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Operational Medicine 2001
GMO Manual

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General Medical Officer (GMO) Manual: Clinical Section

Diarrheal Disease

Department of the Navy
Bureau of Medicine and Surgery

Introduction

Diarrhea at sea

Clinical Evaluation

Etiologies

Diarrhea in the field

Treatment

 

Prevention

Introduction

Diarrhea and dysentery have had an important impact on military operations throughout history. Early in Operation Desert Shield an epidemic of diarrhea occurred with attack rates of 10 percent of the force strength per week in some units, with 50 percent of all troops affected. In general, estimates of diarrheal disease in travelers to the developing world range from 20 to 55 percent.

Etiologies

The etiology of diarrhea associated with foreign deployments is the same as "traveler’s diarrhea" in civilians (called Turista). The most common causative agents are enterotoxigenic strains of E. Coli (ETEC). They are responsible for 40 to 50 percent of all cases, and result in a self limited, noninvasive watery diarrhea (3 to 5 days). Invasive diarrhea is caused by Shigella (5 to 15 percent) of cases, Salmonella (5 to 10 percent) and Campylobacter (5 percent). These bacterial pathogens are more likely to cause a severe invasive diarrhea with bloody stools (i.e., dysentery), severe abdominal cramping, and smaller volume stools. Campylobacter is the most common pathogen in SE Asia, ahead of ETEC. Aeromonas is a common pathogen in this region as well. In Japan and Thailand, Vibrio parahemolyticus may be a significant problem, especially in association with seafood consumption. Protozoal disease due to Giardia may occur in 2 to 5 percent and produces a chronic intermittent diarrhea with malabsorption, weight loss and excessive flatulence. Amebiasis is responsible for only 1 percent of cases, but can cause a severe dysenteric picture.

Diarrhea at sea

Diarrhea at sea is generally associated with port calls when crewmembers consume local food. Port of call associated diarrhea usually begins on the 2nd day in port and a cluster of cases will usually peak on the 1st day back at sea and end by the 7th day at sea. In 80 percent of cases, there are 5 or less bowel movements during the entire episode (i.e., self-limited) and only about 10 percent of cases will require binnacle listing and 3 percent hydration in sick bay.

Diarrhea in the field

Provision of ice for cooling fluids in a field environment is particularly problematic. Despite the best training and intentions, fomites in field conditions rapidly contaminate ice machines or vats of ice and act as a point source for epidemic outbreaks.

The diagnostic approach to diarrheal disease in the field can be both simple and effective. The most important decision is to divide the cases into two broad categories: invasive and noninvasive. This can be done with an exam of the stool for fecal leukocytes using a methylene blue stain. Under field conditions, a stool guaiac test can be performed with similar sensitivity to the fecal leukocyte test. A positive test suggests invasive diarrhea. The stool culture is one of the most cost ineffective diagnostic tests available with only 2 percent of samples positive at a cost of $2000.00/positive. If available, stool cultures should be obtained in cases of invasive diarrhea, those who do not respond to empiric therapy, and in symptomatic food workers. Stool for ova and parasites would be most reasonable for patients with diarrhea of more than a week duration and in cases of invasive diarrhea.

Clinical Evaluation

The clinical evaluation should focus on the degree of dehydration, skin turgor, vital signs, and orthostatic changes. Monitoring of urine output and specific gravity may be critical important in patients requiring significant rehydration.

Treatment

The treatment for all cases of diarrhea includes rehydration. For mild cases, this can be as simple as fruit drinks and soda crackers. For moderate to severe diarrhea, oral rehydration can be highly effective using prepackaged oral rehydration salts (ORS) to replace the approximate 135 mEq of sodium, 45 mEq of bicarbonate, and 15 mEq of potassium lost in each liter of stool. In the absence of ORS packets, a balanced electrolyte solution for moderate diarrhea can be concocted from the following home brewed method; five tsp. sugar, one teaspoon of salt, and one liter of potable water, ideally with the juice of two oranges to replete potassium losses. More severe cases or those with vomiting may require intravenous rehydration with Lactated Ringers solution and supplemental potassium and bicarbonate. Kaopectate has minimal to no effect on fluid losses or resolution of diarrhea. The use of loperamide (imodium) alone for noninvasive diarrhea (fecal leukocyte or stool guaiac negative, not systemically toxic) can reduce the duration of diarrhea by about 50 percent.

