CASE 10

A 40-year-old man presents to the clinic complaining of having 10 episodes of watery,

nonbloody diarrhea that started last night. He vomited twice last night but has been able
to tolerate liquids today. He has had intermittent abdominal cramps as well. He reports
having muscle aches, weakness, headache, and low-grade temperature. He is here
with his daughter, who started with the same symptoms this morning. On questioning,
he states that he has no significant medical history, no surgeries, and does not take any
medications. He does not smoke cigarettes, drink alcohol, use any illicit drugs, and has
never had a blood transfusion. He and his family returned to the United States
yesterday, following a week-long vacation in Mexico.

On examination, he is not in acute distress. His blood pressure is 110/60 mm Hg, his
pulse is 98 beats/min, his respiratory rate is 16 breaths/min, and his temperature is
99.1°F (37.2°C). His mucous membranes are dry. His bowel sounds are hyperactive
and his abdomen is mildly tender throughout, but there is no rebound tenderness and
no guarding. A rectal examination is normal and his stool is guaiac negative. The
remainder of his examination is unremarkable.

What is the most likely diagnosis?

What is your next step?

What are potential complications?

ANSWERS TO CASE 10:

Acute Diarrhea
Summary: A 40-year-old man who recently returned from Mexico with profuse, acute,
nonbloody diarrhea, and dry mucous membranes on examination, which are consistent
with developing dehydration. An ill family member with identical symptoms suggests an
infectious cause of this acute illness.
Most likely diagnosis: Acute gastroenteritis
Next step: Fecal leukocyte or fecal lactoferrin testing; rehydration with oral or IV
fluids
Potential complication: Dehydration and electrolyte abnormalities

ANALYSIS
Objectives
1. To clearly understand when and how to do a workup for acute diarrhea,
considering the most probable etiologies of diarrhea such as virus, Escherichia
coli, Shigella, Salmonella, Giardia, and amebiasis.
2. To understand the role of fecal leukocytes and stool occult blood in the
evaluation of acute diarrhea.
3. To understand that volume replacement and correction of electrolyte
abnormalities are a key component in the treatment and prevention of diarrhea
complications.

Considerations
This 40-year-old man developed severe diarrhea, nausea, and vomiting. His most
immediate problem is volume depletion, as evidenced by his dry mucous
membranes. The priority is to replace the lost intravascular volume, usually with
intravenous normal saline. Electrolytes and renal function should be evaluated and
abnormalities corrected. While correcting and/or preventing further dehydration, you
need to determine the etiology of the diarrhea. Up to 90% of acute diarrhea is
infectious in etiology. He does not have any history compatible with chronic diarrhea,
causes of which include Crohn disease, ulcerative colitis, gluten intolerance, irritable
bowel syndrome, and parasites. He had been in Mexico recently, which predisposes
him to different pathogens: E coli, Campylobacter, Shigella, Salmonella, and Giardia.
Bacterial infections are more likely to be the source of acute diarrhea in individuals who
have recently traveled, ingested contaminated food, or have other medical conditions.
He does not have bloody stools. The presence of blood in the stool would suggest
an invasive bacterial infection, such as hemorrhagic or enteroinvasive E coli species,
Yersinia species, Shigella, and Entamoeba histolytica.
Examination of the stool for leukocytes is an inexpensive test that helps to
differentiate between the types of infectious diarrhea. If leukocytes are present in the
stool, the suspicion is higher for Salmonella, Shigella, Yersinia, enterohemorrhagic and
enteroinvasive E coli, Clostridium difficile, Campylobacter, and E histolytica. Fecal
lactoferrin immunoassay testing kits have increased in popularity due to their ease of
use and faster results compared to fecal leukocytes. Lactoferrin is an iron-binding
protein that is found in polymorphonuclear neutrophils (PMN) and bodily secretions
such as breast milk. Gastrointestinal inflammation causes immune activated PMNs to
release lactoferrin. Lactoferrin elevations in stool can be seen with irritable bowel
syndrome, intestinal bacterial infections, parasitic infections, and other conditions.
Lactoferrin will be low in viral infections, making it a useful test for distinguishing viral
from bacterial diarrhea. In general, ova and parasite evaluation is unhelpful, unless the
history strongly points toward a parasitic source or the diarrhea is prolonged. The
majority of the diarrheas are viral, self-limited, and do not need further evaluation. In this
particular patient, because of his recent travel to Mexico, traveler’s diarrhea (TD) should
be strongly considered and treated with the appropriate antibiotic.

