Evaluation of acute diarrhea

Diseases

Summary

Diarrhea can be defined as the passage of:[1] [2]

Three or more loose or liquid stools per 24 hours, and/or
Stools that are more frequent than what is normal for the individual lasting <14 days, and/or
Stool weight greater than 200 g/day.

Based on duration, diarrhea is classified as:[2] [3] [4] [5]

Acute (≤14 days)

Persistent (>14 days), or

Chronic (>4 weeks).

Epidemiology

In 2016, diarrhea was the eighth leading cause of death among all ages and the fifth leading cause of death among children younger than 5 years.[6]

Worldwide, it has been estimated that there are 2 billion episodes of diarrheal illness per year.[4] Death due to diarrhea disproportionately affects postneonatal children <5 years.[4] However, with implementation of improved access to oral rehydration therapy (ORT), vitamin supplementation, rotavirus vaccines, and education on feeding and weaning, it is estimated that mortality has dropped from 3.9 million deaths in 1967 to 526,000 in 2015.[7] Additionally, new antisecretory agents have shown promise in conjunction with ORT to reduce diarrhea volume burden.[8] Despite the improvement, diarrhea remains the third leading cause of death in postneonatal children <5 years, after pneumonia and preterm birth/neonatal disorders.[9] [10]

Around 47.8 million cases of acute diarrheal infection occur each year in the US, with an estimated cost of at least US$150 million to the healthcare economy.[11] [12]

Basic pathophysiology

Normally, approximately 10 liters of fluid consisting of ingested food and drink, in addition to secretions from the salivary glands, stomach, pancreas, bile ducts, and duodenum, enters the gastrointestinal tract every day. The small intestine is the major site for reabsorption. Overall, about 99% of the fluid is reabsorbed, leaving 0.1 liter to be excreted in the feces. Diarrhea occurs when various factors interfere with this normal process, resulting in decreased absorption or increased secretion of fluid and electrolytes, or increase in bowel motility.

Improved understanding of the pathophysiology of infectious diarrhea, and the factors that promote the spread of causative infectious agents, will lead to practical approaches for preventing and responding to outbreaks.[13]

Citations

Key Articles

Riddle MS, DuPont HL, Connor BA. ACG clinical guideline: diagnosis, treatment, and prevention of acute diarrheal infections in adults. Am J Gastroenterol. 2016 May;111(5):602-22.[Abstract][Full Text]
World Gastroenterology Organisation. Acute diarrhea in adults and children: a global perspective. 2012 [internet publication].[Full Text]
Shane AL, Mody RK, Crump JA, et al. 2017 Infectious Diseases Society of America clinical practice guidelines for the diagnosis and management of infectious diarrhea. Clin Infect Dis. 2017 Nov 29;65(12):e45-80.[Abstract][Full Text]
McDonald LC, Gerding DN, Johnson S, et al. Clinical practice guidelines for clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018 Mar 19;66(7):e1-48.[Abstract][Full Text]

