Gastrointestinal
Diarrhea
#Diarrhea
Intake
- Onset: *** acute if <14 days, chronic if >4 stools/day for 30+ days
- Frequency: *** all time of day/night or only after meals
- Characteristics: *** color, consistency, blood, mucus, odor
- Associated Symptoms: *** fever, n/v, abdominal pain (better or worse after stool), bloating, weight loss, fatigue
- Food History: *** new foods, noted triggers, sweeteners, spicy, fried/fatty foods
- Travel History: *** tap water, fruit, raw food, street food, swimming
- Exposures: *** sick contacts, daycares, hospitals
- Medication Use: *** antibiotics, laxatives, magnesium, PPIs, antacids, NSAIDs, metformin, colchicine, SSRIs, chemo
- Notable PMH: *** IBD, IBS, celiac, immunosuppression, previous abdominal surgeries, anxiety/depression
- Red Flags: *** fever, bloody stool, severe abdominal pain, dehydration, immunocompromised, iron deficiency, weight loss, thin stool
Plan
- Acute - stool culture, stool viral panel, O+P, C Diff
- If evidence of severe systemic infection: CTAP
- Chronic - CMP, CBC, stool culture, O+P, fecal calprotectin or lactoferrin, ESR/CRP, fecal fat, anti-tissue transglutaminase ab (tTG) with total IgA, stool lytes (Na, K, pH), TSH, colonoscopy if c/f IBD
- Loperamide 4mg PO, then 2mg after each stool (max 8-16mg per day) for symptom relief; busmuth subsalicylate
- Traveler’s Diarrhea - levoflox 500mg daily, azithro 500mg daily for 3-5 days
- Replenish losses with pedialyte or other sports drinks
Differential
Acute (<14 Days)
- Bacterial - E Coli, Salmonella, Campylobacter, Shigella, C Diff
- Viral - Norovirus, Rotavirus
- Parasite - Giardia, cryptosporidium
- Food Poisoning
- Medications - antibiotics, laxatives, magnesium, PPIs, antacids, NSAIDs, metformin, colchicine, SSRIs, chemo
Chronic (30+ days)
- Inflammatory (IBD)
- IBS-D
- Celiac
- Malabsorption - lactose intolerance, SIBO, pancreatic insufficiency
- Secretory - hyperthyroidism, addison, neuroendocrine tumor, DM, amyloid, bile salts
- Meds - antibiotics, laxatives, magnesium, PPIs, antacids, NSAIDs, metformin, colchicine, SSRIs, chemo
Template coming soon!
Patient Guidance and Information
Acute Gastroenteritis
Hello ***,
Based on the symptoms you've reported, it appears you may be experiencing gastroenteritis, often referred to as a stomach bug. This condition is usually caused by a viral or bacterial infection and can result in symptoms such as diarrhea, stomach cramps, nausea, and sometimes vomiting and fever.
Gastroenteritis often resolves on its own within a few days. In the meantime, it is important to stay well-hydrated. Dehydration can occur with diarrhea and vomiting, so make sure to drink plenty of fluids. Water is good, but you might also consider oral rehydration solutions like Pedialyte or sports drinks, which can help replenish lost electrolytes.
While you're experiencing diarrhea, a bland diet can help. Consider the BRAT diet (Bananas, Rice, Applesauce, Toast) and other easy-to-digest foods. Once your symptoms start to improve, you can gradually return to your normal diet.
If you feel the need, over-the-counter treatments like loperamide (Imodium) can be used to control your diarrhea. However, if your symptoms persist for more than a week, or if they worsen (such as high fever, severe abdominal pain, blood in stool, or signs of dehydration like dry mouth, decreased urine output, or dizziness), please contact our office or seek immediate medical attention.
If You Remember Nothing Else
The history will be key for determining the etiology of a patient’s diarrhea. Most acute diarrheal illnesses will be self-limited and won’t require workup or treatment beyond useual supportive care with fluids, electrolytes, and loperamide. Some red flags include weight loss, bloody stools, severe pain, or evidence of dehydration. Chronic diarrhea warrants a thorough workup to evaluate for infectious, inflammatory, functional, and malabsorptive etiologies.
Clinical Pearls
- Loperamide acts on peripheral mu opioid receptors and is selective for the intestinal receptors; it slows peristalsis and transit time and also has antisecretory activity and can lead to increased sphincter tone leading to less incontinence; it can lead to drowsiness; avoid if c/f C Diff or bacterial diarrhea, ileus,acute IBD flare, toxic megacolon; can prolong QT; usually works within 48 hours of starting
- Acute diarrhea is usually due to a viral infection or food poisoning and do not require antibiotics unless there is a sign of a severe systemic infection
- Bacterial toxins that can cause food poisoning include bacillus cereus or staph aureus
- Osmotic diarrhea symptoms should improve with fasting
- Measure stool osmotic gap = 290 - 2 * (stool Na + stool K) ; normal is 50-100;
- If 24 hour fecal fat is >20g it likely represents pancreatic dysfunction, 14-20 is more likely small bowel disease
- CREON (pancrelipase) are pancreatic enzymes that are used in patients with malabsorption syndrome due to pancreatic deficiency
- Cholestyramine can be used if there is concernfor bile acid malabsorption especially after cholecystectomy
- FODMAP diet is a serial elimination diet to see food triggers leading to symptoms in patients with IBS
Character of Diarrhea
- Large volume, watery - Often associated with small bowel diseases or conditions that produce secretory diarrhea such as bacterial overgrowth, celiac disease, or the use of certain medications.
- Greasy, foul-smelling, difficult to flush (steatorrhea) - These characteristics may suggest malabsorption disorders such as pancreatic insufficiency or diseases affecting the terminal ileum (e.g., Crohn's disease) where bile acids are typically absorbed.
- Blood and mucus present - Suggestive of invasive infections or inflammatory conditions of the colon, such as inflammatory bowel disease or ischemic colitis.
- Sudden urge to defecate, often following meals - This could suggest irritable bowel syndrome, especially when associated with abdominal pain that is relieved by defecation.
- Nocturnal diarrhea - Often associated with organic disease, such as inflammatory bowel disease or malabsorption syndromes. Functional diarrheas, like irritable bowel syndrome, typically do not cause nocturnal symptoms.
- Watery diarrhea that persists despite fasting - This could suggest a secretory diarrhea, such as that produced by certain types of tumors (e.g., neuroendocrine tumors) or chronic infections.
Trials and Literature
Other Resources
Tweetorials
Video
