Differential Diagnoses

Appendicitis
Carcinoid Tumor
Giardiasis
Glucose-galactose malabsorption
Intestinal Enterokinase Deficiency
Intestinal Protozoal Diseases
Intussusception
Meckel Diverticulum Imaging
Microvillus Inclusion Disease
Pediatric Crohn Disease
Pediatric Hyperthyroidism
Pediatric Irritable Bowel Syndrome (IBS)
Pediatric Malabsorption Syndromes
Pediatric Short Bowel Syndrome
Protein Intolerance
Shigella Infection
Sinonasal Manifestations of Cystic Fibrosis
Ulcerative Colitis Imaging

Workup

King CK, Glass R, Bresee JS, Duggan C. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21. 52:1-16. [QxMD MEDLINE Link].
Fischer TK, Viboud C, Parashar U, Malek M, Steiner C, Glass R, et al. Hospitalizations and deaths from diarrhea and rotavirus among children J Infect Dis</i>. 2007 Apr 15. 195(8):1117-25. [QxMD MEDLINE Link].
Cortese MM, Tate JE, Simonsen L, Edelman L, Parashar UD. Reduction in gastroenteritis in United States children and correlation with early rotavirus vaccine uptake from national medical claims databases. Pediatr Infect Dis J. 2010 Jun. 29(6):489-94. [QxMD MEDLINE Link].
Talbert A, Thuo N, Karisa J, Chesaro C, Ohuma E, Ignas J, et al. Diarrhoea complicating severe acute malnutrition in kenyan children: a prospective descriptive study of risk factors and outcome. PLoS One. 2012. 7(6):e38321. [QxMD MEDLINE Link]. [Full Text].
Lubbert C, Zimmermann L, Borchert J, Horner B, Mutters R, Rodloff AC. Epidemiology and Recurrence Rates of Clostridium difficile Infections in Germany: A Secondary Data Analysis. Infect Dis Ther. 2016 Oct 21. [QxMD MEDLINE Link].
Esposito DH, Holman RC, Haberling DL, Tate JE, Podewils LJ, Glass RI, et al. Baseline estimates of diarrhea-associated mortality among United States children before rotavirus vaccine introduction. Pediatr Infect Dis J. 2011 Nov. 30(11):942-7. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. 2006 Jan. 25(1):2-7. [QxMD MEDLINE Link].
Heyman MB, Abrams SA, SECTION ON GASTROENTEROLOGY, HEPATOLOGY, AND NUTRITION., COMMITTEE ON NUTRITION. Fruit Juice in Infants, Children, and Adolescents: Current Recommendations. Pediatrics. 2017 May 22. [QxMD MEDLINE Link].
Yi J, Sederdahl BK, Wahl K, et al. Rotavirus and Norovirus in Pediatric Healthcare-Associated Gastroenteritis. Open Forum Infect Dis. 2016 Aug 30. 3 (4):ofw181. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
[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. [QxMD MEDLINE Link].
Kling J. Green Tea and Pomegranate Extract Help Fight Diarrhea in Children. Medscape Medical News. Available at http://www.medscape.com/viewarticle/833747. Accessed: October 24, 2014.
Guandalini S. Probiotics for prevention and treatment of diarrhea. J Clin Gastroenterol. 2011 Nov. 45 Suppl:S149-53. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link]. [Full Text].
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.
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Barclay L. Zinc supplements reduce diarrhea in children. Medscape Medical News. May 15, 2014. [Full Text].
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. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Guandalini S. Treatment of acute diarrhea in the new millennium. J Pediatr Gastroenterol Nutr. 2000 May. 30(5):486-9. [QxMD MEDLINE Link].
Guandalini S, Dincer AP. Nutritional management in diarrhoeal disease. Baillieres Clin Gastroenterol. 1998 Dec. 12(4):697-717. [QxMD MEDLINE Link].
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.
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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.
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.
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. [QxMD MEDLINE Link].
Sullivan PB. Nutritional management of acute diarrhea. Nutrition. 1998 Oct. 14(10):758-62. [QxMD MEDLINE Link].
[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. [QxMD MEDLINE Link].
Arasaradnam RP, Brown S, Forbes A, Fox MR, Hungin P, Kelman L, et al. Guidelines for the investigation of chronic diarrhoea in adults: British Society of Gastroenterology, 3rd edition. Gut. 2018 Apr 13. [QxMD MEDLINE Link].
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Table 1. Stool Characteristics and Determining Their Source

Stool Characteristics	Small Bowel	Large Bowel
Appearance	Watery	Mucoid and/or bloody
Volume	Large	Small
Frequency	Increased	Highly increased
Blood	Possibly positive but never gross blood	Commonly grossly bloody
pH	Possibly < 5.5	>5.5
Reducing substances	Possibly positive	Negative
WBCs	< 5/high power field	Commonly >10/high power field
Serum WBCs	Normal	Possible leukocytosis, bandemia
Organisms	Viral 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

