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{{otheruses}}
{{db-attack|blanked=yes}}
{{see also|Gastroenteritis}}
{{Infobox_Disease |
Name = Diarrhea |
Image = |
Caption = |
DiseasesDB = 3742 |
ICD10 = {{ICD10|A|09||a|00}}, {{ICD10|K|59|1|k|55}} |
ICD9 = {{ICD9|787.91}} |
ICDO = |
OMIM = |
MedlinePlus = |
eMedicineSubj = ped |
eMedicineTopic = 583 |
MeshID = D003967 |
}}

In [[medicine]], '''diarrhea''' (from the [[Ancient Greek language|Greek]], "diarrhoia" meaning "a flowing through"<ref>{{cite journal |author=medterms dictionary |title=Definition of Diarrhea |journal=Medterms.com |url=http://www.medterms.com/script/main/art.asp?articlekey=2985}}</ref>), also spelled '''diarrhoea''' (see [[Spelling_differences#Simplification_of_ae_.28.C3.A6.29_and_oe_.28.C5.93.29|spelling differences]]), is the condition of having frequent loose or liquid [[bowel movement]]s. [[Acute (medical)|Acute]] diarrhea is a common cause of death in [[Developing country|developing countries]] and the second most common cause of [[Infant mortality|infant deaths]] worldwide. The loss of [[fluids]] through diarrhea can cause severe [[dehydration]] which is one cause of death in diarrhea sufferers. Along with [[water]], sufferers also lose dangerous amounts of important [[salt]]s, [[electrolyte]]s, and other [[nutrient]]s.

==Causes==
{{seealso|List of causes of diarrhea}}
[[File:Stomach colon rectum diagram.svg|right|thumb|250px|Diagram of the human [[gastrointestinal tract]].]]

Diarrhea commonly results from [[gastroenteritis]] caused by [[virus (biology)|viral]] infections, [[parasites]] or [[bacterium|bacteria]]l toxins.<ref name="pmid16267716">{{cite journal
|author=Wilson ME
|title=Diarrhea in nontravelers: risk and etiology
|journal=Clin. Infect. Dis.
|volume=41 Suppl 8
|issue=
|pages=S541–6
|year=2005
|pmid=16267716
|doi=10.1086/432949
|url=http://www.journals.uchicago.edu/cgi-bin/resolve?CID36827
}}</ref> In sanitary living conditions where there is ample food and a supply of clean water, an otherwise healthy patient usually recovers from viral infections in a few days. However, for ill or [[malnourished]] individuals, diarrhea can lead to severe [[dehydration]] and can become life-threatening without treatment.<ref name="pmid12608880">{{cite journal
|author=Alam NH, Ashraf H
|title=Treatment of infectious diarrhea in children
|journal=Paediatr Drugs
|volume=5
|issue=3
|pages=151–65
|year=2003
|pmid=12608880
|doi=
}}</ref>

Diarrhea can also be a symptom of more serious diseases, such as [[dysentery]], [[cholera]], or [[botulism]], and can also be indicative of a chronic syndrome such as [[Crohn's disease]] or severe [[Amanita phalloides#Symptoms|mushroom poisoning]] syndromes. Though [[appendicitis]] patients do not generally have violent diarrhea, it is a common symptom of a ruptured [[vermiform appendix|appendix]]. It is also an effect of severe [[radiation sickness]].

Symptomatic treatment for diarrhea involves the patient consuming adequate amounts of water to replace that loss, preferably mixed with [[electrolyte]]s to provide essential [[salt]]s and some amount of [[nutrient]]s. For many people, further treatment is unnecessary. The following types of diarrhea indicate medical supervision is required:

*Diarrhea in infants
*Moderate or severe diarrhea in young children;
*Diarrhea associated with blood
*Diarrhea that continues for more than two days;
*Diarrhea that is associated with more general illness such as non-cramping [[abdominal pain]], [[fever]], [[weight loss]], etc;
*[[Traveler's diarrhea|Diarrhea in travelers]], since they are more likely to have exotic infections such as parasites;
*Diarrhea in food handlers, because of the potential to infect others;
*Diarrhea in institutions such as hospitals, child care centers, or geriatric and convalescent homes.

A severity score is used to aid diagnosis in children.<ref name="pmid2371542">{{cite journal |author=Ruuska T, Vesikari T |title=Rotavirus disease in Finnish children: use of numerical scores for clinical severity of diarrhoeal episodes |journal=Scand. J. Infect. Dis. |volume=22 |issue=3 |pages=259–67 |year=1990 |pmid=2371542| doi = 10.3109/00365549009027046}}</ref>

==Types of diarrhea==

===Secretory diarrhea===
Secretory diarrhea means that there is an increase in the active secretion, or there is an inhibition of absorption. There is little to no structural damage. The most common cause of this type of diarrhea is a [[cholera toxin]] that stimulates the secretion of [[anion]]s, especially [[chloride]] ions. Therefore, to maintain a charge balance in the [[Lumen (anatomy)|lumen]], sodium is carried with it, along with water. <ref>http://www.webmd.com/digestive-disorders/digestive-diseases-diarrhea</ref>