APPROACH TO:
Acute Diarrhea

DEFINITIONS
ACUTE DIARRHEA: Diarrhea presents for fewer than 2-week duration
CHRONIC DIARRHEA: Diarrhea presents for longer than 4-week duration
DIARRHEA: Passage of abnormally liquid or poorly formed stool in increased frequency
(three or more times a day)
SUBACUTE DIARRHEA: Diarrhea presents for 2- to 4-week duration

CLINICAL APPROACH
Etiologies
Approximately 90% of acute diarrhea is caused by infectious etiologies, with the
remainder caused by medications, ischemia, and toxins. Infectious etiologies often
depend on the patient population. Travelers to Mexico will frequently contract
enterotoxigenic E coli as a causative agent. Traveler’s diarrhea is a common entity
and can be induced by a variety of bacteria, viruses, and parasites (Table 10–1).
Campers are often affected by Giardia. Contaminated food and water supplies account
for the high incidence of diarrhea in developing countries.

Table 10–1 • COMMON ETIOLOGIES OF TRAVELER’S DIARRHEA

 Consumption of foods is also frequently a culprit. Salmonella or Shigella can be
found in undercooked chicken, enterohemorrhagic E coli from undercooked
hamburger, and Staphylococcus aureus or Salmonella from creamy foods. Raw
seafood may harbor Vibrio, Salmonella, or hepatitis A. Sometimes, the timing of the
diarrhea following food ingestion is helpful. For example, illness within 6 hours of
eating a salad containing mayonnaise suggests S aureus, within 8 to 12 hours
suggests Clostridium perfringens, and within 12 to 14 hours suggests E coli.
Daycare settings are particularly common for Shigella, Giardia, and rotavirus to be
transmitted. Patients in nursing homes, or who were recently in the hospital, may
develop C difficile colitis from antibiotic use. Consuming cold meats, raw milk, and soft
cheeses increases the risk of listeriosis. Pregnant women are advised to avoid foods
associated with listeriosis because they are at a significantly higher risk of infection.
Immunocompromised patients (AIDS) are more susceptible to parasitic gastrointestinal
infections.

Clinical Presentation
Most patients with acute diarrhea have self-limited processes and do not require
much workup. Exceptions to this rule include profuse diarrhea, dehydration, fever
exceeding 100.4°F (38.0°C), bloody diarrhea, severe abdominal pain, duration of the
diarrhea for more than 48 hours, and children, elderly patients, and
immunocompromised patients. Traveler’s diarrhea is characterized by more than three
loose stools in a 24-hour period accompanied by abdominal cramping, nausea,
vomiting, fever, or tenesmus. Most cases occur within the first 2 weeks of travel.
Past and recent medical history should include exposures to medications and foods,
travel history, and coworkers, classmates, or family members with similar symptoms. A
history of a viral illness may provide a clue to the etiology. The initial evaluation should
determine if the patient can tolerate oral intake. The patient who is both vomiting and
having diarrhea is more prone to dehydration and more likely to need hospital
admission for IV hydration.
The physical examination should focus on the vital signs, clinical impression of the
volume status, and abdominal examination. Volume status is determined by observing
whether the mucous membranes are moist or dry, the skin has good turgor, and the
capillary refill is normal or delayed. Stool cultures have limited benefit due to high cost
and inefficient results. The use of stool cultures should be limited to individuals with
bloody diarrhea, diarrhea lasting for more than 3 to 7 days, immunocompromised
patients, and evidence of systemic disease or severe dehydration. Ova and parasite
evaluation is generally unhelpful, except in selected circumstances of very high
suspicion. Testing for C difficile toxins A and B is recommended in patients who develop
diarrhea within 3 days of hospitalization, during antibiotic treatment, or within 3 months
of discontinuing antibiotics. Although classically associated with clindamycin, any
antibiotic can cause pseudomembranous colitis. A complete blood count,
electrolytes, and renal function tests are sometimes indicated.

