DIARRHEA

ANSARI MOHD. ADNAN A

ROLL NO .-01
2nd YEAR BSC NURSING
VJCON
Definition
 The term "diarrheal disease" refers to a
group of diseases in which the predominant
symptom is diar- rhea.
 WHO defines "acute diarrhea” as an attack
of sudden onset, which lasts 3-7 days but
may last upto 10-14 days. It is caused by an
infection of the bowel. If diarrhea lasts for
more than 14 days, it is chronic diarrhea.
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 Diarrhea can cause dehydration and

malnutrition if not treated timely.
 Diarrhea is also defined as the passage of
loose, liquid or watery stools. These liquid
stools are usually passed more than three
times a day. However, it is the recent change
in consistency and character of stools rather
than the numbers of stools that is more
important. Passing of even one large liquid
stool in children is also diarrhea.
Problem

 Diarrhealdiseases are important health

problem especially affecting young
children. Although the mortality rate due to
diarrhea has been reduced to 1.2 million
during the year 2000 from 4.6 million in
1980, diarrhea continues to be major
health problem among children in the
developing countries. In 2011, there were
0.7 million deaths of under five children
showing a decline by a third over the last
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 decade. This is attributed to rehydration

therapy. In India, acute diarrheal diseases
account for about 8% of deaths in under
five years age group. During the year 2011
out of total 10.6 million cases of diarrhea in
under five, 1293 died in India. Diarrhea is a
leading cause of death during emergency
and natural disasters, Diarrheal diseases
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 also
cause a heavy economic burden on
health services.
Epidemiological Factors

 Agent Factor :-
 Diarrhea is caused by a number of
organisms. Many of these organisms have
been discovered only in the recent years.
These include viruses, bacteria, protozoa
and fungi.
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1 Viruses: There are many types of viruses

which cause diarrhea, such as rotavirus,
coronavirus, adenovirus, astrovirus,
norwalk viruses and enteroviruses.
Rotavirus is the single most common cause
of diarrhea. Nearly all children below the
age of 2 years are infected at least once
and repeat infections are common. In
temperate climates, the incidence of
rotavirus gastroenteritis is highest during
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 the winter season, whereas in tropical
areas, it occurs throughout the year.
 2. Bacterial causes: Vibrio cholera,
salmonella, shigella, enterotoxigenic E.coil
and campylobacter jejuni cause significant
number of cases of diarrhea.They produce
potent enterotoxin similar to the one
produced by vibrio cholerae.
 Ecoli is a gram negative bacteria found in
normal intestine of man.
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 Itis a major cause of watery diarrhea in
adults and children. Salmonella causes
inflammation of the bowel epithelium. Both
Salmonella and Vibrio cholera, 01 cause
diarrhea and dehydration. Shigella causes a
high percentage of mortality due to
diarrhea disease. Shigella also causes
about 699% of all episodes of diarrhea in
young children world wide.
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3 Others: Amoeba, giardia and intestinal

worms also cause diarrhea. Besides the
above some parenteral infections (non-
digestive origin), eg. ENT infections,
respiratory or urinary infection, malaria
and bacterial meningitis may also cause
diarrhea.
Reservoir Of Infection

 Forsome enteric infections, eg. Ecoli,

shigella, V. cholera, Giardia and E.
histolytica, man is the reser voir. For some
enteric pathogens, animals are the
reservoirs for example, campylobacter
jejuni and salmonella spp.
Host Factor
 1. Age: Children 6 months to 2 years are
the most affected, Malnourished children
are also commonly affected. Incidence is
highest in the age group 6-11 months when
weaning occurs which is associated with
declining maternal antibodies and
introduction of infection through
contaminated food or direct contact with
soil contaminated with feces when the
infant crawls or licks things lying on the
floor.
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2 Others: Poverty, prematurity,

immunodeficiency, poor personal and
domestic hygiene are also contributory
factors.
Environmental Factors

1 In tropical areas, rotavirus diarrhea

occurs throughout the year, but more
frequently in cool months.
 2 Bacterial diarrhea occurs more frequently
in warm and rainy seasons in the tropical
areas. Viral diarrhea occurs during winter
in temperature climates.
Mode Of Transmission

 Mostof the pathogenic organisms

mentioned above are transmitted primarily
by fecal-oral route. It may be water borne,
food-borne or direct transmission by
fingers, flies, fomites or dirt.
 Incubationperiod :-Varies from a few hours
to a few days according to type of microbes
involved.
Control of diarrheal diseases

 TheDiarrheal Diseases Control (DDC)

programme of WHO since 1980, advocated
a number of interventions for control of
diarrheal diseases. These measures centre
round the wide spread use of Oral
Rehydration Therapy.
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 Measures for diarrheal diseases control as

recommended by WHO:
 1 Appropriate clinical
management/treatment.
 2 Better MCH care practices.
 3. Preventive strategies.
 4. Preventing diarrhea epidemic.
Appropriate Clinical
Management/Treatment

