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Diarrhea can be described as an abnormal increase in the frequency, volume or liquidity of your stools. The condition usually lasts a few hours to a couple of days. Diarrhea is typically associated with abdominal cramps. The most common causes of diarrhea include:
Other causes include medications, such as antibiotics that disturb the natural balance of the bacteria in your intestines, artificial sweeteners and lactose, which is a sugar found in milk. Diarrhea that persists for more than a couple of days is considered chronic and may be a sign of an underlying condition, such as inflammatory bowel disease or an infection. In these cases, diarrhea may lead to dehydration and requires the care of your doctor. Dehydration occurs when the body has lost too much fluid and electrolytes -- the salts potassium and sodium. The fluid and electrolytes lost during diarrhea need to be replaced promptly because the body cannot function properly without them. Signs and symptoms associated with diarrhea may include:
Frequent loose, watery stools Abdominal cramps Abdominal pain Fever Bleeding Lightheadedness or dizziness from dehydration
Diarrhea caused by a viral infection, such as a stomach virus, or bacterial infection also may cause vomiting. In addition, blood and mucus in the stools may appear with diarrhea caused by bacterial infections.
What is diarrhea?
Diarrhea is an increase in the frequency of bowel movements or a decrease in the form of stool (greater looseness of stool). Although changes in frequency of bowel movements and looseness of stools can vary independently of each other, changes often occur in both. Diarrhea needs to be distinguished from four other conditions. Although these conditions may accompany diarrhea, they often have different causes and different treatments than diarrhea. These other conditions are:
1.
incontinence of stool, which is the inability to control (delay) bowel movements until an appropriate time, for example, until one can get to the toilet
2.
rectal urgency, which is a sudden urge to have a bowel movement that is so strong that if a toilet is not immediately available there will be incontinence
3.
incomplete evacuation, which is a sensation that another bowel movement is necessary soon after a bowel movement, yet there is difficulty passing further stool the second time
4.
Acute diarrhea lasts from a few days up to a week. Chronic diarrhea can be defined in several ways but almost always lasts more than three weeks.
It is important to distinguish between acute and chronic diarrhea because they usually have different causes, require different diagnostic tests, and require different treatment.
cubes. Toxins produced by ETEC cause the sudden onset of diarrhea, abdominal cramps, nausea, and sometimes vomiting. These symptoms usually occur 3-7 days after arrival in the foreign country and generally subside within 3 days. Occasionally, other bacteria or parasites can cause diarrhea in travelers (for example, Shigella, Giardia, Campylobacter). Diarrhea caused by these other organisms usually lasts longer than 3 days. Bacterial enterocolitis Disease-causing bacteria usually invade the small intestines and colon and cause enterocolitis (inflammation of the small intestine and colon). Bacterial enterocolitis is characterized by signs of inflammation (blood or pus in the stool, fever) and abdominal pain and diarrhea. Campylobacter jejuni is the most common bacterium that causes acute enterocolitis in the U.S. Other bacteria that cause enterocolitis include Shigella, Salmonella, and EPEC. These bacteria usually are acquired by drinking contaminated water or eating contaminated foods such as vegetables, poultry, and dairy products. Enterocolitis caused by the bacterium Clostridium difficile is unusual because it often is caused by antibiotic treatment. Clostridium difficile is also the most common nosocomial infection (infection acquired while in the hospital) to cause diarrhea. Unfortunately, infection also is increasing among individuals who have neither taken antibiotics or been in the hospital. E. coli O157:H7 is a strain of E. coli that produces a toxin that causes hemorrhagic enterocolitis (enterocolitis with bleeding). There was a famous outbreak of hemorrhagic enterocolitis in the U.S. traced to contaminated ground beef in hamburgers (hence it is also called hamburger colitis). Approximately 5% of patients infected with E. coli O157:H7, particularly children, can develop hemolytic uremic syndrome (HUS), a syndrome that can lead to kidney failure . Some evidence suggests that prolonged use of anti-diarrhea agents or use of antibiotics may increase the chance of developing HUS. Parasites Parasitic infections are not common causes of diarrhea in the U. S. Infection with Giardia lamblia occurs among individuals who hike in the mountains or travel abroad and is transmitted by contaminated drinking water. Infection with Giardia usually is not associated with inflammation; there is no blood or pus in the stool and little fever. Infection with amoeba (amoebic dysentery) usually occurs during travel abroad to undeveloped countries and is associated with signs of inflammation--blood or pus in the stool and fever. Cryptosporidium is a diarrhea-producing parasite that is spread by contaminated water because it can survive chlorination. Cyclospora is a diarrhea-producing parasite that has been associated with contaminated raspberries from Guatemala. Drugs Drug-induced diarrhea is very common because many drugs cause diarrhea. The clue to drug-induced diarrhea is that the diarrhea begins soon after treatment with the drug is begun. The medications that most frequently cause diarrhea are antacids and nutritional supplements that contain magnesium. Other classes of medication that cause diarrhea include:
nonsteroidal anti-inflammatory drugs (NSAIDs), chemotherapy medications, antibiotics, medications to control irregular heartbeats (antiarrhythmics), and
misoprostol (Cytotec), quinidine (Quinaglute, Quinidex), olsalazine (Dipentum), colchicine (Colchicine), metoclopramide (Reglan), and cisapride (Propulsid, Motilium).
