Giới thiệu
Diarrhea in Adults - Infectious_Disease Background 1Diarrhea is the change in normal bowel movements characterized by an increase in frequency, water content, or volume of stools. This is characterized as ≥3 episodes/day or at least 200-250 g/stool per day.
Dịch tễ học
The estimated yearly cases of diarrhea are at 1.5 billion worldwide. This is the leading cause of death in many developing countries, with a higher mortality in women. The morbidity and mortality are high in children <5 years old, the elderly (≥65 years old), and the immunocompromised. The highest mortality rates are observed in South Asia and sub-Saharan Africa in children while South Asia had the highest diarrheal disease deaths among older adults.
Asia, especially South and Southeast Asia, accounted for the highest number of diarrhea cases among older adults as well as the highest incidence rates. Central Europe experienced the greatest increase in incidence rate, whereas high-income North America recorded the largest decline. A study conducted in China found that viral pathogens were more frequently detected in patients younger than 5 years old, while bacterial pathogens were more prevalent among those aged 18–45 years old.
Nguyên nhân
Non-infectious Etiology of Diarrhea
Persistent diarrhea for non-travelers may be due to non-infectious causes, including irritable bowel syndrome (IBS), inflammatory bowel disease (IBD) or gluten-sensitive enteropathy. Other non-infectious causes of diarrhea may include alcoholism, use of medications and laxatives, irradiation, enteral feeding, food allergy, cirrhosis and biliary obstruction, tropical or celiac sprue, pancreatic insufficiency, adrenal insufficiency, thyrotoxicosis, carcinoid tumor, stress with autonomic stimulation, colon cancer, bowel obstruction, botulism, hemolytic uremic syndrome, and intra-abdominal abscess.
Toxin-Induced Food Poisoning or Viral Gastroenteritis
Bacterial Toxin-Induced Food Poisoning
Bacterial toxin-induced food poisoning is caused by Staphylococcus aureus, Bacillus cereus, Clostridium perfringens, Clostridium botulinum, or enterotoxigenic Escherichia coli (ETEC).
Viral Gastroenteritis
Viral gastroenteritis is caused by adenovirus serotype 40/41, astrovirus, human caliciviruses (eg norovirus, sapovirus), and rotavirus. Norovirus is the leading cause of infectious diarrhea in adults and the major cause of foodborne gastroenteritis worldwide.
Traveler’s Diarrhea
Diarrhea in Adults - Infectious_Disease Background 2
The causes of acute traveler’s diarrhea will vary from one geographical area to another. Bacteria are responsible for 80-90% of cases, parasites in 10%, and viruses in 5-8% of cases. Toxigenic Escherichia coli is one of the most frequently identified organisms. Campylobacter infections seem to predominate as the cause of traveler’s diarrhea in North Africa and Southeast Asia. Yersinia enterocolitica is common in individuals with travel to Asia. Other common organisms are enteroaggregative E coli (EAEC), Salmonella, Shigella spp and viruses (eg rotavirus, norovirus). Parasites should be considered in diarrhea that lasts >14 days.
Please see Parasitic
Infections disease
management chart for further information.
Watery Diarrhea
Severe dehydration with severe watery diarrhea is most likely caused by Vibrio cholerae subgroup O1 as well as ETEC. Vibrio O139, other non-O1 vibrios and occasionally Vibrio parahaemolyticus, Aeromonas sp and enteropathogenic E coli (EPEC) can cause a similar clinical picture (though diarrhea by these organisms is usually milder). Other potential pathogens for an acute watery diarrhea may include norovirus, rotavirus, Campylobacter, non-typhoidal Salmonella, Shigella, Listeria monocytogenes, ETEC, Cryptosporidium parvum, Cystoisospora belli, Giardia, Entamoeba histolytica, Balantidium coli, and microsporidia. Persistent watery diarrhea may be caused by EAEC, Giardia, C parvum/hominis, Cyclospora cayetanensis, and C belli.
Bloody Diarrhea
Shigella spp is the most common cause of acute bloody diarrhea. S dysenteriae and S flexneri may cause a more severe disease with high fever, the former producing Shiga toxin. S boydii and S sonnei cause a milder disease. Campylobacter jejuni infection is suggested by a history of exposure to cattle and poultry and the presence of animals near the patient’s cooking area. Salmonella enteritidis, Y enterocolitica, C difficile, EHEC and enteroinvasive E coli (EIEC) can also produce bloody diarrhea. Other potential pathogens for a bloody diarrhea may include cytomegalovirus, non-cholera Vibrio spp, Plesiomonas shigelloides, Y enterocolitica, B coli, and E histolytica. Persistent bloody diarrhea may be caused by Mycobacterium tuberculosis, B coli, or E histolytica. The incubation period is from 1-7 days.
Sinh lý bệnh
Inflammatory diarrhea (ie watery or bloody diarrhea) is characterized by enterocyte damage, villus atrophy, and crypt hyperplasia. There is stimulation of intestinal secretion by inflammatory mediators, reduced absorption of the damaged epithelium and immune-mediated vascular damage or ulceration from severe inflammation which allows leakage of blood, pus, and protein from capillaries and lymphatics contributing to the diarrhea. Lymphocyte, phagocyte, and fibroblast activation releases inflammatory mediators that induce intestinal chloride secretion. Interleukin-1 (IL-1) and tumor necrosis factor (TNF) released into the blood cause fever, anorexia and malaise.
