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1. Shard Calculation

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Calculated Shard: 163 (from laksa156)

2. Crawled Status Check

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curl -X POST \
  'http://laksa163.int.ahrefs:8124/' \
  -H 'Content-Type: text/plain' \
  -H 'X-ClickHouse-Database: crawler3' \
  -H 'Authorization: Basic YXBpOg==' \
  -d 'SELECT getAhrefsURLFromUnparsed(src_unparsed) AS found_url, ifNull(toUnixTimestamp(download_stamp), 0) AS crawl_time, ifNull(toUnixTimestamp(props_url_first_seen), 0) AS first_indexed_time, download_http_code AS http_code, src_unparsed AS src_unparsed, src_root_hash AS src_root_hash, history_drop_reason AS history_drop_reason, meta_title AS meta_title, meta_descriptions AS meta_descriptions, attrs_boilerpipe_text AS attrs_boilerpipe_text, attrs_markdown AS attrs_markdown, attrs_readable_markdown AS attrs_readable_markdown, meta_canonical AS meta_canonical FROM crawler3.page_info_local FINAL PREWHERE (src_root_hash, src_unparsed) IN ((getAhrefsRootHashFromUnparsed(getAhrefsUnparsedNoserviceFromURL(\'https://www.amboss.com/us/knowledge/diarrhea/\')), getAhrefsUnparsedNoserviceFromURL(\'https://www.amboss.com/us/knowledge/diarrhea/\'))) FORMAT JSONEachRow'

Response:

{"found_url":"https:\/\/www.amboss.com\/us\/knowledge\/diarrhea\/","crawl_time":1775101494,"first_indexed_time":0,"http_code":200,"src_unparsed":"com,amboss!www,\/us\/knowledge\/diarrhea\/ s443","src_root_hash":"8617922158668995163","history_drop_reason":null,"meta_title":"Diarrhea - Knowledge @ AMBOSS","meta_descriptions":["Diagnostic approach Inflammatory diarrhea or noninflammatory diarrhea that is not self-limited: stool GI pathogen panel (PCR) or culture Severe illness with fever: CBC, CMP, ESR, CRP, blood cultu...","Diagnostic approach Inflammatory diarrhea or noninflammatory diarrhea that is not self-limited: stool GI pathogen panel (PCR) or culture Severe illness with fever: CBC, CMP, ESR, CRP, blood cultu..."],"attrs_boilerpipe_text":"Last updated: February 27, 2026\nQuick guide\nDiagnostic testing is not indicated for most cases of\n.\nSummary\nDiarrhea, defined as three or more loose stools per day or more frequent stool passage than is normal for the individual, is a common disease with a monthly\nprevalence\nof around 5% in the United States.\nAcute diarrhea\nlasts\n14 days\nor less and is almost always caused by an infectious agent, typically a\nvirus\n. Testing is seldom required, as the disease tends to be\nself-limited\nand care is primarily supportive.\nPersistent diarrhea\n, lasting\n15–30 days\n, is also typically caused by an infectious agent, but stool testing for pathogens is generally warranted to confirm the diagnosis.\nChronic diarrhea\n, defined as diarrhea lasting longer than\n30 days\n, has an extensive differential diagnosis. A thorough history followed by systematic stool and blood testing is required to identify the specific etiology. The presence of any\nred flags\nfor severe or rapidly progressing diarrheal disease (e.g.,\nsepsis\n, extreme\ndehydration\n, blood in the stool) mandates escalation of testing and, in some cases,\nempiric antibiotics for bacterial gastroenteritis\n. Ensuring adequate oral hydration, correcting\ndehydration\n, and providing symptomatic relief are fundamental components in the care of all patients with diarrhea. Curative treatment is directed toward the underlying cause.\nDefinitions\nThe WHO defines diarrhea as\n≥ 3\nloose or watery stools per day or more frequent passage than is normal for the individual.\n[1]\n[2]\nEtiology\nFor etiologies of acute, persistent, or\nchronic diarrhea\n, see specific subsections below.\nOverview of pathogens causing watery and bloody diarrhea\nOverview\nType of diarrhea\nPathogen\nPathogen\ncharacteristics\nAssociated disorders\nWatery diarrhea\nEnterotoxigenic\nEscherichia coli\nHeat-labile toxin\nHeat-stable toxin\nTraveler's diarrhea\nClostridioides difficile\nToxin A\n(\nenterotoxin\n)\nToxin B\n(cytotoxin)\nAssociated with\nantibiotic\nand\nPPI\nuse\nPseudomembranous colitis\nRarely causes bloody diarrhea\nClostridium perfringens\nHeat-labile enterotoxin\nClostridium perfringens alpha toxin\nGas gangrene\nVibrio cholerae\nStraight or curved (\ncomma-shaped\n)\nCholera toxin\n(\nenterotoxin\n): “\nrice water\n” diarrhea\nTransmission via contaminated water or uncooked seafood (e.g., raw shellfish)\nCholera\nViruses\nNorovirus\n(most common cause)\nFecal-oral\nor\nairborne transmission\nGastroenteritis\nRotavirus\nFecal-oral transmission\nPrevention: attenuated\nvaccine\nfor children\nAdenovirus\nTransmission via contaminated water or\nfecal-oral route\nProtozoa\nGiardia lamblia\nTransmission via ingestion of contaminated water (e.g., lakes, rivers, ponds, swimming pools)\nMost commonly affects hikers or campers\nGiardiasis\nCryptosporidia\nFecal-oral transmission\n(\noocysts\nare typically excreted in stool and contaminate drinking water)\nCryptosporidiosis\nImmunocompromised individuals\n: potentially\nlife-threatening\nprotracted diarrhea and\/or\nbiliary tract\ninfections (e.g.,\ncholangitis\n,\ncholecystitis\n)\nCystoisospora belli\n[3]\nFoodborne\nContaminated water\nCystoisosporiasis\nImmunocompromised individuals\n: chronic profuse diarrhea,\nacalculous cholecystitis\n,\nAIDS cholangiopathy\nBloody diarrhea\nE.coli\nEnteroinvasive\nE. coli\nDirect invasion of the intestinal\nepithelium\nand formation of\nenterotoxins\nGastroenteritis\nEnterohemorrhagic\nE. coli\nShiga toxin\nMost common\nserotype\n:\n(\nO157:H7\n)\nHemolytic uremic syndrome\nCampylobacter jejuni\nCurved or\nspiral‑shaped\nwith polar\nflagellum\nGrows best at\n37–42°C\nCampylobacter enteritis\n(especially in children)\nCommonly precedes\nreactive arthritis\nand Guillain‑Barré syndrome\nNontyphoidal\nSalmonella\nNo\nlactose\nfermentation\nFlagellar motility\nHosts: humans, animals, and animal products (e.g., reptiles,\npoultry\n, pets,\neggs\n)\nSalmonellosis\nShigella\nSlow\/absent\nlactose\nfermentation\nShiga toxin\nLow infectious dose required (\nlow ID\n50\n)\nHumans are the only host.\nBacillary dysentery\nYersinia enterocolitica\nReservoir: contaminated pork and milk products\nYersiniosis\n(\noutbreaks\noften occur in\nday-care\nsettings)\nMay manifest as\npseudoappendicitis\nReactive arthritis\nProtozoa\n:\nEntamoeba histolytica\nFecal-oral transmission\nAmebic cysts are excreted in stool and can contaminate drinking water or food.\nAmebic dysentery\nAmebic liver abscess\nInfectious causes\n[4]\n[5]\nConditions\nViral\nNorovirus infection\nRotavirus infection\nAdenovirus\ninfection\n(mainly\nserotype\n3\n, 40,\nand 41\n)\n[6]\nCytomegalovirus infection\nBacterial\nCampylobacter enteritis\nShigellosis\nSalmonellosis\nCholera\nDiarrheagenic E. coli\ninfection (\ntravelers' diarrhea\n)\nYersiniosis\n(especially in day care centers)\nClostridioides difficile\ninfection\n(\nantibiotic\n-associated\ndiarrhea)\nTyphoid fever\nMycobacterium\navium-intracellulare\nTropheryma whipplei\n(i.e.,\nWhipple disease\n)\nLegionella\ninfection\nParasitic\nProtozoan\nGiardiasis\nAmebiasis\nCryptosporidiosis\nCystoisosporiasis\nHelminth infections\nToxocariasis\nEnterobiasis\nAscariasis\nTrichinosis\nTaenia infections\n(\ntaeniasis\n)\nHookworm infection\nDiphyllobothriasis\nIntestinal capillariasis\nNoninfectious\n[7]\n[8]\n[9]\nConditions\nFoodborne toxins\nS. aureus\nintoxication\nBotulism\nBacillus cereus\ninfection\nTetrodotoxin\n,\nciguatoxin\nFood poisoning\nAflatoxin\nHistamine\ntoxicity\n[7]\nChemical contaminants (e.g., lead,\ncadmium\n,\ninsecticides,\narsenic\n)\n[8]\nMushroom poisoning\n[9]\nGastrointestinal\nMalnutrition\n:\nvitamin deficiency\n(e.g.,\npellagra\n)\nMalabsorption\nor\nmaldigestion\nCeliac disease\nLactose intolerance\nExocrine pancreatic insufficiency\n(e.g., due to\nchronic pancreatitis\n)\nDiabetic autonomic neuropathy\nBile acid diarrhea\n(e.g., due to\nileal\nresection,\nbiliary-enteric fistula\n,\ncholestasis\n,\npostcholecystectomy diarrhea\n)\nAmyloidosis\nof the\ngastrointestinal tract\nColitis\nInflammatory bowel disease\nCrohn disease\nUlcerative colitis\nIrritable bowel syndrome\nMicroscopic colitis\nIschemic colitis\nRadiation colitis\nTumor\n\/stenotic processes:\nparadoxical diarrhea\n(involuntary seepage of liquid feces in patients with chronic\nconstipation\n)\nClassification\nDiarrhea is often classified as watery, fatty, and\/or inflammatory to facilitate diagnosis and management. This classification scheme is most relevant for the\napproach to\nchronic diarrhea\n.\nClassification of diarrhea by functional pathology\n[10]\n[11]\n[12]\nPathophysiology\nAssociated disorders\nInflammatory diarrhea\nDamage to the intestinal\nmucosa\nmay cause\ncytokine\n-induced\nwater hypersecretion, impair absorption of osmotically active substances or fat, and\/or disrupt water and\nelectrolyte\nabsorption.\nMucus,\nblood\n, and\nleukocytes\npresent in the stool.\nUlcerative colitis\n,\nCrohn disease\nColorectal cancer\nInfections\nShigellosis\n(\nbacillary dysentery\n)\nNontyphoidal:\nsalmonellosis\nEnteroinvasive Escherichia coli\n,\nenterohemorrhagic E. coli\n(\nO157:H7\n)\nCampylobacteriosis\nYersiniosis\nAmebiasis\n(\namebic dysentery\ncaused by\nEntamoeba histolytica\n)\nClostridioides difficile\n(rarely bloody)\nFatty diarrhea\nMalabsorption\nAlterations of the intestinal\nmucosa\n→ impaired\nabsorption of digested food\nMalabsorption\ndisorders or history of\nileal\nresection\nInfections\nGiardiasis\nSmall intestinal bacterial overgrowth\n(\nSIBO\n)\nTropical sprue\nWhipple disease\nAmyloidosis\nMaldigestion\nLack of digestive enzymes\n→ impaired\nbreakdown of food in the intestinal lumen\n→\nmalabsorption\nof\ncarbohydrates\n,\nproteins\n, fats,\nfat-soluble vitamins\n(A, D, E, K), and\nvitamin B\n12\nExocrine pancreatic insufficiency\nBile acid diarrhea\nWatery diarrhea\nSecretory diarrhea\nActive secretion of water\ninto the intestinal lumen via inhibition or activation of enzymes\n(e.g.,\n↑\ncAMP\nactivity)\nNeuroendocrine disorders, e.g.:\nCarcinoid syndrome\nGastrinoma\nEndocrine disorders, e.g.:\nHyperthyroidism\nAddison disease\nDiabetes mellitus\nFoodborne infections\nCholera\n(“rice water” diarrhea)\nEnterotoxigenic E. coli\n(\ntraveler's diarrhea\n)\nC. perfringens\nC. difficile\n(associated with\nantibiotic\nand\nPPI\nuse)\nProtozoa\n: e.g.,\ngiardiasis\n,\ncryptosporidiosis\nViruses\n: e.g.,\nnorovirus\n,\nrotavirus\n,\nadenovirus\nOsmotic diarrhea\nPoor absorption or excessive ingestion of\nhydrophilic\nsubstances (e.g., salts, sugars,\nlaxatives\n) causes water to be drawn into the intestinal lumen.\nOsmotic\nlaxatives\n: e.g.,\nmagnesium citrate\nCarbohydrate malabsorption\n: e.g.,\nlactose intolerance\n,\nfructose intolerance\n(may also present as\nfatty diarrhea\n)\nFunctional diarrheal disorders\n[10]\nRapid intestinal passage due to increased bowel activity\nDiarrhea-predominant IBS\n(\nIBS-D\n)\nFunctional diarrhea\n[10]\n[13]\nManagement\nThough 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.\nIn older adults, rule out\nfecal impaction\n, which can manifest atypically with\nparadoxical diarrhea\n(due to decreased rectal sensation) and nonspecific symptoms (e.g., functional decline,\ndelirium\n).\n[14]\nAntibiotics\nshould only be utilized for specific indications.\nClinical assessment of diarrhea\n[10]\n[12]\nKey features of the disease presentation that facilitate efficient testing and prompt diagnosis include:\nDuration of diarrheal illness\nStool characteristics\n:\nwatery, fatty, or bloody stools\nAssociated symptoms\nFever\nAbdominal\npain\nand cramping\nNausea and vomiting\nin cases of\ngastroenteritis\nSigns of\ndehydration\nChronic cases:\nmalnutrition\nand, in children,\nfailure to thrive\nWeight loss\nDefecation urgency,\ntenesmus\n, and\/or nocturnal symptoms\nCharacteristic clinical features in diarrhea according to functional pathology\nInflammatory diarrhea\nFrequent and small volume stools\nBloody or\npurulent\nstools\nAbdominal\npain\n,\ntenesmus\nMay be associated with\nfever\n, weight loss, fatigue\nFatty diarrhea\nGreasy or oily stools\nStools that are difficult to flush\nDecreases with\nfasting\nMay be associated with weight loss\nWatery diarrhea\nSecretory diarrhea\nLoose, watery stools\nNo change with\nfasting\nNocturnal diarrhea present\nFunctional diarrheal disorders\nDecreases with\nfasting\nDecreased at night\nOsmotic diarrhea\nDecreases with\nfasting\nDecreased at night\nFood triggers\nAssess for the presence of\nrisk factors\nfor specific etiologies, including:\nMore than\n700 medications\ncan cause diarrhea and, therefore, the introduction of a new medication within\n6–8 weeks\nof the onset of diarrhea should be considered as a potential cause.\n[15]\nChronic diarrhea\nis common after\nbariatric surgery\n.\n[19]\n[20]\nDiagnostics\nGeneral principles\n[10]\n[12]\n[22]\n[25]\nAcute diarrhea\nTesting is not required in the majority of cases.\nIndications for testing include the presence of\nred flags in diarrhea\nand\nrisk factors\nfor specific etiologies.\nPersistent diarrhea\n: Testing is usually limited to stool studies for\ninfectious gastroenteritis\n.\nChronic diarrhea\nTesting is initially broad with advanced\nfollow-up\ntesting as indicated.\n[21]\n[25]\nRepeat stool testing for\ninfectious gastroenteritis\n.\nDiagnostic testing is seldom indicated in\nacute diarrhea\nin the absence of\nred flag symptoms\n.\nTesting for diarrhea\nFor specific indications for testing, see the respective subsections below on acute, persistent, and\nchronic diarrhea\n.\nEndoscopic studies have limited diagnostic value in\nacute diarrhea\nbut are commonly needed for the workup of\nchronic diarrhea\nto evaluate for the presence of inflammatory or\nneoplastic\ndiseases\n. Their utility in\npersistent diarrhea\nis uncertain.\nStool diagnostic studies\nStool diagnostic studies\nin diarrhea\nSuspected etiology\nTest\nPurpose\nInfectious diseases\nStool culture\nIdentification of infectious agents (e.g., in\nbacterial gastroenteritis\n)\nStool microscopy\nVisualization of\nova\nor\nparasites\nin the stool\nCulture-independent methods, e.g.,\nmultiplex molecular diagnostic panel for diarrhea\n(\nPCR\n)\nIdentification of infectious agents in bacterial, viral, and\nprotozoal\ngastroenteritis\n[25]\nQuantitative culture of small intestinal\naspirate\nUsed to diagnose\nSIBO\n(\ngold standard test\nfor bacterial overgrowth)\nStool tests for C. difficile infection\n(e.g., toxin test)\nIdentification of\nC. difficile infection\nInflammation\nStool microscopy\nVisualization of fecal\nleukocytes\nFecal occult blood test\n(\nFOBT\n)\nTo screen for\nmalignancy\nand\nmucosal\ninflammation\nFIT DNA test\nTo screen for\ncolonic\ncancer and\nadenomatous polyps\nFecal calprotectin\nand\nlactoferrin\nMarkers of\ninflammatory bowel disease\n(\nIBD\n)\nMalabsorption\nSudan stain\nQualitative test for\nsteatorrhea\n72-hour quantitative fecal fat estimation\nQuantitative test for\nsteatorrhea\nFecal elastase-1\nConfirmation of\nsteatorrhea\ndue to\nexocrine pancreatic insufficiency\nStool\nelectrolytes\n(e.g.,\nNa\n+\n,\nK\n+\n)\nUsed to calculate\nstool osmotic gap\nStool\npH\nIdentification of\ncarbohydrate malabsorption\nStool osmotic gap\n[11]\n[16]\n[18]\nLow\nstool osmotic gap\nHigh\nstool osmotic gap\nOsmotic gap\n< 50\nmOsm\/kg\n≥ 100\nmOsm\/kg\nInterpretation\nSecretory diarrhea\n(\n↑ secretion\nand\/or inhibition of water absorption)\nor\nfunctional diarrhea\n(increased intestinal movement)\nOsmotic diarrhea\n(osmotic pull of ingested substances draws water into the intestinal lumen)\nExample causes\nFoodborne infections (e.g.,\nVibrio cholerae\n,\nenterotoxigenic E. coli\n)\nEndocrine tumors\n(e.g.,\nVIPoma\n, medullary\ncarcinoma\nof the\nthyroid\n,\ngastrinoma\n)\nImpaired absorption of\nbile acids\nand\/or salts (\nbile acid diarrhea\n)\nOsmotic laxative\ningestion\n(e.g.,\nmagnesium citrate\n)\nMalabsorption\n(e.g.,\nceliac disease\n,\nWhipple disease\n)\nPancreatic\ninsufficiency\nThe loss of\nbicarbonate\n-rich fluid in severe diarrhea may cause nonanion gap\nmetabolic acidosis\n.\nSupportive care\nAcute or persistent diarrhea (≤ 30 days)\nThe management of\nacute diarrhea\nis primarily supportive, as the disease is usually a\nself-limited\nviral infection. Further management focuses on determining whether diagnostic testing and directed therapy are needed (e.g.,\nantibiotic therapy\nfor\nbacterial gastroenteritis\n).\n[22]\nIf symptoms of an\nacute abdomen\nare present, consider an urgent\nCT abdomen\nto identify\nischemic\n, hemorrhagic, obstructive, and\/or inflammatory diseases.\n[28]\nWhen indicated, stool studies in patients with\nacute diarrhea\nshould include tests that can detect the presence of\nSalmonella\n,\nShigella\n,\nCampylobacter\n,\nYersinia\n,\nC. difficile infection\n, and\nShiga toxin-producing E. coli\n.\n[31]\nNoninflammatory diarrhea (\nwatery diarrhea\n)\n[21]\n[25]\n[31]\nInflammatory diarrhea\n(\ndysentery\n)\n[28]\nIn patients with prominent abdominal\npain\nand\/or bloody diarrhea, evaluate for\nischemic colitis\n,\nulcerative colitis\n, and\nCrohn disease\nif stool testing does not indicate an infectious etiology.\nPersistent diarrhea\nhas a broader differential diagnosis than\nacute diarrhea\n. Parasitic infection (e.g.,\ngiardiasis\n), recurrent bacterial infection (e.g.,\nC. difficile infection\n), and noninfectious causes (e.g.,\nIBS-D\n) must be considered.\n[32]\nEtiology of acute and persistent diarrhea\nViral\n[21]\nNorovirus infection\nRotavirus infection\nAdenovirus\ninfection (mainly\nserotypes\n3\n, 40,\nand 41\n)\n[6]\nCytomegalovirus infection\nCoronavirus\n(\nCOVID-19\n)\nBacterial\nCholera\n(“rice water” diarrhea)\nEnterotoxigenic E. coli\ninfection (\ntraveler's diarrhea\n)\nC. perfringens\ninfection\nC. difficile\ninfection (associated with\nantibiotic\nand\nPPI\nuse)\nShigellosis\n(\nbacillary dysentery\n)\nNontyphoidal:\nsalmonellosis\nEnteroinvasive E. coli\n,\nenterohemorrhagic E. coli\n(\nO157:H7\n) infection\nCampylobacteriosis\nYersiniosis\nLegionella\nParasitic\nGiardiasis\nAmebiasis\nCryptosporidiosis\nEnterobiasis\nAscariasis\nFood poisoning\nS. aureus\ninfection\nBotulism\nBacillus cereus\ninfection\nAflatoxin\nHistamine\ntoxicity\n[7]\nTetrodotoxin\n,\nciguatoxin\nMedications\nAntibiotics\nLaxatives\nPPIs\nSSRIs\nNSAIDs\nOther\nChemical contaminants (e.g., lead,\ncadmium\n, insecticides,\narsenic\n)\n[8]\nMushroom poisoning\n[9]\nBowel ischemia\nNeutropenic enterocolitis\nChronic diarrhea (> 30 days)\nThe differential diagnosis of\nchronic diarrhea\nis extensive. A systematic approach with efficient use of testing is needed to arrive at a diagnosis quickly.\n[10]\n[12]\n[33]\nChronic diarrhea\ncan be classified as inflammatory, fatty, or watery. Grouping patients into broad categories based on clinical features and basic laboratory findings narrows the differential diagnosis and facilitates efficient advanced testing.\n[18]\nIBS-D\nis an intermediate diagnosis; it does not eliminate the possibility of another disease. Evaluation should continue if symptoms persist despite treatment for\nIBS-D\n.\n[12]\nChronic diarrhea\nis commonly classified as watery, fatty, or inflammatory.\nEtiology of chronic diarrhea\n[12]\nInflammatory\nInflammatory bowel disease\n:\nCrohn disease\n,\nulcerative colitis\nInvasive infections\nBacterial: e.g.,\npseudomembranous colitis\n,\ntuberculosis\nViral: e.g.,\nCMV\nParasitic: e.g.,\nEntamoeba histolytica\nMedications: e.g.,\nPPIs\n,\nNSAIDs\n,\ntyrosine kinase inhibitors\nOther: e.g.,\nischemic colitis\n,\nradiation colitis\n,\nmalignancy\n(e.g.,\ncolon cancer\n,\nlymphoma\n)\nFatty\nMalabsorption\nInfections:\nSIBO\n,\ntropical sprue\n,\nWhipple disease\n,\ngiardiasis\nMedications: e.g.,\naminoglycosides\n,\nantiretroviral drugs\nOther: e.g.,\nceliac disease\n, postsurgical changes, lymphatic obstruction\nMaldigestion\nInadequate\nbile acid\nconcentration: e.g., due to hepatobiliary disease or\nileal\nresection\nExocrine pancreatic insufficiency\n: e.g., due to\nchronic pancreatitis\nor\ncystic fibrosis\nWatery\nSecretory\nInfections: e.g.,\ngiardiasis\n,\ncryptosporidiosis\n,\nSIBO\nMedications: e.g.,\nstimulant laxatives\n,\nlevodopa\n,\ncaffeine\nNeuroendocrine tumors\n[11]\nEndocrine diseases: e.g.,\nhyperthyroidism\n,\nAddison disease\n,\ndiabetes mellitus\nOther:\nbile acid\nmalabsorption\n,\nIBD\n,\nmicroscopic colitis\nFunctional\nIrritable bowel syndrome\n(\nIBS\n)\nMedications: e.g.,\nprokinetics\nFunctional diarrhea\nOsmotic\nCarbohydrate malabsorption\nUnabsorbed sugars in the diet and\/or in chewing\ngum\n: e.g.,\nsorbitol\n,\nmannitol\nEnzymatic dysfunction: e.g.,\nlactase deficiency\nMedications: e.g.,\nosmotic laxatives\nOther: e.g.,\nceliac disease\n,\nFODMAP\nintolerance,\nenteral feeding\nOrder initial studies. See also “Testing for diarrhea” in “Diagnostics.”\nAlways test for\nGiardia\ninfection in\nchronic diarrhea\n.\n[24]\nPerform guided diagnostics based on\ncharacteristic clinical features in diarrhea\nand the results of initial diagnostic testing.\nDiagnostic workup of patients with\nchronic diarrhea\nClassification\nInitial results\nFurther diagnostics\nInflammatory diarrhea\nFecal\nleukocytes\npresent.\nFecal occult blood positive\nCalprotectin or\nlactoferrin\npositive\nElevated\nCRP\nColonoscopy\nwith\nmucosal\nbiopsies\n(always required): can identify\nIBD\n,\ncolon cancer\n,\nischemic colitis\n,\nradiation colitis\n, and\npseudomembranous colitis\nTesting for infectious diseases: e.g.,\nparasites\n(\namebiasis\n) and\nC. difficile infection\nFatty diarrhea\n[10]\n[12]\n[16]\nIncreased fecal fat, e.g.:\nSudan stain\npositive\n72-hour fecal fat estimation\nelevated\nMucosal\ndisease:\nceliac disease panel\nand\nEGD\nwith\nbiopsies\nLuminal disease\nPancreatic function tests\n(e.g.,\nfecal elastase-1\n): can identify\nexocrine pancreatic insufficiency\n[18]\nHydrogen breath test\nand\nEGD\nwith\nsmall bowel aspiration\nand cultures: can identify\nSIBO\n[34]\nWatery diarrhea\n[11]\nSecretory diarrhea\nor\nfunctional diarrheal disorders\nLow\nstool osmotic gap\n(\n< 50\nmOsm\/kg\n)\nNo fecal\nleukocytes\nNo fecal fat\nTFTs\n,\ncortisol\nlevel,\ndiabetes mellitus screening\n: can detect endocrine disorders\nSerum\ngastrin\n,\nVIP\n,\ncalcitonin\nlevel: can detect\nneuroendocrine tumors\nEvaluation for\nbile acid\nmalabsorption\nand\nSIBO\nRome IV criteria for IBS\n: may indicate\nfunctional diarrhea\nOsmotic diarrhea\nHigh\nstool osmotic gap\n(\n≥ 100\nmOsm\/kg)\nNo fecal\nleukocytes\nNo fecal fat\nStool\npH\n< 6\nsuggests\ncarbohydrate malabsorption\n;\nconsider the following:\n[11]\nCeliac disease panel\nLactose hydrogen breath test\n: can diagnose\nlactase deficiency\nSmall intestine biopsy\n: can diagnose\nceliac disease\nor infectious diseases (e.g.,\nWhipple disease\n)\nStool\npH\n≥ 6\nsuggests\nantacid\nand\/or\nlaxative\ningestion\nIn\nwatery diarrhea\n, the\nstool osmotic gap\ndifferentiates osmotic from\nsecretory diarrhea\n. In osmotic\nwatery diarrhea\n, a stool\npH\n< 6\nsuggests\ncarbohydrate malabsorption\n.\nEndoscopic studies with\nmucosal\nbiopsies\nare required to diagnose\ninflammatory diarrhea\nin patients with\nchronic diarrhea\n.\nDifferential diagnoses\nReferences:\n[11]\n[22]\n[23]\nThe differential diagnoses listed here are not exhaustive.\nSubtypes and variants\nTraveler's diarrhea\n[36]\n[37]\nDefinition\n:\n≥ 3\nunformed stools with at least one additional\nenteric\nsymptom occurring after recent travel\nEpidemiology\nThe highest rates occur after travel to Africa and South, Central, and West Asia.\nApproximately 25% of all travelers develop\ntraveler's diarrhea\n.\nEtiology\nEnterotoxigenic E. coli\n(\nETEC\n)\nis the most common cause of\ntraveler's diarrhea\nglobally.\nCampylobacter jejuni\nis the most common cause in Southeast Asia.\nOther pathogens\nClinical features\n:\nexudative\n-inflammatory or\nsecretory diarrhea\n, abdominal cramping, abdominal\npain\nAntibiotics for\ntraveler's diarrhea\n: Reserve for moderate to severe illness.\n[25]\n[32]\n[36]\nFor most destinations:\nciprofloxacin\n(\noff label\n)\nOR\nrifaximin\n[36]\nFor travelers to South or Southeast Asia:\nazithromycin\n(\noff label\n)\n[36]\nSupportive care\n[25]\nTreatment for\ndehydration\n(e.g.,\noral rehydration solution\n)\nBismuth subsalicylate\nfor patients with mild to moderate illness\nLoperamide\nfor patients receiving\nantibiotic therapy\n(can reduce the duration of illness)\nSee “\nAntidiarrheal agents\n” for dosages.\nPostinfectious sequelae\nPostinfectious IBS\n: may occur in\n3–20%\nof patients\nReactive arthritis\n: may last months to years\nGuillain-Barre syndrome\n: may develop\n1–4 weeks\nafter infection (most commonly after\nCampylobacter\ninfection)\nAntibiotic\ntreatment is not recommended in patients with mild\ntraveler's diarrhea\n.\nBismuth subsalicylate\nis an\nantidiarrheal agent\nused to treat\ntraveler's diarrhea\n(caused by\nenterotoxigenic Escherichia coli\n).\nPharmacological prophylaxis for\ntraveler's diarrhea\n[25]\n[36]\nConsider for travelers to high-risk areas (under specialist guidance); options include:\nFactitious diarrhea\n[11]\nDefinition\n:\nself-induced diarrhea, usually due to\nlaxative abuse\n(often occurs in individuals with\nfactitious disorders\n)\n, or dilution of stools with solutions\nEpidemiology\nMost prevalent in women\nPatients are usually\nhealth care professionals\n.\nHistory of multiple hospital admissions\nClinical features\n:\nchronic diarrhea\nwithout an identifiable cause\nDiagnostics\nLaboratory tests:\nmetabolic acidosis\n,\nmetabolic alkalosis\n,\nhypokalemia\n,\nhypermagnesemia\nStool\nosmolarity\n< 290 mOsm\/L\n: indicates dilution of the stool with a hypotonic solution\n> 600 mOsm\/L\n: indicates dilution of the stool with a hypertonic solution\nLaxative\nscreen\n[18]\nColonoscopy\n: may show\nmelanosis coli\nin cases of anthraquinone\nabuse\nTreatment\nLaxative abuse\nTypes of\nlaxative\nClinical features\nOsmotic diarrhea\n,\nmeteorism\nDehydration\nHypokalemia\nMelanosis coli\n: benign\nhyperpigmentation\nof the\ncolonic\nmucosa\ncaused by anthraquinone abuse\n[39]\nReferences\nSweetser S. Evaluating the Patient With Diarrhea: A Case-Based Approach.\nMayo Clinic Proceedings\n. 2012; 87 (6): p.596-602.\ndoi:\n10.1016\/j.mayocp.2012.02.015\n.\n|\nOpen in Read by QxMD\nJamshed N, Lee Z-E, Olden KW. Diagnostic Approach to Chronic Constipation in Adults.\nAm Fam Physician\n. 2011; 84 (3): p.299-306.\nBurgers K, Lindberg B, Bevis ZJ. Chronic Diarrhea in Adults: Evaluation and Differential Diagnosis..\nAm Fam Physician\n. 2020; 101 (8): p.472-480.\nSchiller LR. Evaluation of chronic diarrhea and irritable bowel syndrome with diarrhea in adults in the era of precision medicine.\nAm J Gastroenterol\n. 2018; 113 (5): p.660-669.\ndoi:\n10.1038\/s41395-018-0032-9\n.\n|\nOpen in Read by QxMD\nAbraham B, Sellin JH. Drug-induced diarrhea.\nCurr Gastroenterol Rep\n. 2007; 9 (5): p.365-372.\ndoi:\n10.1007\/s11894-007-0044-x\n.\n|\nOpen in Read by QxMD\nSemrad CE.\nApproach to the Patient with Diarrhea and Malabsorption\n. Elsevier ; 2012: p. 895-913\nFarahmandfar MR, Chabok M, Alade M, Bouhelal A, Patel B. Post Cholecystectomy Diarrhoea—A Systematic Review.\nSurgical Science\n. 2012; 03 (06): p.332-338.\ndoi:\n10.4236\/ss.2012.36065\n.\n|\nOpen in Read by QxMD\nSchiller LR, Pardi DS, Sellin JH. Chronic Diarrhea: Diagnosis and Management.\nClinical Gastroenterology and Hepatology\n. 2017; 15 (2): p.182-193.e3.\ndoi:\n10.1016\/j.cgh.2016.07.028\n.\n|\nOpen in Read by QxMD\nBorbély YM, Osterwalder A, Kröll D, Nett PC, Inglin RA. Diarrhea after bariatric procedures: Diagnosis and therapy.\nWorld Journal of Gastroenterology\n. 2017; 23 (26): p.4689.\ndoi:\n10.3748\/wjg.v23.i26.4689\n.\n|\nOpen in Read by QxMD\nMa IT, Madura JA 2nd. Gastrointestinal Complications After Bariatric Surgery.\nGastroenterol Hepatol\n. 2015; 11 (8): p.526-35.\nBarr W, Smith A. Acute diarrhea in adults.\nAm Fam Physician\n. 2014; 89 (3): p.180-189.\nJameson JL, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J.\nHarrison's Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2)\n. McGraw-Hill Education \/ Medical ; 2018\nHammer HF. Management of Chronic Diarrhea in Primary Care:  The Gastroenterologists Advice.\nDigestive Diseases\n. 2021.\ndoi:\n10.1159\/000515219\n.\n|\nOpen in Read by QxMD\nSmalley W, Falck-Ytter C, Carrasco-Labra A, Wani S, Lytvyn L, Falck-Ytter Y. AGA Clinical Practice Guidelines on the Laboratory Evaluation of Functional Diarrhea and Diarrhea-Predominant Irritable Bowel Syndrome in Adults (IBS-D).\nGastroenterology\n. 2019; 157 (3): p.851-854.\ndoi:\n10.1053\/j.gastro.2019.07.004\n.\n|\nOpen in Read by QxMD\nCamilleri M, Sellin JH, Barrett KE. Pathophysiology, Evaluation, and Management of Chronic Watery Diarrhea.\nGastroenterology\n. 2017; 152 (3): p.515-532.e2.\ndoi:\n10.1053\/j.gastro.2016.10.014\n.\n|\nOpen in Read by QxMD\nPimentel M, Saad RJ, Long MD, Rao SSC. ACG Clinical Guideline: Small Intestinal Bacterial Overgrowth.\nAm J Gastroenterol\n. 2020; 115 (2): p.165-178.\ndoi:\n10.14309\/ajg.0000000000000501\n.\n|\nOpen in Read by QxMD\nVijayvargiya P, Camilleri M, Shin A, Saenger A. Methods for Diagnosis of Bile Acid Malabsorption in Clinical Practice.\nClinical Gastroenterology and Hepatology\n. 2013; 11 (10): p.1232-1239.\ndoi:\n10.1016\/j.cgh.2013.04.029\n.\n|\nOpen in Read by QxMD\nRiddle MS, DuPont HL, Connor BA. ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults.\nAm J Gastroenterol\n. 2016; 111 (5): p.602-622.\ndoi:\n10.1038\/ajg.2016.126\n.\n|\nOpen in Read by QxMD\nDuPont HL. Acute Infectious Diarrhea in Immunocompetent Adults.\nN Engl J Med\n. 2014; 370 (16): p.1532-1540.\ndoi:\n10.1056\/nejmra1301069\n.\n|\nOpen in Read by QxMD\nShane AL, Mody RK, Crump JA, et al. 2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea.\nClin Infect Dis\n. 2017; 65 (12): p.e45-e80.\ndoi:\n10.1093\/cid\/cix669\n.\n|\nOpen in Read by QxMD\nDuPont HL. Persistent Diarrhea.\nJAMA\n. 2016; 315 (24): p.2712.\ndoi:\n10.1001\/jama.2016.7833\n.\n|\nOpen in Read by QxMD\nQiu FZ, Shen XX, Li GX, et al. Adenovirus associated with acute diarrhea: a case-control study..\nBMC Infect Dis\n. 2018; 18 (1): p.450.\ndoi:\n10.1186\/s12879-018-3340-1\n.\n|\nOpen in Read by QxMD\nHistamine Toxicity.\nhttps:\/\/www.aaaai.org\/conditions-and-treatments\/related-conditions\/histamine-toxicity\n. Updated: March 1, 2017. Accessed: March 1, 2017.\nOverview of Food Poisoning.\nhttp:\/\/www.msdmanuals.com\/home\/injuries-and-poisoning\/poisoning\/overview-of-food-poisoning\n. Updated: March 1, 2017. Accessed: March 1, 2017.\nJuckett G, Trivedi R. Evaluation of Chronic Diarrhea.\nAm Fam Physician\n. 2011; 84 (10): p.1119-1126.\nDuPont HL. Adverse Effect of Lomotil Therapy in Shigellosis.\nJAMA\n. 1973; 226 (13): p.1525.\ndoi:\n10.1001\/jama.1973.03230130013006\n.\n|\nOpen in Read by QxMD\nSingh N, Narayan S. Racecadotril : A Novel Antidiarrheal.\nMed J Armed Forces India\n. 2008; 64 (4): p.361-2.\ndoi:\n10.1016\/S0377-1237(08)80022-6\n.\n|\nOpen in Read by QxMD\nBenjamin I.\nAndreoli and Carpenter's Cecil Essentials of Medicine\n. Elsevier Health Sciences ; 2016\nDiarrhoeal disease.\nhttp:\/\/www.who.int\/mediacentre\/factsheets\/fs330\/en\/\n. Updated: April 1, 2013. Accessed: March 1, 2017.\nSchiller LR, Pardi DS, Spiller R, et al. Gastro 2013 APDW\/WCOG Shanghai Working Party Report: Chronic diarrhea: Definition, classification, diagnosis.\nJ Gastroenterol Hepatol\n. 2013; 29 (1): p.6-25.\ndoi:\n10.1111\/jgh.12392\n.\n|\nOpen in Read by QxMD\nDellon ES, Ringel Y. Treatment of functional diarrhea.\nCurr Treat Options Gastroenterol\n. 2006; 9 (4): p.331-342.\ndoi:\n10.1007\/s11938-006-0015-6\n.\n|\nOpen in Read by QxMD\nTravelers' Diarrhea.\nhttps:\/\/web.archive.org\/web\/20240929175416\/https:\/\/wwwnc.cdc.gov\/travel\/yellowbook\/2024\/preparing\/travelers-diarrhea\n. Updated: November 22, 2019. Accessed: September 29, 2024.\nGiddings SL, Stevens AM, Leung DT. Traveler’s Diarrhea.\nMed Clin North Am\n. 2016; 100 (2): p.317-330.\ndoi:\n10.1016\/j.mcna.2015.08.017\n.\n|\nOpen in Read by QxMD\nHerbert L. DuPont, Charles D. Ericsson, P. C. Johnson, F. Javier de la Cabada. Use of Bismuth Subsalicylate for the Prevention of Travelers' Diarrhea.\nClinical Infectious Diseases\n. 1990; 12 (Supplement_1): p.S64-S67.\ndoi:\n10.1093\/clinids\/12.supplement_1.s64\n.\n|\nOpen in Read by QxMD\nFreeman HJ. “Melanosis” in the small and large intestine.\nWorld J Gastroenterol\n. 2008; 14 (27): p.4296.\ndoi:\n10.3748\/wjg.14.4296\n.\n|\nOpen in Read by QxMD\nWalters JR, Pattni SS. Managing bile acid diarrhoea..\nTherap Adv Gastroenterol.\n. 2010; 3 (6): p.349-57.\ndoi:\n10.1177\/1756283X10377126\n.\n|\nOpen in Read by QxMD\nFarrugia A, Arasaradnam R. Bile acid diarrhoea: pathophysiology, diagnosis and management.\nFrontline Gastroenterology\n. 2020; 12 (6): p.500-507.\ndoi:\n10.1136\/flgastro-2020-101436\n.\n|\nOpen in Read by QxMD\nGuidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV.\nhttps:\/\/web.archive.org\/web\/20260126024001\/https:\/\/clinicalinfo.hiv.gov\/sites\/default\/files\/guidelines\/documents\/adult-adolescent-oi\/guidelines-adult-adolescent-oi.pdf\n. Updated: July 14, 2025. Accessed: January 25, 2026.\nKasper DL, Fauci AS, Hauser SL, et al.\nHarrison's Principles of Internal Medicine\n. McGraw-Hill Education ; 2015\nWalker HK, Hall WD, Hurst WJ, Silverman ME, Morrison G.\nClinical Methods: The History, Physical, and Laboratory Examinations\n. Butterworths ; 1990\nSaad RJ, Chey WD. Breath Testing for Small Intestinal Bacterial Overgrowth: Maximizing Test Accuracy.\nClin Gastroenterol Hepatol\n. 2014; 12 (12): p.1964-1972.\ndoi:\n10.1016\/j.cgh.2013.09.055\n.\n|\nOpen in Read by QxMD","attrs_markdown":"[![ambossIcon](https:\/\/manus-media.amboss.com\/2020\/07\/amboss-icon.svg)![ambossIcon](https:\/\/knowledge.manus.amboss.com\/\/_next\/static\/media\/ambossMobileLogo.f21d813f.svg)](https:\/\/www.amboss.com\/)\n\nExpand all sections\n\n[Start free trial](https:\/\/next.amboss.com\/us\/registration?nextLink=%2Farticle%2F6M0jpg)[Log in](https:\/\/next.amboss.com\/us\/login?nextLink=%2Farticle%2F6M0jpg)\n\n# Diarrhea\nLast updated: February 27, 2026\n\n## Quick guide![toggle arrow icon](https:\/\/manus-media.amboss.com\/icons\/chevron_up.svg)\n## Diagnostic approach\n- [Inflammatory diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z321586a3cfe84e9365a55d0ed20fb62a)\n  or noninflammatory diarrhea that is not\n  [self-limited]()\n  : stool\n  [GI pathogen panel]()\n  (\n  [PCR](https:\/\/www.amboss.com\/us\/knowledge\/Laboratory_methods#Z3a8f5e31aa62111944442fd86660cc27)\n  ) or culture\n- Severe illness with\n  [fever](https:\/\/www.amboss.com\/us\/knowledge\/Fever#Za5de83449ff6a749e6c1348b93b1f3b1)\n  :\n  [CBC](https:\/\/www.amboss.com\/us\/knowledge\/Laboratory_medicine#Z4ccf935251884533761ac0c529e17a64)\n  ,\n  [CMP](https:\/\/www.amboss.com\/us\/knowledge\/Laboratory_medicine#Z7213a5e3683814d58d65a66c5bc3ebc8)\n  ,\n  [ESR](https:\/\/www.amboss.com\/us\/knowledge\/Laboratory_medicine#Zde306dd72fd9fa8f94347d3f2edafc20)\n  ,\n  [CRP](https:\/\/www.amboss.com\/us\/knowledge\/Laboratory_medicine#Z51ad1e101a45a8de708a6dda0321755d)\n  ,\n  [blood cultures](https:\/\/www.amboss.com\/us\/knowledge\/Blood_cultures#Zbbc1ac48182c8850d109967ff3d2e390)\n- [Risk factors for C. difficile infection](https:\/\/www.amboss.com\/us\/knowledge\/Clostridioides_difficile_infection#Zcec32f67ae45a4b1cf8f0cc5aebd5531):\n  [C. difficile](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Z429d21670093a08ffb061528b0561719)\n  [PCR](https:\/\/www.amboss.com\/us\/knowledge\/Laboratory_methods#Z3a8f5e31aa62111944442fd86660cc27)\n  or\n  [EIA]()\n\nDiagnostic testing is not indicated for most cases of\n\n[acute diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z9902a484faaf54b4fa1ffaf3a5642113)\n\n.\n\n## Management checklist\n- Mild to [moderate dehydration](https:\/\/www.amboss.com\/us\/knowledge\/Dehydration_and_hypovolemia#Z3e5c63fd98cfbd4f25d0b664d4f03f46):\n  [oral rehydration therapy](https:\/\/www.amboss.com\/us\/knowledge\/Dehydration_and_hypovolemia#Zbadf5641ef1ee8851ce3026721b8d40a)\n- [Severe dehydration](https:\/\/www.amboss.com\/us\/knowledge\/Dehydration_and_hypovolemia#Zeba0372b757bc3e729c979470fccb192):\n  [IV fluid resuscitation](https:\/\/www.amboss.com\/us\/knowledge\/Shock#Zee3c52d5a0e0844921b94c537f7d8ba3)\n- [Antidiarrheal agents](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zc9c4c39a6ce3413ed32214ba89c1e777)\n  (as needed):\n  [bismuth](https:\/\/www.amboss.com\/us\/knowledge\/Helicobacter_pylori_infection#Z5ff316bf4e8912c06dc600df2a9e8b09)\n  (safe for all patients),\n  [loperamide](https:\/\/www.amboss.com\/us\/knowledge\/Opioids#Z1881077ac71cd771cb44b7db04569ac0)\n  (for patients with noninflammatory diarrhea)\n- [Supportive therapy for gastroenteritis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z4af26ac012a1ba5baaeb3984fc722116)\n- [Empiric antibiotics for bacterial gastroenteritis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z8bc7c574b3a32ce97b6e98deca3d7a27) as indicated\n- Suspected\n  [C. difficile infection](https:\/\/www.amboss.com\/us\/knowledge\/Clostridioides_difficile_infection#Zb508f99ee028a9d8582608f40bc36f5f)\n  : [antibiotic therapy for CDI](https:\/\/www.amboss.com\/us\/knowledge\/Clostridioides_difficile_infection#Z43f44aea11b5aaeae031f90cc2c21617)\n- [Traveler's diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zed77ffe538dae231e40fe0542e7b245a)\n  :\n  [ciprofloxacin](https:\/\/www.amboss.com\/us\/knowledge\/Overview_of_antibiotic_therapy#Z3f1dbc417664139dda097bcd516ceeed)\n  (\n  [off label](https:\/\/www.amboss.com\/us\/knowledge\/Fundamentals_of_pharmacology#Zb37ab5e3f79a4ddd6b356eb84fa0067a)\n  )\n  (most destinations) OR\n  [azithromycin](https:\/\/www.amboss.com\/us\/knowledge\/Overview_of_antibiotic_therapy#Z9884c173cd8bcd36d44eb85ea8acfec2)\n  (\n  [off label](https:\/\/www.amboss.com\/us\/knowledge\/Fundamentals_of_pharmacology#Zb37ab5e3f79a4ddd6b356eb84fa0067a)\n  )\n  (travelers to South or Southeast Asia)\n## [Red flag features]()\n- [Fever](https:\/\/www.amboss.com\/us\/knowledge\/Fever#Za5de83449ff6a749e6c1348b93b1f3b1)\n- [Hypotension](https:\/\/www.amboss.com\/us\/knowledge\/Cardiovascular_examination#Zb5022b8fa3fa419ab039a0f8d70866a2)\n- [Severe dehydration](https:\/\/www.amboss.com\/us\/knowledge\/Dehydration_and_hypovolemia#Zeba0372b757bc3e729c979470fccb192)\n- Bloody stools\n- Severe abdominal [pain](https:\/\/www.amboss.com\/us\/knowledge\/Principles_of_pain_management#Zd673a3f7ee36023aab5a267899e984cc)\n- Chronic illness\n- [Immunocompromise](https:\/\/www.amboss.com\/us\/knowledge\/Adaptive_immune_system#Z1af19ecc772907dd339670b5fb0e8b51)\n- Age \\> 65 years\n- Recent [antibiotic](https:\/\/www.amboss.com\/us\/knowledge\/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3) use\n- \\> 48 hours duration without improvement\n## Life-threatening causes\n- [Hemolytic uremic syndrome](https:\/\/www.amboss.com\/us\/knowledge\/Hemolytic_uremic_syndrome#Z759bb631d23a3535c2b55dfd91c4807b)\n- [Gas gangrene](https:\/\/www.amboss.com\/us\/knowledge\/Gas_gangrene#Zc843bd9262a7db4767485d787d9c2653)\n- [Shigellosis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Zd4a3455e8ec3d03f2e705d784ba584b0)\n- [Cholera](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Zba6a00519c1b345599491aa93180aacf)\n- [Ischemic colitis](https:\/\/www.amboss.com\/us\/knowledge\/Intestinal_ischemia#Za5a3e828cf2d10df3a9693a9fc3b2c34)\n\n## Summary![toggle arrow icon](https:\/\/manus-media.amboss.com\/icons\/chevron_up.svg)\nDiarrhea, defined as three or more loose stools per day or more frequent stool passage than is normal for the individual, is a common disease with a monthly [prevalence](https:\/\/www.amboss.com\/us\/knowledge\/Population_health#Z44a0fb80a8923b6e2fb8ff1f83d5803a) of around 5% in the United States. [Acute diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z9902a484faaf54b4fa1ffaf3a5642113) lasts 14 days or less and is almost always caused by an infectious agent, typically a [virus](https:\/\/www.amboss.com\/us\/knowledge\/General_virology#Zcdc83877f75d9d9b9a07ece6544f646c). Testing is seldom required, as the disease tends to be [self-limited]() and care is primarily supportive. [Persistent diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zd56cfaa165f80b20fe15e54d5f2c0023), lasting 15–30 days, is also typically caused by an infectious agent, but stool testing for pathogens is generally warranted to confirm the diagnosis. [Chronic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a), defined as diarrhea lasting longer than 30 days, has an extensive differential diagnosis. A thorough history followed by systematic stool and blood testing is required to identify the specific etiology. The presence of any [red flags]() for severe or rapidly progressing diarrheal disease (e.g., [sepsis](https:\/\/www.amboss.com\/us\/knowledge\/Sepsis#Zb3de189fac0d57eac5b7798e127a5e19), extreme [dehydration](https:\/\/www.amboss.com\/us\/knowledge\/Dehydration_and_hypovolemia#Zbd78324053c153c16ea5cb2574249398), blood in the stool) mandates escalation of testing and, in some cases, [empiric antibiotics for bacterial gastroenteritis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z8bc7c574b3a32ce97b6e98deca3d7a27). Ensuring adequate oral hydration, correcting [dehydration](https:\/\/www.amboss.com\/us\/knowledge\/Dehydration_and_hypovolemia#Zbd78324053c153c16ea5cb2574249398), and providing symptomatic relief are fundamental components in the care of all patients with diarrhea. Curative treatment is directed toward the underlying cause.\n\n## Definitions![toggle arrow icon](https:\/\/manus-media.amboss.com\/icons\/chevron_up.svg)\nThe WHO defines diarrhea as ≥ 3 loose or watery stools per day or more frequent passage than is normal for the individual.  \\[1\\]\\[2\\]\n\n## Etiology![toggle arrow icon](https:\/\/manus-media.amboss.com\/icons\/chevron_up.svg)\nFor etiologies of acute, persistent, or [chronic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a), see specific subsections below.\n\n## [Overview of pathogens causing watery and bloody diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z8e48114f95d466b966813a8876de0264)\n| Overview |   |   |   |   |\n|---|---|---|---|---|\n| Type of diarrhea | [Pathogen]() | [Pathogen]() characteristics | Associated disorders |   |\n| [Watery diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z16ed63f1f94f558cfbffed53ce14a7fb) | Enterotoxigenic [Escherichia coli](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Z2018b58c3c7835457287264e40fa1a3c) | [Heat-labile toxin](https:\/\/www.amboss.com\/us\/knowledge\/Diarrheagenic_E._coli#Zb07ccb32bbf8bafda07228b738b272b0) [Heat-stable toxin](https:\/\/www.amboss.com\/us\/knowledge\/Diarrheagenic_E._coli#Z05a3bf9bd37c476e311abbdb16510192) | [Traveler's diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zed77ffe538dae231e40fe0542e7b245a) |   |\n| [Clostridioides difficile](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Z429d21670093a08ffb061528b0561719) | [Toxin A](https:\/\/www.amboss.com\/us\/knowledge\/Clostridioides_difficile_infection#Z953ec09a4d6afc7094cd488f8493999f) ([enterotoxin]()) [Toxin B](https:\/\/www.amboss.com\/us\/knowledge\/Clostridioides_difficile_infection#Za0f3dac89ddbb94c6ce33441f7ca29d0) (cytotoxin) Associated with [antibiotic](https:\/\/www.amboss.com\/us\/knowledge\/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3) and [PPI](https:\/\/www.amboss.com\/us\/knowledge\/Proton_pump_inhibitors#Z2753e50142e2f5b7089b165accdcc900) use | [Pseudomembranous colitis](https:\/\/www.amboss.com\/us\/knowledge\/Clostridioides_difficile_infection#Z9a45a83f4126940236032056da651cf6) Rarely causes bloody diarrhea |   |   |\n| [Clostridium perfringens](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Z927388b963f796f8c6f170841d77b930) | [Heat-labile enterotoxin](https:\/\/www.amboss.com\/us\/knowledge\/Diarrheagenic_E._coli#Zb07ccb32bbf8bafda07228b738b272b0) [Clostridium perfringens alpha toxin](https:\/\/www.amboss.com\/us\/knowledge\/Gas_gangrene#Z29badee7cb2803331016ab554584eccc) | [Gas gangrene](https:\/\/www.amboss.com\/us\/knowledge\/Gas_gangrene#Zc843bd9262a7db4767485d787d9c2653) |   |   |\n| [Vibrio cholerae](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Z5040d5b8f384d034307ec998d5706c4a) | Straight or curved (comma-shaped) [Cholera toxin](https:\/\/www.amboss.com\/us\/knowledge\/General_bacteriology#Z463b688997a9f1dd2f1a2f94cbafd0f9) ([enterotoxin]()): “rice water” diarrhea Transmission via contaminated water or uncooked seafood (e.g., raw shellfish) | [Cholera](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Zba6a00519c1b345599491aa93180aacf) |   |   |\n| [Viruses](https:\/\/www.amboss.com\/us\/knowledge\/General_virology#Zcdc83877f75d9d9b9a07ece6544f646c) | [Norovirus](https:\/\/www.amboss.com\/us\/knowledge\/General_virology#Z85b05d149dafb61d67a5c48e9a2fdb65) (most common cause) | Fecal-oral or [airborne transmission]() | [Gastroenteritis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Zcbd93ce063d015f699fd07ed09015b7f) |   |\n| [Rotavirus](https:\/\/www.amboss.com\/us\/knowledge\/General_virology#Z0b6c006e84714af76f7c43bebbeb2315) | [Fecal-oral transmission]() Prevention: attenuated [vaccine](https:\/\/www.amboss.com\/us\/knowledge\/Vaccination#Zce79039ee0c9c756b2e006d3be169afc) for children |   |   |   |\n| [Adenovirus](https:\/\/www.amboss.com\/us\/knowledge\/General_virology#Z5251a57602a66d951ca7a8a66643ee51) | Transmission via contaminated water or [fecal-oral route]() |   |   |   |\n| [Protozoa](https:\/\/www.amboss.com\/us\/knowledge\/General_parasitology#Z8f4f3567860a31947bee8edff7ea6bd5) | [Giardia lamblia](https:\/\/www.amboss.com\/us\/knowledge\/Giardiasis#Zc37e227ee434dce8d190d098017db709) | Transmission via ingestion of contaminated water (e.g., lakes, rivers, ponds, swimming pools) Most commonly affects hikers or campers | [Giardiasis](https:\/\/www.amboss.com\/us\/knowledge\/Giardiasis#Z7285e874bce9a0f39983534a6c838736) |   |\n| [Cryptosporidia](https:\/\/www.amboss.com\/us\/knowledge\/Food_poisoning#Z2838c305630a575a1e345dd9004ef9ea) | [Fecal-oral transmission]() ([oocysts]() are typically excreted in stool and contaminate drinking water) | [Cryptosporidiosis](https:\/\/www.amboss.com\/us\/knowledge\/HIV-associated_conditions#Z50d6fcd479428e63a00b9454e02cad44) [Immunocompromised individuals](https:\/\/www.amboss.com\/us\/knowledge\/Adaptive_immune_system#Z1af19ecc772907dd339670b5fb0e8b51): potentially life-threatening protracted diarrhea and\/or [biliary tract](https:\/\/www.amboss.com\/us\/knowledge\/Gallbladder_and_bile#Zadee0fdc5649284d46b022246819e246) infections (e.g., [cholangitis](https:\/\/www.amboss.com\/us\/knowledge\/Acute_cholangitis#Z9f187436aa934749f4437c12be5f3f0d), [cholecystitis](https:\/\/www.amboss.com\/us\/knowledge\/Acute_cholecystitis#Z08db08956e4ea1aca8e4c7e965b533f7)) |   |   |\n| [Cystoisospora belli](https:\/\/www.amboss.com\/us\/knowledge\/General_parasitology#Za983f2c51a6b8452adfa91552fb181e2) \\[3\\] | Foodborne Contaminated water | [Cystoisosporiasis](https:\/\/www.amboss.com\/us\/knowledge\/HIV-associated_conditions#Z1e782fdfd6ae6a71daf64a4e1644b0a9) [Immunocompromised individuals](https:\/\/www.amboss.com\/us\/knowledge\/Adaptive_immune_system#Z1af19ecc772907dd339670b5fb0e8b51): chronic profuse diarrhea, [acalculous cholecystitis](https:\/\/www.amboss.com\/us\/knowledge\/Acute_cholecystitis#Z9df8abcc0e36c38f478f48e212ad298f), [AIDS cholangiopathy](https:\/\/www.amboss.com\/us\/knowledge\/HIV-associated_conditions#Z1c0318dbf51f5c7bf9c39ff805ed97cc) |   |   |\n| Bloody diarrhea | [E.coli](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Z2018b58c3c7835457287264e40fa1a3c) | Enteroinvasive [E. coli](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Z2018b58c3c7835457287264e40fa1a3c) | Direct invasion of the intestinal [epithelium](https:\/\/www.amboss.com\/us\/knowledge\/General_histology#Z23c08800c35f1f71236b85bd916db48b) and formation of [enterotoxins]() | [Gastroenteritis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Zcbd93ce063d015f699fd07ed09015b7f) |\n| Enterohemorrhagic [E. coli](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Z2018b58c3c7835457287264e40fa1a3c) | [Shiga toxin](https:\/\/www.amboss.com\/us\/knowledge\/General_bacteriology#Zfa20332b82d5b9c5a7b6dca8046aa7bd) Most common [serotype](): ([O157:H7](https:\/\/www.amboss.com\/us\/knowledge\/Hemolytic_uremic_syndrome#Zd789cca34b9c96af9a9c7abd264b2c7b)) | [Hemolytic uremic syndrome](https:\/\/www.amboss.com\/us\/knowledge\/Hemolytic_uremic_syndrome#Z759bb631d23a3535c2b55dfd91c4807b) |   |   |\n| [Campylobacter jejuni](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Z4a3deabcd49cf50e8c48e5f0d5dcc506) | Curved or spiral‑shaped with polar [flagellum](https:\/\/www.amboss.com\/us\/knowledge\/General_bacteriology#Z7c98d422c4fed8c895c3dc3e0552a936) Grows best at 37–42°C | [Campylobacter enteritis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z9273c5a7cf1820c124f8fe4d5648df30) (especially in children) Commonly precedes [reactive arthritis](https:\/\/www.amboss.com\/us\/knowledge\/Reactive_arthritis#Z004554eda6fc600767f0d5dbaca1925d) and Guillain‑Barré syndrome |   |   |\n| Nontyphoidal [Salmonella](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Zcf62cfeb3796c44845f303785e4bb88c) | No [lactose](https:\/\/www.amboss.com\/us\/knowledge\/Carbohydrates#Z42d58e097395e9a8d8ade84fd063faf8) fermentation Flagellar motility Hosts: humans, animals, and animal products (e.g., reptiles, poultry, pets, eggs) | [Salmonellosis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z2681adc9ab180885765f48f6f730b912) |   |   |\n| [Shigella](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Z40dc9a1dcc2df2a82a0c4586e5023158) | Slow\/absent [lactose](https:\/\/www.amboss.com\/us\/knowledge\/Carbohydrates#Z42d58e097395e9a8d8ade84fd063faf8) fermentation [Shiga toxin](https:\/\/www.amboss.com\/us\/knowledge\/General_bacteriology#Zfa20332b82d5b9c5a7b6dca8046aa7bd) Low infectious dose required (low ID50) Humans are the only host. | [Bacillary dysentery](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Zd4a3455e8ec3d03f2e705d784ba584b0) |   |   |\n| [Yersinia enterocolitica](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Zc40fd992d4c98f7805725c8ed0f57d89) | Reservoir: contaminated pork and milk products | [Yersiniosis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z6c552143f411315b80f346c0c8707af5) ([outbreaks]() often occur in day-care settings) May manifest as [pseudoappendicitis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Zf1754d56a2add64869210dbfd4f92e81) [Reactive arthritis](https:\/\/www.amboss.com\/us\/knowledge\/Reactive_arthritis#Z004554eda6fc600767f0d5dbaca1925d) |   |   |\n| [Protozoa](https:\/\/www.amboss.com\/us\/knowledge\/General_parasitology#Z8f4f3567860a31947bee8edff7ea6bd5): [Entamoeba histolytica](https:\/\/www.amboss.com\/us\/knowledge\/Amebiasis#Z4001b357f1b712e83d6027a4dfa5731b) | [Fecal-oral transmission]() Amebic cysts are excreted in stool and can contaminate drinking water or food. | [Amebic dysentery](https:\/\/www.amboss.com\/us\/knowledge\/Amebiasis#Z9c6cd303635910835de37919e22415b9) [Amebic liver abscess](https:\/\/www.amboss.com\/us\/knowledge\/Amebiasis#Z8ac81fd9234b63200c6b963a90cf89b2) |   |   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Infectious causes \\[4\\]\\[5\\]\n|   | Conditions |   |\n|---|---|---|\n| Viral | [Norovirus infection](https:\/\/www.amboss.com\/us\/knowledge\/Norovirus_infection#Z2bf1564153a0ab14e52c587da9c8a8c3) [Rotavirus infection](https:\/\/www.amboss.com\/us\/knowledge\/Rotavirus_infection#Zb2e7858cefe0481ba26809cf4d9b84ec) [Adenovirus](https:\/\/www.amboss.com\/us\/knowledge\/General_virology#Z5251a57602a66d951ca7a8a66643ee51) infection (mainly [serotype]() 3, 40, and 41) \\[6\\] [Cytomegalovirus infection](https:\/\/www.amboss.com\/us\/knowledge\/Cytomegalovirus_infection#Za3ec0dd921d428ed745a6ec39879cf55) |   |\n| Bacterial | [Campylobacter enteritis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z9273c5a7cf1820c124f8fe4d5648df30) [Shigellosis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Zd4a3455e8ec3d03f2e705d784ba584b0) [Salmonellosis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z2681adc9ab180885765f48f6f730b912) [Cholera](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Zba6a00519c1b345599491aa93180aacf) [Diarrheagenic E. coli](https:\/\/www.amboss.com\/us\/knowledge\/Diarrheagenic_E._coli#Z815e7a84a36e420726cf0f61cc8adecb) infection ([travelers' diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zed77ffe538dae231e40fe0542e7b245a)) [Yersiniosis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z6c552143f411315b80f346c0c8707af5) (especially in day care centers) [Clostridioides difficile](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Z429d21670093a08ffb061528b0561719) infection ([antibiotic](https:\/\/www.amboss.com\/us\/knowledge\/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3)\\-associated diarrhea) [Typhoid fever](https:\/\/www.amboss.com\/us\/knowledge\/Typhoid_and_paratyphoid_fever#Z1ee997715fd7396129b4d9a3ed02fe95) [Mycobacterium](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Z4a9b83c1d67197ddc3d9a490e25786e1) [avium-intracellulare](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Zded29315a7549c1929e9d93cedf7dadf) [Tropheryma whipplei]() (i.e., [Whipple disease](https:\/\/www.amboss.com\/us\/knowledge\/Whipple_disease#Z83c04868f8c75273c89d8c6e966623e4)) [Legionella]() infection |   |\n| Parasitic | [Protozoan](https:\/\/www.amboss.com\/us\/knowledge\/General_parasitology#Z8f4f3567860a31947bee8edff7ea6bd5) | [Giardiasis](https:\/\/www.amboss.com\/us\/knowledge\/Giardiasis#Z7285e874bce9a0f39983534a6c838736) [Amebiasis](https:\/\/www.amboss.com\/us\/knowledge\/Amebiasis#Z4500356668f80dc7e2e4d3b731ae9d1f) [Cryptosporidiosis](https:\/\/www.amboss.com\/us\/knowledge\/HIV-associated_conditions#Z50d6fcd479428e63a00b9454e02cad44) [Cystoisosporiasis](https:\/\/www.amboss.com\/us\/knowledge\/HIV-associated_conditions#Z1e782fdfd6ae6a71daf64a4e1644b0a9) |\n| [Helminth infections](https:\/\/www.amboss.com\/us\/knowledge\/Helminth_infections#Ze09d3cf63ef1a16aa7f42af8f475cdb4) | [Toxocariasis](https:\/\/www.amboss.com\/us\/knowledge\/Helminth_infections#Zaf51d242a662ad2b921e57ce9d1c4771) [Enterobiasis](https:\/\/www.amboss.com\/us\/knowledge\/Helminth_infections#Z626348337721606624cdbdbddc89d761) [Ascariasis](https:\/\/www.amboss.com\/us\/knowledge\/Helminth_infections#Z3bdf0551665f902bb7f7437f1345d942) [Trichinosis](https:\/\/www.amboss.com\/us\/knowledge\/Helminth_infections#Z243c73c82e8ca80fdc4b642de846d545) [Taenia infections](https:\/\/www.amboss.com\/us\/knowledge\/Helminth_infections#Za9ad8a6dab1ea0231507c2575b7beaad) ([taeniasis](https:\/\/www.amboss.com\/us\/knowledge\/Helminth_infections#Z3f0c9aad18cbe66acdd552e41e47c05c)) [Hookworm infection](https:\/\/www.amboss.com\/us\/knowledge\/Helminth_infections#Z1179ff83d232cf99bd01e86f8e2433fa) [Diphyllobothriasis](https:\/\/www.amboss.com\/us\/knowledge\/Helminth_infections#Z0c51a37492e70b72b9c73aed0be65260) [Intestinal capillariasis](https:\/\/www.amboss.com\/us\/knowledge\/Helminth_infections#Z5dc93e2865dfbf1ff6ab72d0b15a5d08) |   |\n## Noninfectious \\[7\\]\\[8\\]\\[9\\]\n|   | Conditions |\n|---|---|\n| Foodborne toxins | [S. aureus](https:\/\/www.amboss.com\/us\/knowledge\/Staphylococcal_diseases#Zaf074edfb4940be0ed1d4fcfc4ea0dee) intoxication [Botulism](https:\/\/www.amboss.com\/us\/knowledge\/Botulism#Za2a9894ca446f0fe0aac693516c52c4d) [Bacillus cereus](https:\/\/www.amboss.com\/us\/knowledge\/Food_poisoning#Z6843256bc452c182cae6e8c9c5cbe589) infection [Tetrodotoxin](https:\/\/www.amboss.com\/us\/knowledge\/Food_poisoning#Zd578525a352862bd6098cbff0e02482f), [ciguatoxin]() |\n| [Food poisoning](https:\/\/www.amboss.com\/us\/knowledge\/Food_poisoning#Z5a858064f0cd40e4546f181bf46734f2) | [Aflatoxin](https:\/\/www.amboss.com\/us\/knowledge\/General_mycology#Z91b3abebde0a7a99c3942b9bd3060cc2) [Histamine](https:\/\/www.amboss.com\/us\/knowledge\/Hypersensitivity_reactions#Zae1b7b5f59d06769c8445ee3e4389b73) toxicity \\[7\\] Chemical contaminants (e.g., lead, [cadmium](https:\/\/www.amboss.com\/us\/knowledge\/Metal_poisoning#Z04ffe297e862ba3e4a25b62b6a06105e), insecticides, [arsenic](https:\/\/www.amboss.com\/us\/knowledge\/Metal_poisoning#Zf2f349b64906a39b338222ac30067f86)) \\[8\\] [Mushroom poisoning](https:\/\/www.amboss.com\/us\/knowledge\/Poisoning#Ze39c09d250439022bca488e44824b3d5) \\[9\\] |\n| Gastrointestinal | [Malnutrition](https:\/\/www.amboss.com\/us\/knowledge\/Acute_primary_malnutrition_in_children#Zda3f71521662770b01113749ba7d264b): [vitamin deficiency](https:\/\/www.amboss.com\/us\/knowledge\/Vitamins#Zca3fa352d946554fdd5b7c076e0c9cb0) (e.g., [pellagra](https:\/\/www.amboss.com\/us\/knowledge\/Vitamins#Zb703ea9bd25901f12978608f57990f1a)) |\n| [Malabsorption](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb) or [maldigestion](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Z325814c45b1a9856fa3d65839f7681f5) [Celiac disease](https:\/\/www.amboss.com\/us\/knowledge\/Celiac_disease#Z1999c64abb6e85ce70f8cdc66810a65b) [Lactose intolerance](https:\/\/www.amboss.com\/us\/knowledge\/Lactose_intolerance#Z8597682de9e4e8655c2f5df7319b32f3) [Exocrine pancreatic insufficiency](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Z4880cedb9eb57d620afb59b2c9e39a8b) (e.g., due to [chronic pancreatitis](https:\/\/www.amboss.com\/us\/knowledge\/Chronic_pancreatitis#Z1e14e388e4042dc43defefb9f88695e1)) [Diabetic autonomic neuropathy](https:\/\/www.amboss.com\/us\/knowledge\/Diabetic_neuropathy#Z5f4a07d5cb1ff81fcc5c7c2bfb24806f) [Bile acid diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z0f6aa3c63b0331881c8804e04e01ca5c) (e.g., due to [ileal](https:\/\/www.amboss.com\/us\/knowledge\/Small_intestine#Zf3a10de88f22b839a2769aa9ae031960) resection, [biliary-enteric fistula](https:\/\/www.amboss.com\/us\/knowledge\/Fistulas#Z1787c9a9b3b830805f4bf55265169989), [cholestasis](https:\/\/www.amboss.com\/us\/knowledge\/Jaundice_and_cholestasis#Z3811ba77a88bcd2cc789df34c5379055), [postcholecystectomy diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Cholecystectomy#Z6f71e303d7401f08b7ba2e85ef912a69)) [Amyloidosis](https:\/\/www.amboss.com\/us\/knowledge\/Amyloidosis#Zdf99d1ab14839f4c6288ceaf8447ef25) of the [gastrointestinal tract](https:\/\/www.amboss.com\/us\/knowledge\/Gastrointestinal_tract#Zf0833058b7152af8b5653b79f76fb153) |   |\n| [Colitis](https:\/\/www.amboss.com\/us\/knowledge\/Large_intestine#Z579996fe3b9825568e212d9393d5d9a2) [Inflammatory bowel disease](https:\/\/www.amboss.com\/us\/knowledge\/Crohn_disease#Z4272f924349255b3e4babe86d4e939c9) [Crohn disease](https:\/\/www.amboss.com\/us\/knowledge\/Crohn_disease#Zef70853af5e87c95d210bf8df682f64c) [Ulcerative colitis](https:\/\/www.amboss.com\/us\/knowledge\/Ulcerative_colitis#Zbb0aec0a5fe14ad0aae10a9341c457fc) [Irritable bowel syndrome](https:\/\/www.amboss.com\/us\/knowledge\/Irritable_bowel_syndrome#Z2b30a84dc4106c4e8aad1e6c9202f3ea) [Microscopic colitis](https:\/\/www.amboss.com\/us\/knowledge\/Microscopic_colitis#Z98c8e90c538959e074e80c55a532e1bc) [Ischemic colitis](https:\/\/www.amboss.com\/us\/knowledge\/Intestinal_ischemia#Za5a3e828cf2d10df3a9693a9fc3b2c34) [Radiation colitis](https:\/\/www.amboss.com\/us\/knowledge\/Radiation_injury#Ze0a9ed89b6c1c4ea08173fa19b2b74f9) |   |\n| [Tumor](https:\/\/www.amboss.com\/us\/knowledge\/General_oncology#Z333a818dbf71a509f924e54006a41fb6)\/stenotic processes: [paradoxical diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z03319666a4dfb1ca98ba5a66ae368c65) (involuntary seepage of liquid feces in patients with chronic [constipation](https:\/\/www.amboss.com\/us\/knowledge\/Constipation#Z65fd66f9cecf14d85a69e656c3a69417) ) |   |\n\n## Classification![toggle arrow icon](https:\/\/manus-media.amboss.com\/icons\/chevron_up.svg)\nDiarrhea is often classified as watery, fatty, and\/or inflammatory to facilitate diagnosis and management. This classification scheme is most relevant for the approach to [chronic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a).