Organism	Incubation	Duration	Vomiting	Fever	Abdominal Pain
Rotavirus	1-7 d	4-8 d	Yes	Low	No
Adenovirus	8-10 d	5-12 d	Delayed	Low	No
Norovirus	1-2 d	2 d	Yes	No	No
Astrovirus	1-2 d	4-8 d	+/-	+/-	No
Calicivirus	1-4 d	4-8 d	Yes	+/-	No
Aeromonas species	None	0-2 wk	+/-	+/-	No
Campylobacter species	2-4 d	5-7 d	No	Yes	Yes
C difficile	Variable	Variable	No	Few	Few
C perfringens	Minimal	1 d	Mild	No	Yes
Enterohemorrhagic E coli	1-8 d	3-6 d	No	+/-	Yes
Enterotoxigenic E coli	1-3 d	3-5 d	Yes	Low	Yes
Plesiomonas species	None	0-2 wk	+/-	+/-	+/-
Salmonella species	0-3 d	2-7 d	Yes	Yes	Yes
Shigella species	0-2 d	2-5 d	No	High	Yes
Vibrio species	0-1 d	5-7 d	Yes	No	Yes
Y enterocolitica	None	1-46 d	Yes	Yes	Yes
Giardia species	2 wk	1+ wk	No	No	Yes
Cryptosporidium species	5-21 d	Months	No	Low	Yes
Entamoeba species	5-7 d	1-2+ wk	No	Yes	No

Table 3. Dehydration Severity, Signs, and Symptoms

Hydration	0-5% Dehydration (Mild)	5-10% Dehydration (Moderate)	10% or More (Severe)
General	Well	Restless	Lethargic
Eyes	Normal	Sunken	Very sunken
Tears	Present	Absent	Absent
Mouth	Moist	Dry	Very dry
Thirst	Drinks normally	Thirsty	Drinks poorly
Skin	Pinch retracts immediately	Pinch retracts slowly	Pinch stays folded

Table 4. Common Bacteria and Optimum Culture Mediums

Organism	Detection Method	Microbiologic Characteristics
Aeromonas species	Blood agar	Oxidase-positive flagellated gram-negative bacillus (GNB)
Campylobacter species	Skirrow agar	Rapidly motile curved gram-negative rod (GNR); Campylobacter jejuni 90% and Campylobacter coli 5% of infections
C difficile	Cycloserine-cefoxitin-fructose-egg (CCFE) agar; enzyme immunoassay (EIA) for toxin; latex agglutination (LA) for protein	Anaerobic spore-forming gram-positive rod (GPR); toxin-mediated diarrhea; produces pseudomembranous colitis
C perfringens	None available	Anaerobic spore-forming GPR; toxin-mediated diarrhea
E coli	MacConkey eosin-methylene blue (EMB) or Sorbitol-MacConkey (SM) agar	Lactose-producing GNR
Plesiomonas species	Blood agar	Oxidase-positive GNR
Salmonella species	Blood, MacConkey EMB, xylose-lysine-deoxycholate (XLD), or Hektoen enteric (HE) agar	Nonlactose non–H2S-producing GNR

Table 5. Probiotic Efficacy in Diarrhea

Condition	Patients and Controls	Most-Studied Probiotics	Evidence of Efficacy (- to +++)
Prevention of Daycare Diarrhea	2000	Lactobacillus GG Bifidobacterium lactis Lactobacillus reuteri Lactobacillus casei Bifidobacterium bifidum + Streptococcus thermophilus	+
Prevention of Nosocomial Diarrhea	1000	Lactobacillus GG	++
Prevention of Antibiotic-Associated Diarrhea	2000	Lactobacillus GG Saccharomyces boulardii	+++
Infectious Diarrhea	3500	Lactobacillus GG Saccharomyces boulardii	+++
Persistent Diarrhea	460	Lactobacillus GG	+

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Author

Stefano Guandalini, MD, AGAF Founder and Director Emeritus, Celiac Disease Center, University of Chicago; Former Chief, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Chicago Medicine; Professor Emeritus, The University of Chicago Pritzker School of Medicine

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

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Imaware.health.

Coauthor(s)

Richard E Frye, MD, PhD Professor of Child Health, University of Arizona College of Medicine at Phoenix; Chief of Neurodevelopmental Disorders, Director of Autism and Down Syndrome and Fragile X Programs, Division of Neurodevelopmental Disorders, Department of Neurology, Barrow Neurological Institute at Phoenix Children's Hospital

Richard E Frye, MD, PhD is a member of the following medical societies: American Academy of Neurology, American Academy of Pediatrics, Child Neurology 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, 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. for: Abbott Nutritional, Abbvie, speakers' bureau.

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.

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