25 Diarrhea
Diarrhea is one of the most common abnormal manifestations of gastrointestinal (GI) dysfunction in the intensive care unit (ICU); the reported incidence is between 2% and 63%.1 Diarrhea is best defined as bowel movements that, owing to increased frequency, abnormal consistency, or increased volume, cause discomfort to the patient or the caregiver. This definition demonstrates the subjectivity in diagnosing diarrhea, a fact that complicates interpretation of the literature and limits applicability of guidelines. The impact of diarrhea on patient care in the ICU, including its cost in morbidity and mortality, is unknown. However, it is undeniable that diarrhea remains a persistent problem in many ICUs.
Criteria
Several criteria are used to diagnose diarrhea:
Pathophysiology
Clinical Consequences of Diarrhea
Untreated, diarrhea can lead to multiple problems. These include:
Diagnosis
Treatment
Treatment is dependent on identification of the underlying cause. One or several reasons for the presence of diarrhea generally can be identified. Once identified, the causes of diarrhea should be eliminated, modified, or treated. In particular, iatrogenic causes of diarrhea should be identified and corrected whenever feasible. For example, prolonged courses of prophylactic antibiotics are no better than short courses for the prevention of surgical site infections; therefore, adherence to current guidelines to limit antibiotics is important.12,13
Bulk-forming agents are sometimes given to patients to improve the consistency of the fecal bolus. These agents have to be used in the appropriate amount, since they can also be a cause of diarrhea.14
Antibiotics to treat infectious diarrhea also should be used with caution. If the diarrhea is causing minimal discomfort and is of no physiologic consequence, waiting for arrival of results of tests for C. difficile may be advised.15
Restoring normal colonic flora has become an increasingly frequent practice in the ICU. Provision of prebiotics and probiotics in different presentations is now being suggested, but the implications of such therapies are not clear and require further investigation.11,16 Soluble fiber may have a role in restoring normal colonic function and flora.
Cunha BA. Nosocomial diarrhea. Crit Care Clin. 1998;14:329-338.
This article reviews both noninfectious and infectious causes of nosocomial diarrhea.
Dallal RM, Harbrecht BG, Boujoukas AJ, et al. Fulminant Clostridium difficile: an underappreciated and increasing cause of death and complications. Ann Surg. 2002;235:363-372.
Nelson RL, Glenny AM, Song F. Antimicrobial prophylaxis for colorectal surgery. Cochrane Database Syst Rev 2009;1:CD001181.
Pilotto A, Franceshi M, Vitale D, Zaninelli A, DiMario F, Seripa D, et al. The prevalence of diarrhea and its association with drug use in elderly outpatients: a multicenter study. FIRI; SOFIA Project Investigators. Am J Gastroenterol. 2008;103:2816-2823.
Wiesen P, van Gossum A, Presier JC. Diarrhoea in the critically ill. Curr Opin Crit Care. 2006;12:149-154.
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