Updated: 9/4/2022

Diarrhea

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  • Snapshot
    • A 3-year-old boy with no significant past medical history is brought to urgent care for 2 days of watery diarrhea. He had been attending daycare 2 times a week, and several other kids have also experienced similar symptoms. He has had 5-6 bowel movements per day and has not been able to eat much. His parents have been encouraging him to drink oral electrolyte solution. On physical exam, he is noted to have sunken eyes, poor skin turgor, and increased capillary refill time.
  • Introduction
    • Overview
      • acute diarrhea is characterized by acute onset of > 3 bowel movements/day lasting < 14 days and is often caused by infection
      • persistent diarrhea lasts 2-4 weeks
      • chronic diarrhea lasts > 4 weeks and is often caused by underlying conditions such as inflammatory bowel disease or fat malabsorption
  • Epidemiology
    • Incidence
      • very common
      • rotavirus is most common cause of infectious diarrhea worldwide
        • vaccine available
      • acute diarrhea is the second cause of childhood mortality in the world
    • Demographics
      • viral diarrhea is most common in children
        • especially rotavirus and adenovirus
  • Etiology
    • Infections
      • viruses
      • bacteria
      • parasites
    • Drug-induced
      • quinidine
      • colchicine
      • cytotoxic agents
      • chemotherapy
    • Food allergies
    • Toxic ingestions
    • Autoimmune
    • Small intestine bacterial overgrowth, often secondary to scleroderma or diabetes
  • Pathogenesis
    • types of diarrhea
      • exudative/inflammatory diarrhea
        • frequent, small-volume, bloody stools
        • indicates disrupted and inflamed mucosa
        • etiologies
          • infectious (i.e., Shigella, Salmonella, E. coli, Campylobacter, and amebiasis)
          • idiopathic inflammatory bowel disease (ulcerative colitis and Crohn disease)
          • ischemic colitis
      • fatty diarrhea
        • weight loss and greasy or bulky stools that float that are often chronic
        • etiologies
          • fat malabsorption
      • watery diarrhea
        • osmotic diarrhea
          • due to osmotic pull of water into the intestinal lumen
          • etiologies
            • giardiasis
            • laxatives
            • lactose intolerance
        • secretory diarrhea
          • due to active secretion of water
          • etiologies
            • infectious (i.e., enterotoxic E. coli and Vibrio)
            • carcinoid syndrome
            • gastrinoma
            • drugs (i.e., colchicine)
      • Infectious Bloody Vs Watery Diarrhea
      • Bloody Diarrhea
      • Watery Diarrhea
      • Campylobacter
      • E. histolytica
      • Enterohemorrhagic E. coli
      • Enteroinvasive E. coli
      • Non-thypoidal Salmonella
      • Shigella
      • Y. enterocolitica
      • C. difficile
      • C. perfringens
      • Enterotoxigenic E. coli
      • Giardia
      • Cryptosporidium
      • V. cholerae
      • Rotavirus
      • Norovirus
      • Adenovirus
      • S. aureus
      • High Yield Risk Factors
      • Exposure
      • Risk Factors
      • Associated Organisms
      • Daycare
      • Rotavirus, astrovirus, 
      • calicivirus, Campylobacter, Shigella, Giardia, Cryptosporidium
      • Food
      • Dairy
      • Eggs
      • Beef
      • Poultry
      • Pork
      • Seafood
      • Oysters
      • Rice/Pasta
      • Campylobacter and Salmonella
      •  Salmonella 
      •  E. coli
      •  Campylobacter
      •  C. perfringens
      •  Y. enterocolitica
      •  Astrovirus
      •  Vibrio
      •  Calicivirus
      •  Bacillus cereus
      • Water exposure
      • Swimming Pools
      • Contaminated water with cysts
      • Shigella
      • Giardia, E. histolytica, and Cryptosporidium
      • Travel history
      • "Traveler's" diarrhea
      •  Cruise ships
      •  Camping/hiking
      • E. coli, Giardia, Salmonella, Shigella, and Campylobacter
      • Norovirus
      •  Giardia
      • Past medical history
      • Antibiotics/hospitalization
      • C. difficile and rotavirus
      • Pets
      • Dog feces
      •  Turtles/reptiles
      •  Other animals/pets
      • Yersinia enterocolitica
      •  Non-typhoidal Salmonella
      •  Campylobacter
  • Presentation
    • Symptoms
      • common symptoms
        • dehydration
          • lethargy
          • feeling of thirst
        • diarrhea
          • foul-smelling along with stools that float
          • bloody diarrhea
        • other enteric symptoms
          • nausea
          • vomiting
          • abdominal pain/cramping
    • Physical exam
      • inspection
        • dry mucous membranes
        • sunken eyes
        • poor skin turgor
        • delayed capillary refill
  • Studies
    • Acute diarrhea does not routinely require laboratory evaluation, unless clinical presentation includes
      • high fever
      • bloody diarrhea
      • severe abdominal pain
      • requires hospitalization
      • elderly
      • immunocompromised status
    • Serum labs
      • complete blood count
    • Stool studies
      • ova and parasite examination
      • C. difficile toxin
      • leukocyte presence suggests enteroinvasive infection
      • pH < 5.5 usually indicates viral illness and can also indicate lactase deficiency
      • culture
      • enzyme immunoassay for rotavirus and adenovirus antigens
      • latex agglutination assay for rotavirus
  • Differential
    • Chronic diarrhea, which lasts 4 weeks or more, suggests other etiologies, such as fat malabsorption syndrome
    • Radiation injury
      • high doses of radiation classically cause diarrhea and lymphopenia (poor prognosis)
    • Chronic Diarrhea
      • Malabsorption syndromes
      • Celiac disease
      • Lactose intolerance
      • Pancreatic insufficiency
      • Diabetic neuropathy
      • Inflammatory bowel disease
      • Crohn disease
      • Ulcerative colitis
      • Other gastrointestinal causes
      • Microscopic colitis
      • Irritable bowel syndrome
      • Endocrinological
      • Carcinoid
      • Gastrinoma
      • Drug-induced
      • Quinidine
      • Colchicine
      • Chemotherapy
      • Other
      • Severe combined immunodeficiency
      • Arsenic poisoning
      • Vitamin C toxicity
      • Vitamin B3 deficiency
  • Treatment
    • Medical
      • supportive care
        • modalities
          • oral rehydration (preferred)
            • no need for advanced studies in healthy, well-appearing individuals
          • intravenous rehydration
          • electrolyte repletion
      • antibiotics
        • indication
          • for bacterial etiologies causing moderate or severe diarrhea and not responsive to rehydration
          • metronidazole or tinidazole for Giardia infections
          • doxycycline for V. cholerae
          • oral vancomycin for C. difficile infection
      • anti-motility agents
        • indication
          • may prolong certain infectious diarrhea, such as Shigella-induced gastroenteritis
          • acute diarrhea
        • modalities
          • loperamide
          • bismuth salicylate
  • Complications
    • Dehydration
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(M2.GI.17.4671) A 24-year-old woman presents with 3 days of diarrhea. She was recently on vacation in Peru and admits that on her last day of the trip she enjoyed a dinner of the local food and drink. Upon return to the United States the next day, she developed abdominal cramps and watery diarrhea, occurring about 3-5 times per day. She has not noticed any blood or mucous in her stool. Vital signs are stable. On physical examination, she is well appearing in no acute distress. Which of the following is commonly associated with the likely underlying illness?

