Iin Novita Nurhidayati Mahmuda

FAKULTAS KEDOKTERAN UMS

Infectious
diarrhea
DIARRHEA
DEFINITION

Stool weight in excess of 200 grams per day.

A good working definition is three or more loose or watery

stools per day
A definite decrease in consistency and increase in frequency
based upon an individual baseline.

Diarrhea reflects increased water content of the stool,

whether due to impaired water absorption and/or active
water secretion by the bowel.
Intestinal Fluid Movement (water follows solutes)
 Diarrhea occurs when SB/colon solute
loads exceed their absorptive capacities.

Small
bowel

Colon

NORMAL DIARRHEA
DIARRHEA - Mechanisms
•Too much input

•Not enough absorption

•Combination of both
Mechanisms of Diarrhea
•Secretory Diarrhea
•Osmotic diarrhea/malabsorption
•Increased bowel motility
•Decreased bowel surface area
•Inflammation
Secretory Diarrhea - A problem of excess input of
electrolytes (NaCl) with water following.
Clinical Manifestations of
Secretory Diarrhea
•Large volume, watery diarrhea
•Little response to fasting
•Stool compositon is similar to plasma
• (high NaCl)
•Dehydration and plasma electrolyte imbalance are
common
•No WBC or RBC in stool
Causes of Intestinal Secretion
•Bacterial toxins
• Cholera, E. coli, Shigella, etc.
•Inflammatory mediators
• prostaglandins
•Circulating hormones
• Gastrin (Z-E syndrome), Vasoactive intestinal polypeptide (VIP)
Consequences of Large Volume
Diarrhea/Secretory Diarrhea
•Dehydration due to massive loss of fluid overwhelming
homeostatic mechanisms
•Electrolyte abnormalities
• Hypokalemia (loss of K in stools)
• Acidosis (loss of bicarbonate in stools)
• Hyponatremia (loss of Na in stools and oral intake of free water)
•Mild malabsorption due to rapid transit and dilution of
digestive enzymes
 Pathophysiology of Osmotic Diarrhea

Oral Input:
150 mmoles of
Stool Output:
600 ml volume
sorbitol
150 mmoles sorbitol
250 mls of volume
15 mmoles Na
= 600 mM
15 mmoles Cl
concentration
Clinical Manifestations of
Osmotic Diarrhea
•Moderate volume of stool
•Improves/disappears when oral intake stops
•Moderately watery/soft stool
•Often associated with increased flatus if due to
carbohydrate malabsorption (see malabsorption lecture)
•No WBC or RBC in stool
Examples of Osmotic Diarrhea
•Ingestion of non-absorbable compounds
• Magnesium salts
• Antacids (Mylanta)
• Laxatives (Milk of Magnesia)
• Sugars
• Lactulose, sorbitol, mannitol, fructose, lactose
•Malabsorption of specific carbohydrates
• Disaccharidase deficiency
•Generalized malabsorption of nutrients
Diarrhea Due to
Increased Bowel
Motility
Rapid intestinal motility
may result in diarrhea
due to reduced contact
time between luminal
contents and bowel
mucosa.

Examples include:
Anxiety
Hyperthyroidism
Irritable bowel syndrome
Postvagotomy diarrhea
(dumping syndrome)
Bowel infection (viral gastroenteritis)
Clues to Increased Bowel Motility
•Moderate diarrhea - usually watery
•Often occurs after meals - accentuated gastro-colic reflex
•No WBC, RBC in stool
•Recently eaten food visable in stools
•Louder bowel sounds often apparent
•No diagnostic tests- often must rule-out
secretory/osmotic/inflammatory causes
Consequences of Increased
Bowel Motility

•Malabsorption
• Nutrients (if small bowel is involved)
•Diarrhea and urgency
•Increased bowel sounds (if severe)
•Crampy abdominal pain (if severe)
Loss of Bowel Surface Area
•Functionally equivalent to increased bowel motility
•Underlying process causing loss of surface area may
produce additional symptoms/signs
•Causes include surgical resection, mucosal disease, fistulas
 Pig small intestinal villi before (A) and after (B) viral
gastroenteritis.
Viral infection temporarily destroys mature villus enterocytes
and can cause some malabsorption/secretion.
 Inflammation-induced diarrhea
Results from several mechanisms

