BULE HORA UNIVERSITY

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Outline
Definition
Epidemiology
Etiology
Pathogenesis
Clinical manifestations
Assessment of diarrhea
Treatment
Prevention

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 Diarrhea
Definition
Loose stool > 3x/24hrs. (WHO)
An increase in the fluidity, volume and
frequency of stools.
A young infant normally has ~5g/kg of stool
output per day.
The greatest volume of intestinal water is
absorbed in the small bowel; the colon
concentrates intestinal contents against a high
osmotic gradient.

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 Diarrhea Cont…
• An small intestine absorb 10-11 L/day of
ingested & secreted fluid, whereas the colon
abs0.5-1 L.
• Thus, disorders of small bowel produce
voluminous diarrhea, whereas disorders of
colonic absorption produce lower volume.
Epidemiology
• 3-4 episodes/child /year.
• 3.2 million deaths/year 2ry to acute diarrhea.
• 30% of the deaths in the hospitals especially in
developing counties.
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Major causes of mortality among
children under 5
Burden usually severe in less developed
countries; in Ethiopia among the 5 common
killers of under 5 children. ARI
Perinatal
22% 20%

FACT
Malnutrit
ion Diarrhoea
60% 12%

Malaria
Other 8%
29%
Measles
HIV 5%
4% Bule Hora University 5
 Transmission
 Fecal- oral
 Direct & Indirect contact

Infected animal Infected person

Food Water
Susceptible person
Incidence
Very peak 6-12months of age  weaning + the
time when maternal immunity is used up!
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 Behavioral risk factors
Inadeqate breast feeding(first 4-6
months).
Using feeding bottles
Eating food hrs after cooking.
Drinking contaminated water
Not washing hands
Host factors
Malnutrition, Measles,
Immunosupression, young age
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Types Greatest Danger
1. Acute watery diarrhea Dehydration
(80% of cases) K +loss

2. Bloody diarrhea Tissue damage

(Dysentry) 10% of cases Toxemia(sepsis)

3. Persistent diarrhea(> Malnutrition

2 wks) 10% of cases

4. Chronic diarrhea Malnutrition

(4wks or more) Bule Hora University 8
Causative agents of acute diarrhea
Viral Bacterial parasites

Rota virus Campaylobactor Giardia

jejuni
Enteric adenovirus Closteridum defficil E. histolitica
and perfringens
CMV E.coli cryptosporidium

HSV Shigella and Isospora belli

salmonella
Vibro cholera strongloidosis

Staph.aureus Trichuris trichuria

Yersina
enterocolitica
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Etiology of Chronic Diarrhea

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Pathogenic Mechanisms
Inoculum size
Adherence
Toxin Production
– Enterotoxin
– Cytotoxin
– Neurotoxin
• Invasion

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 Inoculum size
– 10-100 organisms
• Shigella
- < 1000 microorganisms
• Entero-hemorrhagic E. coli
• Salmonella typhi
• Campylobacter jejuni

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– 10^5 to 10^8 organisms
• Vibrio cholera
• Salmonella (nontyphoidal)

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 Toxin Production –
 Enterotoxin: cause watery diarrhea by acting
directly on secretory mechanisms in the
intestinal mucosa
• Vibrio cholera, ETEC, Clostridium
perfringens
 Cytotoxin: cause destruction of mucosal cells
and associated with inflammatory diarrhea
• Shigella, Shiga-like toxin or verotoxin (EHEC) –
 Neurotoxin: act directly on central or
peripheral nervous system
• Staphylococcus aureus, Bacillus cereus

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Staphylococcus Aureus enterotoxin
(neurotoxin)
 Heat-stable toxin – Increases peristalsis by
sympathetic activation, resulting in intense
vomiting
Bacillus Cereus enterotoxin – Two
enterotoxins
 Emetic: incubation period 1-6 hours
 Diarrheal: Incubation period 10-12 hours

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Pathogenesis
Under normal circumstances the absorptive
process for water and electrolytes > secretion.
Diarrhea results when there is an alteration of
these mechanisms.
Absorption= =>Villous
Na, Amino acid, Glucose
Glucose facilitates the absorption of Na 25x ↑
Secretion ==> Crypts
Chloride
e.g. V.cholera toxin mediated conversion of ATP CAMP

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 Mechanisms of Diarrhea
1. Osmotic diarrhea
Defect present:
Digestive enzyme deficiencies
Ingestion of unabsorbable solute
Examples:
Lactase deficiency
Comments:
Stop with fasting, No stool WBCs