\n\n| Classification of diarrhea by functional pathology \\[10\\]\\[11\\]\\[12\\] |   |   |   |\n|---|---|---|---|\n|   | Pathophysiology | Associated disorders |   |\n| Inflammatory diarrhea | Damage to the intestinal [mucosa]() may cause [cytokine](https:\/\/www.amboss.com\/us\/knowledge\/Cytokines_and_eicosanoids#Z1a9b57a2010f274f4a0f49e6010d30cf)\\-induced water hypersecretion, impair absorption of osmotically active substances or fat, and\/or disrupt water and [electrolyte](https:\/\/www.amboss.com\/us\/knowledge\/Laboratory_medicine#Z562f1491861b33bdb5af572388e99541) absorption. Mucus, blood, and [leukocytes](https:\/\/www.amboss.com\/us\/knowledge\/Basics_of_hematology#Z18a02873023ccef6d8ea2b461e0b7446) present in the stool. | [Ulcerative colitis](https:\/\/www.amboss.com\/us\/knowledge\/Ulcerative_colitis#Zbb0aec0a5fe14ad0aae10a9341c457fc), [Crohn disease](https:\/\/www.amboss.com\/us\/knowledge\/Crohn_disease#Zef70853af5e87c95d210bf8df682f64c) [Colorectal cancer](https:\/\/www.amboss.com\/us\/knowledge\/Colorectal_cancer#Z5f9a21e2819d2a5004da275e0fe8e909) Infections [Shigellosis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Zd4a3455e8ec3d03f2e705d784ba584b0) ([bacillary dysentery](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Zd4a3455e8ec3d03f2e705d784ba584b0)) Nontyphoidal: [salmonellosis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z2681adc9ab180885765f48f6f730b912) [Enteroinvasive Escherichia coli](https:\/\/www.amboss.com\/us\/knowledge\/Diarrheagenic_E._coli#Z12cd4e274bbe847f6b9e96d592684c87), [enterohemorrhagic E. coli](https:\/\/www.amboss.com\/us\/knowledge\/Diarrheagenic_E._coli#Z44cb042afe41a43945e6b3c55e424917) ([O157:H7](https:\/\/www.amboss.com\/us\/knowledge\/Hemolytic_uremic_syndrome#Zd789cca34b9c96af9a9c7abd264b2c7b)) [Campylobacteriosis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z9273c5a7cf1820c124f8fe4d5648df30) [Yersiniosis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z6c552143f411315b80f346c0c8707af5) [Amebiasis](https:\/\/www.amboss.com\/us\/knowledge\/Amebiasis#Z4500356668f80dc7e2e4d3b731ae9d1f) ([amebic dysentery](https:\/\/www.amboss.com\/us\/knowledge\/Amebiasis#Z9c6cd303635910835de37919e22415b9) caused by [Entamoeba histolytica](https:\/\/www.amboss.com\/us\/knowledge\/Amebiasis#Z4001b357f1b712e83d6027a4dfa5731b)) [Clostridioides difficile](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Z429d21670093a08ffb061528b0561719) (rarely bloody) |   |\n| Fatty diarrhea | [Malabsorption](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb) | Alterations of the intestinal [mucosa]() → impaired absorption of digested food | [Malabsorption](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb) disorders or history of [ileal](https:\/\/www.amboss.com\/us\/knowledge\/Small_intestine#Zf3a10de88f22b839a2769aa9ae031960) resection Infections [Giardiasis](https:\/\/www.amboss.com\/us\/knowledge\/Giardiasis#Z7285e874bce9a0f39983534a6c838736) [Small intestinal bacterial overgrowth](https:\/\/www.amboss.com\/us\/knowledge\/Small_intestinal_bacterial_overgrowth#Z9aa32f677362a235a8ae39e011711f1b) ([SIBO](https:\/\/www.amboss.com\/us\/knowledge\/Small_intestinal_bacterial_overgrowth#Z9aa32f677362a235a8ae39e011711f1b)) [Tropical sprue](https:\/\/www.amboss.com\/us\/knowledge\/Tropical_sprue#Z98af9796a545c9279ebf232edfbe9a0f) [Whipple disease](https:\/\/www.amboss.com\/us\/knowledge\/Whipple_disease#Z83c04868f8c75273c89d8c6e966623e4) [Amyloidosis](https:\/\/www.amboss.com\/us\/knowledge\/Amyloidosis#Zdf99d1ab14839f4c6288ceaf8447ef25) |\n| [Maldigestion](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Z325814c45b1a9856fa3d65839f7681f5) | Lack of digestive enzymes → impaired breakdown of food in the intestinal lumen → [malabsorption](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb) of [carbohydrates](https:\/\/www.amboss.com\/us\/knowledge\/Carbohydrates#Z9749463e67a1dd52c34fed592810f23d), [proteins](https:\/\/www.amboss.com\/us\/knowledge\/Proteins_and_peptides#Z6dee07cab92e13d1f6baa3a3ce402f23), fats, [fat-soluble vitamins](https:\/\/www.amboss.com\/us\/knowledge\/Vitamins#Zcfe26218c03945e1fad98ef8c9095aa2) (A, D, E, K), and [vitamin B12](https:\/\/www.amboss.com\/us\/knowledge\/Vitamins#Z938e3f87e91ee8469e94c3ace50e692d) | [Exocrine pancreatic insufficiency](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Z4880cedb9eb57d620afb59b2c9e39a8b) [Bile acid diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z0f6aa3c63b0331881c8804e04e01ca5c) |   |\n| Watery diarrhea | Secretory diarrhea | Active secretion of water  into the intestinal lumen via inhibition or activation of enzymes (e.g., ↑ [cAMP](https:\/\/www.amboss.com\/us\/knowledge\/Signal_transduction#Z64a7426bbad2bf440e8e5d9e67c2a51a) activity) | Neuroendocrine disorders, e.g.: [Carcinoid syndrome](https:\/\/www.amboss.com\/us\/knowledge\/Carcinoid_syndrome#Zd3e3a67dbd397d8bd3f339c574f42e55) [Gastrinoma](https:\/\/www.amboss.com\/us\/knowledge\/Gastrinoma#Z33515a1b2df6a4fe21ef0162d7a1eac7) Endocrine disorders, e.g.: [Hyperthyroidism](https:\/\/www.amboss.com\/us\/knowledge\/Hyperthyroidism_and_thyrotoxicosis#Z7efc7350132a2f2a3e4cc7763e7f07f8) [Addison disease](https:\/\/www.amboss.com\/us\/knowledge\/Adrenal_insufficiency#Z7b47bf57fd367b1b9891e4155e39236f) [Diabetes mellitus](https:\/\/www.amboss.com\/us\/knowledge\/Diabetes_mellitus#Z1235e572dd827cff7d31e954b3f94489) Foodborne infections [Cholera](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Zba6a00519c1b345599491aa93180aacf) (“rice water” diarrhea) [Enterotoxigenic E. coli](https:\/\/www.amboss.com\/us\/knowledge\/Diarrheagenic_E._coli#Z458147f1e1273e554884140b40317779) ([traveler's diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zed77ffe538dae231e40fe0542e7b245a)) [C. perfringens](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Z927388b963f796f8c6f170841d77b930) [C. difficile](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Z429d21670093a08ffb061528b0561719) (associated with [antibiotic](https:\/\/www.amboss.com\/us\/knowledge\/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3) and [PPI](https:\/\/www.amboss.com\/us\/knowledge\/Proton_pump_inhibitors#Z2753e50142e2f5b7089b165accdcc900) use) [Protozoa](https:\/\/www.amboss.com\/us\/knowledge\/General_parasitology#Z8f4f3567860a31947bee8edff7ea6bd5): e.g., [giardiasis](https:\/\/www.amboss.com\/us\/knowledge\/Giardiasis#Z7285e874bce9a0f39983534a6c838736), [cryptosporidiosis](https:\/\/www.amboss.com\/us\/knowledge\/HIV-associated_conditions#Z50d6fcd479428e63a00b9454e02cad44) [Viruses](https:\/\/www.amboss.com\/us\/knowledge\/General_virology#Zcdc83877f75d9d9b9a07ece6544f646c): e.g., [norovirus](https:\/\/www.amboss.com\/us\/knowledge\/General_virology#Z85b05d149dafb61d67a5c48e9a2fdb65), [rotavirus](https:\/\/www.amboss.com\/us\/knowledge\/General_virology#Z0b6c006e84714af76f7c43bebbeb2315), [adenovirus](https:\/\/www.amboss.com\/us\/knowledge\/General_virology#Z5251a57602a66d951ca7a8a66643ee51) |\n| Osmotic diarrhea | Poor absorption or excessive ingestion of [hydrophilic](https:\/\/www.amboss.com\/us\/knowledge\/Fundamentals_of_pharmacology#Zb09f3ec1f97e13e2b9d5705d30995d93) substances (e.g., salts, sugars, [laxatives]()) causes water to be drawn into the intestinal lumen. | Osmotic [laxatives](): e.g., [magnesium citrate](https:\/\/www.amboss.com\/us\/knowledge\/Constipation#Z11bef431cda663471cbd64d3249255bf) [Carbohydrate malabsorption](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Z1659a0f218ffe905f7bddb7c54efb326): e.g., [lactose intolerance](https:\/\/www.amboss.com\/us\/knowledge\/Lactose_intolerance#Z8597682de9e4e8655c2f5df7319b32f3), [fructose intolerance](https:\/\/www.amboss.com\/us\/knowledge\/Inborn_errors_of_carbohydrate_metabolism#Z357a9d683ee4b5a50331c5099527ef8f) (may also present as [fatty diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Chronic_pancreatitis#Z416510d2bd6fcd19b4e328d62b6b10db)) |   |\n| Functional diarrheal disorders \\[10\\] | Rapid intestinal passage due to increased bowel activity | [Diarrhea-predominant IBS](https:\/\/www.amboss.com\/us\/knowledge\/Irritable_bowel_syndrome#Z34fd0bc151761f2495a7470c6d9f6187) ([IBS-D](https:\/\/www.amboss.com\/us\/knowledge\/Irritable_bowel_syndrome#Z34fd0bc151761f2495a7470c6d9f6187)) [Functional diarrhea]()  \\[10\\]\\[13\\] |   |\n\n## Management![toggle arrow icon](https:\/\/manus-media.amboss.com\/icons\/chevron_up.svg)\n## Approach to diarrhea \\[11\\]\n- Detailed history and [physical examination](https:\/\/www.amboss.com\/us\/knowledge\/Physical_examination#Z5208bc2efbfd3c982ffbeacf78ebfcb3)\n  - Exclude [fecal incontinence](https:\/\/www.amboss.com\/us\/knowledge\/Fecal_incontinence#Z62ff0b685d439994bb91355e521425cb) and [fecal impaction](https:\/\/www.amboss.com\/us\/knowledge\/Constipation#Z11561139d5df6c8531690de0277d8ce5); see “[Differential diagnoses of diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z76d5f3cc56d63c0f0c5f7338674a18e5).”\n  - Rule out [medication-induced diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Za759d71c55e5fd9dfcf2e30c0240601a) and consider [factitious diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zbc1bd66027e74ada7dd91439bb674a26).\n  - Classify diarrhea:\n    - By duration of diarrheal illness: acute, persistent, or chronic\n    - By clinical presentation: watery, fatty, inflammatory\n  - Identify any [red flags in diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zee4bebab517fe015dea25941aafb8133) and [risk factors](https:\/\/www.amboss.com\/us\/knowledge\/Interpreting_medical_evidence#Zbc0d0ff153bc5c7a27589815d0c842fd) for specific causes.\n  - Review medical and surgical history.\n- [Supportive care](): Start oral hydration (or [IV fluids](https:\/\/www.amboss.com\/us\/knowledge\/Intravenous_fluid_therapy#Z0ca66c2df4b99953c5a0cb25aed87835)) and offer symptom relief.\n- Diagnostics: Obtain only when appropriate.\n- Directed therapy: Consider empiric or targeted therapy (e.g., [antibiotics](https:\/\/www.amboss.com\/us\/knowledge\/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3)) based on clinical presentation and study results.\n\nThough 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.\n\nIn older adults, rule out [fecal impaction](https:\/\/www.amboss.com\/us\/knowledge\/Constipation#Z11561139d5df6c8531690de0277d8ce5), which can manifest atypically with [paradoxical diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z03319666a4dfb1ca98ba5a66ae368c65) (due to decreased rectal sensation) and nonspecific symptoms (e.g., functional decline, [delirium](https:\/\/www.amboss.com\/us\/knowledge\/Delirium#Zfd56fee25cf9f50f32c800e64a6e652a)). \\[14\\]\n\n[Antibiotics](https:\/\/www.amboss.com\/us\/knowledge\/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3) should only be utilized for specific indications.\n\n## Clinical assessment of diarrhea \\[10\\]\\[12\\]\nKey features of the disease presentation that facilitate efficient testing and prompt diagnosis include:\n\n- Duration of diarrheal illness\n  - Acute diarrhea: duration ≤ 14 days\n  - Persistent diarrhea: duration 15–30 days\n  - Chronic diarrhea: duration \\> 30 days\n- Stool characteristics: watery, fatty, or bloody stools\n- Associated symptoms\n  - [Fever](https:\/\/www.amboss.com\/us\/knowledge\/Fever#Za5de83449ff6a749e6c1348b93b1f3b1)\n  - Abdominal [pain](https:\/\/www.amboss.com\/us\/knowledge\/Principles_of_pain_management#Zd673a3f7ee36023aab5a267899e984cc) and cramping\n  - [Nausea and vomiting](https:\/\/www.amboss.com\/us\/knowledge\/Nausea_and_vomiting#Z2f0b48ef2acaab783b03e4c8d2404f90) in cases of [gastroenteritis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Zcbd93ce063d015f699fd07ed09015b7f)\n  - Signs of [dehydration](https:\/\/www.amboss.com\/us\/knowledge\/Dehydration_and_hypovolemia#Zbd78324053c153c16ea5cb2574249398)\n  - Chronic cases: [malnutrition](https:\/\/www.amboss.com\/us\/knowledge\/Acute_primary_malnutrition_in_children#Zda3f71521662770b01113749ba7d264b) and, in children, [failure to thrive](https:\/\/www.amboss.com\/us\/knowledge\/Growth_faltering#Zc00b4a95101cc1636c126219e267922c)\n  - Weight loss\n  - Defecation urgency, [tenesmus](), and\/or nocturnal symptoms\n\n| Characteristic clinical features in diarrhea according to functional pathology |   |   |   |\n|---|---|---|---|\n| [Inflammatory diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z321586a3cfe84e9365a55d0ed20fb62a) | Frequent and small volume stools Bloody or [purulent](https:\/\/www.amboss.com\/us\/knowledge\/Skin_and_soft_tissue_infections#Zfdfb82d83e675513c49619bc646fd20c) stools Abdominal [pain](https:\/\/www.amboss.com\/us\/knowledge\/Principles_of_pain_management#Zd673a3f7ee36023aab5a267899e984cc), [tenesmus]() May be associated with [fever](https:\/\/www.amboss.com\/us\/knowledge\/Fever#Za5de83449ff6a749e6c1348b93b1f3b1), weight loss, fatigue |   |   |\n| [Fatty diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Chronic_pancreatitis#Z416510d2bd6fcd19b4e328d62b6b10db) | Greasy or oily stools Stools that are difficult to flush Decreases with [fasting]() May be associated with weight loss |   |   |\n| [Watery diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z16ed63f1f94f558cfbffed53ce14a7fb) | [Secretory diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Za81182120613af86b266ff31432e241e) | Loose, watery stools | No change with [fasting]() Nocturnal diarrhea present |\n| [Functional diarrheal disorders](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z68e249c3723fb43d54724dbf2018af91) | Decreases with [fasting]() Decreased at night |   |   |\n| [Osmotic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z7169e994f812b120ea2df94d1042192e) | Decreases with [fasting]() Decreased at night Food triggers |   |   |\n## Risk factors for diarrhea\nAssess for the presence of [risk factors](https:\/\/www.amboss.com\/us\/knowledge\/Interpreting_medical_evidence#Zbc0d0ff153bc5c7a27589815d0c842fd) for specific etiologies, including:\n\n- Recent travel : associated with [traveler's diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zed77ffe538dae231e40fe0542e7b245a)\n- Occupational or recreational exposure\n  - May be associated with an infectious [disease outbreak](https:\/\/www.amboss.com\/us\/knowledge\/Preventive_medicine#Zb9ca40a0578ba8d7b6aca23a46b8fa85)\n  - Potential routes of exposure include:\n    - Ingestion of contaminated food or beverages at a high-risk event (e.g., picnic, restaurant, buffet)\n    - Daycare (e.g., in a daycare attendee, family member of attendee, or daycare staff member)\n    - Direct contact with contaminated surfaces or objects\n    - Direct contact with an infected individual (e.g., shaking hands, sharing food)\n    - Animal contact\n- Recent hospitalization: associated with [health care-associated infections](https:\/\/www.amboss.com\/us\/knowledge\/Hospital-acquired_infections#Z52d549c84757de6454eb2a99eb6af0b3) (e.g., [C. difficile infection](https:\/\/www.amboss.com\/us\/knowledge\/Clostridioides_difficile_infection#Zb508f99ee028a9d8582608f40bc36f5f))\n- Medication use\n  - May cause medication-induced diarrhea\n  - Medications commonly associated with diarrhea include:  \\[15\\]\n    - [Broad-spectrum antibiotics]() (especially [cephalosporins](https:\/\/www.amboss.com\/us\/knowledge\/Overview_of_antibiotic_therapy#Z4262765e59da723c5a2c667f56a6a5e6))\n    - [Antacids](https:\/\/www.amboss.com\/us\/knowledge\/Dyspepsia#Z483f046dcff29152f098e8a15dc67c9b) and [PPIs](https:\/\/www.amboss.com\/us\/knowledge\/Proton_pump_inhibitors#Z2753e50142e2f5b7089b165accdcc900)\n    - [NSAIDs](https:\/\/www.amboss.com\/us\/knowledge\/Non-opioid_analgesics#Z6d53b6cfe3376a70645a5c797293e56a)\n    - [Metformin](https:\/\/www.amboss.com\/us\/knowledge\/Diabetes_medications#Zfbd744168d541d2a68c84d499f310cb7)\n    - [Colchicine](https:\/\/www.amboss.com\/us\/knowledge\/Gout_and_hyperuricemia#Za7ec01fa067126441bfca71d4f27200f)\n    - [Cholesterol](https:\/\/www.amboss.com\/us\/knowledge\/Lipids_and_their_metabolism#Ze08bc636c83ae44d6c771f5646271b57)\\-lowering agents\n    - [Antineoplastic drugs](https:\/\/www.amboss.com\/us\/knowledge\/Chemotherapeutic_agents#Z4c7ae79c18cb3c2f3e1fa98185b2d78d)\n- [Surgery](https:\/\/www.amboss.com\/us\/knowledge\/Surgery_clerkship#Za68e01313423572283ce418087f356cb) \\[16\\]\n  - [Cholecystectomy](https:\/\/www.amboss.com\/us\/knowledge\/Cholecystectomy#Z3486fd991ff5fe473eaf21f11207abc3)  \\[17\\]\n  - [Bowel resection](https:\/\/www.amboss.com\/us\/knowledge\/Bowel_surgery#Z7595405398cd55688013c6e46b2ad835): may cause [short bowel syndrome](https:\/\/www.amboss.com\/us\/knowledge\/Short_bowel_syndrome#Za10f503b15c657e5a54cfdd10ec96b86)  \\[18\\]\n  - [Vagotomy](https:\/\/www.amboss.com\/us\/knowledge\/Peptic_ulcer_disease#Z98ec91193d90025e95eec0e8cf166269): induces rapid gastric emptying, which may disrupt the protective effect of [stomach acid](https:\/\/www.amboss.com\/us\/knowledge\/Gastrointestinal_tract#Z2b222329949064378f320c11017a71ee) \\[18\\]\n  - Gastric and\/or esophageal [surgery](https:\/\/www.amboss.com\/us\/knowledge\/Surgery_clerkship#Za68e01313423572283ce418087f356cb), e.g., [bariatric surgery](https:\/\/www.amboss.com\/us\/knowledge\/Bowel_surgery#Z484c1fb65fa7e725740f20c975c9b284): may result in fat [malabsorption](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb), [SIBO](https:\/\/www.amboss.com\/us\/knowledge\/Small_intestinal_bacterial_overgrowth#Z9aa32f677362a235a8ae39e011711f1b), or [dumping syndrome](https:\/\/www.amboss.com\/us\/knowledge\/Gastric_cancer#Zde1937c1ec3116f80e7913e779046415)\n- [Radiation therapy](https:\/\/www.amboss.com\/us\/knowledge\/Radiation_therapy#Zd120147b0e92bb22668d9e60dfbdc88b): may cause secondary enterocolitis  \\[16\\]\n\nMore 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. \\[15\\]\n\n[Chronic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a) is common after [bariatric surgery](https:\/\/www.amboss.com\/us\/knowledge\/Bowel_surgery#Z484c1fb65fa7e725740f20c975c9b284). \\[19\\]\\[20\\]\n\n## Red flags in diarrhea \\[21\\]\\[22\\]\\[23\\]\\[24\\]\n- Acute or [persistent diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zd56cfaa165f80b20fe15e54d5f2c0023)\n  - Symptoms of [inflammatory diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z321586a3cfe84e9365a55d0ed20fb62a) ([dysentery]())\n    - Systemic symptoms, e.g., [fever](https:\/\/www.amboss.com\/us\/knowledge\/Fever#Za5de83449ff6a749e6c1348b93b1f3b1), [hypotension](https:\/\/www.amboss.com\/us\/knowledge\/Cardiovascular_examination#Zb5022b8fa3fa419ab039a0f8d70866a2)\n    - [Severe dehydration](https:\/\/www.amboss.com\/us\/knowledge\/Dehydration_and_hypovolemia#Zeba0372b757bc3e729c979470fccb192)\n    - Bloody stools\n    - Severe abdominal [pain](https:\/\/www.amboss.com\/us\/knowledge\/Principles_of_pain_management#Zd673a3f7ee36023aab5a267899e984cc)\n  - Patient characteristics that suggest an increased risk of severe disease\n    - Chronic illness or [immunocompromise](https:\/\/www.amboss.com\/us\/knowledge\/Adaptive_immune_system#Z1af19ecc772907dd339670b5fb0e8b51)\n    - Age \\> 65 years\n    - Recent [antibiotic](https:\/\/www.amboss.com\/us\/knowledge\/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3) use\n  - \\> 48 hours duration without improvement\n- [Chronic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a)\n  - [Hypoalbuminemia](https:\/\/www.amboss.com\/us\/knowledge\/Protein_analysis#Zce0a143c68aec2c1a90253380ded229b)\n  - Bloody stools\n  - Symptoms wake the patient from [sleep](https:\/\/www.amboss.com\/us\/knowledge\/Circadian_rhythm,_sleep,_and_induced_states_of_altered_consciousness#Z87820e6f09bd9fe77318b1db22779b43)\n  - [Unintended weight loss](https:\/\/www.amboss.com\/us\/knowledge\/Unexpected_weight_changes#Z94c9bf238c1d855d6f6b40427e518bea)\n  - [Family history](https:\/\/www.amboss.com\/us\/knowledge\/Medical_history#Z0ccd21fcf57fab20ffb12c037f4d9af3) of GI cancer\n  - Symptom onset after 50 years of age\n\n## Diagnostics![toggle arrow icon](https:\/\/manus-media.amboss.com\/icons\/chevron_up.svg)\n## General principles \\[10\\]\\[12\\]\\[22\\]\\[25\\]\n- [Acute diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z9902a484faaf54b4fa1ffaf3a5642113)\n  - Testing is not required in the majority of cases.\n  - Indications for testing include the presence of [red flags in diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zee4bebab517fe015dea25941aafb8133) and [risk factors](https:\/\/www.amboss.com\/us\/knowledge\/Interpreting_medical_evidence#Zbc0d0ff153bc5c7a27589815d0c842fd) for specific etiologies.\n- [Persistent diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zd56cfaa165f80b20fe15e54d5f2c0023): Testing is usually limited to stool studies for [infectious gastroenteritis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z4ec5f6e716f0557299b9deed9d09e225).\n- [Chronic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a)\n  - Testing is initially broad with advanced follow-up testing as indicated. \\[21\\]\\[25\\]\n  - Repeat stool testing for [infectious gastroenteritis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z4ec5f6e716f0557299b9deed9d09e225).\n\nDiagnostic testing is seldom indicated in [acute diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z9902a484faaf54b4fa1ffaf3a5642113) in the absence of [red flag symptoms]().\n\n## Testing for diarrhea\nFor specific indications for testing, see the respective subsections below on acute, persistent, and [chronic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a).\n\n- Blood tests\n  - [CBC](https:\/\/www.amboss.com\/us\/knowledge\/Laboratory_medicine#Z4ccf935251884533761ac0c529e17a64): To evaluate for [anemia](https:\/\/www.amboss.com\/us\/knowledge\/Anemia#Zd40074de20e25de472779d74fcfd35af), [leukocytosis](https:\/\/www.amboss.com\/us\/knowledge\/Leukocytosis#Zb1919b7d94d10a63debcb709eaa693f3), and\/or [leukopenia](https:\/\/www.amboss.com\/us\/knowledge\/Leukopenia#Z32c33fd60ac86084730cc1ba4078a8f5)\n  - [CMP](https:\/\/www.amboss.com\/us\/knowledge\/Laboratory_medicine#Z7213a5e3683814d58d65a66c5bc3ebc8): Assessment of [laboratory findings in dehydration](https:\/\/www.amboss.com\/us\/knowledge\/Dehydration_and_hypovolemia#Z07083a9024530b20bdd9ef8b38fc6e79) (e.g., [electrolyte](https:\/\/www.amboss.com\/us\/knowledge\/Laboratory_medicine#Z562f1491861b33bdb5af572388e99541) abnormalities, [AKI](https:\/\/www.amboss.com\/us\/knowledge\/Acute_kidney_injury#Z6deecfc16edc5ff8ed1ad2f586f55305)) and\/or [liver](https:\/\/www.amboss.com\/us\/knowledge\/Liver#Zd0ed3eb208321943f24b364e0a464294) disease\n  - [CRP](https:\/\/www.amboss.com\/us\/knowledge\/Laboratory_medicine#Z51ad1e101a45a8de708a6dda0321755d), [ESR](https:\/\/www.amboss.com\/us\/knowledge\/Laboratory_medicine#Zde306dd72fd9fa8f94347d3f2edafc20): [Markers of inflammation](https:\/\/www.amboss.com\/us\/knowledge\/Laboratory_medicine#Zb4c8f1543d29d334dcb50edc6af8a2a2)\n  - [Blood cultures](https:\/\/www.amboss.com\/us\/knowledge\/Blood_cultures#Zbbc1ac48182c8850d109967ff3d2e390): Identification of [bacteremia](https:\/\/www.amboss.com\/us\/knowledge\/Bacteremia#Z4bd3a5213bcec7021a2d08026fec3ee5)\n  - Blood gases: Assessment of acid-base status\n  - [Celiac disease serology](https:\/\/www.amboss.com\/us\/knowledge\/Celiac_disease#Z63d359b4e2570234feebde9aaebff219): Initial testing for [celiac disease](https:\/\/www.amboss.com\/us\/knowledge\/Celiac_disease#Z1999c64abb6e85ce70f8cdc66810a65b)\n- Breath tests \\[26\\]\n  - [Hydrogen breath test](https:\/\/www.amboss.com\/us\/knowledge\/Lactose_intolerance#Z4187a69143c8be5cfd157107e8edb65a) (e.g., [glucose hydrogen breath test](), [lactose hydrogen breath test](https:\/\/www.amboss.com\/us\/knowledge\/Lactose_intolerance#Z4187a69143c8be5cfd157107e8edb65a)): Diagnosis of [SIBO](https:\/\/www.amboss.com\/us\/knowledge\/Small_intestinal_bacterial_overgrowth#Z9aa32f677362a235a8ae39e011711f1b) and [carbohydrate](https:\/\/www.amboss.com\/us\/knowledge\/Carbohydrates#Z9749463e67a1dd52c34fed592810f23d) intolerance\n  - [C-D-xylose breath test](): Diagnosis of intestinal [malabsorption](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb) and [SIBO](https:\/\/www.amboss.com\/us\/knowledge\/Small_intestinal_bacterial_overgrowth#Z9aa32f677362a235a8ae39e011711f1b)\n- CT abdomen or [MRI](https:\/\/www.amboss.com\/us\/knowledge\/Magnetic_resonance_imaging#Zefb6206a3f821bf7e5942b654dc6f6cf) abdomen: Identification of inflammation, structural disease, and\/or [ischemia](https:\/\/www.amboss.com\/us\/knowledge\/Cellular_changes_and_adaptive_responses#Zbc05e544d46e794a60ac9ce9ec6883af) \\[12\\]\n- Endoscopic studies \\[12\\]\\[18\\]\n  - [Upper endoscopy](https:\/\/www.amboss.com\/us\/knowledge\/Esophagogastroduodenoscopy#Z1a617ceb3d8b9832108168a091314359) or [enteroscopy]() with [biopsy]() (± [aspiration](https:\/\/www.amboss.com\/us\/knowledge\/Pneumonia#Z351264651d762713a247d997f6eae551)): Diagnosis of [mucosal]() disease (e.g., [celiac disease](https:\/\/www.amboss.com\/us\/knowledge\/Celiac_disease#Z1999c64abb6e85ce70f8cdc66810a65b)), infection, or [malignancy](https:\/\/www.amboss.com\/us\/knowledge\/General_oncology#Z8c3bce39ca977e0f872b6d9fb3be8cfb) in the [small intestine](https:\/\/www.amboss.com\/us\/knowledge\/Small_intestine#Zf1014e183938553009e5ecdbb0650b43)\n  - [Colonoscopy](https:\/\/www.amboss.com\/us\/knowledge\/Colonoscopy#Za4aebc8baa131b83620292e8d0363739) with [biopsies](): Diagnosis of inflammatory disease, infection, or [malignancy](https:\/\/www.amboss.com\/us\/knowledge\/General_oncology#Z8c3bce39ca977e0f872b6d9fb3be8cfb)\n\nEndoscopic studies have limited diagnostic value in [acute diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z9902a484faaf54b4fa1ffaf3a5642113) but are commonly needed for the workup of [chronic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a) to evaluate for the presence of inflammatory or [neoplastic](https:\/\/www.amboss.com\/us\/knowledge\/General_oncology#Za6c03f509be1b3d9dfdc8402fad24824) diseases. Their utility in [persistent diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zd56cfaa165f80b20fe15e54d5f2c0023) is uncertain.\n\n### Stool diagnostic studies\n- Stool culture: can be indicated if [red flags in diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zee4bebab517fe015dea25941aafb8133) are present (e.g., suspected invasive [bacterial enteritis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z7c0d1a3ebf70c528338a93b779e17e08))\n- [Stool tests for CDI](https:\/\/www.amboss.com\/us\/knowledge\/Clostridioides_difficile_infection#Z5ae7beb055f147f1241e95ce050c0395): if [C. difficile infection](https:\/\/www.amboss.com\/us\/knowledge\/Clostridioides_difficile_infection#Zb508f99ee028a9d8582608f40bc36f5f) is suspected\n\n| [Stool diagnostic studies](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z1af96922654e42529740851250ec9081) in diarrhea |   |   |\n|---|---|---|\n| Suspected etiology | Test | Purpose |\n| Infectious diseases | [Stool culture](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z6dddefa904a8f33be48aaa7f09f23fa3) | Identification of infectious agents (e.g., in [bacterial gastroenteritis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z7c0d1a3ebf70c528338a93b779e17e08)) |\n| [Stool microscopy](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z3ffb13377faf28eb8d88ac5d1c53433a) | Visualization of [ova](https:\/\/www.amboss.com\/us\/knowledge\/Female_reproductive_organs#Z6f9cf85e209c336035854438760d1213) or [parasites]() in the stool |   |\n| Culture-independent methods, e.g., [multiplex molecular diagnostic panel for diarrhea]() ([PCR](https:\/\/www.amboss.com\/us\/knowledge\/Laboratory_methods#Z3a8f5e31aa62111944442fd86660cc27)) | Identification of infectious agents in bacterial, viral, and [protozoal](https:\/\/www.amboss.com\/us\/knowledge\/General_parasitology#Z8f4f3567860a31947bee8edff7ea6bd5) [gastroenteritis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Zcbd93ce063d015f699fd07ed09015b7f)  \\[25\\] |   |\n| Quantitative culture of small intestinal [aspirate](https:\/\/www.amboss.com\/us\/knowledge\/Pneumonia#Z351264651d762713a247d997f6eae551) | Used to diagnose [SIBO](https:\/\/www.amboss.com\/us\/knowledge\/Small_intestinal_bacterial_overgrowth#Z9aa32f677362a235a8ae39e011711f1b) ([gold standard test]() for bacterial overgrowth) |   |\n| [Stool tests for C. difficile infection](https:\/\/www.amboss.com\/us\/knowledge\/Clostridioides_difficile_infection#Z5ae7beb055f147f1241e95ce050c0395) (e.g., toxin test) | Identification of [C. difficile infection](https:\/\/www.amboss.com\/us\/knowledge\/Clostridioides_difficile_infection#Zb508f99ee028a9d8582608f40bc36f5f) |   |\n| Inflammation | [Stool microscopy](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z3ffb13377faf28eb8d88ac5d1c53433a) | Visualization of fecal [leukocytes](https:\/\/www.amboss.com\/us\/knowledge\/Basics_of_hematology#Z18a02873023ccef6d8ea2b461e0b7446) |\n| [Fecal occult blood test](https:\/\/www.amboss.com\/us\/knowledge\/Colorectal_cancer#Z24f19e4cfd2826fe2f4df3e70c80fd38) ([FOBT](https:\/\/www.amboss.com\/us\/knowledge\/Colorectal_cancer#Z24f19e4cfd2826fe2f4df3e70c80fd38)) | To screen for [malignancy](https:\/\/www.amboss.com\/us\/knowledge\/General_oncology#Z8c3bce39ca977e0f872b6d9fb3be8cfb) and [mucosal]() inflammation |   |\n| [FIT DNA test](https:\/\/www.amboss.com\/us\/knowledge\/Colorectal_cancer#Z943342f2c2fcf6a86ea87e55a141b8a7) | To screen for [colonic](https:\/\/www.amboss.com\/us\/knowledge\/Large_intestine#Ze19293358dc6c65dc95f936bb8fca493) cancer and [adenomatous polyps](https:\/\/www.amboss.com\/us\/knowledge\/Colonic_polyps#Z31bea48c0b1a3349c4fa653243445fe3) |   |\n| [Fecal calprotectin](https:\/\/www.amboss.com\/us\/knowledge\/Crohn_disease#Z0da0114e6bf8ec43ad71096d5e3f97f1) and [lactoferrin](https:\/\/www.amboss.com\/us\/knowledge\/Innate_immune_system#Z341d9eb537374add3f4e1350946c378f) | Markers of [inflammatory bowel disease](https:\/\/www.amboss.com\/us\/knowledge\/Crohn_disease#Z4272f924349255b3e4babe86d4e939c9) ([IBD](https:\/\/www.amboss.com\/us\/knowledge\/Crohn_disease#Z4272f924349255b3e4babe86d4e939c9)) |   |\n| [Malabsorption](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb) | [Sudan stain](https:\/\/www.amboss.com\/us\/knowledge\/Cellular_changes_and_adaptive_responses#Z78716b286b479e2c380f54ed824c20fc) | Qualitative test for [steatorrhea](https:\/\/www.amboss.com\/us\/knowledge\/Chronic_pancreatitis#Z416510d2bd6fcd19b4e328d62b6b10db) |\n| [72-hour quantitative fecal fat estimation](https:\/\/www.amboss.com\/us\/knowledge\/Chronic_pancreatitis#Zd212c09e9c64621940c1a0ced94a9c98) | Quantitative test for [steatorrhea](https:\/\/www.amboss.com\/us\/knowledge\/Chronic_pancreatitis#Z416510d2bd6fcd19b4e328d62b6b10db) |   |\n| [Fecal elastase-1](https:\/\/www.amboss.com\/us\/knowledge\/Chronic_pancreatitis#Zf555d89ae453336db1900a0d4d2df7e7) | Confirmation of [steatorrhea](https:\/\/www.amboss.com\/us\/knowledge\/Chronic_pancreatitis#Z416510d2bd6fcd19b4e328d62b6b10db) due to [exocrine pancreatic insufficiency](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Z4880cedb9eb57d620afb59b2c9e39a8b) |   |\n| Stool [electrolytes](https:\/\/www.amboss.com\/us\/knowledge\/Laboratory_medicine#Z562f1491861b33bdb5af572388e99541) (e.g., Na\\+, [K\\+](https:\/\/www.amboss.com\/us\/knowledge\/Water_and_electrolyte_metabolism#Z115ce86297429aa2893d16c3493aae24)) | Used to calculate [stool osmotic gap](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Ze3350ca8675573e0158f73d116234534) |   |\n| Stool [pH]() | Identification of [carbohydrate malabsorption](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Z1659a0f218ffe905f7bddb7c54efb326) |   |\n\n- Stool osmotic gap \\[11\\]\\[16\\]\\[18\\]\n  - An equation used in patients with [watery diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z16ed63f1f94f558cfbffed53ce14a7fb) to differentiate between osmotic, secretory, and [functional diarrhea]()\n  - Calculation: 290 - \\[2 × (stool [sodium](https:\/\/www.amboss.com\/us\/knowledge\/Water_and_electrolyte_metabolism#Z420309902608f05802e6d9d942b6e0b1) \\+ stool [potassium](https:\/\/www.amboss.com\/us\/knowledge\/Water_and_electrolyte_metabolism#Z115ce86297429aa2893d16c3493aae24))\\]\n  - Normal [stool osmotic gap](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Ze3350ca8675573e0158f73d116234534): 50–100 mOsm\/kg\n\n|   | Low [stool osmotic gap](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Ze3350ca8675573e0158f73d116234534) | High [stool osmotic gap](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Ze3350ca8675573e0158f73d116234534) |\n|---|---|---|\n| Osmotic gap | \\< 50 mOsm\/kg | ≥ 100 mOsm\/kg |\n| Interpretation | [Secretory diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Za81182120613af86b266ff31432e241e) (↑ secretion and\/or inhibition of water absorption) or [functional diarrhea]() (increased intestinal movement) | [Osmotic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z7169e994f812b120ea2df94d1042192e) (osmotic pull of ingested substances draws water into the intestinal lumen) |\n| Example causes | Foodborne infections (e.g., [Vibrio cholerae](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Z5040d5b8f384d034307ec998d5706c4a), [enterotoxigenic E. coli](https:\/\/www.amboss.com\/us\/knowledge\/Diarrheagenic_E._coli#Z458147f1e1273e554884140b40317779)) Endocrine tumors (e.g., [VIPoma](https:\/\/www.amboss.com\/us\/knowledge\/Pancreatic_neuroendocrine_tumors#Za2856a318ce5fbd49335eab336d6fa66), medullary [carcinoma](https:\/\/www.amboss.com\/us\/knowledge\/General_oncology#Z22674f156f136302ff6142f806db0d5a) of the [thyroid](https:\/\/www.amboss.com\/us\/knowledge\/Thyroid_gland_and_parathyroid_glands#Za09b3ec4cbcf889fc4f7b34cecb45f4d), [gastrinoma](https:\/\/www.amboss.com\/us\/knowledge\/Gastrinoma#Z33515a1b2df6a4fe21ef0162d7a1eac7)) Impaired absorption of [bile acids](https:\/\/www.amboss.com\/us\/knowledge\/Gallbladder_and_bile#Z86b474a966e0cc8faf1092967eaf82f4) and\/or salts ([bile acid diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z0f6aa3c63b0331881c8804e04e01ca5c)) | [Osmotic laxative](https:\/\/www.amboss.com\/us\/knowledge\/Constipation#Z6beba559f6dfabe7c19e807cf28747b9) ingestion (e.g., [magnesium citrate](https:\/\/www.amboss.com\/us\/knowledge\/Constipation#Z11bef431cda663471cbd64d3249255bf)) [Malabsorption](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb) (e.g., [celiac disease](https:\/\/www.amboss.com\/us\/knowledge\/Celiac_disease#Z1999c64abb6e85ce70f8cdc66810a65b), [Whipple disease](https:\/\/www.amboss.com\/us\/knowledge\/Whipple_disease#Z83c04868f8c75273c89d8c6e966623e4)) [Pancreatic](https:\/\/www.amboss.com\/us\/knowledge\/Pancreas#Z0842648c05a9f12b182c77d4baeb7a3a) insufficiency |\n\nThe loss of [bicarbonate](https:\/\/www.amboss.com\/us\/knowledge\/Gastrointestinal_tract#Z6cdbbc46116e490c8de4fb6acf44242c)\\-rich fluid in severe diarrhea may cause nonanion gap [metabolic acidosis](https:\/\/www.amboss.com\/us\/knowledge\/Acid-base_disorders#Ze6ecd1a689f21c50f6f1d77dcd2bd10b).\n\n## Supportive care![toggle arrow icon](https:\/\/manus-media.amboss.com\/icons\/chevron_up.svg)\n## [Dehydration and hypovolemia](https:\/\/www.amboss.com\/us\/knowledge\/Dehydration_and_hypovolemia#Z63f60424ca0cc1f9dff5b2daf66767c2) \\[21\\]\nTherapy is guided by [clinical features of dehydration and hypovolemia](https:\/\/www.amboss.com\/us\/knowledge\/Dehydration_and_hypovolemia#Zcab074498485cc9f54c032767e39fc62) and [laboratory findings in dehydration and hypovolemia](https:\/\/www.amboss.com\/us\/knowledge\/Dehydration_and_hypovolemia#Z07083a9024530b20bdd9ef8b38fc6e79).\n\n- Mild to [moderate dehydration](https:\/\/www.amboss.com\/us\/knowledge\/Dehydration_and_hypovolemia#Z3e5c63fd98cfbd4f25d0b664d4f03f46): Start [oral rehydration therapy](https:\/\/www.amboss.com\/us\/knowledge\/Dehydration_and_hypovolemia#Zbadf5641ef1ee8851ce3026721b8d40a), e.g., use [oral rehydration solution](https:\/\/www.amboss.com\/us\/knowledge\/Dehydration_and_hypovolemia#Z22573072c2ce7ea0ba0873c3024dc043).  \\[21\\]\n- Severe cases\n  - Start [IV fluid resuscitation](https:\/\/www.amboss.com\/us\/knowledge\/Shock#Zee3c52d5a0e0844921b94c537f7d8ba3) (e.g., with [normal saline](https:\/\/www.amboss.com\/us\/knowledge\/Intravenous_fluid_therapy#Zca7fd28598a951a5b85443bbe965acd0)) and monitor [hemodynamic parameters](https:\/\/www.amboss.com\/us\/knowledge\/Shock#Z6ec4d92bf58a162b02eda183b4a0c2ae).\n  - Consider hospitalization.\n\n[Acute diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z9902a484faaf54b4fa1ffaf3a5642113) is usually a [self-limited]() viral infection and management primarily supportive.\n\nEarly rehydration is especially important in children.\n\n## Antidiarrheal agents \\[16\\]\\[25\\]\n- [Bismuth subsalicylate](https:\/\/www.amboss.com\/us\/knowledge\/Helicobacter_pylori_infection#Z5ff316bf4e8912c06dc600df2a9e8b09)   \\[25\\]\n  - Converts to [bismuth](https:\/\/www.amboss.com\/us\/knowledge\/Helicobacter_pylori_infection#Z5ff316bf4e8912c06dc600df2a9e8b09) and [salicylic acid](https:\/\/www.amboss.com\/us\/knowledge\/Antiplatelet_agents#Z4a1b60265ac61c4eb5912ac673ac7d32) in the [GI tract](https:\/\/www.amboss.com\/us\/knowledge\/Gastrointestinal_tract#Zf0833058b7152af8b5653b79f76fb153)\n  - Has antisecretory, antimicrobial, and antiinflammatory effects\n  - Can be used in bacterial diarrhea\n- [Loperamide](https:\/\/www.amboss.com\/us\/knowledge\/Opioids#Z1881077ac71cd771cb44b7db04569ac0)  ;  \\[25\\]\\[27\\]\\[28\\]\n  - [Opioid](https:\/\/www.amboss.com\/us\/knowledge\/Opioids#Z434daecbc44532c03b0313928f0c321d) [receptor](https:\/\/www.amboss.com\/us\/knowledge\/Signal_transduction#Z3ff0122a3c004eebed96e9db47e16ea4) [agonist](https:\/\/www.amboss.com\/us\/knowledge\/Fundamentals_of_pharmacology#Zf82b0b9262366f2b5031a517d5e8c951) that increases [intestinal transit time]()\n  - Best initial treatment for [chemotherapy-induced diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Complications_of_cancer_therapy#Z621a8f3ccfa630117bdd8b12809786b9)\n  - Cautions\n    - Should not be used for \\> 48 hours without reevaluation of the patient\n    - Should be avoided if the patient is [febrile](https:\/\/www.amboss.com\/us\/knowledge\/Fever#Za5de83449ff6a749e6c1348b93b1f3b1) or has bloody stools (dysenteric diarrhea)\n- Racecadotril (not available in the US) \\[16\\]\\[29\\]\n  - Enkephalinase inhibitor that reduces the hypersecretion of [electrolytes](https:\/\/www.amboss.com\/us\/knowledge\/Laboratory_medicine#Z562f1491861b33bdb5af572388e99541) and water into the intestinal lumen\n  - Appears to be well-tolerated and effective in bacterial diarrhea\n\n[Loperamide](https:\/\/www.amboss.com\/us\/knowledge\/Opioids#Z1881077ac71cd771cb44b7db04569ac0) should be avoided in patients with suspected invasive diarrhea with inflammatory features, as it reduces intestinal motility, which consequently increases the risk of bacterial [colonization](https:\/\/www.amboss.com\/us\/knowledge\/General_bacteriology#Zd3b45ccb844489c4640c0435288e368e) and invasion. \\[30\\]\n\n## Acute or persistent diarrhea (≤ 30 days)![toggle arrow icon](https:\/\/manus-media.amboss.com\/icons\/chevron_up.svg)\n## Approach to [acute diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z9902a484faaf54b4fa1ffaf3a5642113) (≤ 14 days) \\[21\\]\\[22\\]\\[25\\]\\[28\\]\nThe management of [acute diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z9902a484faaf54b4fa1ffaf3a5642113) is primarily supportive, as the disease is usually a [self-limited]() viral infection. Further management focuses on determining whether diagnostic testing and directed therapy are needed (e.g., [antibiotic therapy](https:\/\/www.amboss.com\/us\/knowledge\/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3) for [bacterial gastroenteritis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z7c0d1a3ebf70c528338a93b779e17e08)). \\[22\\]\n\n- Start hydration and offer symptom relief; see “[Supportive care]().”\n- Determine whether the diarrhea is inflammatory ([dysentery]()) or noninflammatory.\n- Reserve [stool diagnostic testing](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z1af96922654e42529740851250ec9081) for [pathogen]() identification ([stool cultures](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z6dddefa904a8f33be48aaa7f09f23fa3) with or without culture-independent methods) for specific scenarios \\[25\\]\n  - The presence of [red flags in diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zee4bebab517fe015dea25941aafb8133) (e.g., [inflammatory diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z321586a3cfe84e9365a55d0ed20fb62a), [sepsis](https:\/\/www.amboss.com\/us\/knowledge\/Sepsis#Zb3de189fac0d57eac5b7798e127a5e19))\n  - The presence of [risk factors](https:\/\/www.amboss.com\/us\/knowledge\/Interpreting_medical_evidence#Zbc0d0ff153bc5c7a27589815d0c842fd) for specific infectious diseases (e.g., [risk factors for C. difficile infection](https:\/\/www.amboss.com\/us\/knowledge\/Clostridioides_difficile_infection#Zcec32f67ae45a4b1cf8f0cc5aebd5531))\n  - High risk of infecting others (e.g., daycare workers, food handlers, current known or suspected disease [outbreaks]())\n  - If the results would alter management\n- Consider [empiric antibiotics for bacterial gastroenteritis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z8bc7c574b3a32ce97b6e98deca3d7a27)  after stool samples have been obtained. \\[28\\]\n- Start targeted treatment based on the results; see also “[Infectious gastroenteritis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z4ec5f6e716f0557299b9deed9d09e225).”\n\nIf symptoms of an [acute abdomen](https:\/\/www.amboss.com\/us\/knowledge\/Acute_abdomen#Z24dc105fa608cb7dad9e5eada9a97d2b) are present, consider an urgent CT abdomen to identify [ischemic](https:\/\/www.amboss.com\/us\/knowledge\/Cellular_changes_and_adaptive_responses#Zbc05e544d46e794a60ac9ce9ec6883af), hemorrhagic, obstructive, and\/or inflammatory diseases. \\[28\\]\n\nWhen indicated, stool studies in patients with [acute diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z9902a484faaf54b4fa1ffaf3a5642113) should include tests that can detect the presence of [Salmonella](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Zcf62cfeb3796c44845f303785e4bb88c), [Shigella](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Z40dc9a1dcc2df2a82a0c4586e5023158), [Campylobacter](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Za64f770db8dc668f93db5788517d1bc0), [Yersinia](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Zfcf2a7b96fa589ca6dd7ada0b75e48bb), [C. difficile infection](https:\/\/www.amboss.com\/us\/knowledge\/Clostridioides_difficile_infection#Zb508f99ee028a9d8582608f40bc36f5f), and [Shiga toxin-producing E. coli](https:\/\/www.amboss.com\/us\/knowledge\/Diarrheagenic_E._coli#Z11eef8782d53e8058dd72294470db3f7). \\[31\\]\n\n### Noninflammatory diarrhea ([watery diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z16ed63f1f94f558cfbffed53ce14a7fb)) \\[21\\]\\[25\\]\\[31\\]\n- Mild symptoms (e.g., daily activities of life are not affected)\n  - \\< 7 days: Diagnostic testing is not recommended.\n  - ≥ 7 days: Consider stool studies for [pathogen]() identification if the results may alter management, e.g., initiation of targeted therapy.\n- Moderate to severe symptoms (e.g., daily activities of life are affected)\n  - For [traveler's diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zed77ffe538dae231e40fe0542e7b245a), start [empiric antibiotics](https:\/\/www.amboss.com\/us\/knowledge\/Overview_of_antibiotic_therapy#Z0d92af1eab239465721da02549c61854). \\[31\\]\n  - \\< 72 hours: symptom control (e.g., [loperamide](https:\/\/www.amboss.com\/us\/knowledge\/Opioids#Z1881077ac71cd771cb44b7db04569ac0)); no diagnostic testing recommended\n  - ≥ 72 hours: Obtain stool studies for [pathogen]() identification and targeted therapy.\n- Severe symptoms, [fever](https:\/\/www.amboss.com\/us\/knowledge\/Fever#Za5de83449ff6a749e6c1348b93b1f3b1), or patients at risk for severe disease: Obtain stool studies for [pathogen]() identification and targeted therapy.\n### [Inflammatory diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z321586a3cfe84e9365a55d0ed20fb62a) ([dysentery]()) \\[28\\]\n- No or low-grade [fever](https:\/\/www.amboss.com\/us\/knowledge\/Fever#Za5de83449ff6a749e6c1348b93b1f3b1): [stool cultures](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z6dddefa904a8f33be48aaa7f09f23fa3) or [multiplex molecular diagnostic panel for diarrhea]() ([PCR](https:\/\/www.amboss.com\/us\/knowledge\/Laboratory_methods#Z3a8f5e31aa62111944442fd86660cc27))\n- Severe illness with [fever](https:\/\/www.amboss.com\/us\/knowledge\/Fever#Za5de83449ff6a749e6c1348b93b1f3b1)\n  - Obtain blood tests (e.g., [CBC](https:\/\/www.amboss.com\/us\/knowledge\/Laboratory_medicine#Z4ccf935251884533761ac0c529e17a64), [CMP](https:\/\/www.amboss.com\/us\/knowledge\/Laboratory_medicine#Z7213a5e3683814d58d65a66c5bc3ebc8), [inflammatory markers](https:\/\/www.amboss.com\/us\/knowledge\/Laboratory_medicine#Zb4c8f1543d29d334dcb50edc6af8a2a2), and [blood cultures](https:\/\/www.amboss.com\/us\/knowledge\/Blood_cultures#Zbbc1ac48182c8850d109967ff3d2e390)) and stool studies for [pathogen]() identification and targeted therapy.\n  - Consider [empiric antibiotics for bacterial gastroenteritis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z8bc7c574b3a32ce97b6e98deca3d7a27). \\[31\\]\n## Approach to [persistent diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zd56cfaa165f80b20fe15e54d5f2c0023) (15–30 days) \\[28\\]\\[32\\]\n- Review associated symptoms, history, and stool appearance.\n- Obtain stool studies for [pathogen]() identification (including [parasites]()) in all patients.\n- Avoid routine blood tests, imaging, and endoscopy in patients with a negative stool workup and no [red flag symptoms]().\n- Offer [empiric antibiotics](https:\/\/www.amboss.com\/us\/knowledge\/Overview_of_antibiotic_therapy#Z0d92af1eab239465721da02549c61854) to patients with suspected [traveler's diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zed77ffe538dae231e40fe0542e7b245a).\n- Start targeted treatment based on diagnostic results; see also “[Infectious gastroenteritis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z4ec5f6e716f0557299b9deed9d09e225).”\n\nIn patients with prominent abdominal [pain](https:\/\/www.amboss.com\/us\/knowledge\/Principles_of_pain_management#Zd673a3f7ee36023aab5a267899e984cc) and\/or bloody diarrhea, evaluate for [ischemic colitis](https:\/\/www.amboss.com\/us\/knowledge\/Intestinal_ischemia#Za5a3e828cf2d10df3a9693a9fc3b2c34), [ulcerative colitis](https:\/\/www.amboss.com\/us\/knowledge\/Ulcerative_colitis#Zbb0aec0a5fe14ad0aae10a9341c457fc), and [Crohn disease](https:\/\/www.amboss.com\/us\/knowledge\/Crohn_disease#Zef70853af5e87c95d210bf8df682f64c) if stool testing does not indicate an infectious etiology.\n\n[Persistent diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zd56cfaa165f80b20fe15e54d5f2c0023) has a broader differential diagnosis than [acute diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z9902a484faaf54b4fa1ffaf3a5642113). Parasitic infection (e.g., [giardiasis](https:\/\/www.amboss.com\/us\/knowledge\/Giardiasis#Z7285e874bce9a0f39983534a6c838736)), recurrent bacterial infection (e.g., [C. difficile infection](https:\/\/www.amboss.com\/us\/knowledge\/Clostridioides_difficile_infection#Zb508f99ee028a9d8582608f40bc36f5f)), and noninfectious causes (e.g., [IBS-D](https:\/\/www.amboss.com\/us\/knowledge\/Irritable_bowel_syndrome#Z34fd0bc151761f2495a7470c6d9f6187)) must be considered. \\[32\\]\n\n## Etiology of acute and persistent diarrhea \\[10\\]\\[11\\]\\[15\\]\\[22\\]\n| [Etiology of acute and persistent diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Za0cd177df9550f81889873b6038f2072) |   |\n|---|---|\n| Viral \\[21\\] | [Norovirus infection](https:\/\/www.amboss.com\/us\/knowledge\/Norovirus_infection#Z2bf1564153a0ab14e52c587da9c8a8c3) [Rotavirus infection](https:\/\/www.amboss.com\/us\/knowledge\/Rotavirus_infection#Zb2e7858cefe0481ba26809cf4d9b84ec) [Adenovirus](https:\/\/www.amboss.com\/us\/knowledge\/General_virology#Z5251a57602a66d951ca7a8a66643ee51) infection (mainly [serotypes]() 3, 40, and 41) \\[6\\] [Cytomegalovirus infection](https:\/\/www.amboss.com\/us\/knowledge\/Cytomegalovirus_infection#Za3ec0dd921d428ed745a6ec39879cf55) [Coronavirus](https:\/\/www.amboss.com\/us\/knowledge\/General_virology#Zc9fd2c044745d5b6f6ef5fe6293d10c5) ([COVID-19](https:\/\/www.amboss.com\/us\/knowledge\/COVID-19_\\(coronavirus_disease_2019\\)#Z82f1d759ff02927000d2ccd223409135)) |\n| Bacterial | [Cholera](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Zba6a00519c1b345599491aa93180aacf) (“rice water” diarrhea) [Enterotoxigenic E. coli](https:\/\/www.amboss.com\/us\/knowledge\/Diarrheagenic_E._coli#Z458147f1e1273e554884140b40317779) infection ([traveler's diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zed77ffe538dae231e40fe0542e7b245a)) [C. perfringens](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Z927388b963f796f8c6f170841d77b930) infection [C. difficile](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Z429d21670093a08ffb061528b0561719) infection (associated with [antibiotic](https:\/\/www.amboss.com\/us\/knowledge\/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3) and [PPI](https:\/\/www.amboss.com\/us\/knowledge\/Proton_pump_inhibitors#Z2753e50142e2f5b7089b165accdcc900) use) [Shigellosis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Zd4a3455e8ec3d03f2e705d784ba584b0) ([bacillary dysentery](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Zd4a3455e8ec3d03f2e705d784ba584b0)) Nontyphoidal: [salmonellosis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z2681adc9ab180885765f48f6f730b912) [Enteroinvasive E. coli](https:\/\/www.amboss.com\/us\/knowledge\/Diarrheagenic_E._coli#Z12cd4e274bbe847f6b9e96d592684c87), [enterohemorrhagic E. coli](https:\/\/www.amboss.com\/us\/knowledge\/Diarrheagenic_E._coli#Z44cb042afe41a43945e6b3c55e424917) ([O157:H7](https:\/\/www.amboss.com\/us\/knowledge\/Hemolytic_uremic_syndrome#Zd789cca34b9c96af9a9c7abd264b2c7b)) infection [Campylobacteriosis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z9273c5a7cf1820c124f8fe4d5648df30) [Yersiniosis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z6c552143f411315b80f346c0c8707af5) [Legionella]() |\n| Parasitic | [Giardiasis](https:\/\/www.amboss.com\/us\/knowledge\/Giardiasis#Z7285e874bce9a0f39983534a6c838736) [Amebiasis](https:\/\/www.amboss.com\/us\/knowledge\/Amebiasis#Z4500356668f80dc7e2e4d3b731ae9d1f) [Cryptosporidiosis](https:\/\/www.amboss.com\/us\/knowledge\/HIV-associated_conditions#Z50d6fcd479428e63a00b9454e02cad44) [Enterobiasis](https:\/\/www.amboss.com\/us\/knowledge\/Helminth_infections#Z626348337721606624cdbdbddc89d761) [Ascariasis](https:\/\/www.amboss.com\/us\/knowledge\/Helminth_infections#Z3bdf0551665f902bb7f7437f1345d942) |\n| [Food poisoning](https:\/\/www.amboss.com\/us\/knowledge\/Food_poisoning#Z5a858064f0cd40e4546f181bf46734f2) | [S. aureus](https:\/\/www.amboss.com\/us\/knowledge\/Staphylococcal_diseases#Zaf074edfb4940be0ed1d4fcfc4ea0dee) infection [Botulism](https:\/\/www.amboss.com\/us\/knowledge\/Botulism#Za2a9894ca446f0fe0aac693516c52c4d) [Bacillus cereus](https:\/\/www.amboss.com\/us\/knowledge\/Food_poisoning#Z6843256bc452c182cae6e8c9c5cbe589) infection [Aflatoxin](https:\/\/www.amboss.com\/us\/knowledge\/General_mycology#Z91b3abebde0a7a99c3942b9bd3060cc2) [Histamine](https:\/\/www.amboss.com\/us\/knowledge\/Hypersensitivity_reactions#Zae1b7b5f59d06769c8445ee3e4389b73) toxicity \\[7\\] [Tetrodotoxin](https:\/\/www.amboss.com\/us\/knowledge\/Food_poisoning#Zd578525a352862bd6098cbff0e02482f), [ciguatoxin]() |\n| Medications | [Antibiotics](https:\/\/www.amboss.com\/us\/knowledge\/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3) [Laxatives]() [PPIs](https:\/\/www.amboss.com\/us\/knowledge\/Proton_pump_inhibitors#Z2753e50142e2f5b7089b165accdcc900) [SSRIs](https:\/\/www.amboss.com\/us\/knowledge\/Antidepressants#Zb1bb43280a4d0d86f2d53818b9e8afc8) [NSAIDs](https:\/\/www.amboss.com\/us\/knowledge\/Non-opioid_analgesics#Z6d53b6cfe3376a70645a5c797293e56a) |\n| Other | Chemical contaminants (e.g., lead, [cadmium](https:\/\/www.amboss.com\/us\/knowledge\/Metal_poisoning#Z04ffe297e862ba3e4a25b62b6a06105e), insecticides, [arsenic](https:\/\/www.amboss.com\/us\/knowledge\/Metal_poisoning#Zf2f349b64906a39b338222ac30067f86)) \\[8\\] [Mushroom poisoning](https:\/\/www.amboss.com\/us\/knowledge\/Poisoning#Ze39c09d250439022bca488e44824b3d5) \\[9\\] [Bowel ischemia](https:\/\/www.amboss.com\/us\/knowledge\/Intestinal_ischemia#Z25168aee9d4e0266b8ee7dae3d33cc08) [Neutropenic enterocolitis](https:\/\/www.amboss.com\/us\/knowledge\/Acute_abdomen#Za3c81a83e806ab8e4e5f85cb4d572b6c) |\n\n## Chronic diarrhea (\\> 30 days)![toggle arrow icon](https:\/\/manus-media.amboss.com\/icons\/chevron_up.svg)\n## Approach to [chronic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a)\nThe differential diagnosis of [chronic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a) is extensive. A systematic approach with efficient use of testing is needed to arrive at a diagnosis quickly. \\[10\\]\\[12\\]\\[33\\]\n\n- Provide general [supportive care]().\n- Assess for a possible health care-related etiology: e.g., [medication-induced diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Za759d71c55e5fd9dfcf2e30c0240601a)\n- Consider factitious diarrhea.  \\[11\\]\n- Order [initial diagnostics for chronic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Ze651f57896e4f957eed2c9bdc3d9b8ed).\n- Consider a preliminary diagnosis of [IBS-D](https:\/\/www.amboss.com\/us\/knowledge\/Irritable_bowel_syndrome#Z34fd0bc151761f2495a7470c6d9f6187) if all of the following criteria are met:  \\[18\\]\n  - Initial tests are normal.\n  - No [red flags]() are present.\n  - [Rome IV criteria for IBS](https:\/\/www.amboss.com\/us\/knowledge\/Irritable_bowel_syndrome#Zc16da4fdfa96f2bd9cf45f216019665a) are met.\n- Consider further investigations: e.g., additional advanced tests, therapeutic trials\n- Start directed therapy once a likely [etiology of chronic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z395de845da244c411a1fe280649e48a0) has been identified.\n\n[Chronic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a) can be classified as inflammatory, fatty, or watery. Grouping patients into broad categories based on clinical features and basic laboratory findings narrows the differential diagnosis and facilitates efficient advanced testing. \\[18\\]\n\n[IBS-D](https:\/\/www.amboss.com\/us\/knowledge\/Irritable_bowel_syndrome#Z34fd0bc151761f2495a7470c6d9f6187) is an intermediate diagnosis; it does not eliminate the possibility of another disease. Evaluation should continue if symptoms persist despite treatment for [IBS-D](https:\/\/www.amboss.com\/us\/knowledge\/Irritable_bowel_syndrome#Z34fd0bc151761f2495a7470c6d9f6187). \\[12\\]\n\n## Etiology of chronic diarrhea \\[12\\]\n[Chronic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a) is commonly classified as watery, fatty, or inflammatory.\n\n| [Etiology of chronic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z395de845da244c411a1fe280649e48a0) \\[12\\] |   |   |\n|---|---|---|\n| Inflammatory | [Inflammatory bowel disease](https:\/\/www.amboss.com\/us\/knowledge\/Crohn_disease#Z4272f924349255b3e4babe86d4e939c9): [Crohn disease](https:\/\/www.amboss.com\/us\/knowledge\/Crohn_disease#Zef70853af5e87c95d210bf8df682f64c), [ulcerative colitis](https:\/\/www.amboss.com\/us\/knowledge\/Ulcerative_colitis#Zbb0aec0a5fe14ad0aae10a9341c457fc) Invasive infections Bacterial: e.g., [pseudomembranous colitis](https:\/\/www.amboss.com\/us\/knowledge\/Clostridioides_difficile_infection#Z9a45a83f4126940236032056da651cf6), [tuberculosis](https:\/\/www.amboss.com\/us\/knowledge\/Tuberculosis#Zcaeed890b290faa5ec7ec5e02a1039fe) Viral: e.g., [CMV](https:\/\/www.amboss.com\/us\/knowledge\/Herpes_virus_infections#Zad44d620172736914bbe3c52435de665) Parasitic: e.g., [Entamoeba histolytica](https:\/\/www.amboss.com\/us\/knowledge\/Amebiasis#Z4001b357f1b712e83d6027a4dfa5731b) Medications: e.g., [PPIs](https:\/\/www.amboss.com\/us\/knowledge\/Proton_pump_inhibitors#Z2753e50142e2f5b7089b165accdcc900), [NSAIDs](https:\/\/www.amboss.com\/us\/knowledge\/Non-opioid_analgesics#Z6d53b6cfe3376a70645a5c797293e56a), [tyrosine kinase inhibitors](https:\/\/www.amboss.com\/us\/knowledge\/Chemotherapeutic_agents#Z1d95c73e140242a536db072ff6adf252) Other: e.g., [ischemic colitis](https:\/\/www.amboss.com\/us\/knowledge\/Intestinal_ischemia#Za5a3e828cf2d10df3a9693a9fc3b2c34), [radiation colitis](https:\/\/www.amboss.com\/us\/knowledge\/Radiation_injury#Ze0a9ed89b6c1c4ea08173fa19b2b74f9), [malignancy](https:\/\/www.amboss.com\/us\/knowledge\/General_oncology#Z8c3bce39ca977e0f872b6d9fb3be8cfb) (e.g., [colon cancer](https:\/\/www.amboss.com\/us\/knowledge\/Colorectal_cancer#Z5f9a21e2819d2a5004da275e0fe8e909), [lymphoma](https:\/\/www.amboss.com\/us\/knowledge\/General_oncology#Z2586a20a2f640af294a4d86b9f8439d0)) |   |\n| Fatty | [Malabsorption](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb) | Infections: [SIBO](https:\/\/www.amboss.com\/us\/knowledge\/Small_intestinal_bacterial_overgrowth#Z9aa32f677362a235a8ae39e011711f1b), [tropical sprue](https:\/\/www.amboss.com\/us\/knowledge\/Tropical_sprue#Z98af9796a545c9279ebf232edfbe9a0f), [Whipple disease](https:\/\/www.amboss.com\/us\/knowledge\/Whipple_disease#Z83c04868f8c75273c89d8c6e966623e4), [giardiasis](https:\/\/www.amboss.com\/us\/knowledge\/Giardiasis#Z7285e874bce9a0f39983534a6c838736) Medications: e.g., [aminoglycosides](https:\/\/www.amboss.com\/us\/knowledge\/Overview_of_antibiotic_therapy#Zec4668b75aadd8ddccaf2d3dada94e20), [antiretroviral drugs](https:\/\/www.amboss.com\/us\/knowledge\/Human_immunodeficiency_virus_infection#Zcccdef45b4e6e14c8b8fd8bd48515808) Other: e.g., [celiac disease](https:\/\/www.amboss.com\/us\/knowledge\/Celiac_disease#Z1999c64abb6e85ce70f8cdc66810a65b), postsurgical changes, lymphatic obstruction |\n| [Maldigestion](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Z325814c45b1a9856fa3d65839f7681f5) | Inadequate [bile acid](https:\/\/www.amboss.com\/us\/knowledge\/Gallbladder_and_bile#Z86b474a966e0cc8faf1092967eaf82f4) concentration: e.g., due to hepatobiliary disease or [ileal](https:\/\/www.amboss.com\/us\/knowledge\/Small_intestine#Zf3a10de88f22b839a2769aa9ae031960) resection [Exocrine pancreatic insufficiency](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Z4880cedb9eb57d620afb59b2c9e39a8b): e.g., due to [chronic pancreatitis](https:\/\/www.amboss.com\/us\/knowledge\/Chronic_pancreatitis#Z1e14e388e4042dc43defefb9f88695e1) or [cystic fibrosis](https:\/\/www.amboss.com\/us\/knowledge\/Cystic_fibrosis#Z3ae6b1b2983d98afcd8339f505ed3f99) |   |\n| Watery | Secretory | Infections: e.g., [giardiasis](https:\/\/www.amboss.com\/us\/knowledge\/Giardiasis#Z7285e874bce9a0f39983534a6c838736), [cryptosporidiosis](https:\/\/www.amboss.com\/us\/knowledge\/HIV-associated_conditions#Z50d6fcd479428e63a00b9454e02cad44), [SIBO](https:\/\/www.amboss.com\/us\/knowledge\/Small_intestinal_bacterial_overgrowth#Z9aa32f677362a235a8ae39e011711f1b) Medications: e.g., [stimulant laxatives](https:\/\/www.amboss.com\/us\/knowledge\/Constipation#Za767330be9fd22123118b1e0addddf55), [levodopa](https:\/\/www.amboss.com\/us\/knowledge\/Medication_for_Parkinson_disease#Z18482e8eccd3978e1e99c57ecdc4fd2f), [caffeine](https:\/\/www.amboss.com\/us\/knowledge\/Substance-related_and_addictive_disorders#Z9cbb9bc1131781093113ffce4e367923) [Neuroendocrine tumors](https:\/\/www.amboss.com\/us\/knowledge\/Neuroendocrine_neoplasms#Z688b3fb7764fe32e74754d4b26c6fc89)  \\[11\\] Endocrine diseases: e.g., [hyperthyroidism](https:\/\/www.amboss.com\/us\/knowledge\/Hyperthyroidism_and_thyrotoxicosis#Z7efc7350132a2f2a3e4cc7763e7f07f8), [Addison disease](https:\/\/www.amboss.com\/us\/knowledge\/Adrenal_insufficiency#Z7b47bf57fd367b1b9891e4155e39236f), [diabetes mellitus](https:\/\/www.amboss.com\/us\/knowledge\/Diabetes_mellitus#Z1235e572dd827cff7d31e954b3f94489) Other: [bile acid](https:\/\/www.amboss.com\/us\/knowledge\/Gallbladder_and_bile#Z86b474a966e0cc8faf1092967eaf82f4) [malabsorption](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb), [IBD](https:\/\/www.amboss.com\/us\/knowledge\/Crohn_disease#Z4272f924349255b3e4babe86d4e939c9), [microscopic colitis](https:\/\/www.amboss.com\/us\/knowledge\/Microscopic_colitis#Z98c8e90c538959e074e80c55a532e1bc) |\n| Functional | [Irritable bowel syndrome](https:\/\/www.amboss.com\/us\/knowledge\/Irritable_bowel_syndrome#Z2b30a84dc4106c4e8aad1e6c9202f3ea) ([IBS](https:\/\/www.amboss.com\/us\/knowledge\/Irritable_bowel_syndrome#Z2b30a84dc4106c4e8aad1e6c9202f3ea)) Medications: e.g., [prokinetics]() [Functional diarrhea]() |   |\n| Osmotic | [Carbohydrate malabsorption](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Z1659a0f218ffe905f7bddb7c54efb326) Unabsorbed sugars in the diet and\/or in chewing [gum](https:\/\/www.amboss.com\/us\/knowledge\/Oral_cavity#Z3ab30934681b06d8591bf18cb03ce2d7): e.g., [sorbitol](https:\/\/www.amboss.com\/us\/knowledge\/Carbohydrates#Z77d45a3fdde3bf65b74cebef6dec2d7f), [mannitol](https:\/\/www.amboss.com\/us\/knowledge\/Diuretics#Ze73562869635139c2688bf31a791bef1) Enzymatic dysfunction: e.g., [lactase deficiency](https:\/\/www.amboss.com\/us\/knowledge\/Lactose_intolerance#Zd10b2b1e3672bf92a1e23fc1962405dc) Medications: e.g., [osmotic laxatives](https:\/\/www.amboss.com\/us\/knowledge\/Constipation#Z6beba559f6dfabe7c19e807cf28747b9) Other: e.g., [celiac disease](https:\/\/www.amboss.com\/us\/knowledge\/Celiac_disease#Z1999c64abb6e85ce70f8cdc66810a65b), [FODMAP](https:\/\/www.amboss.com\/us\/knowledge\/Irritable_bowel_syndrome#Zd9aa5f552109b4cf13d7666f5e99cebe) intolerance, [enteral feeding](https:\/\/www.amboss.com\/us\/knowledge\/Specialized_nutrition_support#Z3c9fb1a42ea89ef188431d15c5ad1445) |   |\n## Initial diagnostics for chronic diarrhea \\[10\\]\\[12\\]\\[24\\]\\[33\\]\nOrder initial studies. See also “Testing for diarrhea” in “Diagnostics.”