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Diarrhea is defined by the World Health Organization as having three or more loose or liquid stools per day, or as having more stools than is normal for that person.
Acute diarrhea is defined as an abnormally frequent discharge of semisolid or fluid fecal matter from the bowel, lasting less than 14 days, by World Gastroenterology Organization.
Another possible cause of diarrhea is irritable bowel syndrome (IBS), which usually presents with abdominal discomfort relieved by defecation and unusual stool (diarrhea or constipation) for at least 3 days a week over the previous 3 months. Symptoms of diarrhea-predominant IBS can be managed through a combination of dietary changes, soluble fiber supplements and medications such as loperamide or codeine. About 30% of patients with diarrhea-predominant IBS have bile acid malabsorption diagnosed with an abnormal SeHCAT test.
Gastroenteritis typically involves both diarrhea and vomiting, or less commonly, presents with only one or the other. Abdominal cramping may also be present. Signs and symptoms usually begin 12–72 hours after contracting the infectious agent. If due to a viral agent, the condition usually resolves within one week. Some viral causes may also be associated with fever, fatigue, headache, and muscle pain. If the stool is bloody, the cause is less likely to be viral and more likely to be bacterial. Some bacterial infections may be associated with severe abdominal pain and may persist for several weeks.
Children infected with rotavirus usually make a full recovery within three to eight days. However, in poor countries treatment for severe infections is often out of reach and persistent diarrhea is common. Dehydration is a common complication of diarrhea, and a child with a significant degree of dehydration may have a prolonged capillary refill, poor skin turgor, and abnormal breathing. Repeat infections are typically seen in areas with poor sanitation, and malnutrition, stunted growth, and long-term cognitive delays can result.
Reactive arthritis occurs in 1% of people following infections with "Campylobacter" species, and Guillain–Barré syndrome occurs in 0.1%. Hemolytic uremic syndrome (HUS) may occur due to infection with Shiga toxin-producing "Escherichia coli" or "Shigella" species, causing low platelet counts, poor kidney function, and low red blood cell count (due to their breakdown). Children are more predisposed to getting HUS than adults. Some viral infections may produce benign infantile seizures.
The onset of TD usually occurs within the first week of travel, but may occur at any time while traveling, and even after returning home, depending on the incubation period of the infectious agent. Bacterial TD typically begins abruptly, but "Cryptosporidium" may incubate for seven days, and "Giardia" for 14 days or more, before symptoms develop. Typically, a traveler experiences four to five loose or watery bowel movements each day. Other commonly associated symptoms are abdominal cramping, bloating, fever, and malaise. Appetite may decrease significantly. Though unpleasant, most cases of TD are mild, and resolve in a few days without medical intervention.
Blood or mucus in the diarrhea, significant abdominal pain, or high fever suggests a more serious cause, such as cholera, characterized by a rapid onset of weakness and torrents of watery diarrhea with flecks of mucus (described as "rice water" stools). Medical care should be sought in such cases; dehydration is a serious consequence of cholera, and may trigger serious sequelae—including, in rare instances, death—as rapidly as 24 hours after onset if not addressed promptly.
The main symptom of gastroenteritis is diarrhea. Other symptoms may include:
- Abdominal pain or cramping
- Nausea
- Vomiting
- Low grade fever
Because of the symptoms of vomiting and diarrhea, people who have gastroenteritis can become dehydrated quickly. It is very important to watch for signs of dehydration.
Other potential causes of signs and symptoms that mimic those seen in gastroenteritis that need to be ruled out include appendicitis, volvulus, inflammatory bowel disease, urinary tract infections, and diabetes mellitus. Pancreatic insufficiency, short bowel syndrome, Whipple's disease, coeliac disease, and laxative abuse should also be considered. The differential diagnosis can be complicated somewhat if the person exhibits "only" vomiting or diarrhea (rather than both).
Appendicitis may present with vomiting, abdominal pain, and a small amount of diarrhea in up to 33% of cases. This is in contrast to the large amount of diarrhea that is typical of gastroenteritis. Infections of the lungs or urinary tract in children may also cause vomiting or diarrhea. Classical diabetic ketoacidosis (DKA) presents with abdominal pain, nausea, and vomiting, but without diarrhea. One study found that 17% of children with DKA were initially diagnosed as having gastroenteritis.
