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Diarrhea
Specialty	Infectious diseases, gastroenterology

Diarrhea (from the Greek, "diarrhoia" meaning "a flowing through"), also spelled diarrhoea, is the condition of having three or more loose or liquid bowel movements per day. It is a common cause of death in developing countries and the second most common cause of infant deaths worldwide. The loss of fluids through diarrhea can cause dehydration and electrolyte imbalances. In 2009 diarrhea was estimated to have caused 1.1 million deaths in people aged 5 and over and 1.5 million deaths in children under the age of 5. Oral rehydration salts and zinc tablets are the treatment of choice and have been estimated to have saved 50 million children in the past 25 years.

Definition

Diarrhea is defined by the World Health Organization as having 3 or more loose or liquid stools per day or as having more stools than is normal for that person.

Secretory diarrhea

Secretory diarrhea means that there is an increase in the active secretion, or there is an inhibition of absorption. There is little to no structural damage. The most common cause of this type of diarrhea is a cholera toxin that stimulates the secretion of anions, especially chloride ions. Therefore, to maintain a charge balance in the lumen, sodium is carried with it, along with water. In this type of diarrhea intestinal fluid secretion is isotonic with plasma even during fasting .

Osmotic diarrhea

Osmotic diarrhea occurs when too much water is drawn into the bowels. This can be the result of maldigestion (e.g., pancreatic disease or Coeliac disease), in which the nutrients are left in the lumen to pull in water. Osmotic diarrhea can also be caused by osmotic laxatives (which work to alleviate constipation by drawing water into the bowels). In healthy individuals, too much magnesium or vitamin C or undigested lactose can produce osmotic diarrhea and distention of the bowel. A person who has lactose intolerance can have difficulty absorbing lactose after an extraordinarily high intake of dairy products. In persons who have fructose malabsorption, excess fructose intake can also cause diarrhea. High-fructose foods that also have a high glucose content are more absorbable and less likely to cause diarrhea. Sugar alcohols such as sorbitol (often found in sugar-free foods) are difficult for the body to absorb and, in large amounts, may lead to osmotic diarrhea.

Exudative diarrhea

Exudative diarrhea occurs with the presence of blood and pus in the stool. This occurs with inflammatory bowel diseases, such as Crohn's disease or ulcerative colitis, and other severe infections.

Motility-related diarrhea

Motility-related diarrhea is caused by the rapid movement of food through the intestines (hypermotility). If the food moves too quickly through the GI tract, there is not enough time for sufficient nutrients and water to be absorbed. This can be due to a vagotomy or diabetic neuropathy, or a complication of menstruation. Hyperthyroidism can produce hypermotility and lead to pseudodiarrhea and occasionally real diarrhea. Diarrhea can be treated with antimotility agents (such as loperamide). Hypermotility can be observed in patients who have had portions of their bowel removed, allowing less total time for absorption of nutrients.

Inflammatory diarrhea

Inflammatory diarrhea occurs when there is damage to the mucosal lining or brush border, which leads to a passive loss of protein-rich fluids, and a decreased ability to absorb these lost fluids. Features of all three of the other types of diarrhea can be found in this type of diarrhea. It can be caused by bacterial infections, viral infections, parasitic infections, or autoimmune problems such as inflammatory bowel diseases. It can also be caused by tuberculosis, colon cancer, and enteritis.

Dysentery

Generally, if there is blood visible in the stools, it is not diarrhea, but dysentery. The blood is trace of an invasion of bowel tissue. Dysentery is a symptom of, among others, Shigella, Entamoeba histolytica, and Salmonella.

Differential diagnosis

Diarrhea is most commonly due to viral gastroenteritis with rotavirus accounting for 40% of cases in children under five.(p. 17)

It can also be the part of the presentations of a number of medical conditions such as: Crohn's disease or mushroom poisoning.

Infectious

There are many causes of infectious diarrhea, which include viruses, bacteria and parasites. Norovirus is the most common cause of viral diarrhea in adults, but rotavirus is the most common cause in children under five years old. Adenovirus types 40 and 41), and astroviruses cause a significant number of infections.

The bacterium campylobacter is a common cause of bacterial diarrhea, but infections by salmonellae, shigellae and some strains of Escherichia coli (E.coli) are frequent. In the elderly, particularly those who have been treated with antibiotics for unrelated infections, a toxin produced by Clostridium difficile often causes severe diarrhea.

Parasites do not often cause diarrhea except for the protozoan Giardia, which can cause chronic infections if these are not diagnosed and treated with drugs such as metronidazole, and Entamoeba histolytica.

Other infectious agents such as parasites and bacterial toxins also occur. In sanitary living conditions where there is ample food and a supply of clean water, an otherwise healthy person usually recovers from viral infections in a few days. However, for ill or malnourished individuals, diarrhea can lead to severe dehydration and can become life-threatening.

Malabsorption

Malabsorption is the inability to absorb food, mostly in the small bowel but also due to the pancreas.

Causes include celiac disease (intolerance to wheat, rye, and barley gluten, the protein of the grain), lactose intolerance (intolerance to milk sugar, common in non-Europeans), fructose malabsorption, pernicious anemia (impaired bowel function due to the inability to absorb vitamin B12), loss of pancreatic secretions (may be due to cystic fibrosis or pancreatitis), short bowel syndrome (surgically removed bowel), radiation fibrosis (usually following cancer treatment), and other drugs, including agents used in chemotherapy.