===Osmotic diarrhea===
Osmotic diarrhea occurs when too much water is drawn into the bowels.
This can be the result of maldigestion (e.g., pancreatic disease or [[Coeliac disease]]), in which the nutrients are left in the lumen to pull in water. Osmotic diarrhea can also be caused by osmotic [[laxatives]] (which work to alleviate [[constipation]] by drawing water into the bowels). In healthy individuals, too much [[magnesium]] or [[vitamin C]] or undigested [[lactose]] can produce osmotic diarrhea and distention of the bowel. A person who does not have [[lactose intolerance]] can have difficulty absorbing lactose after an extraordinarily high intake of dairy products. In persons who do not have [[fructose malabsorption]], excess fructose intake can still cause diarrhea. High-fructose foods that also have a high glucose content are more absorbable and less likely to cause diarrhea. Sugar alcohols such as sorbitol (often found in sugar-free foods) are difficult for the body to absorb and, in large amounts, may lead to osmotic diarrhea. <ref>http://www.webmd.com/digestive-disorders/digestive-diseases-diarrhea</ref>

===Exudative diarrhea===
Exudative diarrhea occurs with the presence of blood and pus in the stool. This occurs with [[inflammatory bowel diseases]], such as [[Crohn's disease]] or [[ulcerative colitis]], and other severe infections. <ref>http://www.webmd.com/digestive-disorders/digestive-diseases-diarrhea</ref>

===Motility-related diarrhea===
[[Motility]]-related diarrhea is caused by the rapid movement of food through the intestines (hypermotility). If the food moves too quickly through the GI tract, there is not enough time for sufficient nutrients and water to be absorbed. This can be due to a [[vagotomy]] or [[diabetic neuropathy]], or a complication of [[menstruation]]. [[Hyperthyroidism]] can produce hypermotility and lead to [[pseudodiarrhea]] and occasionally real diarrhea. Diarrhea can be treated with antimotility agents (such as [[loperamide]]).

===Inflammatory diarrhea===
Inflammatory diarrhea occurs when there is damage to the mucosal lining or brush border, which leads to a passive loss of protein-rich fluids, and a decreased ability to absorb these lost fluids. Features of all three of the other types of diarrhea can be found in this type of diarrhea. It can be caused by bacterial infections, viral infections, parasitic infections, or autoimmune problems such as inflammatory bowel diseases. It can also be caused by tuberculosis, colon cancer, and enteritis.

===Dysentery===
Generally, if there is blood visible in the stools, it is not diarrhea, but [[dysentery]]. The blood is trace of an invasion of bowel tissue. Dysentery is caused by an excess of water by a release of antidiuretic hormone from the posterior pituitary gland. Dysentery is a symptom of, among others, ''[[Shigella]]'', ''[[Entamoeba histolytica]]'', and ''[[Salmonella]]''.

==Infectious diarrhea==
{{main|Infectious diarrhea}}
There are many causes of infectious diarrhea, which include [[virus]]es, [[bacteria]] and parasites. <ref name="pmid18813221">{{cite journal | author = Navaneethan U, Giannella RA | title = Mechanisms of infectious diarrhea | journal = Nature Clinical Practice. Gastroenterology & Hepatology | volume = 5 | issue = 11 | pages = 637–47 | year = 2008 | month = November | pmid = 18813221 | doi = 10.1038/ncpgasthep1264 | url = | issn = | accessdate = 2009-08-03}}</ref> [[Norovirus]] is the most common cause of viral diarrhea in adults, <ref name="pmid19084472">{{cite journal | author = Patel MM, Hall AJ, Vinjé J, Parashar UD | title = Noroviruses: a comprehensive review | journal = Journal of Clinical Virology : the Official Publication of the Pan American Society for Clinical Virology | volume = 44 | issue = 1 | pages = 1–8 | year = 2009 | month = January | pmid = 19084472 | doi = 10.1016/j.jcv.2008.10.009 | url = | issn = | accessdate = 2009-08-03}}</ref> but [[rotavirus]] is the most common cause in children under five years old. <ref name="pmid19457420">{{cite journal | author = Greenberg HB, Estes MK | title = Rotaviruses: from pathogenesis to vaccination | journal = Gastroenterology | volume = 136 | issue = 6 | pages = 1939–51 | year = 2009 | month = May | pmid = 19457420 | doi = 10.1053/j.gastro.2009.02.076 | url = | issn = | accessdate = 2009-08-03}}</ref> [[Adenovirus]] types 40 and 41),<ref name="pmid1962727">{{cite journal | author = Uhnoo I, Svensson L, Wadell G | title = Enteric adenoviruses | journal = Baillière's Clinical Gastroenterology | volume = 4 | issue = 3 | pages = 627–42 | year = 1990 | month = September | pmid = 1962727 | doi = | url = | issn = | accessdate = 2009-08-03}}</ref> and [[astrovirus]]es cause a significant number of infections.<ref name="pmid12442031">{{cite journal | author = Mitchell DK | title = Astrovirus gastroenteritis | journal = The Pediatric Infectious Disease Journal | volume = 21 | issue = 11 | pages = 1067–9 | year = 2002 | month = November | pmid = 12442031 | doi = 10.1097/01.inf.0000036683.11146.c7 | url = | issn = | accessdate = 2009-08-03}}</ref>

