Acute and Chronic Diarrhea

Question 1

What is the definition of acute diarrhea?

Answer 1

Loose or watery stools lasting < 14 days.

Question 2

What is the definition of chronic diarrhea?

Answer 2

Loose or watery stools occurring at least 3x/day for > 14 days.

Question 3

What is the most common cause of diarrhea in children?

Answer 3

Almost all diarrhea in children is due to an infectious agent, most commonly rotavirus.

Question 4

If a patient presents with diarrhea, what six findings would prompt a more thorough evaluation for the underlying cause (since most diarrhea is self-limited and doesn’t require extensive evaluation)?

Answer 4

Infants < 2 months of age, gross blood in the stool, WBCs on microscopic exam of the stool, toxic-appearing child, immunocompromised child, or diarrhea that develops during hospitalization or after a course of antibiotics.

Question 5

What additional laboratory testing should be performed in patients who present with diarrhea and concerning laboratory or physical exam findings?

Answer 5

Stool studies should be performed to look for invasive bacterial infection.

Question 6

Why are C. difficile toxin assays unreliable in children < 1 year of age?

Answer 6

Enterocytes in infants have not yet developed the receptor for c. difficile toxin.

Question 7

What should be on the differential for a child who presents with acute diarrhea and recent travel?

Answer 7

Toxigenic E. coli (Montezuma’s revenge) and giardia.

Question 8

What should be on the differential for a child who presents with acute diarrhea and exposure to pet reptiles?

Answer 8

Salmonella

Question 9

What should be on the differential for a child who presents with acute diarrhea, fever, and elevated WBCs?

Answer 9

Shigella

Question 10

What should be on the differential for a child who presents with acute diarrhea and hemolytic uremic syndrome?

Answer 10

E. coli O157:H7

Question 11

What should be on the differential for a child who presents with acute diarrhea and a history of swimming in lakes or drinking well water?

Answer 11

Giardia

Question 12

What should be on the differential for a child who presents with acute diarrhea and consumption of pork intestines?

Answer 12

Yersinia

Question 13

What are the indications for IV therapy in a child with diarrhea?

Answer 13

Shock, stool output > 10 ml/kg/hour, ileus, and monosaccharide intolerance.

Question 14

What is the recommended treatment for acute diarrhea in an otherwise stable patient?

Answer 14

Oral rehydration therapy

Question 15

Do children with resolving diarrhea require special diets?

Answer 15

No. After achieving rehydration, resume the child’s age-appropriate normal diet. The traditional bland diet results in a longer recovery time and has never been validated in a clinical trial.

Question 16

List 5 categories of antidiarrheal agents.

Answer 16

Adsorbents, antimotility agents, probiotics, antisecretory agents, and bismuth subsalicylate.

Question 17

How do adsorbents function in the setting of an acute diarrheal illness?

Answer 17

They mainly alter stool consistency (make it seem more solid) and do not affect absolute fecal water loss or shorten the length of the infection.

Question 18

How do antimotility drugs function in the setting of an acute diarrheal infection?

Answer 18

These agents are generally opiates. They reduce gut motility but do not shorten the course of illness and can be dangerous in children since they may induce ileus and can worsen the underlying bacterial infection.

Question 19

How do probiotics function in the setting of an acute diarrheal infection?

Answer 19

They are microorganisms that can be taken to modulate diarrhea which is due to bacterial or viral etiologies. Saccharomyces boulardii is a nonpathogenic yeast that is helpful in reducing the recurrence rate of C. difficile, and Lactobacillus rhamnosus GG lessens the severity of rotavirus infection.

Question 20

How do antisecretory agents function in the setting of an acute diarrheal infection?

Answer 20

They act by stimulating sodium and chloride absorption and inhibiting chloride secretion.

Question 21

List two examples of antisecretory agents for treating diarrhea.

Answer 21

Somatostatin and octreotide.

Question 22

How does bismuth subsalicylate function as an antidiarrheal agent?

Answer 22

It has antimicrobial, antisecretory, and adsorbent properties.

Question 23

In which situations would the use of bismuth subsalicylate be contraindicated?

Answer 23

Children and adolescents who are recovering from varicella or a flu-like illness should not use bismuth subsalicylate due to its association with Reye syndrome.

Question 24

What side effect should parents be cautioned to expect with the use of bismuth subsalicylate?

Answer 24

This agent results in the formation of dark black stools.

Question 25

If a patient with an acute diarrheal illness has flecks of white throughout the bowel on abdominal plain film, what question should you ask the caregivers?

Answer 25

Ask if the child has taken any OTC medications recently. Bismuth subsalicylate can be radioopaque, which would account for the white flecks.

Question 26

What are the most common causes of chronic diarrhea in developing countries?

Answer 26

Infection and malnutrition.

Question 27

List 8 potential etiologies for chronic diarrhea in children in the U.S.

Answer 27

IBS, functional diarrhea, postenteritis syndrome, carbohydrate malabsorption syndromes, Celiac disease, IBD, cystic fibrosis, and Giardia.

Question 28

What is the most common cause of diarrhea in older children and adolescents?

Answer 28

Irritable bowel syndrome.

Question 29

What diet might one recommend to a patient diagnosed with irritable bowel syndrome?

Answer 29

The low FODMAP (short-chain carbohydrate) diet.

Question 30

What is the definition of functional (Toddler’s) diarrhea?

Answer 30

It occurs in otherwise healthy infants or toddlers who have ≥ 3 loose stools per day without a specific cause. There is no associated pain with passage of stool.

Question 31

By what age does a patient with functional diarrhea (toddler’s diarrhea) typically obtain a normal stool pattern?

Answer 31

Most children obtain a normal stool pattern by 4 years of age.

Question 32

What is postenteritis syndrome?

Answer 32

In a small number of otherwise healthy children, chronic diarrhea develops after a bout of infectious gastroenteritis. The offending agent causes mucosal damage to the small intestine, resulting in the chronic diarrhea.

Question 33

What treatment may be helpful in patients with postenteritis syndrome?

Answer 33

Probiotic treatment can be helpful for recovery of the mucosa.

Question 34

What is the most common parasite to cause diarrhea in the U.S.?

Answer 34

Giardia