Acute diarrhea history and symptoms

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Chandrakala Yannam, MD [2]

The hallmark of acute diarrhea is the sudden onset of 3 or more stools per day, lasting less than 4 weeks. The most common symptoms of acute diarrhea include increased frequency of bowel movements, abdominal pain, elevation of body temperature and symptoms of fluid loss (dark or scant urine, excessive thirst, dizziness, fatigue).

• Acute diarrhea is usually self limiting.
• Medical evaluation for acute diarrhea is recommended for patients with fever, mucoid or bloody diarrhea, abdominal pain and symptoms of dehydration (dizziness or light headedness, dark urine, fatigue).
• Hospital admission is required for individuals who present with acute diarrhea, if there is a medical history of immunosuppression (eg, treatment for malignancy, transplantation, or advanced HIV infection), with preexisting bowel disease ( such as inflammatory bowel disease or ischemic colitis) or with significant vascular or cardiovascular disease.
• Symptoms of acute diarrhea include loose stools (watery, bloody or mucoid), fever, abdominal pain, excessive thirst, dark or scant urine and light headedness.

• Initial evaluation of patients who present with acute diarrhea include:^[1][2][3][4]
  • Duration of symptoms
  • Frequency and nature of stools:
    • It can suggest whether the diarrhea is originating in the small or the large bowel.
      • Diarrhea of small bowel origin is typically watery, of large volume and associated with abdominal cramping, bloating, and gas. Fever is less common and stools are mostly watery.
      • Diarrhea of large intestinal origin often presents with frequent, regular, small volume, and painful bowel movements. Fever and bloody or mucoid stools are common.
  • History of associated symptoms: Fever, abdominal pain, nausea and vomiting
  • Symptoms of volume depletion: Dark or scant urine, dizziness, confusion
  • History of immunosuppression and other bowel diseases: Inflammatory bowel disease, HIV, history of malignancy and transplantation
  • History towards potential exposure: Food history, travel history, exposure to pets
    • Travel history:
      • Travel history may be helpful in identifying a cause for diarrhea.
      • The risk of traveler’s diarrhea is high in regions where hygienic practices and sanitation are poor.
      • Traveler’s diarrhea risk also varies with season of the year, higher risk during warmer months and rainy seasons.
      • Risk by geographic regions:
        • High risk: South and Southeast Asia, Central and western Africa, South and Central America, and Mexico
        • Moderate risk: Caribbean Islands, South Africa, Central and East Asia, Eastern Europe, and the Middle East
        • Low risk: the United States, Canada, Singapore, Japan,Northern and Western Europe, Australia and New Zealand
      • Common organisms that cause diarrhea among travelers include:
        • Enterotoxigenic E.coli ETEC (leading cause)
        • Shigella
        • Salmonella
        • Campylobacter
        • Rotavirus
    • Other organisms that are prevalent in particular parts of the world include the following:
      • Nonspecific foreign travel history: Consider Enterotoxigenic E coli (ETEC), Aeromonas, Giardia, Plesiomonas, Salmonella, and Shigella species
      • Travel to Africa: Entamoeba species, Vibrio cholerae
      • Travel to South America and Central America: Entamoeba species, V. cholerae, enterotoxigenic E coli
      • Travel to Asia: V. cholerae
      • Travel to Australia: Yersinia species
      • Travel to Canada: Yersinia species
      • Travel to Europe: Yersinia species
      • Travel to India: Entamoeba species, V. cholerae
      • Travel to Japan: Vibrio parahaemolyticus
      • Travel to Mexico: Aeromonas, Entamoeba, Plesiomonas, and Yersinia species
      • New Guinea: Clostridium species
  • Day care history: Certain pathogens spread very quickly in daycare.
    • Virus:
      • Rotavirus
      • Astrovirus
      • Calcivirus
    • Bacteria:
      • Campylobacter
      • Shigella
    • Protozoa:
      • Giardia
      • Cryptosporidium species
• Food history:
  • Intake of raw or uncooked food is a common cause of infectious diarrhea. Consumption of undercooked or raw meat or fish, unpasteurized dairy products, or certain organic vitamin preperations may suggest certain pathogens.
    • Meats: C. perfringens, Aeromonas, Campylobacter, and Salmonella species
    • Dairy food: Campylobacter, Salmonella species, Listeria especially in pregnancy.
    • Eggs: Salmonella species
    • Seafood: Astrovirus, Aeromonas, Plesiomonas, and Vibrio species
    • Poultry: Campylobacter species
    • Oysters: Calicivirus and Plesiomonas and Vibrio species
    • Vegetables: Aeromonas species and C. perfringens
    • Ground beef: EHEC
    • Pork: C. perfringens, Y. enterocolitica
  • Although it is often difficult to know which food exposure was the potential cause, the timing of onset of symptoms following exposure to the suspected food can be an important clue to find the diagnosis.
    • Up to 6 hrs: Ingestion of a preformed toxin produced by Staphylococcus aureus or Bacillus cereus, if nausea and vomiting were the initial symptoms.
    • Between 8 to 16 hours: Suggests infection with Clostridium perfringens
    • After 16 hours: Most commonly either viral or other bacterial infection (eg, contamination of food with enterotoxigenic E.coli, EHEC or other pathogens).

• Water exposure:
  • Water is the main source for organisms that cause diarrhea.
  • Swimming pools have been associated with outbreaks of infection with Shigella species.
  • Aeromonas infection is associated with exposure to the marine environment.
  • Certain organisms are resistant to chlorination (Giardia, Cryptosporidium, and Entamoeba), so exposure to contaminated water should raise the suspicion of infection with these pathogens.
  • Camping history with exposure to water sources may also suggest infection with Giardia.

• Exposure to animals:
  • Poultry, petting zoos has been associated with Salmonella and Campylobacter infections.
• Medical history:
  • Various medical conditions can make patients prone to infections.
    • C. difficile: Hospitalization, antibiotic administration
    • Plesiomonas species: Liver diseases or malignancy
    • Salmonella species: Intestinal dysmotility, malnutrition, achlorhydria, hemolytic anemia (especially sickle cell disease), immunosuppression, malaria
    • Rotavirus: Hospitalization
    • Giardia species: Agammaglobulinemia, chronic pancreatitis, achlorhydria, cystic fibrosis
    • Cryptosporidia species: Immunocompromised state
    • Vibrio: Cirrhosis
    • Yersinia: Hemochromatosis
• Intake of fruit or vegetable juices (particularly in children)
• Lactose intolerance
• History of abdominal or gall bladder removal surgery
• Age>50 yrs

Common symptoms of acute diarrhea include:

• Loose stools: watery or mucoid or bloody
• Fever
• Abdominal pain
• Urgency to have a bowel movement
• Nausea or vomiting
• Bloating
• Symptoms of dehydration:
  • Excessive thirst
  • Dry mouth or tongue
  • Scant or no urination, dark-colored urine
  • Weakness
  • Dizziness or lightheadedness
  • Fatigue

Less common symptoms of acute diarrhea include:

• Weight loss if diarrhea persists longer
• Malnutrition
• Confusion or agitation
• Disorientation
• Fainting
• Seizures
• Abdominal guarding
• Stupor or coma

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