The bacterium [[campylobacter]] is a common cause of bacterial diarrhea, but infections by [[salmonella]]e, [[shigella]]e and some strains of ''[[Escherichia coli]]'' (E.coli) are frequent. <ref name="pmid19116615">{{cite journal | author = Viswanathan VK, Hodges K, Hecht G | title = Enteric infection meets intestinal function: how bacterial pathogens cause diarrhoea | journal = Nature Reviews. Microbiology | volume = 7 | issue = 2 | pages = 110–9 | year = 2009 | month = February | pmid = 19116615 | doi = 10.1038/nrmicro2053 | url = | issn = | accessdate = 2009-08-03}}</ref> In the elderly, particularly those who have been treated with antibiotics for unrelated infections, a toxin produced by ''[[Clostridium difficile]]'' often causes severe diarrhea.<ref name="pmid19528959">{{cite journal | author = Rupnik M, Wilcox MH, Gerding DN | title = Clostridium difficile infection: new developments in epidemiology and pathogenesis | journal = Nature Reviews. Microbiology | volume = 7 | issue = 7 | pages = 526–36 | year = 2009 | month = July | pmid = 19528959 | doi = 10.1038/nrmicro2164 | url = | issn = | accessdate = 2009-08-03}}</ref>

Parasites do not often cause diarrhea except for the protozoan ''[[Giardia]]'', which can cause chronic infections if these are not diagnosed and treated with drugs such as [[metronidazole]], <ref name="pmid18394362">{{cite journal | author = Kiser JD, Paulson CP, Brown C | title = Clinical inquiries. What's the most effective treatment for giardiasis? | journal = The Journal of Family Practice | volume = 57 | issue = 4 | pages = 270–2 | year = 2008 | month = April | pmid = 18394362 | doi = | url = http://www.jfponline.com/Pages.asp?AID=6066 | issn = | accessdate = 2009-08-03}}</ref> and '' [[Entamoeba histolytica]]'' <ref name="pmid16973041">{{cite journal | author = Dans L, Martínez E | title = Amoebic dysentery | journal = Clinical Evidence | volume = | issue = 15 | pages = 1007–13 | year = 2006 | month = June | pmid = 16973041 | doi = | url = | issn = | accessdate = 2009-08-03}}</ref><ref name="pmid19370624">{{cite journal | author = Gonzales ML, Dans LF, Martinez EG | title = Antiamoebic drugs for treating amoebic colitis | journal = Cochrane Database of Systematic Reviews (Online) | volume = | issue = 2 | pages = CD006085 | year = 2009 | pmid = 19370624 | doi = 10.1002/14651858.CD006085.pub2 | url = | issn = | accessdate = 2009-08-03}}</ref>

==Malabsorption==
[[Malabsorption]] is the inability to absorb food, mostly in the small bowel but also due to the [[pancreas]].

Causes include [[celiac disease]] (intolerance to wheat, rye, and barley [[gluten]], the protein of the grain), [[lactose intolerance]] (intolerance to milk sugar, common in non-Europeans), [[fructose malabsorption]], [[pernicious anemia]] (impaired bowel function due to the inability to absorb [[vitamin B12]]), loss of pancreatic secretions (may be due to [[cystic fibrosis]] or [[pancreatitis]]), [[short bowel syndrome]] (surgically removed bowel), radiation fibrosis (usually following cancer treatment), and other drugs, including agents used in [[chemotherapy]].

==Inflammatory bowel disease==
The two overlapping types here are of unknown origin:
* [[Ulcerative colitis]] is marked by chronic bloody diarrhea and inflammation mostly affects the distal [[colon (anatomy)|colon]] near the [[rectum]].
* [[Crohn's disease]] typically affects fairly well demarcated segments of bowel in the colon and often affects the end of the small bowel.

