Table of Contents
Diarrhea is defined as a stool frequency of more than 3 stools per day, which have a high water content of over 75 % and increased stool weight, about 250 g. Acute diarrhea usually lasts two to three days, and the reason is infections or intoxication. Prolonged diarrhea is chronic and can be caused by food intolerance, inflammatory bowel disease or tumors.
Classification according to the emergence of diarrhea
|Diarrhea form||Pathomechanism||Possible Causes|
|Secretory diarrhea||The mucosa of the intestine releases active water or electrolytes from where water follows osmotically.||Chronic inflammatory bowel disease, food poisoning, intake of laxatives|
|Osmotic diarrhea||Unabsorbed, osmotically active molecules, such as food ingredients or medicines pull water into the intestinal lumen.||Lactose intolerance, celiac disease, laxatives, sorbitol|
|Exudative diarrhea||Inflammations of the intestinal mucosa leading to the accumulation of stool with mucus and blood.||Chronic inflammatory bowel diseases, bacterial/parasitic infections, colon Ca|
|Hypermotile diarrhea||Increased intestinal motility leads to a reduced transit time of the stool, such that not enough water can be withdrawn.||Irritable bowel syndrome, hyperthyroidism, diabetic polyneuropathy|
|Steatorrhea||Decreased amount of enzymes and bile acids leads to insufficient digestion and absorption of fats.||Exocrine pancreatic insufficiency, condition after cholecystectomy|
Food poisoning as a cause of diarrhea
Foodstuff can have a toxic effect on the human body for various reasons. The most common triggers of food poisoning are caused by toxins produced by bacteria, but even heavy metals such as lead or toxic chemicals can be present in the food and lead to poisoning with symptoms such as diarrhea.
Food poisoning with bacterial toxins
The disease occurs due to the intake of bacterial toxins, the multiplication of bacteria itself is no trigger. In most cases, there is a contamination of food with Staphylococcus aureus. One reason can be a lack of hand hygiene in the preparation of food. The bacteria are indeed killed by cooking, but not the enterotoxins they release. Very rapid onset of symptoms, about 30 minutes to 2 hours after eating, and an equally short duration of diarrhea symptoms are characteristic. Classically, several people are affected at the same time. Even bacillus and clostridia species can form enterotoxins and cause similar symptoms.
Other food poisonings
Other triggers of food intoxication include toxic metals such as arsenic, lead, zinc, and antimony. Even fungal toxins such as muscarinic (fly agaric) and amatoxin (Amanita phalloides) lead to diarrhea, amongst other symptoms. Saxitoxins, which can be accumulated in steamed mussels and oysters, leading to a disease pattern that is called paralytic shellfish poisoning which results in nausea with vomiting and diarrhea with abdominal cramps.
- 179 million cases/year
- 17 million food-borne
- ~ 2 million hospitalizations
- ~ 3,000 deaths
- 83 % elderly
- $ 6 billion in medical care and lost productivity
US Causes—Rates/100k people:
- Salmonella: 13.6
- Campylobacter: 13
- Shiga toxin-producing E. coli: 0.04—0.41
- Vibrio: 0.45
- Yersinia: 0.29
In foodborne infections, pathogenic germs are absorbed by the food, and the microorganisms multiply in the intestine. Even these often produce toxins, which is why there can be no clear separation of the food poisoning here.
Etiology of salmonellosis
The salmonella enteritis is caused by the consumption of contaminated drinking water or infectious food as a result of insufficient hygiene. The pathogen is Salmonella enteritidis, however out of the more than 2,600 known salmonella serotypes, another 30 pathogens are gastroenteritis pathogens. In 2004, a new subspecies called Salmonella choleraesuis was discovered, which is very resistant against antibiotics and more frequently results in the death of patients.