1. Stimulated secretion and inhibited absorption

2. Stimulation of enteric nerves causing propulsive contractions and
stimulated secretion
3. Mucosal destruction and increased permeability
4. Nutrient maldigestion malabsorption
Clinical Manifestations of
Inflammatory Diarrhea
•Fever and systemic signs of inflammation (if
severe/invasive organism)
•Small to moderate volume of diarrhea
•Bloody diarrhea and/or WBC/RBC in stool
•except in mild inflammation like viral/microscopic colitis
•Often accompanied by rapid motility/abdominal
cramps
•Urgency/tenesmus if rectum is involved
Differential Diagnosis of
Inflammatory Diarrhea

•Infectious diarrhea
•viral, bacterial, parasitic
•Idiopathic inflammatory bowel disease
• Crohn’s disease, Ulcerative colitis
• microscopic colitis
•Response to ischemia/injury
Normal
air-contrast
barium enema
Air-contrast barium enema showing mucosal ulcerations and
inflammation in ulcerative colitis.
This reduces absorptive surface area.
Crohn’s Disease
of the Terminal
Ileum

Inflammation
damages the
mucosa,
reducing the
surface area
for absorption.
Clues to Inflammatory Diarrhea on Gram Stain:
Presence of WBC/RBC;

PMNs

RBCs
 Inflammation and Diarrhea
Normal Colon Ulcerative
Colitis/Shigella dysentry
ETIOLOGY
 Non infectious
•Drugs
•Food allergies, food intolerance
•Gastrointestinal diseases such as inflammatory bowel
disease, Celiac disease
•Other disease states such as thyrotoxicosis, HIV and the
carcinoid syndrome.
Small bowel infections
•Watery diarrhea
•Large volume
•Abdominal cramping
•Bloating, gas
•Weight loss
•Fever is rarely a significant symptom
•Stool does not contain occult blood or inflammatory cells.
Large intestinal diarrheas
•Frequent,
•Regular
•Small volume
•Often painful bowel movements.
• Fever
•Bloody or mucoid stools are common,
•Red blood cells and inflammatory cells may be seen
routinely on the stool smear.
DIARRHEA Classification
(according duration)
•Acute diarrhea : is 14 days in duration.
Most patients with acute diarrhea have three to seven movements per day
with total stool volume less than one liter per day.

In severe acute infectious diarrhea, the number of stools may reach 20

or more per day, with defecation occurring every 20 or 30 minutes. In
this situation, the total daily volume of stool may exceed two liters

•Persistent diarrhea — more than 14 days in duration

•Chronic — more than 30 days in duration

Infectious Diarrhea
 Bacteria
•Salmonella
•Campylobacter jejuni
•Shigella
• Escherichia coli

•Clostridium difficile
•Vibrio Cholerae
 Viruses

• Rotavirus

• Adenovirus types 40 and 41

•Astrovirus
 Protozoa Helminths
•Cryptosporidium

•Giardia •Schistosoma

• Cyclospora •Trichuris trichuria

• Entamoeba histolytica
Small bowel Colon
• Bacteria :
• Bacteria :
Campylobacter*
Salmonell
Shigella
Escherichia coli
Clostridium difficile
Clostridiu perfringens
Yersinia
Staphylococcus aureus
Vibrio parahaemolyticus
Aeromonas hydrophila
Enteroinvasive E. coli
Bacillus cereus
Plesiomonas shigelloides
Vibrio cholera
Klebsiella oxytoca (rare)
Small Bowel Colon
•Virus : •Virus :
• Rotovirus
• Norovirus •Cytomegalovirus*
•Adenovirus
•Protozoa : •Herpes simplex virus
• Cryptosporidium*
• Microsporidium*
• Isospora •Protozoa :
• Cyclospora
• Giardia lamblia
•Entamoeba histolytica

•
Bloody diarrhea
Watery diarrhea

Penetrating diarrhea
•Most cases of acute infectious gastroenteritis are probably
viral, in most studies, stool culture has been positive in
only 1.5 to 5.6 percent of cases.

•In contrast, bacterial causes are responsible for most cases

of severe diarrhea.

•Protozoa are less commonly identified as the etiologic

agents of acute gastrointestinal illness.

The term gastroenteritis typically refers to bacterial of viral infections the affect
both the stomach and small/large intestines. These patients present with nausea,
vomiting, and abdominal pain, as well as diarrhea.
DIAGNOSTIC APPROACH
•Careful history to determine the duration of symptoms

•The frequency and characteristics of the stool

•Evidence of extracellular volume depletion (eg, decreased

skin turgor, orthostatic hypotension).

