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Diarrhea: Acute, Sub acute, &


Chronic
•! Definition:
o! Diarrhea: is the passage of loose\watery stool at least 3 times per 24 hours (>200 ml).
o! Classification based on duration:
!! Acute: <2 weeks
!! Sub-acute: 2-4 weeks
!! Chronic: >4 weeks
o! Classification based on etiology: " mainly for acute
!! Community acquired
!! Nosocomial/ Hospital-acquired
•! Acute:
1.! Community acquired:
a.! Viral:
!! Rotavirus
!! Norovirus
b.! Bacterial:
!! SEVERE WATERY DIARRHEA:
1.! Mechanism:
#! Fluid loss from the proximal small intestine without cellular
injury.
2.! Course:
#! Acute, brief 1-3 days
#! Self limited.
3.! Common microorganisms:
Organism Notes
Enterotoxigenic E.coli #! Gram –ve rods, enterobacterae
ii.! #! Normal colonizer of the lower GIT
#! Produces toxins:
!! Labile toxin
!! Stable toxin
Vibrio cholera #! Curved vibrio, gram –ve rods with long filamentous pilli.
#! Found in salty water
#! Complications:
!! Isotonic dehydration.
!! Hypovolemic shock.
!! Hypokalemia S&S.
!! Metabolic acidosis.
#! Characterized by:
!! Rice watery stool
!! No fever = No inflammation
Salmonella ------------------------------
Listeria ------------------------------

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!! DYSENTERY (BLOODY) DIARRHEA:
1.! Primary site for colonization: colon.
2.! Characteristics:
Note: CHESS
#! Diarrhea in smaller volume than in watery commonly cause
diarrhea BUT lasts longer. bloody stool:
#! Diarrhea with BLOOD + PUS. Campylobacter,
#! Inflammation and/or distinctive changes in Hemorrhagic E.coli,
E.histolytica,
the colonic mucosa.
Salmonella,
3.! Presents as: fever, abdominal pain and cramps, Shigella.
& tenesmus.
#! Most cases resolve spontaneously in 2-7
days.
4.! Common pathogens:
Organism Notes
Shigella ----------------------
Campylobacter Associated with poultry, eggs, and milk.
Salmonella
E.coli 0157:H7 Associated with the development of hemolytic uremic
Enterohemolytic E.coli syndrome.
Enteroinvasive E.coli Dysentery.
Vibrio parahemolyticus Associated with shellfish consumption.
Vibrio vulnificus Increased incidence in ptx with liver disease or high iron states.

Yerisinia Enterocolitica ----------------------

!! ENTERIC FEVER (TYPHOID FEVER):


1.! Salmonella enterica serovar typhi
2.! Presents as: gradual onset of a systemic infection with fever and
abdominal pain " (diarrhea is not a constant feature!)
!! DIARRHEAL DISEASE WITH VOMITING AS A PROMINENT
FEATURE:
Organism Notes

Bacillus cereus Chinese food and reheated rice.


Staphylococcus aureus Dairy, cole slaw, picnics.
Clostridium perfinges Meat that has been sitting out for long time.

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!! Nosocomial/ Hospital-acquired:
$! Infants:
!! Rotavirus " winter time, breakouts.
!! Enteropathogenic E.coli (EPEC): infantile diarrhea.
$! Adults:
!! Antibiotic associated diarrhea:
#! S\E of antibiotics (erythromycin, augmentin, cephalexin, Clindamycin)
#! C.difficile overgrowth (takes 3 days).
!! Non- antibiotic associated diarrhea:
#! CT contrast.
#! Laxatives, magnesium, and sorbitol.
#! Tube feed diarrhea
•! Sub-acute:
1.! Travelers’ diarrhea: ingestion of fecally contaminated food, water, or ice.
Stool Notes
exam
Stool +ive :bloody diarrhea and mostly by gram negative
lactoferrin rods.
-ive: non-bloody diarrhea
Bacteria Mostly causes food poisoning
Parasites To check for ova, and giardia antigen
Protozoa To check for cysts and trophozoites.
Viruses By exclusion of other causes.
Immunoassay for Rotavirus.

a.! Causes:
i.! 80% is bacterial cause.
ii.! 50% of all cases: Enterotoxigenic E.coli.
iii.! 10%-20% of cases: Shigella.
iv.! Other: campylobacter jejuni.
•! Diagnosis of Acute & Subacute Diarrhea:
o! Exclude infection (stool study) ** GOLD STANDARD for acute diarrhea.
#! Checking for: mucus, blood (RBCs), WBCs.
o! If negative " go for Endoscopy.

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•! Management of Acute & Subacute Diarrhea:


Diarrhea Management Antibiotic Notes

Bloody •! If stable, •! In severe cases.


observe. •! Ciprofloxacin
•! Adequate fluid (fluroquinilones) +\-
replacement. metronidazole.
•! V.vulnificus: doxycycline.
•! In severe cases.
•! Most cases are self-
•! Ciprofloxacin
Non-Bloody limited.
(fluroquinilones) +\-
metronidazole. •! Do not wait for
For AIDS ptxs: culture.
•! Cryptosporidosis:
paromomycin or
metronidazole.
•! Isospora: trimethoprim
C.difficile: •! Metronidazole. •! C.difficile positive in
Pseudomemb- •! If symptoms don’t abate after stool exam.
ranous colitis 2days: Vancomycin.

