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''{{Otheruses}}
When you blow chunks out your bum bum
{{See also|Gastroenteritis}}
{{Infobox symptom |
Name = Diarrhea |
Image = Multiple rotavirus particles.jpg|
Caption = An electron micrograph of [[rotavirus]], the cause of nearly 40% of hospitalizations from diarrhea in children under 5.<ref name=WHO2010a/>|
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 |
}}

'''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''', is the condition of having three or more loose or liquid [[bowel movement]]s per day.<ref name=WHO2010>{{cite web |url=http://www.who.int/topics/diarrhoea/en/ |title=Diarrhoea |format= |work=World Health Organization |accessdate=}}</ref> It 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 [[dehydration]] and electrolyte imbalances. In 2009 diarrhea was estimated to have caused 1.1 million deaths in people aged 5 and over<ref>[http://www.straitstimes.com/Breaking%2BNews/Tech%2Band%2BScience/Story/STIStory_448440.html Straits Times:Diarrhoea kills 3 times more]</ref> and 1.5 million deaths in children under the age of 5.<ref name=WHO2010a>{{cite web |url=http://whqlibdoc.who.int/publications/2009/9789241598415_eng.pdf |title=whqlibdoc.who.int |format=pdf |work=[[World Health Organization]] |accessdate=}}</ref> [[Oral rehydration salts]] and zinc tablets are the treatment of choice and have been estimated to have saved 50 million children in the past 25 years.<ref name=WHO2010a/>

==Definition==
Diarrhea is defined by the [[World Health Organization]] as having 3 or more loose or liquid stools per day or as having more stools than is normal for that person.<ref name=WHO2010/>

===Secretory===
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. In this type of diarrhea intestinal fluid secretion is isotonic with plasma even during fasting .<ref name="webmd.com">http://www.webmd.com/digestive-disorders/digestive-diseases-diarrhea</ref>

===Osmotic===
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 has [[lactose intolerance]] can have difficulty absorbing lactose after an extraordinarily high intake of dairy products. In persons who have [[fructose malabsorption]], excess fructose intake can also 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 name="webmd.com"/>

===Exudative===
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 name="webmd.com"/>

===Motility-related===
[[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]]{{Citation needed|date=November 2009}}. [[Hyperthyroidism]] can produce hypermotility and lead to [[pseudodiarrhea]] and occasionally real diarrhea. Diarrhea can be treated with antimotility agents (such as [[loperamide]]). Hypermotility can be observed in patients who have had portions of their bowel removed, allowing less total time for absorption of nutrients.

===Inflammatory===
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. {{Citation needed|date=January 2010}}

===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 a symptom of, among others, ''[[Shigella]]'', ''[[Entamoeba histolytica]]'', and ''[[Salmonella]]''.

==Differential diagnosis==
{{See also|List of causes of diarrhea}}
[[File:Stomach colon rectum diagram.svg|right|thumb|Diagram of the human [[gastrointestinal tract]].]]

Diarrhea is most commonly due to viral [[gastroenteritis]] with [[rotavirus]] accounting for 40% of cases in children under five.<ref name=WHO2010a/>(p. 17) In [[traveler's diarrhea|travelers]] however [[bacterial infections]] predominate.<ref>{{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 |month=December |pmid=16267716 |doi=10.1086/432949 |url=}}</ref>

It can also be the part of the presentations of a number of medical conditions such as: [[Crohn's disease]] or [[Amanita phalloides#Symptoms|mushroom poisoning]].

===Infections===
{{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 = 10.1016/0950-3528(90)90053-J| 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 | doi_brokendate = 2009-12-18}}</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>

Other infectious agents such as [[parasites]] and [[bacterium|bacteria]]l toxins also occur.<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 |month=December |pmid=16267716 |doi=10.1086/432949 |url=}}</ref> In sanitary living conditions where there is ample food and a supply of clean water, an otherwise healthy person 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.<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= |url=}}</ref>

===Malabsorption===
{{Main|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===
{{Main|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) which usually presents with abdominal discomfort relieved by defecation and unusual stool (diarrhea or [[constipation]]) 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> There is no direct treatment for IBS, however symptoms can be managed through a combination of dietary changes, soluble fiber supplements, and/or medications.

