Acute Diarrhea

Aka: Acute Diarrhea, Diarrhea, Acute Infectious Diarrhea, Infectious Diarrhea, Bacterial Diarrhea, Acute Inflammatory Diarrhea, Dysentery, Infectious Colitis

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II. Definitions

  1. Gastroenteritis
    1. Inflammation of the Gastrointestinal Tract (Stomache and Small Intestine)
    2. Typical presentation is Vomiting followed by Diarrhea
    3. Most typically secondary to Viral Gastroenteritis
      1. Can also be caused by Bacteria with ingestion of preformed toxin
  2. Diarrhea
    1. Frequent liquid, loose or watery stools
      1. Adults: >200 g/day of stool (at least 3 Bowel Movements daily)
      2. Children: >20 g/kg/day of stool
    2. Timing
      1. Acute Diarrhea: Duration <2 weeks
        1. Considered prolonged when duration >7 days
      2. Persistent Diarrhea: Duration 2 to 4 weeks
      3. Chronic Diarrhea: Duration >4 weeks
        1. Chronic Fatty Diarrhea
        2. Chronic Inflammatory Diarrhea
        3. Chronic Watery Diarrhea

III. Epidemiology

  1. Foodbourne Diarrhea cases: 48 million/year U.S.
  2. As many as 179 million outpatient visits in the U.S. per year
  3. Hospitalizations: 128,000 to 500,000/year U.S
  4. Deaths: 3000 to 5000 per year U.S. (2.5 Million/year worldwide)

IV. Pathophysiology

  1. Small Intestine secretes and reabsorbs 10 liters/day
    1. Extrusion of Chloride from villus crypt cell (cAMP)
    2. Absorption at villus tip
  2. Diarrhea classified as one of 3 types
    1. Watery Diarrhea
      1. Secretory Diarrhea
        1. Stool Sodium high (60-120 meq/L)
        2. Hypersecretion by intestinal crypts
      2. Osmotic Diarrhea (osmotic loss of free water)
        1. Stool Sodium low (30-40 meq/L)
        2. Ingestion of non-digestable agents that draw water from the bowel wall
    2. Inflammatory Diarrhea (Dysentery)
      1. Severe Diarrhea with pus or blood present in the stool
      2. Associated with fever, Abdominal Pain and tenesmus
    3. Fatty Diarrhea (Malabsorption)
      1. See Chronic Diarrhea
      2. Large greasy, frothy pale stools with foul odor
  3. Serum Electrolyte loss
    1. Serum Bicarbonate loss
    2. Serum Potassium loss

V. Causes: Acute Vomiting (Gastroenteritis)

  1. See Vomiting Causes
  2. See Foodborne Illness
  3. Severe Emergency Department cases in adults
    1. Norovirus (26%)
    2. Rotavirus (18%)
    3. Salmonella (5.3%)
    4. Bresee (2012) J Infect Dis 205 (9): 1374-81 [PubMed]

VI. Causes: Acute Diarrhea

  1. See Chronic Diarrhea for systemic medical condition causes of Diarrhea
  2. See Drug-Induced Diarrhea
  3. Noninfectious Causes
    1. See Osmotic Diarrhea
    2. See Secretory Diarrhea
    3. Common Causes
      1. Partial Intestinal Obstruction
      2. Toxic Ingestions
      3. Endocrine Causes (Thyroid disease)
      4. Inflammatory Bowel Disease (and other inflammatory and Allergic Conditions)
        1. Crohn Disease
        2. Ulcerative Colitis
        3. Radiation Enteritis
      5. Drug Withdrawal (e.g. Opioid Withdrawal)
      6. Cholinergic Toxicity (e.g. Organophosphate Poisoning)
      7. Mesenteric Ischemia
  4. Extra-intestinal and non-Gastroenteritis infections
    1. Diverticulitis
    2. Appendicitis
    3. Otitis Media
    4. Sepsis
    5. Sexually Transmitted Disease
  5. Infectious Diarrhea Causes
    1. See Infectious Diarrhea Causes
    2. See Foodborne Illness
    3. See Waterborne Illness
    4. Viruses (30-40% of episodes) - Non-Inflammatory Diarrhea
      1. Norovirus (90% of non-Bacterial diarhea)
      2. Rotavirus (esp. children)
      3. COVID-19
    5. Bacteria and Parasites (20-30% of episodes)
      1. Inflammatory Diarrhea from Bacteria and Parasites (Dysentery)
        1. Campylobacter jejuni (most common Bacteria)
        2. Salmonella
        3. Shigella
        4. Shiga-toxin producing E. coli (e.g. E. coli 0157:H7, Enterohemorrhagic E. coli)
          1. Causes 30% of infectious bloody Diarrhea
        5. Clostridioides difficile
        6. Entamoeba histolytica
        7. Yersinia
      2. Non-Inflammatory Diarrhea from Bacteria and Parasites
        1. Enterotoxigenic E. coli
        2. Clostridium perfringens
        3. Bacillus Cereus
        4. Staphylococcus Aureus
        5. Giardia
        6. Cryptosporidium
        7. Vibrio Cholerae