QID: 107175

Raw oysters

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(0/8)

Soft cheese

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(0/8)

Fried rice

25%

(2/8)

Ground meat

0%

(0/8)

Unwashed fruits and vegetables

75%

(6/8)

M 6 B

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(M2.GI.16.37) A 30-year-old male presents to the emergency department with a complaint of abdominal pain. The patient states he was at a barbecue around noon. Lunch was arranged as a buffet without refrigeration. Within 2 to 3 hours, he had abdominal pain associated with multiple episodes of vomiting, retching, and watery diarrhea. On exam, vital signs are T 99.1, HR 103, BP 110/55, RR 14. Abdominal exam is significant for pain to deep palpation without any rebounding or guarding. There is no blood on fecal occult testing (FOBT). What is the most likely cause of this patient's presentation?

QID: 104922

Salmonella enteritidis

9%

(1/11)

Listeria monocytogenes

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(0/11)

Staphylococcus aureus

91%

(10/11)

Campylobacter jejuni

0%

(0/11)

Vibrio cholerae

0%

(0/11)

M 6 D

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(M2.OMB.4838) A 30-year-old man presents to the emergency department with diarrhea. He states he has had profuse, watery diarrhea for the past 24 hours. He notes that eating and drinking make him defecate so he has refrained from eating. He is otherwise healthy and takes no medications. His temperature is 97.7°F (36.5°C), blood pressure is 84/64 mmHg, pulse is 130/min, respirations are 17/min, and oxygen saturation is 99% on room air. Physical exam reveals dry mucous membranes with an otherwise benign exam. The patient is given 1L of normal saline and drinks 1L of oral fluids. His blood pressure is subsequently 120/70 mmHg and pulse 95/min. Which of the following is the most appropriate next step in management?

QID: 216584

Ciprofloxacin

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Rest and oral rehydration

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Stool culture

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Stool ova and parasite study

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Stool PCR

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M 11

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(M2.OMB.4839) A 44-year-old man presents to the emergency department acutely confused. The patient’s wife states she found him lethargic at home. He has been sick the past week with diarrhea and has been staying home from work. He is otherwise healthy and does not take any medications. His temperature is 97.5°F (36.4°C), blood pressure is 62/32 mmHg, pulse is 185/min, respirations are 25/min, and oxygen saturation is 98% on room air. The patient has profuse, bloody diarrhea while in the emergency department. The patient is given 3L of ringer lactate and subsequently appears less confused, with a blood pressure of 100/70 mmHg. He is able to drink oral fluids and protect his airway. An ECG is performed as seen in Figure A. He continues to have diarrhea while in the emergency department. Which of the following is contraindicated in the management of this patient?

QID: 216585
FIGURES:

Ceftriaxone

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Loperamide

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Magnesium

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Norepinephrine

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(0/0)

Normal saline

0%

(0/0)

M 11

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