Diarrhea

For other uses, see Diarrhea (disambiguation).

Diarrhea
Other names	Diarrhoea (or diarrhœa)
An electron micrograph of rotavirus, the cause of nearly 40% of hospitalizations from diarrhea in children under five [1]
Specialty	Infectious disease, gastroenterology
Symptoms	Loose frequent bowel movements, dehydration [2]
Causes	Usually infection (viral, bacterial, parasitic) [2]
Risk factors	Contaminated food or water [2]
Prevention	Handwashing, rotavirus vaccination, breastfeeding [2]
Treatment	Oral rehydration solution, zinc supplementation [2]
Frequency	≈2.4 billion (2015) [3]
Deaths	1.53 million (2019) [4]

Diarrhea (American English), also spelled diarrhoea or diarrhœa (British English), is the condition of having at least three loose, liquid, or watery bowel movements in a day. ^[2] It often lasts for a few days and can result in dehydration due to fluid loss. ^[2] Signs of dehydration often begin with loss of the normal stretchiness of the skin and irritable behaviour. ^[2] This can progress to decreased urination, loss of skin color, a fast heart rate, and a decrease in responsiveness as it becomes more severe. ^[2] Loose but non-watery stools in babies who are exclusively breastfed, however, are normal. ^[2]

What is diarrhea, how is it caused, treated and prevented (see also script).

The most common cause is an infection of the intestines due to a virus, bacterium, or parasite—a condition also known as gastroenteritis. ^[2] These infections are often acquired from food or water that has been contaminated by feces, or directly from another person who is infected. ^[2] The three types of diarrhea are: short duration watery diarrhea, short duration bloody diarrhea, and persistent diarrhea (lasting more than two weeks, which can be either watery or bloody). ^[2] The short duration watery diarrhea may be due to cholera, although this is rare in the developed world. ^[2] If blood is present, it is also known as dysentery. ^[2] A number of non-infectious causes can result in diarrhea. ^[5] These include lactose intolerance, irritable bowel syndrome, non-celiac gluten sensitivity, celiac disease, inflammatory bowel disease such as ulcerative colitis, hyperthyroidism, bile acid diarrhea, and a number of medications. ^{[5] [6] [7]} In most cases, stool cultures to confirm the exact cause are not required. ^[8]

Diarrhea can be prevented by improved sanitation, clean drinking water, and hand washing with soap. ^[2] Breastfeeding for at least six months and vaccination against rotavirus is also recommended. ^[2] Oral rehydration solution (ORS)—clean water with modest amounts of salts and sugar—is the treatment of choice. ^[2] Zinc tablets are also recommended. ^[2] These treatments have been estimated to have saved 50 million children in the past 25 years. ^[1] When people have diarrhea it is recommended that they continue to eat healthy food, and babies continue to be breastfed. ^[2] If commercial ORS is not available, homemade solutions may be used. ^[9] In those with severe dehydration, intravenous fluids may be required. ^[2] Most cases, however, can be managed well with fluids by mouth. ^[10] 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. ^[8] Loperamide may help decrease the number of bowel movements but is not recommended in those with severe disease. ^[8]

About 1.7 to 5 billion cases of diarrhea occur per year. ^{[2] [5] [11]} It is most common in developing countries, where young children get diarrhea on average three times a year. ^[2] Total deaths from diarrhea are estimated at 1.53 million in 2019—down from 2.9 million in 1990. ^[4] In 2012, it was the second most common cause of deaths in children younger than five (0.76 million or 11%). ^{[2] [12]} Frequent episodes of diarrhea are also a common cause of malnutrition and the most common cause in those younger than five years of age. ^[2] Other long term problems that can result include stunted growth and poor intellectual development. ^[12]

Terminology

The word diarrhea is from the Ancient Greek διάρροια from διάdia "through" and ῥέωrheo "flow".

Diarrhea is the spelling in American English, whereas diarrhoea is the spelling in British English.

Slang terms for the condition include "the runs", "the squirts" (or "squits" in Britain ^[13] ) and "the trots". ^{[14] [15]}

The word is often pronounced as /ˌdaɪəˈriːə/ DY-ə-REE-ə.

Definition

Bristol stool scale

Diarrhea is defined by the World Health Organization as having three or more loose or liquid stools per day, or as having more stools than is normal for that person. ^[2]

Acute diarrhea is defined as an abnormally frequent discharge of semisolid or fluid fecal matter from the bowel, lasting less than 14 days, by World Gastroenterology Organization. ^[16] Acute diarrhea that is watery may be known as AWD (Acute Watery Diarrhoea.) ^[17]

Secretory

Secretory diarrhea means that there is an increase in the active secretion, or there is an inhibition of absorption. There is little to no structural damage. The most common cause of this type of diarrhea is a cholera toxin that stimulates the secretion of anions, especially chloride ions (Cl^–). Therefore, to maintain a charge balance in the gastrointestinal tract, sodium (Na⁺) is carried with it, along with water. In this type of diarrhea intestinal fluid secretion is isotonic with plasma even during fasting. ^{[18] [19]} It continues even when there is no oral food intake.

Osmotic

Osmotic diarrhea occurs when too much water is drawn into the bowels. If a person drinks solutions with excessive sugar or excessive salt, these can draw water from the body into the bowel and cause osmotic diarrhea. ^{[20] [19]} Osmotic diarrhea can also result from maldigestion (e.g., pancreatic disease or coeliac disease) in which the nutrients are left in the lumen to pull in water. Or it can be caused by osmotic laxatives (which work to alleviate constipation by drawing water into the bowels). In healthy individuals, too much magnesium, vitamin C or undigested lactose can produce osmotic diarrhea and distention of the bowel. A person who has lactose intolerance can have difficulty absorbing lactose after an extraordinarily high intake of dairy products. In persons who have fructose malabsorption, excess fructose intake can also cause diarrhea. High-fructose foods that also have a high glucose content are more absorbable and less likely to cause diarrhea. Sugar alcohols such as sorbitol (often found in sugar-free foods) are difficult for the body to absorb and, in large amounts, may lead to osmotic diarrhea. ^[18] In most of these cases, osmotic diarrhea stops when the offending agent (e.g., milk or sorbitol) is stopped.

Exudative

Exudative diarrhea occurs with the presence of blood and pus in the stool. This occurs with inflammatory bowel diseases, such as Crohn's disease or ulcerative colitis, and other severe infections such as E. coli or other forms of food poisoning. ^{[19] [18]}

Inflammatory

Inflammatory diarrhea occurs when there is damage to the mucosal lining or brush border, which leads to a passive loss of protein-rich fluids and a decreased ability to absorb these lost fluids. Features of all three of the other types of diarrhea can be found in this type of diarrhea. ^[21] It can be caused by bacterial infections, viral infections, parasitic infections, or autoimmune problems such as inflammatory bowel diseases. It can also be caused by tuberculosis, colon cancer, and enteritis. ^[19]

Dysentery

If there is blood visible in the stools, it is also known as dysentery. The blood is a trace of an invasion of bowel tissue. Dysentery is a symptom of, among others, Shigella , Entamoeba histolytica , and Salmonella . ^[19]

Health effects

Diarrheal disease may have a negative impact on both physical fitness and mental development. "Early childhood malnutrition resulting from any cause reduces physical fitness and work productivity in adults", ^[22] and diarrhea is a primary cause of childhood malnutrition. ^[23] Further, evidence suggests that diarrheal disease has significant impacts on mental development and health; it has been shown that, even when controlling for helminth infection and early breastfeeding, children who had experienced severe diarrhea had significantly lower scores on a series of tests of intelligence. ^{[22] [24]}

