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Normal bowel frequency ranges from three times a day to three times a week in the normal population. Worldwide, acute diarrhea constitutes a major cause of morbidity and mortality, especially among the very young, very old, and infirm.
Diarrhea is more prevalent among adults who are exposed to children and non-toilet-trained infants, particularly in a daycare setting. Approximately 8-9 L of fluid enters the intestines daily – 1-2 L represents food and liquid intake, and the rest is from endogenous sources such as salivary, gastric, pancreatic, biliary, and intestinal secretions.
Acute watery diarrhea is most commonly seen with traveler's diarrhea caused by enterotoxigenic E.
Exudative diarrhea results from extensive injury of the small bowel or colon mucosa as a result of inflammation or ulceration, leading to a loss of mucus, serum proteins, and blood into the bowel lumen. Noninfectious causes of diarrhea include: inflammatory bowel disease, irritable bowel syndrome, ischemic bowel disease, partial small bowel obstruction, pelvic abscess in the rectosigmoid area, fecal impaction, carcinoid syndrome, food allergies, the ingestion of poorly absorbable sugars such as lactulose, and acute alcohol ingestion. Patients ingesting toxins or those with toxigenic infection typically have nausea and vomiting as prominent symptoms, along with watery diarrhea but rarely have a high fever. Infection with invasive bacteria such as Campylobacter, Salmonella, and Shigella spp., and organisms that produce cytotoxins, such as C. Hemolytic-uremic syndrome and thrombotic thrombocytopenic purpura can occur in infections with enterohemorrhagic E. Epidemiologic risk factors should be investigated for certain diarrheal diseases and their spread. Conducting a careful interview can provide valuable clues that will aid in diagnosing and choosing the most appropriate and cost- effective investigation. The presence of blood is a useful clue, suggesting infection by invasive organisms, inflammation, ischemia, or neoplasm. A medical evaluation of acute diarrhea is not warranted in the previously healthy patient if symptoms are mild, moderate, spontaneously improve within 48 hours, and are not accompanied by fever, chills, severe abdominal pain, or blood in the stool.
The physical examination in acute diarrhea is helpful in determining the severity of disease and hydration status. The history and physical examination can help lead to a diagnosis but, for treatment of some organisms, a specific diagnosis is required, which will lead to more specific therapy and prevention of unneeded interventions. Stool evaluation for fecal leukocytes (or lactoferrin, a byproduct of white blood cells) is a useful initial test because it may support a diagnosis of inflammatory diarrhea.
Indications for stool culture are bloody diarrhea, a toxic-appearing patient (fever, severe abdominal pain), possible epidemic, history of traveler's diarrhea, immunosuppression, or persistent diarrhea. Stool testing for ova and parasites should be done if the patient is at risk for parasitic infection.
When organisms are not identified on stool cultures for ova and parasites, a sigmoidoscopy should be performed and biopsies obtained. The principal components of the treatment of acute diarrhea are fluid and electrolyte replacement, dietary modifications, and drug therapy. In most cases of acute diarrhea, fluid and electrolyte replacement are the most important forms of therapy. Bismuth subsalicylate, somewhat less effective than loperamide, is effective in relieving symptoms of diarrhea, nausea, and abdominal pain in patients with traveler's diarrhea.
Because most patients have mild, self-limited disease caused by viruses or noninvasive bacteria, routine empirical treatment is not warranted.
Diarrhea is one of the most common illnesses in all age groups and is second only to the common cold as a cause of lost days of work or school. Acute diarrhea is a common problem worldwide, with high morbidity and mortality in high-risk groups, such as the very young, older adults, and immunocompromised individuals. Infectious agents are responsible for most cases of acute diarrhea, and may act via numerous mechanisms.
Prevention of dehydration is the most important therapeutic intervention for the management of individuals with acute diarrhea. The use of nonspecific antidiarrheals, especially loperamide, is safe for most cases of acute diarrhea. Salmonella has its outbreaks here and there, often transmitted in contaminated eggs or mayonnaise. As discussed elsewhere these are by no means the only pathogens that lead to gastroenteritis as can be seen from this link. In contrast to this in the case of food poisoning after a meal contaminated with staphylococcus aureus, symptoms of severe nausea and vomiting occur 2 to 8 hours following the meal, but the diarrhea is non bloody. These lead to acute abdominal pain with initially watery diarrhea, which within 24 hours turns into a bloody diarrhea. In Campylobacter infection there is initially abdominal pain and diarrhea similar to shigellosis or salmonellosis with blood in the stool.
