Emp Diarrea

EMERGENCY MEDICINE
PRACTICE
.
EMPRACTICE NET
A N E V I D E N C E - B A S E D A P P ROAC H T O E M E RG E N C Y M E D I C I N E
July 2004
Diarrhea: Identifying Serious

Illness And Providing Relief
Volume 6, Number 7
Authors
Its a stormy day, yet the ED is furiously busy. As you pick up your next patients chart,
you glance at the chief complaintdiarrhea. Why would anyone come out on a day
like this, for something like that? you wonder. Then your eye catches the patients age
(60) and vital signstemperature, 38.7C (101.7F); pulse, 124 beats per minute;
respiratory rate, 24 breaths per minute; blood pressure, 102/50 mmHg. This man seems
a bit sicker than the run-of-the-mill diarrhea patient. A quick glance into his room
confirms your suspicion; hes pale, sweaty, ill-looking. He clearly needs help. But is an
extensive work-up really going to be cost-effectiveand wont it keep you from treating
other patients in a timely manner? Besides, dont most of these cases run their course
with a little help from fluids and symptomatic treatment?
IARRHEA is a common condition that can stem from many causes.

Fortunately, the care of the ED patient with diarrhea is usually straightforwarda targeted history and physical examination, followed by symptomatic
remedies. However, the temptation to dismiss a case as just diarrhea can be
quite dangerous, as serious disease processes can present with diarrhea as the
chief complaint. Some patients require more systematic investigation or even
hospitalization. Clinical judgment based on the current evidence can help guide
a cost-effective work-up of patients with diarrhea that will identify patients
with more severe etiologies or at risk for complications.
Critical Appraisal Of The Literature

Given that diarrhea is such a ubiquitous part of the human condition, its not
surprising that the literature on the subject is truly voluminous. Thousands of
studies address the epidemiology, etiology, pathophysiology, evaluation,
treatment, differential diagnosis, and other features of patients with diarrhea.
Thankfully, a number of well-done reviews, meta-analyses, and position
statements from expert medical organizations condense the findings, making
the job of the practicing emergency physician caring for patients with diarrhea
much easier.1-19
In general, the preponderance of evidence tends to support the following
practices in patients with diarrhea:
Associate Editor
Andy Jagoda, MD, FACEP,
Vice-Chair of Academic
Affairs, Department of
Emergency Medicine;
Residency Program Director;
Director, International Studies
Program, Mount Sinai School of
Medicine, New York, NY.
Editorial Board
William J. Brady, MD, Associate
Professor and Vice Chair,
Department of Emergency
Medicine, University of Virginia,
Charlottesville, VA.
Judith C. Brillman, MD, Professor,
Medicine, The University of
New Mexico Health Sciences

Center School of Medicine,
Albuquerque, NM.
Francis M. Fesmire, MD, FACEP,
Director, Heart-Stroke Center,
Erlanger Medical Center;
Assistant Professor of Medicine,
UT College of Medicine,
Chattanooga, TN.
Valerio Gai, MD, Professor and
Chair, Department of Emergency
Medicine, University of Turin,
Italy.
Michael J. Gerardi, MD, FAAP,
FACEP, Clinical Assistant
Professor, Medicine, University
of Medicine and Dentistry of
New Jersey; Director, Pediatric
Emergency Medicine,
Childrens Medical Center,
Michael D. Burg, MD, FACEP

Residency Program Director, Department of
Emergency Medicine, Onze Lieve Vrouwe Gasthuis
(Hospital), Amsterdam, The Netherlands.
Hoori Hovanessian, MD, FACEP
Assistant Clinical Professor, Department of
Emergency Medicine, UCSFFresno, University
Medical Center, Fresno, CA; Presbyterian
Intercommunity Hospital, Whittier, CA.
Peer Reviewers
Andy Jagoda, MD, FACEP
Vice-Chair of Academic Affairs, Department of
Emergency Medicine; Residency Program Director;
Director, International Studies Program, Mount Sinai
School of Medicine, New York, NY.
Earl J. Reisdorff, MD, FACEP
Director of Medical Education, Ingham Regional
Medical Center; Associate Professor, Michigan
State University Emergency Medicine Residency,
Lansing MI.
CME Objectives
Upon completing this article, you should be able to:
1. construct a broad differential diagnosis for
diarrheal illness in adults and children;
2. describe aspects of a targeted history and physical
examination for patients with diarrhea, including
indications for diagnostic testing;
3. identify ED patients at high risk for serious or
life-threatening diarrheal illnesses; and
4. describe treatment strategies for ED patients
with diarrhea.
Date of original release: July 1, 2004.

Date of most recent review: June 15, 2004.
See Physician CME Information on back page.
Atlantic Health System;

Medicine, Morristown
Memorial Hospital.
Attending, Massachusetts
General Hospital; Faculty, Harvard
Affiliated Emergency Medicine
Residency, Boston, MA.
Michael A. Gibbs, MD, FACEP,

Chief, Department of
Emergency Medicine,
Maine Medical Center,
Portland, ME.
Michael S. Radeos, MD, MPH,

Attending Physician, Department
of Emergency Medicine, Lincoln
Medical and Mental Health Center,
Bronx, NY; Assistant Professor in
Emergency Medicine, Weill College
of Medicine, Cornell University,
New York, NY.
Gregory L. Henry, MD, FACEP,

CEO, Medical Practice Risk
Assessment, Inc., Ann Arbor,
MI; Clinical Professor, Department
of Emergency Medicine,
University of Michigan Medical
School, Ann Arbor, MI; Past
President, ACEP.
Francis P. Kohrs, MD, MSPH, Lifelong
Medical Care, Berkeley, CA.
Steven G. Rothrock, MD, FACEP,

FAAP, Associate Professor of
Emergency Medicine, University
of Florida; Orlando Regional
Medical Center; Medical Director
of Orange County Emergency
Medical Service, Orlando, FL.
Keith A. Marill, MD, Emergency
Alfred Sacchetti, MD, FACEP,
Research Director, Our Lady of

Lourdes Medical Center, Camden,
NJ; Assistant Clinical Professor
of Emergency Medicine,
Thomas Jefferson University,
Philadelphia, PA.
Corey M. Slovis, MD, FACP, FACEP,
Professor of Emergency Medicine
and Chairman, Department of
Emergency Medicine, Vanderbilt
University Medical Center;
Medical Director, Metro Nashville
EMS, Nashville, TN.
Charles Stewart, MD, FACEP,
Colorado Springs, CO.
Thomas E. Terndrup, MD, Professor
and Chair, Department of
Emergency Medicine, University
of Alabama at Birmingham,
Birmingham, AL.
COPYRIGHTED MATERIALDO NOT PHOTOCOPY OR DISTRIBUTE ELECTRONICALLY WITHOUT WRITTEN CONSENT OF EB PRACTICE, LLC
Etiology, Epidemiology, And Pathophysiology
Evaluating the patient: The presence of a dry axilla

supports the diagnosis of hypovolemia, and moist
mucous membranes and a tongue without furrows
argue against it. In adults, the capillary refill time and
poor skin turgor have no proven diagnostic value.3
Acute body weight changes provide the best measures
of dehydration in children. Mucous membrane
hydration, capillary refill time, absence of tears, and
alterations in mental status are the next best associated
measures.4 Important features of the history include
how the illness began; stool characteristics (frequency
and quantity); travel history; occupation; day care
center attendance or nursing home residence; whether
the patient has ingested raw or undercooked meat, raw
seafood, or raw milk; whether the patients contacts are
ill; the patients sexual contacts, medications, and other
medical conditions, if any.2,5 Red-flag findings include
severe dehydration, bloody or febrile diarrhea, or
illness in infants, elderly, or immunocompromised
patients.5 Serial evaluations over several hours can
improve the diagnostic accuracy in patients in whom
the etiology is unclear.1
Etiology
Diarrhea is a change in normal bowel movements characterized by an increase in the water content, volume, or
frequency of stools. Fluid secretion into the gut and
increased gut motility together produce both the increased
stooling frequency and the increased stool liquidity.16,20 The
passage of more than 200 grams of stool per day is considered to be diarrhea; two to three bowel movements per day
is the upper limit of normal.
An episode of diarrhea lasting 14 days or less is
generally defined as acute diarrhea, while persistent
diarrhea refers to episodes lasting longer than 14 days.
Chronic diarrhea is generally defined as diarrhea that
lasts more than 30 days.
Epidemiology
Virtually every human being experiences diarrhea at some
point. Causes may range from the mild to the life-threatening, although the clinical course is generally brief and selflimited in developed nations. However, worldwide,
diarrheal illnesses are the second most common cause of
death and the leading cause of death in children.21
Diarrhea is a common cause of morbidity even in the
United States. The number of hospital admissions due to
gastroenteritis in the United States is estimated to be 450,000
per year.20 Additionally, the U.S. prevalence of chronic
diarrhea approaches 5%.22
Laboratory testing: Routine testing for specific

pathogens is not recommended.4 Reserve laboratory
testing and stool cultures for select circumstances.
Criteria vary but often include bloody diarrhea,
weight loss, diarrhea leading to dehydration, fever,
neurologic involvement, sudden onset of severe
abdominal pain, persistent (> 7 days) diarrhea, or
possible community-acquired diarrhea, travelers
diarrhea, or nosocomial diarrhea.2,5 Maintain a lower
threshold for ordering if the patient is pediatric,
elderly, or immunocompromised.2
Pathophysiology
Diarrhea is broadly categorized as one of two typeseither
secretory or osmotic.
The poorly named secretory diarrhea actually occurs
due to abnormal electrolyte transport across the intestinal
epithelial cells. Increased secretion and/or decreased
absorption result. The diarrhea is not related to the intestinal
contents and therefore typically does not stop with fasting.
Infection (e.g., cholera) is the most common cause of
secretory diarrhea. The fluid losses can be enormous.
Osmotic diarrhea results from the presence of nonabsorbable solute that exerts an osmotic pressure effect
across the intestinal mucosa, resulting in excessive water
output. Because the diarrhea is caused by the solute, it tends
to stop during fasting. Sorbitol, a poorly absorbed sugar, is
capable of causing osmotic diarrhea.20
Another way that diarrhea is commonly classified is as
infectious vs. noninfectious or inflammatory vs. noninflammatory. Symptoms such as fever, bloody diarrhea,
and severe cramping suggest an invasive bacterial pathogen
such as Shigella, Salmonella, Yersinia, or Campylobacter. The
presence of nausea and vomiting strongly suggests a viral
agent, and prior antibiotic use suggests possible Clostridium
difficile enteritis. Absence of these factors suggests a noninfectious cause. Inflammatory diarrhea can be bloody and
associated with fever and abdominal cramps. The causes
can be infectious or non-infectious. Non-inflammatory
diarrhea tends to be watery and can be associated with
nausea, vomiting, and abdominal cramps.
Rehydration: Initiate rehydration (oral whenever

possible).5 In children, clear liquids are not recommended as a substitute for oral rehydration solutions or
regular diets to prevent or treat dehydration.4
Diet: Refeeding of the usual diet at the earliest opportunity should be encouraged to prevent or limit dehydration. Very frequent (e.g., every 10-60 minutes), small
feedings may be better tolerated if vomiting is present.
The BRAT diet (bananas, rice, applesauce, and toast)
affords no advantage unless these foods are part of the
regular diet.4
Medications: Antibiotic therapy can reduce illness
duration by one or two days in most cases. Criteria for
empiric antibiotic therapy vary, but consideration of
risks must be weighed against any potential benefits. In
children, antimicrobial therapies are recommended
only when special risks or evidence of serious bacterial
infection is present.4 Institute selective therapy for
travelers diarrhea, shigellosis, and Campylobacter
infection.5 Avoid administering antimotility agents with
bloody diarrhea or proven infection with Shiga toxinproducing Escherichia coli.5 Anti-diarrheal agents and
antiemetics are not recommended for use in children
with acute gastroenteritis.4
Emergency Medicine Practice
EMPractice.net July 2004
Entamoeba histolytica, and Cryptosporidium.2

Signs and symptoms such as bloody diarrhea, weight
loss, diarrhea leading to dehydration, fever, prolonged
diarrhea (3 or more unformed stools per day, persisting
several days), neurologic involvement (such as paresthesias,
motor weakness, cranial nerve palsies), and/or severe
abdominal pain may suggest infectious causes and drive the
need for laboratory testing, especially in young, elderly, or
immunocompromised patients.2
The differential diagnosis of diarrhea with abdominal pain

is vast. While patients who present with vomiting, diarrhea,
and abdominal cramps and who have benign abdominal
examinations may seem like clear-cut cases of gastroenteritisand most patients will respond well given rehydration
and antiemeticsit is important to be aware that the
differential diagnosis includes more severe etiologies that
require different management approaches. (See Table 1.)
Irritable Bowel Syndrome

Infectious Enteritis
Patients with irritable bowel syndrome can have abdominal

pain or discomfort, constipation, diarrhea, or an alternating
course of constipation and diarrhea. A mucoid rectal
discharge is present in about half of afflicted patients.23
Evaluation of these patients fails to produce an organic basis
for the disease; patients do not experience weight loss, fever,
or rectal bleeding. While symptoms vary from person to
person, irritable bowel syndrome is typically characterized
by abdominal pain or discomfort for at least 12 weeks out of
the previous 12 months; abdominal pain that is relieved by
having a bowel movement; and changes in frequency or
appearance of stool when an episode starts. Eliciting a
history suggestive of irritable bowel syndrome requires
referral to exclude more serious disease processes.
Infectious causes of diarrhea are commonly seen in the ED.