Diarrhea can cause electrolyte imbalances, kidney impairment, dehydration, and defective immune system responses. When oral drugs are administered, the efficiency of the drug is to produce a therapeutic effect and the lack of this effect may be due to the medication travelling too quickly through the digestive system, limiting the time that it can be absorbed. Clinicians try to treat the diarrheas by reducing the dosage of medication, changing the dosing schedule, discontinuation of the drug, and rehydration. The interventions to control the diarrhea are not often effective. Diarrhea can have a profound effect on the quality of life because fecal incontinence is one of the leading factors for placing older adults in long term care facilities (nursing homes). ^[19]

Causes

Diagram of the human gastrointestinal tract

In the latter stages of human digestion, ingested materials are inundated with water and digestive fluids such as gastric acid, bile, and digestive enzymes in order to break them down into their nutrient components, which are then absorbed into the bloodstream via the intestinal tract in the small intestine. Prior to defecation, the large intestine reabsorbs the water and other digestive solvents in the waste product in order to maintain proper hydration and overall equilibrium. ^[25] Diarrhea occurs when the large intestine is prevented, for any number of reasons, from sufficiently absorbing the water or other digestive fluids from fecal matter, resulting in a liquid, or "loose", bowel movement. ^[26]

Acute diarrhea is most commonly due to viral gastroenteritis with rotavirus, which accounts for 40% of cases in children under five. ^[1] In travelers, however, bacterial infections predominate. ^[27] Various toxins such as mushroom poisoning and drugs can also cause acute diarrhea.

Chronic diarrhea can be the part of the presentations of a number of chronic medical conditions affecting the intestine. Common causes include ulcerative colitis, Crohn's disease, microscopic colitis, celiac disease, irritable bowel syndrome, and bile acid malabsorption. ^[28]

Infections

Main article: Infectious diarrhea

There are many causes of infectious diarrhea, which include viruses, bacteria and parasites. ^[29] Infectious diarrhea is frequently referred to as gastroenteritis. ^[30] Norovirus is the most common cause of viral diarrhea in adults, ^[31] but rotavirus is the most common cause in children under five years old. ^[32] Adenovirus types 40 and 41, ^[33] and astroviruses cause a significant number of infections. ^[34] Shiga-toxin producing Escherichia coli, such as E coli o157:h7, are the most common cause of infectious bloody diarrhea in the United States. ^[35]

Campylobacter spp. are a common cause of bacterial diarrhea, but infections by Salmonella spp., Shigella spp. and some strains of Escherichia coli are also a frequent cause. ^[36]

In the elderly, particularly those who have been treated with antibiotics for unrelated infections, a toxin produced by Clostridioides difficile often causes severe diarrhea. ^[37]

Parasites, particularly protozoa e.g., Cryptosporidium spp., Giardia spp., Entamoeba histolytica , Blastocystis spp., Cyclospora cayetanensis , are frequently the cause of diarrhea that involves chronic infection. The broad-spectrum antiparasitic agent nitazoxanide has shown efficacy against many diarrhea-causing parasites. ^[38]

Other infectious agents, such as parasites or bacterial toxins, may exacerbate symptoms. ^[27] In sanitary living conditions where there is ample food and a supply of clean water, an otherwise healthy person usually recovers from viral infections in a few days. However, for ill or malnourished individuals, diarrhea can lead to severe dehydration and can become life-threatening. ^[39]

Sanitation

Poverty often leads to unhygienic living conditions, as in this community in the Indian Himalayas. Such conditions promote contraction of diarrheal diseases, as a result of poor sanitation and hygiene.

Open defecation is a leading cause of infectious diarrhea leading to death. ^[40]

Poverty is a good indicator of the rate of infectious diarrhea in a population. This association does not stem from poverty itself, but rather from the conditions under which impoverished people live. The absence of certain resources compromises the ability of the poor to defend themselves against infectious diarrhea. "Poverty is associated with poor housing, crowding, dirt floors, lack of access to clean water or to sanitary disposal of fecal waste (sanitation), cohabitation with domestic animals that may carry human pathogens, and a lack of refrigerated storage for food, all of which increase the frequency of diarrhea ... Poverty also restricts the ability to provide age-appropriate, nutritionally balanced diets or to modify diets when diarrhea develops so as to mitigate and repair nutrient losses. The impact is exacerbated by the lack of adequate, available, and affordable medical care." ^[41]

One of the most common causes of infectious diarrhea is a lack of clean water. Often, improper fecal disposal leads to contamination of groundwater. This can lead to widespread infection among a population, especially in the absence of water filtration or purification. Human feces contains a variety of potentially harmful human pathogens. ^[42]

Nutrition

Proper nutrition is important for health and functioning, including the prevention of infectious diarrhea. It is especially important to young children who do not have a fully developed immune system. Zinc deficiency, a condition often found in children in developing countries can, even in mild cases, have a significant impact on the development and proper functioning of the human immune system. ^{[43] [44]} Indeed, this relationship between zinc deficiency and reduced immune functioning corresponds with an increased severity of infectious diarrhea. Children who have lowered levels of zinc have a greater number of instances of diarrhea, severe diarrhea, and diarrhea associated with fever. ^[45] Similarly, vitamin A deficiency can cause an increase in the severity of diarrheal episodes. However, there is some discrepancy when it comes to the impact of vitamin A deficiency on the rate of disease. While some argue that a relationship does not exist between the rate of disease and vitamin A status, ^[46] others suggest an increase in the rate associated with deficiency. ^[47] Given that estimates suggest 127 million preschool children worldwide are vitamin A deficient, this population has the potential for increased risk of disease contraction. ^[48]

Malabsorption

Main article: Malabsorption

Malabsorption is the inability to absorb food fully, mostly from disorders in the small bowel, but also due to maldigestion from diseases of the pancreas.

Causes include:^{[ citation needed ]}

• enzyme deficiencies or mucosal abnormality, as in food allergy and food intolerance, e.g. celiac disease (gluten intolerance), lactose intolerance (intolerance to milk sugar, common in non-Europeans), and fructose malabsorption.
• pernicious anemia , or impaired bowel function due to the inability to absorb vitamin B₁₂,
• loss of pancreatic secretions, which may be due to cystic fibrosis or pancreatitis,
• structural defects, like short bowel syndrome (surgically removed bowel) and radiation fibrosis, such as usually follows cancer treatment and other drugs, including agents used in chemotherapy; and
• certain drugs, like orlistat, which inhibits the absorption of fat.

Inflammatory bowel disease

Main article: Inflammatory bowel disease

The two overlapping types here are of unknown origin:

• Ulcerative colitis is marked by chronic bloody diarrhea and inflammation mostly affects the distal colon near the rectum.
• Crohn's disease typically affects fairly well demarcated segments of bowel in the colon and often affects the end of the small bowel.

Irritable bowel syndrome

Main article: Irritable bowel syndrome

Another possible cause of diarrhea is irritable bowel syndrome (IBS), which usually presents with abdominal discomfort relieved by defecation and unusual stool (diarrhea or constipation) for at least three days a week over the previous three months. ^[49] Symptoms of diarrhea-predominant IBS can be managed through a combination of dietary changes, soluble fiber supplements and medications such as loperamide or codeine. About 30% of patients with diarrhea-predominant IBS have bile acid malabsorption diagnosed with an abnormal SeHCAT test. ^[50]

Other diseases

Diarrhea can be caused by other diseases and conditions, namely:

• Chronic ethanol ingestion ^[51]
• Hyperthyroidism ^[52]
• Certain medications ^[52]
• Bile acid malabsorption ^[52]
• Ischemic bowel disease: This usually affects older people and can be due to blocked arteries.
• Microscopic colitis, a type of inflammatory bowel disease where changes are seen only on histological examination of colonic biopsies.
• Bile salt malabsorption (primary bile acid diarrhea) where excessive bile acids in the colon produce a secretory diarrhea.
• Hormone-secreting tumors: some hormones, e.g. serotonin, can cause diarrhea if secreted in excess (usually from a tumor).
• Chronic mild diarrhea in infants and toddlers may occur with no obvious cause and with no other ill effects; this condition is called toddler's diarrhea.
• Environmental enteropathy
• Radiation enteropathy following treatment for pelvic and abdominal cancers.

