresses the role of the interprofessional team in caring for patients with this condition.

Objectives:

Identify the epidemiology of diarrhea.

Determine the etiologies of acute and chronic diarrhea.

Identify the management options available for acute and chronic diarrhea.

Communicate interprofessional team strategies for improving care coordination and optimizing outcomes for
patients with diarrhea.

Access free multiple choice questions on this topic.

Introduction
The normal water content value in stools is approximately 10 mL/kg/day in infants and young children or 200 g/day
in teenagers and adults. Diarrhea is the augmentation of water content in stools because of an imbalance in the normal
functioning of physiologic processes of the small and large intestine responsible for the absorption of various ions,
other substrates, and, consequently, water.

Acute diarrhea is the onset of 3 or more loose or watery stools a day lasting 14 days or less. However, chronic or
persistent diarrhea is labeled when an episode lasts beyond 14 days. Infection commonly causes acute diarrhea.
Noninfectious etiologies become more common as the duration of diarrhea becomes chronic. This distinction is
important because treatment and management are based on the duration and specific etiology. Rehydration therapy is
an important aspect of managing any patient with diarrhea.[1] Prevention of infectious diarrhea includes proper
handwashing to prevent the spread of infection.[2]

The term "acute gastroenteritis" is synonymously used with "acute diarrhea"; however, the former is a misnomer. The
term gastroenteritis signifies both gastric and small intestinal involvement, whereas, practically, it is rarely seen in
acute diarrhea, even if it is the infective form of diarrhea. Additionally, enteritis is also not always present. Examples
of infectious diarrhea without enteritis include cholera and shigellosis. Hence, using the term acute diarrhea instead of
acute gastroenteritis is more clinically appropriate.

Etiology
Diarrhea is categorized into acute or chronic and infectious or non-infectious based on the duration and type of
symptoms. Acute diarrhea is defined as an episode lasting less than 2 weeks. Infection most commonly causes acute
diarrhea. Most cases result from a viral infection, and the course is self-limited. Chronic diarrhea is defined as a
duration lasting longer than 2 weeks and tends to be non-infectious. Common causes include malabsorption,

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inflammatory bowel disease, and medication side effects.[3] Following are some important considerations to be made
while diagnosing and managing diarrhea, as the identification of the etiological agent is very important:

Stool characteristics vary between different causes, such as consistency, color, volume, and frequency

The presence or absence of associated intestinal symptoms, such as nausea/vomiting, fever, and abdominal pain

Exposure to child daycare where commonly encountered pathogens are rotavirus, astrovirus,
calicivirus; Shigella, Campylobacter, Giardia, and Cryptosporidium species

History of the ingestion of infected food, such as raw or contaminated foods

History of water exposure from swimming pools, camping, or marine environment

Travel history is crucial as common pathogens affect certain regions; enterotoxigenic Escherichia coli is the
predominant pathogen [4]

Animal exposure has been historically linked with diarrhea, such as young dogs/cats: Campylobacter; turtles:
salmonella [5]

Predisposing factors such as hospitalization, antibiotic use, immunosuppression [6]

Epidemiology
Norovirus is associated with approximately one-fifth of all infectious diarrhea cases, with similar prevalence in
children and adults. It is estimated to cause over 200,000 deaths annually in developing countries.[7] Historically,
rotavirus was the most common cause of severe disease in young children globally. Rotavirus vaccination programs
have decreased the prevalence of diarrhea cases associated with rotavirus.

In developing regions, an average of 3 episodes of diarrhea per child per year is reported in children less than 5 years
old. However, certain other areas report 6 to 8 episodes per year per child. In these circumstances, malnutrition plays
an additional role in the development of diarrhea.[8]

A common cause of chronic diarrhea includes inflammatory bowel disease, Crohn disease, and ulcerative colitis. In
Europe, the incidence of ulcerative colitis and Crohn disease has increased overall from 6.0 per 100,000 person-years
in ulcerative colitis and 1.0 per 100,000 person-years in Crohn disease in 1962 to 9.8 per 100,000 person-years and
6.3 per 100,000 person-years in 2010, respectively.[9]

A study conducted by Lübbert et al observed the occurrence of Clostridium difficile-related infection in Germany to
be 83 cases/100,000 population in 2012. The chance of recurrence escalated with each relapse in these cases.[10]

