Diarrhea happens when the body absorbs less water and electrolytes than usual, leading to watery stools. This happens because of changes in the way the small and large intestines absorb ions, organic substances, and water. In babies and young children, the normal water content in stools is about 10 mL/kg/d, while in teenagers and adults, it’s about 200 g/d. When diarrhea occurs, the amount of water in the stool goes up.

Signs and symptoms

Acute diarrhea is when someone suddenly has 3 or more loose stools per day and it lasts for up to 14 days. If the episode goes on for more than 14 days, it’s called chronic or persistent diarrhea. This difference matters not just for labeling and studying the condition but also for practical reasons. Long-lasting diarrhea often comes from different causes, presents different challenges for treatment, and has a different outlook.

The clinical presentation and course of diarrhea therefore depend on its cause and the host. Consider the following to determine the source/cause of the patient’s diarrhea:

Stool characteristics (eg, consistency, color, volume, frequency)
Presence of associated enteric symptoms (eg, nausea/vomiting, fever, abdominal pain)
Use of child daycare (common pathogens: rotavirus, astrovirus, calicivirus; Campylobacter, Shigella, Giardia, and Cryptosporidium species [spp])
Food ingestion history (eg, raw/contaminated foods, food poisoning)
Water exposure (eg, swimming pools, marine environment)
Camping history (possible exposure to contaminated water sources)
Travel history (common pathogens affect specific regions; also consider rotavirus and Shigella, Salmonella, and Campylobacter spp regardless of specific travel history, as these organisms are prevalent worldwide)
Animal exposure (eg, young dogs/cats: Campylobacter spp; turtles: Salmonella spp)
Predisposing conditions (eg, hospitalization, antibiotic use, immunocompromised state)

Signs and symptoms of diarrhea may include the following:

Dehydration: Lethargy, depressed consciousness, sunken anterior fontanel, dry mucous membranes, sunken eyes, lack of tears, poor skin turgor, delayed capillary refill
Failure to thrive and malnutrition: Reduced muscle/fat mass or peripheral edema
Abdominal pain/cramping
Borborygmi
Perianal erythema

Diagnosis

Fecal laboratory studies include the following:

Examination for ova and parasites
Leukocyte count
pH level: A pH level of 5.5 or less or the presence of reducing substances indicates carbohydrate intolerance, which is usually secondary to viral illness
Examination of exudates for presence/absence of leukocytes
Cultures: Always culture for Salmonella, Shigella, Campylobacter spp, and Y enterocolitis in the presence of clinical signs of colitis or if fecal leukocytes are present; look for Clostridium difficile in those with diarrhea characterized by colitis and/or bloody stools; assess for Escherichia coli, particularly O157:H7, with bloody diarrhea and a history of eating ground beef; screen for Vibrio and Plesiomonas spp with a history of eating raw seafood or foreign travel
Enzyme immunoassay for rotavirus or adenovirus antigens
Latex agglutination assay for rotavirus

Other laboratory studies may include the following:

Serum albumin levels: Low in protein-losing enteropathies from enteroinvasive intestinal infections (eg, Salmonella spp, enteroinvasive E coli)
Fecal alpha1-antitrypsin levels: High in enteroinvasive intestinal infections
Anion gap to determine the nature of diarrhea (ie, osmolar vs secretory)
Intestinal biopsy: May be indicated in the presence of chronic or protracted diarrhea, as well as in cases in which a search for a cause is believed to be mandatory (eg, in patients with acquired immunodeficiency syndrome [AIDS] or patients who are otherwise severely immunocompromised)

Management

Acute-onset diarrhea is usually self-limited; however, an acute infection can have a protracted course. Management is generally supportive: In most cases, the best option for the treatment of acute-onset diarrhea is the early use of oral rehydration therapy (ORT). [1]

Pharmacotherapy

Vaccines (eg, rotavirus) can help increase resistance to infection. Antimicrobial and antiparasitic agents may be used to treat diarrhea caused by specific organisms and/or clinical circumstances. Such medications include the following:

Cefixime
Ceftriaxone
Cefotaxime
Erythromycin
Furazolidone
Iodoquinol
Metronidazole
Paromomycin
Quinacrine
Sulfamethoxazole and trimethoprim
Vancomycin
Tetracycline
Nitazoxanide
Rifaximin

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