3/7/2015 Diarrhea Clinical Presentation: History, Physical, Causes

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Diarrhea Clinical PresentationAuthor: Stefano Guandalini, MD; Chief Editor: Carmen Cuffari, MD more...

Updated: Oct 30, 2014

HistoryAcute diarrhea in developed countries is almost invariably a benign, selflimited condition, subsiding within a fewdays. The clinical presentation and course of illness depend on the etiology of the diarrhea and on the host. Forexample, rotavirus is more commonly associated with vomiting, dehydration, and a greater number of work days lostthan nonrotavirus gastroenteritis.

A prospective study conducted in the United States in 604 children aged 336 months in community settingsbefore the introduction of rotavirus vaccine found that the highest incidence of acute diarrhea was in Januaryand August, with an overall incidence of 2.21 episodes per personyear.[8] Close to 90% of episodes wereacute (ie, lasting < 14 d, with a median duration of 2 d and a median of 6 stools per day).Diarrhea implies an increase in stool volume and diminished stool consistency.

In children younger than 2 years, diarrhea is defined as daily stools with a volume greater than 10mL/kg.In children older than 2 years, diarrhea is defined as daily stools with a weight greater than 200 g. Inpractice, this typically means loosetowatery stools passed 3 or more times per day.Individual stool patterns widely vary; for example, breastfed children may normally have 56 stools perday.

Flatulence associated with foulsmelling stools that float suggests fat malabsorption, which can be observedwith infection with Giardia lamblia.Knowledge of the characteristics of consistency, color, volume, and frequency can be helpful in determiningwhether the source is from the small or large bowel. Table 1 outlines these characteristics and demonstratesthat an index of suspicion can be easily generated for a specific set of organisms.

Table 1. Stool Characteristics and Determining Their Source (Open Table in a new window)

StoolCharacteristics Small Bowel Large Bowel

Appearance Watery Mucoid and/or bloodyVolume Large SmallFrequency Increased Highly increased

Blood Possibly positive but never grossblood Commonly grossly bloody

pH Possibly < 5.5 >5.5Reducingsubstances Possibly positive Negative

WBCs < 5/high power field Commonly >10/high power fieldSerum WBCs Normal Possible leukocytosis, bandemia

Organisms

Viral

RotavirusAdenovirusCalicivirusAstrovirusNorovirus

Invasive bacteria

Escherichia Coli (enteroinvasive,enterohemorrhagic)Shigella speciesSalmonella speciesCampylobacter speciesYersinia speciesAeromonas speciesPlesiomonas species

Enterotoxigenic bacteria

E coliKlebsiellaClostridium perfringensCholera speciesVibrio species

Toxic bacteria

Clostridium difficile

Parasites

Giardia speciesCryptosporidium species

Parasites

Entamoeba organisms

See the list below:

Associated systemic symptoms include the following:Some enteric infections commonly have systemic symptoms, whereas others less commonly areassociated with systemic features.Table 2 outlines the frequency of some of these symptoms with particular organisms. It also outlinesincubation periods and usual duration of symptoms of common organisms. Certain organisms (eg, Cdifficile, Giardia, Entamoeba species) may be associated with a protracted course.

Table 2. Organisms and Frequency of Symptoms (Open Table in a new window)

Organism Incubation Duration Vomiting Fever Abdominal PainRotavirus 17 d 48 d Yes Low NoAdenovirus 810 d 512 d Delayed Low No

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Norovirus 12 d 2 d Yes No NoAstrovirus 12 d 48 d +/ +/ NoCalicivirus 14 d 48 d Yes +/ NoAeromonas species None 02 wk +/ +/ NoCampylobacter species 24 d 57 d No Yes YesC difficile Variable Variable No Few FewC perfringens Minimal 1 d Mild No YesEnterohemorrhagic E coli 18 d 36 d No +/ YesEnterotoxigenic E coli 13 d 35 d Yes Low YesPlesiomonas species None 02 wk +/ +/ +/Salmonella species 03 d 27 d Yes Yes YesShigella species 02 d 25 d No High YesVibrio species 01 d 57 d Yes No YesY enterocolitica None 146 d Yes Yes YesGiardia species 2 wk 1+ wk No No YesCryptosporidium species 521 d Months No Low YesEntamoeba species 57 d 12+ wk No Yes No

See the list below:

Daycare considerations are as follows:Certain organisms are spread quickly in daycare. These organisms include rotavirus; astrovirus;calicivirus; and Campylobacter, Shigella, Giardia, and Cryptosporidium species.Increase in daycare usage has raised the incidence of rotavirus and Cryptosporidium species.