==Irritable Bowel Syndrome==
{{main|Irritable Bowel Syndrome}}
Another possible cause of diarrhea is Irritable Bowel Syndrome (IBS). Symptoms defining IBS: abdominal discomfort or pain relieved by defecation and unusual stool (diarrhea or [[constipation]] or both) or stool frequency, for at least 3 days a week over the previous 3 months.<ref>{{cite journal |author=Longstreth GF, Thompson WG, Chey WD, Houghton LA, Mearin F, Spiller RC |title=Functional bowel disorders |journal=Gastroenterology |volume=130 |issue=5 |pages=1480–91 |year=2006 |pmid=16678561 |doi=10.1053/j.gastro.2005.11.061 |url=}}</ref> IBS symptoms can be present in patients with a variety of conditions including food allergies, infective diarrhea, celiac, and inflammatory bowel diseases. Treating the underlying condition (celiac disease, food allergy, bacterial [[dysbiosis]], etc.) usually resolves the diarrhea.<ref>Wangen, S. "The Irritable Bowel Syndrome Solution". page 113. 2006; Innate Health Publishing. ISBN 978-0-9768537-8-7. Excerpted with the author's permission at http://www.IBSTreatmentCenter.com</ref> IBS can cause visceral hypersensitivity. While there is no direct treatment for undifferentiated IBS, symptoms, including diarrhea, can sometimes be managed through a combination of dietary changes, soluble fiber supplements, and/or medications.

It is important to note that IBS can often be confused with [[Giardiasis]] since false negative tests for [[giardia]] can result in a misdiagnoses of the actual cause, a parasitic infection.<ref name=IProt>[http://findarticles.com/p/articles/mi_m3225/is_n8_v53/ai_18408730 Intestinal Protozoa]</ref>

==Other important causes==
*[[Ischemia|Ischemic]] bowel disease. This usually affects older people and can be due to blocked arteries.
*[[Bowel cancer]]: Some (but not all) bowel cancers may have associated diarrhea. Cancer of the large intestine is most common.
*Hormone-secreting tumors: some hormones (e.g. [[serotonin]]) can cause diarrhea if excreted in excess (usually from a tumor).
*Bile salt diarrhea: excess bile salt entering the [[colon (anatomy)|colon]] rather than being absorbed at the end of the [[small intestine]] can cause diarrhea, typically shortly after eating. Bile salt diarrhea is a bad side-effect of [[gallbladder]] removal. It is usually treated with [[cholestyramine]], a [[bile acid sequestrant]].
*[[Celiac Disease]]
*Intestinal [[protozoa]] such as [[Giardiasis]]<ref name=IProt/>

==Alcohol==
Chronic diarrhea can be caused by chronic [[ethanol]] ingestion.<ref name=Harrison>Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL. [[Harrison's Principles of Internal Medicine]]. New York: McGraw-Hill, 2005. ISBN 0-07-139140-1.</ref> Consumption of [[alcohol]] affects the body's capability to absorb water – this is often a symptom that accompanies a [[hangover]] after a [[binge drinking]] session. The alcohol itself is absorbed in the intestines and as the intestinal cells absorb it, the toxicity causes these cells to lose their ability to absorb water. This leads to an outpouring of fluid from the intestinal lining, which is in turn poorly absorbed. The diarrhea usually lasts for several hours until the alcohol is detoxified and removed from the digestive system. Symptoms range from person to person and are influenced by both the amount consumed as well as physiological differences.


==Treatment==
In many cases of diarrhea, replacing lost fluid and salts is the only treatment needed. This is usually by mouth &ndash; [[oral rehydration therapy]] &ndash; or, in very severe cases, [[intravenously]].

Diet restriction such as limiting milk has no effect on the duration of diarrhea.<ref>{{cite web |url=http://www.bestbets.org/bets/bet.php?id=1728 |title=BestBets: Does Withholding milk feeds reduce the duration of diarrhoea in children with acute gastroenteritis? |format= |work= |accessdate=}}</ref> Medicines such [[loperamide]] (Imodium), [[bismuth subsalicylate]] (as found in [[Pepto-Bismol|Pepto Bismol]] and [[Kaopectate]]) may be beneficial, however they may be contraindicated in certain situations.<ref name="pmid18192963">{{cite journal
|author=Schiller LR
|title=Management of diarrhea in clinical practice: strategies for primary care physicians
|journal=Rev Gastroenterol Disord
|volume=7 Suppl 3
|issue=
|pages=S27–38
|year=2007
|pmid=18192963
|doi=
|url=http://www.medreviews.com/pubmed.cfm?j=3&v=7Suppl3&i=&p=S27
}}</ref> Prescribed medications sometimes contain [[pain-killer]]s, such as [[morphine]] or [[codeine]], to counter the [[cramps]] that can accompany diarrhea.

==Evolutionary medicine==
According to two researchers into [[evolutionary medicine]], [[Randolph M. Nesse|Nesse]] and [[George C. Williams|Williams]],<ref>Nesse, R. M. Williams, G. C. (1994) 'Why We Get Sick: The New Science of Darwinian Medicine' (section,''Evolution and healing'', pp. 37–38) Vintage Books New York pp. ISBN 0-679-74674-9 </ref> diarrhea functions as an evolved expulsion defense mechanism. As a result, if it is stopped, there might be a delay in illness recovery. They cite in support of this argument research carried out by DuPont and Hornick that was published in the [[Journal of the American Medical Association]] (JAMA)<ref>DuPont, H. L. Hornick, R. B. (1973) "Adverse effect of lomotil therapy in shigellosis". JAMA. 226: 1525–1528 {{PMID|4587313}} </ref> showed that treating ''Shigella'' with the anti-diarrhea drug ([[Lomotil]]) caused people to stay [[fever]]ish twice as long as those not so treated. The researchers indeed themselves observed that: "Lomotil may be contraindicated in shigellosis. Diarrhea may represent a defense mechanism".

