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Diarrhea Differential Diagnoses

  • Author: Stefano Guandalini, MD; Chief Editor: Carmen Cuffari, MD  more...
 
Updated: Aug 19, 2015
 
 
 
Contributor Information and Disclosures
Author

Stefano Guandalini, MD Founder and Medical Director, Celiac Disease Center, Chief, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Chicago Medical Center; Professor, Department of Pediatrics, Section of Gastroenterology, Hepatology and Nutrition, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

Stefano Guandalini, MD is a member of the following medical societies: American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, European Society for Paediatric Gastroenterology, Hepatology & Nutrition, North American Society for the Study of Celiac Disease

Disclosure: Received consulting fee from AbbVie for consulting.

Coauthor(s)

Richard E Frye, MD, PhD Associate Professor, Department of Pediatrics, University of Arkansas for Medical Sciences

Richard E Frye, MD, PhD is a member of the following medical societies: American Academy of Neurology, Child Neurology Society, International Neuropsychological Society, American Academy of Pediatrics

Disclosure: Nothing to disclose.

M Akram Tamer, MD Professor, Program Director, Department of Pediatrics, University of Miami, Leonard M Miller School of Medicine

M Akram Tamer, MD is a member of the following medical societies: American Medical Association, Florida Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Carmen Cuffari, MD Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine

Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, Royal College of Physicians and Surgeons of Canada

Disclosure: Received honoraria from Prometheus Laboratories for speaking and teaching; Received honoraria from Abbott Nutritionals for speaking and teaching.

Additional Contributors

Chris A Liacouras, MD Director of Pediatric Endoscopy, Division of Gastroenterology and Nutrition, Children's Hospital of Philadelphia; Associate Professor of Pediatrics, University of Pennsylvania School of Medicine

Chris A Liacouras, MD is a member of the following medical societies: American Gastroenterological Association

Disclosure: Nothing to disclose.

References
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  7. Mehal JM, Esposito DH, Holman RC, Tate JE, Sinden LL, Parashar UD. Risk Factors for Diarrhea-Associated Infant Mortality in the United States, 2005-2007. Pediatr Infect Dis J. 2012 Mar 9. [Medline].

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  9. Guarino A, Albano F, Ashkenazi S, et al. European Society for Paediatric Gastroenterology, Hepatology, and Nutrition/European Society for Paediatric Infectious Diseases evidence-based guidelines for the management of acute gastroenteritis in children in Europe: executive summary. J Pediatr Gastroenterol Nutr. 2008 May. 46(5):619-21. [Medline].

  10. [Guideline] Atia AN, Buchman AL. Oral rehydration solutions in non-cholera diarrhea: a review. Am J Gastroenterol. 2009 Oct. 104(10):2596-604; quiz 2605. [Medline].

  11. Guandalini S. Probiotics for prevention and treatment of diarrhea. J Clin Gastroenterol. 2011 Nov. 45 Suppl:S149-53. [Medline].

  12. Ruiz-Palacios GM, Perez-Schael I, Velazquez FR, et al. Safety and efficacy of an attenuated vaccine against severe rotavirus gastroenteritis. N Engl J Med. 2006 Jan 5. 354(1):11-22. [Medline]. [Full Text].

  13. Soares-Weiser K, MacLehose H, Bergman H, Ben-Aharon I, Nagpal S, Goldberg E, et al. Vaccines for preventing rotavirus diarrhoea: vaccines in use. Cochrane Database of Systematic Reviews. 2012.

  14. Platts-Mills JA, Babji S, Bodhidatta L, et al. Pathogen-specific burdens of community diarrhoea in developing countries: a multisite birth cohort study (MAL-ED). Lancet Glob Health. 2015 Sep. 3 (9):e564-75. [Medline].

  15. Abubakar I, Aliyu SH, Arumugam C, Usman NK, Hunter PR. Treatment of cryptosporidiosis in immunocompromised individuals: systematic review and meta-analysis. Br J Clin Pharmacol. 2007 Apr. 63(4):387-93. [Medline].

  16. Barclay L. Zinc supplements reduce diarrhea in children. Medscape Medical News. May 15, 2014. [Full Text].

  17. Bellemare S, Hartling L, Wiebe N, et al. Oral rehydration versus intravenous therapy for treating dehydration due to gastroenteritis in children: a meta-analysis of randomised controlled trials. BMC Med. 2004 Apr 15. 2:11. [Medline]. [Full Text].