Medications

Over 700 medications, such as penicillin, are known to cause diarrhea. ^{[53] [54]} The classes of medications that are known to cause diarrhea are laxatives, antacids, heartburn medications, antibiotics, anti-neoplastic drugs, anti-inflammatories as well as many dietary supplements. ^[19]

Pathophysiology

Ion transporters targeted by enteric infections ^[55]

Function	Transporter
Absorption	NHE, SGLT1, ENaC, DRA
Secretion	CaCC, NKCC1, CFTR
Absorption and secretion	Sodium potassium ATPase

Evolution

According to two researchers, Nesse and Williams, diarrhea may function as an evolved expulsion defense mechanism. As a result, if it is stopped, there might be a delay in recovery. ^[56] They cite in support of this argument research published in 1973 that found that treating Shigella with the anti-diarrhea drug (Co-phenotrope, Lomotil) caused people to stay feverish twice as long as those not so treated. The researchers indeed themselves observed that: "Lomotil may be contraindicated in shigellosis. Diarrhea may represent a defense mechanism". ^[57]

Diagnostic approach

The following types of diarrhea may indicate further investigation is needed:

• In infants
• Moderate or severe diarrhea in young children
• Associated with blood
• Continues for more than two days
• Associated non-cramping abdominal pain, fever, weight loss, etc.
• In travelers
• In food handlers, because of the potential to infect others;
• In institutions such as hospitals, child care centers, or geriatric and convalescent homes.

A severity score is used to aid diagnosis in children. ^[58]

When diarrhea lasts for more than four weeks a number of further tests may be recommended including: ^[59]

• Complete blood count and a ferritin if anemia is present
• Thyroid stimulating hormone
• Tissue transglutaminase for celiac disease
• Fecal calprotectin to exclude inflammatory bowel disease
• Stool tests for ova and parasites as well as for Clostridioides difficile
• A colonoscopy or fecal immunochemical testing for cancer, including biopsies to detect microscopic colitis
• Testing for bile acid diarrhea with SeHCAT, 7α-hydroxy-4-cholesten-3-one or fecal bile acids depending on availability
• Hydrogen breath test looking for lactose intolerance
• Further tests if immunodeficiency, pelvic radiation disease or small intestinal bacterial overgrowth suspected.

A 2019 guideline recommended that testing for ova and parasites was only needed in people who are at high risk though they recommend routine testing for giardia. ^[60] Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were not recommended. ^[60]

Epidemiology

Deaths due to diarrhoeal diseases per million persons in 2012

  0–2

  3–10

  11–18

  19–30

  31–46

  47–80

  81–221

  222–450

  451–606

  607–1799

Disability-adjusted life year for diarrhea per 100,000 inhabitants in 2004

  no data

  < 500

  500–1000

  1000–1500

  1500–2000

  2000–2500

  2500–3000

  3000–3500

  3500–4000

  4000–4500

  4500–5000

  5000–6000

  > 6000

Worldwide in 2004, approximately 2.5 billion cases of diarrhea occurred, which resulted in 1.5 million deaths among children under the age of five. ^[1] Greater than half of these were in Africa and South Asia. ^[1] This is down from a death rate of 4.5 million in 1980 for gastroenteritis. ^[62] Diarrhea remains the second leading cause of infant mortality (16%) after pneumonia (17%) in this age group. ^[1]

The majority of such cases occur in the developing world, with over half of the recorded cases of childhood diarrhea occurring in Africa and Asia, with 696 million and 1.2 billion cases, respectively, compared to only 480 million in the rest of the world. ^[63]

Infectious diarrhea resulted in about 0.7 million deaths in children under five years old in 2011 and 250 million lost school days. ^{[64] [65]} In the Americas, diarrheal disease accounts for a total of 10% of deaths among children aged 1–59 months while in South East Asia, it accounts for 31.3% of deaths. ^[66] It is estimated that around 21% of child mortalities in developing countries are due to diarrheal disease. ^[67]

The World Health Organization has reported that "deaths due to diarrhoeal diseases have dropped by 45%, from sixth leading cause of death in 2000 to thirteenth in 2021." ^[68]

Even though diarrhea is best known in humans, it affects many other species, notably among primates. ^[69] The cecal appendix, when present, appears to afford some protection against diarrhea to young primates. ^[70]

Prevention

Sanitation

Further information: WASH § Health aspects

Numerous studies have shown that improvements in drinking water and sanitation (WASH) lead to decreased risks of diarrhoea. ^[71] Such improvements might include for example use of water filters, provision of high-quality piped water and sewer connections. ^[71]

In institutions, communities, and households, interventions that promote hand washing with soap lead to significant reductions in the incidence of diarrhea. ^[72] The same applies to preventing open defecation at a community-wide level and providing access to improved sanitation. ^{[64] [73]} This includes use of toilets and implementation of the entire sanitation chain connected to the toilets (collection, transport, disposal or reuse of human excreta).

There is limited evidence that safe disposal of child or adult feces can prevent diarrheal disease. ^{[74] [75]}

Hand washing

Basic sanitation techniques can have a profound effect on the transmission of diarrheal disease. The implementation of hand washing using soap and water, for example, has been experimentally shown to reduce the incidence of disease by approximately 30–48%. ^{[76] [77] [72]} Hand washing in developing countries, however, is compromised by poverty as acknowledged by the CDC: "Handwashing is integral to disease prevention in all parts of the world; however, access to soap and water is limited in a number of less developed countries. This lack of access is one of many challenges to proper hygiene in less developed countries." Solutions to this barrier require the implementation of educational programs that encourage sanitary behaviours. ^[78]

Water

Given that water contamination is a major means of transmitting diarrheal disease, efforts to provide clean water supply and improved sanitation have the potential to dramatically cut the rate of disease incidence. In fact, it has been proposed that we might expect an 88% reduction in child mortality resulting from diarrheal disease as a result of improved water sanitation and hygiene. ^{[42] [79]} Similarly, a meta-analysis of numerous studies on improving water supply and sanitation shows a 22–27% reduction in disease incidence, and a 21–30% reduction in mortality rate associated with diarrheal disease. ^[80]

Chlorine treatment of water, for example, has been shown to reduce both the risk of diarrheal disease, and of contamination of stored water with diarrheal pathogens. ^[81]

Vaccination

Immunization against the pathogens that cause diarrheal disease is a viable prevention strategy, however it does require targeting certain pathogens for vaccination. In the case of Rotavirus, which was responsible for around 6% of diarrheal episodes and 20% of diarrheal disease deaths in the children of developing countries, use of a Rotavirus vaccine in trials in 1985 yielded a slight (2–3%) decrease in total diarrheal disease incidence, while reducing overall mortality by 6–10%. Similarly, a Cholera vaccine showed a strong reduction in morbidity and mortality, though the overall impact of vaccination was minimal as Cholera is not one of the major causative pathogens of diarrheal disease. ^[82] Since this time, more effective vaccines have been developed that have the potential to save many thousands of lives in developing nations, while reducing the overall cost of treatment, and the costs to society. ^{[83] [84]}

Rotavirus vaccine decreases the rates of diarrhea in a population. ^{[1] [85]} New vaccines against rotavirus, Shigella, Enterotoxigenic Escherichia coli (ETEC), and cholera are under development, as well as other causes of infectious diarrhea.^{[ medical citation needed ]}

Nutrition

Dietary deficiencies in developing countries can be combated by promoting better eating practices. Zinc supplementation proved successful showing a significant decrease in the incidence of diarrheal disease compared to a control group. ^{[86] [87]} The majority of the literature suggests that vitamin A supplementation is advantageous in reducing disease incidence. ^[88] Development of a supplementation strategy should take into consideration the fact that vitamin A supplementation was less effective in reducing diarrhea incidence when compared to vitamin A and zinc supplementation, and that the latter strategy was estimated to be significantly more cost effective. ^[89]

