5/10/23, 10:54 AM Diarrhoea - MRCEM Success

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Diarrhoea
Gastroenterology &
Hepatology
MRCEM Success

USEFUL LINKS
 NICE CKS

CURRICULUM CODE
GC5 Gastrointestinal Infections
GP5 Diarrhoea SuP4 Diarrhoea

KEYWORDS
Diarrhoea Gastroenteritis

RELATED TOPICS

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Gastroenterology & Hepatology

Surgical Emergencies

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Diarrhoea LAST UPDATED: 12TH

FEBRUARY 2021
GASTROENTEROLOGY & HEPATOLOGY /
SURGICAL EMERGENCIES  Bookmark

Diarrhoea is a symptom, of which there are many causes. Many different definitions of
diarrhoea have been suggested, but the World Health Organization defines diarrhoea as 'the
passage of three or more loose or liquid stools per day (or more frequent passage than is
normal for the individual)'. Acute diarrhoea is defined as lasting for less than 14 days,
persistent diarrhoea is defined as lasting more than 14 days and chronic diarrhoea is defined
as lasting more than 4 weeks.

Mechanisms of diarrhoea
Osmotic diarrhoea
Osmotic diarrhoea occurs when a soluble compound cannot be absorbed by the
small intestine, and thus draws fluid into the intestinal lumen. Examples include:
osmotic laxatives; magnesium-based antacids; and foods containing mannitol,
sorbitol, or xylitol. Osmotic diarrhoea can also be due to generalised
malabsorption (for example, coeliac disease and pancreatic insufficiency).
Secretory diarrhoea
Secretory diarrhoea results from increased secretion of fluid and electrolytes
into the intestine with decreased absorption. Infections with such organisms as
Vibrio cholerae, E. Coli, and C. difficile can cause secretory diarrhoea, as can bile
salts in the colon (for example, after ileal resection) some drugs (for example,
laxatives, diuretics, theophylline, cholinergic drugs, prostaglandins, caffeine,
and ethanol) and gut allergies.

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Inflammatory diarrhoea
Damage to intestinal mucosal cells affects absorption of fluid and electrolytes
and results in fluid and blood loss. Infection (for example, Shigella) and
conditions such as ulcerative colitis and Crohn's disease are causes of
inflammatory diarrhoea.
Increased intestinal motility
This may present with an increased frequency of stool passage without an
increase in volume. It can occur with endocrine conditions such as diabetes and
hyperthyroidism.

Causes
Causes of acute diarrhoea:
Infection
Viruses
Norovirus, sapovirus, rotavirus
Bacterial causes
Salmonella species, Campylobacter jejuni, Shigella species, Escherichia
coli and Clostridium difficile
Parasitic causes
Cryptosporidium, Giardia, Entamoeba histolytica, and Cyclospora
Drugs
Laxatives, allopurinol, angiotensin-II receptor blockers, antibiotics,
chemotherapy, magnesium-containing antacids, metformin, nonsteroidal anti-
inflammatory drugs, proton pump inhibitors, and selective serotonin reuptake
inhibitors
Other causes
Anxiety
Food allergy
Acute appendicitis
Pelvic radiation treatment
Intestinal ischaemia
Early presentation of a chronic cause (for example, a first presentation of
inflammatory bowel disease)
Common causes of chronic diarrhoea:
Irritable bowel syndrome
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Diet
Inflammatory bowel disease (Crohn's disease, ulcerative colitis).
Microscopic colitis
Coeliac disease
Other causes of malabsorption e.g. lactose intolerance and pancreatic insufficiency
Colorectal cancer
Bile acid diarrhoea
Drugs
Constipation and faecal impaction (leading to overflow)

Assessment
Determine the onset, duration, frequency, and severity of symptoms.
Enquire about the presence of red flag symptoms:
e.g. blood in stool, recent hospital treatment or antibiotics, weight loss,
evidence of dehydration
Attempt to ascertain the underlying cause:
Features suggesting infection include:
Fever
Vomiting
Recent contact with a person with diarrhoea
Exposure to possible sources of enteric infection (for example, having
eaten meals out, or recent farm or petting zoo visits)
Travel abroad — increases the likelihood of infection. Ask about potential
exposures such as raw milk or untreated water
Being in a higher risk group such as food handlers, nursing home
residents, and recently hospitalised people
Assess for complications of diarrhoea, such as dehydration
See table below
Perform an abdominal examination to assess for pain or tenderness, distension, mass,
increased or decreased bowel sounds, or liver enlargement.
Consider a rectal examination to assess for rectal tenderness, stool consistency, and
for blood, mucus, and possible malignancy.

