Acute Diarrhea
Shajia Shelby, MD
Anna Trauernicht, MD
Children’s Hospital and Medical Center, University of Nebraska
Medical Center
2013
Resident Education Series
Reviewed by Edward Hoffenberg, MD of the Professional Education
Introduction
• Derived from Greek dia means
“through” and rhien “to flow”
Definition
• Sudden onset of increased fluid content of the
stool above normal
• Duration:
• Acute: < 2 weeks
• Volume:
• Infants and toddlers >10 mL/kg/day
• Older children > 200 mL/day
• From Practical viewpoint:
• Decrease in consistency (to loose or liquid) and
increase in frequency of bowel movements to ≥ 3 per
day
Epidemiology
• WHO estimates: Diarrheal disease cause 17%
of deaths in children < 5 yrs worldwide
• In United States:
• Annually 38 million cases,
• 2 million to 3.7 million physician visits,
• 320,000 hospitalizations
• associated with up to 9% of all hospitalizations in
children < 5yrs
• 325 to 425 deaths
• Seasonal peak in the winter
Lancet 2005; 365:1147-1152
J Pediatr 1991; 118:S27-S33
Pathophysiology
• Four processes that either individually or
collectively contribute to diarrhea
– Secretory
– Cytotoxic
– Osmotic
– Inflammatory
Effect of bacterial enterotoxin on mucosal
cells of the small intestine
• Enterotoxin
stimulates secretion
of fluid and
electrolytes from
mucosal crypt cells
– Mediated through
prostaglandins
– Affects cAMP, GMP
and calcium ion flows
– Blocks absorption of
fluid and electrolye by
the villi
Thomas G. DeWitt Pediatrics in Review 1989;11;6
Cytotoxic Process
• Destruction of small intestinal mucosal villi
by infectious viral agent
• Villi shorten after cell lysis
• Decreased small bowel surface area
decreases capability of small intestine to
absorb fluid and electrolytes
• Proportional increase in secretion with
marked decrease in absorptive function of
small bowel mucosa
Osmotic Process
• Commonly seen in malabsorption
syndromes
• Lactose intolerance
• Malabsorbed substance is osmotically
active, leading to a net flux of water into
the intestinal lumen – resulting in loose
diarrheal stools
• Large intestinal flora is inundated with
increased CHO, which then is
metabolized and produces gas,
abdominal pain and decreased stool pH
Inflammatory Process
• Inflammation of mucosa and submucosa of terminal
ileum and large bowel
• Invasion by a bacterial agent causes edema along with
mucosal bleeding and leukocytic infiltration
• Inflammation causes increased colon motility and
frequent stooling with tenesmus
• Alteration in GI motility – often with secretory and
cytotoxic processes
• Luminal dilation, delayed gastric emptying (cause
nausea and vomiting), rapid intestinal transit time with
marked peristaltic rushes
Cause of Acute Diarrhea:
Infectious / Inflammatory
Secretory Cytotoxic
• E. coli • Rotavirus
• Vibrio cholerae • Norwalk agent
• Clostridium difficle • Cryptosporidium
• Clostridium perfringes • Escherichia coli
• Aeromonas hydrophila
• Staphylococcus aureus Dysenteric
• Vibrio parahemolyticus
• Campylobacter fetus
• Clostridium difficle
• Bacillus cereus
• Salmonella
• Shigella
• Shigella
• Salmonella
• Yersinia
• Yersinia enterocolitics
enterocolitica
• Giardia lamblia
• Entamoeba histolytica
Thomas G. DeWitt Pediatrics in Review 1989;11;6
Causes of Acute Diarrhea
• Drug Induced
• Vitamin Deficiency
– Antibiotic associated
– Laxatives – Niacin, Folate
– Antacids that contain
magnesium • Vitamin Toxicity
– Opiate withdrawl
– Vitamin B3, C, Niacin
• Surgical conditions • Disorders of
– Acute appendicitis
– Intussusception Malabsorption
– Lactase deficiency
• Heavy metals or toxins – Sucrase-isomaltase
– Copper, tin, zinc deficiency
– Chemotherapy or radiation
induced enteritis • Food allergies or
intolerance
– Cow’s milk or soy protein 11
Indications of Moderate to
Severe Disease
• Age < 3 months
• Weight <8 kg