Inflammatory bowel disease

The two overlapping types here are of unknown origin:

• Ulcerative colitis is marked by chronic bloody diarrhea and inflammation mostly affects the distal colon near the rectum.
• Crohn's disease typically affects fairly well demarcated segments of bowel in the colon and often affects the end of the small bowel.

Irritable bowel syndrome

Another possible cause of diarrhea is irritable bowel syndrome (IBS) which usually presents with abdominal discomfort relieved by defecation and unusual stool (diarrhea or constipation) for at least 3 days a week over the previous 3 months. There is no direct treatment for IBS, however symptoms can be managed through a combination of dietary changes, soluble fiber supplements, and/or medications.

Alcohol

Chronic diarrhea can be caused by chronic ethanol ingestion. Consumption of alcohol affects the body's capability to absorb water – this is often a symptom that accompanies a hangover after a binge drinking session. The alcohol itself is absorbed in the intestines and as the intestinal cells absorb it, the toxicity causes these cells to lose their ability to absorb water. This leads to an outpouring of fluid from the intestinal lining, which is in turn poorly absorbed. The diarrhea usually lasts for several hours until the alcohol is detoxified and removed from the digestive system. Symptoms range from person to person and are influenced by the amount consumed as well as physiological differences.

Other causes

• Ischemic bowel disease. This usually affects older people and can be due to blocked arteries.
• Bowel cancer: Some (but not all) bowel cancers may have associated diarrhea. Cancer of the large intestine is most common.
• Hormone-secreting tumors: some hormones (e.g., serotonin) can cause diarrhea if excreted in excess (usually from a tumor).
• Bile salt diarrhea: excess bile salt entering the colon rather than being absorbed at the end of the small intestine can cause diarrhea, typically shortly after eating. Bile salt diarrhea is a bad side-effect of gallbladder removal. It is usually treated with cholestyramine, a bile acid sequestrant.
• Celiac Disease
• Intestinal protozoa such as Giardiasis

Pathophysiology

Evolution

According to two researchers, Nesse and Williams, diarrhea may function as an evolved expulsion defense mechanism. As a result, if it is stopped, there might be a delay in recovery. They cite in support of this argument research published in 1973 which found that treating Shigella with the anti-diarrhea drug (Lomotil) caused people to stay feverish twice as long as those not so treated. The researchers indeed themselves observed that: "Lomotil may be contraindicated in shigellosis. Diarrhea may represent a defense mechanism".

Diagnostic approach

The following types of diarrhea may indicate further investigation is needed:

• Diarrhea in infants
• Moderate or severe diarrhea in young children;
• Diarrhea associated with blood
• Diarrhea that continues for more than two days;
• Diarrhea that is associated with more general illness such as non-cramping abdominal pain, fever, weight loss, etc;
• Diarrhea in travelers, since they are more likely to have exotic infections such as parasites;
• Diarrhea in food handlers, because of the potential to infect others;
• Diarrhea in institutions such as hospitals, child care centers, or geriatric and convalescent homes.

A severity score is used to aid diagnosis in children.

Management

In many cases of diarrhea, replacing lost fluid and salts is the only treatment needed. This is usually by mouth – oral rehydration therapy – or, in severe cases, intravenously. Diet restrictions such as the BRAT diet are no longer recommended. Research does not support the limiting of milk to children as doing so has no effect on duration of diarrhea.

Medications such as loperamide (Imodium), bismuth subsalicylate may be beneficial, however they may be contraindicated in certain situations.

Medications

Absorbents are products that can bind water and make stools semi solid. Most of these absorbent products are available without a prescription and include donnagel, rheaban, kaopectate, diasorb, Polycarp, mitrolan and konsyl fiber. However, these compounds can also cause severe constipation when taken in excess.

Anti motility agents are drugs that relax the bowel and prevent diarrhea. Drugs like Imodium and diphenoxylate are sometimes given to people whom have severe diarrhea. Even though these drugs are safe, they should not be used without first discussing with your physician. These drugs can sometimes make bacterial colitis worse, induce excess drowsiness and are also addictive.

Bismuth compounds like Pepto-Bismol can help reduce some types of diarrhea and is well tolerated. Pepto-Bismol should not be taken by people whom are allergic to aspirin.

Alternative therapies

Probiotics are bacterial supplements that can help prevent recurrence of diarrhea. The most widely used probiotics include lactobacillus and saccharomyces boulardii. For those who suffer from lactose intolerance, recommend taking digestive enzymes containing lactase when consuming dairy products.

Epidemiology

World wide in 2004 approximately 2.5 billion cases of diarrhea occurred which results in 1.5 million deaths among children under the age of five. Greater than half of these were in Africa and South Asia. This is down from a death rate of 5 million per year two decades ago. Diarrhea remains the second leading cause of death (16%) after pneumonia (17%) in this age group.

References

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External links

• Travelers' Diarrhea
• Rehydration Project

• Gastroenterology
• Water-borne diseases
• Symptoms
• Digestive disease symptoms
• Conditions diagnosed by stool test