Definition

An increase in the frequency of

bowel movements (3x per day or
more) and a decrease in the form of
stool (greater looseness of stool) with
or without blood.

How is diarrhea
defined?
Frequency of bowel movements
Absolute diarrhea having more bowel movements
than normal.
Healthy individuals the maximum number of daily
bowel movements is approximately three, diarrhea
can be defined as any number of stools greater than
three.
Consistency of stools
Stools that are liquid or watery are always abnormal
and considered diarrheal.

Stool Characteristics and

Determining Their Source
Stool
Characteristics

Small Bowel

Large Bowel

Appearance

Watery

Mucoid and/or bloody

Volume

Large

Small

Frequency

Increased

Highly increased

Blood

Possibly positive but

never gross blood

Commonly grossly
bloody

pH

Possibly <5.5

>5.5

Reducing
substances

Possibly positive

Negative

WBCs

<5/high power field

Commonly >10/high
power field

Serum WBCs

Normal

Possible leukocytosis,
bandemia

Stool Characteristics and Determining

Their Source
Small Bowel
Organisms

Large Bowel

Viral
Rotavirus
Adenovirus
Calicivirus
Astrovirus
Norovirus

Invasive bacteria
Escherichia Coli
(enteroinvasive,
enterohemorrhagic)
Shigella species
Salmonella species
Campylobacter
species
Yersinia species
Aeromonas species
Plesiomonas species

Enterotoxigenic
bacteria
E coli
Klebsiella
Clostridium
perfringens
Cholera species

Toxic bacteria
Clostridium difficile

Stool Characteristics and

Determining Their Source
Small Bowel
Organisms

Parasites
Giardia species
Cryptosporidium
species

Large Bowel
Parasites
Entamoeba
organisms

Types of Diarrhea
Acute diarrhea lasts from a few
days up to a week (<14 days).
Chronic diarrhea can be defined
in several ways but almost always
lasts more than three weeks.

Organisms and Frequency of Symptoms

Incubation

Duration

Vomiting

Fever

Abdominal
Pain

1-7 d

4-8 d

Yes

Low

No

8-10 d

5-12 d

Delayed

Low

No

Norovirus

1-2 d

2d

Yes

No

No

Astrovirus

1-2 d

4-8 d

+/-

+/-

No

Calicivirus

1-4 d

4-8 d

Yes

+/-

No

Aeromonas
species

None

0-2 wk

+/-

+/-

No

Campylobacter
species

2-4 d

5-7 d

No

Yes

Yes

C difficile

Variable

Variable

No

Few

Few

C perfringens

Minimal

1d

Mild

No

Yes

Enterohemorrhagi
c E coli

1-8 d

3-6 d

No

+/-

Yes

Enterotoxigenic E
coli

1-3 d

3-5 d

Yes

Low

Yes

Plesiomonas
species

None

0-2 wk

+/-

+/-

+/-

Salmonella
species

0-3 d

2-7 d

Yes

Yes

Yes

Shigella species

0-2 d

2-5 d

No

High

Yes

Vibrio species

0-1 d

5-7 d

Yes

No

Yes

Yenterocolitica

None

1-46 d

Yes

Yes

Yes

Giardia species

2 wk

1+ wk

No

No

Yes

5-21 d

Months

No

Low

Yes

Organism
Rotavirus
Adenovirus

Cryptosporidium

Shigella sp.
Group A: Shigella dysenteriae (or
Shiga bacillus, 13 serotypes)
developed country
Group B: Shigella flexneri (6
serotypes, 15 subtypes)
Group C: Shigella boydii (18
serotypes)
Group D: Shigella sonnei (1 serotype)

Invasion of the
Underlying Tissue

Intercellular dissemination facilitated by the IpaB protein

lyses the plasma membrane.

The infected host cells produce an inflammatory (IL-8, IL-10)

chemotaxis of polymorphonuclear leukocytes disruption of the
epithelial barriers integrity disruption of epithelial absorption
the characteristic diarrhea and abdominal cramps.

Shigella may cause mucosal destruction in the form of

ulcerations of the colonic mucosa the presence of blood in
the stools.

Enteroinvasive E.coli
EIEC is closely related to Shigella sp. in

biochemical and serological

characteristics, pathogenic mechanisms,
and virulence determinants.
Infection with EIEC leads to watery

diarrhea, with dysentery syndrome in

only some of the patients.

Salmonella sp. (non

typhoidal)
The bacteria penetrate and damage
the intestinal mucosa ingested by
macrophages multiply in
mesenteric lymphoid tissues.
Attachment and penetration to intestinal
mucosal cells
Secretory response

Salmonella sp. (non

typhoidal)
They have the ability to induce enterocytes to take them into
the cytoplasm bacteria-mediated endocytosis.
Salmonella invade the intestinal epithelial barrier interact
with macrophages and lymphocytes in Peyers patches
marked enlargement and necrosis of the lymphoid tissue.
Invasion of epithelial cells stimulates the release of
proinflammatory cytokines inflammatory reaction.
The acute inflammatory response causes diarrhea and leads to
ulceration and destruction of the mucosa.
From the submucosal lymphoid tissue or Peyers patches
enter the systemic circulation causing fever and other
systemic diseases.