Breastfeeding

Breastfeeding practices have been shown to have a dramatic effect on the incidence of diarrheal disease in poor populations. Studies across a number of developing nations have shown that those who receive exclusive breastfeeding during their first 6 months of life are better protected against infection with diarrheal diseases. ^[90] One study in Brazil found that non-breastfed infants were 14 times more likely to die from diarrhea than exclusively breastfed infants. ^[91] Exclusive breastfeeding is currently recommended for the first six months of an infant's life by the WHO, ^{[92] [93]} with continued breastfeeding until at least two years of age. ^[93]

Others

Probiotics decrease the risk of diarrhea in those taking antibiotics. ^[94] Insecticide spraying may reduce fly numbers and the risk of diarrhea in children in a setting where there is seasonal variations in fly numbers throughout the year. ^[95]

Management

In many cases of diarrhea, replacing lost fluid and salts is the only treatment needed. This is usually by mouth – oral rehydration therapy – or, in severe cases, intravenously. ^[1] Diet restrictions such as the BRAT diet are no longer recommended. ^[96] Research does not support the limiting of milk to children as doing so has no effect on duration of diarrhea. ^[97] To the contrary, WHO recommends that children with diarrhea continue to eat as sufficient nutrients are usually still absorbed to support continued growth and weight gain, and that continuing to eat also speeds up recovery of normal intestinal functioning. ^[20] CDC recommends that children and adults with cholera also continue to eat. ^[98] There is no evidence that early refeeding in children can cause an increase in inappropriate use of intravenous fluid, episodes of vomiting, and risk of having persistent diarrhea. ^[99]

Medications such as loperamide (Imodium) and bismuth subsalicylate may be beneficial; however they may be contraindicated in certain situations. ^[100]

Fluids

See also: Management of dehydration

A person consuming oral rehydration solution

Oral rehydration solution (ORS) (a slightly sweetened and salty water) can be used to prevent dehydration. Standard home solutions such as salted rice water, salted yogurt drinks, vegetable and chicken soups with salt can be given. Home solutions such as water in which cereal has been cooked, unsalted soup, green coconut water, weak tea (unsweetened), and unsweetened fresh fruit juices can have from half a teaspoon to full teaspoon of salt (from one-and-a-half to three grams) added per liter. Clean plain water can also be one of several fluids given. ^[20] There are commercial solutions such as Pedialyte, and relief agencies such as UNICEF widely distribute packets of salts and sugar. A WHO publication for physicians recommends a homemade ORS consisting of one liter water with one teaspoon salt (3 grams) and two tablespoons sugar (18 grams) added ^[20] (approximately the "taste of tears" ^[101] ). Rehydration Project recommends adding the same amount of sugar but only one-half a teaspoon of salt, stating that this more dilute approach is less risky with very little loss of effectiveness. ^[102] Both agree that drinks with too much sugar or salt can make dehydration worse. ^{[20] [102]}

Appropriate amounts of supplemental zinc and potassium should be added if available. But the availability of these should not delay rehydration. As WHO points out, the most important thing is to begin preventing dehydration as early as possible. ^[20] In another example of prompt ORS hopefully preventing dehydration, CDC recommends for the treatment of cholera continuing to give Oral Rehydration Solution during travel to medical treatment. ^[98]

Vomiting often occurs during the first hour or two of treatment with ORS, especially if a child drinks the solution too quickly, but this seldom prevents successful rehydration since most of the fluid is still absorbed. WHO recommends that if a child vomits, to wait five or ten minutes and then start to give the solution again more slowly. ^[20]

Drinks especially high in simple sugars, such as soft drinks and fruit juices, are not recommended in children under five as they may increase dehydration. A too rich solution in the gut draws water from the rest of the body, just as if the person were to drink sea water. ^{[20] [103]} Plain water may be used if more specific and effective ORT preparations are unavailable or are not palatable. ^[103] Additionally, a mix of both plain water and drinks perhaps too rich in sugar and salt can alternatively be given to the same person, with the goal of providing a medium amount of sodium overall. ^[20] A nasogastric tube can be used in young children to administer fluids if warranted. ^[104]

Eating

The WHO recommends a child with diarrhea continue to be fed. Continued feeding speeds the recovery of normal intestinal function. In contrast, children whose food is restricted have diarrhea of longer duration and recover intestinal function more slowly. The WHO states "Food should never be withheld and the child's usual foods should not be diluted. Breastfeeding should always be continued." ^[20] In the specific example of cholera, the CDC makes the same recommendation. ^[98] Breast-fed infants with diarrhea often choose to breastfeed more, and should be encouraged to do so. ^[20] In young children who are not breast-fed and live in the developed world, a lactose-free diet may be useful to speed recovery. ^[105] Eating food containing soluble fibre may help, but insoluble fibre might make it worse. ^[106]

Medications

Main article: Antidiarrhoeal

Antidiarrheal agents can be classified into four different groups: antimotility, antisecretory, adsorbent, and anti-infectious. ^[107] While antibiotics are beneficial in certain types of acute diarrhea, they are usually not used except in specific situations. ^{[108] [109]} There are concerns that antibiotics may increase the risk of hemolytic uremic syndrome in people infected with Escherichia coli O157:H7. ^[110] In resource-poor countries, treatment with antibiotics may be beneficial. ^[109] However, some bacteria are developing antibiotic resistance, particularly Shigella. ^[111] Antibiotics can also cause diarrhea, and antibiotic-associated diarrhea is the most common adverse effect of treatment with general antibiotics.

While bismuth compounds (Pepto-Bismol) decreased the number of bowel movements in those with travelers' diarrhea, they do not decrease the length of illness. ^[112] Anti-motility agents like loperamide are also effective at reducing the number of stools but not the duration of disease. ^[8] These agents should be used only if bloody diarrhea is not present. ^[113]

Diosmectite, a natural aluminomagnesium silicate clay, is effective in alleviating symptoms of acute diarrhea in children, ^[114] and also has some effects in chronic functional diarrhea, radiation-induced diarrhea, and chemotherapy-induced diarrhea. ^[52] Another absorbent agent used for the treatment of mild diarrhea is kaopectate.

Racecadotril an antisecretory medication may be used to treat diarrhea in children and adults. ^[107] It has better tolerability than loperamide, as it causes less constipation and flatulence. ^[115] However, it has little benefit in improving acute diarrhea in children. ^[116]

Bile acid sequestrants such as cholestyramine can be effective in chronic diarrhea due to bile acid malabsorption. Therapeutic trials of these drugs are indicated in chronic diarrhea if bile acid malabsorption cannot be diagnosed with a specific test, such as SeHCAT retention. ^[117]

Alternative therapies

Zinc supplementation may benefit children over six months old with diarrhea in areas with high rates of malnourishment or zinc deficiency. ^[118] This supports the World Health Organization guidelines for zinc, but not in the very young.

A Cochrane Review from 2020 concludes that probiotics make little or no difference to people who have diarrhea lasting 2 days or longer and that there is no proof that they reduce its duration. ^[119] The probiotic lactobacillus can help prevent antibiotic-associated diarrhea in adults but possibly not children. ^[120] For those with lactose intolerance, taking digestive enzymes containing lactase when consuming dairy products often improves symptoms.

