ACUTE DIARRHEAL

DISEASE
DR. SARAH BAKHSH
RESIDENT COMMUNITY MEDICINE FCPS II
Saudi Board (Family Medicine)
MBBS (King Edward Medical University)
Learning Objectives

 Define diarrhea and diarrheal disease

 Understand global burden of diarrhea
 Learn different causes of diarrhea with
epidemiological determinants
 Define mode of transmission of diarrhea
 Discuss short and long term goals for
controlling of diarrhea
ACUTE DIARRHEAL
DISEASES
 Diarrhea:

loose liquid/watery stools, passed >3 times a day.

Recent change in consistency is more important
than quantity
 Diarrheal disease:
Group of diseases in which the predominant
symptom is diarrhea
CLASSIFICATION OF DIARRHEAL
DISEASES
TYPES OF CAUSES DURATION CHARACTERISTICS

DIARRHEA

1. ACUTE V. CHOLERA LESS THAN 14 DEHYDRATION

WEIGHT LOSS
WATERY E.COLI DAYS
DIARRHEA ROTA VIRUS
2. ACUTE SHIGELLA ACUTE ONSET DAMAGE TO
INTESTINAL
BLOODY LESS THAN 14 MUCOSA
DIARRHEA DAYS SEPSIS
(DYSENTRY) MALNUTRITION
DEHYDRATION

3. PERSISTENT IN MORE THAN MALNUTRITION

NON INTESTINAL
DIARRHEA ASSOCIATION 14 DAYS INFECTION
WITH AIDS

4. DIARRHEA MORE THAN INFECTIONS

WITH SEVERE 14 DAYS DEHYDRATION
MALNUTRITION HEART FAILURE
DEFICIENCIES
Prevalence

 Diarrheakills more than 525000 children every year;

more than AIDS, malaria, and measles combined.
 9% of death worldwide (2019)
 Diarrhea is a leading cause of malnutrition in children
under five years old (2nd leading cause of death in
children under 5)
Percentage of deaths among children under age 5 attributable to diarrhea, 2019

Source: WHO and Maternal and Child Epidemiology Estimation Group (MCEE)
provisional estimates 2019
EPIDEMIOLOGICAL
DETERMINANTS
1. AGENT FACTORS
VIRUSES BACTERIA OTHERS

Rota viruses Campylobacter jejuni E.Histolytica

Astroviruses Escherichia coli Giardia intestinalis

Adenoviruses Shigella Trichuriasis

Calicivirus Salmonela Cryptosporidium

Norwalk group viruses Vibrio cholerae Intestinal worms

Enteroviruses Bacillus cereus

(Viruses):

A) Rotavirus
•Discovered in 1973
•Leading cause of severe dehydrating diarrhea in children
< 5 yrs
•Incidence peak during winter season
•Shed in very high concentration ( >10 12particles / gram)
for many days in stool and vomit of the infected person
•Transmission is through fecal-oral route & directly from
person to person, also indirectly –fomites (objects or
materials likely to carry infections)

•
(Bacteria)
E coli
 Diarrhea is mediated by toxins
 Causes acute watery diarrhea
 Travelers' diarrhea
 Spreads mainly by contaminated food
and water
Epidemiological Determinants
(cont’d)

2. RESERVOIR OF INFECTION:

man & animal

o Enterotoxigenic E. coli, Shigella, V. Cholerae, Giardia lamblia

and E. histolytica – man is principle reservoir and

transmission originate from humans

o Campylobacter jejune, Salmonella- animals are important

reservoir and transmission originates from both animal and

human feces
3. HOST FACTORS
Age
 Children age 6 months to 2 years (esp. 6 -11 months when
weaning starts
 Children <6 months age who are on artificial feeding
 Reason-- declining levels of maternally acquired antibodies, lack of active immunity
in infants, introduction of contaminated food and direct contact with human or
animal feces when infant starts to crawl
Nutritional Status
 Person with Malnutrition – vicious cycle( malnutrition –
infection- diarrhea- malnutrition)
 Contributory factors-- poverty, prematurity, reduced gastric acidity,
immunodeficiency, lack of personal and domestic hygiene and
incorrect feeding practices
4. ENVIROMENTAL FACTORS
• Bacterial diarrhea:- warm climate

• Viral diarrhea :- cold climate (winters), in tropical areas rotavirus

infection occurs through out the year

• Complex emergencies and natural disasters:- Displacement of

population into temporary, overcrowded shelters is often associated
with polluted water sources, inadequate sanitation, poor hygiene
practices, contaminated food and malnutrition.
Pathogenic Causes of Diarrhea in Children

Agent PATHOGEN % OF CASES

Viruses Rotavirus 15 -25%

Bacteria E. Coli 10 -20 %

Shigella 5 -15 %

Campylobacter Jejuni 10 -15 %

V .Cholerae 5- 10%

Salmonella 1-5 %

Protozoans Cryptosporidium 5- 15%

Non-Digestive Causes of Diarrhea in
Children

1. ENT infections
2. Respiratory infections
3. UTIs
4. Malaria
5. Bacterial meningitis
6. Simple teething
7. Malnutrition; leads to Kwashiorkor, celiac
disease and pellagra, all are associated with
diarrhea
Signs and Symptoms of Dehydration

