Diarrhea and Dehydration

Diarrhea is exceedingly common in pediatric and adult populations worldwide. Dehydration and electrolyte (e.g., sodium, potassium, bicarbonate) losses associated with severe diarrhea account for significant morbidity and may lead to mortality in cases of acute gastroenteritis, especially in countries with poor access to adequate healthcare. Rota-virus infection is the most common cause of diarrhea in U.S. infants and children, especially in winter months and temperate climates; Norwalk-like virus is the most common agent in adults (King et al., 2003).

A thorough history should be the first step in evaluating the patient who presents with a significant diarrheal illness, including the following (Guerrant et al., 2001):

■ When and how the illness began (abrupt or gradual onset and duration of symptoms)

■ Stool characteristics (watery, bloody, mucous, purulent, greasy)

■ Frequency of bowel movements and relative quantity of stool produced

■ Presence of dysenteric symptoms (fever, tenesmus, blood/pus in stool)

■ Symptoms of volume depletion (increased thirst, tachycardia, orthostasis, decreased urine output, lethargy, decreased skin turgor, decreased tear production)

■ Associated symptoms and their frequency and intensity (nausea, vomiting, abdominal pain, cramps, headache, myalgias, altered sensorium)

Box 38-1 Differential Diagnosis for Abdominal Pain Based on Location

Left upper quadrant

Cardiac: Angina pectoris, myocardial infarction Dermatologie: Herpes zoster

Gastric: Peptic ulcer disease, gastritis, pyloric stenosis, hiatal hernia

Intestinal: High fecal impaction, perforated colon, diverticulitis

Pancreatic: Pancreatitis, neoplasm, stone in pancreatic duct or ampulla

Pulmonary: Pneumonia, empyema, pulmonary infarction

Renal: Calculi, pyelonephritis, neoplasm

Splenic: Splenomegaly, rupture, abscess, splenic infarction

Trauma

Vascular: Dissecting or ruptured aortic aneurysm

Right upper quadrant

Biliary: Calculi, infection, inflammation, neoplasm

Cardiac: Myocardial ischemia or infarction (particularly involving the inferior wall), pericarditis

Dermatologie. Herpes zoster

Fitz-Hugh-Curtis syndrome (perihepatitis)

Gastric: peptic ulcer disease, pyloric stenosis, neoplasm, alcoholic gastritis, hiatal hernia

Hepatic: Hepatitis, abscess, hepatic congestion, neoplasm, trauma Pancreatic: Pancreatitis, neoplasm, stone in pancreatic duct or ampulla Pulmonary: Pneumonia, pulmonary infarction, right-sided pleurisy Renal: calculi, infection, inflammation, neoplasm, rupture of kidney Intestinal: retrocecal appendicitis, intestinal obstruction, high fecal impaction, diverticulitis Trauma

Left lower quadrant

Intestinal: Diverticulitis, intestinal obstruction, perforated ulcer, inflammatory bowel disease, perforated descending colon, inguinal hernia, neoplasm, appendicitis Psoas abscess

Renal: Renal or ureteral calculi, pyelonephritis, neoplasm Reproductive: Ectopic pregnancy, ovarian cyst, torsion of ovarian cyst, salpingitis, tuboovarian abscess, mittelschmerz, endometriosis, seminal vesiculitis Trauma

Vascular: Dissecting, ruptured, or leaking aortic aneurysm

Right lower quadrant

Cholecystitis

Intestinal: Acute appendicitis, regional enteritis, incarcerated hernia, cecal diverticulitis, intestinal obstruction, perforated ulcer, perforated cecum, Meckel's diverticulitis Psoas abscess

Reproductive: Ectopic pregnancy, ovarian cyst, torsion of ovarian cyst, salpingitis, tuboovarian abscess, mittelschmerz, endometriosis, seminal vesiculitis

Renal: Renal or ureteral calculi, pyelonephritis, neoplasm Trauma

Vascular: Dissecting, ruptured, or leaking aortic aneurysm

Other regions

Epigastric

Biliary: Cholecystitis, cholangitis

Cardiac: Angina, myocardial infarction, pericarditis

Duodenal: Peptic ulcer disease, duodenitis

Gastric: Peptic ulcer disease, gastric outlet obstruction, gastric ulcer Hepatitic: Hepatitis, abscess

