What causes Acute Diarrhea

Diarrhea is loose, watery stools (bowel movements). You have diarrhea if you have loose stools three or more times in one day. Acute diarrhea is diarrhea that lasts a short time. It is a common problem. It usually lasts about one or two days, but it may last longer. Then it goes away on its own.

Most cases of acute, watery diarrhea are caused by viruses (viral gastroenteritis). The most common ones in children are rotavirus and in adults are norovirus (this is sometimes called “cruise ship diarrhea” due to well publicized epidemics) ¹. When a specific organism is identified, the most common causes of acute diarrhea in the United States are Salmonella, Campylobacter, Shigella, and Shiga toxin–producing Escherichia coli (enterohemorrhagic E. coli) ².

Bacteria are a common cause of traveler’s diarrhea.

Clinically, acute infectious diarrhea is classified into two pathophysiologic syndromes, commonly referred to as ³:

• Noninflammatory (mostly viral, milder disease) and
• Inflammatory (mostly invasive or with toxin-producing bacteria, more severe disease).

Diarrhea lasting more than a few days may be a sign of a more serious problem. Chronic diarrhea — diarrhea that lasts at least four weeks — can be a symptom of a chronic disease. Chronic diarrhea symptoms may be continual, or they may come and go.

Table 1. Noninflammatory vs. Inflammatory Diarrheal Syndromes

Factor	Noninflammatory	Inflammatory
Etiology	Usually viral, but can be bacterial or parasitic	Generally invasive or toxin-producing bacteria
Pathophysiology	More likely to promote intestinal secretion without significant disruption in the intestinal mucosa	More likely to disrupt mucosal integrity, which may lead to tissue invasion and destruction
History and examination findings	Nausea, vomiting; normothermia; abdominal cramping; larger stool volume; nonbloody, watery stool	Fever, abdominal pain, tenesmus, smaller stool volume, bloody stool
Laboratory findings	Absence of fecal leukocytes	Presence of fecal leukocytes
Common pathogens	Enterotoxigenic Escherichia coli, Clostridium perfringens, Bacillus cereus, Staphylococcus aureus, Rotavirus, Norovirus, Giardia, Cryptosporidium, Vibrio cholerae	Salmonella (non-Typhi species), Shigella, Campylobacter, Shiga toxin–producing E. coli, enteroinvasive E. coli, Clostridium difficile, Entamoeba histolytica, Yersinia
Other	Generally milder disease	Generally more severe disease
	Severe fluid loss can still occur, especially in malnourished patients

[Source ⁴]

Clues to the Diagnosis of Acute Diarrhea

The onset, duration, severity, and frequency of diarrhea should be noted, with particular attention to stool character (e.g., watery, bloody, mucus-filled, purulent, bilious). The patient should be evaluated for signs of dehydration, including decreased urine output, thirst, dizziness, and change in mental status. Vomiting is more suggestive of viral illness or illness caused by ingestion of a preformed bacterial toxin. Symptoms more suggestive of invasive bacterial (inflammatory) diarrhea include fever, tenesmus, and grossly bloody stool ⁵.

A food and travel history is helpful to evaluate potential exposures. Children in day care, nursing home residents, food handlers, and recently hospitalized patients are at high risk of infectious diarrheal illness. Pregnant women have a 12-fold increased risk of listeriosis ⁶, which is primarily contracted by consuming cold meats, soft cheeses, and raw milk ⁷. Recent sick contacts and use of antibiotics and other medications should be noted in patients with acute diarrhea. Sexual practices that include receptive anal and oral-anal contact increase the possibility of direct rectal inoculation and fecal-oral transmission.

The history should also include gastroenterologic disease or surgery; endocrine disease; radiation to the pelvis; and factors that increase the risk of immunosuppression, including human immunodeficiency virus infection, long-term steroid use, chemotherapy, and immunoglobulin A deficiency. History findings associated with causes of diarrhea are summarized in Table 2 and clinical features by pathogen are summarized in Table 3.

Table 2. Potential Causes of Acute Diarrhea

History		Potential pathogen/etiology
Afebrile, abdominal pain with bloody diarrhea		Shiga toxin–producing Escherichia coli
Bloody stools		Salmonella, Shigella, Campylobacter, Shiga toxin–producing E. coli, Clostridium difficile, Entamoeba histolytica, Yersinia
Camping, consumption of untreated water		Giardia
Consumption of food commonly associated with foodborne illness
	Fried rice	Bacillus cereus
	Raw ground beef or seed sprouts	Shiga toxin–producing E. coli (e.g., E. coli O157:H7)
	Raw milk	Salmonella, Campylobacter, Shiga toxin–producing E. coli, Listeria
	Seafood, especially raw or undercooked shellfish	Vibrio cholerae, Vibrio parahaemolyticus
	Undercooked beef, pork, or poultry	Staphylococcus aureus, Clostridium perfringens, Salmonella, Listeria (beef, pork, poultry), Shiga toxin–producing E. coli (beef and pork), B. cereus (beef and pork), Yersinia (beef and pork), Campylobacter (poultry)
Exposure to day care centers		Rotavirus, Cryptosporidium, Giardia, Shigella
Fecal-oral sexual contact		Shigella, Salmonella, Campylobacter, protozoal disease
Hospital admission		C. difficile, treatment adverse effect
Human immunodeficiency virus infection, immunosuppression		Cryptosporidium, Microsporida, Isospora, Cytomegalovirus, Mycobacterium aviumintracellulare complex, Listeria
Medical conditions associated with diarrhea		Endocrine: Hyperthyroidism, adrenocortical insufficiency, carcinoid tumors, medullary thyroid cancer
		Gastrointestinal: Ulcerative colitis, Crohn disease, irritable bowel syndrome, celiac disease, lactose intolerance, ischemic colitis, colorectal cancer, short bowel syndrome, malabsorption, gastrinoma, VIPoma, bowel obstruction, constipation with overflow
		Other: Appendicitis, diverticulitis, human immunodeficiency virus infection, systemic infections, amyloidosis, adnexitis
Medications or other therapies associated with diarrhea		Antibiotics (especially broad-spectrum), laxatives, antacids (magnesium- or calcium-based), chemotherapy, colchicine, pelvic radiation therapy
		Less common: Proton pump inhibitors, mannitol, nonsteroidal anti-inflammatory drugs, angiotensin-converting enzyme inhibitors, cholesterol-lowering medications, lithium
Persistent diarrhea with weight loss		Giardia, Cryptosporidium, Cyclospora
Pregnancy		Listeria
Recent antibiotic use		C. difficile
Receptive anal intercourse, with or without rectal pain or proctitis		Herpes simplex virus infection, chlamydia, gonorrhea, syphilis
Rectal pain or proctitis		Campylobacter, Salmonella, Shigella, E. histolytica, C. difficile, Giardia
Rice-water stools		V. cholerae
Several persons with common food exposure have acute onset of symptoms		Food poisoning with preformed toxins
			Onset of symptoms within 6 hours: Staphylococcus, B. cereus (typically causes vomiting)
			Onset of symptoms within 8 to 16 hours: C. perfringens type A (typically causes diarrhea)
Travel to a developing country		Enterotoxigenic E. coli is most common
		Many other pathogens (e.g., Shigella, Salmonella, E. histolytica, Giardia, Cryptosporidium, Cyclospora, enteric viruses) are possible because of poorly cleaned or cooked food, or fecal contamination of food or water

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Table 3. Clinical Features of Acute Diarrhea Caused by Select Pathogens

Pathogen	Fever	Abdominal pain	Nausea, vomiting, or both	Fecal evidence of inflammation	Bloody stool	Heme-positive stools
Bacterial
Campylobacter	Common	Common	Occurs	Common	Occurs	Variable
Clostridium difficile	Occurs	Occurs	Not common	Common	Occurs	Occurs
Salmonella	Common	Common	Occurs	Common	Occurs	Variable
Shiga toxin–producing Escherichia coli	Not common	Common	Occurs	Not common	Common	Common
Shigella	Common	Common	Common	Common	Occurs	Variable
Vibrio	Variable	Variable	Variable	Variable	Variable	Variable
Yersinia	Common	Common	Occurs	Occurs	Occurs	Occurs
Parasitic
Cryptosporidium	Variable	Variable	Occurs	None to mild	Not common	Not common
Cyclospora	Variable	Variable	Occurs	Not common	Not common	Not common
Entamoeba histolytica	Occurs	Occurs	Variable	Variable	Variable	Common
Giardia	Not common	Common	Occurs	Not common	Not common	Not common
Viral
Norovirus	Variable	Common	Common	Not common	Not common	Not common

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Who gets diarrhea ?

