Acute Diarrhoea

Dr Muhammad Sajjad Sabir MBBS, MCPS ,FCPS(Pediatrics(

Acute Diarrhoea

Definit ionsIncreased frequency and water content of stools than is normal for the individualUsually: ≥ 3 stools per day

(consistency softer than normal --or–one watery stool)stool weight >10g /kgstool weight >200g/day

Diarrhea Acute diarrhea:

Short in duration (less than 2 weeks). Persistent diarrhea:

Starts acutely & lasts more than 2 weeks

Severe Persistent diarrhea: dehydration +ve Dysentery:

Loose stool containing blood

Chronic Diarrhea

Definit ion“Chronic diarrhea is defined as a diarrheal episode that lasts for ≥14 days’’

Common Causes Common Causes of of

Acute DiarrhoeaAcute Diarrhoea

Viral gastroenteritis Infection – highly contagious

Viral gastroenteritis (“stomach flu”)

Rotavirus

Usually cause explosive, watery diarrhoea

Typically last only 48-72hrs

Usually no blood and pus in stool

Bacterial enterocolitis Sign of inflammation – blood or pus in stool,

fever

E. Coli bacteria

•Contaminated food or water

•Usually affect small kids

Bacterial enterocolitis Sign of inflammation – blood or pus in

stool, fever

Salmonella enteritidis bact

•In contaminated raw or undercooked chicken and

eggs

Bacterial enterocolitis Sign of inflammation – blood or pus in

stool, fever

Shigella bacteriaCampylobacter

bacteria

Cryptosporidium

• in contaminated water – can survive

chlorination

Parasites

Giardia lamblia

• in contaminated water

•Usually not associated with inflammation

• Food Poisoning

Staphylococcus aureus

• Produces toxins in food before it is eaten

•Usually food contaminated left unrefrigerated overnight

• Food Poisoning

Clostridium perfringens

• Multiplies in food

•Produces toxins in SI after contaminated food is eaten

Common Causes of Acute Common Causes of Acute Diarrhoea – cont.Diarrhoea – cont.

• Traveller’s Diarrhoea• Drugs / medications

History Duration Frequency Consistency Presence of blood / mucus Fever Feeding Vomiting Abdominal pain

PhysicalExamination

WHO Classification of Dehydration

No dehydration

Some dehydration

Severe dehydration

Severe DehydrationIf any two of the following signs are present, severe dehydration should be diagnosed:

lethargy or unconsciousness sunken eyes skin pinch goes back very slowly(2 seconds or more) not able to drink or drinks poorly

Skin pinch goes back very slowly

(2 seconds or more)

Some DehydrationIf the child has two or more of the

following signs, the child has some dehydration:

restlessness/irritability thirsty and drinks eagerly sunken eyes skin pinch goes back slowly

No Dehydration

Drinks well Eyes -- not sunken Skin pinch goes back rapidly Passing urine normally

Degree of Dehydration

Factors No Dehydration< 3% loss of body weight

Some Dehydration 3-9% loss of body weight

Severe Dehydration >9% loss of body weight

General Condition

Well, alert Restless, thirsty, irri table

Drowsy, cold extremities, lethargic

Eyes Normal Sunken Very sunken, dry

Anterior fontanelle

Normal depressed Very depressed

Tears Present Absent Absent

Mouth /Tongue Moist Sticky Dry

Skin turgor Slightly decrease Decreased Very decreased

Pulse (N=110-120 beat/min)

Slightly increase Rapid, weak Rapid, sometime impalpable

BP (N=90/60 mm Hg)

Normal Deceased Deceased, may be unrecordable

Resp Rate Slightly increased Increased Deep, rapid

Urine output Normal Reduced Markedly reduced

Management

Severe or prolonged episode of diarrhoea

Fever Repeated vomiting, Refusal to drink fluids Severe abdominal pain Diarrhoea with blood or mucus Signs of dehydration

When Treatment is Needed?When Treatment is Needed?

Laboratory Investigation Blood CP Serum Electrolytes Urea & Creatinine Stool R/E

mucus, blood, and leukocytes G. lamblia and E. histolytica

Culture blood stool: cholera, shigella, campylobacter

Management of

Severe Dehydration

Severe Dehydration Start IV fluid immediately If the child can drink, give ORS by

mouth Give 100 ml/kg Ringer’s lactate (or, if not available, Normal Saline) If in shock 20ml N/Saline Bolus*

* Repeat once if radial pulse sti l l very weak/undetectable

AGE First give 30 ml/kg in:

Then give70 ml/kg in:

Infants (< 12 months)

1 hour* 5 hours

Children(12 mo to 5 yrs)

30 minutes* 2 ½ hours

Diarrhoea Treatment Plan C:

* Repeat once if radial pulse sti l l very weak/undetectable

Administration of IV f luid (100 ml) to a severely dehydrated child

Monitoring Reassess the child every 15–30 minutes

until a strong radial pulse is present. If hydration is not improving, give the IV

solution more rapidly Sunken eyes recover more slowly than

other signs and are less useful for monitoring

When the full amount of IV fluid has been given, reassess the child’s hydration status

Management of

Some Dehydration

Diarrhoea Treatment Plan B:Treat some dehydration with ORS

DETERMINE AMOUNT OF ORS TO GIVE DURING FIRST 4 HOURS

ORS required ( in

ml)=weight (in kg) X 75

Diarrhoea Treatment Plan B:

— If the child wants more ORS give more

— Infants under 6 months who are not breastfed, also give 100–200 ml clean water during this period

TEACH THE MOTHER HOW TO MIX ORS HOW TO GIVE ORS

GIVE THE MOTHER 2 PACKETS OF ORS TO USE AT HOME

Diarrhoea Treatment Plan B:

SHOW THE MOTHER HOW MUCH FLUID TO GIVE IN ADDITION TO THE USUAL FLUID INTAKE:

Up to 2 years 50 to 100 ml after each loose stool

2 years or more 100 to 200 ml after each loose stool

Diarrhoea Treatment Plan B:

Diarrhoea Treatment Plan B:

SHOW THE MOTHER HOW TO GIVE ORS

— Give frequent small sips from a CUP

— If the child vomits: Wait 10 minutes Then continue ORS , but more slowly

— Continue breastfeeding whenever the child wants

Diarrhoea Treatment Plan B:

Explain 3 Rules of Home Treatment 1. GIVE EXTRA FLUID 2. CONTINUE FEEDING 3. WHEN TO RETURN

WHEN TO RETURNIf child develops any of the following signs:

— drinking poorly or unable to drink or breastfeed

— becomes more sick — develops a fever — has blood in the stool

Managementof

Child with No Dehydration

If there is no dehydration, teach the mother thethree rules of home treatment: (i) give extra fluid (ii) continue feeding (iii) return if the child develops any of

following signs:— drinking poorly or unable to drink or breastfeed— becomes more sick— develops a fever— has blood in the stool.

Diarrhoea Treatment Plan A :

TELL THE MOTHER: — Breastfeed frequently and for longer at

each feed — If exclusively breastfed, give ORS or

clean water in addition to breast milk — If not exclusively breastfed, give one or

more of the following: ORS solution Food-based f luids (such as soup, r ice water,

yoghurt drinks) Clean water

Diarrhoea Treatment Plan A :

Role of Antibiotics

Indicated when Fever Blood/mucus in stool Severe or prolonged episode of diarrhoea Severe abdominal pain Amoebiasis Giardiasis

Oral Co-trimoxazol Naladixic acid Cefixime

Injectable Ampiciline Cirofloxacine Ceftriaxone

Metronidazolonly when Amoebiasis Giardiasis

Role of Antibiotics

Role of Zinc 25% reduction in duration of

diarrhoea episode

30% reduction in stool volume

Decreases morbidity & mortality

Prevents recurrent diarrhoea

Zinc supplementation is efficacious in reducing severity and duration of diarrhoea

dose of Zn 2 RDAs per day for 10-14 days 10 mg per day < 6 months age 20 mg per day > six months age

Role of Zinc

Role of ProbioticsProbiotic – Live microorganisms

(bacteria or yeasts) which, when administered in adequate amounts, confer a health benefit on the host

Examples Saccharomyces boulardii (Enflore) Lactobacilli Enterococci Bifidobacteria

Mechanism of action of Probiotics competit ion for nutrit ion destruction of receptor site for toxin producing protease aid host with both the digestion and absorption of

nutrients Produce abundant lactate--lowering pH of intestine ,

l imit ing the growth of certain enteropathogens (eg Salmonella

colonise intestinal epithelia---depriving pathogens of attachment sites

increasing macrophage activity enhancing the production of immunoglobulins (eg

IgA) destroy the invading organism

Potential Advantages of Probiotics

Multiple Mechanisms of Action Resistance is Infrequent Use May Reduce Exposure to Antibiotics Delivery of Microbial Enzymes Well Tolerated Benefit to Risk Ratio is Favorable

How to prepare ORS at home

Thanks….

But it’s not the end !!!

Prevention

Wash your hands frequently, especially after using the toilet, changing diapers

Wash your hands before and after preparing food

Wash diarrhea-soiled clothing in detergent and chlorine bleach

Never drink unpasteurized milk or untreated water

Proper hygiene

access to clean water safe sanitation hygiene education exclusive breast-feeding improved weaning practices immunizing all children; especially measles keeping food and water clean washing hands with soap (the baby's as well)

before touching food sanitary disposal of stools

Prevention

Points to Remember Gastroenterit is is acute self-l imited

i l lness Diarrhea and vomiting in infancy and

childhood is usually due to viral gastroenterit is

Fluid replacement with ORS is mainstay of management

Breast feeding should be continued, but formula feeding should cease unti l recovery.

Antibiotics usually not required Antidiarrhoeal and antiemetics

agents are contraindicated zinc supplementation should be

given as an adjunct Use Probiotics

Points to Remember

Thank You for Being Patient Ti l l the End

SOLUTION

glucose (g/L)

Na (mmol/L)

K(mmol/L)

Cl (mmol/L)

BASE (mmol/L)

OSMOLARITY

(mOsm/L)

Low osmolali ty

ORS13.5 75 20 65 10 245

WHO (2002) 13.5 75 20 65 30 245

WHO (1975) 20 90 20 80 10 311

Pedialyte 25 45 20 35 30 250

COMPOSITION OF COMMERCIAL ORS AND COMMONLY CONSUMED BEVERAGES