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food implicates food poisoning Day care attendance or exposure to unpurified water (camping, swimming) may result in infection with Giardia or Cryptosporidium Large Cyclospora outbreaks have been traced to contaminated produce Recent travel abroad suggests traveler s diarrhea (see 30) Antibiotic administration within the preceding several weeks increases the likelihood of Clostridium difficile colitis Finally, risk factors for HIV infection or sexually transmitted diseases should be determined (AIDSassociated diarrhea is discussed in 31; infectious proctitis is discussed in this chapter under Anorectal Disorders) Persons engaging in anal intercourse or oral-anal sexual activities are at risk for a variety of infections that cause proctitis, including gonorrhea, syphilis, lymphogranuloma venereum, and herpes simplex The nature of the diarrhea helps distinguish among different infectious causes (Table 14 5)

and stachyose, ie, cruciferous vegetables, legumes, nuts, and some cereals Activated charcoal may afford relief Simethicone is of no proved benefit Complaints of chronic abdominal distention or bloating are common Some of these patients may produce excess gas However, many patients have impaired small bowel gas propulsion or enhance visceral sensitivity to gas distention Many of these patients have an underlying functional gastrointestinal disorder such as irritable bowel syndrome or functional dyspepsia Reduction of dietary fat, which delays intestinal gas clearance, may be helpful Rifaximin, 400 mg twice daily, a nonabsorbable oral antibiotic with high activity against enteric bacteria, has been shown to reduce abdominal bloating and flatulence in approximately 40% of treated patients compared with 20% of controls Symptom improvement may be attributable to suppression of gas-producing colonic bacteria; however, relapse occurs within days after stopping the antibiotic Further trials are needed to clarify the role of nonabsorbable antibiotics in symptom management

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Azpiroz F et al Abdominal bloating Gastroenterology 2005 Sep;129(3):1060 78 [PMID: 16143143] Chitkara DK et al Aerophagia in adults: a comparison with functional dyspepsia Aliment Pharmacol Ther 2005 Nov 1;22(9):855 8 [PMID: 16225495] Sharara A et al A randomized double-blind placebo-controlled trial of rifaximin in patients with abdominal bloating and flatulence Am J Gastroenterol 2006 Feb;101(2):326 33 [PMID: 16454838]

Watery, nonbloody diarrhea associated with periumbilical cramps, bloating, nausea, or vomiting suggests a small bowel source caused by either a toxin-producing bacterium (enterotoxigenic Escherichia coli [ETEC], Staphylococcus aureus, Bacillus cereus, Clostridium perfringens) or other agents (viruses, Giardia) that disrupt normal absorption and secretory process in the small intestine Prominent vomiting suggests viral enteritis or S aureus food poisoning Although typically mild, the diarrhea (which originates in the small intestine) can be voluminous and

Diarrhea can range in severity from an acute self-limited episode to a severe, life-threatening illness To properly evaluate the complaint, the physician must determine the patient s normal bowel pattern and the nature of the current symptoms Approximately 10 L of fluid enter the duodenum daily, of which all but 15 L are absorbed by the small intestine The colon absorbs most of the remaining fluid, with < 200 mL lost in the stool Although diarrhea sometimes is defined as a stool weight of more than 200 300 g/24 h, quantification of stool weight is necessary only in some patients with chronic diarrhea In most cases, the physician s working definition of diarrhea is increased stool frequency (more than three bowel movements per day) or liquidity of feces The causes of diarrhea are myriad In clinical practice, it is helpful to distinguish acute from chronic diarrhea, as the evaluation and treatment are entirely different (Tables 14 5 and 14 6) Table 14 5 Causes of acute infectious diarrhea

Noninflammatory Diarrhea Viral Noroviruses Rotavirus Protozoal Giardia lamblia Cryptosporidium Cyclospora Bacterial 1 Preformed enterotoxin production Staphylococcus aureus Bacillus cereus Clostridium perfringens 2 Enterotoxin production Inflammatory Diarrhea Viral Cytomegalovirus Protozoal Entamoeba histolytica

Diarrhea acute in onset and persisting for less than 2 weeks is most commonly caused by infectious agents, bacterial toxins (either preformed or produced in the gut), or drugs Community outbreaks (including nursing homes, schools, cruise ships) suggest a viral etiology or a common food source Similar recent illnesses in family members suggest an infectious origin Ingestion of improperly stored or prepared

Bacterial 1 Cytotoxin production Enterohemorrhagic E coli O157:H5 (EHEC) Vibrio parahaemolyticus Clostridium difficile 2 Mucosal invasion Shigella Campylobacter jejuni Salmonella Enteroinvasive E coli (EIEC) Aeromonas Plesiomonas Yersinia enterocolitica Chlamydia Neisseria gonorrhoeae Listeria monocytogenes

result in dehydration with hypokalemia and metabolic acidosis (eg, cholera) Because tissue invasion does not occur, fecal leukocytes are not present

FIGURE 4-29

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