Different animals can be carriers of the salmonella pathogen, such as poultry, swine, and reptiles; thus many foods such as eggs, meat, milk, and mussels can be contaminated with salmonella. Even in the case of adequate hygiene by the slaughter staff, who is the chronic carrier of salmonella, salmonella enteritidis can be transferred to the meat. In countries with inadequate treatment of water, the feces of infected animals can contaminate the drinking water and thus serve as a source of infection.
Symptoms of salmonella enteritis
In most cases, infection occurs in the warm season, especially among children and elderly people. It is a matter of invasive gastroenteritis. Typical symptoms of salmonella enteritis are vomiting and diarrhea after an incubation period of a few hours up to seven days. Patients also develop spasmodic abdominal pain. The duration of the disease is generally only for a few days.
Diagnosis of Salmonellosis
Appropriate investigation material is stool and vomit. Onoz- and Xylose Lysine Desoxycholate Agar in the culture serve as differentiation media. The classification in subtypes is based on the O-antigens and is useful for epidemiological investigations.
A salmonellosis disease is notifiable under the Infection Protection Act.
Treatment and prophylaxis of salmonellosis
There should be no antibiotic treatment since this leads to an extension of bacterial elimination. In only about 5 % of the patients, it comes to systemic infection with fever and massive fluid loss, such that hospitalization becomes necessary. Ciproflaxin and ampicillin are then suitable for children.
A small percentage of the patients do not completely eliminate the salmonella, such that they are asymptomatic chronic carriers for a long time and receive a prohibition of employment on activities involving food handling.
The prophylactic measures include cooking of poultry meat and eggs, as well as the strict separation of cutlery and cutting boards which are used before and after cooking, in order to avoid cross-contamination.
Etiology of typhoid
Salmonella typhi also usually spreads by unsanitary conditions during the preparation of food and beverages. Thus, it leads to infections among Europeans, especially in long-distance travel to Africa, Southeast Asia, and Latin America.
Disease pattern of the typhoid fever
The course of the disease can be divided into three stages. The incubation period varies, with 10 days being average.
- Stadium incrementi during the 1st week after infection: It results in unspecific general symptoms like a headache, fatigue, constipation and a staircase-shaped increase in fever.
- Stadium fastigii in the 2nd—3rd week of infection:
After approximately 8 days, a very high fever (up to 41 ° C) is reached, which persists. Relative bradycardia, leukopenia, and splenomegaly are added to this. A reddish, spotty rash, the so-called roseola, with prominence on the upper body and abdomen is typical, so are disturbances of consciousness, which give the disease its name. One can often notice the typhoid tongue, which is characterized by a white-gray coating in the middle, with reddish tongue tip and edges.
By destroying the Peyer’s patches of the small intestine, it leads to pea soup diarrhea from the 14th disease day onwards. Other possible symptoms include meningitis, osteomyelitis, and a bowel perforation.
- Stadium decrementi with stepwise decreasing fever.
Diagnosis of typhoid fever
The detection of salmonella infection is dependent on the disease week. One week after infection, the detection in blood cultures can be carried out; an antibody screening of blood serum is possible in the second week. From the third week on, a culture from stool samples can succeed.
In addition, the typical leukopenia is found in the blood, often along with a lack of eosinophilic granulocytes.
Treatment of typhoid fever
The antibiotic treatment is carried out with ciprofloxacin or ceftriaxone of the 3rd generation such as cephalosporins.
As is the case of salmonellosis, some of the affected remain chronic carriers for up to one year, especially if they have not received antibiotics. The salmonella survives in the gall bladder and the bile ducts, favored by gallstones.
Prophylaxis of the typhoid disease
Particularly in tropical destinations, hygiene is the best protection against infection. Thus, the consumption of insufficiently cooked foods and tap water should be avoided. In addition, the vaccination can be done with a dead or non-pathogenic live vaccine, whereby it should be noted that adequate protection is achieved in only about 60 % of the vaccinated people.
