As diarrhea or diarrhea (including diarrhea ; of Greek διάρροια diárrhoia , diarrhea ', abdominal flow' from διά diá by 'and ῥέω Rheo flow.'; Cf. Ruhr ), the multiple of excretion to liquid chair designated. Diarrhea can be a symptom of many diseases (e.g. infections , food poisoning , tumors ). It is estimated that around four billion people worldwide suffer from diarrhea each year, and 7.5 million people (mostly children) die as a result.
The normal frequency (three times a day to three times a week) and consistency (barely shaped to hard) of bowel movements differ from person to person. The subjective assessment of what is “normal” bowel movements also differs greatly. The medical definition of diarrhea in adults is a stool weight of over 200–250 g with more than three bowel movements per day and a high water content (over 75 percent).
Acute diarrhea is usually easy and heals without further measures (e.g. medication). Severe and prolonged diarrhea, on the other hand, can be dangerous due to the loss of water / electrolytes and require (drug) therapy.
Pseudodiarrhea must be differentiated from diarrhea , e.g. B. in the context of irritable bowel syndrome . The stool frequency and water content are increased, but the weight of the stool is not abnormally increased. The paradoxical diarrhea with rather reduced stool weight, which can be a symptom of colon cancer, is also not diarrhea in the strict sense .
Classification of diarrhea
Classification according to duration
Depending on the duration of the diarrhea, a somewhat vague distinction can be made between acute and chronic diarrhea. The acute diarrhea lasts a maximum of two to three weeks and usually infectious or toxic causes. Prolonged diarrhea is referred to as chronic diarrhea , for which many causes such as food intolerance, chronic intestinal diseases or tumors come into question.
Classification according to the origin of the disease
Diarrhea can be further differentiated according to the pathomechanism, i.e. how the disease develops. The diseases and mechanisms are explained in detail under "Causes".
|Forms of diarrhea after the onset of disease|
|Diarrhea form||Pathomechanism||Possible causes (examples)|
|Osmotic diarrhea||Unabsorbed food components, medication or other substances osmotically draw water into the intestinal lumen||Lactose intolerance , celiac disease , use of laxatives, excessive sorbitol consumption|
|Secretory diarrhea||The intestinal lining actively releases water, or electrolytes, which water follows||Food poisoning, inflammatory bowel disease, use of laxatives|
|Exudative diarrhea||Inflammation of the intestinal lining causes mucus and blood to be added to the stool||Invasive bacteria , parasites, colon carcinoma, inflammatory bowel disease|
|Hypermotile diarrhea||Due to an increase in bowel movements and the resulting shorter retention time of the stool in the bowel, not enough fluid can be absorbed.||Hyperthyroidism , irritable bowel syndrome, diabetic polyneuropathy|
|Steatorrhea (fatty stool)||Lack of digestive enzymes (especially lipases) for adequate nutrient breakdown and absorption, or there are not enough bile acids in the intestine to emulsify all ingested fats for effective fat breakdown||Exocrine pancreatic insufficiency , gallbladder removal|
Forms of diarrhea can also be classified according to the cause. Infections and food intolerances usually lead to acute diarrhea, while chronic intestinal diseases, diseases of the exocrine pancreas and carcinoma are examples of the causes of chronic diarrhea.
The most common triggers of diarrhea are bacteria and viruses that lead to gastroenteritis . The most important germ in the world is the cholera pathogen , Vibrio cholerae , which affects around six million people worldwide and kills over 100,000. In Germany, however, cholera is extremely rare, where infections are often caused by human noroviruses and human rotaviruses or salmonella . Diarrhea is often caused by spoiled food: the trigger here are toxins produced by bacteria (see below: "Food poisoning").
In Germany there is a reporting requirement for many diarrhea pathogens. 30 to 50% of all travelers to (sub) tropical countries develop traveler's diarrhea of varying severity. The most important protective measure against all forms of infectious diarrhea is personal hygiene and the consumption of non-polluted water and food.
In the case of diarrheal diseases that are triggered by bacteria, a distinction is made between three mechanisms:
- Secretion-type pathogens are, for example, Vibrio cholerae or ETEC ( Enterotoxic E. coli , the main pathogen of travelers' diarrhea ). They act on the intestinal lining, causing it to release electrolytes and water into the intestine.
- Representatives of the invasion type are, for example, Shigella , Campylobacter , Clostridioides difficile ( antibiotic-associated colitis , see also under drugs) or EIEC / EHEC ( enteroinvasive or enterohaemorrhagic E. coli ). These penetrate into the mucous membrane cells of the intestine, multiply there and lead to the destruction of the cells.
- Penetration-type pathogens are Salmonella and Yersinia . These are absorbed by the intestinal mucosa and channeled into the connective tissue below, where they cause an inflammatory reaction . How this leads to diarrhea is not yet fully understood.
Very often diarrhea is also caused by viruses. The main representatives of these viruses are human rotaviruses and human noroviruses . In the (sub) tropical countries, intestinal parasitosis plays an even more important role in diarrheal diseases than in the northern countries .