Ingestion of contaminated food or water is the typical
culprit; recent travel, exposure to other ill persons, recent
hospitalization, child care center attendance, and nursing
home residence should all raise the index of suspicion. (See
Table 2 on page 4.)
Common bacterial agents include Campylobacter,
Salmonella, and Shigella species, as well as E. coli. Viral
infections may be caused by rotavirus, Norwalk virus,
cytomegalovirus, herpes simplex virus, and viral hepatitis.
In developed countries, parasitic diarrhea is generally only a
concern among travelers and those with prolonged diarrhea. Parasites that cause diarrhea include Giardia lamblia,
Table 1. Typical Characteristics Of Different Etiologies Of Diarrhea.

Infectious
watery diarrhea (compared to the voluminous amounts

produced as a consequence of gastroenteritis), mild or
absent fever
Viral gastroenteritis
Diarrhea with aches, chills, cold symptoms, nausea or
vomiting; history suggesting recent consumption of
contaminated food or exposure to other ill persons,
especially day care; with or without fever
Vascular
Ischemic bowel disease
Diarrhea, severe abdominal pain, older patient, history of
peripheral vascular disease
Bacterial diarrhea or Giardia

Diarrhea, history suggesting recent consumption of contaminated food, with or without fever (see Table 2 on page 4)
Malabsorption
Travelers diarrhea
Recent foreign travel, prolonged illness (see also Table 3 on
page 6)
e.g., celiac disease or lactose intolerance

Diarrhea, gas, bloating, and stomach pains that seems to be
triggered by certain foods
Functional bowel disorders
Medications
Irritable bowel syndrome

Variable symptoms but prolonged course; bowel movements that alternate between constipation and diarrhea,
especially if episodes are related to stress
Recent new medicine, especially antibiotics, high blood

pressure medications, cancer drugs/radiation therapy,
some herbal medicines
Intestinal obstruction
Severe abdominal pain along with nausea, vomiting, and
diarrhea
Toxins
Radiation enteritis
Tenesmus, bleeding, and diarrhea stemming from malabsorption; can persist for two or three months after
treatment cessation
Fecal impaction/other blockage

Chronic constipation followed by recent watery diarrhea
Inflammatory
Arsenic, mushroom poisoning, pesticides, etc.

Varies; usually diarrhea is one of several symptoms
Inflammatory bowel disease (includes Crohns disease and

ulcerative colitis)
Frequent bowel movements mixed with blood or mucus
Other systemic conditions

e.g., food allergies, colon cancer, hyperthyroidism
Typically a longer course plus other suggestive symptoms;
see also Table 3 on page 6
Appendicitis
Vomiting that follows abdominal pain, small amounts of
July 2004 EMPractice.net
Differential Diagnosis
Inflammatory Bowel Disease
Eliciting a family history of inflammatory bowel disease or

other risk factors for it will allow rapid evaluation of this
condition by referral to a gastroenterologist.24 The diagnosis
rests on the clinical history, stool studies to exclude infection, and colonoscopy to determine the presence and extent
of disease.
Inflammatory bowel disease is a general term that refers to

illnesses that cause chronic inflammation in the intestines,
typically causing diarrhea and abdominal cramps. The two
major types of inflammatory bowel disease are Crohns
disease and ulcerative colitis.
Crohns disease is a chronic inflammation of the
intestines that is usually confined to the ileum. It is characterized by abdominal cramps or pain, diarrhea (sometimes
bloody), fever, and anorexia. The clinical course may be
erratic, with frequent relapses interspersed with periods of
symptom remission.24
Ulcerative colitis, which is also a chronic inflammatory
disease, is confined to the colon and rectum. Patients with
mild disease may present with fewer than four bowel
movements per day, whereas patients with severe disease
may experience more than six bowel movements per day
along with weight loss, fever, and anemia. While the
diarrhea is often bloody, many patients do not have grossly
bloody stools, even with exacerbations. It too may be
characterized by periods of remission.
A documented history of inflammatory bowel disease
will aid in providing patients appropriate evaluation and
treatment. Some patients, however, will have episodic
symptoms for years before being correctly diagnosed.
Ischemic Bowel Disease

Ischemic bowel disease should be considered in adults with
abdominal pain, especially if they are older than 50 years or
have a history of peripheral vascular disease. Most patients
with acute mesenteric ischemia will present with severe
abdominal pain, although there can be a paucity of physical
findings. The abdominal pain may be followed by a rapid
and forceful bowel movement.25 Other patients may have
chronic mesenteric ischemia with chronic intermittent
abdominal pain of up to several months duration (intestinal
angina) followed by an acute attack of pain. These patients
may experience weight loss, as well as occasional diarrhea
and bloating.26 Occult fecal blood is present in up to 75% of
patients.27 Bloody diarrhea may occur in those with ischemic
colitis (inflammation of the colon caused by insufficient
blood flow to the colon); those with small bowel ischemia
will have voluminous diarrhea.28 Individuals at increased
risk for ischemic bowel disease include patients with
Table 2. Agents Causing Infectious Diarrhea And Their Associated Symptoms.

Campylobacter jejuni
dysentery. Diarrhea containing blood and mucus, fever,

abdominal cramps, chills, and vomiting; 12-50 hours from
ingestion of bacteria; can last a few days to two weeks.
Symptoms: fever, headache and muscle pain followed by

diarrhea (sometimes bloody), abdominal pain and nausea
that appear 2-5 days after eating; may last 7-10 days.
Staphylococcus aureus
Clostridium perfringens
Symptoms: severe nausea, abdominal cramps, vomiting, and

diarrhea occur 1-6 hours after eating; recovery within 2-3
dayslonger if severe dehydration occurs.
Symptoms: diarrhea and gas pains may appear 8-24 hours

after eating; usually last about one day, but less severe
symptoms may persist for 1-2 weeks.
Vibrio parahaemolyticus
Escherichia coli 0157:H7
Symptoms: Diarrhea, abdominal cramps, nausea, vomiting,

headache, fever, and chills; onset four hours to four days
after eating; lasts about 2.5 days.
Symptoms: diarrhea or bloody diarrhea, abdominal cramps,

nausea, and malaise; can begin 2-5 days after food is eaten,
lasting about eight days. Very young patients can develop
hemolytic uremic syndrome, which causes acute kidney
failure. A similar illness, thrombotic thrombocytopenic
purpura, may occur in older adults.
Cyclospora cayetanensis
Symptoms: Nausea, vomiting, loss of appetite, and diarrhea;
onset within two days; lasts one week to two months.
Cryptosporidium parvum
Listeria monocytogenes
Symptoms: Profuse watery diarrhea, abdominal pain, appetite

loss, vomiting, and low-grade fever, onset within 1-12 days.
Symptoms: fever, chills, headache, backache, sometimes

abdominal pain and diarrhea; onset from 7-30 days after
eating, but most symptoms are reported 48-72 hours after
consumption of contaminated food; primarily affects
pregnant women and their fetuses, newborns, the elderly,
people with cancer, and those with impaired immune
systems; can cause fetal and infant death.
Giardia lamblia
Symptoms: Sudden onset of explosive watery stools,
abdominal cramps, anorexia, nausea, and vomiting; onset
within 1-3 days.
Salmonella (many types)
Viral gastroenteritis from Norwalk

and Norwalk-like viruses
Symptoms: stomach pain, diarrhea, nausea, chills, fever, and

headache usually appear 8-72 hours after eating; may last
1-2 days; all age groups are susceptible, but symptoms are
most severe for the elderly, the infirm, and infants.
Symptoms: Nausea, vomiting, diarrhea, abdominal pain,

headache, and low-grade fever; onset within 1-2 days; lasts
about 36 hours.
Adapted from: U.S. Food and Drug Administration Center for Food
Safety and Applied Nutrition Web site (http://www.cfsan.fda.gov/~dms/
qa-fdb12.html, http://www.cfsan.fda.gov/~dms/unwelcom.html).
Shigella (many types)

Symptoms: disease referred to as shigellosis or bacillary
Miscellaneous Causes
Many other entities should be considered in the differential
diagnosis of diarrhea, including melena, laxative abuse,
partial bowel obstruction, various malabsorption syndromes (e.g., Whipples disease, small bowel bacterial
overgrowth, celiac sprue), food allergy, rectosigmoid
abscess, colon cancer, diverticulitis, hyperthyroidism, and
pernicious anemia. Many medications (as well as herbal
remedies) can cause diarrhea. In pediatric patients, ageappropriate problems such as intussusception and Meckels
diverticulum should be considered in the differential
diagnosis of diarrhea. Uncommon causes of diarrhea
include mushroom poisoning, ciguatera fish poisoning,
arsenic ingestion, and exposure to pesticides, sodium
fluoride, thallium, or zinc. In most of these cases, diarrhea is
part of a symptom complex, and other suggestive elements
of the history are present.
Radiation Enteritis
Radiation therapy is used to treat a number of urologic,
gynecologic, and colorectal cancers. During the radiation
treatment period, most patients experience tenesmus,
bleeding, and diarrhea.30 Malabsorption from mucosal
damage and bacterial overgrowth are two factors that
contribute to these symptoms.26 Symptoms can start within
hours of initial treatment and usually resolve two or three
months after treatment cessation,30 although some patients
may develop chronic problems necessitating surgery. The
rectum is the most commonly inflamed site given its
proximity to the irradiated tissue; the terminal ileum can
also be irradiated in patients undergoing treatment for
pelvic malignancies.
Treatment of acute radiation enteritis involves temporary discontinuation of radiation therapy, selective intravenous fluid administration, and antimotility medications.
Sucralfate may ameliorate the symptoms of radiation
enteritis. In one double-blind placebo-controlled trial of
patients with prostate or bladder cancer randomized to
receive either oral sucralfate or placebo, those patients
receiving sucralfate had improvement in the frequency and
consistency of bowel movements, and fewer patients
required treatment with anti-diarrheal preparations.31
Prehospital Care
Initial prehospital assessment should focus on the patients
vital signs and mental status. Transport hemodynamically
stable patients without further intervention. Follow local
EMS protocols for hypotension/shock for patients who are
hemodynamically unstable; usually, this includes establishing at least one large-bore intravenous line and infusing
crystalloid solution and expediting the transport of unstable
patients for further evaluation and care.
While gastrointestinal infections may be caused by a
variety of agents, including bacteria, viruses, and protozoa,
only a few agents have been documented in person-toperson transmission. Generally, adherence to either standard or contact precautions will minimize the risk of
transmitting enteric pathogens.36
Appendicitis
Patients with appendicitis can have vomiting as well as
loose stools. Rectal irritation by an inflamed pelvic appendix
can produce small amounts of watery diarrhea, as compared to the voluminous amounts produced as a consequence of gastroenteritis.32 In Rothrock et als study of 181
children younger than 13 years who were ultimately found
to have appendicitis, 27% were initially misdiagnosed.
Patients in this group were more likely to be younger, have
vomiting before pain, and have diarrhea (in addition to
constipation, dysuria, and upper respiratory tract symptoms).33 A retrospective case series review of 63 children
younger than 3 years ultimately diagnosed with appendicitis found that 57% were initially misdiagnosed; diarrhea
was commonly reported.34 A retrospective review of 87
patients with appendicitis revealed that six patients (7%)
required more than one ED visit before their diagnosis was
established. The initial diagnosis in two of these patients
was gastroenteritis. These six patients were more likely to
have a normal appetite, to have diarrhea, and to be afebrile.35 While most patients with appendicitis present with
right lower quadrant abdominal pain, 15% of appendices
are in atypical locations, causing pain in locations other than
the right lower quadrant.32 Gastroenteritis can present with
fevers higher (>103F) than those seen with appendicitis,
and in general, vomiting and diarrhea precede abdominal
pain, whereas vomiting follows abdominal pain in appendicitis. Because appendicitis will steadily worsen, while
Emergency Department Evaluation

