Diarrhea is a common symptom, usually indicative of a mild illness and often the cause of self-medication.
Statistically, there are a case of acute diarrhea per year per capita of more than 20 years. In half the cases, it causes a drop in business, but giving cause for medical consultation for only 18% of people.
Yet the number and characteristics of these patients consulting their general practitioner or emergency services are not known. Nevertheless, it seems that motivation is linked mainly to check the intensity of the symptoms but remains independent of the pathogen in question or of its invasive nature.
Acute diarrhea is defi ned by the sudden change in the number and / or the appearance of stools that become more frequent, unformed or liquidiennes. This symptom may be associated with other symptoms of digestive origin such as abdominal pain, nausea or vomiting. They reflect an acute attack of the small intestine and / or colon and cause malabsorption water and an interruption of the enterohepatic cycle.
They can be observed at any age of life, but are more often reported in children or young adults.
Acute diarrhea are often infectious and remain self-limited evolution.
However other causes of acute diarrhea (infectious pathology intra- or extra-abdominal, ischemic bowel, or inflammatory enterocolitis postantibiotic diarrhea) should be systematically sought.
The evocation of acute diarrhea requires the collection of anamnestic elements and elimination of extra-intestinal causes to retain the diagnosis of presumed infectious diarrhea (or gastroenteritis). The care will be adapted to the severity of the disease and terrain.
The questioning sometimes allows to find the existence of a consistent food intake within a few days before the symptoms or an epidemic. In the case of joint infection, food examination must be comprehensive in order to recognize as precisely as possible the food responsible.
Overseas travel, countries visited and living conditions during the trip, the associated debilitating pathologies must be accurately collected.
The assessment of diarrhea
– Start date, day number and appearance of stools, presence of mucus or blood, there is a rectal syndrome
– Research and accompanying signs
– Fever, chills, nausea and vomiting, abdominal pain, hydration status, sign ENT, skin, joints, meningeal
– Used to specify the clinical picture.
We distinguish schematically common acute diarrhea stool made of liquid stool sometimes with abdominal pain and fever, cholera-like syndrome that is often profuse watery diarrhea that can lead to dehydration without cell element to the direct stool examination. Often diffuse abdominal pain predominant peri-umbilical is common. This syndrome usually corresponds to impairment of hail. Finally dysentery due to bowel movements glairosanglantes with many leukocytes and erythrocytes on direct examination of stools. These emissions can be significant initially, but quickly become small volume. A rectal syndrome (épreinte, tenesmus, false needs) is sometimes associated. This syndrome corresponds to a colon and / or rectal involvement.
The main complication of infectious acute diarrhea is dehydration. This may be clinically obvious – intense asthenia, hypotension, tachycardia, dry mucosa
– But it can also be estimated on the amount of losses (stool frequency, vomiting) and the subject’s ability to maintain hydration.
The inclusion of a preexisting dehydration or likely to settle quickly (elderly treated with diuretic, undernutrition), the inability to taking vital medication or his impending imbalance (oral anticoagulation) are important. It can be concluded as the main gravity factors associated with mortality: Associated extreme ages and immunosuppressive diseases.
Other complications of infectious diarrhea are the occurrence of gastrointestinal bleeding or perforation, the occurrence of toxic megacolon or major toxin syndrome with high fever, neurological signs and / or skin. The presence of abdominal bloating and / or stopping of bowel sounds requires the completion of an abdomen plain film and domes looking for a complication (toxic megacolon, pneumoperitoneum) and a close monitoring evolution.
Acute diarrhea well tolerated in healthy adults is a mild infection and requires minimal prescription. Additional tests are not systematic.
The stool may optionally be moved but does not allow the identification of a pathogen that in 40% of patients. It allows to evoke an invasive diarrhea before the presence by direct examination of polymorphonuclear associated or not with that of red blood cells. Culture of Salmonella, Shigella, Campylobacter is performed by all the laboratories, but requires two to three days. The search for other germs or toxin of Clostridium difficult if prior treatment with antibiotics, is to discuss with the microbiologist. The stool is interesting in poisoning and epidemics for precise serotyping. It deserves to be performed in severe pictures, but the result does not affect the treatment and often returns after healing the sick.