The yersiniosis is an infectious disease caused by the bacterium Yersinia enterocolitica or Y. pseudotuberculosis. The pathogen is spread worldwide (Y. pseudotuberculosis more in Eastern Europe), and animals such as pigs or cattle serve as a reservoir. Therefore, the infection can be carried out through contaminated meat, dairy products, and drinking water.
Symptoms of yersiniosis
Depending on the age of onset, other symptoms occur after an infection with yersinia.
- Yersinia gastroenteritis: Especially in infants. It results in self-limiting bloody diarrhea with exsiccosis.
Pseudoappendicitis (lymphadenitis of intestinalis) or Morbus Maßhoff:
In older children and adolescents it results in inflammation with concomitant swelling of the mesenteric lymph nodes. Typically results in a lymph node conglomerate around the vermiform appendix, such that at the hospital the misdiagnosed appendicitis is often detected with fever and abdominal pain and mass around the appendix in the sonography.
- Enterocolitis: The enterocolitis caused by yersinia is invasive gastroenteritis. The bacterial cells migrate through the mucosa of the intestine and result in inflammation in the Peyer’s patches. The hereby resulting diarrhea continues 10—14 days and is accompanied by colicky abdominal pain.
After weeks to months following an enteral infection with yersinia, a common result are inflammatory late-onset diseases, such as reactive arthritis, pyomyositis and persistent ileitis (Pseudo-Crohn). These late effects are very frequently associated with the HLA type B27.
Diagnostics of the yersinia infection
The aim should be the direct detection of yersinia from blood culture, stool or infected lymph nodes. The so-called CIN breeding ground (Cefsulodin Irgasan-Novobiocin Agar) serves as the selective agar on which porthole-shaped red colonies grow after 1-2 days.
A namely obligation to notify the authorities exists during the detection of an acute infection with yersinia.
Treatment of yersiniosis
Usually, only symptomatic treatment for rehydration takes place. Severe gastroenteritis and systemic infections are treated with a combination of ciprofloxacin and ceftriaxone.
The shigellosis, or bacterial dysentery, is fecal-oral transmitted dysentery, which mainly affects the colon.
Etiology of the bacterial dysentery
Several shigella species come into question as pathogens. They are divided into groups from A to D.
|A||S. dysenteriae||Tropics||Serious disease patterns by the formation of endo- and ectotoxin, the lethality of 60 %.|
|B||S. flexneri||Worldwide||Mild progressive form, since no ectotoxin is observed.|
|C||S. boydii||Middle East, North Africa||Mild course|
|D||S. sonnei||Central Europe||Summer diarrhea in children, no exotoxin, approximately 80 % of the shigellosis cases|
The only reservoir for pathogens is the human body, such that the fecal-oral transmission occurs via contaminated food and drinking water.
Symptoms of the shigella dysentery
Diarrhea occurs after an incubation period of 2–10 days. In the mild progressive form this is referred to as white dysentery and in severe, bloody progressive form as red dysentery. Characteristically, the diarrhea is accompanied by abdominal pain and tenesmus with defecation. Even loss of appetite, fever, and consequences of electrolyte loss are common. Gastrointestinal bleeding and intestinal perforation may occur as complications.
Diagnostics of the shigellosis
At the beginning of the disease, one histologically observes catarrhal dysentery, an inflamed, swollen intestinal mucosa. In severe cases, the image changes into pseudomembranous-necrotizing dysentery. The histological image then resembles a chronic inflammatory bowel disease.
The diagnosis is made on the basis of clinical symptoms and a rectum smear since the shigella dies in the stool sample after a short time.
Treatment of the shigella dysentery
The treatment should be symptomatic, which means balancing the water and electrolyte losses. In addition, a calculated antibiotic treatment can be started with a quinolone. Many shigella are however affected by an R-plasmid resistant to numerous antibiotics, such that a change of antibiotic treatment after antibiogram is meaningful.
Treatment of choice: ciprofloxacin or azithromycin.
