ACUTE AND CHRONIC

DIARRHEA
• PRESENTER: IAN ODUOR
• FACILITATOR: DR. SOME
 DEFINITION:
• Clinically, diarrhea defined as stools that are
looser and/or more frequent than normal; or
24 hr stool weight >200 g (physiological
definition, less useful clinically)
 CLASSIFICATION:
• small volume (tablespoons of stool; typical of
colonic diseases) versus large volume (> 1/2
cup stool; typical of small bowel diseases)
• acute vs. chronic
• watery (bowel disease) vs. steatorrhea
• secretory (diarrhea persists with fasting) vs.
osmotic (diarrhea stops with fasting)
 ACUTE:
INFECTIOUS: IATROGENIC:
Bacterial Drugs
Viral Surgery
Parasitic Radiation
Fungal (rare)

OSMOTIC AGENTS:
Lactose
Laxative abuse
Sugars (sorbitol, mannitol & xylitol)
 CHRONIC:
FUNCTIONAL: INFLAMMATORY:
IBS IBD
Constipation with Microscopic/collagenous colitis
overflow diarrhea

MALDIGESTION/MALABSORPTION: METABOLIC:
Pancreatic disease Hyperthyroidism
Celiac disease Addisons disease
Short bowel syndrome Uremia
Small intestinal bacterial overgrowth Cystic fibrosis
 CHRONIC:
NEOPLASTIC: IATROGENIC:
Medullary thyroid carcinoma Drugs, alcohol, caffeine
Gastrinoma Surgery
VIPoma Radiation
Small bowel lymphoma Laxative abuse
Carcinoid tumours
Colorectal cancer
Large villous adenoma of rectum

MISCELLANEOUS:
Incontinence
Chronic mesenteric ischemia
 PATHOPHYSIOLOGY:
• Diarrhea is the reversal of the normal net
absorptive status of water and electrolytes
absorption to secretion.
• Such derangement can be the result of either an
osmotic force or an active secretory state.
 Osmotic Diarrhea:
• Diarhea is osmolar in nature.
• Observed after ingestion of unabsorbable
sugars. (lactulose/lactose in lactose
malabsorbers)
• Stool output is proportional to intake of
unabsorbable substrate.
• Usually not massive and the diarrheal stool
promptly regress with discontinuation of
offending nutrient.
 Osmotic Diarrhea:
• Stool ion gap is high exceeding 100mOsm/kg.
• Ion gap= [ (total osmolality of stool) – (conc. of
electrolytes)]
• Ion gap = 290- [(Na+K)*2]
• Total osmolality assumed to be 290mOsm/kg.
 Secretory Diarrhea:
• The epithelial cells ion transport process are
turned into a state of active secretion.
• Commonest cause is the bacterial infection of the
gut.
• After colonization the enteric pathogens may
adhere or invade the epithelium.
• Toxins secreted by the organisms act by
stimulating adenylate cyclase and increasing cAMP.
• This results in the secretion of Cl from intestinal
crypts and inhibition of absorption of NaCl at the
villus tips.
 Secretory Diarrhea:
• Secretion of free water into the intestinal lumen
then ensues resulting in watery diarrhea.
• Inlammatory cells contribute to activated
secretion by inducing release of agents such as
prostaglandins.
• Features of secretory diarrhea include:
– A high purging rate
– A lack of response to fasting
– Normal stool ion gap
 ACUTE DIARRHEA:

• Acute diarrhea is defined as the abrupt onset

of 3 or more loose stools per day and lasts no
longer than 14 days; or greater than 200g of
stool in a 24hr period.
• Most commonly due to infections.
• Most infections are self-limiting and resolve in
7 days
 Classification
• Broadly divided and classified into
inflammatory and non-inflammatory diarrhea.
• Mechanisms:
– Stimulation of intestinal water secretion and
inhibition of water absorption (Le. Secretory
problem}
– In inflammatory diarrhea, organisms and cytotoxins
invade mucosa, killing mucosal cells, further
perpetuating the diarrhea
 INFLAMMATORY NON-INFLAMMATORY

DEFINITION Disruption of intestinal No disruption of intestinal

mucosa. mucosa.