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 Mechanisms Cont…
2. Secretory Diarrhea
Defect:
Increased secretion
Decreased absorption(virus villus
damage)
Examples:
Cholera
Toxinogenic E.coli
Comments:
Persists during fasting
No stool leukocytes
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Mechanisms Cont…
3. Exudative Diarrhea:
Defects:
Inflammation
Decreased colonic
reabsorption
Increased motility
Examples:
Bacterial enteritis
Comments:
Blood, mucus and WBCs in
stool
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 Mechanisms Cont…
4. Increased motility:
Defect:
Decreased transit time
Example:
Irritable bowel syndrome,
thyrotoxicosis, post vagotomy dumping
syndrome
5. Decreased motility:
Defect:
Defect in neurotransmiting
unitsstasis(bacterial over growth)
Example:
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Associated Clinical manifestations
– Fever: may be suggestive of an
inflammatory process & also occurs as a
result of dehydration,
– Vomiting suggests organisms that infect the
upper intestine (enteric viruses, enterotoxin-
producing bacteria, Giardia, &
cryptosporidium),
– Severe abdominal pain & tenesmus
Effects of diarrhea include:
— Dehydration, metabolic acidosis,
malnutrition, and sepsis, etc.

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 Clinical approach to Infectious
Diarrheas
Watery Diarrhea Bloody diarrhea Enteric Fever
(Dysentery)

Mechanism Non inflammatory Inflammatory Penetrating

(enterotoxin) (invasion or systemic infection
cytotoxin
Location Proximal small Colon or distal Distal small bowel
bowel small bowel

Pathogens Vibrio cholera ETEC Shigella spp. Salmonella typhi

Clostridium Salmonella Yersinia
Perfringens Bacillus (Nontyphoidal) enterocolitica
cereus Campylobacter
Stapholococcus jejuni EIEC (EHEC)
aureus Clostridium difficile

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 Assessment of Diarrhea
—For how long?
—Is there blood in the stool?
—Assess for sign of DHN
—Look at the child’s general condition.
—Is the child: Lethargic or unconscious?
Restless and irritable?
— Look for sunken eyes.
—Offer the child fluid. Is the child: Not able
to drink or drinking poorly? Drinking
eagerly, thirsty?
—Pinch the skin of the abdomen. Does it go
back: Very slowly (longer than 2
seconds)? Slowly?
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 Assessment Cont…
Mistakes in taking a skin pinch:
◦ Pinching either too close to the midline or too far
laterally
◦ Pinching the skin in an horizontal direction
◦ Not pinching the skin long enough
◦ Releasing the skin so that the finger and thumb
remain in a closed position

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Classification of skin pinches:
◦ Normal — it goes back
immediately
◦ Slowly — the fold is visible for
less than 2 second
◦ Very slowly — the fold is visible
for more than 2 seconds

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 Assessment Cont…
Severe dehydration will have two of these signs:
◦ sensorium abnormally sleepy or lethargic
◦ sunken eyes
◦ drinking poorly or not at all
◦ very slow skin pinch
Some dehydration will have two of these signs:
◦ restlessness or irritability
◦ sunken eyes
◦ drinking eagerly
◦ slow skin pinch
No dehydration
◦ None of these signs
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Assessment Cont…

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 Laboratory Investigation
 CBC
 Stool specimen(mucus, blood,
WBC)
 Rectal swab

 Culture blood

 Stool culture: in bloody diarrhea,

WBC, immunocompromized
 Serum electrolytes
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Treatment of diarrhea
Main principle in management of acute
diarrhea is

1. Replace lost water and salts.

2. Continue to feed to prevent malnutrition.
3.Antibiotics & antiprotozoals when
needed.
4.Prevention of diarrhea

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 Treatment Cont…
No sign of DHN  Plan A

◦ Fluid deficit < 5 %

◦ Can be treated at home
◦ More fluid than usual to prevent DHN
◦ Appropriate supply of foods to prevent
malnutrition
◦ Bring back the baby to the health inistitution,
if diarrhea doesn’t get better or gets worse.

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 Home Fluids for Diarrhoea Must Be:
Safe when given in large volume.
Easy to prepare.
Acceptable color and palatability.
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
 Give frequent small sips from a cup.
 If the child vomits, wait 10 minutes, continue,
but slowly.
 Continue giving extra fluid until the diarrhea stops.

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Home Fluids for Diarrhoea Must Be:
Ideal home fluids contain:
◦ salts and nutrients (sodium, potassium,
chloride, and bicarbonate)
◦ calories to replenish diet
Examples of home fluids:
◦ ORS solution
◦ salted soup
◦ salted drinks

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 Unsuitable fluids
• Fluids which are sweetened with sugar,
which can cause osmotic diarrhoea and
hypernatraemia.
Examples:
• soft drinks
• sweetened fruit drinks
• sweetened tea.
• Fluids which are stimulant, diuretic or
purgative effects eg, coffee

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Some DHN  Plan B
Fluid deficit 5-10%
ORS 75ml/kg over 4-6 hrs.
Reassess the degree of DHN
◦ If no sign of DHN home Rx with
replacement of on going losses(50-
100ml/bowel motion).
◦ If sign of some DHN repeat plan B
◦ If worse  IV RX

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Plan B

 Oral Rehydration Solution (ORS):

• Effective in all types diarrhea
• Can prevent dehydration if given early in the
disease.
• Cheap, easy to administer; can be given by
mother at home.
• No chance of overhydration or electrolyte
overdose.