\n\n- Stool studies\n  - Repeat stool testing for [infectious gastroenteritis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z4ec5f6e716f0557299b9deed9d09e225).\n  - Perform fecal [leukocyte](https:\/\/www.amboss.com\/us\/knowledge\/Basics_of_hematology#Z18a02873023ccef6d8ea2b461e0b7446), calprotectin, and [lactoferrin](https:\/\/www.amboss.com\/us\/knowledge\/Innate_immune_system#Z341d9eb537374add3f4e1350946c378f) studies and a [FOBT](https:\/\/www.amboss.com\/us\/knowledge\/Colorectal_cancer#Z24f19e4cfd2826fe2f4df3e70c80fd38).\n  - Consider further studies to help classify diarrhea: e.g., [fecal fat estimation](https:\/\/www.amboss.com\/us\/knowledge\/Chronic_pancreatitis#Zd212c09e9c64621940c1a0ced94a9c98), [stool osmotic gap](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Ze3350ca8675573e0158f73d116234534), stool [pH]()  \\[12\\]\\[16\\]\n- Blood tests: Obtain [CRP](https:\/\/www.amboss.com\/us\/knowledge\/Laboratory_medicine#Z51ad1e101a45a8de708a6dda0321755d) levels , [CBC](https:\/\/www.amboss.com\/us\/knowledge\/Laboratory_medicine#Z4ccf935251884533761ac0c529e17a64), [CMP](https:\/\/www.amboss.com\/us\/knowledge\/Laboratory_medicine#Z7213a5e3683814d58d65a66c5bc3ebc8), and [diagnostic studies for anemia](https:\/\/www.amboss.com\/us\/knowledge\/Anemia#Z41148dd29e7cce04c2a3fd5dc6cf2720). \\[12\\]\n- Imaging studies \\[12\\]\n  - Use imaging studies to evaluate [red flags in diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zee4bebab517fe015dea25941aafb8133) and consider initially to rule out structural disease.\n  - Preferred modality: CT abdomen or [MRI](https:\/\/www.amboss.com\/us\/knowledge\/Magnetic_resonance_imaging#Zefb6206a3f821bf7e5942b654dc6f6cf) abdomen with enterography\n\nAlways test for Giardia infection in [chronic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a). \\[24\\]\n\n## Subsequent evaluation \\[10\\]\\[11\\]\nPerform guided diagnostics based on characteristic clinical features in diarrhea and the results of initial diagnostic testing.\n\n| Diagnostic workup of patients with [chronic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a) |   |   |   |\n|---|---|---|---|\n| Classification | Initial results | Further diagnostics |   |\n| [Inflammatory diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z321586a3cfe84e9365a55d0ed20fb62a) | Fecal [leukocytes](https:\/\/www.amboss.com\/us\/knowledge\/Basics_of_hematology#Z18a02873023ccef6d8ea2b461e0b7446) present. Fecal occult blood positive Calprotectin or [lactoferrin](https:\/\/www.amboss.com\/us\/knowledge\/Innate_immune_system#Z341d9eb537374add3f4e1350946c378f) positive Elevated [CRP](https:\/\/www.amboss.com\/us\/knowledge\/Laboratory_medicine#Z51ad1e101a45a8de708a6dda0321755d) | [Colonoscopy](https:\/\/www.amboss.com\/us\/knowledge\/Colonoscopy#Za4aebc8baa131b83620292e8d0363739) with [mucosal]() [biopsies]() (always required): can identify [IBD](https:\/\/www.amboss.com\/us\/knowledge\/Crohn_disease#Z4272f924349255b3e4babe86d4e939c9), [colon cancer](https:\/\/www.amboss.com\/us\/knowledge\/Colorectal_cancer#Z5f9a21e2819d2a5004da275e0fe8e909), [ischemic colitis](https:\/\/www.amboss.com\/us\/knowledge\/Intestinal_ischemia#Za5a3e828cf2d10df3a9693a9fc3b2c34), [radiation colitis](https:\/\/www.amboss.com\/us\/knowledge\/Radiation_injury#Ze0a9ed89b6c1c4ea08173fa19b2b74f9), and [pseudomembranous colitis](https:\/\/www.amboss.com\/us\/knowledge\/Clostridioides_difficile_infection#Z9a45a83f4126940236032056da651cf6) Testing for infectious diseases: e.g., [parasites]() ([amebiasis](https:\/\/www.amboss.com\/us\/knowledge\/Amebiasis#Z4500356668f80dc7e2e4d3b731ae9d1f)) and [C. difficile infection](https:\/\/www.amboss.com\/us\/knowledge\/Clostridioides_difficile_infection#Zb508f99ee028a9d8582608f40bc36f5f) |   |\n| [Fatty diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Chronic_pancreatitis#Z416510d2bd6fcd19b4e328d62b6b10db) \\[10\\]\\[12\\]\\[16\\] | Increased fecal fat, e.g.: [Sudan stain](https:\/\/www.amboss.com\/us\/knowledge\/Cellular_changes_and_adaptive_responses#Z78716b286b479e2c380f54ed824c20fc) positive [72-hour fecal fat estimation](https:\/\/www.amboss.com\/us\/knowledge\/Chronic_pancreatitis#Zd212c09e9c64621940c1a0ced94a9c98) elevated | [Mucosal]() disease: [celiac disease panel](https:\/\/www.amboss.com\/us\/knowledge\/Celiac_disease#Z63d359b4e2570234feebde9aaebff219) and [EGD](https:\/\/www.amboss.com\/us\/knowledge\/Esophagogastroduodenoscopy#Z1a617ceb3d8b9832108168a091314359) with [biopsies]() Luminal disease [Pancreatic function tests](https:\/\/www.amboss.com\/us\/knowledge\/Laboratory_medicine#Zc0f762af46ed9109bda61d0feb7a5ab3) (e.g., [fecal elastase-1](https:\/\/www.amboss.com\/us\/knowledge\/Chronic_pancreatitis#Zf555d89ae453336db1900a0d4d2df7e7)): can identify [exocrine pancreatic insufficiency](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Z4880cedb9eb57d620afb59b2c9e39a8b) \\[18\\] [Hydrogen breath test](https:\/\/www.amboss.com\/us\/knowledge\/Lactose_intolerance#Z4187a69143c8be5cfd157107e8edb65a)  and [EGD](https:\/\/www.amboss.com\/us\/knowledge\/Esophagogastroduodenoscopy#Z1a617ceb3d8b9832108168a091314359) with [small bowel aspiration]() and cultures: can identify [SIBO](https:\/\/www.amboss.com\/us\/knowledge\/Small_intestinal_bacterial_overgrowth#Z9aa32f677362a235a8ae39e011711f1b) \\[34\\] |   |\n| [Watery diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z16ed63f1f94f558cfbffed53ce14a7fb) \\[11\\] | [Secretory diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Za81182120613af86b266ff31432e241e) or [functional diarrheal disorders](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z68e249c3723fb43d54724dbf2018af91) | Low [stool osmotic gap](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Ze3350ca8675573e0158f73d116234534) (\\< 50 mOsm\/kg) No fecal [leukocytes](https:\/\/www.amboss.com\/us\/knowledge\/Basics_of_hematology#Z18a02873023ccef6d8ea2b461e0b7446) No fecal fat | [TFTs](https:\/\/www.amboss.com\/us\/knowledge\/Hyperthyroidism_and_thyrotoxicosis#Zc2daec2f86dc7f7edf504314f5e9de68), [cortisol](https:\/\/www.amboss.com\/us\/knowledge\/Adrenal_gland#Z68437810c311fa1e0e910fecfa30be04) level, [diabetes mellitus screening](https:\/\/www.amboss.com\/us\/knowledge\/Diabetes_mellitus#Z880b3ed63aba809ccba7ae2a7afb386d): can detect endocrine disorders Serum [gastrin](https:\/\/www.amboss.com\/us\/knowledge\/Gastrointestinal_tract#Z16fdc87a47049d4522f49bf193d34fcb), [VIP](https:\/\/www.amboss.com\/us\/knowledge\/Gastrointestinal_tract#Z2a13d7814300b48684ebf0f62ffc0318), [calcitonin](https:\/\/www.amboss.com\/us\/knowledge\/Hypocalcemia#Z8f09b075f4d87191d15890436cb2a4a5) level: can detect [neuroendocrine tumors](https:\/\/www.amboss.com\/us\/knowledge\/Neuroendocrine_neoplasms#Z688b3fb7764fe32e74754d4b26c6fc89) Evaluation for [bile acid](https:\/\/www.amboss.com\/us\/knowledge\/Gallbladder_and_bile#Z86b474a966e0cc8faf1092967eaf82f4) [malabsorption](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb) and [SIBO](https:\/\/www.amboss.com\/us\/knowledge\/Small_intestinal_bacterial_overgrowth#Z9aa32f677362a235a8ae39e011711f1b) [Rome IV criteria for IBS](https:\/\/www.amboss.com\/us\/knowledge\/Irritable_bowel_syndrome#Zc16da4fdfa96f2bd9cf45f216019665a): may indicate [functional diarrhea]() |\n| [Osmotic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z7169e994f812b120ea2df94d1042192e) | High [stool osmotic gap](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Ze3350ca8675573e0158f73d116234534) (≥ 100 mOsm\/kg) No fecal [leukocytes](https:\/\/www.amboss.com\/us\/knowledge\/Basics_of_hematology#Z18a02873023ccef6d8ea2b461e0b7446) No fecal fat | Stool [pH]() \\< 6 suggests [carbohydrate malabsorption](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Z1659a0f218ffe905f7bddb7c54efb326);  consider the following: \\[11\\] [Celiac disease panel](https:\/\/www.amboss.com\/us\/knowledge\/Celiac_disease#Z63d359b4e2570234feebde9aaebff219) [Lactose hydrogen breath test](https:\/\/www.amboss.com\/us\/knowledge\/Lactose_intolerance#Z4187a69143c8be5cfd157107e8edb65a): can diagnose [lactase deficiency](https:\/\/www.amboss.com\/us\/knowledge\/Lactose_intolerance#Zd10b2b1e3672bf92a1e23fc1962405dc) [Small intestine biopsy](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Z4c414f1e711c5ae69ceece6cee9f425e): can diagnose [celiac disease](https:\/\/www.amboss.com\/us\/knowledge\/Celiac_disease#Z1999c64abb6e85ce70f8cdc66810a65b) or infectious diseases (e.g., [Whipple disease](https:\/\/www.amboss.com\/us\/knowledge\/Whipple_disease#Z83c04868f8c75273c89d8c6e966623e4)) Stool [pH]() ≥ 6 suggests [antacid](https:\/\/www.amboss.com\/us\/knowledge\/Dyspepsia#Z483f046dcff29152f098e8a15dc67c9b) and\/or [laxative]() ingestion |   |\n\nIn [watery diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z16ed63f1f94f558cfbffed53ce14a7fb), the [stool osmotic gap](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Ze3350ca8675573e0158f73d116234534) differentiates osmotic from [secretory diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Za81182120613af86b266ff31432e241e). In osmotic [watery diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z16ed63f1f94f558cfbffed53ce14a7fb), a stool [pH]() \\< 6 suggests [carbohydrate malabsorption](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Z1659a0f218ffe905f7bddb7c54efb326).\n\nEndoscopic studies with [mucosal]() [biopsies]() are required to diagnose [inflammatory diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z321586a3cfe84e9365a55d0ed20fb62a) in patients with [chronic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a).\n\n## Therapeutic trials \\[10\\]\\[11\\]\\[18\\]\\[24\\]\n- Indications\n  - Consider if a diagnosis has not been established after a thorough evaluation.\n  - Consider if diagnostic tests for specific etiologies are not available.\n- Examples of empiric therapies for specific causes \\[18\\]\n  - [Elimination diets](): e.g., [lactose](https:\/\/www.amboss.com\/us\/knowledge\/Carbohydrates#Z42d58e097395e9a8d8ade84fd063faf8)\\-free diet for [lactose intolerance](https:\/\/www.amboss.com\/us\/knowledge\/Lactose_intolerance#Z8597682de9e4e8655c2f5df7319b32f3)\n  - [Empiric antibiotics](https:\/\/www.amboss.com\/us\/knowledge\/Overview_of_antibiotic_therapy#Z0d92af1eab239465721da02549c61854): e.g., [rifaximin](https:\/\/www.amboss.com\/us\/knowledge\/Hepatic_encephalopathy#Za8e7b6e3b08d56feebf985f44969b261) for suspected [SIBO](https:\/\/www.amboss.com\/us\/knowledge\/Small_intestinal_bacterial_overgrowth#Z9aa32f677362a235a8ae39e011711f1b) \\[34\\]\n  - [Cholestyramine](https:\/\/www.amboss.com\/us\/knowledge\/Second-line_lipid-lowering_agents#Z1de5d1df48f548f9d227c6743af88c42) for suspected [bile acid](https:\/\/www.amboss.com\/us\/knowledge\/Gallbladder_and_bile#Z86b474a966e0cc8faf1092967eaf82f4) [malabsorption](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb) \\[35\\]\n  - Oral [steroids](https:\/\/www.amboss.com\/us\/knowledge\/Glucocorticoids#Z3733d22ef7bb87f743207060acda0451) for [microscopic colitis](https:\/\/www.amboss.com\/us\/knowledge\/Microscopic_colitis#Z98c8e90c538959e074e80c55a532e1bc)\n  - [Pancreatic enzyme](https:\/\/www.amboss.com\/us\/knowledge\/Pancreas#Zb4592cc9a760c08db00e5b2e0bcb8d80) replacement therapy for [exocrine pancreatic insufficiency](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Z4880cedb9eb57d620afb59b2c9e39a8b)\n\n## Differential diagnoses![toggle arrow icon](https:\/\/manus-media.amboss.com\/icons\/chevron_up.svg)\n- [Fecal incontinence](https:\/\/www.amboss.com\/us\/knowledge\/Fecal_incontinence#Z62ff0b685d439994bb91355e521425cb)\n  - Involuntary release of stool, usually without a sensation of urgency\n  - May indicate abnormal neuromuscular function or anorectal structure\n  - Diagnosis is made based on history and a [digital rectal examination](https:\/\/www.amboss.com\/us\/knowledge\/Abdominal_examination#Z5d3564efeb645a3f97c92377b2f3ca28).\n- Impaction with fecal overflow (paradoxical diarrhea)\n  - Rectal distention relaxes the [internal anal sphincter](https:\/\/www.amboss.com\/us\/knowledge\/Hemorrhoids#Z5d181799c154206768eba201b5b182f0), allowing leakage of stool.\n  - Diagnosis is made based on a [digital rectal examination](https:\/\/www.amboss.com\/us\/knowledge\/Abdominal_examination#Z5d3564efeb645a3f97c92377b2f3ca28).\n- [Pseudodiarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z03319666a4dfb1ca98ba5a66ae368c65)\n  - Frequent passage of small amounts of stool\n  - Usually accompanied by [fecal urgency]() or the feeling of incomplete emptying of the [rectum](https:\/\/www.amboss.com\/us\/knowledge\/Large_intestine#Z0ebdfdd5b18e5097d9a31ac997523231)\n  - Often accompanies [IBS](https:\/\/www.amboss.com\/us\/knowledge\/Irritable_bowel_syndrome#Z2b30a84dc4106c4e8aad1e6c9202f3ea) and [proctitis](https:\/\/www.amboss.com\/us\/knowledge\/Proctitis#Z93005674e3e45d8ad4a9fe34183b999d)\n\nReferences:\\[11\\]\\[22\\]\\[23\\]\n\nThe differential diagnoses listed here are not exhaustive.\n\n## Subtypes and variants![toggle arrow icon](https:\/\/manus-media.amboss.com\/icons\/chevron_up.svg)\n## Traveler's diarrhea \\[36\\]\\[37\\]\n- Definition: ≥ 3 unformed stools with at least one additional [enteric]() symptom occurring after recent travel\n- [Epidemiology](https:\/\/www.amboss.com\/us\/knowledge\/Epidemiology#Z4c4f63797573af64476acb67d715be49)\n  - The highest rates occur after travel to Africa and South, Central, and West Asia.\n  - Approximately 25% of all travelers develop [traveler's diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zed77ffe538dae231e40fe0542e7b245a).\n- Etiology\n  - [Enterotoxigenic E. coli](https:\/\/www.amboss.com\/us\/knowledge\/Diarrheagenic_E._coli#Z458147f1e1273e554884140b40317779) ([ETEC](https:\/\/www.amboss.com\/us\/knowledge\/Diarrheagenic_E._coli#Z458147f1e1273e554884140b40317779)) is the most common cause of [traveler's diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zed77ffe538dae231e40fe0542e7b245a) globally.\n  - [Campylobacter jejuni](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Z4a3deabcd49cf50e8c48e5f0d5dcc506) is the most common cause in Southeast Asia.\n  - Other pathogens\n    - Bacterial: [Shigella](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Z40dc9a1dcc2df2a82a0c4586e5023158) spp., [Salmonella](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Zcf62cfeb3796c44845f303785e4bb88c) spp., other [E. coli](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Z2018b58c3c7835457287264e40fa1a3c) strains (e.g., [EAEC](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Za7272c791289de3f342534103a939841))\n    - Viral: [norovirus](https:\/\/www.amboss.com\/us\/knowledge\/General_virology#Z85b05d149dafb61d67a5c48e9a2fdb65), [rotavirus](https:\/\/www.amboss.com\/us\/knowledge\/General_virology#Z0b6c006e84714af76f7c43bebbeb2315), [astrovirus](https:\/\/www.amboss.com\/us\/knowledge\/General_virology#Zc55a1d58333a52b6c627a91623b6b333)\n    - [Protozoal](https:\/\/www.amboss.com\/us\/knowledge\/General_parasitology#Z8f4f3567860a31947bee8edff7ea6bd5): [Giardia duodenalis](https:\/\/www.amboss.com\/us\/knowledge\/Giardiasis#Zc37e227ee434dce8d190d098017db709), [E. histolytica](https:\/\/www.amboss.com\/us\/knowledge\/Amebiasis#Z4001b357f1b712e83d6027a4dfa5731b)\n- Clinical features: [exudative]()\\-inflammatory or [secretory diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Za81182120613af86b266ff31432e241e), abdominal cramping, abdominal [pain](https:\/\/www.amboss.com\/us\/knowledge\/Principles_of_pain_management#Zd673a3f7ee36023aab5a267899e984cc)\n- Antibiotics for traveler's diarrhea: Reserve for moderate to severe illness. \\[25\\]\\[32\\]\\[36\\]\n  - For most destinations: [ciprofloxacin](https:\/\/www.amboss.com\/us\/knowledge\/Overview_of_antibiotic_therapy#Z3f1dbc417664139dda097bcd516ceeed) ([off label](https:\/\/www.amboss.com\/us\/knowledge\/Fundamentals_of_pharmacology#Zb37ab5e3f79a4ddd6b356eb84fa0067a))  OR [rifaximin](https:\/\/www.amboss.com\/us\/knowledge\/Hepatic_encephalopathy#Za8e7b6e3b08d56feebf985f44969b261)   \\[36\\]\n  - For travelers to South or Southeast Asia: [azithromycin](https:\/\/www.amboss.com\/us\/knowledge\/Overview_of_antibiotic_therapy#Z9884c173cd8bcd36d44eb85ea8acfec2) ([off label](https:\/\/www.amboss.com\/us\/knowledge\/Fundamentals_of_pharmacology#Zb37ab5e3f79a4ddd6b356eb84fa0067a))  \\[36\\]\n- [Supportive care]() \\[25\\]\n  - Treatment for [dehydration](https:\/\/www.amboss.com\/us\/knowledge\/Dehydration_and_hypovolemia#Zbd78324053c153c16ea5cb2574249398) (e.g., [oral rehydration solution](https:\/\/www.amboss.com\/us\/knowledge\/Dehydration_and_hypovolemia#Z22573072c2ce7ea0ba0873c3024dc043))\n  - [Bismuth subsalicylate](https:\/\/www.amboss.com\/us\/knowledge\/Helicobacter_pylori_infection#Z5ff316bf4e8912c06dc600df2a9e8b09) for patients with mild to moderate illness\n  - [Loperamide](https:\/\/www.amboss.com\/us\/knowledge\/Opioids#Z1881077ac71cd771cb44b7db04569ac0) for patients receiving [antibiotic therapy](https:\/\/www.amboss.com\/us\/knowledge\/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3) (can reduce the duration of illness)\n  - See “[Antidiarrheal agents](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zc9c4c39a6ce3413ed32214ba89c1e777)” for dosages.\n- Postinfectious sequelae\n  - [Postinfectious IBS](): may occur in 3–20% of patients\n  - [Reactive arthritis](https:\/\/www.amboss.com\/us\/knowledge\/Reactive_arthritis#Z004554eda6fc600767f0d5dbaca1925d): may last months to years\n  - [Guillain-Barre syndrome](https:\/\/www.amboss.com\/us\/knowledge\/Guillain-Barr%C3%A9_syndrome#Zf193c1b0b16db4d30e7f29d4e766d3e8): may develop 1–4 weeks after infection (most commonly after [Campylobacter](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Za64f770db8dc668f93db5788517d1bc0) infection)\n\n[Antibiotic](https:\/\/www.amboss.com\/us\/knowledge\/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3) treatment is not recommended in patients with mild [traveler's diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zed77ffe538dae231e40fe0542e7b245a).\n\n[Bismuth subsalicylate](https:\/\/www.amboss.com\/us\/knowledge\/Helicobacter_pylori_infection#Z5ff316bf4e8912c06dc600df2a9e8b09) is an [antidiarrheal agent](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zc9c4c39a6ce3413ed32214ba89c1e777) used to treat [traveler's diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zed77ffe538dae231e40fe0542e7b245a) (caused by [enterotoxigenic Escherichia coli](https:\/\/www.amboss.com\/us\/knowledge\/Diarrheagenic_E._coli#Z458147f1e1273e554884140b40317779)).\n\n### Pharmacological prophylaxis for traveler's diarrhea \\[25\\]\\[36\\]\nConsider for travelers to high-risk areas (under specialist guidance); options include:\n\n- [Bismuth subsalicylate](https:\/\/www.amboss.com\/us\/knowledge\/Helicobacter_pylori_infection#Z5ff316bf4e8912c06dc600df2a9e8b09) ([off label](https:\/\/www.amboss.com\/us\/knowledge\/Fundamentals_of_pharmacology#Zb37ab5e3f79a4ddd6b356eb84fa0067a))  \\[25\\]\\[36\\]\\[38\\]\n  - Consider for travelers with no contraindications for use.\n  - Should be taken with meals and at bedtime\n- [Antibiotic prophylaxis](https:\/\/www.amboss.com\/us\/knowledge\/Overview_of_antibiotic_therapy#Z59b09641b101520dcac91806ce3bc6c4) (generally discouraged) :\n  - Consider short-term administration in travelers who are at high-risk for developing serious complications.\n  - Agents include [fluoroquinolones](https:\/\/www.amboss.com\/us\/knowledge\/Overview_of_antibiotic_therapy#Z6b160289536b8a7a7a2c161a02014e7c), [azithromycin](https:\/\/www.amboss.com\/us\/knowledge\/Overview_of_antibiotic_therapy#Z9884c173cd8bcd36d44eb85ea8acfec2), and [rifaximin](https:\/\/www.amboss.com\/us\/knowledge\/Hepatic_encephalopathy#Za8e7b6e3b08d56feebf985f44969b261).\n- Probiotics, prebiotics, and synbiotics are not recommended.\n## Factitious diarrhea \\[11\\]\n- Definition: self-induced diarrhea, usually due to [laxative abuse](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zf400d371a3aeaaef09f5533381e99329) (often occurs in individuals with [factitious disorders](https:\/\/www.amboss.com\/us\/knowledge\/Somatic_symptom_and_related_disorders#Za429ee6281b4bad77a94b44df89f4036)), or dilution of stools with solutions\n- [Epidemiology](https:\/\/www.amboss.com\/us\/knowledge\/Epidemiology#Z4c4f63797573af64476acb67d715be49)\n  - Most prevalent in women\n  - Patients are usually [health care professionals]().\n  - History of multiple hospital admissions\n- Clinical features: [chronic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a) without an identifiable cause\n- Diagnostics\n  - Laboratory tests: [metabolic acidosis](https:\/\/www.amboss.com\/us\/knowledge\/Acid-base_disorders#Ze6ecd1a689f21c50f6f1d77dcd2bd10b) , [metabolic alkalosis](https:\/\/www.amboss.com\/us\/knowledge\/Acid-base_disorders#Z46196a0a09cd3ccdd01835db5b427a7c) , [hypokalemia](https:\/\/www.amboss.com\/us\/knowledge\/Hypokalemia#Z1454fccf44cdd1776601d443f63ca03c), [hypermagnesemia](https:\/\/www.amboss.com\/us\/knowledge\/Hypermagnesemia#Z80b32d5d74b73a5c759d3ecd2043a7e6)\n  - Stool [osmolarity](https:\/\/www.amboss.com\/us\/knowledge\/Intravenous_fluid_therapy#Zdeae47858e4e2ccdf3ffe701a1970e95)\n    - \\< 290 mOsm\/L: indicates dilution of the stool with a hypotonic solution\n    - \\> 600 mOsm\/L: indicates dilution of the stool with a hypertonic solution\n  - [Laxative]() screen \\[18\\]\n  - [Colonoscopy](https:\/\/www.amboss.com\/us\/knowledge\/Colonoscopy#Za4aebc8baa131b83620292e8d0363739): may show [melanosis coli](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z21e7a77240bb6cafa756a1d9e263da87) in cases of anthraquinone  abuse\n- Treatment\n  - Correction of [electrolyte](https:\/\/www.amboss.com\/us\/knowledge\/Laboratory_medicine#Z562f1491861b33bdb5af572388e99541) disturbances and [dehydration](https:\/\/www.amboss.com\/us\/knowledge\/Dehydration_and_hypovolemia#Zbd78324053c153c16ea5cb2574249398)\n  - Referral for [psychotherapy](https:\/\/www.amboss.com\/us\/knowledge\/Psychotherapy_and_defense_mechanisms#Zf708bc74cb22922dcaead5dadff629f1)\n### Laxative abuse\n- Types of [laxative]()\n  - Bulking agent: e.g., flaxseed\n  - [Osmotic laxatives](https:\/\/www.amboss.com\/us\/knowledge\/Constipation#Z6beba559f6dfabe7c19e807cf28747b9): e.g., [lactulose](https:\/\/www.amboss.com\/us\/knowledge\/Constipation#Z0852fd0c491f2b6f0a759881cabda4f6), macrogols ([polyethylene glycol](https:\/\/www.amboss.com\/us\/knowledge\/Constipation#Zcde79976b13e9812a2b43638e222638a)), [magnesium sulfate](https:\/\/www.amboss.com\/us\/knowledge\/Antiarrhythmic_drugs#Z0ff5d7d7c8e365d789ab5203a4d3be0d), [sodium](https:\/\/www.amboss.com\/us\/knowledge\/Water_and_electrolyte_metabolism#Z420309902608f05802e6d9d942b6e0b1) sulfate\n  - Diphenolic [laxatives](): [bisacodyl](https:\/\/www.amboss.com\/us\/knowledge\/Constipation#Zbf46603548ee0c75699c6ca00fd4012e), [sodium picosulfate](https:\/\/www.amboss.com\/us\/knowledge\/Constipation#Zdb1b407c1514de705a12a3d578503d44)\n  - Anthraquinones: e.g., [senna](https:\/\/www.amboss.com\/us\/knowledge\/Constipation#Zc0086a2d59642def31185968e7198850), aloe vera, rhubarb\n- Clinical features\n  - [Osmotic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z7169e994f812b120ea2df94d1042192e), [meteorism]()\n  - [Dehydration](https:\/\/www.amboss.com\/us\/knowledge\/Dehydration_and_hypovolemia#Zbd78324053c153c16ea5cb2574249398)\n  - [Hypokalemia](https:\/\/www.amboss.com\/us\/knowledge\/Hypokalemia#Z1454fccf44cdd1776601d443f63ca03c)\n  - Melanosis coli: benign [hyperpigmentation]() of the [colonic](https:\/\/www.amboss.com\/us\/knowledge\/Large_intestine#Ze19293358dc6c65dc95f936bb8fca493) [mucosa]() caused by anthraquinone abuse  \\[39\\]\n    - [Colonoscopy](https:\/\/www.amboss.com\/us\/knowledge\/Colonoscopy#Za4aebc8baa131b83620292e8d0363739): patches of dark brown pigmentation interspersed with pale [mucosa]()\n    - [Biopsy](): [lipofuscin](https:\/\/www.amboss.com\/us\/knowledge\/Cellular_changes_and_adaptive_responses#Z9dfa90b47fb5223ad397e9ba918a6301)\\-laden [macrophages](https:\/\/www.amboss.com\/us\/knowledge\/Basics_of_hematology#Z0e19366f91c1f6b0bdaabf9f6bd6d2b8) demonstrated on [periodic acid-Schiff](https:\/\/www.amboss.com\/us\/knowledge\/Pathology_techniques#Z3b9e905f86b4ae250a18aa356f30b003) 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)\n\n## Bile acid diarrhea\n- Definition: [secretory diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Za81182120613af86b266ff31432e241e) with or without [steatorrhea](https:\/\/www.amboss.com\/us\/knowledge\/Chronic_pancreatitis#Z416510d2bd6fcd19b4e328d62b6b10db) due to increased [colonic](https:\/\/www.amboss.com\/us\/knowledge\/Large_intestine#Ze19293358dc6c65dc95f936bb8fca493) secretion and motility secondary to an increased concentration of [bile acids](https:\/\/www.amboss.com\/us\/knowledge\/Gallbladder_and_bile#Z86b474a966e0cc8faf1092967eaf82f4) within the [colon](https:\/\/www.amboss.com\/us\/knowledge\/Large_intestine#Ze19293358dc6c65dc95f936bb8fca493)\n- [Epidemiology](https:\/\/www.amboss.com\/us\/knowledge\/Epidemiology#Z4c4f63797573af64476acb67d715be49): approx. 1% [global]() [prevalence](https:\/\/www.amboss.com\/us\/knowledge\/Population_health#Z44a0fb80a8923b6e2fb8ff1f83d5803a) \\[40\\]\n- Etiology\n  - [Ileal](https:\/\/www.amboss.com\/us\/knowledge\/Small_intestine#Zf3a10de88f22b839a2769aa9ae031960) dysfunction or decreased [bile acid](https:\/\/www.amboss.com\/us\/knowledge\/Gallbladder_and_bile#Z86b474a966e0cc8faf1092967eaf82f4) reabsorption in the [ileum](https:\/\/www.amboss.com\/us\/knowledge\/Small_intestine#Zf3a10de88f22b839a2769aa9ae031960) (e.g., due to [ileal](https:\/\/www.amboss.com\/us\/knowledge\/Small_intestine#Zf3a10de88f22b839a2769aa9ae031960) resection, [Crohn disease](https:\/\/www.amboss.com\/us\/knowledge\/Crohn_disease#Zef70853af5e87c95d210bf8df682f64c))\n  - Postcholecystectomy\n  - Hepatic overproduction of [bile acids](https:\/\/www.amboss.com\/us\/knowledge\/Gallbladder_and_bile#Z86b474a966e0cc8faf1092967eaf82f4)\n  - [Biliary-enteric fistula](https:\/\/www.amboss.com\/us\/knowledge\/Fistulas#Z1787c9a9b3b830805f4bf55265169989)\n- Clinical features\n  - Bowel frequency and urgency\n  - [Fecal incontinence](https:\/\/www.amboss.com\/us\/knowledge\/Fecal_incontinence#Z62ff0b685d439994bb91355e521425cb)\n  - Abdominal cramping, abdominal [pain](https:\/\/www.amboss.com\/us\/knowledge\/Principles_of_pain_management#Zd673a3f7ee36023aab5a267899e984cc)\n  - Nocturnal [fecal urgency]()\n  - [Bloating](), flatulence\n- Management \\[41\\]\n  - First-line: [bile](https:\/\/www.amboss.com\/us\/knowledge\/Gallbladder_and_bile#Z4d90dfc94eec0585c748e9b6c6899d95)\\-acid sequestrants (e.g., [cholestyramine](https:\/\/www.amboss.com\/us\/knowledge\/Second-line_lipid-lowering_agents#Z1de5d1df48f548f9d227c6743af88c42), [colestipol](https:\/\/www.amboss.com\/us\/knowledge\/Second-line_lipid-lowering_agents#Z68ba6641495fdd1c0f72726e29d4eecb))\n  - Dietary intervention: low-fat diet\n\n## References![toggle arrow icon](https:\/\/manus-media.amboss.com\/icons\/chevron_up.svg)\n1. Sweetser S. Evaluating the Patient With Diarrhea: A Case-Based Approach. *Mayo Clinic Proceedings*. 2012; 87 (6): p.596-602.doi: [10\\.1016\/j.mayocp.2012.02.015](https:\/\/dx.doi.org\/10.1016\/j.mayocp.2012.02.015) . \\| [Open in Read by QxMD](https:\/\/read.qxmd.com\/doi\/10.1016\/j.mayocp.2012.02.015)\n2. Jamshed N, Lee Z-E, Olden KW. Diagnostic Approach to Chronic Constipation in Adults. *Am Fam Physician*. 2011; 84 (3): p.299-306.\n3. Burgers K, Lindberg B, Bevis ZJ. Chronic Diarrhea in Adults: Evaluation and Differential Diagnosis.. *Am Fam Physician*. 2020; 101 (8): p.472-480.\n4. Schiller LR. Evaluation of chronic diarrhea and irritable bowel syndrome with diarrhea in adults in the era of precision medicine. *Am J Gastroenterol*. 2018; 113 (5): p.660-669.doi: [10\\.1038\/s41395-018-0032-9](https:\/\/dx.doi.org\/10.1038\/s41395-018-0032-9) . \\| [Open in Read by QxMD](https:\/\/read.qxmd.com\/doi\/10.1038\/s41395-018-0032-9)\n5. Abraham B, Sellin JH. Drug-induced diarrhea. *Curr Gastroenterol Rep*. 2007; 9 (5): p.365-372.doi: [10\\.1007\/s11894-007-0044-x](https:\/\/dx.doi.org\/10.1007\/s11894-007-0044-x) . \\| [Open in Read by QxMD](https:\/\/read.qxmd.com\/doi\/10.1007\/s11894-007-0044-x)\n6. Semrad CE. *Approach to the Patient with Diarrhea and Malabsorption*. Elsevier ; 2012: p. 895-913\n7. Farahmandfar MR, Chabok M, Alade M, Bouhelal A, Patel B. Post Cholecystectomy Diarrhoea—A Systematic Review. *Surgical Science*. 2012; 03 (06): p.332-338.doi: [10\\.4236\/ss.2012.36065](https:\/\/dx.doi.org\/10.4236\/ss.2012.36065) . \\| [Open in Read by QxMD](https:\/\/read.qxmd.com\/doi\/10.4236\/ss.2012.36065)\n8. Schiller LR, Pardi DS, Sellin JH. Chronic Diarrhea: Diagnosis and Management. *Clinical Gastroenterology and Hepatology*. 2017; 15 (2): p.182-193.e3.doi: [10\\.1016\/j.cgh.2016.07.028](https:\/\/dx.doi.org\/10.1016\/j.cgh.2016.07.028) . \\| [Open in Read by QxMD](https:\/\/read.qxmd.com\/doi\/10.1016\/j.cgh.2016.07.028)\n9. Borbély YM, Osterwalder A, Kröll D, Nett PC, Inglin RA. Diarrhea after bariatric procedures: Diagnosis and therapy. *World Journal of Gastroenterology*. 2017; 23 (26): p.4689.doi: [10\\.3748\/wjg.v23.i26.4689](https:\/\/dx.doi.org\/10.3748\/wjg.v23.i26.4689) . \\| [Open in Read by QxMD](https:\/\/read.qxmd.com\/doi\/10.3748\/wjg.v23.i26.4689)\n10. Ma IT, Madura JA 2nd. Gastrointestinal Complications After Bariatric Surgery. *Gastroenterol Hepatol*. 2015; 11 (8): p.526-35.\n11. Barr W, Smith A. Acute diarrhea in adults. *Am Fam Physician*. 2014; 89 (3): p.180-189.\n12. Jameson JL, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. *Harrison's Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2)*. McGraw-Hill Education \/ Medical ; 2018\n13. Hammer HF. Management of Chronic Diarrhea in Primary Care: The Gastroenterologists Advice. *Digestive Diseases*. 2021.doi: [10\\.1159\/000515219](https:\/\/dx.doi.org\/10.1159\/000515219) . \\| [Open in Read by QxMD](https:\/\/read.qxmd.com\/doi\/10.1159\/000515219)\n14. Smalley W, Falck-Ytter C, Carrasco-Labra A, Wani S, Lytvyn L, Falck-Ytter Y. AGA Clinical Practice Guidelines on the Laboratory Evaluation of Functional Diarrhea and Diarrhea-Predominant Irritable Bowel Syndrome in Adults (IBS-D). *Gastroenterology*. 2019; 157 (3): p.851-854.doi: [10\\.1053\/j.gastro.2019.07.004](https:\/\/dx.doi.org\/10.1053\/j.gastro.2019.07.004) . \\| [Open in Read by QxMD](https:\/\/read.qxmd.com\/doi\/10.1053\/j.gastro.2019.07.004)\n15. Camilleri M, Sellin JH, Barrett KE. Pathophysiology, Evaluation, and Management of Chronic Watery Diarrhea. *Gastroenterology*. 2017; 152 (3): p.515-532.e2.doi: [10\\.1053\/j.gastro.2016.10.014](https:\/\/dx.doi.org\/10.1053\/j.gastro.2016.10.014) . \\| [Open in Read by QxMD](https:\/\/read.qxmd.com\/doi\/10.1053\/j.gastro.2016.10.014)\n16. Pimentel M, Saad RJ, Long MD, Rao SSC. ACG Clinical Guideline: Small Intestinal Bacterial Overgrowth. *Am J Gastroenterol*. 2020; 115 (2): p.165-178.doi: [10\\.14309\/ajg.0000000000000501](https:\/\/dx.doi.org\/10.14309\/ajg.0000000000000501) . \\| [Open in Read by QxMD](https:\/\/read.qxmd.com\/doi\/10.14309\/ajg.0000000000000501)\n17. Vijayvargiya P, Camilleri M, Shin A, Saenger A. Methods for Diagnosis of Bile Acid Malabsorption in Clinical Practice. *Clinical Gastroenterology and Hepatology*. 2013; 11 (10): p.1232-1239.doi: [10\\.1016\/j.cgh.2013.04.029](https:\/\/dx.doi.org\/10.1016\/j.cgh.2013.04.029) . \\| [Open in Read by QxMD](https:\/\/read.qxmd.com\/doi\/10.1016\/j.cgh.2013.04.029)\n18. Riddle MS, DuPont HL, Connor BA. ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults. *Am J Gastroenterol*. 2016; 111 (5): p.602-622.doi: [10\\.1038\/ajg.2016.126](https:\/\/dx.doi.org\/10.1038\/ajg.2016.126) . \\| [Open in Read by QxMD](https:\/\/read.qxmd.com\/doi\/10.1038\/ajg.2016.126)\n19. DuPont HL. Acute Infectious Diarrhea in Immunocompetent Adults. *N Engl J Med*. 2014; 370 (16): p.1532-1540.doi: [10\\.1056\/nejmra1301069](https:\/\/dx.doi.org\/10.1056\/nejmra1301069) . \\| [Open in Read by QxMD](https:\/\/read.qxmd.com\/doi\/10.1056\/nejmra1301069)\n20. Shane AL, Mody RK, Crump JA, et al. 2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea. *Clin Infect Dis*. 2017; 65 (12): p.e45-e80.doi: [10\\.1093\/cid\/cix669](https:\/\/dx.doi.org\/10.1093\/cid\/cix669) . \\| [Open in Read by QxMD](https:\/\/read.qxmd.com\/doi\/10.1093\/cid\/cix669)\n21. DuPont HL. Persistent Diarrhea. *JAMA*. 2016; 315 (24): p.2712.doi: [10\\.1001\/jama.2016.7833](https:\/\/dx.doi.org\/10.1001\/jama.2016.7833) . \\| [Open in Read by QxMD](https:\/\/read.qxmd.com\/doi\/10.1001\/jama.2016.7833)\n22. Qiu FZ, Shen XX, Li GX, et al. Adenovirus associated with acute diarrhea: a case-control study.. *BMC Infect Dis*. 2018; 18 (1): p.450.doi: [10\\.1186\/s12879-018-3340-1](https:\/\/dx.doi.org\/10.1186\/s12879-018-3340-1) . \\| [Open in Read by QxMD](https:\/\/read.qxmd.com\/doi\/10.1186\/s12879-018-3340-1)\n23. Histamine Toxicity. *<https:\/\/www.aaaai.org\/conditions-and-treatments\/related-conditions\/histamine-toxicity>*. Updated: March 1, 2017. Accessed: March 1, 2017.\n24. Overview of Food Poisoning. *<http:\/\/www.msdmanuals.com\/home\/injuries-and-poisoning\/poisoning\/overview-of-food-poisoning>*. Updated: March 1, 2017. Accessed: March 1, 2017.\n25. Juckett G, Trivedi R. Evaluation of Chronic Diarrhea. *Am Fam Physician*. 2011; 84 (10): p.1119-1126.\n26. DuPont HL. Adverse Effect of Lomotil Therapy in Shigellosis. *JAMA*. 1973; 226 (13): p.1525.doi: [10\\.1001\/jama.1973.03230130013006](https:\/\/dx.doi.org\/10.1001\/jama.1973.03230130013006) . \\| [Open in Read by QxMD](https:\/\/read.qxmd.com\/doi\/10.1001\/jama.1973.03230130013006)\n27. Singh N, Narayan S. Racecadotril : A Novel Antidiarrheal. *Med J Armed Forces India*. 2008; 64 (4): p.361-2.doi: [10\\.1016\/S0377-1237(08)80022-6](https:\/\/dx.doi.org\/10.1016\/S0377-1237\\(08\\)80022-6) . \\| [Open in Read by QxMD](https:\/\/read.qxmd.com\/doi\/10.1016\/S0377-1237\\(08\\)80022-6)\n28. Benjamin I. *Andreoli and Carpenter's Cecil Essentials of Medicine*. Elsevier Health Sciences ; 2016\n29. Diarrhoeal disease. *<http:\/\/www.who.int\/mediacentre\/factsheets\/fs330\/en\/>*. Updated: April 1, 2013. Accessed: March 1, 2017.\n30. Schiller LR, Pardi DS, Spiller R, et al. Gastro 2013 APDW\/WCOG Shanghai Working Party Report: Chronic diarrhea: Definition, classification, diagnosis. *J Gastroenterol Hepatol*. 2013; 29 (1): p.6-25.doi: [10\\.1111\/jgh.12392](https:\/\/dx.doi.org\/10.1111\/jgh.12392) . \\| [Open in Read by QxMD](https:\/\/read.qxmd.com\/doi\/10.1111\/jgh.12392)\n31. Dellon ES, Ringel Y. Treatment of functional diarrhea. *Curr Treat Options Gastroenterol*. 2006; 9 (4): p.331-342.doi: [10\\.1007\/s11938-006-0015-6](https:\/\/dx.doi.org\/10.1007\/s11938-006-0015-6) . \\| [Open in Read by QxMD](https:\/\/read.qxmd.com\/doi\/10.1007\/s11938-006-0015-6)\n32. Travelers' Diarrhea. *<https:\/\/web.archive.org\/web\/20240929175416\/https:\/\/wwwnc.cdc.gov\/travel\/yellowbook\/2024\/preparing\/travelers-diarrhea>*. Updated: November 22, 2019. Accessed: September 29, 2024.\n33. Giddings SL, Stevens AM, Leung DT. Traveler’s Diarrhea. *Med Clin North Am*. 2016; 100 (2): p.317-330.doi: [10\\.1016\/j.mcna.2015.08.017](https:\/\/dx.doi.org\/10.1016\/j.mcna.2015.08.017) . \\| [Open in Read by QxMD](https:\/\/read.qxmd.com\/doi\/10.1016\/j.mcna.2015.08.017)\n34. Herbert L. DuPont, Charles D. Ericsson, P. C. Johnson, F. Javier de la Cabada. Use of Bismuth Subsalicylate for the Prevention of Travelers' Diarrhea. *Clinical Infectious Diseases*. 1990; 12 (Supplement\\_1): p.S64-S67.doi: [10\\.1093\/clinids\/12.supplement\\_1.s64](https:\/\/dx.doi.org\/10.1093\/clinids\/12.supplement_1.s64) . \\| [Open in Read by QxMD](https:\/\/read.qxmd.com\/doi\/10.1093\/clinids\/12.supplement_1.s64)\n35. Freeman HJ. “Melanosis” in the small and large intestine. *World J Gastroenterol*. 2008; 14 (27): p.4296.doi: [10\\.3748\/wjg.14.4296](https:\/\/dx.doi.org\/10.3748\/wjg.14.4296) . \\| [Open in Read by QxMD](https:\/\/read.qxmd.com\/doi\/10.3748\/wjg.14.4296)\n36. Walters JR, Pattni SS. Managing bile acid diarrhoea.. *Therap Adv Gastroenterol.*. 2010; 3 (6): p.349-57.doi: [10\\.1177\/1756283X10377126](https:\/\/dx.doi.org\/10.1177\/1756283X10377126) . \\| [Open in Read by QxMD](https:\/\/read.qxmd.com\/doi\/10.1177\/1756283X10377126)\n37. Farrugia A, Arasaradnam R. Bile acid diarrhoea: pathophysiology, diagnosis and management. *Frontline Gastroenterology*. 2020; 12 (6): p.500-507.doi: [10\\.1136\/flgastro-2020-101436](https:\/\/dx.doi.org\/10.1136\/flgastro-2020-101436) . \\| [Open in Read by QxMD](https:\/\/read.qxmd.com\/doi\/10.1136\/flgastro-2020-101436)\n38. Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. *<https:\/\/web.archive.org\/web\/20260126024001\/https:\/\/clinicalinfo.hiv.gov\/sites\/default\/files\/guidelines\/documents\/adult-adolescent-oi\/guidelines-adult-adolescent-oi.pdf>*. Updated: July 14, 2025. Accessed: January 25, 2026.\n39. Kasper DL, Fauci AS, Hauser SL, et al. *Harrison's Principles of Internal Medicine*. McGraw-Hill Education ; 2015\n40. Walker HK, Hall WD, Hurst WJ, Silverman ME, Morrison G. *Clinical Methods: The History, Physical, and Laboratory Examinations*. Butterworths ; 1990\n41. Saad RJ, Chey WD. Breath Testing for Small Intestinal Bacterial Overgrowth: Maximizing Test Accuracy. *Clin Gastroenterol Hepatol*. 2014; 12 (12): p.1964-1972.doi: [10\\.1016\/j.cgh.2013.09.055](https:\/\/dx.doi.org\/10.1016\/j.cgh.2013.09.055) . \\| [Open in Read by QxMD](https:\/\/read.qxmd.com\/doi\/10.1016\/j.cgh.2013.09.055)\n\n- [© 2026 AMBOSS](https:\/\/www.amboss.com\/us)\n- [Medical Knowledge](https:\/\/www.amboss.com\/us\/knowledge)\n- [Terms and Conditions](https:\/\/www.amboss.com\/us\/legal\/terms)\n- [Privacy](https:\/\/www.amboss.com\/us\/privacy)\n- [Privacy Settings](https:\/\/www.amboss.com\/us\/knowledge\/diarrhea\/)\n- [Legal Notice](https:\/\/www.amboss.com\/us\/legal\/imprint)\n- [Get Support & Contact Us](https:\/\/support.amboss.com\/hc\/en-us)\n\nSign up and get unlimited access.\n\n[Start free trial](https:\/\/next.amboss.com\/us\/registration?nextLink=%2Farticle%2F6M0jpg)\n\nEvidence-based content, created and peer-reviewed by physicians. Read the [disclaimer](https:\/\/www.amboss.com\/us\/disclaimer)","attrs_readable_markdown":"Last updated: February 27, 2026\n\n## Quick guide![toggle arrow icon](https:\/\/manus-media.amboss.com\/icons\/chevron_up.svg)\nDiagnostic testing is not indicated for most cases of\n\n.\n\n## Summary![toggle arrow icon](https:\/\/manus-media.amboss.com\/icons\/chevron_up.svg)\nDiarrhea, defined as three or more loose stools per day or more frequent stool passage than is normal for the individual, is a common disease with a monthly [prevalence](https:\/\/www.amboss.com\/us\/knowledge\/Population_health#Z44a0fb80a8923b6e2fb8ff1f83d5803a) of around 5% in the United States. [Acute diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z9902a484faaf54b4fa1ffaf3a5642113) lasts 14 days or less and is almost always caused by an infectious agent, typically a [virus](https:\/\/www.amboss.com\/us\/knowledge\/General_virology#Zcdc83877f75d9d9b9a07ece6544f646c). Testing is seldom required, as the disease tends to be [self-limited]() and care is primarily supportive. [Persistent diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zd56cfaa165f80b20fe15e54d5f2c0023), lasting 15–30 days, is also typically caused by an infectious agent, but stool testing for pathogens is generally warranted to confirm the diagnosis. [Chronic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a), defined as diarrhea lasting longer than 30 days, has an extensive differential diagnosis. A thorough history followed by systematic stool and blood testing is required to identify the specific etiology. The presence of any [red flags]() for severe or rapidly progressing diarrheal disease (e.g., [sepsis](https:\/\/www.amboss.com\/us\/knowledge\/Sepsis#Zb3de189fac0d57eac5b7798e127a5e19), extreme [dehydration](https:\/\/www.amboss.com\/us\/knowledge\/Dehydration_and_hypovolemia#Zbd78324053c153c16ea5cb2574249398), blood in the stool) mandates escalation of testing and, in some cases, [empiric antibiotics for bacterial gastroenteritis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z8bc7c574b3a32ce97b6e98deca3d7a27). Ensuring adequate oral hydration, correcting [dehydration](https:\/\/www.amboss.com\/us\/knowledge\/Dehydration_and_hypovolemia#Zbd78324053c153c16ea5cb2574249398), and providing symptomatic relief are fundamental components in the care of all patients with diarrhea. Curative treatment is directed toward the underlying cause.\n\n## Definitions![toggle arrow icon](https:\/\/manus-media.amboss.com\/icons\/chevron_up.svg)\nThe WHO defines diarrhea as ≥ 3 loose or watery stools per day or more frequent passage than is normal for the individual.  \\[1\\]\\[2\\]\n\n## Etiology![toggle arrow icon](https:\/\/manus-media.amboss.com\/icons\/chevron_up.svg)\nFor etiologies of acute, persistent, or [chronic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a), see specific subsections below.\n\n## [Overview of pathogens causing watery and bloody diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z8e48114f95d466b966813a8876de0264)\n| Overview |   |   |   |   |\n|---|---|---|---|---|\n| Type of diarrhea | [Pathogen]() | [Pathogen]() characteristics | Associated disorders |   |\n| [Watery diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z16ed63f1f94f558cfbffed53ce14a7fb) | Enterotoxigenic [Escherichia coli](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Z2018b58c3c7835457287264e40fa1a3c) | [Heat-labile toxin](https:\/\/www.amboss.com\/us\/knowledge\/Diarrheagenic_E._coli#Zb07ccb32bbf8bafda07228b738b272b0) [Heat-stable toxin](https:\/\/www.amboss.com\/us\/knowledge\/Diarrheagenic_E._coli#Z05a3bf9bd37c476e311abbdb16510192) | [Traveler's diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zed77ffe538dae231e40fe0542e7b245a) |   |\n| [Clostridioides difficile](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Z429d21670093a08ffb061528b0561719) | [Toxin A](https:\/\/www.amboss.com\/us\/knowledge\/Clostridioides_difficile_infection#Z953ec09a4d6afc7094cd488f8493999f) ([enterotoxin]()) [Toxin B](https:\/\/www.amboss.com\/us\/knowledge\/Clostridioides_difficile_infection#Za0f3dac89ddbb94c6ce33441f7ca29d0) (cytotoxin) Associated with [antibiotic](https:\/\/www.amboss.com\/us\/knowledge\/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3) and [PPI](https:\/\/www.amboss.com\/us\/knowledge\/Proton_pump_inhibitors#Z2753e50142e2f5b7089b165accdcc900) use | [Pseudomembranous colitis](https:\/\/www.amboss.com\/us\/knowledge\/Clostridioides_difficile_infection#Z9a45a83f4126940236032056da651cf6) Rarely causes bloody diarrhea |   |   |\n| [Clostridium perfringens](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Z927388b963f796f8c6f170841d77b930) | [Heat-labile enterotoxin](https:\/\/www.amboss.com\/us\/knowledge\/Diarrheagenic_E._coli#Zb07ccb32bbf8bafda07228b738b272b0) [Clostridium perfringens alpha toxin](https:\/\/www.amboss.com\/us\/knowledge\/Gas_gangrene#Z29badee7cb2803331016ab554584eccc) | [Gas gangrene](https:\/\/www.amboss.com\/us\/knowledge\/Gas_gangrene#Zc843bd9262a7db4767485d787d9c2653) |   |   |\n| [Vibrio cholerae](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Z5040d5b8f384d034307ec998d5706c4a) | Straight or curved (comma-shaped) [Cholera toxin](https:\/\/www.amboss.com\/us\/knowledge\/General_bacteriology#Z463b688997a9f1dd2f1a2f94cbafd0f9) ([enterotoxin]()): “rice water” diarrhea Transmission via contaminated water or uncooked seafood (e.g., raw shellfish) | [Cholera](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Zba6a00519c1b345599491aa93180aacf) |   |   |\n| [Viruses](https:\/\/www.amboss.com\/us\/knowledge\/General_virology#Zcdc83877f75d9d9b9a07ece6544f646c) | [Norovirus](https:\/\/www.amboss.com\/us\/knowledge\/General_virology#Z85b05d149dafb61d67a5c48e9a2fdb65) (most common cause) | Fecal-oral or [airborne transmission]() | [Gastroenteritis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Zcbd93ce063d015f699fd07ed09015b7f) |   |\n| [Rotavirus](https:\/\/www.amboss.com\/us\/knowledge\/General_virology#Z0b6c006e84714af76f7c43bebbeb2315) | [Fecal-oral transmission]() Prevention: attenuated [vaccine](https:\/\/www.amboss.com\/us\/knowledge\/Vaccination#Zce79039ee0c9c756b2e006d3be169afc) for children |   |   |   |\n| [Adenovirus](https:\/\/www.amboss.com\/us\/knowledge\/General_virology#Z5251a57602a66d951ca7a8a66643ee51) | Transmission via contaminated water or [fecal-oral route]() |   |   |   |\n| [Protozoa](https:\/\/www.amboss.com\/us\/knowledge\/General_parasitology#Z8f4f3567860a31947bee8edff7ea6bd5) | [Giardia lamblia](https:\/\/www.amboss.com\/us\/knowledge\/Giardiasis#Zc37e227ee434dce8d190d098017db709) | Transmission via ingestion of contaminated water (e.g., lakes, rivers, ponds, swimming pools) Most commonly affects hikers or campers | [Giardiasis](https:\/\/www.amboss.com\/us\/knowledge\/Giardiasis#Z7285e874bce9a0f39983534a6c838736) |   |\n| [Cryptosporidia](https:\/\/www.amboss.com\/us\/knowledge\/Food_poisoning#Z2838c305630a575a1e345dd9004ef9ea) | [Fecal-oral transmission]() ([oocysts]() are typically excreted in stool and contaminate drinking water) | [Cryptosporidiosis](https:\/\/www.amboss.com\/us\/knowledge\/HIV-associated_conditions#Z50d6fcd479428e63a00b9454e02cad44) [Immunocompromised individuals](https:\/\/www.amboss.com\/us\/knowledge\/Adaptive_immune_system#Z1af19ecc772907dd339670b5fb0e8b51): potentially life-threatening protracted diarrhea and\/or [biliary tract](https:\/\/www.amboss.com\/us\/knowledge\/Gallbladder_and_bile#Zadee0fdc5649284d46b022246819e246) infections (e.g., [cholangitis](https:\/\/www.amboss.com\/us\/knowledge\/Acute_cholangitis#Z9f187436aa934749f4437c12be5f3f0d), [cholecystitis](https:\/\/www.amboss.com\/us\/knowledge\/Acute_cholecystitis#Z08db08956e4ea1aca8e4c7e965b533f7)) |   |   |\n| [Cystoisospora belli](https:\/\/www.amboss.com\/us\/knowledge\/General_parasitology#Za983f2c51a6b8452adfa91552fb181e2) \\[3\\] | Foodborne Contaminated water | [Cystoisosporiasis](https:\/\/www.amboss.com\/us\/knowledge\/HIV-associated_conditions#Z1e782fdfd6ae6a71daf64a4e1644b0a9) [Immunocompromised individuals](https:\/\/www.amboss.com\/us\/knowledge\/Adaptive_immune_system#Z1af19ecc772907dd339670b5fb0e8b51): chronic profuse diarrhea, [acalculous cholecystitis](https:\/\/www.amboss.com\/us\/knowledge\/Acute_cholecystitis#Z9df8abcc0e36c38f478f48e212ad298f), [AIDS cholangiopathy](https:\/\/www.amboss.com\/us\/knowledge\/HIV-associated_conditions#Z1c0318dbf51f5c7bf9c39ff805ed97cc) |   |   |\n| Bloody diarrhea | [E.coli](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Z2018b58c3c7835457287264e40fa1a3c) | Enteroinvasive [E. coli](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Z2018b58c3c7835457287264e40fa1a3c) | Direct invasion of the intestinal [epithelium](https:\/\/www.amboss.com\/us\/knowledge\/General_histology#Z23c08800c35f1f71236b85bd916db48b) and formation of [enterotoxins]() | [Gastroenteritis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Zcbd93ce063d015f699fd07ed09015b7f) |\n| Enterohemorrhagic [E. coli](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Z2018b58c3c7835457287264e40fa1a3c) | [Shiga toxin](https:\/\/www.amboss.com\/us\/knowledge\/General_bacteriology#Zfa20332b82d5b9c5a7b6dca8046aa7bd) Most common [serotype](): ([O157:H7](https:\/\/www.amboss.com\/us\/knowledge\/Hemolytic_uremic_syndrome#Zd789cca34b9c96af9a9c7abd264b2c7b)) | [Hemolytic uremic syndrome](https:\/\/www.amboss.com\/us\/knowledge\/Hemolytic_uremic_syndrome#Z759bb631d23a3535c2b55dfd91c4807b) |   |   |\n| [Campylobacter jejuni](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Z4a3deabcd49cf50e8c48e5f0d5dcc506) | Curved or spiral‑shaped with polar [flagellum](https:\/\/www.amboss.com\/us\/knowledge\/General_bacteriology#Z7c98d422c4fed8c895c3dc3e0552a936) Grows best at 37–42°C | [Campylobacter enteritis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z9273c5a7cf1820c124f8fe4d5648df30) (especially in children) Commonly precedes [reactive arthritis](https:\/\/www.amboss.com\/us\/knowledge\/Reactive_arthritis#Z004554eda6fc600767f0d5dbaca1925d) and Guillain‑Barré syndrome |   |   |\n| Nontyphoidal [Salmonella](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Zcf62cfeb3796c44845f303785e4bb88c) | No [lactose](https:\/\/www.amboss.com\/us\/knowledge\/Carbohydrates#Z42d58e097395e9a8d8ade84fd063faf8) fermentation Flagellar motility Hosts: humans, animals, and animal products (e.g., reptiles, poultry, pets, eggs) | [Salmonellosis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z2681adc9ab180885765f48f6f730b912) |   |   |\n| [Shigella](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Z40dc9a1dcc2df2a82a0c4586e5023158) | Slow\/absent [lactose](https:\/\/www.amboss.com\/us\/knowledge\/Carbohydrates#Z42d58e097395e9a8d8ade84fd063faf8) fermentation [Shiga toxin](https:\/\/www.amboss.com\/us\/knowledge\/General_bacteriology#Zfa20332b82d5b9c5a7b6dca8046aa7bd) Low infectious dose required (low ID50) Humans are the only host. | [Bacillary dysentery](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Zd4a3455e8ec3d03f2e705d784ba584b0) |   |   |\n| [Yersinia enterocolitica](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Zc40fd992d4c98f7805725c8ed0f57d89) | Reservoir: contaminated pork and milk products | [Yersiniosis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z6c552143f411315b80f346c0c8707af5) ([outbreaks]() often occur in day-care settings) May manifest as [pseudoappendicitis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Zf1754d56a2add64869210dbfd4f92e81) [Reactive arthritis](https:\/\/www.amboss.com\/us\/knowledge\/Reactive_arthritis#Z004554eda6fc600767f0d5dbaca1925d) |   |   |\n| [Protozoa](https:\/\/www.amboss.com\/us\/knowledge\/General_parasitology#Z8f4f3567860a31947bee8edff7ea6bd5): [Entamoeba histolytica](https:\/\/www.amboss.com\/us\/knowledge\/Amebiasis#Z4001b357f1b712e83d6027a4dfa5731b) | [Fecal-oral transmission]() Amebic cysts are excreted in stool and can contaminate drinking water or food. | [Amebic dysentery](https:\/\/www.amboss.com\/us\/knowledge\/Amebiasis#Z9c6cd303635910835de37919e22415b9) [Amebic liver abscess](https:\/\/www.amboss.com\/us\/knowledge\/Amebiasis#Z8ac81fd9234b63200c6b963a90cf89b2) |   |   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Infectious causes \\[4\\]\\[5\\]\n|   | Conditions |   |\n|---|---|---|\n| Viral | [Norovirus infection](https:\/\/www.amboss.com\/us\/knowledge\/Norovirus_infection#Z2bf1564153a0ab14e52c587da9c8a8c3) [Rotavirus infection](https:\/\/www.amboss.com\/us\/knowledge\/Rotavirus_infection#Zb2e7858cefe0481ba26809cf4d9b84ec) [Adenovirus](https:\/\/www.amboss.com\/us\/knowledge\/General_virology#Z5251a57602a66d951ca7a8a66643ee51) infection (mainly [serotype]() 3, 40, and 41) \\[6\\] [Cytomegalovirus infection](https:\/\/www.amboss.com\/us\/knowledge\/Cytomegalovirus_infection#Za3ec0dd921d428ed745a6ec39879cf55) |   |\n| Bacterial | [Campylobacter enteritis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z9273c5a7cf1820c124f8fe4d5648df30) [Shigellosis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Zd4a3455e8ec3d03f2e705d784ba584b0) [Salmonellosis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z2681adc9ab180885765f48f6f730b912) [Cholera](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Zba6a00519c1b345599491aa93180aacf) [Diarrheagenic E. coli](https:\/\/www.amboss.com\/us\/knowledge\/Diarrheagenic_E._coli#Z815e7a84a36e420726cf0f61cc8adecb) infection ([travelers' diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zed77ffe538dae231e40fe0542e7b245a)) [Yersiniosis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z6c552143f411315b80f346c0c8707af5) (especially in day care centers) [Clostridioides difficile](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Z429d21670093a08ffb061528b0561719) infection ([antibiotic](https:\/\/www.amboss.com\/us\/knowledge\/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3)\\-associated diarrhea) [Typhoid fever](https:\/\/www.amboss.com\/us\/knowledge\/Typhoid_and_paratyphoid_fever#Z1ee997715fd7396129b4d9a3ed02fe95) [Mycobacterium](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Z4a9b83c1d67197ddc3d9a490e25786e1) [avium-intracellulare](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Zded29315a7549c1929e9d93cedf7dadf) [Tropheryma whipplei]() (i.e., [Whipple disease](https:\/\/www.amboss.com\/us\/knowledge\/Whipple_disease#Z83c04868f8c75273c89d8c6e966623e4)) [Legionella]() infection |   |\n| Parasitic | [Protozoan](https:\/\/www.amboss.com\/us\/knowledge\/General_parasitology#Z8f4f3567860a31947bee8edff7ea6bd5) | [Giardiasis](https:\/\/www.amboss.com\/us\/knowledge\/Giardiasis#Z7285e874bce9a0f39983534a6c838736) [Amebiasis](https:\/\/www.amboss.com\/us\/knowledge\/Amebiasis#Z4500356668f80dc7e2e4d3b731ae9d1f) [Cryptosporidiosis](https:\/\/www.amboss.com\/us\/knowledge\/HIV-associated_conditions#Z50d6fcd479428e63a00b9454e02cad44) [Cystoisosporiasis](https:\/\/www.amboss.com\/us\/knowledge\/HIV-associated_conditions#Z1e782fdfd6ae6a71daf64a4e1644b0a9) |\n| [Helminth infections](https:\/\/www.amboss.com\/us\/knowledge\/Helminth_infections#Ze09d3cf63ef1a16aa7f42af8f475cdb4) | [Toxocariasis](https:\/\/www.amboss.com\/us\/knowledge\/Helminth_infections#Zaf51d242a662ad2b921e57ce9d1c4771) [Enterobiasis](https:\/\/www.amboss.com\/us\/knowledge\/Helminth_infections#Z626348337721606624cdbdbddc89d761) [Ascariasis](https:\/\/www.amboss.com\/us\/knowledge\/Helminth_infections#Z3bdf0551665f902bb7f7437f1345d942) [Trichinosis](https:\/\/www.amboss.com\/us\/knowledge\/Helminth_infections#Z243c73c82e8ca80fdc4b642de846d545) [Taenia infections](https:\/\/www.amboss.com\/us\/knowledge\/Helminth_infections#Za9ad8a6dab1ea0231507c2575b7beaad) ([taeniasis](https:\/\/www.amboss.com\/us\/knowledge\/Helminth_infections#Z3f0c9aad18cbe66acdd552e41e47c05c)) [Hookworm infection](https:\/\/www.amboss.com\/us\/knowledge\/Helminth_infections#Z1179ff83d232cf99bd01e86f8e2433fa) [Diphyllobothriasis](https:\/\/www.amboss.com\/us\/knowledge\/Helminth_infections#Z0c51a37492e70b72b9c73aed0be65260) [Intestinal capillariasis](https:\/\/www.amboss.com\/us\/knowledge\/Helminth_infections#Z5dc93e2865dfbf1ff6ab72d0b15a5d08) |   |\n## Noninfectious \\[7\\]\\[8\\]\\[9\\]\n|   | Conditions |\n|---|---|\n| Foodborne toxins | [S. aureus](https:\/\/www.amboss.com\/us\/knowledge\/Staphylococcal_diseases#Zaf074edfb4940be0ed1d4fcfc4ea0dee) intoxication [Botulism](https:\/\/www.amboss.com\/us\/knowledge\/Botulism#Za2a9894ca446f0fe0aac693516c52c4d) [Bacillus cereus](https:\/\/www.amboss.com\/us\/knowledge\/Food_poisoning#Z6843256bc452c182cae6e8c9c5cbe589) infection [Tetrodotoxin](https:\/\/www.amboss.com\/us\/knowledge\/Food_poisoning#Zd578525a352862bd6098cbff0e02482f), [ciguatoxin]() |\n| [Food poisoning](https:\/\/www.amboss.com\/us\/knowledge\/Food_poisoning#Z5a858064f0cd40e4546f181bf46734f2) | [Aflatoxin](https:\/\/www.amboss.com\/us\/knowledge\/General_mycology#Z91b3abebde0a7a99c3942b9bd3060cc2) [Histamine](https:\/\/www.amboss.com\/us\/knowledge\/Hypersensitivity_reactions#Zae1b7b5f59d06769c8445ee3e4389b73) toxicity \\[7\\] Chemical contaminants (e.g., lead, [cadmium](https:\/\/www.amboss.com\/us\/knowledge\/Metal_poisoning#Z04ffe297e862ba3e4a25b62b6a06105e), insecticides, [arsenic](https:\/\/www.amboss.com\/us\/knowledge\/Metal_poisoning#Zf2f349b64906a39b338222ac30067f86)) \\[8\\] [Mushroom poisoning](https:\/\/www.amboss.com\/us\/knowledge\/Poisoning#Ze39c09d250439022bca488e44824b3d5) \\[9\\] |\n| Gastrointestinal | [Malnutrition](https:\/\/www.amboss.com\/us\/knowledge\/Acute_primary_malnutrition_in_children#Zda3f71521662770b01113749ba7d264b): [vitamin deficiency](https:\/\/www.amboss.com\/us\/knowledge\/Vitamins#Zca3fa352d946554fdd5b7c076e0c9cb0) (e.g., [pellagra](https:\/\/www.amboss.com\/us\/knowledge\/Vitamins#Zb703ea9bd25901f12978608f57990f1a)) |\n| [Malabsorption](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb) or [maldigestion](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Z325814c45b1a9856fa3d65839f7681f5) [Celiac disease](https:\/\/www.amboss.com\/us\/knowledge\/Celiac_disease#Z1999c64abb6e85ce70f8cdc66810a65b) [Lactose intolerance](https:\/\/www.amboss.com\/us\/knowledge\/Lactose_intolerance#Z8597682de9e4e8655c2f5df7319b32f3) [Exocrine pancreatic insufficiency](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Z4880cedb9eb57d620afb59b2c9e39a8b) (e.g., due to [chronic pancreatitis](https:\/\/www.amboss.com\/us\/knowledge\/Chronic_pancreatitis#Z1e14e388e4042dc43defefb9f88695e1)) [Diabetic autonomic neuropathy](https:\/\/www.amboss.com\/us\/knowledge\/Diabetic_neuropathy#Z5f4a07d5cb1ff81fcc5c7c2bfb24806f) [Bile acid diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z0f6aa3c63b0331881c8804e04e01ca5c) (e.g., due to [ileal](https:\/\/www.amboss.com\/us\/knowledge\/Small_intestine#Zf3a10de88f22b839a2769aa9ae031960) resection, [biliary-enteric fistula](https:\/\/www.amboss.com\/us\/knowledge\/Fistulas#Z1787c9a9b3b830805f4bf55265169989), [cholestasis](https:\/\/www.amboss.com\/us\/knowledge\/Jaundice_and_cholestasis#Z3811ba77a88bcd2cc789df34c5379055), [postcholecystectomy diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Cholecystectomy#Z6f71e303d7401f08b7ba2e85ef912a69)) [Amyloidosis](https:\/\/www.amboss.com\/us\/knowledge\/Amyloidosis#Zdf99d1ab14839f4c6288ceaf8447ef25) of the [gastrointestinal tract](https:\/\/www.amboss.com\/us\/knowledge\/Gastrointestinal_tract#Zf0833058b7152af8b5653b79f76fb153) |   |\n| [Colitis](https:\/\/www.amboss.com\/us\/knowledge\/Large_intestine#Z579996fe3b9825568e212d9393d5d9a2) [Inflammatory bowel disease](https:\/\/www.amboss.com\/us\/knowledge\/Crohn_disease#Z4272f924349255b3e4babe86d4e939c9) [Crohn disease](https:\/\/www.amboss.com\/us\/knowledge\/Crohn_disease#Zef70853af5e87c95d210bf8df682f64c) [Ulcerative colitis](https:\/\/www.amboss.com\/us\/knowledge\/Ulcerative_colitis#Zbb0aec0a5fe14ad0aae10a9341c457fc) [Irritable bowel syndrome](https:\/\/www.amboss.com\/us\/knowledge\/Irritable_bowel_syndrome#Z2b30a84dc4106c4e8aad1e6c9202f3ea) [Microscopic colitis](https:\/\/www.amboss.com\/us\/knowledge\/Microscopic_colitis#Z98c8e90c538959e074e80c55a532e1bc) [Ischemic colitis](https:\/\/www.amboss.com\/us\/knowledge\/Intestinal_ischemia#Za5a3e828cf2d10df3a9693a9fc3b2c34) [Radiation colitis](https:\/\/www.amboss.com\/us\/knowledge\/Radiation_injury#Ze0a9ed89b6c1c4ea08173fa19b2b74f9) |   |\n| [Tumor](https:\/\/www.amboss.com\/us\/knowledge\/General_oncology#Z333a818dbf71a509f924e54006a41fb6)\/stenotic processes: [paradoxical diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z03319666a4dfb1ca98ba5a66ae368c65) (involuntary seepage of liquid feces in patients with chronic [constipation](https:\/\/www.amboss.com\/us\/knowledge\/Constipation#Z65fd66f9cecf14d85a69e656c3a69417) ) |   |\n\n## Classification![toggle arrow icon](https:\/\/manus-media.amboss.com\/icons\/chevron_up.svg)\nDiarrhea is often classified as watery, fatty, and\/or inflammatory to facilitate diagnosis and management. This classification scheme is most relevant for the approach to [chronic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a).