DIARRHEA

Diarrhea, also spelled diarrhea, 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 five and over and 1.5 million deaths in children under the age of 5. Oral rehydration solutions and zinc tablets are the treatment of choice and have been estimated to have saved 50 million children in the past 25 years. Homemade solutions recommended by WHO include salted drinks (e.g., salted rice water or a salted yogurt drink) and vegetable or chicken soup with salt. If available, supplemental potassium and supplemental zinc can be added to or given with this homemade solution. It’s also recommended that persons with diarrhea, if able, continue or resume eating as this speeds recovery of normal intestinal function and generally leads to diarrhea of shorter duration. Clean plain water can be one of several fluids given. There are commercial solutions such as Pedialyte, and relief agencies such as UNICEF widely distribute packets of salts and sugar. A homemade solution can be made by adding between one-half to one teaspoon of salt (about 2-3 grams) and six teaspoons of sugar (about 18 grams) to one liter of water. If the person drinks solutions with too much sugar or too much salt, these can draw fluid from the body to the bowel, cause osmotic diarrhea, and make dehydration worse. In a WHO publication, it’s stated that a homemade Oral rehydration solution (ORS) should approximately have the taste of tears.

DEFINITION

The World Health Organization defines diarrhea as having three or more loose or liquid stools per day or having more stools than normal for that person.

SECRETORY

Secretory diarrhea means 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. It continues even when there is no oral food intake.

OSMOTIC

Osmotic diarrhea occurs when too much water is drawn into the bowels. If a person drinks solutions with excessive sugar or excessive salt, these can draw water from the body into the bowel and cause osmotic diarrhea. Osmotic diarrhea can also 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. Or it can be caused by osmotic laxatives (which work to alleviate constipation by drawing water into the bowels). Too much magnesium or vitamin C, or undigested lactose, can produce osmotic diarrhea and distention of the bowel in healthy individuals. 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. In most cases, osmotic diarrhea stops when the offending agent (e.g., milk, sorbitol) is stopped.

EXUDATIVE

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 such as E. coli or other forms of food poisoning.

MOTILITY-RELATED

The rapid movement of food causes Motility-related diarrhea through the intestines (hypermotility). If the food moves too quickly through the gastrointestinal 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[citation needed]. 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 people who have had portions of their bowel removed, allowing less total time for absorption of nutrients.

INFLAMMATORY

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 a 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, which accounts for 40% of cases in children under five. In travelers, however, bacterial infections predominate. Various toxins such as mushroom poisoning and drugs can also cause acute diarrhea. Chronic diarrhea can be part of the presentation of a number of chronic medical conditions affecting the intestine. Common causes include ulcerative colitis, Crohn’s disease, microscopic colitis, celiac disease, irritable bowel syndrome, and bile acid malabsorption.

INFECTIONS

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 Salmonellae, Shigellae, and some Escherichia coli (E.coli) are frequent. In the elderly, particularly those 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 metronidazole and Entamoeba histolytica. Other infectious agents such as parasites and bacterial toxins also occur. Insanitary 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 fully, mostly from disorders in the small bowel and maldigestion from diseases of the pancreas. Causes include enzyme deficiencies or mucosal abnormality, as in food allergy and food intolerance, e.g., celiac disease (gluten intolerance), lactose intolerance (intolerance to milk sugar, common in non-Europeans), and fructose malabsorption. Pernicious anemia, or impaired bowel function due to the inability to absorb vitamin B12, loss of pancreatic secretions, which may be due to cystic fibrosis or pancreatitis, structural defects, like short bowel syndrome (surgically removed bowel), and radiation fibrosis, such as usually follows cancer treatment and other drugs, including agents used in chemotherapy; and certain medications, like orlistat, which inhibits the absorption of fat. Inflammatory bowel disease main article: 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 bowel segments 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 three days a week over the previous three months. Symptoms of diarrhea-predominant IBS can be managed through a combination of dietary changes, soluble fiber supplements, and medications such as loperamide or codeine. About 30% of patients with diarrhea-predominant IBS have bile acid malabsorption diagnosed with an abnormal SeHCAT test.

OTHER CAUSES

Diarrhea can be caused by chronic ethanol ingestion. Ischemic bowel disease. This usually affects older people and can be due to blocked arteries. Microscopic colitis is a type of inflammatory bowel disease where changes are only seen on colonic biopsies’ histological examination. Bile salt malabsorption (primary bile acid diarrhea), where excessive bile acids in the colon produce secretory diarrhea. Hormone-secreting tumors: some hormones (e.g., serotonin) can cause diarrhea if excreted in excess (usually from a tumor). Chronic mild diarrhea in infants and toddlers may occur with no obvious cause and with no other ill effects; this condition is called toddler’s diarrhea.

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 (Co-phenotrope, 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: In infants, Moderate or severe diarrhea in young children Associated with blood Continues for more than two days Associated non-cramping abdominal pain, fever, weight loss, etc. In travelers In food handlers, because of the potential to infect others; In institutions such as hospitals, child care centers, or senior and convalescent homes. A severity score is used to aid diagnosis in children.