History
History Of Present Illness
Obtaining a thorough history is crucial. Certain issues
are important to address during patient assessment.
They include:
Type and volume of stools: Also note whether the
stools contain any blood. (Note that melena may not
be perceived by the patient to be bloody; ask about
blackened stools as well. See also the March 2004
issue of Emergency Medicine Practice, Gastrointestinal
Bleeding: An Evidence-Based ED Approach To
Risk Stratification.)
Associated symptoms such as nausea, vomiting,
abdominal pain, fever, and tenesmus: When vomiting
is a prominent feature of the patients symptoms,
viruses are the more likely etiologic agents.12,37 Fever
greater than 38.5C (101.3F) is usually associated with
intestinal inflammation due to invasive bacteria (e.g.,
uncomplicated gastroenteritis generally resolves with fluids,

a period of observation can help identify patients with
appendicitis if the diagnosis is unclear.
hypovolemia, sepsis, cardiac arrhythmias, congestive heart

failure, and those using vasoconstrictive medications or
drugs (e.g., digitalis, pseudoephedrine, cocaine, amphetamines).29 Ischemia may progress to infarct unless detected
and treated early.
dance, and occupational hazards such as food handling

or working with animals.
Shigella, Salmonella, or Campylobacter species), enteric

viruses, or toxin-induced damage due to Clostridium
difficile or Entamoeba histolytica.37
Past Medical History
Character and location of any abdominal pain: Pain is

common in patients with mesenteric ischemia, inflammatory bowel disease, and irritable bowel syndrome.22
The patients past medical history also provides essential

information for the management of patients with diarrhea.
Are you treating an otherwise healthy 20-year-old woman, a
patient with HIV/AIDS, or a 70-year-old diabetic man with
a history of congestive heart failure taking numerous
medications? Is the patient undergoing cancer treatment?
Consider pathogens that affect immunosuppressed hosts in
patients receiving chemotherapy. Acute radiation enteritis is
a concern in those who have undergone radiation treatment
within the past six weeks. Inquire about other gastrointestinal ailments such as Crohns disease or ulcerative colitis.
Duration of symptoms: Symptom duration can help

narrow the differential diagnosis. Viral gastroenteritis
usually lasts 12-60 hours.2 Thus, it is less likely that
diarrhea lasting more than a couple of days or so is
viral. Diarrhea lasting greater than two weeks often has
a different etiology (see Table 3) than diarrhea that has
been present for less than two weeks.37
Weight loss: Determine whether the patient has lost
weight. Patients with diarrhea may have weight loss
because of both increased output and reduced intake.
Substantial weight loss is more likely due to ischemia,
neoplasm, or malabsorptive syndromes.22 Weight loss
may be an indicator of dehydration in children.
Medications
Obtaining a history of medication usespecifically including prescription, over-the-counter, and herbal preparationsis important, since many can cause diarrhea. Some of
the more common offenders include laxatives, antibiotics,
colchicine, and magnesium- or calcium-containing antacids.
If there is a history of antibiotic use within the past three
months, C. difficile-induced diarrhea is an important
consideration.38 Diabetics using a relatively new class of
hypoglycemic medications known as alpha-glucosidase
inhibitors (e.g., acarbose, miglitol) may develop abdominal
pain, bloating, and diarrhea. Artificial sweeteners containing sorbitol or mannitol are poorly absorbed and may cause
diarrhea. Patients on enteral tube feedings may also develop
diarrhea.28 The elderly are more likely to be on multiple
medications and may be more susceptible to adverse effects.
Indicators of dehydration: Asking about urine output,

dizziness, thirst, and syncopeas well as asking
family members or prehospital personnel about altered
mental statusis useful in assessing the patients
volume status.
Epidemiological risk factors: Further questions should
focus on the patients recent diet, and specifically
whether there has been any ingestion of seafood, raw
or undercooked meat, eggs, or milk products. In
addition, ask about recent foreign travel or local
outings involving lake or stream swimming or visits to
a farm, ill contacts, group living arrangements (e.g.,
nursing home, college dormitory) or day care atten-
Review Of Systems
A brief review of systems is additionally helpful. A
patient who is currently menstruating may have guaiacpositive stools secondary to stool sample contamination
from menstrual blood. The patients pregnancy status is
important for antibiotic selection, use of medications
for symptomatic treatment of the diarrhea, and decisions
about managing her hemodynamic status. Ask the patient
about the ability to get to the bathroom on time. Some
individuals complain of diarrhea when the real problem
is fecal incontinence.
Table 3. Common Causes Of Diarrhea

Persisting Longer Than Two Weeks.
Parasites
Cryptosporidium parvum, Cyclospora cayetanensis, Entamoeba histolytica, Giardia lamblia, microsporidia
Bacteria
Campylobacter, Clostridium difficile, Escherichia coli, Listeria
monocytogenes, Salmonella enteritidis, Shigella
Social History
Viral infections
The patients occupational history may be relevant if they

work as a veterinarian, food handler, or day care center or
nursing home employee. The patients sexual preference
and whether they engage in receptive anal intercourse
should be ascertained as this may expand the differential
diagnosis to include AIDS-associated diarrhea as well as
proctitis secondary to sexually transmitted diseases.
Inquire about alcohol and drug use. Patients who abuse
alcohol may present with various abdominal complaints,
including diarrhea and melena. Opioid withdrawal
frequently involves nausea, vomiting, and diarrhea. Patients
with eating disorders or those attempting to lose weight
should be questioned about laxative abuse.
HIV
Medications
Antibiotics, high blood pressure medications, cancer drugs/
radiation therapy
Noninfectious food sources

Food allergies; certain food additives (sorbitol, fructose, and
others) are also implicated
Other systemic conditions

Diabetes, thyroid and other endocrine diseases; malignancies/tumors; previous surgery of the abdomen or gastrointestinal tract; conditions causing reduced blood flow
to the intestine such as ischemic bowel disease
more timely results and are therefore more useful in the ED

setting than stool cultures in identifying causes of inflammatory diarrhea. A selective approach to fecal leukocyte/
lactoferrin testing in patients with diarrhea is recommended, yet the precise approach remains a matter of
dispute. Community-acquired or travelers diarrhea,
nosocomial diarrhea, and diarrhea persisting more than
seven days have been suggested by the Infectious Diseases
Society of America as indications for testing.5 The utility of
these tests lies in helping to determine whether antibiotic
treatment is indicated.37
Occult blood, fecal leukocytes, and fecal lactoferrin are
often found in the stools of patients with inflammatory
diarrhea. The most common pathogens in patients with a
positive test result include Shigella, Salmonella, Campylobacter,
Aeromonas, Yersinia, non-cholera Vibrio species,40,41 and
Clostridium difficile.42
Fecal leukocytes are generally seen in the stool of
patients with shigellosis, salmonellosis, Campylobacter,
enteroinvasive E. coli, enterohemorrhagic E. coli, or staphylococcal enterocolitis.43 Other conditions in which fecal
leukocytes may be seen include Entamoeba histolytica
enteritis, Crohns disease, ulcerative colitis, and
pseudomembraneous colitis.44
Lactoferrin is a protein found in leukocytes. The fecal
lactoferrin assay can measure levels of lactoferrin released
from damaged or deteriorated leukocytes in stool specimens.43 Although more research is needed, some studies
indicate that fecal lactoferrin is more sensitive than fecal
leukocytes or occult blood as a screening tool for detecting
invasive pathogens45,46 as well as for detecting other causes
of inflammatory diarrhea such as ulcerative colitis and
Crohns disease.47,48 The test is slightly costlier than fecal
leukocyte testing, but it is quicker and easier to perform and
is not limited by the need for a fresh stool specimen.49
Guaiac-positive stools, as well as the findings of fecal
leukocytes and fecal lactoferrin, are all predictive of finding
an identifiable bacterial pathogen on stool culture.37 In one
prospective study of 873 patients, stool cultures were
ordered in 549 episodes (62.6%), most frequently for patients
with fever, more than 10 stools per day, or visibly bloody
stools. Enteropathogens were identified in 168 episodes
(30.6%).39 In another well-designed study of 1040 patients,
the absence of occult blood in the stool was a reliable
indicator for a lack of enteroinvasive bacteria.40
While patients with a chief complaint of diarrhea rarely

present with an imminent life threat, the initial assessment
of any ED patient should include a rapid assessment of
the ABCs. Hypovolemic or septic shock may require
the patients airway to be secured and the patient to
be ventilated.
Secondary Survey
A secondary survey allows for further assessment of the
patients volume status as well as the presence or absence of
systemic toxicity. Is the patient febrile? Is postural hypotension present? Are the mucus membranes dry? For infants, is
the anterior fontanelle sunken? Is the pediatric patient
producing any tears when crying? Note the patients skin
turgor, jugular venous pressure, capillary refill, and the
presence or absence of sunken eyes. Also, evaluate the
patients mental status. Is the patient awake, alert, and able
to answer questions? Is the patient lethargic or completely
unresponsive? Other features of diagnostic significance
include the presence of flushing or rashes on the skin,
mouth ulcers, thyroid masses, wheezing, arthritis, heart
murmurs, hepatomegaly or abdominal masses, ascites,
and edema.16
The abdominal examination should include auscultation of bowel sounds as well as the presence or absence
of tenderness or peritoneal signs. A rectal examination
can determine whether the stools are grossly bloody,
melanotic, or guaiac-positive. Given the fact that melanotic
stools are usually liquid, the patient may refer to this type
of stool simply as diarrhea. Thus, a rectal examination
may play an important role in assessing the nature of the
stools. Selected female patients may require a pelvic
examination depending on the degree and location of
their abdominal pain.
Diagnostic Studies
Blood Tests
Routine CBC counts or chemistry panels are unnecessary in
most patients since diarrhea is a self-limited problem in
most cases. A chemistry panel may reveal an electrolyte
imbalance or the degree of dehydration in systemically ill
patients, or in those with severe or persistent diarrhea. In
patients with bloody diarrhea, obtain a CBC and platelet
count to exclude hemolytic uremic syndrome. (Hemolytic
uremic syndrome is discussed in further detail in the section
on pediatric patients later in this article.) Eosinophilia on the
leukocyte differential can point to food allergy, collagenvascular diseases, neoplasm, parasitic infections, or eosinophilic gastroenteritis or colitis.22 Such diagnostic testing
should be reserved for select cases in which clinical or
epidemiologic factors or disease severity suggest their
need.5 Unfortunately, the literature does not provide clearcut indications for such testing.
Stool Culture
While readily obtainable tests such as heme- or leukocytepositive stools can provide the ED practitioner with
valuable information, stool cultures may be advisable under
certain circumstances.
The use of antibiotics in certain cases of bacterial
diarrhea can produce undesirable outcomes, so determining
the causative agent via stool cultures can be helpful.
For instance, treatment of salmonellosis can prolong the
carrier state and lead to a higher clinical relapse rate.28
The likelihood of hemolytic uremic syndrome in patients
infected with E. coli 0157:H7 is increased with the use of
antibiotics.50 Empiric antibiotic use may increase the risk
Fecal Leukocyte/Lactoferrin Testing

Fecal leukocytes and fecal lactoferrin testing can provide
Physical Examination
Primary Survey
patients who have been on antibiotics within the past three

months (suggests C. difficile).
Ideally, stool samples should be sent for culture within
two hours after passage to allow for detection of certain
pathogens that perish quickly. If the patient is unable to
provide a stool sample, a rectal swab can be brought to the
lab in transport media and then cultured.28
Routine stool cultures in most laboratories will identify
Shigella, Campylobacter, and Salmonella.2 (In patients who
develop diarrhea after three days of hospitalization, C.
difficile testing will have a higher yield (15%-20%), whereas
standard stool cultures will have poor yields.28)
of C. difficile colitis.
Determination of antimicrobial susceptibility is also
important given the emergence of resistance to some
commonly used antibiotics. Finally, negative stool culture
results may be important prerequisites for the diagnosis of
certain ailments such as inflammatory bowel disease.
Stool cultures can also play a role in identifying agents
that have significant public health consequences. An
outbreak of illness due to Salmonella enteritidis serves to
illustrate this point. The state public health laboratory in
Minnesota received a higher-than-expected number of
reports of Salmonella isolates from local clinical laboratories
in 1994. These reports ultimately led to the detection of a
nationwide outbreak of Salmonella enteritidis infection due to
contaminated ice cream that had been widely distributed
(with patients afflicted in 41 states). An estimated 220,000
people were affected by this outbreak.51 Elimination of the
contaminated product from the market potentially prevented the spread of this infection to thousands of others.
These preventive measures were possible because stool
cultures were obtained on the first patients who presented
to their physicians with diarrhea.
While these examples provide compelling evidence for
obtaining stool cultures on patients with diarrhea, the yield
on routinely obtained stool cultures is low. In six studies
conducted between 1980 and 1997, stool cultures were
positive in 1.5%-5.6% of cases.5 This translates to a cost of
$952-$1200 for each positive culture obtained. Interestingly,
in the study with a positive culture yield of 5.6%, 63% of the
patients had grossly bloody stools, while 91% presented
with a history of bloody diarrhea.52
Therefore, experts recommend restricting the use of
stool cultures. In patients in whom vomiting is a prominent
feature of their disease, viral agents are the likely etiology
and stool cultures will have a low yield. Proposed criteria
that suggest a higher yield from stool cultures include
history of bloody stools (grossly bloody or heme-positive
stools) or stools containing leukocytes or lactoferrin;
immunocompromised patients; fever higher than 38.5C
(101.3F); systemic illness or an illness that is clinically
severe or persistent; and patients with severe abdominal
pain.2,28,53 Selective cultures can be considered in specific
circumstances such as bloody diarrhea in afebrile patients
with a history of ingestion of unpasteurized juice or milk or
undercooked beef (suggests enterohemorrhagic E. coli);
patients who have consumed shellfish within 72 hours of
the onset of illness (suggests Vibrio parahemolyticus); and
Stool Testing For Parasites

