Evaluation of diarrhea in children

Official reprint from UpToDate
www.uptodate.com ©2015 UpToDate
Author
Gary R Fleisher, MD
Section Editors
Stephen J Teach, MD, MPH
Teresa K Duryea, MD
Deputy Editor
James F Wiley, II, MD, MPH
Evaluation of diarrhea in children
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Apr 2015. | This topic last updated: Jun 19, 2014.
INTRODUCTION — Diarrhea refers to the passage of loose or watery stools. The World Health Organization
(WHO) defines a case as the passage of three or more loose or watery stools per day [1]. Nevertheless,
absolute limits of normalcy are difficult to define; any deviation from the child's usual pattern should arouse some
concern (particularly with ill appearance, the passage of blood or mucus, or dehydration) regardless of the actual
number of stools or their water content.
CAUSES — Acute infectious gastroenteritis due to viruses accounts for most bouts of diarrhea in developed
countries, resulting in more than 1.5 million outpatient visits and 200,000 hospitalizations in the United States
annually [1]. However, watery and/or frequent stools may be the initial manifestation of a wide spectrum of acute
and chronic disorders (table 1) [2]. Although viruses cause most cases of diarrhea in the developing countries as
well, other pathogens occur more often than in the developed countries including E. coli, Cryptosporidium,
Entamoeba histolytica, and Giardia lamblia. As in the developed countries, norovirus has surpassed rotavirus in
frequency in those regions that have introduced the rotavirus vaccine [3]. (See "Epidemiology, clinical
manifestations, and diagnosis of cryptosporidiosis", section on 'Epidemiology'.)
Life-threatening conditions — A number of disorders causing diarrhea may be life threatening in children
(table 1 and algorithm 1A) [4]. Particularly urgent are intussusception, hemolytic uremic syndrome (HUS),
pseudomembranous colitis, appendicitis, toxic megacolon, and in very young infants, the congenital secretory
diarrheas.
Intussusception — Intussusception is most common from 6 to 12 months of age, and the vast majority of
cases occur in the first two years of life. Most children with intussusception develop the sudden onset of
intermittent, severe, crampy abdominal pain, accompanied by inconsolable crying and drawing up of the legs
toward the abdomen, but some present with bloody diarrhea. The episodes of pain usually occur at 15 to 20
minute intervals. They become more frequent and may be followed initially by emesis of gastric contents. Bilious
emesis may develop as the obstruction progresses. Between the painful episodes, the child may behave
normally. As a result, initial symptoms can be confused with gastroenteritis. As symptoms progress, increasing
lethargy develops, which can be mistaken for meningitis.
The attacks also can be separated by periods of apathy followed by vomiting and the passage of "currant jelly"
stool (representing a mixture of blood and mucus). A sausage-shaped abdominal mass may be felt in the right
side of abdomen. The prevalence of blood in the stool is as high as 70 percent if occult blood is included and
increases with the duration of symptoms. However, the classically described triad of pain, a palpable sausage-
shaped abdominal mass, and currant-jelly stool is seen in less than 15 percent of patients at the time of
presentation. Up to 20 percent of young infants have no obvious pain. Patients do not pass blood or mucus or
develop an abdominal mass in approximately one-third of cases. Some infants and many older children have
pain alone without other signs or symptoms. (See "Intussusception in children".)
Hemolytic uremic syndrome — Hemolytic uremic syndrome (HUS), although uncommon, merits
consideration in any child with bloody diarrhea, particularly in the first five years of life, because it is a potentially
fatal illness. It complicates 6 to 9 percent of enterohemorrhagic E. coli infections with the 0157:H7 strain and
usually begins 5 to 10 days after the onset of diarrhea. HUS, which has a sudden onset, is characterized by the
triad of (see "Clinical manifestations and diagnosis of Shiga toxin-producing Escherichia coli (STEC) hemolytic
uremic syndrome (HUS) in children", section on 'Clinical and laboratory manifestations'):
®
®
Microangiopathic hemolytic anemia●
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Children typically have a prodromal illness with abdominal pain, vomiting, and diarrhea that precedes the
development of HUS by a few days, as a result of which a patient may have no signs of hemolysis or renal
failure when seen earlier in the course. The diarrhea and associated gastrointestinal complaints may mimic
those of ulcerative colitis, other enteric infections, and appendicitis. (See "Clinical manifestations and diagnosis
of Shiga toxin-producing Escherichia coli (STEC) hemolytic uremic syndrome (HUS) in children", section on
'Diagnosis'.)
Pseudomembranous colitis — This rare but serious disorder results from an overgrowth of toxin-producing
clostridial organisms in the bowel. The typical presentation is acute watery diarrhea with lower abdominal pain,
low-grade fever, and leukocytosis, starting during or shortly after antibiotic administration. The course can be
fulminant, progressing from diarrhea to toxic megacolon and shock [5]. Community-associated infection with a
highly toxigenic strain of Clostridium difficile has been reported in otherwise healthy children who had minimal or
no exposure to antibiotics. (See "Clostridium difficile infection in children: Clinical features and diagnosis" and
"Clostridium difficile infection in children: Microbiology, pathogenesis, and epidemiology", section on
'Hypervirulent strain (NAP1/BI/027)'.)