See also

• Medicine portal

• Dysentery  – Inflammation of the intestine causing diarrhea with blood
• Fernando Mazariegos  – Guatemalan scientist (1938–2018)
• Mucorrhea  – Discharge of mucus

References

1. "whqlibdoc.who.int" (PDF). World Health Organization . Archived (PDF) from the original on 8 November 2010.
2. "Diarrhoeal disease Factsheet". World Health Organization. 2 May 2017. Archived from the original on 11 November 2020. Retrieved 29 October 2020.
3. Vos T, Allen C, Arora M, Barber RM, Bhutta ZA, Brown A, et al. (GBD 2015 Disease and Injury Incidence and Prevalence Collaborators) (October 2016). "Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015". Lancet. 388 (10053): 1545–1602. doi:10.1016/S0140-6736(16)31678-6. PMC   5055577 . PMID   27733282.
4. Dadonaite B, Ritchie H, Roser M (1 November 2018). "Diarrheal diseases". Our World in Data. Archived from the original on 19 June 2022. Retrieved 28 April 2022.
5. Abdelmalak B, Doyle J, eds. (2013). Anesthesia for otolaryngologic surgery. Cambridge University Press. pp. 282–287. ISBN   978-1-107-01867-9.
6. Sapone A, Bai JC, Ciacci C, Dolinsek J, Green PH, Hadjivassiliou M, et al. (February 2012). "Spectrum of gluten-related disorders: consensus on new nomenclature and classification". BMC Medicine (Review). 10: 13. doi: 10.1186/1741-7015-10-13 . PMC   3292448 . PMID   22313950.
7. Slattery SA, Niaz O, Aziz Q, Ford AC, Farmer AD (July 2015). "Systematic review with meta-analysis: the prevalence of bile acid malabsorption in the irritable bowel syndrome with diarrhoea" (PDF). Alimentary Pharmacology & Therapeutics. 42 (1): 3–11. doi: 10.1111/apt.13227 . PMID   25913530. S2CID   34603226. Archived (PDF) from the original on 9 May 2020. Retrieved 23 September 2019.
8. DuPont HL (April 2014). "Acute infectious diarrhea in immunocompetent adults". The New England Journal of Medicine. 370 (16): 1532–40. doi:10.1056/nejmra1301069. PMID   24738670.
9. Crockett ME, Keystone JS (2012). "Protection of Travelers". In Fischer M, Long SS, Prober CG (eds.). Principles and practice of pediatric infectious diseases (4th ed.). Edinburgh: Elsevier Saunders. p. 82. ISBN   978-1-4557-3985-1.
10. ACEP (14 October 2013). "Nation's Emergency Physicians Announce List of Test and Procedures to Question as Part of Choosing Wisely Campaign". Choosing Wisely. Archived from the original on 17 May 2014. Retrieved 18 June 2014.
11. Vos T, Barber RM, Bell B, Bertozzi-Villa A, Biryukov S, Bolliger I, et al. (Global Burden of Disease Study 2013 Collaborators) (August 2015). "Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013". Lancet. 386 (9995): 743–800. doi:10.1016/s0140-6736(15)60692-4. PMC   4561509 . PMID   26063472.
12. "Global Diarrhea Burden". CDC. 24 January 2013. Archived from the original on 7 July 2014. Retrieved 18 June 2014.
13. The dictionary definition of squits at Wiktionary
14. The dictionary definition of runs at Wiktionary
15. "Definition of Diarrhea by Merriam-Webster". Merriam Webster . Archived from the original on 11 December 2018. Retrieved 11 December 2018.
16. "WGO Practice Guideline – Acute diarrhea". Archived from the original on 22 February 2011. Retrieved 9 March 2011.
17. "Cholera outbreak toobox" (PDF). WHO. June 2019. Archived (PDF) from the original on 30 May 2022. Retrieved 2 May 2022.
18. "The Basics of Diarrhea". Webmd.com. 17 February 2011. Archived from the original on 11 March 2011. Retrieved 9 March 2011.
19. Moon C, Zhang W, Sundaram N, Yarlagadda S, Reddy VS, Arora K, et al. (December 2015). "Drug-induced secretory diarrhea: A role for CFTR". Pharmacological Research. 102: 107–112. doi:10.1016/j.phrs.2015.08.024. PMC   4684461 . PMID   26429773.
20. "The Treatment Of Diarrhea, A manual for physicians and other senior health workers" (PDF). Sometimes needs to be downloaded twice. See "4.2 Treatment Plan A: home therapy to prevent dehydration and malnutrition", "4.3 Treatment Plan B: oral rehydration therapy for children with some dehydration", and "4.4 Treatment Plan C: for patients with severe dehydration" on pages 8 to 16 (12–20 in PDF). See also "8. Management of Diarrhoea with Severe Malnutrition" on pages 22–24 (26–30 in PDF) and "Annex 2: Oral and Intravenous Rehydration Solutions" on pages 33–37 (37–41 in PDF). World Health Organization. 2005. Archived from the original (PDF) on 19 October 2011.
21. Sweetser S (June 2012). "Evaluating the patient with diarrhea: a case-based approach". Mayo Clinic Proceedings. 87 (6): 596–602. doi: 10.1016/j.mayocp.2012.02.015 . PMC   3538472 . PMID   22677080.
22. Disease Control Priorities Project. "Public Health Significance of Diarrheal Illnesses". The World Bank Group. Archived from the original on 25 January 2014. Retrieved 12 October 2013.
23. Guerrant RL, Schorling JB, McAuliffe JF, de Souza MA (July 1992). "Diarrhea as a cause and an effect of malnutrition: diarrhea prevents catch-up growth and malnutrition increases diarrhea frequency and duration". The American Journal of Tropical Medicine and Hygiene. 47 (1 Pt 2): 28–35. doi:10.4269/ajtmh.1992.47.28. PMID   1632474.
24. Grantham-McGregor SM, Walker SP, Chang S (February 2000). "Nutritional deficiencies and later behavioural development". The Proceedings of the Nutrition Society. 59 (1): 47–54. doi: 10.1017/S0029665100000069 . PMID   10828173.
25. Maton A, Hopkins J, McLaughlin CM, Johnson S, Warner MQ, LaHart D, et al. (1993). Human Biology and Health . Englewood Cliffs, NJ: Prentice Hall. ISBN   978-0-13-981176-0. OCLC   32308337.
26. "Diarrhea: Types, Causes, Complications & Treatment". Cleveland Clinic. Archived from the original on 19 July 2022. Retrieved 19 July 2022.
27. Wilson ME (December 2005). "Diarrhea in nontravelers: risk and etiology". Clinical Infectious Diseases. 41. 41 (Suppl 8): S541-6. doi: 10.1086/432949 . PMID   16267716.
28. "Microscopic colitis - Symptoms and causes". Mayo Clinic. Archived from the original on 3 April 2022. Retrieved 19 July 2022.
29. Navaneethan U, Giannella RA (November 2008). "Mechanisms of infectious diarrhea". Nature Clinical Practice. Gastroenterology & Hepatology. 5 (11): 637–47. doi:10.1038/ncpgasthep1264. PMID   18813221. S2CID   34096072.
30. Schlossberg D (2008). Clinical Infectious Disease. Cambridge University Press. p. 349. ISBN   978-1-139-57665-9. Archived from the original on 14 January 2023. Retrieved 9 September 2017.
31. Patel MM, Hall AJ, Vinjé J, Parashar UD (January 2009). "Noroviruses: a comprehensive review". Journal of Clinical Virology. 44 (1): 1–8. doi:10.1016/j.jcv.2008.10.009. PMID   19084472.
32. Greenberg HB, Estes MK (May 2009). "Rotaviruses: from pathogenesis to vaccination". Gastroenterology. 136 (6): 1939–51. doi:10.1053/j.gastro.2009.02.076. PMC   3690811 . PMID   19457420.
33. Uhnoo I, Svensson L, Wadell G (September 1990). "Enteric adenoviruses". Baillière's Clinical Gastroenterology. 4 (3): 627–42. doi:10.1016/0950-3528(90)90053-J. PMID   1962727.