People of all ages can get diarrhea. On average, adults In the United States have acute diarrhea once a year. Young children have it an average of twice a year.

People who visit developing countries are at risk for traveler’s diarrhea. It is caused by consuming contaminated food or water.

What causes diarrhea ?

The most common causes of diarrhea include:

• Bacteria from contaminated food or water
• Viruses such as the flu, norovirus, or rotavirus . Rotavirus is the most common cause of acute diarrhea in children.
• Parasites, which are tiny organisms found in contaminated food or water
• Medicines such as antibiotics, cancer drugs, and antacids that contain magnesium
• Food intolerances and sensitivities, which are problems digesting certain ingredients or foods. An example is lactose intolerance.
• Diseases that affect the stomach, small intestine, or colon, such as Crohn’s disease
• Problems with how the colon functions, such as irritable bowel syndrome

Some people also get diarrhea after stomach surgery, because sometimes the surgeries can cause food to move through your digestive system more quickly.

Sometimes no cause can be found. If your diarrhea goes away within a few days, finding the cause is usually not necessary.

What other symptoms might you have with diarrhea ?

Other possible symptoms of diarrhea include:

• Cramps or pain in the abdomen
• An urgent need to use the bathroom (tenesmus)
• Loss of bowel control

If a virus or bacteria is the cause of your diarrhea, you may also have a fever, chills, and bloody stools.

Diarrhea can cause dehydration, which means that your body does not have enough fluid to work properly. Dehydration can be serious, especially for children, older adults, and people with weakened immune systems.

When should you see a doctor for diarrhea ?

Although it is usually not harmful, diarrhea can become dangerous or signal a more serious problem. Contact your health care provider if you have:

• Signs of dehydration
• Diarrhea for more than 2 days, if you are an adult. For children, contact the provider if it lasts more than 24 hours.
• Severe pain in your abdomen or rectum (for adults)
• A fever of 102 degrees or higher
• Stools containing blood or pus
• Stools that are black and tarry

If children have diarrhea, parents or caregivers should not hesitate to call a health care provider. Diarrhea can be especially dangerous in newborns and infants.

How is the cause of diarrhea diagnosed ?

Because most watery diarrhea is self-limited, testing is usually not indicated ⁸. In general, specific diagnostic investigation can be reserved for patients with severe dehydration, more severe illness, persistent fever, bloody stool, or immunosuppression, and for cases of suspected nosocomial infection or outbreak.

To find the cause of diarrhea, your health care provider may:

• Do a physical exam
• Ask about any medicines you are taking
• Test your stool or blood to look for bacteria, parasites, or other signs of disease or infection
• Ask you to stop eating certain foods to see whether your diarrhea goes away

If you have chronic diarrhea, your health care provider may perform other tests to look for signs of disease (see Chronic Diarrhea below).

What are the treatments for diarrhea ?

Diarrhea is treated by replacing lost fluids and electrolytes to prevent dehydration. Depending on the cause of the problem, you may need medicines to stop the diarrhea or treat an infection.

Adults with diarrhea should drink water, fruit juices, sports drinks, sodas without caffeine, and salty broths. As your symptoms improve, you can eat soft, bland food.

Children with diarrhea should be given oral rehydration solutions to replace lost fluids and electrolytes.

REHYDRATION THERAPY

The first step to treating acute diarrhea is rehydration, preferably oral rehydration ⁹. The accumulated fluid deficit (calculated roughly as the difference between the patient’s normal weight and his or her weight at presentation with diarrheal illness) must first be addressed. Next, the focus should turn to the replacement of ongoing losses and the continuation of maintenance fluids. An oral rehydration solution (ORS) must contain a mixture of salt and glucose in combination with water to best use the intestine’s sodium-glucose coupled cellular transport mechanism.

In 2002, the World Health Organization endorsed an oral rehydration solution (ORS) with reduced osmolarity (250 mOsm per L or less compared with the prior standard of 311 mOsm per L). The reduced osmolarity ORS decreases stool outputs, episodes of emesis, and the need for intravenous rehydration ¹⁰, without increasing hyponatremia, compared with the standard ORS ¹¹.

• A reduced osmolarity oral rehydration solution (ORS) can be roughly duplicated by mixing 1/2 teaspoon of salt, 6 teaspoons of sugar, and 1 liter of water. If oral rehydration is not feasible, intravenous rehydration may be necessary.

Feeding

Early refeeding decreases intestinal permeability caused by infections, reduces illness duration, and improves nutritional outcomes ¹², ¹³. This is particularly important in developing countries where underlying preexisting malnutrition is often a factor. Although the BRAT diet (bananas, rice, applesauce, and toast) and the avoidance of dairy are commonly recommended, supporting data for these interventions are limited. Instructing patients to refrain from eating solid food for 24 hours also does not appear useful ¹⁴.

Things you Should Avoid Eating or Drinking

• You should avoid certain kinds of foods when you have diarrhea, including fried foods and greasy foods.
• Avoid fruits and vegetables that can cause gas, such as broccoli, peppers, beans, peas, berries, prunes, chickpeas, green leafy vegetables, and corn.
• Avoid caffeine, alcohol, and carbonated drinks.
• Limit or cut out milk and other dairy products if they are making your diarrhea worse or causing gas and bloating.

Anti-diarrheal Medications

The antimotility agent loperamide (Imodium) may reduce the duration of diarrhea by as much as one day and increase the likelihood of clinical cure at 24 and 48 hours when given with antibiotics for traveler’s diarrhea ¹⁵. A loperamide/simethicone combination has demonstrated faster and more complete relief of acute nonspecific diarrhea and gas-related discomfort compared with either medication alone ¹⁶.

Loperamide may cause dangerous prolongation of illness in patients with some forms of bloody or inflammatory diarrhea and, therefore, should be restricted to patients with nonbloody stool ¹⁷. The antisecretory drug bismuth subsalicylate (Pepto-Bismol) is a safe alternative in patients with fever and inflammatory diarrhea. There is inadequate evidence to recommend the use of the absorbents kaolin/pectin, activated charcoal, or attapulgite (no longer available in the United States). The antisecretory drug racecadotril, widely used in Europe but unavailable in the United States, appears to be more tolerable and as effective as loperamide ¹⁸.

ANTIBIOTIC THERAPY

Because acute diarrhea is most often self-limited and caused by viruses, routine antibiotic use is not recommended for most adults with nonsevere, watery diarrhea. Additionally, the overuse of antibiotics can lead to resistance (e.g., Campylobacter), harmful eradication of normal flora, prolongation of illness (e.g., superinfection with C. difficile), prolongation of carrier state (e.g., delayed excretion of Salmonella), induction of Shiga toxins (e.g., from Shiga toxin–producing E. coli), and increased cost.

However, when used appropriately, antibiotics are effective for shigellosis, campylobacteriosis, C. difficile, traveler’s diarrhea, and protozoal infections. Antibiotic treatment of traveler’s diarrhea (usually a quinolone) is associated with decreased severity of illness and a two-or three-day reduction in duration of illness ¹⁹. If the patient’s clinical presentation suggests the possibility of Shiga toxin–producing E. coli (e.g., bloody diarrhea, history of eating seed sprouts or rare ground beef, proximity to an outbreak), antibiotic use should be avoided because it may increase the risk of hemolytic uremic syndrome ²⁰. Conservative management without antibiotic treatment is less successful for diarrhea lasting more than 10 to 14 days, and testing and treatment for protozoal infections should be considered.1 Antibiotics may be considered in patients who are older than 65 years, immunocompromised, severely ill, or septic. Table 4 summarizes antibiotic therapy for acute diarrhea ²¹.