Food history can be helpful.Ingestion of raw or contaminated food is a common cause of infectious diarrhea.Organisms that cause food poisoning include the following:

Dairy food Campylobacter and Salmonella speciesEggs Salmonella speciesMeats C perfringens and Aeromonas, Campylobacter, and Salmonella speciesGround beef Enterohemorrhagic E coliPoultry Campylobacter speciesPork C perfringens, Y enterocoliticaSeafood Astrovirus and Aeromonas, Plesiomonas, and Vibrio speciesOysters Calicivirus and Plesiomonas and Vibrio speciesVegetables Aeromonas species and C perfringens

Water exposure can contribute to diarrhea.Water is a major reservoir for many organisms that cause diarrhea.Swimming pools have been associated with outbreaks of infection with Shigella species; Aeromonasorganisms are associated with exposure to the marine environment.Giardia, Cryptosporidium, and Entamoeba organisms are resistant to water chlorination; therefore,exposure to contaminated water should raise index of suspicion for these parasites.

A history of camping suggests exposure to water sources contaminated with Giardia organisms.Travel history may indicate a cause for diarrhea.

Enterotoxigenic E coli is the leading cause of traveler's diarrhea.Rotavirus and Shigella, Salmonella, and Campylobacter organisms are prevalent worldwide and needto be considered regardless of specific travel history.Risk of contracting diarrhea while traveling is, by far, highest for persons traveling to Africa.Travel to Central and South America and Eastern European countries is also associated with arelatively high risk of contracting diarrhea.Other organisms that are prevalent in particular parts of the world include the following:

Nonspecific foreign travel history Enterotoxigenic E coli and Aeromonas, Giardia,Plesiomonas, Salmonella, and Shigella speciesUnderdeveloped tropical visit C perfringensTravel to Africa Entamoeba species, Vibrio choleraeTravel to South America and Central America Entamoeba species, V cholerae, enterotoxigenicE coliTravel to Asia V choleraeTravel to Australia Yersinia speciesTravel to Canada Yersinia speciesTravel to Europe Yersinia speciesTravel to India Entamoeba species, V choleraeTravel to Japan Vibrio parahaemolyticusTravel to Mexico Aeromonas, Entamoeba, Plesiomonas, and Yersinia speciesNew Guinea Clostridium species

Animal exposure can contribute to diarrhea.Exposure to young dogs or cats is associated with Campylobacter organisms.Exposure to turtles is associated with Salmonella organisms.

Certain medical conditions predispose patients to infection, including the following:C difficile Hospitalization, antibiotic administrationPlesiomonas species Liver diseases or malignancySalmonella species Intestinal dysmotility, malnutrition, achlorhydria, hemolytic anemia (especiallysickle cell disease), immunosuppression, malariaRotavirus HospitalizationGiardia species Agammaglobulinemia, chronic pancreatitis, achlorhydria, cystic fibrosisCryptosporidia species Immunocompromised or immunosuppressed state

PhysicalThe following may be observed:

DehydrationDehydration is the principal cause of morbidity and mortality.Assess every patient with diarrhea for signs, symptoms, and severity.Lethargy, depressed consciousness, sunken anterior fontanel, dry mucous membranes, sunken eyes,lack of tears, poor skin turgor, and delayed capillary refill are obvious and important signs ofdehydration. Table 3 below details dehydration severity and symptoms.

3/7/2015 Diarrhea Clinical Presentation: History, Physical, Causes

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Table 3. Dehydration Severity, Signs, and Symptoms (Open Table in a new window)

Hydration

05% Dehydration

(Mild)

510% Dehydration

(Moderate)

10% or More

(Severe)

General Well Restless LethargicEyes Normal Sunken Very sunkenTears Present Absent AbsentMouth Moist Dry Very dryThirst Drinks normally Thirsty Drinks poorlySkin Pinch retracts immediately Pinch retracts slowly Pinch stays folded

Failure to thrive and malnutritionReduced muscle and fat mass or peripheral edema may be clues to the presence of carbohydrate, fat,and/or protein malabsorption.Giardia organisms can cause intermittent diarrhea and fat malabsorption.