\n\n| Classification of diarrhea by functional pathology \\[10\\]\\[11\\]\\[12\\] |   |   |   |\n|---|---|---|---|\n|   | Pathophysiology | Associated disorders |   |\n| Inflammatory diarrhea | Damage to the intestinal [mucosa]() may cause [cytokine](https:\/\/www.amboss.com\/us\/knowledge\/Cytokines_and_eicosanoids#Z1a9b57a2010f274f4a0f49e6010d30cf)\\-induced water hypersecretion, impair absorption of osmotically active substances or fat, and\/or disrupt water and [electrolyte](https:\/\/www.amboss.com\/us\/knowledge\/Laboratory_medicine#Z562f1491861b33bdb5af572388e99541) absorption. Mucus, blood, and [leukocytes](https:\/\/www.amboss.com\/us\/knowledge\/Basics_of_hematology#Z18a02873023ccef6d8ea2b461e0b7446) present in the stool. | [Ulcerative colitis](https:\/\/www.amboss.com\/us\/knowledge\/Ulcerative_colitis#Zbb0aec0a5fe14ad0aae10a9341c457fc), [Crohn disease](https:\/\/www.amboss.com\/us\/knowledge\/Crohn_disease#Zef70853af5e87c95d210bf8df682f64c) [Colorectal cancer](https:\/\/www.amboss.com\/us\/knowledge\/Colorectal_cancer#Z5f9a21e2819d2a5004da275e0fe8e909) Infections [Shigellosis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Zd4a3455e8ec3d03f2e705d784ba584b0) ([bacillary dysentery](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Zd4a3455e8ec3d03f2e705d784ba584b0)) Nontyphoidal: [salmonellosis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z2681adc9ab180885765f48f6f730b912) [Enteroinvasive Escherichia coli](https:\/\/www.amboss.com\/us\/knowledge\/Diarrheagenic_E._coli#Z12cd4e274bbe847f6b9e96d592684c87), [enterohemorrhagic E. coli](https:\/\/www.amboss.com\/us\/knowledge\/Diarrheagenic_E._coli#Z44cb042afe41a43945e6b3c55e424917) ([O157:H7](https:\/\/www.amboss.com\/us\/knowledge\/Hemolytic_uremic_syndrome#Zd789cca34b9c96af9a9c7abd264b2c7b)) [Campylobacteriosis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z9273c5a7cf1820c124f8fe4d5648df30) [Yersiniosis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z6c552143f411315b80f346c0c8707af5) [Amebiasis](https:\/\/www.amboss.com\/us\/knowledge\/Amebiasis#Z4500356668f80dc7e2e4d3b731ae9d1f) ([amebic dysentery](https:\/\/www.amboss.com\/us\/knowledge\/Amebiasis#Z9c6cd303635910835de37919e22415b9) caused by [Entamoeba histolytica](https:\/\/www.amboss.com\/us\/knowledge\/Amebiasis#Z4001b357f1b712e83d6027a4dfa5731b)) [Clostridioides difficile](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Z429d21670093a08ffb061528b0561719) (rarely bloody) |   |\n| Fatty diarrhea | [Malabsorption](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb) | Alterations of the intestinal [mucosa]() → impaired absorption of digested food | [Malabsorption](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb) disorders or history of [ileal](https:\/\/www.amboss.com\/us\/knowledge\/Small_intestine#Zf3a10de88f22b839a2769aa9ae031960) resection Infections [Giardiasis](https:\/\/www.amboss.com\/us\/knowledge\/Giardiasis#Z7285e874bce9a0f39983534a6c838736) [Small intestinal bacterial overgrowth](https:\/\/www.amboss.com\/us\/knowledge\/Small_intestinal_bacterial_overgrowth#Z9aa32f677362a235a8ae39e011711f1b) ([SIBO](https:\/\/www.amboss.com\/us\/knowledge\/Small_intestinal_bacterial_overgrowth#Z9aa32f677362a235a8ae39e011711f1b)) [Tropical sprue](https:\/\/www.amboss.com\/us\/knowledge\/Tropical_sprue#Z98af9796a545c9279ebf232edfbe9a0f) [Whipple disease](https:\/\/www.amboss.com\/us\/knowledge\/Whipple_disease#Z83c04868f8c75273c89d8c6e966623e4) [Amyloidosis](https:\/\/www.amboss.com\/us\/knowledge\/Amyloidosis#Zdf99d1ab14839f4c6288ceaf8447ef25) |\n| [Maldigestion](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Z325814c45b1a9856fa3d65839f7681f5) | Lack of digestive enzymes → impaired breakdown of food in the intestinal lumen → [malabsorption](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb) of [carbohydrates](https:\/\/www.amboss.com\/us\/knowledge\/Carbohydrates#Z9749463e67a1dd52c34fed592810f23d), [proteins](https:\/\/www.amboss.com\/us\/knowledge\/Proteins_and_peptides#Z6dee07cab92e13d1f6baa3a3ce402f23), fats, [fat-soluble vitamins](https:\/\/www.amboss.com\/us\/knowledge\/Vitamins#Zcfe26218c03945e1fad98ef8c9095aa2) (A, D, E, K), and [vitamin B12](https:\/\/www.amboss.com\/us\/knowledge\/Vitamins#Z938e3f87e91ee8469e94c3ace50e692d) | [Exocrine pancreatic insufficiency](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Z4880cedb9eb57d620afb59b2c9e39a8b) [Bile acid diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z0f6aa3c63b0331881c8804e04e01ca5c) |   |\n| Watery diarrhea | Secretory diarrhea | Active secretion of water  into the intestinal lumen via inhibition or activation of enzymes (e.g., ↑ [cAMP](https:\/\/www.amboss.com\/us\/knowledge\/Signal_transduction#Z64a7426bbad2bf440e8e5d9e67c2a51a) activity) | Neuroendocrine disorders, e.g.: [Carcinoid syndrome](https:\/\/www.amboss.com\/us\/knowledge\/Carcinoid_syndrome#Zd3e3a67dbd397d8bd3f339c574f42e55) [Gastrinoma](https:\/\/www.amboss.com\/us\/knowledge\/Gastrinoma#Z33515a1b2df6a4fe21ef0162d7a1eac7) Endocrine disorders, e.g.: [Hyperthyroidism](https:\/\/www.amboss.com\/us\/knowledge\/Hyperthyroidism_and_thyrotoxicosis#Z7efc7350132a2f2a3e4cc7763e7f07f8) [Addison disease](https:\/\/www.amboss.com\/us\/knowledge\/Adrenal_insufficiency#Z7b47bf57fd367b1b9891e4155e39236f) [Diabetes mellitus](https:\/\/www.amboss.com\/us\/knowledge\/Diabetes_mellitus#Z1235e572dd827cff7d31e954b3f94489) Foodborne infections [Cholera](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Zba6a00519c1b345599491aa93180aacf) (“rice water” diarrhea) [Enterotoxigenic E. coli](https:\/\/www.amboss.com\/us\/knowledge\/Diarrheagenic_E._coli#Z458147f1e1273e554884140b40317779) ([traveler's diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zed77ffe538dae231e40fe0542e7b245a)) [C. perfringens](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Z927388b963f796f8c6f170841d77b930) [C. difficile](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Z429d21670093a08ffb061528b0561719) (associated with [antibiotic](https:\/\/www.amboss.com\/us\/knowledge\/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3) and [PPI](https:\/\/www.amboss.com\/us\/knowledge\/Proton_pump_inhibitors#Z2753e50142e2f5b7089b165accdcc900) use) [Protozoa](https:\/\/www.amboss.com\/us\/knowledge\/General_parasitology#Z8f4f3567860a31947bee8edff7ea6bd5): e.g., [giardiasis](https:\/\/www.amboss.com\/us\/knowledge\/Giardiasis#Z7285e874bce9a0f39983534a6c838736), [cryptosporidiosis](https:\/\/www.amboss.com\/us\/knowledge\/HIV-associated_conditions#Z50d6fcd479428e63a00b9454e02cad44) [Viruses](https:\/\/www.amboss.com\/us\/knowledge\/General_virology#Zcdc83877f75d9d9b9a07ece6544f646c): e.g., [norovirus](https:\/\/www.amboss.com\/us\/knowledge\/General_virology#Z85b05d149dafb61d67a5c48e9a2fdb65), [rotavirus](https:\/\/www.amboss.com\/us\/knowledge\/General_virology#Z0b6c006e84714af76f7c43bebbeb2315), [adenovirus](https:\/\/www.amboss.com\/us\/knowledge\/General_virology#Z5251a57602a66d951ca7a8a66643ee51) |\n| Osmotic diarrhea | Poor absorption or excessive ingestion of [hydrophilic](https:\/\/www.amboss.com\/us\/knowledge\/Fundamentals_of_pharmacology#Zb09f3ec1f97e13e2b9d5705d30995d93) substances (e.g., salts, sugars, [laxatives]()) causes water to be drawn into the intestinal lumen. | Osmotic [laxatives](): e.g., [magnesium citrate](https:\/\/www.amboss.com\/us\/knowledge\/Constipation#Z11bef431cda663471cbd64d3249255bf) [Carbohydrate malabsorption](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Z1659a0f218ffe905f7bddb7c54efb326): e.g., [lactose intolerance](https:\/\/www.amboss.com\/us\/knowledge\/Lactose_intolerance#Z8597682de9e4e8655c2f5df7319b32f3), [fructose intolerance](https:\/\/www.amboss.com\/us\/knowledge\/Inborn_errors_of_carbohydrate_metabolism#Z357a9d683ee4b5a50331c5099527ef8f) (may also present as [fatty diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Chronic_pancreatitis#Z416510d2bd6fcd19b4e328d62b6b10db)) |   |\n| Functional diarrheal disorders \\[10\\] | Rapid intestinal passage due to increased bowel activity | [Diarrhea-predominant IBS](https:\/\/www.amboss.com\/us\/knowledge\/Irritable_bowel_syndrome#Z34fd0bc151761f2495a7470c6d9f6187) ([IBS-D](https:\/\/www.amboss.com\/us\/knowledge\/Irritable_bowel_syndrome#Z34fd0bc151761f2495a7470c6d9f6187)) [Functional diarrhea]()  \\[10\\]\\[13\\] |   |\n\n## Management![toggle arrow icon](https:\/\/manus-media.amboss.com\/icons\/chevron_up.svg)\nThough 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.\n\nIn older adults, rule out [fecal impaction](https:\/\/www.amboss.com\/us\/knowledge\/Constipation#Z11561139d5df6c8531690de0277d8ce5), which can manifest atypically with [paradoxical diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z03319666a4dfb1ca98ba5a66ae368c65) (due to decreased rectal sensation) and nonspecific symptoms (e.g., functional decline, [delirium](https:\/\/www.amboss.com\/us\/knowledge\/Delirium#Zfd56fee25cf9f50f32c800e64a6e652a)). \\[14\\]\n\n[Antibiotics](https:\/\/www.amboss.com\/us\/knowledge\/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3) should only be utilized for specific indications.\n\n## Clinical assessment of diarrhea \\[10\\]\\[12\\]\nKey features of the disease presentation that facilitate efficient testing and prompt diagnosis include:\n\n- Duration of diarrheal illness\n- Stool characteristics: watery, fatty, or bloody stools\n- Associated symptoms\n  - [Fever](https:\/\/www.amboss.com\/us\/knowledge\/Fever#Za5de83449ff6a749e6c1348b93b1f3b1)\n  - Abdominal [pain](https:\/\/www.amboss.com\/us\/knowledge\/Principles_of_pain_management#Zd673a3f7ee36023aab5a267899e984cc) and cramping\n  - [Nausea and vomiting](https:\/\/www.amboss.com\/us\/knowledge\/Nausea_and_vomiting#Z2f0b48ef2acaab783b03e4c8d2404f90) in cases of [gastroenteritis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Zcbd93ce063d015f699fd07ed09015b7f)\n  - Signs of [dehydration](https:\/\/www.amboss.com\/us\/knowledge\/Dehydration_and_hypovolemia#Zbd78324053c153c16ea5cb2574249398)\n  - Chronic cases: [malnutrition](https:\/\/www.amboss.com\/us\/knowledge\/Acute_primary_malnutrition_in_children#Zda3f71521662770b01113749ba7d264b) and, in children, [failure to thrive](https:\/\/www.amboss.com\/us\/knowledge\/Growth_faltering#Zc00b4a95101cc1636c126219e267922c)\n  - Weight loss\n  - Defecation urgency, [tenesmus](), and\/or nocturnal symptoms\n\n| Characteristic clinical features in diarrhea according to functional pathology |   |   |   |\n|---|---|---|---|\n| [Inflammatory diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z321586a3cfe84e9365a55d0ed20fb62a) | Frequent and small volume stools Bloody or [purulent](https:\/\/www.amboss.com\/us\/knowledge\/Skin_and_soft_tissue_infections#Zfdfb82d83e675513c49619bc646fd20c) stools Abdominal [pain](https:\/\/www.amboss.com\/us\/knowledge\/Principles_of_pain_management#Zd673a3f7ee36023aab5a267899e984cc), [tenesmus]() May be associated with [fever](https:\/\/www.amboss.com\/us\/knowledge\/Fever#Za5de83449ff6a749e6c1348b93b1f3b1), weight loss, fatigue |   |   |\n| [Fatty diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Chronic_pancreatitis#Z416510d2bd6fcd19b4e328d62b6b10db) | Greasy or oily stools Stools that are difficult to flush Decreases with [fasting]() May be associated with weight loss |   |   |\n| [Watery diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z16ed63f1f94f558cfbffed53ce14a7fb) | [Secretory diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Za81182120613af86b266ff31432e241e) | Loose, watery stools | No change with [fasting]() Nocturnal diarrhea present |\n| [Functional diarrheal disorders](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z68e249c3723fb43d54724dbf2018af91) | Decreases with [fasting]() Decreased at night |   |   |\n| [Osmotic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z7169e994f812b120ea2df94d1042192e) | Decreases with [fasting]() Decreased at night Food triggers |   |   |\n\nAssess for the presence of [risk factors](https:\/\/www.amboss.com\/us\/knowledge\/Interpreting_medical_evidence#Zbc0d0ff153bc5c7a27589815d0c842fd) for specific etiologies, including:\n\nMore 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. \\[15\\]\n\n[Chronic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a) is common after [bariatric surgery](https:\/\/www.amboss.com\/us\/knowledge\/Bowel_surgery#Z484c1fb65fa7e725740f20c975c9b284). \\[19\\]\\[20\\]\n\n## Diagnostics![toggle arrow icon](https:\/\/manus-media.amboss.com\/icons\/chevron_up.svg)\n## General principles \\[10\\]\\[12\\]\\[22\\]\\[25\\]\n- [Acute diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z9902a484faaf54b4fa1ffaf3a5642113)\n  - Testing is not required in the majority of cases.\n  - Indications for testing include the presence of [red flags in diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zee4bebab517fe015dea25941aafb8133) and [risk factors](https:\/\/www.amboss.com\/us\/knowledge\/Interpreting_medical_evidence#Zbc0d0ff153bc5c7a27589815d0c842fd) for specific etiologies.\n- [Persistent diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zd56cfaa165f80b20fe15e54d5f2c0023): Testing is usually limited to stool studies for [infectious gastroenteritis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z4ec5f6e716f0557299b9deed9d09e225).\n- [Chronic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a)\n  - Testing is initially broad with advanced follow-up testing as indicated. \\[21\\]\\[25\\]\n  - Repeat stool testing for [infectious gastroenteritis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z4ec5f6e716f0557299b9deed9d09e225).\n\nDiagnostic testing is seldom indicated in [acute diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z9902a484faaf54b4fa1ffaf3a5642113) in the absence of [red flag symptoms]().\n\n## Testing for diarrhea\nFor specific indications for testing, see the respective subsections below on acute, persistent, and [chronic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a).\n\nEndoscopic studies have limited diagnostic value in [acute diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z9902a484faaf54b4fa1ffaf3a5642113) but are commonly needed for the workup of [chronic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a) to evaluate for the presence of inflammatory or [neoplastic](https:\/\/www.amboss.com\/us\/knowledge\/General_oncology#Za6c03f509be1b3d9dfdc8402fad24824) diseases. Their utility in [persistent diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zd56cfaa165f80b20fe15e54d5f2c0023) is uncertain.\n\n### Stool diagnostic studies\n| [Stool diagnostic studies](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z1af96922654e42529740851250ec9081) in diarrhea |   |   |\n|---|---|---|\n| Suspected etiology | Test | Purpose |\n| Infectious diseases | [Stool culture](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z6dddefa904a8f33be48aaa7f09f23fa3) | Identification of infectious agents (e.g., in [bacterial gastroenteritis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z7c0d1a3ebf70c528338a93b779e17e08)) |\n| [Stool microscopy](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z3ffb13377faf28eb8d88ac5d1c53433a) | Visualization of [ova](https:\/\/www.amboss.com\/us\/knowledge\/Female_reproductive_organs#Z6f9cf85e209c336035854438760d1213) or [parasites]() in the stool |   |\n| Culture-independent methods, e.g., [multiplex molecular diagnostic panel for diarrhea]() ([PCR](https:\/\/www.amboss.com\/us\/knowledge\/Laboratory_methods#Z3a8f5e31aa62111944442fd86660cc27)) | Identification of infectious agents in bacterial, viral, and [protozoal](https:\/\/www.amboss.com\/us\/knowledge\/General_parasitology#Z8f4f3567860a31947bee8edff7ea6bd5) [gastroenteritis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Zcbd93ce063d015f699fd07ed09015b7f)  \\[25\\] |   |\n| Quantitative culture of small intestinal [aspirate](https:\/\/www.amboss.com\/us\/knowledge\/Pneumonia#Z351264651d762713a247d997f6eae551) | Used to diagnose [SIBO](https:\/\/www.amboss.com\/us\/knowledge\/Small_intestinal_bacterial_overgrowth#Z9aa32f677362a235a8ae39e011711f1b) ([gold standard test]() for bacterial overgrowth) |   |\n| [Stool tests for C. difficile infection](https:\/\/www.amboss.com\/us\/knowledge\/Clostridioides_difficile_infection#Z5ae7beb055f147f1241e95ce050c0395) (e.g., toxin test) | Identification of [C. difficile infection](https:\/\/www.amboss.com\/us\/knowledge\/Clostridioides_difficile_infection#Zb508f99ee028a9d8582608f40bc36f5f) |   |\n| Inflammation | [Stool microscopy](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z3ffb13377faf28eb8d88ac5d1c53433a) | Visualization of fecal [leukocytes](https:\/\/www.amboss.com\/us\/knowledge\/Basics_of_hematology#Z18a02873023ccef6d8ea2b461e0b7446) |\n| [Fecal occult blood test](https:\/\/www.amboss.com\/us\/knowledge\/Colorectal_cancer#Z24f19e4cfd2826fe2f4df3e70c80fd38) ([FOBT](https:\/\/www.amboss.com\/us\/knowledge\/Colorectal_cancer#Z24f19e4cfd2826fe2f4df3e70c80fd38)) | To screen for [malignancy](https:\/\/www.amboss.com\/us\/knowledge\/General_oncology#Z8c3bce39ca977e0f872b6d9fb3be8cfb) and [mucosal]() inflammation |   |\n| [FIT DNA test](https:\/\/www.amboss.com\/us\/knowledge\/Colorectal_cancer#Z943342f2c2fcf6a86ea87e55a141b8a7) | To screen for [colonic](https:\/\/www.amboss.com\/us\/knowledge\/Large_intestine#Ze19293358dc6c65dc95f936bb8fca493) cancer and [adenomatous polyps](https:\/\/www.amboss.com\/us\/knowledge\/Colonic_polyps#Z31bea48c0b1a3349c4fa653243445fe3) |   |\n| [Fecal calprotectin](https:\/\/www.amboss.com\/us\/knowledge\/Crohn_disease#Z0da0114e6bf8ec43ad71096d5e3f97f1) and [lactoferrin](https:\/\/www.amboss.com\/us\/knowledge\/Innate_immune_system#Z341d9eb537374add3f4e1350946c378f) | Markers of [inflammatory bowel disease](https:\/\/www.amboss.com\/us\/knowledge\/Crohn_disease#Z4272f924349255b3e4babe86d4e939c9) ([IBD](https:\/\/www.amboss.com\/us\/knowledge\/Crohn_disease#Z4272f924349255b3e4babe86d4e939c9)) |   |\n| [Malabsorption](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb) | [Sudan stain](https:\/\/www.amboss.com\/us\/knowledge\/Cellular_changes_and_adaptive_responses#Z78716b286b479e2c380f54ed824c20fc) | Qualitative test for [steatorrhea](https:\/\/www.amboss.com\/us\/knowledge\/Chronic_pancreatitis#Z416510d2bd6fcd19b4e328d62b6b10db) |\n| [72-hour quantitative fecal fat estimation](https:\/\/www.amboss.com\/us\/knowledge\/Chronic_pancreatitis#Zd212c09e9c64621940c1a0ced94a9c98) | Quantitative test for [steatorrhea](https:\/\/www.amboss.com\/us\/knowledge\/Chronic_pancreatitis#Z416510d2bd6fcd19b4e328d62b6b10db) |   |\n| [Fecal elastase-1](https:\/\/www.amboss.com\/us\/knowledge\/Chronic_pancreatitis#Zf555d89ae453336db1900a0d4d2df7e7) | Confirmation of [steatorrhea](https:\/\/www.amboss.com\/us\/knowledge\/Chronic_pancreatitis#Z416510d2bd6fcd19b4e328d62b6b10db) due to [exocrine pancreatic insufficiency](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Z4880cedb9eb57d620afb59b2c9e39a8b) |   |\n| Stool [electrolytes](https:\/\/www.amboss.com\/us\/knowledge\/Laboratory_medicine#Z562f1491861b33bdb5af572388e99541) (e.g., Na\\+, [K\\+](https:\/\/www.amboss.com\/us\/knowledge\/Water_and_electrolyte_metabolism#Z115ce86297429aa2893d16c3493aae24)) | Used to calculate [stool osmotic gap](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Ze3350ca8675573e0158f73d116234534) |   |\n| Stool [pH]() | Identification of [carbohydrate malabsorption](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Z1659a0f218ffe905f7bddb7c54efb326) |   |\n\n- Stool osmotic gap \\[11\\]\\[16\\]\\[18\\]\n\n|   | Low [stool osmotic gap](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Ze3350ca8675573e0158f73d116234534) | High [stool osmotic gap](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Ze3350ca8675573e0158f73d116234534) |\n|---|---|---|\n| Osmotic gap | \\< 50 mOsm\/kg | ≥ 100 mOsm\/kg |\n| Interpretation | [Secretory diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Za81182120613af86b266ff31432e241e) (↑ secretion and\/or inhibition of water absorption) or [functional diarrhea]() (increased intestinal movement) | [Osmotic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z7169e994f812b120ea2df94d1042192e) (osmotic pull of ingested substances draws water into the intestinal lumen) |\n| Example causes | Foodborne infections (e.g., [Vibrio cholerae](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Z5040d5b8f384d034307ec998d5706c4a), [enterotoxigenic E. coli](https:\/\/www.amboss.com\/us\/knowledge\/Diarrheagenic_E._coli#Z458147f1e1273e554884140b40317779)) Endocrine tumors (e.g., [VIPoma](https:\/\/www.amboss.com\/us\/knowledge\/Pancreatic_neuroendocrine_tumors#Za2856a318ce5fbd49335eab336d6fa66), medullary [carcinoma](https:\/\/www.amboss.com\/us\/knowledge\/General_oncology#Z22674f156f136302ff6142f806db0d5a) of the [thyroid](https:\/\/www.amboss.com\/us\/knowledge\/Thyroid_gland_and_parathyroid_glands#Za09b3ec4cbcf889fc4f7b34cecb45f4d), [gastrinoma](https:\/\/www.amboss.com\/us\/knowledge\/Gastrinoma#Z33515a1b2df6a4fe21ef0162d7a1eac7)) Impaired absorption of [bile acids](https:\/\/www.amboss.com\/us\/knowledge\/Gallbladder_and_bile#Z86b474a966e0cc8faf1092967eaf82f4) and\/or salts ([bile acid diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z0f6aa3c63b0331881c8804e04e01ca5c)) | [Osmotic laxative](https:\/\/www.amboss.com\/us\/knowledge\/Constipation#Z6beba559f6dfabe7c19e807cf28747b9) ingestion (e.g., [magnesium citrate](https:\/\/www.amboss.com\/us\/knowledge\/Constipation#Z11bef431cda663471cbd64d3249255bf)) [Malabsorption](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb) (e.g., [celiac disease](https:\/\/www.amboss.com\/us\/knowledge\/Celiac_disease#Z1999c64abb6e85ce70f8cdc66810a65b), [Whipple disease](https:\/\/www.amboss.com\/us\/knowledge\/Whipple_disease#Z83c04868f8c75273c89d8c6e966623e4)) [Pancreatic](https:\/\/www.amboss.com\/us\/knowledge\/Pancreas#Z0842648c05a9f12b182c77d4baeb7a3a) insufficiency |\n\nThe loss of [bicarbonate](https:\/\/www.amboss.com\/us\/knowledge\/Gastrointestinal_tract#Z6cdbbc46116e490c8de4fb6acf44242c)\\-rich fluid in severe diarrhea may cause nonanion gap [metabolic acidosis](https:\/\/www.amboss.com\/us\/knowledge\/Acid-base_disorders#Ze6ecd1a689f21c50f6f1d77dcd2bd10b).\n## Supportive care![toggle arrow icon](https:\/\/manus-media.amboss.com\/icons\/chevron_up.svg)\n## Acute or persistent diarrhea (≤ 30 days)![toggle arrow icon](https:\/\/manus-media.amboss.com\/icons\/chevron_up.svg)\nThe management of [acute diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z9902a484faaf54b4fa1ffaf3a5642113) is primarily supportive, as the disease is usually a [self-limited]() viral infection. Further management focuses on determining whether diagnostic testing and directed therapy are needed (e.g., [antibiotic therapy](https:\/\/www.amboss.com\/us\/knowledge\/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3) for [bacterial gastroenteritis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z7c0d1a3ebf70c528338a93b779e17e08)). \\[22\\]\n\nIf symptoms of an [acute abdomen](https:\/\/www.amboss.com\/us\/knowledge\/Acute_abdomen#Z24dc105fa608cb7dad9e5eada9a97d2b) are present, consider an urgent CT abdomen to identify [ischemic](https:\/\/www.amboss.com\/us\/knowledge\/Cellular_changes_and_adaptive_responses#Zbc05e544d46e794a60ac9ce9ec6883af), hemorrhagic, obstructive, and\/or inflammatory diseases. \\[28\\]\n\nWhen indicated, stool studies in patients with [acute diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z9902a484faaf54b4fa1ffaf3a5642113) should include tests that can detect the presence of [Salmonella](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Zcf62cfeb3796c44845f303785e4bb88c), [Shigella](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Z40dc9a1dcc2df2a82a0c4586e5023158), [Campylobacter](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Za64f770db8dc668f93db5788517d1bc0), [Yersinia](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Zfcf2a7b96fa589ca6dd7ada0b75e48bb), [C. difficile infection](https:\/\/www.amboss.com\/us\/knowledge\/Clostridioides_difficile_infection#Zb508f99ee028a9d8582608f40bc36f5f), and [Shiga toxin-producing E. coli](https:\/\/www.amboss.com\/us\/knowledge\/Diarrheagenic_E._coli#Z11eef8782d53e8058dd72294470db3f7). \\[31\\]\n\n### Noninflammatory diarrhea ([watery diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z16ed63f1f94f558cfbffed53ce14a7fb)) \\[21\\]\\[25\\]\\[31\\]\n### [Inflammatory diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z321586a3cfe84e9365a55d0ed20fb62a) ([dysentery]()) \\[28\\]\nIn patients with prominent abdominal [pain](https:\/\/www.amboss.com\/us\/knowledge\/Principles_of_pain_management#Zd673a3f7ee36023aab5a267899e984cc) and\/or bloody diarrhea, evaluate for [ischemic colitis](https:\/\/www.amboss.com\/us\/knowledge\/Intestinal_ischemia#Za5a3e828cf2d10df3a9693a9fc3b2c34), [ulcerative colitis](https:\/\/www.amboss.com\/us\/knowledge\/Ulcerative_colitis#Zbb0aec0a5fe14ad0aae10a9341c457fc), and [Crohn disease](https:\/\/www.amboss.com\/us\/knowledge\/Crohn_disease#Zef70853af5e87c95d210bf8df682f64c) if stool testing does not indicate an infectious etiology.\n\n[Persistent diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zd56cfaa165f80b20fe15e54d5f2c0023) has a broader differential diagnosis than [acute diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z9902a484faaf54b4fa1ffaf3a5642113). Parasitic infection (e.g., [giardiasis](https:\/\/www.amboss.com\/us\/knowledge\/Giardiasis#Z7285e874bce9a0f39983534a6c838736)), recurrent bacterial infection (e.g., [C. difficile infection](https:\/\/www.amboss.com\/us\/knowledge\/Clostridioides_difficile_infection#Zb508f99ee028a9d8582608f40bc36f5f)), and noninfectious causes (e.g., [IBS-D](https:\/\/www.amboss.com\/us\/knowledge\/Irritable_bowel_syndrome#Z34fd0bc151761f2495a7470c6d9f6187)) must be considered. \\[32\\]\n\n| [Etiology of acute and persistent diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Za0cd177df9550f81889873b6038f2072) |   |\n|---|---|\n| Viral \\[21\\] | [Norovirus infection](https:\/\/www.amboss.com\/us\/knowledge\/Norovirus_infection#Z2bf1564153a0ab14e52c587da9c8a8c3) [Rotavirus infection](https:\/\/www.amboss.com\/us\/knowledge\/Rotavirus_infection#Zb2e7858cefe0481ba26809cf4d9b84ec) [Adenovirus](https:\/\/www.amboss.com\/us\/knowledge\/General_virology#Z5251a57602a66d951ca7a8a66643ee51) infection (mainly [serotypes]() 3, 40, and 41) \\[6\\] [Cytomegalovirus infection](https:\/\/www.amboss.com\/us\/knowledge\/Cytomegalovirus_infection#Za3ec0dd921d428ed745a6ec39879cf55) [Coronavirus](https:\/\/www.amboss.com\/us\/knowledge\/General_virology#Zc9fd2c044745d5b6f6ef5fe6293d10c5) ([COVID-19](https:\/\/www.amboss.com\/us\/knowledge\/COVID-19_\\(coronavirus_disease_2019\\)#Z82f1d759ff02927000d2ccd223409135)) |\n| Bacterial | [Cholera](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Zba6a00519c1b345599491aa93180aacf) (“rice water” diarrhea) [Enterotoxigenic E. coli](https:\/\/www.amboss.com\/us\/knowledge\/Diarrheagenic_E._coli#Z458147f1e1273e554884140b40317779) infection ([traveler's diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zed77ffe538dae231e40fe0542e7b245a)) [C. perfringens](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Z927388b963f796f8c6f170841d77b930) infection [C. difficile](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Z429d21670093a08ffb061528b0561719) infection (associated with [antibiotic](https:\/\/www.amboss.com\/us\/knowledge\/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3) and [PPI](https:\/\/www.amboss.com\/us\/knowledge\/Proton_pump_inhibitors#Z2753e50142e2f5b7089b165accdcc900) use) [Shigellosis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Zd4a3455e8ec3d03f2e705d784ba584b0) ([bacillary dysentery](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Zd4a3455e8ec3d03f2e705d784ba584b0)) Nontyphoidal: [salmonellosis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z2681adc9ab180885765f48f6f730b912) [Enteroinvasive E. coli](https:\/\/www.amboss.com\/us\/knowledge\/Diarrheagenic_E._coli#Z12cd4e274bbe847f6b9e96d592684c87), [enterohemorrhagic E. coli](https:\/\/www.amboss.com\/us\/knowledge\/Diarrheagenic_E._coli#Z44cb042afe41a43945e6b3c55e424917) ([O157:H7](https:\/\/www.amboss.com\/us\/knowledge\/Hemolytic_uremic_syndrome#Zd789cca34b9c96af9a9c7abd264b2c7b)) infection [Campylobacteriosis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z9273c5a7cf1820c124f8fe4d5648df30) [Yersiniosis](https:\/\/www.amboss.com\/us\/knowledge\/Infectious_gastroenteritis#Z6c552143f411315b80f346c0c8707af5) [Legionella]() |\n| Parasitic | [Giardiasis](https:\/\/www.amboss.com\/us\/knowledge\/Giardiasis#Z7285e874bce9a0f39983534a6c838736) [Amebiasis](https:\/\/www.amboss.com\/us\/knowledge\/Amebiasis#Z4500356668f80dc7e2e4d3b731ae9d1f) [Cryptosporidiosis](https:\/\/www.amboss.com\/us\/knowledge\/HIV-associated_conditions#Z50d6fcd479428e63a00b9454e02cad44) [Enterobiasis](https:\/\/www.amboss.com\/us\/knowledge\/Helminth_infections#Z626348337721606624cdbdbddc89d761) [Ascariasis](https:\/\/www.amboss.com\/us\/knowledge\/Helminth_infections#Z3bdf0551665f902bb7f7437f1345d942) |\n| [Food poisoning](https:\/\/www.amboss.com\/us\/knowledge\/Food_poisoning#Z5a858064f0cd40e4546f181bf46734f2) | [S. aureus](https:\/\/www.amboss.com\/us\/knowledge\/Staphylococcal_diseases#Zaf074edfb4940be0ed1d4fcfc4ea0dee) infection [Botulism](https:\/\/www.amboss.com\/us\/knowledge\/Botulism#Za2a9894ca446f0fe0aac693516c52c4d) [Bacillus cereus](https:\/\/www.amboss.com\/us\/knowledge\/Food_poisoning#Z6843256bc452c182cae6e8c9c5cbe589) infection [Aflatoxin](https:\/\/www.amboss.com\/us\/knowledge\/General_mycology#Z91b3abebde0a7a99c3942b9bd3060cc2) [Histamine](https:\/\/www.amboss.com\/us\/knowledge\/Hypersensitivity_reactions#Zae1b7b5f59d06769c8445ee3e4389b73) toxicity \\[7\\] [Tetrodotoxin](https:\/\/www.amboss.com\/us\/knowledge\/Food_poisoning#Zd578525a352862bd6098cbff0e02482f), [ciguatoxin]() |\n| Medications | [Antibiotics](https:\/\/www.amboss.com\/us\/knowledge\/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3) [Laxatives]() [PPIs](https:\/\/www.amboss.com\/us\/knowledge\/Proton_pump_inhibitors#Z2753e50142e2f5b7089b165accdcc900) [SSRIs](https:\/\/www.amboss.com\/us\/knowledge\/Antidepressants#Zb1bb43280a4d0d86f2d53818b9e8afc8) [NSAIDs](https:\/\/www.amboss.com\/us\/knowledge\/Non-opioid_analgesics#Z6d53b6cfe3376a70645a5c797293e56a) |\n| Other | Chemical contaminants (e.g., lead, [cadmium](https:\/\/www.amboss.com\/us\/knowledge\/Metal_poisoning#Z04ffe297e862ba3e4a25b62b6a06105e), insecticides, [arsenic](https:\/\/www.amboss.com\/us\/knowledge\/Metal_poisoning#Zf2f349b64906a39b338222ac30067f86)) \\[8\\] [Mushroom poisoning](https:\/\/www.amboss.com\/us\/knowledge\/Poisoning#Ze39c09d250439022bca488e44824b3d5) \\[9\\] [Bowel ischemia](https:\/\/www.amboss.com\/us\/knowledge\/Intestinal_ischemia#Z25168aee9d4e0266b8ee7dae3d33cc08) [Neutropenic enterocolitis](https:\/\/www.amboss.com\/us\/knowledge\/Acute_abdomen#Za3c81a83e806ab8e4e5f85cb4d572b6c) |\n\n## Chronic diarrhea (\\> 30 days)![toggle arrow icon](https:\/\/manus-media.amboss.com\/icons\/chevron_up.svg)\nThe differential diagnosis of [chronic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a) is extensive. A systematic approach with efficient use of testing is needed to arrive at a diagnosis quickly. \\[10\\]\\[12\\]\\[33\\]\n\n[Chronic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a) can be classified as inflammatory, fatty, or watery. Grouping patients into broad categories based on clinical features and basic laboratory findings narrows the differential diagnosis and facilitates efficient advanced testing. \\[18\\]\n\n[IBS-D](https:\/\/www.amboss.com\/us\/knowledge\/Irritable_bowel_syndrome#Z34fd0bc151761f2495a7470c6d9f6187) is an intermediate diagnosis; it does not eliminate the possibility of another disease. Evaluation should continue if symptoms persist despite treatment for [IBS-D](https:\/\/www.amboss.com\/us\/knowledge\/Irritable_bowel_syndrome#Z34fd0bc151761f2495a7470c6d9f6187). \\[12\\]\n\n[Chronic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a) is commonly classified as watery, fatty, or inflammatory.\n\n| [Etiology of chronic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z395de845da244c411a1fe280649e48a0) \\[12\\] |   |   |\n|---|---|---|\n| Inflammatory | [Inflammatory bowel disease](https:\/\/www.amboss.com\/us\/knowledge\/Crohn_disease#Z4272f924349255b3e4babe86d4e939c9): [Crohn disease](https:\/\/www.amboss.com\/us\/knowledge\/Crohn_disease#Zef70853af5e87c95d210bf8df682f64c), [ulcerative colitis](https:\/\/www.amboss.com\/us\/knowledge\/Ulcerative_colitis#Zbb0aec0a5fe14ad0aae10a9341c457fc) Invasive infections Bacterial: e.g., [pseudomembranous colitis](https:\/\/www.amboss.com\/us\/knowledge\/Clostridioides_difficile_infection#Z9a45a83f4126940236032056da651cf6), [tuberculosis](https:\/\/www.amboss.com\/us\/knowledge\/Tuberculosis#Zcaeed890b290faa5ec7ec5e02a1039fe) Viral: e.g., [CMV](https:\/\/www.amboss.com\/us\/knowledge\/Herpes_virus_infections#Zad44d620172736914bbe3c52435de665) Parasitic: e.g., [Entamoeba histolytica](https:\/\/www.amboss.com\/us\/knowledge\/Amebiasis#Z4001b357f1b712e83d6027a4dfa5731b) Medications: e.g., [PPIs](https:\/\/www.amboss.com\/us\/knowledge\/Proton_pump_inhibitors#Z2753e50142e2f5b7089b165accdcc900), [NSAIDs](https:\/\/www.amboss.com\/us\/knowledge\/Non-opioid_analgesics#Z6d53b6cfe3376a70645a5c797293e56a), [tyrosine kinase inhibitors](https:\/\/www.amboss.com\/us\/knowledge\/Chemotherapeutic_agents#Z1d95c73e140242a536db072ff6adf252) Other: e.g., [ischemic colitis](https:\/\/www.amboss.com\/us\/knowledge\/Intestinal_ischemia#Za5a3e828cf2d10df3a9693a9fc3b2c34), [radiation colitis](https:\/\/www.amboss.com\/us\/knowledge\/Radiation_injury#Ze0a9ed89b6c1c4ea08173fa19b2b74f9), [malignancy](https:\/\/www.amboss.com\/us\/knowledge\/General_oncology#Z8c3bce39ca977e0f872b6d9fb3be8cfb) (e.g., [colon cancer](https:\/\/www.amboss.com\/us\/knowledge\/Colorectal_cancer#Z5f9a21e2819d2a5004da275e0fe8e909), [lymphoma](https:\/\/www.amboss.com\/us\/knowledge\/General_oncology#Z2586a20a2f640af294a4d86b9f8439d0)) |   |\n| Fatty | [Malabsorption](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb) | Infections: [SIBO](https:\/\/www.amboss.com\/us\/knowledge\/Small_intestinal_bacterial_overgrowth#Z9aa32f677362a235a8ae39e011711f1b), [tropical sprue](https:\/\/www.amboss.com\/us\/knowledge\/Tropical_sprue#Z98af9796a545c9279ebf232edfbe9a0f), [Whipple disease](https:\/\/www.amboss.com\/us\/knowledge\/Whipple_disease#Z83c04868f8c75273c89d8c6e966623e4), [giardiasis](https:\/\/www.amboss.com\/us\/knowledge\/Giardiasis#Z7285e874bce9a0f39983534a6c838736) Medications: e.g., [aminoglycosides](https:\/\/www.amboss.com\/us\/knowledge\/Overview_of_antibiotic_therapy#Zec4668b75aadd8ddccaf2d3dada94e20), [antiretroviral drugs](https:\/\/www.amboss.com\/us\/knowledge\/Human_immunodeficiency_virus_infection#Zcccdef45b4e6e14c8b8fd8bd48515808) Other: e.g., [celiac disease](https:\/\/www.amboss.com\/us\/knowledge\/Celiac_disease#Z1999c64abb6e85ce70f8cdc66810a65b), postsurgical changes, lymphatic obstruction |\n| [Maldigestion](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Z325814c45b1a9856fa3d65839f7681f5) | Inadequate [bile acid](https:\/\/www.amboss.com\/us\/knowledge\/Gallbladder_and_bile#Z86b474a966e0cc8faf1092967eaf82f4) concentration: e.g., due to hepatobiliary disease or [ileal](https:\/\/www.amboss.com\/us\/knowledge\/Small_intestine#Zf3a10de88f22b839a2769aa9ae031960) resection [Exocrine pancreatic insufficiency](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Z4880cedb9eb57d620afb59b2c9e39a8b): e.g., due to [chronic pancreatitis](https:\/\/www.amboss.com\/us\/knowledge\/Chronic_pancreatitis#Z1e14e388e4042dc43defefb9f88695e1) or [cystic fibrosis](https:\/\/www.amboss.com\/us\/knowledge\/Cystic_fibrosis#Z3ae6b1b2983d98afcd8339f505ed3f99) |   |\n| Watery | Secretory | Infections: e.g., [giardiasis](https:\/\/www.amboss.com\/us\/knowledge\/Giardiasis#Z7285e874bce9a0f39983534a6c838736), [cryptosporidiosis](https:\/\/www.amboss.com\/us\/knowledge\/HIV-associated_conditions#Z50d6fcd479428e63a00b9454e02cad44), [SIBO](https:\/\/www.amboss.com\/us\/knowledge\/Small_intestinal_bacterial_overgrowth#Z9aa32f677362a235a8ae39e011711f1b) Medications: e.g., [stimulant laxatives](https:\/\/www.amboss.com\/us\/knowledge\/Constipation#Za767330be9fd22123118b1e0addddf55), [levodopa](https:\/\/www.amboss.com\/us\/knowledge\/Medication_for_Parkinson_disease#Z18482e8eccd3978e1e99c57ecdc4fd2f), [caffeine](https:\/\/www.amboss.com\/us\/knowledge\/Substance-related_and_addictive_disorders#Z9cbb9bc1131781093113ffce4e367923) [Neuroendocrine tumors](https:\/\/www.amboss.com\/us\/knowledge\/Neuroendocrine_neoplasms#Z688b3fb7764fe32e74754d4b26c6fc89)  \\[11\\] Endocrine diseases: e.g., [hyperthyroidism](https:\/\/www.amboss.com\/us\/knowledge\/Hyperthyroidism_and_thyrotoxicosis#Z7efc7350132a2f2a3e4cc7763e7f07f8), [Addison disease](https:\/\/www.amboss.com\/us\/knowledge\/Adrenal_insufficiency#Z7b47bf57fd367b1b9891e4155e39236f), [diabetes mellitus](https:\/\/www.amboss.com\/us\/knowledge\/Diabetes_mellitus#Z1235e572dd827cff7d31e954b3f94489) Other: [bile acid](https:\/\/www.amboss.com\/us\/knowledge\/Gallbladder_and_bile#Z86b474a966e0cc8faf1092967eaf82f4) [malabsorption](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb), [IBD](https:\/\/www.amboss.com\/us\/knowledge\/Crohn_disease#Z4272f924349255b3e4babe86d4e939c9), [microscopic colitis](https:\/\/www.amboss.com\/us\/knowledge\/Microscopic_colitis#Z98c8e90c538959e074e80c55a532e1bc) |\n| Functional | [Irritable bowel syndrome](https:\/\/www.amboss.com\/us\/knowledge\/Irritable_bowel_syndrome#Z2b30a84dc4106c4e8aad1e6c9202f3ea) ([IBS](https:\/\/www.amboss.com\/us\/knowledge\/Irritable_bowel_syndrome#Z2b30a84dc4106c4e8aad1e6c9202f3ea)) Medications: e.g., [prokinetics]() [Functional diarrhea]() |   |\n| Osmotic | [Carbohydrate malabsorption](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Z1659a0f218ffe905f7bddb7c54efb326) Unabsorbed sugars in the diet and\/or in chewing [gum](https:\/\/www.amboss.com\/us\/knowledge\/Oral_cavity#Z3ab30934681b06d8591bf18cb03ce2d7): e.g., [sorbitol](https:\/\/www.amboss.com\/us\/knowledge\/Carbohydrates#Z77d45a3fdde3bf65b74cebef6dec2d7f), [mannitol](https:\/\/www.amboss.com\/us\/knowledge\/Diuretics#Ze73562869635139c2688bf31a791bef1) Enzymatic dysfunction: e.g., [lactase deficiency](https:\/\/www.amboss.com\/us\/knowledge\/Lactose_intolerance#Zd10b2b1e3672bf92a1e23fc1962405dc) Medications: e.g., [osmotic laxatives](https:\/\/www.amboss.com\/us\/knowledge\/Constipation#Z6beba559f6dfabe7c19e807cf28747b9) Other: e.g., [celiac disease](https:\/\/www.amboss.com\/us\/knowledge\/Celiac_disease#Z1999c64abb6e85ce70f8cdc66810a65b), [FODMAP](https:\/\/www.amboss.com\/us\/knowledge\/Irritable_bowel_syndrome#Zd9aa5f552109b4cf13d7666f5e99cebe) intolerance, [enteral feeding](https:\/\/www.amboss.com\/us\/knowledge\/Specialized_nutrition_support#Z3c9fb1a42ea89ef188431d15c5ad1445) |   |\n\nOrder initial studies. See also “Testing for diarrhea” in “Diagnostics.”\n\nAlways test for Giardia infection in [chronic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a). \\[24\\]\n\nPerform guided diagnostics based on characteristic clinical features in diarrhea and the results of initial diagnostic testing.\n\n| Diagnostic workup of patients with [chronic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a) |   |   |   |\n|---|---|---|---|\n| Classification | Initial results | Further diagnostics |   |\n| [Inflammatory diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z321586a3cfe84e9365a55d0ed20fb62a) | Fecal [leukocytes](https:\/\/www.amboss.com\/us\/knowledge\/Basics_of_hematology#Z18a02873023ccef6d8ea2b461e0b7446) present. Fecal occult blood positive Calprotectin or [lactoferrin](https:\/\/www.amboss.com\/us\/knowledge\/Innate_immune_system#Z341d9eb537374add3f4e1350946c378f) positive Elevated [CRP](https:\/\/www.amboss.com\/us\/knowledge\/Laboratory_medicine#Z51ad1e101a45a8de708a6dda0321755d) | [Colonoscopy](https:\/\/www.amboss.com\/us\/knowledge\/Colonoscopy#Za4aebc8baa131b83620292e8d0363739) with [mucosal]() [biopsies]() (always required): can identify [IBD](https:\/\/www.amboss.com\/us\/knowledge\/Crohn_disease#Z4272f924349255b3e4babe86d4e939c9), [colon cancer](https:\/\/www.amboss.com\/us\/knowledge\/Colorectal_cancer#Z5f9a21e2819d2a5004da275e0fe8e909), [ischemic colitis](https:\/\/www.amboss.com\/us\/knowledge\/Intestinal_ischemia#Za5a3e828cf2d10df3a9693a9fc3b2c34), [radiation colitis](https:\/\/www.amboss.com\/us\/knowledge\/Radiation_injury#Ze0a9ed89b6c1c4ea08173fa19b2b74f9), and [pseudomembranous colitis](https:\/\/www.amboss.com\/us\/knowledge\/Clostridioides_difficile_infection#Z9a45a83f4126940236032056da651cf6) Testing for infectious diseases: e.g., [parasites]() ([amebiasis](https:\/\/www.amboss.com\/us\/knowledge\/Amebiasis#Z4500356668f80dc7e2e4d3b731ae9d1f)) and [C. difficile infection](https:\/\/www.amboss.com\/us\/knowledge\/Clostridioides_difficile_infection#Zb508f99ee028a9d8582608f40bc36f5f) |   |\n| [Fatty diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Chronic_pancreatitis#Z416510d2bd6fcd19b4e328d62b6b10db) \\[10\\]\\[12\\]\\[16\\] | Increased fecal fat, e.g.: [Sudan stain](https:\/\/www.amboss.com\/us\/knowledge\/Cellular_changes_and_adaptive_responses#Z78716b286b479e2c380f54ed824c20fc) positive [72-hour fecal fat estimation](https:\/\/www.amboss.com\/us\/knowledge\/Chronic_pancreatitis#Zd212c09e9c64621940c1a0ced94a9c98) elevated | [Mucosal]() disease: [celiac disease panel](https:\/\/www.amboss.com\/us\/knowledge\/Celiac_disease#Z63d359b4e2570234feebde9aaebff219) and [EGD](https:\/\/www.amboss.com\/us\/knowledge\/Esophagogastroduodenoscopy#Z1a617ceb3d8b9832108168a091314359) with [biopsies]() Luminal disease [Pancreatic function tests](https:\/\/www.amboss.com\/us\/knowledge\/Laboratory_medicine#Zc0f762af46ed9109bda61d0feb7a5ab3) (e.g., [fecal elastase-1](https:\/\/www.amboss.com\/us\/knowledge\/Chronic_pancreatitis#Zf555d89ae453336db1900a0d4d2df7e7)): can identify [exocrine pancreatic insufficiency](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Z4880cedb9eb57d620afb59b2c9e39a8b) \\[18\\] [Hydrogen breath test](https:\/\/www.amboss.com\/us\/knowledge\/Lactose_intolerance#Z4187a69143c8be5cfd157107e8edb65a)  and [EGD](https:\/\/www.amboss.com\/us\/knowledge\/Esophagogastroduodenoscopy#Z1a617ceb3d8b9832108168a091314359) with [small bowel aspiration]() and cultures: can identify [SIBO](https:\/\/www.amboss.com\/us\/knowledge\/Small_intestinal_bacterial_overgrowth#Z9aa32f677362a235a8ae39e011711f1b) \\[34\\] |   |\n| [Watery diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z16ed63f1f94f558cfbffed53ce14a7fb) \\[11\\] | [Secretory diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Za81182120613af86b266ff31432e241e) or [functional diarrheal disorders](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z68e249c3723fb43d54724dbf2018af91) | Low [stool osmotic gap](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Ze3350ca8675573e0158f73d116234534) (\\< 50 mOsm\/kg) No fecal [leukocytes](https:\/\/www.amboss.com\/us\/knowledge\/Basics_of_hematology#Z18a02873023ccef6d8ea2b461e0b7446) No fecal fat | [TFTs](https:\/\/www.amboss.com\/us\/knowledge\/Hyperthyroidism_and_thyrotoxicosis#Zc2daec2f86dc7f7edf504314f5e9de68), [cortisol](https:\/\/www.amboss.com\/us\/knowledge\/Adrenal_gland#Z68437810c311fa1e0e910fecfa30be04) level, [diabetes mellitus screening](https:\/\/www.amboss.com\/us\/knowledge\/Diabetes_mellitus#Z880b3ed63aba809ccba7ae2a7afb386d): can detect endocrine disorders Serum [gastrin](https:\/\/www.amboss.com\/us\/knowledge\/Gastrointestinal_tract#Z16fdc87a47049d4522f49bf193d34fcb), [VIP](https:\/\/www.amboss.com\/us\/knowledge\/Gastrointestinal_tract#Z2a13d7814300b48684ebf0f62ffc0318), [calcitonin](https:\/\/www.amboss.com\/us\/knowledge\/Hypocalcemia#Z8f09b075f4d87191d15890436cb2a4a5) level: can detect [neuroendocrine tumors](https:\/\/www.amboss.com\/us\/knowledge\/Neuroendocrine_neoplasms#Z688b3fb7764fe32e74754d4b26c6fc89) Evaluation for [bile acid](https:\/\/www.amboss.com\/us\/knowledge\/Gallbladder_and_bile#Z86b474a966e0cc8faf1092967eaf82f4) [malabsorption](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb) and [SIBO](https:\/\/www.amboss.com\/us\/knowledge\/Small_intestinal_bacterial_overgrowth#Z9aa32f677362a235a8ae39e011711f1b) [Rome IV criteria for IBS](https:\/\/www.amboss.com\/us\/knowledge\/Irritable_bowel_syndrome#Zc16da4fdfa96f2bd9cf45f216019665a): may indicate [functional diarrhea]() |\n| [Osmotic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z7169e994f812b120ea2df94d1042192e) | High [stool osmotic gap](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Ze3350ca8675573e0158f73d116234534) (≥ 100 mOsm\/kg) No fecal [leukocytes](https:\/\/www.amboss.com\/us\/knowledge\/Basics_of_hematology#Z18a02873023ccef6d8ea2b461e0b7446) No fecal fat | Stool [pH]() \\< 6 suggests [carbohydrate malabsorption](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Z1659a0f218ffe905f7bddb7c54efb326);  consider the following: \\[11\\] [Celiac disease panel](https:\/\/www.amboss.com\/us\/knowledge\/Celiac_disease#Z63d359b4e2570234feebde9aaebff219) [Lactose hydrogen breath test](https:\/\/www.amboss.com\/us\/knowledge\/Lactose_intolerance#Z4187a69143c8be5cfd157107e8edb65a): can diagnose [lactase deficiency](https:\/\/www.amboss.com\/us\/knowledge\/Lactose_intolerance#Zd10b2b1e3672bf92a1e23fc1962405dc) [Small intestine biopsy](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Z4c414f1e711c5ae69ceece6cee9f425e): can diagnose [celiac disease](https:\/\/www.amboss.com\/us\/knowledge\/Celiac_disease#Z1999c64abb6e85ce70f8cdc66810a65b) or infectious diseases (e.g., [Whipple disease](https:\/\/www.amboss.com\/us\/knowledge\/Whipple_disease#Z83c04868f8c75273c89d8c6e966623e4)) Stool [pH]() ≥ 6 suggests [antacid](https:\/\/www.amboss.com\/us\/knowledge\/Dyspepsia#Z483f046dcff29152f098e8a15dc67c9b) and\/or [laxative]() ingestion |   |\n\nIn [watery diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z16ed63f1f94f558cfbffed53ce14a7fb), the [stool osmotic gap](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Ze3350ca8675573e0158f73d116234534) differentiates osmotic from [secretory diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Za81182120613af86b266ff31432e241e). In osmotic [watery diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z16ed63f1f94f558cfbffed53ce14a7fb), a stool [pH]() \\< 6 suggests [carbohydrate malabsorption](https:\/\/www.amboss.com\/us\/knowledge\/Malabsorption#Z1659a0f218ffe905f7bddb7c54efb326).\n\nEndoscopic studies with [mucosal]() [biopsies]() are required to diagnose [inflammatory diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z321586a3cfe84e9365a55d0ed20fb62a) in patients with [chronic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a).\n\n## Differential diagnoses![toggle arrow icon](https:\/\/manus-media.amboss.com\/icons\/chevron_up.svg)\nReferences:\\[11\\]\\[22\\]\\[23\\]\n\nThe differential diagnoses listed here are not exhaustive.\n\n## Subtypes and variants![toggle arrow icon](https:\/\/manus-media.amboss.com\/icons\/chevron_up.svg)\n## Traveler's diarrhea \\[36\\]\\[37\\]\n- Definition: ≥ 3 unformed stools with at least one additional [enteric]() symptom occurring after recent travel\n- [Epidemiology](https:\/\/www.amboss.com\/us\/knowledge\/Epidemiology#Z4c4f63797573af64476acb67d715be49)\n  - The highest rates occur after travel to Africa and South, Central, and West Asia.\n  - Approximately 25% of all travelers develop [traveler's diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zed77ffe538dae231e40fe0542e7b245a).\n- Etiology\n  - [Enterotoxigenic E. coli](https:\/\/www.amboss.com\/us\/knowledge\/Diarrheagenic_E._coli#Z458147f1e1273e554884140b40317779) ([ETEC](https:\/\/www.amboss.com\/us\/knowledge\/Diarrheagenic_E._coli#Z458147f1e1273e554884140b40317779)) is the most common cause of [traveler's diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zed77ffe538dae231e40fe0542e7b245a) globally.\n  - [Campylobacter jejuni](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Z4a3deabcd49cf50e8c48e5f0d5dcc506) is the most common cause in Southeast Asia.\n  - Other pathogens\n- Clinical features: [exudative]()\\-inflammatory or [secretory diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Za81182120613af86b266ff31432e241e), abdominal cramping, abdominal [pain](https:\/\/www.amboss.com\/us\/knowledge\/Principles_of_pain_management#Zd673a3f7ee36023aab5a267899e984cc)\n- Antibiotics for traveler's diarrhea: Reserve for moderate to severe illness. \\[25\\]\\[32\\]\\[36\\]\n  - For most destinations: [ciprofloxacin](https:\/\/www.amboss.com\/us\/knowledge\/Overview_of_antibiotic_therapy#Z3f1dbc417664139dda097bcd516ceeed) ([off label](https:\/\/www.amboss.com\/us\/knowledge\/Fundamentals_of_pharmacology#Zb37ab5e3f79a4ddd6b356eb84fa0067a))  OR [rifaximin](https:\/\/www.amboss.com\/us\/knowledge\/Hepatic_encephalopathy#Za8e7b6e3b08d56feebf985f44969b261)   \\[36\\]\n  - For travelers to South or Southeast Asia: [azithromycin](https:\/\/www.amboss.com\/us\/knowledge\/Overview_of_antibiotic_therapy#Z9884c173cd8bcd36d44eb85ea8acfec2) ([off label](https:\/\/www.amboss.com\/us\/knowledge\/Fundamentals_of_pharmacology#Zb37ab5e3f79a4ddd6b356eb84fa0067a))  \\[36\\]\n- [Supportive care]() \\[25\\]\n  - Treatment for [dehydration](https:\/\/www.amboss.com\/us\/knowledge\/Dehydration_and_hypovolemia#Zbd78324053c153c16ea5cb2574249398) (e.g., [oral rehydration solution](https:\/\/www.amboss.com\/us\/knowledge\/Dehydration_and_hypovolemia#Z22573072c2ce7ea0ba0873c3024dc043))\n  - [Bismuth subsalicylate](https:\/\/www.amboss.com\/us\/knowledge\/Helicobacter_pylori_infection#Z5ff316bf4e8912c06dc600df2a9e8b09) for patients with mild to moderate illness\n  - [Loperamide](https:\/\/www.amboss.com\/us\/knowledge\/Opioids#Z1881077ac71cd771cb44b7db04569ac0) for patients receiving [antibiotic therapy](https:\/\/www.amboss.com\/us\/knowledge\/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3) (can reduce the duration of illness)\n  - See “[Antidiarrheal agents](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zc9c4c39a6ce3413ed32214ba89c1e777)” for dosages.\n- Postinfectious sequelae\n  - [Postinfectious IBS](): may occur in 3–20% of patients\n  - [Reactive arthritis](https:\/\/www.amboss.com\/us\/knowledge\/Reactive_arthritis#Z004554eda6fc600767f0d5dbaca1925d): may last months to years\n  - [Guillain-Barre syndrome](https:\/\/www.amboss.com\/us\/knowledge\/Guillain-Barr%C3%A9_syndrome#Zf193c1b0b16db4d30e7f29d4e766d3e8): may develop 1–4 weeks after infection (most commonly after [Campylobacter](https:\/\/www.amboss.com\/us\/knowledge\/Bacteria_overview#Za64f770db8dc668f93db5788517d1bc0) infection)\n\n[Antibiotic](https:\/\/www.amboss.com\/us\/knowledge\/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3) treatment is not recommended in patients with mild [traveler's diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zed77ffe538dae231e40fe0542e7b245a).\n\n[Bismuth subsalicylate](https:\/\/www.amboss.com\/us\/knowledge\/Helicobacter_pylori_infection#Z5ff316bf4e8912c06dc600df2a9e8b09) is an [antidiarrheal agent](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zc9c4c39a6ce3413ed32214ba89c1e777) used to treat [traveler's diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zed77ffe538dae231e40fe0542e7b245a) (caused by [enterotoxigenic Escherichia coli](https:\/\/www.amboss.com\/us\/knowledge\/Diarrheagenic_E._coli#Z458147f1e1273e554884140b40317779)).\n\n### Pharmacological prophylaxis for traveler's diarrhea \\[25\\]\\[36\\]\nConsider for travelers to high-risk areas (under specialist guidance); options include:\n\n## Factitious diarrhea \\[11\\]\n- Definition: self-induced diarrhea, usually due to [laxative abuse](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Zf400d371a3aeaaef09f5533381e99329) (often occurs in individuals with [factitious disorders](https:\/\/www.amboss.com\/us\/knowledge\/Somatic_symptom_and_related_disorders#Za429ee6281b4bad77a94b44df89f4036)), or dilution of stools with solutions\n- [Epidemiology](https:\/\/www.amboss.com\/us\/knowledge\/Epidemiology#Z4c4f63797573af64476acb67d715be49)\n  - Most prevalent in women\n  - Patients are usually [health care professionals]().\n  - History of multiple hospital admissions\n- Clinical features: [chronic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a) without an identifiable cause\n- Diagnostics\n  - Laboratory tests: [metabolic acidosis](https:\/\/www.amboss.com\/us\/knowledge\/Acid-base_disorders#Ze6ecd1a689f21c50f6f1d77dcd2bd10b) , [metabolic alkalosis](https:\/\/www.amboss.com\/us\/knowledge\/Acid-base_disorders#Z46196a0a09cd3ccdd01835db5b427a7c) , [hypokalemia](https:\/\/www.amboss.com\/us\/knowledge\/Hypokalemia#Z1454fccf44cdd1776601d443f63ca03c), [hypermagnesemia](https:\/\/www.amboss.com\/us\/knowledge\/Hypermagnesemia#Z80b32d5d74b73a5c759d3ecd2043a7e6)\n  - Stool [osmolarity](https:\/\/www.amboss.com\/us\/knowledge\/Intravenous_fluid_therapy#Zdeae47858e4e2ccdf3ffe701a1970e95)\n    - \\< 290 mOsm\/L: indicates dilution of the stool with a hypotonic solution\n    - \\> 600 mOsm\/L: indicates dilution of the stool with a hypertonic solution\n  - [Laxative]() screen \\[18\\]\n  - [Colonoscopy](https:\/\/www.amboss.com\/us\/knowledge\/Colonoscopy#Za4aebc8baa131b83620292e8d0363739): may show [melanosis coli](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z21e7a77240bb6cafa756a1d9e263da87) in cases of anthraquinone  abuse\n- Treatment\n### Laxative abuse\n- Types of [laxative]()\n- Clinical features\n  - [Osmotic diarrhea](https:\/\/www.amboss.com\/us\/knowledge\/Diarrhea#Z7169e994f812b120ea2df94d1042192e), [meteorism]()\n  - [Dehydration](https:\/\/www.amboss.com\/us\/knowledge\/Dehydration_and_hypovolemia#Zbd78324053c153c16ea5cb2574249398)\n  - [Hypokalemia](https:\/\/www.amboss.com\/us\/knowledge\/Hypokalemia#Z1454fccf44cdd1776601d443f63ca03c)\n  - Melanosis coli: benign [hyperpigmentation]() of the [colonic](https:\/\/www.amboss.com\/us\/knowledge\/Large_intestine#Ze19293358dc6c65dc95f936bb8fca493) [mucosa]() caused by anthraquinone abuse  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Shane AL, Mody RK, Crump JA, et al. 2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea. *Clin Infect Dis*. 2017; 65 (12): p.e45-e80.doi: [10\\.1093\/cid\/cix669](https:\/\/dx.doi.org\/10.1093\/cid\/cix669) . \\| [Open in Read by QxMD](https:\/\/read.qxmd.com\/doi\/10.1093\/cid\/cix669)\n21. DuPont HL. Persistent Diarrhea. *JAMA*. 2016; 315 (24): p.2712.doi: [10\\.1001\/jama.2016.7833](https:\/\/dx.doi.org\/10.1001\/jama.2016.7833) . \\| [Open in Read by QxMD](https:\/\/read.qxmd.com\/doi\/10.1001\/jama.2016.7833)\n22. Qiu FZ, Shen XX, Li GX, et al. Adenovirus associated with acute diarrhea: a case-control study.. *BMC Infect Dis*. 2018; 18 (1): p.450.doi: [10\\.1186\/s12879-018-3340-1](https:\/\/dx.doi.org\/10.1186\/s12879-018-3340-1) . \\| [Open in Read by QxMD](https:\/\/read.qxmd.com\/doi\/10.1186\/s12879-018-3340-1)\n23. Histamine Toxicity. *<https:\/\/www.aaaai.org\/conditions-and-treatments\/related-conditions\/histamine-toxicity>*. Updated: March 1, 2017. Accessed: March 1, 2017.\n24. Overview of Food Poisoning. *<http:\/\/www.msdmanuals.com\/home\/injuries-and-poisoning\/poisoning\/overview-of-food-poisoning>*. Updated: March 1, 2017. Accessed: March 1, 2017.\n25. Juckett G, Trivedi R. Evaluation of Chronic Diarrhea. *Am Fam Physician*. 2011; 84 (10): p.1119-1126.\n26. DuPont HL. Adverse Effect of Lomotil Therapy in Shigellosis. *JAMA*. 1973; 226 (13): p.1525.doi: [10\\.1001\/jama.1973.03230130013006](https:\/\/dx.doi.org\/10.1001\/jama.1973.03230130013006) . \\| [Open in Read by QxMD](https:\/\/read.qxmd.com\/doi\/10.1001\/jama.1973.03230130013006)\n27. Singh N, Narayan S. 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Bile acid diarrhoea: pathophysiology, diagnosis and management. *Frontline Gastroenterology*. 2020; 12 (6): p.500-507.doi: [10\\.1136\/flgastro-2020-101436](https:\/\/dx.doi.org\/10.1136\/flgastro-2020-101436) . \\| [Open in Read by QxMD](https:\/\/read.qxmd.com\/doi\/10.1136\/flgastro-2020-101436)\n38. Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. *<https:\/\/web.archive.org\/web\/20260126024001\/https:\/\/clinicalinfo.hiv.gov\/sites\/default\/files\/guidelines\/documents\/adult-adolescent-oi\/guidelines-adult-adolescent-oi.pdf>*. Updated: July 14, 2025. Accessed: January 25, 2026.\n39. Kasper DL, Fauci AS, Hauser SL, et al. *Harrison's Principles of Internal Medicine*. McGraw-Hill Education ; 2015\n40. Walker HK, Hall WD, Hurst WJ, Silverman ME, Morrison G. *Clinical Methods: The History, Physical, and Laboratory Examinations*. Butterworths ; 1990\n41. Saad RJ, Chey WD. Breath Testing for Small Intestinal Bacterial Overgrowth: Maximizing Test Accuracy. *Clin Gastroenterol Hepatol*. 2014; 12 (12): p.1964-1972.doi: [10\\.1016\/j.cgh.2013.09.055](https:\/\/dx.doi.org\/10.1016\/j.cgh.2013.09.055) . \\| [Open in Read by QxMD](https:\/\/read.qxmd.com\/doi\/10.1016\/j.cgh.2013.09.055)","meta_canonical":"com,amboss!www,\/us\/knowledge\/diarrhea s443"}

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Meta Description	Diagnostic approach Inflammatory diarrhea or noninflammatory diarrhea that is not self-limited: stool GI pathogen panel (PCR) or culture Severe illness with fever: CBC, CMP, ESR, CRP, blood cultu..., Diagnostic approach Inflammatory diarrhea or noninflammatory diarrhea that is not self-limited: stool GI pathogen panel (PCR) or culture Severe illness with fever: CBC, CMP, ESR, CRP, blood cultu...