Early treatment with the appropriate antibiotic, based on culture and sensitivity results, stops the diarrhea in 2 days and reduces the stool volumes to about half. People who had typhoid fever, but thought that it was a viral gastroenteritis and treated it at home, develop a high percentage of carrier state. Abdominal pain may develop more and there could be several complications developing as he bacteria cause ulcerations in the gut. Once the acute phase is over, this type of patient needs to have an elective cholecystectomy with antibiotic coverage before and 2 weeks after the surgery, after which usually the disease is conquered. Clostridium perfringes is a particularly vicious bacterium as it produces a toxin that eats through the wall of either the small or large bowel.
However, it appears that a compromised immune status is required for it to occur and this may be the reason why it occurs more commonly in starved populations in Central and South America, in some parts of Africa and in Asia.
This outline is only a teaching aid to patients and should stimulate you to ask the right questions when seeing your doctor.
Increased stooling, with stool consistency less solid than normal, constitutes a satisfactory, if somewhat imprecise, definition of diarrhea.
It is also more prevalent in travelers to tropical regions, homosexual males, persons with underlying immunosuppression, and those living in nonhygienic environments who are exposed to contaminated water or foods.
Most of the fluid, about 6-7 L, is absorbed in the small intestine, and only about 1-2 L is presented to the colon. Risk factors for this type of transmission include improper disposal of feces, lack of proper hand washing following defecation, and contact with feces before handling food.

Increased fecal water and electrolyte excretion results from impaired water and electrolyte absorption by the inflamed intestine rather than from secretion of water and electrolytes into the exudates. Diarrhea is one of the most frequent adverse effects of prescription medications; it is important to note that drug-related diarrhea usually occurs after a new drug is initiated or the dosage increased.
Diarrhea caused by small intestine disease is typically high volume, watery, and often associated with malabsorption. Important clinical features include: abrupt versus gradual onset of symptoms, symptom duration, including bowel movement frequency, stool quantities, dysentery with fever, tenesmus, hematochezia or pus in the stool, signs of volume depletion (including thirst, tachycardia,and orthostasis), decreased urine output, skin turgor, and lethargy or confusion.
Vomiting that begins within 6 hours of ingesting a food should suggest food poisoning caused by preformed toxin from bacteria such as S.
These risk factors include: recent travel to an underdeveloped area, daycare center exposure, consumption of raw meat, eggs, shellfish, and unpasteurized milk products, contact with reptiles or pets with diarrhea, a history of other ill people in a shared dormitory facility, recent antibiotic use, and a history of HIV or medically induced immunosuppression. Acute diarrheas are usually infectious in origin and, for the most part, resolve with or without intervention before a diagnosis is made. Large-volume diarrhea suggests small bowel or proximal colonic disease, whereas small frequent stools associated with urgency suggest left colon or rectal disease.
On the other hand, evaluation is indicated if symptoms are severe or prolonged, the patient appears toxic, there is evidence of colitis (occult or gross blood in the stools, severe abdominal pain or tenderness, and fever), or empirical therapy has failed. Fecal testing should be performed in patients with a history of diarrhea longer than 1 day who have the following symptoms: fever, bloody stools, systemic illness, recent or remote antibiotic treatment, hospital admission, or signs of dehydration as described earlier. If the test is negative, stool culture may not be necessary, but culture is indicated if the test is positive. Multiple stool samples should be collected at different times because shedding of parasites may be intermittent. Mucosal biopsy is helpful in differentiating infectious colitis from inflammatory bowel disease. All recommendations agree with the guidelines on acute infectious diarrhea in adults published by the American College of Gastroenterology. If patients are otherwise healthy and are not dehydrated, adequate oral intake can be achieved with soft drinks, fruit juice, broth, soup, and salted crackers. The most effective agents are the opioid derivatives-loperamide, diphenoxylate-atropine, and tincture of opium. Bismuth subsalicylate is contraindicated in HIV-infected patients because it may cause bismuth encephalopathy.
Empirical treatment is indicated for those patients with suspected invasive bacterial infection, traveler's diarrhea, or immunosuppression. Diagnostic studies are warranted for patients with fever or bloody diarrhea, or if the affected individual is immunocompromised. Caution in use of these agents is urged when there is fever, chills, or bloody diarrhea, or when Clostridium difficile is suspected (diarrhea occurring after antibiotic use). Antibiotics may also be used for early Campylobacter infection and for suspected or confirmed cases of C.
