Diarrhea
Basic Information 
Definition
Abnormal frequency and liquidity of fecal discharge. Diarrhea may be defined as an undefined mass of fecal material and urine that is evacuated from the cloaca of a bird. Polyuria is defined as formed stool with a large quantity of urine surrounding the fecal material.
Epidemiology
Genetics and Breed Predisposition
No specific genetic/breed predisposition. Certain bird species (e.g., Lories) normally have a “loose” stool caused by dietary intake.
Risk Factors
• Hepatic disease: atoxoplasmosis
• Bacterial infection: Campylobacter spp., Chlamydophila psittaci, Escherichia coli, Pseudomonas spp., Aeromonas spp., Salmonella spp., Citrobacter spp.
• Viral infection (see Viral Diseases): adenovirus, avian polyomavirus, herpesvirus, circovirus, proventricular dilatation disease (PDD) (see Proventricular Dilatation Disease), paramyxovirus
• Foods with elevated water content
• Ingested toxins: lead, zinc, pesticides
• Ingested foreign bodies (see Foreign Bodies)
• Intestinal parasitism: coccidiosis, Cryptosporidia spp., Microsporidia spp., Giardia spp., Hexamita spp.
Contagion and Zoonosis
• Diarrhea caused by the bacterial infection C. psittaci (see Chlamydophila psittaci); this organism is a zoonotic intracellular bacterium that can infect humans exposed to birds that are diagnosed with this disease.
• The intestinal parasite Giardia spp. may cause disease in humans. Although intermittently diagnosed in avian species, bird handlers should be aware of the possible zoonotic potential.
Etiology and Pathophysiology
• Liquid unformed stool may be caused by physiologic abnormalities that include decreased intestinal transit time to malabsorption syndromes.
• Discolored stool that is liquid and unformed may be associated with gastrointestinal hemorrhage, bacterial and viral infections, dyes, and food items.
• Whole seed/undigested food in stool is usually an indication of abnormal digestive processes (e.g., pancreatitis, neoplasia, PDD) and/or hypermotility of the digestive tract (e.g., colibacillosis, salmonellosis, viral infection).
Diagnosis 
Differential Diagnosis
• Hepatic disease: atoxoplasmosis
• Bacterial infection: Campylobacter spp., C. psittaci, E. coli, Pseudomonas spp., Aeromonas spp., Salmonella spp., Citrobacter spp.
• Viral infection: adenovirus, avian polyomavirus, herpesvirus, circovirus, PDD, paramyxovirus
• Foods with elevated water content
• Ingested toxins: lead, zinc, pesticides
• Intestinal parasitism: coccidiosis, Cryptosporidia spp., Microsporidia spp., Giardia spp., Hexamita spp.
Initial Database
• Cytologic examination of fecal, cloacal, crop, and/or proventricular lavage fluid. Retrieved fluid can be mixed with saline or counterstain to identify microorganisms.
• Gram stains of fecal, cloacal, crop, and/or proventricular swabs
• Fecal Gram stains: assessment of intestinal flora
• Direct fecal examination: protozoal parasite evaluation
• Fecal flotation: intestinal parasite examination
• Complete blood count (CBC): leukocytosis with concurrent heterophilia may be observed when gastroenteritis is present as a result of infectious processes involving bacterial organisms. Hypochromic regenerative anemia occurs in some cases of lead toxicity.
• Plasma biochemistry panel: amylase may be elevated in pancreatitis cases
• Culture and sensitivity of swab submitted from cloaca, crop, and/or proventriculus mucosa
Advanced or Confirmatory Testing
• Impression smears of abnormal masses
• Biopsy of abnormal tissue (e.g., renal, hepatic)
• Heavy metal–specific testing
Lead tissue concentrations in the liver, kidney, and brain of 3 to 6 ppm wet weight are suggestive of lead toxicosis; greater than 6 ppm is diagnostic. Blood levels for lead intoxication in birds, 0.25 ppm (significant when associated with clinical signs); >0.5 ppm is considered high.
