Diarrhea Differential Diagnoses

  • Author: Stefano Guandalini, MD; Chief Editor: Carmen Cuffari, MD   more...
 
Updated: Apr 26, 2012
 
 

Differential Diagnoses

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Contributor Information and Disclosures
Author

Stefano Guandalini, MD  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, European Society for Paediatric Gastroenterology, Hepatology & Nutrition, and North American Society for Pediatric Gastroenterology and Nutrition

Disclosure: Nothing to disclose.

Coauthor(s)

Richard E Frye, MD, PhD  Assistant Professor, Departments of Pediatrics and Neurology, University of Texas Medical School at Houston

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

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 and Florida Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

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 is a member of the following medical societies: American Gastroenterological Association

Disclosure: Nothing to disclose.

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.

Steven M Schwarz, MD, FAAP, FACN, AGAF  Professor of Pediatrics, Children's Hospital at Downstate, State University of New York Downstate Medical Center

Steven M Schwarz, MD, FAAP, FACN, AGAF is a member of the following medical societies: American Academy of Pediatrics, American College of Nutrition, American College of Physician Executives, American Gastroenterological Association, American Pediatric Society, Gastroenterology Research Group, New York Academy of Medicine, North American Society for Pediatric Gastroenterology and Nutrition, and Society for Pediatric Research

Disclosure: Curemark, LLC Consulting fee Board membership; Centocor, Inc. Grant/research funds Independent contractor; Johnson & Johnson, Inc. Grant/research funds Independent contractor

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, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

References

  1. Vernacchio L, Vezina RM, Mitchell AA, Lesko SM, Plaut AG, Acheson DW. Diarrhea in American infants and young children in the community setting: incidence, clinical presentation and microbiology. Pediatr Infect Dis J. Jan 2006;25(1):2-7. [Medline].

  2. King CK, Glass R, Bresee JS, Duggan C. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. Nov 21 2003;52:1-16. [Medline].

  3. 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. May 2008;46(5):619-21. [Medline].

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

  5. Guandalini S. Probiotics for children with diarrhea: an update. J Clin Gastroenterol. Jul 2008;42 Suppl 2:S53-7. [Medline].

  6. Guandalini S. Probiotics for children with diarrhea: an update. J Clin Gastroenterol. Jul 2008;42 Suppl 2:S53-7. [Medline].

  7. [Best Evidence] 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. Jan 5 2006;354(1):11-22. [Medline]. [Full Text].

  8. 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.

  9. 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. Apr 2007;63(4):387-93. [Medline].

  10. 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. Apr 15 2004;2:11. [Medline]. [Full Text].

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

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

  13. 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. Jul 2006;25(7):584-9. [Medline].

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

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

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

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

  18. 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. May 1997;24(5):522-7. [Medline].

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

  20. [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. May 1997;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. 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
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