Treatment
Most cases of diarrhea resolve spontaneously in a few days without treatment.
Replacement of fluids and electrolytes is the first step in treating the consequences of
acute diarrhea. For mildly dehydrated individuals who can tolerate oral fluids, solutions
such as the World Health Organization oral rehydration solution or commercially
available drinks, such as Pedialyte or Gatorade, often are all that is needed. It is no
longer recommended that patients avoid eating solid foods for 24 hours. Increased
intestinal permeability caused by gastrointestinal infections can be limited by early
refeeding. Those with more serious volume deficits, elderly patients, and infants
generally require hospitalization and intravenous hydration.
If a parasitic infection is the cause of the diarrhea, prescription antibiotics may ease
the symptoms. Antibiotics sometimes, but not always, help ease symptoms of bacterial
diarrhea. However, antibiotics will not help viral diarrhea, which is the most common
kind of infectious diarrhea. Over-the-counter antimotility or antisecretory medications
may help to slow down the frequency of the stools, but they do not speed the recovery.
Certain infections may be made worse by over-the-counter medications because they
prevent your body from getting rid of the organism that is causing the diarrhea.
Probiotics, supplements that contain live organisms such as Lactobacillus sp or
Saccharomyces Boulardii, may reduce the incidence of antibiotic-related diarrhea and
the duration/severity of all-cause infectious diarrhea (Level A recommendation). Zinc
supplementation has shown promising results for decreasing the duration and severity
of the diarrheal illnesses in children. Better relief of acute diarrhea with excessive gas
may be possible with combined loperamide and simethicone compared to either
medication alone.

Prevention
Hand washing is a simple and effective way to prevent the spread of viral
diarrhea. Adults, children, and clinic and hospital personnel should be encouraged to
wash their hands. Because viral diarrhea spreads easily, children with diarrhea should
not attend school or child care until their illness has resolved.
To prevent diarrhea caused by contaminated food, use dairy products that have been
pasteurized. Serve food immediately or refrigerate it after it has been cooked. Do not
leave food out at room temperature because it promotes the growth of bacteria.
Travelers to locations, such as developing countries, where there is poor sanitation
and frequent contamination of food and water, need to be cautious to reduce their risk
of developing diarrhea. They should be advised to eat hot and well-cooked foods, and
to drink bottled water, soda, wine, or beer served in its original container. Avoid drinks
served over ice. Beverages from boiled water, such as coffee and tea, are usually safe.
Recommend the use of bottled water even for teeth brushing. Also recommend avoiding
raw fruits and vegetables unless they are peeled by the consumer immediately before
being eaten. Patients should avoid tap water and ice cubes. In all, these
recommendations may reduce but not completely eliminate one’s risk of developing
traveler’s diarrhea.

Traveler’s Prophylaxis and Treatment

The best method for preventing TD is to avoid contaminated food and water.
Antibiotic prophylaxis is not indicated unless the patient is at increased risk for
complications from diarrhea or dehydration, such as underlying inflammatory bowel
disease, renal disease, or an immunocompromised state. Fluoroquinolones are typically
used for prophylaxis. Studies have shown that the antibacterial and antisecretory effects
of bismuth subsalicylate decrease the incidence of traveler’s diarrhea. Bismuth
subsalicylate should be avoided in persons allergic to aspirin, pregnant women, or those
taking methotrexate, probenecid, or doxycycline for malaria prophylaxis.
When antibiotics are indicated, therapy with a quinolone antibiotic should be started
as soon as possible after the diarrhea begins. Most commonly, ciprofloxacin (500 mg
twice daily) is given for 3 days. Quinolones cannot be used in children or pregnant
women. Azithromycin, given as a single 1000-mg dose in adults or 10 mg/kg daily for 3
days in children, is another effective drug for the treatment of TD. Azithromycin also can
be used in pregnant women with traveler’s diarrhea. Rifaximin given as 200 mg three
times a day for 3 days can be used in TD caused by noninvasive strains of E coli.
However, rifaximin is not effective against infections associated with fever or blood in
the stool. Rifaximin is safe for use in children under the age of 12. Trimethoprim-
sulfamethoxazole, doxycycline, and ampicillin were popular drugs used in the past to
treat TD, but increased resistance now limits their use. The evidence is insufficient
regarding the efficacy of probiotics as prophylaxis for TD.