Appendicitis — Appendicitis typically begins with diffuse abdominal pain followed by vomiting, often in
association with constipation. The three most predictive clinical features are (see "Acute appendicitis in children:
Clinical manifestations and diagnosis", section on 'Clinical manifestations'):
Less commonly, appendicitis may cause diarrhea. In a retrospective series of 63 children less than three years of
age with appendicitis, 33 percent had diarrhea as an initial symptom. The presumed mechanism for the diarrhea
is irritation of the colon by the inflamed appendix. The stools are usually of low volume and with mucus. (See
"Acute appendicitis in children: Clinical manifestations and diagnosis", section on 'Clinical features by age'.)
The diagnosis of appendicitis as the cause of diarrhea may be delayed because the classic constellation of
findings is absent. This is particularly true in very young children or among patients of any age who have both a
perforated appendix and a long duration of illness. However, abdominal tenderness will be greater than would be
expected with gastroenteritis. (See "Acute appendicitis in children: Clinical manifestations and diagnosis",
section on 'Clinical features by age'.)
Toxic megacolon — Toxic megacolon can occur as a complication of Shigella infection, pseudomembranous
colitis, Hirschsprung disease, or inflammatory bowel disease. These conditions are reviewed elsewhere. (See
"Shigella infection: Clinical manifestations and diagnosis", section on 'Toxic megacolon' and "Congenital
aganglionic megacolon (Hirschsprung disease)" and "Management of severe or refractory ulcerative colitis in
children and adolescents".)
Congenital secretory diarrheas — Congenital secretory diarrheas are characterized by profuse watery
diarrhea beginning at or shortly after birth and are rare. They are caused by a variety of inherited disorders that
disrupt nutrient digestion, absorption, or transport, enterocyte development and function, or enteroendocrine
function (table 2). (See "Overview of the causes of chronic diarrhea in children", section on 'Congenital secretory
and osmotic diarrheas'.)
Common conditions — The common causes of diarrhea are infections with viruses and bacteria, diarrhea due
to a systemic infection other than gastrointestinal, diarrhea associated with antibiotic administration, and feeding
related diarrhea [4].
Thrombocytopenia●
Acute renal failure●
Pain in the right lower quadrant●
Abdominal wall rigidity●
Migration of periumbilical pain to the right lower quadrant●
By far, the single most common diarrheal disorder seen in the emergency department and in general
practice is viral gastroenteritis. In one series of children two months to two years of age, a viral etiology was
identified in 60 percent of all cases of diarrhea and in 85 percent of moderately severe and severe episodes
[6]. In a prospective case control study that evaluated the infectious etiology of diarrhea in 254 children with
●
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Other conditions — Cryptosporidium is an intracellular protozoan parasite that is associated with sporadic
outbreaks of self-limited diarrhea in immunocompetent hosts, sometimes in relationship to contaminated drinking
water; chronic life-threatening illness in immunocompromised patients, especially those with human
immunodeficiency virus; and diarrhea and malnutrition in young children in developing countries. (See
"Epidemiology, clinical manifestations, and diagnosis of cryptosporidiosis", section on 'Epidemiology'.)
Toxic ingestions (such as contaminated food and organophosphates) can cause diarrhea. (See "Differential
diagnosis of microbial foodborne disease" and "Organophosphate and carbamate poisoning".)
A number of uncommon conditions (table 1) can cause diarrhea that is usually chronic. These include primary
immunodeficiencies, diarrhea related to HIV infection, food allergies, celiac disease, inflammatory bowel disease,
cystic fibrosis, acrodermatitis enteropathica, secretory tumors, endocrine disorders (particularly hyperthyroidism),
and neonatal drug withdrawal. (See "Overview of the causes of chronic diarrhea in children" and "Clinical
manifestations of food allergy: An overview" and "Zinc deficiency and supplementation in children and
adolescents", section on 'Acrodermatitis enteropathica' and "Clinical characteristics of carcinoid tumors" and
"Neonatal abstinence syndrome".)
ACUTE DIARRHEA
History — There are a number of historical factors to consider. Among the first is the immune status of the child,
as immunocompromise increases the risk for infections with unusual organisms, the prevalence of which varies
with the degree of immunosuppression and the nature of the underlying condition.
Another feature of the illness to identify is whether the diarrhea is acute or chronic. An acute diarrheal illness is
typically defined as a duration of five days or less. Symptoms that have persisted for longer suggest other
diagnoses, such as those discussed below. (See 'Chronic diarrhea' below.)
Institutionalized children and those recently returning from developing countries are more likely to have bacterial
or parasitic pathogens. (See "Travelers' diarrhea: Microbiology, epidemiology, and prevention".)
A history of recent antibiotic use suggests the possibility of pseudomembranous colitis. (See "Clostridium difficile
infection in children: Clinical features and diagnosis", section on 'Symptomatic disease'.)