  18. Bryce J, Boschi-Pinto C, Shibuya K, Black RE,. WHO estimates of the causes of death in children. Lancet. 2005 Mar 26-Apr 1. 365(9465):1147-52. [Medline].

  19. Charles MD, Holman RC, Curns AT, et al. Hospitalizations associated with rotavirus gastroenteritis in the United States, 1993-2002. Pediatr Infect Dis J. 2006 Jun. 25(6):489-93. [Medline].

  20. Coffin SE, Elser J, Marchant C, et al. Impact of acute rotavirus gastroenteritis on pediatric outpatient practices in the United States. Pediatr Infect Dis J. 2006 Jul. 25(7):584-9. [Medline].

  21. Girard MP, Steele D, Chaignat CL, Kieny MP. A review of vaccine research and development: human enteric infections. Vaccine. 2006 Apr 5. 24(15):2732-50. [Medline].

  22. Guandalini S. Treatment of acute diarrhea in the new millennium. J Pediatr Gastroenterol Nutr. 2000 May. 30(5):486-9. [Medline].

  23. Guandalini S, Dincer AP. Nutritional management in diarrhoeal disease. Baillieres Clin Gastroenterol. 1998 Dec. 12(4):697-717. [Medline].

  24. Guandalini S, Kahn S. Acute diarrhea. Walker A, Goulet O, Kleinman J, et al eds. Pediatric Gastrointestinal Disease. Ontario, Canada: Brian C. Decker; 2008. Vol 1: 252-64/Chapter 15.

  25. Matson DO, Staat MA, Azimi P, Itzler R, Bernstein DI, Ward RL, et al. Burden of rotavirus hospitalisations in young children in three paediatric hospitals in the United States determined by active surveillance compared to standard indirect methods. J Paediatr Child Health. 2012 Apr 25. [Medline].

  26. Mayo-Wilson E, Junior JA, Imdad A, Dean S, Chan XH, Chan ES, et al. Zinc supplementation for preventing mortality, morbidity, and growth failure in children aged 6 months to 12 years of age. Cochrane Database Syst Rev. 2014 May 15. 5:CD009384. [Medline].

  27. Miller RC, Petereit DG, Sloan JA, et al. A phase III randomized study of sulfasalazine versus placebo in the prevention of acute diarrhea in patients receiving pelvic radiation therapy [abstract LBA2]. Presented at American Society for Radiation Oncology (ASTRO) 55th Annual Meeting; September 22, 2013; Atlanta, Georgia.

  28. Mulcahy N. Recommended drug may cause diarrhea with radiation. October 3, 2013. Medscape Medical News. Available at http://www.medscape.com/viewarticle/812057. Accessed: October 7, 2013.

  29. Sandhu BK, Isolauri E, Walker-Smith JA, et al. A multicentre study on behalf of the European Society of Paediatric Gastroenterology and Nutrition Working Group on Acute Diarrhoea. Early feeding in childhood gastroenteritis. J Pediatr Gastroenterol Nutr. 1997 May. 24(5):522-7. [Medline].

  30. Sullivan PB. Nutritional management of acute diarrhea. Nutrition. 1998 Oct. 14(10):758-62. [Medline].

  31. [Guideline] Walker-Smith JA, Sandhu BK, Isolauri E, et al. Guidelines prepared by the ESPGAN Working Group on Acute Diarrhoea. Recommendations for feeding in childhood gastroenteritis. European Society of Pediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr. 1997 May. 24(5):619-20. [Medline].