Referenced Articles

1. World Health Organization. Health topics - diarrhoea. 2017 [internet publication].[Full Text]
2. Riddle MS, DuPont HL, Connor BA. ACG clinical guideline: diagnosis, treatment, and prevention of acute diarrheal infections in adults. Am J Gastroenterol. 2016 May;111(5):602-22.[Abstract][Full Text]
3. Arasaradnam RP, Brown S, Forbes A, et al. Guidelines for the investigation of chronic diarrhoea in adults: British Society of Gastroenterology, 3rd edition. Gut. 2018 Aug;67(8):1380-99.[Abstract][Full Text]
4. World Gastroenterology Organisation. Acute diarrhea in adults and children: a global perspective. 2012 [internet publication].[Full Text]
5. Shane AL, Mody RK, Crump JA, et al. 2017 Infectious Diseases Society of America clinical practice guidelines for the diagnosis and management of infectious diarrhea. Clin Infect Dis. 2017 Nov 29;65(12):e45-80.[Abstract][Full Text]
6. GBD 2016 Diarrhoeal Disease Collaborators. Estimates of the global, regional, and national morbidity, mortality, and aetiologies of diarrhoea in 195 countries: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Infect Dis. 2018 Nov;18(11):1211-28.[Abstract][Full Text]
7. Black R, Fontaine O, Lamberti L, et al. Drivers of the reduction in childhood diarrhea mortality 1980-2015 and interventions to eliminate preventable diarrhea deaths by 2030. J Glob Health. 2019 Dec;9(2):020801.[Abstract][Full Text]
8. Eberlin M, Chen M, Mueck T, et al. Racecadotril in the treatment of acute diarrhea in children: a systematic, comprehensive review and meta-analysis of randomized controlled trials. BMC Pediatr. 2018 Apr 3;18(1):124.[Abstract][Full Text]
9. Centers for Disease Control and Prevention. Global diarrhea burden. Dec 2015 [internet publication].[Full Text]
10. World Health Organization. Children: reducing mortality. Oct 2017 [internet publication].[Full Text]
11. Scallan E, Griffin PM, Angulo FJ, et al. Foodborne illness acquired in the United States: unspecified agents. Emerg Infect Dis. 2011 Jan;17(1):16-22.[Abstract][Full Text]
12. Scallan E, Hoekstra RM, Angulo FJ, et al. Foodborne illness acquired in the United States: major pathogens. Emerg Infect Dis. 2011 Jan;17(1):7-15.[Abstract][Full Text]
13. Pawlowski SW, Warren CA, Guerrant R. Diagnosis and treatment of acute or persistent diarrhea. Gastroenterology. 2009 May;136(6):1874-86.[Abstract][Full Text]
14. Field M. Intestinal ion transport and the pathophysiology of diarrhea. J Clin Invest. 2003 Apr;111(7):931-43.[Abstract][Full Text]
15. Koplan JP, Fineberg HV, Ferraro MJ, et al. Value of stool cultures. Lancet. 1980 Aug 23;2(8191):413-6.[Abstract]
16. Fischer Walker CL, Sack D, Black RE. Etiology of diarrhea in older children, adolescents and adults: a systematic review. PLoS Negl Trop Dis. 2010 Aug 3;4(8):e768.[Abstract][Full Text]
17. Boyce TG, Swerdlow DL, Griffin PM. Escherichia coli O157:H7 and the hemolytic-uremic syndrome. N Engl J Med. 1995 Aug 10;333(6):364-8.[Abstract]
18. Wong CS, Jelacic S, Habeeb RL, et al. The risk of the hemolytic-uremic syndrome after antibiotic treatment of Escherichia coli O157:H7 infections. N Engl J Med. 2000 Jun 29;342(26):1930-6.[Abstract][Full Text]
19. Carter AO, Borczyk AA, Carlson JA, et al. A severe outbreak of Escherichia coli O157:H7--associated hemorrhagic colitis in a nursing home. N Engl J Med. 1987 Dec 10;317(24):1496-500.[Abstract]
20. Panos GZ, Betsi GI, Falagas ME. Systematic review: are antibiotics detrimental or beneficial for the treatment of patients with Escherichia coli O157:H7 infection? Aliment Pharmacol Ther. 2006 Sep 1;24(5):731-42.[Abstract][Full Text]
21. Marder EP, Cieslak PR, Cronquist AB, et al. Incidence and trends of infections with pathogens transmitted commonly through food and the effect of increasing use of culture-independent diagnostic tests on surveillance - Foodborne Diseases Active Surveillance Network, 10 US sites, 2013-2016. MMWR Morb Mortal Wkly Rep. 2017 Apr 21;66(15):397-403.[Abstract][Full Text]
22. Schwerer B. Antibodies against gangliosides: a link between preceding infection and immunopathogenesis of Guillain-Barré syndrome. Microbes Infect. 2002 Mar;4(3):373-84.[Abstract]
23. Altekruse SF, Stern NJ, Fields PI, et al. Campylobacter jejuni: an emerging foodborne pathogen. Emerg Infect Dis. 1999 Jan-Feb;5(1):28-35.[Abstract][Full Text]
