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6.07 Diarrhea


Presentation

Complaints may range from acute, copious diarrhea producing shock, to concern because an occasional stool is not well formed. Typically, there is crampy pain throughout the abdomen, especially before a diarrhea stool, and some irritation of the anus. Tenesmus (the frequent urge to defecate) can exist without diarrhea.

What to do:

What not to do:

Discussion

Most cases of mild to moderate diarrhea (defined as no more than five unformed stools a day without fever, blood or significant cramps, pain, nausea or vomiting) can be handled without an investigation of the etiology.

When you prescribe bran or psyllium, patients may remind you that they have diarrhea, not constipation, but, because these agents absorb water in the gut lumen, they can relieve both problems, and obviate the rebound constipation often produced by the narcotic and binding agents also used to treat diarrhea.

The three commonest causes of diffuse colonic inflammation and thus fecal leukocyte exudate are Shigella, Salmonella and Campylobacter. Fecal leucocytes can also be a sign of ulcerative colitis and allergic colitis.

Most bacterial diarrheas do not require treatment with antibiotics, which can produce a carrier state. The presumptive ciprofloxacin strategy described for the ED will suite most patients, but may have to be modified in follow up based upon the patient's course and stool culture results. Early empiric treatment of traveller's diarrhea with a single 500mg dose of ciprofloxacin can reduce the duration and severity of the illness.

Infants can become severely dehydrated in short order with viral diarrhea. Old patients medicated for pain or psychosis can develop a fecal impaction which can also present as diarrhea. Irritable bowel syndrome, food allergy, lactose intolerance and parasite infestation can produce relapsing diarrhea, but the pattern may only become apparent on follow up.

References:


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from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
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Craig Feied, MD
Mark Smith, MD
Jon Handler, MD
Michael Gillam, MD