VII. Risk Factors

  1. See Chronic Diarrhea for systemic medical condition causes of Diarrhea
  2. See Infectious Diarrhea Causes
  3. Recent travel to endemic area
    1. See Traveler's Diarrhea
    2. Travel to a developing area is associated with a 25% chance of developing Diarrhea
    3. Those with Diarrhea in a developing area have an 80% chance of Bacterial Diarrhea
  4. Food associated illness
    1. See Foodborne Illness
    2. Associated with raw meats, poultry, fish, seafood, milk, rice
  5. Wilderness travel (or in developing country)
    1. See Waterborne Illness
    2. Hiking in wilderness areas (especially drinking from mountain streams)
    3. Consider Giardia, Entamoeba histolytica, Cryptospordium
  6. Day care exposure
    1. Consider Rotavirus, Cryptosporidium, Giardia, Shigella
  7. High-risk sexual behavior
    1. See Infectious Diarrhea Causes
    2. Fecal-oral sexual contact: Shigella, Salmonella, Campylobacter, Protozoa
    3. Receptive anal intercourse: Herpes Simplex Virus, Chlamydia, Gonorrhea, Syphilis
  8. Antibiotic use within 6 months or recent hospitalizations
    1. See Clostridium difficile
    2. C. Difficile Incidence in unexplained Diarrhea after 3 or more day hospitalization: 15-20%
    3. Risk of infection after Antibiotics in first month (7-10 fold increased risk)
      1. Risk persists more than 3 months after Antibiotics (2-3 fold increased risk)
    4. Consider Klebsiella oxytoca (uncommon)
      1. Like Clostridium difficile, causes Antibiotic-Associated Diarrhea, that may be hemorrhagic
      2. Improves after stopping Antibiotics and NSAIDs
  9. Immunosuppression (e.g. HIV Infection, Chemotherapy, longterm Corticosteroids, Immunoglobulin A Deficiency)
    1. See Diarrhea in HIV
    2. Consider Cryptosporidium, Microsporida, Isospora, Cytomegalovirus
    3. Consider Mycobacterium Avium Intracellulare complex, Listeria monocytogenes

VIII. History: Diarrhea

  1. See Vomiting
  2. Stool size
    1. Frequent small volume stools
      1. Large Bowel
    2. Frequent large volume stools
      1. Small Bowel
  3. Stool consistency
    1. Rice-water stools (Vibrio Cholerae)
  4. Provocative agents
    1. Foods
    2. Milk
    3. Sorbitol
    4. New medications (see Medication-Induced Diarrhea)
  5. Inflammatory Diarrhea associated findings
    1. Blood or mucous present in stool
    2. Fever (typically absent in Shiga-toxin producing E. coli 0157:H7)
    3. Abdominal Pain
    4. Tenesmus (or Rectal Pain or Proctitis)
  6. Other associated findings
    1. Paresthesias (consider Neurotoxin such as Ciquatera toxin)
  7. Acute symptoms in multiple people with same food exposure (Preformed toxins)
    1. See Foodborne Illness
    2. Symptom onset within 6 hours (presents with Vomiting)
      1. Staphylococcus Aureus (often from cold mayonnaise-based salads)
      2. Bacillus Cereus (meats, rice)
    3. Symptom onset within 8-16 hours (presents with Diarrhea)
      1. Clostridium perfringens (Cooked meats)

IX. Symptoms

  1. Fever
    1. Campylobacter
    2. Salmonella typhi
    3. Shigella
    4. Yersinia
    5. May also occur with Clostridium difficile and Entamoeba histolytica
  2. Abdominal Pain
    1. Campylobacter
    2. Salmonella typhi
    3. Shigella
    4. Shiga-toxin producing E. coli (e.g. E. coli 0157:H7, Enterohemorrhagic E. coli)
    5. Yersinia
    6. Giardia
    7. Norovirus
    8. May also occur with Clostridium difficile and Entamoeba histolytica
  3. Nausea or Vomiting
    1. Shigella
    2. Norovirus
    3. Also occur with Campylobacter, Salmonella, E. coli 0157:H7, Yersinia, Cryptosporidium, Cyclospora, Giardia
  4. Bloody stool
    1. Shiga-toxin producing E. coli (e.g. E. coli 0157:H7, Enterohemorrhagic E. coli)
      1. Causes 30% of infectious bloody Diarrhea
    2. May also occur with Campylobacter, Clostridium difficile, Salmonella, Shigella, Yersinia