Mild dehydration Moderate dehydration Severe dehydration

Lassitude Apathy/tiredness Profound apathy
Anorexia Dizziness Weakness
Nausea Nausea Confusion
Lightheadedness Headache Coma
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Mild dehydration Moderate dehydration Severe dehydration

Postural Muscle cramps
hypotension
Usually no signs Pinched face Shock
Dry tongue Tachycardia
Sunken eyes Marked peripheral
Reduced skin vasoconstriction
elasticity SBP < 90 mmHg
Postural Oliguria or anuria
hypotension
Tachycardia
Oliguria

Investigations
Send a faecal specimen for routine microbiology investigation if a person with
diarrhoea has:
Symptoms/signs or a clinical indication:
The person is systemically unwell; needs hospital admission, and/or
antibiotics.
There is blood or pus in the stool.
The person is immunocompromised.
The person has recently received antibiotics, a proton pump inhibitor
(PPI) or been in hospital — also request specific testing for Clostridium
difficile.
Diarrhoea occurs after foreign travel — also request tests for ova, cysts,
and parasites and state the countries visited on the form.
Amoebae, Giardia, or cryptosporidium are suspected, particularly if
diarrhoea is persistent (2 weeks or more) or the person has travelled to an
at-risk area.
There is a need to exclude infectious diarrhoea (for example severe
abdominal pain, exacerbation of inflammatory bowel disease, or irritable
bowel syndrome).
A public health indication:
Diarrhoea in high-risk people (for example food handlers, healthcare
workers, elderly residents in care homes).
Suspected food poisoning (for example after a barbeque, restaurant meal,
or eating eggs, chicken, or shellfish).
Outbreaks of diarrhoea in the family or community, when isolating the
organism may help pinpoint the source of the outbreak.
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Contacts of people infected with certain organisms, for example,

Escherichia coli O157 or C. difficile, where there may be serious clinical
sequelae to an infection.
Close household contacts of a person with Giardia infection.
Diagnostic tests that may be considered in the diagnostic evaluation of acute
diarrhoea in people with severe illness are:
FBC. This can help with assessing the severity of the diarrhoea (look for
haemoconcentration, anaemia, and leucocytosis with left shift)
Serum chemistry. Electrolytes, urea nitrogen, and creatinine (look for
hypokalaemia, acidosis, and renal dysfunction). Serum albumin and lactic acid
(look for low albumin or elevated lactic acid)
Consider blood tests if infection and the other causes of acute diarrhoea have been
excluded and it is suspected that an episode of acute diarrhoea is due to a chronic
cause.
Full blood count — to detect anaemia.
Urea and electrolytes.
Liver function tests, including albumin level.
Calcium.
Vitamin B12 and red blood cell folate.
Iron status (ferritin).
Thyroid function tests.
ESR (erythrocyte sedimentation rate) and CRP (C-reactive protein).
Testing for coeliac disease — immunoglobulin A (IgA), and IgA tissue
transglutaminase (tTG), or IgA endomysial antibody (EMA).

Management
Arrange emergency admission to hospital if:
The person is vomiting and unable to retain oral fluids, or
They have features of severe dehydration or shock
Other factors that influence the threshold for admission include (use clinical

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judgment):
Older age (people 60 years of age or older are more at risk of complications).
Home circumstances and level of support.
Fever.
Bloody diarrhoea.
Abdominal pain and tenderness.
Increased risk of poor outcome, for example coexisting medical conditions, or
drugs
Further management will depend on the cause

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