DIARRHEA

OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF MEDICINE
BIOCHEMISTRY DEPARTMENT
SECTION B1
GROUP 8

REPORTERS
Cobankiat, Clarine
Come, Christian Kenneth
Concepcion, Kevin Chuck

MEMBERS
Collado, Janssen
Colobong, Carlomar
Contreras, Rio
reatment and OBJECTIVES
• Discuss diarrhea and the various metabolic
changes observed with it.
• Evaluate the nutritional status of the
patient presented on each case.
• Determine the adequacy of the patients’
diet before and during diarrhea.
• Explain the corresponding treatments for
each case.
WHAT IS DIARRHEA ?
 DIARRHEA

• It is the passage of 3 or more loose or liquid stools

per day, or more frequently for the individual (WHO)

• It is usually a symptom of gastrointestinal infection,

which can be caused by a variety of bacterial, viral
and parasitic organisms.
 DIARRHEA

• Infection is spread through contaminated food

or drinking-water, or from person to person as a
result of poor hygiene.

• Severe diarrhea leads to fluid loss(dehydration),

and may be life-threatening, particularly in
young children and people who are
malnourished or have impaired immunity.
CLASSIFICATION OF DIARRHEA
 CLASSIFICATION OF DIARRHEA

1. DURATION
1. Acute Diarrhea
2. Chronic Diarrhea
2. CAUSE
3. Infectious
4. Non-infectious
3. MECHANISM
5. Osmotic
6. Secretory
 CLASSIFICATION OF DIARRHEA
• DURATION
 CLASSIFICATION OF DIARRHEA
DURATION: ACUTE DIARRHEA

• Lasting less than 4 weeks

• Cause by infections and are self limiting
• Viruses (adenovirus and rotavirus),Bacteria (salmonella,
shigella, Escherichia colli )
• Protozoa (giardia lamblia and entamoebahistolytica)
• Consumption of potentially contaminated food and
drinks is another risk factor for infectious diarrhea
 CLASSIFICATION OF DIARRHEA
DURATION: CHRONIC DIARRHEA