===Other causes===
*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>
*[[Ischemia|Ischemic]] bowel disease. This usually affects older people and can be due to blocked arteries.
*Hormone-secreting tumors: some hormones (e.g., [[serotonin]]) can cause diarrhea if excreted in excess (usually from a tumor).

==Pathophysiology==
===Evolution===
According to two researchers, [[Randolph M. Nesse|Nesse]] and [[George C. Williams|Williams]], diarrhea may function as an evolved expulsion defense mechanism. As a result, if it is stopped, there might be a delay in recovery.<ref>{{cite book |author=Williams, George; Nesse, Randolph M. |title=Why we get sick: the new science of Darwinian medicine |publisher=Vintage Books |location=New York |year=1996 |pages=36-38 |isbn=0-679-74674-9 |oclc= |doi= |accessdate=}}</ref> They cite in support of this argument research published in 1973 which found 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".<ref>{{cite journal |author=DuPont HL, Hornick RB |title=Adverse effect of lomotil therapy in shigellosis |journal=JAMA |volume=226 |issue=13 |pages=1525–8 |year=1973 |month=December |pmid=4587313 |doi= |url=}}</ref>

==Diagnostic approach==
The following types of diarrhea may indicate further investigation is needed:

*In infants
*Moderate or severe diarrhea in young children
*Associated with blood
*Continues for more than two days
*Associated non-cramping [[abdominal pain]], [[fever]], [[weight loss]], etc
*In [[Traveler's diarrhea|travelers]]
*In food handlers, because of the potential to infect others;
*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>

==Prevention==
A [[rotavirus vaccine]] has the potential to decrease rates of diarrhea.<ref name=WHO2010a/>

==Management==
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 severe cases, [[intravenously]].<ref name=WHO2010a/> Diet restrictions such as the [[BRAT diet]] are no longer recommended.<ref>{{cite journal |author=King CK, Glass R, Bresee JS, Duggan C |title=Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy |journal=MMWR Recomm Rep |volume=52 |issue=RR-16 |pages=1–16 |year=2003 |month=November |pmid=14627948 |doi= |url=http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm}}</ref> Research does not support the limiting of milk to children as doing so has no effect on 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>

Medications such as [[loperamide]] (Imodium), [[bismuth subsalicylate]] 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=}}</ref>

===Medications===
;Antibiotics
While antibiotics are beneficial in certain type of acute diarrhea they are usually not used except in specific situations.<ref>{{cite journal |author=Dryden MS, Gabb RJ, Wright SK |title=Empirical treatment of severe acute community-acquired gastroenteritis with ciprofloxacin |journal=Clin. Infect. Dis. |volume=22 |issue=6 |pages=1019–25 |year=1996 |month=June |pmid=8783703 |doi= |url=}}</ref><ref name=CE08/> There are concerns that antibiotic may increase the risk of [[hemolytic uremic syndrome]] in people infected with [[Escherichia coli O157:H7]].<ref>{{cite journal |author=Wong CS, Jelacic S, Habeeb RL, Watkins SL, Tarr PI |title=The risk of the hemolytic-uremic syndrome after antibiotic treatment of Escherichia coli O157:H7 infections |journal=N. Engl. J. Med. |volume=342 |issue=26 |pages=1930–6 |year=2000 |month=June |pmid=10874060 |doi= |url=}}</ref> In resource poor countries treatment with antibiotics may be beneficial.<ref name=CE08>{{cite journal |author=de Bruyn G |title=Diarrhoea in adults (acute) |journal=Clin Evid (Online) |volume=2008 |issue= |pages= |year=2008 |pmid=19450323 |doi= |url=}}</ref>

;Anti motility agents
Anti motility agents like [[loperamide]] are effective at reducing the duration of diarrhea.<ref name=CE08/>

;Bismuth compounds
While bismuth compounds ([[Pepto-Bismol]]) decreased the number of bowel movements in those with travelers' diarrhea it does not decrease the length of illness.<ref>{{cite journal |author=DuPont HL, Ericsson CD, Farthing MJ, ''et al.'' |title=Expert review of the evidence base for self-therapy of travelers' diarrhea |journal=J Travel Med |volume=16 |issue=3 |pages=161–71 |year=2009 |pmid=19538576 |doi=10.1111/j.1708-8305.2009.00300.x |url=}}</ref> These agents should only be used if bloody diarrhea is not present.<ref>{{cite journal |author=Pawlowski SW, Warren CA, Guerrant R |title=Diagnosis and treatment of acute or persistent diarrhea |journal=Gastroenterology |volume=136 |issue=6 |pages=1874–86 |year=2009 |month=May |pmid=19457416 |doi=10.1053/j.gastro.2009.02.072 |url=}}</ref>