Two features of the diarrheal illness, either alone or in combination, that are particularly helpful in sorting through
the differential diagnosis are the presence of fever and bloody or mucousy diarrhea. (See 'Algorithmic approach
to the patient' below.)
Physical examination — The patient who requires volume resuscitation must be quickly identified. Clinical
a median age younger than two years coming to a pediatric emergency department, a viral etiology was
identified in 54 percent of patients while virus isolation only occurred in 5 percent of matched controls [7].
(See "Viral gastroenteritis in children: Epidemiology, clinical presentation, and diagnosis".)
Extraintestinal infections (such as otitis media, urinary tract infections, and pneumonia) can cause acute
diarrhea that is usually mild and self-limited. (See "Acute otitis media in children: Epidemiology,
microbiology, clinical manifestations, and complications", section on 'Symptoms and signs'.)
●
Antibiotic associated diarrhea (AAD) occurs commonly with many antibiotics, including amoxicillin which is
frequently prescribed in pediatrics. In one prospective series, 18 percent of children less than two years of
age developed diarrhea associated with antibiotic use [8]. The pathophysiology of AAD is poorly
understood, but is likely related to disruption in fecal flora [9].
●
Overfeeding (particularly with hyperosmolar fluids) may cause diarrhea as the result of increased osmotic
load. Diarrhea may also occur when intake of solid foods is limited (sometimes referred to as "starvation
stools"). (See "Malnutrition in children in developing countries: Clinical assessment", section on 'Diarrhea
and dehydration'.)
●
Lactase deficiency, when it occurs in younger children, this is usually a transient problem, caused by
mucosal injury from an enteric infection [10]. In older children and adolescents, this may be a primary
lactase deficiency (also known as adult-type hypolactasia or lactase nonpersistence), that affects up to 70
percent of normal adults. (See "Lactose intolerance".)
●
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evidence of dehydration such as decreased urine output, tachycardia, and dry mucus membranes are already
apparent at a deficit of 5 percent of body weight. The most useful signs for predicting a volume deficit of 5
percent or more include delayed capillary refill time greater than two seconds, reduced skin turgor, and deep
respirations with or without an increase in respiratory rate, particularly if a combination of these findings is
present. (See "Clinical assessment and diagnosis of hypovolemia (dehydration) in children", section on 'Degree
of dehydration'.)
In addition to identifying volume depletion, a thorough examination must be performed because systemic,
non-enteric infections, particularly otitis media, may cause diarrhea. A palpable mass or peritonitis suggests
appendicitis, intussusception or, less commonly, toxic megacolon. Generalized toxicity and/or shock may occur
with hemolytic uremic syndrome or with sepsis, such as from Salmonella or staphylococcal toxic shock
syndrome [11]. (See "Clinical manifestations and diagnosis of Shiga toxin-producing Escherichia coli (STEC)
hemolytic uremic syndrome (HUS) in children", section on 'Clinical and laboratory manifestations'.)
Laboratory testing and imaging — Information gathered from the history and physical examination will suggest
useful laboratory tests and imaging studies:
Imaging studies such as abdominal ultrasound, abdominal computed tomography, and air contrast enema may
also be helpful in children with diarrhea and findings suggestive of intussusception, and less commonly,
appendicitis as follows:
Algorithmic approach to the patient — An algorithmic approach provides clinical guidance to the diagnostic
approach of diarrhea in children (algorithm 1A and algorithm 1B and algorithm 2) [4].
Immunocompromised patients are at risk for unusual infections and require a rigorous approach in accordance
with protocols specific to the underlying disorder. First, the physician should determine whether the child appears
seriously ill (algorithm 1A) or has signs of a surgical abdominal process. A palpable mass or peritonitis suggests
appendicitis, intussusception, or, less commonly, toxic megacolon. Generalized toxicity and/or shock may occur
Diarrhea usually results in isotonic volume depletion. Although clinically significant electrolyte disturbances
do not occur frequently, children who are ill-appearing or who have significant dehydration requiring
intravenous rehydration should have serum electrolytes measured. (See "Clinical assessment and
diagnosis of hypovolemia (dehydration) in children".)
●
A stool culture should be performed in febrile children with frankly bloody or mucousy diarrhea. A bacterial
pathogen will be identified in 15 to 20 percent of cases [12-14]. Routine cultures of stool are not
recommended for nonbloody diarrhea of brief duration in otherwise healthy children. Stool for Clostridium
difficile should be sent in patients with bloody diarrhea who have been on antibiotics. Stool for ova and
parasites is indicated for children who have traveled to or reside in an endemic area.
●
Viral antigen tests of stool (especially for rotavirus during times of high prevalence) may be helpful in
distinguishing acute viral gastroenteritis from a bacterial process, but they are generally not necessary for
most patients.
●
Infants and young children with urinary tract infections may have diarrhea. Thus, a urine culture should be
obtained in young children at risk for urinary tract infection when diarrhea occurs in a febrile child and no
other source of infection is identified. (See "Urinary tract infections in infants and children older than one
month: Clinical features and diagnosis", section on 'Decision to obtain'.)