•! Chronic:
o! Classified according to the characteristic of stool:
a)! SECRETORY:
1.! Mechanism:
#! Derangement of electrolyte and fluid transport across the intestinal
epithelium.
#! (Special channels in the walls are disturbed).
2.! Etiology:
#! Medication: ethanol, stimulant laxatives.
#! Anatomical defects (bowel resection) and Congenital (chloridorrhea, mucosal
defect…).
#! Toxins (e.g. vibrio cholera).
#! Hormones & neuroendocrine tumors (e.g. VIPoma, gastrinoma…).
3.! NOT affected by FASTING!
b)! OSMOTIC:
1.! Mechanism:
#! Osmotically active solute " driving water into the lumen.
2.! Etiology:
#! Osmotic laxatives (poorly absorbed ions: Mg++, SO4+).
#! Non-absorbable sugars (artificial sweeteners, lactose intolerance).
3.! Gets better with FASTING!

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Osmotic gap
50-100mosm\kg

>100
Osmotic diarrhea <50
Normal pH: 7-7.5

pH High pH Low Secretory


Diarrhea

ions sugar

c)! FATTY
1.! Characteristics: malodourous, bulky stool, difficult to flush
#! Floating is due to gas not fat.
2.! Mechanism:
#! Mal-absorption:
%! Mucosal diseases (celiac disease)
%! Short bowel syndrome (after surgery)
#! Mal- digestion:
%! Pancreatic insufficiency (chronic pancreatitis)
%! Cholecystectomy:
$! Mechanism: bile will drain directly into small intestine " exceed
the terminal ilium absorptive capacity" too much bile reaching
the colon " diarrhea
#! Post-mucosal lymphatic obstruction.

d)! INFLAMMATORY
1.! Presents as: pain, fever, cramps, and bloody diarrhea.
2.! Etiology:
#! Inflammatory bowel disease (IBD)" crohn’s disease, and ulcerative colitis.
#! Infections (C. diff colitis, Yersinia, TB)
#! Always exclude infection in inflammatory (bloody) diarrhea, even if you
are sure of your diagnosis.

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Ulcerative Colitis Crohn’s Disease


Location Colon mainly. The entire gastrointestinal
tract most commonly the
area of transition between
the small and large intestine.
Disease Development Uniform progression spread Skipped lesions
from rectum to the entire
colon.
Intestinal Symptoms Bloody diarrhea, abdominal Diarrhea not necessarily
pain, weight loss, and ulcers bloody, weight loss,
with bleeding. abdominal pain, toxic
megacolon, and colonic
perforation.
Extraintestinal Symptoms Liver disease, anemia, fever, Fistulas, perianal abscess,
arthritis, skin changes. fever, anemia, arthritis, and
skin changes.

e)! MOTILITY DISORDER


1.! Etiology:
#! Diabetic neuropathy " disturbance in symp. / parasymp.
#! Hyperthyroidism " bowels hyper-motile
#! Addison’s disease
#! Irritable Bowel Syndrome (IBS):
$! Mechanism: stress " hyperactive colon.
$! More in females.
$! Presentation: chronic lower abdominal PAIN+ changes in the bowel
habits (diarrhea, constipation, or both).
$! Dx.: Manning and Rome criteria.
Manning Criteria Rome III Criteria
The likelihood of IBS is proportional to the number of manning Should be fulfilled for the last 3 months with symptoms
criteria points present. onset at least 6 month prior to the diagnosis.

1.! Pain relieved by defecation. Recurrent abdominal pain or discomfort for 3


2.! More frequent stools at the onset of day\week for the last 3 months with 2 of the
pain. following:
3.! Looser stool at the onset of pain. 1.! Change in the frequency of stool.
4.! Visible abdominal distention. 2.! Improvement with defecation.
5.! Passage of mucus. 3.! Change of the stool appearance or
6.! Sensation of incomplete evacuation. form.
•! Diagnosis of Chronic Diarrhea:
o! CBC: looking for leukocytosis.
o! Chemistry: looking for electrolyte disturbances.
o! Stool: occult blood.
o! Fecal leukocyte: suggestive of infections.
o! Biopsy for inflammatory bowel disease.
•! Management of Chronic Diarrhea:
o! Treat underlying cause
o! Symptomatic

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References:
1.! Kumar P, Clark M. Kumar & Clark's clinical medicine.
2.! Le T, Krause K. First aid for the basic sciences. New York: McGraw-Hill Medical; 2012.
3.! Le T, Bhushan V, Singh Bagga H. First aid for the USMLE step 2 CK. New York: McGraw-Hill Medical; 2010.
4.! Bergin J. Medicine recall. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2008.
5.! Collins P, Fox C. Gastroenterology. Edinburgh: Mosby; 2008.
6.! Fischer C. Master the boards.
7.! Agabegi S, Agabegi E, Ring A. Step-up to medicine. Philadelphia: Wolters Kluwer/Lippincott Williams &
Wilkins; 2013.

Written By: Haifa Al-Issa. Reviewed By: Roaa Amer.


Haneen Al-Farhan.
Format editor: Roaa Amer.