Acute Diarrhea Christine Criscuolo Higgins, M.D. CHRISTUS Santa Rosa FMRP Faculty Development Fellowship 25 October 2005

Is just a little case of diarrhea… Second leading causes of all death worldwide Second leading causes of all death worldwide Most common cause of morbidity and mortality in children worldwide Most common cause of morbidity and mortality in children worldwide Accounts for 9% of hospitalizations in children <5 years old in the United States Accounts for 9% of hospitalizations in children <5 years old in the United States You will likely suffer from diarrhea in the near future! You will likely suffer from diarrhea in the near future!

Objectives Review the epidemiology and most common etiologies of diarrhea Review the epidemiology and most common etiologies of diarrhea Discuss specific characteristics of most common viral and bacterial pathogens Discuss specific characteristics of most common viral and bacterial pathogens Identify the most important aspects of the H&P in a patient with diarrhea Identify the most important aspects of the H&P in a patient with diarrhea Discuss proper laboratory evaluation and treatment of diarrhea Discuss proper laboratory evaluation and treatment of diarrhea

What we will NOT cover Parasitic diarrhea Parasitic diarrhea Noninfectious Diarrhea Noninfectious Diarrhea Traveler’s Diarrhea Traveler’s Diarrhea C. diff Diarrhea C. diff Diarrhea Diarrhea in patients who are immunocompromised Diarrhea in patients who are immunocompromised Treatment of severe diarrhea requiring hospitalization Treatment of severe diarrhea requiring hospitalization

Definition Stool weight in excess of 200 gm/day Stool weight in excess of 200 gm/day 3 or more loose or watery stools/day 3 or more loose or watery stools/day Alteration in normal bowel movement characterized by decreased consistency and increased frequency Alteration in normal bowel movement characterized by decreased consistency and increased frequency Less than 14 days in duration Less than 14 days in duration

Epidemiology episodes per person annually in the general population episodes per person annually in the general population 2.4 episodes per child <3 years old annually 2.4 episodes per child <3 years old annually 5 episodes per year for children <3 years old and in daycare 5 episodes per year for children <3 years old and in daycare Seasonal peak in the winter Seasonal peak in the winter

Etiology Viral: 70-80% of infectious diarrhea in developed countries Viral: 70-80% of infectious diarrhea in developed countries Bacterial: 10-20% of infectious diarrhea but responsible for most cases of severe diarrhea Bacterial: 10-20% of infectious diarrhea but responsible for most cases of severe diarrhea Protozoan: less than 10% Protozoan: less than 10%

Viral Diarrhea Rotavirus Rotavirus Norovirus (Norwalk-like) Norovirus (Norwalk-like) Enteric Adenovirus Enteric Adenovirus Astrovirus Astrovirus

Rotavirus Leading cause of hospitalization for diarrhea in children Leading cause of hospitalization for diarrhea in children Most prevalent during winter season Most prevalent during winter season Fecal-oral transmission: viral shedding can persist for 21 days Fecal-oral transmission: viral shedding can persist for 21 days Acute onset of fever followed by watery diarrhea (10-20 BM/day) and can persist for up to a week Acute onset of fever followed by watery diarrhea (10-20 BM/day) and can persist for up to a week

Norovirus Most common cause of diarrheal outbreaks/epidemics Most common cause of diarrheal outbreaks/epidemics Multiple modes of fecal-oral transmission Multiple modes of fecal-oral transmission Acute onset of nausea and vomiting, watery diarrhea with abdominal cramps and can persist for 1-3 days Acute onset of nausea and vomiting, watery diarrhea with abdominal cramps and can persist for 1-3 days

Enteric Adenovirus Primarily affects children < 4 years old Primarily affects children < 4 years old Fecal-oral transmission Fecal-oral transmission Clinical picture similar to rotavirus (fever and watery diarrhea) Clinical picture similar to rotavirus (fever and watery diarrhea)

Astrovirus Primarily affects children < 4 years old and immunocompromised Primarily affects children < 4 years old and immunocompromised Seasonal peak in the winter Seasonal peak in the winter Fecal-oral transmission: viral shedding can occur for several weeks Fecal-oral transmission: viral shedding can occur for several weeks Fever, nausea and vomiting, abdominal pain, and diarrhea lasting up to a week Fever, nausea and vomiting, abdominal pain, and diarrhea lasting up to a week