In developed countries, testing for ova and parasites in
patients with acute diarrhea is rarely indicated.54 Cases in
which testing for ova and parasites may be appropriate
include patients who present with diarrhea lasting more
than 14 days, the immunocompromised, and patients who
have not responded to antimicrobial therapy.2 Other
situations in which to consider ova and parasite testing
include a community outbreak of diarrhea with a suspected
waterborne cause, exposure to infants at a day care center,
patients with a history of travel to endemic areas such as
Russia (Giardia, Cryptosporidium), Nepal (Cyclospora), or
mountainous regions of North America (Giardia). In patients
with chronic bloody diarrhea and a paucity of fecal leukocytes, consider amebiasis.5 As with routine stool cultures,
stool culture for ova and parasites in patients in whom
diarrhea develops three or more days after hospitalization
has an extremely low yield.49
Endoscopy/Computed Tomography
Lower gastrointestinal endoscopy should be considered in
patients with rectal bleeding, severe abdominal pain, fever,
as well as negative stool tests for pathogens or otherwise
unexplained chronic diarrhea lasting longer than three
weeks.20 Biopsy and evaluation of the colonic mucosa is
crucial to exclude the presence of C. difficile
pseudomembraneous colitis, inflammatory bowel disease,
ischemic colitis, microscopic or collagenous colitis (types of
inflammatory bowel disease), and malignancy.20 In one
study, 809 HIV-negative patients with chronic non-bloody
diarrhea underwent colonoscopy. Fifteen percent of these
patients had an inflammatory cause of diarrhea, including
microscopic colitis and, to a lesser extent, Crohns disease
and ulcerative colitis.55
Key Points In The Management Of Patients With Diarrhea

For most patients, diarrheal illness is short and self-limited.
dependent on a complete history and physical examination

rather than on extensive, costly laboratory testing.
While the presence of abdominal discomfort and loose stools

can be consistent with gastroenteritis, this symptom complex
may also signal appendicitis, ischemic bowel disease,
inflammatory bowel disease, radiation enteritis, irritable bowel
syndrome, and a wide variety of other disorders.
Treatment for many forms of diarrhea consists of

rehydration and symptomatic relief.
Pediatric, elderly, chronically ill, or immunocompromised
patients are at greatest risk for serious etiologies and/or
complications, including dehydration.
Correct diagnosis of an acute diarrheal illness is largely
Treatment
Treatment decisions are influenced by several factors,
including the patients hydration status, the need for
symptomatic relief, and the likelihood of the presence of a
bacterial pathogen.
Rehydration
Rehydration can be accomplished by oral or intravenous
fluid administration. In patients with moderate-to-severe
dehydration, as well as those in whom vomiting disallows
adequate oral fluid intake, intravenous hydration speeds up
the recovery process. In many cases, rehydration can be
achieved with oral rehydration solutions. Fluids used for
rehydration should contain sodium, potassium, and
glucose.28 Various commercial types of oral rehydration
solutions (such as Pedialyte, Lytren, and Rehydrolyte) are
available. Various home preparations have been proposed,
although they are not recommended in children. Additionally, sports drinks, which are designed to replenish fluids
and electrolytes lost by sweating, are inadequate to replace
diarrheal sodium losses. These solutions can be effective if
they are supplemented with another source of salt such as
pretzels or crackers.16,22
The use of the BRAT diet (bananas, rice, applesauce,
toast) is commonly recommended, although evidence-based
data supporting its use are sparse. One evidence-based
clinical practice guideline suggests that continued use of the
patients preferred, usual, and age-appropriate diet should
be encouraged, and that the BRAT diet offers no advantage
unless those foods are part of the usual diet.4
Empiric Antibiotic Therapy

Authorities disagree on the indications for empiric antibiotic
therapy in diarrheal illness. When effective, antibiotics
shorten the course of an acute diarrheal illness by one
or two days. This potential benefit should be balanced
against the risk of drug-induced side-effects. The expense
of therapy and the broader societal issue of antibiotic
resistance induced by antibiotic overuse should also
be considered.5
Interestingly, although physicians often believe that
patients expect antibiotics for a variety of ailments, one
study found that patient satisfaction with medical care in
the case of diarrheal illness correlates poorly with receiving
antibiotics. An additional finding of this same study is that
physicians are not adept at identifying which patients
expect antibiotics.58
Empiric antibiotics should be considered for patients
with acute dysentery or those with moderate-to-severe
travelers diarrhea.5 Diarrhea lasting longer than two to
two-and-a-half days has a higher probability of having a
non-viral cause; thus, empiric antibiotics can be given in
these cases as well. Other criteria for empiric antibiotic
therapy include fever greater than 38.5C (101.3F) plus
either leukocyte-, lactoferrin-, or hemoccult-positive stools.28
Table 4 on page 13 lists the pharmaceutical regimens
recommended for patients with diarrheal illnesses. In most
instances, fluoroquinolones for adults and trimethoprimsulfamethoxazole (TMP-SMX) for children are reasonable
Symptomatic Therapy
Symptomatic therapy may be used in selected patients with
diarrhea. Patients who are afebrile and have non-bloody
diarrhea as well as most patients with chronic diarrhea
associated with inflammatory bowel disease may benefit
from the use of antimotility agents.28 Antimotility agents
should generally be avoided in patients with high fever,
sepsis, immunocompromise, bloody diarrhea, or suspected
inflammatory diarrhea because of delayed clearance of
Continued on page 13
enteric pathogens, prolonged fever, and toxic megacolon,28,53

although some argue that antimotility agents may be
used in patients with nondysenteric forms of diarrhea
caused by enteroinvasive pathogens as long as antibiotics
are also prescribed.
Agents available for diarrhea relief include loperamide,
diphenoxylate, and bismuth subsalicylate.
Loperamide is a commonly recommended antimotility
agent because of its safety and efficacy profile. It slows
intraluminal flow of liquid by inhibiting peristalsis, which
allows for increased intestinal absorption of fluid and
electrolytes, which in turn results in substantial stool
volume reduction. When used with antibiotics in patients
with travelers diarrhea or bacillary dysentery, loperamide
can reduce the duration of diarrhea by one day.53 It is an
opiate that does not penetrate the nervous system; thus,
there are no CNS side-effects or potential for addiction.
Diphenoxylate is less costly than loperamide; however,
it is chemically related to meperidine, can penetrate the
CNS, and may be habit-forming.
Bismuth subsalicylate helps alleviate symptoms of
dyspepsia, nausea, and diarrhea. It exerts its anti-diarrheal
effects via an antisecretory mechanism, binding of bacterial
toxins, and by its inherent antimicrobial activity. It helps
alleviate nausea and vomiting by a topical effect on the
gastric mucosa and is preferred when vomiting is a prominent complaint. It has been used effectively in children with
diarrhea as well as in patients with travelers diarrhea.57
In patients with unexplained diarrhea and a negative

colonoscopic examination, upper gastrointestinal tract
infections (Giardia, bacterial overgrowth syndrome)
and small bowel and pancreatic diseases resulting in
malabsorption should be considered. Biopsies obtained by
upper endoscopy can determine etiologies such as celiac
sprue (which causes the malabsorption of gluten),
Whipples disease (a malabsorption illness caused by
Tropheryma whippelii), or other malabsorptive syndromes.
CT scanning of the abdomen and pelvis may provide
further information about small bowel and colonic disease
or extrinsic disease processes such as pancreatic tumors
that can cause diarrhea.56
Although these are not primary diagnostic considerations, a working knowledge of these options is important
to facilitate the work-up of patients who present to the ED
with persistent diarrhea and a negative initial evaluation.
Is the patient stable?
YES
NO
ABCs, resuscitate, then history and

physical examination (Class I)
History and physical examination

(Class I)
Provide symptomatic therapy
Rehydration (IV or oral) (Class I)

Antiemetics as needed (Class II)
Antipyretics as needed (Class II)
Antibiotics as indicated (Class II)
Antimotility agents as indicated (Class II)
Other symptomatic relief as needed (Class II)
Diagnostic evaluation as indicated
Potentially serious diagnosis

possible, or patient too ill
to discharge
Acute, self-limited process likely
Patient too ill to discharge
Diagnosis clear
and stable clinical state
Consult and/or admit (Class II)
Consult and/or admit (Class I)
Clinical Pathway: Approach To Patients With Diarrhea
Discharge (Class I)
The evidence for recommendations is graded using the following scale. For complete definitions, see back page. Class I: Definitely
recommended. Definitive, excellent evidence provides support. Class II: Acceptable and useful. Good evidence provides support. Class III:
May be acceptable, possibly useful. Fair-to-good evidence provides support. Indeterminate: Continuing area of research.
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending
upon a patients individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright 2004 EB Practice, LLC. 1-800-249-5770. No part of this publication may be reproduced in any format
without written consent of EB Practice, LLC.
10
Diarrhea (loose, watery bowel movements) is often caused by an infection. Many infections that cause diarrhea
simply go away by themselves. Diarrhea can also be caused by other things, like medications, bleeding into the
stomach or bowels, diseases of the bowels, appendicitis, and many others. Diarrhea can happen by itself or may
happen with other symptoms, like cramps or pain in the stomach and bowel area, fever, vomiting, rash, or bleeding
from the rear end. You can become dehydrated (lose too much water) because of diarrhea.
at the pharmacy or supermarket. Let your child eat a
regular diet as soon as possible. If your child is
vomiting, try having him or her drink very small
amounts of liquid until the vomiting stops.
Adults
Signs of dehydration
You are very thirsty
You feel weak or dizzy
You faint or feel like you might faint
Your skin is dry or very loose
Your urine is dark
Do Not:
Dont use water or sports drinks for your
dehydrated child (use an oral rehydration
solution instead)
Dont withhold dairy products (milk, cheese, ice
cream) from your child
Dont have your child drink fruit juices like prune,
apple, or grape juice (these can cause diarrhea)
How to avoid or treat dehydration

For the first 1-2 days: Drink lots of fluids, such as
caffeine-free sodas, sports drinks, and flavored
mineral water, or an oral rehydration solution that you
can buy at the supermarket or pharmacy. Nibble on
salted crackers or pretzels (you need the salt) and
drink some orange juice or eat some bananas (for the
potassium, needed for the heart and muscles. You are
probably drinking enough if you are not thirsty and
your urine is pale yellow.
After the first 1-2 days: Try plain potatoes,
noodles, rice, boiled cereals, bread, and other similar
items. Go back to your regular diet if the diarrhea
is gone.
Medications
Use all medications exactly as your doctor advises.
You have been prescribed:
______________________________
______________________________
______________________________
You may also use:
______________________________
______________________________
______________________________
Do Not:
Dont drink milk or eat dairy products (cheese, ice
cream) for 2-3 days
Dont drink caffeine (tea, cola, coffee)
Dont drink alcohol
Dont drink fruit juices like prune, apple, or grape
juice (these can cause diarrhea)
Reasons to return to the Emergency

Department:
You are dehydrated
You are vomiting and cannot eat or drink
You have a fever over _____ F ( _____ C )
You have blood, pus, or mucus in your diarrhea or
bowel movements
You have pain in the stomach or bowel area
You have bloody, black, or wine-colored diarrhea
or bowel movements
Your sickness lasts more than _____ days
You are not getting better at home
You have any other problems that concern you
Children
Signs of dehydration
Your child is very thirsty
Your child is very weak, sleepy, or cranky
Your childs skin feels cool, doughy, or loose
Your child cries but does not make tears
Your child does not make as much urine as usual
How to avoid or treat dehydration
Use an oral rehydration solution that you can buy
See your own doctor in _____ days.
Copyright 2004 EB Practice, LLC. 1-800-249-5770. No part of this publication may be reproduced in any format
without written consent of EB Practice, LLC.
11
Sample Discharge Instructions For Patients With Diarrhea
Ten Pitfalls To Avoid

