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EMPRACTICE NET
A N E V I D E N C E - B A S E D A P P ROAC H T O E M E RG E N C Y M E D I C I N E
July 2004
Volume 6, Number 7
Authors
Its a stormy day, yet the ED is furiously busy. As you pick up your next patients chart,
you glance at the chief complaintdiarrhea. Why would anyone come out on a day
like this, for something like that? you wonder. Then your eye catches the patients age
(60) and vital signstemperature, 38.7C (101.7F); pulse, 124 beats per minute;
respiratory rate, 24 breaths per minute; blood pressure, 102/50 mmHg. This man seems
a bit sicker than the run-of-the-mill diarrhea patient. A quick glance into his room
confirms your suspicion; hes pale, sweaty, ill-looking. He clearly needs help. But is an
extensive work-up really going to be cost-effectiveand wont it keep you from treating
other patients in a timely manner? Besides, dont most of these cases run their course
with a little help from fluids and symptomatic treatment?
Editorial Board
William J. Brady, MD, Associate
Professor and Vice Chair,
Department of Emergency
Medicine, University of Virginia,
Charlottesville, VA.
Judith C. Brillman, MD, Professor,
Department of Emergency
Medicine, The University of
Attending, Massachusetts
General Hospital; Faculty, Harvard
Affiliated Emergency Medicine
Residency, Boston, MA.
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Etiology
Diarrhea is a change in normal bowel movements characterized by an increase in the water content, volume, or
frequency of stools. Fluid secretion into the gut and
increased gut motility together produce both the increased
stooling frequency and the increased stool liquidity.16,20 The
passage of more than 200 grams of stool per day is considered to be diarrhea; two to three bowel movements per day
is the upper limit of normal.
An episode of diarrhea lasting 14 days or less is
generally defined as acute diarrhea, while persistent
diarrhea refers to episodes lasting longer than 14 days.
Chronic diarrhea is generally defined as diarrhea that
lasts more than 30 days.
Epidemiology
Virtually every human being experiences diarrhea at some
point. Causes may range from the mild to the life-threatening, although the clinical course is generally brief and selflimited in developed nations. However, worldwide,
diarrheal illnesses are the second most common cause of
death and the leading cause of death in children.21
Diarrhea is a common cause of morbidity even in the
United States. The number of hospital admissions due to
gastroenteritis in the United States is estimated to be 450,000
per year.20 Additionally, the U.S. prevalence of chronic
diarrhea approaches 5%.22
Pathophysiology
Diarrhea is broadly categorized as one of two typeseither
secretory or osmotic.
The poorly named secretory diarrhea actually occurs
due to abnormal electrolyte transport across the intestinal
epithelial cells. Increased secretion and/or decreased
absorption result. The diarrhea is not related to the intestinal
contents and therefore typically does not stop with fasting.
Infection (e.g., cholera) is the most common cause of
secretory diarrhea. The fluid losses can be enormous.
Osmotic diarrhea results from the presence of nonabsorbable solute that exerts an osmotic pressure effect
across the intestinal mucosa, resulting in excessive water
output. Because the diarrhea is caused by the solute, it tends
to stop during fasting. Sorbitol, a poorly absorbed sugar, is
capable of causing osmotic diarrhea.20
Another way that diarrhea is commonly classified is as
infectious vs. noninfectious or inflammatory vs. noninflammatory. Symptoms such as fever, bloody diarrhea,
and severe cramping suggest an invasive bacterial pathogen
such as Shigella, Salmonella, Yersinia, or Campylobacter. The
presence of nausea and vomiting strongly suggests a viral
agent, and prior antibiotic use suggests possible Clostridium
difficile enteritis. Absence of these factors suggests a noninfectious cause. Inflammatory diarrhea can be bloody and
associated with fever and abdominal cramps. The causes
can be infectious or non-infectious. Non-inflammatory
diarrhea tends to be watery and can be associated with
nausea, vomiting, and abdominal cramps.
