Management

• Detailed history and physical examination

• Supportive care: Start oral hydration (or IV fluids) and offer symptom relief.

• Diagnostics: Obtain only when appropriate.

• Directed therapy: Consider empiric or targeted therapy (e.g., antibiotics) based on clinical presentation and study results.

Though most patients with diarrhea have mild symptoms and can be managed as outpatients, some patients may present with severe and even life-threatening symptoms that require hospitalization.

In older adults, rule out fecal impaction, which can manifest atypically with paradoxical diarrhea (due to decreased rectal sensation) and nonspecific symptoms (e.g., functional decline, delirium).

Antibiotics should only be utilized for specific indications.

Key features of the disease presentation that facilitate efficient testing and prompt diagnosis include:

• Duration of diarrheal illness

  • Acute diarrhea: duration ≤ 14 days

  • Persistent diarrhea: duration 15–30 days

  • Chronic diarrhea: duration > 30 days

• Stool characteristics: watery, fatty, or bloody stools

• Associated symptoms

  • Fever

  • Abdominal pain and cramping

  • Nausea and vomiting in cases of gastroenteritis

  • Signs of dehydration

  • Chronic cases: malnutrition and, in children, failure to thrive

  • Weight loss

  • Defecation urgency, tenesmus, and/or nocturnal symptoms

Assess for the presence of risk factors for specific etiologies, including:

• Recent travel : associated with traveler's diarrhea

• Occupational or recreational exposure

  • May be associated with an infectious disease outbreak

  • Potential routes of exposure include:

    • Ingestion of contaminated food or beverages at a high-risk event (e.g., picnic, restaurant, buffet)

    • Daycare (e.g., in a daycare attendee, family member of attendee, or daycare staff member)

    • Direct contact with contaminated surfaces or objects

    • Direct contact with an infected individual (e.g., shaking hands, sharing food)

    • Animal contact

• Recent hospitalization: associated with health care-associated infections (e.g., C. difficile infection)

• Medication use

  • May cause medication-induced diarrhea

  • Medications commonly associated with diarrhea include: [14]

    • Broad-spectrum antibiotics (especially cephalosporins)

    • Antacids and PPIs

• Surgery [15]

  • Cholecystectomy [16]

  • Bowel resection: may cause short bowel syndrome

• Radiation therapy: may cause secondary enterocolitis

More than 700 medications can cause diarrhea and, therefore, the introduction of a new medication within 6–8 weeks of the onset of diarrhea should be considered as a potential cause. [14]

Chronic diarrhea is common after bariatric surgery.

• Acute or persistent diarrhea

  • Symptoms of inflammatory diarrhea (dysentery)

    • Systemic symptoms, e.g., fever, hypotension

    • Severe dehydration

    • Bloody stools

    • Severe abdominal pain

  • Patient characteristics that suggest an increased risk of severe disease

    • Chronic illness or immunocompromise

    • Age > 65 years

    • Recent antibiotic use

  • > 48 hours duration without improvement

• Chronic diarrhea

  • Hypoalbuminemia

  • Bloody stools

  • Symptoms wake the patient from sleep

  • Unintended weight loss

  • Family history of GI cancer

  • Symptom onset after 50 years of age