Intestinal: High small bowel obstruction, early appendicitis Pancreatitis

Pulmonary: Pneumonia, pleurisy, pneumothorax Subphrenic abscess

Vascular: Dissecting, ruptured, or leaking aortic aneurysm, mesenteric ischemia

Periumbilical

Intestinal: Small bowel obstruction or gangrene, early appendicitis Vascular: Mesenteric thrombosis, dissecting, ruptured, or leaking aortic aneurysm

Suprapubic

Genitourinary: Cystitis, rupture of urinary bladder

Intestinal: Colonic obstruction or gangrene, diverticulitis, appendicitis

Reproductive: Ectopic pregnancy, mittelschmerz, torsion of ovarian cyst, pelvic inflammatory disease, salpingitis, endometriosis, rupture of endometrioma

Diffuse

Genitourinary: Urinary tract infection, pelvic inflammatory disease Intestinal: Diverticulitis, early appendicitis, gastroenteritis, inflammatory bowel disease, intestinal obstruction, irritable bowel syndrome, mesenteric adenitis, insufficiency, or infarction

Metabolic: Toxins, lead poisoning, uremia, drug overdose, diabetic ketoacidosis, heavy metal poisoning Pancreatitis Peritonitis Pneumonia (rare) Sickle cell crisis Trauma

Other: Acute intermittent porphyria, tabes dorsalis, periarteritis nodosa, Henoch-Schönlein purpura, adrenal insufficiency Vascular: Aortic aneurysm

Modified from Differential diagnosis. In Ferri FF. Ferri's Clinical Advisor 2010. Philadelphia, Saunders-Elsevier, 2010.

In addition, all patients should be asked about potential epidemiologic risk factors for diarrheal diseases, including the following:

■ Travel to an underdeveloped area

■ Daycare center attendance or employment

■ Consumption of unsafe foods (e.g., raw meats, eggs, or shellfish; unpasteurized milk or juices) or swimming in or drinking untreated fresh surface water from a lake or stream

■ Visiting a farm or petting zoo or having contact with reptiles or with pets with diarrhea

■ Knowledge of other ill persons (e.g., in a dormitory, office, or social function)

■ Recent or regular medications (e.g., antibiotics, antacids, antimotility agents)

■ Underlying medical conditions predisposing to infectious diarrhea (AIDS, immunosuppressive medications, prior gastrectomy, extremes of age)

■ Receptive anal intercourse or oral-anal sexual contact

■ Occupation as a food-handler or caregiver

In the majority of patients with acute gastroenteritis, the "gold standard" stool cultures and ova and parasite testing are seldom required, because the disease is most often viral in etiology and self-limited. In more severe cases with dehydration, metabolic derangement, longer duration, bloody stools (dysentery) and mucus in the stool, or known or suspected transmission of a pathogen, these tests are often required to identify the pathogen and to direct appropriate antimicrobial therapy (Table 38-1). Viral cultures are rarely performed and are unnecessary, except in rare cases and immunocom-promised patients. Although fecal leukocytes and lactoferrin often suggest an inflammatory etiology of diarrhea, there is no consensus regarding the routine use of these tests in the initial testing of patients with either community-acquired or nosocomial diarrhea. Hospitalized patients with diarrhea, especially those with abdominal pain, should be tested for Clostridium difficile toxin (Guerrant et al., 2001). Oral metronidazole and oral vancomycin have been shown to be equally effective in the treatment of C. difficile-associated diarrhea (CDAD). Vancomycin is significantly more expensive and may select for colonization with vancomycin-resis-tant enterococci (VRE), and thus metronidazole should be recommended as first-line therapy.

Nonpathogenic causes of diarrhea should be considered when a viral etiology is unlikely and a diagnostic evaluation has not identified a pathogen. Differential diagnosis includes irritable bowel syndrome, inflammatory or ischemic bowel disease, laxative abuse, partial bowel obstruction, rectosigmoid abscess, Whipple's disease, pernicious anemia, diabetes mellitus, malabsorption syndromes (e.g. celiac disease), small bowel diverticulosis, and scleroderma in primarily adult patients, and an appropriate workup should be considered.

KEY TREATMENT

Oral metronidazole and vancomycin are equally effective in the treatment of Clostridium difficile-associated diarrhea (Guerrant et al., 2001) (SOR: A).

In cases of traveler's diarrhea, (e.g. enterotoxigenic Escherichia coli, Shigella, Salmonella, or Campylobacter), prompt treatment with a fluoroquinolone or, in children, trimethoprim-sulfamethoxazole (TMP-SMX) has been shown to reduce the duration of the illness from 3 to 5 days to less than 1 to 2 days (Guerrant et al., 2001) (SOR: A).

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