 Treatment measures include:

 1 Treatment of cases with oral rehydration
therapy in mild to moderate cases.
 2. Intravenous therapy for severely
dehydrated cases.
 3. Appropriate maintenance therapy for
and electrolyte balance.
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 4. Appropriate feeding.
 5. Appropriatechemotherapy for specific
diarrheal disease, Le appropriate drugs.
 Oral Rehydration Therapy.
Oral Rehydration Therapy is the main stay
in the management of diarrhea..
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 It is based on the fact that oral glucose

increases the absorption of salt and water
in the intestine and corrects electrolyte
and water imbalance. More recently, an
improved ORS formulation has been
developed with reduced the osmolarity of
ORS solution to avoid adverse effects of
hypertonicity on net fluid absorption by
reducing the concentration of glucose and
sodium chloride in the solution.
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 Decreasing the sodium concentration of ORS
solution to 75 mOsm/L improves the
efficacy of the ORS regimen for children
with acute non-cholera diarrhea. Given
below is the recommended formulation of
reduced osmolarity ORS by WHO and UNICEF
since january 2004 (See table 4.8).
Table : composition or reduced
osmolarity ORS
Reduced Osmolarity Grams/litre
ORS.
Sodium chloride 2.6
Glucose, anhydrous 13.5
Potassium chloride 1.5
Trisodium citrate 2.9
dehydrate
Total weight 20.5
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Reduced Osmolarity Mmol/Litre
ORS
Sodium 75
Chloride 65
Glucose, anhydrous 75
Potassium 20
Citrate 10
Total osmolarity 245
Previously recommended composition of
oral Rehydration Solution (ORS) consisted of:

 Sodium chloride-3.5 g
 Sodium bicarbonate-2.5g
 Potassium chloride -1.5g
 Glucose-20g
 Water-1 litre
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 Diarrheacan cause dehydration when not

controlled timely ORS helps to control
diarrhea and pre- vent dehydration. In
severe episodes of diarrhea, dehydration
may occur despite giving ORS. In such
cases, dehydration level should be assessed
and correct amount of fluids either orally
or intrave nously are recommended.
Table : Assesment of dehydration

Dehydration
Mild Severe
Patients Thirsty, alert, Drowsy, limp,
appearance restless cold, sweaty,
may be
comatosed.
Radial pulse Normal rate Rapid, feeble
and volume pulse
sometimes
impalpable.
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Blood Normal Less than 80
pressure mm Hg; may
be
unrecordabl
e.
Skin Pinch Pinch
elasticity retracts retracts very
immediately slowly (more
than 2
second).
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Tongue Moist Very dry
Ant fontanelle Normal Very sunken
(depressed).
Urine flow Normal Very little or
none
%body weight 4-5% 10% or more
loss
Estimated 40-50 ml/kg 100-110 ml/kg
fluid deficit
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 When obvious signs of dehydration exist,

the water deficit is some where between
50-100 ml/kg of body weight. The
guidelines for oral rehydration are given in
table.
Table : guidelines for oral Rehydration
Therapy (for all ages(during the first four
hours
Age Unde 4-11 1-2 2-4 5-14 15
r Mont Years years Years years
4mo hs or
nths Over
Weig Unde 5-7.9 8- 11- 16- 30 Or
ht r5 10.9 15.9 29.9 over
Oral 200- 400- 600- 800- 1200- 2200-
soluti 400 600 800 1200 2200 4000
on
The actual amount given will depend on
patient’s desire to drink and observation of
signs of dehydration:
 The actual amount given will depend on
patient's desire to drink and observation of
signs of dehydration: 1 For children under
the age of 2 years, give 1 teaspoon every 1-
2 minutes and offer frequent sips out of a
cup. If the child has passed stool, give 50-
100 ml after each stool.2 If the child
vomits, wait for 10 minutes, then try again
giving slowly, a spoonful every 2-3 minutes.
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3 If the child wants to drink more and does

not vomit, he can be given more amount. If
the child refuses to drink the required
amount and there are not signs of
dehydration, then resume the normal
treatment plan for hydration.
 4.If the child is breast-fed, breast feeding
should be continued during ORS rehydration
treatment.
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 5. Non breast-fed infants under age 6
months should be given an additional 100-
200 ml of clean water during the first four
hours.
 Older children and adults can be given
as much water as they want in addition to
ORS solution. ORS can be prepared at home
by primary health care workers and
patient’s relatives by mixing 5 g (1 level
teaspoon) table salt and 30 g (6 level
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 Teaspoons)of sugar in one litre of clean
water and used safely. until the proper
mixture is obtained.
 Packets of "Oral Rehydration Mixture are
also available freely at all the primary
health centres. sub-centres, hospitals and
chemist shops. The contents of the packet
can be dissolved in one litre of drinking
water and used within 24 hours
Intravenous therapy
 Intravenous fluid infusion is only required
to treat severely dehydrated patients who
are in shock and/unable to drink. Such
patients should be transferred to the
hospital or treatment center.
 Appropriate maintenance therapy.
 When the initial fluid and electrolyte
deficit has been corrected-oral
rehydration, oral fluids should be started
for maintenance therapy as per the thirst
felt by the patient.
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 General principle is that the oral fluids

intake should equal the rate of continuing
stool loss which should be measured. See
guidelines for the maintenance therapy in
table
Table : guidelines for maintenance therapy
Amount of diarrhea Amount of oral fluid

