Diarrhea, also spelled diarrhoea, is the condition of having at least three loose or
liquid bowel movements each day. It often lasts for a few days and can result in
dehydration due to fluid loss.
Signs of dehydration often begin with loss of the
normal stretchiness of the skin and irritable behaviour. This can progress to
decreased urination, loss of skin color, a fast heart rate, and a decrease in
responsiveness as it becomes more severe. Loose but non-watery stools in babies
who are exclusively breastfed, however, are normal.
The most common cause is an infection of the intestines due to either a virus,
bacteria, or parasite - a condition also known as gastroenteritis.These infections are
often acquired from food or water that has been contaminated by feces, or directly
from another person who is infected. The three types of diarrhea are: short duration
watery diarrhea, short duration bloody diarrhea, and persistent diarrhea (lasting
more than two weeks).The short duration watery diarrhea may be due to an
infection by cholera, although this is rare in the developed world. If blood is
present it is also known as dysentery.
A number of non-infectious causes can
result in diarrhea.These include lactose intolerance, irritable bowel syndrome, non-
celiac gluten sensitivity, celiac disease, inflammatory bowel disease,
hyperthyroidism, bile acid diarrhea, and a number of medications.In most cases,
stool cultures to confirm the exact cause are not required.
3. Diarrhea can be prevented by improved sanitation, clean drinking water, and hand
washing with soap. Breastfeeding for at least six months and vaccination against
rotavirus is also recommended. Oral rehydration solution (ORS)--clean water with
modest amounts of salts and sugar—is the treatment of choice. Zinc tablets are also
recommended. These treatments have been estimated to have saved 50 million
children in the past 25 years. When people have diarrhea it is recommended that
they continue to eat healthy food and babies continue to be breastfed. If
commercial ORS are not available, homemade solutions may be used. In those
with severe dehydration, intravenous fluids may be required. Most cases; however,
can be managed well with fluids by mouth. Antibiotics, while rarely used, may be
recommended in a few cases such as those who have bloody diarrhea and a high
fever, those with severe diarrhea following travelling, and those who grow specific
bacteria or parasites in their stool. Loperamide may help decrease the number of
bowel movements but is not recommended in those with severe disease.
About 1.7 to 5 billion cases of diarrhea occur per year. It is most common in
developing countries, where young children get diarrhea on average three times a
year. Total deaths from diarrhea are estimated at 1.26 million in 2013 – down from
2.58 million in 1990.In 2012, it was the second most common cause of deaths in
children younger than five (0.76 million or 11%) Frequent episodes of diarrhea are
also a common cause of malnutrition and the most common cause in those younger
than five years of age. Other long term problems that can result include stunted
growth and poor intellectual development.
Acute diarrhea is one of the most commonly reported illnesses in the United States,
second only to respiratory infections.
An abnormal looseness of the stool, changes in stool frequency, consistency,
urgency and continence.
Government of Bangladesh has set a goal for 100% sanitation by 2013.
But, recurrent floods, cyclone and prolonged water logging make it harder to
adapt appropriate sanitation for the displaced and those who are living with
flood and water logging conditions.
What is Acute Diarrhea?
An increased number of stools or looser form than is customary for the patient,
lasting less than 2 weeks, and often associated with abdominal symptoms such as
cramping, bloating, and gas. Although often mild, acute diarrhea can lead to severe
dehydration as a result of large fluid and electrolyte losses.
What causes acute diarrhea?
Acute, watery diarrhea is usually caused by a virus (viral gastroenteritis.)
Medications such as antibiotics and drugs that contain magnesium products are
also common offenders. Recent dietary changes can also lead to acute diarrhea.
These including intake of coffee, tea, colas, dietetic foods, gums or mints that
contain poorly absorbable sugars. Acute bloody diarrhea suggests a bacterial cause
like Campylobacter, Salmonella or Shigella. Traveling to developing areas of the
world can result in exposure to bacterial pathogens common in certain areas.
Eating contaminated foods such as ground beef or fresh fruit can cause diarrhea
due to E.coli 0157:H7.
Most episodes of acute diarrhea resolve quickly and without antibiotic therapy with
simple dietary modifications. See a doctor if your feel ill, have bloody diarrhea,
severe abdominal pain or diarrhea lasting more than 48 hours.