X. Exam

  1. See Vomiting
  2. Evaluate for signs of Dehydration
    1. Tachycardia
    2. Dry mucous membranes
    3. Decreased Urine Output
    4. Altered Level of Consciousness
    5. Capillary Refill
    6. Poor Skin Turgor
    7. Sunken Fontanelles (infants)
  3. Eye Exam
    1. Episcleritis
      1. Consider Inflammatory Bowel Disease such as Reiters Syndrome
  4. Thyroid exam
  5. Skin Exam
    1. Erythema Nodosum
      1. Consider Inflammatory Bowel Disease
  6. Abdominal exam
    1. Benign Abdomen despite severe pain
      1. Consider Mesenteric Ischemia (especially if grossly bloody stool)
    2. Bowel sounds
      1. Hyperactive bowel sounds
        1. Typical in Diarrheal illness
      2. Hypoactive bowel sounds
        1. Bowel Obstruction
  7. Rectal Exam
    1. Anal Fissures
      1. Consider Inflammatory Bowel Disease
    2. Bloody stool (occult or gross)
      1. Consistent with Acute Inflammatory Diarrhea
      2. Concurrent fever, Abdominal Pain, tenesmus also suggest Acute Inflammatory Diarrhea
      3. Consider Inflammatory Bowel Disease
      4. Consider Mesenteric Ischemia

XI. Labs

  1. See specific tests for indications
  2. Precautions
    1. Labs are expensive and do not alter management in most cases (in the United States)
    2. Directed history and exam are most useful
  3. General indications for lab testing
    1. Dysentery (Bloody Diarrhea, Fever, Abdominal Pain, Tenesmus)
    2. Sepsis
    3. Persistently more than 6 stools daily
    4. More than 1 week of symptoms without improvement
    5. Hospital admission for Dehydration
    6. History suggestive of specific Parasite or pathogen
    7. Recent travel with moderate to severe Diarrhea (esp. with fever)
    8. Public health implications
      1. Food handlers, healthcare workers or childcare workers
      2. Nursing Home residents
    9. High risk patient
      1. Age >65 years old
      2. Infant <12 months
      3. Pregnancy
      4. Immunocompromised state
      5. Men who have Sex with Men
  4. Labs performed as indicated
    1. Enteric Pathogens Nucleic Acid Test Panels (PCR, NAAT)
      1. May include Campylobacter, Salmonella, Shigella, Vibrio, Yersina, Norovirus, Rotavirus, Shiga-Toxin
      2. Some panels (e.g. Biofire FilmArray) include C. Diff, as well as >20 other Bacteria, Parasites and viruses
    2. Stool Antigens
      1. Giardia lambliaAntigen
        1. Indicated for Diarrhea >7 days and >10 stools/day
      2. CryptosporidiumAntigen
        1. Immunocompromised patients
      3. Clostridium difficile Toxin
        1. Follows hospitalization for >3 days or
        2. Antibiotic use within prior 3 months
      4. RotavirusAntigen
        1. Indicated for defining local outbreak
    3. Medication levels
      1. Theophylline level
      2. Lithium level
    4. Pregnancy Test
      1. Consider in all women of reproductive age with significant gastrointestinal symptoms
    5. Serum Electrolytes (basic metabolic panel)
      1. Normal in 99% of young, healthy adults with Acute Gastroenteritis in the first 24 hours
        1. Olshaker (1989) Ann Emerg Med 18(3): 258-60 [PubMed]
      2. Indications
        1. Prolonged Diarrhea
        2. Dehydration requiring IV fluids
        3. Toxic or ill appearance
        4. Serious comorbid condition
      3. Findings
        1. Hyponatremia
        2. Hypernatremia
        3. Metabolic Acidosis
        4. Hypoglycemia
    6. Other testing to consider
      1. Hepatitis A Serology
      2. Complete Blood Count and Blood Cultures (Sepsis)
  5. Older tests that have mostly been replaced in U.S. by more specific testing as above
    1. Fecal lactoferin
      1. Poor Test Specificity
    2. Fecal Leukocytes
      1. Stool Guaiac has the same Positive Predictive Value to identify Bacterial Diarrhea
      2. Bloody stool without Fecal Leukocytes suggests E coli 0157:H7 or Entamoeba histolytica
      3. Decreased Test Sensitivity with any delay in evaluation (samples easily degrade)
    3. Stool Culture
      1. Replaced by Enteric Pathogens Nucleic Acid Test Panels (PCR)
      2. Expensive and very low test senstitivity (5%)
      3. Indications
        1. Toxic appearance
        2. Prolonged Diarrhea >4 days
        3. Blood or pus in stool (or other signs of Inflammatory Diarrhea)
        4. Immunocompromised patients
    4. Ova and Parasites
      1. Low yield (requires multiple samples)
      2. Specific Stool ParasiteAntigens are preferred with better accuracy
      3. Indications
        1. Travel to developing countries
        2. Watery Diarrhea >7 days