reaches the colon and pulls water (by osmosis) into the colon. This leads to diarrhea. Although lactose is the most common form of sugar malabsorption, other sugars in the diet also may cause diarrhea, including fructose and sorbitol. Fat malabsorption. Malabsorption of fat is the inability to digest or absorb fat. Fat malabsorption may occur because of reduced pancreatic secretions that are necessary for normal digestion of fat (for example, due topancreatitis or pancreatic cancer) or by diseases of the lining of the small intestine that prevent the absorption of digested fat (for example, celiac disease). Undigested fat enters the last part of the small intestine and colon where bacteria turn it into substances (chemicals) that cause water to be secreted by the small intestine and colon. Passage through the small intestine and colon also may be more rapid when there is malabsorption of fat. Endocrine diseases. Several endocrine diseases (imbalances of hormones) may cause diarrhea, for example, an over-active thyroid gland (hyperthyroidism) and an under-active pituitary or adrenal gland (Addison's disease). Laxative abuse. The abuse of laxatives by individuals who want attention or to lose weight is an occasional cause of chronic diarrhea.
Dehydration is common among adult patients with acute diarrhea who have large amounts of stool, particularly when the intake of fluids is limited by lethargy or is associated with nausea and vomiting.
It also is common in infants and young children who develop viral gastroenteritis or bacterial infection. Patients with mild dehydration may experience only thirst and dry mouth.
Moderate to severe dehydration may cause orthostatic hypotension with syncope (fainting upon standing due to a reduced volume of blood, which causes a drop in blood pressure upon standing), a diminished urine output, severe weakness, shock, kidney failure,confusion, acidosis (too much acid in the blood), and coma. Electrolytes (minerals) also are lost with water when diarrhea is prolonged or severe, and mineral or electrolyte deficiencies may occur. The most common deficiencies occur with sodium and potassium. Abnormalities of chloride and bicarbonate also may develop. Finally, there may be irritation of the anus due to the frequent passage of watery stool containing irritating substances.
High fever (temperature greater than 101 F) Moderate or severe abdominal pain or tenderness Bloody diarrhea that suggests severe intestinal inflammation
Diarrhea in persons with serious underlying illness for whom dehydration may have more serious consequences, for example, persons with diabetes,heart disease, and AIDS Severe diarrhea that shows no improvement after 48 hours. Moderate or severe dehydration Prolonged vomiting that prevents intake of fluids orally Acute diarrhea in pregnant women because of concern for the health of the fetus
Diarrhea that occurs during or immediately after completing a course of antibiotics because the diarrhea may represent antibiotic-associatedinfection with C. difficile that requires treatment Diarrhea after returning from developing countries or from camping in the mountains because there may be infection with Giardia (for which there is treatment) Diarrhea that develops in patients with chronic intestinal diseases such as colitis, or Crohn's disease because the diarrhea may represent worsening of the underlying disease or a complication of the disease, both requiring treatment
Acute diarrhea in an infant or young child in order to ensure the appropriate use of oral liquids (type, amount, and rate), to prevent or treat dehydration, and to prevent complications of inappropriate use of liquids such as seizures and abnormal blood electrolytes
Chronic diarrhea
Measurement of blood pressure in the upright and supine (lying) positions can demonstrate orthostatic hypotension and confirm the presence of dehydration. If moderate or severe dehydration or electrolyte deficiencies are likely, blood electrolytes can be measured.
Examination of a small amount of stool under the microscope may reveal white blood cells indicating that intestinal inflammation is present and prompting further testing, particularly bacterial cultures of stool and examination of stool for parasites.
If antibiotics have been taken within the previous two weeks, stool should be tested for the toxin of C. difficile.
Testing stool or blood for viruses is performed only rarely, since there is no specific treatment for the viruses that cause gastroenteritis.
If there has been recent travel to undeveloped countries or the mountains, stool may be examined under the microscope for Giardia and other parasites.