Blood cultures are useful for very febrile diarrhea associated immunosuppression or typhoid fever is suspected.
The rest of the standard laboratory tests has no etiological interest, but can afford to check the state of hydration and ionic losses in case of severe symptoms.
A number of extra-abdominal or abdominal infectious diseases may be accompanied by diarrhea, sometimes in the foreground, and mislead diagnosis. This is the case of acute appendicitis, ischemic colitis, inflammation pericolic (waist deep abscess, diverticulitis, cholecystitis) that require further systematic abdominal examination and rigorous searching for localized pain, or a defense signs of peritoneal irritation at pelvic touches. Non digestive infections may also be accompanied by diarrhea especially pneumonia and some outbreaks ENT (otitis, tonsillitis).
Similarly diarrhea can favor the development of urinary or gynecological infection requiring a complete and careful physical examination.
Returning from a trip to an endemic area, we systematically eliminate malaria by producing a blood smear and a thick drop. Finally many drugs especially antibiotics can cause acute diarrhea. In case of doubt, do not hesitate to ask an opinion from a surgeon and regularly review the patient to have iterative physical examinations.
It opposes schematically two main types of bacterial diarrhea.
Invasive diarrhea realize a severe form with dysentery with colic, tenesmus, fever, blood and mucus in the stool.
They are observed with Shigella, Salmonella (Box 1), enterotoxigenic Escherichia coli, Yersinia, and Campylobacter jejuni.
Box 1. Salmonellosis
Typhoid fever has become rare in France (about 150 to 200 cases are reported each year, two thirds are imported back from a trip) but with endemic resistance per household throughout Mediterranean Europe .However, Salmonella infections represent a significant proportion of acute infectious diarrhea, constantly growing, responsible for significant morbidity and a significant mortality in the subject fragile. The management of these infections primarily requires accurate clinical assessment of the importance and the potential severity of symptoms for adapting investigations and therapeutic measures to be implemented.
The clinical picture of typhoid fever is dominated by fever associated with headache and abdominal discomfort, appearing after an incubation for 1 to 3 weeks. Diagnosis is suggested by in state phase before the combination of a tray fi fever, insomnia and sometimes clouding with cutaneous or mucosal signs (rose spots) (angina Duguet).
Diarrhea can miss (replaced by constipation), and usually appears belatedly (melon juice). The presence of splenomegaly or a disassociated pulse can help diagnosis. Otherwise it is based on the absence of leukocytosis, blood cultures and serology Vidal. Rapid serological techniques used in emergencies are being developed.
The current frequency of resistance to aminopenicillins, cotrimoxazole and chloramphenicol up to 30% of isolated strains, treatment of typhoid fever as a first line uses a new quinolone or a third generation cephalosporin for ten days. Man is the only reservoir, it is necessary to seek a chronic carrier by repeated stool cultures. This is most often associated with a biliary stone disease. Mortality from typhoid fever in France remains very low, less than 1%.
Among the 500 or 600 outbreaks of food-borne infections reported every year in France (representing 8 000 to 10 000 patients, but the actual number is estimated ten times the reported number) about half is linked to salmonella, mostly S. typhimurium and S. enteritidis. Mortality is low (0.1%), but 6% of affected individuals, however, require hospitalization. The declaration is mandatory.
Toxigenic diarrhea which are very abundant water diarrhea dehydration officials.
The type is cholera (exceptional in France), but toxigenic diarrhea are also seen with the enterotoxigenicEscherichia coli, Staphylococcus aureus, Clostridium perfringens and Aeromonas hydrophila.
They are secondary to disruption of water flow at the small induced by bacterial toxins. Following the taking of contaminated food, then they take the food poisoning name.
The diarrhea in adults viral, unlike the child, are relatively rare and account for only 10-30% of infectious diarrhea in adults. The main offending viruses are rotavirus, Norwalk virus, adenoviruses and enteroviruses.