SITE Small bowel+_ colon. Usually small intestine.

SIGMOIDOSCOPY Usually abnormal mucosa Usually normal.

seen.

SYMPTOMS Bloody (not always) Watery, little or no blood

Small volume, high Large volume
frequency Upper/periumbilical
Often lower abdominal pain/cramp ± shock
cramping with urgency ±
tenesmus
May have fever ± shock
 INFLAMMATORY NON-INFLAMMATORY

INVESTIGATIONS Fecal WBC and RBC Fecal WBC negative.

present.

ETIOLOGY INFECTIOUS INFECTIOUS

BACTERIAL BACTERIAL
Shigella Salmonella enteritis
Salmonella typhi S. aureus
Campylobacter B. cereus
Yersinia c. perfringens
E.Coli (EHEC 01 57:H7) E. coli (ETEC, EPEC)
C. difficile Vibro cholerae
PROTOZOAL PROTOZOAL
E. histolytica (amebiasis) Giardia lamblia
Strongyloids VIRAL
DRUGS Rotavirus
NSAIDs Norwalk
INFLAMMATORY BOWEL CMV
DISEASE DRUGS
Antacids
Antibiotics
Laxatives.lactulose
Colchicine
 INFAMMATORY NON-INFLAMMATORY

DIFFERENTIAL DIAGNOSIS Acute presentation of a Chronic diarrheal illness.

chronic diarrheal condition.

SIGNIFICANCE Higher yield with stool C&S. Chief life-threatening

Can progress to life problem is fluid depletion
threatening megacolon, and electrolyte
perforation, hemorrhage. disturbances.
 Risk Factors
• Food (seafood, chicken, turkey, eggs, beef)
• Medications: antibiotics, laxatives.
• Others: high risk sexual activity, infectious
outbreaks, family history (IBD)
 CHRONIC DIARRHEA:
• Passage of frequent unformed stool for more
than 14 days.
• Differential similar to that of acute diarrhea,
except that majority of cases are non
infectious.
 Investigations of chronic diarrhea
• Guided by history
• Stool analysis for C. difficile toxins, C&S, O&P,
fecal fat, WBC.
• Blood for: CBC, chemistry, CRP, TSH, celiac
serology(Ttg, protein electrophoresis)
• Colonoscopy and ileoscopy with biopsy.
• Small bowel biopsy.
• Upper GI endoscopy with biopsy.
• Endoscopy capsule.
• Trial of lactose free diet.
 Pathogens In Infectious Diarrhea
Bacteria (invasive)