===Alternative therapies===
[[probiotic|Probiotics]] are bacterial supplements that can help prevent recurrence of diarrhea. The most widely used probiotics include [[lactobacillus]] and [[saccharomyces boulardii]]. For those who suffer from lactose intolerance, taking digestive [[enzyme|enzymes]] containing [[lactase]] when consuming dairy products is recommended.{{who|date=February 2010}}

==Epidemiology==
[[Image:Diarrhoeal diseases world map - DALY - WHO2004.svg|thumb|[[Disability-adjusted life year]] for diarrhea per 100,000&nbsp;inhabitants in 2004.<ref>{{cite web |url=http://www.who.int/entity/healthinfo/global_burden_disease/gbddeathdalycountryestimates2004.xls |title=Mortality and Burden of Disease Estimates for WHO Member States in 2004 |format=xls |work=[[World Health Organization]] |accessdate=}}</ref><div class="references-small" style="-moz-column-count:3; column-count:3;">
{{legend|#b3b3b3|no data}}
{{legend|#ffff65|<&nbsp;500}}
{{legend|#fff200|500-1000}}
{{legend|#ffdc00|1000-1500}}
{{legend|#ffc600|1500-2000}}
{{legend|#ffb000|2000-2500}}
{{legend|#ff9a00|2500-3000}}
{{legend|#ff8400|3000-3500}}
{{legend|#ff6e00|3500-4000}}
{{legend|#ff5800|4000-4500}}
{{legend|#ff4200|4500-5000}}
{{legend|#ff2c00|5000-6000}}
{{legend|#cb0000|>&nbsp;6000}}
</div>]]

World wide in 2004 approximately 2.5 billion cases of diarrhea occurred which results in 1.5 million deaths among children under the age of five.<ref name=WHO2010a/> Greater than half of these were in Africa and South Asia.<ref name=WHO2010a/> This is down from a death rate of 5 million per year two decades ago.<ref name=WHO2010a/> Diarrhea remains the second leading cause of death (16%) after [[pneumonia]] (17%) in this age group.<ref name=WHO2010a/>

==References==
{{reflist|2}}

==External links==
{{sisterlinks|display=Diarrhea}}

*[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}}
{{Digestive system and abdomen symptoms and signs}}

[[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]]
[[kk:Тышқақ]]
[[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 05:20, 28 February 2010

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

Diarrhea (from the Greek, "diarrhoia" meaning "a flowing through"[2]), also spelled diarrhoea, is the condition of having three or more loose or liquid bowel movements per day.[3] It 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 dehydration and electrolyte imbalances. In 2009 diarrhea was estimated to have caused 1.1 million deaths in people aged 5 and over[4] and 1.5 million deaths in children under the age of 5.[1] Oral rehydration salts and zinc tablets are the treatment of choice and have been estimated to have saved 50 million children in the past 25 years.[1]

Definition

Diarrhea is defined by the World Health Organization as having 3 or more loose or liquid stools per day or as having more stools than is normal for that person.[3]

Secretory

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. In this type of diarrhea intestinal fluid secretion is isotonic with plasma even during fasting .[5]

Osmotic

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 has lactose intolerance can have difficulty absorbing lactose after an extraordinarily high intake of dairy products. In persons who have fructose malabsorption, excess fructose intake can also 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.[5]

Exudative

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.[5]

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[citation needed]. Hyperthyroidism can produce hypermotility and lead to pseudodiarrhea and occasionally real diarrhea. Diarrhea can be treated with antimotility agents (such as loperamide). Hypermotility can be observed in patients who have had portions of their bowel removed, allowing less total time for absorption of nutrients.

Inflammatory

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. [citation needed]

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 a symptom of, among others, Shigella, Entamoeba histolytica, and Salmonella.