Table 4.  Summary of Antibiotic Therapy for Acute Diarrhea

Organism	Therapy effectiveness	Preferred medication
Bacterial
Campylobacter	Proven in dysentery and sepsis, possibly effective in enteritis	Azithromycin (Zithromax), 500 mg once per day for 3 to 5 days
Alternative medications: Erythromycin, 500 mg four times per day for 3 to 5 days
Comments: Consider prolonged treatment if the patient is immunocompromised
——————————————————————
Clostridium difficile	Proven	Metronidazole (Flagyl), 500 mg three times per day for 10 days
Alternative medications: Vancomycin, 125 mg four times per day for 10 days
Comments: If an antimicrobial agent is causing the diarrhea, it should be discontinued if possible
——————————————————————
Enteropathogenic/enteroinvasive Escherichia coli	Possible	Ciprofloxacin, 500 mg twice per day for 3 days
Alternative medications: TMP/SMX DS, 160/800 mg twice per day for 3 days
Comments: —
Enterotoxigenic E. coli	Proven	Ciprofloxacin, 500 mg twice per day for 3 days
Alternative medications: TMP/SMX DS, 160/800 mg twice per day for 3 days
Comments: Enterotoxigenic E. coli is the most common cause of traveler’s diarrhea
——————————————————————
Salmonella, non-Typhi species	Doubtful in enteritis; proven in severe infection, sepsis, or dysentery	—
Alternative medications: Options for severe disease: Ciprofloxacin, 500 mg twice per day for 5 to 7 days Or TMP/SMX DS, 160/800 mg twice per day for 5 to 7 days Or Azithromycin, 500 mg per day for 5 to 7 days
Comments: In addition to patients with severe disease, it is appropriate to treat patients younger than 12 months or older than 50 years, and patients with a prosthesis, valvular heart disease, severe atherosclerosis, malignancy, or uremia And Patients who are immunocompromised should be treated for 14 days
Shiga toxin–producing E. coli	Controversial	No treatment
Alternative medications: No treatment
Comments: The role of antibiotics is unclear; they are generally avoided because of their association with hemolytic uremic syndrome. Antimotility agents should be avoided.
——————————————————————
Shigella	Proven in dysentery	Ciprofloxacin, 500 mg twice per day for 3 days, or 2-g single dose
Alternative medications: Azithromycin, 500 mg twice per day for 3 days Or TMP/SMX DS, 160/800 mg twice per day for 5 days Or Ceftriaxone (Rocephin), 2- to 4-g single dose
Comments: Use of TMP/SMX is limited because of resistance. Patients who are immunocompromised should be treated for 7 to 10 days
——————————————————————
Vibrio cholerae	Proven	Doxycycline, 300-mg single dose
Alternative medications: Azithromycin, 1-g single dose Or Tetracycline, 500 mg four times per day for 3 days Or TMP/SMX DS, 160/800 mg twice per day for 3 days
Comments: Doxycycline and tetracycline are not recommended in children because of possible tooth discoloration
——————————————————————
Yersinia	Not needed in mild disease or enteritis, proven in severe disease or bacteremia	—-
Options for severe disease: Doxycycline combined with an aminoglycoside Or TMP/SMX DS, 160/800 mg twice per day for 5 days Or Ciprofloxacin, 500 mg twice per day for 7 to 10 days
Comments: —
——————————————————————
Protozoal
Cryptosporidium	Possible	Therapy may not be necessary in immunocompetent patients with mild disease or in patients with AIDS who have a CD4 cell count greater than 150 cells per mm3
Options for severe disease: Nitazoxanide (Alinia), 500 mg twice per day for 3 days (may offer longer treatment for refractory cases in patients with AIDS)
Comments: Highly active antiretroviral therapy, which achieves immune reconstitution, is adequate to eradicate intestinal disease in patients with AIDS
——————————————————————
Cyclospora or Isospora	Proven	TMP/SMX DS, 160/800 mg twice per day for 7 to 10 days Or AIDS or immunosuppression: TMP/SMX DS, 160/800 mg twice to four times per day for 10 to 14 days, then three times weekly for maintenance
Options for severe disease: —
Comments: —
——————————————————————
Entamoeba histolytica	Proven	Metronidazole, 750 mg three times per day for 5 to 10 days, plus paromomycin, 25 to 35 mg per kg per day in 3 divided doses for 5 to 10 days
Alternative medications: Tinidazole (Tindamax), 2 g per day for 3 days, plus paromomycin, 25 to 35 mg per kg per day in 3 divided doses for 5 to 10 days
Comments: If the patient has severe disease or extraintestinal infection, including hepatic abscess, serology will be positive
——————————————————————
Giardia	Proven	Metronidazole, 250 to 750 mg three times per day for 7 to 10 days
Alternative medications: Tinidazole, 2-g single dose
Comments: Relapses may occur
——————————————————————
Microsporida	Proven	Albendazole (Albenza), 400 mg twice per day for 3 weeks
Alternative medications: —
Comments: Highly active antiretroviral therapy, which achieves immune reconstitution, is adequate to eradicate intestinal disease in patients with AIDS
——————————————————————
DS = double strength; TMP/SMX = trimethoprim/sulfamethoxazole.

[Source ⁴]

PROBIOTICS

Probiotics are thought to work by stimulating the immune system and competing for binding sites on intestinal epithelial cells. Their use in children with acute diarrhea is associated with reduced severity and duration of illness (an average of about one less day of illness) ²². Although many species are generally categorized as probiotics, even closely related strains may have different clinical effects. Effects of strain-specific probiotics need to be verified in adult studies before a specific evidence-based recommendation can be made ⁸.

ZINC SUPPLEMENTATION

Research in children suggests that zinc supplementation (20 mg per day for 10 days in children older than two months) may play a crucial role in treating and preventing acute diarrhea, particularly in developing countries. Studies demonstrate a decrease in the risk of dehydration, and in the duration and severity of the diarrheal episode by an estimated 20% to 40% ²³. Additional research is needed to evaluate potential benefits of zinc supplementation in the adult population.

Can diarrhea be prevented ?

Two types of diarrhea can be prevented – rotavirus diarrhea and traveler’s diarrhea. There are vaccines for rotavirus. They are given to babies in two or three doses.

You can help prevent traveler’s diarrhea by being careful about what you eat and drink when you are in developing countries:

• Use only bottled or purified water for drinking, making ice cubes, and brushing your teeth
• If you do use tap water, boil it or use iodine tablets
• Make sure that the cooked food you eat is fully cooked and served hot
• Avoid unwashed or unpeeled raw fruits and vegetables

Diarrhea in infants

Normal baby stools are soft and loose. Newborns have frequent stools, sometimes with every feeding. For these reasons, you may have trouble knowing when your baby has diarrhea.

Your baby may have diarrhea if you see changes in the stool, such as more stools all of a sudden; possibly more than one stool per feeding or really watery stools.

Causes of Diarrhea in Infants ²⁴

Diarrhea in babies usually does not last long. Most often, it is caused by a virus and goes away on its own. Your baby could also have diarrhea with:

• A change in your baby’s diet or a change in the mother’s diet if breastfeeding.
• Use of antibiotics by the baby, or use by the mother if breastfeeding.
• A bacterial infection. Your baby will need to take antibiotics to get better.
• A parasite infection. Your baby will need to take medicine to get better.
• Rare diseases such as cystic fibrosis.

Diarrhea Causes Dehydration

Infants and young children under age 3 can become dehydrated quickly and get really sick. Dehydration means that your baby does not have enough water or liquids. Watch your baby closely for signs of dehydration, which include:

• Dry eyes and little to no tears when crying
• Fewer wet diapers than usual
• Less active than usual, lethargic
• Irritable
• Dry mouth
• Dry skin that does not spring back to its usual shape after being pinched
• Sunken eyes
• Sunken fontanelle (the soft spot on top of the head)

What is the best way to treat infant diarrhea ?

Most children with mild diarrhea can continue to eat a normal diet including formula or milk. Breastfeeding can continue. If your baby seems bloated or gassy after drinking cow’s milk or formula, see your pediatrician to discuss a temporary change in diet. Special fluids for mild illness are not usually necessary.