A food poisoning leading to diarrhea because proliferate in the tainted food bacteria and toxins while so-called enterotoxins could make. Representatives of these bacteria are Staphylococcus aureus , Clostridium perfringens and Bacillus cereus . The proliferation of bacteria is favored by insufficient hygiene during preparation and excessively warm storage. The actual cause of the diarrhea is not the bacteria themselves, but the absorption of the enterotoxins that have already formed. Since the enterotoxins from Staphylococcus aureus, for example, are very stable to heat, cooking food that has already spoiled does not provide protection.
Lactose intolerance is also common . In Germany around 15% of the population is affected, in Asian ethnic groups over 95%. Depending on the severity of the intolerance, gas, diarrhea and abdominal pain can occur. In the intestine, milk sugar (lactose) can be broken down by the enzyme lactase into the simple sugars glucose and galactose. In the case of lactose intolerance - which is the normal case for the majority of the world's adult population - this enzyme is completely or partially missing, so that lactose is broken down by bacteria in the large intestine. This creates the gases carbon dioxide and hydrogen and short-chain fatty acids , which are osmotically active, i.e. attract water, and thus cause diarrhea. This cause can be clarified relatively easily with the lactose breath test .
Another form of food intolerance is food allergies , e.g. B. against strawberries, milk, nuts, egg white or fish.
Taking antibiotics can lead to diarrhea, as they not only act on bacterial pathogens, but also damage the bacteria of the physiological intestinal flora. The spectrum of antibiotic-associated diarrhea ranges from only a little softened stool to Clostridioides difficile- associated diarrhea with the serious complication of pseudomembranous colitis .
Of course, the use and abuse of laxative drugs called laxatives can also lead to diarrhea. In particular, the abuse of laxatives with the aim of weight reduction leads to electrolyte losses, which in turn can lead to constipation or, in extreme cases, life-threatening cardiac arrhythmias.
Diarrhea is also a possible side effect of some other drugs , such as cancer drugs ( cytostatics ) and iron supplements, or dietary supplements such as vitamin C ( ascorbic acid ). Excessive consumption of the sugar substitute sorbitol (e.g. in chewing gum) also has a laxative effect.
The "poor utilization" of nutrients is called " malassimilation ". A further distinction is made between diseases in which the food is not properly “broken down” ( maldigestion ), and diseases in which the absorption of the broken down food components is impaired ( malabsorption ).
Surgical removal of the stomach ( gastrectomy ), an inadequately functioning pancreas ( exocrine pancreatic insufficiency ), the loss of bile acids or the occlusion of the biliary tract can lead to maldigestion . All these diseases have in common that the digestive enzymes necessary to break down the food that is fed in do not reach the intestine or are not produced at all or are not produced in sufficient quantities.
In the case of malabsorption, the nutrients are not absorbed by the intestinal lining. This is the case, for example, with indigenous sprue (gluten intolerance), Whipple's disease , amyloidosis or after removal of the small intestine.
- Poisoning ( intoxication ) with, for example, arsenic, mercury, alcohol or mushrooms
- Inflammatory bowel disease . In Crohn's disease , the diarrhea is typically without blood, whereas in ulcerative colitis it is bloody and slimy.
- hormonal (endocrine) diseases (e.g. hyperthyroidism )
- Allergy ( idiosyncrasy )
- psychological triggers (e.g. stress , fear )
- Irritable bowel syndrome
The basic medical diagnosis of diarrheal diseases includes an anamnesis , which should include questions about the frequency of bowel movements, the condition of the stool and pain. Stays abroad and medication intake should also be determined . During the basic physical examination, the abdomen is felt ( palpation ) and listened to ( auscultation ); on this occasion, attention should also be paid to signs of dehydration ( desiccosis ). In addition, it may be necessary to inspect the chair (chair visit) and to carry out a digital rectal examination .
The attempt to specifically detect any pathogens that may be present is not medically necessary in uncomplicated cases - especially from a cost-benefit perspective. However, it is necessary when identifying outbreaks and with regard to the statutory reporting obligation.
Further examination options are, for example:
- Laboratory tests of the blood
- Endoscopy (e.g. colonoscopy )
- Ultrasound examination of the abdomen (abdomen sonography )
- Lactose tolerance test
- Analysis of food, drinking water, etc.
The most important basic therapy is fluid and electrolyte replacement (i.e. drinking).
If possible - as with any disease - the cause should be identified and eliminated (causal therapy). In most cases, antibiotic therapy is not necessary or useful. Symptomatic treatment can be useful in some situations.
