Gatot Sugiharto, MD, Internist

RS Mitra Keluarga Waru

Definition (1)
Increased liquidity, frequency or decreased
consistency of stools
Increase in daily stool weight above 200gm
Differentiate from incontinence and IBS
Acute lasts less than 7 - 14 days
Chronic lasts more than 2 - 3 weeks

Definition (2)
Gastroenteritis : characterized by inflammation of
the gastrointestinal tract that involves both the
stomach and the small intestine, resulting in some
combination of diarrhea, vomiting, and abdominal
pain and cramping.
Also been called stomach flu and gastric flu

Mechanisms

Osmotic Diarrhea
Results from poorly absorbable
osmotically active solutes in the gut
lumen
Stops when the patient is fasting

Some Causes of Osmotic Diarrhea

Carbohydrate malab
gluc-galact malab
fructose malab
disaccaridase def
ingestion (poorly absorbable
carbs)

lactulose
sorbitol
fructose
fiber

Magnesium-Induced
Nutritional supplements
antacids
laxatives

GI Lavage solutions
Laxative
sodium citrate
sodium phophate
sodium sulfate

Secretory Diarrhea
Results from abnormal ion transport in intestinal
epithelial cells
Main categories of secretory diarrhea
congenital defects of ion absorptive process
intestinal resection
diffuse mucosal disease
abnormal mediators
Diarrhea persist despite of fasting

Some Causes of Secretory Diarrhea

Laxatives
Phenolophthalein, aloe

Medications
diuretics

Irritans
coffee, tea, cola, ETOH

Bacterial Toxins
S.aureus, C.perf +bot, B.cereus

Congenital
Bacterial entertoxins
V. cholera, C.diff, Y.enterocol,
toxigenic E. coli

Endogenous laxatives
bile acids, LCFA

Hormone producing
tumors

Deranged Motility
Enhanced Motility (Intestinal Hurry) - decrease
contact time of the stool to the absorptive surface
Abnormally slow motility may results in bacterial
overgrowth and resultant diarrhea

Exudation
Results from disruption of the intestinal mucosa
from inflammation or ulceration
Blood, mucus and serum proteins in gut lumen
bacillary dysentery
Inflammatory bowel disease (IBD)
Colitis ulseratif
Crohns disease

Approach to Patients with Diarrhea

History
Characteristics of the onset of diarrhea should be
precisely noted (congenital, abrupt, gradual)
Pattern of diarrhea should be recorded
(continuous or intermittent)
Duration of the symptoms
Epidemiological factors (travel, exposure to
contaminated food or water, illness in other
contacts)

History
Stool characteristics should be investigated
(watery, bloody, fatty)
Presence of fecal incontinence
Presence of abdominal pain
Presence of weight loss
Aggravating factors (diet or stress)
Mitigating factors (alteration of diet, OTC meds)
Previous evaluations

History
Iatrogenic causes (medication history, surgical
history, radiation history)
Factitious diarrhea (history of eating disorders,
secondary gain and malingering)
Careful ROS (hyperthyroidism, diabetes mellitus,
CVD, AIDS, etc)

Acute Diarrhea

Acute Diarrhea

Acute Diarrhea
Less than 2-3 weeks duration
Majority of cases are mild and self limiting
4 million deaths world-wide per year in children
under 5 years
Categories
infectious
noninfectious
drugs, fecal impaction, elixir diarrhea, enteral feedings,
chemotherapy or radiation therapy, runners diarrhea

Who Needs Evaluation?

High fever (>102F)

Hypotension
Bloody diarrhea
Severe abdominal pain
Immunocompromised persons

Diagnostic Tests for Acute Diarrhea

Spot Stool Sample
Culture, Ova and Parasite, C.diff toxin
Fecal leukocytes inflammatory
Blood Tests
CBC, electrolytes, SMA 7, blood culture
Plain X-rays
Endoscopy
Isolation rate of pathogen from stool (rarely
successful < 3%)

Causes of acute diarrhea

Non
inflamatory
diarrhea

Agent

Inflamatory
diarrhea

Agent

Viral

Norwalk virus, Norwalk

like virus, Rotavirus

Viral

Cytomegalovirus

Protozoal

Giardia lamblia,
Cryptosporidium

Protozoal

Entamoeba hystolytica

Bacterial

Preformed enterotoxin :
Staphylococcus aureus,
Bacillus cereus,
Clostridium perfringens

Bacterial

Cytotoxin production :
Enterohemorrhagic E.coli
(EHEC), Vibrio parahemolitycus, Clostridium difficile

Enterotoxin production :
ETEC, Vibrio cholerae

Mucosal infection : Shigella,

Campylobacter jejuni, Salmonella, Enteroinvasive E.coli
(EIEC), Aeromonas, Plesiomonas, Yersinia enterocolica,
Chlamydia, Neisseria Go,
Listeria monocytogenes

Empirical AB (while awaiting culture) based on : Fecal leukocyte (+), Bloody diarrhea, abd pain, dehidration, >
stools/24h, immunocompromized, elderly