XII. Evaluation: Labs for specific presentations

  1. See Labs and Endoscopy below
  2. Inflammatory Diarrhea or Dysentery
    1. Enteric Pathogens Nucleic Acid Test Panels (PCR) or Stool Cultures (SSCE)
      1. Salmonella including Salmonella typhi
      2. Shigella
      3. Campylobacter
      4. Escherichia coli 0157:H7 (STEC: Shiga Toxin E coli)
        1. Shiga Toxin (if bloody stool)
        2. Avoid Antimicrobial Agents
    2. Clostridium difficile Toxins
      1. Indicated for recent Antibiotics or Chemotherapy
    3. Consider Antibiotic coverage (if not STEC)
      1. Quinolone if suspected Shigellosis
      2. Macrolide for suspected Campylobacter
  3. Nosocomial Diarrhea (after 3 days of hospitalization)
    1. Clostridium difficile Toxins
    2. Enteric Pathogens Nucleic Acid Test Panels (PCR) or SSCE culture
      1. Especially if nosocomial outbreak, age over 65 years, comorbidity or Immunocompromised
    3. Discontinue Antibiotics if possible
    4. Consider Flagyl if worsens or persists
  4. Persistent Diarrhea >7 days (esp. Immunocompromised)
    1. Fecal Lactoferrin (preferred over Fecal Leukocytes)
      1. High Test Sensitivity for SSCE Bacteria (up to 93%) as well as increased in Inflammatory Bowel Disease
    2. Parasitic Infection evaluation (esp. if adominal bloating, Eructation, Nausea)
      1. Giardia
      2. Cryptosporidium
      3. Cyclospora
      4. Isospora belli
  5. Immunocompromised
    1. See Diarrhea in HIV
    2. Consider Clostridium difficile Toxin (especially if recent Antibiotics or hospitalization)
    3. Consider Nucleic Acid Amplification Tests or SSCE Stool Culture (especially if Inflammatory Diarrhea)
    4. Consider Parasitic Infections (e.g. Cryptosporidium, especially if present >7 days)
    5. Consider other opportunistic infections (especially in HIV positive patients)
      1. Microsporidia
      2. Mycobacterium Avium Intracellulare Complex
      3. Cytomegalovrius

XIII. Evaluation: Endoscopy

  1. Indications
    1. Unclear diagnosis with persistent symptoms
    2. Suspected Tuberculosis
    3. Diffuse colitis (e.g. Clostridium difficile)
    4. Noninfectious Diarrhea cause evaluation (e.g. Inflammatory Bowel Disease)
    5. Does not distinguish Infectious from Inflammatory Diarrhea
    6. Immunocompromised condition (e.g. AIDS, HIV Infection)
  2. Sexually Transmitted Disease (STD)
    1. Lesions in Distal 15 cm in homosexual men
    2. Herpes Virus
    3. NeisseriaGonorrhea
      1. Nonspecific findings limited to Rectum
      2. Biopsy and Culture show superficial exudates
    4. Syphilis
      1. Rectal Papules, Chancres, and ulcers
    5. Chlamydia (Lymphogranuloma venereum)
      1. Similar to Inflammatory Bowel Disease

XIV. Management: Vomiting

  1. See Vomiting
  2. See Antiemetic
  3. See Vomiting Management in Children
  4. See Vomiting in Pregnancy

XV. Management: General

  1. See Diarrhea Management in Children
  2. See Traveler's Diarrhea Management
  3. Intravenous Fluid indications
    1. Severe Dehydration
    2. Shock
    3. Sepsis
    4. Altered Mental Status
  4. Electrolyte solutions containing Glucose (not Artificial Sweetener)
    1. Glucose assists with water reabsorption
    2. Oral Rehydration Solution (ORS) is preferred but may not be tolerated well
      1. See Oral Rehydration Solution
      2. Pedialyte, Rehydrate or Infalyte in children
    3. Gatorade or similar
      1. May be used as alternative (but not ideally formulated to match Diarrheal losses)
      2. Requires 1:1 dilution with water to half strength
  5. Dietary guidance
    1. Early reintroduction of food is recommended
      1. Decreases Diarrhea severity and duration
      2. Restores nutritional status earlier
      3. Duggan (1997) J Pediatr 131(6): 801-8 [PubMed]
    2. BRAT diet
      1. Includes Bananas, rice, apple sauce, toast, soup, crackers
      2. Reasonable and non-harmful, but not evidence-based
      3. Likely too restrictive, and patients are now encouraged to eat what they will tolerate
    3. Avoid provocative agents that worsen Diarrhea
      1. Caffeine
      2. Sorbitol
      3. Lactose and dairy products
        1. Typically restricted with Diarrheal illness, but not an evidence-based recommendation
  6. Adjunctive measures
    1. Probiotics
      1. Show benefit in Pediatric Diarrhea, but not verified in adults
      2. Consider Lactobacillus GG (Culturelle) or Saccharomyces boulardii (Florastor)
      3. Decreases Diarrhea duration by one day, and decreases risk of prolonged Diarrhea
      4. Collinson (2020) Cochrane Database Syst Rev (12):CD003048 [PubMed]
    2. Zinc
      1. Reduces severity of Pediatric Diarrhea in developing countries, but not evaluated in adults in U.S.
  7. Antidiarrheal medications
    1. Loperamide (Imodium)
      1. Antimotility properties
      2. Do not use Loperamide if fever or bloody stool are present (Inflammatory Diarrhea)
    2. Bismuth Subsalicylate (Pepto-Bismol)
      1. May be used in Inflammatory Diarrhea
      2. Antisecretory properties
      3. Contraindicated in children (contains Salicylates)