Viral gastroenteritis
Diarrhea with aches, chills, cold symptoms, nausea or
vomiting; history suggesting recent consumption of
contaminated food or exposure to other ill persons,
especially day care; with or without fever
Vascular
Ischemic bowel disease
Diarrhea, severe abdominal pain, older patient, history of
peripheral vascular disease
Malabsorption
Travelers diarrhea
Recent foreign travel, prolonged illness (see also Table 3 on
page 6)
Medications
Intestinal obstruction
Severe abdominal pain along with nausea, vomiting, and
diarrhea
Toxins
Radiation enteritis
Tenesmus, bleeding, and diarrhea stemming from malabsorption; can persist for two or three months after
treatment cessation
Inflammatory
Appendicitis
Vomiting that follows abdominal pain, small amounts of
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Differential Diagnosis
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Staphylococcus aureus
Clostridium perfringens
Vibrio parahaemolyticus
Cyclospora cayetanensis
Symptoms: Nausea, vomiting, loss of appetite, and diarrhea;
onset within two days; lasts one week to two months.
Cryptosporidium parvum
Listeria monocytogenes
Giardia lamblia
Symptoms: Sudden onset of explosive watery stools,
abdominal cramps, anorexia, nausea, and vomiting; onset
within 1-3 days.
Miscellaneous Causes
Many other entities should be considered in the differential
diagnosis of diarrhea, including melena, laxative abuse,
partial bowel obstruction, various malabsorption syndromes (e.g., Whipples disease, small bowel bacterial
overgrowth, celiac sprue), food allergy, rectosigmoid
abscess, colon cancer, diverticulitis, hyperthyroidism, and
pernicious anemia. Many medications (as well as herbal
remedies) can cause diarrhea. In pediatric patients, ageappropriate problems such as intussusception and Meckels
diverticulum should be considered in the differential
diagnosis of diarrhea. Uncommon causes of diarrhea
include mushroom poisoning, ciguatera fish poisoning,
arsenic ingestion, and exposure to pesticides, sodium
fluoride, thallium, or zinc. In most of these cases, diarrhea is
part of a symptom complex, and other suggestive elements
of the history are present.
Radiation Enteritis
Radiation therapy is used to treat a number of urologic,
gynecologic, and colorectal cancers. During the radiation
treatment period, most patients experience tenesmus,
bleeding, and diarrhea.30 Malabsorption from mucosal
damage and bacterial overgrowth are two factors that
contribute to these symptoms.26 Symptoms can start within
hours of initial treatment and usually resolve two or three
months after treatment cessation,30 although some patients
may develop chronic problems necessitating surgery. The
rectum is the most commonly inflamed site given its
proximity to the irradiated tissue; the terminal ileum can
also be irradiated in patients undergoing treatment for
pelvic malignancies.
Treatment of acute radiation enteritis involves temporary discontinuation of radiation therapy, selective intravenous fluid administration, and antimotility medications.
Sucralfate may ameliorate the symptoms of radiation
enteritis. In one double-blind placebo-controlled trial of
patients with prostate or bladder cancer randomized to
receive either oral sucralfate or placebo, those patients
receiving sucralfate had improvement in the frequency and
consistency of bowel movements, and fewer patients
required treatment with anti-diarrheal preparations.31
Prehospital Care
Initial prehospital assessment should focus on the patients
vital signs and mental status. Transport hemodynamically
stable patients without further intervention. Follow local
EMS protocols for hypotension/shock for patients who are
hemodynamically unstable; usually, this includes establishing at least one large-bore intravenous line and infusing
crystalloid solution and expediting the transport of unstable
patients for further evaluation and care.
While gastrointestinal infections may be caused by a
variety of agents, including bacteria, viruses, and protozoa,
only a few agents have been documented in person-toperson transmission. Generally, adherence to either standard or contact precautions will minimize the risk of
transmitting enteric pathogens.36
Appendicitis
Patients with appendicitis can have vomiting as well as
loose stools. Rectal irritation by an inflamed pelvic appendix
can produce small amounts of watery diarrhea, as compared to the voluminous amounts produced as a consequence of gastroenteritis.32 In Rothrock et als study of 181
children younger than 13 years who were ultimately found
to have appendicitis, 27% were initially misdiagnosed.
