Family medicine acute diarrhea case file

Family medicine acute diarrhea case file

Eugene C. Toy MD, Donald Briscoe, MD, FA  AFP, Bruce Britton, MD, Joel J. Heidelbaugh, MD, FA  AFP, FACG

Case 10

A 40-year-old man presents to the clinic complaining of having 10 episodes of watery, nonbloody diarrhea that started last night. He vomited twice last night but has been able to tolerate liquids today. He has had intermittent abdominal cramps as well. He reports having muscle aches, weakness, headache, and lowgrade temperature. He is here with his daughter, who started with the same symptoms this morning. On questioning, he states that he has no significant medical history, no surgeries, and does not take any medications. He does not smoke cigarettes, drink alcohol, use any illicit drugs, and has never had a blood transfusion. He and his family returned to the United States yesterday, following a week-long vacation in Mexico.

On examination, he is not in acute distress. His blood pressure is 110/60 mm Hg, his pulse is 98 beats/min, his respiratory rate is 16 breaths/min, and his temperature is 99.1°F (37.2°C). His mucous membranes are dry. His bowel sounds are hyperactive and his abdomen is mildly tender throughout, but there is no rebound tenderness and no guarding. A rectal examination is normal and his stool is guaiac negative. The remainder of his examination is unremarkable.

⯈ What is the most likely diagnosis?

⯈ What is your next step?

⯈ What are potential complications?

ANSWER TO CASE 10:

Acute Diarrhea

Summary: A 40-year-old man who recently returned from Mexico with profuse, acute, nonbloody diarrhea, and dry mucous membranes on examination, which are consistent with developing dehydration. An ill family member with identical symptoms suggests an infectious cause of this acute illness.

• Most likely diagnosis: Acute gastroenteritis
• Next step: Fecal leukocyte or fecal lactoferrin testing; rehydration with oral or IV fluids
• Potential complication: Dehydration and electrolyte abnormalities

ANALYSIS

Objectives

1. To clearly understand when and how to do a workup for acute diarrhea, considering the most probable etiologies of diarrhea such as virus, Escherichia coli, Shigella, Salmonella, Giardia, and amebiasis.
2. To understand the role of fecal leukocytes and stool occult blood in the evaluation of acute diarrhea.
3. To understand that volume replacement and correction of electrolyte abnormalities are a key component in the treatment and prevention of diarrhea complications.

Considerations

This 40-year-old man developed severe diarrhea, nausea, and vomiting. His most immediate problem is volume depletion, as evidenced by his dry mucous membranes. The priority is to replace the lost intravascular volume, usually with intravenous normal saline. Electrolytes and renal function should be evaluated and abnormalities corrected. While correcting and/or preventing further dehydration, you need to determine the etiology of the diarrhea. Up to 90% of acute diarrhea is infectious in etiology. He does not have any history compatible with chronic diarrhea, causes of which include Crohn disease, ulcerative colitis, gluten intolerance, irritable bowel syndrome, and parasites. He had been in Mexico recently, which predisposes him to different pathogens: E coli, Campylobacter, Shigella, Salmonella, and Giardia. Bacterial infections are more likely to be the source of acute diarrhea in individuals who have recently traveled, ingested contaminated food, or have other medical conditions. He does not have bloody stools. The presence of blood in the stool would suggest an invasive bacterial infection, such as hemorrhagic or enteroinvasive E coli species, Yersinia species, Shigella, and Entamoeba histolytica.

Examination of the stool for leukocytes is an inexpensive test that helps to differentiate between the types of infectious diarrhea. If leukocytes are present in the stool, the suspicion is higher for Salmonella, Shigella, Yersinia, enterohemorrhagic and enteroinvasive E coli, Clostridium difficile, Campylobacter, and E histolytica. Fecal lactoferrin immunoassay testing kits have increased in popularity due to their ease of use and faster results compared to fecal leukocytes. Lactoferrin is an iron-binding protein that is found in polymorphonuclear neutrophils (PMN) and bodily secretions such as breast milk. Gastrointestinal inflammation causes immune activated PMNs to release lactoferrin. Lactoferrin elevations in stool can be seen with irritable bowel syndrome, intestinal bacterial infections, parasitic infections, and other conditions. Lactoferrin will be low in viral infections, making it a useful test for distinguishing viral from bacterial diarrhea. In general, ova and parasite evaluation is unhelpful, unless the history strongly points toward a parasitic source or the diarrhea is prolonged. The majority of the diarrheas are viral, self-limited, and do not need further evaluation. In this particular patient, because of his recent travel to Mexico, traveler's diarrhea (TD) should be strongly considered and treated with the appropriate antibiotic.