Infection with Escherichia coli
The most well-known bacterium in the world is responsible for about 160 million diarrheal diseases and 1 million cases of death yearly.
Infections with enteropathogenic E. coli
Enteropathogenic E.coli strains, short EPEC, are a common diarrheal pathogen in infants and young children in developing countries. Through the EPEC adhesion factor EAF, the bacteria bind to the epithelial cells of the small intestine and inject toxins in the enterocytes using a type III secretion system.
Infections with enterotoxigenic E. coli
The transmission of ETEC occurs in tropical countries through contaminated food and drinking water. For the attachment to the mucosa of the intestine, these strains have specific fimbriae called colonization factors. The pathogenic effect is caused by one of the cholera toxins similar to the heat-labile enterotoxin and two heat-stable (up to 100°C) toxins. Guanylate cyclase is stimulated through the toxins, among other things, whereby the sodium absorption is inhibited, and more water is extracted from the intestine. It often results in massive watery diarrheas, which are self-limiting in the form of traveler’s diarrhea. In children, it can lead to life-threatening courses through dehydration.
Infections with enteroinvasive E. coli
The infection with EIEC resembles a shigella infection. The bacteria penetrate the epithelial cells of the colon and lead to a granulocytic inflammation with the discharge of blood and mucus. Even EIEC strains have toxins, which additionally lead to water and electrolyte loss.
Treatment of choice for E. coli (non-Shiga toxin-producing) infections: Ciprofloxacin, or trimethoprim/sulfamethoxazole, or azithromycin.
Infections with enterohemorrhagic E. coli
Enterohemorrhagic E. coli, the so-called EHEC, are Shiga toxin-producing E. coli with additional pathogenicity. Even 10—100 bacteria are enough for food poisoning with EHEC. The infection occurs mainly via milk and raw meat, but can also occur during close contact from person to person.
The Vera toxin present in the EHEC bacteria is phage-encoded and like the Shiga toxin acts neurotoxic and necrotic. In addition, EHEC has a plasmid-encoded hemolysin that triggers the hemorrhagic-uremic syndrome, short HUS. The hemolytic-uremic syndrome, which is also called the Gasser syndrome, is microangiopathic hemolytic anemia with thrombocytopenia and acute renal failure caused by bacterial toxins. If only 2 of these symptoms are present, one speaks of incomplete enteropathic HUS. With diarrhea, it is about the typical HUS, which is common in children. The atypical HUS without diarrhea occurs more commonly in adults.
The detection of EHEC is achieved through the PCR. The treatment should be symptomatic with electrolytes and infusions and plasmapheresis. Loperamide and antibiotics are absolutely contraindicated as they do not act against the toxins and there are indications that HUS symptoms occur more frequently among antibiosis. Since 2009, there is a monoclonal antibody called eculizumab, which inhibits the complement system and reduces the mortality with atypical HUS.
The suspicion or evidence of an EHEC infection is notifiable under the law if an HUS is present, two or more people are sick, or the sick person works in the food industry. The suspicion, the illness, and death by a bacterial HUS is also notifiable under the law.
Infections with enteroaggregative E. coli
Following the attachment to the intestinal epithelium by fimbriae, it results in diarrhea of secretory type through enterotoxins. Increased mucus production is typical, which delays the elimination of the pathogen, such that the disease can drag on for weeks. In case of immunosuppressed patients, such as HIV patients, EAEC is the most frequent cause of bacterial enteritis.
Clostridium botulinum is the producer of the most potent toxin in the world. Under anaerobic conditions, such as in animal carcasses or insufficiently heated canned food, this bacterium can multiply and produce botulinum toxin. Infants can become infected even by eating contaminated honey, as their intestinal flora has not yet fully developed.
