DIARRHEA

Diarrhea is a common symptom that can range in severity from an acute, self-limited annoyance to a severe, life-threatening illness. Patients may use the term "diarrhea" to refer to increased frequency of bowel movements, increased stool liquidity, a sense of fecal urgency, or fecal incontinence

Definition
In the normal state, approximately 10 L of fluid enter the duodenum daily, of which all but 1.5 L are absorbed by the small intestine. The colon

absorbs most of the remaining fluid, with only 100 mL lost in the stool.
From a medical standpoint, diarrhea is defined as a stool weight of more than 250 g/24 h

ACUTE DIARRHEA
Diarrhea that is acute in onset and persists for less than 3 weeks is most commonly caused by infectious agents, bacterial toxins (either ingested preformed in food or produced in the gut), or drugs Recent ingestion of improperly stored or prepared food implicates

food poisoning, especially if other people were similarly affected.

Exposure to unpurified water (camping, swimming) may result in infection with Giardia or Cryptosporidium

TRAVELER'S DIARRHEA
Whenever a person travels from one country to another particularly if the change involves a marked difference in climate, social conditions, or sanitation standards and facilitiesdiarrhea is likely to develop within 210 days

 There may be up to ten or even more loose stools per day, often accompanied by abdominal cramps, nausea, occasionally vomiting, and rarely fever. The stools do not usually contain mucus or blood, there are no systemic manifestations of infection. The illness usually subsides

spontaneously within 15 days, although 10% remain symptomatic for a

week or longer, and in 2% symptoms persist for longer than a month

 Bacteria cause 80% of cases of traveler's diarrhea, with enterotoxigenic E coli, Shigella species, and Campylobacter jejuni

being the most common pathogens.

Contributory causes may at times include unusual food and drink, change in living habits, occasional viral infections (adenoviruses or

rotaviruses), and change in bowel flora

 Prophylaxis is started upon entry into the destination country and is continued for 1 or 2 days after leaving. For stays of more than 3 weeks,

prophylaxis is not recommended because of the cost and increased

toxicity. For prophylaxis, bismuth subsalicylate is effective but turns the tongue and the stools blue and can interfere with doxycycline absorption, which may be needed for malaria prophylaxis. norfloxacin 400 mg, ciprofloxacin 500 mg, ofloxacin 300 mg, or trimethoprim-sulfamethoxazole 160/800 mg. daily for 5 days

Noninflammatory Diarrhea
Watery, nonbloody diarrhea associated with abdominal cramps, bloating, nausea, or vomiting (singly or in any combination) suggests small bowel

enteritis caused by either a toxin-producing bacterium (enterotoxigenic E

coli, Staphylococcus aureus) or other agents (viruses, Giardia) that disrupt the normal absorption and secretory process in the small intestine.

 Prominent vomiting suggests viral enteritis or S aureus food poisoning. Though typically mild, the diarrhea (which originates in the small intestine) may be voluminous (ranging from 10 to 200 mL/kg/24 h) and result in dehydration with hypokalemia and

metabolic acidosis due to loss of HCO3 in the stool (eg, cholera).

Because tissue invasion does not occur, fecal leukocytes are not present.

Inflammatory Diarrhea
The presence of fever and bloody diarrhea (dysentery) indicates colonic tissue damage caused by invasion (shigellosis, salmonellosis,

Campylobacter or Yersinia infection, amebiasis) or a toxin (C difficile, E

coli). Because these organisms involve predominantly the colon, the diarrhea is small in volume (< 1 L/d) and associated with left lower

quadrant cramps and urgency

 Fecal leukocytes are present in infections with invasive organisms. E coli is a toxigenic, noninvasive organisms that may be acquired from contaminated meat or unpasteurized juice and has resulted in several outbreaks of an acute, often severe hemorrhagic colitis. In

immunocompromised and HIV-infected patients, cytomegalovirus may

result in intestinal ulceration with watery or bloody diarrhea

Treatment
Diet :The overwhelming majority of adults have mild diarrhea that will not lead to dehydration provided the patient takes adequate oral fluids containing carbohydrates and electrolytes Patients will find it more comfortable to rest the bowel by avoiding high-fiber foods, fats, milk products, caffeine, and alcohol. Frequent feedings of fruit drinks, tea, "flat" carbonated beverages, and soft, easily digested foods (eg, soups, crackers) are encouraged

Rehydration
In more severe diarrhea, dehydration can occur quickly, especially in children.