34. Mitchell DK (November 2002). "Astrovirus gastroenteritis". The Pediatric Infectious Disease Journal. 21 (11): 1067–9. doi:10.1097/00006454-200211000-00018. PMID   12442031. S2CID   3177998.
35. Akhondi H, Simonsen KA (2022), "Bacterial Diarrhea", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID   31869107, archived from the original on 15 June 2022, retrieved 19 July 2022
36. Viswanathan VK, Hodges K, Hecht G (February 2009). "Enteric infection meets intestinal function: how bacterial pathogens cause diarrhoea". Nature Reviews. Microbiology. 7 (2): 110–9. doi:10.1038/nrmicro2053. PMC   3326399 . PMID   19116615.
37. Rupnik M, Wilcox MH, Gerding DN (July 2009). "Clostridium difficile infection: new developments in epidemiology and pathogenesis". Nature Reviews. Microbiology. 7 (7): 526–36. doi:10.1038/nrmicro2164. PMID   19528959. S2CID   23376891.
38. Rossignol JF, Lopez-Chegne N, Julcamoro LM, Carrion ME, Bardin MC (March 2012). "Nitazoxanide for the empiric treatment of pediatric infectious diarrhea". Transactions of the Royal Society of Tropical Medicine and Hygiene. 106 (3): 167–73. doi:10.1016/j.trstmh.2011.11.007. PMID   22301075.
39. Alam NH, Ashraf H (2003). "Treatment of infectious diarrhea in children". Paediatric Drugs. 5 (3): 151–65. doi: 10.2165/00128072-200305030-00002 . PMID   12608880. S2CID   26076784.
40. "WHO | Diarrhoeal disease". Who.int. Archived from the original on 1 April 2014. Retrieved 10 March 2014.
41. Jamison DT (2006). Disease control priorities in developing countries (2nd ed.). New York: Oxford Univ. Press. ISBN   978-0-8213-6179-5.
42. Brown J, Cairncross S, Ensink JH (August 2013). "Water, sanitation, hygiene and enteric infections in children". Archives of Disease in Childhood. 98 (8): 629–34. doi:10.1136/archdischild-2011-301528. PMC   3717778 . PMID   23761692.
43. Black RE, Sazawal S (May 2001). "Zinc and childhood infectious disease morbidity and mortality". The British Journal of Nutrition. 85 (Suppl 2): S125-9. doi: 10.1079/bjn2000304 . PMID   11509100.
44. Shankar AH, Prasad AS (August 1998). "Zinc and immune function: the biological basis of altered resistance to infection". The American Journal of Clinical Nutrition. 68 (2 Suppl): 447S–463S. doi: 10.1093/ajcn/68.2.447S . PMID   9701160.
45. Bahl R, Bhandari N, Hambidge KM, Bhan MK (August 1998). "Plasma zinc as a predictor of diarrheal and respiratory morbidity in children in an urban slum setting". The American Journal of Clinical Nutrition. 68 (2 Suppl): 414S–417S. doi: 10.1093/ajcn/68.2.414S . PMID   9701154.
46. Rice AL, West KP, Black RE (2004). "Vitamin A deficiency" (PDF). In Ezzati M, Lopez AD, Rodgers A, Murray CJ (eds.). Comparative quantification of health risks: global and regional burden of disease attributes to selected major risk factors. Vol. 1. Geneva: World Health Organization. pp. 211–56, especially 238–240. Archived (PDF) from the original on 31 July 2020. Retrieved 30 December 2018.
47. Sommer A, Katz J, Tarwotjo I (November 1984). "Increased risk of respiratory disease and diarrhea in children with preexisting mild vitamin A deficiency". The American Journal of Clinical Nutrition. 40 (5): 1090–5. doi: 10.1093/ajcn/40.5.1090 . PMID   6496388.
48. West KP (September 2002). "Extent of vitamin A deficiency among preschool children and women of reproductive age". The Journal of Nutrition. 132 (9 Suppl): 2857S–2866S. doi: 10.1093/jn/132.9.2857S . PMID   12221262.
49. Longstreth GF, Thompson WG, Chey WD, Houghton LA, Mearin F, Spiller RC (April 2006). "Functional bowel disorders". Gastroenterology. 130 (5): 1480–91. doi:10.1053/j.gastro.2005.11.061. PMID   16678561.
50. Wedlake L, A'Hern R, Russell D, Thomas K, Walters JR, Andreyev HJ (October 2009). "Systematic review: the prevalence of idiopathic bile acid malabsorption as diagnosed by SeHCAT scanning in patients with diarrhoea-predominant irritable bowel syndrome". Alimentary Pharmacology & Therapeutics. 30 (7): 707–17. doi: 10.1111/j.1365-2036.2009.04081.x . PMID   19570102. S2CID   11327665.
51. Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL (2005). Harrison's Principles of Internal Medicine. New York: McGraw-Hill. ISBN   978-0-07-139140-5.
52. Lee KJ (October 2015). "Pharmacologic Agents for Chronic Diarrhea". Intestinal Research. 13 (4): 306–12. doi:10.5217/ir.2015.13.4.306. PMC   4641856 . PMID   26576135.
53. Vallerand A (2017). Davis's drug guide for nurses. Philadelphia: F.A. Davis Company. pp. 989–994. ISBN   978-0-8036-5705-2.
54. Dekel R, Sperber AD. "Diarrhea & Incontinence Caused by Medication". International Foundation for Gastrointestinal Disorders (IFFGD). Archived from the original on 24 February 2017. Retrieved 18 May 2017.
55. Das S, Jayaratne R, Barrett KE (2018). "The Role of Ion Transporters in the Pathophysiology of Infectious Diarrhea". Cellular and Molecular Gastroenterology and Hepatology. 6 (1): 33–45. doi:10.1016/j.jcmgh.2018.02.009. PMC   6007821 . PMID   29928670.
56. Williams G, Nesse RM (1996). Why we get sick: the new science of Darwinian medicine. New York: Vintage Books. pp. 36–38. ISBN   978-0-679-74674-4.
57. DuPont HL, Hornick RB (December 1973). "Adverse effect of lomotil therapy in shigellosis". JAMA. 226 (13): 1525–8. doi:10.1001/jama.226.13.1525. PMID   4587313.
58. Ruuska T, Vesikari T (1990). "Rotavirus disease in Finnish children: use of numerical scores for clinical severity of diarrhoeal episodes". Scandinavian Journal of Infectious Diseases. 22 (3): 259–67. doi:10.3109/00365549009027046. PMID   2371542.
59. Arasaradnam RP, Brown S, Forbes A, Fox MR, Hungin P, Kelman L, et al. (August 2018). "Guidelines for the investigation of chronic diarrhoea in adults: British Society of Gastroenterology, 3rd edition". Gut. 67 (8): 1380–1399. doi:10.1136/gutjnl-2017-315909. PMC   6204957 . PMID   29653941.
60. Smalley W, Falck-Ytter C, Carrasco-Labra A, Wani S, Lytvyn L, Falck-Ytter Y (September 2019). "AGA Clinical Practice Guidelines on the Laboratory Evaluation of Functional Diarrhea and Diarrhea-Predominant Irritable Bowel Syndrome in Adults (IBS-D)". Gastroenterology. 157 (3): 851–854. doi: 10.1053/j.gastro.2019.07.004 . PMID   31302098.
61. "Mortality and Burden of Disease Estimates for WHO Member States in 2004" (xls). World Health Organization . Archived from the original on 28 August 2021. Retrieved 4 October 2020.
62. Mandell GL, Bennett JE, Dolin R (2004). Mandell's Principles and Practices of Infection Diseases (6th ed.). Churchill Livingstone. ISBN   978-0-443-06643-6. Archived from the original on 18 October 2013.
63. "Diarrhoea: why children are still dying and what can be done" (PDF). World Health Organization. Archived (PDF) from the original on 19 October 2013. Retrieved 12 October 2013.
64. "Call to action on sanitation" (PDF). United Nations. Archived from the original (PDF) on 19 August 2014. Retrieved 15 August 2014.
65. Walker CL, Rudan I, Liu L, Nair H, Theodoratou E, Bhutta ZA, et al. (April 2013). "Global burden of childhood pneumonia and diarrhoea". Lancet. 381 (9875): 1405–1416. doi:10.1016/S0140-6736(13)60222-6. PMC   7159282 . PMID   23582727.