Patients in this group were more likely to be younger, have
vomiting before pain, and have diarrhea (in addition to
constipation, dysuria, and upper respiratory tract symptoms).33 A retrospective case series review of 63 children
younger than 3 years ultimately diagnosed with appendicitis found that 57% were initially misdiagnosed; diarrhea
was commonly reported.34 A retrospective review of 87
patients with appendicitis revealed that six patients (7%)
required more than one ED visit before their diagnosis was
established. The initial diagnosis in two of these patients
was gastroenteritis. These six patients were more likely to
have a normal appetite, to have diarrhea, and to be afebrile.35 While most patients with appendicitis present with
right lower quadrant abdominal pain, 15% of appendices
are in atypical locations, causing pain in locations other than
the right lower quadrant.32 Gastroenteritis can present with
fevers higher (>103F) than those seen with appendicitis,
and in general, vomiting and diarrhea precede abdominal
pain, whereas vomiting follows abdominal pain in appendicitis. Because appendicitis will steadily worsen, while
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Medications
Obtaining a history of medication usespecifically including prescription, over-the-counter, and herbal preparationsis important, since many can cause diarrhea. Some of
the more common offenders include laxatives, antibiotics,
colchicine, and magnesium- or calcium-containing antacids.
If there is a history of antibiotic use within the past three
months, C. difficile-induced diarrhea is an important
consideration.38 Diabetics using a relatively new class of
hypoglycemic medications known as alpha-glucosidase
inhibitors (e.g., acarbose, miglitol) may develop abdominal
pain, bloating, and diarrhea. Artificial sweeteners containing sorbitol or mannitol are poorly absorbed and may cause
diarrhea. Patients on enteral tube feedings may also develop
diarrhea.28 The elderly are more likely to be on multiple
medications and may be more susceptible to adverse effects.
Review Of Systems
A brief review of systems is additionally helpful. A
patient who is currently menstruating may have guaiacpositive stools secondary to stool sample contamination
from menstrual blood. The patients pregnancy status is
important for antibiotic selection, use of medications
for symptomatic treatment of the diarrhea, and decisions
about managing her hemodynamic status. Ask the patient
about the ability to get to the bathroom on time. Some
individuals complain of diarrhea when the real problem
is fecal incontinence.
Bacteria
Campylobacter, Clostridium difficile, Escherichia coli, Listeria
monocytogenes, Salmonella enteritidis, Shigella
Social History
Viral infections
HIV
Medications
Antibiotics, high blood pressure medications, cancer drugs/
radiation therapy
Secondary Survey
A secondary survey allows for further assessment of the
patients volume status as well as the presence or absence of
systemic toxicity. Is the patient febrile? Is postural hypotension present? Are the mucus membranes dry? For infants, is
the anterior fontanelle sunken? Is the pediatric patient
producing any tears when crying? Note the patients skin
turgor, jugular venous pressure, capillary refill, and the
presence or absence of sunken eyes. Also, evaluate the
patients mental status. Is the patient awake, alert, and able
to answer questions? Is the patient lethargic or completely
unresponsive? Other features of diagnostic significance
include the presence of flushing or rashes on the skin,
mouth ulcers, thyroid masses, wheezing, arthritis, heart
murmurs, hepatomegaly or abdominal masses, ascites,
and edema.16
The abdominal examination should include auscultation of bowel sounds as well as the presence or absence
of tenderness or peritoneal signs. A rectal examination
can determine whether the stools are grossly bloody,
melanotic, or guaiac-positive. Given the fact that melanotic
stools are usually liquid, the patient may refer to this type
of stool simply as diarrhea. Thus, a rectal examination
may play an important role in assessing the nature of the
stools. Selected female patients may require a pelvic
examination depending on the degree and location of
their abdominal pain.
Diagnostic Studies
Blood Tests
Routine CBC counts or chemistry panels are unnecessary in
most patients since diarrhea is a self-limited problem in
most cases. A chemistry panel may reveal an electrolyte
imbalance or the degree of dehydration in systemically ill
patients, or in those with severe or persistent diarrhea. In
patients with bloody diarrhea, obtain a CBC and platelet
count to exclude hemolytic uremic syndrome. (Hemolytic
uremic syndrome is discussed in further detail in the section
on pediatric patients later in this article.) Eosinophilia on the
leukocyte differential can point to food allergy, collagenvascular diseases, neoplasm, parasitic infections, or eosinophilic gastroenteritis or colitis.22 Such diagnostic testing
should be reserved for select cases in which clinical or
epidemiologic factors or disease severity suggest their
need.5 Unfortunately, the literature does not provide clearcut indications for such testing.