There may be mentioned that when giardiasis induce symptoms are rarely acute and whose treatment is based on metronidazole (Flagyl®) and amoebiasis.
Many bacteria have been described as responsible for diarrheal symptoms: Mycobacterium tuberculosis, Treponema, chlamydia, etc.
Their participation in the acute diarrheal tables remains anecdotal. Diarrhea homosexual patient may be related to other germs: herpes, chlamydia, gonorrhea, cryptosporidium.
The goal of treatment of acute diarrhea is to offset losses, reduce the duration of symptoms and prevent the occurrence of possible septic metastatic foci in frail patients.
Maintaining proper hydration is done as much as possible orally. The substitution liquid little importance, but must contain glucose (which promotes the absorption of water and electrolytes through the intestinal active transport), sodium and potassium.
The ion balance is achieved satisfactorily by renal homeostasis dice patient when the contributions are sufficient.The available preparations (Adiaril®) may be attached if significant liquidiennes diarrhea.
The use of intravenous requiring hospitalization is useful only in cases of dehydration or total proven food intolerance. Ringer solutions lactate® or glucose 5% with 4 to 6 g / L NaCl and 1 to 2 g / L Kcal can be used to quickly compensate for the losses (50% by 3 hours, all in 24 hours ). As soon as possible the oral route should be preferred.
No special diet can not be recommended outside light meals avoiding dairy products. Prescribing antimotility derivatives of opiates such as loperamide (Imodium) is not against-indicated outside severe dysentery syndromes where it is best to avoid them.
Until recent years the antibiotic treatment of patients with infectious acute diarrhea was recommended to the chronic carrier risk increase of certain bacteria (Salmonella typhi not) and the self-limited nature of diarrhea leading to spontaneous healing. Only patients considered fragile or immunocompromised (solid or hematological cancer, transplantation, HIV, corticosteroids) or holders of cardiovascular abnormality (rheumatic valve disease, stent, aneurysm) or orthopedic hardware or with severe sepsis or extreme age were candidate for antibiotic therapy.Recently antibiotic treatment has been implicated in the risk of hemolytic uremic syndrome and thrombocytopenic purpura induced by the toxin of E. enterohemorrhagic E. coli 0157: H7 causing a release of the toxin.
However the experience for travelers’ diarrhea (which are the main pathogens enterotoxigenic Escherichia coli, Shigella and Salmonella followed by Campylobacter jejuni then) showed a benefit for patients treated with antibiotics regardless of the intensity of symptoms and the presence or absence of a germ solved in terms of comfort and abdominal term evolution (reduction between 1.2 days and 3 days of the duration of symptoms).
Antibiotics have proven efficacy are cotrimoxazole (Bactrim), fluoroquinolones and third generation cephalosporins.
The excellent oral bioavailability, a sensitivity spectrum with the main offending agents (E. coli, Shigella, Salmonella,Campylobacter and Vibrio cholerae), a treatment time can be very short (3-5 days) are the fluoroquinolones treatment of choice as first line. Ciprofloxacin (Ciflox®) 500 mg / x2 / d or ofloxacin (Oflocet®) 200 mg / x2 / d can be chosen indiscriminately. Chronic carriage risks are negligible, the man is not a natural reservoir for the bacterium and some studies even showing with quinolones decreased fecal shedding of Salmonella to three weeks.
The simple hygiene tips can prevent contamination in the surroundings: do not make the kitchen for the community and wash thoroughly after using the toilet.
Finally, it is necessary to inform the patient on the evolution of the disease and recommend if symptoms persist for more than three to five days if they change or worsen, to see again soon. Hospitalization should be proposed when the clinical tolerance is bad, in frail subjects, very old or immunocompromised during severe dysentery syndromes.Monitoring of several hours associated with implementing the symptomatic treatment (analgesics, antipyretics Rehydration, antiemetic and antidiarrheal) allows more often, when response to treatment is suffi cient, then arrange outpatient follow up with an early revaluation.
Otherwise a proctosigmoidoscopy can be discussed quickly to clarify the etiology and impact of diarrhea.