●
Abdominal ultrasound is a noninvasive technique to identify an intussusception. It is also useful in the initial
evaluation of appendicitis, particularly in girls where there may be a possibility of ovarian torsion. (See
"Intussusception in children", section on 'Ultrasonography' and "Acute appendicitis in children: Diagnostic
imaging", section on 'Ultrasonography (US)'.)
●
Contrast enema confirms the ultrasound diagnosis and in most cases provides treatment of ileocolic
intussusception. (See "Intussusception in children", section on 'Nonoperative reduction'.)
●
Abdominal computed tomography can provide important diagnostic information in patients who may have a
significant intraabdominal process, including appendicitis. (See "Acute appendicitis in children: Diagnostic
imaging", section on 'Computed tomography (CT)'.)
●
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with hemolytic uremic syndrome and with sepsis, such as from Salmonella [11] or staphylococcal toxic shock
syndrome. Seizures may be seen with shigellosis, occasionally before the onset of diarrhea. Profuse diarrhea in
associate with excessive salivation, lacrimation, and urination suggests organophosphate ingestion.
Immunocompromised patients (algorithm 1B) are at risk for unusual infections and require a rigorous approach in
accordance with protocols specific to the underlying disorder.
Next, the physician focuses on those with acute diarrhea (algorithm 1B), as these patients are more likely to
require a diagnostic or therapeutic intervention. Fever and bloody or mucousy diarrhea, either alone or in
combination, are particularly helpful in sorting through the differential diagnosis (algorithm 1B):
Febrile with non-bloody diarrhea — The presence of fever in an immunocompetent child with diarrhea is
the hallmark of infection. Most febrile children with nonbloody diarrhea have viral enteritis. (See "Viral
gastroenteritis in children: Epidemiology, clinical presentation, and diagnosis".)
Afebrile with non-bloody diarrhea — Many afebrile children with nonbloody diarrhea will also have viral
enteritis. For those taking antibiotics, such as amoxicillin, the diarrhea may be related to the medication [8,9].
Overfeeding may cause diarrhea during the first 6 to 12 months of life. The tip-off to this diagnosis is the history
of excessive fluid intake in an overweight child [15].
Febrile with bloody diarrhea — Febrile children with bloody and/or mucousy diarrhea typically have
infectious bacterial enteritis. (See "Epidemiology and causes of acute diarrhea in resource-rich countries",
section on 'Bloody diarrhea'.)
Possible exceptions include the following:
Afebrile with bloody diarrhea — Afebrile children with bloody diarrhea represent the most worrisome
category because most patients with intussusception, hemolytic-uremic syndrome (HUS), and
pseudomembranous colitis have this symptom constellation:
Blood is seen in the stool of up to 10 percent of children with diarrhea. In most cases, the blood appears in
small quantities as drops on the surface of the stool and should not be construed as ominous.
●
A small percentage of children with diarrhea, however, have more profuse rectal bleeding. Particularly in
these patients, one must exclude life-threatening disorders such as intussusception, HUS, and
pseudomembranous colitis. (See "Lower gastrointestinal bleeding in children: Causes and diagnostic
approach", section on 'Causes of bleeding'.)
●
Mucousy diarrhea, with or without blood, suggests bacterial enteritis [13,14].●
Pseudomembranous colitis is an important consideration in children with bloody diarrhea who have also
received antibiotic therapy, especially if systemic toxicity, abdominal distension, and gross blood in the
stools are present. (See "Clostridium difficile infection in children: Clinical features and diagnosis", section
on 'Symptomatic disease'.)
●
Amebiasis merits consideration in children or immigrants from endemic areas (eg, India, Africa, Mexico,
Central and South America) and, less commonly, among travelers to these regions. (See "Intestinal
Entamoeba histolytica amebiasis", section on 'Epidemiology'.)
●
An occasional child with inflammatory bowel disease may present with an initial episode of acute, bloody
diarrhea. In most of these cases, the physician can elicit a preceding history of weight loss or recurrent
abdominal pain. (See "Clinical presentation and diagnosis of inflammatory bowel disease in infants,
children, and adolescents", section on 'Symptoms suggesting colitis'.)
●
Intussusception should be considered carefully in any child less than one year of age with grossly bloody
diarrhea that does not appear to have an infectious cause. A history of severe, colicky abdominal pain in a
lethargic child warrants an abdominal ultrasound or contrast enema. (See "Intussusception in children",
section on 'Clinical manifestations'.)
●
Bloody diarrhea with pallor, purpura, elevated serum blood urea nitrogen or creatinine, and hematuria point
to HUS. (See "Clinical manifestations and diagnosis of Shiga toxin-producing Escherichia coli (STEC)
hemolytic uremic syndrome (HUS) in children", section on 'Clinical and laboratory manifestations'.)
●
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The most common diagnosis, infectious bacterial enteritis, should be made only after exclusion of the more
serious disorders by history, physical examination, and occasionally, laboratory or imaging studies.