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Table 1. Stool Characteristics and Determining Their Source
Stool CharacteristicsSmall BowelLarge Bowel
AppearanceWateryMucoid and/or bloody
VolumeLargeSmall
FrequencyIncreasedHighly increased
BloodPossibly positive but never gross bloodCommonly grossly bloody
pHPossibly < 5.5>5.5
Reducing substancesPossibly positiveNegative
WBCs< 5/high power fieldCommonly >10/high power field
Serum WBCsNormalPossible leukocytosis, bandemia
OrganismsViral
  • Rotavirus
  • Adenovirus
  • Calicivirus
  • Astrovirus
  • Norovirus
Invasive bacteria
  • Escherichia Coli (enteroinvasive, enterohemorrhagic)
  • Shigella species
  • Salmonella species
  • Campylobacter species
  • Yersinia species
  • Aeromonas species
  • Plesiomonas species
Enterotoxigenic bacteria
  • E coli
  • Klebsiella
  • Clostridium perfringens
  • Cholera species
  • Vibrio species
Toxic bacteria
  • Clostridium difficile
Parasites
  • Giardia species
  • Cryptosporidium species
Parasites
  • Entamoeba organisms
Table 2. Organisms and Frequency of Symptoms
OrganismIncubationDurationVomitingFeverAbdominal Pain
Rotavirus1-7 d4-8 dYesLowNo
Adenovirus8-10 d5-12 dDelayedLowNo
Norovirus1-2 d2 dYesNoNo
Astrovirus1-2 d4-8 d+/-+/-No
Calicivirus1-4 d4-8 dYes+/-No
Aeromonas speciesNone0-2 wk+/-+/-No
Campylobacter species2-4 d5-7 dNoYesYes
C difficileVariableVariableNoFewFew
C perfringensMinimal1 dMildNoYes
Enterohemorrhagic E coli1-8 d3-6 dNo+/-Yes
Enterotoxigenic E coli1-3 d3-5 dYesLowYes
Plesiomonas speciesNone0-2 wk+/-+/-+/-
Salmonella species0-3 d2-7 dYesYesYes
Shigella species0-2 d2-5 dNoHighYes
Vibrio species0-1 d5-7 dYesNoYes
Y enterocoliticaNone1-46 dYesYesYes
Giardia species2 wk1+ wkNoNoYes
Cryptosporidium species5-21 dMonthsNoLowYes
Entamoeba species5-7 d1-2+ wkNoYesNo
Table 3. Dehydration Severity, Signs, and Symptoms
Hydration0-5% Dehydration



(Mild)



5-10% Dehydration



(Moderate)



10% or More



(Severe)



GeneralWellRestlessLethargic
EyesNormalSunkenVery sunken
TearsPresentAbsentAbsent
MouthMoistDryVery dry
ThirstDrinks normallyThirstyDrinks poorly
SkinPinch retracts immediatelyPinch retracts slowlyPinch stays folded
Table 4. Common Bacteria and Optimum Culture Mediums
OrganismDetection MethodMicrobiologic Characteristics
Aeromonas speciesBlood agarOxidase-positive flagellated gram-negative bacillus (GNB)
Campylobacter speciesSkirrow agarRapidly motile curved gram-negative rod (GNR); Campylobacter jejuni 90% and Campylobacter coli 5% of infections
C difficileCycloserine-cefoxitin-fructose-egg (CCFE) agar; enzyme immunoassay (EIA) for toxin; latex agglutination (LA) for proteinAnaerobic spore-forming gram-positive rod (GPR); toxin-mediated diarrhea; produces pseudomembranous colitis
C perfringensNone availableAnaerobic spore-forming GPR; toxin-mediated diarrhea
E coliMacConkey eosin-methylene blue (EMB) or Sorbitol-MacConkey (SM) agarLactose-producing GNR
Plesiomonas speciesBlood agarOxidase-positive GNR
Salmonella speciesBlood, MacConkey EMB, xylose-lysine-deoxycholate (XLD), or Hektoen enteric (HE) agarNonlactose non–H2S-producing GNR
Table 5. Probiotic Efficacy in Diarrhea
ConditionPatients and ControlsMost-Studied ProbioticsEvidence of Efficacy



(- to +++)



Prevention of Daycare Diarrhea2000Lactobacillus GG



Bifidobacterium lactis



Lactobacillus reuteri



Lactobacillus casei



Bifidobacterium bifidum + Streptococcus thermophilus



+
Prevention of Nosocomial Diarrhea1000Lactobacillus GG++
Prevention of Antibiotic-Associated Diarrhea2000Lactobacillus GG



Saccharomyces boulardii



+++
Infectious Diarrhea3500Lactobacillus GG



Saccharomyces boulardii



+++
Persistent Diarrhea460Lactobacillus GG+
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