Make sure your baby gets plenty of liquids so she does not get dehydrated.

Keep breastfeeding your baby if you are nursing. Breastfeeding helps prevent diarrhea, and your baby will recover quicker.
If you are using formula, make it full strength unless your health care provider gives you different advice.

If your baby still seems thirsty after or between feedings, talk to your provider about giving your baby Pedialyte or Infalyte. Your provider may recommend these extra liquids that contain electrolytes.

Try giving your baby 1 ounce (2 tablespoons or 30 milliliters) of Pedialyte or Infalyte, every 30 to 60 minutes.

• DO NOT water down Pedialyte or Infalyte.
• DO NOT give sports drinks to young infants.
• DO NOT try to prepare these special fluids yourself. Use only commercially available fluids—brand-name and generic brands are equally effective.
• DO NOT give your baby ant-diarrhea medicine unless your provider says it is OK.

Try giving your baby a Pedialyte popsicle.

If your baby throws up, give them only a little bit of liquid at a time. Start with as little as 1 teaspoon (5 ml) of liquid every 10 to 15 minutes. DO NOT give your baby solid foods when she is vomiting.

If your child is not vomiting, these fluids can be used in very generous amounts until the child starts making normal amounts of urine again.

Feeding Your Baby

If your baby was on solid foods before the diarrhea began, start with foods that are easy on the stomach, such as:

• Bananas
• Crackers
• Toast
• Pasta
• Cereal

DO NOT give your baby food that makes diarrhea worse, such as:

• Apple juice
• Milk
• Fried foods
• Full-strength fruit juice

Preventing Diaper Rash

Your baby might get diaper rash because of the diarrhea. To prevent diaper rash:

• Change your baby’s diaper frequently.
• Clean your baby’s bottom with water. Cut down on using baby wipes while your baby has diarrhea.
• Let your baby’s bottom air dry.
• Use a diaper cream.

Wash your hands well to keep you and other people in your household from getting sick. Diarrhea caused by germs can spread easily.

When to see the Doctor

See your healthcare provider if your baby is a newborn (under 3 months old) and has diarrhea.

Also see your doctor if your child has signs of being dehydrated, including:

• Dry and sticky mouth
• No tears when crying
• No wet diaper for 6 hours

Know the signs that your baby is not getting better, including:

• Fever and diarrhea that last for more than 2 to 3 days
• More than 8 stools in 8 hours
• Vomiting continues for more than 24 hours
• Diarrhea contains blood, mucus, or pus
• Your baby is much less active than normal (is not sitting up at all or looking around)
• Seems to have stomach pain

Do’s for Infant Diarrhea

• Watch for signs of dehydration which occur when a child loses too much fluid and becomes dried out. Symptoms of dehydration include a decrease in urination, no tears when baby cries, high fever, dry mouth, weight loss, extreme thirst, listlessness, and sunken eyes.
• Keep your pediatrician informed if there is any significant change in how your child is behaving.
• Report if your child has blood in his stool.
• Report if your child develops a high fever (more than 102°F or 39°C).
• Continue to feed your child if she is not vomiting. You may have to give your child smaller amounts of food than normal or give your child foods that do not further upset his or her stomach.
• Use diarrhea replacement fluids that are specifically made for diarrhea if your child is thirsty.

Don’ts for Infant Diarrhea

• Try to make special salt and fluid combinations at home unless your pediatrician instructs you and you have the proper instruments.
• Prevent the child from eating if she is hungry.
• Use boiled milk or other salty broth and soups.
• Use “anti-diarrhea” medicines unless prescribed by your pediatrician.

What is Traveler’s Diarrhea

Traveler’s diarrhea is caused by a variety of pathogens but most commonly bacteria found in food and water, often related to poor hygiene practices in local restaurants ²⁵. Food and water contaminated with fecal matter are the main sources of infection. Unsafe foods and beverages include salads, unpeeled fruits, raw or poorly cooked meats and seafood, unpasteurized dairy products, and tap water. Eating in restaurants increases the probability of contracting traveler’s diarrhea ²⁶ and food from street vendors is particularly risky ²⁷. Cold sauces, salsas, and foods that are cooked and then reheated also are risky ²⁸.

Traveler’s diarrhea is rarely dangerous in adults. It can be more serious in children.

The classic definition of traveler’s diarrhea is three or more unformed stools in 24 hours with at least one of the following symptoms:

• fever,
• nausea,
• vomiting,
• abdominal cramps,
• tenesmus (continual or recurrent inclination to evacuate the bowels),
• bloody stools.

Food poisoning is part of the differential diagnosis of traveler’s diarrhea. Gastroenteritis from preformed toxins (e.g., Staphylococcus aureus, Bacillus cereus) is characterized by a short incubation period (one to six hours), and symptoms typically resolve within 24 hours ²⁹. Seafood ingestion syndromes such as diarrhetic shellfish poisoning, ciguatera poisoning, and scombroid poisoning also can cause diarrhea in travelers. These syndromes can be distinguished from traveler’s diarrhea by symptoms such as perioral numbness and reversal of temperature sensation (ciguatera poisoning) or flushing and warmth (scombroid poisoning) ³⁰.

Milder forms can present with fewer than three stools (e.g., an abrupt bout of watery diarrhea with abdominal cramps). Most cases occur within the first two weeks of travel and last about four days without treatment ³¹. Although traveler’s diarrhea rarely is life threatening, it can result in significant morbidity; one in five travelers with diarrhea is bedridden for a day and more than one third have to alter their activities ³².

An estimated 30% to 70% of travelers experience travelers’ diarrhea, depending on where they go and what time of year. Countries are generally divided into 3 risk groups: high, intermediate, and low.

1. Destinations with high risk: Asia, the Middle East, Africa, Mexico, and Central and South America.
2. Destinations with intermediate risk: Eastern Europe, South Africa, and some Caribbean islands.
3. Destinations with low risk: the United States, Canada, Australia, New Zealand, Japan, and Northern and Western Europe.

Common Causes of Traveler’s Diarrhea

In contrast to the largely viral etiology of gastroenteritis in the United States, diarrhea acquired in developing countries is caused mainly by bacteria ³³. Bacteria such as enterotoxigenic Escherichia coli, enteroaggregative E. coli, Campylobacter, Salmonella, and Shigella are common causes of traveler’s diarrhea ³⁴. Parasites and viruses are less common etiologies.

Enterotoxigenic Escherichia coli is the pathogen most frequently isolated, but other types of E. coli such as enteroaggregative E. coli have been recognized as common causes of traveler’s diarrhea ³⁵. Invasive pathogens such as Campylobacter, Shigella, and non-typhoid Salmonella are relatively common depending on the region, while Aeromonas and non-cholera Vibrio species are encountered less frequently.

Bacteria

• Enterotoxigenic Escherichia coli
• Other E. coli types (e.g., enteroaggregative E. coli)
• Campylobacter
• Salmonella (non-typhoid)
• Shigella
• Aeromonas
• Vibrio (non-cholera)

Parasites

• Giardia lambli
• Entamoeba histolytica
• Cyclospora cayetanensis
• Cryptosporidium parvum

Viruses

• Rotavirus
• Noroviruses

Protozoal parasites such as Giardia lamblia, Entamoeba histolytica, and Cyclospora cayetanensis are uncommon causes of traveler’s diarrhea, but increase in importance when diarrhea lasts for more than two weeks ³⁶. Parasites are diagnosed more frequently in returning travelers because of longer incubation periods (often one to two weeks) and because bacterial pathogens may have been treated with antibiotics. Rotavirus and noroviruses are infrequent causes of traveler’s diarrhea, although noroviruses have been responsible for outbreaks on cruise ships.