Replacement of the electrolytes
The most important measure - especially in the case of long-term diarrhea - is to replace the lost water and electrolytes . Depending on the severity of the diarrhea, this can be done orally or parenterally (using a venous access ). Ready-made electrolyte mixtures are available for this purpose, but you can also use a self-made oral rehydration solution . This is particularly relevant in developing countries, where diarrheal diseases such as cholera occur regularly, but appropriate medication is often not available. The World Health Organization (WHO) currently recommends the following electrolyte mixture per liter of clean (or boiled) drinking water:
- 2.6 g sodium chloride (table salt)
- 13.5 g glucose (grape sugar)
- 2.9 g sodium citrate
- 1.5 g potassium chloride
In addition to the supply of electrolytes, the added sugar facilitates the absorption of water into the body, since glucose is always absorbed from the intestine together with sodium and water then passively follows the sodium. If ready-to-use rehydration solutions are not available, this mixture can approximately also be prepared yourself. To do this, the following ingredients are dissolved in a specific ratio in one liter (boiled and cooled) drinking water (e.g. non-carbonated mineral water):
- ¼ teaspoon salt (for sodium chloride)
- 2 Ess spoon sugar or honey (for glucose)
- ¼ teaspoon baking powder (for sodium bicarbonate or sodium citrate)
- ½ cup orange juice or 1–2 mashed bananas (for potassium)
(no official information from WHO)
Although this recipe is a reasonably good approximation of the composition recommended by the WHO, it is not recommended for children under five years of age due to the potential risks (e.g. incorrect preparation), as they are particularly sensitive to electrolyte fluctuations. There are numerous deviations from this self-made solution on the Internet, but these are largely based on the outdated recommendations of the WHO.
The previously common electrolyte therapy with a combination of soft drink (e.g. cola ) and savory biscuits is no longer recommended. Cola contains more than eight times the amount of sugar recommended by the WHO for the rehydration solution (≥ 110 g / L) and thus has a massively increased osmolar activity (up to 780 mOsm / L), which binds water and causes diarrhea in general Usually reinforced. The resulting relative excess sodium in the blood ( hypernatremia ) as well as the uncovered (and increased by cola) lack of potassium ( hypokalemia ) put a strain on the already shifted electrolyte balance in the body.
Loperamide and other opiates
Opioids (which includes loperamide) and opiates are mainly known from the treatment of severe pain. They also have a constipating effect , which is used in symptomatic diarrhea treatment. With loperamide is a means for that inhibits bowel movements (motility). These drugs can provide relief to the patient, but must not be used in the case of severe bacterial intestinal infections that are associated with fever and bloody diarrhea, as the elimination of pathogens and the excretion of toxins are suppressed. In children under two years of age, loperamide can also penetrate the nervous system and lead to respiratory arrest and delirium , while in older children and adults the entry into the nervous system is prevented by the blood-brain barrier . For this reason, loperamide must not be used in children under two years of age and should only be dosed very carefully according to body weight in children between two and twelve years of age. In principle, loperamide should only be used for a short time (max. 48 hours) and preferably as a bridging travel medication for severe diarrhea until appropriate medical care is obtained.
If diarrhea cannot be successfully treated by other means, tincture of opium can be prescribed. Since August 2018, discontinued opium tincture has been available as a finished medicinal product in Germany and other countries under the trade name Dropizol (ATC Code A07DA02, group of motility inhibitors) . It is approved for the treatment of severe diarrhea, such as: B. in diarrhea caused by cytostatics, radiation or neuroendocrine tumors, if the use of other antidiarrheal drugs has not achieved sufficient effect. The application and the treatment results are currently being investigated in a prospective study in Germany and Austria. The analgesic effect of tincture of opium is mainly due to the morphine, while all the alkaloids it contains work together to alleviate diarrhea. In the gastrointestinal tract , opium tincture primarily attacks μ- opioid receptors , reduces intestinal motility, reduces secretion, slows down intestinal peristalsis , and increases the tone of the anal sphincter. The dose for combating diarrhea is significantly smaller than that for combating pain. Opium tincture must be prescribed on a BtM prescription .
In most cases, antibiotic therapy does not make sense, but it is mandatory for typhoid , cholera , giardiasis ( lamblia dysentery ), amebiasis ( Entamoeba histolytica ), for Clostridioides difficile , which occurs in children when they are older than one year.
Under no circumstances should antibiotics be used in the case of diarrhea caused by EHEC ( enterohaemorrhagic E. Coli ), as in this case they can lead to life-threatening kidney failure. The administration of antibiotics for travelers' diarrhea has been well researched. A preventive (prophylactic) administration of antibiotics should under no circumstances take place, above all because they can promote the development of resistant pathogens . In the presence of traveller's diarrhea, the duration of the diarrhea can in some cases be shortened by taking antibiotics.
A German multicenter study at 131 medical practices was able to show that a plant combination with myrrh (plus chamomile and coffee charcoal ) is effective and tolerable for intestinal diseases with chronic and acute diarrhea. The herbal combination of three was particularly effective at alleviating the symptoms of diarrhea in irritable bowel patients. Myrrh lowers the tension of the smooth intestinal muscles, reduces the strength of intestinal contractions and can thus alleviate intestinal cramps.
If the intestinal flora is damaged, for example after previous antibiotic therapy, probiotic treatment can help normalize bowel movements.
- Gastroenteritis , also diarrhea and vomiting called
- Traveller's diarrhea , including traveller's diarrhea
- Constipation or constipation
- Irritable bowel syndrome , also nervous bowel
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