There are also immunologic tests that can be done on samples of stool to diagnose infection with Giardia. Chronic diarrhea. With chronic diarrhea, the focus usually shifts from dehydration and infection (with the exception of Giardia, which occasionally causes chronic infections) to the diagnosis of non-infectious causes of diarrhea. (See the prior discussion of common causes of chronic diarrhea.)
This may require X-rays of the intestines (upper gastrointestinal seriesor barium enema), or endoscopy (esophagogastroduodenoscopy or EGD, or colonoscopy) with biopsies.
Fat malabsorption can be diagnosed by measuring the fat in a 72 hour collection of stool.
Sugar malabsorption can be diagnosed by eliminating the offending sugar from the diet or by performing a hydrogen breath test. Hydrogen breath testing also can be used to diagnose bacterial overgrowth of the small intestine.
An under-active pituitary or adrenal gland and an overactive thyroid gland can be diagnosed by measuring blood levels of cortisol and thyroid hormone, respectively.
Celiac disease can be diagnosed with blood tests and a biopsy of the small intestine.
Older children and adults. During mild cases of diarrhea, diluted fruit juices, soft drinks containing sugar, sports drinks such as Gatorade, and water can be used to prevent dehydration. Caffeine and lactose containing dairy products should be temporarily avoided since they can aggravate diarrhea, the latter primarily in individuals with transient lactose intolerance. If there is no nausea and vomiting, solid foods should be continued. Foods that usually are well tolerated during a diarrheal illness include rice, cereal, bananas, potatoes, and lactose-free products. ORS can be used for moderately severe diarrhea that is accompanied by dehydration in children older than 10 years of age and in adults. These solutions are given at 50 ml/kg over 4-6 hours for mild dehydration or 100 ml/kg over 6 hours for moderate dehydration. After rehydration, the ORS solution can be used to maintain hydration at 100 ml to 200 ml/kg over 24 hours until the diarrhea stops. Directions on the solution label usually state the amounts that are appropriate. After rehydration, older children and adults should resume solid food as soon as any nausea and vomiting subside. Solid food should begin with rice, cereal, bananas, potatoes, and lactose free and low fat products. The variety of foods can be expanded as the diarrhea subsides.
Equalactin is the antidiarrheal product containing attapulgite; however the laxative, Konsyl, also contains attapulgite. Attapulgite and polycarbophil remain in the intestine and, therefore, have no side effects outside of the gastrointestinal tract. They may occasionally cause constipation and bloating. One concern is that absorbents also can bind medications and interfere with their absorption into the body. For this reason, it often is recommended that medications and absorbents be taken several hours apart so that they are physically separated within the intestine.
Anti-motility medications. Anti-motility medications are drugs that relax the muscles of the small intestine and/or the colon. Relaxation results in slower flow of intestinal contents. Slower flow allows more time for water to be absorbed from the intestine and colon and reduces the water content of stool. Cramps, due to spasm of the intestinal muscles, also are relieved by the muscular relaxation. The two main anti-motility medications are loperamide (Imodium), which is available without a prescription, and diphenoxylate (Lomotil), which requires a prescription. Both medications are related to opiates (for example, codeine) but neither has the pain-relieving effects of opiates. Loperamide (Imodium), though related to opiates, does not cause addiction. Diphenoxylate is a man-made medication that at high doses can be addictive because of its opiate-like, euphoric (mood-elevating) effects. In order to prevent abuse of diphenoxylate and addiction, a second medication, atropine, is added to loperamide in Lomotil. If too much Lomotil is ingested, unpleasant side effects from too much atropine will occur. Loperamide and diphenoxylate are safe and well-tolerated. There are some precautions, however, that should be observed.
Anti-motility medications should not be used without a doctor's guidance to treat diarrhea caused by moderate or severe ulcerative colitis, C. difficile colitis, and intestinal infections by bacteria that invade the intestine (for example, Shigella). Their use can lead to more serious inflammation and prolong the infections.
Diphenoxylate can cause drowsiness or dizziness, and caution should be used if driving or performing tasks that require alertness and coordination are required. Anti-motility medications should not be used in children younger than two years of age.
Most unimportant, acute diarrhea should improve within 72 hours. If symptoms do not improve or if they worsen, a doctor should be consulted before continuing treatment with anti-motility medications. Bismuth compounds. Many bismuth-containing preparations are available around the world. Bismuth subsalicylate (Pepto-Bismol) is available in the United States. It contains two potentially active ingredients, bismuth and salicylate (aspirin). It is not clear how effective bismuth compounds are, except in traveler's diarrhea and the treatment of H. pylori infection of the stomach where they have been shown to be effective. It also is not clear how bismuth subsalicylate might work. It is thought to have some antibiotic-like properties that affect bacteria that cause diarrhea. The salicylate is anti-inflammatory and could reduce secretion of water by reducing inflammation. Bismuth also might directly reduce the secretion of water by the intestine. Pepto-Bismol is well-tolerated. Minor side effects include darkening of the stool and tongue. There are several precautions that should be observed when using Pepto-Bismol.