Approach To:

Acute Diarrhea

DEFINITIONS

ACUTE DIARRHEA: Diarrhea presents for fewer than 2-week duration

CHRONIC DIARRHEA: Diarrhea presents for longer than 4-week duration

DIARRHEA: Passage of abnormally liquid or poorly formed stool in increased frequency (three or more times a day)

SUBACUTE DIARRHEA: Diarrhea presents for 2- to 4-week duration

CLINICAL APPROACH

Etiologies

Approximately 90% of acute diarrhea is caused by infectious etiologies, with the remainder caused by medications, ischemia, and toxins. Infectious etiologies often depend on the patient population. Travelers to Mexico will frequently contract enterotoxigenic E coli as a causative agent. Traveler's diarrhea is a common entity and can be induced by a variety of bacteria, viruses, and parasites (Table 10-1). Campers are often affected by Giardia. Contaminated food and water supplies account for the high incidence of diarrhea in developing countries.

Consumption of foods is also frequently a culprit. Salmonella or Sbigella can be found in undercooked chicken, enterohemorrhagic E coli from undercooked hamburger, and Staphylococcus aureus or Salmonella from creamy foods. Raw seafood may harbor Vibrio, Salmonella, or hepatitis A. Sometimes, the timing of the diarrhea following food ingestion is helpful. For example, illness within 6 hours of eating a salad containing mayonnaise suggests S aureus, within 8 to 12 hours suggests Clostridium perfringens, and within 12 to 14 hours suggests E coli.

Daycare settings are particularly common for Shigella, Giardia, and rotavirus to be transmitted. Patients in nursing homes, or who were recently in the hospital, may develop C difficile colitis from antibiotic use. Consuming cold meats, raw milk, and soft cheeses increases the risk of listeriosis. Pregnant women are advised to avoid foods associated with listeriosis because they are at a significantly higher risk of infection. Immunocompromised patients (AIDS) are more susceptible to parasitic gastrointestinal infections.

Clinical Presentation

Most patients with acute diarrhea have self-limited processes and do not require much workup. Exceptions to this rule include profuse diarrhea, dehydration, fever exceeding 100.4°F (38.0°C), bloody diarrhea, severe abdominal pain, duration of the diarrhea for more than 48 hours, and children, elderly patients, and immunocompromised patients. Traveler's diarrhea is characterized by more than three loose stools in a 24-hour period accompanied by abdominal cramping, nausea, vomiting, fever, or tenesmus. Most cases occur within the first 2 weeks of travel.

Past and recent medical history should include exposures to medications and foods, travel history, and coworkers, classmates, or family members with similar symptoms. A history of a viral illness may provide a clue to the etiology. The initial evaluation should determine if the patient can tolerate oral intake. The patient who is both vomiting and having diarrhea is more prone to dehydration and more likely to need hospital admission for IV hydration.

The physical examination should focus on the vital signs, clinical impression of the volume status, and abdominal examination. Volume status is determined by observing whether the mucous membranes are moist or dry, the skin has good turgor, and the capillary refill is normal or delayed. Stool cultures have limited benefit due to high cost and inefficient results. The use of stool cultures should be limited to individuals with bloody diarrhea, diarrhea lasting for more than 3 to 7 days, immunocompromised patients, and evidence of systemic disease or severe dehydration. Ova and parasite evaluation is generally unhelpful, except in selected circumstances of very high suspicion. Testing for C difficile toxins A and B is recommended in patients who develop diarrhea within 3 days of hospitalization, during antibiotic treatment, or within 3 months of discontinuing antibiotics. Although classically associated with clindamycin, any antibiotic can cause pseudomembranous colitis. A complete blood count, electrolytes, and renal function tests are sometimes indicated.