COMPREHENSION QUESTIONS

10.1 Several friends develop vomiting and diarrhea 6 hours after eating food at a
private party. Which of the following is the most likely etiology of the
symptoms?
A. Rotavirus
B. Giardia
C. E coli
D. S aureus
E. Cryptosporidium
10.2 A 40-year-old man travels to Mexico and develops diarrhea 1 day after
coming back to the United States. Which of the following is the most likely
etiology of the symptoms?
A. Rotavirus
B. Giardia
 C. E coli
D. S aureus
E. Cryptosporidium
10.3 A young woman eats raw seafood and 2 days later develops fever,
abdominal cramping, and watery diarrhea. Which of the following is the most
likely etiology of the symptoms?
A. Rotavirus
B. Giardia
C. E coli
D. S aureus
E. Vibrio
10.4 During the winter, a young daycare worker develops watery diarrhea.
Which of the following is the most likely etiology of the symptoms?
A. Rotavirus
B. Giardia
C. E coli
D. S aureus
E. Cryptosporidium
10.5 A 45-year-old man presents with 3 days of watery diarrhea and abdominal
cramping. He has no sick contacts and has not traveled recently. He is not
currently taking any medications, but he was prescribed amoxicillin 2 weeks
ago for a sinus infection. Which of the following tests is most likely to identify
the cause of his diarrhea?
A. Stool guaiac
B. Evaluation of stool for fecal leukocytes
C. Evaluation of stool for ova and parasites
D. C difficile toxin immunoassay
10.6 In the patient described in question 10.5, which of the following is the
treatment of choice for his diarrhea?
A. Ciprofloxacin
B. Azithromycin
C. Metronidazole
D. Loperamide

ANSWERS

10.1 D. S aureus toxin usually causes vomiting and diarrhea within a few hours
of food ingestion.
 10.2 C. E coli is the most common etiology for traveler’s diarrhea.
10.3 E. Vibrio is a common cause of diarrhea among people who eat raw
seafood.
10.4 A. Rotavirus is a common etiology for watery diarrhea, especially in the
winter.
10.5 D. Although any antibiotic can cause C difficile colitis, clindamycin,
cephalosporins, and penicillins are the most commonly implicated.
10.6 C. Metronidazole or oral vancomycin can be used to treat C difficile.
Ciprofloxacin and azithromycin can be used for treatment of traveler’s
diarrhea. Loperamide can decrease the frequency of bowel movements but
is contraindicated in any patient with suspected C difficile colitis.

CLINICAL PEARLS
Most acute diarrheas are self-limited.

Be cautious when assessing diarrhea in a child, elderly patient, or

immunosuppressed host.

Dehydration, bloody diarrhea, high fever, and diarrhea that do not respond to therapy
after 48 hours are warning signs of possible complicated diarrhea.

In general, acute, uncomplicated diarrhea can be treated with oral electrolyte and
fluid replacement.

REFERENCES
Barr W, Smith A. Acute diarrhea in adults. Am Fam Physician. 2014;89(3):180-189.
Centers for Disease Control and Prevention. Travelers’ health—2014 Yellow Book. Available
at: http://wwwnc.cdc.gov/travel/page/yellowbook-home. Accessed May 24, 2015.
Kligler B, Cohrssen A. Probiotics. Am Fam Physician. 2008;18(9):1073-1078.
LaRocque RC, Ryan ET, Calderwood SB. Acute infectious diarrheal diseases and bacterial
food poisoning. In: Kasper D, Fauci A, Hauser S, et al, eds. Harrison’s Principles of
Internal Medicine. 19th ed. New York, NY: McGraw-Hill Education; 2015. Available at:
http://accessmedicine.mhmedical.com/content.aspx?bookid=1130&sectionid=79734063.
Accessed May 24, 2015.
Yates J. Traveler’s diarrhea. Am Fam Physician. 2005;71:2095-2100, 2107-2108.