Management

Algorithm for Acute Diarrhea

Noninfectious

Infectious
Assess severity, duration
immocompetence of host

Rehydration

Symptomatic therapy
Continues

Possible abx
antidiarrheal agents

Eval and Rx of
underlying cause

resolves

Treatment for Acute Diarrhea

Symptomatic
fluid replacement (oral replacement /or IV fluids)
antidiarrheals
Bismuth subsalicylate
Antimicrobial therapy
Quinolones
Metronidazole
TPA- SMZ
Rifaximin

Antidiarrheals and Infectious Acute Diarrheas

Bismuth Subsalicylates (Pepto-Bismol)
Safe and efficacious
Antidiarrheal effects, antibacterial, antiinflammatory
Loperamide
safe in travelers diarrhea
Kaolin-pectin, opiates, anti-cholingerics
not effective

Antibiotics in Acute Diarrheas

Recommended

Shigellosis
Cholera
Travelers diarrhea
Pseudomembranous
enterocolitis
parasites
STDs

Not Recommended
E.coli 0157:H7

Antibiotics
First Line
Ciprofloxacin - effective against most enteric
infections
Metronidazole - if symptoms suggest Giardia/E.
histolityca
Second Line
Cotrimoxasole - effective second line therapy for
most infectious diarrheas

Various type of acute

diarrhea

Nosocomial Acute Diarrheas

Fecal impaction
Drugs
Elixir Diarrhea
Enteral Feedings
Infectious Nosocomial Diarrhea
Chemotherapy/Radiation Therapy

Infectious Nosocomial Diarrheas

Usually from C.difficile
Salmonella, Shigella : extremely rare if diarrhea
develops after 3-4 days in hospital
In the immunosuppressed, viral infections are an
important cause

Salmonella food poisoning

Contaminated poultry especially egg yolk
Incubation : 8- 48 Hrs
Diarrhea, low temp. Bacteria grow on surface with
little invasion
No Abx unless immune compromised
Pt remains as carrier for up to 2 months

Enteric fever
Caused by Salmonella typhi, incubation 2 w
Fever, bradycardia, altered behavior, constipation
followed by diarrhea
2nd week: Rose spots on abdomen & thorax,
Spleenomegally and Lymphadenopathy
Rx: Chloramphenicol, Ciprofloxacin, Ampicillin

Travelers diarrhea
E coli produces heat labile enterotoxin and heat
stable, causes 40 - 75%
Diarrhea lasts 3- 5 days
Other pathogens - Shigella, Salmonella, Rotavirus,
Giardia
Rx: Ciprofloxacin, TMP- SMA, Aztreonam
The primary source of infection is ingestion of
fecally - contaminated food or water

Runners Diarrhea
20-40% of runners (more common in women)
Mechanism
release of GI hormones
release of inflammatory mediators
?ischemia

Chronic Diarrhea
At least 3 to 4 weeks duration
Accounts for 30% of patients in GI practices
Categories
Organic : malabsorpitive, secretory, exudative
(inflammatory)
Functional

Diagnostic Test for Chronic Diarrhea (1)

Blood tests
CBC, SMA, ESR, Thyroid function
Stool studies
Spot : WBCs, occult blood, O+P, culture, giardia
Ag
Quantitative
volume/weight, electrolytes, osmolality, fat, pH
fecal osm gap: 290-2([Na] + [K])

Diagnostic Test for Chronic Diarrhea (2)

Endoscopy
Colonoscopy with biopsies
Upper endoscopy
biopsies
aspiration for bacterial counts and parasites

Radiology
Plain Radiographs
UGI/Small Bowel Series

Malabsorptive Diarrhea
Fat Malabsorption
intraluminal maldigestion
mucosal malabsorption
postmucosal malabsorption
intestinal lymphangiectasia, vasculitis

Carbohydrate Malabsorption
Protein Malabsorption (Azotorrhea)

Malabsorptive Diarrheas (Fat)

Intraluminal Phase
Cirhosis
Bile duct obstruction
Bacterial overgrowth
Pacreatic exocrine insufficiency

Mucosal Phase
Drugs
Infectious disease
Immune system dz
Tropical sprue
Celiac sprue
Whipples dz
A-beta-lipoproteinemia

Malabsoprtive Diarrhea (Carbs)

Sorbitol diarrhea
Fructose diarrhea
Glucose-galactose deficiency
Diasaccharidase deficiency

Medical usages of enemas

As a bowel stimulant relieve constipation and fecal
impaction.
Bowel stimulating enemas consist of water as a
mechanical stimulant
Made up of water with baking soda (sodium bicarbonate) or
water with a mild hand soap
Buffered sodium phosphate solution draws additional water
from the bloodstream into the colon to increase the
effectiveness of the enema, causing intense cramping or
"griping."

 Mineral oil functions as a lubricant and stool softener

Glycerol bowel mucosa irritant induce peristalsis.
Other types of enema solutions : equal parts of milk and
molasses heated together above normal body temperature
Isotonic saline solution least irritating, having a neutral
concentration gradient.
This neither draws electrolytes. Thus, a salt water solution can
be used when a longer period of retention is desired, such as
to soften an impaction.

 Diarrhea was a leading cause of death among sold

iers during the American Civil War!