XVI. Management: Antibiotics

  1. Use is controversial with potentially serious complications (e.g. Hemolytic Uremic Syndrome)
  2. Advantages
    1. Antibiotics appear to shorten Diarrhea course by 24 hours
    2. Effect is regardless of stool guiaic, fecal Leukocyte or Stool Culture result
  3. Disadvantages
    1. Most Acute Diarrheal is non-infectious, viral or self-limited
    2. Increased Antibiotic Resistance
    3. Increased risk of prolonged carrier state with certain infections (e.g. Salmonella)
    4. Increased risk of developing Hemolytic Uremic Syndrome with E. coli 0157:H7
    5. Increased risk of Clostridium difficile
  4. Contraindications
    1. Grossly bloody Diarrhea or other signs of Escherichia coli 0157:H7 (STEC: Shiga Toxin E coli)
      1. Risk of Hemolytic Uremic Syndrome increases with Antibiotic use
  5. Indications
    1. Findings suggestive of Bacterial Diarrhea
      1. Guiaic positive stool (not grossly bloody stool)
      2. Fecal Leukocyte positive
    2. Overseas travel
    3. Diarrheal illness lasting longer than 10-14 days
    4. Immunocompromised patients
    5. Severe illness or Sepsis
    6. Age over 65 years old
  6. Empiric Antibiotics
    1. See Traveler's Diarrhea Management
    2. Ciprofloxacin (adults)
      1. Empiric adult dose: 500 to 1000 mg once or 500 mg twice daily for 3 days
      2. Preferred agent for E. coli (ETEC, EIEC), Shigella
      3. Also covers Campylobacter, Salmonella, Yersinia, Cryptosporidium
    3. Trimethoprim-Sulfamethoxazole (Septra, Bactrim)
      1. Empiric adult dose: One DS twice daily for 3-5 days
      2. Preferred agent for Cyclospora or Isospora
      3. Also covers E. coli (ETEC, EIEC), Salmonella, Shigella, Vibrio Cholerae, Yersinia (Septra has higher resistance rates)
      4. Used in combination with Aminoglycoside to treat non-Vibrio Cholerae
    4. Azithromycin
      1. Empiric adult dose: 500 mg daily for 3 days
      2. Preferred agent for Campylobacter
      3. Also covers E. coli (ETEC), Salmonella, Shigella, Vibrio Cholerae
    5. Third Generation Cephalosporin (e.g. Cefdinir, Cefpodoxime)
      1. Consider in children for Shigella, Salmonella
      2. Ceftriaxone is a first line agent in Non-Typhoidal Salmonella and Shigella
      3. Covers Yersinia enterocolitica and Salmonella enterica, typhi or paratyphi (Ceftriaxone)
  7. Other Antibiotics used for specific indications
    1. Metronidazole
      1. Preferred agent for Entamoeba histolytica
      2. Alternative agent for Clostridium difficile (but high failure rate), and Giardia
    2. Azithromycin
      1. Campylobacter (treat with 3-5 day course)
      2. Shigella
    3. Ciprofloxacin
      1. Non-Typhoidal Salmonella (other Fluoroquinolones are also effective)
      2. Salmonella enterica, typhi or paratyphi
      3. Shigella (Reduces duration and shedding)
      4. Campylobacter (alternative agent)
      5. Yersinia enterocolitica
    4. Doxycycline
      1. Preferred agent for Vibrio Cholerae
      2. Used in combination with Ceftriaxone to treat non-Vibrio Cholerae
      3. Also covers Yersinia (when combined with an Aminoglycoside)
    5. Oral Vancomycin
      1. Alternative agent for Clostridium difficile
    6. Fidaxomicin (Dificid)
      1. Preferred agent for Clostridium difficile
    7. Amoxicillin
      1. Non-Typhoidal Salmonella
  8. Antiparasitic Agents used for specific indications
    1. See Metronidazole indications above
    2. Albendazole (Albenza)
      1. Preferred agent for Microsporida
    3. Tindazole (Tindazole)
      1. Covers Entamoeba histolytica (when treated in combination with Paromomycin)
      2. Preferred agent for Giardia
    4. Nitazoxanide (Alinia)
      1. Covers Cryptosporidium
      2. Preferred agent for Giardia

