Diarrhea
Diarrhea: Excerpt from Pediatric Complaints and Diagnostic Dilemmas
Christina Lin Master
Approach to the Patient with Diarrhea
I. Definition of the Complaint
Diarrhea is one of the most common reasons for which patients seek medical care.
It is a condition that continues to be associated with significant morbidity
and mortality worldwide despite medical advances. It is characterized by an
increase in the frequency, volume, or liquid content of stool in a given
individual, compared with his or her usual pattern.
Diarrhea may be further characterized by the duration of the symptoms, with
acute episodes of diarrhea resolving anywhere from 72 hours to 2 weeks and
chronic diarrhea generally lasting longer than 2 weeks. Another important
distinction in the type of diarrhea is whether it is secretory or osmotic in
nature. Agents that disrupt the normal absorption of intestinal luminal fluid
at the cellular level cause a profuse and voluminous secretory diarrhea that
continues regardless of the patient
's oral intake. Osmotic diarrhea, on the other hand, is the result of poorly
absorbed substances that draw fluid into the intestinal lumen. This type of
diarrhea tends to improve with fasting.
The most common causes of diarrhea are infectious, with viral etiologies
occurring more frequently than bacterial. The differential diagnosis of
diarrhea, however, is quite long and includes some rare causes. Many cases of
diarrhea occur in children who are otherwise well-appearing, whereas some cases
occur in children who are ill-appearing because of poor nutrition, lack of
hydration, or other systemic reasons.
II. Complaint by Cause and Frequency
The myriad causes of diarrhea can be stratified by age (Table 17-1) or by
diagnostic category (Table 17-2).
III. Clarifying Questions
A thorough history can provide clues to facilitate accurate diagnosis for the
child who presents with diarrhea. Consideration of the age and appearance of
the patient, the length and course of the illness, and associated clinical
features provides a useful framework for creating a differential diagnosis. The
following questions may help provide clues to the diagnosis.
• How long has the diarrhea lasted?
— Diarrhea that has lasted less than 2 weeks is acute diarrhea, rather than
chronic. Acute diarrhea is more likely to be infectious (viral or bacterial) in
origin. Chronic diarrhea raises the concern for other diagnoses such as
malabsorptive conditions (e.g., cystic fibrosis, celiac disease), although
infectious causes (e.g., parasitic) and postinfectious conditions (e.g.,
postinfectious carbohydrate malabsorption) are still possible.
• Is there any blood or mucus in the stool?
— In the acute setting, blood or mucus in the stool increases the possibility of
an enteroinvasive agent (e.g., enteroinvasive
Escherichia coli, Salmonella spp., Shigella spp.). In the chronic setting, inflammatory bowel disease should be considered.
In a systemically ill-appearing child, hemolytic-uremic syndrome (HUS) must be
considered.
• Is there abdominal pain or cramping? Is tenesmus present?
— Acute infectious gastroenteritis can manifest with abdominal cramping, whereas
a chronic history of cramping or tenesmus raises the possibility of
inflammatory bowel disease.
• Is there any vomiting?
— Vomiting may be associated with acute infectious gastroenteritis. However, if
bilious vomiting is noted, especially in a neonate or an infant, an anatomic
condition (e.g., malrotation, incarcerated hernia) must be considered.
• Is fever present?
— Presence of a fever acutely may indicate either an enteroinvasive infectious
agent or systemic illness (e.g., pneumonia) with an associated nonspecific
diarrhea. In a toxic-appearing child, sepsis and toxic shock syndrome must be
considered. In a patient with a history of chronic diarrhea with acute
exacerbations associated with fever, inflammatory bowel disease is a distinct
possibility.
• Does the patient appear systemically ill?
— In acute diarrhea, a systemically ill-appearing child should raise the concern
for sepsis (e.g.,
Salmonella spp., E. coli), especially in a neonate or infant. If oliguria is also present, HUS must be
considered in addition to simple dehydration associated with diarrheal losses.
