Diarrhea is defined as the frequent passage of watery, loose stools, or passing more than three liquid bowel movements daily. Diarrhea occurs when not enough water is removed from the stool, making the stool loose and poorly-formed. Normally, stool is 60-90% water; diarrhea usually occurs when the percentage exceeds 90%.
is best defined as an abnormal looseness of the stool, and may include changes in stool frequency, consistency, urgency and continence, often with the related symptoms of cramping
. The symptom of diarrhea, however, is to a large extent subjective; people define it based on their own experience. Diarrhea becomes a problem when the change in bowel habits becomes annoying or distressing to the individual, or when it is associated with or causes a change in the person's well-being.Acute Diarrhea
Acute diarrhea is defined as the passage of a greater number of stools of looser form than is customary, with a duration lasting no longer than 2 weeks, often with discomfort from associated gas, cramping and bloating. Severity of diarrhea may be defined as mild (no changes in activities required by the patient), moderate (change in activities required but the person is able to function), or severe (patient is disabled, often confined to bed or room). The incidence of acute diarrhea in the United States is approximately one episode per person per year, making it one of the most common medical disorders seen by primary care practitioners.Chronic Diarrhea
Chronic diarrhea, especially if associated with abdominal pain
or systemic symptoms, can limit activity, adversely influence quality of life, and pose diagnostic and management challenges to health care providers. Chronic diarrhea is defined as an increased stool frequency and fluidity (looseness) lasting more than two weeks. It should be distinguished from other conditions such as incontinence
, which is involuntary defecation. Careful history and physical examination can determine the likely cause of most chronic diarrhea and direct subsequent diagnostic evaluation and treatment. One approach to the problem is to determine whether diarrheal stools are bloody, fatty or watery.
Incidence; Causes and Development
In the United States, acute diarrhea
is the second most commonly reported illness after respiratory infections. Worldwide, diarrhea is the leading cause of death in children under four years of age.Diarrhea
is classified into four categories: osmotic, secretory, exudative, or rapid intestinal transit diarrhea.
Stool may contain too much water if it travels too quickly through the digestive tract, if certain components of the stool prevent the large intestine from absorbing water, or if water is being secreted by the large intestine into the stool. There are many different causes, including drugs and chemicals; infection with viruses, bacteria
, or parasites
; certain foods; stress; tumors
; and chronic disorders such as irritable bowel syndrome
bowel disease, and malabsorption
syndromes.Causes of Acute Diarrhea:
The volume of the diarrhea may help to localize the disease process within the GI tract
. Frequent, small-volume bowel movements typically are associated with diseases of the left colon
or rectum, and watery large-volume diarrhea suggest disorders of the small bowel
or proximal colon. Urgency and cramping
typically indicates inflammation
in the rectum. Nocturnal diarrhea may be seen in infectious colitis
or severe inflammatory bowel disease, and is not a feature of irritable bowel syndrome.
It is important to investigate medication use; acute diarrhea is a common side-effect of a "new" medicine or one containing magnesium
. Antibiotic-associated diarrhea is frequent, whether as a result of the medication itself or secondary to the production of a toxin by Clostridium difficile
. The use of alcohol or illicit drugs (particularly methamphetamine) is another factor.
The intake of coffee, tea or colas may lead to caffeine- or methylxanthine-induced diarrhea. Dietetic foods, gums or mints may contain poorly-absorbed sugars such as sorbitol or mannitol which cause osmotic diarrhea.
"Traveler's diarrhea", usually caused by enterotoxigenic Escherichia coli
, is very common, particularly in travelers to developing portions of the world, such as Mexico, the Mid-East and India. Some more unusual infections are suggested by the site of the recent travel. For example, camping in the mountains (and drinking untreated water) raises concern for Giardia lamblia
infection. With increased international and adventure travel have come more exotic pathogens that need to be considered. Infection with Cyclospora cayetanensis
or Cryptosporidium parvum
from travel to Nepal or St. Petersburg (Leningrad) respectively, are illustrative.