In the United States, before specific antirotavirus immunization was introduced in 2006, a cumulative occurrence of 1
hospitalization for the cases of diarrhea per 23-27 children by the age of 5 years was noted. Moreover, over 50,000
hospitalizations were noted. Based on these facts, rotavirus was found to be responsible for 4-5% of all childhood
hospitalizations, costing nearly 1 billion US dollars.[11]

Pathophysiology
Diarrhea results from reduced water absorption by the bowel or increased water secretion. Most acute diarrheal cases
have an infectious etiology. Chronic diarrhea is commonly categorized into 3 groups: watery, fatty (malabsorption), or
infectious. Another way of classifying the pathophysiology of diarrhea is into secretory and osmotic forms.

Lactose intolerance causes watery diarrhea, which causes increased water secretion into the intestinal lumen.[12]
Patients typically have symptoms of bloating and flatulence along with watery diarrhea. The enzyme lactase breaks
down lactose in the intestine. The byproducts are readily absorbed by the epithelial cells. When lactase is decreased or
absent, lactose cannot be absorbed and remains in the gut lumen. Lactose is osmotically active, and it retains and
attracts water, leading to watery diarrhea.

Common causes of fatty diarrhea include celiac disease and chronic pancreatitis. The pancreas releases enzymes that
are necessary for the breakdown of food. Enzymes are released from the pancreas and aid in the digestion of fats,
carbohydrates, and proteins. Once broken down, the products are available for uptake in the gut. Patients with chronic
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pancreatitis have insufficient enzyme release, leading to malabsorption. Symptoms often include upper abdominal
pain, flatulence, and foul-smelling, bulky, pale stools due to malabsorption of fats.[12]

In the secretory form of diarrhea, bacterial and viral infections are the common causes. In this instance, the watery
stool results from injury to the gut epithelium. Epithelial cells line the intestinal tract and facilitate water absorption,
electrolytes, and other solutes. Infectious etiologies cause damage to the epithelial cells, which leads to increased
intestinal permeability. The damaged epithelial cells cannot absorb water from the intestinal lumen, leading to loose
stool.

History and Physical

In developed regions, acute diarrhea is almost always a benign, self-resolving condition that subsides in a few days.
The duration of illness and clinical presentation vary depending on the etiology of diarrhea and the host factors. For
instance, rotavirus diarrhea commonly presents with vomiting, dehydration, and more workdays lost than
nonrotavirus diarrhea.

Knowledge of certain diarrhea-associated factors, such as volume, consistency, color, and frequency, helps distinguish
the source. The following table outlines these characteristics that can be utilized to narrow down the list of differential
diagnoses:

Daycare centers are also responsible for certain causes of diarrhea:[13]

Certain pathogens spread quickly in daycare. These include rotavirus, astrovirus; calicivirus, and Shigella,
Giardia, Campylobacter, and Cryptosporidium

The increasing trend of daycare usage has increased the occurrence of rotavirus and Cryptosporidium-related
infections.[14]

As various foods can lead to gastrointestinal infections, food history is important:

Consumption of raw or contaminated food items is commonly associated with infectious diarrhea.

Organisms that are commonly found associated with infectious diarrhea include the following:

Dairy products - Campylobacter and Salmonella species[15]

Eggs - Salmonella species

Meats - Clostridium perfringens, Campylobacter, Aeromonas, and Salmonella species

Poultry - Campylobacter species

Ground beef - Enterohemorrhagic E coli[16]

Seafood - Astrovirus, Aeromonas, Plesiomonas, and Vibrio species

Pork - C perfringens, Y enterocolitica[17]

Oysters - Calicivirus, Plesiomonas, and Vibrio species

Vegetables - Aeromonas species and C perfringens

The American Academy of Pediatrics advises that when evaluating children with persistent diarrhea,
excessive flatulence, bloating, and abdominal pain, the provider should determine the quantity of juice
consumed.[18]

Swimming pools harbor Shigella species, and Aeromonas organisms are causative agents of infectious diarrhea in the
marine environment.