Since it contains aspirin, patients who are allergic to aspirin should not take Pepto-Bismol.
Pepto-Bismol should not be used with other aspirin-containing medications since too much aspirin may be ingested and lead to aspirin toxicity, the most common manifestation of which is ringing in the ears. The aspirin in Pepto-Bismol can accentuate the effects of anticoagulants, particularly warfarin (Coumadin), and lead to excessive bleeding. It also may cause abnormal bleeding in people who have a tendency to bleed because of genetic disorders or underlying diseases, for example, cirrhosis, that may cause abnormal bleeding.
The aspirin in Pepto-Bismol can aggravate stomach and duodenal ulcer disease.
Pepto-Bismol and aspirin-containing products should not be given to children and teenagers with chickenpox, influenza, and other viral infections because they may cause Reye's syndrome. Reye's syndrome is a serious illness affecting primarily the liver and brain that can lead to liver failure and coma, with a mortality rate of at least 20%.
Pepto-Bismol should not be given to infants and children younger than two years of age.
Diarrhea At A Glance
both. Diarrhea is an increase in the frequency of bowel movements, an increase in the looseness of stool or
Diarrhea is caused by increased secretion of fluid into the intestine, reduced absorption of fluid from the intestine or rapid passage of stool through the intestine. Diarrhea can be defined absolutely or relatively. Absolute diarrhea is defined as more than five bowel movements a day or liquid stools. Relative diarrhea is defined as an increase in the number of bowel movements per day or an increase in the looseness of stools compared with an individual's usual bowel habit.
Diarrhea may be either acute or chronic, and each has different causes and treatments.
Complications of diarrhea include dehydration, electrolytes (mineral) abnormalities, and irritation of the anus. Dehydration can be treated with oral rehydration solutions and, if necessary, with intravenous fluids.
Tests that are useful in the evaluation of acute diarrhea include examination of stool for white blood cells and parasites, cultures of stool for bacteria, testing of stool for the toxin of C. difficile and blood tests for electrolyte abnormalities.
Tests that are useful in the evaluation of chronic diarrhea include examination of stool for parasites, upper gastrointestinal X-rays (UGI series), barium enema, esophago-gastro-duodenoscopy (EGD) with biopsies, colonoscopywith biopsies, hydrogen breath testing, and measurement of fat in the stool.
Diarrhea may be treated with absorbents, anti-motility medications, and bismuth compounds.
Antibiotics should not be used in treating diarrhea unless there is a culture-proven bacterial infection that requires antibiotics, severe diarrhea that is likely to be infectious in origin, or when an individual has serious underlying diseases.
Diarrhea At A Glance
both. Diarrhea is an increase in the frequency of bowel movements, an increase in the looseness of stool or
Diarrhea is caused by increased secretion of fluid into the intestine, reduced absorption of fluid from the intestine or rapid passage of stool through the intestine. Diarrhea can be defined absolutely or relatively. Absolute diarrhea is defined as more than five bowel movements a day or liquid stools. Relative diarrhea is defined as an increase in the number of bowel movements per day or an increase in the looseness of stools compared with an individual's usual bowel habit.
Diarrhea may be either acute or chronic, and each has different causes and treatments.
Complications of diarrhea include dehydration, electrolytes (mineral) abnormalities, and irritation of the anus. Dehydration can be treated with oral rehydration solutions and, if necessary, with intravenous fluids.
Tests that are useful in the evaluation of acute diarrhea include examination of stool for white blood cells and parasites, cultures of stool for bacteria, testing of stool for the toxin of C. difficile and blood tests for electrolyte abnormalities.
Tests that are useful in the evaluation of chronic diarrhea include examination of stool for parasites, upper gastrointestinal X-rays (UGI series), barium enema, esophago-gastro-duodenoscopy (EGD) with biopsies, colonoscopy with biopsies, hydrogen breath testing, and measurement of fat in the stool.
Diarrhea may be treated with absorbents, anti-motility medications, and bismuth compounds.
Antibiotics should not be used in treating diarrhea unless there is a culture-proven bacterial infection that requires antibiotics, severe diarrhea that is likely to be infectious in origin, or when an individual has serious underlying diseases.