Therapeutic interventions — Children with life-threatening causes for diarrhea warrant specific therapy dictated
by the underlying condition. (See 'Life-threatening conditions' above.)
Parenteral fluid resuscitation with an isotonic solution (eg, normal saline) should be initiated promptly in children
with moderate to severe dehydration or circulatory compromise and may be particularly important in preventing
oliguric renal failure in those patients with hemolytic uremic syndrome. Patients with toxic megacolon and
intussusception may also have significant ongoing third space losses that must be replaced. (See "Treatment
and prognosis of Shiga toxin-producing Escherichia coli (STEC) hemolytic uremic syndrome (HUS) in children",
section on 'Fluid' and "Treatment of hypovolemia (dehydration) in children".)
Most children with diarrhea will not require intravenous hydration. Treatment with oral rehydration solutions
should be encouraged as the first line therapy for both rehydration and maintenance therapy in patients who
have mild to moderate dehydration and can drink. (See "Oral rehydration therapy".)
Antibiotics should not be used for children with acute bloody diarrhea unless a specific pathogen has been
isolated. Antibiotic therapy may be a risk factor for the development of hemolytic uremic syndrome in patients
with bloody diarrhea due to E. Coli O157:H7, which may be indistinguishable from bloody diarrhea seen with
other non E Coli bacterial etiologies [16]. (See "Clinical manifestations, diagnosis and treatment of
enterohemorrhagic Escherichia coli (EHEC) infection", section on 'Treatment'.)
Probiotics refer to products derived from food sources, especially cultured milk products. The list of such
microorganisms continues to grow and includes a variety of different strains of bacteria. Probiotics appear to
have only a modest effect on recovery from infectious diarrhea. Systematic reviews also suggest that probiotics
(including various bacterial species and the yeast S. boulardii) are effective in reducing the incidence of diarrhea
in patients who are taking antibiotics. However, discordant data have been published and there is little detailed
information regarding the optimal dose or timing of supplementation or the effects on subgroups of patients. The
use of probiotics for these indications is discussed in more detail separately. (See "Probiotics for gastrointestinal
diseases", section on 'Antibiotic-associated diarrhea' and "Probiotics for gastrointestinal diseases", section on
'Infectious diarrhea'.)
Disposition — The majority of children with infectious diarrhea have mild to moderate dehydration and can be
managed as outpatients after receiving appropriate assessment and oral rehydration therapy.
Hospital admission is warranted in children with any one of the following findings:
Persistent symptoms — The child who returns with the persistence of an acute diarrheal illness, initially
presumed to be viral in origin and with no evidence of malnutrition or dehydration, often can be managed without
an extensive evaluation. Common causes, in addition to persistent viral infection, are:
Prior antibiotic therapy raises the possibility of pseudomembranous colitis. (See "Clostridium difficile
infection in children: Clinical features and diagnosis", section on 'Symptomatic disease'.)
●
Diagnosis of or strong clinical suspicion for a life-threatening cause of diarrhea, such as HUS or other
systemic illnesses (see 'Life-threatening conditions' above)
●
Severe dehydration or significant electrolyte abnormalities upon presentation (see "Clinical assessment and
diagnosis of hypovolemia (dehydration) in children", section on 'Degree of dehydration')
●
Lack of improvement with rehydration●
Continued copious diarrhea that is likely to lead to recurrent dehydration if intravenous replacement of
ongoing losses does not occur
●
Inability to drink●
Bacterial infections●
Parasitic infections●
Starvation stools in the child who inadvertently has been continued on a clear liquid diet for several days●
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A stool culture should be obtained, and testing for clostridial toxin is indicated in children who have had recent
antibiotic therapy. Gradual refeeding is recommended if the child has remained on a clear liquid diet.
CHRONIC DIARRHEA — A brief initial evaluation of the child with chronic diarrhea in the acute setting (eg,
emergency department) is described below (algorithm 2 and table 1). A more comprehensive diagnostic
approach to chronic diarrheal diseases in developed countries is discussed in detail separately. (See "Overview
of the causes of chronic diarrhea in children" and "Approach to the diagnosis of chronic diarrhea in children in
developed countries".)
In the developing world, chronic diarrhea typically is associated with serial enteric infections and malnutrition.
This common pathophysiology calls for a distinct algorithmic approach to diagnosis and treatment, which is
discussed separately. (See "Persistent diarrhea in children in developing countries".)
History — The following historical features may indicate serious underlying disease:
Physical examination — The child's overall state of nutrition may indicate the severity and/or duration of
symptoms. Physical findings associated with inflammatory bowel disease such as weight loss, arthritis or
aphthous ulcers may point to that diagnosis.
Laboratory testing — A stool culture diagnoses serious infections of the gastrointestinal tract and provides a
head start on the evaluation for the physician who subsequently sees the child. Parasitic infections merit
consideration as well, particularly in individuals with a history of recent immigration, travel to an underdeveloped
country, or backcountry camping.