Giardia, Cryptosporidium, and Entamoeba stay unaffected by water chlorination; therefore, suspicion for these
parasites should be high in contaminated water. Also, there is an association between Campylobacter infection,
agriculture, and drinking water.[19]

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Travel history is important as it may direct towards the underlying causative agent of infectious diarrhea.
Enterotoxigenic E coli is by far the leading cause of traveler's diarrhea. Following are some common associations
between certain areas and causative pathogens:

Evaluation
A patient with acute diarrhea typically has a self-limited course and is not require labs or imaging. A stool culture is
warranted in a patient with bloody diarrhea or severe illness to rule out bacterial causes. Bloody stools require
additional testing for Shiga toxin and lactoferrin. A recent antibiotic or hospitalization patient requires testing for
Clostridium difficile infection. Imaging is not ordered routinely in a patient with acute diarrhea. However, an
abdominal CT may be required when a patient presents with significant peritoneal signs.

A thorough history is important to determine what labs and imaging need to be ordered to distinguish the cause of
chronic diarrhea.[20] Basic lab work for a patient with chronic diarrhea includes a complete blood count, basic
metabolic panel, stimulating thyroid hormone, erythrocyte sedimentation rate, liver panel, and a stool analysis. The
physician should categorize the type of chronic diarrhea as either watery, fatty, or inflammatory based on the patient’s
history and physical exam. Once a probable diagnosis is determined, additional labs and testing specific to the
suspected etiology should be ordered.

A stool pH under 5.5 or an abundance of reducing substances in diarrhea signifies carbohydrate intolerance, usually
secondary to viral illnesses.[21] It is transient. Enteroinvasive infections affecting the large bowel cause neutrophils
and other leucocytes to be shed into the stool. The presence of leukocytes in stools eliminates the possibility of
enterotoxigenic E coli, Vibrio, and viruses.

If the stool sample can not be cultured within 2 hours of specimen collection, it should be refrigerated at 4°C or
placed in a transport medium. The yield of stool cultures is low; however, it is helpful when the culture is positive.
Stool should always be cultured for Salmonella, Shigella, Campylobacter, C Difficile, and Yersinia enterocolitica if
there are signs of colitis or fecal leucocytosis.[22]

Looking for Clostridium difficile is advisable in the presence of colitis or blood in stools. An important note is that
acute-onset diarrhea secondary to C difficile infection may occur with no antibiotic use history. In diarrheal cases with
a history of ground beef ingestion and enterohemorrhagic E coli present in the stool, one should determine the type
of E coli. Hemolytic uremic syndrome can result from infection with E coli O157:H7.[23]

Rotavirus antigen is tested by enzyme immunoassay and latex agglutination of the stool. Enzyme immunoassay can
also be used to detect adenovirus antigens. The best way to find parasites is to examine the stool for ova and parasites.
The stool examination should be performed every 3 days or on alternate days.

Treatment / Management
An important aspect of diarrhea management is replenishing fluid and electrolyte loss.[24] Patients should be
encouraged to drink diluted fruit juice, Pedialyte, or Gatorade. In more severe cases of diarrhea, IV fluid rehydration
may become necessary.[25] Eating foods that are lower in fiber may aid in making stool firmer. A bland 'BRAT' diet,
including bananas, toast, oatmeal, white rice, applesauce, and soup/broth, is well tolerated and may improve
symptoms.[26] Anti-diarrheal therapy with anti-secretory or anti-motility agents may be started to reduce the
frequency of stools. However, they should be avoided in adults with bloody diarrhea or high fever because they can
worsen severe intestinal infections. Empiric antibiotic therapy with an oral fluoroquinolone can be considered in
patients with more severe symptoms. Probiotic supplementation has been shown to reduce the severity and duration of
symptoms and should be encouraged in patients with acute diarrhea.

The treatment of chronic diarrhea is specific to its etiology.[28] The first step is categorizing diarrhea as watery, fatty,
or inflammatory. Once categorized, an algorithm can be used to determine the next step in management. Most cases
require additional fecal studies, lab work, or imaging. More invasive procedures like colonoscopy or upper endoscopy
may be required.