Stool Culture
While readily obtainable tests such as heme- or leukocytepositive stools can provide the ED practitioner with
valuable information, stool cultures may be advisable under
certain circumstances.
The use of antibiotics in certain cases of bacterial
diarrhea can produce undesirable outcomes, so determining
the causative agent via stool cultures can be helpful.
For instance, treatment of salmonellosis can prolong the
carrier state and lead to a higher clinical relapse rate.28
The likelihood of hemolytic uremic syndrome in patients
infected with E. coli 0157:H7 is increased with the use of
antibiotics.50 Empiric antibiotic use may increase the risk
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Physical Examination
Primary Survey
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of C. difficile colitis.
Determination of antimicrobial susceptibility is also
important given the emergence of resistance to some
commonly used antibiotics. Finally, negative stool culture
results may be important prerequisites for the diagnosis of
certain ailments such as inflammatory bowel disease.
Stool cultures can also play a role in identifying agents
that have significant public health consequences. An
outbreak of illness due to Salmonella enteritidis serves to
illustrate this point. The state public health laboratory in
Minnesota received a higher-than-expected number of
reports of Salmonella isolates from local clinical laboratories
in 1994. These reports ultimately led to the detection of a
nationwide outbreak of Salmonella enteritidis infection due to
contaminated ice cream that had been widely distributed
(with patients afflicted in 41 states). An estimated 220,000
people were affected by this outbreak.51 Elimination of the
contaminated product from the market potentially prevented the spread of this infection to thousands of others.
These preventive measures were possible because stool
cultures were obtained on the first patients who presented
to their physicians with diarrhea.
While these examples provide compelling evidence for
obtaining stool cultures on patients with diarrhea, the yield
on routinely obtained stool cultures is low. In six studies
conducted between 1980 and 1997, stool cultures were
positive in 1.5%-5.6% of cases.5 This translates to a cost of
$952-$1200 for each positive culture obtained. Interestingly,
in the study with a positive culture yield of 5.6%, 63% of the
patients had grossly bloody stools, while 91% presented
with a history of bloody diarrhea.52
Therefore, experts recommend restricting the use of
stool cultures. In patients in whom vomiting is a prominent
feature of their disease, viral agents are the likely etiology
and stool cultures will have a low yield. Proposed criteria
that suggest a higher yield from stool cultures include
history of bloody stools (grossly bloody or heme-positive
stools) or stools containing leukocytes or lactoferrin;
immunocompromised patients; fever higher than 38.5C
(101.3F); systemic illness or an illness that is clinically
severe or persistent; and patients with severe abdominal
pain.2,28,53 Selective cultures can be considered in specific
circumstances such as bloody diarrhea in afebrile patients
with a history of ingestion of unpasteurized juice or milk or
undercooked beef (suggests enterohemorrhagic E. coli);
patients who have consumed shellfish within 72 hours of
the onset of illness (suggests Vibrio parahemolyticus); and
Endoscopy/Computed Tomography
Lower gastrointestinal endoscopy should be considered in
patients with rectal bleeding, severe abdominal pain, fever,
as well as negative stool tests for pathogens or otherwise
unexplained chronic diarrhea lasting longer than three
weeks.20 Biopsy and evaluation of the colonic mucosa is
crucial to exclude the presence of C. difficile
pseudomembraneous colitis, inflammatory bowel disease,
ischemic colitis, microscopic or collagenous colitis (types of
inflammatory bowel disease), and malignancy.20 In one
study, 809 HIV-negative patients with chronic non-bloody
diarrhea underwent colonoscopy. Fifteen percent of these
patients had an inflammatory cause of diarrhea, including
microscopic colitis and, to a lesser extent, Crohns disease
and ulcerative colitis.55
Treatment
Treatment decisions are influenced by several factors,
including the patients hydration status, the need for
symptomatic relief, and the likelihood of the presence of a
bacterial pathogen.