Summary of Viral Diarrhea Most likely cause of infectious diarrhea Most likely cause of infectious diarrhea Rotavirus and Norovirus are most common Rotavirus and Norovirus are most common Symptoms usually include low grade fever, nausea and vomiting, abdominal cramps, and watery diarrhea lasting up to 1 week Symptoms usually include low grade fever, nausea and vomiting, abdominal cramps, and watery diarrhea lasting up to 1 week Viral shedding can occur for weeks after symptoms resolve Viral shedding can occur for weeks after symptoms resolve

Bacterial Diarrhea Campylobacter Campylobacter Salmonella Salmonella Shigella Shigella Enterohemorrhagic Escherichia coli Enterohemorrhagic Escherichia coli

Campylobacter Most common bacterial pathogen Most common bacterial pathogen Transmitted through ingestion of contaminated food or by direct contact with fecal material Transmitted through ingestion of contaminated food or by direct contact with fecal material Symptoms include diarrhea (+/- blood), abdominal cramps (can be severe), malaise, fever Symptoms include diarrhea (+/- blood), abdominal cramps (can be severe), malaise, fever Usually self-limited and does not require antibiotics Usually self-limited and does not require antibiotics

Salmonella Most common in children <4 years old and a peak in the first few months of life Most common in children <4 years old and a peak in the first few months of life Transmitted via ingestion of contaminated food and contact with infected animals Transmitted via ingestion of contaminated food and contact with infected animals Symptoms include fever, diarrhea, and abdominal cramping Symptoms include fever, diarrhea, and abdominal cramping Antimicrobial therapy can prolong fecal shedding Antimicrobial therapy can prolong fecal shedding

Shigella Fecal-oral transmission Fecal-oral transmission Symptoms include fever, abdominal cramps, tenesmus, and mucoid stools with or without blood Symptoms include fever, abdominal cramps, tenesmus, and mucoid stools with or without blood Can lead to serious complications Can lead to serious complications Antimicrobial treatment shortens duration of illness and limits fecal shedding Antimicrobial treatment shortens duration of illness and limits fecal shedding

E. Coli O157:H7 Transmission via contaminated food and water Transmission via contaminated food and water Symptoms include bloody diarrhea, severe abdominal pain, and sometimes fever Symptoms include bloody diarrhea, severe abdominal pain, and sometimes fever Can lead to serious complications Can lead to serious complications Antibiotics have no proven benefit and may increase the risk of complications Antibiotics have no proven benefit and may increase the risk of complications

Summary of Bacterial Diarrhea Can affect all age groups Can affect all age groups Fecal-oral transmission, often through contaminated food Fecal-oral transmission, often through contaminated food Typical symptoms include bloody diarrhea, severe cramping, and malaise Typical symptoms include bloody diarrhea, severe cramping, and malaise Antibiotic treatment not always necessary Antibiotic treatment not always necessary

History and Physical Exam 3 main goals 3 main goals –Estimate the level of dehydration –Identify likely causes on the basis of history and clinical findings –Determine if additional studies and/or medications are necessary

History Onset, frequency, quantity, and character of diarrhea Onset, frequency, quantity, and character of diarrhea Associated symptoms: nausea, vomiting, fever, abdominal pain, tenesmus, malaise Associated symptoms: nausea, vomiting, fever, abdominal pain, tenesmus, malaise Recent oral intake Recent oral intake Signs and symptoms of dehydration Signs and symptoms of dehydration

Physical Exam Vitals, vitals, vitals! Vitals, vitals, vitals! Abdominal exam Abdominal exam Presence of occult blood Presence of occult blood Signs of dehydration Signs of dehydration

Laboratory Evaluation Unnecessary for patients who present within 1 day from onset of diarrhea Unnecessary for patients who present within 1 day from onset of diarrhea Warning signs/symptoms: bloody diarrhea, high fever, severe abd pain, dehydration, or comorbid condition Warning signs/symptoms: bloody diarrhea, high fever, severe abd pain, dehydration, or comorbid condition Fecal leukocytes followed by bacterial culture, ova & parasites, viral antigens Fecal leukocytes followed by bacterial culture, ova & parasites, viral antigens CBC, chemistries CBC, chemistries

Treatment Fluid replacement Fluid replacement –Fluids or Oral Rehydration Solutions (ORS) –Parenteral rehydration Early refeeding Early refeeding Symptomatic Treatment Symptomatic Treatment –Oral bismuth –Loperamide Antibiotics Antibiotics