==See also==
* [[Constipation]]
* [[Drinking water]]
* [[Feces]]
* [[Steatorrhea]] (fatty diarrhea)
* [[Traveler's diarrhea]]
* [[Wilderness diarrhea]]
* [[Foodborne illness|Food poisoning]]
* [[Shigella]]
* [[Rotavirus]]
* [[ETEC]]

==Notes==
{{Refimprovesect|date=December 2007}}
{{reflist|2}}

== External links ==
{{wiktionarypar|diarrhea}}
*{{cite journal |author=Victora CG, Bryce J, Fontaine O, Monasch R |title=Reducing deaths from diarrhoea through oral rehydration therapy |journal=Bull. World Health Organ. |volume=78 |issue=10 |pages=1246–55 |year=2000 |pmid=11100619 |doi= |url=}}
*{{cite journal |author=Parashar UD, Bresee JS, Glass RI |title=The global burden of diarrhoeal disease in children |journal=Bull. World Health Organ. |volume=81 |issue=4 |pages=236 |year=2003 |pmid=12764488 |doi=10.1590/S0042-96862003000400003 |url=http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S0042-96862003000400003&lng=en&nrm=iso&tlng=en}}
*[http://www.cdc.gov/ncidod/dbmd/diseaseinfo/travelersdiarrhea_g.htm Travelers' Diarrhea]
*[http://rehydrate.org/diarrhoea/index.html Rehydration Project]

<!--spacing, please do not remove-->

{{Gastroenterology}}

[[Category:Gastroenterology]]
[[Category:Water-borne diseases]]
[[Category:Symptoms]]
[[Category:Digestive disease symptoms]]
[[Category:Conditions diagnosed by stool test]]

[[ang:Meteūtsiht]]
[[ar:إسهال]]
[[ast:Foria]]
[[ay:Jiphilla jaqukipata]]
[[bn:উদরাময়]]
[[zh-min-nan:Làu-sái]]
[[bg:Диария]]
[[ca:Diarrea]]
[[cs:Průjem]]
[[cy:Dolur rhydd]]
[[da:Diarre]]
[[de:Durchfall]]
[[dv:ބޭރަށް ހިންގުން]]
[[es:Diarrea]]
[[eo:Diareo]]
[[fa:اسهال‌]]
[[fr:Diarrhée]]
[[gd:Buinneach]]
[[gl:Diarrea]]
[[ko:설사]]
[[hi:अतिसार]]
[[hr:Proljev]]
[[id:Diare]]
[[is:Niðurgangur]]
[[it:Diarrea]]
[[he:שלשול]]
[[ku:سکچوون]]
[[la:Alvei profluvium]]
[[lt:Viduriavimas]]
[[hu:Hasmenés]]
[[ms:Diarea]]
[[nl:Diarree]]
[[ja:下痢]]
[[no:Diaré]]
[[nn:Diaré]]
[[oc:Diarrèa]]
[[pl:Biegunka]]
[[pt:Diarreia]]
[[ro:Diaree]]
[[qu:Q'icha]]
[[ru:Диарея]]
[[sq:Diarreja]]
[[scn:Cacaredda]]
[[simple:Diarrhea]]
[[sk:Hnačka]]
[[sl:Driska]]
[[ckb:سکچوون]]
[[sr:Дијареја]]
[[sh:Proljev]]
[[su:Diaré]]
[[fi:Ripuli]]
[[sv:Diarré]]
[[te:అతిసారం]]
[[tr:İshal]]
[[uk:Діарея]]
[[ur:اسہال]]
[[vi:Tiêu chảy]]
[[zh:腹瀉]]

Revision as of 01:40, 10 September 2009

For other uses, see Diarrhea (disambiguation).
See also: Gastroenteritis
Diarrhea
SpecialtyInfectious diseases, gastroenterology Edit this on Wikidata

In medicine, diarrhea (from the Greek, "diarrhoia" meaning "a flowing through"[1]), also spelled diarrhoea (see spelling differences), is the condition of having frequent loose or liquid bowel movements. Acute diarrhea is a common cause of death in developing countries and the second most common cause of infant deaths worldwide. The loss of fluids through diarrhea can cause severe dehydration which is one cause of death in diarrhea sufferers. Along with water, sufferers also lose dangerous amounts of important salts, electrolytes, and other nutrients.

Causes

See also: List of causes of diarrhea
Diagram of the human gastrointestinal tract.