Abdominal painNonspecific nonfocal abdominal pain and cramping are common with some organisms.Pain usually does not increase with palpation.With focal abdominal pain worsened by palpation, rebound tenderness, or guarding, be alert forpossible complications or for another noninfectious diagnosis.

Borborygmi: Significant increases in peristaltic activity can cause an audible and/or palpable increase inbowel activity.Perianal erythema

Frequent stools can cause perianal skin breakdown, particularly in young children.Secondary carbohydrate malabsorption often results in acidic stools.Secondary bile acid malabsorption can result in a severe diaper dermatitis that is often characterizedas a "burn."

CausesAlthough infectious agents are by far the most common cause for sporadic or endemic episodes of acute diarrhea,one should not dismiss other causes that can lead to the same presentation.

Causes of diarrhea with acute onset include the following:Infections

Enteric infections (including food poisoningExtraintestinal infections

DruginducedAntibioticassociatedLaxativesAntacids that contain magnesiumOpiate withdrawalOther drugs

Food allergies or intolerancesCow's milk protein allergySoy protein allergyMultiple food allergiesOlestraMethylxanthines (caffeine, theobromine, theophylline)

Disorders of digestive/absorptive processesGlucosegalactose malabsorptionSucraseisomaltase deficiencyLateonset (adulttype) hypolactasia, resulting in lactose intolerance

Chemotherapy or radiationinduced enteritisSurgical conditions

Acute appendicitisIntussusception

Vitamin deficienciesNiacin deficiencyFolate deficiency

Vitamin toxicityVitamin CNiacin, vitamin B3

Ingestion of heavy metals or toxins (eg, copper, tin, zinc)Ingestion of plants (eg, hyacinths, daffodils, azalea, mistletoe, Amanita species mushrooms

Infectious causes of acute diarrhea in developed countriesViruses

Rotavirus 2540% of casesNorovirus 1020% of casesCalicivirus 120% of casesAstrovirus 49% of casesEnterictype adenovirus 24% of cases

BacteriaCampylobacter jejuni 68% of casesSalmonella 37% of casesE Coli 35% of casesShigella 03% of casesY enterocolitica 12% of casesC difficile 02% of casesVibrio parahaemolyticus 01% of casesV cholerae UnknownAeromonas hydrophila 02% of cases

ParasitesCryptosporidium 13% of cases

3/7/2015 Diarrhea Clinical Presentation: History, Physical, Causes

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G lamblia 13% of cases

Contributor Information and DisclosuresAuthorStefano Guandalini, MD Founder and Medical Director, Celiac Disease Center, Chief, Section of PediatricGastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Chicago Medical Center;Professor, Department of Pediatrics, Section of Gastroenterology, Hepatology and Nutrition, University of ChicagoDivision of the Biological Sciences, The Pritzker School of Medicine

Stefano Guandalini, MD is a member of the following medical societies: American GastroenterologicalAssociation, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, European Societyfor Paediatric Gastroenterology, Hepatology & Nutrition, North American Society for the Study of Celiac Disease

Disclosure: Received consulting fee from AbbVie for consulting.

Coauthor(s)Richard E Frye, MD, PhD Associate Professor, Department of Pediatrics, University of Arkansas for MedicalSciences

Richard E Frye, MD, PhD is a member of the following medical societies: American Academy of Neurology, ChildNeurology Society, International Neuropsychological Society, American Academy of Pediatrics

Disclosure: Nothing to disclose.

M Akram Tamer, MD Professor, Program Director, Department of Pediatrics, University of Miami, Leonard MMiller School of Medicine

M Akram Tamer, MD is a member of the following medical societies: American Medical Association, FloridaMedical Association

Disclosure: Nothing to disclose.

Specialty Editor BoardMary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College ofPharmacy; EditorinChief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief EditorCarmen Cuffari, MD Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, JohnsHopkins University School of Medicine

Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology,American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatologyand Nutrition, Royal College of Physicians and Surgeons of Canada

Disclosure: Received honoraria from Prometheus Laboratories for speaking and teaching; Received honorariafrom Abbott Nutritionals for speaking and teaching.

Additional ContributorsChris A Liacouras, MD Director of Pediatric Endoscopy, Division of Gastroenterology and Nutrition, Children'sHospital of Philadelphia; Associate Professor of Pediatrics, University of Pennsylvania School of Medicine

Chris A Liacouras, MD is a member of the following medical societies: American Gastroenterological Association

Disclosure: Nothing to disclose.

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