• Campylobacter jejuni
– Source: Uncooked meat, especially poultry.
– Incubation: 2-10 days.
– Symptoms: Prodrome of fever, headache, myalgia,
and/or malaise precedes diarrhea, abdominal pain
and fever.
– Duration: <1 week.
– Treatment: Supportive (macrolide or
fluoroquinolones if > 1 week or bloody diarrhea)
• Enteroinvasive E. coli (EIEC)
– Source: contaminated water/food.
– Incubation: 1-3 days.
– Symptoms: fever, abdominal pain, tenesmus, scant
stool containing mucus and blood.
– Duration: 7-10 days.
– Treatment: unnecessary, supportive only,
treatment hastens the resolution of symptoms
especially in severe cases.
• Salmonella typhi & paratyphi:
– Source: feco-oral contaminated food and water.
– Incubation: 10-14 days.
– Symptoms: sudden onset crampy abdominal pain
and diarrhea. Prolonged fever (sometimes upto 4
weeks if left untreated), headache, rash (rose
spots)
– Duration: less than 5-7 days diarrhea.
– Treatment: empiric treatment with ceftriaxone and
azithromycin, fluoroquinolones first line if
susceptible.
• Shigella dysenteriae
– Source: feco-oral contaminated food and water.
– Incubation: 1-4 days
– Symptoms: fever, malaise, anorexia, limited watery
diarrhea, progressing to frequent passage of small
bloody mucopurulent stools.
– Duration: < 1 week.
– Treatment: ciprofloxacin, antidiarrheals may
increase risk of megacolon.
– Very small inoculum needed for infection and
complications include toxic megacolon and HUS.
• Yersinia enterocolitica, Y. pseudotuberculosis
– Source: contaminated food and unpasteurized milk.
– Incubation: 5 days
– Symptoms: acute diarrhea, low grade fever, cramping,
nausea and vomiting, hematochezia.
– Duration: 2 weeks to months.
– Treatment: supportive. Fluoroquinolones only for
septicemia, metastatic focal infections, or
immunosuppression or enterocolitis.
• Non-typhoidal salmonellosis: S. typhimurium & S.
enteritidis.
– Source: contaminated animal food products,
espacially eggs, milk, meat, poultry.
– Incubation: 12-72 hrs
– Symptoms: nausea, vomiting, diarrhea, adominal
cramping, fever >38 degrees celcius.
– Duration: 3-7 days diarrhea, < 72hrs fever.
– Treatment: supportive. Ciprofloxacin not
recommended unless in the extremes of age,
immunosuppression, aneurysm, prosthetic valve
grafts/joints.
 Bacteria Non-invasive/Toxin Mediated
• B. cereus type A (emetic) (preformed exotoxin)
– Source: rice dishes.
– Incubation: 1-6 hrs.
– Symptoms: nausea, vomiting and cramps.
– Duration: < 12 hrs.
– Treatment: symptomatic.
• B. cereus type B: diarrheal (secondary
endotoxin)
– Source: meat, vegetables, dried beans and cereals.
– Incubation: 8-16 hrs.
– Symptoms: large volume watery diarrhea.
– Duration: < 24hrs
– Treatment: symtomatic.
• Enterotoxigenic E. coli. (EHEC/STEC) i.e 0157:H7
– Source: verotoxin (aka shiga like toxin). Feco-oral,
contamination of hamburger, raw milk, drinking and
recreational water.
– Incubation: 3-8 days
– Symptoms: gross bloody diarrhea, fever almost
always absent.
– Duration: 5-10 days
– Treatment: supportive. Monitor renal function.
Antibiotics and antidiarrheals may increase risk of
HUS
– 10% develop HUS which has a 5% mortality
especially in the elderly and children.
• Enterotoxigenic E.coli: (ETEC) colonization of
the colon + enterotoxin production.
– Source: LT and/or ST contaminated water/food.
– Incubation: 1-3 days.
– Symptoms: watery diarrhea, cramps.
– Duration: 3 days.
– Treatment: supportive. loperamide, quinolone or
azithromycin.
– Most common cause of travelers diarrhea.
• Clostridium deficile.
– Source: normally present in colon in small numbers.
– Incubation: unclear
– Symptoms: unformed to watery or mucoid stools
with characteristic odour.
– Duration: unclear
– Treatment: 1st line metronidazole ( IV/ PO). 2nd line
vancomycin PO.
– Usually follows antibiotic treatment (especially
clindamycin). Can cause pseudomembranous colitis.
• Clostridium perfringens: (secondary enterotoxin)
– Source: contaminated food especially meat and
poultry.
– Incubation: 8-12 hrs.
– Symptoms: Sudden onset watery diarrhea, cramps,
rarely vomiting.
– Duration: < 24 hrs.
– Treatment: supportive, antibiotics not effective as
disease is toxin mediated.
– Clostridium spores are heat resistant.
• Staphylococcus aureus: heat-stable preformed
exotoxin.
– Source: Unrefrigerated meat and diary products
(custard, pudding, potato salad, mayonnaise)
