This topic has been running through my mind quite a bit lately. Infectious diarrhea is one of the world’s most vicious killers, but is susceptible to basic public health measures such as clean water and good sanitation, which is why cholera-ridden Americans aren’t dropping dead in pools of their own feces. (Citizens of other countries aren’t quite so lucky.)
There are many causes to this common problem—various bacteria, viruses, parasites, and a host of non-infectious causes. Even in here in the U.S., public health measures sometimes fail us, as seen in the ongoing Salmonella outbreak.
But diarrhea isn’t just a load of crap. Let me explain.
First of all, what is “diarrhea”? The scientific definition is—for people on a “Western” diet—greater than 200g of stool in 24 hours. While this may be nice and standard, I don’t usually ask my patients to collect and weigh their stool. A more useful operational definition is the more vague “increase in frequency and change in consistency (looser) of stool”.
Most of us “know” if we have diarrhea, but in the office, I need to know. Someone who simply has had a few cramps and one extra bowel movement requires a different work up than someone with ten episodes of watery stool and a fever.
Some notable infectious diarrheas:
Norovirus: A common cause of “food poisoning”, this is the infamous “cruise ship” virus. It is very, very contagious, and can be deposited on foods, surfaces, anywhere, really. Thankfully, the horrid symptoms don’t last very long.
Salmonella: This lovely bacterium is infamously infectious—only a few individual bacteria need be ingested to cause illness. They usually cause “dysentery”—a bloody, crampy, feverish diarrhea. It can be found in eggs, meat, and, apparently, tomatoes.
Campylobacter: Now this bacteria is a real winner. It can cause inflammation throughout the whole bowel, often leading to “pseudo-appendicitis”, that is, it is often associated with abdominal pain that mimics appendicitis and other abdominal diseases. To add to the fun, it is sometimes associated with Guillain-Barre syndrome, a paralytic disorder.
Pseudomembranous colitis: This is a really, really fun one. Clostridium difficile is a bacterium that lives in the gut. It can cause disease in anyone, but people who are given antibiotics often kill off more beneficial gut bacteria, leaving this one to take over the joint. It produces a toxin that makes you quite ill, with a fever, remarkably high white count, and sometimes (not frequently, thankfully), it can actually cause your colon to swell to the diameter of your leg. That’s not good—you can tell by the name of the condition: “toxic megacolon”. In hospitals, we try our best to prevent this, by avoiding unnecessary antibiotics, isolating infected patients, and washing our hands frequently. Unfortunately, this bacterium can form spores which are highly resistant to, well, everything.
Cholera: Vibrio cholerae is a fascinating organism that causes a devastating disease. It is passed from feces into water, and then ingested, so poor sanitation and poor water quality are the big problems here. It loves events like Cyclone Nargis. A toxin produced by the bacteria causes water to poor out of the gut by the gallon until the victim has literally shit themselves to death. It’s hard to imagine a worse way to go (OK, maybe not that hard, but still…).
So why bother talking about diarrhea? Sure, there is a certain amount of guilty scatological pleasure (isn’t there??), but really, why bother?
Because infectious diarrheal illnesses are preventable, and they sicken and kill millions every year. Did I mention that they’re preventable?
Access to clean water, appropriate sewerage/latrines prevent most of these infections. Good medical care for those who still get ill saves lives.
But here in the industrialized, wealthy U.S., we still have deadly outbreaks of diarrheal illnesses. Enterotoxic E. coli infections, C. diff., Salmonella, cryptosporosis— all of these have caused disease and death here at home. Much of this can be attributed to food contamination, health care-related infections, and in the case of cryptosporosis, contaminated water supplies—in other words, we should be able to do better.
Diarrhea is common, nasty and preventable, and no part of the world in unaffected. Let’s do better.