Diarrhea commonly results from gastroenteritis caused by viral infections, parasites or bacterial toxins.[2] In sanitary living conditions where there is ample food and a supply of clean water, an otherwise healthy patient usually recovers from viral infections in a few days. However, for ill or malnourished individuals, diarrhea can lead to severe dehydration and can become life-threatening without treatment.[3]

Diarrhea can also be a symptom of more serious diseases, such as dysentery, cholera, or botulism, and can also be indicative of a chronic syndrome such as Crohn's disease or severe mushroom poisoning syndromes. Though appendicitis patients do not generally have violent diarrhea, it is a common symptom of a ruptured appendix. It is also an effect of severe radiation sickness.

Symptomatic treatment for diarrhea involves the patient consuming adequate amounts of water to replace that loss, preferably mixed with electrolytes to provide essential salts and some amount of nutrients. For many people, further treatment is unnecessary. The following types of diarrhea indicate medical supervision is required:

  • Diarrhea in infants
  • Moderate or severe diarrhea in young children;
  • Diarrhea associated with blood
  • Diarrhea that continues for more than two days;
  • Diarrhea that is associated with more general illness such as non-cramping abdominal pain, fever, weight loss, etc;
  • Diarrhea in travelers, since they are more likely to have exotic infections such as parasites;
  • Diarrhea in food handlers, because of the potential to infect others;
  • Diarrhea in institutions such as hospitals, child care centers, or geriatric and convalescent homes.

A severity score is used to aid diagnosis in children.[4]

Types of diarrhea

Secretory diarrhea

Secretory diarrhea means that there is an increase in the active secretion, or there is an inhibition of absorption. There is little to no structural damage. The most common cause of this type of diarrhea is a cholera toxin that stimulates the secretion of anions, especially chloride ions. Therefore, to maintain a charge balance in the lumen, sodium is carried with it, along with water. [5]

Osmotic diarrhea

Osmotic diarrhea occurs when too much water is drawn into the bowels. This can be the result of maldigestion (e.g., pancreatic disease or Coeliac disease), in which the nutrients are left in the lumen to pull in water. Osmotic diarrhea can also be caused by osmotic laxatives (which work to alleviate constipation by drawing water into the bowels). In healthy individuals, too much magnesium or vitamin C or undigested lactose can produce osmotic diarrhea and distention of the bowel. A person who does not have lactose intolerance can have difficulty absorbing lactose after an extraordinarily high intake of dairy products. In persons who do not have fructose malabsorption, excess fructose intake can still cause diarrhea. High-fructose foods that also have a high glucose content are more absorbable and less likely to cause diarrhea. Sugar alcohols such as sorbitol (often found in sugar-free foods) are difficult for the body to absorb and, in large amounts, may lead to osmotic diarrhea. [6]

Exudative diarrhea

Exudative diarrhea occurs with the presence of blood and pus in the stool. This occurs with inflammatory bowel diseases, such as Crohn's disease or ulcerative colitis, and other severe infections. [7]

Motility-related diarrhea is caused by the rapid movement of food through the intestines (hypermotility). If the food moves too quickly through the GI tract, there is not enough time for sufficient nutrients and water to be absorbed. This can be due to a vagotomy or diabetic neuropathy, or a complication of menstruation. Hyperthyroidism can produce hypermotility and lead to pseudodiarrhea and occasionally real diarrhea. Diarrhea can be treated with antimotility agents (such as loperamide).

Inflammatory diarrhea

Inflammatory diarrhea occurs when there is damage to the mucosal lining or brush border, which leads to a passive loss of protein-rich fluids, and a decreased ability to absorb these lost fluids. Features of all three of the other types of diarrhea can be found in this type of diarrhea. It can be caused by bacterial infections, viral infections, parasitic infections, or autoimmune problems such as inflammatory bowel diseases. It can also be caused by tuberculosis, colon cancer, and enteritis.

Dysentery

Generally, if there is blood visible in the stools, it is not diarrhea, but dysentery. The blood is trace of an invasion of bowel tissue. Dysentery is caused by an excess of water by a release of antidiuretic hormone from the posterior pituitary gland. Dysentery is a symptom of, among others, Shigella, Entamoeba histolytica, and Salmonella.

Infectious diarrhea

Main article: Infectious diarrhea

There are many causes of infectious diarrhea, which include viruses, bacteria and parasites. [8] Norovirus is the most common cause of viral diarrhea in adults, [9] but rotavirus is the most common cause in children under five years old. [10] Adenovirus types 40 and 41),[11] and astroviruses cause a significant number of infections.[12]

The bacterium campylobacter is a common cause of bacterial diarrhea, but infections by salmonellae, shigellae and some strains of Escherichia coli (E.coli) are frequent. [13] In the elderly, particularly those who have been treated with antibiotics for unrelated infections, a toxin produced by Clostridium difficile often causes severe diarrhea.[14]

Parasites do not often cause diarrhea except for the protozoan Giardia, which can cause chronic infections if these are not diagnosed and treated with drugs such as metronidazole, [15] and Entamoeba histolytica [16][17]

Malabsorption

Malabsorption is the inability to absorb food, mostly in the small bowel but also due to the pancreas.