Differential diagnosis

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

Diarrhea is most commonly due to viral gastroenteritis with rotavirus accounting for 40% of cases in children under five.[1](p. 17) In travelers however bacterial infections predominate.[6]

It can also be the part of the presentations of a number of medical conditions such as: Crohn's disease or mushroom poisoning.

Infections

Main article: Infectious diarrhea

There are many causes of infectious diarrhea, which include viruses, bacteria and parasites.[7] Norovirus is the most common cause of viral diarrhea in adults,[8] but rotavirus is the most common cause in children under five years old.[9] Adenovirus types 40 and 41,[10] and astroviruses cause a significant number of infections.[11]

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.[12] In the elderly, particularly those who have been treated with antibiotics for unrelated infections, a toxin produced by Clostridium difficile often causes severe diarrhea.[13]

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,[14] and Entamoeba histolytica.[15][16]

Other infectious agents such as parasites and bacterial toxins also occur.[17] In sanitary living conditions where there is ample food and a supply of clean water, an otherwise healthy person 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.[18]

Malabsorption

Main article: 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

Main article: 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) which usually presents with abdominal discomfort relieved by defecation and unusual stool (diarrhea or constipation) for at least 3 days a week over the previous 3 months.[19] There is no direct treatment for IBS, however symptoms can be managed through a combination of dietary changes, soluble fiber supplements, and/or medications.

Other causes

  • Diarrhea can be caused by chronic ethanol ingestion.[20]
  • Ischemic bowel disease. This usually affects older people and can be due to blocked arteries.
  • Hormone-secreting tumors: some hormones (e.g., serotonin) can cause diarrhea if excreted in excess (usually from a tumor).

Pathophysiology

Evolution

According to two researchers, Nesse and Williams, diarrhea may function as an evolved expulsion defense mechanism. As a result, if it is stopped, there might be a delay in recovery.[21] They cite in support of this argument research published in 1973 which found 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".[22]

Diagnostic approach

The following types of diarrhea may indicate further investigation is needed:

  • In infants
  • Moderate or severe diarrhea in young children
  • Associated with blood
  • Continues for more than two days
  • Associated non-cramping abdominal pain, fever, weight loss, etc
  • In travelers
  • In food handlers, because of the potential to infect others;
  • In institutions such as hospitals, child care centers, or geriatric and convalescent homes.

A severity score is used to aid diagnosis in children.[23]

Prevention

A rotavirus vaccine has the potential to decrease rates of diarrhea.[1]

Management

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 severe cases, intravenously.[1] Diet restrictions such as the BRAT diet are no longer recommended.[24] Research does not support the limiting of milk to children as doing so has no effect on duration of diarrhea.[25]

Medications such as loperamide (Imodium), bismuth subsalicylate may be beneficial, however they may be contraindicated in certain situations.[26]

Medications

Antibiotics

While antibiotics are beneficial in certain type of acute diarrhea they are usually not used except in specific situations.[27][28] There are concerns that antibiotic may increase the risk of hemolytic uremic syndrome in people infected with Escherichia coli O157:H7.[29] In resource poor countries treatment with antibiotics may be beneficial.[28]

Anti motility agents

Anti motility agents like loperamide are effective at reducing the duration of diarrhea.[28]

Bismuth compounds

While bismuth compounds (Pepto-Bismol) decreased the number of bowel movements in those with travelers' diarrhea it does not decrease the length of illness.[30] These agents should only be used if bloody diarrhea is not present.[31]

Alternative therapies

Probiotics are bacterial supplements that can help prevent recurrence of diarrhea. The most widely used probiotics include lactobacillus and saccharomyces boulardii. For those who suffer from lactose intolerance, taking digestive enzymes containing lactase when consuming dairy products is recommended.[who?]

Epidemiology

Disability-adjusted life year for diarrhea per 100,000 inhabitants in 2004.[32]
  no data
  < 500
  500-1000
  1000-1500
  1500-2000
  2000-2500
  2500-3000
  3000-3500
  3500-4000
  4000-4500
  4500-5000
  5000-6000
  > 6000

World wide in 2004 approximately 2.5 billion cases of diarrhea occurred which results in 1.5 million deaths among children under the age of five.[1] Greater than half of these were in Africa and South Asia.[1] This is down from a death rate of 5 million per year two decades ago.[1] Diarrhea remains the second leading cause of death (16%) after pneumonia (17%) in this age group.[1]