66. Walker CL, Aryee MJ, Boschi-Pinto C, Black RE (2012). "Estimating diarrhea mortality among young children in low and middle income countries". PLOS ONE. 7 (1): e29151. Bibcode:2012PLoSO...729151F. doi: 10.1371/journal.pone.0029151 . PMC   3250411 . PMID   22235266.
67. Kosek M, Bern C, Guerrant RL (2003). "The global burden of diarrhoeal disease, as estimated from studies published between 1992 and 2000". Bulletin of the World Health Organization. 81 (3): 197–204. PMC   2572419 . PMID   12764516.
68. "The top 10 causes of death". www.who.int. Archived from the original on 24 September 2021. Retrieved 12 August 2024.
69. Hird DW, Anderson JH, Bielitzki JT (1 October 1984). "Diarrhea in nonhuman primates: a survey of primate colonies for incidence rates and clinical opinion". Laboratory Animal Science. 34 (5): 465–470. ISSN   0023-6764. PMID   6513506. Archived from the original on 15 April 2024. Retrieved 4 July 2024.
70. Collard MK, Bardin J, Marquet B, Laurin M, Ogier-Denis É (23 September 2023). "Correlation between the presence of a cecal appendix and reduced diarrhea severity in primates: new insights into the presumed function of the appendix". Scientific Reports. 13 (1): 15897. Bibcode:2023NatSR..1315897C. doi:10.1038/s41598-023-43070-5. ISSN   2045-2322. PMC   10517977 . PMID   37741857.
71. Wolf J, Prüss-Ustün A, Cumming O, Bartram J, Bonjour S, Cairncross S, et al. (August 2014). "Assessing the impact of drinking water and sanitation on diarrhoeal disease in low- and middle-income settings: systematic review and meta-regression" (PDF). Tropical Medicine & International Health. 19 (8): 928–42. doi: 10.1111/tmi.12331 . PMID   24811732. S2CID   22903164. Archived (PDF) from the original on 13 April 2020. Retrieved 17 December 2019.
72. Ejemot-Nwadiaro RI, Ehiri JE, Arikpo D, Meremikwu MM, Critchley JA (January 2021). "Hand-washing promotion for preventing diarrhoea". The Cochrane Database of Systematic Reviews. 12 (1): CD004265. doi:10.1002/14651858.CD004265.pub4. PMC   8094449 . PMID   33539552.
73. Spears D, Ghosh A, Cumming O (2013). "Open defecation and childhood stunting in India: an ecological analysis of new data from 112 districts". PLOS ONE. 8 (9): e73784. Bibcode:2013PLoSO...873784S. doi: 10.1371/journal.pone.0073784 . PMC   3774764 . PMID   24066070.
74. Majorin F, Torondel B, Ka Seen Chan G, Clasen T, et al. (Cochrane Infectious Diseases Group) (September 2019). "Interventions to improve disposal of child faeces for preventing diarrhoea and soil-transmitted helminth infection". The Cochrane Database of Systematic Reviews. 2019 (9): CD011055. doi:10.1002/14651858.CD011055.pub2. PMC   6757260 . PMID   31549742.
75. Clasen TF, Bostoen K, Schmidt WP, Boisson S, Fung IC, Jenkins MW, et al. (Cochrane Infectious Diseases Group) (June 2010). "Interventions to improve disposal of human excreta for preventing diarrhoea". The Cochrane Database of Systematic Reviews. 2010 (6): CD007180. doi:10.1002/14651858.CD007180.pub2. PMC   6532559 . PMID   20556776.
76. Curtis V, Cairncross S (May 2003). "Effect of washing hands with soap on diarrhoea risk in the community: a systematic review". The Lancet. Infectious Diseases. 3 (5): 275–81. doi:10.1016/S1473-3099(03)00606-6. PMID   12726975.
77. Cairncross S, Hunt C, Boisson S, Bostoen K, Curtis V, Fung IC, et al. (April 2010). "Water, sanitation and hygiene for the prevention of diarrhoea". International Journal of Epidemiology. 39 (Suppl 1): i193-205. doi:10.1093/ije/dyq035. PMC   2845874 . PMID   20348121.
78. "Diarrheal Diseases in Less Developed Countries". CDC. Archived from the original on 4 November 2013. Retrieved 28 October 2013.
79. Black RE, Morris SS, Bryce J (June 2003). "Where and why are 10 million children dying every year?". Lancet. 361 (9376): 2226–34. doi:10.1016/S0140-6736(03)13779-8. PMID   12842379. S2CID   14509705.
80. Esrey SA, Feachem RG, Hughes JM (1985). "Interventions for the control of diarrhoeal diseases among young children: improving water supplies and excreta disposal facilities". Bulletin of the World Health Organization. 63 (4): 757–72. PMC   2536385 . PMID   3878742.
81. Arnold BF, Colford JM (February 2007). "Treating water with chlorine at point-of-use to improve water quality and reduce child diarrhea in developing countries: a systematic review and meta-analysis". The American Journal of Tropical Medicine and Hygiene. 76 (2): 354–64. doi: 10.4269/ajtmh.2007.76.354 . PMID   17297049.
82. de Zoysa I, Feachem RG (1985). "Interventions for the control of diarrhoeal diseases among young children: rotavirus and cholera immunization". Bulletin of the World Health Organization. 63 (3): 569–83. PMC   2536413 . PMID   3876173.
83. Rheingans RD, Antil L, Dreibelbis R, Podewils LJ, Bresee JS, Parashar UD (November 2009). "Economic costs of rotavirus gastroenteritis and cost-effectiveness of vaccination in developing countries" (PDF). The Journal of Infectious Diseases. 200 (Suppl 1): S16-27. doi: 10.1086/605026 . PMID   19817595. Archived (PDF) from the original on 27 February 2024. Retrieved 27 February 2024.
84. Oral cholera vaccines in mass immunization campaigns (PDF). WHO. 2010. pp. 6–8. ISBN   978-92-4-150043-2. Archived (PDF) from the original on 3 September 2014.
85. Soares-Weiser K, Goldberg E, Tamimi G, Pitan OC, Leibovici L, et al. (Cochrane Infectious Diseases Group) (26 January 2004). "Rotavirus vaccine for preventing diarrhoea". The Cochrane Database of Systematic Reviews. 2004 (1): CD002848. doi:10.1002/14651858.CD002848.pub2. PMC   6532746 . PMID   14973994.
86. Black RE (May 2003). "Zinc deficiency, infectious disease and mortality in the developing world". The Journal of Nutrition. 133 (5 Suppl 1): 1485S–9S. doi: 10.1093/jn/133.5.1485S . PMID   12730449.
87. Bhutta ZA, Black RE, Brown KH, Gardner JM, Gore S, Hidayat A, et al. (December 1999). "Prevention of diarrhea and pneumonia by zinc supplementation in children in developing countries: pooled analysis of randomized controlled trials. Zinc Investigators' Collaborative Group". The Journal of Pediatrics. 135 (6): 689–97. doi: 10.1016/S0022-3476(99)70086-7 . PMID   10586170.
88. Mayo-Wilson E, Imdad A, Herzer K, Yakoob MY, Bhutta ZA (August 2011). "Vitamin A supplements for preventing mortality, illness, and blindness in children aged under 5: systematic review and meta-analysis". BMJ. 343: d5094. doi:10.1136/bmj.d5094. PMC   3162042 . PMID   21868478.
89. Chhagan MK, Van den Broeck J, Luabeya KK, Mpontshane N, Bennish ML (September 2014). "Cost of childhood diarrhoea in rural South Africa: exploring cost-effectiveness of universal zinc supplementation". Public Health Nutrition. 17 (9): 2138–45. doi: 10.1017/S1368980013002152 . PMC   11108711 . PMID   23930984.