 Dry mouth
 Dry Eyes
 Sweating may stop (anhidrosis)
 Muscle cramps
 Nausea and vomiting
 Heart palpitations
 Light-headedness (especially when standing)
 Lethargy
 Decreased urine output, deeper yellow urine
With severe dehydration, confusion and weakness will occur as the
brain and other body organs receive lesser blood supply. Finally, coma,
organ failure, and death eventually will occur if the dehydration
remains untreated
CLINICAL ASSESSMENT OF
DIARRHEA IN CHILDREN:
 1. GPE
 2.Child’s reaction when offered drinks:
see if taken eagerly or with
encouragement
 3. Elasticity of the skin
 Assessment of dehydration
Mild Severe
Patient’s appearance Thirsty, alert, restless Drowsy, limp, cold,
sweaty, may be
comatosed
Radial pulse Normal rate and volume Rapid, feeble, sometime
impalpable
Blood Pressure Normal <80 mmHg, OR
unrecordable
Skin elasticity Pinch retracts Pinch retracts very
immediately slowly (more than 2
seconds)
Tongue Moist Very dry
Ant. Fontanelle Normal Very sunken
Urine flow Normal Little OR None
% of body loss 4-5% 10% or more
Estimated fluid deficit 40-50ml 100-110 ml/kg
 Mode of Transmission

 Fecal-oral route:-
 Water-borne
 Food- borne
 Direct ( fingers, fomites or
dirt )
 CONTROL OF DIARRHEAL
DISEASE

BETTER
MCH
SHORT TERM LONG TERM SERVICES

APPROPRIATE PREVENTING
REHYDRATION CLINICAL PREVENTING STRATEGIES
THERAPY MANAGEMENT
EPIDEMICS

FLY
CHEMOTHERAPY CONTROL

SANITATION HEALTH
EDUCATION

APPROPRIATE ZINC
FEEDING SUPPLEMENTATION
IMMUNIZATION
Control of Diarrheal Diseases
SHORT –TERM
a. APPROPRIATE CLINICAL MANAGEMENT
 ORAL REHYDRATION THERAPY
 Aim: To prevent dehydration and reduce mortality
 Through: oral rehydration salt
INGREDIENTS ORS ORS Bicarbonate
citrate(REDUCE GRAMS/LITRE
D OSMOLAR)
GRAMS/LITRE

Sodium chloride 3.5 3.5

Potassium chloride 1.5 1.5

Tri-sodium citrate Sodium bicarbonate

2.9 2.5
Glucose anhydrous 20 20
TYPES: COMPARISON OF
OSMALRITIES OF ORS
INGREDIENTS REDUCED SODIUM
OSMOLAR ORS BICARBONATE
ORS
GLUCOSE 75 111
SODIUM 75 90
POTASSIUM 20 20
CHLORIDE 65 80
CITRATE 10 10
OSMALARITY m 245 311
Osm/kg
ORS Citrate is better one because:-
Tri-sodium citrate has made product more stable
Less stool because of direct effect of tri-sodium citrate in
increasing intestinal absorption of sodium and water
Guidelines for oral
rehydration
Guidelines for oral rehydration therapy (for all ages) during the first four
hours
 (*) The age of patients should only be used if weight is not known.
 The approximate amount of ORS required in ml is also calculated by multiplying the pt.s’ wt.
(expressed
Age (*) in kg)Under
by 75 4-11 1-2 yrs 2-4 yrs 5-14 15 or over
4 months yrs
Weight(kg Under 5 5-7.9 8-10.9 11- 16-29.9 30 or over
) 15.9
ORS 200-400 400-600 600-800 800- 1200- 2200-4000
solution 1200 2200
ml)
 Initial treatment with ORS is given over a period of 4 hrs.
 Amount of ORS in ml is calculated by multiplying child's wt
in kg by 75
 ORS is given slowly during this time by spoonfuls or sips
 Breast feeding should be continued and encouraged.
 After each stool, give ORS as follows:

Under 2 years 2-10 years Adults

age
50-100 ml of ORS 100-200 ml as much as they
If the child vomits, wait for 10 minutes, then try want
again, slowly spoon full every 2-3
minutes
 After 4 hrs child is re-assessed and re-classified for
dehydration
MODELS FOR EXAMS
ORS Prepared at Home:
Fluids to be avoided during
diarrhea
 Drinks sweetened with sugar ( can cause osmotic
diarrhea and hypernatremia)

 Commercial carbonated beverages

 Commercial fruit juices

 Sweetened tea (laxative effect)

 Coffee (stimulant or purgative effect)

b) Intravenous Rehydration
Required in severe dehydration , patient in shock and those unable to
drink
 Solutions recommended by WHO are:
 Ringers lactate solution: adequate concentration sodium and
potassium and lactate yields bicarbonate for correction of acidosis
 Diarrhea treatment solution(DTS):it contains in 1 litre sodium
chloride(4g) sodium acetate(6.5g) potassium chloride(1g) glucose
(10g)
 Normal saline: to be used only if nothing else is available (poorest
solution); it will not correct acidosis and does not replace potassium
Treatment Plan For Rehydration
Therapy