In 2003, the recommendations were put forward by the Center for Disease Control (CDC) for treating acute diarrhea
in children on both an outpatient and inpatient basis, including indications for referral.[27]

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Indications for referral and further medical evaluation of children include the following:

Under 3 months old

Weighs less than 8 kg (17.6 lbs)

History of premature birth, chronic illnesses, or concurrent medical conditions

Fever of 38ºC (100.4 F) or higher in children less than 3 months old or 39ºC (102.2 F) or higher in
children between 3 and 36 months of age

Grossly bloody stool

High-output diarrhea

Persistent vomiting

Signs of dehydration, such as sunken eyes, decreased tear film, dry mucous membranes, and oliguria/anuria

Mental status alterations

Inadequate response to oral rehydration or the caregiver's inability to administer oral rehydration

Treatment of dehydration is summarized in the following table:

Therapies advised for some nonviral causes of diarrhea include the following:

E coli - Trimethoprim-sulfamethoxazole (TMP-SMX). Parenteral second or third-generation cephalosporins are

indicated for systemic complications.

Aeromonas species - Third-generation and fourth-generation cephalosporins (cefixime).

Campylobacter species - Erythromycin

C difficile - Discontinue causative antibiotics. Use oral metronidazole or vancomycin. Vancomycin is reserved
for a child who is seriously ill.

C perfringens - Antibiotics are not recommended for treatment.

Cryptosporidium parvum - paromomycin and nitazoxanide.

Entamoeba histolytica - Metronidazole followed by paromomycin or iodoquinol.

G lamblia - Metronidazole or nitazoxanide.

Plesiomonas species - TMP-SMX or any other cephalosporin.

Salmonella species—Treatment prolongs carrier state. TMP-SMX is the first-line medication, but resistance
exists. For invasive disease, use ceftriaxone and cefotaxime.

Shigella species - Treatment shortens illness duration. TMP-SMX is the first-line medication, but there is
resistance. Cefixime, ceftriaxone, and cefotaxime are recommended for invasive diseases.

V cholerae - Doxycycline is the first-line, and erythromycin is the second-line antibiotic.

Yersinia species: TMP-SMX, cefixime, cefotaxime, and ceftriaxone are used.

Differential Diagnosis
The following are the differentials that need to be considered when dealing with a patient with diarrhea:

Appendicitis

Carcinoid tumor

Giardiasis

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Glucose-galactose malabsorption

Intestinal enterokinase deficiency

Intussusception

Meckel diverticulum imaging

Pediatric Crohn disease

Pediatric hyperthyroidism

Pediatric malabsorption syndromes

Prognosis
In developed regions, with proper management, the prognosis is very good. However, data reveal an increase in
diarrhea-related mortality among US children between the mid-1980s and 2006. Between 2005 and 2007, 1087
diarrhea-related infant deaths were recorded, with 86% of deaths occurring in low birthweight (less than 2500 g)
infants. These risk factors included male gender, black ethnicity, and low Apgar score (less than 7).[28]

Dehydration and secondary malnutrition become the common causes of death. Parenteral fluids should be given for
severe dehydration. Once malnutrition ensues, the prognosis becomes grave unless parenteral nutrition is started in a
hospital setting.

Complications
Common complications of common pathogens are:

Aeromonas caviae - Intussusception, hemolytic-uremic syndrome (HUS), gram-negative sepsis

Campylobacter species - Bacteremia, meningitis, urinary tract infection, pancreatitis, cholecystitis, Reiter
syndrome (RS)

C difficile - Chronic diarrhea

C perfringens - Enteritis necroticans

Plesiomonas species - Septicemia

Enterohemorrhagic E coli O157:H7 - HUS

Enterohemorrhagic E coli - Hemorrhagic colitis

Salmonella species - Seizures, RS, HUS, perforation, enteric fever

Vibrio species - Rapid dehydration

Giardia species - Chronic fat malabsorption

Rotavirus - Isotonic dehydration, carbohydrate intolerance

Y enterocolitica - Appendicitis, intussusception, perforation, toxic megacolon, peritonitis, cholangitis,

bacteremia, RS

Cryptosporidium species - Chronic diarrhea

Entamoeba species - Liver abscess, colonic perforation

Deterrence and Patient Education

Education is crucial for prevention and treatment. Proper oral rehydration therapy prevents dehydration. Intestinal
mucosa heals faster if refeeding is started earlier. Caregivers emphasize hygiene and proper food preparation practices
to prevent infections and their spread in the future.

