Acute Diarrhea	37
Mahesh Kumar Goenka and Nisha D. Kapoor

A 40-year-old male patient with no signiÞcant previous medical history was admitted to the ICU with 1-day history of passing watery diarrhea, about 20Ð25 episodes with crampy pain in the abdomen. On examination, he was afebrile with signs of dehydration in the form of dry skin, loss of skin turgor, pulse of 100/min, and BP of 90/60 mmHg. He was drowsy and had the reduced urinary output. His central venous pressure (CVP) was 3, and arterial blood gas (ABG) analysis revealed metabolic acidosis.

Acute severe diarrhea in the ICU may be seen in two situations: a patient with acute severe diarrhea gets admitted to the ICU or a patient admitted to the ICU for any other illness develops a new-onset diarrhea.

Step 1: Initiate resuscitation

¥After taking care of airway and breathing, ßuid and electrolyte resuscitation is the mainstay of therapy. It is important to assess the severity of dehydration and treat it.

¥Check vital signs such as tachycardia, hypotension, orthostatic hypotension, skin turgor, sunken eyes, sensorium, and dry mucous membranes.

¥AbdomenÑbowel sounds, distension, and tenderness.

¥Place the central line and check CVP. Give ßuids to maintain CVP between 8 and 12 cm H2O.

M.K. Goenka, D.M., M.N.A.M.S. (*)

Institute of Gastrosciences, Apollo Gleneagles Hospitals, Kolkata, India e-mail: [e-mail]

N.D. Kapoor, M.D., D.N.B.

Department of Gastroenterology, Columbia Asia Hospital, New Delhi, India

R. Chawla and S. Todi (eds.), ICU Protocols: A stepwise approach,	299
DOI 10.1007/978-81-322-0535-7_37, © Springer India 2012

300		M.K. Goenka and N.D. Kapoor
Table 37.1 Various causes of diarrhea
1.	Infectious causes:
	a.	BacteriaÑVibrio cholerae, Shigella, Salmonella, Campylobacter, E. coli
	b.	VirusÑRotavirus, Adenovirus, Norovirus
	c.	ParasitesÑGiardia, amoeba, Microsporidium, Cryptosporidium, Cyclospora,
		Strongyloides
2. Inßammatory causes: Inßammatory bowel disease, Ischemic colitis, Diverticulitis
3.	Food poisoning/allergy
4. First presentation of any chronic diarrhea
5.	Medications:
	a.	Acid-reducing agents (e.g., histamine H2-receptor antagonists and proton pump
		inhibitors) and antacids (e.g., those that contain magnesium)
	b.	Antiarrhythmics (e.g., quinidine)
	c.	Antibiotics (most)
	d.	Anti-inßammatory agents (e.g., nonsteroidal anti-inßammatory drugs [NSAIDs], gold
		salts, and 5-aminosalicylates)
	e.	Antihypertensives (e.g., b-adrenergic receptor blocking drugs)
	f.	Antineoplastic agents (many)

g.Antiretroviral agents

h.Colchicine

i. Herbal products, heavy metals j. Theophylline

k. Vitamin and mineral supplements (e.g., vitamin C and magnesium) l. Recent antibiotic use or hospitalization

m. Prostaglandin (e.g., misoprostol) n. Hyperosmolar feeds

o. Laxatives, Sorbital

¥Fluids to be used:

ÐRingerÕs lactate

ÐNormal saline with potassium chloride 20 mEq/L

¥Additional potassium and magnesium are required as suggested by the biochemistry results.

¥Place FoleyÕs catheter and measure hourly urinary output.

Step 2: Take detail history from the patient/family

Take a detail history of the following:

¥Duration of symptoms, frequency, characteristics of stool, amount, and weight loss

¥Medications (see Table 37.1)Ñvery common causes of diarrhea in the ICU

¥Abdominal symptoms or constitutional symptoms

¥Travel, food habits, and sexual activity

¥Water source

¥Sick contacts

37 Acute Diarrhea	301

¥Comorbidities (e.g., diabetes and pancreatitis)

¥Family history or past history of bowel disease (e.g., inßammatory bowel disease)

Step 3: Identify the cause of diarrhea

Severe diarrhea is usually of infective origin. However, other etiologies should be kept in mind (Table 37.1).

