Diarrhea Overview Diarrhea is the frequent passage of loose, watery, soft stools with or without abdominal bloating, pressure, and crampsDiarrhea is one of the most common illnesses in all age groups and is second only to the common cold as a cause of lost days of work or school. It is estimated that there are almost 218 million cases of acute diarrhea per year in adults in the US. Diarrhea and related complications can cause severe illness. The most significant cause of severe illness is loss of water and salts (electrolytes). In diarrhea, fluid passes out of the body before it can be absorbed in the intestines. When the ability to drink fluids fast enough to compensate for the water lost with diarrhea is impaired, dehydration can result. Most deaths from diarrhea occur in the very young and the elderly, whose health may be put at risk from a moderate amount of dehydration. Diarrhea can be further defined in the following ways: chronic diarrhea is the presence of loose or liquid stools for over two weeks; acute enteritis is inflammation of the intestine; gastroenteritis is diarrhea associated with nausea and vomiting; or dysentery is diarrhea that contains blood, pus, or mucus. Diarrhea Causes Viral infections cause most cases of diarrhea and are typically associated with mild-to-moderate symptoms with frequent, watery bowel movements, abdominal cramps, and a low-grade fever. Diarrhea generally lasts approximately 3 to 7 days. The following are common causes of diarrhea caused by viral infections: rotavirus is a common cause of diarrhea in infants; norovirus) is the most common cause of epidemics of diarrhea among adults and schoolage children adenovirus infections are common in all age groups. Bacterial infections cause the more serious cases of diarrhea. Typically, infection with bacteria occurs from contaminated foods or drinks (food poisoning). Bacterial infections also cause severe symptoms, often with vomiting, fever, and severe abdominal cramps or abdominal pain. Bowel movements occur frequently and may be watery. The following are examples of causes of diarrhea caused by bacterial infections: In more serious cases, the stool may contain mucus, pus, or blood. Most of these infections are associated with local outbreaks of disease. Family members or others eating the same food may have similar illnesses. Foreign travel is a common way to contract traveler!!!1s diarrhea. Campylobacter, salmonellae, and shigella organisms are the most common causes of bacterial diarrhea. Less common causes are Escherichia coli (commonly called E coli) and Yersinia, listeria, and species of bacteria. Use of antibiotics can lead to an overgrowth of Clostridium difficile (C diff) bacteria in the intestines. Parasites cause infection of the digestive system by the use of contaminated water. Common parasitic causes of diarrhea include Giardia lamblia, Entamoeba histolytica, and Cryptosporidium. Intestinal disorders or diseases including inflammatory bowel disease, irritable bowel syndrome, diverticulitis, and celiac disease can cause diarrhea. Reaction to certain medications can cause diarrhea. Common medications include antibiotics, blood pressure medications, cancer drugs, and antacids (especially ones containing magnesium). Intolerance to foods such as artificial sweeteners and lactose (the sugar found in milk) can cause diarrhea. Diarrhea Symptoms Watery, liquid stools: The stools may be of any color. The passage of red stools suggests intestinal bleeding and could be a sign of a more severe infection. The passage of thick, tarry black stools suggests significant bleeding in the stomach or upper portions of the intestine and is not usually caused by acute infections. Abdominal cramps: Occasionally diarrhea is accompanied with mild-to-moderate abdominal pain. Severe abdominal pain is not common and, if present, may suggest more severe disease. Fever: A high fever is not common. If present, the patient may have a more severe illness than acute diarrhea. Dehydration: If diarrhea leads to dehydration, it is a sign of potentially serious disease. Examples of signs and symptoms of dehydration include: Adults may be very thirsty and have a dry mouth. The skin of older people may appear to be loose. Elderly may also become very sleepy or have behavior changes and confusion when dehydrated. Dehydrated infants and children may have sunken eyes, dry mouths, and urinate less frequently than usual. They may appear very sleepy or may refuse to eat or drink. When to Seek Medical Care Diarrhea can usually be treated well with home care. In come cases, it may become more severe. A person should go to a hospital emergency department in the following situations: if the person has had diarrhea along with high fever, moderate-to-severe abdominal pain, or dehydration that cannot be managed by drinking fluids; if the diarrhea appears to contain blood (it may be bright red or may look like black, thick tar); or If the person is very sleepy and is not acting like their usual selves (others may notice this and take the person to the emergency department). Call a health care practitioner if a person has any of these complications: he or she is vomiting and unable to tolerate any food or drink; he or she shows signs of dehydration; he or she has a high fever, significant abdominal pain, very frequent loose bowel movements, or bloody diarrhea; if he or she is elderly or has serious underlying medical problems, particularly diabetes, heart, kidney, or liver disease, or HIV or AIDS (contact a health care practitioner when diarrhea first begins as the person may be at higher risk for developing complications); a parent or caregiver needs advice about preventing dehydration in newborns and infants; his or her symptoms do not improve in two to three days or appear to become worse; or he or she develops diarrhea after travel in their home country, or foreign travel. Exams and Tests Stool cultures (when a sample of the stool is taken and examined in the lab for certain bacteria or parasites) are not usually necessary unless there is high fever, blood in the stool, recent travel, or prolonged disease. In some cases, the health care practitioner may send a sample of the stool (or sometimes a cotton swab from the patient!!!1s rectum) to the laboratory to evaluate if the cause of diarrhea can be determined (such as certain bacteria or parasites present in the body). It usually takes approximately one to two days for results of these tests. A colonoscopy is an endoscope procedure that allows the physician