XVII. Management: Admission Criteria

  1. Severe Diarrhea with difficulty maintaining hydration
  2. Very young or very old
  3. Severe comorbid illness
  4. Severe pain
  5. High fever
  6. Intractable Vomiting

XVIII. Prevention

  1. See Water Disinfection
  2. See Traveler's Diarrhea Prevention
  3. See Foodborne Illness Prevention
  4. Hand Washing
    1. Wash with soap and water for at least 20 seconds ("Mary had a little lamb...") before rinsing
    2. Decreases Infectious Diarrhea Incidence by one third
    3. Ejemot (2008) Cochrane Database Syst Rev (1):CD004265 [PubMed]
  5. Healthcare workers and food workers should not return to work until symptoms have resolved for 48 hours
  6. Vaccinations
    1. Rotavirus (part of Primary Series in U.S. for infants)
    2. Typhoid Vaccine (frequently required for overseas Travel Immunizations)
    3. Cholera Vaccine
  7. CDC Reportable Illnesses (National Notifiable Diseases Surveillance System or NNDSS)
    1. https://wwwn.cdc.gov/nndss/data-and-statistics.html
    2. Listeria monocytogenes
    3. Typhoid Fever (Salmonella typhi)
    4. Trichinellosis
    5. Cyclospora
    6. Vibrio
    7. Shiga-toxin producing E. coli (e.g. E. coli 0157:H7, Enterohemorrhagic E. coli)
    8. Giardiasis
    9. Foodborne Botulism
    10. Shigella
    11. Post-Diarrhea; Hemolytic Uremic Syndrome

XIX. Complications: Postinfectious Diarrhea Conditions

  1. Erythema Nodosum
  2. Glomerulonephritis
  3. Guillain-Barre Syndrome
  4. Hemolytic Anemia
  5. Hemolytic Uremic Syndrome
  6. IgA Nephropathy
  7. Lactose Intolerance (transient)
  8. Meningitis
  9. Reactive Arthritis
  10. Postinfectious Irritable Bowel Syndrome
  11. Bowel Perforation

XX. Resources

  1. IDSA Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea (2017)
    1. https://academic.oup.com/cid/article/65/12/e45/4557073

XXI. References

  1. Glauser and Schafer (2020) Crit Dec Emerg Med 34(1):3-12
  2. May and Mason in Herbert (2021) EM:Rap 21(6): 15-6
  3. Herbert (2012) EM:RAP-C3 2(4): 2
  4. Barr (2014) Am Fam Physician 89(3): 180-9 [PubMed]
  5. Guerrant (2001) Clin Infect Dis 32:331-48 [PubMed]
  6. Meisenheimer (2022) Am Fam Physician 106(1): 72-80 [PubMed]
  7. Scallen (2011) Emerg Infect Dis 17(1): 7-15 [PubMed]
  8. Shane (2017) Clin Infect Dis 65(12): e45-80 [PubMed]

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Related Studies

Ontology: Diarrhea (C0011991)

Definition (CCC) Abnormal frequency and fluidity of feces
Definition (MEDLINEPLUS)

Diarrhea means that you have loose, watery stools more than three times in one day. You may also have cramps, bloating, nausea and an urgent need to have a bowel movement.

Causes of diarrhea include bacteria, viruses or parasites, certain medicines, food intolerances and diseases that affect the stomach, small intestine or colon. In many cases, no cause can be found.

Although usually not harmful, diarrhea can become dangerous or signal a more serious problem. You should talk to your doctor if you have a strong pain in your abdomen or rectum, a fever, blood in your stools, severe diarrhea for more than three days or symptoms of dehydration. If your child has diarrhea, do not hesitate to call the doctor for advice. Diarrhea can be dangerous in children.

