Post Category → International Medicine

Acute Diarrhea (in developing countries)

A clinic near JalapaHPI:

1yo M, ex-term, previously healthy, with 8d tactile fever/diarrhea, initially watery, presenting now due to bloody diarrhea x1d. Mother reports 8-10 episodes/day, decreased PO intake and urine output x4d and changes in behavior (lethargy, irritability). No vomiting, no e/o abdominal pain, no cough, no seizures, no weight loss, no known sick contacts.

PMH:

  • Full term
  • No perinatal complications
  • Vaccination history unknown

SHx:

  • Meeting all developmental milestones
  • No sick contacts

PSH/FH/Meds/Allergies:

None

Physical Exam:

  • VS:   HR 135    BP 86/60    RR 24    T N/A    Wt 11kg (60%)
  • General: Patient was initially examined after initial rehydration with IVF. Well-appearing child, interactive and smiling.
  • HEENT: NC/AT, PERRL, MMM no lesions, no nuchal rigidity
  • CV: RRR, normal S1/S2
  • Lungs: CTAB
  • Abd: +BS, soft, NT/ND, no rebound/guarding
  • Ext: Warm, well-perfused, 2+ peripheral pulses (radial, DP, PT), capillary refill <2s
  • Skin: No visible skin lesions
  • Neuro: Alert and responsive

Assessment/Plan:

1yo healthy male with fever, bloody diarrhea and history consistent with dehydration. Most likely cause of acute diarrhea in this patient is infectious, particularly Shigella spp given presence of blood. Other concerning causes of diarrhea in this patient with reports of fever and changes in mental status include a serious bacterial illness (meningitis, pneumonia, UTI), however, these are less likely given the predominant, voluminous diarrhea and absence of symptoms associated with each. Other considerations include appendicitis, volvulus, intussusception, however again copious diarrhea in association with a benign abdominal exam makes these causes less likely. Early presentation of chronic diarrhea cannot be ruled out, however unlikely given association with fever and local prevalence of infectious causes.

Management included IV rehydration, followed by maintenance with PO ORS, early nutritional support, and ciprofloxacin 15mg/kg IV q12h.

Types and causes of acute diarrhea: 1, 2

Types and Causes of Acute Diarrhea

Assessment of Hydration Status

 

Dehydration Level
Variable/Sign Mild (3-5%) Moderate (6-9%) Severe (>10%)
General appearance Restless, alert Drowsy, postural hypotension Limp, cold, sweaty, cyanotic extremities
Radial pulse Normal rate, strength Rapid, weak Rapid, thready, sometimes impalpable
Respiration* Normal Deep Deep and rapid
Anterior fontanelle Normal Sunken Very sunken
SBP Normal Normal or low Low
Capillary refill* Normal (<2s) Prolonged (2-4s) Markedly prolonged (>4s)
Skin turgor* Normal Pinch retracts slowly Pinch retracts very slowly
Eyes Normal Sunken Grossly sunken
Tears Present Absent Absent
Mucous membranes Moist Dry Very Dry

* = sensitivity > 70% 3,4

Management of Acute Diarrhea: 5,6

Management of Acute Diarrhea

Pathogens causing diarrhea: 6

Pathogen Epidemiology/Transmission Comments Incubation Fever Abd. pain N/V Bloody stool Stool WBC Stool Heme
S. aureus, B. cereus Food poisoning with preformed toxin Vomiting > diarrhea 1-6h X – ✓ X X X
C. perfringens Spores germinate in meats, poultry 6-24h X – ✓ X X X
Norovirus Winter outbreaks in schools, nursing homes, cruise ships Adults: diarrhea

Children: vomiting

 1-2d – ✓ – X X X
Rotavirus #1 MCC children Vaccine available 1-2d – ✓ – X X X
Campylobacter #1 MCC invasive enterocolitis in US

Undercooked poultry

 GBS 2-5d ✓ ✓ – – ✓ –
Salmonella #2 MCC enterocolitis in US Outbreaks

Undercooked egg, dairy, poultry

 1-3d ✓ ✓ – – ✓ –
Shigella Community-acquired, person-to-person 1-3d ✓ ✓ ✓ – ✓ –
EIEC Outbreaks

Undercooked beef, raw seed sprouts

 Produces Shiga toxin 1-8d – ✓ – ✓ – ✓
C. difficile Nosocomial Leukocytosis – – X – ✓ –
E. histolytica Travel to tropical regions – – – – – ✓
Giardia Day care, waterborne transmission 1-3d X ✓ – X X X
Vibrio Contaminated water, seafood 1-3d – – – – – –
Yersinia Foodborne transmission Mesenteric lympadenitis (simulates acute appendicitis) 1-3d ✓ ✓ – – – –

References:

  1. Huilan, S., Zhen, L. G., Mathan, M. M., Mathew, M. M., Olarte, J., Espejo, R., Khin Maung, U., et al. (1991). Etiology of acute diarrhoea among children in developing countries: a multicentre study in five countries. Bulletin of the World Health Organization, 69(5), 549–555.
  2. Navaneethan, U., & Giannella, R. A. (2008). Mechanisms of infectious diarrhea. Nature clinical practice. Gastroenterology & hepatology, 5(11), 637–647. doi:10.1038/ncpgasthep1264
  3. Steiner, M. J., DeWalt, D. A., & Byerley, J. S. (2004). Is this child dehydrated? JAMA : the journal of the American Medical Association, 291(22), 2746–2754. doi:10.1001/jama.291.22.2746
  4. Gorelick, M. H., Shaw, K. N., & Murphy, K. O. (1997). Validity and reliability of clinical signs in the diagnosis of dehydration in children. Pediatrics, 99(5), E6.
  5. Harris, JB, Pietroni M. Approach to the child with acute diarrhea in developing countries. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2013.
  6. Thielman, N. M., & Guerrant, R. L. (2004). Clinical practice. Acute infectious diarrhea. The New England journal of medicine, 350(1), 38–47. doi:10.1056/NEJMcp031534