PREVENTION

A rotavirus vaccine decreases the rates of diarrhea in a population. New vaccines against rotavirus, Shigella, ETEC, and cholera are under development and other causes of infectious diarrhea. Probiotics decrease the risk of diarrhea in those taking antibiotics. In institutions and communities, interventions that promote handwashing lead to significant reductions in diarrhea incidence.

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 does not affect diarrhea duration. Medications such as loperamide (Imodium) and bismuth subsalicylate may be beneficial; however, they may be contraindicated in certain situations.

FLUIDS

To prevent dehydration and electrolyte loss, it is widely recommended a person begin drinking Oral Rehydration Solution (ORS) as soon as possible. This strategy adds modest amounts of sugar and salt to the water. There are prepackaged ORS products available. A person can also use home products such as lightly salted soup and lightly salted water from rice cooking. Supplemental zinc and potassium are also helpful, but ORS should not be delayed if these are not immediately available. Oral Rehydration Solution (ORS) can be used to prevent dehydration and, in many cases, is quite literally a lifesaver. Standard home solutions such as salted rice water, salted yogurt drinks, vegetable and chicken soups with salt can be given. Home solutions such as water in which cereal has been cooked, unsalted soup, green coconut water, weak tea (unsweetened), and unsweetened fresh fruit juices can have half a teaspoon to a full teaspoon of salt (from one-and-a-half to three grams) added per liter. Clean plain water can also be one of several fluids given. There are commercial solutions such as Pedialyte, and relief agencies such as UNICEF widely distribute packets of salts and sugar. A WHO publication for physicians recommends a homemade ORS consisting of one liter of water with one teaspoon salt (3 grams) and two tablespoons of sugar (18 grams) added (approximately the taste of tears). Rehydration Project recommends adding the same amount of sugar but only one-half a teaspoon of salt, stating that this more dilute approach is less risky with very little loss of effectiveness. Both agree that drinks with too much sugar or salt can make dehydration worse. Appropriate amounts of supplemental zinc and potassium should be added if available. But the availability of these should not delay rehydration. As WHO points out, the most important thing is to begin preventing dehydration as early as possible. In another example of prompt ORS hopefully preventing dehydration, CDC recommends for the treatment of cholera to give Oral Rehydration Solution during travel to medical treatment. Vomiting often occurs during the first hour or two of treatment with ORS, especially if a child drinks the solution too quickly, but this seldom prevents successful rehydration since most of the fluid is still absorbed. WHO recommends that if a child vomits, wait five or ten minutes and then start to give the solution again more slowly. WHO recommends a child with diarrhea continue to be fed. Continued feeding speeds the recovery of normal intestinal function.

In contrast, children whose food is restricted have diarrhea of a longer duration and recover intestinal function more slowly. A child should also continue to be breastfed. In the example of cholera treatment, CDC also recommends that persons continue to eat and children continue to be breastfed.

ANTIBIOTICS

While antibiotics are beneficial in certain acute diarrhea types, they are usually not used except in specific situations. There are concerns that antibiotics may increase the risk of a hemolytic uremic syndrome in people infected with Escherichia coli O157:H7. In resource-poor countries, treatment with antibiotics may be beneficial. However, some bacteria are developing antibiotic resistance, particularly Shigella. Antibiotics can also cause diarrhea, and antibiotic-associated diarrhea is the most common adverse effect of treating general antibiotics.

BISMUTH COMPOUNDS

While bismuth compounds (Pepto-Bismol) decreased the number of bowel movements in travelers’ diarrhea, they do not decrease the length of illness. These agents should only be used if bloody diarrhea is not present.

ANIT MOTILITY AGENTS

Anti motility agents like loperamide are effective at reducing the duration of diarrhea. Codeine is used to treat diarrhea to slow down peristalsis and the passage of fecal material through the bowels – this means that more time is given for water to reabsorb back into the body a firmer stool, and also means that feces is passed less frequently.

BILE ACID SEQUESTRANTS

Bile acid sequestrants such as cholestyramine, colestipol, and colesevelam can effectively manage chronic diarrhea due to bile acid malabsorption. Therapeutic trials of these drugs are indicated in chronic diarrhea if bile acid malabsorption cannot be diagnosed with a specific test, such as SeHCAT retention.

ALTERNATIVE THERAPIES

Zinc supplementation benefits children suffering from diarrhea in developing countries, but only in infants over six months old. This supports the World Health Organisation guidelines for zinc, but not in the very young. Probiotics reduce the duration of symptoms by one day and reduced the chances of symptoms lasting longer than four days by 60%. The probiotic lactobacillus can help prevent antibiotic-associated diarrhea in adults but possibly not children. For those with lactose intolerance, taking digestive enzymes containing lactase when consuming dairy products is recommended.

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.

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