24. Bartlett JG, Gerding DN. Clinical recognition and diagnosis of Clostridium difficile infection. Clin Infect Dis. 2008 Jan 15;46(1):S12-8.[Abstract]
25. Galindo CL, Sha J, Fadl AA, et al. Host immune responses to aeromonas virulence factors. Curr Immunol Rev. 2006;2:13.
26. Rutala WA, Sarubi FA Jr, Finch CS, et al. Oyster-associated outbreak of diarrhoeal disease possibly caused by Plesiomonas shigelloides. Lancet. 1982 Mar 27;1(8274):739.[Abstract]
27. Mahler H, Pasi A, Kramer JM, et al. Fulminant liver failure in association with the emetic toxin of Bacillus cereus. N Engl J Med. 1997 Apr 17;336(16):1142-8.[Abstract][Full Text]
28. Petrillo TM, Beck-Sague CM, Songer JG, et al. Enteritis necroticans (pigbel) in a diabetic child. N Engl J Med. 2000 Apr 27;342(17):1250-3.[Abstract][Full Text]
29. Högenauer C, Langner C, Beubler E, et al. Klebsiella oxytoca as a causative organism of antibiotic-associated hemorrhagic colitis. N Engl J Med. 2006 Dec 7;355(23):2418-26.[Abstract][Full Text]
30. Glass RI, Kilgore PE, Holman RC, et al. The epidemiology of rotavirus diarrhea in the United States: surveillance and estimates of disease burden. J Infect Dis. 1996 Sep;174(Suppl 1):S5-11.[Abstract]
31. Soares-Weiser K, Bergman H, Henschke N, et al. Vaccines for preventing rotavirus diarrhoea: vaccines in use. Cochrane Database Syst Rev. 2019 Oct 28;2019(10):CD008521.[Abstract][Full Text]
32. Deneen VC, Hunt JM, Paule CR, et al. The impact of foodborne calicivirus disease: the Minnesota experience. J Infect Dis. 2000 May;181(suppl 2):S281-3.[Abstract][Full Text]
33. Bresee JS, Widdowson MA, Monroe SS, et al. Foodborne viral gastroenteritis: challenges and opportunities. Clin Infect Dis. 2002 Sep 15;35(6):748-53.[Abstract][Full Text]
34. European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN), European Society for Pediatric Infectious Diseases (ESPID). ESPGHAN/ESPID evidence-based guidelines for the management of acute gastroenteritis in children in Europe: update 2014. J Pediatr Gastroenterol Nutr. 2014 Jul;59(1):132-52.[Abstract][Full Text]
35. Mitchell DK, Matson DO, Jiang X, et al. Molecular epidemiology of childhood astrovirus infection in child care centers. J Infect Dis. 1999 Aug;180(2):514-7.[Abstract][Full Text]
36. Esahli H, Breback K, Bennet R, et al. Astroviruses as a cause of nosocomial outbreaks of infant diarrhea. Pediatr Infect Dis J. 1991 Jul;10(7):511-5.[Abstract]
37. Grohmann GS, Glass RI, Pereira HG, et al; Enteric Opportunistic Infections Working Group. Enteric viruses and diarrhea in HIV-infected patients. N Engl J Med. 1993 Jul 1;329(1):14-20.[Abstract][Full Text]
38. Li E, Stanley SL Jr. Protozoa. Amebiasis. Gastroenterol Clin North Am. 1996 Sep;25(3):471-92.[Abstract]
39. Petri WA Jr. Recent advances in amebiasis. Crit Rev Clin Lab Sci. 1996;33(1):1-37.[Abstract]
40. Kappus KD, Lundgren RG Jr, Juranek DD, et al. Intestinal parasitism in the United States: Update on a continuing problem. Am J Trop Med Hyg. 1994 Jun;50(6):705-13.[Abstract]
41. Fayer R, Ungar BL. Cryptosporidium spp. and cryptosporidiosis. Microbiol Rev. 1986 Dec;50(4):458-83.[Abstract][Full Text]
42. Kansouzidou A, Charitidou C, Varnis T, et al. Cyclospora cayetanensis in a patient with travelers' diarrhea: case report and review. J Travel Med. 2004 Jan-Feb;11(1):61-3.[Abstract][Full Text]
43. Huang P, Weber JT, Sosin DM, et al. The first reported outbreak of diarrheal illness associated with Cyclospora in the United States. Ann Intern Med. 1995 Sep 15;123(6):409-14.[Abstract]
44. Schiller LR, Sellin JH. Diarrhea. In: Feldman M, Friedman LS, Brandt LJ, ed. Sleisenger and Fordtran's gastrointestinal and liver disease. 8th ed. Philadelphia, PA: Saunders Elsevier; 2006:159-86.
45. Wardlaw T, Salama P, Brocklehurst C, et al. Diarrhoea: why children are still dying and what can be done. Lancet. 2010 Mar 13;375(9718):870-2.[Abstract][Full Text]
46. Azad MA, Islam M, Butler T. Colonic perforation in Shigella dysenteriae 1 infection. Pediatr Infect Dis. 1986 Jan-Feb;5(1):103-4.[Abstract]
47. Su C, Lichtenstein GR. Ulcerative colitis. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran's gastrointestinal and liver disease. 8th ed. Philadelphia, PA: Saunders Elsevier; 2006:2530-2.