Living in proximity to farm animals, or visiting petting zoos may lead to exposure to Salmonella
, Brucella, or Cryptosporidia. Eating contaminated foods such as ground beef may expose a person to Escherichia coli
O157:H7, a cause of bloody diarrhea. Campylobacter infection may result from eating undercooked chicken or turkey. Health care workers are at increased risk for nosocomial infections (e.g. Clostridium difficile
). Sexual orientation and practices may yield clues as to the etiology of diarrhea. Anal intercourse is a risk factor for proctitis
, caused by Entamoeba histolytica
, Treponema pallidum
), Neisseria gonorrhoeae
or Herpes simplex
in addition to more common bacterial
pathogens. With the AIDS
pandemic, one needs to be alert for opportunistic infections that may present as acute diarrheal illness.Causes of Chronic Diarrhea
The most likely cause of chronic bloody diarrhea is inflammatory bowel disease (IBD), i.e. ulcerative colitis
or Crohn's disease
. Symptoms of tenesmus
or incomplete evacuation suggest rectal inflammation. A palpable abdominal
mass or tenderness, perianal fistulae, oral aphthous ulcers
, sacroiliac, spinal or peripheral arthropathy, or skin changes (erythema nodosum
or pyoderma gangrenosum
) all suggest a diagnosis of inflammatory bowel disease.
Less common causes of chronic bloody diarrhea include ischemia
, infections (Campylobacter jejuni
, Clostridium difficile
, Entamoeba histolytica
, Yersinia and Cytomegalovirus
), radiation or chemotherapy
, and colon cancer or polyps
Irritable bowel syndrome (IBS
) is the reason patients most commonly seek attention for chronic watery diarrhea. It is important to distinguish IBS from other conditions that cause chronic diarrhea, since in most persons with IBS, the problem is frequent defecation rather than voluminous diarrhea. Abdominal pain
is the key symptom of IBS, and frequent stools often contain mucus and are accompanied by or preceded by abdominal cramps
, and abdominal pain is the key symptom of IBS. Periods of loose stools can be interspersed with periods of constipation
. IBS symptoms may worsen during times of emotional or physiologic stress. Those with especially severe symptoms and persistent lower abdominal pain may have been physically or sexually abused in the past. While a diagnosis of "non-disease" is often difficult to make, irritable bowel syndrome
is thought to be a functional disorder (dysmotility) since no anatomic or organic intestinal problems are found to explain the symptoms.
Maldigestion or malabsorption
of fat can lead to chronic diarrhea
. Fatty stools typically are bulky, greasy, and particularly malodorous. They may float because of excess gas content resulting from bacterial
fermentation of unabsorbed dietary material. Individuals with maldigestion often are not systemically ill and can maintain their weight and activity in spite of massive steatorrhea
because of a voracious appetite. The most frequent cause of maldigestion is pancreatic
insufficiency caused by chronic pancreatitis
. Those with suspected maldigestion should be asked about alcohol abuse, the most common cause of chronic pancreatitis in the United States. Severe or recurrent abdominal pain
, profound weight loss, abdominal
trauma or a positive family history may suggest less common causes of pancreatic insufficiency such as traumatic or hereditary pancreatitis, cystic fibrosis
, congenital structural pancreatic abnormalities (pancreas
divisum) or pancreatic cancer. Bile
salt deficiency due to biliary tract obstruction, cholestatic liver
overgrowth or excessive stool losses (IBD, terminal ileal resection) also can lead to maldigestion but usually this is not associated with significant steatorrhea
mucosal disease or surgical resection (e.g., for Crohn's disease
or bowel infarction) leads to malabsorption
of fats as well as carbohydrates
, proteins, vitamins and minerals, all of which can result in weight loss and various systemic signs and symptoms. Gluten-sensitive enteropathy (celiac
sprue) is the most common mucosal cause of malabsorption in the United States. Individuals with sprue are likely to have a positive family history, history of diabetes
or skin lesions
herpetiformis) and have manifestations of panmalabsorption dating back to childhood or adolescence. Short stature, weakness due to multifactorial anemia
, folate and occasional vitamin B12
deficiency), bone pain and spontaneous fractures from vitamin D
and calcium malabsorption
and bleeding related to vitamin K
deficiency, gas and bloating
due to carbohydrate
malabsorption, and edema
from albumin and protein loss are typical complaints of those with sprue and other small bowel
mucosal diseases. Whipple's disease, tropical sprue, and Zollinger-Ellison syndrome are less common mucosal conditions leading to malabsorption.