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 Methods of administration: spoon, cup,
dropper, syringe, naso-gastric tube.
 Types of ORS

Solution Glu Na K Cl
g/dl mEq/L meq/L meq/L
WHO 2.0 90 20 80

Rehydralyte 2.5 75 20 65

Pedialyte 2.5 45 20 35

Infalyte 2.0 50 20 40

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 Severe DHN  Plan C
Fluid deficit 10-15%.
IV fluid RL  30ml/kg in the 1st hr to
combat circulatory collapse.
70ml/kg in the 5hrs (half of the time is
required for grown up children).
Reassess after the 1st hr  strong pulse &
↑BP , if not repeat 30ml/kg.
Reassess an infant after 6 hours and a child
after 3 hours.
 Classify dehydration choose plan (A, B,
or C) to continue treatment.
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Indication for IV rehydration
1.Severe dehydration.
2.Severe and repeated vomiting.
3.Paralytic ileus and abdominal distension.
4.Glucose malabsorption.
The preferred IV solution is R/L lactate which
will be changed to bicarbonate.
Also give ORS (about 5 ml/kg/hour) as soon
as the child can drink: usually after 3-4
hours (infants) or 1-2 hours (children).
RL = Na + 130, K+ 4, Cl- 109 and lactate 28
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Treatment Cont…
 Antimicrobialtherapy is administered to
selected patients –
- to shorten the clinical course
- to decrease excretion of pathogens
- to prevent complications

 Giveantiprotozoal for patients with proven

ameabiasis and no response to treatment for
shigella

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TREATMENT OF DHN IN SAM
CHILD

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Monitoring of a SAM patient who is on
treatment for dehydration
 V/S
 CNS: Restless, irritable , Lethargic
 Sunken eyes
 Thirsty
 Weight
 Urine
 Liver size
 Loss: Diarrhea or vomiting

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After rehydration, ReSoMal after each loose

◦ Edematous Children: give 30 ml after each

watery stool.
◦ Non-edematous children:
 < 2 years: give 50-100 ml after each watery stool
 2 years and older: give 100 -200 ml after each
watery stool

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 Composition of ReSoMal, Standard WHO_ORS and
reduced Osmolarity ORS
Composition ReSoMal Standard ORS Reduced osmolarity ORS
(mmol/L) (mmol/L)

Glucose 125 111 75

Sodium 45 90 75

Potassium 40 20 20

Chloride 70 80 65

Citrate 7 10 10

Magnesium 3 .. ..

Zinc 0.3 .. ..

Copper 0.045 .. ..

Osmolarity 300 311 245

(mOsm/L)

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Persistent Diarrhea
Diarrhoea that occurs for 14 or more
days
Less than 10 percent of all diarrhoea
but associated with 30 to 50 percent of
diarrhoea deaths.
Malnutrition greatly increases the risk
of death.

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 Causes
Proximate Causes
◦ Secondary disaccharidase deficiency
◦ Salmonella sp.
◦ Shigella sp.
◦ Enteroadherent E. coli
◦ Cryptosporidium

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 Contributing Factors
◦ Protein energy malnutrition
◦ Micronutrient deficiencies
◦ Immunodeficiency

 mortality is 8 to 10 times higher than that with

acute diarrhea
 may need nutritional rehabilitation
 may need investigation for immune
deficiencies and/or resistant bacteria

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Risk factors for Persistent Diarrhea
Age of baby < 1 yr.
Malnutrition
Recent introduction of animal milk
Recent acute diarrhea
Previous persistent diarrhea

N.B Important cause of mortality

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Treatment of persistent
diarrhea
Correct Dehydration

Correct Nutritional Problems

◦ Reduce disaccharides
◦ Increase energy intake
◦ Supplement micronutrients (possibly)
Give Antibiotics for Dysentery

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Avoid These Therapies
◦ Antibiotics for watery diarrhoea
◦ Anti-motility agents
◦ Diluted feeds

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Prevention
 Wash your hands frequently,
especially after using the toilet,
changing diapers.
 Wash your hands before and after
preparing food.
 Breast feeding,
 Nutrition,
 Hygienic food preparation,
 Vaccination Vs rotavirus,
measles………
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Points to Remember
 Gastroenteritis is acute self-limited illness.
 Diarrhea and vomiting in infancy and childhood is
usually due to viral gastroenteritis.
 Fluid replacement with ORS is the mainstay of
management.
 Breast feeding should be continued, but formula
feeding should cease until recovery.
 Antibiotics and antiemetics agents are not usually
needed.

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Thank You

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