Hospitalizations involving gastroenteritis in the United States, 1985: the special burden of disease among the elderly. The more common among these are cholera, a type of gastroenteritis that is often found after wars and disasters when the drinking water is contaminated. But necrotizing enteritis and shigellosis are also not infrequently found when stool samples of people with diarrhea are sent in for analysis and culture. With botulism there is an abrupt onset of feeling nauseous, vomiting and experiencing abdominal pain typically about 18 to 36 hours after ingesting the contaminated food.
If carriers of Salmonella work in the food industry (which is unlawful), they could cause a host of new infections. In the small intestine( distal ileum), the ulcerations may now cause bloody diarrhea (about 3rd week), but if one of the ulcers goes deep enough this can suddenly perforate and cause an acute abdomen, which is a surgical emergency. Outbreaks of this disease have been linked in third world countries to consumption of contaminated dried pork that was not cooked properly. But it also occurs in leukemia, AIDS and chronically debilitated patients as well as in low weight newborns and younger children. Acute diarrhea is defined as three or more stools per day of decreased form from the normal, lasting for less than 14 days.
Other risk factors include improper food hygiene, inadequate food refrigeration, food exposure to flies, and consumption of contaminated water.
Yersinia infection and other enteric bacterial infections may be accompanied by Reiter's syndrome (arthritis, urethritis, and conjunctivitis), thyroiditis, pericarditis, or glomerulonephritis. In cases of homosexual males, in addition to immunosuppression, there are two other disease transmission routes that lead to an increased susceptibility to infectious agents that cause diarrhea.
All current and recent medications should be reviewed, specifically new medications, antibiotics, antacids, and the possibility of alcohol abuse. Vital signs (including temperature and orthostatic evaluation of pulse and blood pressure) and signs of volume depletion (including dry mucous membranes, decreased skin turgor, and confusion) should be carefully evaluated. However, clinicians should remember that inflammatory diarrhea with a noninfectious cause, such as inflammatory bowel disease, ischemic or radiation-induced colitis, and diverticulitis, can be positive for stool leukocytes. Multiple stool cultures are usually not necessary because bacteria usually shed continuously. Imaging studies may be required in patients with severe disease in order to rule out intestinal perforation, ileus or evidence of colitis. In those with excessive fluid losses and dehydration, more aggressive measures such as IV fluids or oral rehydration therapy with isotonic electrolyte solutions containing glucose or starch should be instituted.
Patients should be encouraged to take frequent feedings of fruit drinks, tea, flat carbonated beverages, and soft, easily digested foods such as bananas, applesauce, rice, potatoes, noodles, crackers, toast, and soup. These agents inhibit intestinal peristalsis, facilitating intestinal absorption, and have antisecretory properties. Other complications can set in such as meningitis, septic arthritis , enlarged liver and spleen and bacterial endocarditis(heart valve infection). In hospital intravenous 3rd generation cephalosporins (cefaperazone or cefotriaxone) are given.
Symptoms range from mild diarrhea to acute vomiting and acute abdominal pain with subsequent shock from septicemia or peritonitis with bowel perforation.
Although many organisms simply impair the normal absorptive processes in the small intestine and colon, others organisms, such as Vibrio cholerae, secrete a toxin that causes the small intestinal cells to secrete, rather than absorb, fluid and electrolytes.