1. The patient had nausea, vomiting, and diarrheatypical
gastroenteritis, right?
While thats often the case, a more thorough evaluation is
required. Gastrointestinal symptoms are notoriously nonspecific. Plus, a wide variety of extra-abdominal conditions
can present with abdominal complaints (diabetic
ketoacidosis, thyrotoxicosis, poisonings, pneumonia).
a diagnosis of viral gastroenteritis, which is often a

wastebasket category and implies premature closure of the
diagnostic thought process.
7. In the ED, everybody with vomiting and diarrhea looks
sick at firstbut if they look better after rehydration, its
usually okay to discharge them. This 65-year-old man
looked pretty good after he was rehydrated. How was I
supposed to know that hed get worse at home? We cant
admit everyone.
It seems prudent to be more concerned about those
at the extremes of age (the pediatric and geriatric set),
immunocompromised individuals, and those with
severe abdominal pain. Severe abdominal pain is not
typically associated with gastroenteritis or most common
enteric pathogens.
Loose stools may also be present in patients with
ischemic bowel disease. Consider this diagnosis in the
elderly and in those with a history of vascular disease.
C. difficile-associated diarrhea is a consideration in
anyone who has been taking antibiotics during the past
three months. Certain antibiotics (e.g., clindamycin) place
the patient at particularly high risk for toxin-induced colitis.
2. The patient had nausea, vomiting, and diarrhea. I

diagnosed viral gastroenteritis and discharged her in
stable condition. She never told me that she recently
returned from an overseas trip!
Travelers, patients recently discharged from the hospital,
patients with recent medication use (especially antibiotics),
and the immunocompromised are susceptible to a much
wider range of etiologies. Inquire routinely about these
aspects of their medical history. Patients often do not
realize the significance of these factors.
3. The patient reported diarrhea. He didnt tell me his stool
was black! How was I supposed to know that he had a
gastrointestinal bleed?
Many patients either dont know the characteristics of the
stool theyre passing or fail to recognize the significance of
various abnormalities (blood, mucus, melena). Ask the
patient for specifics, and if any doubt remains about what is
being passed, do a rectal examination.
8. I didnt give Mr. Jones an antimotility drug because I was

always taught it might make the patient worse. I never
expected him to become so dehydrated that hed pass out!
While its true that there are cases in which antimotility
drugs are contraindicated, they can be of significant benefit
for both comfort and for preventing dehydration in most
adults with diarrhea.

gastroenteritis. How was I supposed to know it was
appendicitis? (Part 1)
Unfortunately, there are no absolute guidelines. While
appendicitis remains a primarily clinical diagnosis,
quantifying might help. Appendicitis patients tend to have
one or two emesis episodes after their abdominal pain
begins, and they typically pass one or two loose stools.
Those with gastroenteritis, on the other hand, tend to have
multiple episodes of vomiting and voluminous loose stools.
9. When I discharged Mrs. Smith, she was stable, taking

oral fluids, and had no abdominal painbut later she
came back in shock, severely dehydrated. What could I
have done differently?
Written discharge instructions that the patient and her
family can understand and use are critically important. Key
reasons to return to the ED include profuse diarrhea,
dehydration (manifested by weakness, lethargy, altered
mental status, syncope/near-syncope, thirst, decreased
urine output), sustained fever, severe or persistent
abdominal pain, bloody or mucoid stools, and the inability
to take and retain oral fluids. (See also the Sample
Discharge Instructions For Patients With Diarrhea on page
11.) Instructions must be clear and specific.

gastroenteritis. How was I supposed to know it was
appendicitis? (Part 2)
Serial abdominal examinations can be extremely helpful
in identifying appendicitis. Patients with gastroenteritis
generally improve with time and fluids. While the pulse
and blood pressure of patients with appendicitis may
improve with intravenous fluids, abdominal signs and
symptoms like localized tenderness, guarding, and
rebound typically persist.
10. I know that diarrhea can occasionally have serious

sequelae, but it simply isnt practical to send everyone
for follow-up!
Thats true, but be careful. In general, otherwise healthy
patients whose symptoms resolve quickly do not require
follow-up. But certain subsets of patientssuch as those
with chronic symptoms, the elderly, the very young, the
immunocompromised, and those with co-morbid
illnessesshould be referred for follow-up. And, as
mentioned in the prior item, discharge instructions should
be very clear about circumstances under which patients
should seek further medical care.
6. The patient had nausea, vomiting, and diarrhea, but was

otherwise unremarkable. I diagnosed viral gastroenteritis
and discharged her in stable condition. I had to diagnose
something, right? Too bad she got worse and had to return
to the ED a couple of days later.
Many entities seem like viral gastroenteritis that arent. If
the diagnosis is unclear, stick to the facts and write
vomiting and diarrhea with dehydration (or something
similar) on the chart. Dont paint yourself into a corner with
12
choices.5 Empiric therapy with metronidazole (or other

anti-Giardia agent) can also be considered in patients
with diarrhea lasting 2-4 weeks, without systemic symptoms or dysentery.16
In suspected cases of C. difficile-associated diarrhea,
the offending antibiotic should be stopped if possible
and treatment with oral metronidazole begun. Metronidazole should be stopped if the assay for C. difficile toxin
is negative.14
When empiric antibiotic therapy is not employed
judiciously, it can be ineffective or even harmful. If vomiting
is a prominent symptom of the illness, a viral source is more
likely. Antibiotics should also not be used if the diarrhea is
thought to be due to Shiga toxin-producing E. coli. This
decision will involve physician judgment since no diagnostic test will yield an immediate result to help the clinician.
Keep in mind that Shiga toxin-producing E. coli (E. coli
0157:H7 being the most common type) causes bloody
diarrhea. E. coli 0157:H7 outbreaks have been associated
with undercooked ground beef as well as with fresh
produce such as unpasteurized apple cider, cabbage, and
alfalfa sprouts.2
diarrhea include quinolones, TMP-SMX, as well as nonabsorbable or poorly absorbed antibiotics such as rifaximin
and aztreonam.59,60 A comparison of two different doses of
TMP-SMX with or without loperamide vs. loperamide alone
in American adults with acute diarrhea in Mexico revealed
that combination therapy with TMP-SMX and loperamide
was the most efficacious regimen.61
Several studies have also provided data regarding the
efficacy and safety of rifaximin for the treatment of
travelers diarrhea. Adults with acute travelers diarrhea
who took rifaximin vs. placebo for three days had earlier
resolution of symptoms (average, slightly more than one
day).62 A randomized, controlled trial comparing rifaximin
with TMP-SMX revealed an 11% clinical failure rate with
rifaximin vs. a 29% clinical failure rate with TMP-SMX.63 In
another comparison of rifaximin with ciprofloxacin, no
significant differences were noted between the two treatment groups.59
There is an increasing emergence of fluoroquinoloneresistant Campylobacter, with the rate of resistance exceeding
80% in Southern Asia.53 For patients with travel histories
to this part of the world, erythromycin or azithromycin
are alternatives.53
Travelers Diarrhea
Prevention Of Travelers Diarrhea
Antibiotics commonly used in the treatment of travelers
Advising patients on ways to minimize the risk of travelers

diarrhea for future trips may be helpful, as well. Beverages
should be carbonated or steaming hot. Uncarbonated
water, bottled water, and even ice may be unsafe. Dry
foods (bread), acidic foods (citrus), and foods with high
sugar content (jellies, syrups) are safe. Buffet items and
green, leafy vegetables (which are washed in water)
should be avoided.57
Advise travelers to take along loperamide or bismuth
subsalicylate as well as an antibiotic. (However, note that
sulfa-based medications can produce photosensitivity.)
One randomized, controlled comparison of bismuth
subsalicylate with loperamide showed similar efficacy;
however, the loperamide group passed fewer stools than
the bismuth subsalicylate group.64 On the other hand,
bismuth subsalicylate has the additional advantage of
alleviating nausea and vomiting and has been shown to
prevent travelers diarrhea. In a randomized, double-blind,
placebo-controlled trial, diarrhea developed in 23% of
students receiving bismuth subsalicylate compared with
61% of students taking a placebo. The treatment group
experienced fewer intestinal complaints and were less likely
to pass loose or watery stools. In subjects in whom diarrhea
did occur, enteropathogens were identified less commonly
in the treatment group (33%) compared to the placebo
group (71%).57
Table 4. Empiric Antibiotic Therapy

Regimens For Suspected Infectious
Diarrhea.
1. Temperature greater than 38.5C (101.3F) and one
of the following:
Guaiac-positive stools or presence of fecal leukocytes or
fecal lactoferrin
Also, consider empiric antibiotics in patients with
diarrhea lasting longer than 48 hours
Treatment:
A fluoroquinolone in adults
Trimethoprim-sulfamethoxazole in children
Treatment period: 1-5 days
2. Moderate-to-severe travelers diarrhea

Treatment:
A fluoroquinolone in adults
Trimethoprim-sulfamethoxazole in children
Treatment period: 1-5 days
3. Diarrhea for 2-4 weeks without systemic symptoms

or dysentery
Treatment:
Consider a seven- to 10-day course of metronidazole or
other anti-Giardia agent
4. Nosocomial diarrhea
Treatment:
Special Circumstances
Stop the suspected offending antibiotic

Metronidazole (first line) or vancomycin (in case of
metronidazole failure or when metronidazole is
contraindicated or not tolerated)
Treatment period: 10 days if assay for C. difficile is positive.
Stop antibiotic if assay for C. difficile is negative.
Immunocompromized Patients
Patients with HIV/AIDS are especially prone to diarrheal
illnesses. About half of North American AIDS patients will
develop diarrhea at some point in their illness. The incidence of diarrhea in AIDS patients throughout the develop-
13
Continued from page 9
ing world approaches 100%.65

While HIV/AIDS patients are at risk for all of the
diarrheal ailments that afflict the immunocompetent
population, they can develop enteric infections from a
variety of unusual viral, parasitic, protozoal, and bacterial
organisms. Malignancies affecting the gastrointestinal tract,
such as lymphoma and Kaposis sarcoma, may produce
diarrhea, as can many antiretroviral medications.65,66 Finally,
many AIDS patients receive multiple or sustained courses of
antibiotics, predisposing them to C. difficile-associated
diarrhea.66 Therefore, it is important to maintain a broad
differential diagnosis, consider a more aggressive diagnostic
strategy, involve consultants early when appropriate, and
consider hospitalization to improve diagnostic certainty
through a combination of testing, observation, and consultant involvement. (See also the January 2002 issue of
Emergency Medicine Practice, HIV-Related Illnesses: The
Challenge Of ED Management.)
Because certain symptoms may suggest particular
organisms (see Table 5), the approach to the HIV/AIDS
patient with diarrhea begins with the history. Definitive
diagnosis, however, is likely to result from either microbiological studies or endoscopy.65,66 Begin by assessing the
patients immune status. Ask about specific exposures
(sexual practices, travel history, and medications including
recent antibiotics). Inquire also about the stool characteristics (bloody, mucoid, watery) and all associated symptoms
(e.g., fever, vomiting, abdominal pain or cramping, tenesmus, bloating, weight loss).65,66 What may seem like an acute
bout of diarrhea may actually represent the beginning of
chronic symptoms. Routine laboratory tests should be
ordered based on the clinical situation.65 Many authorities
recommend that in AIDS patients, a stool culture should be
done, along with C. difficile toxin and ova and parasite
testing.66 If these studies are negative, referral to a gastroenterologist for endoscopic investigations could be the next
step in the patients evaluation.65,66 In the AIDS patient with
chronic diarrhea and a negative microbiological work-up for
infectious agents, authorities are divided on the best
approach. Some advocate symptomatic care, some a course
of empiric antibiotics, and still others suggest endoscopy
with gastrointestinal mucosal biopsy; symptoms and
disease stage guide these decisions.17 Endoscopy often

