Acute Diarrhea

Differential Overview

❑ Viral gastroenteritis

❑ Staphylococcal enterotoxin

❑ E. coli

❑ Salmonella

❑ Campylobacter

❑ Drugs

❑ C. difficile colitis

❑ Giardia

❑ Shigella

❑ Yersinia

❑ Entamoeba histolytica

❑ Typhoid fever

❑ Vibrio parahaemolyticus

❑ Cryptosporidia

❑ Cholera

❑ Strongyloides

Diagnostic Approach

Most cases of acute diarrhea are self-limited. Red flags to prompt further evaluation include: profuse watery diarrhea with dehydration; passage of blood or mucous; temperature .38.5˚C, duration .48 hours; severe abdominal pain in a patient over 50; or an immunocompromised patient.

Symptoms that begin within 6 hours of eating suspect food suggest a preformed toxin of Staph aureus or Bacillus cereus, at 8 to 14 hours Clostridium perfringens, and over 14 hours from viral agents or bacterial contamination of food with E. coli.

Secretory diarrhea is characterized by the absence of fever and prominent nausea/vomiting with watery stools that persist when fasting. It is caused by a toxin (Staph, E. coli, Vibrio cholera), gastrin (pancreatic cancer), calcitonin (medullary carcinoma of the thyroid), or vasoactive intestinal peptide
(VIP). Invasive infection with exudative diarrhea is associated with systemic
symptoms, fever, chills, and blood, pus, and proteinaceous material in
the stools. It is most commonly found with infections such as Salmonella, Shigella, Campylobacter, or enterohemorrhagic E. coli. Bloody diarrhea usually indicates invasive infection, but the differential also includes superior mesenteric artery thrombosis, inflammatory bowel disease, and drug-induced or ischemic colitis.

Small bowel diarrhea is characterized by passage of large loose stools, and with periumbilical pain. Large bowel diarrhea has frequent passage of small stools, with tenesmus.

Common pathogens in HIV-associated diarrhea are cytomegalovirus, Cryptosporidia, Isospora, Salmonella, and Giardia.

Clinical Findings

Viral gastroenteritis  Symptoms begin abruptly, with diarrhea, nausea, vomiting, headache, low-grade fever, abdominal cramps, and malaise. The abdomen is diffusely mildly tender, and bowel sounds are hyperactive. Diarrhea is small bowel in type.

Staphylococcal enterotoxin  Classic food poisoning develops, with acute nausea, vomiting, cramps, and diarrhea 2 to 8 hours after eating food that has spoiled due to lack of refrigeration.

E. coli  Enterotoxigenic strains produce a secretory watery diarrhea, typical traveler’s diarrhea. Enterohemorrhagic strains produce dysentery with hemorrhagic colitis and fever.

Salmonella  Invasive infection produces an enterotoxin-mediated secretory watery diarrhea, cramps, and fever, which can progress to dysentery or bacteremia. Sources include contaminated eggs or poultry, with an incubation period of 12 to 36 hours.

Campylobacter  Prominent cramps and strongly malodorous stools are typical symptoms. Stools can be watery or hemorrhagic. Poultry and pets are sources.

Drugs  Phenolphthalein, magnesium-containing antacids, caffeine, digoxin, quinidine, procainamide, antibiotics, NSAIDs, colchicine, lovastatin, and fluoxetine are frequent causes, but almost any drug is capable of causing diarrhea.

C. difficile colitis  Suspect this when diarrhea occurs following the use of
broad-spectrum antibiotics. The patient becomes febrile and exhibits
toxicity.

Giardia  Mild diarrhea with cramping and gas is a frequent presentation. Heavy small bowel infection may produce loose, watery or greasy, foul, yellow stools (steatorrhea) and mucus, without blood. Malabsorption with significant weight loss often occurs when symptoms persist more than 10 days.

Shigella  Because of a fecal-oral route of spread, Shigella is often seen in day care centers and rural areas of developing countries. Either small or large bowel presentations may occur. The patient may exhibit toxicity with fever, bloody diarrhea, nausea, vomiting, and cramps.

Yersinia  Fever, polyarthritis, and erythema nodosum develop in 10% to 40%. Localized infection of the terminal ileum and cecum can cause right lower quadrant abdominal pain.

Entamoeba histolytica  The spectrum ranges from mild to fulminant with acute bloody diarrhea, usually with lower abdominal pain. Often, these patients have traveled to rural areas with inadequate sanitation.

Typhoid fever  “Pea soup” diarrhea may develop in the third week of an illness characterized by progressive fever, relative bradycardia, rose spots (evanescent trunk rash), splenomegaly, cough, headache, and right lower quadrant abdominal pain.

Vibrio parahaemolyticus  Mild symptoms develop after an incubation period of hours to days after eating raw seafood, especially oysters, salmon, and red snapper sushi.

Cryptosporidia  This prominent pathogen in HIV infection produces a profuse, watery diarrhea. It may also come from day care centers or occupational contact with dung.

Cholera  A spectrum of diarrhea from mild to gray, watery, mucoid “rice water” stools with fluid losses in excess of 1 liter/hour may occur.

Strongyloides  Infection is marked by epigastric abdominal pain, watery diarrhea, urticaria, perianal itching, bronchospasm, cough, and wheezing. Endemic regions include the southern United States, Central America, tropical Asia, and Africa.

Pictures

Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.

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