The prevalence of specific organisms varies with travel destination. Available data suggest that E. coli is the predominant cause of traveler’s diarrhea in Latin America, the Caribbean, and Africa, while invasive pathogens are relatively uncommon. Enterotoxigenic E. coli and enteroaggregative E. coli may be responsible for up to 71 percent of cases of traveler’s diarrhea in Mexico ³⁵. In contrast, Campylobacter is a leading cause of traveler’s diarrhea in Thailand ³⁷ and also is common in Nepal ²⁶. Regional variation also exists with parasitic causes of traveler’s diarrhea ³⁵. For example, Cyclospora is endemic in Nepal, Peru, and Haiti.

Prevention of Traveler’s diarrhea

You can reduce your risk of travelers’ diarrhea by staying away from the bacteria that cause it. Adults may also take an antacid medicine (e.g., Pepto-Bismol* [Bismuth subsalicylate], the equivalent of two 262-mg tabs or 2 fluid oz (60 mL) 4 times a day for up to three weeks), which can decrease the incidence of travelers’ diarrhea up to 50%. However, Pepto-Bismol is not recommended for pregnant women or children aged 3 years or younger. Avoid if allergic to aspirin or on anticoagulants, probenecid (Benemid), or methotrexate (Rheumatrex). Furthermore, bismuth subsalicylate interferes with the absorption of doxycycline (Vibramycin), it should not be taken by travelers using doxycycline for malaria prophylaxis. Travelers should be warned about possible reversible side effects of bismuth subsalicylate, such as a black tongue, dark stools, and tinnitus.

Probiotics are a more natural approach to prophylaxis of traveler’s diarrhea. Probiotics colonize the gastrointestinal tract and theoretically prevent pathogenic organisms from infecting the gut. Studies ³⁸, ³⁹ of Lactobacillus GG (Culturelle) have suggested protection rates of up to 47 percent. More studies are needed to confirm the efficacy of probiotic prophylaxis.

Boiling is the best way to purify water. Iodination or chlorination is acceptable but does not kill Cryptosporidium or Cyclospora, and increased contact time is required to kill Giardia in cold or turbid water ⁴⁰. Filters with iodine resins generally are effective in purifying water, although it is uncertain whether the contact time with the resin is sufficient to kill viruses. Bottled water generally is safe if the cap and seal are intact.

How to prevent traveler’s diarrhea:

Water and other drinks

• Do not use tap water to drink or brush your teeth.
• Do not use ice made from tap water.
• Use only boiled water (boiled for at least 5 minutes) for mixing baby formula.
• For infants, breastfeeding is the best and safest food source. However, the stress of traveling may reduce the amount of milk you make.
• Drink only pasteurized milk.
• Drink bottled drinks if the seal on the bottle hasn’t been broken.
• Sodas and hot drinks are often safe.

Food

• Do not eat raw fruits and vegetables unless you peel them. Wash all fruits and vegetables before eating them.
• Do not eat raw leafy vegetables (e.g. lettuce, spinach, cabbage) because they are hard to clean.
• Do not eat raw or rare meats.
• Avoid shellfish.
• Do not buy food from street vendors.
• Eat hot, well-cooked foods. Heat kills the bacteria. But do not eat hot foods that have been sitting around for a long time.

Keep your hands clean.

Wash your hands often with soap and water or use an alcohol-based hand sanitizer after using the bathroom and before eating. Good hand hygiene prevents the spread of germs.

• Watch children carefully so they do not put things in their mouth or touch dirty items and then put their hands in their mouth.
• If possible, keep infants from crawling on dirty floors.
• Check to see that utensils and dishes are clean.

Eat and drink safely.

Stick to safe food and water habits. Some tips include:

• Eat food that is cooked and served hot, fruits and vegetables you have washed in clean water or peeled yourself, and pasteurized dairy products.
• Don’t eat food served at room temperature, food from street vendors, or raw or undercooked (rare) meat or fish.
• Drink bottled water that is sealed, ice made with bottled or disinfected water, and bottled or canned carbonated drinks.
• Don’t drink tap or well water or drinks with ice made with tap or well water or unpasteurized milk.

Treatment of Traveler’s diarrhea

If you find yourself suffering from travelers’ diarrhea, here are some things you can do to manage it.

Mild diarrhea can be tolerated, is not distressing, and does not prevent you from participating in planned activities.

The goal of the traveler’s diarrhea diet is to make your symptoms better and prevent you from getting dehydrated.

Table 5. Antibiotics Used for the Treatment of Traveler’s Diarrhea 

Antibiotic	Dosage	Comments
Ciprofloxacin (Cipro)	500 mg twice daily for one to three days	Other quinolones (e.g., ofloxacin [Floxin], norfloxacin [Noroxin], and levofloxacin [Levaquin]) are presumed to be effective as well.
Rifaximin (Xifaxan)	200 mg three times daily for three days	Not effective in persons with dysentery
Azithromycin (Zithromax)	In adults: 500 mg daily for one to three days or 1,000 mg in a single dose	Antibiotic of choice in children and pregnant women, and for quinolone-resistant Campylobacter
	In children: 10 mg per kg daily for three days

[Source ⁴¹]

Fluoroquinolones are not approved by the U.S. Food and Drug Administration (FDA) for use in children, and rifaximin is approved only for children 12 years and older. Therefore, azithromycin is the drug of choice for most children with traveler’s diarrhea ⁴². Another option is nalidixic acid (Neggram) in a dosage of 55 mg per kg per day divided into four doses, not to exceed 1 g in 24 hours ⁴². Loperamide is approved for children older than two years, but should not be used in children with dysentery. Bismuth subsalicylate should be avoided for prophylaxis in children because of the possible risk of Reye’s syndrome.

Pregnant women may be at higher risk of traveler’s diarrhea than nonpregnant women because of lowered gastric acidity and increased gastrointestinal transit time ⁴³. Quinolones (FDA pregnancy category C) generally are not advised during pregnancy, but azithromycin (FDA pregnancy category B) is safe. Oral rehydration should be emphasized. Although rifaximin is not absorbed, the safety of this medication in pregnant women has not been established. Loperamide (FDA pregnancy category B) may be used, but bismuth subsalicylate (FDA pregnancy category D) should be avoided. Being careful with food and water is particularly important during pregnancy because infections such as listeriosis can cause miscarriage, and hepatitis E can result in maternal mortality.

To treat mild diarrhea:

• Drink lots of fluids to prevent dehydration.
• Drink 8 to 10 glasses of clear fluids every day. Water or an oral rehydration solution is best.
• Drink at least 1 cup (240 milliliters) of liquid every time you have a loose bowel movement.
• Eat small meals every few hours instead of three big meals.
• Eat some salty foods, such as pretzels, soup, and sports drinks.
• Eat foods that are high in potassium, such as bananas, potatoes without the skin, and fruit juices.
• Take over-the-counter medications such as loperamide (e.g., Imodium) to manage symptoms. These medicines can help decrease the number of times you need to go to the bathroom, making it easier to ride on an airplane or bus. Always consult a health-care provider before giving over-the-counter medications to infants or children. Pregnant women and children aged 3 years or younger should avoid medicines containing bismuth, such as Pepto-Bismol or Kaopectate.

Moderate diarrhea is distressing and can interfere with your planned activities.

Dehydration means your body does not have as much water and fluids as it should. It is a very big problem for children or people who are in a hot climate. Signs of severe dehydration include:

• Decreased urine (fewer wet diapers in infants)
• Dry mouth
• Sunken eyes
• Few tears when crying

Give your child fluids for the first 4 to 6 hours. At first, try 1 ounce (2 tablespoons or 30 milliliters) of fluid every 30 to 60 minutes.

• You can use an over-the-counter drink, such as Pedialyte or Infalyte. Do not add water to these drinks.
• You can also try Pedialyte frozen fruit-flavored pops.
• Fruit juice or broth with water added to it may also help. These drinks can give your child important minerals that are being lost in the diarrhea.
• If you are breastfeeding your infant, keep doing it. If you are using formula, use it at half-strength for 2 to 3 feedings after the diarrhea starts. Then you can begin regular formula feedings.

In developing countries, many health agencies stock packets of salts to mix with water. If these fluids are not available, you can make an emergency solution by mixing:

• 1/2 teaspoon (3 grams) of salt
• 2 tablespoons (25 grams) sugar or rice powder
• 1/4 teaspoon (1.5 grams) potassium chloride (salt substitute)
• 1/2 teaspoon (2.5 grams) trisodium citrate (can be replaced with baking soda)
• 1 liter of clean water

Get medical help right away if you or your child has symptoms of severe dehydration, or if you have a fever or bloody stools.