Mild diarrhea 100 ml/kg body weight per

( not more than one stool day until diarrhea stops
every 2 hours or longer

Severe diarrhea Replace stool losses volume

(More than one stool every for volume, if not measurable
2 hours of more than 5 ml of give 10-15 ml/kg body weight
stool/kg per hour) per hour
Appropriate Feeding
 Feeding during diarrhea should be
promoted as per the child's ability to eat.
 1 Offer normal diet to the child as soon as
he is able to eat.
2Infants below 6 months can be treated
with breast feeding alone, when there are
no signs of dehydration
 3.
Those with moderate or severe
dehydration should be given Oral
Rehydration Solution (ORS).
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 4. Breast feeding should continue along
with ORS after each liquid stool. Breasting
feeding provides nutrients, rehydrates the
infant and gives protective antibodies.
 Appropriate chemotherapy.
Antibiotics should only be given where
cause is identified as shigella, typhoid or
cholera.
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 Drugs : For diarrhea due to cholera, the
drug of choice is doxicycline, tetracycline,
TMP-SMX and erythromycin (Please see
under the topic cholero). For diarrhea due
to shigella, the drug of choice is
ciprofloxacin.
 Themedicines which should not be given in
the treatment of diarrhea are: Neomycin,
purgative.
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 Tinctureof opium or atropine, cardiotonics
such as coramine, steroids, oxygen,
charcoal, kaolin, pectin, bismuth and
mexaform.
 ZincSupplementation:
 To reduce the severity and duration of
episode of diarrhea, 10 mg of zinc for
infants aged below 6 months and 20 mg for
for children older than 6 months for 10-14
days is recommended by the WHO and the
UNICEF
Better M.C.H. Care Practices

 This include the following:

 1).Maternal nutrition: Prenatal nutrition
and postnatal nutrition should include (20-
25 g extra pro- tein) and 500 additional
calories per day to reduce the low birth
weight problem and improves breast milk
quality.
 2. Child nutrition: Measures to improve
child nutrition also help to reduce the
occurrence and se verity of diarrhea. These
include:
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A Exclusive breast feeding up to 6 months of
age of the infant, discouraging commercial
feeding. Breast feeding should be continued as
long as possible.
B Weaning feeding should start after 6 months
of age the infant with locally available
nutritious foods prepared hygienically at home
and given in small amount in between breasts
feeds such as khichdi, dal, mashed potatoes,
mashed vegetables, banana or other seasonal
fruit Poor rearing practices induce risk of
diarrhea
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 C. Supplementary feeding. To improve child
nutrition, supplementary food should be
given to children from 6-59 months of age.
This strengthens the immune response of
the child Care should be taken to maintain
food hygiene from preparation to feeding d
 D. Vitamin A supplementation: It must be
given as per the national immunization
schedule t decreases the mortality,
severity, duration and complications due to
diarrhea.
Prevention strategies
 These include the followings:
 1 Sanitation: Improving environmental
sanitation and hygiene lessens the risk of
infection Safe water supply, safe excreta
disposal, fly control, hand washing with
soap and water before handing food and
after defecation and after disposing off a
child’s stool all help to prevent and control
diarrheal diseases. All families should have
a clean and functional latrine.
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 2. Health education: Health workers should
emphasize the need for sanitation, personal
hygiene, food and milk hygiene, hand
washing, breast feeding, appropriate
weaning practices and immunization of
children.
 3. Immunization: Immunization against
measles is a potential vaccine which can
prevent up to 20% of diarrheal deaths in
children under 5 years of age. Cholera
vaccination with (Oral-Dukoral) vaccine can
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 Be given to children aged 2-5 years. To
protect against typhoid, the Vi
polysaccharide. vaccine is recommended
for child above 2 years of age
 4 Fly control: Flies spread infections (food-
borne infection), so fly control measures to
prevent their breeding and destroying them
by environmental sanitation, insecticidal
control measures and employing measures
of protection from flies should be adopted
by people.
Preventing Diarrhea Epidemic

A programme of epidemiological
surveillance should be strengthened. An
integrated and coordnated primary health
care approach should be used for control of
diarrheal diseases by involving water supply
and excreta disposal, communicable
disease control, nutrition, mother and child
health education activities.
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