Rehydration
Rehydration can be accomplished by oral or intravenous
fluid administration. In patients with moderate-to-severe
dehydration, as well as those in whom vomiting disallows
adequate oral fluid intake, intravenous hydration speeds up
the recovery process. In many cases, rehydration can be
achieved with oral rehydration solutions. Fluids used for
rehydration should contain sodium, potassium, and
glucose.28 Various commercial types of oral rehydration
solutions (such as Pedialyte, Lytren, and Rehydrolyte) are
available. Various home preparations have been proposed,
although they are not recommended in children. Additionally, sports drinks, which are designed to replenish fluids
and electrolytes lost by sweating, are inadequate to replace
diarrheal sodium losses. These solutions can be effective if
they are supplemented with another source of salt such as
pretzels or crackers.16,22
The use of the BRAT diet (bananas, rice, applesauce,
toast) is commonly recommended, although evidence-based
data supporting its use are sparse. One evidence-based
clinical practice guideline suggests that continued use of the
patients preferred, usual, and age-appropriate diet should
be encouraged, and that the BRAT diet offers no advantage
unless those foods are part of the usual diet.4
Symptomatic Therapy
Symptomatic therapy may be used in selected patients with
diarrhea. Patients who are afebrile and have non-bloody
diarrhea as well as most patients with chronic diarrhea
associated with inflammatory bowel disease may benefit
from the use of antimotility agents.28 Antimotility agents
should generally be avoided in patients with high fever,
sepsis, immunocompromise, bloody diarrhea, or suspected
inflammatory diarrhea because of delayed clearance of
Continued on page 13
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YES
NO
Diagnosis clear
and stable clinical state
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Discharge (Class I)
The evidence for recommendations is graded using the following scale. For complete definitions, see back page. Class I: Definitely
recommended. Definitive, excellent evidence provides support. Class II: Acceptable and useful. Good evidence provides support. Class III:
May be acceptable, possibly useful. Fair-to-good evidence provides support. Indeterminate: Continuing area of research.
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending
upon a patients individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright 2004 EB Practice, LLC. 1-800-249-5770. No part of this publication may be reproduced in any format
without written consent of EB Practice, LLC.
10
Diarrhea (loose, watery bowel movements) is often caused by an infection. Many infections that cause diarrhea
simply go away by themselves. Diarrhea can also be caused by other things, like medications, bleeding into the
stomach or bowels, diseases of the bowels, appendicitis, and many others. Diarrhea can happen by itself or may
happen with other symptoms, like cramps or pain in the stomach and bowel area, fever, vomiting, rash, or bleeding
from the rear end. You can become dehydrated (lose too much water) because of diarrhea.
at the pharmacy or supermarket. Let your child eat a
regular diet as soon as possible. If your child is
vomiting, try having him or her drink very small
amounts of liquid until the vomiting stops.
Adults
Signs of dehydration
You are very thirsty
You feel weak or dizzy
You faint or feel like you might faint
Your skin is dry or very loose
Your urine is dark
Do Not:
Dont use water or sports drinks for your
dehydrated child (use an oral rehydration
solution instead)
Dont withhold dairy products (milk, cheese, ice
cream) from your child
Dont have your child drink fruit juices like prune,
apple, or grape juice (these can cause diarrhea)
Medications
Use all medications exactly as your doctor advises.
You have been prescribed:
______________________________
______________________________
______________________________
You may also use:
______________________________
______________________________
______________________________
Do Not:
Dont drink milk or eat dairy products (cheese, ice
cream) for 2-3 days
Dont drink caffeine (tea, cola, coffee)
Dont drink alcohol
Dont drink fruit juices like prune, apple, or grape
juice (these can cause diarrhea)
Children
Signs of dehydration
Your child is very thirsty
Your child is very weak, sleepy, or cranky
Your childs skin feels cool, doughy, or loose
Your child cries but does not make tears
Your child does not make as much urine as usual
How to avoid or treat dehydration
Use an oral rehydration solution that you can buy
Copyright 2004 EB Practice, LLC. 1-800-249-5770. No part of this publication may be reproduced in any format
without written consent of EB Practice, LLC.