Algorithmic approach to the patient — A child with chronic diarrhea who presents in an acute care setting is
infrequently seriously ill. The evaluation usually requires a period of observation and ancillary studies rather than
urgent diagnostic and therapeutic intervention. Urgent conditions are suggested by a history of bloody diarrhea
or the physical finding of abdominal tenderness (algorithm 2).
Appendicitis and bacterial enteritis are urgent conditions that must be identified. Other less urgent diagnoses
include Hirschsprung disease or cystic fibrosis. (See "Congenital aganglionic megacolon (Hirschsprung
disease)" and "Cystic fibrosis: Overview of gastrointestinal disease" and "Overview of the causes of chronic
diarrhea in children" and "Approach to the diagnosis of chronic diarrhea in children in developed countries".)
Disposition — The child with chronic diarrhea who is well-appearing and tolerates oral fluids can be managed
as an outpatient. The key factor in successfully diagnosing the etiology of the diarrhea is good follow-up with a
primary care provider.
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and
“Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5 to 6 grade
reading level, and they answer the four or five key questions a patient might have about a given condition. These
articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond
Secondary lactase deficiency following viral enteritis●
A history of delayed passage of meconium, constipation since birth, and abdominal distension are
compatible with Hirschsprung disease.
●
Malabsorptive stools and respiratory infections suggest cystic fibrosis.●
Failure to thrive, thrush, and pneumonia occur in association with human immunodeficiency virus (HIV)
infection.
●
A prolonged history of diarrhea (>1 month) points to inflammatory bowel disease, particularly if the diarrhea
is bloody, or to irritable bowel syndrome, malabsorption (eg, cystic fibrosis), immunodeficiency, secretory
disorders, or anatomic abnormalities (eg, Hirschsprung disease). (See "Epidemiology and environmental
factors in inflammatory bowel disease in children and adolescents".)
●
In those children with diarrhea of intermediate duration (one to four weeks), the physician should consider
an appendiceal abscess (particularly with the finding of abdominal tenderness or a history of abdominal
pain), bacterial enteritis, and parasitic infestations.
●
th th
7 de 17 14/05/2015 01:06 p. m.

the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written
at the 10 to 12 grade reading level and are best for patients who want in-depth information and are
comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these
topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on
“patient info” and the keyword(s) of interest.)
SUMMARY
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REFERENCES
King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration,
maintenance, and nutritional therapy. MMWR Recomm Rep 2003; 52:1.
1.
Cohen MB. Etiology and mechanisms of acute infectious diarrhea in infants in the United States. J Pediatr
1991; 118:S34.
2.
Becker-Dreps S, Bucardo F, Vilchez S, et al. Etiology of childhood diarrhea after rotavirus vaccine
introduction: a prospective, population-based study in Nicaragua. Pediatr Infect Dis J 2014; 33:1156.
3.
Fleisher GR. Diarrhea. In: Textbook of Pediatric Emergency Medicine, 6th edition, Fleisher GR, Ludwig S.
(Eds), Lippincott, Williams & Wilkins, Philadelphia, PA 2010. p.212.
4.
th th
Basics topic (see "Patient information: Diarrhea in children (The Basics)")●
Beyond the Basics topic (see "Patient information: Acute diarrhea in children (Beyond the Basics)")●
The approach to the evaluation of acute diarrhea is summarized in the algorithms (algorithm 1A-B). The
table summarizes the causes of diarrhea, highlighting the most common and the most life threatening
pediatric conditions (table 1).
●
Two features of acute diarrheal illness, either alone or in combination, that are particularly helpful in sorting
through the differential diagnosis are the presence of fever and bloody or mucousy diarrhea. (See 'History'
above and 'Algorithmic approach to the patient' above.)
●
The patient with acute diarrhea who requires volume resuscitation must be quickly identified. Clinical
evidence of dehydration such as decreased urine output, tachycardia, and dry mucus membranes are
already apparent at a deficit of 5 percent of body weight. The most useful signs for predicting a volume
deficit of 5 percent or more include delayed capillary refill time greater than two seconds, reduced skin
turgor, and deep respirations with or without an increase in respiratory rate, particularly if a combination of
these findings is present. (See 'Physical examination' above.)
●
In addition to identifying volume depletion, a thorough examination must be performed because systemic,
non-enteric infections, particularly otitis media, may cause acute diarrhea. A palpable mass or peritonitis
suggests appendicitis, intussusception or, less commonly, toxic megacolon. Generalized toxicity and/or
shock may occur with hemolytic uremic syndrome or with sepsis, such as from Salmonella or
staphylococcal toxic shock syndrome. (See 'Physical examination' above.)
●
Ancillary studies in children with acute diarrhea are based upon a careful history and physical examination.
(See 'Laboratory testing and imaging' above.)
●
A brief initial evaluation of the child with chronic diarrhea in the acute setting (eg, emergency department) is
described above (algorithm 2 and table 1). (See 'Chronic diarrhea' above.)