After the intake of poison, there is an inhibition of acetylcholine secretion at the neuromuscular junction. First, the eye muscles are paralyzed, then other facial and pharyngeal muscles. Even vomiting and diarrhea are typical before death due to suffocation or cardiac arrest. The treatment is done with an antiserum, which reduces the mortality from about 90 % to 10 %.
Clostridium difficile infections
Clostridium difficile is an obligate anaerobic spore former with the ubiquitous occurrence. Approximately 80 % of the infants and < 5 % of the adults are infected. The infection usually occurs nosocomially (48 hours after hospital admission until 4 weeks after dismissal), fecal-oral route. The diarrhea is highly contagious, even indirectly via surfaces.
Risk factors for Clostridium difficile infection:
- previous antibiotic therapy (in particular, Clindamycin, ampicillin, and cephalosporins)
- Old age
- Therapy with PPI and/or NSAIDs
- GI underlying disease
Clinical symptoms are watery, greenish diarrhea with a foul odor, lower abdominal pain, fever, leukocytosis, and hypoalbuminemia.
For the disease definition, one or more of the following points must hold true:
- Diarrhea/toxic megacolon with detection of C. difficile enterotoxin A and/or cytotoxin B or cultural evidence of toxin-producing C. difficile in the stool
- Pseudomembranous colitis in the endoscopy
- Histopathologic evidence of a C. difficile infection through endoscopy, colectomy or autopsy
The toxin proof is the gold standard for the diagnosis, but it is seldom applied. As a routine, enzyme immunoassay (EIA) is mostly used.
The treatment of Clostridium difficile-associated enterocolitis consists of the completion of the previous antibiotic therapy (if acceptable from a clinical perspective) and an additional antibiotic therapy in case of persistent/severe symptoms, old/critically ill patients or if the current antibiotic therapy needs to be continued. Suitable for this, in order to avoid the selection of vancomycin-resistant enterococci, are Metronidazole in uncomplicated courses and Vancomycin in severe courses, during pregnancy or in children below 10 years. The surgical treatment can be necessary for intestinal perforation or toxic megacolon.
In case of VA CDI, the prophylaxis of an infected patient should be strictly observed with isolation in single rooms for up to 48 hours after cessation of symptoms.
In severe cases, the local health authorities must be notified (e.g. ICU requiring/surgery requiring a course, recurrent infection, death from CDI < 30d after diagnosis).
Cholera, or bile diarrhea and vomiting, is caused due to an infection with Vibrio cholerae. The transmission usually occurs through contaminated water in poorer countries without adequate supplies of clean drinking water. Approximately 85 % of the infections proceed inapparently; the other 15 % are associated with typical symptoms.
After an incubation period of 2–3 days, it results in diarrhea and vomiting, whereby the diarrhea is interspersed with flakes of mucus and is therefore called rice water stool. Due to massive exsiccosis, it then results in subnormal temperature and a typical facial expression with a pointed nose, sunken cheeks, and standing skin folds.
This is subsequently followed by general body reactions such as dizziness and coma. The diagnosis can be done quickly through microscopy and stool culture. The definitive diagnosis is done with the help of antiserum. For rehydration, the WHO-Oral Solution consisting of glucose, sodium chloride, sodium citrate, and potassium chloride is recommended. In addition, there are several oral cholera vaccines, which are administered in different endemic areas.
The lambliasis or giardiasis is an infection of the intestinal tract caused by the protozoan Giardia intestinalis. Typical symptoms of the Lamblia dysentery are diarrhea, flatulence, and malnutrition in case of prolonged illness. The detection of trophozoites or cysts is done using microscopy of stool or from the biopsy of the intestinal tract. Even an antigen detection using ELISA or PCR is possible. It is presumed that a resolved infection can cause lactose intolerance or other food intolerances with persistent gastrointestinal complaints.
Treatment of choice: Metronidazole.
The infection with Giardia is notifiable under the law.