produces a definitive diagnosis in AIDS patients with
chronic diarrhea and negative stool studies.67
ED treatment options include rehydration, antimotility
agents, and empiric antibiotics, as discussed earlier in this
article. Consultation or referral to the patients primary care
provider or infectious disease specialist regarding antibiotic
therapy or changes in antiretroviral therapy are advisable.
Elderly Patients
Diarrheal illnesses are important causes of death and
disability in the elderly. Not only are more serious etiologies
more common in the elderly, the physiological stresses of
diarrheal illness are more challenging for this population.
Age-related declines in immune system functioning,
physiologic changes of aging, medications (e.g., those that
inhibit gastric acid secretion, antibiotics, vasoconstrictors,
and others), and environmental factors (e.g., group living in
nursing homes) all contribute to the elderly patients
susceptibility to develop diarrhea.68
Furthermore, elderly patients with diarrhea are often
profoundly dehydrated due to fluid losses associated with
their illness, fever, an age-related disordered thirst mechanism, co-existing illnesses (e.g., diabetes mellitus), medications (e.g., diuretics) and limited access to fluids due to
infirmity. Prompt, adequate rehydration is essential;
however, intravenous rehydration of the elderly individual
may be complicated by the presence of cardiovascular
disease or renal dysfunction, thus limiting rapid, largevolume fluid administration.68
Ischemic colitis, diverticulitis, bacterial overgrowth,
and colonic malignancies are all more common in the
elderly and may present with loose stool.7,68,69 Infections
notably, C. difficile, E. coli 0157:H7 and Salmonella species
are more common in the elderly.68,70 Infectious diarrhea in
the elderly is associated with a higher mortality rate.68
If medications are indicated for an elderly patient with
diarrhea, be aware of drug interactions and side-effects,
particularly if the patient is already on multiple medications. Antacids may reduce the potency of fluoroquinolones.
Additionally, fluoroquinolones can increase theophylline
and warfarin levels and can either increase or decrease
phenytoin levels. Metronidazole can cause nausea and
vomiting, exacerbating the situation for a patient who
initially presented with a gastrointestinal complaint.
Drinking alcohol while taking metronidazole must be
strictly avoided since a disulfiram-like reaction can ensue.
Also, warfarin, phenytoin, and phenobarbital metabolism
may all increase in the patient on metronidazole, potentiating their effect.68
Be particularly cautious when evaluating elderly
patients with diarrhea combined with abdominal pain.
Elderly patients with abdominal pain tend to have more
serious, often surgical, illnesses that present atypically
or go unrecognized longer.69 (See also the premier issue
of Emergency Medicine Practice, Assessing Abdominal
Pain In Adults: A Rational, Cost-Effective, And EvidenceBased Strategy.) Specific surgical diagnoses to consider
Table 5. Diarrheal Syndromes In Patients

With HIV/AIDS.
Abdominal cramps, bloating, nausea
Possible agents: Cryptosporidia, microsporidia, isospora,
giardia, cyclospora, and Mycobacterium avium complex
Profuse watery diarrhea, weight loss, electrolyte

disturbance (especially in advanced disease)
Possible agent: Cryptosporidia
Bloody stools, fever, abdominal cramps

Possible agents: Invasive bacteria, C. difficile,
cytomegalovirus
Adapted from: Sax PE. Opportunistic infections in HIV disease: down
but not out. Infect Dis Clin North Am 2001;15(2):433-55.
14
Pediatric Patients
Diarrhea is very common in children, especially among
those who attend day care. While most children in developed nations have mild, self-limited disease, pediatric
patients are susceptible to more adverse outcomes
especially dehydrationthan their healthy adult counterparts.21 In the United States, about 9% of all hospitalizations
of children younger than 5 years are because of diarrhea.71
While pediatric patients are susceptible to more
adverse outcomes from diarrheal illnesses, the approach is
generally the same. As with adults, infectious causes
predominate, although children have more of a predisposition to rotavirus. Another common non-infectious cause in
children is the excessive consumption of sugary, clear
liquids, which can cause copious, watery stools. The wary
practitioner should also keep more serious diagnoses such
as intussusception and Meckels diverticulum in mind.
In most cases, prevention of dehydration is the primary
consideration. Oral rehydration methods are preferred.
After rehydration, recommend prompt resumption of a
Cost- And Time-Effective Strategies For Patients With Diarrhea

1. Consider minimizing testing in those with acute
gastroenteritis by obtaining an adequate history and
performing a sufficient physical examination.
Routine laboratory testing is unhelpful for most patients with
acute diarrheal illnesses. The white blood cell count is neither
sensitive nor specific for any particular illness characterized
by diarrhea. The white blood cell differential is often similarly
unhelpful. Hemoglobin and hematocrit levels may be useful
in those patients with blood loss, but otherwise are of limited
to no value. Electrolytes are rarely disordered significantly in
young patients with short periods of diarrhea. Renal function
tests are a poor screen for dehydration. Urine-specific gravity
may be somewhat more helpful, but easily observable clinical
features like skin perfusion, vital signs, urine output, and
thirst may be best of all.
Caveat: The WBC count can be helpful in identifying C.
difficile (which may require admission) or enteric fever. In
addition, eosinophilia may indicate alternative diagnoses.
bloody stools, grossly bloody, or heme-positive stools), stool

samples positive for leukocytes or lactoferrin, patients whose
symptoms last longer than two days, and in all other patients
to whom empiric antibiotics will be prescribed.
4. Do not order stool testing for ova and parasites in the ED.
Testing for ova and parasites in patients with acute diarrhea
is rarely indicated in the United States.
5. Oral rehydration is superior to intravenous rehydration
in most patients able to tolerate oral intake.
The cost difference is enormous in favor of oral rehydration
and it also provides one important indicator of the patients
suitability for discharge (ability to tolerate oral fluids). In
addition, several studies indicate faster recovery times with
early refeeding. If the gut works, use it.
Caveat: Intravenous rehydration with or without oral
supplementation can be much quickerwhich may be an
important consideration in high-volume EDs.
2. Test for C. difficile toxin in those patients with a

suggestive history, including antibiotic use in the past
three months.
This is one situation for which testing is truly indicated.
Treatment for C. difficile is relatively inexpensive and effective.
In this setting, test for the toxin; treat empirically pending the
culture results if strong clinical suspicion is present.
6. Reassess, reassess, reassess and provide good

discharge instructions.
Prior to discharging any patient with gastrointestinal
complaints, recheck the vital signs, repeat the abdominal
examination, and document your findings. Make sure
that all patients can take oral fluids without developing
vomiting or other intolerable symptoms. Those who cant
are more likely to bounce back to the ED and may be
quite unhappy about a second visit for the same illness.
Finally, make sure that patients and their caregivers can
comply with discharge instructions and understand reasons
to return to the hospital.
3. Order stool cultures selectively.

In general, stool cultures are expensive, time-consuming, low
yield, and not helpful to the emergency physician. Consider
obtaining stool cultures only in patients with a temperature
greater than 38.5C (101.3F), bloody stools (history of
15
regular diet, supplemented with oral rehydration solution

as tolerated. In vomiting children, frequent, small-volume
oral intake is recommended.4
In children, as a general rule, pharmacologic agents
should not be used to treat acute diarrhea.21 While some
well-designed studies have shown statistically significant
results for certain agents, the results were not clinically
significant, and published evidence-based guidelines do not
support their use in children.4,21 Antibiotic use may be
considered in patients in high-risk categories or with serious
bacterial infections.4
Hemolytic uremic syndrome is a complication of E. coli
0157:H7 infection that occurs primarily in children. While
rare, it is the most common cause of acute kidney failure in
infants and children. Early symptoms include vomiting and
diarrhea (sometimes bloody), fever, and irritability or
lethargy. Later, urine output, decreased consciousness,
pallor, bruising, petechiae, or jaundice may occur. An
enlarged liver or spleen may be present. Laboratory studies
will show evidence of hemolytic anemia and acute renal
failure. Administration of packed red blood cells may be
necessary, and severe cases may require dialysis. Nevertheless, most children receiving treatment recover completely
with no long-term consequences.
in the elderly patient with diarrhea include bowel

obstruction, appendicitis, mesenteric ischemia, neoplasm,
and diverticulitis.69
Pregnant Patients
than those in the placebo group.77

It should be noted that the studies referenced above
were conducted primarily in the developing world, where
zinc deficiency in children is prevalent. In the United States,
zinc administration to children with diarrheal illnesses is not
a part of standard therapy.
Constipation is usually more of a problem than diarrhea

during pregnancy; however, when diarrhea does occur,
treatment principles are similar. Preventing dehydration in
pregnant patients is a top priority, as it is dangerous for both
mother and fetus. Replete disordered electrolytes as needed
and provide symptomatic relief. Antibiotic and other
medication use in the pregnant patient with diarrhea should
be guided by an assessment of the individual patients riskbenefit ratio based on symptom severity and pregnancy risk
category of the medication. Loperamide is the safest
antimotility agent since it acts peripherally (unlike
diphenoxlylate) and does not contain salicylates (unlike
bismuth subsalicylate).72 Of the antibiotics generally used
for diarrhea treatment, none are considered relatively safe in
pregnancy except metronidazole (a Category B drug) after
the first trimester if the benefits outweigh the risks. The
quinolones and TMP-SMX are either to be avoided or used
with caution depending on stage of pregnancy. If doubts
exist about antibiotic use in the pregnant patient, the best
approach is to coordinate treatment with the patients
obstetrician-gynecologist or consult a medical reference that
lists teratogenic agents.
Ramoplanin For C. difficile-Associated Diarrhea

A new antibiotic, ramoplanin, is currently in Phase
II development for C. difficile-associated diarrhea.
This antibiotic also has activity against vancomycinresistant Enterococcus species and other enteric
organisms.78 Ramoplanin is an oral agent and is
not systemically absorbed.79
Disposition
Probiotics are microorganisms that some have used in a

variety of settings and clinical circumstances to colonize the
intestine to prevent or treat diarrhea.
One recent meta-analysis of probiotic use in children
hospitalized with acute gastroenteritis found that probiotics
are a useful adjuvant along with rehydration therapy in
acute gastroenteritis.73 Another meta-analysis of oral
Lactobacillus (the most-studied probiotic) treatment of
children with acute infectious diarrhea found that diarrhea
duration was reduced an average of 0.7 days, and stool
frequency decreased by an average of 1.6 per day.74 A third
recent meta-analysis of probiotics for antibiotic-associated
diarrhea found that diarrhea occurred in 23% of patients
not receiving a probiotic agent and in 13% of patients
receiving a probiotic.75 This meta-analysis involved
children and adults.
While probiotics are not standard therapy for adults or
children with diarrhea in the United States, they are
available over-the-counter in a variety of retail outlets, and
patients may ask about their utility in diarrheal illnesses.
For patients with diarrheal illness, disposition decisions rely

heavily on physician judgment. Clinically stable patients
with benign physical examinations and diagnoses that
present low risk for complicationsthe most common
scenariocan be safely discharged with good follow-up
instructions. Ill patients who fail to respond adequately to
simple ED measures like rehydration and symptom relief
may either be held in the ED or admitted to an observation
area or to the hospital, depending on local resources and
hospital policies. A brief hospital admission can provide
dramatic improvement, especially for patients at the
extremes of age or with serious co-morbidities. Patients who
represent diagnostic dilemmas or who present atypically
could require either a period of observation or immediate
further investigation depending on the level of concern.
Given the incredibly broad differential diagnosis of
diarrheal illness, no definitive rules are available to guide
decision-making. Again, maintain a heightened level of
alertness when evaluating the very old and the very young,
those with multiple or serious co-morbidities, and the
immunocompromised.
Patients with chronic diarrhea deserve special mention
because they often need extensive evaluation to determine
the cause of their symptoms. This diagnostic evaluation
usually exceeds the scope of most ED capabilities. Coordination of care with a gastroenterologist is advised in these
cases. The role of the emergency physician is to exclude
serious illness, ensure patient stability, begin an investigation to exclude infectious causes of diarrhea, and provide
timely referral for further evaluation.
Zinc
Preventive Measures
In 2000, a pooled analysis of randomized, controlled trials of

zinc therapy in children under 5 years of age with diarrhea
concluded that zinc supplementation reduces the duration
and severity of acute and persistent diarrhea.76
A more recent randomized, controlled clinical trial
studied the effects of zinc administration in children with
diarrhea. This study was done in Nepalese children 6-35
months of age with acute diarrhea. Findings were that zinc
supplementation substantially reduced diarrhea duration
and that those in the zinc group were more likely to vomit
Emergency physicians should also teach patients and