– Incubation: 2-4 hrs.
– Symptoms: Sudden onset severe nausea, cramps,
vomiting, prostration, diarrhea.
– Duration: 1-2 days.
– Treatment: Supportive.+_ antiemetics
• Vibrio cholerae.
– Source: contaminated food and water. Especially shell
fish.
– Incubation: 1-3 days.
– Symptoms: Painless voluminous diarrhea without
abdominal cramps or fever.
– Duration: 3-7 days
– Treatment: aggressive fluid and electrolyte
resuscitation. Tetracycline and quinolones
(ciprofloxacin).
– Massive watery diarrhea (1-3L/d). Mortality < 1% with
treatment.
 Parasites
• Crptosporidium:
– Source: feco-oral.
– Incubation: 7 days.
– Symptoms: Non bloody, watery diarrhea, fever.
– Duration: 1-20 days.
– Treatment: nitazoxanide, paramomycin.
• Entamoeba histolytica.
– Source: world-wide endemic areas. Feco-oral.
– Incubation: ranges from asymptomatic to severe
grossly bloody diarrhea. Fever, weight loss.
– Duration: variable.
– Treatment: metronidazole + iodoquinol if invasive.
Only iodoquinol for non-invasive.
– May resemble IBD.
– If untreated may cause liver abscess.
– Sigmoidoscopy shows flat ulcers with yellow
exudates.
• Giardia lamblia:
– Source: feco-oral. Contaminated food/water (travel
related ‘beaver fever’).
– Incubation: ranges from asymptomatic to acute
watery diarrhea with abdominal pain to protracted
course of flatulence, abdominal distention and
anorexia.
– Duration: variable.
– Treatment: Metronidazole. Treatment of
asymptomatic carriers not generally recommended.
 Viruses
• Rotavirus
– Source: feco-oral.
– Incubation: 2-4 days.
– Symptoms: Watery diarrhea, vomiting, fever.
– Duration: 3-8 days.
– Treatment: Supportive. Vaccine available given at
2, 4 & 6 months of age. Can cause severe
dehydration.
• Norovirus: includes norwalk virus.
– Source: feco-oral.
– Incubation: 24 hrs.
– Symptoms: Nausea, vomiting, abdominal cramps,
loose watery diarrhea.
– Duration: 24 hrs
– Treatment: supportive
– Often causes epidemics.
 PRESENTATION:
• The clinical presentation and course of illness
depend on the etiology of the diarrhea and on
the host.
• Presence of associated enteric symptoms:
nausea/vomiting, fever, abdominal pain.
• Dehydration.
• Malnutrition.
• Cramping.
• Borborgymi
• Perianal erythema.
 HISTORY:
• Food ingestion history.
• Water exposure (swimming pools marine
environment.)
• Travel history.
• Animal exposure (young dogs and cats
campylobacter spp.)
• Predisposing conditions (hospitalization,
antibiotic use, immunocompromised state)
 INVESTIGATIONS
• Stool pH: less than 5.5 indicates carbohydrate
intolerance, which is usually secondary to viral
illness and transient in nature.
• Stool microscopy: enteroinvasive infections of
large bowel cause leukocytes, predominantly
neutrophils to be shed in stool.
– Absence of fecal leukocytes doesn’t eliminate the
possibility of enteroinvasive organisms.
– However presence of fecal leukocytes eliminates
consideration of ETEC, vibrio spp and viruses
• Exudates if any examined for leukocytes: such
exudates highly suggestive of colitis.
• Culture: choose appropriate optimum culture
medium for the suspected organisms.
– Always culture stool for Salmonella, Shigella and
Campylobacter and Y. enterocolitica in the presence
of clinical signs of colitis or if fecal leukocytes are
found.
• Enzyme immunoassay: Rotavirus antigen. Also
latex agglutination assay of the stool. Adenovirus
antigens can also be detected by enzyme
immunoassay.
• Anion Gap of stool: used to ascertain the
nature of diarrhea.
• Procedures: intestinal biopsy.
enteroscopy
 MANAGEMENT:
• HISTORY:
– Onset, frequency, quantity.
– Character: bilious/bloody/mucoid.
– Vomiting, abdominal pain, cramping.
– Past medical history, underlying medical condition.
– Epidemiological clues.
• PHYSICAL EXAMINATION:
– Body weight.
– Temperature.
– Heart & respiratory rate.
– Blood pressure.
• ASSESS DEHYDRATION:
– General appearance alertness
– Pulse and blood pressure
– Postural hypotension
– Mucous membranes and tears
– Sunken eyes, skin turgor.
– Capillary refill, jugular venous pressure.
• Signs of dehydration in adults:
– Pulse rate >90
– Postural hypotension
– Supine hypotension and absence of palpable pulse.
– Decreased mean arterial pressure.
– Narrowing pulse pressure.
– Dry tongue
– Sunken eyeballs
– Skin pinch
– Urine flow
– Inability to sweat.
 Classification of dehydration:
SUBJECTIVE MILD MODERATE SEVERE