NIH: National Institute of Diabetes and Digestive and Kidney Diseases
Definition (NCI) Watery bowel movements.(NICHD)
Definition (NCI_NCI-GLOSS) Frequent and watery bowel movements.
Definition (NCI_CTCAE) A disorder characterized by frequent and watery bowel movements.
Definition (NAN) Passage of loose, unformed stools
Definition (MSH) An increased liquidity or decreased consistency of FECES, such as running stool. Fecal consistency is related to the ratio of water-holding capacity of insoluble solids to total water, rather than the amount of water present. Diarrhea is not hyperdefecation or increased fecal weight.
Definition (CSP) increased liquidity or decreased consistency of feces, such as running stool; fecal consistency is related to the ratio of water-holding capacity of insoluble solids to total water, rather than the amount of water present; diarrhea is not hyperdefecation or increased fecal weight.
Concepts Sign or Symptom (T184)
MSH D003967
ICD9 787.91
ICD10 R19.7
SnomedCT 267060006, 162108007, 162103003, 267061005, 139383004, 162105005, 139381002, 300388003, 62315008
LNC MTHU013347, LA15424-7
English Diarrheas, DIARRHOEA, STOOLS LOOSE, Diarrhea symptom NOS, Diarrhea symptoms, Diarrhoea symptom NOS, Diarrhoea symptoms, diarrhea, diarrhea (symptom), Diarrhea NOS, Diarrhoea NOS, Diarrhea, unspecified, Diarrhea [Disease/Finding], rndx diarrhea (diagnosis), rndx diarrhea, loose bowel motion, watery stools, bowels loose movement, watery stool, bowel loose movements, diarrheas, Runs(diarrhoea), diarrhea symptoms, diarrhea running, loose bowel movement, diarrhoea symptoms, symptoms diarrhea, The runs, The trots, Diarrhoea (finding), Diarrhea symptom NOS (finding), Finding of diarrhea (finding), Diarrhoea (disorder), Finding of diarrhoea, Finding of diarrhea, Diarrhoea symptoms (finding), Loose stools, DIARRHEA, Diarrhoea, D - Diarrhea, D - Diarrhoea, Loose bowel movement, Loose bowel motions, Observation of diarrhea, Observation of diarrhoea, Diarrhea (finding), Diarrhea, NOS, Diarrhea symptoms (finding), Diarrhea, Runs(diarrhea), diarrhoea, runs(diarrhea), runs(diarrhoea), Diarrhea symptom NOS (context-dependent category), Diarrhea symptoms (context-dependent category), Diarrhea symptom (finding), Diarrhea symptom, Diarrhoea symptom
French DIARRHEE, Diarrhée SAI, SELLES LIQUIDES, Diarrhée
Portuguese DIARREIA, Diarreia NE, FEZES LIQUIDAS, Diarreia
Spanish DIARREA, síntoma de diarrea (hallazgo), síntoma de diarrea, Diarrea NEOM, síntoma de diarrea, SAI (categoría dependiente del contexto), síntomas de diarrea (categoría dependiente del contexto), síntomas de diarrea, HECES BLANDAS, síntoma de diarrea, SAI, síntoma de diarrea, SAI (hallazgo), hallazgo de diarrea (hallazgo), hallazgo de diarrea, diarrea (hallazgo), diarrea, Diarrea
Dutch diarree NAO, diarree, Diarree
German Diarrhoe NNB, DURCHFALL, STUHLERWEICHUNG, Diarrhoe, Durchfall
Italian Diarrea NAS, Crisi diarroica, Diarrea
Japanese 下痢, 下痢ＮＯＳ, ｹﾞﾘ, ｹﾞﾘNOS
Swedish Diarre
Czech diarea, průjem, Průjem NOS, Průjem
Finnish Ripuli
Russian DIAREIA, ДИАРЕЯ
Croatian PROLJEV
Polish Biegunka, Rozwolnienie
Hungarian Diarrhoea, Diarrhoea k.m.n., Hasmenés, Hasmenés k.m.n.
Norwegian Diaré
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Dysentery (C0013369)