their families about simple preventive measures to reduce
disease transmission, especially when a patient is being
discharged with a transmissible diarrheal illness. Norwalklike viruses, in particular, are infectious in very low concentrations and are easily spread from person to person by
droplets, or even by contaminated objects. Asymptomatic
carriers can also transmit these viruses. In addition,
infectious agents are easily spread among the institutionalized elderly due to poor personal hygiene (secondary to
Controversies/Cutting Edge
Probiotics
16
Guerrant RL, Van Gilder T, Steiner TS, et al; Infectious Diseases Society
of America. Practice guidelines for the management of infectious
diarrhea. Clin Infect Dis 2001 Feb 1;32(3):331-351. (Practice guideline)
6.
No authors listed. Practice parameters for the treatment of sigmoid
diverticulitis. The Standards Task Force. The American Society of
Colon and Rectal Surgeons. Dis Colon Rectum 2000 Mar;43(3):289.
(Practice guideline)
7.
Wong WD, Wexner SD, Lowry A, et al. Practice parameters for the
treatment of sigmoid diverticulitissupporting documentation. The
Standards Task Force. The American Society of Colon and Rectal
Surgeons. Dis Colon Rectum 2000 Mar;43(3):290-297. (Practice
guideline)
8.
No authors listed. American Gastroenterological Association Medical
Position Statement: guidelines on intestinal ischemia. Gastroenterology
2000 May;118(5):951-953. (Practice guideline)
9.
Brandt LJ, Boley SJ. AGA technical review on intestinal ischemia.
American Gastrointestinal Association. Gastroenterology 2000
May;118(5):954-968. (Review)
10. Hanauer SB, Sandborn W; Practice Parameters Committee of the
American College of Gastroenterology. Management of Crohns
disease in adults. Am J Gastroenterol 2001 Mar;96(3):635-643. (Practice
guideline)
11. No authors listed; American Gastroenterology Association. American
Gastroenterological Association medical position statement: irritable
bowel syndrome. Gastroenterology 2002 Dec;123(6):2105-2107. (Practice
guideline)
12. No authors listed. Norwalk-like viruses: public health consequences
and outbreak management. MMWR Recomm Rep 2001 Jun
1:50(RR09);1-18. (Review)
13. Sampson HA, Sicherer SH, Birnbaum AH. AGA technical review on
the evaluation of food allergy in gastrointestinal disorders. American
Gastroenterological Association. Gastroenterology 2001 Mar;120(4):10261040. (Review)
14. Fekety R. Guidelines for the diagnosis and management of Clostridium
difficile-associated diarrhea and colitis. American College of Gastroenterology, Practice Parameters Committee. Am J Gastroenterol 1997
May;92(5):739-750. (Practice guideline)
15. Andersson RE. Meta-analysis of the clinical and laboratory diagnosis
of appendicitis. Br J Surg 2004 Jan;91(1):28-37. (Meta-analysis; 24
studies)
16. Fine KD, Schiller LR. AGA technical review on the evaluation and
management of chronic diarrhea. Gastroenterology 1999 Jun;116(6):14641486. (Review)
17. No authors listed. American Gastroenterological Association medical
position statement: guidelines for the management of malnutrition
and cachexia, chronic diarrhea, and hepatobiliary disease in patients
with human immunodeficiency virus infection. Gastroenterology 1996
Dec;111(6):1722-1723. (Practice guideline)
18. American College of Radiology, Expert Panel on Gastrointestinal
Imaging. Imaging recommendations for patients with Crohns disease.
Reston, VA: American College of Radiology; 2001. (Review)
19. Eisen GM, Dominitz JA, Faigel DO, et al; American Society for
Gastrointestinal Endoscopy. Use of endoscopy in diarrheal illnesses.
Gastrointest Endosc 2001 Dec;54(6):821-823. (Practice guideline)
20. Schiller LR, Sellin JH. Diarrhea. In: Feldman M, Friedman LS,
Sleisenger MH, eds. Sleisenger and Fordtrans Gastrointestinal and Liver
Disease. 7th ed. Philadelphia: WB Saunders; 2002:131-153. (Textbook
chapter)
21.* No authors listed. Practice parameter: the management of acute
gastroenteritis in young children. American Academy of Pediatrics,
Provisional Committee on Quality Improvement, Subcommittee on
Acute Gastroenteritis. Pediatrics 1996 Mar;97(3):424-435. (Practice
guideline)
22. No authors listed. American Gastroenterological Association medical
position statement: guidelines for the evaluation and management of
chronic diarrhea. Gastroenterology 1999 Jun;116(6):1461-1463. (Practice
guideline)
23. Hasler WL. The irritable bowel syndrome. Med Clin North Am 2002
Nov;86(6):1525-1551. (Review)
24. Andres PG, Friedman LS. Epidemiology and the natural course of
inflammatory bowel disease. Gastroenterol Clin North Am 1999
Jun;28(2):255-281, vii. (Review)
25. Burns BJ, Brandt LJ. Intestinal ischemia. Gastroenterol Clin North Am
2003 Dec;32(4):1127-1143. (Review)
26. Tabrez S, Roberts IM. Malabsorption and malnutrition. Prim Care 2001
Sep;28(3):505-522, v. (Review)
27. Brandt LJ, Boley SJ. Intestinal ischemia. In: Feldman M, Friedman LS,
Sleisenger MH, eds. Sleisenger and Fordtrans Gastrointestinal and Liver
Summary
A simple approach focused on obtaining a thorough history
and performing a focused physical examination is generally
sufficient for most ED patients presenting with diarrhea.
Selective laboratory testing can be helpful but should not be
the cornerstone of patient evaluation. Symptomatic treatment is simple and well-supported in the literature.
Differentiating between those patients requiring
symptomatic treatment prior to discharge, those needing
hospitalization and more systematic investigation, and
those with more serious disease processes masquerading as
simple diarrhea remains the most essential element of the
ED encounter. It is easy to confuse the common (gastroenteritis) with the rare (poisonings), the serious (appendicitis),
and the deadly (gastrointestinal hemorrhage). If there is a
doubt about the diagnosis, ED observation and repeated
examinations can be helpful. Patients warranting a greater
level of concern are the very young, the elderly, immunocompromised individuals, those with major comorbidities,
and those with unusual or atypical presentations such as
severe abdominal pain.
References
Evidence-based medicine requires a critical appraisal of the
literature based upon study methodology and number of
subjects. Not all references are equally robust. The findings
of a large, prospective, randomized, and blinded trial
should carry more weight than a case report.
To help the reader judge the strength of each reference,
pertinent information about the study, such as the type of
study and the number of patients in the study, will be
included in bold type following the reference, where
available. In addition, the most informative references cited
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Hand-washing with soap is a simple, effective measure
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28.* Gore JI, Surawicz C. Severe acute diarrhea. Gastroenterol Clin North Am
2003 Dec;32(4):1249-1267. (Review)
29. Osorio J, Farreras N, Ortiz De Zarate L, et al. Cocaine-induced
mesenteric ischaemia. Dig Surg 2000;17(6):648-651. (Case report)
30. Saclarides TJ. Radiation injuries of the gastrointestinal tract. Surg Clin
North Am 1997 Feb;77(1):261-268. (Review)
31. Henriksson R, Franzen L, Littbrand B. Effects of sucralfate on acute
and late bowel discomfort following radiotherapy of pelvic cancer. J
Clin Oncol 1992 Jun;10(6):969-975. (Randomized, controlled trial; 70
patients)
32. Irish MS, Pearl RH, Caty MG, et al. The approach to common
abdominal diagnosis in infants and children. Pediatr Clin North Am
1998 Aug;45(4):729-772. (Review)
33. Rothrock SG, Skeoch G, Rush JJ, et al. Clinical features of misdiagnosed appendicitis in children. Ann Emerg Med 1991 Jan;20(1):45-50.
(Retrospective; 181 patients)
34. Horwitz JR, Gursoy M, Jaksic T, et al. Importance of diarrhea as a
presenting symptom of appendicitis in very young children. Am J Surg
1997 Feb;173(2):80-82. (Retrospective; 63 patients)
35. Reynolds SL. Missed appendicitis in a pediatric emergency department. Pediatr Emerg Care 1993 Feb;9(1):1-3. (Retrospective; 87 patients)
36. Bolyard EA, Tablan OC, Williams WW, et al. Guideline for infection
control in healthcare personnel, 1998. Hospital Infection Control
Practices Advisory Committee. Infect Control Hosp Epidemiol 1998
Jun;19(6):407-463. (Practice guideline)
37.* DuPont HL. Guidelines on acute infectious diarrhea in adults. The
Practice Parameters Committee of the American College of Gastroenterology. Am J Gastroenterol 1997 Nov;92(11):1962-1975. (Practice
guideline)
38. Brar HS, Surawicz CM. Pseudomembranous colitis: an update. Can J
Gastroenterol 2000 Jan;14(1):51-56. (Review)
39. Talan D, Moran GJ, Newdow M, et al; EMERGEncy ID NET Study
Group. Etiology of bloody diarrhea among patients presenting to
United States emergency departments: prevalence of Escherichia coli
0157:H7 and other enteropathogens. Clin Infect Dis 2001 Feb
15;32(4):573-580. (Prospective; 873 patients)
40. McNeely WS, Dupont HL, Mathewson JJ, et al. Occult blood versus
fecal leukocytes in the diagnosis of bacterial diarrhea: a study of U.S.
travelers to Mexico and Mexican children. Am J Trop Med Hyg 1996
Oct;55(4):430-433. (Comparative; 1040 patients)
41. Harris JC, Dupont HL, Hornick RB. Fecal leukocytes in diarrheal
illness. Ann Intern Med 1972 May;76(5):697-703. (169 patients with
diarrhea)
42. Manabe YC, Vinetz JM, Moore RD, et al. Clostridium difficile colitis: an
efficient clinical approach to diagnosis. Ann Intern Med 1995 Dec
1;123(11):835-840. (Prospective; 268 inpatients)
43. Turgeon DK, Fritsche TR. Laboratory approaches to infectious
diarrhea. Gastroenterol Clin North Am 2001 Sep;30(3):693-707. (Review)
44. Lieberman JM. Rotavirus and other viral causes of gastroenteritis.
Pediatr Ann 1994 Oct;23(10):529-532, 534-535. (Review)
45. Huicho L, Garaycochea V, Uchima N, et al. Fecal lactoferrin, fecal
leukocytes and occult blood in the diagnostic approach to childhood
invasive diarrhea. Pediatr Infect Dis J 1997 Jul;16(7):644-647. (Prospective; 125 patients with diarrhea)
46. Choi SW, Park CH, Silva TM, et al. To culture or not to culture: fecal
lactoferrin screening for inflammatory bacterial diarrhea. J Clin
Microbiol 1996 Apr;34(4):928-932. (Retrospective, cost-benefit analysis;
55 patients)
47. Fine KD, Ogunji F, George J, et al. Utility of a rapid fecal latex
agglutination test detecting the neutrophil protein, lactoferrin, for
diagnosing inflammatory causes of chronic diarrhea. Am J Gastroenterol
1998 Aug;93(8):1300-1305. (Non-random sample; 103 patients)
48. Kane SV, Sandborn WJ, Rufo PA, et al. Fecal lactoferrin is a sensitive
and specific marker in identifying intestinal inflammation. Am J
Gastroenterol 2003 Jun;98(6):1309-1314. (Prospective, comparative; 215
patients)
49. Hamer DH, Gorbach SL. Infectious diarrhea and bacterial food
poisoning. In: Feldman M, Friedman LS, Sleisenger MH, eds. Sleisenger
and Fordtrans Gastrointestinal and Liver Disease. 7th ed. Philadelphia:
WB Saunders; 2002:1864-1913. (Textbook chapter)
50. Wong CS, Jelacic S, Habeeb RL, et al. The risk of the hemolytic-uremic
syndrome after antibiotic treatment of Escherichia coli 0157:H7
infections. N Engl J Med 2000 Jun 29;342(26):1930-1936. (Prospective
cohort; 71 patients)
51. Hennessy TW, Hedberg CW, Slutsker L, et al. A national outbreak of
Salmonella enteritidis infections from ice cream. The Investigation Team.
52.
18
77.
78.
79.
Pharmacol Ther 2002 Aug;16(8):1461-1467. (Meta-analysis)

Bhutta ZA, Bird SM, Black RE, et al. Therapeutic effects of oral zinc in
acute and persistent diarrhea in children in developing countries:
pooled analysis of randomized controlled trials. Am J Clin Nutr 2000
Dec;72(6):1516-1522. (Meta-analysis)
Strand TA, Chandyo RK, Bahl R, et al. Effectiveness and efficacy of
zinc for the treatment of acute diarrhea in young children. Pediatrics
2002 May;109(5):898-903. (Randomized, controlled trial; 1792
children)
Wong MT, Kauffman CA, Standiford HC, et al; Ramoplanin VRE2
Clinical Study Group. Effective suppression of vancomycin-resistant
Enterococcus species in asymptomatic gastrointestinal carriers by a
novel glycolipodepsipeptide, ramoplanin. Clin Infect Dis 2001 Nov
1;33(9):1476-1482. (Multicenter, randomized, controlled trial; 68
patients)
Montecalvo MA. Ramoplanin: a novel antimicrobial agent with the
potential to prevent vancomycin-resistant enterococcal infection in
high-risk patients. J Antimicrob Chemother 2003 Jun;51 Suppl 3:iii31-35.
(Review)
Physician CME Questions

