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Overview

Classification

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Gastroenteritis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Viral
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Bacterial
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Parasites
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Common
 
Less Common
 
 
 
 
 
 
 
Common
 
 
 
 
 
 
 
 
 
 
 
 
Less Common
 
 
 
 
Helminthic
 
Protozoal
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Rotavirus
Norovirus
❑Enteric Adenovirus
Astroviruses
 
❑Kobuviruses
Enterovirus
Orthoreovirus
❑Torovirus
Coronavirus
(including SARS)
Parvovirus
 
 
 
Gram Positive
 
 
 
 
 
Gram Negative
 
 
 
 
 
Gram Positive
 
 
 
Gram Negative
 
Trichinella spiralis
Trichuris trichiura
Strongyloides stercoralis
Taenia solium
Taenia saginata
Diphyllobothrium latum
Schistosoma mansoni
 
Giardia lamblia
Entamoeba histolytica
Cryptosporidium parvum
Cyclospora cayetanensis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Clostridium perfringens
Clostridium difficile
 
 
Dysentric diarreha
 
 
 
Watery diarrhea
 
 
Bacillus cereus
Listeria monocytogenes
 
 
 
Bacteroides fragilis
Aeromonas hydrophila
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Shigella sp., ❑Campylobactersp.
 
 
 
Escherichia coli
(ETEC, EPEC, EHEC, EAEC, EIEC)§
Salmonella sp.
Yersinia enterocolitica
Vibrio cholerae
Vibrio parahemolyticus
 



§ EHEC, EIEC, EPEC and EAEC may cause bloody diarrhea, but they are classically associated with watery diarrhea.
† Either Salmonella and Yersinia can cause dysentery.
Entamoeba histolytica may cause dysentery

Patient Evaluation

Initial Management

Shown below is an algorithm depicting the initial management of acute diarrhea is based on the 2001 IDSA practice guidelines for the management of infectious diarrhea.[1]

 
 
 
 
Characterize the symptoms:

❑ Onset
❑ Duration
❑ Pattern (continuous or intermittent)
❑ Stool characteristic (watery, bloody, mucous or greasy)
❑ Frequency of bowel movements
❑ Dysenteric symptoms (fever, tenesmus, blood and/or pus in stool)


Associated symptoms:
Abdominal pain
Nausea and vomiting
❑ Weight loss


Epidemiological factors:
❑ Travel
❑ Food (raw meat, eggs, shellfish, unpasteurized cheese or milk)
❑ Outbreaks
❑ Sexual history
❑ Day care attendance
❑ Previous evaluations
❑ Medications, radiation therapy or surgery
❑ Underlying medical condition (cancer, diabetes, hyperthyroidism or AIDS)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:

Temperature
Pulse
Blood pressure
❑ Respiratory rate
❑ Signs of volume depletion (decreased skin turgor, dry mucosa)
❑ Abdominal tenderness

❑ Level of consciousness
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assessment of volume status
General conditionNormalIrritable/less active*Lethargic/comatose§
EyesNormalSunken -
MucosaNormalDry -
ThirstNormalThirstyUnable to drink§
Radial pulseNormalLow volume*Absent/ uncountable§
Skin turgorNormalReduced -

† Some dehydration = At least two signs, including at least one key sign (*) are present.

‡ Severe dehydration = Signs of “some dehydration” plus at least one key sign (§) are present.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No dehydration
 
Some dehydration
 
Severe dehydration
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Start altered diet

❑ Stop lactose products
❑ Avoid alcohol and high osmolar supplements
❑ Drink 8-10 large glasses of clear fluids (Fruit juices, soft drinks etc)
❑ Eat frequent small meals (Rice, potato, banana, pastas etc)


Can start oral rehydration therapy (ORT) for replacement of stool losses
 
❑ Start ORT at a volume of 50-100 mL/kg
❑ Start altered diet
❑ Reassess status every 4 hr
 
❑ Start IV fluids: Ringer lactate at 30ml/kg in the first 1/2hr and 70ml/kg for the next 2 1/2 hr, if unavailable use normal saline
CBC
Electrolytes
❑ Assess status every 15 mins until strong pulse felt and then every 1 hr
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patient stable and able to drink
❑ Start ORT at a volume of 100 mL/kg over 4 hour
❑ Calculate the continuing stool and emesis losses every hour for additional maintenance ORT therapy
❑ Reassess status every 4 hr
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hemodynamic stabilized
Proceed to Diagnosis and Management
 
 

Diagnostic and Management approach



 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Passage of ≥3 unformed stools in 24 h
+
an enteric symptom (nausea, vomiting, abdominal pain/cramps, tenesmus, fecal urgency, moderate to severe flatulence)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Watery diarrhea
± Vomiting
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Dysenteric diarrhea (passage of grossly bloody stools)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mild Illness
 
 
 
 
 
 
Moderate to Severe
 
 
 
 
 
 
 
No or low-grade fever(≤100°F)
 
 
 
Severe illness with fever≥(101°F) in a single case (not outbreak)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hydration only
May use loperamide 4 mg initially to control stooling
 
Travel associated
 
 
 
 
Non travel associated
 
 
 
 
 
 
 
 
 
Non travel associated
 
 
Travel associated
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Antibiotic therapy
 
No or low-grade fever (≤100°F)
 
 
 
Fever (≥101°F)
 
 
 
 
 
 
 
 
 
 
 
 
Empiric treatment
Azithromycin 1 g in single dose OR
500 mg once daily for 3 days
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
<72 h duration
 
≥72 h duration
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Loperamide therapy for 48 h
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Microbiologic assessment and appropriate treatment
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Persistent diarrhea (14–30 days)
should be worked up by culture and/or culture independent microbiologic assessment, then treatment with anti microbial agent directed to cause
 
 
 
 
 
 
 
 
 
 

Illness severity:

  • Severe: Total disability due to diarrhea;
  • Moderate: Able to function but with forced change in activities due to illness;
  • Mild: No change in activities


Synopsis

Organism Age predilection Travel History Incubation Size Incubation Time History and Symptoms Diarrhea type Additional Findings
Fever N/V Cramping Abd Pain Small Bowel Large Bowel Inflammatory Non-inflammatory
Viral Rotavirus <2 y
Norovirus <5 y
Adenovirus
Astrovirus <5 y
Bacterial Escherichia coli ETEC
EPEC <6 m
EIEC
EHEC
EAEC
Salmonella sp.
Shigella sp.
Campylobacter sp.
Yersinia enterocolitica
Clostridium difficile
Vibrio cholerae Any age - 108-1010 24-48 h - Hypotension, tachycardia, decreased skin turgor
Parasites

Special consideration

General principles for treatment

Prevention

❑ E.Coli species
❑ Salmonella species
❑ Shigella
❑ Campilobacter
❑ Vibrio species|D04=❑ Bacillus cereus
❑ Bacteroids fragilis
❑ Aeromonas
❑ Staphylococcus aureus

  1. Guerrant RL, Van Gilder T, Steiner TS, Thielman NM, Slutsker L, Tauxe RV; et al. (2001). "Practice guidelines for the management of infectious diarrhea". Clin Infect Dis. 32 (3): 331–51. doi:10.1086/318514. PMID 11170940.