Definition (MSH) Acute inflammation of the intestine associated with infectious DIARRHEA of various etiologies, generally acquired by eating contaminated food containing TOXINS, BIOLOGICAL derived from BACTERIA or other microorganisms. Dysentery is characterized initially by watery FECES then by bloody mucoid stools. It is often associated with ABDOMINAL PAIN; FEVER; and DEHYDRATION.
Concepts Disease or Syndrome (T047)
MSH D004403
ICD9 009.2
SnomedCT 186165000, 154279005, 186167008, 154268000, 266180003, 266173000, 111939009, 19213003, 236076004
English Dysentery, Infectious diarrhoea NOS, INFECT DIARRHEAL DIS, infectious diarrhea, infectious diarrhea (diagnosis), Diarrhea infectious, Diarrhoea infectious, Dysentery NOS, Dysyntery, Infectious diarrhea NOS, Dysentery [Disease/Finding], dysyntery, dysentery, dysenteries, infectious diarrhoea, Diarrhoea: [infectious] or [travellers], Infectious diarrhoea NOS (disorder), Diarrhoea: [infectious] or [travellers] (disorder), Diarrhea: [infectious] or [travellers], Diarrhea-infective NOS, Diarrhoea-infective NOS, Infectious diarrhea NOS (disorder), Dysentery (diagnosis), intestinal infections dysentery, Diarrheal Disease, Infectious, Infectious Diarrheal Diseases, Infectious Diarrheal Disease, Infectious diarrhea, Infectious diarrhoea, Infective diarrhea, Infective diarrhoea, Dysentery (disorder), Infectious diarrheal disease (disorder), Infectious diarrheal disease, Infectious diarrhoeal disease, Infective diarrhea (disorder), diarrhea; infectious, infectious; diarrhea, Dysentery, NOS, Infectious diarrheal disease, NOS, Infectious diarrhoeal disease, NOS, Infectious diarrheal disease NOS
Dutch infectieuze diarree, dysenterie NAO, diarree; infectieus, infectieus; diarree, diarree infectieus, dysenterie, Dysenterie
French Dysentérie SAI, Diarrhée infectieuse, Dysenterie, Maladie diarrhéique infectieuse
German Ruhr NNB, Diarrhoe, infektioes, infektioese Diarrhoe, Diarrhoe infektioes, Dysenterie, Ruhr
Italian Dissenteria NAS, Diarrea infettiva, Dissenteria
Portuguese Disenteria NE, Diarreia infecciosa, Disenteria
Spanish Disentería NEOM, diarrea infecciosa, SAI (trastorno), diarrea infecciosa, SAI, Infectious diarrhoea NOS, Infectious diarrhea NOS, diarrea infecciosa (trastorno), diarrea infecciosa, disentería (trastorno), disentería, enfermedad diarreica infecciosa (trastorno), enfermedad diarreica infecciosa, Diarrea infecciosa, Disentería
Japanese 感染性下痢, 赤痢ＮＯＳ, ｾｷﾘ, ｾｷﾘNOS, ｶﾝｾﾝｾｲｹﾞﾘ, 赤痢
Swedish Dysenteri
Czech dyzentérie, Infekční průjem, Průjem infekčního původu, Dyzenterie, Dyzenterie NOS, úplavice, dysenterie, dyzenterie
Finnish Dysenteria
Russian DIZENTERIIA, ДИЗЕНТЕРИЯ
Croatian DIZENTERIJA, SRDOBOLJA, INFEKTIVNA CRIJEVNA BOLEST
Polish Czerwonka
Hungarian Fertőző hasmenés, fertőzéses hasmenés, dysenteria k.m.n., dysenteria, Vérhas, Hasmenés, fertőző
Norwegian Dysenteri
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Infectious colitis (C0277524)

Definition (NCI) A viral or bacterial infectious process affecting the large intestine.
Concepts Disease or Syndrome (T047)
ICD10 A09
SnomedCT 39341005
English septic colitis (diagnosis), septic colitis, Infectious Colitis, Infectious colitis NOS, Colitis;infectious, infectious colitis, infective colitis, infectious colitis (diagnosis), Infectious colitis, Infective colitis, Septic colitis, Infectious colitis (disorder), colitis; infectious, colitis; septic, infectious; colitis, septic; colitis, Infectious colitis, NOS, Septic colitis, NOS
Czech Infekční kolitida
Dutch infectieuze colitis, colitis; infectieus, colitis; septisch, infectieus; colitis, septisch; colitis
French Colite infectieuse
German infektioese Kolitis
Hungarian Fertőző colitis
Italian Colite infettiva
Japanese 感染性大腸炎, ｶﾝｾﾝｾｲﾀﾞｲﾁｮｳｴﾝ
Spanish Colitis infecciosa, colitis infecciosa (trastorno), colitis infecciosa, colitis séptica
Portuguese Colite infecciosa
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Acute diarrhea (C0740441)

Concepts Disease or Syndrome (T047)
SnomedCT 409966000
Dutch acute diarree
French Diarrhée aiguë
German akute Diarrhoe
Italian Diarrea acuta
Portuguese Diarreia aguda
Spanish Diarrea aguda, diarrea aguda (trastorno), diarrea aguda
Czech Akutní průjem
Japanese 急性下痢, ｷｭｳｾｲｹﾞﾘ
English acute diarrhea, Acute diarrhea, Acute diarrhoea, Acute diarrhea (disorder), Diarrhea;acute, Diarrhoea;acute, acute diarrhoea
Hungarian Acut hasmenés
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Bacterial diarrhoea (C0849784)

Concepts Disease or Syndrome (T047)
English Bacterial diarrhea, Bacterial diarrhoea, Diarrhoea;bacterial, bacterial diarrhea, bacterial; diarrhea, diarrhea; bacterial, diarrhea; specified organism, bacterial, Diarrhea;bacterial, bacterial diarrhoea
Dutch bacteriële diarree, bacterieel; diarree, diarree; bacterieel, diarree; gespecificeerd organisme, bacterieel
French Diarrhée bactérienne
German bakterielle Diarrhoe
Italian Diarrea batterica
Portuguese Diarreia bacteriana
Spanish Diarrea bacteriana
Japanese 細菌性下痢, ｻｲｷﾝｾｲｹﾞﾘ
Czech Bakteriální průjem
Hungarian Bacterialis diarrhoea, bacterialis hasmenés
Derived from the NIH UMLS (Unified Medical Language System)

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