To treat moderate diarrhea:

• Drink lots of fluids to prevent dehydration. Oral rehydration salt is widely available in stores and pharmacies in most countries. Mix as directed in clean water.
• Take over-the-counter medications such as loperamide (Imodium) to manage symptoms. Pregnant women and children aged 3 years or younger should avoid medicines containing bismuth, such as Pepto-Bismol or Kaopectate.
• Consider taking an antibiotic if your doctor has prescribed you one.

Severe diarrhea is debilitating and completely prevents you from participating in planned activities.

To treat severe diarrhea:

• Take antibiotics if prescribed by your doctor.
• You can also take over-the-counter medicines to manage symptoms.
• Stay hydrated by drinking lots of fluids, such as oral rehydration solution.
• Seek health care if you are unable to tolerate fluids or if you develop signs of dehydration. It is especially important to look out for signs of dehydration in infants and young children.

Travelers’ diarrhea can make international travel unpleasant. Following the treatment advice can help resolve symptoms within just a few days, so you can get back to enjoying your trip.

Complications of Travelers’ diarrhea

Dehydration is the main complication of traveler’s diarrhea, especially in children and older adults. Because E. coli O157:H7 is a rare cause of traveler’s diarrhea, there is little risk of hemolyticuremic syndrome. Other complications include Guillain-Barré syndrome after Campylobacter enteritis, Reiter’s syndrome (especially in persons who are HLA-B27 positive), Clostridium difficile colitis after antibiotic use, and postinfectious irritable bowel. These conditions may appear after the traveler has returned home.

If diarrhea persists despite antibiotic treatment, medical attention should be sought. Parasitic causes should be suspected in travelers who return with prolonged diarrhea or who do not respond to antibiotics. For those traveling to remote areas for extended periods, it is reasonable to discuss empiric treatment of protozoal infections (e.g., metronidazole [Flagyl] 250 mg three times a day for five days or tinidazole [Fasigyn] in a single 2–g dose for Giardia) ⁴⁴.

What is Chronic Diarrhea

Diarrhea that lasts for more than 2-4 weeks is considered persistent or chronic ⁴⁵. In an otherwise healthy person, chronic diarrhea can be a nuisance at best or become a serious health issue. For someone who has a weakened immune system, chronic diarrhea may represent a life-threatening illness.

What causes chronic diarrhea ?

Chronic diarrhea has many different causes; these causes can be different for children and adults. Chronic diarrhea sometimes is classified on whether or not it is caused by an infection. The cause of chronic diarrhea sometimes remains unknown.

Chronic diarrhea may be divided into three basic categories:

1. Watery,
2. Fatty (malabsorption), and
3. Inflammatory (with blood and pus).

However, not all chronic diarrhea is strictly watery, malabsorptive, or inflammatory, because some categories overlap. The differential diagnosis of chronic diarrhea is described in Table 2 below.

Watery diarrhea may be subdivided into ⁴⁶:

• Osmotic (water retention due to poorly absorbed substances),
• Secretory (reduced water absorption), and
• Functional (hypermotility) types.

Osmotic laxatives, such as sorbitol, induce osmotic diarrhea. Secretory diarrhea can be distinguished from osmotic and functional diarrhea by virtue of higher stool volumes (greater than 1 L per day) that continue despite fasting and occur at night. Stimulant laxatives fall into this secretory category because they increase motility ⁴⁷. Persons with functional disorders have smaller stool volumes (less than 350 mL per day) and no diarrhea at night ⁴⁷.

Table 6. Differential Diagnosis of Chronic Diarrhea

Watery
Secretory (often nocturnal; unrelated to food intake; fecal osmotic gap < 50 mOsm per kg*)
	Alcoholism
	Bacterial enterotoxins (e.g., cholera)
	Bile acid malabsorption
	Brainerd diarrhea (epidemic secretory diarrhea)
	Congenital syndromes
	Crohn disease (early ileocolitis)
	Endocrine disorders (e.g., hyperthyroidism [increases motility])
	Medications
	Microscopic colitis (lymphocytic and collagenous subtypes)
	Neuroendocrine tumors (e.g., gastrinoma, vipoma, carcinoid tumors, mastocytosis)
	Nonosmotic laxatives (e.g., senna, docusate sodium [Colace])
	Postsurgical (e.g., cholecystectomy, gastrectomy, vagotomy, intestinal resection)
	Vasculitis
Osmotic (fecal osmotic gap > 125 mOsm per kg*)
	Carbohydrate malabsorption syndromes (e.g., lactose, fructose)
	Celiac disease
	Osmotic laxatives and antacids (e.g., magnesium, phosphate, sulfate)
	Sugar alcohols (e.g., mannitol, sorbitol, xylitol)
Functional (distinguished from secretory types by hypermotility, smaller volumes, and improvement at night and with fasting)
	Irritable bowel syndrome
Fatty (bloating and steatorrhea in many, but not all cases)
Malabsorption syndrome (damage to or loss of absorptive ability)
	Amyloidosis
	Carbohydrate malabsorption (e.g., lactose intolerance)
	Celiac sprue (gluten enteropathy)–various clinical presentations
	Gastric bypass
	Lymphatic damage (e.g., congestive heart failure, some lymphomas)
	Medications (e.g., orlistat [Xenical; inhibits fat absorption], acarbose [Precose; inhibits carbohydrate absorption])
	Mesenteric ischemia
	Noninvasive small bowel parasite (e.g., Giardia)
	Postresection diarrhea
	Short bowel syndrome
	Small bowel bacterial overgrowth (> 105 bacteria per mL)
	Tropical sprue
	Whipple disease (Tropheryma whippelii infection)
Maldigestion (loss of digestive function)
	Hepatobiliary disorders
	Inadequate luminal bile acid
	Loss of regulated gastric emptying
	Pancreatic exocrine insufficiency
Inflammatory or exudative (elevated white blood cell count, occult or frank blood or pus)
Inflammatory bowel disease Crohn disease (ileal or early Crohn disease may be secretory)
	Diverticulitis
	Ulcerative colitis
	Ulcerative jejunoileitis
Invasive infectious diseases
	Clostridium difficile (pseudomembranous) colitis–antibiotic history
	Invasive bacterial infections (e.g., tuberculosis, yersiniosis)
	Invasive parasitic infections (e.g., Entamoeba)–travel history
	Ulcerating viral infections (e.g., cytomegalovirus, herpes simplex virus)
Neoplasia
	Colon carcinoma
	Lymphoma
	Villous adenocarcinoma
Radiation colitis

---

[Source ⁴⁸]