Fluid Replacement ORS: Infalyte, Pedialyte, Naturalyte and Rehydralyte ORS: Infalyte, Pedialyte, Naturalyte and Rehydralyte Covered by WIC and Medicaid (if a prescription is written) Covered by WIC and Medicaid (if a prescription is written) Must be used or thrown out 24 hours after opening/mixing Must be used or thrown out 24 hours after opening/mixing

AAP Guidelines Diarrhea with no dehydration – normal diet and supplemental ORS with each diarrheal episode. Diarrhea with no dehydration – normal diet and supplemental ORS with each diarrheal episode. Diarrhea with mild dehydration – seek medical care, give ORS in the doctor's office, and cont. ORS and normal diet at home. Diarrhea with mild dehydration – seek medical care, give ORS in the doctor's office, and cont. ORS and normal diet at home. Moderate - severe dehydration – consider intravenous hydration, especially if patient is also vomiting Moderate - severe dehydration – consider intravenous hydration, especially if patient is also vomiting

Early Refeeding Luminal contents help promote growth of new enterocytes and facilitate mucosal repair Luminal contents help promote growth of new enterocytes and facilitate mucosal repair Can shorten duration of the disease Can shorten duration of the disease Lactose restriction is not necessary except in severe disease Lactose restriction is not necessary except in severe disease

Symptomatic Treatment Only in patients who are afebrile and have nonbloody diarrhea Only in patients who are afebrile and have nonbloody diarrhea Not recommended by the AAP Not recommended by the AAP Loperamide – inhibits peristalsis and has antisecretory properties Loperamide – inhibits peristalsis and has antisecretory properties Bismuth subsalicylate – may help with nausea, vomiting, and abdominal pain, as well as shorten duration of illness Bismuth subsalicylate – may help with nausea, vomiting, and abdominal pain, as well as shorten duration of illness

Empiric Antibiotics Empiric antibiotic therapy generally not beneficial and can be harmful Empiric antibiotic therapy generally not beneficial and can be harmful Those with more than eight stools/day, diarrhea >1 wk, volume depletion, immunosuppresion, or warning signs Those with more than eight stools/day, diarrhea >1 wk, volume depletion, immunosuppresion, or warning signs Fluoroquinolone or Azithromyzin Fluoroquinolone or Azithromyzin

Specific Antibiotic Therapy Viral – of course not! Viral – of course not! Campylobacter – only if severe Campylobacter – only if severe Salmonella – can prolong fecal shedding, only prescribe if severe Salmonella – can prolong fecal shedding, only prescribe if severe Shigella – proven beneficial Shigella – proven beneficial E. Coli O157:H7 – can be harmful E. Coli O157:H7 – can be harmful

In Summary Extremely common Extremely common Most is viral in origin and self-limited Most is viral in origin and self-limited A good H&P is crucial A good H&P is crucial Warning signs include high fever, severe abd. pain, dehydration, and bloody stool Warning signs include high fever, severe abd. pain, dehydration, and bloody stool Fluid replacement is most important Fluid replacement is most important Antibiotics are usually not necessary Antibiotics are usually not necessary

References Dennehy P.H., Acute Diarrheal Disease in Children: Epidemiology, Prevention, and Treatment. Infect Dis Clin North A 2005;(19) 3: Dennehy P.H., Acute Diarrheal Disease in Children: Epidemiology, Prevention, and Treatment. Infect Dis Clin North A 2005;(19) 3: Wanke C.A., Approach to the patient with acute diarrhea. Up To Date (updated Jan. 4, 2005) Wanke C.A., Approach to the patient with acute diarrhea. Up To Date (updated Jan. 4, 2005) Blacklow N.R., Epidemiology of viral gastroennteritis in adults. Up To Date (updated March 3, 2005) Blacklow N.R., Epidemiology of viral gastroennteritis in adults. Up To Date (updated March 3, 2005) Thielman N.M., (2004) Acute Infectious Diarrhea. N Engl J Med 2004;350: Thielman N.M., (2004) Acute Infectious Diarrhea. N Engl J Med 2004;350: Burkhart D.M., Management of Acute Gastroenteritis in Children. Am Fam Physician Dec;60(9): Burkhart D.M., Management of Acute Gastroenteritis in Children. Am Fam Physician Dec;60(9):