• History of premature birth, chronic medical conditions
or concurrent illness
• Fever ≥ 38° C for infants <3 mo or ≥ 39° C for children 3
to 36 months
• Visible blood in the stool
• High output diarrhea
• Persistent emesis
• Signs of dehydration
• Mental status changes
• Inadequate response to or caregiver unable to
administer ORT
Adapted from King et al MMWR Recomm Rep 2003
Physical Examination of the
Child With Diarrhea
• Growth chart • Rectal exam
• Vital signs • Stool sample
• Muscle mass • Color Consistency
• Subcutaneous fat
• ? Occult blood →
• Pubertal stage
• Hemoccult
Psychomotor
development • ? pH → Indicator
• Skin (perianal) • ? Fermentation →
• ENT region- otitis media
Clinitest
• Abdomen
– Organomegaly
– Tenderness
Robert wyllie Pediatric gastroentestinal and liver disease p115
Signs of Dehydration
J E Colletti et al journal of Emeregency Medicine 2010
Treatment of Dehydration
King et al MMWR Recom Rep 2003
Composition of Oral
Rehydration Solution
Early Refeeding
• Early refeeding is recommended in managing acute
gastroenteritis
• Luminal contents are known growth factors for enterocytes and
help facilitate mucosal repair after injury
• Almost all infants with acute gastroenteritis can tolerate
breastfeeding
• Diluted formula does not provide any benefit over full-strength
formula
• Infants with the most severe diarrhea may require lactose-
free formula until mucosal recovery is complete at around 2
weeks
• Older children can consume a regular age-appropriate diet
• BRAT diet not recommended
Other Treatment Options
• Antibiotics
• Zinc
• Immunoglobulin
• Drugs
• Probiotics
Antibiotics
• May prolong illness, increase carrier state & increased
morbidity
• Antibiotic use always indicated
• V. cholera, Shigella and Giardia lamblia
• Antimicrobial therapy in selected circumstances
• Enetropathogenic E. Coli when running a prolonged
course
• Enteroinvasive E. Coli based on serologic, genetic and
pathogenic similarities with shigella
• Yersinia infection in subjects with sickle cell disease
• Salmonella infection in very young infants, if febrile or
with positive blood culture
Zinc
• Micronutrient deficiency in malnourished children with
diarrhea
• Zinc supplementation in acute diarrhea (WHO/UNICEF in
2004)
• Infants > 6 months of age – 10mg/day
• Children with 20mg/day
• Duration 10- 14 days
• Any of zinc salts ie, sulphate, gluconate or acetate may be
used
• Benefits – can shorten course and severity
Bahl R et al J Pediatr 2002
Immunoglobulin
• Oral or enteral immunoglobulin in
treatment of rotavirus diarrhea
(immunocompromised or
immunocompetent)
• Current evidence does not
support the use of oral
immunoglobulin preparations to
prevent rotavirus infection in low
birth weight infants
Haque KN et al Cochrane Database Syst Rev. 2011 Nov 9;(11)
Probiotics
• Modify the composition of the colonic microflora and
act against enteric pathogens, their mechanism of
action is yet to be defined
• May be effective for acute diarrhea, in addition to ORS
• Proof of efficacy is limited to few strains, Lactobacillus
rhamnosus GG (LGG) and the yeast Saccharomyces
boulardii
• For acute diarrhea in developed countries shorten
duration of diarrhea by 1 day
– Effects seen when administered early in course and
dose of 1billion CFU/d
• Efficacy is evident in viral diarrheas of mild to
moderate degree, less or absent in invasive bacterial
diarrhea
Alfredo Guarino et al Expert Opin Pharmacother. 2012 Jan;13(1)
Prevention
• Education
• Sanitation
• Hygiene
• Simple hand washing has decreased incidence
by >50%
• Breast feeding
• Food safety
• Food safety has also been effective in
decreasing the incidence by >50%
• Appropriate use of oral rehydration therapy
• Probiotics
• Development of vaccinations
• Rota virus vaccine – RotaTeq and Rotarix
Matson DO J Pediatr 2006
