DIARRHOEA

⚫ Defined as passage of abnormally liquid or

unformed stools at an increased frequency
⚫ Stool weight more than 200 g/ day
⚫ Classification
•Acute - < 2 weeks
•Persistent- 2 to 4 weeks
•Chronic- > 4 weeks
⚫ Two common conditions associated with passage
of stools < 200g/day
1. Pseudo diarrhoea
2.Fecal incontinence
Acute Diarrhoea
Causes
90 % - INFECTIOUS AGENTS
10 % - Medications , Toxic ingestions,
Ischeamia
Infectious Agents
⚫ Fecal-oral transmission
⚫ Bacterias,Viruses,Parasites
Pathogen Incubation Period
Bacillus cereus, Staphylococcus aureus 1-8 hr

Clostridium perfringens 8-24 hr

Vibrio cholerae, enterotoxigenic 8–72 h
Escherichia coli, Klebsiella pneumoniae,
Aeromonas species

Enteropathogenic and enteroadherent E. 1-8 days

coli, Giardia organisms

C. difficile 1–3 d
Hemorrhagic E. coli 12–72 h
Rotavirus and norovirus 1–3 d
Salmonella, Campylobacter, and 12 h–11 d
Aeromonas species, Vibrio
parahaemolyticus, Yersinia
Pathogenesis of Bacterial
Diarrhoea
⚫without mucosal
injury
mediated by:
Enterotoxin
s Adhesins
⚫with
mucosal
injury
mediated by:
Adhesins
PATHOGENESIS VIRAL DIARRHOEA
⚫ VIRAL DIARRHOEA
Effect on villus structure and
function Enzyme damage
Significant effect on digestion and
absorption
⚫ Rotavirus
Norwalk virus
Enteric
Adenovirus
HIGH RISK GROUPS
1.Travellers – ETEC, EAEC ,Campylobacter,
Shigella
2 . Consumers of certain foods
- picnic,banquet,restaurant
3.Immunodeficiancy persons
4. Institutionalised persons
The agents include
1 . Toxin producers
Preformed toxin – B.Cereus , Staph aureus,
C.perfringens
Enterotoxin – V.cholera,ETEC
2. Enteroadherant
EAEC,Giardia
,Cryptosporidium
3 . Cytoxin Producers
C. difficile
4 . Invasive
Ro
ta
virus,Salm
onella,Ca
mpylobact
er
V.
parahmoly
• Infectious diarrhea may be associated with
systemic manifestations
– Reiter's syndrome - arthritis, urethritis, and
conjunctivitis may accompany or follow infections
by Salmonella, Campylobacter, Shigella, and
Yersinia.
– Hemolytic-uremic syndrome - enterohemorrhagic
E. coli (O157:H7) and Shigella
Clinical features
⚫ Preformed & Entero toxin
Profuse watery diarrhoea +
vomitting
•Enteroadherant
High fever + Abdominal cramps
•Invasive – Bloody diarrhoea
Other Causes
⚫ A/E of certain drugs – Antibiotics,NSAIDs,
Antiarrythmics, Bronchodialaters,Antacids
⚫ Occlusive or Non occlusive
colitis Above 50 years
Lower abdominal pain
preceeding watery, then bloody
diarrhoea
Approach to Patient
• Most episodes of acute diarrhea are mild and self-limited
and do not justify the cost and potential morbidity rate of
diagnostic or pharmacologic interventions.

• Indications for evaluation include

– profuse diarrhea with dehydration,
– grossly bloody stools,
– fever 38.5°C (101°F),
– duration >48 h without improvement,
– recent antibiotic use,
– new community outbreaks,
– associated severe abdominal pain in patients >50 years,
– elderly (70 years)
– immunocompromised patients.
 History and Physical
Exam
⚫ Main goals
⚫Estimate the level of dehydration

⚫Identify likely causes on the basis

of history and clinical findings
Histor
y⚫Onset, frequency, quantity, and character
of diarrhea
⚫ Associated symptoms:
nausea, vomiting, fever, abdominal
pain, tenesmus, malaise
⚫ Recent oral intake
⚫ Signs and symptoms of
dehydration
Physical Exam
⚫Vitals, vitals, vitals!
⚫Abdominal exam
⚫Presence of occult
blood
⚫Signs of dehydration
 Investigation
s of diagnosis in those
• The cornerstone
suspected of severe acute infectious diarrhea
is microbiologic analysis of the stool.

• Workup includes
a) cultures for bacterial and viral pathogens,
b) direct inspection for ova and parasites
c) immunoassays for certain bacterial toxins (C.
difficile), viral antigens (rotavirus), and protozoal
antigens (Giardia, E. histolytica).
• If stool studies are unrevealing, flexible sigmoidoscopy
with biopsies and upper endoscopy with duodenal
aspirates and biopsies may be indicated.

• Structural examination by sigmoidoscopy, colonoscopy,

or abdominal CT scanning (or other imaging
approaches) may be appropriate in patients with
uncharacterized persistent diarrhea to exclude IBD or
as an initial approach in patients with suspected
noninfectious acute diarrhea caused by ischemic colitis,
diverticulitis, or partial bowel obstruction.
Treatment
⚫ Fluid & electrolyte replacemet
Oral sugar & electrolyte solution
I.V rehydration
⚫ Moderately severe, non febrile & non bloody diarrhoea
– Loperamide
⚫ Antibiotics
⚫ Empirical therapy
Febrile – Ciprofloxacin 500 mg bid for 3-5 days
Suspected giardiasis – Metronidasole
250 mg qid for 7 days
⚫ Antibiotic prophylaxis
Cotrimoxazole,Ciprofloxacin
In Summary
⚫Extremely common
⚫Most is viral in origin and self-limited
⚫A good H&P is crucial
⚫Warning signs include high fever, severe
abd. pain, dehydration, and bloody stool
⚫Fluid replacement is most important
⚫Antibiotics are usually not necessary
GOOD NUTRITION AND
HYGIENE CAN PREVENT
MOSTDIARRHE
A
THANK
YOU