The most common form of dysentery is bacillary dysentery, which is typically a mild illness, causing symptoms normally consisting of mild stomach pains and frequent passage of stool or diarrhea. Symptoms normally present themselves after one to three days, and are usually no longer present after a week. The frequency of urges to defecate, the large volume of liquid feces passed, and the presence of mucus, pus, and blood depends on the pathogen causing the disease. Temporary lactose intolerance can occur, as well. In some caustic occasions severe abdominal pain, fever, shock, and delirium can all be symptoms.
In extreme cases, dysentery patients may pass more than one litre of fluid per hour. More often, individuals will complain of nausea, abdominal pain, and frequent watery and usually foul-smelling diarrhea, accompanied by mucus, blood, rectal pain, and fever. Vomiting, rapid weight-loss, and generalized muscle aches sometimes also accompany dysentery. On rare occasions, the amoebic parasite will invade the body through the bloodstream and spread beyond the intestines. In such cases, it may more seriously infect other organs such as the brain, lungs, and most commonly the liver.
Traveler's diarrhea (TD) is a stomach and intestinal infection. TD is defined as the passage of unformed stool (one or more by some definitions, three or more by others) while traveling. It may be accompanied by abdominal cramps, nausea, fever, and bloating. Occasionally bloody diarrhea may occur. Most travelers recover within four days with little or no treatment. About 10% of people may have symptoms for a week.
Bacteria are responsible for more than half of cases. The bacteria enterotoxigenic "Escherichia coli" (ETEC) are typically the most common except in Southeast Asia, where "Campylobacter" is more prominent. About 10% to 20% of cases are due to norovirus. Protozoa such as "Giardia" may cause longer term disease. The risk is greatest in the first two weeks of travel and among young adults. People affected are more often from the developed world.
Recommendations for prevention include eating only properly cleaned and cooked food, drinking bottled water, and frequent hand washing. The oral cholera vaccine, while effective for cholera, is of questionable use for traveler's diarrhea. Preventative antibiotics are generally discouraged. Primary treatment includes drinking lots of fluids and replacing lost salts (oral rehydration therapy). Antibiotics are recommended for significant or persistent symptoms, and can be taken with loperamide to decrease diarrhea. Hospitalization is required in less than 3% of cases.
Estimates of the percentage of people affected range from 20 to 50% among travelers to the developing world. TD is particularly common among people travelling to Asia (except Japan), the Middle East, Africa, Mexico, and Central and South America. The risk is moderate in Southern Europe, Russia, and China. TD has been linked to later irritable bowel syndrome and Guillain–Barré syndrome. It has colloquially been known by a number of names, including "Montezuma's revenge" and "Delhi belly".
Depending on the cause of the inflammation, symptoms may last from one day to more than a week.
Gastroenteritis caused by viruses may last one to two days. Most people recover easily from a short episode of vomiting and diarrhea by drinking clear fluids to replace the fluid that was lost and then gradually progressing to a normal diet. But for others, especially infants and the elderly, the loss of bodily fluid with gastroenteritis can cause dehydration, which can be a life-threatening illness unless it is treated and fluids in the body are replaced.
The mouth, skin, and lips may appear dry due to dehydration. Lower abdominal tenderness may also be present.
Common symptoms of "Staphylococcus aureus" food poisoning include: a rapid onset which is usually 1–6 hours, nausea, explosive vomiting for up to 24 hours, abdominal cramps/pain, headache, weakness, diarrhea and usually a subnormal body temperature. Symptoms usually start one to six hours after eating and last less than 12 hours. The duration of some cases may take two or more days to fully resolve.
The average incubation periods for giardiasis and cryptosporidiosis are each 7 days. Certain other bacterial and viral agents have shorter incubation periods, although hepatitis may take weeks to manifest itself. The onset usually occurs within the first week of return from the field, but may also occur at any time while hiking.
Most cases begin abruptly and usually result in increased frequency, volume, and weight of stool. Typically, a hiker experiences at least four to five loose or watery bowel movements each day. Other commonly associated symptoms are nausea, vomiting, abdominal cramping, bloating, low fever, urgency, and malaise, and usually the appetite is affected. The condition is much more serious if there is blood or mucus in stools, abdominal pain, or high fever. Dehydration is a possibility. Life-threatening illness resulting from WAD is extremely rare but can occur in people with weakened immune systems.
Some people may be carriers and not exhibit symptoms.