July 2004 EMPractice.net
11
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12
diarrhea include quinolones, TMP-SMX, as well as nonabsorbable or poorly absorbed antibiotics such as rifaximin
and aztreonam.59,60 A comparison of two different doses of
TMP-SMX with or without loperamide vs. loperamide alone
in American adults with acute diarrhea in Mexico revealed
that combination therapy with TMP-SMX and loperamide
was the most efficacious regimen.61
Several studies have also provided data regarding the
efficacy and safety of rifaximin for the treatment of
travelers diarrhea. Adults with acute travelers diarrhea
who took rifaximin vs. placebo for three days had earlier
resolution of symptoms (average, slightly more than one
day).62 A randomized, controlled trial comparing rifaximin
with TMP-SMX revealed an 11% clinical failure rate with
rifaximin vs. a 29% clinical failure rate with TMP-SMX.63 In
another comparison of rifaximin with ciprofloxacin, no
significant differences were noted between the two treatment groups.59
There is an increasing emergence of fluoroquinoloneresistant Campylobacter, with the rate of resistance exceeding
80% in Southern Asia.53 For patients with travel histories
to this part of the world, erythromycin or azithromycin
are alternatives.53
Travelers Diarrhea
Treatment:
A fluoroquinolone in adults
Trimethoprim-sulfamethoxazole in children
Treatment period: 1-5 days
4. Nosocomial diarrhea
Treatment:
Special Circumstances
Immunocompromized Patients
Patients with HIV/AIDS are especially prone to diarrheal
illnesses. About half of North American AIDS patients will
develop diarrhea at some point in their illness. The incidence of diarrhea in AIDS patients throughout the develop-
13
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Elderly Patients
Diarrheal illnesses are important causes of death and
disability in the elderly. Not only are more serious etiologies
more common in the elderly, the physiological stresses of
diarrheal illness are more challenging for this population.
Age-related declines in immune system functioning,
physiologic changes of aging, medications (e.g., those that
inhibit gastric acid secretion, antibiotics, vasoconstrictors,
and others), and environmental factors (e.g., group living in
nursing homes) all contribute to the elderly patients
susceptibility to develop diarrhea.68
Furthermore, elderly patients with diarrhea are often
profoundly dehydrated due to fluid losses associated with
their illness, fever, an age-related disordered thirst mechanism, co-existing illnesses (e.g., diabetes mellitus), medications (e.g., diuretics) and limited access to fluids due to
infirmity. Prompt, adequate rehydration is essential;
however, intravenous rehydration of the elderly individual
may be complicated by the presence of cardiovascular
disease or renal dysfunction, thus limiting rapid, largevolume fluid administration.68
Ischemic colitis, diverticulitis, bacterial overgrowth,
and colonic malignancies are all more common in the
elderly and may present with loose stool.7,68,69 Infections
notably, C. difficile, E. coli 0157:H7 and Salmonella species
are more common in the elderly.68,70 Infectious diarrhea in
the elderly is associated with a higher mortality rate.68
If medications are indicated for an elderly patient with
diarrhea, be aware of drug interactions and side-effects,
particularly if the patient is already on multiple medications. Antacids may reduce the potency of fluoroquinolones.
Additionally, fluoroquinolones can increase theophylline
and warfarin levels and can either increase or decrease
phenytoin levels. Metronidazole can cause nausea and
vomiting, exacerbating the situation for a patient who
initially presented with a gastrointestinal complaint.
Drinking alcohol while taking metronidazole must be
strictly avoided since a disulfiram-like reaction can ensue.
Also, warfarin, phenytoin, and phenobarbital metabolism
may all increase in the patient on metronidazole, potentiating their effect.68
Be particularly cautious when evaluating elderly
patients with diarrhea combined with abdominal pain.
Elderly patients with abdominal pain tend to have more
serious, often surgical, illnesses that present atypically
or go unrecognized longer.69 (See also the premier issue
of Emergency Medicine Practice, Assessing Abdominal
Pain In Adults: A Rational, Cost-Effective, And EvidenceBased Strategy.) Specific surgical diagnoses to consider
14
Pediatric Patients
Diarrhea is very common in children, especially among
those who attend day care. While most children in developed nations have mild, self-limited disease, pediatric
patients are susceptible to more adverse outcomes
especially dehydrationthan their healthy adult counterparts.21 In the United States, about 9% of all hospitalizations
of children younger than 5 years are because of diarrhea.71
While pediatric patients are susceptible to more
adverse outcomes from diarrheal illnesses, the approach is
generally the same. As with adults, infectious causes
predominate, although children have more of a predisposition to rotavirus. Another common non-infectious cause in
children is the excessive consumption of sugary, clear
liquids, which can cause copious, watery stools. The wary
practitioner should also keep more serious diagnoses such
as intussusception and Meckels diverticulum in mind.