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Boilerpipe Text	Last updated: February 27, 2026 Quick guide Diagnostic testing is not indicated for most cases of . Summary Diarrhea, defined as three or more loose stools per day or more frequent stool passage than is normal for the individual, is a common disease with a monthly prevalence of around 5% in the United States. Acute diarrhea lasts 14 days or less and is almost always caused by an infectious agent, typically a virus . Testing is seldom required, as the disease tends to be self-limited and care is primarily supportive. Persistent diarrhea , lasting 15–30 days , is also typically caused by an infectious agent, but stool testing for pathogens is generally warranted to confirm the diagnosis. Chronic diarrhea , defined as diarrhea lasting longer than 30 days , has an extensive differential diagnosis. A thorough history followed by systematic stool and blood testing is required to identify the specific etiology. The presence of any red flags for severe or rapidly progressing diarrheal disease (e.g., sepsis , extreme dehydration , blood in the stool) mandates escalation of testing and, in some cases, empiric antibiotics for bacterial gastroenteritis . Ensuring adequate oral hydration, correcting dehydration , and providing symptomatic relief are fundamental components in the care of all patients with diarrhea. Curative treatment is directed toward the underlying cause. Definitions The WHO defines diarrhea as ≥ 3 loose or watery stools per day or more frequent passage than is normal for the individual. [1] [2] Etiology For etiologies of acute, persistent, or chronic diarrhea , see specific subsections below. Overview of pathogens causing watery and bloody diarrhea Overview Type of diarrhea Pathogen Pathogen characteristics Associated disorders Watery diarrhea Enterotoxigenic Escherichia coli Heat-labile toxin Heat-stable toxin Traveler's diarrhea Clostridioides difficile Toxin A ( enterotoxin ) Toxin B (cytotoxin) Associated with antibiotic and PPI use Pseudomembranous colitis Rarely causes bloody diarrhea Clostridium perfringens Heat-labile enterotoxin Clostridium perfringens alpha toxin Gas gangrene Vibrio cholerae Straight or curved ( comma-shaped ) Cholera toxin ( enterotoxin ): “ rice water ” diarrhea Transmission via contaminated water or uncooked seafood (e.g., raw shellfish) Cholera Viruses Norovirus (most common cause) Fecal-oral or airborne transmission Gastroenteritis Rotavirus Fecal-oral transmission Prevention: attenuated vaccine for children Adenovirus Transmission via contaminated water or fecal-oral route Protozoa Giardia lamblia Transmission via ingestion of contaminated water (e.g., lakes, rivers, ponds, swimming pools) Most commonly affects hikers or campers Giardiasis Cryptosporidia Fecal-oral transmission ( oocysts are typically excreted in stool and contaminate drinking water) Cryptosporidiosis Immunocompromised individuals : potentially life-threatening protracted diarrhea and/or biliary tract infections (e.g., cholangitis , cholecystitis ) Cystoisospora belli [3] Foodborne Contaminated water Cystoisosporiasis Immunocompromised individuals : chronic profuse diarrhea, acalculous cholecystitis , AIDS cholangiopathy Bloody diarrhea E.coli Enteroinvasive E. coli Direct invasion of the intestinal epithelium and formation of enterotoxins Gastroenteritis Enterohemorrhagic E. coli Shiga toxin Most common serotype : ( O157:H7 ) Hemolytic uremic syndrome Campylobacter jejuni Curved or spiral‑shaped with polar flagellum Grows best at 37–42°C Campylobacter enteritis (especially in children) Commonly precedes reactive arthritis and Guillain‑Barré syndrome Nontyphoidal Salmonella No lactose fermentation Flagellar motility Hosts: humans, animals, and animal products (e.g., reptiles, poultry , pets, eggs ) Salmonellosis Shigella Slow/absent lactose fermentation Shiga toxin Low infectious dose required ( low ID 50 ) Humans are the only host. Bacillary dysentery Yersinia enterocolitica Reservoir: contaminated pork and milk products Yersiniosis ( outbreaks often occur in day-care settings) May manifest as pseudoappendicitis Reactive arthritis Protozoa : Entamoeba histolytica Fecal-oral transmission Amebic cysts are excreted in stool and can contaminate drinking water or food. Amebic dysentery Amebic liver abscess Infectious causes [4] [5] Conditions Viral Norovirus infection Rotavirus infection Adenovirus infection (mainly serotype 3 , 40, and 41 ) [6] Cytomegalovirus infection Bacterial Campylobacter enteritis Shigellosis Salmonellosis Cholera Diarrheagenic E. coli infection ( travelers' diarrhea ) Yersiniosis (especially in day care centers) Clostridioides difficile infection ( antibiotic -associated diarrhea) Typhoid fever Mycobacterium avium-intracellulare Tropheryma whipplei (i.e., Whipple disease ) Legionella infection Parasitic Protozoan Giardiasis Amebiasis Cryptosporidiosis Cystoisosporiasis Helminth infections Toxocariasis Enterobiasis Ascariasis Trichinosis Taenia infections ( taeniasis ) Hookworm infection Diphyllobothriasis Intestinal capillariasis Noninfectious [7] [8] [9] Conditions Foodborne toxins S. aureus intoxication Botulism Bacillus cereus infection Tetrodotoxin , ciguatoxin Food poisoning Aflatoxin Histamine toxicity [7] Chemical contaminants (e.g., lead, cadmium , insecticides, arsenic ) [8] Mushroom poisoning [9] Gastrointestinal Malnutrition : vitamin deficiency (e.g., pellagra ) Malabsorption or maldigestion Celiac disease Lactose intolerance Exocrine pancreatic insufficiency (e.g., due to chronic pancreatitis ) Diabetic autonomic neuropathy Bile acid diarrhea (e.g., due to ileal resection, biliary-enteric fistula , cholestasis , postcholecystectomy diarrhea ) Amyloidosis of the gastrointestinal tract Colitis Inflammatory bowel disease Crohn disease Ulcerative colitis Irritable bowel syndrome Microscopic colitis Ischemic colitis Radiation colitis Tumor /stenotic processes: paradoxical diarrhea (involuntary seepage of liquid feces in patients with chronic constipation ) Classification Diarrhea is often classified as watery, fatty, and/or inflammatory to facilitate diagnosis and management. This classification scheme is most relevant for the approach to chronic diarrhea . Classification of diarrhea by functional pathology [10] [11] [12] Pathophysiology Associated disorders Inflammatory diarrhea Damage to the intestinal mucosa may cause cytokine -induced water hypersecretion, impair absorption of osmotically active substances or fat, and/or disrupt water and electrolyte absorption. Mucus, blood , and leukocytes present in the stool. Ulcerative colitis , Crohn disease Colorectal cancer Infections Shigellosis ( bacillary dysentery ) Nontyphoidal: salmonellosis Enteroinvasive Escherichia coli , enterohemorrhagic E. coli ( O157:H7 ) Campylobacteriosis Yersiniosis Amebiasis ( amebic dysentery caused by Entamoeba histolytica ) Clostridioides difficile (rarely bloody) Fatty diarrhea Malabsorption Alterations of the intestinal mucosa → impaired absorption of digested food Malabsorption disorders or history of ileal resection Infections Giardiasis Small intestinal bacterial overgrowth ( SIBO ) Tropical sprue Whipple disease Amyloidosis Maldigestion Lack of digestive enzymes → impaired breakdown of food in the intestinal lumen → malabsorption of carbohydrates , proteins , fats, fat-soluble vitamins (A, D, E, K), and vitamin B 12 Exocrine pancreatic insufficiency Bile acid diarrhea Watery diarrhea Secretory diarrhea Active secretion of water into the intestinal lumen via inhibition or activation of enzymes (e.g., ↑ cAMP activity) Neuroendocrine disorders, e.g.: Carcinoid syndrome Gastrinoma Endocrine disorders, e.g.: Hyperthyroidism Addison disease Diabetes mellitus Foodborne infections Cholera (“rice water” diarrhea) Enterotoxigenic E. coli ( traveler's diarrhea ) C. perfringens C. difficile (associated with antibiotic and PPI use) Protozoa : e.g., giardiasis , cryptosporidiosis Viruses : e.g., norovirus , rotavirus , adenovirus Osmotic diarrhea Poor absorption or excessive ingestion of hydrophilic substances (e.g., salts, sugars, laxatives ) causes water to be drawn into the intestinal lumen. Osmotic laxatives : e.g., magnesium citrate Carbohydrate malabsorption : e.g., lactose intolerance , fructose intolerance (may also present as fatty diarrhea ) Functional diarrheal disorders [10] Rapid intestinal passage due to increased bowel activity Diarrhea-predominant IBS ( IBS-D ) Functional diarrhea [10] [13] Management 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 ). [14] Antibiotics should only be utilized for specific indications. Clinical assessment of diarrhea [10] [12] Key features of the disease presentation that facilitate efficient testing and prompt diagnosis include: Duration of diarrheal illness 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 Characteristic clinical features in diarrhea according to functional pathology Inflammatory diarrhea Frequent and small volume stools Bloody or purulent stools Abdominal pain , tenesmus May be associated with fever , weight loss, fatigue Fatty diarrhea Greasy or oily stools Stools that are difficult to flush Decreases with fasting May be associated with weight loss Watery diarrhea Secretory diarrhea Loose, watery stools No change with fasting Nocturnal diarrhea present Functional diarrheal disorders Decreases with fasting Decreased at night Osmotic diarrhea Decreases with fasting Decreased at night Food triggers Assess for the presence of risk factors for specific etiologies, including: 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. [15] Chronic diarrhea is common after bariatric surgery . [19] [20] Diagnostics General principles [10] [12] [22] [25] Acute diarrhea Testing is not required in the majority of cases. Indications for testing include the presence of red flags in diarrhea and risk factors for specific etiologies. Persistent diarrhea : Testing is usually limited to stool studies for infectious gastroenteritis . Chronic diarrhea Testing is initially broad with advanced follow-up testing as indicated. [21] [25] Repeat stool testing for infectious gastroenteritis . Diagnostic testing is seldom indicated in acute diarrhea in the absence of red flag symptoms . Testing for diarrhea For specific indications for testing, see the respective subsections below on acute, persistent, and chronic diarrhea . Endoscopic studies have limited diagnostic value in acute diarrhea but are commonly needed for the workup of chronic diarrhea to evaluate for the presence of inflammatory or neoplastic diseases . Their utility in persistent diarrhea is uncertain. Stool diagnostic studies Stool diagnostic studies in diarrhea Suspected etiology Test Purpose Infectious diseases Stool culture Identification of infectious agents (e.g., in bacterial gastroenteritis ) Stool microscopy Visualization of ova or parasites in the stool Culture-independent methods, e.g., multiplex molecular diagnostic panel for diarrhea ( PCR ) Identification of infectious agents in bacterial, viral, and protozoal gastroenteritis [25] Quantitative culture of small intestinal aspirate Used to diagnose SIBO ( gold standard test for bacterial overgrowth) Stool tests for C. difficile infection (e.g., toxin test) Identification of C. difficile infection Inflammation Stool microscopy Visualization of fecal leukocytes Fecal occult blood test ( FOBT ) To screen for malignancy and mucosal inflammation FIT DNA test To screen for colonic cancer and adenomatous polyps Fecal calprotectin and lactoferrin Markers of inflammatory bowel disease ( IBD ) Malabsorption Sudan stain Qualitative test for steatorrhea 72-hour quantitative fecal fat estimation Quantitative test for steatorrhea Fecal elastase-1 Confirmation of steatorrhea due to exocrine pancreatic insufficiency Stool electrolytes (e.g., Na + , K + ) Used to calculate stool osmotic gap Stool pH Identification of carbohydrate malabsorption Stool osmotic gap [11] [16] [18] Low stool osmotic gap High stool osmotic gap Osmotic gap < 50 mOsm/kg ≥ 100 mOsm/kg Interpretation Secretory diarrhea ( ↑ secretion and/or inhibition of water absorption) or functional diarrhea (increased intestinal movement) Osmotic diarrhea (osmotic pull of ingested substances draws water into the intestinal lumen) Example causes Foodborne infections (e.g., Vibrio cholerae , enterotoxigenic E. coli ) Endocrine tumors (e.g., VIPoma , medullary carcinoma of the thyroid , gastrinoma ) Impaired absorption of bile acids and/or salts ( bile acid diarrhea ) Osmotic laxative ingestion (e.g., magnesium citrate ) Malabsorption (e.g., celiac disease , Whipple disease ) Pancreatic insufficiency The loss of bicarbonate -rich fluid in severe diarrhea may cause nonanion gap metabolic acidosis . Supportive care Acute or persistent diarrhea (≤ 30 days) The management of acute diarrhea is primarily supportive, as the disease is usually a self-limited viral infection. Further management focuses on determining whether diagnostic testing and directed therapy are needed (e.g., antibiotic therapy for bacterial gastroenteritis ). [22] If symptoms of an acute abdomen are present, consider an urgent CT abdomen to identify ischemic , hemorrhagic, obstructive, and/or inflammatory diseases. [28] When indicated, stool studies in patients with acute diarrhea should include tests that can detect the presence of Salmonella , Shigella , Campylobacter , Yersinia , C. difficile infection , and Shiga toxin-producing E. coli . [31] Noninflammatory diarrhea ( watery diarrhea ) [21] [25] [31] Inflammatory diarrhea ( dysentery ) [28] In patients with prominent abdominal pain and/or bloody diarrhea, evaluate for ischemic colitis , ulcerative colitis , and Crohn disease if stool testing does not indicate an infectious etiology. Persistent diarrhea has a broader differential diagnosis than acute diarrhea . Parasitic infection (e.g., giardiasis ), recurrent bacterial infection (e.g., C. difficile infection ), and noninfectious causes (e.g., IBS-D ) must be considered. [32] Etiology of acute and persistent diarrhea Viral [21] Norovirus infection Rotavirus infection Adenovirus infection (mainly serotypes 3 , 40, and 41 ) [6] Cytomegalovirus infection Coronavirus ( COVID-19 ) Bacterial Cholera (“rice water” diarrhea) Enterotoxigenic E. coli infection ( traveler's diarrhea ) C. perfringens infection C. difficile infection (associated with antibiotic and PPI use) Shigellosis ( bacillary dysentery ) Nontyphoidal: salmonellosis Enteroinvasive E. coli , enterohemorrhagic E. coli ( O157:H7 ) infection Campylobacteriosis Yersiniosis Legionella Parasitic Giardiasis Amebiasis Cryptosporidiosis Enterobiasis Ascariasis Food poisoning S. aureus infection Botulism Bacillus cereus infection Aflatoxin Histamine toxicity [7] Tetrodotoxin , ciguatoxin Medications Antibiotics Laxatives PPIs SSRIs NSAIDs Other Chemical contaminants (e.g., lead, cadmium , insecticides, arsenic ) [8] Mushroom poisoning [9] Bowel ischemia Neutropenic enterocolitis Chronic diarrhea (> 30 days) The differential diagnosis of chronic diarrhea is extensive. A systematic approach with efficient use of testing is needed to arrive at a diagnosis quickly. [10] [12] [33] Chronic diarrhea can be classified as inflammatory, fatty, or watery. Grouping patients into broad categories based on clinical features and basic laboratory findings narrows the differential diagnosis and facilitates efficient advanced testing. [18] IBS-D is an intermediate diagnosis; it does not eliminate the possibility of another disease. Evaluation should continue if symptoms persist despite treatment for IBS-D . [12] Chronic diarrhea is commonly classified as watery, fatty, or inflammatory. Etiology of chronic diarrhea [12] Inflammatory Inflammatory bowel disease : Crohn disease , ulcerative colitis Invasive infections Bacterial: e.g., pseudomembranous colitis , tuberculosis Viral: e.g., CMV Parasitic: e.g., Entamoeba histolytica Medications: e.g., PPIs , NSAIDs , tyrosine kinase inhibitors Other: e.g., ischemic colitis , radiation colitis , malignancy (e.g., colon cancer , lymphoma ) Fatty Malabsorption Infections: SIBO , tropical sprue , Whipple disease , giardiasis Medications: e.g., aminoglycosides , antiretroviral drugs Other: e.g., celiac disease , postsurgical changes, lymphatic obstruction Maldigestion Inadequate bile acid concentration: e.g., due to hepatobiliary disease or ileal resection Exocrine pancreatic insufficiency : e.g., due to chronic pancreatitis or cystic fibrosis Watery Secretory Infections: e.g., giardiasis , cryptosporidiosis , SIBO Medications: e.g., stimulant laxatives , levodopa , caffeine Neuroendocrine tumors [11] Endocrine diseases: e.g., hyperthyroidism , Addison disease , diabetes mellitus Other: bile acid malabsorption , IBD , microscopic colitis Functional Irritable bowel syndrome ( IBS ) Medications: e.g., prokinetics Functional diarrhea Osmotic Carbohydrate malabsorption Unabsorbed sugars in the diet and/or in chewing gum : e.g., sorbitol , mannitol Enzymatic dysfunction: e.g., lactase deficiency Medications: e.g., osmotic laxatives Other: e.g., celiac disease , FODMAP intolerance, enteral feeding Order initial studies. See also “Testing for diarrhea” in “Diagnostics.” Always test for Giardia infection in chronic diarrhea . [24] Perform guided diagnostics based on characteristic clinical features in diarrhea and the results of initial diagnostic testing. Diagnostic workup of patients with chronic diarrhea Classification Initial results Further diagnostics Inflammatory diarrhea Fecal leukocytes present. Fecal occult blood positive Calprotectin or lactoferrin positive Elevated CRP Colonoscopy with mucosal biopsies (always required): can identify IBD , colon cancer , ischemic colitis , radiation colitis , and pseudomembranous colitis Testing for infectious diseases: e.g., parasites ( amebiasis ) and C. difficile infection Fatty diarrhea [10] [12] [16] Increased fecal fat, e.g.: Sudan stain positive 72-hour fecal fat estimation elevated Mucosal disease: celiac disease panel and EGD with biopsies Luminal disease Pancreatic function tests (e.g., fecal elastase-1 ): can identify exocrine pancreatic insufficiency [18] Hydrogen breath test and EGD with small bowel aspiration and cultures: can identify SIBO [34] Watery diarrhea [11] Secretory diarrhea or functional diarrheal disorders Low stool osmotic gap ( < 50 mOsm/kg ) No fecal leukocytes No fecal fat TFTs , cortisol level, diabetes mellitus screening : can detect endocrine disorders Serum gastrin , VIP , calcitonin level: can detect neuroendocrine tumors Evaluation for bile acid malabsorption and SIBO Rome IV criteria for IBS : may indicate functional diarrhea Osmotic diarrhea High stool osmotic gap ( ≥ 100 mOsm/kg) No fecal leukocytes No fecal fat Stool pH < 6 suggests carbohydrate malabsorption ; consider the following: [11] Celiac disease panel Lactose hydrogen breath test : can diagnose lactase deficiency Small intestine biopsy : can diagnose celiac disease or infectious diseases (e.g., Whipple disease ) Stool pH ≥ 6 suggests antacid and/or laxative ingestion In watery diarrhea , the stool osmotic gap differentiates osmotic from secretory diarrhea . In osmotic watery diarrhea , a stool pH < 6 suggests carbohydrate malabsorption . Endoscopic studies with mucosal biopsies are required to diagnose inflammatory diarrhea in patients with chronic diarrhea . Differential diagnoses References: [11] [22] [23] The differential diagnoses listed here are not exhaustive. Subtypes and variants Traveler's diarrhea [36] [37] Definition : ≥ 3 unformed stools with at least one additional enteric symptom occurring after recent travel Epidemiology The highest rates occur after travel to Africa and South, Central, and West Asia. Approximately 25% of all travelers develop traveler's diarrhea . Etiology Enterotoxigenic E. coli ( ETEC ) is the most common cause of traveler's diarrhea globally. Campylobacter jejuni is the most common cause in Southeast Asia. Other pathogens Clinical features : exudative -inflammatory or secretory diarrhea , abdominal cramping, abdominal pain Antibiotics for traveler's diarrhea : Reserve for moderate to severe illness. [25] [32] [36] For most destinations: ciprofloxacin ( off label ) OR rifaximin [36] For travelers to South or Southeast Asia: azithromycin ( off label ) [36] Supportive care [25] Treatment for dehydration (e.g., oral rehydration solution ) Bismuth subsalicylate for patients with mild to moderate illness Loperamide for patients receiving antibiotic therapy (can reduce the duration of illness) See “ Antidiarrheal agents ” for dosages. Postinfectious sequelae Postinfectious IBS : may occur in 3–20% of patients Reactive arthritis : may last months to years Guillain-Barre syndrome : may develop 1–4 weeks after infection (most commonly after Campylobacter infection) Antibiotic treatment is not recommended in patients with mild traveler's diarrhea . Bismuth subsalicylate is an antidiarrheal agent used to treat traveler's diarrhea (caused by enterotoxigenic Escherichia coli ). Pharmacological prophylaxis for traveler's diarrhea [25] [36] Consider for travelers to high-risk areas (under specialist guidance); options include: Factitious diarrhea [11] Definition : self-induced diarrhea, usually due to laxative abuse (often occurs in individuals with factitious disorders ) , or dilution of stools with solutions Epidemiology Most prevalent in women Patients are usually health care professionals . History of multiple hospital admissions Clinical features : chronic diarrhea without an identifiable cause Diagnostics Laboratory tests: metabolic acidosis , metabolic alkalosis , hypokalemia , hypermagnesemia Stool osmolarity < 290 mOsm/L : indicates dilution of the stool with a hypotonic solution > 600 mOsm/L : indicates dilution of the stool with a hypertonic solution Laxative screen [18] Colonoscopy : may show melanosis coli in cases of anthraquinone abuse Treatment Laxative abuse Types of laxative Clinical features Osmotic diarrhea , meteorism Dehydration Hypokalemia Melanosis coli : benign hyperpigmentation of the colonic mucosa caused by anthraquinone abuse [39] References Sweetser S. Evaluating the Patient With Diarrhea: A Case-Based Approach. Mayo Clinic Proceedings . 2012; 87 (6): p.596-602. doi: 10.1016/j.mayocp.2012.02.015 . \| Open in Read by QxMD Jamshed N, Lee Z-E, Olden KW. Diagnostic Approach to Chronic Constipation in Adults. Am Fam Physician . 2011; 84 (3): p.299-306. Burgers K, Lindberg B, Bevis ZJ. Chronic Diarrhea in Adults: Evaluation and Differential Diagnosis.. Am Fam Physician . 2020; 101 (8): p.472-480. Schiller LR. Evaluation of chronic diarrhea and irritable bowel syndrome with diarrhea in adults in the era of precision medicine. Am J Gastroenterol . 2018; 113 (5): p.660-669. doi: 10.1038/s41395-018-0032-9 . \| Open in Read by QxMD Abraham B, Sellin JH. Drug-induced diarrhea. Curr Gastroenterol Rep . 2007; 9 (5): p.365-372. doi: 10.1007/s11894-007-0044-x . \| Open in Read by QxMD Semrad CE. Approach to the Patient with Diarrhea and Malabsorption . Elsevier ; 2012: p. 895-913 Farahmandfar MR, Chabok M, Alade M, Bouhelal A, Patel B. Post Cholecystectomy Diarrhoea—A Systematic Review. Surgical Science . 2012; 03 (06): p.332-338. doi: 10.4236/ss.2012.36065 . \| Open in Read by QxMD Schiller LR, Pardi DS, Sellin JH. Chronic Diarrhea: Diagnosis and Management. Clinical Gastroenterology and Hepatology . 2017; 15 (2): p.182-193.e3. doi: 10.1016/j.cgh.2016.07.028 . \| Open in Read by QxMD Borbély YM, Osterwalder A, Kröll D, Nett PC, Inglin RA. Diarrhea after bariatric procedures: Diagnosis and therapy. World Journal of Gastroenterology . 2017; 23 (26): p.4689. doi: 10.3748/wjg.v23.i26.4689 . \| Open in Read by QxMD Ma IT, Madura JA 2nd. Gastrointestinal Complications After Bariatric Surgery. Gastroenterol Hepatol . 2015; 11 (8): p.526-35. Barr W, Smith A. Acute diarrhea in adults. Am Fam Physician . 2014; 89 (3): p.180-189. Jameson JL, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. Harrison's Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2) . McGraw-Hill Education / Medical ; 2018 Hammer HF. Management of Chronic Diarrhea in Primary Care: The Gastroenterologists Advice. Digestive Diseases . 2021. doi: 10.1159/000515219 . \| Open in Read by QxMD Smalley W, Falck-Ytter C, Carrasco-Labra A, Wani S, Lytvyn L, Falck-Ytter Y. AGA Clinical Practice Guidelines on the Laboratory Evaluation of Functional Diarrhea and Diarrhea-Predominant Irritable Bowel Syndrome in Adults (IBS-D). Gastroenterology . 2019; 157 (3): p.851-854. doi: 10.1053/j.gastro.2019.07.004 . \| Open in Read by QxMD Camilleri M, Sellin JH, Barrett KE. Pathophysiology, Evaluation, and Management of Chronic Watery Diarrhea. Gastroenterology . 2017; 152 (3): p.515-532.e2. doi: 10.1053/j.gastro.2016.10.014 . \| Open in Read by QxMD Pimentel M, Saad RJ, Long MD, Rao SSC. ACG Clinical Guideline: Small Intestinal Bacterial Overgrowth. Am J Gastroenterol . 2020; 115 (2): p.165-178. doi: 10.14309/ajg.0000000000000501 . \| Open in Read by QxMD Vijayvargiya P, Camilleri M, Shin A, Saenger A. Methods for Diagnosis of Bile Acid Malabsorption in Clinical Practice. Clinical Gastroenterology and Hepatology . 2013; 11 (10): p.1232-1239. doi: 10.1016/j.cgh.2013.04.029 . \| Open in Read by QxMD Riddle MS, DuPont HL, Connor BA. ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults. Am J Gastroenterol . 2016; 111 (5): p.602-622. doi: 10.1038/ajg.2016.126 . \| Open in Read by QxMD DuPont HL. Acute Infectious Diarrhea in Immunocompetent Adults. N Engl J Med . 2014; 370 (16): p.1532-1540. doi: 10.1056/nejmra1301069 . \| Open in Read by QxMD Shane AL, Mody RK, Crump JA, et al. 2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea. Clin Infect Dis . 2017; 65 (12): p.e45-e80. doi: 10.1093/cid/cix669 . \| Open in Read by QxMD DuPont HL. Persistent Diarrhea. JAMA . 2016; 315 (24): p.2712. doi: 10.1001/jama.2016.7833 . \| Open in Read by QxMD Qiu FZ, Shen XX, Li GX, et al. Adenovirus associated with acute diarrhea: a case-control study.. BMC Infect Dis . 2018; 18 (1): p.450. doi: 10.1186/s12879-018-3340-1 . \| Open in Read by QxMD Histamine Toxicity. https://www.aaaai.org/conditions-and-treatments/related-conditions/histamine-toxicity . Updated: March 1, 2017. Accessed: March 1, 2017. Overview of Food Poisoning. http://www.msdmanuals.com/home/injuries-and-poisoning/poisoning/overview-of-food-poisoning . Updated: March 1, 2017. Accessed: March 1, 2017. Juckett G, Trivedi R. Evaluation of Chronic Diarrhea. Am Fam Physician . 2011; 84 (10): p.1119-1126. DuPont HL. Adverse Effect of Lomotil Therapy in Shigellosis. JAMA . 1973; 226 (13): p.1525. doi: 10.1001/jama.1973.03230130013006 . \| Open in Read by QxMD Singh N, Narayan S. Racecadotril : A Novel Antidiarrheal. Med J Armed Forces India . 2008; 64 (4): p.361-2. doi: 10.1016/S0377-1237(08)80022-6 . \| Open in Read by QxMD Benjamin I. Andreoli and Carpenter's Cecil Essentials of Medicine . Elsevier Health Sciences ; 2016 Diarrhoeal disease. http://www.who.int/mediacentre/factsheets/fs330/en/ . Updated: April 1, 2013. Accessed: March 1, 2017. Schiller LR, Pardi DS, Spiller R, et al. Gastro 2013 APDW/WCOG Shanghai Working Party Report: Chronic diarrhea: Definition, classification, diagnosis. J Gastroenterol Hepatol . 2013; 29 (1): p.6-25. doi: 10.1111/jgh.12392 . \| Open in Read by QxMD Dellon ES, Ringel Y. Treatment of functional diarrhea. Curr Treat Options Gastroenterol . 2006; 9 (4): p.331-342. doi: 10.1007/s11938-006-0015-6 . \| Open in Read by QxMD Travelers' Diarrhea. https://web.archive.org/web/20240929175416/https://wwwnc.cdc.gov/travel/yellowbook/2024/preparing/travelers-diarrhea . Updated: November 22, 2019. Accessed: September 29, 2024. Giddings SL, Stevens AM, Leung DT. Traveler’s Diarrhea. Med Clin North Am . 2016; 100 (2): p.317-330. doi: 10.1016/j.mcna.2015.08.017 . \| Open in Read by QxMD Herbert L. DuPont, Charles D. Ericsson, P. C. Johnson, F. Javier de la Cabada. Use of Bismuth Subsalicylate for the Prevention of Travelers' Diarrhea. Clinical Infectious Diseases . 1990; 12 (Supplement_1): p.S64-S67. doi: 10.1093/clinids/12.supplement_1.s64 . \| Open in Read by QxMD Freeman HJ. “Melanosis” in the small and large intestine. World J Gastroenterol . 2008; 14 (27): p.4296. doi: 10.3748/wjg.14.4296 . \| Open in Read by QxMD Walters JR, Pattni SS. Managing bile acid diarrhoea.. Therap Adv Gastroenterol. . 2010; 3 (6): p.349-57. doi: 10.1177/1756283X10377126 . \| Open in Read by QxMD Farrugia A, Arasaradnam R. Bile acid diarrhoea: pathophysiology, diagnosis and management. Frontline Gastroenterology . 2020; 12 (6): p.500-507. doi: 10.1136/flgastro-2020-101436 . \| Open in Read by QxMD Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. https://web.archive.org/web/20260126024001/https://clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/adult-adolescent-oi/guidelines-adult-adolescent-oi.pdf . Updated: July 14, 2025. Accessed: January 25, 2026. Kasper DL, Fauci AS, Hauser SL, et al. Harrison's Principles of Internal Medicine . McGraw-Hill Education ; 2015 Walker HK, Hall WD, Hurst WJ, Silverman ME, Morrison G. Clinical Methods: The History, Physical, and Laboratory Examinations . Butterworths ; 1990 Saad RJ, Chey WD. Breath Testing for Small Intestinal Bacterial Overgrowth: Maximizing Test Accuracy. Clin Gastroenterol Hepatol . 2014; 12 (12): p.1964-1972. doi: 10.1016/j.cgh.2013.09.055 . \| Open in Read by QxMD
Markdown	[![ambossIcon](https://manus-media.amboss.com/2020/07/amboss-icon.svg)![ambossIcon](https://knowledge.manus.amboss.com//_next/static/media/ambossMobileLogo.f21d813f.svg)](https://www.amboss.com/) Expand all sections [Start free trial](https://next.amboss.com/us/registration?nextLink=%2Farticle%2F6M0jpg)[Log in](https://next.amboss.com/us/login?nextLink=%2Farticle%2F6M0jpg) # Diarrhea Last updated: February 27, 2026 ## Quick guide![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg) ## Diagnostic approach - [Inflammatory diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z321586a3cfe84e9365a55d0ed20fb62a) or noninflammatory diarrhea that is not [self-limited]() : stool [GI pathogen panel]() ( [PCR](https://www.amboss.com/us/knowledge/Laboratory_methods#Z3a8f5e31aa62111944442fd86660cc27) ) or culture - Severe illness with [fever](https://www.amboss.com/us/knowledge/Fever#Za5de83449ff6a749e6c1348b93b1f3b1) : [CBC](https://www.amboss.com/us/knowledge/Laboratory_medicine#Z4ccf935251884533761ac0c529e17a64) , [CMP](https://www.amboss.com/us/knowledge/Laboratory_medicine#Z7213a5e3683814d58d65a66c5bc3ebc8) , [ESR](https://www.amboss.com/us/knowledge/Laboratory_medicine#Zde306dd72fd9fa8f94347d3f2edafc20) , [CRP](https://www.amboss.com/us/knowledge/Laboratory_medicine#Z51ad1e101a45a8de708a6dda0321755d) , [blood cultures](https://www.amboss.com/us/knowledge/Blood_cultures#Zbbc1ac48182c8850d109967ff3d2e390) - [Risk factors for C. difficile infection](https://www.amboss.com/us/knowledge/Clostridioides_difficile_infection#Zcec32f67ae45a4b1cf8f0cc5aebd5531): [C. difficile](https://www.amboss.com/us/knowledge/Bacteria_overview#Z429d21670093a08ffb061528b0561719) [PCR](https://www.amboss.com/us/knowledge/Laboratory_methods#Z3a8f5e31aa62111944442fd86660cc27) or [EIA]() Diagnostic testing is not indicated for most cases of [acute diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z9902a484faaf54b4fa1ffaf3a5642113) . ## Management checklist - Mild to [moderate dehydration](https://www.amboss.com/us/knowledge/Dehydration_and_hypovolemia#Z3e5c63fd98cfbd4f25d0b664d4f03f46): [oral rehydration therapy](https://www.amboss.com/us/knowledge/Dehydration_and_hypovolemia#Zbadf5641ef1ee8851ce3026721b8d40a) - [Severe dehydration](https://www.amboss.com/us/knowledge/Dehydration_and_hypovolemia#Zeba0372b757bc3e729c979470fccb192): [IV fluid resuscitation](https://www.amboss.com/us/knowledge/Shock#Zee3c52d5a0e0844921b94c537f7d8ba3) - [Antidiarrheal agents](https://www.amboss.com/us/knowledge/Diarrhea#Zc9c4c39a6ce3413ed32214ba89c1e777) (as needed): [bismuth](https://www.amboss.com/us/knowledge/Helicobacter_pylori_infection#Z5ff316bf4e8912c06dc600df2a9e8b09) (safe for all patients), [loperamide](https://www.amboss.com/us/knowledge/Opioids#Z1881077ac71cd771cb44b7db04569ac0) (for patients with noninflammatory diarrhea) - [Supportive therapy for gastroenteritis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z4af26ac012a1ba5baaeb3984fc722116) - [Empiric antibiotics for bacterial gastroenteritis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z8bc7c574b3a32ce97b6e98deca3d7a27) as indicated - Suspected [C. difficile infection](https://www.amboss.com/us/knowledge/Clostridioides_difficile_infection#Zb508f99ee028a9d8582608f40bc36f5f) : [antibiotic therapy for CDI](https://www.amboss.com/us/knowledge/Clostridioides_difficile_infection#Z43f44aea11b5aaeae031f90cc2c21617) - [Traveler's diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Zed77ffe538dae231e40fe0542e7b245a) : [ciprofloxacin](https://www.amboss.com/us/knowledge/Overview_of_antibiotic_therapy#Z3f1dbc417664139dda097bcd516ceeed) ( [off label](https://www.amboss.com/us/knowledge/Fundamentals_of_pharmacology#Zb37ab5e3f79a4ddd6b356eb84fa0067a) ) (most destinations) OR [azithromycin](https://www.amboss.com/us/knowledge/Overview_of_antibiotic_therapy#Z9884c173cd8bcd36d44eb85ea8acfec2) ( [off label](https://www.amboss.com/us/knowledge/Fundamentals_of_pharmacology#Zb37ab5e3f79a4ddd6b356eb84fa0067a) ) (travelers to South or Southeast Asia) ## [Red flag features]() - [Fever](https://www.amboss.com/us/knowledge/Fever#Za5de83449ff6a749e6c1348b93b1f3b1) - [Hypotension](https://www.amboss.com/us/knowledge/Cardiovascular_examination#Zb5022b8fa3fa419ab039a0f8d70866a2) - [Severe dehydration](https://www.amboss.com/us/knowledge/Dehydration_and_hypovolemia#Zeba0372b757bc3e729c979470fccb192) - Bloody stools - Severe abdominal [pain](https://www.amboss.com/us/knowledge/Principles_of_pain_management#Zd673a3f7ee36023aab5a267899e984cc) - Chronic illness - [Immunocompromise](https://www.amboss.com/us/knowledge/Adaptive_immune_system#Z1af19ecc772907dd339670b5fb0e8b51) - Age \> 65 years - Recent [antibiotic](https://www.amboss.com/us/knowledge/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3) use - \> 48 hours duration without improvement ## Life-threatening causes - [Hemolytic uremic syndrome](https://www.amboss.com/us/knowledge/Hemolytic_uremic_syndrome#Z759bb631d23a3535c2b55dfd91c4807b) - [Gas gangrene](https://www.amboss.com/us/knowledge/Gas_gangrene#Zc843bd9262a7db4767485d787d9c2653) - [Shigellosis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Zd4a3455e8ec3d03f2e705d784ba584b0) - [Cholera](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Zba6a00519c1b345599491aa93180aacf) - [Ischemic colitis](https://www.amboss.com/us/knowledge/Intestinal_ischemia#Za5a3e828cf2d10df3a9693a9fc3b2c34) ## Summary![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg) Diarrhea, defined as three or more loose stools per day or more frequent stool passage than is normal for the individual, is a common disease with a monthly [prevalence](https://www.amboss.com/us/knowledge/Population_health#Z44a0fb80a8923b6e2fb8ff1f83d5803a) of around 5% in the United States. [Acute diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z9902a484faaf54b4fa1ffaf3a5642113) lasts 14 days or less and is almost always caused by an infectious agent, typically a [virus](https://www.amboss.com/us/knowledge/General_virology#Zcdc83877f75d9d9b9a07ece6544f646c). Testing is seldom required, as the disease tends to be [self-limited]() and care is primarily supportive. [Persistent diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Zd56cfaa165f80b20fe15e54d5f2c0023), lasting 15–30 days, is also typically caused by an infectious agent, but stool testing for pathogens is generally warranted to confirm the diagnosis. [Chronic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a), defined as diarrhea lasting longer than 30 days, has an extensive differential diagnosis. A thorough history followed by systematic stool and blood testing is required to identify the specific etiology. The presence of any [red flags]() for severe or rapidly progressing diarrheal disease (e.g., [sepsis](https://www.amboss.com/us/knowledge/Sepsis#Zb3de189fac0d57eac5b7798e127a5e19), extreme [dehydration](https://www.amboss.com/us/knowledge/Dehydration_and_hypovolemia#Zbd78324053c153c16ea5cb2574249398), blood in the stool) mandates escalation of testing and, in some cases, [empiric antibiotics for bacterial gastroenteritis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z8bc7c574b3a32ce97b6e98deca3d7a27). Ensuring adequate oral hydration, correcting [dehydration](https://www.amboss.com/us/knowledge/Dehydration_and_hypovolemia#Zbd78324053c153c16ea5cb2574249398), and providing symptomatic relief are fundamental components in the care of all patients with diarrhea. Curative treatment is directed toward the underlying cause. ## Definitions![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg) The WHO defines diarrhea as ≥ 3 loose or watery stools per day or more frequent passage than is normal for the individual. \[1\]\[2\] ## Etiology![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg) For etiologies of acute, persistent, or [chronic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a), see specific subsections below. ## [Overview of pathogens causing watery and bloody diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z8e48114f95d466b966813a8876de0264) \| Overview \| \| \| \| \| \|---\|---\|---\|---\|---\| \| Type of diarrhea \| [Pathogen]() \| [Pathogen]() characteristics \| Associated disorders \| \| \| [Watery diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z16ed63f1f94f558cfbffed53ce14a7fb) \| Enterotoxigenic [Escherichia coli](https://www.amboss.com/us/knowledge/Bacteria_overview#Z2018b58c3c7835457287264e40fa1a3c) \| [Heat-labile toxin](https://www.amboss.com/us/knowledge/Diarrheagenic_E._coli#Zb07ccb32bbf8bafda07228b738b272b0) [Heat-stable toxin](https://www.amboss.com/us/knowledge/Diarrheagenic_E._coli#Z05a3bf9bd37c476e311abbdb16510192) \| [Traveler's diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Zed77ffe538dae231e40fe0542e7b245a) \| \| \| [Clostridioides difficile](https://www.amboss.com/us/knowledge/Bacteria_overview#Z429d21670093a08ffb061528b0561719) \| [Toxin A](https://www.amboss.com/us/knowledge/Clostridioides_difficile_infection#Z953ec09a4d6afc7094cd488f8493999f) ([enterotoxin]()) [Toxin B](https://www.amboss.com/us/knowledge/Clostridioides_difficile_infection#Za0f3dac89ddbb94c6ce33441f7ca29d0) (cytotoxin) Associated with [antibiotic](https://www.amboss.com/us/knowledge/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3) and [PPI](https://www.amboss.com/us/knowledge/Proton_pump_inhibitors#Z2753e50142e2f5b7089b165accdcc900) use \| [Pseudomembranous colitis](https://www.amboss.com/us/knowledge/Clostridioides_difficile_infection#Z9a45a83f4126940236032056da651cf6) Rarely causes bloody diarrhea \| \| \| \| [Clostridium perfringens](https://www.amboss.com/us/knowledge/Bacteria_overview#Z927388b963f796f8c6f170841d77b930) \| [Heat-labile enterotoxin](https://www.amboss.com/us/knowledge/Diarrheagenic_E._coli#Zb07ccb32bbf8bafda07228b738b272b0) [Clostridium perfringens alpha toxin](https://www.amboss.com/us/knowledge/Gas_gangrene#Z29badee7cb2803331016ab554584eccc) \| [Gas gangrene](https://www.amboss.com/us/knowledge/Gas_gangrene#Zc843bd9262a7db4767485d787d9c2653) \| \| \| \| [Vibrio cholerae](https://www.amboss.com/us/knowledge/Bacteria_overview#Z5040d5b8f384d034307ec998d5706c4a) \| Straight or curved (comma-shaped) [Cholera toxin](https://www.amboss.com/us/knowledge/General_bacteriology#Z463b688997a9f1dd2f1a2f94cbafd0f9) ([enterotoxin]()): “rice water” diarrhea Transmission via contaminated water or uncooked seafood (e.g., raw shellfish) \| [Cholera](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Zba6a00519c1b345599491aa93180aacf) \| \| \| \| [Viruses](https://www.amboss.com/us/knowledge/General_virology#Zcdc83877f75d9d9b9a07ece6544f646c) \| [Norovirus](https://www.amboss.com/us/knowledge/General_virology#Z85b05d149dafb61d67a5c48e9a2fdb65) (most common cause) \| Fecal-oral or [airborne transmission]() \| [Gastroenteritis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Zcbd93ce063d015f699fd07ed09015b7f) \| \| \| [Rotavirus](https://www.amboss.com/us/knowledge/General_virology#Z0b6c006e84714af76f7c43bebbeb2315) \| [Fecal-oral transmission]() Prevention: attenuated [vaccine](https://www.amboss.com/us/knowledge/Vaccination#Zce79039ee0c9c756b2e006d3be169afc) for children \| \| \| \| \| [Adenovirus](https://www.amboss.com/us/knowledge/General_virology#Z5251a57602a66d951ca7a8a66643ee51) \| Transmission via contaminated water or [fecal-oral route]() \| \| \| \| \| [Protozoa](https://www.amboss.com/us/knowledge/General_parasitology#Z8f4f3567860a31947bee8edff7ea6bd5) \| [Giardia lamblia](https://www.amboss.com/us/knowledge/Giardiasis#Zc37e227ee434dce8d190d098017db709) \| Transmission via ingestion of contaminated water (e.g., lakes, rivers, ponds, swimming pools) Most commonly affects hikers or campers \| [Giardiasis](https://www.amboss.com/us/knowledge/Giardiasis#Z7285e874bce9a0f39983534a6c838736) \| \| \| [Cryptosporidia](https://www.amboss.com/us/knowledge/Food_poisoning#Z2838c305630a575a1e345dd9004ef9ea) \| [Fecal-oral transmission]() ([oocysts]() are typically excreted in stool and contaminate drinking water) \| [Cryptosporidiosis](https://www.amboss.com/us/knowledge/HIV-associated_conditions#Z50d6fcd479428e63a00b9454e02cad44) [Immunocompromised individuals](https://www.amboss.com/us/knowledge/Adaptive_immune_system#Z1af19ecc772907dd339670b5fb0e8b51): potentially life-threatening protracted diarrhea and/or [biliary tract](https://www.amboss.com/us/knowledge/Gallbladder_and_bile#Zadee0fdc5649284d46b022246819e246) infections (e.g., [cholangitis](https://www.amboss.com/us/knowledge/Acute_cholangitis#Z9f187436aa934749f4437c12be5f3f0d), [cholecystitis](https://www.amboss.com/us/knowledge/Acute_cholecystitis#Z08db08956e4ea1aca8e4c7e965b533f7)) \| \| \| \| [Cystoisospora belli](https://www.amboss.com/us/knowledge/General_parasitology#Za983f2c51a6b8452adfa91552fb181e2) \[3\] \| Foodborne Contaminated water \| [Cystoisosporiasis](https://www.amboss.com/us/knowledge/HIV-associated_conditions#Z1e782fdfd6ae6a71daf64a4e1644b0a9) [Immunocompromised individuals](https://www.amboss.com/us/knowledge/Adaptive_immune_system#Z1af19ecc772907dd339670b5fb0e8b51): chronic profuse diarrhea, [acalculous cholecystitis](https://www.amboss.com/us/knowledge/Acute_cholecystitis#Z9df8abcc0e36c38f478f48e212ad298f), [AIDS cholangiopathy](https://www.amboss.com/us/knowledge/HIV-associated_conditions#Z1c0318dbf51f5c7bf9c39ff805ed97cc) \| \| \| \| Bloody diarrhea \| [E.coli](https://www.amboss.com/us/knowledge/Bacteria_overview#Z2018b58c3c7835457287264e40fa1a3c) \| Enteroinvasive [E. coli](https://www.amboss.com/us/knowledge/Bacteria_overview#Z2018b58c3c7835457287264e40fa1a3c) \| Direct invasion of the intestinal [epithelium](https://www.amboss.com/us/knowledge/General_histology#Z23c08800c35f1f71236b85bd916db48b) and formation of [enterotoxins]() \| [Gastroenteritis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Zcbd93ce063d015f699fd07ed09015b7f) \| \| Enterohemorrhagic [E. coli](https://www.amboss.com/us/knowledge/Bacteria_overview#Z2018b58c3c7835457287264e40fa1a3c) \| [Shiga toxin](https://www.amboss.com/us/knowledge/General_bacteriology#Zfa20332b82d5b9c5a7b6dca8046aa7bd) Most common [serotype](): ([O157:H7](https://www.amboss.com/us/knowledge/Hemolytic_uremic_syndrome#Zd789cca34b9c96af9a9c7abd264b2c7b)) \| [Hemolytic uremic syndrome](https://www.amboss.com/us/knowledge/Hemolytic_uremic_syndrome#Z759bb631d23a3535c2b55dfd91c4807b) \| \| \| \| [Campylobacter jejuni](https://www.amboss.com/us/knowledge/Bacteria_overview#Z4a3deabcd49cf50e8c48e5f0d5dcc506) \| Curved or spiral‑shaped with polar [flagellum](https://www.amboss.com/us/knowledge/General_bacteriology#Z7c98d422c4fed8c895c3dc3e0552a936) Grows best at 37–42°C \| [Campylobacter enteritis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z9273c5a7cf1820c124f8fe4d5648df30) (especially in children) Commonly precedes [reactive arthritis](https://www.amboss.com/us/knowledge/Reactive_arthritis#Z004554eda6fc600767f0d5dbaca1925d) and Guillain‑Barré syndrome \| \| \| \| Nontyphoidal [Salmonella](https://www.amboss.com/us/knowledge/Bacteria_overview#Zcf62cfeb3796c44845f303785e4bb88c) \| No [lactose](https://www.amboss.com/us/knowledge/Carbohydrates#Z42d58e097395e9a8d8ade84fd063faf8) fermentation Flagellar motility Hosts: humans, animals, and animal products (e.g., reptiles, poultry, pets, eggs) \| [Salmonellosis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z2681adc9ab180885765f48f6f730b912) \| \| \| \| [Shigella](https://www.amboss.com/us/knowledge/Bacteria_overview#Z40dc9a1dcc2df2a82a0c4586e5023158) \| Slow/absent [lactose](https://www.amboss.com/us/knowledge/Carbohydrates#Z42d58e097395e9a8d8ade84fd063faf8) fermentation [Shiga toxin](https://www.amboss.com/us/knowledge/General_bacteriology#Zfa20332b82d5b9c5a7b6dca8046aa7bd) Low infectious dose required (low ID50) Humans are the only host. \| [Bacillary dysentery](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Zd4a3455e8ec3d03f2e705d784ba584b0) \| \| \| \| [Yersinia enterocolitica](https://www.amboss.com/us/knowledge/Bacteria_overview#Zc40fd992d4c98f7805725c8ed0f57d89) \| Reservoir: contaminated pork and milk products \| [Yersiniosis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z6c552143f411315b80f346c0c8707af5) ([outbreaks]() often occur in day-care settings) May manifest as [pseudoappendicitis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Zf1754d56a2add64869210dbfd4f92e81) [Reactive arthritis](https://www.amboss.com/us/knowledge/Reactive_arthritis#Z004554eda6fc600767f0d5dbaca1925d) \| \| \| \| [Protozoa](https://www.amboss.com/us/knowledge/General_parasitology#Z8f4f3567860a31947bee8edff7ea6bd5): [Entamoeba histolytica](https://www.amboss.com/us/knowledge/Amebiasis#Z4001b357f1b712e83d6027a4dfa5731b) \| [Fecal-oral transmission]() Amebic cysts are excreted in stool and can contaminate drinking water or food. \| [Amebic dysentery](https://www.amboss.com/us/knowledge/Amebiasis#Z9c6cd303635910835de37919e22415b9) [Amebic liver abscess](https://www.amboss.com/us/knowledge/Amebiasis#Z8ac81fd9234b63200c6b963a90cf89b2) \| \| \| 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### Infectious causes \[4\]\[5\] \| \| Conditions \| \| \|---\|---\|---\| \| Viral \| [Norovirus infection](https://www.amboss.com/us/knowledge/Norovirus_infection#Z2bf1564153a0ab14e52c587da9c8a8c3) [Rotavirus infection](https://www.amboss.com/us/knowledge/Rotavirus_infection#Zb2e7858cefe0481ba26809cf4d9b84ec) [Adenovirus](https://www.amboss.com/us/knowledge/General_virology#Z5251a57602a66d951ca7a8a66643ee51) infection (mainly [serotype]() 3, 40, and 41) \[6\] [Cytomegalovirus infection](https://www.amboss.com/us/knowledge/Cytomegalovirus_infection#Za3ec0dd921d428ed745a6ec39879cf55) \| \| \| Bacterial \| [Campylobacter enteritis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z9273c5a7cf1820c124f8fe4d5648df30) [Shigellosis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Zd4a3455e8ec3d03f2e705d784ba584b0) [Salmonellosis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z2681adc9ab180885765f48f6f730b912) [Cholera](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Zba6a00519c1b345599491aa93180aacf) [Diarrheagenic E. coli](https://www.amboss.com/us/knowledge/Diarrheagenic_E._coli#Z815e7a84a36e420726cf0f61cc8adecb) infection ([travelers' diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Zed77ffe538dae231e40fe0542e7b245a)) [Yersiniosis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z6c552143f411315b80f346c0c8707af5) (especially in day care centers) [Clostridioides difficile](https://www.amboss.com/us/knowledge/Bacteria_overview#Z429d21670093a08ffb061528b0561719) infection ([antibiotic](https://www.amboss.com/us/knowledge/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3)\-associated diarrhea) [Typhoid fever](https://www.amboss.com/us/knowledge/Typhoid_and_paratyphoid_fever#Z1ee997715fd7396129b4d9a3ed02fe95) [Mycobacterium](https://www.amboss.com/us/knowledge/Bacteria_overview#Z4a9b83c1d67197ddc3d9a490e25786e1) [avium-intracellulare](https://www.amboss.com/us/knowledge/Bacteria_overview#Zded29315a7549c1929e9d93cedf7dadf) [Tropheryma whipplei]() (i.e., [Whipple disease](https://www.amboss.com/us/knowledge/Whipple_disease#Z83c04868f8c75273c89d8c6e966623e4)) [Legionella]() infection \| \| \| Parasitic \| [Protozoan](https://www.amboss.com/us/knowledge/General_parasitology#Z8f4f3567860a31947bee8edff7ea6bd5) \| [Giardiasis](https://www.amboss.com/us/knowledge/Giardiasis#Z7285e874bce9a0f39983534a6c838736) [Amebiasis](https://www.amboss.com/us/knowledge/Amebiasis#Z4500356668f80dc7e2e4d3b731ae9d1f) [Cryptosporidiosis](https://www.amboss.com/us/knowledge/HIV-associated_conditions#Z50d6fcd479428e63a00b9454e02cad44) [Cystoisosporiasis](https://www.amboss.com/us/knowledge/HIV-associated_conditions#Z1e782fdfd6ae6a71daf64a4e1644b0a9) \| \| [Helminth infections](https://www.amboss.com/us/knowledge/Helminth_infections#Ze09d3cf63ef1a16aa7f42af8f475cdb4) \| [Toxocariasis](https://www.amboss.com/us/knowledge/Helminth_infections#Zaf51d242a662ad2b921e57ce9d1c4771) [Enterobiasis](https://www.amboss.com/us/knowledge/Helminth_infections#Z626348337721606624cdbdbddc89d761) [Ascariasis](https://www.amboss.com/us/knowledge/Helminth_infections#Z3bdf0551665f902bb7f7437f1345d942) [Trichinosis](https://www.amboss.com/us/knowledge/Helminth_infections#Z243c73c82e8ca80fdc4b642de846d545) [Taenia infections](https://www.amboss.com/us/knowledge/Helminth_infections#Za9ad8a6dab1ea0231507c2575b7beaad) ([taeniasis](https://www.amboss.com/us/knowledge/Helminth_infections#Z3f0c9aad18cbe66acdd552e41e47c05c)) [Hookworm infection](https://www.amboss.com/us/knowledge/Helminth_infections#Z1179ff83d232cf99bd01e86f8e2433fa) [Diphyllobothriasis](https://www.amboss.com/us/knowledge/Helminth_infections#Z0c51a37492e70b72b9c73aed0be65260) [Intestinal capillariasis](https://www.amboss.com/us/knowledge/Helminth_infections#Z5dc93e2865dfbf1ff6ab72d0b15a5d08) \| \| ## Noninfectious \[7\]\[8\]\[9\] \| \| Conditions \| \|---\|---\| \| Foodborne toxins \| [S. aureus](https://www.amboss.com/us/knowledge/Staphylococcal_diseases#Zaf074edfb4940be0ed1d4fcfc4ea0dee) intoxication [Botulism](https://www.amboss.com/us/knowledge/Botulism#Za2a9894ca446f0fe0aac693516c52c4d) [Bacillus cereus](https://www.amboss.com/us/knowledge/Food_poisoning#Z6843256bc452c182cae6e8c9c5cbe589) infection [Tetrodotoxin](https://www.amboss.com/us/knowledge/Food_poisoning#Zd578525a352862bd6098cbff0e02482f), [ciguatoxin]() \| \| [Food poisoning](https://www.amboss.com/us/knowledge/Food_poisoning#Z5a858064f0cd40e4546f181bf46734f2) \| [Aflatoxin](https://www.amboss.com/us/knowledge/General_mycology#Z91b3abebde0a7a99c3942b9bd3060cc2) [Histamine](https://www.amboss.com/us/knowledge/Hypersensitivity_reactions#Zae1b7b5f59d06769c8445ee3e4389b73) toxicity \[7\] Chemical contaminants (e.g., lead, [cadmium](https://www.amboss.com/us/knowledge/Metal_poisoning#Z04ffe297e862ba3e4a25b62b6a06105e), insecticides, [arsenic](https://www.amboss.com/us/knowledge/Metal_poisoning#Zf2f349b64906a39b338222ac30067f86)) \[8\] [Mushroom poisoning](https://www.amboss.com/us/knowledge/Poisoning#Ze39c09d250439022bca488e44824b3d5) \[9\] \| \| Gastrointestinal \| [Malnutrition](https://www.amboss.com/us/knowledge/Acute_primary_malnutrition_in_children#Zda3f71521662770b01113749ba7d264b): [vitamin deficiency](https://www.amboss.com/us/knowledge/Vitamins#Zca3fa352d946554fdd5b7c076e0c9cb0) (e.g., [pellagra](https://www.amboss.com/us/knowledge/Vitamins#Zb703ea9bd25901f12978608f57990f1a)) \| \| [Malabsorption](https://www.amboss.com/us/knowledge/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb) or [maldigestion](https://www.amboss.com/us/knowledge/Malabsorption#Z325814c45b1a9856fa3d65839f7681f5) [Celiac disease](https://www.amboss.com/us/knowledge/Celiac_disease#Z1999c64abb6e85ce70f8cdc66810a65b) [Lactose intolerance](https://www.amboss.com/us/knowledge/Lactose_intolerance#Z8597682de9e4e8655c2f5df7319b32f3) [Exocrine pancreatic insufficiency](https://www.amboss.com/us/knowledge/Malabsorption#Z4880cedb9eb57d620afb59b2c9e39a8b) (e.g., due to [chronic pancreatitis](https://www.amboss.com/us/knowledge/Chronic_pancreatitis#Z1e14e388e4042dc43defefb9f88695e1)) [Diabetic autonomic neuropathy](https://www.amboss.com/us/knowledge/Diabetic_neuropathy#Z5f4a07d5cb1ff81fcc5c7c2bfb24806f) [Bile acid diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z0f6aa3c63b0331881c8804e04e01ca5c) (e.g., due to [ileal](https://www.amboss.com/us/knowledge/Small_intestine#Zf3a10de88f22b839a2769aa9ae031960) resection, [biliary-enteric fistula](https://www.amboss.com/us/knowledge/Fistulas#Z1787c9a9b3b830805f4bf55265169989), [cholestasis](https://www.amboss.com/us/knowledge/Jaundice_and_cholestasis#Z3811ba77a88bcd2cc789df34c5379055), [postcholecystectomy diarrhea](https://www.amboss.com/us/knowledge/Cholecystectomy#Z6f71e303d7401f08b7ba2e85ef912a69)) [Amyloidosis](https://www.amboss.com/us/knowledge/Amyloidosis#Zdf99d1ab14839f4c6288ceaf8447ef25) of the [gastrointestinal tract](https://www.amboss.com/us/knowledge/Gastrointestinal_tract#Zf0833058b7152af8b5653b79f76fb153) \| \| \| [Colitis](https://www.amboss.com/us/knowledge/Large_intestine#Z579996fe3b9825568e212d9393d5d9a2) [Inflammatory bowel disease](https://www.amboss.com/us/knowledge/Crohn_disease#Z4272f924349255b3e4babe86d4e939c9) [Crohn disease](https://www.amboss.com/us/knowledge/Crohn_disease#Zef70853af5e87c95d210bf8df682f64c) [Ulcerative colitis](https://www.amboss.com/us/knowledge/Ulcerative_colitis#Zbb0aec0a5fe14ad0aae10a9341c457fc) [Irritable bowel syndrome](https://www.amboss.com/us/knowledge/Irritable_bowel_syndrome#Z2b30a84dc4106c4e8aad1e6c9202f3ea) [Microscopic colitis](https://www.amboss.com/us/knowledge/Microscopic_colitis#Z98c8e90c538959e074e80c55a532e1bc) [Ischemic colitis](https://www.amboss.com/us/knowledge/Intestinal_ischemia#Za5a3e828cf2d10df3a9693a9fc3b2c34) [Radiation colitis](https://www.amboss.com/us/knowledge/Radiation_injury#Ze0a9ed89b6c1c4ea08173fa19b2b74f9) \| \| \| [Tumor](https://www.amboss.com/us/knowledge/General_oncology#Z333a818dbf71a509f924e54006a41fb6)/stenotic processes: [paradoxical diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z03319666a4dfb1ca98ba5a66ae368c65) (involuntary seepage of liquid feces in patients with chronic [constipation](https://www.amboss.com/us/knowledge/Constipation#Z65fd66f9cecf14d85a69e656c3a69417) ) \| \| ## Classification![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg) Diarrhea is often classified as watery, fatty, and/or inflammatory to facilitate diagnosis and management. This classification scheme is most relevant for the approach to [chronic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a). \| Classification of diarrhea by functional pathology \[10\]\[11\]\[12\] \| \| \| \| \|---\|---\|---\|---\| \| \| Pathophysiology \| Associated disorders \| \| \| Inflammatory diarrhea \| Damage to the intestinal [mucosa]() may cause [cytokine](https://www.amboss.com/us/knowledge/Cytokines_and_eicosanoids#Z1a9b57a2010f274f4a0f49e6010d30cf)\-induced water hypersecretion, impair absorption of osmotically active substances or fat, and/or disrupt water and [electrolyte](https://www.amboss.com/us/knowledge/Laboratory_medicine#Z562f1491861b33bdb5af572388e99541) absorption. Mucus, blood, and [leukocytes](https://www.amboss.com/us/knowledge/Basics_of_hematology#Z18a02873023ccef6d8ea2b461e0b7446) present in the stool. \| [Ulcerative colitis](https://www.amboss.com/us/knowledge/Ulcerative_colitis#Zbb0aec0a5fe14ad0aae10a9341c457fc), [Crohn