Zinc concentrations in the pancreas of 26.11 µg/g on a dry weight basis were considered normal in cockatiels; concentrations of 312.4-2418 µg/g were considered toxic. In liver, subclinical birds are less than 40 ppm wet weight, and concentrations greater than 75 ppm were correlated with toxicosis. Normal zinc blood levels in parrots is <2.5 ppm. 2.6-3.4 is reported as above normal levels and 3.5-4.4 is high. Any zinc blood levels above 4.5 ppm is considered toxic. Normal zinc levels for waterfowl and poultry are slightly higher than those used for parrots.
Treatment 
Acute General Treatment
• All treatment is to be performed on a stable patient.
Administer warmed crystalloid fluids SC, IV, IO (50-150 mL/kg/d maintenance plus dehydration deficit factored in if needed) at a rate of 10-25 mL/kg over a 5-minute period or at a continuous rate of 100 mL/kg/q 24 h.
Increase environmental temperature to 85°F-90°F (29°C-32°C).
Provide a humidified environment by placing warm moist towels in the incubator.
• Surgical considerations: patient should be stabilized and on chelation therapy before any surgical procedure is attempted. Removal of heavy metal objects from the gastrointestinal tract of the stable patient should be attempted. Surgical procedures to remove objects from the gastrointestinal tract include the following:
Use of a small, very strong magnet, glued to the tip of an enteral feeding tube, to remove zinc-coated ferrous items
Endoscopic removal of foreign objects (e.g., string, cloth, leather, wood) or heavy metal particles or gastric lavage can be attempted in stable patients of sufficient size.
Occasionally, proventriculotomy or enterotomy procedures may be necessary if other attempts to remove foreign objects fail.
Appropriate antimicrobial therapy based on culture and sensitivity and suitable diagnostic testing
Appropriate antiparasitic medication based on culture and sensitivity
Sucralfate 25 mg/kg PO q 8 h: esophageal, crop, and gastrointestinal protectant
Kaolin/pectin 2 mL/kg PO q 6-12 h: intestinal protectant, antidiarrheal
Bismuth subsalicylate 1-2 mL/kg PO q 12 h: intestinal protectant, antidiarrheal
Cimetidine 5 mg/kg PO, IM q 8-12 h: proventriculitis, gastric ulceration
Chronic Treatment
Celecoxib 10 mg/kg PO q 24 h × 6-24 weeks: PDD has been advocated as a treatment although clinical response of avian patients to this therapy has been universally disappointing.
Possible Complications
• d-Penicillamine: do not give if lead is present in the gastrointestinal tract (increases absorption of heavy metal particles)
• d-Penicillamine: extremely unpalatable even when mixed with liquid corn syrup. Birds may have severe reaction (e.g., retching, convulsions) when this drug is given orally.
• Cathartics may cause diarrhea and are contraindicated in birds that present with diarrhea, dehydration, and hypovolemia.
Recommended Monitoring
• Repeat CBC and plasma chemistry panel to monitor treatment response and recovery.
• Monitor hydration status on a daily basis.
• Monitor eating habits and stool volume, consistency, color, and odor as a response to treatment.
• If parasites and/or microorganisms are the primary cause of diarrhea, retest for treatment response and status of infection.
Prognosis and Outcome 
• Acute cases that have a treatable cause have a good prognosis toward complete resolution.
• Chronic cases of diarrhea in which the patient is in poor physical condition upon presentation have a more guarded prognosis.
• Disease processes that cause diarrhea that cannot be treated to resolution (e.g., circovirus, proventricular dilatation disease) have a grave prognosis over time. This is the case even though the disease condition may be stabilized for a period of time.
Pearls & Considerations 
Comments
• A quick diagnosis of the primary cause of diarrhea in an avian patient often results in an effective treatment regimen.
• Diarrhea in avian patients has many causes.
• It is important to know the difference between diarrhea and polyuria.
• Stabilization of the avian patient that presents with diarrhea through appropriate hydration therapy will help restore the patient’s overall physical condition.
Prevention
• Reduce stress within the bird’s environment.
• Provide an appropriate diet.
• Quarantine all new birds and birds that have been exposed to other avian species at bird shows and bird fairs for 30 days.
• Owners must maintain immune competent animals.
• Provide clean water and discourage the use of untreated well water and automatic watering systems.
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