References

  1. ^ a b c d e f g h i j "whqlibdoc.who.int" (pdf). World Health Organization.
  2. ^ medterms dictionary. "Definition of Diarrhea". Medterms.com.
  3. ^ a b "Diarrhoea". World Health Organization.
  4. ^ Straits Times:Diarrhoea kills 3 times more
  5. ^ a b c http://www.webmd.com/digestive-disorders/digestive-diseases-diarrhea
  6. ^ Wilson ME (2005). "Diarrhea in nontravelers: risk and etiology". Clin. Infect. Dis. 41 Suppl 8: S541–6. doi:10.1086/432949. PMID 16267716. {{cite journal}}: Unknown parameter |month= ignored (help)
  7. ^ 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)
  8. ^ 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)
  9. ^ 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)
  10. ^ Uhnoo I, Svensson L, Wadell G (1990). "Enteric adenoviruses". Baillière's Clinical Gastroenterology. 4 (3): 627–42. doi:10.1016/0950-3528(90)90053-J. PMID 1962727. {{cite journal}}: |access-date= requires |url= (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  11. ^ 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 |doi_brokendate= ignored (|doi-broken-date= suggested) (help); Unknown parameter |month= ignored (help)
  12. ^ 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)
  13. ^ 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)
  14. ^ 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)
  15. ^ 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)
  16. ^ 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)
  17. ^ Wilson ME (2005). "Diarrhea in nontravelers: risk and etiology". Clin. Infect. Dis. 41 Suppl 8: S541–6. doi:10.1086/432949. PMID 16267716. {{cite journal}}: Unknown parameter |month= ignored (help)
  18. ^ Alam NH, Ashraf H (2003). "Treatment of infectious diarrhea in children". Paediatr Drugs. 5 (3): 151–65. PMID 12608880.
  19. ^ 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)
  20. ^ 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.
  21. ^ Williams, George; Nesse, Randolph M. (1996). Why we get sick: the new science of Darwinian medicine. New York: Vintage Books. pp. 36–38. ISBN 0-679-74674-9.{{cite book}}: CS1 maint: multiple names: authors list (link)
  22. ^ DuPont HL, Hornick RB (1973). "Adverse effect of lomotil therapy in shigellosis". JAMA. 226 (13): 1525–8. PMID 4587313. {{cite journal}}: Unknown parameter |month= ignored (help)
  23. ^ 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.
  24. ^ King CK, Glass R, Bresee JS, Duggan C (2003). "Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy". MMWR Recomm Rep. 52 (RR-16): 1–16. PMID 14627948. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  25. ^ "BestBets: Does Withholding milk feeds reduce the duration of diarrhoea in children with acute gastroenteritis?".
  26. ^ Schiller LR (2007). "Management of diarrhea in clinical practice: strategies for primary care physicians". Rev Gastroenterol Disord. 7 Suppl 3: S27–38. PMID 18192963.
  27. ^ Dryden MS, Gabb RJ, Wright SK (1996). "Empirical treatment of severe acute community-acquired gastroenteritis with ciprofloxacin". Clin. Infect. Dis. 22 (6): 1019–25. PMID 8783703. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  28. ^ a b c de Bruyn G (2008). "Diarrhoea in adults (acute)". Clin Evid (Online). 2008. PMID 19450323.
  29. ^ Wong CS, Jelacic S, Habeeb RL, Watkins SL, Tarr PI (2000). "The risk of the hemolytic-uremic syndrome after antibiotic treatment of Escherichia coli O157:H7 infections". N. Engl. J. Med. 342 (26): 1930–6. PMID 10874060. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  30. ^ DuPont HL, Ericsson CD, Farthing MJ; et al. (2009). "Expert review of the evidence base for self-therapy of travelers' diarrhea". J Travel Med. 16 (3): 161–71. doi:10.1111/j.1708-8305.2009.00300.x. PMID 19538576. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  31. ^ Pawlowski SW, Warren CA, Guerrant R (2009). "Diagnosis and treatment of acute or persistent diarrhea". Gastroenterology. 136 (6): 1874–86. doi:10.1053/j.gastro.2009.02.072. PMID 19457416. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  32. ^ "Mortality and Burden of Disease Estimates for WHO Member States in 2004" (xls). World Health Organization.


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