Oral rehydration with fluids containing glucose, Na+, K+, Cl, and
bicarbonate or citrate is preferred in most cases to intravenous fluids because it is inexpensive, safe, and highly effective in almost all awake

patients

Oral rehydration solution (ORS)

An easy mixture is I. 1 tsp salt (3.5 g),

II. 1 tsp baking soda (2.5 g NaHCO3)

III. 8 tsp sugar (40 g) IV. 8 oz orange juice (1.5 g KCl), diluted to 1 L with water.

Alternatively, oral electrolyte solutions are readily available. Fluids

should be given at rates of 50200 mL/kg/24 h depending on the hydration status. Intravenous fluids (lactated Ringer's solution) are preferred acutely in patients with severe dehydration.

Antidiarrheal Agents
Loperamide is the preferred drug in a dosage of 4 mg initially,
followed by 2 mg after each loose stool (maximum:16 mg/24 h)
Diphenoxylate with Atropine: One tablet three or four times daily

Bismuth subsalicylate (Pepto-Bismol), two tablets or 30 mL four

times daily, reduces symptoms in patients with traveler's diarrhea by virtue of its anti-inflammatory and antibacterial properties

Antibiotic Therapy
Empiric treatment-fluoroquinolones (eg, ciprofloxacin, 500 mg twice daily) for 57 days. These agents provide good antibiotic coverage against most invasive bacterial pathogens, including Shigella, Salmonella, Campylobacter and Yersinia

Alternative agents are trimethoprim-sulfamethoxazole, 160/800 mg

twice daily, or erythromycin, 250500 mg four times daily

CHRONIC DIARRHEA
Etiology The causes of chronic diarrhea may be grouped into six major pathophysiologic categories

Osmotic Diarrheas
As stool leaves the colon, fecal osmolality is equal to the serum osmolality, ie, approximately 290 mosm/kg. Under normal circumstances, the major osmoles are Na+, K+, Cl, and HCO3. An increased osmotic gap implies that the diarrhea is caused by ingestion or malabsorption of an osmotically active substance The most common causes of osmotic diarrhea are disaccharidase

deficiency (lactase deficiency), laxative abuse, and malabsorption

syndromes. Osmotic diarrheas resolve during fasting. Osmotic diarrheas caused by malabsorbed carbohydrates are characterized by abdominal distention, bloating and flatulence due to increased colonic

gas production.

Malabsorptive Conditions
The major causes of mal absorption are small mucosal intestinal diseases, intestinal resections, lymphatic obstruction, small

intestinal bacterial overgrowth and pancreatic insufficiency

Secretory Conditions
Increased intestinal secretion or decreased absorption results in a watery diarrhea that may be large in volume (110 L/d) but with a

normal osmotic gap

There is little change in stool output during the fasting state. In serious conditions, significant or dehydration and electrolyte bile salt

imbalance may develop. Major causes include endocrine tumors

(stimulating intestinal pancreatic secretion), malabsorption (stimulating colonic secretion), and laxative abuse

Inflammatory Conditions
Diarrhea is present in most patients with inflammatory bowel disease (ulcerative colitis, microscopic colitis). A variety of other

symptoms may be present, including abdominal pain, fever and

weight loss

Motility Disorders
Abnormal intestinal motility secondary to systemic disorders or surgery may result in diarrhea due to rapid transit or to stasis of

intestinal

contents

with

bacterial

overgrowth

resulting

in

malabsorption

Chronic Infections
Chronic parasitic infections may cause diarrhea through a number of
mechanisms. Agents most commonly associated with diarrhea include the protozoans Giardia, E histolytica, and the intestinal nematodes

Immunocompromised patients, especially those with AIDS, are

susceptible to a number of infectious agents that can cause acute or chronic diarrhea Chronic diarrhea in AIDS is commonly caused by Microsporida, Cryptosporidium, cytomegalovirus and Mycobacterium avium complex.

Treatment
Loperamide: 4 mg initially, then 2 mg after each loose stool (maximum: 16 mg/d)

Diphenoxylate with Atropine: One tablet three or four times daily

Codeine: Because of their addictive potential, these drugs are generally avoided except in cases of chronic, intractable diarrhea. Codeine may be given in a dosage of 1560 mg every 4 hours as needed;

 Clonidine: 2-Adrenergic agonists inhibit intestinal electrolyte secretion. A clonidine patch that delivers 0.10.2 mg/d for 7 days may be useful in

some patients with secretory diarrheas and diabetes.

. Octreotide: This somatostatin analog stimulates intestinal fluid and electrolyte absorption and inhibits secretion. Furthermore, it inhibits the release of gastrointestinal peptides. It is very useful in treating secretory diarrheas due to and in some cases of diarrhea associated with AIDS. Effective doses range from 50 mg to 250 mg subcutaneously three times daily. A dosage of 4 g one to three times daily is recommended

 Cholestyramine: This bile salt binding resin may be useful in patients with bile salt-induced diarrhea secondary to intestinal resection or ileal disease