What tests are needed to diagnose acute diarrhea?
In patients with mild acute diarrhea, no laboratory evaluation is needed because the
illness generally resolves quickly. Your doctor may perform stool cultures or
5. parasite exams if your diarrhea is severe or bloody or if you traveled to an area
where infections are common.
How is acute diarrhea treated?
It is important to take plenty of fluid and salt to avoid dehydration. Milk and dairy
products should be avoided for 24 to 48 hours as they can make diarrhea worse.
Initial dietary choices when refeeding should begin with soups and broth.
Anti-diarrheal drug therapy can be helpful to control severe symptoms, and
includes bismuth subsalicylate and antimotility agents such as loperamide. These,
however, should be avoided in people with high fever or bloody diarrhea and in
children because the use of antidiarrheals can lead to complications of hemolytic
uremic syndrome in cases of Shiga toxin E coli (E coli 0157:H7).
Your doctor may prescribe antibiotics if you have high fever, dysentery, or
moderate to severe traveler's diarrhea.
Although most episodes of diarrhea are acute and completely resolve, diarrhea may
persist and be associated with abdominal pain or other symptoms. If diarrhea lasts
more than two weeks, we call it chronic diarrhea. It is important to notice if the
diarrhea stools are bloody, oily (fatty) or watery, which can help your doctor arrive
at the most likely cause of your symptoms.
What causes chronic bloody diarrhea?
Chronic bloody diarrhea is most likely due to Inflammatory Bowel Disease (IBD).
These include ulcerative colitis or Crohn's disease. Pain with defecation suggests
rectal inflammation. Tell your doctor if you have a family history of IBD, have
unintentional weight loss, fever, abdominal cramping or decreased appetite, which
might suggest a diagnosis of IBD.
Other less common causes include ischemia of the gut, infections, radiation
therapy and colon cancer or polyps.
6. What causes chronic oily or fatty diarrhea?
Maldigestion or malabsorption syndromes are the cause of fatty stools. Tell your
doctor if you experience bulky, greasy or very bad smelling stools. Chronic
pancreatitis is a cause of pancreatic insufficiency, which leads to maldigestion and
fatty stools. Alcohol abuse is a common cause of chronic pancreatitis in the United
States. Other causes of chronic pancreatitis include cystic fibrosis, hereditary
pancreatitis, trauma to the pancreas and pancreatic cancer.
Biliary tract obstruction, cholestatic liver disease, and bacterial overgrowth can
also lead to maldigestion problems. Gluten sensitive enteropathy (celiac disease,
celiac sprue) is the most common small bowel disease causing fat malabsorption.
Additional common causes of malabsorption in the United States are other small
bowel mucosal diseases or surgical resection of the small bowel. Whipple’s
disease, tropical sprue and Zollinger-Ellison syndrome are very uncommon
conditions that can lead to malabsorption.
What causes chronic watery diarrhea?
There are may causes of watery diarrhea, including carbohydrate malabsorption
such as lactose, sorbitol, and fructose intolerance, intestinal infections or Irritable
Bowel Syndrome. Certain medications such as NSAIDs, antacids,
antihypertensives, antibiotics and antiarrhythmics can cause diarrhea in some
Symptoms of abdominal bloating and excessive gas after consuming dairy
products suggests lactose intolerance. This condition is more common in African-
Americans and Asian-Americans. Certain soft drinks, juices, dried fruits and gums
contain sorbitol and fructose, which can lead to watery diarrhea in people with
sorbitol and fructose intolerance.
Intestinal infections such as giardiasis, opportunistic infections in someone with
HIV (cryptosporidiosis, microsporidiosis, etc.) can cause chronic watery diarrhea.
Diabetes mellitus may be associated with diarrhea due to nerve damage and
bacterial overgrowth; this occurs mainly in patient's with long-standing, poorly-
7. Irritable Bowel Syndrome (IBS), is a condition often associated with frequent
stools, alteration in bowel habits, and abdominal pain. These symptoms are key
features of this syndrome, though many with IBS have constipation rather than
diarrhea. Emotional or physiologic distress can worsen IBS symptoms. IBS is
recognized as a motility disorder where no anatomic or organic diseases are found
to account for the symptoms.