General state: Alert, active, up and Weak, lethargic, able Dull, inactive. Unable
about. to sit and walk. to sit or walk.

Ability to perform Able to perform daily Able to perform daily Unable to perform
daily activities: activities without activities with some daily activities, stays
difficulty. difficulty. Eg stays in bed or needs
away from work, hospitalization.
needs some support.
Thirst: Not increased. Increased thirst. Feels very thirsty
OBJECTIVE SIGNS MILD MODERATE SEVERE

PULSE: Normal. Tachycardia Tachycardia

BLOOD PRESSURE Normal Normal or Decreased by >

decreased by 10-20 20mmHg systolic
mmHg systolic
POSTURAL No Yes or no Yes
HYPOTENSION

JUGULAR VENOUS Normal Normal or slightly Flat

PRESSURE flat

DRY MUCOSA No Slight Severe

(mouth, tongue)

SKIN TURGOR Good Fair Poor

SUNKEN EYEBALLS No Minimal sunken

• Treatment goal:
– Correcting fluid and electrolyte deficits
– Treat underlying cause
– Treatment of symptoms.
• Mild to moderate dehydration:
– Rehydration therapy:
• ORS 50-100 mL/kg body weight over 3-4 hours
– Replacement of losses:
• 60-120 mL for each diarrheal stool or vomiting episode
– Nutrition:
• Resume normal diet after initial hydration
• Severe dehydration:
– Rehydration therapy
• Rehydrate with Ringers Lactate (100mg/kg) IV within 4-6
hrs then administer ORS to maintain hydration until
patient recovers.
– Replacement of losses:
• 60-120 ml ORS for each diarrheal stool or vomiting
episode.
– Nutrition:
• Resume appropriate diet.
 Fluid replacement

There are 3 elements

A)replacement of established losses
 The average adult with 48 hrs of moderate diarrhoea (6-10
stools per 24hrs) will be 1-2L depleted from diarrhoea
alone .Any ass. Vomiting will compound this.
 Mild dehydration-Give ORS solution after each stool upto 2L
per day
 In moderate dehydration, the deficit is about 2-4L,2.2-4L of
ORS in first 4 hrs,reassess patient regularly during the first
6hrs
 In severe dehydration,deficit is about 6-8L-2 IV large bore
cannula,IV bolus 30mls/kg in 30 mins then slow down.Goal -
200ml/kg over 24hrs,100ml/kg given in first 4hrs.Reassess
patient.
B)Replacement of ongoing losses
• Average adult’s diarrhoea stool accounts for a
loss of 200ml of isotonic fluid. Stool losses shd
be charted and an estimate of ongoing
replacement calculated fluid.
• Commercially available rehydration sachets
produce upto 200ml of ORS, therefore 1 sachet
per diarrhoea stool is appropriate & effective
means of ongoing rehydration