  • A reasonable approach to noninvasive diarrhea is two tablets after the first loose bowel movement, followed by one tablet after each successive bowel movement up to a maximum of 8 tablets/day. Keep in mind that imodium may exacerbate invasive diarrhea when used alone, and that up to 30 percent of invasive pathogens may have fecal leukocyte negative stools.

  • Prescribing a fluroquinolone like Cipro one tab twice a day for 3 days combined with imodium has been shown to further decrease the duration to a mean of 1 hour for noninvasive ETEC diarrhea. Due to increasing worldwide resistance to Septra among shigella and salmonella, the mainstay of treatment for invasive diarrhea has become a quinolone, such as Norfloxacin or Ciprofloxacin 500 mg bid x 3d or alternatively a single one gram dose. In summary, it would be reasonable to treat all cases of invasive diarrhea with a quinolone antibiotic. For those patients who do not respond within 24 to 48 hours to a quinolone, other etiologies should be considered including Clostridium difficile (often associated with the use of antibiotics) or amebiasis. Both of these diseases respond well to Metronidazole (Flagyl) 250mg TID for C. difficile and giardiasis, and 750 mg TID x 10 days for amebic dysentery. If a patient does not respond to empiric antibiotics, noninfectious etiologies such as ulcerative colitis or regional enteritis should be considered in conjunction with a more intensive evaluation.

  • In considering synchronous, simultaneous treatment of troops, consultation with the flight surgeon may be valuable. Air crewmembers may be grounded for 24 hours after use of Ciprofloxacin. This makes a 3 day course of therapy a 4 day mission crippler whereas a single dose of one gram may only affect flight status for the next 24 hours.

Prevention

Prevention of diarrhea can be accomplished by providing safe water and food. Education before high-risk port calls should emphasize avoidance of fresh vegetables and salads, tap water, ice, street vendors, fresh dairy products, and buffets. For those determined to try the local cuisine, admonish accepting only food that comes to you steaming hot, and fruits and vegetables that you peel yourself. Encourage use of bottled water and beverages, and for especially high-risk ports, consider providing box lunches. Antibiotic prophylaxis is generally not indicated due to cost and logistical problems. However, for small groups on missions of limited duration, prophylaxis with Ciprofloxacin can be highly efficacious. Campylobacter strains in SE Asia are increasingly resistant to quinolones, particularly underscoring the need for preventive measures when deploying to this region

Previous review by LCDR James C. Pile MC, USNR, Infectious Disease Department, National Naval Medical Center, Bethesda, MD. Latest review by CDR Doug McNeill, MC, USNR, Senior Medical Officer, USS Saipan, LHA-2 (1999).


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Operational Medicine 2001

Health Care in Military Settings

Bureau of Medicine and Surgery
Department of the Navy
2300 E Street NW
Washington, D.C
20372-5300

Operational Medicine
 Health Care in Military Settings
CAPT Michael John Hughey, MC, USNR
NAVMED P-5139
  January 1, 2001

United States Special Operations Command
7701 Tampa Point Blvd.
MacDill AFB, Florida
33621-5323

This web version is provided by The Brookside Associates Medical Education Division.  It contains original contents from the official US Navy NAVMED P-5139, but has been reformatted for web access and includes advertising and links that were not present in the original version. This web version has not been approved by the Department of the Navy or the Department of Defense. The presence of any advertising on these pages does not constitute an endorsement of that product or service by either the US Department of Defense or the Brookside Associates. The Brookside Associates is a private organization, not affiliated with the United States Department of Defense.

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