One of the most common chief complaints for patients seeking health care.

An estimated 211 million cases of acute gastroenteritis care in United States annually.

In 2010 it was estimated there were 3.7 million ED visits and 1.3 million hospitalizations with a diagnosis of infectious enteritis or gastrointestinal symptoms suggestive foodborne illness.

The Foodborne Diseases Active Surveillance Network (FoodNet) national surveillance system maintained by Centers for Disease Control and Prevention (CDC) is the most comprehensive source of data on the pathogen-specific burden of diarrheal disease in the United States.

Economic impact of acute diarrhea is substantial, and was estimated at $23 billion in the US in 1988.

Defined as a stool weight exceeding 200 g per 24 hours.

Diarrhea is an increase in the volume and weight of daily stool. 

The frequency of bowel movements is usually increased as well.

Suggested as a pattern of more than three unformed bowel movements a day, with more than 25% loose or mushy stool.

A patient’s subjective experience of altered bowel habits may not necessarily fit the physician’s criteria for diarrhea.

Approximately 6.6% of the US population had chronic diarrhea, defined as a predominance of mushy or watery stools. 

Often reported as a decreased stool consistency and increased stool volume.

Typically self limited process, that rarely requires evaluation.

Caused by a wide variety of infectious and noninfectious etiologies, which can make assessment challenging.

Diarrhea is most commonly caused by viral infections but is also often the result of bacterial toxins and sometimes even infection.

Second leading infectious cause of childhood death worldwide, accounting for approximately 500,000 annual deaths in children under 5 years of age: many dying from dehydration.

Associated with bowel resections, neuroendocrine tumors and pancreatic cholera syndrome.

Osmotic diarrhea caused by water and solute movement throughout the gastrointestinal tract without osmotic gradients.

Osmotic diarrhea caused by excessive levels of poorly absorbed osmotically active solutes.

Osmotic diarrhea ceases when patients fast and stool analysis reveals increased osmotic gap because of the presence of osmotically active or nonabsorbed agents.

Causes of osmotic diarrhea include laxatives with poorly absorbed anion (sodium phosphate-Phospho-soda), laxatives containing poorly absorbed cation (magnesium hydroxide-Milk of Magnesia, magnesium citrate-Citrate of Magnesia), lactose intolerance, poorly absorbed carbohydrates and malabsorption syndromes.

Can be caused by enhanced gastrointestinal motility with rapid transit time and decreased absorptive capacity of epithelial cells as seen with vagotomy, gastrectomy, carcinoid, hyperthyroidism and irritable bowel syndrome with diarrhea.

More than 700 drugs may be implicated in onset of diarrhea and 7% of medication side effects result in diarrhea.

Illnesses that cause impaired motility of the bowel such as scleroderma or diabetes can lead to small bowel stasis and bacterial overgrowth with deconjugation of bile acids with resulting diarrhea and steatorrhea.

Inflammation or infectious processes can damage intestinal mucosa and interfere with gastrointestinal absorption, induce secretions, and increase motility resulting in exudative diarrhea.

Exudative diarrhea results in loss of protein, mucus and blood.

Most acute cases associated with infection and resolve without intervention.

Chronic diarrhea defined as lasting more than 4 weeks unlikely to be associated with an infectious process.

Infectious and autoimmune etiologies are the most likely causes for severe chronic diarrhea.

Malignancies of the gastrointestinal tract do not cause diarrhea.

The presence of blood in the stool suggest inflammatory, neoplastic, ischemic or infectious disease as the source of process.

Large volume diarrhea suggest a small bowel or proximal colonic disease process.

Frequent small stools and bowel urgency suggest left sided colon or rectal disease.

Acute diarrhea refers to a process of less than 4 weeks duration and is usually secondary to an infectious agent or toxins.

Infectious and autoimmune etiologies are the most likely causes for severe chronic diarrhea.

Malignancies of the gastrointestinal tract do not cause diarrhea.

Small bowel diarrhea usually has large volume common with vitamin and mineral deficiencies.

Colon-based diarrhea has smaller volume of stool and maybe bloody.

Diarrhea with an osmotic gap below 50 is likely secretory caused by infections, bile acids, and colitis.

Diarrhea with an osmotic gap above 100 is likely osmotic due to excessive intake of artificial sweeteners, or fat/sugar malabsorption.

Chronic bloody diarrhea suggest inflammatory bowel disease such as ulcerative colitis.

If chronic and unassociated with metabolic or nutritional changes suggests the possibility of lactose intolerance, irritable bowel syndrome, microscopic colitis, fecal incontinence, colorectal cancer or laxative abuse.

Can cause a transient lactose intolerance suggesting that avoiding milk during after severe diarrhea is appropriate.

Use of antibiotics that disturb gastrointestinal flora associated with diarrhea in as many as 30% of patients so treated.

Diarrhea evaluation is often associated with unnecessary stool testing.

People with diarrhea should refrain from recreational water activities, food preparation or service, and sexual activities while symptomatic.

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