disease](https://www.amboss.com/us/knowledge/Crohn_disease#Zef70853af5e87c95d210bf8df682f64c) [Colorectal cancer](https://www.amboss.com/us/knowledge/Colorectal_cancer#Z5f9a21e2819d2a5004da275e0fe8e909) Infections [Shigellosis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Zd4a3455e8ec3d03f2e705d784ba584b0) ([bacillary dysentery](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Zd4a3455e8ec3d03f2e705d784ba584b0)) Nontyphoidal: [salmonellosis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z2681adc9ab180885765f48f6f730b912) [Enteroinvasive Escherichia coli](https://www.amboss.com/us/knowledge/Diarrheagenic_E._coli#Z12cd4e274bbe847f6b9e96d592684c87), [enterohemorrhagic E. coli](https://www.amboss.com/us/knowledge/Diarrheagenic_E._coli#Z44cb042afe41a43945e6b3c55e424917) ([O157:H7](https://www.amboss.com/us/knowledge/Hemolytic_uremic_syndrome#Zd789cca34b9c96af9a9c7abd264b2c7b)) [Campylobacteriosis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z9273c5a7cf1820c124f8fe4d5648df30) [Yersiniosis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z6c552143f411315b80f346c0c8707af5) [Amebiasis](https://www.amboss.com/us/knowledge/Amebiasis#Z4500356668f80dc7e2e4d3b731ae9d1f) ([amebic dysentery](https://www.amboss.com/us/knowledge/Amebiasis#Z9c6cd303635910835de37919e22415b9) caused by [Entamoeba histolytica](https://www.amboss.com/us/knowledge/Amebiasis#Z4001b357f1b712e83d6027a4dfa5731b)) [Clostridioides difficile](https://www.amboss.com/us/knowledge/Bacteria_overview#Z429d21670093a08ffb061528b0561719) (rarely bloody) \| \| \| Fatty diarrhea \| [Malabsorption](https://www.amboss.com/us/knowledge/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb) \| Alterations of the intestinal [mucosa]() → impaired absorption of digested food \| [Malabsorption](https://www.amboss.com/us/knowledge/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb) disorders or history of [ileal](https://www.amboss.com/us/knowledge/Small_intestine#Zf3a10de88f22b839a2769aa9ae031960) resection Infections [Giardiasis](https://www.amboss.com/us/knowledge/Giardiasis#Z7285e874bce9a0f39983534a6c838736) [Small intestinal bacterial overgrowth](https://www.amboss.com/us/knowledge/Small_intestinal_bacterial_overgrowth#Z9aa32f677362a235a8ae39e011711f1b) ([SIBO](https://www.amboss.com/us/knowledge/Small_intestinal_bacterial_overgrowth#Z9aa32f677362a235a8ae39e011711f1b)) [Tropical sprue](https://www.amboss.com/us/knowledge/Tropical_sprue#Z98af9796a545c9279ebf232edfbe9a0f) [Whipple disease](https://www.amboss.com/us/knowledge/Whipple_disease#Z83c04868f8c75273c89d8c6e966623e4) [Amyloidosis](https://www.amboss.com/us/knowledge/Amyloidosis#Zdf99d1ab14839f4c6288ceaf8447ef25) \| \| [Maldigestion](https://www.amboss.com/us/knowledge/Malabsorption#Z325814c45b1a9856fa3d65839f7681f5) \| Lack of digestive enzymes → impaired breakdown of food in the intestinal lumen → [malabsorption](https://www.amboss.com/us/knowledge/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb) of [carbohydrates](https://www.amboss.com/us/knowledge/Carbohydrates#Z9749463e67a1dd52c34fed592810f23d), [proteins](https://www.amboss.com/us/knowledge/Proteins_and_peptides#Z6dee07cab92e13d1f6baa3a3ce402f23), fats, [fat-soluble vitamins](https://www.amboss.com/us/knowledge/Vitamins#Zcfe26218c03945e1fad98ef8c9095aa2) (A, D, E, K), and [vitamin B12](https://www.amboss.com/us/knowledge/Vitamins#Z938e3f87e91ee8469e94c3ace50e692d) \| [Exocrine pancreatic insufficiency](https://www.amboss.com/us/knowledge/Malabsorption#Z4880cedb9eb57d620afb59b2c9e39a8b) [Bile acid diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z0f6aa3c63b0331881c8804e04e01ca5c) \| \| \| Watery diarrhea \| Secretory diarrhea \| Active secretion of water into the intestinal lumen via inhibition or activation of enzymes (e.g., ↑ [cAMP](https://www.amboss.com/us/knowledge/Signal_transduction#Z64a7426bbad2bf440e8e5d9e67c2a51a) activity) \| Neuroendocrine disorders, e.g.: [Carcinoid syndrome](https://www.amboss.com/us/knowledge/Carcinoid_syndrome#Zd3e3a67dbd397d8bd3f339c574f42e55) [Gastrinoma](https://www.amboss.com/us/knowledge/Gastrinoma#Z33515a1b2df6a4fe21ef0162d7a1eac7) Endocrine disorders, e.g.: [Hyperthyroidism](https://www.amboss.com/us/knowledge/Hyperthyroidism_and_thyrotoxicosis#Z7efc7350132a2f2a3e4cc7763e7f07f8) [Addison disease](https://www.amboss.com/us/knowledge/Adrenal_insufficiency#Z7b47bf57fd367b1b9891e4155e39236f) [Diabetes mellitus](https://www.amboss.com/us/knowledge/Diabetes_mellitus#Z1235e572dd827cff7d31e954b3f94489) Foodborne infections [Cholera](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Zba6a00519c1b345599491aa93180aacf) (“rice water” diarrhea) [Enterotoxigenic E. coli](https://www.amboss.com/us/knowledge/Diarrheagenic_E._coli#Z458147f1e1273e554884140b40317779) ([traveler's diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Zed77ffe538dae231e40fe0542e7b245a)) [C. perfringens](https://www.amboss.com/us/knowledge/Bacteria_overview#Z927388b963f796f8c6f170841d77b930) [C. difficile](https://www.amboss.com/us/knowledge/Bacteria_overview#Z429d21670093a08ffb061528b0561719) (associated with [antibiotic](https://www.amboss.com/us/knowledge/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3) and [PPI](https://www.amboss.com/us/knowledge/Proton_pump_inhibitors#Z2753e50142e2f5b7089b165accdcc900) use) [Protozoa](https://www.amboss.com/us/knowledge/General_parasitology#Z8f4f3567860a31947bee8edff7ea6bd5): e.g., [giardiasis](https://www.amboss.com/us/knowledge/Giardiasis#Z7285e874bce9a0f39983534a6c838736), [cryptosporidiosis](https://www.amboss.com/us/knowledge/HIV-associated_conditions#Z50d6fcd479428e63a00b9454e02cad44) [Viruses](https://www.amboss.com/us/knowledge/General_virology#Zcdc83877f75d9d9b9a07ece6544f646c): e.g., [norovirus](https://www.amboss.com/us/knowledge/General_virology#Z85b05d149dafb61d67a5c48e9a2fdb65), [rotavirus](https://www.amboss.com/us/knowledge/General_virology#Z0b6c006e84714af76f7c43bebbeb2315), [adenovirus](https://www.amboss.com/us/knowledge/General_virology#Z5251a57602a66d951ca7a8a66643ee51) \| \| Osmotic diarrhea \| Poor absorption or excessive ingestion of [hydrophilic](https://www.amboss.com/us/knowledge/Fundamentals_of_pharmacology#Zb09f3ec1f97e13e2b9d5705d30995d93) substances (e.g., salts, sugars, [laxatives]()) causes water to be drawn into the intestinal lumen. \| Osmotic [laxatives](): e.g., [magnesium citrate](https://www.amboss.com/us/knowledge/Constipation#Z11bef431cda663471cbd64d3249255bf) [Carbohydrate malabsorption](https://www.amboss.com/us/knowledge/Malabsorption#Z1659a0f218ffe905f7bddb7c54efb326): e.g., [lactose intolerance](https://www.amboss.com/us/knowledge/Lactose_intolerance#Z8597682de9e4e8655c2f5df7319b32f3), [fructose intolerance](https://www.amboss.com/us/knowledge/Inborn_errors_of_carbohydrate_metabolism#Z357a9d683ee4b5a50331c5099527ef8f) (may also present as [fatty diarrhea](https://www.amboss.com/us/knowledge/Chronic_pancreatitis#Z416510d2bd6fcd19b4e328d62b6b10db)) \| \| \| Functional diarrheal disorders \[10\] \| Rapid intestinal passage due to increased bowel activity \| [Diarrhea-predominant IBS](https://www.amboss.com/us/knowledge/Irritable_bowel_syndrome#Z34fd0bc151761f2495a7470c6d9f6187) ([IBS-D](https://www.amboss.com/us/knowledge/Irritable_bowel_syndrome#Z34fd0bc151761f2495a7470c6d9f6187)) [Functional diarrhea]() \[10\]\[13\] \| \| ## Management![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg) ## Approach to diarrhea \[11\] - Detailed history and [physical examination](https://www.amboss.com/us/knowledge/Physical_examination#Z5208bc2efbfd3c982ffbeacf78ebfcb3) - Exclude [fecal incontinence](https://www.amboss.com/us/knowledge/Fecal_incontinence#Z62ff0b685d439994bb91355e521425cb) and [fecal impaction](https://www.amboss.com/us/knowledge/Constipation#Z11561139d5df6c8531690de0277d8ce5); see “[Differential diagnoses of diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z76d5f3cc56d63c0f0c5f7338674a18e5).” - Rule out [medication-induced diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Za759d71c55e5fd9dfcf2e30c0240601a) and consider [factitious diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Zbc1bd66027e74ada7dd91439bb674a26). - Classify diarrhea: - By duration of diarrheal illness: acute, persistent, or chronic - By clinical presentation: watery, fatty, inflammatory - Identify any [red flags in diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Zee4bebab517fe015dea25941aafb8133) and [risk factors](https://www.amboss.com/us/knowledge/Interpreting_medical_evidence#Zbc0d0ff153bc5c7a27589815d0c842fd) for specific causes. - Review medical and surgical history. - [Supportive care](): Start oral hydration (or [IV fluids](https://www.amboss.com/us/knowledge/Intravenous_fluid_therapy#Z0ca66c2df4b99953c5a0cb25aed87835)) and offer symptom relief. - Diagnostics: Obtain only when appropriate. - Directed therapy: Consider empiric or targeted therapy (e.g., [antibiotics](https://www.amboss.com/us/knowledge/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3)) 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](https://www.amboss.com/us/knowledge/Constipation#Z11561139d5df6c8531690de0277d8ce5), which can manifest atypically with [paradoxical diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z03319666a4dfb1ca98ba5a66ae368c65) (due to decreased rectal sensation) and nonspecific symptoms (e.g., functional decline, [delirium](https://www.amboss.com/us/knowledge/Delirium#Zfd56fee25cf9f50f32c800e64a6e652a)). \[14\] [Antibiotics](https://www.amboss.com/us/knowledge/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3) should only be utilized for specific indications. ## Clinical assessment of diarrhea \[10\]\[12\] 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](https://www.amboss.com/us/knowledge/Fever#Za5de83449ff6a749e6c1348b93b1f3b1) - Abdominal [pain](https://www.amboss.com/us/knowledge/Principles_of_pain_management#Zd673a3f7ee36023aab5a267899e984cc) and cramping - [Nausea and vomiting](https://www.amboss.com/us/knowledge/Nausea_and_vomiting#Z2f0b48ef2acaab783b03e4c8d2404f90) in cases of [gastroenteritis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Zcbd93ce063d015f699fd07ed09015b7f) - Signs of [dehydration](https://www.amboss.com/us/knowledge/Dehydration_and_hypovolemia#Zbd78324053c153c16ea5cb2574249398) - Chronic cases: [malnutrition](https://www.amboss.com/us/knowledge/Acute_primary_malnutrition_in_children#Zda3f71521662770b01113749ba7d264b) and, in children, [failure to thrive](https://www.amboss.com/us/knowledge/Growth_faltering#Zc00b4a95101cc1636c126219e267922c) - Weight loss - Defecation urgency, [tenesmus](), and/or nocturnal symptoms \| Characteristic clinical features in diarrhea according to functional pathology \| \| \| \| \|---\|---\|---\|---\| \| [Inflammatory diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z321586a3cfe84e9365a55d0ed20fb62a) \| Frequent and small volume stools Bloody or [purulent](https://www.amboss.com/us/knowledge/Skin_and_soft_tissue_infections#Zfdfb82d83e675513c49619bc646fd20c) stools Abdominal [pain](https://www.amboss.com/us/knowledge/Principles_of_pain_management#Zd673a3f7ee36023aab5a267899e984cc), [tenesmus]() May be associated with [fever](https://www.amboss.com/us/knowledge/Fever#Za5de83449ff6a749e6c1348b93b1f3b1), weight loss, fatigue \| \| \| \| [Fatty diarrhea](https://www.amboss.com/us/knowledge/Chronic_pancreatitis#Z416510d2bd6fcd19b4e328d62b6b10db) \| Greasy or oily stools Stools that are difficult to flush Decreases with [fasting]() May be associated with weight loss \| \| \| \| [Watery diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z16ed63f1f94f558cfbffed53ce14a7fb) \| [Secretory diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Za81182120613af86b266ff31432e241e) \| Loose, watery stools \| No change with [fasting]() Nocturnal diarrhea present \| \| [Functional diarrheal disorders](https://www.amboss.com/us/knowledge/Diarrhea#Z68e249c3723fb43d54724dbf2018af91) \| Decreases with [fasting]() Decreased at night \| \| \| \| [Osmotic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z7169e994f812b120ea2df94d1042192e) \| Decreases with [fasting]() Decreased at night Food triggers \| \| \| ## Risk factors for diarrhea Assess for the presence of [risk factors](https://www.amboss.com/us/knowledge/Interpreting_medical_evidence#Zbc0d0ff153bc5c7a27589815d0c842fd) for specific etiologies, including: - Recent travel : associated with [traveler's diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Zed77ffe538dae231e40fe0542e7b245a) - Occupational or recreational exposure - May be associated with an infectious [disease outbreak](https://www.amboss.com/us/knowledge/Preventive_medicine#Zb9ca40a0578ba8d7b6aca23a46b8fa85) - 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](https://www.amboss.com/us/knowledge/Hospital-acquired_infections#Z52d549c84757de6454eb2a99eb6af0b3) (e.g., [C. difficile infection](https://www.amboss.com/us/knowledge/Clostridioides_difficile_infection#Zb508f99ee028a9d8582608f40bc36f5f)) - Medication use - May cause medication-induced diarrhea - Medications commonly associated with diarrhea include: \[15\] - [Broad-spectrum antibiotics]() (especially [cephalosporins](https://www.amboss.com/us/knowledge/Overview_of_antibiotic_therapy#Z4262765e59da723c5a2c667f56a6a5e6)) - [Antacids](https://www.amboss.com/us/knowledge/Dyspepsia#Z483f046dcff29152f098e8a15dc67c9b) and [PPIs](https://www.amboss.com/us/knowledge/Proton_pump_inhibitors#Z2753e50142e2f5b7089b165accdcc900) - [NSAIDs](https://www.amboss.com/us/knowledge/Non-opioid_analgesics#Z6d53b6cfe3376a70645a5c797293e56a) - [Metformin](https://www.amboss.com/us/knowledge/Diabetes_medications#Zfbd744168d541d2a68c84d499f310cb7) - [Colchicine](https://www.amboss.com/us/knowledge/Gout_and_hyperuricemia#Za7ec01fa067126441bfca71d4f27200f) - [Cholesterol](https://www.amboss.com/us/knowledge/Lipids_and_their_metabolism#Ze08bc636c83ae44d6c771f5646271b57)\-lowering agents - [Antineoplastic drugs](https://www.amboss.com/us/knowledge/Chemotherapeutic_agents#Z4c7ae79c18cb3c2f3e1fa98185b2d78d) - [Surgery](https://www.amboss.com/us/knowledge/Surgery_clerkship#Za68e01313423572283ce418087f356cb) \[16\] - [Cholecystectomy](https://www.amboss.com/us/knowledge/Cholecystectomy#Z3486fd991ff5fe473eaf21f11207abc3) \[17\] - [Bowel resection](https://www.amboss.com/us/knowledge/Bowel_surgery#Z7595405398cd55688013c6e46b2ad835): may cause [short bowel syndrome](https://www.amboss.com/us/knowledge/Short_bowel_syndrome#Za10f503b15c657e5a54cfdd10ec96b86) \[18\] - [Vagotomy](https://www.amboss.com/us/knowledge/Peptic_ulcer_disease#Z98ec91193d90025e95eec0e8cf166269): induces rapid gastric emptying, which may disrupt the protective effect of [stomach acid](https://www.amboss.com/us/knowledge/Gastrointestinal_tract#Z2b222329949064378f320c11017a71ee) \[18\] - Gastric and/or esophageal [surgery](https://www.amboss.com/us/knowledge/Surgery_clerkship#Za68e01313423572283ce418087f356cb), e.g., [bariatric surgery](https://www.amboss.com/us/knowledge/Bowel_surgery#Z484c1fb65fa7e725740f20c975c9b284): may result in fat [malabsorption](https://www.amboss.com/us/knowledge/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb), [SIBO](https://www.amboss.com/us/knowledge/Small_intestinal_bacterial_overgrowth#Z9aa32f677362a235a8ae39e011711f1b), or [dumping syndrome](https://www.amboss.com/us/knowledge/Gastric_cancer#Zde1937c1ec3116f80e7913e779046415) - [Radiation therapy](https://www.amboss.com/us/knowledge/Radiation_therapy#Zd120147b0e92bb22668d9e60dfbdc88b): may cause secondary enterocolitis \[16\] 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. \[15\] [Chronic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a) is common after [bariatric surgery](https://www.amboss.com/us/knowledge/Bowel_surgery#Z484c1fb65fa7e725740f20c975c9b284). \[19\]\[20\] ## Red flags in diarrhea \[21\]\[22\]\[23\]\[24\] - Acute or [persistent diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Zd56cfaa165f80b20fe15e54d5f2c0023) - Symptoms of [inflammatory diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z321586a3cfe84e9365a55d0ed20fb62a) ([dysentery]()) - Systemic symptoms, e.g., [fever](https://www.amboss.com/us/knowledge/Fever#Za5de83449ff6a749e6c1348b93b1f3b1), [hypotension](https://www.amboss.com/us/knowledge/Cardiovascular_examination#Zb5022b8fa3fa419ab039a0f8d70866a2) - [Severe dehydration](https://www.amboss.com/us/knowledge/Dehydration_and_hypovolemia#Zeba0372b757bc3e729c979470fccb192) - Bloody stools - Severe abdominal [pain](https://www.amboss.com/us/knowledge/Principles_of_pain_management#Zd673a3f7ee36023aab5a267899e984cc) - Patient characteristics that suggest an increased risk of severe disease - Chronic illness or [immunocompromise](https://www.amboss.com/us/knowledge/Adaptive_immune_system#Z1af19ecc772907dd339670b5fb0e8b51) - Age \> 65 years - Recent [antibiotic](https://www.amboss.com/us/knowledge/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3) use - \> 48 hours duration without improvement - [Chronic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a) - [Hypoalbuminemia](https://www.amboss.com/us/knowledge/Protein_analysis#Zce0a143c68aec2c1a90253380ded229b) - Bloody stools - Symptoms wake the patient from [sleep](https://www.amboss.com/us/knowledge/Circadian_rhythm,_sleep,_and_induced_states_of_altered_consciousness#Z87820e6f09bd9fe77318b1db22779b43) - [Unintended weight loss](https://www.amboss.com/us/knowledge/Unexpected_weight_changes#Z94c9bf238c1d855d6f6b40427e518bea) - [Family history](https://www.amboss.com/us/knowledge/Medical_history#Z0ccd21fcf57fab20ffb12c037f4d9af3) of GI cancer - Symptom onset after 50 years of age ## Diagnostics![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg) ## General principles \[10\]\[12\]\[22\]\[25\] - [Acute diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z9902a484faaf54b4fa1ffaf3a5642113) - Testing is not required in the majority of cases. - Indications for testing include the presence of [red flags in diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Zee4bebab517fe015dea25941aafb8133) and [risk factors](https://www.amboss.com/us/knowledge/Interpreting_medical_evidence#Zbc0d0ff153bc5c7a27589815d0c842fd) for specific etiologies. - [Persistent diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Zd56cfaa165f80b20fe15e54d5f2c0023): Testing is usually limited to stool studies for [infectious gastroenteritis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z4ec5f6e716f0557299b9deed9d09e225). - [Chronic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a) - Testing is initially broad with advanced follow-up testing as indicated. \[21\]\[25\] - Repeat stool testing for [infectious gastroenteritis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z4ec5f6e716f0557299b9deed9d09e225). Diagnostic testing is seldom indicated in [acute diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z9902a484faaf54b4fa1ffaf3a5642113) in the absence of [red flag symptoms](). ## Testing for diarrhea For specific indications for testing, see the respective subsections below on acute, persistent, and [chronic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a). - Blood tests - [CBC](https://www.amboss.com/us/knowledge/Laboratory_medicine#Z4ccf935251884533761ac0c529e17a64): To evaluate for [anemia](https://www.amboss.com/us/knowledge/Anemia#Zd40074de20e25de472779d74fcfd35af), [leukocytosis](https://www.amboss.com/us/knowledge/Leukocytosis#Zb1919b7d94d10a63debcb709eaa693f3), and/or [leukopenia](https://www.amboss.com/us/knowledge/Leukopenia#Z32c33fd60ac86084730cc1ba4078a8f5) - [CMP](https://www.amboss.com/us/knowledge/Laboratory_medicine#Z7213a5e3683814d58d65a66c5bc3ebc8): Assessment of [laboratory findings in dehydration](https://www.amboss.com/us/knowledge/Dehydration_and_hypovolemia#Z07083a9024530b20bdd9ef8b38fc6e79) (e.g., [electrolyte](https://www.amboss.com/us/knowledge/Laboratory_medicine#Z562f1491861b33bdb5af572388e99541) abnormalities, [AKI](https://www.amboss.com/us/knowledge/Acute_kidney_injury#Z6deecfc16edc5ff8ed1ad2f586f55305)) and/or [liver](https://www.amboss.com/us/knowledge/Liver#Zd0ed3eb208321943f24b364e0a464294) disease - [CRP](https://www.amboss.com/us/knowledge/Laboratory_medicine#Z51ad1e101a45a8de708a6dda0321755d), [ESR](https://www.amboss.com/us/knowledge/Laboratory_medicine#Zde306dd72fd9fa8f94347d3f2edafc20): [Markers of inflammation](https://www.amboss.com/us/knowledge/Laboratory_medicine#Zb4c8f1543d29d334dcb50edc6af8a2a2) - [Blood cultures](https://www.amboss.com/us/knowledge/Blood_cultures#Zbbc1ac48182c8850d109967ff3d2e390): Identification of [bacteremia](https://www.amboss.com/us/knowledge/Bacteremia#Z4bd3a5213bcec7021a2d08026fec3ee5) - Blood gases: Assessment of acid-base status - [Celiac disease serology](https://www.amboss.com/us/knowledge/Celiac_disease#Z63d359b4e2570234feebde9aaebff219): Initial testing for [celiac disease](https://www.amboss.com/us/knowledge/Celiac_disease#Z1999c64abb6e85ce70f8cdc66810a65b) - Breath tests \[26\] - [Hydrogen breath test](https://www.amboss.com/us/knowledge/Lactose_intolerance#Z4187a69143c8be5cfd157107e8edb65a) (e.g., [glucose hydrogen breath test](), [lactose hydrogen breath test](https://www.amboss.com/us/knowledge/Lactose_intolerance#Z4187a69143c8be5cfd157107e8edb65a)): Diagnosis of [SIBO](https://www.amboss.com/us/knowledge/Small_intestinal_bacterial_overgrowth#Z9aa32f677362a235a8ae39e011711f1b) and [carbohydrate](https://www.amboss.com/us/knowledge/Carbohydrates#Z9749463e67a1dd52c34fed592810f23d) intolerance - [C-D-xylose breath test](): Diagnosis of intestinal [malabsorption](https://www.amboss.com/us/knowledge/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb) and [SIBO](https://www.amboss.com/us/knowledge/Small_intestinal_bacterial_overgrowth#Z9aa32f677362a235a8ae39e011711f1b) - CT abdomen or [MRI](https://www.amboss.com/us/knowledge/Magnetic_resonance_imaging#Zefb6206a3f821bf7e5942b654dc6f6cf) abdomen: Identification of inflammation, structural disease, and/or [ischemia](https://www.amboss.com/us/knowledge/Cellular_changes_and_adaptive_responses#Zbc05e544d46e794a60ac9ce9ec6883af) \[12\] - Endoscopic studies \[12\]\[18\] - [Upper endoscopy](https://www.amboss.com/us/knowledge/Esophagogastroduodenoscopy#Z1a617ceb3d8b9832108168a091314359) or [enteroscopy]() with [biopsy]() (± [aspiration](https://www.amboss.com/us/knowledge/Pneumonia#Z351264651d762713a247d997f6eae551)): Diagnosis of [mucosal]() disease (e.g., [celiac disease](https://www.amboss.com/us/knowledge/Celiac_disease#Z1999c64abb6e85ce70f8cdc66810a65b)), infection, or [malignancy](https://www.amboss.com/us/knowledge/General_oncology#Z8c3bce39ca977e0f872b6d9fb3be8cfb) in the [small intestine](https://www.amboss.com/us/knowledge/Small_intestine#Zf1014e183938553009e5ecdbb0650b43) - [Colonoscopy](https://www.amboss.com/us/knowledge/Colonoscopy#Za4aebc8baa131b83620292e8d0363739) with [biopsies](): Diagnosis of inflammatory disease, infection, or [malignancy](https://www.amboss.com/us/knowledge/General_oncology#Z8c3bce39ca977e0f872b6d9fb3be8cfb) Endoscopic studies have limited diagnostic value in [acute diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z9902a484faaf54b4fa1ffaf3a5642113) but are commonly needed for the workup of [chronic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a) to evaluate for the presence of inflammatory or [neoplastic](https://www.amboss.com/us/knowledge/General_oncology#Za6c03f509be1b3d9dfdc8402fad24824) diseases. Their utility in [persistent diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Zd56cfaa165f80b20fe15e54d5f2c0023) is uncertain. ### Stool diagnostic studies - Stool culture: can be indicated if [red flags in diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Zee4bebab517fe015dea25941aafb8133) are present (e.g., suspected invasive [bacterial enteritis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z7c0d1a3ebf70c528338a93b779e17e08)) - [Stool tests for CDI](https://www.amboss.com/us/knowledge/Clostridioides_difficile_infection#Z5ae7beb055f147f1241e95ce050c0395): if [C. difficile infection](https://www.amboss.com/us/knowledge/Clostridioides_difficile_infection#Zb508f99ee028a9d8582608f40bc36f5f) is suspected \| [Stool diagnostic studies](https://www.amboss.com/us/knowledge/Diarrhea#Z1af96922654e42529740851250ec9081) in diarrhea \| \| \| \|---\|---\|---\| \| Suspected etiology \| Test \| Purpose \| \| Infectious diseases \| [Stool culture](https://www.amboss.com/us/knowledge/Diarrhea#Z6dddefa904a8f33be48aaa7f09f23fa3) \| Identification of infectious agents (e.g., in [bacterial gastroenteritis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z7c0d1a3ebf70c528338a93b779e17e08)) \| \| [Stool microscopy](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z3ffb13377faf28eb8d88ac5d1c53433a) \| Visualization of [ova](https://www.amboss.com/us/knowledge/Female_reproductive_organs#Z6f9cf85e209c336035854438760d1213) or [parasites]() in the stool \| \| \| Culture-independent methods, e.g., [multiplex molecular diagnostic panel for diarrhea]() ([PCR](https://www.amboss.com/us/knowledge/Laboratory_methods#Z3a8f5e31aa62111944442fd86660cc27)) \| Identification of infectious agents in bacterial, viral, and [protozoal](https://www.amboss.com/us/knowledge/General_parasitology#Z8f4f3567860a31947bee8edff7ea6bd5) [gastroenteritis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Zcbd93ce063d015f699fd07ed09015b7f) \[25\] \| \| \| Quantitative culture of small intestinal [aspirate](https://www.amboss.com/us/knowledge/Pneumonia#Z351264651d762713a247d997f6eae551) \| Used to diagnose [SIBO](https://www.amboss.com/us/knowledge/Small_intestinal_bacterial_overgrowth#Z9aa32f677362a235a8ae39e011711f1b) ([gold standard test]() for bacterial overgrowth) \| \| \| [Stool tests for C. difficile infection](https://www.amboss.com/us/knowledge/Clostridioides_difficile_infection#Z5ae7beb055f147f1241e95ce050c0395) (e.g., toxin test) \| Identification of [C. difficile infection](https://www.amboss.com/us/knowledge/Clostridioides_difficile_infection#Zb508f99ee028a9d8582608f40bc36f5f) \| \| \| Inflammation \| [Stool microscopy](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z3ffb13377faf28eb8d88ac5d1c53433a) \| Visualization of fecal [leukocytes](https://www.amboss.com/us/knowledge/Basics_of_hematology#Z18a02873023ccef6d8ea2b461e0b7446) \| \| [Fecal occult blood test](https://www.amboss.com/us/knowledge/Colorectal_cancer#Z24f19e4cfd2826fe2f4df3e70c80fd38) ([FOBT](https://www.amboss.com/us/knowledge/Colorectal_cancer#Z24f19e4cfd2826fe2f4df3e70c80fd38)) \| To screen for [malignancy](https://www.amboss.com/us/knowledge/General_oncology#Z8c3bce39ca977e0f872b6d9fb3be8cfb) and [mucosal]() inflammation \| \| \| [FIT DNA test](https://www.amboss.com/us/knowledge/Colorectal_cancer#Z943342f2c2fcf6a86ea87e55a141b8a7) \| To screen for [colonic](https://www.amboss.com/us/knowledge/Large_intestine#Ze19293358dc6c65dc95f936bb8fca493) cancer and [adenomatous polyps](https://www.amboss.com/us/knowledge/Colonic_polyps#Z31bea48c0b1a3349c4fa653243445fe3) \| \| \| [Fecal calprotectin](https://www.amboss.com/us/knowledge/Crohn_disease#Z0da0114e6bf8ec43ad71096d5e3f97f1) and [lactoferrin](https://www.amboss.com/us/knowledge/Innate_immune_system#Z341d9eb537374add3f4e1350946c378f) \| Markers of [inflammatory bowel disease](https://www.amboss.com/us/knowledge/Crohn_disease#Z4272f924349255b3e4babe86d4e939c9) ([IBD](https://www.amboss.com/us/knowledge/Crohn_disease#Z4272f924349255b3e4babe86d4e939c9)) \| \| \| [Malabsorption](https://www.amboss.com/us/knowledge/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb) \| [Sudan stain](https://www.amboss.com/us/knowledge/Cellular_changes_and_adaptive_responses#Z78716b286b479e2c380f54ed824c20fc) \| Qualitative test for [steatorrhea](https://www.amboss.com/us/knowledge/Chronic_pancreatitis#Z416510d2bd6fcd19b4e328d62b6b10db) \| \| [72-hour quantitative fecal fat estimation](https://www.amboss.com/us/knowledge/Chronic_pancreatitis#Zd212c09e9c64621940c1a0ced94a9c98) \| Quantitative test for [steatorrhea](https://www.amboss.com/us/knowledge/Chronic_pancreatitis#Z416510d2bd6fcd19b4e328d62b6b10db) \| \| \| [Fecal elastase-1](https://www.amboss.com/us/knowledge/Chronic_pancreatitis#Zf555d89ae453336db1900a0d4d2df7e7) \| Confirmation of [steatorrhea](https://www.amboss.com/us/knowledge/Chronic_pancreatitis#Z416510d2bd6fcd19b4e328d62b6b10db) due to [exocrine pancreatic insufficiency](https://www.amboss.com/us/knowledge/Malabsorption#Z4880cedb9eb57d620afb59b2c9e39a8b) \| \| \| Stool [electrolytes](https://www.amboss.com/us/knowledge/Laboratory_medicine#Z562f1491861b33bdb5af572388e99541) (e.g., Na\+, [K\+](https://www.amboss.com/us/knowledge/Water_and_electrolyte_metabolism#Z115ce86297429aa2893d16c3493aae24)) \| Used to calculate [stool osmotic gap](https://www.amboss.com/us/knowledge/Diarrhea#Ze3350ca8675573e0158f73d116234534) \| \| \| Stool [pH]() \| Identification of [carbohydrate malabsorption](https://www.amboss.com/us/knowledge/Malabsorption#Z1659a0f218ffe905f7bddb7c54efb326) \| \| - Stool osmotic gap \[11\]\[16\]\[18\] - An equation used in patients with [watery diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z16ed63f1f94f558cfbffed53ce14a7fb) to differentiate between osmotic, secretory, and [functional diarrhea]() - Calculation: 290 - \[2 × (stool [sodium](https://www.amboss.com/us/knowledge/Water_and_electrolyte_metabolism#Z420309902608f05802e6d9d942b6e0b1) \+ stool [potassium](https://www.amboss.com/us/knowledge/Water_and_electrolyte_metabolism#Z115ce86297429aa2893d16c3493aae24))\] - Normal [stool osmotic gap](https://www.amboss.com/us/knowledge/Diarrhea#Ze3350ca8675573e0158f73d116234534): 50–100 mOsm/kg \| \| Low [stool osmotic gap](https://www.amboss.com/us/knowledge/Diarrhea#Ze3350ca8675573e0158f73d116234534) \| High [stool osmotic gap](https://www.amboss.com/us/knowledge/Diarrhea#Ze3350ca8675573e0158f73d116234534) \| \|---\|---\|---\| \| Osmotic gap \| \< 50 mOsm/kg \| ≥ 100 mOsm/kg \| \| Interpretation \| [Secretory diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Za81182120613af86b266ff31432e241e) (↑ secretion and/or inhibition of water absorption) or [functional diarrhea]() (increased intestinal movement) \| [Osmotic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z7169e994f812b120ea2df94d1042192e) (osmotic pull of ingested substances draws water into the intestinal lumen) \| \| Example causes \| Foodborne infections (e.g., [Vibrio cholerae](https://www.amboss.com/us/knowledge/Bacteria_overview#Z5040d5b8f384d034307ec998d5706c4a), [enterotoxigenic E. coli](https://www.amboss.com/us/knowledge/Diarrheagenic_E._coli#Z458147f1e1273e554884140b40317779)) Endocrine tumors (e.g., [VIPoma](https://www.amboss.com/us/knowledge/Pancreatic_neuroendocrine_tumors#Za2856a318ce5fbd49335eab336d6fa66), medullary [carcinoma](https://www.amboss.com/us/knowledge/General_oncology#Z22674f156f136302ff6142f806db0d5a) of the [thyroid](https://www.amboss.com/us/knowledge/Thyroid_gland_and_parathyroid_glands#Za09b3ec4cbcf889fc4f7b34cecb45f4d), [gastrinoma](https://www.amboss.com/us/knowledge/Gastrinoma#Z33515a1b2df6a4fe21ef0162d7a1eac7)) Impaired absorption of [bile acids](https://www.amboss.com/us/knowledge/Gallbladder_and_bile#Z86b474a966e0cc8faf1092967eaf82f4) and/or salts ([bile acid diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z0f6aa3c63b0331881c8804e04e01ca5c)) \| [Osmotic laxative](https://www.amboss.com/us/knowledge/Constipation#Z6beba559f6dfabe7c19e807cf28747b9) ingestion (e.g., [magnesium citrate](https://www.amboss.com/us/knowledge/Constipation#Z11bef431cda663471cbd64d3249255bf)) [Malabsorption](https://www.amboss.com/us/knowledge/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb) (e.g., [celiac disease](https://www.amboss.com/us/knowledge/Celiac_disease#Z1999c64abb6e85ce70f8cdc66810a65b), [Whipple disease](https://www.amboss.com/us/knowledge/Whipple_disease#Z83c04868f8c75273c89d8c6e966623e4)) [Pancreatic](https://www.amboss.com/us/knowledge/Pancreas#Z0842648c05a9f12b182c77d4baeb7a3a) insufficiency \| The loss of [bicarbonate](https://www.amboss.com/us/knowledge/Gastrointestinal_tract#Z6cdbbc46116e490c8de4fb6acf44242c)\-rich fluid in severe diarrhea may cause nonanion gap [metabolic acidosis](https://www.amboss.com/us/knowledge/Acid-base_disorders#Ze6ecd1a689f21c50f6f1d77dcd2bd10b). ## Supportive care![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg) ## [Dehydration and hypovolemia](https://www.amboss.com/us/knowledge/Dehydration_and_hypovolemia#Z63f60424ca0cc1f9dff5b2daf66767c2) \[21\] Therapy is guided by [clinical features of dehydration and hypovolemia](https://www.amboss.com/us/knowledge/Dehydration_and_hypovolemia#Zcab074498485cc9f54c032767e39fc62) and [laboratory findings in dehydration and hypovolemia](https://www.amboss.com/us/knowledge/Dehydration_and_hypovolemia#Z07083a9024530b20bdd9ef8b38fc6e79). - Mild to [moderate dehydration](https://www.amboss.com/us/knowledge/Dehydration_and_hypovolemia#Z3e5c63fd98cfbd4f25d0b664d4f03f46): Start [oral rehydration therapy](https://www.amboss.com/us/knowledge/Dehydration_and_hypovolemia#Zbadf5641ef1ee8851ce3026721b8d40a), e.g., use [oral rehydration solution](https://www.amboss.com/us/knowledge/Dehydration_and_hypovolemia#Z22573072c2ce7ea0ba0873c3024dc043). \[21\] - Severe cases - Start [IV fluid resuscitation](https://www.amboss.com/us/knowledge/Shock#Zee3c52d5a0e0844921b94c537f7d8ba3) (e.g., with [normal saline](https://www.amboss.com/us/knowledge/Intravenous_fluid_therapy#Zca7fd28598a951a5b85443bbe965acd0)) and monitor [hemodynamic parameters](https://www.amboss.com/us/knowledge/Shock#Z6ec4d92bf58a162b02eda183b4a0c2ae). - Consider hospitalization. [Acute diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z9902a484faaf54b4fa1ffaf3a5642113) is usually a [self-limited]() viral infection and management primarily supportive. Early rehydration is especially important in children. ## Antidiarrheal agents \[16\]\[25\] - [Bismuth subsalicylate](https://www.amboss.com/us/knowledge/Helicobacter_pylori_infection#Z5ff316bf4e8912c06dc600df2a9e8b09) \[25\] - Converts to [bismuth](https://www.amboss.com/us/knowledge/Helicobacter_pylori_infection#Z5ff316bf4e8912c06dc600df2a9e8b09) and [salicylic acid](https://www.amboss.com/us/knowledge/Antiplatelet_agents#Z4a1b60265ac61c4eb5912ac673ac7d32) in the [GI tract](https://www.amboss.com/us/knowledge/Gastrointestinal_tract#Zf0833058b7152af8b5653b79f76fb153) - Has antisecretory, antimicrobial, and antiinflammatory effects - Can be used in bacterial diarrhea - [Loperamide](https://www.amboss.com/us/knowledge/Opioids#Z1881077ac71cd771cb44b7db04569ac0) ; \[25\]\[27\]\[28\] - [Opioid](https://www.amboss.com/us/knowledge/Opioids#Z434daecbc44532c03b0313928f0c321d) [receptor](https://www.amboss.com/us/knowledge/Signal_transduction#Z3ff0122a3c004eebed96e9db47e16ea4) [agonist](https://www.amboss.com/us/knowledge/Fundamentals_of_pharmacology#Zf82b0b9262366f2b5031a517d5e8c951) that increases [intestinal transit time]() - Best initial treatment for [chemotherapy-induced diarrhea](https://www.amboss.com/us/knowledge/Complications_of_cancer_therapy#Z621a8f3ccfa630117bdd8b12809786b9) - Cautions - Should not be used for \> 48 hours without reevaluation of the patient - Should be avoided if the patient is [febrile](https://www.amboss.com/us/knowledge/Fever#Za5de83449ff6a749e6c1348b93b1f3b1) or has bloody stools (dysenteric diarrhea) - Racecadotril (not available in the US) \[16\]\[29\] - Enkephalinase inhibitor that reduces the hypersecretion of [electrolytes](https://www.amboss.com/us/knowledge/Laboratory_medicine#Z562f1491861b33bdb5af572388e99541) and water into the intestinal lumen - Appears to be well-tolerated and effective in bacterial diarrhea [Loperamide](https://www.amboss.com/us/knowledge/Opioids#Z1881077ac71cd771cb44b7db04569ac0) should be avoided in patients with suspected invasive diarrhea with inflammatory features, as it reduces intestinal motility, which consequently increases the risk of bacterial [colonization](https://www.amboss.com/us/knowledge/General_bacteriology#Zd3b45ccb844489c4640c0435288e368e) and invasion. \[30\] ## Acute or persistent diarrhea (≤ 30 days)![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg) ## Approach to [acute diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z9902a484faaf54b4fa1ffaf3a5642113) (≤ 14 days) \[21\]\[22\]\[25\]\[28\] The management of [acute diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z9902a484faaf54b4fa1ffaf3a5642113) is primarily supportive, as the disease is usually a [self-limited]() viral infection. Further management focuses on determining whether diagnostic testing and directed therapy are needed (e.g., [antibiotic therapy](https://www.amboss.com/us/knowledge/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3) for [bacterial gastroenteritis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z7c0d1a3ebf70c528338a93b779e17e08)). \[22\] - Start hydration and offer symptom relief; see “[Supportive care]().” - Determine whether the diarrhea is inflammatory ([dysentery]()) or noninflammatory. - Reserve [stool diagnostic testing](https://www.amboss.com/us/knowledge/Diarrhea#Z1af96922654e42529740851250ec9081) for [pathogen]() identification ([stool cultures](https://www.amboss.com/us/knowledge/Diarrhea#Z6dddefa904a8f33be48aaa7f09f23fa3) with or without culture-independent methods) for specific scenarios \[25\] - The presence of [red flags in diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Zee4bebab517fe015dea25941aafb8133) (e.g., [inflammatory diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z321586a3cfe84e9365a55d0ed20fb62a), [sepsis](https://www.amboss.com/us/knowledge/Sepsis#Zb3de189fac0d57eac5b7798e127a5e19)) - The presence of [risk factors](https://www.amboss.com/us/knowledge/Interpreting_medical_evidence#Zbc0d0ff153bc5c7a27589815d0c842fd) for specific infectious diseases (e.g., [risk factors for C. difficile infection](https://www.amboss.com/us/knowledge/Clostridioides_difficile_infection#Zcec32f67ae45a4b1cf8f0cc5aebd5531)) - High risk of infecting others (e.g., daycare workers, food handlers, current known or suspected disease [outbreaks]()) - If the results would alter management - Consider [empiric antibiotics for bacterial gastroenteritis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z8bc7c574b3a32ce97b6e98deca3d7a27) after stool samples have been obtained. \[28\] - Start targeted treatment based on the results; see also “[Infectious gastroenteritis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z4ec5f6e716f0557299b9deed9d09e225).” If symptoms of an [acute abdomen](https://www.amboss.com/us/knowledge/Acute_abdomen#Z24dc105fa608cb7dad9e5eada9a97d2b) are present, consider an urgent CT abdomen to identify [ischemic](https://www.amboss.com/us/knowledge/Cellular_changes_and_adaptive_responses#Zbc05e544d46e794a60ac9ce9ec6883af), hemorrhagic, obstructive, and/or inflammatory diseases. \[28\] When indicated, stool studies in patients with [acute diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z9902a484faaf54b4fa1ffaf3a5642113) should include tests that can detect the presence of [Salmonella](https://www.amboss.com/us/knowledge/Bacteria_overview#Zcf62cfeb3796c44845f303785e4bb88c), [Shigella](https://www.amboss.com/us/knowledge/Bacteria_overview#Z40dc9a1dcc2df2a82a0c4586e5023158), [Campylobacter](https://www.amboss.com/us/knowledge/Bacteria_overview#Za64f770db8dc668f93db5788517d1bc0), [Yersinia](https://www.amboss.com/us/knowledge/Bacteria_overview#Zfcf2a7b96fa589ca6dd7ada0b75e48bb), [C. difficile infection](https://www.amboss.com/us/knowledge/Clostridioides_difficile_infection#Zb508f99ee028a9d8582608f40bc36f5f), and [Shiga toxin-producing E. coli](https://www.amboss.com/us/knowledge/Diarrheagenic_E._coli#Z11eef8782d53e8058dd72294470db3f7). \[31\] ### Noninflammatory diarrhea ([watery diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z16ed63f1f94f558cfbffed53ce14a7fb)) \[21\]\[25\]\[31\] - Mild symptoms (e.g., daily activities of life are not affected) - \< 7 days: Diagnostic testing is not recommended. - ≥ 7 days: Consider stool studies for [pathogen]() identification if the results may alter management, e.g., initiation of targeted therapy. - Moderate to severe symptoms (e.g., daily activities of life are affected) - For [traveler's diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Zed77ffe538dae231e40fe0542e7b245a), start [empiric antibiotics](https://www.amboss.com/us/knowledge/Overview_of_antibiotic_therapy#Z0d92af1eab239465721da02549c61854). \[31\] - \< 72 hours: symptom control (e.g., [loperamide](https://www.amboss.com/us/knowledge/Opioids#Z1881077ac71cd771cb44b7db04569ac0)); no diagnostic testing recommended - ≥ 72 hours: Obtain stool studies for [pathogen]() identification and targeted therapy. - Severe symptoms, [fever](https://www.amboss.com/us/knowledge/Fever#Za5de83449ff6a749e6c1348b93b1f3b1), or patients at risk for severe disease: Obtain stool studies for [pathogen]() identification and targeted therapy. ### [Inflammatory diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z321586a3cfe84e9365a55d0ed20fb62a) ([dysentery]()) \[28\] - No or low-grade [fever](https://www.amboss.com/us/knowledge/Fever#Za5de83449ff6a749e6c1348b93b1f3b1): [stool cultures](https://www.amboss.com/us/knowledge/Diarrhea#Z6dddefa904a8f33be48aaa7f09f23fa3) or [multiplex molecular diagnostic panel for diarrhea]() ([PCR](https://www.amboss.com/us/knowledge/Laboratory_methods#Z3a8f5e31aa62111944442fd86660cc27)) - Severe illness with [fever](https://www.amboss.com/us/knowledge/Fever#Za5de83449ff6a749e6c1348b93b1f3b1) - Obtain blood tests (e.g., [CBC](https://www.amboss.com/us/knowledge/Laboratory_medicine#Z4ccf935251884533761ac0c529e17a64), [CMP](https://www.amboss.com/us/knowledge/Laboratory_medicine#Z7213a5e3683814d58d65a66c5bc3ebc8), [inflammatory markers](https://www.amboss.com/us/knowledge/Laboratory_medicine#Zb4c8f1543d29d334dcb50edc6af8a2a2), and [blood cultures](https://www.amboss.com/us/knowledge/Blood_cultures#Zbbc1ac48182c8850d109967ff3d2e390)) and stool studies for [pathogen]() identification and targeted therapy. - Consider [empiric antibiotics for bacterial gastroenteritis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z8bc7c574b3a32ce97b6e98deca3d7a27). \[31\] ## Approach to [persistent diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Zd56cfaa165f80b20fe15e54d5f2c0023) (15–30 days) \[28\]\[32\] - Review associated symptoms, history, and stool appearance. - Obtain stool studies for [pathogen]() identification (including [parasites]()) in all patients. - Avoid routine blood tests, imaging, and endoscopy in patients with a negative stool workup and no [red flag symptoms](). - Offer [empiric antibiotics](https://www.amboss.com/us/knowledge/Overview_of_antibiotic_therapy#Z0d92af1eab239465721da02549c61854) to patients with suspected [traveler's diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Zed77ffe538dae231e40fe0542e7b245a). - Start targeted treatment based on diagnostic results; see also “[Infectious gastroenteritis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z4ec5f6e716f0557299b9deed9d09e225).” In patients with prominent abdominal [pain](https://www.amboss.com/us/knowledge/Principles_of_pain_management#Zd673a3f7ee36023aab5a267899e984cc) and/or bloody diarrhea, evaluate for [ischemic colitis](https://www.amboss.com/us/knowledge/Intestinal_ischemia#Za5a3e828cf2d10df3a9693a9fc3b2c34), [ulcerative colitis](https://www.amboss.com/us/knowledge/Ulcerative_colitis#Zbb0aec0a5fe14ad0aae10a9341c457fc), and [Crohn disease](https://www.amboss.com/us/knowledge/Crohn_disease#Zef70853af5e87c95d210bf8df682f64c) if stool testing does not indicate an infectious etiology. [Persistent diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Zd56cfaa165f80b20fe15e54d5f2c0023) has a broader differential diagnosis than [acute diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z9902a484faaf54b4fa1ffaf3a5642113). Parasitic infection (e.g., [giardiasis](https://www.amboss.com/us/knowledge/Giardiasis#Z7285e874bce9a0f39983534a6c838736)), recurrent bacterial infection (e.g., [C. difficile infection](https://www.amboss.com/us/knowledge/Clostridioides_difficile_infection#Zb508f99ee028a9d8582608f40bc36f5f)), and noninfectious causes (e.g., [IBS-D](https://www.amboss.com/us/knowledge/Irritable_bowel_syndrome#Z34fd0bc151761f2495a7470c6d9f6187)) must be considered. \[32\] ## Etiology of acute and persistent diarrhea \[10\]\[11\]\[15\]\[22\] \| [Etiology of acute and persistent diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Za0cd177df9550f81889873b6038f2072) \| \| \|---\|---\| \| Viral \[21\] \| [Norovirus infection](https://www.amboss.com/us/knowledge/Norovirus_infection#Z2bf1564153a0ab14e52c587da9c8a8c3) [Rotavirus infection](https://www.amboss.com/us/knowledge/Rotavirus_infection#Zb2e7858cefe0481ba26809cf4d9b84ec) [Adenovirus](https://www.amboss.com/us/knowledge/General_virology#Z5251a57602a66d951ca7a8a66643ee51) infection (mainly [serotypes]() 3, 40, and 41) \[6\] [Cytomegalovirus infection](https://www.amboss.com/us/knowledge/Cytomegalovirus_infection#Za3ec0dd921d428ed745a6ec39879cf55) [Coronavirus](https://www.amboss.com/us/knowledge/General_virology#Zc9fd2c044745d5b6f6ef5fe6293d10c5) ([COVID-19](https://www.amboss.com/us/knowledge/COVID-19_\(coronavirus_disease_2019\)#Z82f1d759ff02927000d2ccd223409135)) \| \| Bacterial \| [Cholera](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Zba6a00519c1b345599491aa93180aacf) (“rice water” diarrhea) [Enterotoxigenic E. coli](https://www.amboss.com/us/knowledge/Diarrheagenic_E._coli#Z458147f1e1273e554884140b40317779) infection ([traveler's diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Zed77ffe538dae231e40fe0542e7b245a)) [C. perfringens](https://www.amboss.com/us/knowledge/Bacteria_overview#Z927388b963f796f8c6f170841d77b930) infection [C. difficile](https://www.amboss.com/us/knowledge/Bacteria_overview#Z429d21670093a08ffb061528b0561719) infection (associated with [antibiotic](https://www.amboss.com/us/knowledge/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3) and [PPI](https://www.amboss.com/us/knowledge/Proton_pump_inhibitors#Z2753e50142e2f5b7089b165accdcc900) use) [Shigellosis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Zd4a3455e8ec3d03f2e705d784ba584b0) ([bacillary dysentery](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Zd4a3455e8ec3d03f2e705d784ba584b0)) Nontyphoidal: [salmonellosis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z2681adc9ab180885765f48f6f730b912) [Enteroinvasive E. coli](https://www.amboss.com/us/knowledge/Diarrheagenic_E._coli#Z12cd4e274bbe847f6b9e96d592684c87), [enterohemorrhagic E. coli](https://www.amboss.com/us/knowledge/Diarrheagenic_E._coli#Z44cb042afe41a43945e6b3c55e424917) ([O157:H7](https://www.amboss.com/us/knowledge/Hemolytic_uremic_syndrome#Zd789cca34b9c96af9a9c7abd264b2c7b)) infection [Campylobacteriosis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z9273c5a7cf1820c124f8fe4d5648df30) [Yersiniosis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z6c552143f411315b80f346c0c8707af5) [Legionella]() \| \| Parasitic \| [Giardiasis](https://www.amboss.com/us/knowledge/Giardiasis#Z7285e874bce9a0f39983534a6c838736) [Amebiasis](https://www.amboss.com/us/knowledge/Amebiasis#Z4500356668f80dc7e2e4d3b731ae9d1f) [Cryptosporidiosis](https://www.amboss.com/us/knowledge/HIV-associated_conditions#Z50d6fcd479428e63a00b9454e02cad44) [Enterobiasis](https://www.amboss.com/us/knowledge/Helminth_infections#Z626348337721606624cdbdbddc89d761) [Ascariasis](https://www.amboss.com/us/knowledge/Helminth_infections#Z3bdf0551665f902bb7f7437f1345d942) \| \| [Food poisoning](https://www.amboss.com/us/knowledge/Food_poisoning#Z5a858064f0cd40e4546f181bf46734f2) \| [S. aureus](https://www.amboss.com/us/knowledge/Staphylococcal_diseases#Zaf074edfb4940be0ed1d4fcfc4ea0dee) infection [Botulism](https://www.amboss.com/us/knowledge/Botulism#Za2a9894ca446f0fe0aac693516c52c4d) [Bacillus cereus](https://www.amboss.com/us/knowledge/Food_poisoning#Z6843256bc452c182cae6e8c9c5cbe589) infection [Aflatoxin](https://www.amboss.com/us/knowledge/General_mycology#Z91b3abebde0a7a99c3942b9bd3060cc2) [Histamine](https://www.amboss.com/us/knowledge/Hypersensitivity_reactions#Zae1b7b5f59d06769c8445ee3e4389b73) toxicity \[7\] [Tetrodotoxin](https://www.amboss.com/us/knowledge/Food_poisoning#Zd578525a352862bd6098cbff0e02482f), [ciguatoxin]() \| \| Medications \| [Antibiotics](https://www.amboss.com/us/knowledge/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3) [Laxatives]() [PPIs](https://www.amboss.com/us/knowledge/Proton_pump_inhibitors#Z2753e50142e2f5b7089b165accdcc900) [SSRIs](https://www.amboss.com/us/knowledge/Antidepressants#Zb1bb43280a4d0d86f2d53818b9e8afc8) [NSAIDs](https://www.amboss.com/us/knowledge/Non-opioid_analgesics#Z6d53b6cfe3376a70645a5c797293e56a) \| \| Other \| Chemical contaminants (e.g., lead, [cadmium](https://www.amboss.com/us/knowledge/Metal_poisoning#Z04ffe297e862ba3e4a25b62b6a06105e), insecticides, [arsenic](https://www.amboss.com/us/knowledge/Metal_poisoning#Zf2f349b64906a39b338222ac30067f86)) \[8\] [Mushroom poisoning](https://www.amboss.com/us/knowledge/Poisoning#Ze39c09d250439022bca488e44824b3d5) \[9\] [Bowel ischemia](https://www.amboss.com/us/knowledge/Intestinal_ischemia#Z25168aee9d4e0266b8ee7dae3d33cc08) [Neutropenic enterocolitis](https://www.amboss.com/us/knowledge/Acute_abdomen#Za3c81a83e806ab8e4e5f85cb4d572b6c) \| ## Chronic diarrhea (\> 30 days)![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg) ## Approach to [chronic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a) The differential diagnosis of [chronic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a) is extensive. A systematic approach with efficient use of testing is needed to arrive at a diagnosis quickly. \[10\]\[12\]\[33\] - Provide general [supportive care](). - Assess for a possible health care-related etiology: e.g., [medication-induced diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Za759d71c55e5fd9dfcf2e30c0240601a) - Consider factitious diarrhea. \[11\] - Order [initial diagnostics for chronic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Ze651f57896e4f957eed2c9bdc3d9b8ed). - Consider a preliminary diagnosis of [IBS-D](https://www.amboss.com/us/knowledge/Irritable_bowel_syndrome#Z34fd0bc151761f2495a7470c6d9f6187) if all of the following criteria are met: \[18\] - Initial tests are normal. - No [red flags]() are present. - [Rome IV criteria for IBS](https://www.amboss.com/us/knowledge/Irritable_bowel_syndrome#Zc16da4fdfa96f2bd9cf45f216019665a) are met. - Consider further investigations: e.g., additional advanced tests, therapeutic trials - Start directed therapy once a likely [etiology of chronic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z395de845da244c411a1fe280649e48a0) has been identified. [Chronic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a) can be classified as inflammatory, fatty, or watery. Grouping patients into broad categories based on clinical features and basic laboratory findings narrows the differential diagnosis and facilitates efficient advanced testing. \[18\] [IBS-D](https://www.amboss.com/us/knowledge/Irritable_bowel_syndrome#Z34fd0bc151761f2495a7470c6d9f6187) is an intermediate diagnosis; it does not eliminate the possibility of another disease. Evaluation should continue if symptoms persist despite treatment for [IBS-D](https://www.amboss.com/us/knowledge/Irritable_bowel_syndrome#Z34fd0bc151761f2495a7470c6d9f6187). \[12\] ## Etiology of chronic diarrhea \[12\] [Chronic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a) is commonly classified as watery, fatty, or inflammatory. \| [Etiology of chronic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z395de845da244c411a1fe280649e48a0) \[12\] \| \| \| \|---\|---\|---\| \| Inflammatory \| [Inflammatory bowel disease](https://www.amboss.com/us/knowledge/Crohn_disease#Z4272f924349255b3e4babe86d4e939c9): [Crohn disease](https://www.amboss.com/us/knowledge/Crohn_disease#Zef70853af5e87c95d210bf8df682f64c), [ulcerative colitis](https://www.amboss.com/us/knowledge/Ulcerative_colitis#Zbb0aec0a5fe14ad0aae10a9341c457fc) Invasive infections Bacterial: e.g., [pseudomembranous colitis](https://www.amboss.com/us/knowledge/Clostridioides_difficile_infection#Z9a45a83f4126940236032056da651cf6), [tuberculosis](https://www.amboss.com/us/knowledge/Tuberculosis#Zcaeed890b290faa5ec7ec5e02a1039fe) Viral: e.g., [CMV](https://www.amboss.com/us/knowledge/Herpes_virus_infections#Zad44d620172736914bbe3c52435de665) Parasitic: e.g., [Entamoeba histolytica](https://www.amboss.com/us/knowledge/Amebiasis#Z4001b357f1b712e83d6027a4dfa5731b) Medications: e.g., [PPIs](https://www.amboss.com/us/knowledge/Proton_pump_inhibitors#Z2753e50142e2f5b7089b165accdcc900), [NSAIDs](https://www.amboss.com/us/knowledge/Non-opioid_analgesics#Z6d53b6cfe3376a70645a5c797293e56a), [tyrosine kinase inhibitors](https://www.amboss.com/us/knowledge/Chemotherapeutic_agents#Z1d95c73e140242a536db072ff6adf252) Other: e.g., [ischemic colitis](https://www.amboss.com/us/knowledge/Intestinal_ischemia#Za5a3e828cf2d10df3a9693a9fc3b2c34), [radiation colitis](https://www.amboss.com/us/knowledge/Radiation_injury#Ze0a9ed89b6c1c4ea08173fa19b2b74f9), [malignancy](https://www.amboss.com/us/knowledge/General_oncology#Z8c3bce39ca977e0f872b6d9fb3be8cfb) (e.g., [colon cancer](https://www.amboss.com/us/knowledge/Colorectal_cancer#Z5f9a21e2819d2a5004da275e0fe8e909), [lymphoma](https://www.amboss.com/us/knowledge/General_oncology#Z2586a20a2f640af294a4d86b9f8439d0)) \| \| \| Fatty \| [Malabsorption](https://www.amboss.com/us/knowledge/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb) \| Infections: [SIBO](https://www.amboss.com/us/knowledge/Small_intestinal_bacterial_overgrowth#Z9aa32f677362a235a8ae39e011711f1b), [tropical sprue](https://www.amboss.com/us/knowledge/Tropical_sprue#Z98af9796a545c9279ebf232edfbe9a0f), [Whipple disease](https://www.amboss.com/us/knowledge/Whipple_disease#Z83c04868f8c75273c89d8c6e966623e4), [giardiasis](https://www.amboss.com/us/knowledge/Giardiasis#Z7285e874bce9a0f39983534a6c838736) Medications: e.g., [aminoglycosides](https://www.amboss.com/us/knowledge/Overview_of_antibiotic_therapy#Zec4668b75aadd8ddccaf2d3dada94e20), [antiretroviral drugs](https://www.amboss.com/us/knowledge/Human_immunodeficiency_virus_infection#Zcccdef45b4e6e14c8b8fd8bd48515808) Other: e.g., [celiac disease](https://www.amboss.com/us/knowledge/Celiac_disease#Z1999c64abb6e85ce70f8cdc66810a65b), postsurgical changes, lymphatic obstruction \| \| [Maldigestion](https://www.amboss.com/us/knowledge/Malabsorption#Z325814c45b1a9856fa3d65839f7681f5) \| Inadequate [bile acid](https://www.amboss.com/us/knowledge/Gallbladder_and_bile#Z86b474a966e0cc8faf1092967eaf82f4) concentration: e.g., due to hepatobiliary disease or [ileal](https://www.amboss.com/us/knowledge/Small_intestine#Zf3a10de88f22b839a2769aa9ae031960) resection [Exocrine pancreatic insufficiency](https://www.amboss.com/us/knowledge/Malabsorption#Z4880cedb9eb57d620afb59b2c9e39a8b): e.g., due to [chronic pancreatitis](https://www.amboss.com/us/knowledge/Chronic_pancreatitis#Z1e14e388e4042dc43defefb9f88695e1) or [cystic fibrosis](https://www.amboss.com/us/knowledge/Cystic_fibrosis#Z3ae6b1b2983d98afcd8339f505ed3f99) \| \| \| Watery \| Secretory \| Infections: e.g., [giardiasis](https://www.amboss.com/us/knowledge/Giardiasis#Z7285e874bce9a0f39983534a6c838736), [cryptosporidiosis](https://www.amboss.com/us/knowledge/HIV-associated_conditions#Z50d6fcd479428e63a00b9454e02cad44), [SIBO](https://www.amboss.com/us/knowledge/Small_intestinal_bacterial_overgrowth#Z9aa32f677362a235a8ae39e011711f1b) Medications: e.g., [stimulant laxatives](https://www.amboss.com/us/knowledge/Constipation#Za767330be9fd22123118b1e0addddf55), [levodopa](https://www.amboss.com/us/knowledge/Medication_for_Parkinson_disease#Z18482e8eccd3978e1e99c57ecdc4fd2f), [caffeine](https://www.amboss.com/us/knowledge/Substance-related_and_addictive_disorders#Z9cbb9bc1131781093113ffce4e367923) [Neuroendocrine