Many disorders can cause chronic watery diarrhea
including carbohydrate malabsorption (lactose intolerance
, sorbitol, fructose), intestinal infections or inflammation
, unusual hormone-secreting tumors
, and irritable bowel syndrome
. Careful medication history is important since such medications as NSAIDs
, elixirs (containing sorbitol and fructose), antihypertensives, cholinergic agents, antibiotics, and antiarrhythmics all can cause diarrhea
in some individuals. Most commonly, carbohydrate malabsorption
induces an osmotic diarrhea accompanied by abdominal bloating
that is associated with meals. Such osmotic diarrhea typically abates during periods of fasting. Lactase
deficiency, either ethnically acquired (more common in Asian-Americans, African- Americans) or secondary to acute infectious enteritis
can lead to diarrhea following ingestion of milk, cheese, ice cream and other dairy products. Less commonly recognized causes of diarrhea due to carbohydrate malabsorption
include ingestion of sorbitol and fructose found in certain soft drinks, juices, dried fruits, and "sugar-free" gum or candy. A history of any relation of diarrhea to foods is important to obtain, particularly in children who seem to be more sensitive to ingested sorbitol and fructose and in older adults who may have chronic mesenteric ischemia
can produce chronic symptoms, as can some opportunistic infections (e.g., microsporidiosis, cryptosporidiosis, infection with MAI or CMV
) in immunosuppressed individuals. Epidemics of chronic diarrhea have occurred following ingestion of unpasteurized milk (Brainerd's diarrhea) but no infectious agent has been isolated in such cases. In some individuals, diarrhea may persist for months following apparent acute infectious enteritis
, presumably due to secondary carbohydrate malabsorption
or dysmotility from intestinal neuromuscular injury. An unusual condition, microscopic colitis
, can cause chronic persistent watery diarrhea in middle-aged or older individuals. While the cause of microscopic colitis is unknown, it has been linked to gluten-sensitive enteropathy, diabetes
, and NSAID
use, and can, in some individuals, cause nocturnal stooling and fecal incontinence
Diabetes presumably causes chronic watery diarrhea as a result of intestinal neuropathy
overgrowth, or both. Diabetic
diarrhea can occur at night, be interspersed with periods of constipation
, and be associated with fecal incontinence. Individuals with diabetic diarrhea usually have severe long-standing glucose
intolerance associated with other diabetic complications such as retinopathy
, nephropathy and neuropathy.
Several unusual hormone-producing neoplasms can cause watery diarrhea. These include carcinoid tumors
and tumors producing vasoactive intestinal polypeptide and glucagon. Large volume and frequent watery stools that persist during fasting and that are associated with severe fluid and electrolyte
abnormalities and dehydration characterize these endocrine neoplasms. Family history of multiple endocrine neoplastic syndrome; a history of severe ulcer
disease (Zollinger-Ellison syndrome); episodic hypotension
, vasomotor flushing, or valvular cardiac
disease (carcinoid syndrome); or the presence of a scaling, erythematous dermatitis
(necrolytic migratory erythema in a patient with a glucagonoma) may offer clues to the diagnosis.
Signs and SymptomsDiarrhea
is often associated with gas, cramping
, an urgency to defecate, and, if the diarrhea is caused by an infectious organism or a toxic substance, nausea
Diagnosis and Tests
No firm conclusions can be drawn from the symptoms or the severity of the illness as to its likely cause. Where the cause of chronic diarrhea
remains a mystery, lab testing will generally provide answers.Laboratory Testing for Acute Diarrhea:
In patients with mild, acute diarrhea, no immediate laboratory evaluation is needed as the results often will become available only after symptoms have subsided. Laboratory evaluation should be restricted to patients with severe diarrhea or when illness is complicated by the presence of dysentery
or fever, or when the duration of illness becomes protracted. Stool cultures are not routinely indicated. They should be performed in patients with severe diarrhea and fever, dysentery, fecal leukocytes
or a prolonged (greater than 14 days) diarrheal illness.
Examination of stool for ova and parasites
is indicated in patients with prolonged diarrhea, or who have particular circumstances (e.g., travel, occupation, immunocompromised status) that make them susceptible to parasitic
infestation. When parasites are suspected, obtaining three fresh stool samples for immediate examination will provide optimal yield.Laboratory Testing for Chronic Diarrhea
The purposes of basic laboratory tests are a) to assess the impact of chronic diarrhea on the patient's overall nutritional and electrolyte
status, and b) to form a preliminary judgment about the characteristics of the diarrhea. A complete blood count
should be obtained to look for evidence of anemia
or an abnormal white blood cell
count. Biochemical screening should include serum electrolytes
, tests of renal
function (blood urea nitrogen and creatinine) and a basic nutritional assessment, consisting of a lymphocyte
count and measurements of serum calcium
, total protein and albumin levels.