• lasting for more than 4 weeks

• Watery (Osmotic, Secretory), Inflammatory and Fatty
 CLASSIFICATION OF DIARRHEA
• CAUSE
 CLASSIFICATION OF DIARRHEA
CAUSE: INFECTIOUS DIARRHEA
• Due to bacteria
• Due to viruses
• Due to protozoa
 CLASSIFICATION OF DIARRHEA
CAUSE: NON-INFECTIOUS DIARRHEA
• acute heavy metal poisoning due to ingestion of
copper, zinc, iron or cadmium
 CLASSIFICATION OF DIARRHEA
• MECHANISM
 CLASSIFICATION OF DIARRHEA
MECHANISM: OSMOTIC DIARRHEA
• When poorly absorbable, low molecular
weight aqueous solutes are ingested, their
osmotic force quickly pulls water and,
secondarily, ions in to the intestinal lumen
• Maldigestion
• Ingestion of a poorly absorbed substrate
• Malabsorption
 CLASSIFICATION OF DIARRHEA
MECHANISM: OSMOTIC DIARRHEA
• Example, lactose by someone with congenital
lactase deficiency, or carbohydrate by
someone with gluten-sensitive enteropathy
(celiac disease)
 CLASSIFICATION OF DIARRHEA
MECHANISM: SECRETORY DIARRHEA
• increase in the amount of fluid being drawn
into the lumen of the bowel such that the
ability of the intestines to reabsorb is
overwhelmed
• stool volume of more than one liter daily, with
neutral pH and have no change in the amount
of stool produced with fasting
 CLASSIFICATION OF DIARRHEA
MECHANISM: SECRETORY DIARRHEA
• infectious secretagogues
– Vibrio cholerae, E. coli, Camylobacter jejuni, Salmonella,
Shigella, and Clostridium difficile
– secrete toxins that bind with the structures within the
gut
• Non-infectious secretagogues
– chemicals produced by certain types of cancer
– prostaglandins produced in patients with bowel
inflammation
– substances not well absorbed such as fatty acids and
bile acid
 DIFFERENCE SECRETORY
•Decreased absorption
DEFECT •Increased secretion
•Electrolyte transport
•Watery
STOOL EXAMINATION •Normal osmolality
(ion gap <100 mOsm/kg)
•Cholera
•toxigenic E. coli
EXAMPLES •Neuroblastoma
•congenital chloride diarrhea
•C. Defficile
•AIDS
•Persist during fasting
COMMENT •Bile salt malabsorption
•No stool leukocyte
OSMOTIC
•Maldigestion
•Transport defects
•Ingestion of unabsorbable
substances
•Watery
•Acidic
•Increased osmolality
(ion gap >100 mOsm/kg)
•Lactase deficiency
•glu-gal malabsorption
•Lactulose
•Laxative abuse
•Stops with fasting
•Increased breath hydrogen
in CHO malabsorption
•No stool leukocytes
Stool Osmotic Gap
 SYMPTOMS OF DIARRHEA
Symptoms of uncomplicated diarrhea include:
• Abdominal bloating or cramps
• Thin or loose stools
• Watery stool
• Sense of urgency to have a bowel movement
• Nausea and vomiting
 SYMPTOMS OF DIARRHEA
Symptoms of complicated diarrhea include:
• Blood, mucus, or undigested food in the stool
• Weight loss (dehydration)
• Fever
 PREVENTION AND Management OF
DIARRHEA
• Key measures to prevent diarrhea include:
– access to safe drinking water
– improved sanitation
– exclusive breastfeeding for the first six months
of life
– good personal and food hygiene
– health education about how infections spread
– vaccination
 PREVENTION AND management OF
DIARRHEA
• Key measures to manage diarrhea include:
– Oral rehydration therapy (ORT)
• is a simple treatment for dehydration associated with
diarrhea, particularly gastroenteritis
or gastroenteropathy, such as that caused by cholera or
rotavirus
• ORT consists of a solution of salts and sugars which is
taken by mouth
 PREVENTION AND Management OF
DIARRHEA
• Glucose is actively absorbed by the normal
small bowel and that sodium carried with it
about an equimolar ratio
• During acute diarrhea absorption of sodium
without glucose is impaired.
HOME MADE ORT
 New Formula of Oral Rehydration Salts
Low – Osmolarity Type