The primary symptoms of IBS are abdominal pain or discomfort in association with frequent diarrhea or constipation and a change in bowel habits. Symptoms usually are experienced as acute attacks that subside within one day, but recurrent attacks are likely. There may also be urgency for bowel movements, a feeling of incomplete evacuation (tenesmus), bloating, or abdominal distension. In some cases, the symptoms are relieved by bowel movements. People with IBS, more commonly than others, have gastroesophageal reflux, symptoms relating to the genitourinary system, chronic fatigue syndrome, fibromyalgia, headache, backache, and psychiatric symptoms such as depression and anxiety. About a third of men and women who have IBS also report sexual dysfunction typically in the form of a reduction in libido.
Wilderness-acquired diarrhea – also known as wilderness diarrhea, or backcountry diarrhea – is a variety of traveler's diarrhea in which backpackers and other outdoor enthusiasts are affected. Potential sources are contaminated food or water, or "hand-to-mouth", directly from another person who is infected. Cases generally resolve spontaneously, with or without treatment, and the cause is typically unknown. The National Outdoor Leadership School has recorded about one incident per 5,000 person-field days by following strict protocols on hygiene and water treatment. More limited, separate studies have presented highly varied estimated rates of affliction that range from 3 percent to 74 percent of wilderness visitors. One survey found that long-distance Appalachian Trail hikers reported diarrhea as their most common illness. Based on reviews of epidemiologic data and literature, some researchers believe that the risks have been over-stated and are poorly understood by the public. U.S. adults annually experience 99 million episodes of acute diarrhea annually in a population of about 318 million. A very small fraction of these cases results from infections acquired in the wilderness, and all infectious agents occur in both wilderness and non-wilderness settings.
Bacterial overgrowth can cause a variety of symptoms, many of which are also found in other conditions, making the diagnosis challenging at times. Many of the symptoms are due to malabsorption of nutrients due to the effects of bacteria which either metabolize nutrients or cause inflammation of the small bowel, impairing absorption. The symptoms of bacterial overgrowth include nausea, flatus, constipation, bloating, abdominal distension, abdominal pain or discomfort, diarrhea, fatigue, and weakness. SIBO also causes an increased permeability of the small intestine. Some patients may lose weight. Children with bacterial overgrowth may develop malnutrition and have difficulty attaining proper growth. Steatorrhea, a sticky type of diarrhea where fats are not properly absorbed and spill into the stool, may also occur.
Patients with bacterial overgrowth that is longstanding can develop complications of their illness as a result of malabsorption of nutrients. Anemia may occur from a variety of mechanisms, as many of the nutrients involved in production of red blood cells are absorbed in the affected small bowel. Iron is absorbed in the more proximal parts of the small bowel, the duodenum and jejunum, and patients with malabsorption of iron can develop a microcytic anemia, with small red blood cells. Vitamin B is absorbed in the last part of the small bowel, the ileum, and patients who malabsorb vitamin B can develop a megaloblastic anemia with large red blood cells.
In older adults, small bowel bacterial overgrowth is associated with a higher frequency of diarrhea, a lower body mass index, and a significantly lower serum albumin concentration.
IBS can be classified as either diarrhea-predominant (IBS-D), constipation-predominant (IBS-C), or with alternating stool pattern (IBS-A) or pain-predominant. In some individuals, IBS may have an acute onset and develop after an infectious illness characterized by two or more of: fever, vomiting, diarrhea, or positive stool culture. This postinfective syndrome has consequently been termed "postinfectious IBS" (IBS-PI).
Infection with ETEC can cause profuse, watery diarrhea with no blood or leukocytes and abdominal cramping. Fever, nausea with or without vomiting, chills, loss of appetite, headache, muscle aches and bloating can also occur, but are less common.
Staphylococcal enteritis is an inflammation that is usually caused by eating or drinking substances contaminated with staph enterotoxin. The toxin, not the bacterium, settles in the small intestine and causes inflammation and swelling. This in turn can cause abdominal pain, cramping, dehydration, diarrhea and fever.
"Staphylococcus aureus" is a Gram-positive, facultative anaerobe, coccal (round shaped) bacteria that appears in grape-like clusters that can thrive in high salt and low water activity habitats. "S. aureus" bacteria can live on the skin which is one of the primary modes of transmission. "S. aureus" can cause a range of illnesses from minor skin infections to Staphylococcus aureus food poisoning enteritis. Since humans are the primary source, cross-contamination is the most common way the microorganism is introduced into foods. Foods at high risks are those prepared in large quantities.
