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Acute Diarrhea in Adults WENDY BARR, MD, MPH, MSCE, and ANDREW SMITH, MD Lawrence Family Medicine Residency, Lawrence, Massachusetts

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Acute Diarrhea in Adults WENDY BARR, MD, MPH, MSCE, and ANDREW SMITH, MD Lawrence Family Medicine Residency, Lawrence, Massachusetts Acute Diarrhea in Adults WENDY BARR, MD, MPH, MSCE, and ANDREW SMITH, MD Lawrence Family Medicine Residency, Lawrence, Massachusetts Acute diarrhea in adults is a common problem encountered by family physicians. The most common etiology is viral gastroenteritis, a self-limited disease. Increases in travel, comorbidities, and foodborne illness lead to more bacteria- related cases of acute diarrhea. A history and physical examination evaluating for risk factors and signs of inflammatory diarrhea and/or severe dehydration can direct any needed testing and treatment. Most patients do not require labora- tory workup, and routine stool cultures are not recommended. Treatment focuses on preventing and treating dehydra- tion. Diagnostic investigation should be reserved for patients with severe dehydration or illness, persistent fever, bloody stool, or immunosuppression, and for cases of suspected nosocomial infection or outbreak. Oral rehydration therapy with early refeeding is the preferred treatment for dehydration. Antimotility agents should be avoided in patients with bloody diarrhea, but loperamide/simethicone may improve symptoms in patients with watery diarrhea. Probiotic use may shorten the duration of illness. When used appropriately, antibiotics are effective in the treatment of shigellosis, campylobacteriosis, Clostridium difficile,traveler’s diarrhea, and protozoal infections. Prevention of acute diarrhea is promoted through adequate hand washing, safe food preparation, access to clean water, and vaccinations. (Am Fam Physician. 2014;89(3):180-189. Copyright © 2014 American Academy of Family Physicians.) CME This clinical content cute diarrhea is defined as stool with compares noninflammatory and inflamma- conforms to AAFP criteria increased water content, volume, or tory acute infectious diarrhea.7,8 for continuing medical education (CME). See CME frequency that lasts less than 14 Viral infections are the most common Quiz Questions on page days.1 Diarrheal illness accounts cause of acute diarrhea.9 Bacterial infec- 173. Afor 2.5 million deaths per year worldwide.2 tions are more often associated with travel, Author disclosure: No rel- In the United States, an estimated 48 mil- comorbidities, and foodborne illness. When evant financial affiliations. lion foodborne diarrheal illnesses occur a specific organism is identified, the most ▲ Patient information: annually, resulting in more than 128,000 common causes of acute diarrhea in the A handout on this topic, hospitalizations and 3,000 deaths.3,4 In United States are Salmonella, Campylobacter, written by the authors of the developing world, infectious causes of Shigella, and Shiga toxin–producing Esche- this article, is available acute diarrhea are largely related to con- richia coli (enterohemorrhagic E. coli).10 The at http://www.aafp.org/ 5 afp/2014/0201/p180-s1. taminated food and water supplies. In the Centers for Disease Control and Prevention developed world, technological progress and provides a comprehensive list of foodborne an increase in mass production of food have illnesses at http://www.cdc.gov/foodsafety/ paradoxically contributed to the persistence diseases. of foodborne illness, despite higher stan- dards of food production.6 History and Physical Examination HISTORY Differential Diagnosis The onset, duration, severity, and frequency Scan the QR code below Infectious causes of acute diarrhea include of diarrhea should be noted, with particu- with your mobile device viruses, bacteria, and, less often, parasites. lar attention to stool character (e.g., watery, for easy access to the Noninfectious causes include medication bloody, mucus-filled, purulent, bilious). patient information hand- out on the AFP mobile site. adverse effects, acute abdominal processes, The patient should be evaluated for signs of gastroenterologic disease, and endocrine dehydration, including decreased urine out- disease. put, thirst, dizziness, and change in mental Clinically, acute infectious diarrhea is clas- status. Vomiting is more suggestive of viral sified into two pathophysiologic syndromes, illness or illness caused by ingestion of a commonly referred to as noninflammatory preformed bacterial toxin. Symptoms more (mostly viral, milder disease) and inflamma- suggestive of invasive bacterial (inflamma- tory (mostly invasive or with toxin-produc- tory) diarrhea include fever, tenesmus, and ing bacteria, more severe disease).7,8 Table 1 grossly bloody stool.11 180Downloaded American from the Family American Physician Family Physician website at www.aafp.org/afp.www.aafp.org/afp