Table 7. Common Causes of Chronic Diarrhea

Diagnosis	Clinical findings	Tests
Celiac disease	Chronic malabsorptive diarrhea, fatigue, iron deficiency anemia, weight loss, dermatitis herpetiformis, family history	Immunoglobulin A antiendomysium and antitissue transglutaminase antibodies most accurate; duodenal biopsy is definitive
Clostridium difficile infection	Often florid inflammatory diarrhea with weight loss	Fecal leukocyte level; enzyme immunoassay that detects toxins A and B; positive fecal toxin assay; sigmoidoscopy demonstrating pseudomembranes
	Recent history of antibiotic use, evidence of colitis, fever
	May not resolve with discontinuation of antibiotics
Drug-induced diarrhea	Osmotic (e.g., magnesium, phosphates, sulfates, sorbitol), hypermotility (stimulant laxatives), or malabsorption (e.g., acarbose [Precose], orlistat [Xenical])	Elimination of offending agent; always consider laxative abuse
Endocrine diarrhea	Secretory diarrhea or increased motility (hyperthyroidism)	Thyroid-stimulating hormone level, serum peptide concentrations, urinary histamine level
Giardiasis	Excess gas, steatorrhea (malabsorption)	Giardia fecal antigen test
Infectious enteritis or colitis (diarrhea not associated with C. difficile): bacterial gastroenteritis, viral gastroenteritis, amebic dysentery	Inflammatory diarrhea, nausea, vomiting, fever, abdominal pain	Fecal leukocyte level, elevated erythrocyte sedimentation rate Cultures or stained fecal smears for specific organisms are more definitive
	History of travel, camping, infectious contacts, or day care attendance
Inflammatory bowel disease: Crohn disease, ulcerative colitis	Bloody inflammatory diarrhea, abdominal pain, nausea, vomiting, loss of appetite, family history, eye findings (e.g., episcleritis), perianal fistulae, fever, tenesmus, rectal bleeding, weight loss	Complete blood count, fecal leukocyte level, erythrocyte sedimentation rate, fecal calprotectin level Characteristic intestinal ulcerations on colonoscopy
Irritable bowel syndrome	Stool mucus, crampy abdominal pain, altered bowel habits, watery functional diarrhea after meals, exacerbated by emotional stress or eating	All laboratory test results are normal Increased fiber intake, exercise, dietary modification should be recommended
	More common in women
Ischemic colitis	History of vascular disease; pain associated with eating	Colonoscopy, abdominal arteriography
Microscopic colitis	Watery, secretory diarrhea affecting older persons	Colon biopsy
	Nonsteroidal anti-inflammatory drug association possible
	No response to fasting; nocturnal symptoms

[Source ⁴⁸]

List of Medications Associated with Diarrhea ⁴⁹

Osmotic

• Citrates, phosphates, sulfates
• Magnesium-containing antacids and laxatives
• Sugar alcohols (e.g., mannitol, sorbitol, xylitol)

Secretory

• Antiarrhythmics (e.g., quinine)
• Antibiotics (e.g., amoxicillin/clavulanate [Augmentin])
• Antineoplastics
• Biguanides
• Calcitonin
• Cardiac glycosides (e.g., digitalis)
• Colchicine
• Nonsteroidal anti-inflammatory drugs (may contribute to microscopic colitis)
• Prostaglandins (e.g., misoprostol [Cytotec])
• Ticlopidine

Motility

• Macrolides (e.g., erythromycin)
• Metoclopramide (Reglan)
• Stimulant laxatives (e.g., bisacodyl [Dulcolax], senna)

Malabsorption

• Acarbose (Precose; carbohydrate malabsorption)
• Aminoglycosides
• Orlistat (Xenical; fat malabsorption)
• Thyroid supplements
• Ticlopidine

Pseudomembranous colitis (Clostridium difficile)

• Antibiotics (e.g., amoxicillin, cephalosporins, clindamycin, fluoroquinolones)
• Antineoplastics
• Immunosuppressants.

Chronic Diarrhea caused by an infection may result from:

• Parasites (e.g., Cryptosporidium, Cyclospora, Entamoeba histolytica, Giardia, microsporidia)
• Bacteria (e.g., Aeromonas, Campylobacter, Clostridium difficile, E. coli, Plesiomonas, Salmonella, Shigella)
• Viruses (e.g., norovirus, rotavirus) or
• Unknown causes thought to be infectious (e.g., Brainerd diarrhea)

Chronic Diarrhea not caused by an infection may result from various causes such as:

• Disorders of the pancreas (e.g. chronic pancreatitis, pancreatic enzyme deficiencies, cystic fibrosis)
• Intestinal disorders (e.g. colitis, Crohn’s Disease, irritable bowel syndrome)
• Medications (e.g. antibiotics, laxatives)
• Intolerance to certain foods and food additives (e.g. soy protein, cow’s milk, sorbitol, fructose, olestra)
• Disorders of the thyroid (e.g. hyperthyroidism)
• Previous surgery or radiation of the abdomen or gastrointestinal tract
• Tumors
• Reduced blood flow to the intestine
• Altered immune function (e.g. immunoglobulin deficiencies, AIDS, autoimmune disease)
• Hereditary disorders (e.g. cystic fibrosis, enzyme deficiencies).

How are infections that can cause chronic diarrhea spread ?

Infections that can cause chronic diarrhea usually are spread by ingesting food or water or touching objects contaminated with stool. In general, chronic diarrhea not caused by an infection is not spread to other people.

How can infections that cause chronic diarrhea be prevented ?

Infections that cause chronic diarrhea usually can be prevented by:

• Always drinking clean safe water that has been properly treated,
• Always using proper food handling and preparation techniques,
• Always maintaining good hand hygiene, including always washing hands properly with soap and water before handling food and after using the toilet or changing a diaper.

How is the cause of chronic diarrhea diagnosed ?

Diagnosis of chronic diarrhea can be difficult and requires that your health care provider take a careful health history and perform a physical exam. The types of tests that your health care provider orders will be based on your symptoms and history. Tests may include blood or stool tests. Stool cultures may be used to test for bacteria, parasites or viruses; generally three or more stool samples are collected and examined. Special tests may be required to diagnose some parasites. If these initial tests do not reveal the cause of the diarrhea, additional tests may be done, including radiographs (x-rays) and endoscopy. Endoscopy is a procedure in which a tube is inserted into the mouth or rectum so that the doctor, usually a gastroenterologist, can look at the intestine from the inside.

Who is at risk for serious complications from chronic diarrhea ?

The risk of serious complications from chronic diarrhea depends on the cause of the diarrhea and the age and general health of the patient. Chronic diarrhea from some causes can result in serious nutritional disorders and malnutrition. Severely immunocompromised persons, including those with HIV/AIDS and those receiving chemotherapy for cancer or organ transplantation can be at risk for serious chronic diarrhea. Determining the correct cause of chronic diarrhea is necessary in order to select proper treatment and reduce the risk of serious complications.

How is chronic diarrhea treated ?

The treatment of chronic diarrhea is determined by its cause. Follow the advice of your health care provider.

• Diarrhea caused by an infection sometimes can be treated with antibiotics or other drugs. However, the correct diagnosis must be made so that the proper medication can be prescribed.
• Diarrhea not caused by an infection can be more difficult to diagnose and therefore treat. Long term medical treatment and nutritional support may be necessary. Surgery may be required to treat some causes of chronic diarrhea.

For diarrhea whose cause has not been determined, the following guidelines may help relieve symptoms. Follow the advice of your health care provider.

• Remain well hydrated and avoid dehydration. Serious health problems can occur if the body does not maintain proper fluid levels. Diarrhea may become worse and hospitalization may be required if dehydration occurs.
• Maintain a well-balanced diet. Doing so may help speed recovery.
• Avoid beverages that contain caffeine, such as tea, coffee, and many soft drinks.
• Avoid alcohol; it can lead to dehydration.