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Proper handwashing can prevent the spread of infectious diarrhea. Patients with infectious diarrhea should not return
to work, school, or daycare until their symptoms have resolved. Professionals should encourage parents to vaccinate
their children against rotavirus, a common etiology of viral diarrhea. Probiotic therapy can be considered in patients
taking antibiotics to prevent C. difficile colitis.[29]

To decrease the chance of traveler’s diarrhea, encourage patients to drink bottled water, avoid raw fruits and
vegetables, and only eat hot, well-cooked foods when traveling to developing countries. Bottled water should be used
even when brushing teeth. Prophylactic antibiotics for traveler’s diarrhea are usually not recommended. Antibiotics
can be considered in individuals with underlying medical diseases who may be affected more significantly by
diarrhea.[30]

Enhancing Healthcare Team Outcomes

There are many causes of diarrhea, and the condition is best managed by an interprofessional team that includes
nurses and pharmacists. Most cases of diarrhea can be prevented by maintaining good personal hygiene and
handwashing. In addition, the key is to hydrate the patients. Most viral cases do not require specific treatment, but
bacterial causes may require antibiotics. The outcomes for well-hydrated patients are excellent, but patients at
extremes of age may not tolerate any degree of dehydration.[31][32]

Review Questions

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Disclosure: Valerie Nemeth declares no relevant financial relationships with ineligible companies.

Disclosure: Nicholas Pfleghaar declares no relevant financial relationships with ineligible companies.

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Tables

Stool Small Bowel Large Bowel

features
Appearance Watery
Mucoid/bloody

Volume Large Small

Frequency Increased Excessively increased
Blood It could be present but usually Usually grossly bloody
not gross
pH It could be less than 5.5 More than 5.5
Reducing Usually positive Usually negative
substances
White Less than 5/high power field More than 10/high power
blood cells field
in stool
White Leucocytosis
Usually normal
blood cells
in serum
Pathogens
Rotavirus Escherichia
Coli (enteroinvasive,
Adenovirus
enterohemorrhagic)
Calicivirus
Shigella species
Astrovirus
Salmonella species
Norovirus
Campylobacter species
E coli
Yersinia species
Klebsiella
Aeromonas species
Clostridium perfringens
Plesiomonas species
Cholera species
Clostridium difficile
Vibrio species
Entamoeba organisms
Giardia species

Cryptosporidium species

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Area Pathogen
Nonspecific foreign Enterotoxigenic E coli, Aeromonas,
travel history Giardia, Plesiomonas,
Shigella, and Salmonella species
New Guinea Clostridium perfringens
Africa Entamoeba species, Vibrio
cholerae
South America and Entamoeba species, V cholerae,
Central America enterotoxigenic E coli
Asia Vibrio cholerae
Yersinia species
Australia, Canada,
Europe

India Entamoeba species, V cholerae

Japan Vibrio parahaemolyticus
Mexico Aeromonas, Entamoeba,
Plesiomonas, and Yersinia species

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Extent of Dehydration Rehydration Therapy Replacement of Losses

Minimal or no Not needed
dehydration Less than 10 kg
bodyweight - give 60-
120 mL of oral
rehydration solution for
each episode of loose
stool or vomiting

More than 10 kg
bodyweight - give 120-
140 mL of oral
rehydration solution for
each episode of loose
stool and vomiting

Mild-to-moderate 50-100 mL/kg of oral

dehydration rehydration solution to be Less than 10 kg
given over 3-4 hours bodyweight - give 60-
120 mL of oral
rehydration solution for
each episode of loose
stool or vomiting

More than 10 kg
bodyweight - give 120-
140 mL of oral
rehydration solution for
each episode of loose
stool and vomiting

Severe dehydration Intravenous fluids, such

as normal saline or lactated Less than 10 kg
Ringer solution (20 mL/kg bodyweight - give 60-
until perfusion and mental 120 mL of oral
state improve), followed rehydration solution for
by oral rehydration solution each episode of loose
100 mL/kg over 4 hours or stool or vomiting
half normal saline (5% More than 10 kg
dextrose) IV at twice bodyweight - give 120-
maintenance fluid rates 140 mL of oral
rehydration solution for
each episode of loose
stool and vomiting

If unable to drink, give

through a nasogastric
tube or IV 5% dextrose
(one-fourth normal
saline) along with 20
mEq/L potassium
chloride

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