Copyright © 2013 American AcademyVolume of Family 89, Physicians. Number For3 ◆the February private, noncom 1, 2014- mercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Acute Diarrhea Table 1. Noninflammatory vs. Inflammatory Diarrheal Syndromes Factor Noninflammatory Inflammatory Etiology Usually viral, but can be bacterial or parasitic Generally invasive or toxin-producing bacteria Pathophysiology More likely to promote intestinal secretion without More likely to disrupt mucosal integrity, which significant disruption in the intestinal mucosa may lead to tissue invasion and destruction History and examination Nausea, vomiting; normothermia; abdominal cramping; Fever, abdominal pain, tenesmus, smaller stool findings larger stool volume; nonbloody, watery stool volume, bloody stool Laboratory findings Absence of fecal leukocytes Presence of fecal leukocytes Common pathogens Enterotoxigenic Escherichia coli, Clostridium perfringens, Salmonella (non-Typhi species), Shigella, Bacillus cereus, Staphylococcus aureus, Rotavirus, Campylobacter, Shiga toxin–producing Norovirus, Giardia, Cryptosporidium, Vibrio cholerae E. coli, enteroinvasive E. coli, Clostridium difficile, Entamoeba histolytica, Yersinia Other Generally milder disease Generally more severe disease Severe fluid loss can still occur, especially in malnourished patients Information from references 7 and 8. A food and travel history is helpful to evaluate poten- diarrhea. The abdominal examination is important to tial exposures. Children in day care, nursing home resi- assess for pain and acute abdominal processes. A rectal dents, food handlers, and recently hospitalized patients examination may be helpful in assessing for blood, rectal are at high risk of infectious diarrheal illness. Pregnant tenderness, and stool consistency. women have a 12-fold increased risk of listeriosis,12 which is primarily contracted by consuming cold meats, Diagnostic Testing soft cheeses, and raw milk.13 Recent sick contacts and Because most watery diarrhea is self-limited, testing is use of antibiotics and other medications should be noted usually not indicated.1,16 In general, specific diagnostic in patients with acute diarrhea. Sexual practices that investigation can be reserved for patients with severe include receptive anal and oral-anal contact increase dehydration, more severe illness, persistent fever, bloody the possibility of direct rectal inoculation and fecal-oral stool, or immunosuppression, and for cases of suspected transmission. nosocomial infection or outbreak. The history should also include gastroenterologic disease or surgery; endocrine disease; radiation to the OCCULT BLOOD pelvis; and factors that increase the risk of immuno- It is unclear how much fecal occult blood testing affects suppression, including human immunodeficiency virus pretest probability. Nevertheless, it is a rapid and inex- infection, long-term steroid use, chemotherapy, and pensive test, and when tests are positive for fecal occult immunoglobulin A deficiency. History findings associ- blood in conjunction with the presence of fecal leuko- ated with causes of diarrhea are summarized in Table cytes or lactoferrin, the diagnosis of inflammatory diar- 2,1,7,8,14,15 and clinical features by pathogen are summa- rhea is more common.17 Of note, fecal occult blood testing rized in Table 3.1,14 is 71% sensitive and 79% specific for inflammatory diar- rhea in developed countries, but the sensitivity drops to PHYSICAL EXAMINATION 44% and specificity to 72% in developing countries.18 The primary goal of the physical examination is to assess the patient’s degree of dehydration. Generally ill appear- LEUKOCYTES AND LACTOFERRIN ance, dry mucous membranes, delayed capillary refill Testing stool for leukocytes to screen for inflammatory time, increased heart rate, and abnormal orthostatic diarrhea poses several challenges, including the han- vital signs can be helpful in identifying more severe dling of specimens and the standardization of laboratory dehydration. Fever is more suggestive of inflammatory processing and interpretation. There is a wide variability February 1, 2014 ◆ Volume 89, Number 3 www.aafp.org/afp American Family Physician 181 Acute Diarrhea Table 2. Clues to the Diagnosis of Acute Diarrhea History Potential pathogen/etiology Afebrile, abdominal pain with bloody diarrhea Shiga toxin–producing Escherichia coli Bloody stools Salmonella, Shigella, Campylobacter, Shiga toxin–producing E. coli, Clostridium difficile, Entamoeba histolytica, Yersinia Camping, consumption of untreated water Giardia Consumption of food commonly associated with foodborne illness Fried rice Bacillus cereus Raw ground beef or seed sprouts Shiga toxin–producing E. coli (e.g., E. coli O157:H7) Raw milk Salmonella, Campylobacter, Shiga toxin–producing E. coli, Listeria Seafood, especially raw or undercooked
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