Acute diarrhea in (inflammatory, non-inflammatory, food poising)
SOEPEL Session 3
Internal Medicine Clinical Rotation
A 77 year-old male presented to the Emergency Department with complaints
of two days of copious watery diarrhea. He denied abdominal pain or
cramping, nausea, fever, and blood or mucus in the stool.
The patient had a recent travel history including one week of boating in the
Chesapeake Bay During the boat trip the patient and other travelers
consumed raw oysters. Approximately 24 hours after returning from the
trip, the patient developed symptoms.
RR: 16 /minute.
BP: 132/80 mmHg.
Mucous membranes were tacky.
His abdomen was soft and non- tender, and without rebound, guarding, or
DDx: traveler diarrhea, food poisoning, infectious diarrhea (bacterial).
WBC: 9.1x 10^9 / L with a slight left shift of 83% neutrophils.
+ive for occult blood
- ive for Clostridium difficile toxin and ova and parasites
Moderate white blood cells were present
Relieve the symptoms.
Causes of this presentation.
Proper treatment strategy for this situation.
Increase in the stool weight to >250g/d, accompanied by increase
frequency and liquidity of stool.
Sudden onset of frequency with cramp pains, and a fever =
bowel frequency with loose blood-stained stools =
passage of pale offensive stools that float, often accompanied
by loss of appetite and weight loss, to steatorrhoea. Nocturnal
bowel frequency and urgency usually = organic cause.
Passage of frequent small-volume stools (often formed) =
A- Acute infectious Diarrhea
- <2 weeks.
- It may result from:
Organic substance (mushrooms, shellfish).
Drugs and infectious agents.
1- Inflammatory or
B- Chronic Diarrhea
- >2 weeks
- Divided into 6categories
Motility disorders diarrhea
Suggest involvement of large intestine by
Clinical pt. present presentation:
o Frequent bloody, small volume stools.
o often +fever, +abdominal cramps, + tenesmus and fecal
Infectious agent invades the intestinal
acute inflammation of the
Organisms produced Invasive intestinal
Milder disease caused by:
Affect small intestine and interfere salt and
water balance resulting in:
Large volume watery diarrhea.
Often +nausea, +vomiting and cramps.
A- enterotoxin- mediated diarrhea:
Does not invade the intestinal mucosa and its effect
mediated by its enterotoxins (exotoxin).
No inflammation of intestinal mucosa.
B- Non-Invasive organisms:
The organism exists in the intestinal lumen but does not
invade the tissue.
Disease caused by toxins present in consumed food.
-Incubation period (1-6hr)
-Toxins preformed in food.
-Fever usually absent.
-Incubation period (8-16hr).
-organism produced toxins after
-Vomiting less prominent.
- Abdominal crambs ±,
Fever often –
1. Severity of diarrhea can divided as:
2. Features suggest infectious diarrhea:
Similar recent illness in family members.
Recent ingestion of improperly stored or prepared food.
Exposure to unpurified water in camping.
Recent travel aboard causing( traveler diarrhea).
Antibiotics adm. Within the preceding several weeks increase
likelihood of clostridium difficile colitis.
Look for leukocytosis.
Hb level (may be falsely high due to hemoconcentration due to
Urea, creat. & electrolytes:
Pre-renal acute renal failure.
Electrolytes imbalance: hyponatremia, hypokalemia and low bicarbonate
leukocytes, blood, ova and parasites.
In case of bloody diarrhea.
If ulcerative colitis suspected.
Acute renal failure.
Electrolytes depletion leading to lethargy and
Soft easily digested diet (soups).
Frequent feeding of fruits drinks, tea, cold drinks are encouraged.
Rest bowel by avoiding high fiber diet, fats, milks products, caffeine.
ORS: inexpensive, highly effective (awake pt.), fluids should be
giving 50-200ml/kg/d depend on hydration state.
IV fluids: severe dehydration, normal saline or ringolactate to
restore water and electrolytes.
Dextrose water should be avoided.
Assessment of dehydration using the “Dhaka method”
Mild to moderate diarrhea (improve pt. comfort).
Contraindicated in :
Loperamide (cap. Imodium 2mg) :initially 4mg followed by 2mg
after each loose stool. (max. 16mg/24hr)
3. Antibiotic therapy (empirical treatment):
Not recommended for all pts. With acute diarrhea.
Only Invasive bacterial infection suggested by clinical
Moderate- sever fever.
Present of fecal leukocytes while stool culture in process.
Drug of choice is quinolone such as:
Ciprofloxacin (ciproxin)500mg TPD/5-7days.
If suspect Giardia give metronidazole (flagyl) 250-500mg four times
/day. (Giardia appear –ive in 50% of pts.
(World Gastroenterology Organization Global Guidelines 2012)
Medical diagnosis and management (INAM DANISH).