Multiple host factors that determine the level of illness once exposure to infectious agents has occurred include: age, personal hygiene, gastric acidity and other barriers, intestinal motility, enteric microflora, immunity, and intestinal receptors. Diarrhea caused by colonic involvement is more often associated with frequent small-volume stools, the presence of blood, and a sensation of urgency. Yersinia organisms often infect the terminal ileum and cecum and manifest with right lower quadrant pain and tenderness suggesting acute appendicitis. Enteric fever, caused by Salmonella typhi or Salmonella paratyphi, is a severe systemic illness manifested initially by prolonged high fevers, prostration, confusion, and respiratory symptoms, followed by abdominal tenderness, diarrhea, and rash. These include an increased rate of fecal-oral transmission of all infectious agents spread by this route, including Shigella, Salmonella, Campylobacter, and intestinal protozoa and anal intercourse. Nutritional supplements should also be reviewed, including the intake of sugar-free foods (containing nonabsorbable carbohydrates), fat substitutes, milk products, shellfish, and heavy intake of fruits, fruit juices, or caffeine. A careful abdominal examination, to evaluate for tenderness and distention, and a stool examination to evaluate for grossly bloody stools are warranted. Further investigations will depend on the results of sigmoidoscopy, severity of diarrhea, immune status of the host, and presence of systemic toxicity. Oral rehydration therapy is less expensive, often just as effective, and more practical than intravenous fluids. Dairy products should be avoided, because transient lactase deficiency can be caused by enteric, viral, and bacterial infections. Loperamide may reduce the duration of diarrhea in those with traveler's diarrhea and bacillary dysentery. Empirical antibiotic treatment is also appropriate specifically for early Campylobacter infections and C. About 5% of hamburger’s disease cases develop the dreaded hemolytic-uremic syndrome, which has a high mortality. It behaves initially like a normal gastroenteritis with diarrhea, but next neurological symptoms set in. Later there is usually a 2 week oral follow-up antibiotic therapy ,depending on in vitro testing, with oral ciprofloxacin (Ciloxan, Cipro) or with ampicillin (Omnipen, Ampicin).
There is a high mortality rate as the tissue damage is often irreversible and it is frequently too late by the time the patient arrives at the hospital.
Food and waterborne outbreaks involving a relatively small subset of population and recurrent bouts of illness in others comprise most cases. Bacillus cereus, Clostridium perfringens, Staphylococcus aureus, Salmonella spp., and others cause food poisoning. Anal intercourse can lead to a direct rectal inoculation, resulting in proctitis associated with rectal pain, tenesmus, and passage of small-volume, bloody, mucous stools. A general algorithm for the evaluation and management of acute diarrhea is shown in Figure 11. A number of oral rehydration solutions are available, including Pedialyte, Rehydralyte, Ricelyte (Infalyte), Resol, the World Health Organization formula, and the newer reduced osmolarity formula for children.
Caffeinated beverages and alcohol, which can enhance intestinal motility and secretions, should be avoided. These agents should be avoided in patients with fever, bloody diarrhea, and possible inflammatory diarrhea because they may be associated with prolonged fever in patients with shigellosis, toxic megacolon in patients with C. Most patients with acute diarrhea have a mild and self-limited illness; most treat their illness at home and usually get better without medical intervention. It consists of hemolytic anemia, acute kidney failure and low platelet counts causing severe bleeding.
Usually these would start with the cranial nerves affecting vision (double vision) on both sides, bilateral upper eye lid paralysis with drooping eyelids, speech and swallowing problems.
Acute cholecystitis can also develop and when this happens, the salmonella bug is extremely difficult to eradicate and despite antibiotic treatment the patient becomes a new carrier. The history should include place of residence, drinking water (treated city water or well water), rural conditions, consumption of raw milk, consumption of raw meat or fish, and exposure to farm animals that may spread Salmonella or Brucella organisms. Empirical treatment for Giardia can be prescribed for those with a 2-week or longer history of diarrhea.
This paralysis migrates relentlessly down the body to the breathing muscles and into the upper and lower extremities. For adults two other antibiotics are often used: norfloxacin (Chibroxin, Noroxin) or ciprofloxacin (Ciloxan, Cipro). Patients therefore often present with watery diarrhea, followed within hours or days by bloody diarrhea.
When the incubation period is longer than 14 hours and vomiting is also a significant symptom, accompanied by diarrhea, viral agents should be considered.
Sexual history is important, because specific organisms can cause diarrhea in homosexual men and HIV-infected patients. Diarrhea and related complications can cause severe illness, especially in high-risk groups, such as patients with severe comorbid conditions, underlying immunosuppression, and advanced age. Bacteria that produce inflammation from cytotoxins include Clostridium difficile and hemorrhagic E. Parasites that do not invade the intestinal mucosa, such as Giardia lamblia and Cryptosporidium, usually cause only mild abdominal discomfort. Hand washing is important for prevention; soap and water is more effective than alcohol-based hand sanitizers because alcohol-based sanitizers may not kill viruses.
It is extremely important to immediately call an ambulance and have this patient transported to the Emergency Department of a hospital.
In patients with bloody diarrhea or hemolytic-uremic syndrome, the stool should be evaluated for E. The patient will have to be intubated for several days until the paralysis of the breathing muscles wears off.

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