Causes include celiac disease (intolerance to wheat, rye, and barley gluten, the protein of the grain), lactose intolerance (intolerance to milk sugar, common in non-Europeans), fructose malabsorption, pernicious anemia (impaired bowel function due to the inability to absorb vitamin B12), loss of pancreatic secretions (may be due to cystic fibrosis or pancreatitis), short bowel syndrome (surgically removed bowel), radiation fibrosis (usually following cancer treatment), and other drugs, including agents used in chemotherapy.

Inflammatory bowel disease

The two overlapping types here are of unknown origin:

  • Ulcerative colitis is marked by chronic bloody diarrhea and inflammation mostly affects the distal colon near the rectum.
  • Crohn's disease typically affects fairly well demarcated segments of bowel in the colon and often affects the end of the small bowel.

Irritable Bowel Syndrome

Main article: Irritable Bowel Syndrome

Another possible cause of diarrhea is Irritable Bowel Syndrome (IBS). Symptoms defining IBS: abdominal discomfort or pain relieved by defecation and unusual stool (diarrhea or constipation or both) or stool frequency, for at least 3 days a week over the previous 3 months.[18] IBS symptoms can be present in patients with a variety of conditions including food allergies, infective diarrhea, celiac, and inflammatory bowel diseases. Treating the underlying condition (celiac disease, food allergy, bacterial dysbiosis, etc.) usually resolves the diarrhea.[19] IBS can cause visceral hypersensitivity. While there is no direct treatment for undifferentiated IBS, symptoms, including diarrhea, can sometimes be managed through a combination of dietary changes, soluble fiber supplements, and/or medications.

It is important to note that IBS can often be confused with Giardiasis since false negative tests for giardia can result in a misdiagnoses of the actual cause, a parasitic infection.[20]

Other important causes

  • Ischemic bowel disease. This usually affects older people and can be due to blocked arteries.
  • Bowel cancer: Some (but not all) bowel cancers may have associated diarrhea. Cancer of the large intestine is most common.
  • Hormone-secreting tumors: some hormones (e.g. serotonin) can cause diarrhea if excreted in excess (usually from a tumor).
  • Bile salt diarrhea: excess bile salt entering the colon rather than being absorbed at the end of the small intestine can cause diarrhea, typically shortly after eating. Bile salt diarrhea is a bad side-effect of gallbladder removal. It is usually treated with cholestyramine, a bile acid sequestrant.
  • Celiac Disease
  • Intestinal protozoa such as Giardiasis[20]

Alcohol

Chronic diarrhea can be caused by chronic ethanol ingestion.[21] Consumption of alcohol affects the body's capability to absorb water – this is often a symptom that accompanies a hangover after a binge drinking session. The alcohol itself is absorbed in the intestines and as the intestinal cells absorb it, the toxicity causes these cells to lose their ability to absorb water. This leads to an outpouring of fluid from the intestinal lining, which is in turn poorly absorbed. The diarrhea usually lasts for several hours until the alcohol is detoxified and removed from the digestive system. Symptoms range from person to person and are influenced by both the amount consumed as well as physiological differences.


Treatment

In many cases of diarrhea, replacing lost fluid and salts is the only treatment needed. This is usually by mouth – oral rehydration therapy – or, in very severe cases, intravenously.

Diet restriction such as limiting milk has no effect on the duration of diarrhea.[22] Medicines such loperamide (Imodium), bismuth subsalicylate (as found in Pepto Bismol and Kaopectate) may be beneficial, however they may be contraindicated in certain situations.[23] Prescribed medications sometimes contain pain-killers, such as morphine or codeine, to counter the cramps that can accompany diarrhea.

Evolutionary medicine

According to two researchers into evolutionary medicine, Nesse and Williams,[24] diarrhea functions as an evolved expulsion defense mechanism. As a result, if it is stopped, there might be a delay in illness recovery. They cite in support of this argument research carried out by DuPont and Hornick that was published in the Journal of the American Medical Association (JAMA)[25] showed that treating Shigella with the anti-diarrhea drug (Lomotil) caused people to stay feverish twice as long as those not so treated. The researchers indeed themselves observed that: "Lomotil may be contraindicated in shigellosis. Diarrhea may represent a defense mechanism".