Treatment

Most cases of diarrhea resolve spontaneously in a few days without treatment. Replacement of fluids and electrolytes is the first step in treating the consequences of acute diarrhea. For mildly dehydrated individuals who can tolerate oral fluids, solutions such as the World Health Organization oral rehydration solution or commercially available drinks, such as Pedialyte or Gatorade, often are all that is needed. It is no longer recommended that patients avoid eating solid foods for 24 hours. Increased intestinal permeability caused by gastrointestinal infections can be limited by early refeeding. Those with more serious volume deficits, elderly patients, and infants generally require hospitalization and intravenous hydration.

If a parasitic infection is the cause of the diarrhea, prescription antibiotics may ease the symptoms. Antibiotics sometimes, but not always, help ease symptoms of bacterial diarrhea. However, antibiotics will not help viral diarrhea, which is the most common kind of infectious diarrhea. Over-the-counter antimotility or antisecretory medications may help to slow down the frequency of the stools, but they do not speed the recovery. Certain infections may be made worse by over-the-counter medications because they prevent your body from getting rid of the organism that is causing the diarrhea. Probiotics, supplements that contain live organisms such as Lactobacillus sp or Saccharomyces Boulardii, may reduce the incidence of antibioticrelated diarrhea and the duration/severity of all-cause infectious diarrhea (Level A recommendation). Zinc supplementation has shown promising results for decreasing the duration and severity of the diarrheal illnesses in children. Better relief of acute diarrhea with excessive gas may be possible with combined loperamide and simethicone compared to either medication alone.

Prevention

Hand washing is a simple and effective way to prevent the spread of viral diarrhea. Adults, children, and clinic and hospital personnel should be encouraged to wash their hands. Because viral diarrhea spreads easily, children with diarrhea should not attend school or child care until their illness has resolved.

To prevent diarrhea caused by contaminated food, use dairy products that have been pasteurized. Serve food immediately or refrigerate it after it has been cooked. Do not leave food out at room temperature because it promotes the growth of bacteria.

Travelers to locations, such as developing countries, where there is poor sanitation and frequent contamination of food and water, need to be cautious to reduce their risk of developing diarrhea. They should be advised to eat hot and wellcooked foods, and to drink bottled water, soda, wine, or beer served in its original container. Avoid drinks served over ice. Beverages from boiled water, such as coffee and tea, are usually safe. Recommend the use of bottled water even for teeth brushing. Also recommend avoiding raw fruits and vegetables unless they are peeled by the consumer immediately before being eaten. Patients should avoid tap water and ice cubes. In all, these recommendations may reduce but not completely eliminate one's risk of developing traveler's diarrhea.

Traveler's Prophylaxis and Treatment

The best method for preventing TD is to avoid contaminated food and water. Antibiotic prophylaxis is not indicated unless the patient is at increased risk for complications from diarrhea or dehydration, such as underlying inflammatory bowel disease, renal disease, or an immunocompromised state. Fluoroquinolones are typically used for prophylaxis. Studies have shown that the antibacterial and antisecretory effects of bismuth subsalicylate decrease the incidence of traveler's diarrhea. Bismuth subsalicylate should be avoided in persons allergic to aspirin, pregnant women, or those taking methotrexate, probenecid, or doxycycline for malaria prophylaxis.

When antibiotics are indicated, therapy with a quinolone antibiotic should be started as soon as possible after the diarrhea begins. Most commonly, ciprofloxacin (500 mg twice daily) is given for 3 days. Quinolones cannot be used in children or pregnant women. Azithromycin, given as a single 1000-mg dose in adults or 10 mg/kg daily for 3 days in children, is another effective drug for the treatment of TD. Azithromycin also can be used in pregnant women with traveler's diarrhea. Rifaximin given as 200 mg three times a day for 3 days can be used in TD caused by noninvasive strains of E coli. However, rifaximin is not effective against infections associated with fever or blood in the stool. Rifaximin is safe for use in children under the age of 12. Trimethoprim-sulfamethoxazole, doxycycline, and ampicillin were popular drugs used in the past to treat TD, but increased resistance now limits their use. The evidence is insufficient regarding the efficacy of probiotics as prophylaxis for TD.