 Give IV fluids immediately. If the child can drink,

give ORS by mouth while the drip is set up.
 Give 100ml/kg Ringers Lactate solution(if not
available, normal saline) divided as follows:
AGE First give 30 ml/kg Then give 70ml/kg

Infants( under 12 1 hour 5 hour

months

Children(12 months up 30 minutes 2 ½ hours

to 5 years)
Treatment Plan For Rehydration Therapy

 Reassess the patient every 1-2 hours

 After infusion of 1-2 liters of fluid, rehydration
should be carried out at a somewhat slower rate
until pulse and blood pressure return to normal
 When patient can drink the oral fluids give
ORS at about 5ml/kg/hour
After initial
maintenance fluid and electrolyte deficit has been corrected, then oral fluid is
therapy

used for maintenance therapy

AMOUNT OF DIARRHEA AMOUNT OF ORAL FLUID

MILD DIARRHEA
(not more than 1 stool
every 2 hours or longer or
less than 5 ml stool per kg
per hour)
SEVERE DIARRHEA
(more than one stool every
2 hours or more than 5 ml
of stool per kg per hour)
100 ml/kg body weight per
day until diarrhea stops
Replace stool losses volume
for volume ;if not
measurable give 10-15
ml/kg body weight/hour
APPROPRIATE FEEDING
 Normal feeding should be promoted during diarrhea because breast milk
can rehydrate and prevent further infections because of protective
properties

CHEMOTHERAPY
 AVOID UNNECESSARY ANTIBIOTICS
 Antibiotics are considered only when causes of diarrhea are clearly
identified as shigella, cholera or typhoid
Symptomatic differential
diagnosis of Shigella and Cholera
SYMPTOMS CHOLERA SHIGELLA
DIARRHOEA Acute watery Acute bloody
diarrhea diarrhea
FEVER No Yes
ABDOMINAL PAIN Yes Yes
VOMITING Yes No
RECTAL PAIN no yes
STOOL >3 stools per day, >3 stools per day,
watery- like rice with blood or pus
water
DRUGS OF CHOICE FOR
BACTERIAL DIARRHEA

INFECTION DRUG OF CHOICE

CHOLERA DOXYCYCLIN,TETRACYCLINE,TMP-
SMX
SHIGELLA CIPROFLOXACIN
MEDICINES CONTRAINDICATED
IN TREATMENT OF DIARRHEA

 Neomycin (damages intestinal mucosa)

 Purgatives (worsen diarrhea)
 Tincture of opiates or atropine (decrease intestinal transit time)
 Cardiotonics such as coramine
 Steroids
 Oxygen
 Charcoal,kaolin,pectin,bismuth
 Mexaform
ZINC SUPPLEMENTATION
reduces the duration and severity of episode
 Zinc supplements given for 10-14 days lower the incidence of
diarrhea in the following 2-3 months
 10 mg Zinc for infants <6 months and 20 mg for children older
than 6 months
LONG TERM Control
- BETTER MCH CARE PRACTICES

 MATERNAL NUTRITION
I. Improve perinatal nutrition low birth weight
problems
II. Improve postnatal nutrition increase breast milk
quantity
o CHILD NUTRITION
I. Promotion of breast feeding
II. Appropriate weaning practices
III. Supplementary feeding
IV. Vitamin A supplementation
Long term preventive
strategies
1. SANITATION
 Improved water supply
 Improved excreta disposal
 Improved domestic and food hygiene
 Improved personal hygiene
2. HEALTH EDUCATION
 Help community to maintain preventive practices
o IMMUNIZATION
o MEASELS VACCINE can prevent up to 25% of diarrheal
deaths under 5 years of age
3. Vaccines

 ROTA VIRUS VACCINE

Two live oral ,attenuated vaccines licensed in 2006 :
Monovalent (Rotarix) 2 doses :1st at age of 6 weeks, no later
than age 12 weeks, 2nd should be completed by age of 16
weeks.
Pentavalent (Rota Teq) 3 doses, at the age of 2,4 and 6 months

4. Fly Control
Programs for Control of Diarrheal
Diseases
 DIARRHEAL DISEASES CONTROL PROGRAMME BY
WHO IN 1980
COMPONENTS OF DIARRHOEAL DISEASE CONTROL PROGRAM
CONTROL/PREVENTION OF
DIARRHEAL EPIDEMICS
 Requires strengthening of epidemiological surveillance
systems
Integrated global action plan for
prevention and control of pneumonia
and diarrhea
 proposes a cohesive approach to ending preventable
pneumonia and diarrhea deaths. It brings together
critical services and interventions to create healthy
environments, promotes practices known to protect
children from disease and ensures that every child has
access to proven and appropriate preventive and
treatment measures.
 The goal is ambitious but achievable: to end
preventable childhood deaths due to pneumonia and
diarrhea by 2025.
Thank you