In patients who have a history of chronic diarrhea and failure to thrive,
superimposed episodes of acute diarrhea can make them appear systemically ill,
as in cases of inflammatory bowel disease, celiac disease, or cystic fibrosis.
• Is there failure to thrive?
— A chronic history of diarrhea associated with failure to thrive raises the
concern for malabsorptive conditions such as cystic fibrosis and celiac
disease. Neuroendocrine tumors that cause a secretory diarrhea may manifest
with significant weight loss. Inflammatory bowel disease also commonly
manifests with linear growth arrest in addition to poor weight gain.
• Are there ill contacts with diarrhea?
— The existence of close contacts with similar symptoms may indicate an outbreak
with a common source of contamination (e.g., day care, family reunion,
restaurant), either toxin-associated food poisoning or fecal-oral
contamination.
• Has there been any unusual food exposure?
— In particular, undercooked foods, specifically beef, are of concern as a source
for
E. coli O157:H7 infection resulting in HUS. Improperly stored food is another potential
source for food poisoning. New foods may not be tolerated well and may be the
source of transient diarrhea, or they may cause bloody diarrhea, as in the case
of milk-protein allergy in infants.
• Is there any history of recent travel?
— Foreign travel increases the concern for travelers' diarrhea, often due to strains of E. coli, or unusual organisms, such as Entamoeba histolytica, as a cause of chronic diarrhea. Other parasites, such as Giardia lamblia, and agents such as hepatitis A may also be acquired during travel.
• What is the water source?
— Untreated or contaminated water sources can harbor G. lamblia or Cryptosporidium. Cases of E. coli O157:H7 transmission have also been known to occur with exposure in water
sources such as swimming pools or lakes.
• Are there any pets? Has there been any exposure to animals?
— Unusual pets, such as lizards, can harbor Salmonella, which can then cause diarrhea in children who play with them. Farm animals and
petting zoos are also potential sources for
E. coli 0157:H7 and epidemic cases of HUS.
• Is there a history of recent antibiotic use?
— Clostridium difficile colitis is a common sequela to antibiotic use in children.
• Is there any significant past medical history?
— Failure to thrive is of particular concern with superimposed diarrhea, either
acute or chronic. Former premature infants who had surgical necrotizing
enterocolitis may subsequently have chronic diarrhea due to short-bowel
syndrome. Diarrhea may also be associated with other immune compromising
conditions (e.g., human immunodeficiency virus [HIV] infection) or with
endocrinologic disorders (e.g., hyperthyroidism).
• Is there a significant family history?
— Patients with inflammatory bowel disease may present with family members who
have the same symptoms. Cystic fibrosis and celiac disease have traditionally
been associated with northern European ancestry, although patients of other
ethnicities can also carry these diagnoses.
• Is the diarrhea worse with oral intake? Is it improved with fasting?
— This question helps to differentiate osmotic diarrhea, which characterizes most
cases of diarrhea, from secretory diarrhea, which is much less common and is
often associated with otherwise occult oncologic conditions.
• Is there a rash?
— A petechial, purpuric rash is indicative of Henoch-Schönlein purpura, although, in an ill-appearing child, sepsis would also have to be
considered. Other rashes, such as dermatitis herpetiformis, can be seen in
chronic conditions such as celiac disease. Rashes may also develop due to
nutritional deficiencies.
• Is the weight loss intentional?
— Teenagers who are overly concerned with body image may be using laxatives to
lose weight.
Pictures
Book Source Details
- Book Title: Pediatric Complaints and Diagnostic Dilemmas
- Author(s): Samir S Shah MD; Stephen Ludwig MD
- Year of Publication: 2003
- Copyright Details: Pediatric Complaints and Diagnostic Dilemmas, Copyright © 2003 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
» Next page: Diarrhea - Case 17-1: 2-Month-Old Boy (Pediatric Complaints and Diagnostic Dilemmas)
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