In most cases, prevention of dehydration is the primary
consideration. Oral rehydration methods are preferred.
After rehydration, recommend prompt resumption of a
15
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Pregnant Patients
Disposition
Zinc
Preventive Measures
Controversies/Cutting Edge
Probiotics
16
Guerrant RL, Van Gilder T, Steiner TS, et al; Infectious Diseases Society
of America. Practice guidelines for the management of infectious
diarrhea. Clin Infect Dis 2001 Feb 1;32(3):331-351. (Practice guideline)
6.
No authors listed. Practice parameters for the treatment of sigmoid
diverticulitis. The Standards Task Force. The American Society of
Colon and Rectal Surgeons. Dis Colon Rectum 2000 Mar;43(3):289.
(Practice guideline)
7.
Wong WD, Wexner SD, Lowry A, et al. Practice parameters for the
treatment of sigmoid diverticulitissupporting documentation. The
Standards Task Force. The American Society of Colon and Rectal
Surgeons. Dis Colon Rectum 2000 Mar;43(3):290-297. (Practice
guideline)
8.
No authors listed. American Gastroenterological Association Medical
Position Statement: guidelines on intestinal ischemia. Gastroenterology
2000 May;118(5):951-953. (Practice guideline)
9.
Brandt LJ, Boley SJ. AGA technical review on intestinal ischemia.
American Gastrointestinal Association. Gastroenterology 2000
May;118(5):954-968. (Review)
10. Hanauer SB, Sandborn W; Practice Parameters Committee of the
American College of Gastroenterology. Management of Crohns
disease in adults. Am J Gastroenterol 2001 Mar;96(3):635-643. (Practice
guideline)
11. No authors listed; American Gastroenterology Association. American
Gastroenterological Association medical position statement: irritable
bowel syndrome. Gastroenterology 2002 Dec;123(6):2105-2107. (Practice
guideline)
12. No authors listed. Norwalk-like viruses: public health consequences
and outbreak management. MMWR Recomm Rep 2001 Jun
1:50(RR09);1-18. (Review)
13. Sampson HA, Sicherer SH, Birnbaum AH. AGA technical review on
the evaluation of food allergy in gastrointestinal disorders. American
Gastroenterological Association. Gastroenterology 2001 Mar;120(4):10261040. (Review)
14. Fekety R. Guidelines for the diagnosis and management of Clostridium
difficile-associated diarrhea and colitis. American College of Gastroenterology, Practice Parameters Committee. Am J Gastroenterol 1997
May;92(5):739-750. (Practice guideline)
15. Andersson RE. Meta-analysis of the clinical and laboratory diagnosis
of appendicitis. Br J Surg 2004 Jan;91(1):28-37. (Meta-analysis; 24
studies)
16. Fine KD, Schiller LR. AGA technical review on the evaluation and
management of chronic diarrhea. Gastroenterology 1999 Jun;116(6):14641486. (Review)
17. No authors listed. American Gastroenterological Association medical
position statement: guidelines for the management of malnutrition
and cachexia, chronic diarrhea, and hepatobiliary disease in patients
with human immunodeficiency virus infection. Gastroenterology 1996
Dec;111(6):1722-1723. (Practice guideline)
18. American College of Radiology, Expert Panel on Gastrointestinal
Imaging. Imaging recommendations for patients with Crohns disease.
Reston, VA: American College of Radiology; 2001. (Review)
19. Eisen GM, Dominitz JA, Faigel DO, et al; American Society for
Gastrointestinal Endoscopy. Use of endoscopy in diarrheal illnesses.