Reduced Reduced
grams/litre mmol/litre
osmolarity ORS osmolarity ORS
Sodium chloride 2.6 Sodium 75
Glucose, anhydrous 13.5 Chloride 65
Glucose,
Potassium chloride 1.5 75
anhydrous
Trisodium citrate,
2.9 Potassium 20
dihydrate
Citrate 10
Total Osmolarity 245
DIARRHEA CASE A
• A mother brought her 10-months old, 8-kg
daughter to a health center because of diarrhea of
one day duration which occurred 4 times. There
was no accompanying vomiting. She has been
breastfed since birth. At 5 months old, Lugaw with
fish and vegetables were started. At the onset of
diarrhea, the mother stopped breastfeeding and
giving solid foods and instead shifted to giving
“am” with sugar. The child is alert, with good skin
turgor and adequate urine output.
 Carbohydrates the patient takes
( a quick summary)
• 3 major sources of carbohydrates in the
diet
– Sucrose (disaccharide) – glucose + fructose
– Lactose (disaccharide ) – glucose + galactose
– Starch ( polysaccharide ) – amylase +
amylopectin
• starch – homopolymer of glucose forming an -
glucosidic chain called glucosan
Digestion of Carbohydrates
• Mouth: enzyme ptyalin (-amylase)
• S. Intestine: Pancreatic amylase
– Intestinal epithelial cells: Brush border enzymes or
Disaccharidases
 Disaccharidases
– Function: splits disaccharides into their respective
monosaccharides.
– Location: enterocytes in the brush border
– Lactase  Lactose  Glucose + Galactose
– Sucrase
– Maltase
– -Dextrinase
 Absorption of Carbohydrates
– Glucose & Galactose
• Na-dependent process
• Via SGLT-1
• Exits intestinal cells and absorbed by the capillaries via
GLUT2 transporter
 Lactase (Disaccharidase) Defficiency
• 2 Types
– Congenital Lactase Defficiency
• Autosomal recessive disorder
• Mutation in the gene encoding for Lactase
• Symptoms abate by termination of milk or milk containing products
• Results in removal of unabsorbed lactose in the lumen to the large
intestines
• Flora in the L.intestine ferments Lactose and convert Lactose  Lactate
• Result: Diarrhea and abdominal discomfort
• Irritation of mucosa
– Acquired Lactase Deficiency
• Down regulation of Lactase gene expression
• Presents after childhood
– Effects of Diarrhea in Motility, Fluid volume, Acid-
Base balance and Composition
• Motility: Greatly increased
• Fluid Volume: Increased secretion of Intestinal cells
• Acid-Base balance: Chlorine, Potassium, Sodium
Evaluation of the nutritional status
and hydration state of the patient
Assessment Chart of Hydration
 Ideal weight for age of the patient using
Gomez Classification
• Data:
– Actual body weight: 8 kg.
– Ideal body weight: 19.4 lbs or 8kg (19.4 divided by
0.4536)
– Ideal weight for age = Actual / Ideal x 100
• 8 / 8 x 100 = 100% (with in normal range)
 Adequacy of Px Diet
• BIRTH TO 6 MONTHS OF AGE – breast
milk/formulated milk
• 6 TO 8 MONTHS OF AGE – breast milk/formulated
milk and baby cereals
• 8 TO 12 MONTHS OF AGE – breast milk/formulated
milk, baby cereals with a few servings of finely
chopped meat
– The diet of the patient was inadequate. The early
termination of milk ingestion of the patient lead to the
manifestation of Congenital Lactase Deficiency which
resulted to diarrhea.
 Treatment
• Oral rehydration salts
• Switching to bland, starchy foods like strained
bananas, applesauce, and rice cereal until the
diarrhea stops.
• Switching the diet of the infant by avoiding the
following until diarrhea diminshes:
– Greasy foods
– Too much fiber in the diet
– Milk products
 Biochemical Significance of “AM”
• “AM” is naturally made from rice which contains fiber
• Fiber – a non digestible part of rice that helps promote
regular bowel movement
– Fermented by the colonic microflora with the production of short
chain fatty acids (SCFA), hydrogen, carbon dioxide and biomass.
– Hydrolysed by membranous or extra-cellular enzymes secreted by
bacteria via Embden-Meyerhoff pathway which leads to the
production of pyruvate.
– Pyruvate is immediately converted to acetate, propionate and
butyrate, and gases: carbon dioxide (CO2), hydrogen (H2), and
methane (CH4).
• Fiber helps in diarrhea by increasing fecal bulk but a low fiber
diet (10g) is preferred because too much bulk may aggravate
diarrhea.
DIARRHEA CASE B
 Clinical History:

• Benjie, 3 y/o was brought to the emergency room

because of diarrhea and vomiting of 3 days
duration.
• Diarrhea occurred 6 x a day and vomiting 3 x a day.
• Breastfed for 2 months, then shifted to Bonna 1:2
dilution
• Started solid food at 4 months old.
• Given “lugaw” since the onset of diarrhea
 Physical Examination:

Vital signs:
• Weight: 11 kg.
• Temperature: 37 C.
• CR: 100 bpm
• RR: 20 cpm
SIGNS AND SYMPTOMS
• Sunken eyeballs.
• Dry mouth and tongue.
• Poor skin turgor.
• Decreased urine output.
• Slight distended with hypoactive bowel sound
in the abdomen.
• Serum Electrolytes: Na – Normal;
• K – decreased.
ASSESSMENT
 Nutritional Status
• Breastfed for 2 months,
then shifted to Bonna 1:2
dilution.
• Started solid food at 4
months old.
• Given “lugaw” since the
onset of diarrhea
 Electrolyte status
• Serum Electrolytes: Na – Normal
• K – decreased(hypokalemia)
Normal values:
• Sodium = 135-145 meq/L
• Potassium = 3.5-5 meq/L
Sequence of diarrhea
 • Diarrhea is mainly caused by abnormal fluid and
electrolyte transport by decreased absorption or increased
secretion.
1 • Human colon is capable of absorbing 3-5 L per 24 hrs

• Decreased of small intestinal absorption by more than

50% will lead to diarrhea.
2

• The normal amount of 1.5 L arriving in the cecum might

not be absorbed and then also lead to diarrhea.
3
• The control of fluid balance
– What is monitored: Volume & Osmolality (osmotic pressure via solute
conc.)
– Mechanisms:
• ADH (antidiuretic hormone) , osmoreceptors, & thirst
mechanism
– Osmoreceptors in hypothalamus regulates secretion of ADH from
posterior pituitary
– The higher the osmolality, the more ADH secreted
» ADH causes: (1) thirst center to be stimulated
(2) kidneys to conserve water
• Aldosterone
– Secreted by adrenal cortex
– Causes kidneys to retain sodium ( water follows salt)
– Stimulated by: increase potassium and drop in sodium
 Fluid deficiency --- Dehydration
• Loss of water usually accompanied by loss of electrolytes
» Remember water follows salt
– But can get 3 types of dehydration
• (1) Isotonic dehydration = equal loss of fluid &
electrolytes
• (2) Hypotonic dehydration = loss of more electrolytes
than water
• (3) Hypertonic dehydration = loss of more fluid than
electrolytes
• Causes
• Vomiting & diarrhea,
• Excess sweating
• Insufficient water intake
• Effects of dehydration •Sign and Symptoms:
• Dry mucous • Dry tongue
membranes • Poor skin turgor
• Decreased skin • Concentrated urine
turgor • Decreased urine
• Decreased BP output
• Potassium balance
– Major intracellular cation
– Balance: ingestion = excretion (via
kidneys)
• Aldosterone primarily controls
potassium
• Insulin
• pH also affects potassium secretion
 3 key buffer systems
1.Hemoglobin buffer system (protein)
--- short term

2.Carbonic acid buffer system ---- long

term

3.Phosphate buffer system

– Key points
• Excess vomiting = loss of acid & get
metabolic alkalosis
• Excess diarrhea = loss of bicarbonate &
get metabolic acidosis
• Sx of acidosis = CNS depression
• Sx of alkalosis = CNS irritability
• Both acidosis & alkalosis will lead to coma
 Fluid Replacement
• The general rule is to let the child drink fluid as
much as he wants.
• Fluid replacement alone may suffice for mild
cases. Oral sugar-electrolyte should be
instituted promptly with severe diarrhea to limit
dehydration, which is the major cause of death.
• Profoundly dehydrated patients, especially
infants and the elderly, require intravenous
rehydration.
Role of glucose in oral rehydration solutions

• Glucose in the solution is important because it

forces the small intestine to quickly absorb
the fluid and the electrolytes.
 Nutritional Management

• Fluid and electrolyte replacement

are of central importance to all
forms of acute diarrhea.
 Nutritional Management
EAT THIS NOT THAT
CRACKERS COFFEE
BOILED POTATOES FATTY FOODS
PLAIN RICE HIGH FIBER MEALS
TOAST ALCOHOLIC BEVERAGES
BAKED/STEAMED CHICKEN COLAS
BANANAS JUNK FOOD
DRINK A LOT OF FLUIDS MILK
THANK YOU!