The type of diarrhea
can be defined by evaluation of a random (spot) stool sample. The spot stool sample can be assessed for blood by means of a stool guaiac test (e.g. Hemoccult slide). The presence of blood suggests an inflammatory
or neoplastic cause for the diarrhea, but occult blood
also can be seen in celiac disease
and other sprue-like syndromes. The presence of pus
in the stool indicates an inflammatory cause of diarrhea. This can be assessed by staining a stool smear with Wright's stain and looking for white blood cells
. A latex agglutination test for the neutrophil
enzyme, lactoferrin, is of proven value for detecting neutrophils
in acute infectious diarrheas and in pseudomembranous colitis
. Its value in chronic diarrhea has not yet been assessed.
Diarrhea that contains neither blood, pus
, nor fat is categorized as being watery diarrhea. This usually indicates a problem with the intestinal absorption of salt and water, and can be due to secretory states or to osmotic diarrheas.Ultrasound
examination and abdominal
CT scan have a limited role in the evaluation of chronic diarrhea. Endoscopy
usually is more specific than X-ray studies because it allows direct inspection of the mucosa
, detection of superficial lesions
, and the ability to biopsy
the mucosa. Upper endoscopy facilitates small bowel
mucosal biopsy, which is essential in establishing the diagnosis of proximal small bowel diseases, most commonly celiac
sprue, but also Whipple's disease and Crohn's disease
. In immunosuppressed patients, the diagnosis of parasitic
infestation, e.g. microsporidia, cryptosporidia, Isospora belli, as well as cytomegalovirus
infection can be made by small bowel biopsy. Giardia
lamblia can cause chronic diarrhea
and usually is detected in stool specimens. Occasionally, however, the organism is identified in a small bowel biopsy or by a string test. The latter examination utilizes a swallowed string to obtain a specimen of mucus from the duodenal
lumen, and the mucus is subsequently examined for the presence of the organism. This test is particularly helpful in evaluation of children in whom the risks and discomforts of endoscopy
may not be well tolerated.
A stool pH of less than 5.3 suggests carbohydrate malabsorption
because colonic bacteria
produce short-chain fatty acids
from malabsorbed carbohydrate. If stool pH is over 5.6, it is unlikely that carbohydrate malabsorption by itself explains the diarrhea
. Generalized malabsorption can produce stool pH over 5.3, however, because of buffering by other substances.
abuse continues to be an important and underappreciated cause of chronic diarrhea. Laxative screening includes tests for magnesium
, phosphate and sulfate in stool water or urine.
Several blood tests may be of value in evaluating the causes of diarrhea. Peptide hormone-secreting tumors
are extremely rare causes of diarrhea. In general, peptide hormone levels should not be measured in blood without good evidence for a classical syndrome associated with one of these tumors or identification of a tumor
by computerized tomography, since an abnormal serum peptide level is much more likely to be a false positive than a true positive. Carcinoid tumors that cause diarrhea can be discovered with the help of a 24-hour urine collection for 5- hydroxy indoleacetic acid. Other blood tests that can be of use include thyroid
stimulating hormone, anti-nuclear antibody
, anti-gliadin and anti-endomysial antibodies
for celiac disease
, perinuclear antineutrophil cytoplasmic
antibodies (p-ANCA) for IBD, HLA typing, quantitation of serum immunoglobulin levels, and serum antibodies against human immunodeficiency virus
and Entamoeba histolytica.
Physiologic tests of mucosal absorption and pancreatic
exocrine function help with the diagnosis of unusual cases of chronic diarrhea
. Proximal mucosal absorption can be assessed by the D-xylose test, and the Schilling test and several measurements of bile
can assess more distal small bowel
absorption. Breath hydrogen testing can be of help in evaluating lactase
deficiency and bacterial
overgrowth in the small intestine
. Intubation studies, such as the secretin test, remain the most reliable tests for pancreatic
exocrine function, but measurement of fecal chymotrypsin
concentration or the bentiromide test may be useful screening studies.Laboratory Findings
- Culture of stool yielding Salmonella, Shigella, Yersinia, or Campylobacter.
- Neutrophils in stool – ulcerative colitis, amebiasis, pseudomembranous colitis, enteritis due to Shigella, Campylobacter, Salmonella.
- Presence in stool of Entamoeba histolytica or Giardia lamblia.
- Increased haemoglobin, haematocrit, and BUN reflect haemoconcentration due to loss of fluid and electrolytes in stool.
- Decreased urine sodium and volume due to marked fluid and electrolyte loss in stool.
- Decreased pH and C02 content (metabolic acidosis) due to intestinal loss of bicarbonate; less commonly, metabolic alkalosis occurs as a result of loss of fluid, acid, potassium, and chloride in the stool. This occurs with congenital acid diarrhoea and with villous adenoma.