•Fever and peritoneal signs may be clues to infection with

an invasive enteric pathogen.
Indications for diagnostic
evaluation
•Profuse watery diarrhea with signs of hypovolemia
•Passage of many small volume stools containing blood
and mucus
•Bloody diarrhea
•Temperature 38.5ºC (101.3ºF)
•Passage of 6 unformed stools per 24 hours or a duration of
illness >48 hours
•Severe abdominal pain
•Recent use of antibiotics or hospitalized patients
•Diarrhea in the elderly (70 years of age) or the
immunocompromised
Fecal leukocytes and occult blood
•The variable estimates :may be partially due to differences
in specimen processing and in operator experience. So the
role has been questioned
•The presence of occult blood and fecal leukocytes
supports the diagnosis of a bacterial cause of diarrhea in
the context of the medical history and other diagnostic
evaluation
•Bacterial culture in high risk patients.
•Fecal leukocyte determination is probably not of value in
patients who develop diarrhea while hospitalized, in
whom testing for Clostridium difficile is much more likely
to be helpful
it is reasonable to continue symptomatic therapy
for several days before considering further
evaluation in patients who do not have severe
illness, particularly if occult blood and fecal
leukocytes are absent
When to obtain stool cultures
•Immunocompromised patients, including (HIV)
•Patients with comorbidities that increase the risk for
complications
•Patients with more severe, inflammatory diarrhea
(including bloody diarrhea)
•Patients with underlying inflammatory bowel disease in
whom the distinction between a flare and superimposed
infection is critical
•Some employees, such as food handlers, occasionally
require negative stool cultures to return to work
When to obtain stool for ova and
parasites

•Sending stool samples for ova and parasites is not

cost effective for the majority of patients with acute
diarrhea
•Parasites usually caused persistent/chronic diarrhea
Indications for ova and parasite study
• Persistent diarrhea (associated with Giardia, Cryptosporidium, and
Entamoeba histolytica)
• Persistent diarrhea following travel to special region (associated with
Giardia, Cryptosporidium, and Cyclospora)
• Persistent diarrhea with exposure to infants in daycare centers
(associated with Giardia and Cryptosporidium)
• Diarrhea in a man who has sex with men (MSM) or a patient with AIDS
(associated with Giardia and Entamoeba histolytica in the former, and
a variety of parasites in the latter)
• A community waterborne outbreak (associated with Giardia and
Cryptosporidium)
• Bloody diarrhea with few or no fecal leukocytes (associated with
intestinal amebiasis)
TREATMENT

•Oral rehydration solutions/intravenous rehydration

solution

•Empiric antibiotic therapy

When to treat
Anti bacterial agents
Those with moderate to severe travelers'
diarrhea as characterized by more than four
unformed stools daily, fever, blood, pus, or
mucus in the stool.

Those with more than eight stools per day,

volume depletion, symptoms for more than
one week
Those in whom hospitalization is being
considered and immunocompromised hosts

Signs and symptoms of bacterial diarrhea such as fever,

bloody diarrhea and the presence of occult blood or fecal
leukocytes in the stool
Empiric antibiotic therapy
• We recommend empiric therapy with an oral
fluoroquinolone (ciprofloxacin 500 mg twice daily,
norfloxacin 400 mg twice daily, or levofloxacin 500
mg once daily) for three to five days in.

•Azithromycin (500 mg PO once daily for three days)

and erythromycin (500 mg PO twice daily for five
days) are alternative agents particularly if
fluoroquinolone resistance is suspected .
Symptomatic therapy
The antimotility agent loperamide (Imodium) may be used
for the symptomatic treatment of patients with acute
diarrhea in whom fever is absent or low grade and the
stools are not bloody. The dose of loperamide is two
tablets (4 mg) initially, then 2 mg after each unformed
stool, not to exceed 16 mg/day for 2 days.

Diphenoxylate (Lomotil) is an alternative agent. The dose

of diphenoxylate is two tablets (4 mg) four times daily for 2
days. This drug has central opiate effects and may cause
cholinergic side effects.

Treatment with these agents may mask the

amount of fluid lost, since fluid may pool in
the intestine. Thus, fluids should be used
aggressively when antimotility agents are
employed.
Bismuth subsalicylate
•(Pepto-Bismol)when compared with placebo significantly
reduced the number of unformed stools and increased the
proportion of patients free of symptoms at the end of
treatment trials

•May be used in patients with significant fever and

dysentery, conditions in which loperamide should be
avoided.