90. "Effect of breastfeeding on infant and child mortality due to infectious diseases in less developed countries: a pooled analysis. WHO Collaborative Study Team on the Role of Breastfeeding on the Prevention of Infant Mortality". Lancet. 355 (9202): 451–5. February 2000. doi:10.1016/S0140-6736(00)82011-5. PMID   10841125. S2CID   30952224.
91. Lawrence R (2016). Breastfeeding : a guide for the medical profession, 8th edition. Philadelphia, PA: Elsevier. p. 28. ISBN   978-0-323-35776-0.
92. Sguassero Y. "Optimal duration of exclusive breastfeeding: RHL commentary". WHO. Archived from the original on 3 November 2013. Retrieved 14 October 2013.
93. "Infant and young child feeding". World Health Organization. 3 October 2017. Archived from the original on 8 February 2015. Retrieved 5 January 2018.
94. Hempel S, Newberry SJ, Maher AR, Wang Z, Miles JN, Shanman R, et al. (May 2012). "Probiotics for the prevention and treatment of antibiotic-associated diarrhea: a systematic review and meta-analysis". JAMA: The Journal of the American Medical Association. 307 (18): 1959–69. doi:10.1001/jama.2012.3507. PMID   22570464.
95. Das JK, Hadi YB, Salam RA, Hoda M, Lassi ZS, Bhutta ZA, et al. (Cochrane Infectious Diseases Group) (December 2018). "Fly control to prevent diarrhoea in children". The Cochrane Database of Systematic Reviews. 12 (12): CD011654. doi:10.1002/14651858.CD011654.pub2. PMC   6302900 . PMID   30556598.
96. King CK, Glass R, Bresee JS, Duggan C (November 2003). "Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy". MMWR. Recommendations and Reports. 52 (RR-16): 1–16. PMID   14627948. Archived from the original on 28 October 2014.
97. "BestBets: Does Withholding milk feeds reduce the duration of diarrhoea in children with acute gastroenteritis?". Archived from the original on 4 May 2009.
98. Community Health Worker Training Materials for Cholera Prevention and Control Archived 20 October 2011 at the Wayback Machine , CDC, slides at back are dated 17 November 2010. Page 7 states "...  Continue to breastfeed your baby if the baby has watery diarrhea, even when traveling to get treatment. Adults and older children should continue to eat frequently."
99. Gregorio GV, Dans LF, Silvestre MA, et al. (Cochrane Infectious Diseases Group) (July 2011). "Early versus Delayed Refeeding for Children with Acute Diarrhoea". The Cochrane Database of Systematic Reviews. 2011 (7): CD007296. doi:10.1002/14651858.CD007296.pub2. PMC   6532715 . PMID   21735409.
100. Schiller LR (2007). "Management of diarrhea in clinical practice: strategies for primary care physicians". Reviews in Gastroenterological Disorders. 7 (Suppl 3): S27-38. PMID   18192963.
101. A Guide on Safe Food for Travellers Archived 9 July 2012 at the Wayback Machine , Welcome to South Africa, Host to the 2010 FIFA World Cup (bottom left of page 1).
102. Rehydration Project, "Diarrhoea, Diarrhea, Dehydration, Oral Rehydration, Mother and Child Nutrition, Water, Sanitation, Hygiene – Rehydration Project". Archived from the original on 8 June 2015. Retrieved 22 June 2015. Homemade Oral Rehydration Solution Recipe.
103. "Management of acute diarrhoea and vomiting due to gastroenteritis in children under 5". National Institute of Clinical Excellence. April 2009. Archived from the original on 2 August 2009.
104. Webb A, Starr M (April 2005). "Acute gastroenteritis in children". Australian Family Physician. 34 (4): 227–31. PMID   15861741.
105. MacGillivray S, Fahey T, McGuire W (October 2013). "Lactose avoidance for young children with acute diarrhoea". The Cochrane Database of Systematic Reviews. 10 (10): CD005433. doi:10.1002/14651858.CD005433.pub2. PMC   4276385 . PMID   24173771.
106. "The Facts About Fiber". Archived from the original on 27 July 2020. Retrieved 25 January 2020.
107. Guarino A, Lo Vecchio A, Pirozzi MR (2009). "Clinical role of diosmectite in the management of diarrhea". Expert Opin Drug Metab Toxicol. 5 (4): 433–440. doi:10.1517/17425250902865594. PMID   19379128. S2CID   56519371.
108. Dryden MS, Gabb RJ, Wright SK (June 1996). "Empirical treatment of severe acute community-acquired gastroenteritis with ciprofloxacin". Clinical Infectious Diseases. 22 (6): 1019–25. doi: 10.1093/clinids/22.6.1019 . PMID   8783703.
109. de Bruyn G (March 2008). "Diarrhoea in adults (acute)". BMJ Clinical Evidence. 2008: 0901. PMC   2907942 . PMID   19450323.
110. Wong CS, Jelacic S, Habeeb RL, Watkins SL, Tarr PI (June 2000). "The risk of the hemolytic-uremic syndrome after antibiotic treatment of Escherichia coli O157:H7 infections". The New England Journal of Medicine. 342 (26): 1930–6. doi:10.1056/NEJM200006293422601. PMC   3659814 . PMID   10874060.
111. "Diarrhoeal Diseases". World Health Organization. February 2009. Archived from the original on 15 December 2008.
112. DuPont HL, Ericsson CD, Farthing MJ, Gorbach S, Pickering LK, Rombo L, et al. (2009). "Expert review of the evidence base for self-therapy of travelers' diarrhea". Journal of Travel Medicine. 16 (3): 161–71. doi: 10.1111/j.1708-8305.2009.00300.x . PMID   19538576.
113. Pawlowski SW, Warren CA, Guerrant R (May 2009). "Diagnosis and treatment of acute or persistent diarrhea". Gastroenterology. 136 (6): 1874–86. doi:10.1053/j.gastro.2009.02.072. PMC   2723735 . PMID   19457416.
114. Dupont C, Vernisse B (2009). "Anti-diarrheal effects of diosmectite in the treatment of acute diarrhea in children: a review". Paediatric Drugs. 11 (2): 89–99. doi:10.2165/00148581-200911020-00001. PMC   7100234 . PMID   19301931.
115. Dinnendahl V, Fricke U, eds. (1982). Arzneistoff-Profile (in German). Eschborn, Germany: Govi Pharmazeutischer Verlag. ISBN   978-3-7741-9846-3.
116. Liang Y, Zhang L, Zeng L, Gordon M, Wen J, et al. (Cochrane Infectious Diseases Group) (December 2019). "Racecadotril for acute diarrhoea in children". The Cochrane Database of Systematic Reviews. 2019 (12): CD009359. doi:10.1002/14651858.CD009359.pub2. PMC   6923519 . PMID   31858591.
117. Wilcox C, Turner J, Green J (May 2014). "Systematic review: the management of chronic diarrhoea due to bile acid malabsorption". Alimentary Pharmacology & Therapeutics. 39 (9): 923–39. doi: 10.1111/apt.12684 . PMID   24602022. S2CID   12016216.
118. Lazzerini M, Wanzira H (December 2016). "Oral zinc for treating diarrhoea in children". The Cochrane Database of Systematic Reviews. 12 (12): CD005436. doi:10.1002/14651858.CD005436.pub5. PMC   5450879 . PMID   27996088.
119. Collinson S, Deans A, Padua-Zamora A, Gregorio GV, Li C, Dans LF, et al. (December 2020). "Probiotics for treating acute infectious diarrhoea". The Cochrane Database of Systematic Reviews. 2020 (12): CD003048. doi:10.1002/14651858.CD003048.pub4. PMC   8166250 . PMID   33295643.
120. Kale-Pradhan PB, Jassal HK, Wilhelm SM (February 2010). "Role of Lactobacillus in the prevention of antibiotic-associated diarrhea: a meta-analysis". Pharmacotherapy. 30 (2): 119–26. doi:10.1592/phco.30.2.119. PMID   20099986. S2CID   21836205.

External links

Wikipedia's health care articles can be viewed offline with the Medical Wikipedia app .

• WHO fact sheet on diarrhoeal disease