●
A more comprehensive diagnostic approach to chronic diarrheal diseases in developed and developing
countries is discussed in greater detail separately. (See "Overview of the causes of chronic diarrhea in
children" and "Approach to the diagnosis of chronic diarrhea in children in developed countries" and
"Persistent diarrhea in children in developing countries".)
●
8 de 17 14/05/2015 01:06 p. m.

Prince AS, Neu HC. Antibiotic-associated pseudomembranous colitis in children. Pediatr Clin North Am
1979; 26:261.
5.
Pang XL, Honma S, Nakata S, Vesikari T. Human caliciviruses in acute gastroenteritis of young children in
the community. J Infect Dis 2000; 181 Suppl 2:S288.
6.
Denno DM, Shaikh N, Stapp JR, et al. Diarrhea etiology in a pediatric emergency department: a case
control study. Clin Infect Dis 2012; 55:897.
7.
Turck D, Bernet JP, Marx J, et al. Incidence and risk factors of oral antibiotic-associated diarrhea in an
outpatient pediatric population. J Pediatr Gastroenterol Nutr 2003; 37:22.
8.
Surawicz CM. Antibiotic-associated diarrhea in children: how many dirty diapers? J Pediatr Gastroenterol
Nutr 2003; 37:2.
9.
Heyman MB, Committee on Nutrition. Lactose intolerance in infants, children, and adolescents. Pediatrics
2006; 118:1279.
10.
Torrey S, Fleisher G, Jaffe D. Incidence of Salmonella bacteremia in infants with Salmonella
gastroenteritis. J Pediatr 1986; 108:718.
11.
Finkelstein JA, Schwartz JS, Torrey S, Fleisher GR. Common clinical features as predictors of bacterial
diarrhea in infants. Am J Emerg Med 1989; 7:469.
12.
Gupta DN, Sircar BK, Sengupta PG, et al. Epidemiological and clinical profiles of acute invasive diarrhoea
with special reference to mucoid episodes: a rural community-based longitudinal study. Trans R Soc Trop
Med Hyg 1996; 90:544.
13.
Dutta P, Mitra U, Saha DR, et al. Mucoid presentation of acute enterocolitis in children: a hospital-based
case-control study. Acta Paediatr 1999; 88:822.
14.
Issenman RM, Hewson S, Pirhonen D, et al. Are chronic digestive complaints the result of abnormal
dietary patterns? Diet and digestive complaints in children at 22 and 40 months of age. Am J Dis Child
1987; 141:679.
15.
Wong CS, Jelacic S, Habeeb RL, et al. The risk of the hemolytic-uremic syndrome after antibiotic treatment
of Escherichia coli O157:H7 infections. N Engl J Med 2000; 342:1930.
16.
Topic 6456 Version 15.0
9 de 17 14/05/2015 01:06 p. m.

GRAPHICS
Etiology of diarrhea by age
Cause
Infants and young
children
Older children and
adolescents
Gastrointestinal infections* Viruses
Bacteria
Parasites
Viruses
Bacteria
Parasites
Non-gastrointestional
infections (parenteral diarrhea)
Otitis media
Urinary tract infections
Other systemic infections
Systemic infections
Dietary disturbances Overfeeding
Food allergy
Starvation stools
Starvation stools
Anatomic abnormalities Intussusception
Hirschsprung disease (± toxic
megacolon)
Partial bowel obstruction
Blind loop syndrome
Intestinal lymphangiectasis
Short gut syndrome
Appendicitis
Partial obstruction
Blind loop syndrome
Inflammatory bowel disease Ulcerative colitis (± toxic
megacolon)
Crohn's disease (± toxic
megacolon)
Malabsorption or increased
secretion
Cystic fibrosis
Celiac disease
Disaccharidase deficiency
Acrodermatitis enteropathica
Celiac disease
Acrodermatitis
enteropathica
Secretory neoplasms
Immunodeficiency Severe combined
immunodeficiencies and other
genetic disorders
Human immunodeficiency virus
infection (HIV)
Human immunodeficiency
virus infection (HIV)
Endocrinopathy Congenital adrenal hyperplasia Hyperthyroidism
Hypoparathyroidism
Miscellaneous Antibiotic-associated diarrhea
Pseudomembranous colitis
Toxins
Hemolytic uremic syndrome
Antibiotic-associated
diarrhea
Pseudomembranous colitis
Toxins
Irritable bowel syndrome
10 de 17 14/05/2015 01:06 p. m.

Neonatal drug withdrawal Psychogenic disturbances
Red: Life-threatening cause.
Green: Common cause.
Courtesy of Gary R Fleisher, MD.
Graphic 58814 Version 4.0
11 de 17 14/05/2015 01:06 p. m.

Diarrhea: Seriously ill child
* More likely in older children and adolescents.
• More likely in infants and young children.
12 de 17 14/05/2015 01:06 p. m.