Gastrointest Endosc 2001 Dec;54(6):821-823. (Practice guideline)
20. Schiller LR, Sellin JH. Diarrhea. In: Feldman M, Friedman LS,
Sleisenger MH, eds. Sleisenger and Fordtrans Gastrointestinal and Liver
Disease. 7th ed. Philadelphia: WB Saunders; 2002:131-153. (Textbook
chapter)
21.* No authors listed. Practice parameter: the management of acute
gastroenteritis in young children. American Academy of Pediatrics,
Provisional Committee on Quality Improvement, Subcommittee on
Acute Gastroenteritis. Pediatrics 1996 Mar;97(3):424-435. (Practice
guideline)
22. No authors listed. American Gastroenterological Association medical
position statement: guidelines for the evaluation and management of
chronic diarrhea. Gastroenterology 1999 Jun;116(6):1461-1463. (Practice
guideline)
23. Hasler WL. The irritable bowel syndrome. Med Clin North Am 2002
Nov;86(6):1525-1551. (Review)
24. Andres PG, Friedman LS. Epidemiology and the natural course of
inflammatory bowel disease. Gastroenterol Clin North Am 1999
Jun;28(2):255-281, vii. (Review)
25. Burns BJ, Brandt LJ. Intestinal ischemia. Gastroenterol Clin North Am
2003 Dec;32(4):1127-1143. (Review)
26. Tabrez S, Roberts IM. Malabsorption and malnutrition. Prim Care 2001
Sep;28(3):505-522, v. (Review)
27. Brandt LJ, Boley SJ. Intestinal ischemia. In: Feldman M, Friedman LS,
Sleisenger MH, eds. Sleisenger and Fordtrans Gastrointestinal and Liver
Summary
A simple approach focused on obtaining a thorough history
and performing a focused physical examination is generally
sufficient for most ED patients presenting with diarrhea.
Selective laboratory testing can be helpful but should not be
the cornerstone of patient evaluation. Symptomatic treatment is simple and well-supported in the literature.
Differentiating between those patients requiring
symptomatic treatment prior to discharge, those needing
hospitalization and more systematic investigation, and
those with more serious disease processes masquerading as
simple diarrhea remains the most essential element of the
ED encounter. It is easy to confuse the common (gastroenteritis) with the rare (poisonings), the serious (appendicitis),
and the deadly (gastrointestinal hemorrhage). If there is a
doubt about the diagnosis, ED observation and repeated
examinations can be helpful. Patients warranting a greater
level of concern are the very young, the elderly, immunocompromised individuals, those with major comorbidities,
and those with unusual or atypical presentations such as
severe abdominal pain.
References
Evidence-based medicine requires a critical appraisal of the
literature based upon study methodology and number of
subjects. Not all references are equally robust. The findings
of a large, prospective, randomized, and blinded trial
should carry more weight than a case report.
To help the reader judge the strength of each reference,
pertinent information about the study, such as the type of
study and the number of patients in the study, will be
included in bold type following the reference, where
available. In addition, the most informative references cited
in the paper, as determined by the authors, will be noted by
an asterisk (*) next to the number of the reference.
1.
2.
3.
4.*
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5.*
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52.
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77.
78.
79.
2.
3.
4.
5.
6.
8.
9.
Of the following, which is most valuable in identifying/ruling out appendicitis in the ED?
a. Stool culture
b. WBC count
c. Plain films
d. Serial examinations
14. Lactobacillus:
a. is a probiotic being studied for its ability to prevent
and treat diarrhea.
b. is available only by prescription.
c. has been shown to be ineffective in several recent
meta-analyses.
d. is standard therapy for adults but not children in
the United States.
7.
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76.
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Target Audience: This enduring material is designed for emergency medicine
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Needs Assessment: The need for this educational activity was determined by a
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Date of Original Release: This issue of Emergency Medicine Practice was published
July 1, 2004. This activity is eligible for CME credit through July 1, 2007. The
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Indeterminate
Continuing area of research
No recommendations until
further research
Level of Evidence:
Evidence not available
Higher studies in progress
Results inconsistent,
contradictory
Results not compelling
Significantly modified from: The
Emergency Cardiovascular Care
Committees of the American Heart
Association and representatives
from the resuscitation councils of
ILCOR: How to Develop EvidenceBased Guidelines for Emergency
Cardiac Care: Quality of Evidence
and Classes of Recommendations;
also: Anonymous. Guidelines for
cardiopulmonary resuscitation and
emergency cardiac care. Emergency
Cardiac Care Committee and
Subcommittees, American Heart
Association. Part IX. Ensuring
effectiveness of community-wide
emergency cardiac care. JAMA
1992;268(16):2289-2295.
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