Step 4: Send investigations

Detailed investigations should be done if the patient has any one of the following:

¥Profuse diarrhea with dehydration

¥Grossly bloody stools

¥Fever of more than 38¡C

¥Duration of more than 48 h without improvement

¥Recent antibiotic use

¥New community outbreak

¥Associated severe abdominal pain in the patient older than 50 years

¥Elderly (>70 years)

¥Immunocompromised patients

Investigations

¥Hematology

ÐHemoglobin and hematocrit, total leukocyte count, and differential count

ÐBiochemistryÑarterial blood gases, renal functions, liver functions and electrolytes, and blood glucose

¥Stool tests

ÐFecal WBCsÑsuggest mucosal invasion, especially in Shigella, Campylobacter, EHEC (Entero Hemorrhagic Escherichia coli), and EIEC (Entero Invasive Escherichia coli)

ÐAbsent fecal WBCs in viruses, ETEC (Enterotoxic Escherichia coli), amebiasis, Giardiasis.

ÐC. difficile toxin

ÐAerobic cultureÑfor bacteria

ÐOva/parasites

ÐThe hanging drop for cholera

¥SerologyÑamebic serology

¥ImagingÑplain abdominal radiograph can detect partial obstruction, perforation, colonic dilatation, contrast-enhanced computed tomography (CECT) of the abdomen is advised in protracted cases

Optional investigations

¥AntigenÑGiardia, rotavirus

¥ELISA and PCR for viruses

¥Dark Þeld/phase contrast microscopy for Campylobacter

302	M.K. Goenka and N.D. Kapoor

¥Stool osmolal gap = stool osmolalityÐ2 × (Na++K+); gap of more than 40Ð60 suggests osmotic diarrhea

¥Endoscopy

Step 5: Specific pharmacotherapy

¥May be given empirically in all severe diarrheas

¥Usually Quinolones, Trimethoprim/sulfamethoxazole, Erythromycin, or Doxycycline are used

¥If Giardiasis or Amebiasis suspectedÑMetronidazole

¥If C. difficile suspectedÑMetronidazole or oral Vancomycin

¥Antivirals (Acyclovir, Ganciclovir)Ñherpes simplex virus, cytomegalovirus

¥AntihelminthicsÑStrongyloidiasis

¥Empirical antibiotics are usually recommended especially in:

a.Elderly

b.Immunocompromised

c.Mechanical heart valves

d.Vascular grafts

Step 6: Symptom-relief agents

¥If the cause of diarrhea is not known, palliative treatment can be started to decrease ßuid loss and the patientÕs discomfort.

¥Reduced stool frequency and stool weight may even relieve cramps, but close monitoring is required for complications.

ÐOpiate derivativesÑloperamide 2Ð4 mg four times a day

ÐAnticholinergicsÑdiphenoxylate 2.5Ð5 mg four times a day

ÐRacecadotril (enkephalinase inhibitor), antisecretory activity without affecting intestinal transitÑ1.5 mg/kg thrice a day

ÐSomatostatin analogsÑoctreotide 50Ð250 mcg thrice a day subcutaneously in GVHD and immunodeÞciency syndrome and other causes of secretory diarrhea

Step 7: Probiotics

Variousstudieshaveshownthatprobiotics,especiallyLactobacillus,Bifidobacterium, Saccharomyces boulardii, and combination of various preand probiotics, are helpful in avoiding recurrence of diarrhea and even C. difficile. However, they should be avoided in immunosuppressed patients (Fig. 37.1).

Case Scenario B

A 60-year-old diabetic man, known diabetic and hypertensive, was admitted to the ICU with cerebrovascular accident. After 1 week of stay, he had developed watery diarrhea.

37 Acute Diarrhea	303

Severe diarrhea

Fluid and electrolytes

Stool microbiology

Pathogen found

No	Yes
Empirical therapy + further evaluation	Specific Rx
(sigmoidoscopy/colonoscopy and biopsy,
UGI Endoscopy and biopsy/aspirate, etc.)

Fig. 37.1 Management of acute severe diarrhea

Step 1: Know the causes of acute-onset diarrhea in the ICU

¥Tube feedingÑmost likely to occur with calorie-dense formulas infused directly into the small bowel, a variant of dumping syndrome

¥Antibiotic-associated diarrhea, other medications as listed before (Table 37.1)

¥Pseudomembranous enterocolitisÑClostridium difficile

¥Underlying disease relatedÑdiabetic autonomic neuropathy

¥Laxatives, lactose intolerance

¥Fecal impaction with overßow diarrhea

¥Ischemic colitis

¥Diverticulitis

¥First-time presentation of a disease such as malignancy, radiation colitis, inßammatory bowel disease, and AddisonÕs disease

Step 2: Management is same as mentioned above with a few changes

¥There should be a lower threshold for performing sigmoidoscopy/colonoscopy in these patients.

¥For tube-feed-related diarrhea:

ÐSlow the rate of infusion.

ÐDilute the feeds.

ÐModify the formula to increase Þber.

ÐGive an antidiarrheal agent such as loperamide or diphenoxylate.

¥For antibiotic/laxative/other medication-related diarrhea, stop the offender.