Staphylococcus aureus is a true food poisoning organism. It produces a heat stable enterotoxin when allowed to grow for several hours in foods such as cream-filled baked goods, poultry meat, gravies, eggs, meat salads, puddings and vegetables. It is important to note that the toxins may be present in dangerous amounts in foods that have no signs of spoilage, such as a bad smell, any off color, odor, or textural or flavor change.
Enteritis is the inflammation of the small intestine. It is generally caused by eating or drinking substances that are contaminated with bacteria or viruses. The bacterium and/or toxin settles in the small intestine and cause inflammation and swelling. This in turn can cause abdominal pain, cramping, diarrhea, fever, and dehydration. There are other types of enteritis, the types include: bacterial gastroenteritis, "Campylobacter" enteritis, "E. coli" enteritis, radiation enteritis, "Salmonella" enteritis and "Shigella" enteritis.
Brainerd diarrhea is a sudden-onset watery, explosive diarrhea that lasts for months and does not respond to antibiotics; the cause of Brainerd diarrhea is unknown. Brainerd diarrhea was first described in Brainerd, Minnesota in 1983.
It has been associated with the consumption of raw milk and untreated water. Of the ten outbreaks reported since 1983, nine have been in the U.S. The characteristics of each outbreak have been similar to that caused by an infectious agent. Although a comparatively large outbreak (117 patients) occurred in 1996 in Fannin County, Texas., the largest outbreak (122 patients) was the original one in Brainerd, MN. There have been no secondary cases reported in any of the outbreaks, suggesting that the
causative agent cannot be passed from person to person, but boiling water appears to inactivate the Brainerd agent. Although there is no treatment available, the disease does appear to resolve itself, although this process takes months if not years.
Bile acid malabsorption, known also as bile acid diarrhea, is a cause of several gut-related problems, the main one being chronic diarrhea. It has also been called bile acid-induced diarrhea, cholerheic or choleretic enteropathy and bile salt malabsorption. It can result from malabsorption secondary to gastrointestinal disease, or be a primary disorder, associated with excessive bile acid production. Treatment with bile acid sequestrants is often effective.
Before a diagnosis of toddler's diarrhea is made, the following conditions should be ruled out:
- Celiac sprue (wheat gluten intolerance)
- Cystic fibrosis
- Sugar malabsorption
- Food allergy
Microscopic colitis causes chronic watery diarrhea with greater than 10 bowel movements per day. Some patients report nocturnal diarrhea, abdominal pain, urgency, fecal incontinence, fatigue, dehydration and weight loss. Patients report a significantly diminished quality of life.
Small intestine bacterial overgrowth (SIBO), also termed bacterial overgrowths, or small bowel bacterial overgrowth syndrome (SBBOS), is a disorder of excessive bacterial growth in the small intestine. Unlike the colon (or large bowel), which is rich with bacteria, the small bowel usually has fewer than 10,000 organisms per millilitre. Patients with bacterial overgrowth typically develop symptoms including nausea, bloating, vomiting, diarrhea, malnutrition, weight loss and malabsorption, which is caused by a number of mechanisms.
The diagnosis of bacterial overgrowth is made by a number of techniques, with the gold standard being an aspirate from the jejunum that grows in excess of 10 bacteria per millilitre. Risk factors for the development of bacterial overgrowth include dysmotility; anatomical disturbances in the bowel, including fistulae, diverticula and blind loops created after surgery, and resection of the ileo-cecal valve; gastroenteritis-induced alterations to the small intestine; and the use of certain medications, including proton pump inhibitors.
Small bowel bacterial overgrowth syndrome is treated with an elemental diet or antibiotics, which may be given in a cyclic fashion to prevent tolerance to the antibiotics, sometimes followed by prokinetic drugs to prevent recurrence if dysmotility is a suspected cause.
Bile acid malabsorption was first recognized in patients with ileal disease. When other causes were recognized, and an idiopathic, primary form described, a classification into three types was proposed:
- Type 1: Bile acid malabsorption, secondary to ileal resection, or ileal inflammation (e.g. in Crohn's disease)
- Type 2: Idiopathic bile acid malabsorption, Primary bile acid diarrhea
- Type 3: Secondary to various gastrointestinal diseases including cholecystectomy, vagotomy, small intestinal bacterial overgrowth, radiation enteropathy, celiac disease, chronic pancreatitis, etc.
Gastrinoma causes the following symptoms:
- Hypergastrinemia
- Ulcers of the duodenum, stomach, and small intestine.
- Severe diarrhea.
- Generalized cancer symptoms.