1.
2.
3.
4.
5.
6.
The presence of fever, cramping, and diarrhea is least

likely to be associated with:
a. bacterial diarrhea.
b. inflammatory bowel disease.
c. irritable bowel syndrome.
d. appendicitis.
Which of the following can be ruled out as a cause of

diarrhea persisting longer than two weeks in otherwise healthy U.S. ED patients?
a. Norwalk virus
b. Food allergies
c. Giardia lamblia
d. Ischemic bowel disease
8.
A thorough history of medication use in patients with

diarrhea should include:
a. recent antibiotic use.
b. hypoglycemic medications.
c. herbal medications.
d. vasoconstrictive medications.
e. all of the above.
9.
Which of the following laboratory tests should be

routine in all patients with diarrhea?
a. Chemistry panels
b. Stool culture
c. Fecal leukocyte/lactoferrin testing
d. None of the above
10. In children with mild-to-moderate dehydration, the

preferred rehydration method is:
a. intravenous rehydration.
b. rehydration via commercial oral rehydration
solutions.
c. rehydration via sports drinks.
d. rehydration via consumption of clear liquids.
Which of the following symptoms are viral agents

most likely to produce?
a. Nausea/vomiting
b. Bloody diarrhea
c. Severe abdominal pain
d. Bowel movements that alternate between
constipation and diarrhea
11. Empiric antibiotic therapy should not be

employed for:
a. nosocomial diarrhea.
b. moderate-to-severe travelers diarrhea.
c. diarrhea due to E. coli 0157:H7.
d. any of the above.
In most cases of diarrhea seen in U.S. EDs, the

cause is:
a. an infectious agent that does not require
antibiotics.
b. an infectious agent that requires antibiotics.
c. inflammatory bowel disease.
d. appendicitis.
12. Elderly patients:

a. are more likely to have serious etiologies for
diarrheal illnesses.
b. are more likely to be profoundly dehydrated
due to diarrheal illnesses.
c. are more prone to drug interactions and
side-effects.
d. all of the above.
Abdominal pain, diarrhea, age greater than 50 years,

and a history of peripheral vascular disease should
raise particular concern about:
a. ulcerative colitis.
b. irritable bowel syndrome.
c. appendicitis.
d. ischemic bowel disease.
13. In children with diarrheal illnesses:

a. infectious etiologies are unlikely.
b. oral rehydration methods are preferred.
c. loperamide is recommended.
d. resumption of the childs regular diet should be
delayed until most of the symptoms have passed.
Of the following, which is most valuable in identifying/ruling out appendicitis in the ED?
a. Stool culture
b. WBC count
c. Plain films
d. Serial examinations
14. Lactobacillus:
a. is a probiotic being studied for its ability to prevent
and treat diarrhea.
b. is available only by prescription.
c. has been shown to be ineffective in several recent
meta-analyses.
d. is standard therapy for adults but not children in
the United States.
Fecal leukocytes are present in:

a. infectious causes of diarrhea only.
b. non-infectious causes of diarrhea only.
c. inflammatory causes of diarrhea, including
infectious and non-infectious causes.
d. non-inflammatory causes of diarrhea.
7.
19
76.
Physician CME Information
15. Written discharge instructions should include key

reasons to return to the ED, such as:
a. profuse or bloody diarrhea.
b. dehydration or inability to take and retain
oral fluids.
c. severe or persistent abdominal pain.
d. sustained fever.
e. all of the above.
This CME enduring material is sponsored by Mount Sinai School of Medicine and
has been planned and implemented in accordance with the Essentials and
Standards of the Accreditation Council for Continuing Medical Education. Credit
may be obtained by reading each issue and completing the printed post-tests
administered in December and June or online single-issue post-tests
administered at EMPractice.net.
Target Audience: This enduring material is designed for emergency medicine
physicians.
Needs Assessment: The need for this educational activity was determined by a
survey of medical staff, including the editorial board of this publication; review
of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and
evaluation of prior activities for emergency physicians.
16. Loperamide should not be used in:

a. children less than 5 years.
b. adults with travelers diarrhea.
c. adults with bacillary dysentery.
d. all of the above.
Date of Original Release: This issue of Emergency Medicine Practice was published
July 1, 2004. This activity is eligible for CME credit through July 1, 2007. The
latest review of this material was June 15, 2004.
Discussion of Investigational Information: As part of the newsletter, faculty may
be presenting investigational information about pharmaceutical products that
is outside Food and Drug Administration approved labeling. Information
presented as part of this activity is intended solely as continuing medical
education and is not intended to promote off-label use of any pharmaceutical
product. Disclosure of Off-Label Usage: This issue of Emergency Medicine Practice
discusses no off-label use of any pharmaceutical product.
Coming in Future Issues:

Hand Injuries Herbal Toxicities The Suicidal Patient
Faculty Disclosure: In compliance with all ACCME Essentials, Standards, and

Guidelines, all faculty for this CME activity were asked to complete a full
disclosure statement. The information received is as follows: Dr. Burg reports
that he is a shareholder in Genome Therapeutics, makers of ramoplanin. Dr.
Hovanessian, Dr. Jagoda, and Dr. Reisdorff report no significant financial interest
or other relationship with the manufacturer(s) of any commercial product(s)
discussed in this educational presentation.
Class Of Evidence Definitions

Each action in the clinical pathways section of Emergency Medicine Practice
receives a score based on the following definitions.
Class I
Always acceptable, safe
Definitely useful
Proven in both efficacy and
effectiveness
Level of Evidence:
One or more large prospective
studies are present (with
rare exceptions)
High-quality meta-analyses
Study results consistently
positive and compelling
Class II
Safe, acceptable
Probably useful
Level of Evidence:
Generally higher levels
of evidence
Non-randomized or retrospective studies: historic, cohort, or
case-control studies
Less robust RCTs
Results consistently positive
Class III
May be acceptable
Possibly useful
Considered optional or
alternative treatments
Level of Evidence:
Generally lower or intermediate
levels of evidence
Case series, animal studies,

consensus panels
Occasionally positive results
Accreditation: Mount Sinai School of Medicine is accredited by the Accreditation

Council for Continuing Medical Education to sponsor continuing medical
education for physicians.
Indeterminate
Continuing area of research
No recommendations until
further research
Credit Designation: Mount Sinai School of Medicine designates this educational

activity for up to 4 hours of Category 1 credit toward the AMA Physicians
Recognition Award. Each physician should claim only those hours of credit
actually spent in the educational activity. Emergency Medicine Practice is
approved by the American College of Emergency Physicians for 48 hours
of ACEP Category 1 credit (per annual subscription). Emergency Medicine
Practice has been approved by the American Academy of Family Physicians as
having educational content acceptable for Prescribed credit. Term of approval
covers issues published within one year from the distribution date of July 1,
2003. This issue has been reviewed and is acceptable for up to 4 Prescribed
credits. Credit may be claimed for one year from the date of this issue.
Emergency Medicine Practice has been approved for 48 Category 2-B credit
hours by the American Osteopathic Association.
Level of Evidence:
Evidence not available
Higher studies in progress
Results inconsistent,
contradictory
Results not compelling
Significantly modified from: The
Emergency Cardiovascular Care
Committees of the American Heart
Association and representatives
from the resuscitation councils of
ILCOR: How to Develop EvidenceBased Guidelines for Emergency
Cardiac Care: Quality of Evidence
and Classes of Recommendations;
also: Anonymous. Guidelines for
cardiopulmonary resuscitation and
emergency cardiac care. Emergency
Cardiac Care Committee and
Subcommittees, American Heart
Association. Part IX. Ensuring
effectiveness of community-wide
emergency cardiac care. JAMA
1992;268(16):2289-2295.
Earning Credit: Two Convenient Methods

Print Subscription Semester Program: Paid subscribers with current and valid
licenses in the United States who read all CME articles during each Emergency
Medicine Practice six-month testing period, complete the post-test and the CME
Evaluation Form distributed with the December and June issues, and return it
according to the published instructions are eligible for up to 4 hours of
Category 1 credit toward the AMA Physicians Recognition Award (PRA) for each
issue. You must complete both the post-test and CME Evaluation Form to
receive credit. Results will be kept confidential. CME certificates will be
delivered to each participant scoring higher than 70%.
Online Single-Issue Program: Paid subscribers with current and valid licenses
in the United States who read this Emergency Medicine Practice CME article and
complete the online post-test and CME Evaluation Form at EMPractice.net are
eligible for up to 4 hours of Category 1 credit toward the AMA Physicians
Recognition Award (PRA). You must complete both the post-test and CME
Evaluation Form to receive credit. Results will be kept confidential. CME
certificates may be printed directly from the Web site to each participant
scoring higher than 70%.
Emergency Medicine Practice is not affiliated with any pharmaceutical firm or medical device manufacturer.
President and CEO: Robert Williford. Publisher: Heidi Frost. Research Editors: Ben Abella, MD, University of Chicago; Richard Kwun, MD, Mount Sinai School of Medicine.
Direct all editorial or subscription-related questions to EB Practice, LLC: 1-800-249-5770 Fax: 1-770-500-1316 Non-U.S. subscribers, call: 1-678-366-7933
EB Practice, LLC 305 Windlake Court Alpharetta, GA 30022
E-mail: emp@empractice.net Web Site: EMPractice.net
Emergency Medicine Practice (ISSN 1524-1971) is published monthly (12 times per year) by EB Practice, LLC, 305 Windlake Court, Alpharetta, GA 30022. Opinions expressed are not necessarily
those of this publication. Mention of products or services does not constitute endorsement. This publication is intended as a general guide and is intended to supplement, rather than
substitute, professional judgment. It covers a highly technical and complex subject and should not be used for making specific medical decisions. The materials contained herein are not
intended to establish policy, procedure, or standard of care. Emergency Medicine Practice is a trademark of EB Practice, LLC. Copyright 2004 EB Practice, LLC. All rights reserved. No part of this
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EMERGENCY MEDICINE

Diarrhea: Identifying Serious

IARRHEA is a common condition that can stem from many causes.

Critical Appraisal Of The Literature

New Mexico Health Sciences

Michael D. Burg, MD, FACEP

Date of original release: July 1, 2004.

Atlantic Health System;

Michael A. Gibbs, MD, FACEP,

Michael S. Radeos, MD, MPH,

Gregory L. Henry, MD, FACEP,

Steven G. Rothrock, MD, FACEP,

Keith A. Marill, MD, Emergency

Alfred Sacchetti, MD, FACEP,

Research Director, Our Lady of

Etiology, Epidemiology, And Pathophysiology

Evaluating the patient: The presence of a dry axilla

Laboratory testing: Routine testing for specific

Rehydration: Initiate rehydration (oral whenever

Emergency Medicine Practice

EMPractice.net July 2004

Entamoeba histolytica, and Cryptosporidium.2

The differential diagnosis of diarrhea with abdominal pain

Irritable Bowel Syndrome

Patients with irritable bowel syndrome can have abdominal

Infectious causes of diarrhea are commonly seen in the ED.

Table 1. Typical Characteristics Of Different Etiologies Of Diarrhea.

watery diarrhea (compared to the voluminous amounts

Bacterial diarrhea or Giardia

e.g., celiac disease or lactose intolerance

Functional bowel disorders

Irritable bowel syndrome

Recent new medicine, especially antibiotics, high blood

Fecal impaction/other blockage

Arsenic, mushroom poisoning, pesticides, etc.

Inflammatory bowel disease (includes Crohns disease and

Other systemic conditions

July 2004 EMPractice.net

Emergency Medicine Practice

Inflammatory Bowel Disease

Eliciting a family history of inflammatory bowel disease or

Inflammatory bowel disease is a general term that refers to

Ischemic Bowel Disease

Table 2. Agents Causing Infectious Diarrhea And Their Associated Symptoms.

dysentery. Diarrhea containing blood and mucus, fever,

Symptoms: fever, headache and muscle pain followed by

Symptoms: severe nausea, abdominal cramps, vomiting, and

Symptoms: diarrhea and gas pains may appear 8-24 hours

Escherichia coli 0157:H7

Symptoms: Diarrhea, abdominal cramps, nausea, vomiting,

Symptoms: diarrhea or bloody diarrhea, abdominal cramps,

Symptoms: Profuse watery diarrhea, abdominal pain, appetite

Symptoms: fever, chills, headache, backache, sometimes

Salmonella (many types)

Viral gastroenteritis from Norwalk

Symptoms: stomach pain, diarrhea, nausea, chills, fever, and

Symptoms: Nausea, vomiting, diarrhea, abdominal pain,

Shigella (many types)

Emergency Medicine Practice

EMPractice.net July 2004

July 2004 EMPractice.net

Emergency Department Evaluation

Emergency Medicine Practice

uncomplicated gastroenteritis generally resolves with fluids,