tumors](https://www.amboss.com/us/knowledge/Neuroendocrine_neoplasms#Z688b3fb7764fe32e74754d4b26c6fc89) \[11\] Endocrine diseases: e.g., [hyperthyroidism](https://www.amboss.com/us/knowledge/Hyperthyroidism_and_thyrotoxicosis#Z7efc7350132a2f2a3e4cc7763e7f07f8), [Addison disease](https://www.amboss.com/us/knowledge/Adrenal_insufficiency#Z7b47bf57fd367b1b9891e4155e39236f), [diabetes mellitus](https://www.amboss.com/us/knowledge/Diabetes_mellitus#Z1235e572dd827cff7d31e954b3f94489) Other: [bile acid](https://www.amboss.com/us/knowledge/Gallbladder_and_bile#Z86b474a966e0cc8faf1092967eaf82f4) [malabsorption](https://www.amboss.com/us/knowledge/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb), [IBD](https://www.amboss.com/us/knowledge/Crohn_disease#Z4272f924349255b3e4babe86d4e939c9), [microscopic colitis](https://www.amboss.com/us/knowledge/Microscopic_colitis#Z98c8e90c538959e074e80c55a532e1bc) \| \| Functional \| [Irritable bowel syndrome](https://www.amboss.com/us/knowledge/Irritable_bowel_syndrome#Z2b30a84dc4106c4e8aad1e6c9202f3ea) ([IBS](https://www.amboss.com/us/knowledge/Irritable_bowel_syndrome#Z2b30a84dc4106c4e8aad1e6c9202f3ea)) Medications: e.g., [prokinetics]() [Functional diarrhea]() \| \| \| Osmotic \| [Carbohydrate malabsorption](https://www.amboss.com/us/knowledge/Malabsorption#Z1659a0f218ffe905f7bddb7c54efb326) Unabsorbed sugars in the diet and/or in chewing [gum](https://www.amboss.com/us/knowledge/Oral_cavity#Z3ab30934681b06d8591bf18cb03ce2d7): e.g., [sorbitol](https://www.amboss.com/us/knowledge/Carbohydrates#Z77d45a3fdde3bf65b74cebef6dec2d7f), [mannitol](https://www.amboss.com/us/knowledge/Diuretics#Ze73562869635139c2688bf31a791bef1) Enzymatic dysfunction: e.g., [lactase deficiency](https://www.amboss.com/us/knowledge/Lactose_intolerance#Zd10b2b1e3672bf92a1e23fc1962405dc) Medications: e.g., [osmotic laxatives](https://www.amboss.com/us/knowledge/Constipation#Z6beba559f6dfabe7c19e807cf28747b9) Other: e.g., [celiac disease](https://www.amboss.com/us/knowledge/Celiac_disease#Z1999c64abb6e85ce70f8cdc66810a65b), [FODMAP](https://www.amboss.com/us/knowledge/Irritable_bowel_syndrome#Zd9aa5f552109b4cf13d7666f5e99cebe) intolerance, [enteral feeding](https://www.amboss.com/us/knowledge/Specialized_nutrition_support#Z3c9fb1a42ea89ef188431d15c5ad1445) \| \| ## Initial diagnostics for chronic diarrhea \[10\]\[12\]\[24\]\[33\] Order initial studies. See also “Testing for diarrhea” in “Diagnostics.” - Stool studies - Repeat stool testing for [infectious gastroenteritis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z4ec5f6e716f0557299b9deed9d09e225). - Perform fecal [leukocyte](https://www.amboss.com/us/knowledge/Basics_of_hematology#Z18a02873023ccef6d8ea2b461e0b7446), calprotectin, and [lactoferrin](https://www.amboss.com/us/knowledge/Innate_immune_system#Z341d9eb537374add3f4e1350946c378f) studies and a [FOBT](https://www.amboss.com/us/knowledge/Colorectal_cancer#Z24f19e4cfd2826fe2f4df3e70c80fd38). - Consider further studies to help classify diarrhea: e.g., [fecal fat estimation](https://www.amboss.com/us/knowledge/Chronic_pancreatitis#Zd212c09e9c64621940c1a0ced94a9c98), [stool osmotic gap](https://www.amboss.com/us/knowledge/Diarrhea#Ze3350ca8675573e0158f73d116234534), stool [pH]() \[12\]\[16\] - Blood tests: Obtain [CRP](https://www.amboss.com/us/knowledge/Laboratory_medicine#Z51ad1e101a45a8de708a6dda0321755d) levels , [CBC](https://www.amboss.com/us/knowledge/Laboratory_medicine#Z4ccf935251884533761ac0c529e17a64), [CMP](https://www.amboss.com/us/knowledge/Laboratory_medicine#Z7213a5e3683814d58d65a66c5bc3ebc8), and [diagnostic studies for anemia](https://www.amboss.com/us/knowledge/Anemia#Z41148dd29e7cce04c2a3fd5dc6cf2720). \[12\] - Imaging studies \[12\] - Use imaging studies to evaluate [red flags in diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Zee4bebab517fe015dea25941aafb8133) and consider initially to rule out structural disease. - Preferred modality: CT abdomen or [MRI](https://www.amboss.com/us/knowledge/Magnetic_resonance_imaging#Zefb6206a3f821bf7e5942b654dc6f6cf) abdomen with enterography Always test for Giardia infection in [chronic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a). \[24\] ## Subsequent evaluation \[10\]\[11\] Perform guided diagnostics based on characteristic clinical features in diarrhea and the results of initial diagnostic testing. \| Diagnostic workup of patients with [chronic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a) \| \| \| \| \|---\|---\|---\|---\| \| Classification \| Initial results \| Further diagnostics \| \| \| [Inflammatory diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z321586a3cfe84e9365a55d0ed20fb62a) \| Fecal [leukocytes](https://www.amboss.com/us/knowledge/Basics_of_hematology#Z18a02873023ccef6d8ea2b461e0b7446) present. Fecal occult blood positive Calprotectin or [lactoferrin](https://www.amboss.com/us/knowledge/Innate_immune_system#Z341d9eb537374add3f4e1350946c378f) positive Elevated [CRP](https://www.amboss.com/us/knowledge/Laboratory_medicine#Z51ad1e101a45a8de708a6dda0321755d) \| [Colonoscopy](https://www.amboss.com/us/knowledge/Colonoscopy#Za4aebc8baa131b83620292e8d0363739) with [mucosal]() [biopsies]() (always required): can identify [IBD](https://www.amboss.com/us/knowledge/Crohn_disease#Z4272f924349255b3e4babe86d4e939c9), [colon cancer](https://www.amboss.com/us/knowledge/Colorectal_cancer#Z5f9a21e2819d2a5004da275e0fe8e909), [ischemic colitis](https://www.amboss.com/us/knowledge/Intestinal_ischemia#Za5a3e828cf2d10df3a9693a9fc3b2c34), [radiation colitis](https://www.amboss.com/us/knowledge/Radiation_injury#Ze0a9ed89b6c1c4ea08173fa19b2b74f9), and [pseudomembranous colitis](https://www.amboss.com/us/knowledge/Clostridioides_difficile_infection#Z9a45a83f4126940236032056da651cf6) Testing for infectious diseases: e.g., [parasites]() ([amebiasis](https://www.amboss.com/us/knowledge/Amebiasis#Z4500356668f80dc7e2e4d3b731ae9d1f)) and [C. difficile infection](https://www.amboss.com/us/knowledge/Clostridioides_difficile_infection#Zb508f99ee028a9d8582608f40bc36f5f) \| \| \| [Fatty diarrhea](https://www.amboss.com/us/knowledge/Chronic_pancreatitis#Z416510d2bd6fcd19b4e328d62b6b10db) \[10\]\[12\]\[16\] \| Increased fecal fat, e.g.: [Sudan stain](https://www.amboss.com/us/knowledge/Cellular_changes_and_adaptive_responses#Z78716b286b479e2c380f54ed824c20fc) positive [72-hour fecal fat estimation](https://www.amboss.com/us/knowledge/Chronic_pancreatitis#Zd212c09e9c64621940c1a0ced94a9c98) elevated \| [Mucosal]() disease: [celiac disease panel](https://www.amboss.com/us/knowledge/Celiac_disease#Z63d359b4e2570234feebde9aaebff219) and [EGD](https://www.amboss.com/us/knowledge/Esophagogastroduodenoscopy#Z1a617ceb3d8b9832108168a091314359) with [biopsies]() Luminal disease [Pancreatic function tests](https://www.amboss.com/us/knowledge/Laboratory_medicine#Zc0f762af46ed9109bda61d0feb7a5ab3) (e.g., [fecal elastase-1](https://www.amboss.com/us/knowledge/Chronic_pancreatitis#Zf555d89ae453336db1900a0d4d2df7e7)): can identify [exocrine pancreatic insufficiency](https://www.amboss.com/us/knowledge/Malabsorption#Z4880cedb9eb57d620afb59b2c9e39a8b) \[18\] [Hydrogen breath test](https://www.amboss.com/us/knowledge/Lactose_intolerance#Z4187a69143c8be5cfd157107e8edb65a) and [EGD](https://www.amboss.com/us/knowledge/Esophagogastroduodenoscopy#Z1a617ceb3d8b9832108168a091314359) with [small bowel aspiration]() and cultures: can identify [SIBO](https://www.amboss.com/us/knowledge/Small_intestinal_bacterial_overgrowth#Z9aa32f677362a235a8ae39e011711f1b) \[34\] \| \| \| [Watery diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z16ed63f1f94f558cfbffed53ce14a7fb) \[11\] \| [Secretory diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Za81182120613af86b266ff31432e241e) or [functional diarrheal disorders](https://www.amboss.com/us/knowledge/Diarrhea#Z68e249c3723fb43d54724dbf2018af91) \| Low [stool osmotic gap](https://www.amboss.com/us/knowledge/Diarrhea#Ze3350ca8675573e0158f73d116234534) (\< 50 mOsm/kg) No fecal [leukocytes](https://www.amboss.com/us/knowledge/Basics_of_hematology#Z18a02873023ccef6d8ea2b461e0b7446) No fecal fat \| [TFTs](https://www.amboss.com/us/knowledge/Hyperthyroidism_and_thyrotoxicosis#Zc2daec2f86dc7f7edf504314f5e9de68), [cortisol](https://www.amboss.com/us/knowledge/Adrenal_gland#Z68437810c311fa1e0e910fecfa30be04) level, [diabetes mellitus screening](https://www.amboss.com/us/knowledge/Diabetes_mellitus#Z880b3ed63aba809ccba7ae2a7afb386d): can detect endocrine disorders Serum [gastrin](https://www.amboss.com/us/knowledge/Gastrointestinal_tract#Z16fdc87a47049d4522f49bf193d34fcb), [VIP](https://www.amboss.com/us/knowledge/Gastrointestinal_tract#Z2a13d7814300b48684ebf0f62ffc0318), [calcitonin](https://www.amboss.com/us/knowledge/Hypocalcemia#Z8f09b075f4d87191d15890436cb2a4a5) level: can detect [neuroendocrine tumors](https://www.amboss.com/us/knowledge/Neuroendocrine_neoplasms#Z688b3fb7764fe32e74754d4b26c6fc89) Evaluation for [bile acid](https://www.amboss.com/us/knowledge/Gallbladder_and_bile#Z86b474a966e0cc8faf1092967eaf82f4) [malabsorption](https://www.amboss.com/us/knowledge/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb) and [SIBO](https://www.amboss.com/us/knowledge/Small_intestinal_bacterial_overgrowth#Z9aa32f677362a235a8ae39e011711f1b) [Rome IV criteria for IBS](https://www.amboss.com/us/knowledge/Irritable_bowel_syndrome#Zc16da4fdfa96f2bd9cf45f216019665a): may indicate [functional diarrhea]() \| \| [Osmotic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z7169e994f812b120ea2df94d1042192e) \| High [stool osmotic gap](https://www.amboss.com/us/knowledge/Diarrhea#Ze3350ca8675573e0158f73d116234534) (≥ 100 mOsm/kg) No fecal [leukocytes](https://www.amboss.com/us/knowledge/Basics_of_hematology#Z18a02873023ccef6d8ea2b461e0b7446) No fecal fat \| Stool [pH]() \< 6 suggests [carbohydrate malabsorption](https://www.amboss.com/us/knowledge/Malabsorption#Z1659a0f218ffe905f7bddb7c54efb326); consider the following: \[11\] [Celiac disease panel](https://www.amboss.com/us/knowledge/Celiac_disease#Z63d359b4e2570234feebde9aaebff219) [Lactose hydrogen breath test](https://www.amboss.com/us/knowledge/Lactose_intolerance#Z4187a69143c8be5cfd157107e8edb65a): can diagnose [lactase deficiency](https://www.amboss.com/us/knowledge/Lactose_intolerance#Zd10b2b1e3672bf92a1e23fc1962405dc) [Small intestine biopsy](https://www.amboss.com/us/knowledge/Malabsorption#Z4c414f1e711c5ae69ceece6cee9f425e): can diagnose [celiac disease](https://www.amboss.com/us/knowledge/Celiac_disease#Z1999c64abb6e85ce70f8cdc66810a65b) or infectious diseases (e.g., [Whipple disease](https://www.amboss.com/us/knowledge/Whipple_disease#Z83c04868f8c75273c89d8c6e966623e4)) Stool [pH]() ≥ 6 suggests [antacid](https://www.amboss.com/us/knowledge/Dyspepsia#Z483f046dcff29152f098e8a15dc67c9b) and/or [laxative]() ingestion \| \| In [watery diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z16ed63f1f94f558cfbffed53ce14a7fb), the [stool osmotic gap](https://www.amboss.com/us/knowledge/Diarrhea#Ze3350ca8675573e0158f73d116234534) differentiates osmotic from [secretory diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Za81182120613af86b266ff31432e241e). In osmotic [watery diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z16ed63f1f94f558cfbffed53ce14a7fb), a stool [pH]() \< 6 suggests [carbohydrate malabsorption](https://www.amboss.com/us/knowledge/Malabsorption#Z1659a0f218ffe905f7bddb7c54efb326). Endoscopic studies with [mucosal]() [biopsies]() are required to diagnose [inflammatory diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z321586a3cfe84e9365a55d0ed20fb62a) in patients with [chronic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a). ## Therapeutic trials \[10\]\[11\]\[18\]\[24\] - Indications - Consider if a diagnosis has not been established after a thorough evaluation. - Consider if diagnostic tests for specific etiologies are not available. - Examples of empiric therapies for specific causes \[18\] - [Elimination diets](): e.g., [lactose](https://www.amboss.com/us/knowledge/Carbohydrates#Z42d58e097395e9a8d8ade84fd063faf8)\-free diet for [lactose intolerance](https://www.amboss.com/us/knowledge/Lactose_intolerance#Z8597682de9e4e8655c2f5df7319b32f3) - [Empiric antibiotics](https://www.amboss.com/us/knowledge/Overview_of_antibiotic_therapy#Z0d92af1eab239465721da02549c61854): e.g., [rifaximin](https://www.amboss.com/us/knowledge/Hepatic_encephalopathy#Za8e7b6e3b08d56feebf985f44969b261) for suspected [SIBO](https://www.amboss.com/us/knowledge/Small_intestinal_bacterial_overgrowth#Z9aa32f677362a235a8ae39e011711f1b) \[34\] - [Cholestyramine](https://www.amboss.com/us/knowledge/Second-line_lipid-lowering_agents#Z1de5d1df48f548f9d227c6743af88c42) for suspected [bile acid](https://www.amboss.com/us/knowledge/Gallbladder_and_bile#Z86b474a966e0cc8faf1092967eaf82f4) [malabsorption](https://www.amboss.com/us/knowledge/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb) \[35\] - Oral [steroids](https://www.amboss.com/us/knowledge/Glucocorticoids#Z3733d22ef7bb87f743207060acda0451) for [microscopic colitis](https://www.amboss.com/us/knowledge/Microscopic_colitis#Z98c8e90c538959e074e80c55a532e1bc) - [Pancreatic enzyme](https://www.amboss.com/us/knowledge/Pancreas#Zb4592cc9a760c08db00e5b2e0bcb8d80) replacement therapy for [exocrine pancreatic insufficiency](https://www.amboss.com/us/knowledge/Malabsorption#Z4880cedb9eb57d620afb59b2c9e39a8b) ## Differential diagnoses![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg) - [Fecal incontinence](https://www.amboss.com/us/knowledge/Fecal_incontinence#Z62ff0b685d439994bb91355e521425cb) - Involuntary release of stool, usually without a sensation of urgency - May indicate abnormal neuromuscular function or anorectal structure - Diagnosis is made based on history and a [digital rectal examination](https://www.amboss.com/us/knowledge/Abdominal_examination#Z5d3564efeb645a3f97c92377b2f3ca28). - Impaction with fecal overflow (paradoxical diarrhea) - Rectal distention relaxes the [internal anal sphincter](https://www.amboss.com/us/knowledge/Hemorrhoids#Z5d181799c154206768eba201b5b182f0), allowing leakage of stool. - Diagnosis is made based on a [digital rectal examination](https://www.amboss.com/us/knowledge/Abdominal_examination#Z5d3564efeb645a3f97c92377b2f3ca28). - [Pseudodiarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z03319666a4dfb1ca98ba5a66ae368c65) - Frequent passage of small amounts of stool - Usually accompanied by [fecal urgency]() or the feeling of incomplete emptying of the [rectum](https://www.amboss.com/us/knowledge/Large_intestine#Z0ebdfdd5b18e5097d9a31ac997523231) - Often accompanies [IBS](https://www.amboss.com/us/knowledge/Irritable_bowel_syndrome#Z2b30a84dc4106c4e8aad1e6c9202f3ea) and [proctitis](https://www.amboss.com/us/knowledge/Proctitis#Z93005674e3e45d8ad4a9fe34183b999d) References:\[11\]\[22\]\[23\] The differential diagnoses listed here are not exhaustive. ## Subtypes and variants![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg) ## Traveler's diarrhea \[36\]\[37\] - Definition: ≥ 3 unformed stools with at least one additional [enteric]() symptom occurring after recent travel - [Epidemiology](https://www.amboss.com/us/knowledge/Epidemiology#Z4c4f63797573af64476acb67d715be49) - The highest rates occur after travel to Africa and South, Central, and West Asia. - Approximately 25% of all travelers develop [traveler's diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Zed77ffe538dae231e40fe0542e7b245a). - Etiology - [Enterotoxigenic E. coli](https://www.amboss.com/us/knowledge/Diarrheagenic_E._coli#Z458147f1e1273e554884140b40317779) ([ETEC](https://www.amboss.com/us/knowledge/Diarrheagenic_E._coli#Z458147f1e1273e554884140b40317779)) is the most common cause of [traveler's diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Zed77ffe538dae231e40fe0542e7b245a) globally. - [Campylobacter jejuni](https://www.amboss.com/us/knowledge/Bacteria_overview#Z4a3deabcd49cf50e8c48e5f0d5dcc506) is the most common cause in Southeast Asia. - Other pathogens - Bacterial: [Shigella](https://www.amboss.com/us/knowledge/Bacteria_overview#Z40dc9a1dcc2df2a82a0c4586e5023158) spp., [Salmonella](https://www.amboss.com/us/knowledge/Bacteria_overview#Zcf62cfeb3796c44845f303785e4bb88c) spp., other [E. coli](https://www.amboss.com/us/knowledge/Bacteria_overview#Z2018b58c3c7835457287264e40fa1a3c) strains (e.g., [EAEC](https://www.amboss.com/us/knowledge/Bacteria_overview#Za7272c791289de3f342534103a939841)) - Viral: [norovirus](https://www.amboss.com/us/knowledge/General_virology#Z85b05d149dafb61d67a5c48e9a2fdb65), [rotavirus](https://www.amboss.com/us/knowledge/General_virology#Z0b6c006e84714af76f7c43bebbeb2315), [astrovirus](https://www.amboss.com/us/knowledge/General_virology#Zc55a1d58333a52b6c627a91623b6b333) - [Protozoal](https://www.amboss.com/us/knowledge/General_parasitology#Z8f4f3567860a31947bee8edff7ea6bd5): [Giardia duodenalis](https://www.amboss.com/us/knowledge/Giardiasis#Zc37e227ee434dce8d190d098017db709), [E. histolytica](https://www.amboss.com/us/knowledge/Amebiasis#Z4001b357f1b712e83d6027a4dfa5731b) - Clinical features: [exudative]()\-inflammatory or [secretory diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Za81182120613af86b266ff31432e241e), abdominal cramping, abdominal [pain](https://www.amboss.com/us/knowledge/Principles_of_pain_management#Zd673a3f7ee36023aab5a267899e984cc) - Antibiotics for traveler's diarrhea: Reserve for moderate to severe illness. \[25\]\[32\]\[36\] - For most destinations: [ciprofloxacin](https://www.amboss.com/us/knowledge/Overview_of_antibiotic_therapy#Z3f1dbc417664139dda097bcd516ceeed) ([off label](https://www.amboss.com/us/knowledge/Fundamentals_of_pharmacology#Zb37ab5e3f79a4ddd6b356eb84fa0067a)) OR [rifaximin](https://www.amboss.com/us/knowledge/Hepatic_encephalopathy#Za8e7b6e3b08d56feebf985f44969b261) \[36\] - For travelers to South or Southeast Asia: [azithromycin](https://www.amboss.com/us/knowledge/Overview_of_antibiotic_therapy#Z9884c173cd8bcd36d44eb85ea8acfec2) ([off label](https://www.amboss.com/us/knowledge/Fundamentals_of_pharmacology#Zb37ab5e3f79a4ddd6b356eb84fa0067a)) \[36\] - [Supportive care]() \[25\] - Treatment for [dehydration](https://www.amboss.com/us/knowledge/Dehydration_and_hypovolemia#Zbd78324053c153c16ea5cb2574249398) (e.g., [oral rehydration solution](https://www.amboss.com/us/knowledge/Dehydration_and_hypovolemia#Z22573072c2ce7ea0ba0873c3024dc043)) - [Bismuth subsalicylate](https://www.amboss.com/us/knowledge/Helicobacter_pylori_infection#Z5ff316bf4e8912c06dc600df2a9e8b09) for patients with mild to moderate illness - [Loperamide](https://www.amboss.com/us/knowledge/Opioids#Z1881077ac71cd771cb44b7db04569ac0) for patients receiving [antibiotic therapy](https://www.amboss.com/us/knowledge/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3) (can reduce the duration of illness) - See “[Antidiarrheal agents](https://www.amboss.com/us/knowledge/Diarrhea#Zc9c4c39a6ce3413ed32214ba89c1e777)” for dosages. - Postinfectious sequelae - [Postinfectious IBS](): may occur in 3–20% of patients - [Reactive arthritis](https://www.amboss.com/us/knowledge/Reactive_arthritis#Z004554eda6fc600767f0d5dbaca1925d): may last months to years - [Guillain-Barre syndrome](https://www.amboss.com/us/knowledge/Guillain-Barr%C3%A9_syndrome#Zf193c1b0b16db4d30e7f29d4e766d3e8): may develop 1–4 weeks after infection (most commonly after [Campylobacter](https://www.amboss.com/us/knowledge/Bacteria_overview#Za64f770db8dc668f93db5788517d1bc0) infection) [Antibiotic](https://www.amboss.com/us/knowledge/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3) treatment is not recommended in patients with mild [traveler's diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Zed77ffe538dae231e40fe0542e7b245a). [Bismuth subsalicylate](https://www.amboss.com/us/knowledge/Helicobacter_pylori_infection#Z5ff316bf4e8912c06dc600df2a9e8b09) is an [antidiarrheal agent](https://www.amboss.com/us/knowledge/Diarrhea#Zc9c4c39a6ce3413ed32214ba89c1e777) used to treat [traveler's diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Zed77ffe538dae231e40fe0542e7b245a) (caused by [enterotoxigenic Escherichia coli](https://www.amboss.com/us/knowledge/Diarrheagenic_E._coli#Z458147f1e1273e554884140b40317779)). ### Pharmacological prophylaxis for traveler's diarrhea \[25\]\[36\] Consider for travelers to high-risk areas (under specialist guidance); options include: - [Bismuth subsalicylate](https://www.amboss.com/us/knowledge/Helicobacter_pylori_infection#Z5ff316bf4e8912c06dc600df2a9e8b09) ([off label](https://www.amboss.com/us/knowledge/Fundamentals_of_pharmacology#Zb37ab5e3f79a4ddd6b356eb84fa0067a)) \[25\]\[36\]\[38\] - Consider for travelers with no contraindications for use. - Should be taken with meals and at bedtime - [Antibiotic prophylaxis](https://www.amboss.com/us/knowledge/Overview_of_antibiotic_therapy#Z59b09641b101520dcac91806ce3bc6c4) (generally discouraged) : - Consider short-term administration in travelers who are at high-risk for developing serious complications. - Agents include [fluoroquinolones](https://www.amboss.com/us/knowledge/Overview_of_antibiotic_therapy#Z6b160289536b8a7a7a2c161a02014e7c), [azithromycin](https://www.amboss.com/us/knowledge/Overview_of_antibiotic_therapy#Z9884c173cd8bcd36d44eb85ea8acfec2), and [rifaximin](https://www.amboss.com/us/knowledge/Hepatic_encephalopathy#Za8e7b6e3b08d56feebf985f44969b261). - Probiotics, prebiotics, and synbiotics are not recommended. ## Factitious diarrhea \[11\] - Definition: self-induced diarrhea, usually due to [laxative abuse](https://www.amboss.com/us/knowledge/Diarrhea#Zf400d371a3aeaaef09f5533381e99329) (often occurs in individuals with [factitious disorders](https://www.amboss.com/us/knowledge/Somatic_symptom_and_related_disorders#Za429ee6281b4bad77a94b44df89f4036)), or dilution of stools with solutions - [Epidemiology](https://www.amboss.com/us/knowledge/Epidemiology#Z4c4f63797573af64476acb67d715be49) - Most prevalent in women - Patients are usually [health care professionals](). - History of multiple hospital admissions - Clinical features: [chronic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a) without an identifiable cause - Diagnostics - Laboratory tests: [metabolic acidosis](https://www.amboss.com/us/knowledge/Acid-base_disorders#Ze6ecd1a689f21c50f6f1d77dcd2bd10b) , [metabolic alkalosis](https://www.amboss.com/us/knowledge/Acid-base_disorders#Z46196a0a09cd3ccdd01835db5b427a7c) , [hypokalemia](https://www.amboss.com/us/knowledge/Hypokalemia#Z1454fccf44cdd1776601d443f63ca03c), [hypermagnesemia](https://www.amboss.com/us/knowledge/Hypermagnesemia#Z80b32d5d74b73a5c759d3ecd2043a7e6) - Stool [osmolarity](https://www.amboss.com/us/knowledge/Intravenous_fluid_therapy#Zdeae47858e4e2ccdf3ffe701a1970e95) - \< 290 mOsm/L: indicates dilution of the stool with a hypotonic solution - \> 600 mOsm/L: indicates dilution of the stool with a hypertonic solution - [Laxative]() screen \[18\] - [Colonoscopy](https://www.amboss.com/us/knowledge/Colonoscopy#Za4aebc8baa131b83620292e8d0363739): may show [melanosis coli](https://www.amboss.com/us/knowledge/Diarrhea#Z21e7a77240bb6cafa756a1d9e263da87) in cases of anthraquinone abuse - Treatment - Correction of [electrolyte](https://www.amboss.com/us/knowledge/Laboratory_medicine#Z562f1491861b33bdb5af572388e99541) disturbances and [dehydration](https://www.amboss.com/us/knowledge/Dehydration_and_hypovolemia#Zbd78324053c153c16ea5cb2574249398) - Referral for [psychotherapy](https://www.amboss.com/us/knowledge/Psychotherapy_and_defense_mechanisms#Zf708bc74cb22922dcaead5dadff629f1) ### Laxative abuse - Types of [laxative]() - Bulking agent: e.g., flaxseed - [Osmotic laxatives](https://www.amboss.com/us/knowledge/Constipation#Z6beba559f6dfabe7c19e807cf28747b9): e.g., [lactulose](https://www.amboss.com/us/knowledge/Constipation#Z0852fd0c491f2b6f0a759881cabda4f6), macrogols ([polyethylene glycol](https://www.amboss.com/us/knowledge/Constipation#Zcde79976b13e9812a2b43638e222638a)), [magnesium sulfate](https://www.amboss.com/us/knowledge/Antiarrhythmic_drugs#Z0ff5d7d7c8e365d789ab5203a4d3be0d), [sodium](https://www.amboss.com/us/knowledge/Water_and_electrolyte_metabolism#Z420309902608f05802e6d9d942b6e0b1) sulfate - Diphenolic [laxatives](): [bisacodyl](https://www.amboss.com/us/knowledge/Constipation#Zbf46603548ee0c75699c6ca00fd4012e), [sodium picosulfate](https://www.amboss.com/us/knowledge/Constipation#Zdb1b407c1514de705a12a3d578503d44) - Anthraquinones: e.g., [senna](https://www.amboss.com/us/knowledge/Constipation#Zc0086a2d59642def31185968e7198850), aloe vera, rhubarb - Clinical features - [Osmotic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z7169e994f812b120ea2df94d1042192e), [meteorism]() - [Dehydration](https://www.amboss.com/us/knowledge/Dehydration_and_hypovolemia#Zbd78324053c153c16ea5cb2574249398) - [Hypokalemia](https://www.amboss.com/us/knowledge/Hypokalemia#Z1454fccf44cdd1776601d443f63ca03c) - Melanosis coli: benign [hyperpigmentation]() of the [colonic](https://www.amboss.com/us/knowledge/Large_intestine#Ze19293358dc6c65dc95f936bb8fca493) [mucosa]() caused by anthraquinone abuse \[39\] - [Colonoscopy](https://www.amboss.com/us/knowledge/Colonoscopy#Za4aebc8baa131b83620292e8d0363739): patches of dark brown pigmentation interspersed with pale [mucosa]() - [Biopsy](): [lipofuscin](https://www.amboss.com/us/knowledge/Cellular_changes_and_adaptive_responses#Z9dfa90b47fb5223ad397e9ba918a6301)\-laden [macrophages](https://www.amboss.com/us/knowledge/Basics_of_hematology#Z0e19366f91c1f6b0bdaabf9f6bd6d2b8) demonstrated on [periodic acid-Schiff](https://www.amboss.com/us/knowledge/Pathology_techniques#Z3b9e905f86b4ae250a18aa356f30b003) staining 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## Bile acid diarrhea - Definition: [secretory diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Za81182120613af86b266ff31432e241e) with or without [steatorrhea](https://www.amboss.com/us/knowledge/Chronic_pancreatitis#Z416510d2bd6fcd19b4e328d62b6b10db) due to increased [colonic](https://www.amboss.com/us/knowledge/Large_intestine#Ze19293358dc6c65dc95f936bb8fca493) secretion and motility secondary to an increased concentration of [bile acids](https://www.amboss.com/us/knowledge/Gallbladder_and_bile#Z86b474a966e0cc8faf1092967eaf82f4) within the [colon](https://www.amboss.com/us/knowledge/Large_intestine#Ze19293358dc6c65dc95f936bb8fca493) - [Epidemiology](https://www.amboss.com/us/knowledge/Epidemiology#Z4c4f63797573af64476acb67d715be49): approx. 1% [global]() [prevalence](https://www.amboss.com/us/knowledge/Population_health#Z44a0fb80a8923b6e2fb8ff1f83d5803a) \[40\] - Etiology - [Ileal](https://www.amboss.com/us/knowledge/Small_intestine#Zf3a10de88f22b839a2769aa9ae031960) dysfunction or decreased [bile acid](https://www.amboss.com/us/knowledge/Gallbladder_and_bile#Z86b474a966e0cc8faf1092967eaf82f4) reabsorption in the [ileum](https://www.amboss.com/us/knowledge/Small_intestine#Zf3a10de88f22b839a2769aa9ae031960) (e.g., due to [ileal](https://www.amboss.com/us/knowledge/Small_intestine#Zf3a10de88f22b839a2769aa9ae031960) resection, [Crohn disease](https://www.amboss.com/us/knowledge/Crohn_disease#Zef70853af5e87c95d210bf8df682f64c)) - Postcholecystectomy - Hepatic overproduction of [bile acids](https://www.amboss.com/us/knowledge/Gallbladder_and_bile#Z86b474a966e0cc8faf1092967eaf82f4) - [Biliary-enteric fistula](https://www.amboss.com/us/knowledge/Fistulas#Z1787c9a9b3b830805f4bf55265169989) - Clinical features - Bowel frequency and urgency - [Fecal incontinence](https://www.amboss.com/us/knowledge/Fecal_incontinence#Z62ff0b685d439994bb91355e521425cb) - Abdominal cramping, abdominal [pain](https://www.amboss.com/us/knowledge/Principles_of_pain_management#Zd673a3f7ee36023aab5a267899e984cc) - Nocturnal [fecal urgency]() - [Bloating](), flatulence - Management \[41\] - First-line: [bile](https://www.amboss.com/us/knowledge/Gallbladder_and_bile#Z4d90dfc94eec0585c748e9b6c6899d95)\-acid sequestrants (e.g., [cholestyramine](https://www.amboss.com/us/knowledge/Second-line_lipid-lowering_agents#Z1de5d1df48f548f9d227c6743af88c42), [colestipol](https://www.amboss.com/us/knowledge/Second-line_lipid-lowering_agents#Z68ba6641495fdd1c0f72726e29d4eecb)) - Dietary intervention: low-fat diet ## References![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg) 1. Sweetser S. Evaluating the Patient With Diarrhea: A Case-Based Approach. Mayo Clinic Proceedings. 2012; 87 (6): p.596-602.doi: [10\.1016/j.mayocp.2012.02.015](https://dx.doi.org/10.1016/j.mayocp.2012.02.015) . \\| [Open in Read by QxMD](https://read.qxmd.com/doi/10.1016/j.mayocp.2012.02.015) 2. Jamshed N, Lee Z-E, Olden KW. Diagnostic Approach to Chronic Constipation in Adults. Am Fam Physician. 2011; 84 (3): p.299-306. 3. Burgers K, Lindberg B, Bevis ZJ. Chronic Diarrhea in Adults: Evaluation and Differential Diagnosis.. Am Fam Physician. 2020; 101 (8): p.472-480. 4. Schiller LR. Evaluation of chronic diarrhea and irritable bowel syndrome with diarrhea in adults in the era of precision medicine. Am J Gastroenterol. 2018; 113 (5): p.660-669.doi: [10\.1038/s41395-018-0032-9](https://dx.doi.org/10.1038/s41395-018-0032-9) . \\| [Open in Read by QxMD](https://read.qxmd.com/doi/10.1038/s41395-018-0032-9) 5. Abraham B, Sellin JH. Drug-induced diarrhea. Curr Gastroenterol Rep. 2007; 9 (5): p.365-372.doi: [10\.1007/s11894-007-0044-x](https://dx.doi.org/10.1007/s11894-007-0044-x) . \\| [Open in Read by QxMD](https://read.qxmd.com/doi/10.1007/s11894-007-0044-x) 6. Semrad CE. Approach to the Patient with Diarrhea and Malabsorption. Elsevier ; 2012: p. 895-913 7. Farahmandfar MR, Chabok M, Alade M, Bouhelal A, Patel B. Post Cholecystectomy Diarrhoea—A Systematic Review. Surgical Science. 2012; 03 (06): p.332-338.doi: [10\.4236/ss.2012.36065](https://dx.doi.org/10.4236/ss.2012.36065) . \\| [Open in Read by QxMD](https://read.qxmd.com/doi/10.4236/ss.2012.36065) 8. Schiller LR, Pardi DS, Sellin JH. Chronic Diarrhea: Diagnosis and Management. Clinical Gastroenterology and Hepatology. 2017; 15 (2): p.182-193.e3.doi: [10\.1016/j.cgh.2016.07.028](https://dx.doi.org/10.1016/j.cgh.2016.07.028) . \\| [Open in Read by QxMD](https://read.qxmd.com/doi/10.1016/j.cgh.2016.07.028) 9. Borbély YM, Osterwalder A, Kröll D, Nett PC, Inglin RA. Diarrhea after bariatric procedures: Diagnosis and therapy. World Journal of Gastroenterology. 2017; 23 (26): p.4689.doi: [10\.3748/wjg.v23.i26.4689](https://dx.doi.org/10.3748/wjg.v23.i26.4689) . \\| [Open in Read by QxMD](https://read.qxmd.com/doi/10.3748/wjg.v23.i26.4689) 10. Ma IT, Madura JA 2nd. Gastrointestinal Complications After Bariatric Surgery. Gastroenterol Hepatol. 2015; 11 (8): p.526-35. 11. Barr W, Smith A. Acute diarrhea in adults. Am Fam Physician. 2014; 89 (3): p.180-189. 12. Jameson JL, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. Harrison's Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2). McGraw-Hill Education / Medical ; 2018 13. Hammer HF. Management of Chronic Diarrhea in Primary Care: The Gastroenterologists Advice. Digestive Diseases. 2021.doi: [10\.1159/000515219](https://dx.doi.org/10.1159/000515219) . \\| [Open in Read by QxMD](https://read.qxmd.com/doi/10.1159/000515219) 14. Smalley W, Falck-Ytter C, Carrasco-Labra A, Wani S, Lytvyn L, Falck-Ytter Y. AGA Clinical Practice Guidelines on the Laboratory Evaluation of Functional Diarrhea and Diarrhea-Predominant Irritable Bowel Syndrome in Adults (IBS-D). Gastroenterology. 2019; 157 (3): p.851-854.doi: [10\.1053/j.gastro.2019.07.004](https://dx.doi.org/10.1053/j.gastro.2019.07.004) . \\| [Open in Read by QxMD](https://read.qxmd.com/doi/10.1053/j.gastro.2019.07.004) 15. Camilleri M, Sellin JH, Barrett KE. Pathophysiology, Evaluation, and Management of Chronic Watery Diarrhea. Gastroenterology. 2017; 152 (3): p.515-532.e2.doi: [10\.1053/j.gastro.2016.10.014](https://dx.doi.org/10.1053/j.gastro.2016.10.014) . \\| [Open in Read by QxMD](https://read.qxmd.com/doi/10.1053/j.gastro.2016.10.014) 16. Pimentel M, Saad RJ, Long MD, Rao SSC. ACG Clinical Guideline: Small Intestinal Bacterial Overgrowth. Am J Gastroenterol. 2020; 115 (2): p.165-178.doi: [10\.14309/ajg.0000000000000501](https://dx.doi.org/10.14309/ajg.0000000000000501) . \\| [Open in Read by QxMD](https://read.qxmd.com/doi/10.14309/ajg.0000000000000501) 17. Vijayvargiya P, Camilleri M, Shin A, Saenger A. Methods for Diagnosis of Bile Acid Malabsorption in Clinical Practice. Clinical Gastroenterology and Hepatology. 2013; 11 (10): p.1232-1239.doi: [10\.1016/j.cgh.2013.04.029](https://dx.doi.org/10.1016/j.cgh.2013.04.029) . \\| [Open in Read by QxMD](https://read.qxmd.com/doi/10.1016/j.cgh.2013.04.029) 18. Riddle MS, DuPont HL, Connor BA. ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults. Am J Gastroenterol. 2016; 111 (5): p.602-622.doi: [10\.1038/ajg.2016.126](https://dx.doi.org/10.1038/ajg.2016.126) . \\| [Open in Read by QxMD](https://read.qxmd.com/doi/10.1038/ajg.2016.126) 19. DuPont HL. Acute Infectious Diarrhea in Immunocompetent Adults. N Engl J Med. 2014; 370 (16): p.1532-1540.doi: [10\.1056/nejmra1301069](https://dx.doi.org/10.1056/nejmra1301069) . \\| [Open in Read by QxMD](https://read.qxmd.com/doi/10.1056/nejmra1301069) 20. Shane AL, Mody RK, Crump JA, et al. 2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea. Clin Infect Dis. 2017; 65 (12): p.e45-e80.doi: [10\.1093/cid/cix669](https://dx.doi.org/10.1093/cid/cix669) . \\| [Open in Read by QxMD](https://read.qxmd.com/doi/10.1093/cid/cix669) 21. DuPont HL. Persistent Diarrhea. JAMA. 2016; 315 (24): p.2712.doi: [10\.1001/jama.2016.7833](https://dx.doi.org/10.1001/jama.2016.7833) . \\| [Open in Read by QxMD](https://read.qxmd.com/doi/10.1001/jama.2016.7833) 22. Qiu FZ, Shen XX, Li GX, et al. Adenovirus associated with acute diarrhea: a case-control study.. BMC Infect Dis. 2018; 18 (1): p.450.doi: [10\.1186/s12879-018-3340-1](https://dx.doi.org/10.1186/s12879-018-3340-1) . \\| [Open in Read by QxMD](https://read.qxmd.com/doi/10.1186/s12879-018-3340-1) 23. Histamine Toxicity. <https://www.aaaai.org/conditions-and-treatments/related-conditions/histamine-toxicity>. Updated: March 1, 2017. Accessed: March 1, 2017. 24. Overview of Food Poisoning. <http://www.msdmanuals.com/home/injuries-and-poisoning/poisoning/overview-of-food-poisoning>. Updated: March 1, 2017. Accessed: March 1, 2017. 25. Juckett G, Trivedi R. Evaluation of Chronic Diarrhea. Am Fam Physician. 2011; 84 (10): p.1119-1126. 26. DuPont HL. Adverse Effect of Lomotil Therapy in Shigellosis. JAMA. 1973; 226 (13): p.1525.doi: [10\.1001/jama.1973.03230130013006](https://dx.doi.org/10.1001/jama.1973.03230130013006) . \\| [Open in Read by QxMD](https://read.qxmd.com/doi/10.1001/jama.1973.03230130013006) 27. Singh N, Narayan S. Racecadotril : A Novel Antidiarrheal. Med J Armed Forces India. 2008; 64 (4): p.361-2.doi: [10\.1016/S0377-1237(08)80022-6](https://dx.doi.org/10.1016/S0377-1237\(08\)80022-6) . \\| [Open in Read by QxMD](https://read.qxmd.com/doi/10.1016/S0377-1237\(08\)80022-6) 28. Benjamin I. Andreoli and Carpenter's Cecil Essentials of Medicine. Elsevier Health Sciences ; 2016 29. Diarrhoeal disease. <http://www.who.int/mediacentre/factsheets/fs330/en/>. Updated: April 1, 2013. Accessed: March 1, 2017. 30. Schiller LR, Pardi DS, Spiller R, et al. Gastro 2013 APDW/WCOG Shanghai Working Party Report: Chronic diarrhea: Definition, classification, diagnosis. J Gastroenterol Hepatol. 2013; 29 (1): p.6-25.doi: [10\.1111/jgh.12392](https://dx.doi.org/10.1111/jgh.12392) . \\| [Open in Read by QxMD](https://read.qxmd.com/doi/10.1111/jgh.12392) 31. Dellon ES, Ringel Y. Treatment of functional diarrhea. Curr Treat Options Gastroenterol. 2006; 9 (4): p.331-342.doi: [10\.1007/s11938-006-0015-6](https://dx.doi.org/10.1007/s11938-006-0015-6) . \\| [Open in Read by QxMD](https://read.qxmd.com/doi/10.1007/s11938-006-0015-6) 32. Travelers' Diarrhea. <https://web.archive.org/web/20240929175416/https://wwwnc.cdc.gov/travel/yellowbook/2024/preparing/travelers-diarrhea>. Updated: November 22, 2019. Accessed: September 29, 2024. 33. Giddings SL, Stevens AM, Leung DT. Traveler’s Diarrhea. Med Clin North Am. 2016; 100 (2): p.317-330.doi: [10\.1016/j.mcna.2015.08.017](https://dx.doi.org/10.1016/j.mcna.2015.08.017) . \\| [Open in Read by QxMD](https://read.qxmd.com/doi/10.1016/j.mcna.2015.08.017) 34. Herbert L. DuPont, Charles D. Ericsson, P. C. Johnson, F. Javier de la Cabada. Use of Bismuth Subsalicylate for the Prevention of Travelers' Diarrhea. Clinical Infectious Diseases. 1990; 12 (Supplement\_1): p.S64-S67.doi: [10\.1093/clinids/12.supplement\_1.s64](https://dx.doi.org/10.1093/clinids/12.supplement_1.s64) . \\| [Open in Read by QxMD](https://read.qxmd.com/doi/10.1093/clinids/12.supplement_1.s64) 35. Freeman HJ. “Melanosis” in the small and large intestine. World J Gastroenterol. 2008; 14 (27): p.4296.doi: [10\.3748/wjg.14.4296](https://dx.doi.org/10.3748/wjg.14.4296) . \\| [Open in Read by QxMD](https://read.qxmd.com/doi/10.3748/wjg.14.4296) 36. Walters JR, Pattni SS. Managing bile acid diarrhoea.. Therap Adv Gastroenterol.. 2010; 3 (6): p.349-57.doi: [10\.1177/1756283X10377126](https://dx.doi.org/10.1177/1756283X10377126) . \\| [Open in Read by QxMD](https://read.qxmd.com/doi/10.1177/1756283X10377126) 37. Farrugia A, Arasaradnam R. Bile acid diarrhoea: pathophysiology, diagnosis and management. Frontline Gastroenterology. 2020; 12 (6): p.500-507.doi: [10\.1136/flgastro-2020-101436](https://dx.doi.org/10.1136/flgastro-2020-101436) . \\| [Open in Read by QxMD](https://read.qxmd.com/doi/10.1136/flgastro-2020-101436) 38. Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. <https://web.archive.org/web/20260126024001/https://clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/adult-adolescent-oi/guidelines-adult-adolescent-oi.pdf>. Updated: July 14, 2025. Accessed: January 25, 2026. 39. Kasper DL, Fauci AS, Hauser SL, et al. Harrison's Principles of Internal Medicine. McGraw-Hill Education ; 2015 40. Walker HK, Hall WD, Hurst WJ, Silverman ME, Morrison G. Clinical Methods: The History, Physical, and Laboratory Examinations. Butterworths ; 1990 41. Saad RJ, Chey WD. Breath Testing for Small Intestinal Bacterial Overgrowth: Maximizing Test Accuracy. Clin Gastroenterol Hepatol. 2014; 12 (12): p.1964-1972.doi: [10\.1016/j.cgh.2013.09.055](https://dx.doi.org/10.1016/j.cgh.2013.09.055) . \\| [Open in Read by QxMD](https://read.qxmd.com/doi/10.1016/j.cgh.2013.09.055) - [© 2026 AMBOSS](https://www.amboss.com/us) - [Medical Knowledge](https://www.amboss.com/us/knowledge) - [Terms and Conditions](https://www.amboss.com/us/legal/terms) - [Privacy](https://www.amboss.com/us/privacy) - [Privacy Settings](https://www.amboss.com/us/knowledge/diarrhea/) - [Legal Notice](https://www.amboss.com/us/legal/imprint) - [Get Support & Contact Us](https://support.amboss.com/hc/en-us) Sign up and get unlimited access. [Start free trial](https://next.amboss.com/us/registration?nextLink=%2Farticle%2F6M0jpg) Evidence-based content, created and peer-reviewed by physicians. Read the [disclaimer](https://www.amboss.com/us/disclaimer)
Readable Markdown	Last updated: February 27, 2026 ## Quick guide![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg) Diagnostic testing is not indicated for most cases of . ## Summary![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg) Diarrhea, defined as three or more loose stools per day or more frequent stool passage than is normal for the individual, is a common disease with a monthly [prevalence](https://www.amboss.com/us/knowledge/Population_health#Z44a0fb80a8923b6e2fb8ff1f83d5803a) of around 5% in the United States. [Acute diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z9902a484faaf54b4fa1ffaf3a5642113) lasts 14 days or less and is almost always caused by an infectious agent, typically a [virus](https://www.amboss.com/us/knowledge/General_virology#Zcdc83877f75d9d9b9a07ece6544f646c). Testing is seldom required, as the disease tends to be [self-limited]() and care is primarily supportive. [Persistent diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Zd56cfaa165f80b20fe15e54d5f2c0023), lasting 15–30 days, is also typically caused by an infectious agent, but stool testing for pathogens is generally warranted to confirm the diagnosis. [Chronic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a), defined as diarrhea lasting longer than 30 days, has an extensive differential diagnosis. A thorough history followed by systematic stool and blood testing is required to identify the specific etiology. The presence of any [red flags]() for severe or rapidly progressing diarrheal disease (e.g., [sepsis](https://www.amboss.com/us/knowledge/Sepsis#Zb3de189fac0d57eac5b7798e127a5e19), extreme [dehydration](https://www.amboss.com/us/knowledge/Dehydration_and_hypovolemia#Zbd78324053c153c16ea5cb2574249398), blood in the stool) mandates escalation of testing and, in some cases, [empiric antibiotics for bacterial gastroenteritis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z8bc7c574b3a32ce97b6e98deca3d7a27). Ensuring adequate oral hydration, correcting [dehydration](https://www.amboss.com/us/knowledge/Dehydration_and_hypovolemia#Zbd78324053c153c16ea5cb2574249398), and providing symptomatic relief are fundamental components in the care of all patients with diarrhea. Curative treatment is directed toward the underlying cause. ## Definitions![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg) The WHO defines diarrhea as ≥ 3 loose or watery stools per day or more frequent passage than is normal for the individual. \[1\]\[2\] ## Etiology![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg) For etiologies of acute, persistent, or [chronic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a), see specific subsections below. ## [Overview of pathogens causing watery and bloody diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z8e48114f95d466b966813a8876de0264) \| Overview \| \| \| \| \| \|---\|---\|---\|---\|---\| \| Type of diarrhea \| [Pathogen]() \| [Pathogen]() characteristics \| Associated disorders \| \| \| [Watery diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z16ed63f1f94f558cfbffed53ce14a7fb) \| Enterotoxigenic [Escherichia coli](https://www.amboss.com/us/knowledge/Bacteria_overview#Z2018b58c3c7835457287264e40fa1a3c) \| [Heat-labile toxin](https://www.amboss.com/us/knowledge/Diarrheagenic_E._coli#Zb07ccb32bbf8bafda07228b738b272b0) [Heat-stable toxin](https://www.amboss.com/us/knowledge/Diarrheagenic_E._coli#Z05a3bf9bd37c476e311abbdb16510192) \| [Traveler's diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Zed77ffe538dae231e40fe0542e7b245a) \| \| \| [Clostridioides difficile](https://www.amboss.com/us/knowledge/Bacteria_overview#Z429d21670093a08ffb061528b0561719) \| [Toxin A](https://www.amboss.com/us/knowledge/Clostridioides_difficile_infection#Z953ec09a4d6afc7094cd488f8493999f) ([enterotoxin]()) [Toxin B](https://www.amboss.com/us/knowledge/Clostridioides_difficile_infection#Za0f3dac89ddbb94c6ce33441f7ca29d0) (cytotoxin) Associated with [antibiotic](https://www.amboss.com/us/knowledge/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3) and [PPI](https://www.amboss.com/us/knowledge/Proton_pump_inhibitors#Z2753e50142e2f5b7089b165accdcc900) use \| [Pseudomembranous colitis](https://www.amboss.com/us/knowledge/Clostridioides_difficile_infection#Z9a45a83f4126940236032056da651cf6) Rarely causes bloody diarrhea \| \| \| \| [Clostridium perfringens](https://www.amboss.com/us/knowledge/Bacteria_overview#Z927388b963f796f8c6f170841d77b930) \| [Heat-labile enterotoxin](https://www.amboss.com/us/knowledge/Diarrheagenic_E._coli#Zb07ccb32bbf8bafda07228b738b272b0) [Clostridium perfringens alpha toxin](https://www.amboss.com/us/knowledge/Gas_gangrene#Z29badee7cb2803331016ab554584eccc) \| [Gas gangrene](https://www.amboss.com/us/knowledge/Gas_gangrene#Zc843bd9262a7db4767485d787d9c2653) \| \| \| \| [Vibrio cholerae](https://www.amboss.com/us/knowledge/Bacteria_overview#Z5040d5b8f384d034307ec998d5706c4a) \| Straight or curved (comma-shaped) [Cholera toxin](https://www.amboss.com/us/knowledge/General_bacteriology#Z463b688997a9f1dd2f1a2f94cbafd0f9) ([enterotoxin]()): “rice water” diarrhea Transmission via contaminated water or uncooked seafood (e.g., raw shellfish) \| [Cholera](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Zba6a00519c1b345599491aa93180aacf) \| \| \| \| [Viruses](https://www.amboss.com/us/knowledge/General_virology#Zcdc83877f75d9d9b9a07ece6544f646c) \| [Norovirus](https://www.amboss.com/us/knowledge/General_virology#Z85b05d149dafb61d67a5c48e9a2fdb65) (most common cause) \| Fecal-oral or [airborne transmission]() \| [Gastroenteritis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Zcbd93ce063d015f699fd07ed09015b7f) \| \| \| [Rotavirus](https://www.amboss.com/us/knowledge/General_virology#Z0b6c006e84714af76f7c43bebbeb2315) \| [Fecal-oral transmission]() Prevention: attenuated [vaccine](https://www.amboss.com/us/knowledge/Vaccination#Zce79039ee0c9c756b2e006d3be169afc) for children \| \| \| \| \| [Adenovirus](https://www.amboss.com/us/knowledge/General_virology#Z5251a57602a66d951ca7a8a66643ee51) \| Transmission via contaminated water or [fecal-oral route]() \| \| \| \| \| [Protozoa](https://www.amboss.com/us/knowledge/General_parasitology#Z8f4f3567860a31947bee8edff7ea6bd5) \| [Giardia lamblia](https://www.amboss.com/us/knowledge/Giardiasis#Zc37e227ee434dce8d190d098017db709) \| Transmission via ingestion of contaminated water (e.g., lakes, rivers, ponds, swimming pools) Most commonly affects hikers or campers \| [Giardiasis](https://www.amboss.com/us/knowledge/Giardiasis#Z7285e874bce9a0f39983534a6c838736) \| \| \| [Cryptosporidia](https://www.amboss.com/us/knowledge/Food_poisoning#Z2838c305630a575a1e345dd9004ef9ea) \| [Fecal-oral transmission]() ([oocysts]() are typically excreted in stool and contaminate drinking water) \| [Cryptosporidiosis](https://www.amboss.com/us/knowledge/HIV-associated_conditions#Z50d6fcd479428e63a00b9454e02cad44) [Immunocompromised individuals](https://www.amboss.com/us/knowledge/Adaptive_immune_system#Z1af19ecc772907dd339670b5fb0e8b51): potentially life-threatening protracted diarrhea and/or [biliary tract](https://www.amboss.com/us/knowledge/Gallbladder_and_bile#Zadee0fdc5649284d46b022246819e246) infections (e.g., [cholangitis](https://www.amboss.com/us/knowledge/Acute_cholangitis#Z9f187436aa934749f4437c12be5f3f0d), [cholecystitis](https://www.amboss.com/us/knowledge/Acute_cholecystitis#Z08db08956e4ea1aca8e4c7e965b533f7)) \| \| \| \| [Cystoisospora belli](https://www.amboss.com/us/knowledge/General_parasitology#Za983f2c51a6b8452adfa91552fb181e2) \[3\] \| Foodborne Contaminated water \| [Cystoisosporiasis](https://www.amboss.com/us/knowledge/HIV-associated_conditions#Z1e782fdfd6ae6a71daf64a4e1644b0a9) [Immunocompromised individuals](https://www.amboss.com/us/knowledge/Adaptive_immune_system#Z1af19ecc772907dd339670b5fb0e8b51): chronic profuse diarrhea, [acalculous cholecystitis](https://www.amboss.com/us/knowledge/Acute_cholecystitis#Z9df8abcc0e36c38f478f48e212ad298f), [AIDS cholangiopathy](https://www.amboss.com/us/knowledge/HIV-associated_conditions#Z1c0318dbf51f5c7bf9c39ff805ed97cc) \| \| \| \| Bloody diarrhea \| [E.coli](https://www.amboss.com/us/knowledge/Bacteria_overview#Z2018b58c3c7835457287264e40fa1a3c) \| Enteroinvasive [E. coli](https://www.amboss.com/us/knowledge/Bacteria_overview#Z2018b58c3c7835457287264e40fa1a3c) \| Direct invasion of the intestinal [epithelium](https://www.amboss.com/us/knowledge/General_histology#Z23c08800c35f1f71236b85bd916db48b) and formation of [enterotoxins]() \| [Gastroenteritis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Zcbd93ce063d015f699fd07ed09015b7f) \| \| Enterohemorrhagic [E. coli](https://www.amboss.com/us/knowledge/Bacteria_overview#Z2018b58c3c7835457287264e40fa1a3c) \| [Shiga toxin](https://www.amboss.com/us/knowledge/General_bacteriology#Zfa20332b82d5b9c5a7b6dca8046aa7bd) Most common [serotype](): ([O157:H7](https://www.amboss.com/us/knowledge/Hemolytic_uremic_syndrome#Zd789cca34b9c96af9a9c7abd264b2c7b)) \| [Hemolytic uremic syndrome](https://www.amboss.com/us/knowledge/Hemolytic_uremic_syndrome#Z759bb631d23a3535c2b55dfd91c4807b) \| \| \| \| [Campylobacter jejuni](https://www.amboss.com/us/knowledge/Bacteria_overview#Z4a3deabcd49cf50e8c48e5f0d5dcc506) \| Curved or spiral‑shaped with polar [flagellum](https://www.amboss.com/us/knowledge/General_bacteriology#Z7c98d422c4fed8c895c3dc3e0552a936) Grows best at 37–42°C \| [Campylobacter enteritis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z9273c5a7cf1820c124f8fe4d5648df30) (especially in children) Commonly precedes [reactive arthritis](https://www.amboss.com/us/knowledge/Reactive_arthritis#Z004554eda6fc600767f0d5dbaca1925d) and Guillain‑Barré syndrome \| \| \| \| Nontyphoidal [Salmonella](https://www.amboss.com/us/knowledge/Bacteria_overview#Zcf62cfeb3796c44845f303785e4bb88c) \| No [lactose](https://www.amboss.com/us/knowledge/Carbohydrates#Z42d58e097395e9a8d8ade84fd063faf8) fermentation Flagellar motility Hosts: humans, animals, and animal products (e.g., reptiles, poultry, pets, eggs) \| [Salmonellosis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z2681adc9ab180885765f48f6f730b912) \| \| \| \| [Shigella](https://www.amboss.com/us/knowledge/Bacteria_overview#Z40dc9a1dcc2df2a82a0c4586e5023158) \| Slow/absent [lactose](https://www.amboss.com/us/knowledge/Carbohydrates#Z42d58e097395e9a8d8ade84fd063faf8) fermentation [Shiga toxin](https://www.amboss.com/us/knowledge/General_bacteriology#Zfa20332b82d5b9c5a7b6dca8046aa7bd) Low infectious dose required (low ID50) Humans are the only host. \| [Bacillary dysentery](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Zd4a3455e8ec3d03f2e705d784ba584b0) \| \| \| \| [Yersinia enterocolitica](https://www.amboss.com/us/knowledge/Bacteria_overview#Zc40fd992d4c98f7805725c8ed0f57d89) \| Reservoir: contaminated pork and milk products \| [Yersiniosis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z6c552143f411315b80f346c0c8707af5) ([outbreaks]() often occur in day-care settings) May manifest as [pseudoappendicitis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Zf1754d56a2add64869210dbfd4f92e81) [Reactive arthritis](https://www.amboss.com/us/knowledge/Reactive_arthritis#Z004554eda6fc600767f0d5dbaca1925d) \| \| \| \| [Protozoa](https://www.amboss.com/us/knowledge/General_parasitology#Z8f4f3567860a31947bee8edff7ea6bd5): [Entamoeba histolytica](https://www.amboss.com/us/knowledge/Amebiasis#Z4001b357f1b712e83d6027a4dfa5731b) \| [Fecal-oral transmission]() Amebic cysts are excreted in stool and can contaminate drinking water or food. \| [Amebic dysentery](https://www.amboss.com/us/knowledge/Amebiasis#Z9c6cd303635910835de37919e22415b9) [Amebic liver abscess](https://www.amboss.com/us/knowledge/Amebiasis#Z8ac81fd9234b63200c6b963a90cf89b2) \| \| \| 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### Infectious causes \[4\]\[5\] \| \| Conditions \| \| \|---\|---\|---\| \| Viral \| [Norovirus infection](https://www.amboss.com/us/knowledge/Norovirus_infection#Z2bf1564153a0ab14e52c587da9c8a8c3) [Rotavirus infection](https://www.amboss.com/us/knowledge/Rotavirus_infection#Zb2e7858cefe0481ba26809cf4d9b84ec) [Adenovirus](https://www.amboss.com/us/knowledge/General_virology#Z5251a57602a66d951ca7a8a66643ee51) infection (mainly [serotype]() 3, 40, and 41) \[6\] [Cytomegalovirus infection](https://www.amboss.com/us/knowledge/Cytomegalovirus_infection#Za3ec0dd921d428ed745a6ec39879cf55) \| \| \| Bacterial \| [Campylobacter enteritis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z9273c5a7cf1820c124f8fe4d5648df30) [Shigellosis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Zd4a3455e8ec3d03f2e705d784ba584b0) [Salmonellosis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z2681adc9ab180885765f48f6f730b912) [Cholera](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Zba6a00519c1b345599491aa93180aacf) [Diarrheagenic E. coli](https://www.amboss.com/us/knowledge/Diarrheagenic_E._coli#Z815e7a84a36e420726cf0f61cc8adecb) infection ([travelers' diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Zed77ffe538dae231e40fe0542e7b245a)) [Yersiniosis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z6c552143f411315b80f346c0c8707af5) (especially in day care centers) [Clostridioides difficile](https://www.amboss.com/us/knowledge/Bacteria_overview#Z429d21670093a08ffb061528b0561719) infection ([antibiotic](https://www.amboss.com/us/knowledge/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3)\-associated diarrhea) [Typhoid fever](https://www.amboss.com/us/knowledge/Typhoid_and_paratyphoid_fever#Z1ee997715fd7396129b4d9a3ed02fe95) [Mycobacterium](https://www.amboss.com/us/knowledge/Bacteria_overview#Z4a9b83c1d67197ddc3d9a490e25786e1) [avium-intracellulare](https://www.amboss.com/us/knowledge/Bacteria_overview#Zded29315a7549c1929e9d93cedf7dadf) [Tropheryma whipplei]() (i.e., [Whipple disease](https://www.amboss.com/us/knowledge/Whipple_disease#Z83c04868f8c75273c89d8c6e966623e4)) [Legionella]() infection \| \| \| Parasitic \| [Protozoan](https://www.amboss.com/us/knowledge/General_parasitology#Z8f4f3567860a31947bee8edff7ea6bd5) \| [Giardiasis](https://www.amboss.com/us/knowledge/Giardiasis#Z7285e874bce9a0f39983534a6c838736) [Amebiasis](https://www.amboss.com/us/knowledge/Amebiasis#Z4500356668f80dc7e2e4d3b731ae9d1f) [Cryptosporidiosis](https://www.amboss.com/us/knowledge/HIV-associated_conditions#Z50d6fcd479428e63a00b9454e02cad44) [Cystoisosporiasis](https://www.amboss.com/us/knowledge/HIV-associated_conditions#Z1e782fdfd6ae6a71daf64a4e1644b0a9) \| \| [Helminth infections](https://www.amboss.com/us/knowledge/Helminth_infections#Ze09d3cf63ef1a16aa7f42af8f475cdb4) \| [Toxocariasis](https://www.amboss.com/us/knowledge/Helminth_infections#Zaf51d242a662ad2b921e57ce9d1c4771) [Enterobiasis](https://www.amboss.com/us/knowledge/Helminth_infections#Z626348337721606624cdbdbddc89d761) [Ascariasis](https://www.amboss.com/us/knowledge/Helminth_infections#Z3bdf0551665f902bb7f7437f1345d942) [Trichinosis](https://www.amboss.com/us/knowledge/Helminth_infections#Z243c73c82e8ca80fdc4b642de846d545) [Taenia infections](https://www.amboss.com/us/knowledge/Helminth_infections#Za9ad8a6dab1ea0231507c2575b7beaad) ([taeniasis](https://www.amboss.com/us/knowledge/Helminth_infections#Z3f0c9aad18cbe66acdd552e41e47c05c)) [Hookworm infection](https://www.amboss.com/us/knowledge/Helminth_infections#Z1179ff83d232cf99bd01e86f8e2433fa) [Diphyllobothriasis](https://www.amboss.com/us/knowledge/Helminth_infections#Z0c51a37492e70b72b9c73aed0be65260) [Intestinal capillariasis](https://www.amboss.com/us/knowledge/Helminth_infections#Z5dc93e2865dfbf1ff6ab72d0b15a5d08) \| \| ## Noninfectious \[7\]\[8\]\[9\] \| \| Conditions \| \|---\|---\| \| Foodborne toxins \| [S. aureus](https://www.amboss.com/us/knowledge/Staphylococcal_diseases#Zaf074edfb4940be0ed1d4fcfc4ea0dee) intoxication [Botulism](https://www.amboss.com/us/knowledge/Botulism#Za2a9894ca446f0fe0aac693516c52c4d) [Bacillus cereus](https://www.amboss.com/us/knowledge/Food_poisoning#Z6843256bc452c182cae6e8c9c5cbe589) infection [Tetrodotoxin](https://www.amboss.com/us/knowledge/Food_poisoning#Zd578525a352862bd6098cbff0e02482f), [ciguatoxin]() \| \| [Food poisoning](https://www.amboss.com/us/knowledge/Food_poisoning#Z5a858064f0cd40e4546f181bf46734f2) \| [Aflatoxin](https://www.amboss.com/us/knowledge/General_mycology#Z91b3abebde0a7a99c3942b9bd3060cc2) [Histamine](https://www.amboss.com/us/knowledge/Hypersensitivity_reactions#Zae1b7b5f59d06769c8445ee3e4389b73) toxicity \[7\] Chemical contaminants (e.g., lead, [cadmium](https://www.amboss.com/us/knowledge/Metal_poisoning#Z04ffe297e862ba3e4a25b62b6a06105e), insecticides, [arsenic](https://www.amboss.com/us/knowledge/Metal_poisoning#Zf2f349b64906a39b338222ac30067f86)) \[8\] [Mushroom poisoning](https://www.amboss.com/us/knowledge/Poisoning#Ze39c09d250439022bca488e44824b3d5) \[9\] \| \| Gastrointestinal \| [Malnutrition](https://www.amboss.com/us/knowledge/Acute_primary_malnutrition_in_children#Zda3f71521662770b01113749ba7d264b): [vitamin deficiency](https://www.amboss.com/us/knowledge/Vitamins#Zca3fa352d946554fdd5b7c076e0c9cb0) (e.g., [pellagra](https://www.amboss.com/us/knowledge/Vitamins#Zb703ea9bd25901f12978608f57990f1a)) \| \| [Malabsorption](https://www.amboss.com/us/knowledge/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb) or [maldigestion](https://www.amboss.com/us/knowledge/Malabsorption#Z325814c45b1a9856fa3d65839f7681f5) [Celiac disease](https://www.amboss.com/us/knowledge/Celiac_disease#Z1999c64abb6e85ce70f8cdc66810a65b) [Lactose intolerance](https://www.amboss.com/us/knowledge/Lactose_intolerance#Z8597682de9e4e8655c2f5df7319b32f3) [Exocrine pancreatic insufficiency](https://www.amboss.com/us/knowledge/Malabsorption#Z4880cedb9eb57d620afb59b2c9e39a8b) (e.g., due to [chronic pancreatitis](https://www.amboss.com/us/knowledge/Chronic_pancreatitis#Z1e14e388e4042dc43defefb9f88695e1)) [Diabetic autonomic neuropathy](https://www.amboss.com/us/knowledge/Diabetic_neuropathy#Z5f4a07d5cb1ff81fcc5c7c2bfb24806f) [Bile acid diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z0f6aa3c63b0331881c8804e04e01ca5c) (e.g., due to [ileal](https://www.amboss.com/us/knowledge/Small_intestine#Zf3a10de88f22b839a2769aa9ae031960) resection, [biliary-enteric fistula](https://www.amboss.com/us/knowledge/Fistulas#Z1787c9a9b3b830805f4bf55265169989), [cholestasis](https://www.amboss.com/us/knowledge/Jaundice_and_cholestasis#Z3811ba77a88bcd2cc789df34c5379055), [postcholecystectomy diarrhea](https://www.amboss.com/us/knowledge/Cholecystectomy#Z6f71e303d7401f08b7ba2e85ef912a69)) [Amyloidosis](https://www.amboss.com/us/knowledge/Amyloidosis#Zdf99d1ab14839f4c6288ceaf8447ef25) of the [gastrointestinal tract](https://www.amboss.com/us/knowledge/Gastrointestinal_tract#Zf0833058b7152af8b5653b79f76fb153) \| \| \| [Colitis](https://www.amboss.com/us/knowledge/Large_intestine#Z579996fe3b9825568e212d9393d5d9a2) [Inflammatory bowel disease](https://www.amboss.com/us/knowledge/Crohn_disease#Z4272f924349255b3e4babe86d4e939c9) [Crohn disease](https://www.amboss.com/us/knowledge/Crohn_disease#Zef70853af5e87c95d210bf8df682f64c) [Ulcerative colitis](https://www.amboss.com/us/knowledge/Ulcerative_colitis#Zbb0aec0a5fe14ad0aae10a9341c457fc) [Irritable bowel syndrome](https://www.amboss.com/us/knowledge/Irritable_bowel_syndrome#Z2b30a84dc4106c4e8aad1e6c9202f3ea) [Microscopic colitis](https://www.amboss.com/us/knowledge/Microscopic_colitis#Z98c8e90c538959e074e80c55a532e1bc) [Ischemic colitis](https://www.amboss.com/us/knowledge/Intestinal_ischemia#Za5a3e828cf2d10df3a9693a9fc3b2c34) [Radiation colitis](https://www.amboss.com/us/knowledge/Radiation_injury#Ze0a9ed89b6c1c4ea08173fa19b2b74f9) \| \| \| [Tumor](https://www.amboss.com/us/knowledge/General_oncology#Z333a818dbf71a509f924e54006a41fb6)/stenotic processes: [paradoxical diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z03319666a4dfb1ca98ba5a66ae368c65) (involuntary seepage of liquid feces in patients with chronic [constipation](https://www.amboss.com/us/knowledge/Constipation#Z65fd66f9cecf14d85a69e656c3a69417) ) \| \| ## Classification![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg) Diarrhea is often classified as watery, fatty, and/or inflammatory to facilitate diagnosis and management. This classification scheme is most relevant for the approach to [chronic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a). \| Classification of diarrhea by functional pathology \[10\]\[11\]\[12\] \| \| \| \| \|---\|---\|---\|---\| \| \| Pathophysiology \| Associated disorders \| \| \| Inflammatory diarrhea \| Damage to the intestinal [mucosa]() may cause [cytokine](https://www.amboss.com/us/knowledge/Cytokines_and_eicosanoids#Z1a9b57a2010f274f4a0f49e6010d30cf)\-induced water hypersecretion, impair absorption of osmotically active substances or fat, and/or disrupt water and [electrolyte](https://www.amboss.com/us/knowledge/Laboratory_medicine#Z562f1491861b33bdb5af572388e99541) absorption. Mucus, blood, and [leukocytes](https://www.amboss.com/us/knowledge/Basics_of_hematology#Z18a02873023ccef6d8ea2b461e0b7446) present in the stool. \| [Ulcerative colitis](https://www.amboss.com/us/knowledge/Ulcerative_colitis#Zbb0aec0a5fe14ad0aae10a9341c457fc), [Crohn disease](https://www.amboss.com/us/knowledge/Crohn_disease#Zef70853af5e87c95d210bf8df682f64c) [Colorectal cancer](https://www.amboss.com/us/knowledge/Colorectal_cancer#Z5f9a21e2819d2a5004da275e0fe8e909) Infections [Shigellosis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Zd4a3455e8ec3d03f2e705d784ba584b0) ([bacillary dysentery](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Zd4a3455e8ec3d03f2e705d784ba584b0)) Nontyphoidal: [salmonellosis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z2681adc9ab180885765f48f6f730b912) [Enteroinvasive Escherichia coli](https://www.amboss.com/us/knowledge/Diarrheagenic_E._coli#Z12cd4e274bbe847f6b9e96d592684c87), [enterohemorrhagic E. coli](https://www.amboss.com/us/knowledge/Diarrheagenic_E._coli#Z44cb042afe41a43945e6b3c55e424917) ([O157:H7](https://www.amboss.com/us/knowledge/Hemolytic_uremic_syndrome#Zd789cca34b9c96af9a9c7abd264b2c7b)) [Campylobacteriosis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z9273c5a7cf1820c124f8fe4d5648df30) [Yersiniosis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z6c552143f411315b80f346c0c8707af5) [Amebiasis](https://www.amboss.com/us/knowledge/Amebiasis#Z4500356668f80dc7e2e4d3b731ae9d1f) ([amebic dysentery](https://www.amboss.com/us/knowledge/Amebiasis#Z9c6cd303635910835de37919e22415b9) caused by [Entamoeba histolytica](https://www.amboss.com/us/knowledge/Amebiasis#Z4001b357f1b712e83d6027a4dfa5731b)) [Clostridioides difficile](https://www.amboss.com/us/knowledge/Bacteria_overview#Z429d21670093a08ffb061528b0561719) (rarely bloody) \| \| \| Fatty diarrhea \| [Malabsorption](https://www.amboss.com/us/knowledge/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb) \| Alterations of the intestinal [mucosa]() → impaired absorption of digested food \| [Malabsorption](https://www.amboss.com/us/knowledge/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb) disorders or history of [ileal](https://www.amboss.com/us/knowledge/Small_intestine#Zf3a10de88f22b839a2769aa9ae031960) resection Infections [Giardiasis](https://www.amboss.com/us/knowledge/Giardiasis#Z7285e874bce9a0f39983534a6c838736) [Small intestinal bacterial overgrowth](https://www.amboss.com/us/knowledge/Small_intestinal_bacterial_overgrowth#Z9aa32f677362a235a8ae39e011711f1b) ([SIBO](https://www.amboss.com/us/knowledge/Small_intestinal_bacterial_overgrowth#Z9aa32f677362a235a8ae39e011711f1b)) [Tropical sprue](https://www.amboss.com/us/knowledge/Tropical_sprue#Z98af9796a545c9279ebf232edfbe9a0f) [Whipple disease](https://www.amboss.com/us/knowledge/Whipple_disease#Z83c04868f8c75273c89d8c6e966623e4) [Amyloidosis](https://www.amboss.com/us/knowledge/Amyloidosis#Zdf99d1ab14839f4c6288ceaf8447ef25) \| \| [Maldigestion](https://www.amboss.com/us/knowledge/Malabsorption#Z325814c45b1a9856fa3d65839f7681f5) \| Lack of digestive enzymes → impaired breakdown of food in the intestinal lumen → [malabsorption](https://www.amboss.com/us/knowledge/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb) of [carbohydrates](https://www.amboss.com/us/knowledge/Carbohydrates#Z9749463e67a1dd52c34fed592810f23d), [proteins](https://www.amboss.com/us/knowledge/Proteins_and_peptides#Z6dee07cab92e13d1f6baa3a3ce402f23), fats, [fat-soluble vitamins](https://www.amboss.com/us/knowledge/Vitamins#Zcfe26218c03945e1fad98ef8c9095aa2) (A, D, E, K), and [vitamin B12](https://www.amboss.com/us/knowledge/Vitamins#Z938e3f87e91ee8469e94c3ace50e692d) \| [Exocrine pancreatic insufficiency](https://www.amboss.com/us/knowledge/Malabsorption#Z4880cedb9eb57d620afb59b2c9e39a8b) [Bile acid diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z0f6aa3c63b0331881c8804e04e01ca5c) \| \| \| Watery diarrhea \| Secretory diarrhea \| Active secretion of water into the intestinal lumen via inhibition or activation of enzymes (e.g., ↑ [cAMP](https://www.amboss.com/us/knowledge/Signal_transduction#Z64a7426bbad2bf440e8e5d9e67c2a51a) activity) \| Neuroendocrine disorders, e.g.: [Carcinoid syndrome](https://www.amboss.com/us/knowledge/Carcinoid_syndrome#Zd3e3a67dbd397d8bd3f339c574f42e55) [Gastrinoma](https://www.amboss.com/us/knowledge/Gastrinoma#Z33515a1b2df6a4fe21ef0162d7a1eac7) Endocrine disorders, e.g.: [Hyperthyroidism](https://www.amboss.com/us/knowledge/Hyperthyroidism_and_thyrotoxicosis#Z7efc7350132a2f2a3e4cc7763e7f07f8) [Addison disease](https://www.amboss.com/us/knowledge/Adrenal_insufficiency#Z7b47bf57fd367b1b9891e4155e39236f) [Diabetes mellitus](https://www.amboss.com/us/knowledge/Diabetes_mellitus#Z1235e572dd827cff7d31e954b3f94489) Foodborne infections [Cholera](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Zba6a00519c1b345599491aa93180aacf) (“rice water” diarrhea) [Enterotoxigenic E. coli](https://www.amboss.com/us/knowledge/Diarrheagenic_E._coli#Z458147f1e1273e554884140b40317779) ([traveler's diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Zed77ffe538dae231e40fe0542e7b245a)) [C. perfringens](https://www.amboss.com/us/knowledge/Bacteria_overview#Z927388b963f796f8c6f170841d77b930) [C. difficile](https://www.amboss.com/us/knowledge/Bacteria_overview#Z429d21670093a08ffb061528b0561719) (associated with [antibiotic](https://www.amboss.com/us/knowledge/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3) and [PPI](https://www.amboss.com/us/knowledge/Proton_pump_inhibitors#Z2753e50142e2f5b7089b165accdcc900) use) [Protozoa](https://www.amboss.com/us/knowledge/General_parasitology#Z8f4f3567860a31947bee8edff7ea6bd5): e.g., [giardiasis](https://www.amboss.com/us/knowledge/Giardiasis#Z7285e874bce9a0f39983534a6c838736), [cryptosporidiosis](https://www.amboss.com/us/knowledge/HIV-associated_conditions#Z50d6fcd479428e63a00b9454e02cad44) [Viruses](https://www.amboss.com/us/knowledge/General_virology#Zcdc83877f75d9d9b9a07ece6544f646c): e.g., [norovirus](https://www.amboss.com/us/knowledge/General_virology#Z85b05d149dafb61d67a5c48e9a2fdb65), [rotavirus](https://www.amboss.com/us/knowledge/General_virology#Z0b6c006e84714af76f7c43bebbeb2315), [adenovirus](https://www.amboss.com/us/knowledge/General_virology#Z5251a57602a66d951ca7a8a66643ee51) \| \| Osmotic diarrhea \| Poor absorption or excessive ingestion of [hydrophilic](https://www.amboss.com/us/knowledge/Fundamentals_of_pharmacology#Zb09f3ec1f97e13e2b9d5705d30995d93) substances (e.g., salts, sugars, [laxatives]()) causes water to be drawn into the intestinal lumen. \| Osmotic [laxatives](): e.g., [magnesium citrate](https://www.amboss.com/us/knowledge/Constipation#Z11bef431cda663471cbd64d3249255bf) [Carbohydrate malabsorption](https://www.amboss.com/us/knowledge/Malabsorption#Z1659a0f218ffe905f7bddb7c54efb326): e.g., [lactose intolerance](https://www.amboss.com/us/knowledge/Lactose_intolerance#Z8597682de9e4e8655c2f5df7319b32f3), [fructose intolerance](https://www.amboss.com/us/knowledge/Inborn_errors_of_carbohydrate_metabolism#Z357a9d683ee4b5a50331c5099527ef8f) (may also present as [fatty diarrhea](https://www.amboss.com/us/knowledge/Chronic_pancreatitis#Z416510d2bd6fcd19b4e328d62b6b10db)) \| \| \| Functional diarrheal disorders \[10\] \| Rapid intestinal passage due to increased bowel activity \| [Diarrhea-predominant IBS](https://www.amboss.com/us/knowledge/Irritable_bowel_syndrome#Z34fd0bc151761f2495a7470c6d9f6187) ([IBS-D](https://www.amboss.com/us/knowledge/Irritable_bowel_syndrome#Z34fd0bc151761f2495a7470c6d9f6187)) [Functional diarrhea]() \[10\]\[13\] \| \| ## Management![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg) 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](https://www.amboss.com/us/knowledge/Constipation#Z11561139d5df6c8531690de0277d8ce5), which can manifest atypically with [paradoxical diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z03319666a4dfb1ca98ba5a66ae368c65) (due to decreased rectal sensation) and nonspecific symptoms (e.g., functional decline, [delirium](https://www.amboss.com/us/knowledge/Delirium#Zfd56fee25cf9f50f32c800e64a6e652a)). \[14\] [Antibiotics](https://www.amboss.com/us/knowledge/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3) should only be utilized for specific indications. ## Clinical assessment of diarrhea \[10\]\[12\] Key features of the disease presentation that facilitate efficient testing and prompt diagnosis include: - Duration of diarrheal illness - Stool characteristics: watery, fatty, or bloody stools - Associated symptoms - [Fever](https://www.amboss.com/us/knowledge/Fever#Za5de83449ff6a749e6c1348b93b1f3b1) - Abdominal [pain](https://www.amboss.com/us/knowledge/Principles_of_pain_management#Zd673a3f7ee36023aab5a267899e984cc) and cramping - [Nausea and vomiting](https://www.amboss.com/us/knowledge/Nausea_and_vomiting#Z2f0b48ef2acaab783b03e4c8d2404f90) in cases of [gastroenteritis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Zcbd93ce063d015f699fd07ed09015b7f) - Signs of [dehydration](https://www.amboss.com/us/knowledge/Dehydration_and_hypovolemia#Zbd78324053c153c16ea5cb2574249398) - Chronic cases: [malnutrition](https://www.amboss.com/us/knowledge/Acute_primary_malnutrition_in_children#Zda3f71521662770b01113749ba7d264b) and, in children, [failure to thrive](https://www.amboss.com/us/knowledge/Growth_faltering#Zc00b4a95101cc1636c126219e267922c) - Weight loss - Defecation urgency, [tenesmus](), and/or nocturnal symptoms \| Characteristic clinical features in diarrhea according to functional pathology \| \| \| \| \|---\|---\|---\|---\| \| [Inflammatory diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z321586a3cfe84e9365a55d0ed20fb62a) \| Frequent and small volume stools Bloody or [purulent](https://www.amboss.com/us/knowledge/Skin_and_soft_tissue_infections#Zfdfb82d83e675513c49619bc646fd20c) stools Abdominal [pain](https://www.amboss.com/us/knowledge/Principles_of_pain_management#Zd673a3f7ee36023aab5a267899e984cc), [tenesmus]() May be associated with [fever](https://www.amboss.com/us/knowledge/Fever#Za5de83449ff6a749e6c1348b93b1f3b1), weight loss, fatigue \| \| \| \| [Fatty diarrhea](https://www.amboss.com/us/knowledge/Chronic_pancreatitis#Z416510d2bd6fcd19b4e328d62b6b10db) \| Greasy or oily stools Stools that are difficult to flush Decreases with [fasting]() May be associated with weight loss \| \| \| \| [Watery diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z16ed63f1f94f558cfbffed53ce14a7fb) \| [Secretory diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Za81182120613af86b266ff31432e241e) \| Loose, watery stools \| No change with [fasting]() Nocturnal diarrhea present \| \| [Functional diarrheal disorders](https://www.amboss.com/us/knowledge/Diarrhea#Z68e249c3723fb43d54724dbf2018af91) \| Decreases with [fasting]() Decreased at night \| \| \| \| [Osmotic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z7169e994f812b120ea2df94d1042192e) \| Decreases with [fasting]() Decreased at night Food triggers \| \| \| Assess for the presence of [risk factors](https://www.amboss.com/us/knowledge/Interpreting_medical_evidence#Zbc0d0ff153bc5c7a27589815d0c842fd) for specific etiologies, including: 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. \[15\] [Chronic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a) is common after [bariatric surgery](https://www.amboss.com/us/knowledge/Bowel_surgery#Z484c1fb65fa7e725740f20c975c9b284). \[19\]\[20\] ## Diagnostics![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg) ## General principles \[10\]\[12\]\[22\]\[25\] - [Acute diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z9902a484faaf54b4fa1ffaf3a5642113) - Testing is not required in the majority of cases. - Indications for testing include the presence of [red flags in diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Zee4bebab517fe015dea25941aafb8133) and [risk factors](https://www.amboss.com/us/knowledge/Interpreting_medical_evidence#Zbc0d0ff153bc5c7a27589815d0c842fd) for specific etiologies. - [Persistent diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Zd56cfaa165f80b20fe15e54d5f2c0023): Testing is usually limited to stool studies for [infectious gastroenteritis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z4ec5f6e716f0557299b9deed9d09e225). - [Chronic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a) - Testing is initially broad with advanced follow-up testing as indicated. \[21\]\[25\] - Repeat stool testing for [infectious gastroenteritis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z4ec5f6e716f0557299b9deed9d09e225). Diagnostic testing is seldom indicated in [acute diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z9902a484faaf54b4fa1ffaf3a5642113) in the absence of [red flag symptoms](). ## Testing for diarrhea For specific indications for testing, see the respective subsections below on acute, persistent, and [chronic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a). Endoscopic studies have limited diagnostic value in [acute diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z9902a484faaf54b4fa1ffaf3a5642113) but are commonly needed for the workup of [chronic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a) to evaluate for the presence of inflammatory or [neoplastic](https://www.amboss.com/us/knowledge/General_oncology#Za6c03f509be1b3d9dfdc8402fad24824) diseases. Their utility in [persistent diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Zd56cfaa165f80b20fe15e54d5f2c0023) is uncertain. ### Stool diagnostic studies \| [Stool diagnostic studies](https://www.amboss.com/us/knowledge/Diarrhea#Z1af96922654e42529740851250ec9081) in diarrhea \| \| \| \|---\|---\|---\| \| Suspected etiology \| Test \| Purpose \| \| Infectious diseases \| [Stool culture](https://www.amboss.com/us/knowledge/Diarrhea#Z6dddefa904a8f33be48aaa7f09f23fa3) \| Identification of infectious agents (e.g., in [bacterial gastroenteritis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z7c0d1a3ebf70c528338a93b779e17e08)) \| \| [Stool microscopy](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z3ffb13377faf28eb8d88ac5d1c53433a) \| Visualization of [ova](https://www.amboss.com/us/knowledge/Female_reproductive_organs#Z6f9cf85e209c336035854438760d1213) or [parasites]() in the stool \| \| \| Culture-independent methods, e.g., [multiplex molecular diagnostic panel for diarrhea]() ([PCR](https://www.amboss.com/us/knowledge/Laboratory_methods#Z3a8f5e31aa62111944442fd86660cc27)) \| Identification of infectious agents in bacterial, viral, and [protozoal](https://www.amboss.com/us/knowledge/General_parasitology#Z8f4f3567860a31947bee8edff7ea6bd5) [gastroenteritis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Zcbd93ce063d015f699fd07ed09015b7f) \[25\] \| \| \| Quantitative culture of small intestinal [aspirate](https://www.amboss.com/us/knowledge/Pneumonia#Z351264651d762713a247d997f6eae551) \| Used to diagnose [SIBO](https://www.amboss.com/us/knowledge/Small_intestinal_bacterial_overgrowth#Z9aa32f677362a235a8ae39e011711f1b) ([gold standard test]() for bacterial overgrowth) \| \| \| [Stool tests for C. difficile infection](https://www.amboss.com/us/knowledge/Clostridioides_difficile_infection#Z5ae7beb055f147f1241e95ce050c0395) (e.g., toxin test) \| Identification of [C. difficile infection](https://www.amboss.com/us/knowledge/Clostridioides_difficile_infection#Zb508f99ee028a9d8582608f40bc36f5f) \| \| \| Inflammation \| [Stool microscopy](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z3ffb13377faf28eb8d88ac5d1c53433a) \| Visualization of fecal [leukocytes](https://www.amboss.com/us/knowledge/Basics_of_hematology#Z18a02873023ccef6d8ea2b461e0b7446) \| \| [Fecal occult blood test](https://www.amboss.com/us/knowledge/Colorectal_cancer#Z24f19e4cfd2826fe2f4df3e70c80fd38) ([FOBT](https://www.amboss.com/us/knowledge/Colorectal_cancer#Z24f19e4cfd2826fe2f4df3e70c80fd38)) \| To screen for [malignancy](https://www.amboss.com/us/knowledge/General_oncology#Z8c3bce39ca977e0f872b6d9fb3be8cfb) and [mucosal]() inflammation \| \| \| [FIT DNA test](https://www.amboss.com/us/knowledge/Colorectal_cancer#Z943342f2c2fcf6a86ea87e55a141b8a7) \| To screen for [colonic](https://www.amboss.com/us/knowledge/Large_intestine#Ze19293358dc6c65dc95f936bb8fca493) cancer and [adenomatous polyps](https://www.amboss.com/us/knowledge/Colonic_polyps#Z31bea48c0b1a3349c4fa653243445fe3) \| \| \| [Fecal calprotectin](https://www.amboss.com/us/knowledge/Crohn_disease#Z0da0114e6bf8ec43ad71096d5e3f97f1) and [lactoferrin](https://www.amboss.com/us/knowledge/Innate_immune_system#Z341d9eb537374add3f4e1350946c378f) \| Markers of [inflammatory bowel disease](https://www.amboss.com/us/knowledge/Crohn_disease#Z4272f924349255b3e4babe86d4e939c9) ([IBD](https://www.amboss.com/us/knowledge/Crohn_disease#Z4272f924349255b3e4babe86d4e939c9)) \| \| \| [Malabsorption](https://www.amboss.com/us/knowledge/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb) \| [Sudan stain](https://www.amboss.com/us/knowledge/Cellular_changes_and_adaptive_responses#Z78716b286b479e2c380f54ed824c20fc) \| Qualitative test for [steatorrhea](https://www.amboss.com/us/knowledge/Chronic_pancreatitis#Z416510d2bd6fcd19b4e328d62b6b10db) \| \| [72-hour quantitative fecal fat estimation](https://www.amboss.com/us/knowledge/Chronic_pancreatitis#Zd212c09e9c64621940c1a0ced94a9c98) \| Quantitative test for [steatorrhea](https://www.amboss.com/us/knowledge/Chronic_pancreatitis#Z416510d2bd6fcd19b4e328d62b6b10db) \| \| \| [Fecal elastase-1](https://www.amboss.com/us/knowledge/Chronic_pancreatitis#Zf555d89ae453336db1900a0d4d2df7e7) \| Confirmation of [steatorrhea](https://www.amboss.com/us/knowledge/Chronic_pancreatitis#Z416510d2bd6fcd19b4e328d62b6b10db) due to [exocrine pancreatic insufficiency](https://www.amboss.com/us/knowledge/Malabsorption#Z4880cedb9eb57d620afb59b2c9e39a8b) \| \| \| Stool [electrolytes](https://www.amboss.com/us/knowledge/Laboratory_medicine#Z562f1491861b33bdb5af572388e99541) (e.g., Na\+, [K\+](https://www.amboss.com/us/knowledge/Water_and_electrolyte_metabolism#Z115ce86297429aa2893d16c3493aae24)) \| Used to calculate [stool osmotic gap](https://www.amboss.com/us/knowledge/Diarrhea#Ze3350ca8675573e0158f73d116234534) \| \| \| Stool [pH]() \| Identification of [carbohydrate malabsorption](https://www.amboss.com/us/knowledge/Malabsorption#Z1659a0f218ffe905f7bddb7c54efb326) \| \| - Stool osmotic gap \[11\]\[16\]\[18\] \| \| Low [stool osmotic gap](https://www.amboss.com/us/knowledge/Diarrhea#Ze3350ca8675573e0158f73d116234534) \| High [stool osmotic gap](https://www.amboss.com/us/knowledge/Diarrhea#Ze3350ca8675573e0158f73d116234534) \| \|---\|---\|---\| \| Osmotic gap \| \< 50 mOsm/kg \| ≥ 100 mOsm/kg \| \| Interpretation \| [Secretory diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Za81182120613af86b266ff31432e241e) (↑ secretion and/or inhibition of water absorption) or [functional diarrhea]() (increased intestinal movement) \| [Osmotic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z7169e994f812b120ea2df94d1042192e) (osmotic pull of ingested substances draws water into the intestinal lumen) \| \| Example causes \| Foodborne infections (e.g., [Vibrio cholerae](https://www.amboss.com/us/knowledge/Bacteria_overview#Z5040d5b8f384d034307ec998d5706c4a), [enterotoxigenic E. coli](https://www.amboss.com/us/knowledge/Diarrheagenic_E._coli#Z458147f1e1273e554884140b40317779)) Endocrine tumors (e.g., [VIPoma](https://www.amboss.com/us/knowledge/Pancreatic_neuroendocrine_tumors#Za2856a318ce5fbd49335eab336d6fa66), medullary [carcinoma](https://www.amboss.com/us/knowledge/General_oncology#Z22674f156f136302ff6142f806db0d5a) of the [thyroid](https://www.amboss.com/us/knowledge/Thyroid_gland_and_parathyroid_glands#Za09b3ec4cbcf889fc4f7b34cecb45f4d), [gastrinoma](https://www.amboss.com/us/knowledge/Gastrinoma#Z33515a1b2df6a4fe21ef0162d7a1eac7)) Impaired absorption of [bile acids](https://www.amboss.com/us/knowledge/Gallbladder_and_bile#Z86b474a966e0cc8faf1092967eaf82f4) and/or salts ([bile acid diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z0f6aa3c63b0331881c8804e04e01ca5c)) \| [Osmotic laxative](https://www.amboss.com/us/knowledge/Constipation#Z6beba559f6dfabe7c19e807cf28747b9) ingestion (e.g., [magnesium citrate](https://www.amboss.com/us/knowledge/Constipation#Z11bef431cda663471cbd64d3249255bf)) [Malabsorption](https://www.amboss.com/us/knowledge/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb) (e.g., [celiac disease](https://www.amboss.com/us/knowledge/Celiac_disease#Z1999c64abb6e85ce70f8cdc66810a65b), [Whipple disease](https://www.amboss.com/us/knowledge/Whipple_disease#Z83c04868f8c75273c89d8c6e966623e4)) [Pancreatic](https://www.amboss.com/us/knowledge/Pancreas#Z0842648c05a9f12b182c77d4baeb7a3a) insufficiency \| The loss of [bicarbonate](https://www.amboss.com/us/knowledge/Gastrointestinal_tract#Z6cdbbc46116e490c8de4fb6acf44242c)\-rich fluid in severe diarrhea may cause nonanion gap [metabolic acidosis](https://www.amboss.com/us/knowledge/Acid-base_disorders#Ze6ecd1a689f21c50f6f1d77dcd2bd10b). ## Supportive care![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg) ## Acute or persistent diarrhea (≤ 30 days)![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg) The management of [acute diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z9902a484faaf54b4fa1ffaf3a5642113) is primarily supportive, as the disease is usually a [self-limited]() viral infection. Further management focuses on determining whether diagnostic testing and directed therapy are needed (e.g., [antibiotic therapy](https://www.amboss.com/us/knowledge/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3) for [bacterial gastroenteritis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z7c0d1a3ebf70c528338a93b779e17e08)). \[22\] If symptoms of an [acute abdomen](https://www.amboss.com/us/knowledge/Acute_abdomen#Z24dc105fa608cb7dad9e5eada9a97d2b) are present, consider an urgent CT abdomen to identify [ischemic](https://www.amboss.com/us/knowledge/Cellular_changes_and_adaptive_responses#Zbc05e544d46e794a60ac9ce9ec6883af), hemorrhagic, obstructive, and/or inflammatory diseases. \[28\] When indicated, stool studies in patients with [acute diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z9902a484faaf54b4fa1ffaf3a5642113) should include tests that can detect the presence of [Salmonella](https://www.amboss.com/us/knowledge/Bacteria_overview#Zcf62cfeb3796c44845f303785e4bb88c), [Shigella](https://www.amboss.com/us/knowledge/Bacteria_overview#Z40dc9a1dcc2df2a82a0c4586e5023158), [Campylobacter](https://www.amboss.com/us/knowledge/Bacteria_overview#Za64f770db8dc668f93db5788517d1bc0), [Yersinia](https://www.amboss.com/us/knowledge/Bacteria_overview#Zfcf2a7b96fa589ca6dd7ada0b75e48bb), [C. difficile infection](https://www.amboss.com/us/knowledge/Clostridioides_difficile_infection#Zb508f99ee028a9d8582608f40bc36f5f), and [Shiga toxin-producing E. coli](https://www.amboss.com/us/knowledge/Diarrheagenic_E._coli#Z11eef8782d53e8058dd72294470db3f7). \[31\] ### Noninflammatory diarrhea ([watery diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z16ed63f1f94f558cfbffed53ce14a7fb)) \[21\]\[25\]\[31\] ### [Inflammatory diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z321586a3cfe84e9365a55d0ed20fb62a) ([dysentery]()) \[28\] In patients with prominent abdominal [pain](https://www.amboss.com/us/knowledge/Principles_of_pain_management#Zd673a3f7ee36023aab5a267899e984cc) and/or bloody diarrhea, evaluate for [ischemic colitis](https://www.amboss.com/us/knowledge/Intestinal_ischemia#Za5a3e828cf2d10df3a9693a9fc3b2c34), [ulcerative colitis](https://www.amboss.com/us/knowledge/Ulcerative_colitis#Zbb0aec0a5fe14ad0aae10a9341c457fc), and [Crohn disease](https://www.amboss.com/us/knowledge/Crohn_disease#Zef70853af5e87c95d210bf8df682f64c) if stool testing does not indicate an infectious etiology. [Persistent diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Zd56cfaa165f80b20fe15e54d5f2c0023) has a broader differential diagnosis than [acute diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z9902a484faaf54b4fa1ffaf3a5642113). Parasitic infection (e.g., [giardiasis](https://www.amboss.com/us/knowledge/Giardiasis#Z7285e874bce9a0f39983534a6c838736)), recurrent bacterial infection (e.g., [C. difficile infection](https://www.amboss.com/us/knowledge/Clostridioides_difficile_infection#Zb508f99ee028a9d8582608f40bc36f5f)), and noninfectious causes (e.g., [IBS-D](https://www.amboss.com/us/knowledge/Irritable_bowel_syndrome#Z34fd0bc151761f2495a7470c6d9f6187)) must be considered. \[32\] \| [Etiology of acute and persistent diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Za0cd177df9550f81889873b6038f2072) \| \| \|---\|---\| \| Viral \[21\] \| [Norovirus infection](https://www.amboss.com/us/knowledge/Norovirus_infection#Z2bf1564153a0ab14e52c587da9c8a8c3) [Rotavirus infection](https://www.amboss.com/us/knowledge/Rotavirus_infection#Zb2e7858cefe0481ba26809cf4d9b84ec) [Adenovirus](https://www.amboss.com/us/knowledge/General_virology#Z5251a57602a66d951ca7a8a66643ee51) infection (mainly [serotypes]() 3, 40, and 41) \[6\] [Cytomegalovirus infection](https://www.amboss.com/us/knowledge/Cytomegalovirus_infection#Za3ec0dd921d428ed745a6ec39879cf55) [Coronavirus](https://www.amboss.com/us/knowledge/General_virology#Zc9fd2c044745d5b6f6ef5fe6293d10c5) ([COVID-19](https://www.amboss.com/us/knowledge/COVID-19_\(coronavirus_disease_2019\)#Z82f1d759ff02927000d2ccd223409135)) \| \| Bacterial \| [Cholera](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Zba6a00519c1b345599491aa93180aacf) (“rice water” diarrhea) [Enterotoxigenic E. coli](https://www.amboss.com/us/knowledge/Diarrheagenic_E._coli#Z458147f1e1273e554884140b40317779) infection ([traveler's diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Zed77ffe538dae231e40fe0542e7b245a)) [C. perfringens](https://www.amboss.com/us/knowledge/Bacteria_overview#Z927388b963f796f8c6f170841d77b930) infection [C. difficile](https://www.amboss.com/us/knowledge/Bacteria_overview#Z429d21670093a08ffb061528b0561719) infection (associated with [antibiotic](https://www.amboss.com/us/knowledge/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3) and [PPI](https://www.amboss.com/us/knowledge/Proton_pump_inhibitors#Z2753e50142e2f5b7089b165accdcc900) use) [Shigellosis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Zd4a3455e8ec3d03f2e705d784ba584b0) ([bacillary dysentery](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Zd4a3455e8ec3d03f2e705d784ba584b0)) Nontyphoidal: [salmonellosis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z2681adc9ab180885765f48f6f730b912) [Enteroinvasive E. coli](https://www.amboss.com/us/knowledge/Diarrheagenic_E._coli#Z12cd4e274bbe847f6b9e96d592684c87), [enterohemorrhagic E. coli](https://www.amboss.com/us/knowledge/Diarrheagenic_E._coli#Z44cb042afe41a43945e6b3c55e424917) ([O157:H7](https://www.amboss.com/us/knowledge/Hemolytic_uremic_syndrome#Zd789cca34b9c96af9a9c7abd264b2c7b)) infection [Campylobacteriosis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z9273c5a7cf1820c124f8fe4d5648df30) [Yersiniosis](https://www.amboss.com/us/knowledge/Infectious_gastroenteritis#Z6c552143f411315b80f346c0c8707af5) [Legionella]() \| \| Parasitic \| [Giardiasis](https://www.amboss.com/us/knowledge/Giardiasis#Z7285e874bce9a0f39983534a6c838736) [Amebiasis](https://www.amboss.com/us/knowledge/Amebiasis#Z4500356668f80dc7e2e4d3b731ae9d1f) [Cryptosporidiosis](https://www.amboss.com/us/knowledge/HIV-associated_conditions#Z50d6fcd479428e63a00b9454e02cad44) [Enterobiasis](https://www.amboss.com/us/knowledge/Helminth_infections#Z626348337721606624cdbdbddc89d761) [Ascariasis](https://www.amboss.com/us/knowledge/Helminth_infections#Z3bdf0551665f902bb7f7437f1345d942) \| \| [Food poisoning](https://www.amboss.com/us/knowledge/Food_poisoning#Z5a858064f0cd40e4546f181bf46734f2) \| [S. aureus](https://www.amboss.com/us/knowledge/Staphylococcal_diseases#Zaf074edfb4940be0ed1d4fcfc4ea0dee) infection [Botulism](https://www.amboss.com/us/knowledge/Botulism#Za2a9894ca446f0fe0aac693516c52c4d) [Bacillus cereus](https://www.amboss.com/us/knowledge/Food_poisoning#Z6843256bc452c182cae6e8c9c5cbe589) infection [Aflatoxin](https://www.amboss.com/us/knowledge/General_mycology#Z91b3abebde0a7a99c3942b9bd3060cc2) [Histamine](https://www.amboss.com/us/knowledge/Hypersensitivity_reactions#Zae1b7b5f59d06769c8445ee3e4389b73) toxicity \[7\] [Tetrodotoxin](https://www.amboss.com/us/knowledge/Food_poisoning#Zd578525a352862bd6098cbff0e02482f), [ciguatoxin]() \| \| Medications \| [Antibiotics](https://www.amboss.com/us/knowledge/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3) [Laxatives]() [PPIs](https://www.amboss.com/us/knowledge/Proton_pump_inhibitors#Z2753e50142e2f5b7089b165accdcc900) [SSRIs](https://www.amboss.com/us/knowledge/Antidepressants#Zb1bb43280a4d0d86f2d53818b9e8afc8) [NSAIDs](https://www.amboss.com/us/knowledge/Non-opioid_analgesics#Z6d53b6cfe3376a70645a5c797293e56a) \| \| Other \| Chemical contaminants (e.g., lead, [cadmium](https://www.amboss.com/us/knowledge/Metal_poisoning#Z04ffe297e862ba3e4a25b62b6a06105e), insecticides, [arsenic](https://www.amboss.com/us/knowledge/Metal_poisoning#Zf2f349b64906a39b338222ac30067f86)) \[8\] [Mushroom poisoning](https://www.amboss.com/us/knowledge/Poisoning#Ze39c09d250439022bca488e44824b3d5) \[9\] [Bowel ischemia](https://www.amboss.com/us/knowledge/Intestinal_ischemia#Z25168aee9d4e0266b8ee7dae3d33cc08) [Neutropenic enterocolitis](https://www.amboss.com/us/knowledge/Acute_abdomen#Za3c81a83e806ab8e4e5f85cb4d572b6c) \| ## Chronic diarrhea (\> 30 days)![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg) The differential diagnosis of [chronic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a) is extensive. A systematic approach with efficient use of testing is needed to arrive at a diagnosis quickly. \[10\]\[12\]\[33\] [Chronic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a) can be classified as inflammatory, fatty, or watery. Grouping patients into broad categories based on clinical features and basic laboratory findings narrows the differential diagnosis and facilitates efficient advanced testing. \[18\] [IBS-D](https://www.amboss.com/us/knowledge/Irritable_bowel_syndrome#Z34fd0bc151761f2495a7470c6d9f6187) is an intermediate diagnosis; it does not eliminate the possibility of another disease. Evaluation should continue if symptoms persist despite treatment for [IBS-D](https://www.amboss.com/us/knowledge/Irritable_bowel_syndrome#Z34fd0bc151761f2495a7470c6d9f6187). \[12\] [Chronic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a) is commonly classified as watery, fatty, or inflammatory. \| [Etiology of chronic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z395de845da244c411a1fe280649e48a0) \[12\] \| \| \| \|---\|---\|---\| \| Inflammatory \| [Inflammatory bowel disease](https://www.amboss.com/us/knowledge/Crohn_disease#Z4272f924349255b3e4babe86d4e939c9): [Crohn disease](https://www.amboss.com/us/knowledge/Crohn_disease#Zef70853af5e87c95d210bf8df682f64c), [ulcerative colitis](https://www.amboss.com/us/knowledge/Ulcerative_colitis#Zbb0aec0a5fe14ad0aae10a9341c457fc) Invasive infections Bacterial: e.g., [pseudomembranous colitis](https://www.amboss.com/us/knowledge/Clostridioides_difficile_infection#Z9a45a83f4126940236032056da651cf6), [tuberculosis](https://www.amboss.com/us/knowledge/Tuberculosis#Zcaeed890b290faa5ec7ec5e02a1039fe) Viral: e.g., [CMV](https://www.amboss.com/us/knowledge/Herpes_virus_infections#Zad44d620172736914bbe3c52435de665) Parasitic: e.g., [Entamoeba histolytica](https://www.amboss.com/us/knowledge/Amebiasis#Z4001b357f1b712e83d6027a4dfa5731b) Medications: e.g., [PPIs](https://www.amboss.com/us/knowledge/Proton_pump_inhibitors#Z2753e50142e2f5b7089b165accdcc900), [NSAIDs](https://www.amboss.com/us/knowledge/Non-opioid_analgesics#Z6d53b6cfe3376a70645a5c797293e56a), [tyrosine kinase inhibitors](https://www.amboss.com/us/knowledge/Chemotherapeutic_agents#Z1d95c73e140242a536db072ff6adf252) Other: e.g., [ischemic colitis](https://www.amboss.com/us/knowledge/Intestinal_ischemia#Za5a3e828cf2d10df3a9693a9fc3b2c34), [radiation colitis](https://www.amboss.com/us/knowledge/Radiation_injury#Ze0a9ed89b6c1c4ea08173fa19b2b74f9), [malignancy](https://www.amboss.com/us/knowledge/General_oncology#Z8c3bce39ca977e0f872b6d9fb3be8cfb) (e.g., [colon cancer](https://www.amboss.com/us/knowledge/Colorectal_cancer#Z5f9a21e2819d2a5004da275e0fe8e909), [lymphoma](https://www.amboss.com/us/knowledge/General_oncology#Z2586a20a2f640af294a4d86b9f8439d0)) \| \| \| Fatty \| [Malabsorption](https://www.amboss.com/us/knowledge/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb) \| Infections: [SIBO](https://www.amboss.com/us/knowledge/Small_intestinal_bacterial_overgrowth#Z9aa32f677362a235a8ae39e011711f1b), [tropical sprue](https://www.amboss.com/us/knowledge/Tropical_sprue#Z98af9796a545c9279ebf232edfbe9a0f), [Whipple disease](https://www.amboss.com/us/knowledge/Whipple_disease#Z83c04868f8c75273c89d8c6e966623e4), [giardiasis](https://www.amboss.com/us/knowledge/Giardiasis#Z7285e874bce9a0f39983534a6c838736) Medications: e.g., [aminoglycosides](https://www.amboss.com/us/knowledge/Overview_of_antibiotic_therapy#Zec4668b75aadd8ddccaf2d3dada94e20), [antiretroviral drugs](https://www.amboss.com/us/knowledge/Human_immunodeficiency_virus_infection#Zcccdef45b4e6e14c8b8fd8bd48515808) Other: e.g., [celiac disease](https://www.amboss.com/us/knowledge/Celiac_disease#Z1999c64abb6e85ce70f8cdc66810a65b), postsurgical changes, lymphatic obstruction \| \| [Maldigestion](https://www.amboss.com/us/knowledge/Malabsorption#Z325814c45b1a9856fa3d65839f7681f5) \| Inadequate [bile acid](https://www.amboss.com/us/knowledge/Gallbladder_and_bile#Z86b474a966e0cc8faf1092967eaf82f4) concentration: e.g., due to hepatobiliary disease or [ileal](https://www.amboss.com/us/knowledge/Small_intestine#Zf3a10de88f22b839a2769aa9ae031960) resection [Exocrine pancreatic insufficiency](https://www.amboss.com/us/knowledge/Malabsorption#Z4880cedb9eb57d620afb59b2c9e39a8b): e.g., due to [chronic pancreatitis](https://www.amboss.com/us/knowledge/Chronic_pancreatitis#Z1e14e388e4042dc43defefb9f88695e1) or [cystic fibrosis](https://www.amboss.com/us/knowledge/Cystic_fibrosis#Z3ae6b1b2983d98afcd8339f505ed3f99) \| \| \| Watery \| Secretory \| Infections: e.g., [giardiasis](https://www.amboss.com/us/knowledge/Giardiasis#Z7285e874bce9a0f39983534a6c838736), [cryptosporidiosis](https://www.amboss.com/us/knowledge/HIV-associated_conditions#Z50d6fcd479428e63a00b9454e02cad44), [SIBO](https://www.amboss.com/us/knowledge/Small_intestinal_bacterial_overgrowth#Z9aa32f677362a235a8ae39e011711f1b) Medications: e.g., [stimulant laxatives](https://www.amboss.com/us/knowledge/Constipation#Za767330be9fd22123118b1e0addddf55), [levodopa](https://www.amboss.com/us/knowledge/Medication_for_Parkinson_disease#Z18482e8eccd3978e1e99c57ecdc4fd2f), [caffeine](https://www.amboss.com/us/knowledge/Substance-related_and_addictive_disorders#Z9cbb9bc1131781093113ffce4e367923) [Neuroendocrine tumors](https://www.amboss.com/us/knowledge/Neuroendocrine_neoplasms#Z688b3fb7764fe32e74754d4b26c6fc89) \[11\] Endocrine diseases: e.g., [hyperthyroidism](https://www.amboss.com/us/knowledge/Hyperthyroidism_and_thyrotoxicosis#Z7efc7350132a2f2a3e4cc7763e7f07f8), [Addison disease](https://www.amboss.com/us/knowledge/Adrenal_insufficiency#Z7b47bf57fd367b1b9891e4155e39236f), [diabetes mellitus](https://www.amboss.com/us/knowledge/Diabetes_mellitus#Z1235e572dd827cff7d31e954b3f94489) Other: [bile acid](https://www.amboss.com/us/knowledge/Gallbladder_and_bile#Z86b474a966e0cc8faf1092967eaf82f4) [malabsorption](https://www.amboss.com/us/knowledge/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb), [IBD](https://www.amboss.com/us/knowledge/Crohn_disease#Z4272f924349255b3e4babe86d4e939c9), [microscopic colitis](https://www.amboss.com/us/knowledge/Microscopic_colitis#Z98c8e90c538959e074e80c55a532e1bc) \| \| Functional \| [Irritable bowel syndrome](https://www.amboss.com/us/knowledge/Irritable_bowel_syndrome#Z2b30a84dc4106c4e8aad1e6c9202f3ea) ([IBS](https://www.amboss.com/us/knowledge/Irritable_bowel_syndrome#Z2b30a84dc4106c4e8aad1e6c9202f3ea)) Medications: e.g., [prokinetics]() [Functional diarrhea]() \| \| \| Osmotic \| [Carbohydrate malabsorption](https://www.amboss.com/us/knowledge/Malabsorption#Z1659a0f218ffe905f7bddb7c54efb326) Unabsorbed sugars in the diet and/or in chewing [gum](https://www.amboss.com/us/knowledge/Oral_cavity#Z3ab30934681b06d8591bf18cb03ce2d7): e.g., [sorbitol](https://www.amboss.com/us/knowledge/Carbohydrates#Z77d45a3fdde3bf65b74cebef6dec2d7f), [mannitol](https://www.amboss.com/us/knowledge/Diuretics#Ze73562869635139c2688bf31a791bef1) Enzymatic dysfunction: e.g., [lactase deficiency](https://www.amboss.com/us/knowledge/Lactose_intolerance#Zd10b2b1e3672bf92a1e23fc1962405dc) Medications: e.g., [osmotic laxatives](https://www.amboss.com/us/knowledge/Constipation#Z6beba559f6dfabe7c19e807cf28747b9) Other: e.g., [celiac disease](https://www.amboss.com/us/knowledge/Celiac_disease#Z1999c64abb6e85ce70f8cdc66810a65b), [FODMAP](https://www.amboss.com/us/knowledge/Irritable_bowel_syndrome#Zd9aa5f552109b4cf13d7666f5e99cebe) intolerance, [enteral feeding](https://www.amboss.com/us/knowledge/Specialized_nutrition_support#Z3c9fb1a42ea89ef188431d15c5ad1445) \| \| Order initial studies. See also “Testing for diarrhea” in “Diagnostics.” Always test for Giardia infection in [chronic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a). \[24\] Perform guided diagnostics based on characteristic clinical features in diarrhea and the results of initial diagnostic testing. \| Diagnostic workup of patients with [chronic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a) \| \| \| \| \|---\|---\|---\|---\| \| Classification \| Initial results \| Further diagnostics \| \| \| [Inflammatory diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z321586a3cfe84e9365a55d0ed20fb62a) \| Fecal [leukocytes](https://www.amboss.com/us/knowledge/Basics_of_hematology#Z18a02873023ccef6d8ea2b461e0b7446) present. Fecal occult blood positive Calprotectin or [lactoferrin](https://www.amboss.com/us/knowledge/Innate_immune_system#Z341d9eb537374add3f4e1350946c378f) positive Elevated [CRP](https://www.amboss.com/us/knowledge/Laboratory_medicine#Z51ad1e101a45a8de708a6dda0321755d) \| [Colonoscopy](https://www.amboss.com/us/knowledge/Colonoscopy#Za4aebc8baa131b83620292e8d0363739) with [mucosal]() [biopsies]() (always required): can identify [IBD](https://www.amboss.com/us/knowledge/Crohn_disease#Z4272f924349255b3e4babe86d4e939c9), [colon cancer](https://www.amboss.com/us/knowledge/Colorectal_cancer#Z5f9a21e2819d2a5004da275e0fe8e909), [ischemic colitis](https://www.amboss.com/us/knowledge/Intestinal_ischemia#Za5a3e828cf2d10df3a9693a9fc3b2c34), [radiation colitis](https://www.amboss.com/us/knowledge/Radiation_injury#Ze0a9ed89b6c1c4ea08173fa19b2b74f9), and [pseudomembranous colitis](https://www.amboss.com/us/knowledge/Clostridioides_difficile_infection#Z9a45a83f4126940236032056da651cf6) Testing for infectious diseases: e.g., [parasites]() ([amebiasis](https://www.amboss.com/us/knowledge/Amebiasis#Z4500356668f80dc7e2e4d3b731ae9d1f)) and [C. difficile infection](https://www.amboss.com/us/knowledge/Clostridioides_difficile_infection#Zb508f99ee028a9d8582608f40bc36f5f) \| \| \| [Fatty diarrhea](https://www.amboss.com/us/knowledge/Chronic_pancreatitis#Z416510d2bd6fcd19b4e328d62b6b10db) \[10\]\[12\]\[16\] \| Increased fecal fat, e.g.: [Sudan stain](https://www.amboss.com/us/knowledge/Cellular_changes_and_adaptive_responses#Z78716b286b479e2c380f54ed824c20fc) positive [72-hour fecal fat estimation](https://www.amboss.com/us/knowledge/Chronic_pancreatitis#Zd212c09e9c64621940c1a0ced94a9c98) elevated \| [Mucosal]() disease: [celiac disease panel](https://www.amboss.com/us/knowledge/Celiac_disease#Z63d359b4e2570234feebde9aaebff219) and [EGD](https://www.amboss.com/us/knowledge/Esophagogastroduodenoscopy#Z1a617ceb3d8b9832108168a091314359) with [biopsies]() Luminal disease [Pancreatic function tests](https://www.amboss.com/us/knowledge/Laboratory_medicine#Zc0f762af46ed9109bda61d0feb7a5ab3) (e.g., [fecal elastase-1](https://www.amboss.com/us/knowledge/Chronic_pancreatitis#Zf555d89ae453336db1900a0d4d2df7e7)): can identify [exocrine pancreatic insufficiency](https://www.amboss.com/us/knowledge/Malabsorption#Z4880cedb9eb57d620afb59b2c9e39a8b) \[18\] [Hydrogen breath test](https://www.amboss.com/us/knowledge/Lactose_intolerance#Z4187a69143c8be5cfd157107e8edb65a) and [EGD](https://www.amboss.com/us/knowledge/Esophagogastroduodenoscopy#Z1a617ceb3d8b9832108168a091314359) with [small bowel aspiration]() and cultures: can identify [SIBO](https://www.amboss.com/us/knowledge/Small_intestinal_bacterial_overgrowth#Z9aa32f677362a235a8ae39e011711f1b) \[34\] \| \| \| [Watery diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z16ed63f1f94f558cfbffed53ce14a7fb) \[11\] \| [Secretory diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Za81182120613af86b266ff31432e241e) or [functional diarrheal disorders](https://www.amboss.com/us/knowledge/Diarrhea#Z68e249c3723fb43d54724dbf2018af91) \| Low [stool osmotic gap](https://www.amboss.com/us/knowledge/Diarrhea#Ze3350ca8675573e0158f73d116234534) (\< 50 mOsm/kg) No fecal [leukocytes](https://www.amboss.com/us/knowledge/Basics_of_hematology#Z18a02873023ccef6d8ea2b461e0b7446) No fecal fat \| [TFTs](https://www.amboss.com/us/knowledge/Hyperthyroidism_and_thyrotoxicosis#Zc2daec2f86dc7f7edf504314f5e9de68), [cortisol](https://www.amboss.com/us/knowledge/Adrenal_gland#Z68437810c311fa1e0e910fecfa30be04) level, [diabetes mellitus screening](https://www.amboss.com/us/knowledge/Diabetes_mellitus#Z880b3ed63aba809ccba7ae2a7afb386d): can detect endocrine disorders Serum [gastrin](https://www.amboss.com/us/knowledge/Gastrointestinal_tract#Z16fdc87a47049d4522f49bf193d34fcb), [VIP](https://www.amboss.com/us/knowledge/Gastrointestinal_tract#Z2a13d7814300b48684ebf0f62ffc0318), [calcitonin](https://www.amboss.com/us/knowledge/Hypocalcemia#Z8f09b075f4d87191d15890436cb2a4a5) level: can detect [neuroendocrine tumors](https://www.amboss.com/us/knowledge/Neuroendocrine_neoplasms#Z688b3fb7764fe32e74754d4b26c6fc89) Evaluation for [bile acid](https://www.amboss.com/us/knowledge/Gallbladder_and_bile#Z86b474a966e0cc8faf1092967eaf82f4) [malabsorption](https://www.amboss.com/us/knowledge/Malabsorption#Zae07822252537d684eeec3f2d4ba9adb) and [SIBO](https://www.amboss.com/us/knowledge/Small_intestinal_bacterial_overgrowth#Z9aa32f677362a235a8ae39e011711f1b) [Rome IV criteria for IBS](https://www.amboss.com/us/knowledge/Irritable_bowel_syndrome#Zc16da4fdfa96f2bd9cf45f216019665a): may indicate [functional diarrhea]() \| \| [Osmotic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z7169e994f812b120ea2df94d1042192e) \| High [stool osmotic gap](https://www.amboss.com/us/knowledge/Diarrhea#Ze3350ca8675573e0158f73d116234534) (≥ 100 mOsm/kg) No fecal [leukocytes](https://www.amboss.com/us/knowledge/Basics_of_hematology#Z18a02873023ccef6d8ea2b461e0b7446) No fecal fat \| Stool [pH]() \< 6 suggests [carbohydrate malabsorption](https://www.amboss.com/us/knowledge/Malabsorption#Z1659a0f218ffe905f7bddb7c54efb326); consider the following: \[11\] [Celiac disease panel](https://www.amboss.com/us/knowledge/Celiac_disease#Z63d359b4e2570234feebde9aaebff219) [Lactose hydrogen breath test](https://www.amboss.com/us/knowledge/Lactose_intolerance#Z4187a69143c8be5cfd157107e8edb65a): can diagnose [lactase deficiency](https://www.amboss.com/us/knowledge/Lactose_intolerance#Zd10b2b1e3672bf92a1e23fc1962405dc) [Small intestine biopsy](https://www.amboss.com/us/knowledge/Malabsorption#Z4c414f1e711c5ae69ceece6cee9f425e): can diagnose [celiac disease](https://www.amboss.com/us/knowledge/Celiac_disease#Z1999c64abb6e85ce70f8cdc66810a65b) or infectious diseases (e.g., [Whipple disease](https://www.amboss.com/us/knowledge/Whipple_disease#Z83c04868f8c75273c89d8c6e966623e4)) Stool [pH]() ≥ 6 suggests [antacid](https://www.amboss.com/us/knowledge/Dyspepsia#Z483f046dcff29152f098e8a15dc67c9b) and/or [laxative]() ingestion \| \| In [watery diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z16ed63f1f94f558cfbffed53ce14a7fb), the [stool osmotic gap](https://www.amboss.com/us/knowledge/Diarrhea#Ze3350ca8675573e0158f73d116234534) differentiates osmotic from [secretory diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Za81182120613af86b266ff31432e241e). In osmotic [watery diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z16ed63f1f94f558cfbffed53ce14a7fb), a stool [pH]() \< 6 suggests [carbohydrate malabsorption](https://www.amboss.com/us/knowledge/Malabsorption#Z1659a0f218ffe905f7bddb7c54efb326). Endoscopic studies with [mucosal]() [biopsies]() are required to diagnose [inflammatory diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z321586a3cfe84e9365a55d0ed20fb62a) in patients with [chronic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a). ## Differential diagnoses![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg) References:\[11\]\[22\]\[23\] The differential diagnoses listed here are not exhaustive. ## Subtypes and variants![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg) ## Traveler's diarrhea \[36\]\[37\] - Definition: ≥ 3 unformed stools with at least one additional [enteric]() symptom occurring after recent travel - [Epidemiology](https://www.amboss.com/us/knowledge/Epidemiology#Z4c4f63797573af64476acb67d715be49) - The highest rates occur after travel to Africa and South, Central, and West Asia. - Approximately 25% of all travelers develop [traveler's diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Zed77ffe538dae231e40fe0542e7b245a). - Etiology - [Enterotoxigenic E. coli](https://www.amboss.com/us/knowledge/Diarrheagenic_E._coli#Z458147f1e1273e554884140b40317779) ([ETEC](https://www.amboss.com/us/knowledge/Diarrheagenic_E._coli#Z458147f1e1273e554884140b40317779)) is the most common cause of [traveler's diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Zed77ffe538dae231e40fe0542e7b245a) globally. - [Campylobacter jejuni](https://www.amboss.com/us/knowledge/Bacteria_overview#Z4a3deabcd49cf50e8c48e5f0d5dcc506) is the most common cause in Southeast Asia. - Other pathogens - Clinical features: [exudative]()\-inflammatory or [secretory diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Za81182120613af86b266ff31432e241e), abdominal cramping, abdominal [pain](https://www.amboss.com/us/knowledge/Principles_of_pain_management#Zd673a3f7ee36023aab5a267899e984cc) - Antibiotics for traveler's diarrhea: Reserve for moderate to severe illness. \[25\]\[32\]\[36\] - For most destinations: [ciprofloxacin](https://www.amboss.com/us/knowledge/Overview_of_antibiotic_therapy#Z3f1dbc417664139dda097bcd516ceeed) ([off label](https://www.amboss.com/us/knowledge/Fundamentals_of_pharmacology#Zb37ab5e3f79a4ddd6b356eb84fa0067a)) OR [rifaximin](https://www.amboss.com/us/knowledge/Hepatic_encephalopathy#Za8e7b6e3b08d56feebf985f44969b261) \[36\] - For travelers to South or Southeast Asia: [azithromycin](https://www.amboss.com/us/knowledge/Overview_of_antibiotic_therapy#Z9884c173cd8bcd36d44eb85ea8acfec2) ([off label](https://www.amboss.com/us/knowledge/Fundamentals_of_pharmacology#Zb37ab5e3f79a4ddd6b356eb84fa0067a)) \[36\] - [Supportive care]() \[25\] - Treatment for [dehydration](https://www.amboss.com/us/knowledge/Dehydration_and_hypovolemia#Zbd78324053c153c16ea5cb2574249398) (e.g., [oral rehydration solution](https://www.amboss.com/us/knowledge/Dehydration_and_hypovolemia#Z22573072c2ce7ea0ba0873c3024dc043)) - [Bismuth subsalicylate](https://www.amboss.com/us/knowledge/Helicobacter_pylori_infection#Z5ff316bf4e8912c06dc600df2a9e8b09) for patients with mild to moderate illness - [Loperamide](https://www.amboss.com/us/knowledge/Opioids#Z1881077ac71cd771cb44b7db04569ac0) for patients receiving [antibiotic therapy](https://www.amboss.com/us/knowledge/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3) (can reduce the duration of illness) - See “[Antidiarrheal agents](https://www.amboss.com/us/knowledge/Diarrhea#Zc9c4c39a6ce3413ed32214ba89c1e777)” for dosages. - Postinfectious sequelae - [Postinfectious IBS](): may occur in 3–20% of patients - [Reactive arthritis](https://www.amboss.com/us/knowledge/Reactive_arthritis#Z004554eda6fc600767f0d5dbaca1925d): may last months to years - [Guillain-Barre syndrome](https://www.amboss.com/us/knowledge/Guillain-Barr%C3%A9_syndrome#Zf193c1b0b16db4d30e7f29d4e766d3e8): may develop 1–4 weeks after infection (most commonly after [Campylobacter](https://www.amboss.com/us/knowledge/Bacteria_overview#Za64f770db8dc668f93db5788517d1bc0) infection) [Antibiotic](https://www.amboss.com/us/knowledge/Overview_of_antibiotic_therapy#Z4660f53b2b0c85aa3f9ab01bdf3f14f3) treatment is not recommended in patients with mild [traveler's diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Zed77ffe538dae231e40fe0542e7b245a). [Bismuth subsalicylate](https://www.amboss.com/us/knowledge/Helicobacter_pylori_infection#Z5ff316bf4e8912c06dc600df2a9e8b09) is an [antidiarrheal agent](https://www.amboss.com/us/knowledge/Diarrhea#Zc9c4c39a6ce3413ed32214ba89c1e777) used to treat [traveler's diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Zed77ffe538dae231e40fe0542e7b245a) (caused by [enterotoxigenic Escherichia coli](https://www.amboss.com/us/knowledge/Diarrheagenic_E._coli#Z458147f1e1273e554884140b40317779)). ### Pharmacological prophylaxis for traveler's diarrhea \[25\]\[36\] Consider for travelers to high-risk areas (under specialist guidance); options include: ## Factitious diarrhea \[11\] - Definition: self-induced diarrhea, usually due to [laxative abuse](https://www.amboss.com/us/knowledge/Diarrhea#Zf400d371a3aeaaef09f5533381e99329) (often occurs in individuals with [factitious disorders](https://www.amboss.com/us/knowledge/Somatic_symptom_and_related_disorders#Za429ee6281b4bad77a94b44df89f4036)), or dilution of stools with solutions - [Epidemiology](https://www.amboss.com/us/knowledge/Epidemiology#Z4c4f63797573af64476acb67d715be49) - Most prevalent in women - Patients are usually [health care professionals](). - History of multiple hospital admissions - Clinical features: [chronic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z3db8d1862531c05ca50ab4a49df0b84a) without an identifiable cause - Diagnostics - Laboratory tests: [metabolic acidosis](https://www.amboss.com/us/knowledge/Acid-base_disorders#Ze6ecd1a689f21c50f6f1d77dcd2bd10b) , [metabolic alkalosis](https://www.amboss.com/us/knowledge/Acid-base_disorders#Z46196a0a09cd3ccdd01835db5b427a7c) , [hypokalemia](https://www.amboss.com/us/knowledge/Hypokalemia#Z1454fccf44cdd1776601d443f63ca03c), [hypermagnesemia](https://www.amboss.com/us/knowledge/Hypermagnesemia#Z80b32d5d74b73a5c759d3ecd2043a7e6) - Stool [osmolarity](https://www.amboss.com/us/knowledge/Intravenous_fluid_therapy#Zdeae47858e4e2ccdf3ffe701a1970e95) - \< 290 mOsm/L: indicates dilution of the stool with a hypotonic solution - \> 600 mOsm/L: indicates dilution of the stool with a hypertonic solution - [Laxative]() screen \[18\] - [Colonoscopy](https://www.amboss.com/us/knowledge/Colonoscopy#Za4aebc8baa131b83620292e8d0363739): may show [melanosis coli](https://www.amboss.com/us/knowledge/Diarrhea#Z21e7a77240bb6cafa756a1d9e263da87) in cases of anthraquinone abuse - Treatment ### Laxative abuse - Types of [laxative]() - Clinical features - [Osmotic diarrhea](https://www.amboss.com/us/knowledge/Diarrhea#Z7169e994f812b120ea2df94d1042192e), [meteorism]() - [Dehydration](https://www.amboss.com/us/knowledge/Dehydration_and_hypovolemia#Zbd78324053c153c16ea5cb2574249398) - [Hypokalemia](https://www.amboss.com/us/knowledge/Hypokalemia#Z1454fccf44cdd1776601d443f63ca03c) - Melanosis coli: benign [hyperpigmentation]() of the [colonic](https://www.amboss.com/us/knowledge/Large_intestine#Ze19293358dc6c65dc95f936bb8fca493) [mucosa]() caused by anthraquinone abuse \[39\] 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