Basic Tests for Evaluation of Chronic Diarrhea
Your doctor will want to further assess etiologic factors or complications of
diarrhea by obtaining several tests. These include: a blood count to look for anemia
and infections, an electrolyte and kidney function panel to assess for electrolyte
abnormalities and renal insufficiency, and albumin to assess your nutritional status.
A stool sample may help define the type of diarrhea. The presence of fat, occult
blood, and white blood cells will help determine if a watery, inflammatory, or fatty
diarrhea is present. A bacterial culture and ova/parasite studies of a stool specimen
will also help determine if an infectious etiology is present.
What Radiographic and Endoscopic testing is available for evaluation
of chronic diarrhea?
Radiographic studies are not routinely performed in the evaluation of chronic
diarrhea, as findings seen in radiographic studies are fairly non-specific, but
occasionally can be helpful. These can include an upper GI series or barium
enema. Ultrasound and CT scan of the abdomen can be helpful to evaluate the
pancreas or other intra-abdominal organs.
Endoscopic examination of the colon with flexible sigmoidoscopy and
colonoscopy is more specific than radiographic studies in detecting the etiology of
chronic diarrhea, as this allows direct examination of the bowel mucosa and the
ability to obtain biopsies for microscopic evaluation as is endoscopy for evaluation
of the upper GI tract. Double-balloon enteroscopy and capsule endoscopy are
sometimes used to examine the mucosa of the small intestine that lies beyond the
reach of conventional endoscopies.
8. What's the treatment of chronic diarrhea?
This depends on the etiology of the chronic diarrhea. Often, empiric treatment can
be provided for symptomatic relief, when a specific diagnosis is not reached, or
when a diagnosis that is not specifically treatable is reached. Whether to
empirically treat with antibiotics for treatment of enteric pathogens prior to
initiation of an extensive workup is the decision of the health care provider.
Antimotility agents and opiate antidiarrheal drugs are the most effective agents for
the treatment of chronic diarrhea. They reduce symptoms as well as stool weight.
Finally, in an effort to avoid becoming dehydrated from a chronic diarrhea process,
oral hydration should be encouraged.
Cholera is an acute epidemic infectious disease. It is characterized by watery
diarrhea, extreme loss of fluid and electrolytes, and severe dehydration. It can be
It is caused by the bacterium Vibrio cholera (V. cholera).
Despite being easy to treat, cholera is estimated to affect between 3 and 5 million
people each year, and it causes over 100,000 deaths worldwide.
Due to severe dehydration, fatality rates are high when untreated, especially among
children and infants. Death can occur in otherwise healthy adults within hours.
Those who recover usually have long-term immunity against re-infection.
Cholera was prevalent in the United States in the 1800s, but now it is rare because
there are well-developed sanitary systems and living conditions.
When traveling to Asia, Africa and some parts of Latin America, however, people
need to protect themselves against cholera by having the appropriate vaccinations
9. beforehand, drinking only water that is boiled or from a sealed bottle and following
good handwashing practices.
What is cholera?
Diarrhea is the key symptom of cholera.
The cause of cholera is infection by the V. cholera bacteria. These bacteria were
discovered in 1883.
The German bacteriologist, Robert Koch (1843-1910), studied the disease during
an epidemic in Egypt. He found a bacterium in the intestines of those who had died
of cholera but could neither isolate the organism nor infect animals with it.
Later that year, Koch went to India, where he succeeded in isolating the bacteria.
He discovered that they thrived in damp, dirty linen and moist earth, and in the
stools of patients with the disease.
V. cholera bacteria live in shallow, salty water on microscopic crustaceans. They
can also exist as colonies of biofilms that coat the surface of the water, plants,
stones, shells, and similar items, and they can live among the eggs of midges,
which serve as a reservoir for cholera bacteria.
Toxic strains of cholera bacteria produce a poison that triggers violent diarrhea in
When the bacteria enter areas where humans live, they can quickly cause severe
epidemics. Weather changes, population loss, and improved sanitation can all end
Only around 1 in 20 cholera infections are severe, and a high percentage of
infected people show no symptoms.