Vibrio Cholerae
The diarrhea can be extremely severe, with characteristic
rice water stools, which can lead to rapid dehydration,
circulatory collapse, and death.

Vibrio cholerae secretes cholera toxin (CT) binds to

enterocytes The A subunit catalyzes the ADP-ribosylation
of the GTP binding protein activation of adenylate cyclase
accumulation of cAMP in enterocytes increase in
secretion of chloride and water secretory diarrhea.

Enteropathogenic E.coli
EPEC is an important cause of diarrhea in infants less
than 2 years of age.
EPEC is transmitted by the fecaloral route by personto-person contact.
The symptoms: watery diarrhea, vomiting, and fever.
All EPEC strains induce a characteristic attaching and
effacing (A/E) lesion on the brush border of the
intestine which can be mimicked in tissue culture.

Enterotoxigenic E.coli
ETEC colonizes the mucosal epithelial cells
of the small intestine produces
enterotoxins: heat-labile toxin (LT) and heatstable toxin (ST)
LT is similar to cholera toxin (CT) in
structure, function, and mode of action.
CT stimulate production of the
proinflammatory cytokine(IL-6)
activating the enteric immune system.
Similar to cholera toxin, LT stimulates
mucosal adenylate cyclase activity
inside the cytoplasm of the epithelial

Enterohemorrhagic E.coli
Causes watery diarrhea followed by
bloody diarrhea, an illness
designated hemorrhagic colitis (HC).
The major pathogenic feature of EHEC
is production of the bacteriophageencoded Shiga toxin (or verotoxin).

Enteroaggregative E.coli
Enteroaggregative E. coli (EAEC) is a cause of persistent

diarrhea in children of developing and developed

countries.
Innfects the small bowel and causes diarrhea in less

than 8 hour, which may persist for 14 days.

The diarrhea is usually mucoid and may be watery, with

low-grade fever.
EAEC has also been associated with diarrhea in AIDS

patients.

Rotaviruses

The virus outer capsid protein (vp4) attaches to the glycolipid receptor
on the host cell surface and enters the cytoplasm by direct plasma
membrane penetration.

Several mechanisms of diarrhea due to Rotavirus have been proposed.

The NSP4 enterotoxin activates a Ca2+-dependent signal
transduction pathway or inhibits the Na+-D-glucose symporter and
consequently impairs Cl and Na+ transport into and out of
epithelial cells
the replication of rotaviruses in enterocytes of the small intestine
causing atrophy of the villous cell, detachment of absorptive cells
from the basement membranes, and hyperplasia of the crypt cells
which subsequently leads to diarrhea.

 Activate the enteric nervous system stimulates water

secretion by intestinal cells diarrhea.
A loss of intestinal permeability to macromolecules such
as lactose, which is associated with decreased levels of
intestinal disaccharidases.

Diagnose The Diarrhea

Medical history and physical examination. The doctor will
ask you about your eating habits and medication use and will
examine you for signs of illness.
Stool culture. A sample of stool is analyzed in a laboratory to
check for bacteria, parasites, or other signs of disease and
infection.
Blood tests. Blood tests can be helpful in ruling out certain
diseases.
Fasting tests. To find out if a food intolerance or allergy is
causing the diarrhea, the doctor may ask you to avoid lactose,
carbohydrates, wheat, or other foods to see whether the

 Sigmoidoscopy. For this test, the doctor uses a

special instrument to look at the inside of the
rectum and lower part of the colon.
Colonoscopy. This test is similar to a
sigmoidoscopy, but it allows the doctor to view
the entire colon.
Imaging tests. These tests can rule out
structural abnormalities as the cause of diarrhea.

Management of
Diarrhea

[underlying disease]

Predisposing factors
- Environmental Nutrition Population
- Economic and Social Education
Society behavior
- Cause of the diarrhea
- Inflammatory bowel by causing
agent

Prognosis
Diarrhea can be dangerous in
newborns and infants. In small
children, severe diarrhea lasting just
a day or two can lead to dehydration.
Because a child can die from
dehydration within a few days, the
main treatment for diarrhea in

Complications

Dehydration
Orthostatic hypotension
Shock
Kidney failure
Confusion
Acidosis
Coma

When to Seek Medical

Care
if the person has had diarrhea along with high fever,
moderate-to-severe abdominal pain, or dehydration
that cannot be managed by drinking fluids

if the diarrhea appears to contain blood (it may be

bright red or may look like black, thick tar)

If the person is very sleepy and is not acting like

their usual selves (others may notice this and take
the person to the emergency department).

Call a health care practitioner if a

person has any of these complications:
Vomiting and unable to tolerate any food or drink
Shows signs of dehydration
Has a high fever, significant abdominal pain, very
frequent loose bowel movements, or bloody diarrhea
Elderly or has serious underlying medical problems,
particularly diabetes, heart, kidney, or liver disease,
or HIV or AIDS
Symptoms do not improve in two to three days or
appear to become worse
Develops diarrhea after travel in their home country,
or foreign travel