Entamoeba histolytica passes as a cyst in the small intestine and as a four-core stage thereafter in the colon. There, the amoeba further lives in the form of trophozoites. They form cysts, which are excreted in the stool (up to 50 million per day!). The minuta form of the Entamoeba histolytica causes self-limited diarrhea. The magna-form, on the other hand, penetrates the colonic mucosa and passes from there into the bloodstream. It, then, settles in the form of abscesses in all sorts of organs, including the intestines. Amoebic dysentery, therefore, results in raspberry jelly-like diarrhea with abdominal pain and exsiccosis. Even peritonitis and abscess rupture in the liver are common.
Treatment of choice: Metronidazole plus paromomycin.
Important Clues to the Differential Diagnosis of Diarrhea
The clinical presentation of a patient with a foodborne illness can vary, however, there are some important clues in the clinical history that can make the treating doctor suspect an infectious etiology behind the patient’s diarrhea. They are summarized in the following points:
- Acute abdominal pain that is associated with fever and vomiting is often an indicator of an infectious etiology of diarrhea.
- A recent change in diet, the ingestion of new foods, or eating undercooked foods are important clues for foodborne illness.
- Patients with a long duration of symptoms are more likely to be dehydrated. Moreover, chronic diarrhea is unlikely to be infectious in etiology.
- A history of working in a child-care facility puts the individual at an increased risk of viral diarrhea.
- History of recent hospitalization in a patient who is presenting with diarrhea raises the suspicion of Clostridium difficile infection.
- Patients with immunosuppression due to disease or medication who present with diarrhea are more likely to have an atypical infectious cause.
- History of recent antibiotic use raises the suspicion of clostridium difficile infection.
- Travel history puts the individual at an increased risk of acquiring traveling diarrhea, which is infectious in etiology.
Key Recommendations for the Management of Foodborne Illness per the American Family Physician Guidelines
The American Family Physician guidelines that were formulated in 2015 about the management of foodborne illness can be summarized in four main points:
- Stool cultures are the diagnostic standard for bacterial foodborne illness. They must be performed in any patient suspected to have a bacterial etiology behind their diarrhea. They are positive in up to 40% of the cases.
- A single dose of ondansetron is recommended in children with significant gastroenteritis-related vomiting.
- Patients with a foodborne illness who have diarrhea that is associated with fever and signs of invasive disease such as leukocytosis should receive empiric antibiotic therapy if their symptoms persist for more than one week or if hospitalization is required.
The correct answers can be found below the references.
1. A 28-year-old woman introduces herself in your general medical practice because of diarrhea that has persisted for 3 weeks. She claims to have bought a dog from Greece 2 months prior, which sometimes has rancid grease-smelling, loose stools. Now she is experiencing similar diarrhea and has lost 5 kg of weight. You ask the young woman for the submission of a stool sample. In microscopy, you see the following:
It is most likely infection with:
- Entamoeba histolytica
- Giardia intestinalis
- Enterotoxigenic E. coli
- Shigella dysenteriae
- Yersinia pseudotuberculosis
2. A 44-year-old otherwise healthy woman is accompanied by her husband to the emergency room because of diarrhea, disturbance of consciousness, dysarthria and petechiae on the lower legs. You diagnose acute renal failure with systolic blood pressures up to 210 mmHg. In the hemogram, thrombocytopenia and hemolysis are noticeable. In the blood smear, you see fragmentocytes. You give a diagnosis of hemolytic uremic syndrome with thrombotic thrombocytopenic purpura. You assume an infection with EHEC as the cause. What is the appropriate treatment?
- Loperamide dose
- Antibiosis with ciprofloxacin
- Elotuzumab dose
3. At a birthday party where there was custard in the afternoon, 6 children suddenly fall ill with diarrhea in the evening. After 2 to 3 hours the symptoms cease as suddenly as they appeared. This is most likely a case of diarrhea caused by:
- Salmonella typhi
- Staphylococcus aureus toxin
- Shigella dysenteriae toxin
- Botulinum toxin