Yếu tố nguy cơ
Epidemiological Risk Factors
Diarrhea in Adults - Infectious_Disease Background 3
Place of Residence
The likely pathogens from long-term care residences or prisons include norovirus, rotavirus, Clostridioides difficile, Shiga toxin-producing Escherichia coli (STEC), Shigella, and Giardia.
Travel to a Developing Country
The potential pathogens when travelling to a developing country include norovirus, enteroaggregative E coli (EAEC), enteropathogenic E coli (EPEC), enterotoxigenic E coli (ETEC), Campylobacter, Shigella, non-typhoidal Salmonella, Cryptosporidia, Cyclospora spp, Entamoeba histolytica, Giardia, rarely Vibrio cholerae, and Balantidium coli. Cyclospora spp is a likely pathogen from traveling to tropical or semitropical regions. Rotavirus may be implicated with travel from Africa, Asia or South America.
Cruise Ship Travel
The common pathogen in cruise ship travel is norovirus, and occasionally ETEC.
Daycare Attendance, Employment
The potential pathogens from a daycare include norovirus, rotavirus, Shigella, STEC, Cryptosporidia, and Giardia.
Ingestion of Unsafe, Rotten or Ill-prepared Foods (eg raw meats, eggs, shellfish, etc)
Foodborne infection may be due to Campylobacter spp and Salmonella spp. Poultry may contain non-typhoidal Salmonella, Campylobacter and Shigella spp. Contaminated beef or produce may contain STEC, E coli 0157:H7, enterohemorrhagic E coli (EHEC), and Clostridium perfringens. Pork may contain Yersinia, or C perfringens. Eggs may contain Salmonella spp. Raw shellfish may contain norovirus, Vibrio spp, Plesiomonas shigelloides, Aeromonas sp, Shigella and Salmonella spp. Staphylococcal and clostridial food poisonings may be caused by mayonnaise-containing foods and rice may contain Bacillus cereus.
Swimming or Drinking Untreated Fresh Water
Cryptosporidia is a likely pathogen from swimming in public pools, while Giardia may be present in untreated fresh water. Other pathogens include V cholerae, and norovirus.
Visit to Farm or Contact with Pets with Diarrhea
The potential pathogens from a petting farm or pets include STEC, Campylobacter, Yersinia, Cryptosporidia. Pig feces may contain Y enterocolitica or B coli.
Contact With Other Ill Persons
Recent or Regular Medications (eg antibiotics, antacids, antimotility agents)
The potential pathogen for prior antibiotic use may include C difficile.
Underlying Medical Conditions (eg acquired immunodeficiency syndrome [AIDS], immunosuppressed, elderly)
The potential pathogens in immunosuppressed individuals include cytomegalovirus, Herpes simplex virus, Mycobacterium avium complex, Cryptosporidia, Cystoisospora belli, Histoplasma, Giardia, Salmonella, Shigella, C difficile, and microsporidia.
Receptive Anal or Oral-Anal Sexual Contact
The likely pathogens from anal contact include Shigella (including multidrug resistant species), Campylobacter, Salmonella; and other pathogens such as E histolytica spread via fecal-oral contact.
Occupation as Food-Handler or Caregiver
Phân loại
Diarrhea is categorized as follows:
- Acute diarrhea is a diarrhea lasting for ≤14 days duration. The patient should not have had antibiotic treatment within the past 3 months, no prior hospitalizations and/or no diarrhea after >48 hours of hospital admission
- Prolonged diarrhea is a diarrhea that lasts for 7-13 days
- Persistent diarrhea is a diarrhea lasting for >14 days but <30 days
- Chronic diarrhea may be considered as diarrhea lasting for ≥30 days
- Recurrent diarrhea is a diarrhea that reoccurs after 7 diarrhea-free days
- Infectious diarrhea is a diarrhea of infectious origin (bacterial, viral, protozoal, fungal) and is usually associated with symptoms of nausea and vomiting (N/V), abdominal cramps, fever, malaise, anorexia and dehydration. This is commonly transmitted by the fecal-oral route via food, water and person-to-person contact
- Dysentery (invasive diarrhea) is the presence of visible blood in diarrheic stool
Traveler’s Diarrhea
Classification of Acute Traveler's Diarrhea According to Functional Impact
- Mild diarrhea is characterized by ≤3 loose bowel movements per day or diarrhea that is bearable, and not distressing and the patient is able to travel or engage in other activities as scheduled
- Moderate diarrhea is characterized by ≥4 bowel movements per day or diarrhea that is distressing or interferes with the patient's travel plans or activities
- Severe diarrhea is characterized by ≥6 bowel movements per day or diarrhea that is incapacitating or interferes with the patient's daily activities and prevents planned trips or other activities. Bloody diarrhea (dysentery) is considered severe