• *Recommended ORS solution has 75 mEq/L of

sodium and 75mmol/Lof glucose.
C)Replacement of normal daily requirement
 The aver. Adult has a minimal daily requirement
of 1-1.5L of fluid in addition to the calculations
above
 In mild-moderate diarrhoea encourage pt to drink
normally
 Additional fluids shd also be given to replace
established & ongoing losses including
insensible losses
 Pharmacological Treatment
• Anti-diarrheals:
– Antimotility agents: diphenoxylate, loperamide;
contraindicated in mucosal inflammation.
• Diphenoxylate dosage: initial; 2 tablets or 10ml of liquid
orally 4x a day. Maintenance; 2 tablets (or 10 ml liquid) O.D
• Loperamide dosage: acute diarrhea; Initial: 4 mg orally after
the first loose stool, then Maintenance: 2 mg after each
loose stool, not to exceed 16 mg in any 24-hour period.
Clinical improvement is usually observed within 48 hours.
Chronic diarrhea: Initial; 4 mg orally once followed by 2 mg
orally after each loose stool, not to exceed 16 mg in any 24-
hour period.
Maintenance: The average daily maintenance dosage is 4 to
8 mg
• Side effects: abdominal cramps and toxic megacolon.
– Absorbants: kaolin/pectin, methylcellulose, activated
attapulgite
• Act by absorbing intestinal toxins /microorganisms, or by
coating intestinal mucosa.
• Much less effective than antimotility agents.
• Dosages: PO 60 to 120 mL (regular strength) or 45 to 90
mL (concentrate) after each loose bowel movement.
– Modifiers of fluid transport: bismuth subsalicylate
may be helpful
• Antibiotics: rarely indicated.
– Risks:
• Prolonged excretion of enteric pathogen (especially
salmonella)
• Drug side effect including C. difficile infection.
• Development of resistant strains.
– Indications for antibacterial therapy in acute
diarrhea:
• Septicemia
• Prolonged fever with fecal blood or leucocytes
• Clearly indicated: Shigella, V. cholerae, C. difficile,
enterotoxigenic E. coli, Giardia, Entamoeba histolytica,
Cyclospora
 • Salmonella: always treat Salmonella typhi. Treat other
salmonella only if there is underlying immunodeficiency,
hemolytic anaemia, extremes of age, prosthetic
valves/joints
• Vibrio cholera:
• Tetracycline, 500mg q.i.d for 3 days.
• Shigella spp:
• Ofloxacin, 300mg b.i.d x 3 days
• Norfloxacin, 400mg b.i.d x 3 days
• Ciprofloxacin, 500mg b.i.d x 3 days
• Non-typhoidal spp of Salmonella:
• Antibiotics usually not required
• Flouroquinolones as above x 5-7 days
• Aeromonas spp:
• Antibiotics usually not required.
• Fluoroquinolone x 5-7 days
• Enterotoxigenic E. coli:
• Fluoroquinolone x 3days
• TMP-SMZ, 160-800mg b.i.d x 3 days
• Enteropathogenic E. coli:
• Antibiotics have no established therapeutic value hence
usually not required.
• Enteroinvasive E. coli:
• Fluoroquinolone x 3 days
• Enterohemorrhagic E. coli
• Role of antibiotics unclear and administration should be
avoided as they may be harmful. May predispose to HUS.
• Campylobacter spp:
• Antibiotics usually not required.
• Erythromycin, 500mg b.i.d x 5 days
• Yersinia spp:
• Antibiotics usually not required.
• Fluoroquinolone x 3 days
• Toxigenic clostridium difficile:
• Metronidazole, 250-500mg q.i.d x 10-14 days.
• Cryptosporidium
• Nitazoxanide effective in immunocompetent individuals
• Dosage: 500mg b.i.d x 3 days
• In immunocompromised patients, ARVS should also be
administered to improve patients immune status for
effective treatment. Symptoms may disappear but
cryptosporidiosis is often not curable.
• Dosage in ISS: 1000mg b.i.d x 14 days or until diarrhea
resolves.
• Entamoeba histolytica:
• Metronidazole, 750mg orally t.i.d x 5-10 days
• Giardia lamblia:
• Metronidazole, 250 mg p.o. t.i.d x 5-7 days
• Microsporidium:
• Albendazole, 400mg p.o b.i.d x 21 days.
THANK YOU.