Diarrhea – Acute

Acute diarrhea is an abrupt onset of increased fluid content of stool above about 10 mL/kg/day and increased frequency from 4–5 to more than 20 times daily. It is a major problem worldwide because of excessive loss of fluid and electrolytes in stool. In the U.S., every year diarrhea accounts for 1–2 episodes per child, about 10% of all hospital admissions for children under 5 years of age, and 400 deaths. According to the WHO, about 3 million diarrhea-related deaths occur per year globally.

Differential Diagnosis

• Viral gastroenteritis
  –Rotavirus, most common (winter)
  –Norwalk-like virus
  –Calcivurus
  –Enteric adenovirus
  –Astrovirus
• Bacterial gastroenteritis
  –Campylobacter jejuni (associated with Guillain-Barré syndrome)
  –Salmonella
  –Shigella: May cause seizures (up to 30%), HUS
  –Escherichia coli (various types): Enteropathogenic, enterohemorrhagic (O157:H7) verotoxin can cause HUS (6–8% of cases), enterotoxigenic (traveler's diarrhea), enteroinvasive
  –Clostridium difficile (toxin A or B)
  –Yersinia enterocolitis (mimics acute appendicitis)
  –Vibrio cholerae
  –Aeromonas hydrophila
  –Toxin-mediated food poisoning: Bacillus cereus, Staphylococcus aureus, Clostridium perfringens
  • Parasitic infestations
    –Giardia lamblia
    –Cryptosporidium (severe in AIDS patients)
    –Entamoeba histolytica
  • Food allergies
    –Cow's milk and soy protein allergy are most common in infancy
  • Malbasorption (celiac disease, CF)
  • Lactose or fructose intolerance
  • Overfeeding (relative lactase deficiency)
  • Vitamin deficiency (e.g., niacin )
  • Zinc deficiency
  • Laxative abuse
  • Irritable bowel syndrome
  • Constipation with encopresis
  • Bacterial overgrowth
  • Antibiotics
  • Hirschsprung toxic colitis
  • Adrenogenital syndrome

  Workup and Diagnosis

  • History
    –Duration of diarrhea
    –Frequency and consistency of stool
    –Vomiting, weight loss
    –Diet history
    –History of sick contact
    –Fever and blood mixed in stool more common with invasive pathogens: Salmonella, Shigella, Campylobacter, Yersinia, E. coli O157:H7, and E. histolytica
  • Physical exam
    –Vital signs, look for signs of dehydration
    –Severe cases may present in hypovolemic shock
  • Labs
    –Urinalysis: Specific gravity and ketones
    –Serum electrolytes: Acidosis, hyper- or hyponatremia, hypoglycemia
    –Stool for Rotazyme
    –Stool culture: Salmonella, E. coli, Shigella, Campylobacter, and Yersinia
    –Stool ELISA for C. difficile toxin A and B
    –Stool for ova and parasites
    –Blood culture indicated in the presence of fever
    –CBC may reveal high bandemia with shigellosis
    –Stool for occult blood and WBC is of little value in differentiating viral from bacterial causes

  Treatment

  • Mainstay of treatment is rehydration to correct fluid and electrolyte deficits
    –Oral route is best in mildly to moderately dehydrated children who can tolerate PO fluid
    –IV fluids: Useful in severe to moderate dehydration
    –Estimate fluid deficit using % of weight loss, and add this to maintenance requirement and ongoing losses
    – Correct over 24–48 hours
  • Antibiotics
    –Not necessary in most cases, can precipitate HUS
    –Indicated for V. cholerae, Shigella, and G. lamblia
    –Indicated in selected circumstances: Salmonella in very young infant, if febrile, or positive blood culture
    –Metronidazole for C. difficile (if antibiotic elimination doesn’t help)
  • Refeeding: No benefit to withholding milk, incidence of lactose intolerance overstated
  • Probiotics: Lactobacillus rhamnosus for rotavirus

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

More About Causes of Bloody stool

• Back to symptom: Bloody stool: Introduction (review 352 causes)
• Next Book Extract About Bloody stool: DIARRHEA (Differential Diagnosis in Primary Care)
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More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

 » Next page: DIARRHEA (Differential Diagnosis in Primary Care)

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