Molecular basis of the main forms of congenital diarrheal diseases
Disease Gene Location Function
Defects of digestion, absorption, and transport of nutrients and electrolytes
Congenital lactase deficiency LCT 2q21 Lactase-phlorizin hydrolase
activity
Sucrase-isomaltase
deficiency
EC
3.2.1.48
3q25-q26 Isomaltase-sucrase
Maltase-glucoamylase
deficiency
MGAM 7q34 Maltase-glucoamylase activity
Ion and nutrient transport defects
Glucose-galactose
malabsorption
SLC5A1
(SGLT1)
22q13.1 Na /glucose cotransporter
Fructose malabsorption GLUT5 1p36 Fructose transporter
Fanconi-Bickel syndrome GLUT2 3q26 Basolateral glucose transporter
Cystic fibrosis CFTR 7q31.2 cAMP-dependent Cl channel
Acrodermatitis enteropathica SLC39A4 8q24.3 Zn transporter
Congenital chloride diarrhea SLC26A3
(DRA)
7q22-q31.1 Cl /base exchanger
Congenital sodium diarrhea SPINT2* 19q13.1 Serine-protease inhibitor
Familial diarrhea
syndrome
GUCY2C 12p12.3 Intestinal guanylate cyclase C
(ligand for bacterial
heat-stable enterotoxins)
Lysinuric protein intolerance SLC7A7 14q11 Hydrolyzes
endo-/exopeptidases, amino
acid basolateral transport
Congenital bile acid diarrhea SLC10A2
(ABAT)
13q33 Ileal Na /bile salt transporter
Pancreatic insufficiency
Enterokinase deficiency PRSS7 21q21 Proenterokinase
Trypsinogen deficiency PRSS1 7q35 Trypsinogen synthesis
Pancreatic lipase deficiency PNLIP 10q26.1 Hydrolyzes triglycerides to
fatty acids
Lipid trafficking
Abetalipoproteinemia MTP 4q22 Transfer lipids to
apolipoprotein B
Hypobetalipoproteinemia APOB 2p24 Apolipoprotein that forms
chylomicrons
Chylomicron retention
disease
SAR1B 5q31.1 Intracellular chylomicron
trafficking
Defects of enterocyte differentiation and polarization
Microvillous inclusion disease MY05B 18q21 Intracellular protein trafficking
Congenital tufting enteropathy EpCAM 2p21 Cell-cell interaction
+
–
2+
–
[1]
+
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Syndromic diarrhea Unknown Unknown Unknown
Defects of enteroendocrine cell differentiation
Enteric anendocrinosis NEUROG3 10q21.3 Enteroendocrine cell fate
determination
Enteric dysendocrinosis Unknown Unknown Enteroendocrine cell function
Proprotein convertase 1
deficiency
PCSK1 5q15-q21 Prohormone processing
Defects of modulation of the intestinal immune response
IPEX FOXP3 Xp11.23-q13.3 Transcription factor
IPEX-like syndrome Unknown Unknown Unknown
Immunodeficiency-associated
autoimmune enteropathy
Unknown Unknown Unknown
APS-1 AIRE 21p22.3 Regulation gene transcription
Autoimmune enteropathy with
colitis-GAGD
Unknown Unknown Unknown
cAMP: cyclic adenosine monophosphate; EpCAM: epithelial cell adhesion molecule; NEUROG-3:
neurogenin-3; IPEX: immune dysregulation polyendocrinopathy, enteropathy, X-linked syndrome;
FOXP3: forkhead box P3; APS-1: autoimmune polyglandular syndrome-1; GAGD: generalized
autoimmune gut disorder.
* This mutation has been associated with the syndromic form of congenital sodium diarrhea.
Reference:
Fikerstrand T, Arshad J, Haukanes BI, et al. Familial diarrhea syndrome caused by an activating
GUCY2C mutation. New Engl J Med 2012; 366:1586.
1.
All other entries in this table were reproduced with permission from: Canani RB, Terrin G, Cardillo G, et
al. Congenital Diarrheal Disorders: Improved Understanding of Gene Disorders is Leading to Advances
in Intestinal Physiology and Clinical Management. J Pediatr Gastroenterol Nutr 2010; 50:360. Copyright
© 2010 Lippincott Williams & Wilkins.
14 de 17 14/05/2015 01:06 p. m.

Diarrhea: Acute in a child
* More likely in infants and young children.
• More likely in older children and adolescents.
Δ Only in infants.
15 de 17 14/05/2015 01:06 p. m.

Diarrhea: Chronic in a child
* Symptoms typically >1 month in duration.
• More likely in older children and adolescents.
Δ Only in infants.
◊ More likely in infants and young children.
16 de 17 14/05/2015 01:06 p. m.

Disclosures: Gary R Fleisher, MD Nothing to disclose. Stephen J Teach, MD, MPH Grant/Research Support: Novartis [Asthma
(Omalizumab)]. Teresa K Duryea, MD Nothing to disclose. James F Wiley, II, MD, MPH Nothing to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a
multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced
content is required of all authors and must conform to UpToDate standards of evidence.
Conflict of interest policy
Disclosures
17 de 17 14/05/2015 01:06 p. m.

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