- Increased stool fat due to malabsorption or maldigestion.
- Biopsy of small – or large – intestinal mucosa may show diagnostic pathologic changes.
Treatment and Prevention
Most episodes of acute diarrhea
are managed by the affected person or by a family member with dietary modifications or with the use of available over-the-counter medications – some can assist in reducing frequency of stools, others address symptoms of gas or bloating
and newer combined formulations can do both.Conventional Treatment of Acute Diarrhea
Fluid repletion through oral replacement solutions is important even for the majority of patients who have mild diarrhea. The World Health Organization solution as well as commercially-available preparations can be given both for rehydration and maintenance fluid requirements. These solutions are preferable to dilute fruit juices, non-carbonated soft drinks, or tea with sugar. Dietary modifications also may be helpful to the patient with mild, acute diarrhea. Milk and dairy products should be withheld for 24-48 hours, and initial refeeding may begin with cereals, starches, soups and broth.
Therapy with antidiarrheal medications is indicated for relief of the debilitating symptoms that accompany many diarrheal illnesses. Most patients can take antidiarrheal medications safely to improve their symptoms, although care must be taken not to administer antimotility agents to patients in whom toxin-producing or invasive bacteria
Attapulgite binds water, as a result of which stools are better formed. Attapulgite and kaolin are believed to work also by adsorbing the causative agent (bacteria or germs) and removing it from the body. It is recognized as one of the safer antidiarrheal therapies because it exerts its effect only within the bowel lumen. Another agent, bismuth subsalicylate exerts its effect both through its antisecretory salicylate moiety and possibly also by its antimicrobial
activity; it improves the symptoms of nausea
and vomiting that are associated with gastroenteritis
. Since bismuth subsalicylate contains non-aspirin salicylate, care must be taken when it is used in patients taking medication for anticoagulation, diabetes
Most of the commonly-employed antidiarrheal medications are antimotility agents that act by slowing intestinal motility
, thereby increasing intraluminal fluid time and allowing for greater intestinal fluid absorption. One of the most widely-used and easily-tolerated of these medications is loperamide. Caution must be taken when considering administration of an antimotility antidiarrheal agent in a patient with high fever or dysentery
as these medications may lead to a worsening of infectious diarrhea
due to bowel stasis and increased bowel wall penetration by invasive pathogens (e.g. Shigella). The use of agents such as loperamide in acute diarrhea, and particularly in traveler's diarrhea, is usually safe in the absence of bloody diarrhea or high fever. Patients with diarrhea often have associated symptoms of nausea
, and combination therapy with loperamide and simethicone is now available. Novel antisecretory compounds, which improve diarrhea through more physiologic mechanisms than do currently-available agents, are in development and may become an important part of therapy in the future.
Patients in whom the use of antibiotics may be useful include those who have criteria of severe illness: high fever, signs of systemic toxicity, dysentery
or moderate to severe "traveler's diarrhea". In general, the drug of choice is a fluoroquinolone, given for one to three days. Specific therapy may be directed if stool cultures or other studies reveal a particular pathogen.
When diarrhea is more intense (for example, passage of more than 6 unformed stools per 24 hours, or associated with blood) or lasts longer than 48 hours, medical evaluation and treatment should be sought.Treatment of Chronic Diarrhea
When a specific diagnosis is made, specific treatment often can afford a cure of chronic diarrhea. Some experts recommend that patients should receive antibiotic therapy with metronidazole or antibiotics directed against enteric
pathogens before any evaluation of chronic diarrhea is started. For most patients who have been evaluated to some extent, several other options are recommended. These include use of opiate antidiarrheal drugs, the somatostatin analogue, octreotide, and intraluminal agents, such as clays, charcoal, bile
acid binding resins, bismuth compounds and fiber.
Antimotility agents and opiates are the most effective empiric therapy for diarrhea. They not only relieve symptoms of frequency and urgency, but also reduce stool weight. Many patients respond to diphenoxylate or loperamide, but patients who do not respond to these therapies should be not be denied more potent opiates, such as codeine, opium or morphine, for fear of addiction.
Complications; Seek medical attention if...
Patients with intense diarrhea
and large fluid and electrolyte
losses may develop dehydration that will need medical evaluation. Dehydrating illness is particularly problematic for the very young or very old.
A distended, rigid or tender abdomen
may indicate a potential medical emergency and a requirement for immediate, aggressive evaluation of its cause.