If symptoms appear, they will do so between 12 hours and 5 days after exposure.
They range from mild or asymptomatic to severe.
They typically include:
large volumes of explosive watery diarrhea, sometimes called "rice water
stools" because it can look like water that has been used to wash rice
A person with cholera can quickly lose fluids, up to 20 liters a day, so severe
dehydration and shock can occur.
Signs of dehydration include:
decreased secretion, for example, less sweating
fast heart beat
low blood pressure
dizziness or lightheadedness
rapid weight loss
Shock can lead to collapse of the circulatory system. It is a life-threatening
condition and a medical emergency.
11. Cholera is more common where there is overcrowding and poor sanitation.
Cholera bacteria enter the body through the mouth, often in food or water that has
been contaminated with human waste, due to poor sanitation and hygiene.
They can also enter by eating seafood that is raw or not completely cooked, in
particular shellfish native to estuary environments, such as oysters or crabs.
Poorly cleaned vegetables irrigated by contaminated water sources are another
common source of infection.
In situations where sanitation is severely challenged, such as in refugee camps or
communities with highly limited water resources, a single affected victim can
contaminate all the water for an entire population.
A doctor may suspect cholera if a patient has severe watery diarrhea, vomiting, and
rapid dehydration, especially if they have recently traveled to a place that has a
recent history of cholera, or poor sanitation, or if they have recently consumed
A stool sample will be sent to a laboratory for testing, but if cholera is suspected,
the patient must begin treatment even before the results come back.
12. It is normally dehydration that leads to death from cholera, so the most important
treatment is to give oral hydration solution (ORS), also known as oral rehydration
The treatment consists of large volumes of water mixed with a blend of sugar and
Prepackaged mixtures are commercially available, but widespread distribution in
developing countries is limited by cost, so homemade ORS recipes are often used,
with common household ingredients.
Severe cases of cholera require intravenous fluid replacement. An adult weighing
70 kilograms will need at least 7 liters of intravenous fluids.
Antibiotics can shorten the duration of the illness, but the WHO does not
recommend the mass use of antibiotics for cholera, because of the growing risk of
Anti-diarrheal medicines are not used because they prevent the bacteria from being
flushed out of the body. With proper care and treatment, the fatality rate should be
around 1 percent.
Cholera is often spread through food and because of poor hygiene. Some simple
measures can reduce the risk of contracting cholera.
13. Handwashing is important to prevent the spread of disease.
When traveling in areas where the disease is endemic, it is important to:
Eat only fruit you have peeled.
Avoid salads, raw fish, and uncooked vegetables.
Ensure that food is thoroughly cooked.
Make sure water is bottled or boiled and safe to consume.
Avoid street food, as this can carry cholera and other diseases.
Travelers should learn about cholera before visiting a country where it is prevalent.
Individuals should seek medical attention immediately if they experience
symptoms such as leg cramps, vomiting, and diarrhea while in a community where
the disease exists.
There are currently three cholera vaccines recommended by the World Health
Organization (WHO). These are Dukoral, Shanchol, and Euvichol.
All three require two doses to give full protection.
Dukoral needs to be taken with clean water, and it provides roughly 65 percent
protection for 2 years. Shanchol and Euvichol do not need to be taken with water,
and they provide 65 percent protection for 5 years. All the vaccines offer higher
protection nearer to the time they are given.
People most at risk of consuming food or water infected with the V. cholera
people who work in healthcare and treat individuals with cholera
relief workers who respond to cholera outbreaks
people who are traveling in areas where cholera can still be transmitted that
do not follow hygiene and food safety precautions
14. Wide-spreading epidemics of cholera often occur due to water supplies that are
contaminated with human waste and street food vendors.
The following people are also at risk of a more severe reaction to V. cholera than
people with achlorydia, a condition that removes hydrochloric acid from the
individuals with blood type O
people who have chronic medical conditions
those without access to ORT and other medical services
Effective hygiene measures can help reduce the risk presented by cholera.
For More Information
3. Centers For Disease Control And Prevention.―Cholera-VibriocholeraeInfection.
4. World Health Organization. ―Cholera.‖ February 2014.
http://www.who.int/mediacentre/factsheets/fs107/en/Accessed December 5,2014