to view the entire colon to evaluate for infections or structural abnormalities that could cause diarrhea. Imaging tests such as X-rays or CT scans are performed to rule out structural abnormalities as the cause of diarrhea, particularly when pain is a prominent symptom. Diarrhea Treatment Acute diarrhea may be treated at home. Diarrhea will generally subside in two to three days without specific medical therapy. Self-Care at Home Adults Adults should drink plenty of fluids to avoid dehydration. Replenishing water loss (due to diarrhea) is important. Avoid milk as it can make diarrhea worse. However, sports beverages (such as Gatorade) can be beneficial because they replenish electrolytes in addition to providing hydration. If the patient is able to eat, avoid greasy or fatty foods. Infants and children should be encouraged to follow the "BRAT" diet (bananas, rice, applesauce, and toast). The BRAT diet is a combination of foods used for decades to treat diarrhea. If diarrhea is accompanied by nausea, have the person suck on ice chips until the nausea stops. After the diarrhea subsides, avoid alcoholic beverages and spicy foods for two additional days. Children Dehydration in children of great concern. Infants pose special problems because of their increased risk of dehydration. They should be offered a bottle frequently. Solutions such as Pedialyte may be more appealing than water. These fluids also contain necessary salts lost with diarrhea. Never use salt tablets as they may worsen diarrhea. Children with frequent stools, fever, or vomiting should stay at home and avoid school and day-care until these symptoms go away. This allows the child to rest and recover and prevents other children from being exposed to the viruses or bacteria. Medical Treatment To replace fluids, the health care practitioner will often start an IV line if the patient is dehydrated and cannot eat or drink. Salt solutions flow through the IV, which replaces the lost fluids and salts, often brings quick relief. Antibiotics Antibiotics are not effective for cases of diarrhea caused by viruses. Even the more severe diarrhea caused by bacteria will usually go away in a few days without antibiotics. In fact, antibiotics appear to make some bacterial diarrhea worse, specifically those caused by the E coli bacterium (often a source of food poisoning). Antibiotics may benefit some adults with diarrhea. If selected carefully, antibiotics may decrease the severity of illness and shorten the duration of symptoms. If a person has recently traveled to another country or have been camping (and may have been exposed to contaminated water in the wilderness), a health care practitioner may prescribe specific medication used to treat traveler!!!1s diarrhea for certain intestinal parasites. Over-the-counter antidiarrheal medications The health care practitioner may recommend using over-the-counter antidiarrheal medications. These drugs, such as loperamide (Imodium) and bismuth subsalicylate (Pepto-Bismol, Kaopectate, etc.) may help some individuals with diarrhea, but should be avoided by others. Antidiarrheal medications are not usually recommended for infants and children with diarrhea. Hospitalization If a person has severe diarrhea, especially if they are dehydrated, he or she may require hospitalization to receive IV fluids and to be observed. Medications The use of anti-motility medication, although controversial, does provide relief from diarrhea. These drugs slow down the intestinal movement. These familiar medications include loperamide (Imodium) and bismuth subsalicylate (Pepto-Bismol, Kaopectate, etc). Such medications are not recommended for infants and children younger than five years of age. In otherwise healthy adults who are not severely ill with diarrhea, loperamide is probably safe and is effective in decreasing the number of stools per day and the total duration of the diarrhea. Adults with other serious medical problems and those with severe diarrhea (high fever, abdominal pain, or bloody stool) should see a health care practitioner before using either medication. Electrolyte solutions are available to prevent salt deficiency. Oral electrolyte solutions are available at grocery and drug stores (Pedialyte, Rehydralyte, Naturalyte Solution). Follow label directions, which may specify 1 teaspoonful every 15 minutes for 30 minutes. If the child retains the initial doses, increase the dose to 1 tablespoonful every 15 minutes until the diarrhea stops. Follow-up Avoid becoming dehydrated. Follow the advice the health practitioner provides. Re-contact the health care practitioner if the patient!!!1s diarrhea worsens, if he or she develops a high fever, abdominal pain, or if they have bloody stools Prevention Many cases of diarrhea are spread from person-to-person. The following personal care precautions can help an individual avoid diarrhea and other viral or bacterial infections: Individuals caring for sick children or other adults in any setting should carefully wash their hands after changing diapers, helping an individual use the bathroom, or assisting an individual around the home. Children should be instructed to wash their hands after using the bathroom. Practice safe food-handling. Always wash the hands before and after handling food. Use care when preparing raw poultry or meat. Food should be cooked to the recommended temperatures. Avoid raw or rare meat and poultry. Utensils coming in contact with raw food should be cleaned in soap and hot water. Fruits and vegetables consumed raw should be thoroughly rinsed in clean water. Unpasteurized (raw) milk may be contaminated with bacteria and should always be avoided. Unpasteurized fruit juice or cider should generally be avoided even if the source is known because the fruit may have come in contact with contaminated animal droppings in the orchard. Use caution when traveling, especially to foreign countries. Do not eat foods from street vendors. Don!!!1t drink water or drinks with ice cubes made from tap water if the country is deemed unsafe. Check the Travelers!!!1 Health Web site of the Centers for Disease Control and Prevention for travel information for your destination. Outlook Symptoms should being to improve two to three days after the original diarrheal episode. Loose stools may be persistent longer than other symptoms. Serious disease is usually seen in those who become severely dehydrated, particularly infants, the elderly, or other patient!!!1s with significant medical illnesses. ....................................