See also

Notes

  1. ^ medterms dictionary. "Definition of Diarrhea". Medterms.com.
  2. ^ Wilson ME (2005). "Diarrhea in nontravelers: risk and etiology". Clin. Infect. Dis. 41 Suppl 8: S541–6. doi:10.1086/432949. PMID 16267716.
  3. ^ Alam NH, Ashraf H (2003). "Treatment of infectious diarrhea in children". Paediatr Drugs. 5 (3): 151–65. PMID 12608880.
  4. ^ Ruuska T, Vesikari T (1990). "Rotavirus disease in Finnish children: use of numerical scores for clinical severity of diarrhoeal episodes". Scand. J. Infect. Dis. 22 (3): 259–67. doi:10.3109/00365549009027046. PMID 2371542.
  5. ^ http://www.webmd.com/digestive-disorders/digestive-diseases-diarrhea
  6. ^ http://www.webmd.com/digestive-disorders/digestive-diseases-diarrhea
  7. ^ http://www.webmd.com/digestive-disorders/digestive-diseases-diarrhea
  8. ^ Navaneethan U, Giannella RA (2008). "Mechanisms of infectious diarrhea". Nature Clinical Practice. Gastroenterology & Hepatology. 5 (11): 637–47. doi:10.1038/ncpgasthep1264. PMID 18813221. {{cite journal}}: |access-date= requires |url= (help); Unknown parameter |month= ignored (help)
  9. ^ Patel MM, Hall AJ, Vinjé J, Parashar UD (2009). "Noroviruses: a comprehensive review". Journal of Clinical Virology : the Official Publication of the Pan American Society for Clinical Virology. 44 (1): 1–8. doi:10.1016/j.jcv.2008.10.009. PMID 19084472. {{cite journal}}: |access-date= requires |url= (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  10. ^ Greenberg HB, Estes MK (2009). "Rotaviruses: from pathogenesis to vaccination". Gastroenterology. 136 (6): 1939–51. doi:10.1053/j.gastro.2009.02.076. PMID 19457420. {{cite journal}}: |access-date= requires |url= (help); Unknown parameter |month= ignored (help)
  11. ^ Uhnoo I, Svensson L, Wadell G (1990). "Enteric adenoviruses". Baillière's Clinical Gastroenterology. 4 (3): 627–42. PMID 1962727. {{cite journal}}: |access-date= requires |url= (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  12. ^ Mitchell DK (2002). "Astrovirus gastroenteritis". The Pediatric Infectious Disease Journal. 21 (11): 1067–9. doi:10.1097/01.inf.0000036683.11146.c7. PMID 12442031. {{cite journal}}: |access-date= requires |url= (help); Unknown parameter |month= ignored (help)
  13. ^ Viswanathan VK, Hodges K, Hecht G (2009). "Enteric infection meets intestinal function: how bacterial pathogens cause diarrhoea". Nature Reviews. Microbiology. 7 (2): 110–9. doi:10.1038/nrmicro2053. PMID 19116615. {{cite journal}}: |access-date= requires |url= (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  14. ^ Rupnik M, Wilcox MH, Gerding DN (2009). "Clostridium difficile infection: new developments in epidemiology and pathogenesis". Nature Reviews. Microbiology. 7 (7): 526–36. doi:10.1038/nrmicro2164. PMID 19528959. {{cite journal}}: |access-date= requires |url= (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  15. ^ Kiser JD, Paulson CP, Brown C (2008). "Clinical inquiries. What's the most effective treatment for giardiasis?". The Journal of Family Practice. 57 (4): 270–2. PMID 18394362. Retrieved 2009-08-03. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  16. ^ Dans L, Martínez E (2006). "Amoebic dysentery". Clinical Evidence (15): 1007–13. PMID 16973041. {{cite journal}}: |access-date= requires |url= (help); Unknown parameter |month= ignored (help)
  17. ^ Gonzales ML, Dans LF, Martinez EG (2009). "Antiamoebic drugs for treating amoebic colitis". Cochrane Database of Systematic Reviews (Online) (2): CD006085. doi:10.1002/14651858.CD006085.pub2. PMID 19370624. {{cite journal}}: |access-date= requires |url= (help)CS1 maint: multiple names: authors list (link)
  18. ^ Longstreth GF, Thompson WG, Chey WD, Houghton LA, Mearin F, Spiller RC (2006). "Functional bowel disorders". Gastroenterology. 130 (5): 1480–91. doi:10.1053/j.gastro.2005.11.061. PMID 16678561.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  19. ^ Wangen, S. "The Irritable Bowel Syndrome Solution". page 113. 2006; Innate Health Publishing. ISBN 978-0-9768537-8-7. Excerpted with the author's permission at http://www.IBSTreatmentCenter.com
  20. ^ a b Intestinal Protozoa
  21. ^ Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL. Harrison's Principles of Internal Medicine. New York: McGraw-Hill, 2005. ISBN 0-07-139140-1.
  22. ^ "BestBets: Does Withholding milk feeds reduce the duration of diarrhoea in children with acute gastroenteritis?".
  23. ^ Schiller LR (2007). "Management of diarrhea in clinical practice: strategies for primary care physicians". Rev Gastroenterol Disord. 7 Suppl 3: S27–38. PMID 18192963.
  24. ^ Nesse, R. M. Williams, G. C. (1994) 'Why We Get Sick: The New Science of Darwinian Medicine' (section,Evolution and healing, pp. 37–38) Vintage Books New York pp. ISBN 0-679-74674-9
  25. ^ DuPont, H. L. Hornick, R. B. (1973) "Adverse effect of lomotil therapy in shigellosis". JAMA. 226: 1525–1528 PMID 4587313
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