COMPREHENSION QUESTIONS

10.1 Several friends develop vomiting and diarrhea 6 hours after eating food at a private party. Which of the following is the most likely etiology of the symptoms?

A. Rotavirus

B. Giardia

C. E coli

D. S aureus

E. Cryptosporidium

10.2 A 40-year-old man travels to Mexico and develops diarrhea 1 day after coming back to the United States. Which of the following is the most likely etiology of the symptoms?

A. Rotavirus

B. Giardia

C. E coli

D. S aureus

E. Cryptosporidium

10.3 A young woman eats raw seafood and 2 days later develops fever, abdominal cramping, and watery diarrhea. Which of the following is the most likely etiology of the symptoms?

A. Rotavirus

B. Giardia

C. E coli

D. S aureus

E. Vibrio

10.4 During the winter, a young daycare worker develops watery diarrhea. Which of the following is the most likely etiology of the symptoms?

A. Rotavirus

B. Giardia

C. E coli

D. S aureus

E. Cryptosporidium

10.5 A 45-year-old man presents with 3 days of watery diarrhea and abdominal cramping. He has no sick contacts and has not traveled recently. He is not currently taking any medications, but he was prescribed amoxicillin 2 weeks ago for a sinus infection. Which of the following tests is most likely to identify the cause of his diarrhea?

A. Stool guaiac

B. Evaluation of stool for fecal leukocytes

C. Evaluation of stool for ova and parasites

D. C difficile toxin immunoassay

10.6 In the patient described in question 10.5, which of the following is the treatment of choice for his diarrhea?

A. Ciprofloxacin

B. Azithromycin

c. Metronidazole

D. Loperamide

ANSWERS

10.1 D. S aureus toxin usually causes vomiting and diarrhea within a few hours of food ingestion.

10.2 C. E coli is the most common etiology for traveler's diarrhea.

10.3 E. Vibrio is a common cause of diarrhea among people who eat raw seafood.

10.4 A. Rotavirus is a common etiology for watery diarrhea, especially in the winter.

10.5 D. Although any antibiotic can cause C difficile colitis, clindamycin, cephalosporins, and penicillins are the most commonly implicated.

10.6 C. Metronidazole or oral vancomycin can be used to treat C difficile. Ciprofloxacin and azithromycin can be used for treatment of traveler's diarrhea. Loperamide can decrease the frequency of bowel movements but is contraindicated in any patient with suspected C difficile colitis.

CLINICAL PEARLS

⯈ Most acute diarrheas are self-limited.

⯈ Be cautious when assessing diarrhea in a child, elderly patient, or immunosuppressed host.

⯈ Dehydration, bloody diarrhea, high fever, and diarrhea that do not respond to therapy after 48 hours are warning signs of possible complicated diarrhea.

⯈ In general, acute, uncomplicated diarrhea can be treated with oral electrolyte and fluid replacement.

REFERENCES

Barr W, Smith A. Acute diarrhea in adults. Am Fam Physician. 2014;89(3):180-189. 

Centers for Disease Control and Prevention. Travelers' health-2014 Yellow Book. Available at: http:// wwwnc.cdc.gov I travel/ page/yellowbook-home. Accessed May 24, 2015. 

Kligler B, Cohrssen A. Probiotics. Am Fam Physician. 2008;18(9):1073-1078. 

LaRocque RC, Ryan ET, Calderwood SB. Acute infectious diarrheal diseases and bacterial food poisoning. In: Kasper D, Fauci A, Hauser S, et al, eds. Harrison's Principles of Internal Medicine. 19th ed. New York, NY: McGraw-Hill Education; 2015. Available at: http://accessmedicine.mhmedical.com/ content.aspx?bookid=1130&sectionid=79734063. Accessed May 24, 2015. 

Yates J. Traveler's diarrhea. Am Fam Physician. 2005;71:2095-2100, 2107-2108.

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