1. Diarrheal Diseases – Acute and Chronic. American College of Gastroenterology. http://patients.gi.org/topics/diarrhea-acute-and-chronic/[↩]
2. Centers for Disease Control and Prevention. Preliminary FoodNet data on the incidence of infection with pathogens transmitted commonly through food—10 states, 2009. MMWR Morb Mortal Wkly Rep. 2010;59(14):418–422.[↩]
3. Turgeon DK, Fritsche TR. Laboratory approaches to infectious diarrhea. Gastroenterol Clin North Am. 2001;30(3):693–707.[↩]
4. Acute Diarrhea in Adults. Am Fam Physician. 2014 Feb 1;89(3):180-189. http://www.aafp.org/afp/2014/0201/p180.html[↩][↩][↩][↩]
5. DuPont HL. Guidelines on acute infectious diarrhea in adults. The Practice Parameters Committee of the American College of Gastroenterology. Am J Gastroenterol. 1997;92(11):1962–1975.[↩]
6. Hof H. History and epidemiology of listeriosis. FEMS Immunol Med Microbiol. 2003;35(3):199–202.[↩]
7. Janakiraman V. Listeriosis in pregnancy: diagnosis, treatment, and prevention. Rev Obstet Gynecol. 2008;1(4):179–185.[↩]
8. Farthing M, Salam MA, Lindberg G, et al.; World Gastroenterology Organisation. Acute diarrhea in adults and children: a global perspective. J Clin Gastroenterol. 2013;47(1):12–20.[↩][↩]
9. 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;32(3):331–351.[↩]
10. Hahn S, Kim Y, Garner P. Reduced osmolarity oral rehydration solution for treating dehydration due to diarrhoea in children: systematic review. BMJ. 2001;323(7304):81–85.[↩]
11. Alam NH, Yunus M, Faruque AS, et al. Symptomatic hyponatremia during treatment of dehydrating diarrheal disease with reduced osmolarity oral rehydration solution. JAMA. 2006;296(5):567–573.[↩]
12. Duggan C, Nurko S. “Feeding the gut”: the scientific basis for continued enteral nutrition during acute diarrhea. J Pediatr. 1997;131(6):801–808.[↩]
13. Gadewar S, Fasano A. Current concepts in the evaluation, diagnosis and management of acute infectious diarrhea. Curr Opin Pharmacol. 2005;5(6):559–565.[↩]
14. De Bruyn G. Diarrhea in adults (acute). Am Fam Physician. 2008;78(4):503–504.[↩]
15. Taylor DN, Sanchez JL, Candler W, Thornton S, McQueen C, Echeverria P. Treatment of travelers’ diarrhea: ciprofloxacin plus loperamide compared with ciprofloxacin alone. A placebo-controlled, randomized trial. Ann Intern Med. 1991;114(9):731–734.[↩]
16. Hanauer SB, DuPont HL, Cooper KM, Laudadio C. Randomized, double-blind, placebo-controlled clinical trial of loperamide plus simethicone versus loperamide alone and simethicone alone in the treatment of acute diarrhea with gas-related abdominal discomfort. Curr Med Res Opin. 2007;23(5):1033–1043.[↩]
17. DuPont HL, Hornick RB. Adverse effect of lomotil therapy in shigellosis. JAMA. 1973;226(13):1525–1528.[↩]
18. Matheson AJ, Noble S. Racecadotril. Drugs. 2000;59(4):829–835.[↩]
19. De Bruyn G, Hahn S, Borwick A. Antibiotic treatment for travellers’ diarrhoea. Cochrane Database Syst Rev. 2000;(3):CD002242.[↩]
20. Wong CS, Jelacic S, Habeeb RL, Watkins SL, Tarr PI. The risk of the hemolytic-uremic syndrome after antibiotic treatment of Escherichia coli O157:H7 infections. N Engl J Med. 2000;342(26):1930–1936.[↩]
21. Casburn-Jones AC, Farthing MJ. Management of infectious diarrhoea. Gut. 2004;53(2):296–305.[↩]
22. Allen SJ, Martinez EG, Gregorio GV, Dans LF. Probiotics for treating acute infectious diarrhoea. Cochrane Database Syst Rev. 2010;(11): CD003048.[↩]
23. 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;72(6):1516–1522.[↩]
24. American Academy of Pediatrics. Diarrhea. https://www.healthychildren.org/English/health-issues/conditions/abdominal/Pages/Diarrhea.aspx[↩]
25. Managing Travelers’ Diarrhea While Traveling Abroad. Centers for Disease Control and Prevention. https://www.cdc.gov/features/managing-travelers-diarrhea/index.html[↩]
26. Hoge CW, Shlim DR, Echeverria P, Rajah R, Herrmann JE, Cross JH. Epidemiology of diarrhea among expatriate residents living in a highly endemic environment JAMA. 1996;275:533–8.[↩][↩]
27. Mensah P, Yeboah-Manu D, Owusu-Darko K, Ablordey A. Street foods in Accra, Ghana: how safe are they? Bull World Health Organ. 2002;80:546–54.[↩]
28. Adachi JA, Mathewson JJ, Jiang ZD, Ericsson CD, DuPont HL. Enteric pathogens in Mexican sauces of popular restaurants in Guadalajara, Mexico, and Houston, Texas. Ann Intern Med. 2002;136:884–7.[↩]
29. Tauxe RV, Swerdlow DL, Hughes JM. Foodborne disease. In: Mandell GL, Douglas RG, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett’s Principles and practice of infectious diseases. 5th ed. Philadelphia: Churchill Livingstone, 2000:1150–65.[↩]
30. Barbier HM, Diaz JH. Prevention and treatment of toxic seafoodborne diseases in travelers. J Travel Med. 2003;10:29–37.[↩]
31. von Sonnenburg F, Tornieporth N, Waiyaki P, Lowe B, Peruski LF Jr, DuPont HL, et al. Risk and aetiology of diarrhoea at various tourist destinations. Lancet. 2000;356:133–4.[↩]
32. Hill DR. Occurrence and self-treatment of diarrhea in a large cohort of Americans traveling to developing countries. Am J Trop Med Hyg. 2000;62:585–9.[↩]
33. Jiang ZD, Lowe B, Verenkar MP, Ashley D, Steffen R, Tornieporth N, et al. Prevalence of enteric pathogens among international travelers with diarrhea acquired in Kenya (Mombasa), India (Goa), or Jamaica (Montego Bay). J Infect Dis. 2002;185:497–502.[↩]
34. Traveler’s Diarrhea. Am Fam Physician. 2005 Jun 1;71(11):2095-2100. http://www.aafp.org/afp/2005/0601/p2095.html [↩]
35. Adachi JA, Jiang ZD, Mathewson JJ, Verenkar MP, Thompson S, Martinez-Sandoval F, et al. Enteroaggregative Escherichia coli as a major etiologic agent in traveler’s diarrhea in 3 regions of the world. Clin Infect Dis. 2001;32:1706–9.[↩][↩][↩]
36. Taylor DN, Houston R, Shlim DR, Bhaibulaya M, Ungar BL, Echeverria P. Etiology of diarrhea among travelers and foreign residents in Nepal. JAMA. 1988;260:1245–8.[↩]
37. Sanders JW, Isenbarger DW, Walz SE, Pang LW, Scott DA, Tamminga C, et al. An observational clinic-based study of diarrheal illness in deployed United States military personnel in Thailand: presentation and outcome of Campylobacter infection. Am J Trop Med Hyg. 2002;67:533–8.[↩]
38. Oksanen PJ, Salminen S, Saxelin M, Hamalainen P, Ihantola-Vormisto A, Muurasniemi-Isoviita L, et al. Prevention of travellers’ diarrhoea by Lactobacillus GG. Ann Med. 1990;22:53–6.[↩]
39. Hilton E, Kolakowski P, Singer C, Smith M. Efficacy of Lactobacillus GG as a diarrheal preventive in travelers. J Travel Med. 1997;4:41–3.[↩]
40. Backer H. Water disinfection for international and wilderness travelers. Clin Infect Dis. 2002;34:355–64.[↩]
41. Traveler’s Diarrhea. Am Fam Physician. 2005 Jun 1;71(11):2095-2100. http://www.aafp.org/afp/2005/0601/p2095.html[↩]
42. Stauffer WM, Konop RJ, Kamat D. Traveling with infants and young children. Part III: travelers’ diarrhea. J Travel Med. 2002;9:141–50.[↩][↩]
43. Samuel BU, Barry M. The pregnant traveler. Infect Dis Clin North Am. 1998;12:325–54.[↩]
44. Drugs for parasitic infections. Med Lett Drugs Ther. 2004;46:1–12.[↩]
45. Chronic Diarrhea. Centers for Disease Control and Prevention. https://www.cdc.gov/healthywater/hygiene/disease/chronic_diarrhea.html[↩]
46. Fine KD, Schiller LR. AGA technical review on the evaluation and management of chronic diarrhea. Gastroenterology. 1999;116(6):1464–1486.[↩]
47. Schiller L, Sellin J. Diarrhea. In: Sleisenger MH, Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran’s Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, Management. 9th ed. Philadelphia, Pa.: Saunders/Elsevier; 2010: 211–232.[↩][↩]
48. Evaluation of Chronic Diarrhea. Am Fam Physician. 2011 Nov 15;84(10):1119-1126. http://www.aafp.org/afp/2011/1115/p1119.html[↩][↩]
49. Feldman M, Friedman LS, Sleisenger MH, eds. Sleisenger & Fordtran’s Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, and Management. 7th ed. Philadelphia, Pa.: Saunders; 2002: 137.[↩]