•The dose of bismuth subsalicylate is 30 mL or two tablets

every 30 minutes for eight doses.
Dietary recommendations
•Adequate nutrition during an episode of acute diarrhea is
important to facilitate enterocyte renewal if patients are
anorectic

•A short period of consuming only liquids will not be

harmful.

•Boiled starches and cereals (eg, potatoes, noodles, rice,

wheat, and oat) with salt are indicated in patients with
watery diarrhea; crackers, bananas, soup, and boiled
vegetables may also be consumed
Simptomatik/suportif
SUMMARY AND RECOMMENDATIONS

•Several studies have evaluated the accuracy of fecal

leukocytes alone or in combination with occult blood
testing.

•The ability of these tests to predict the presence of an

inflammatory diarrhea has varied greatly

•We recommend obtaining stool cultures on initial

presentation in immunocompromised patients
(HIV-infected, elderly, patients with comorbidities or with
underlying inflammatory bowel disease), those with
severe or bloody diarrhea, and in food handlers.
•THANK YOU
Shigella infection in adults
•Shigella species are a common cause of bacterial diarrhea
worldwide,

•The organism is not as susceptible to acid as many other

bacterial pathogens; thus, as few as 10 to 100 organisms
can cause disease in part because the organisms can
survive transit through the stomach .

•Ingested bacteria pass into the small intestine where they

multiply, so that several logs more bacteria pass into the
colon, where the organisms enter the colonic cells.
Shigella infection in adults
•Shigella transmission can occur through direct
person-to-person spread as well as from contaminated
food and water; the former accounts for most cases in the
United States while the latter is more important in the
developing world.

•Shigella is a cause of classic dysentery

CLINICAL MANIFESTATIONS

•Fever — 30 to 40 percent
• Abdominal pain — 70 to 93 percent
•Mucoid diarrhea — 70 to 85 percent
•Bloody diarrhea — 35 to 55 percent
•Watery diarrhea — 30 to 40 percent
•Vomiting — 35 percent
CLINICAL MANIFESTATIONS
•The incubation period one to seven days, with an average
of three days
•Fever
•Anorexia and malaise
•Diarrhea initially is watery, but subsequently contains
blood and mucus.
•Tenesmus is a common complaint.
CLINICAL MANIFESTATIONS
•Stool frequency is typically eight to ten per day, may
increase to up to 100 per day.

•Stools are of small volume, such that significant fluid loss

is uncommon (average approximately 30 mL/kg per day)

•In a normal healthy host, the course of disease is generally

self-limited, lasting no more than seven days when left
untreated.
Major complications of Shigella infection

•Complication •Prevalance, percent

•Intestinal : •Unknown
•Proctitis or rectal
prolapse •3
•Toxic megacolon •2.5
•Intestinal obstruction •1
•Colonic perforation
Major complications of Shigella infection

• Systemic: • Prevalance, percent

• Bacteremia •4
• Moderate to severe • 10-12
hypovolemia
• Hyponatremia • 29
• Leukemoid reaction •3
• Neurologic symptoms • 12-45
• Reactive arthritis or Reiter's • 1.4
• Hemolytic-uremic syndrome •1
DIAGNOSIS
•Frequent, small volume, bloody stools,

•Abdominal cramps, and tenesmus, particularly if

accompanied by fever.

•Nausea and vomiting are notably absent in most patients

•Fecal leukocytes are generally present.

DIFFERENTILA DIAGNOSIS
•Shigella
•Salmonella
• Campylobacter
• Yersinia
•Enteroinvasive E. coli
• Clostridium difficile
•Noninfectious inflammatory bowel disease
Fecal leukocytes
•Is associated with a bacterial cause of acute diarrhea in 89
percent of cases .
•had fecal leukocytes (all of which were polymorphonuclear
leukocytes) in 70 to 100 percent of samples tested, with at
least 10 to 25 cells/hpf in the majority of patients .
•In comparison, healthy controls and patients with cholera
or viral diarrhea had no fecal leukocytes.
Stool culture
• Definitive determination by stool culture

•Sheigla requires prompt handling and optimally should be

inoculated onto agar at the bedside.

•Culture from a stool sample may give a better yield than

culture from a rectal swab