48. Singer M, Deutschman CS, Seymour CW, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016 Feb 23;315(8):801-10.[Abstract][Full Text]
49. National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Jan 2024 [internet publication].[Full Text]
50. Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Crit Care Med. 2021 Nov 1;49(11):e1063-143.[Abstract][Full Text]
51. Royal College of Physicians. National early warning score (NEWS) 2. Dec 2017 [internet publication].[Full Text]
52. American College of Emergency Physicians (ACEP) Expert Panel on Sepsis. DART: an evidence-driven tool to guide the early recognition and treatment of sepsis and septic shock. Sep 2022 [internet publication].[Full Text]
53. Academy of Medical Royal Colleges. Statement on the initial antimicrobial treatment of sepsis. Oct 2022 [internet publication].[Full Text]
54. Schlapbach LJ, Watson RS, Sorce LR, et al. International consensus criteria for pediatric sepsis and septic shock. JAMA. 2024 Feb 27;331(8):665-74.[Abstract][Full Text]
55. Society of Critical Care Medicine. Surviving sepsis campaign: hour-1 bundle. 2019 [internet publication].[Full Text]
56. Panush RS, Wallace DJ, Dorff RE, et al. Retraction of the suggestion to use the term "Reiter's syndrome" sixty-five years later: the legacy of Reiter, a war criminal, should not be eponymic honor but rather condemnation. Arthritis Rheum. 2007 Feb;56(2):693-4.[Abstract][Full Text]
57. Naranjo M, Denayer S, Botteldoorn N, et al. Sudden death of a young adult associated with Bacillus cereus food poisoning. J Clin Microbiol. 2011 Dec;49(12):4379-81.[Abstract][Full Text]
58. Shrestha A, Uzal FA, McClane BA. Enterotoxic clostridia: Clostridium perfringens enteric diseases. Microbiol Spectr. 2018 Sep;6(5):10.1128/microbiolspec.GPP3-0003-2017.[Abstract][Full Text]
59. Miller JM, Binnicker MJ, Campbell S, et al. A guide to utilization of the microbiology laboratory for diagnosis of infectious diseases: 2018 update by the Infectious Diseases Society of America and the American Society for Microbiology. Clin Infect Dis. 2018 Aug 31;67(6):e1-94.[Abstract][Full Text]
60. Harris C, Wilkinson F, Mazza D, et al. Evidence based guideline for the management of diarrhoea with or without vomiting in children. Aust Fam Physician. 2008 Jun;37(6 Spec No):22-9.[Abstract]
61. Thielman NM, Guerrant RL. Clinical practice: acute infectious diarrhea. N Engl J Med. 2004 Jan 1;350(1):38-47.[Abstract]
62. Guerrant RL, Shields DS, Thorson SM, et al. Evaluation and diagnosis of acute infectious diarrhea. Am J Med. 1985 Jun 28;78(6B):91-8.[Abstract]
63. Kane SV, Sandborn WJ, Rufo PA, et al. Fecal lactoferrin is a sensitive and specific marker in identifying intestinal inflammation. Am J Gastroenterol. 2003 Jun;98(6):1309-14.[Abstract]
64. Foell D, Wittkowski H, Roth J. Monitoring disease activity by stool analyses: from occult blood to molecular markers of intestinal inflammation and damage. Gut. 2009 Jun;58(6):859-68.[Abstract]
65. McDonald LC, Gerding DN, Johnson S, et al. Clinical practice guidelines for clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018 Mar 19;66(7):e1-48.[Abstract][Full Text]
66. Becker SL, Chatigre JK, Gohou JP, et al. Combined stool-based multiplex PCR and microscopy for enhanced pathogen detection in patients with persistent diarrhoea and asymptomatic controls from Côte d'Ivoire. Clin Microbiol Infect. 2015 Jun;21(6):591;e1-10.[Abstract][Full Text]
67. Shen B, Khan K, Ikenberry SO, et al; ASGE Standards of Practice Committee. The role of endoscopy in the management of patients with diarrhea. Gastrointest Endosc. 2010 May;71(6):887-92.[Abstract][Full Text]
68. Webster J, Osborne S, Rickard CM, et al. Clinically-indicated replacement versus routine replacement of peripheral venous catheters. Cochrane Database Syst Rev. 2019 Jan 23;(1):CD007798.[Abstract][Full Text]
69. Simundic AM, Bölenius K, Cadamuro J, et al. Joint EFLM-COLABIOCLI recommendation for venous blood sampling. Clin Chem Lab Med. 2018;56(12):2015-38.[Abstract]
70. Janda JM, Abbott SL, Morris GJ Jr. Aeromonas, plesiomonas, and edwardsiella. In: Blaser, Smith, Ravdin, et al., eds. Infections of the gastrointestinal tract. New York, NY: Raven Press; 1995.
71. Oberhuber G, Kastner N, Stolte M. Giardiasis: a histologic analysis of 567 cases. Scand J Gastroenterol. 1997 Jan;32(1):48-51.[Abstract]