Download Diarrhoea

Diarrhea
What is Diarrhoea?
Diarrhoea is a symptom characterized by
an abnormal increase in stool frequency
(more than 3 times daily) or liquidity (>
80% water);
The normal frequency of bowel
movements varies with each individual
Diarrhoea
DEFINITIONS – IDSA & WGO
“Diarrhea” is an alteration in a normal bowel movement characterized by an increase in
the water content, volume, or frequency of stools.
In adults, a decrease in consistency (i.e., soft or liquid) and an increase in frequency of bowel
movements to >3 stools per day (24 hrs) have often been used as a definition for epidemiological
investigations.
Diarrhea is defined as daily stools with a mass greater than 15 g/kg for children younger than 2
years and greater than 200 g for children aged 2 years and older.
“Infectious diarrhea” is diarrhea due to an infectious etiology, often accompanied by
symptoms of nausea, vomiting, or abdominal cramps. Dysentery describes an infectious
diarrhea with visible blood and mucus in the stool.
“Acute diarrhea” is an episode of diarrhea of <14 days in duration.
“Persistent diarrhea” is diarrhea of 14 or more days in duration.
Some experts refer to diarrhea that lasts 30 days or more as “chronic.”
Diarrhoea3
Diarrhoea
Causes:
bacterial or viral infection through
ingestion of contaminated food or drink;
1. E.Coli, S.aureus  toxins  mucosal
cells hypersecretion of fluid watery
diarrhoea with little or no fever or other
symptoms;
Diarrhoea
Causes:
2. Invasive E. coli, salmonella and shigella:
directly invade mucosal epithelial cells
and cause an inflammatory reaction
less fluid diarrhoea accompanied by
nausea, vomiting, cramps and
sometimes low-grade fever
Diarrhoea
Causes:
3. Viral infections, which often affect babies and
young children, also produce watery diarrhoea
4. Non-infective causes: stress, alcohol, and hot
spicy food
5. Drugs: antibiotics “all but varying degrees”.
Depends on extent that drug disrupts normal
intestinal microflora. Other: laxatives, misoprostol.
Olsalazine, anticancer, antihypertensive agents,
parasympathomimitic drugs, digoxin, quinidine,
magnesium hydroxide.
6. Chronic diarrhea. Lasts more than 4 weeks.
Protozoal infections, food, IBS, hyperthyroidism.
Diarrhoea
Infectious diarrhea
Infectious diarrhea is further
inflammatory diarrhea.
classified
into
non-inflammatory
and
Non-inflammatory diarrheas
Inflammatory diarrheas
Generally a less severe illness
Generally a more severe illness
Patients present with nonbloody, watery
stools; patients are afebrile and without
significant abdominal pain.
Patients present with bloody diarrhea, severe
abdominal pain, and fever.
Examination of stool specimens does not
reveal the presence of fecal white blood cells
(WBC) or occult blood.
Examination of stool specimens reveals the
presence of large numbers of fecal
leukocytes.
Typically caused by rotaviruses, noroviruses,
Staphylococcus aureus, Bacillus cereus,
Clostridium perfringens, Cryptosporidium
parvum, and Giardia lamblia.
Caused by invasive pathogens including
Campylobacter jejuni, Shigella species,
Salmonella species, Clostridium difficile,
Shiga toxin-producing Escherichia coli
(STEC), and Entamoeba histolytica.
Most patients require only supportive
therapies
Selected persons may benefit from
antimicrobial therapy directed at the
causative pathogen.
Diarrhoea8
Consequences
Normal faeces contain 60-85 % water
Water loss during defecation= 70-200
mL/day
In diarrhoea: water loss 4X normal K
and Na loss fall in plasma pH (acidosis)
serious metabolic consequences
Fluid & electrolyte losses are increased if
vomiting also occurs
Diarrhoea
Consequences
In babies/children: hazardous as high
proportion of total body weight is lost and
dehydration can occur very rapidly
Elderly are also particularly sensitive to
the effects of fluid and electrolytes loss,
especially if on diuretics
Reduction in blood volume + RAS  +
aldosterone (1) loss of K (hypokalemia)
(2) Excessive fluid loss reduction of
renal artery flow renal failure
Diarrhoea
Patient Evaluation: All of the following must
be considered before selecting the most
appropriate management.
Age
Onset and duration or diarrhea
Description of stool
Other symptoms
Medications
Recent travel
Medical history.
Diarrhoea
12
When to refer to a physician
 Very young or very old.
 Blood/mucus in stool.
 High fever (greater than 38.5 ˚C).
 Dehydration or weight loss greater than 5 % of total body
weight. Signs of dehydration: dry mouth, sunken eyes,
crying without tears, dry skin that is less elastic than
normal skin (decreased skin turgor with tenting).
 Severe vomiting..
 Duration: (see following slide)
Diarrhoea
13
Diarrhoea
When to Refer? (Duration)
If diarrhoea lasts more than:
72 hours : adults and older children
48 hours : children < 3 years old & elderly
24 hours in children < 1 year old
Refer Immediately in infants under 3
months old
Diarrhoea
Diarrhoea
16
Treatment of children based on the degree of
dehydration
Diarrhoea
17
Diarrhoea
Treatment
Oral rehydration therapy (ORT)
Opioids
Adsorpants
Dietary management
In UK: belladonna extract
Diarrhoea
Oral rehydration therapy (ORT)
First line treatment of acute diarrhoea
the very young & elderly (particularly
important)
ORT not intended to relieve symptoms
Use of antidiarrheals (antimotility drugs or
adorbants) is regarded unnecessary and
sometimes undesirable
Use of antidiarrheals (for
comfort/convenience) is used as adjunct to
ORT
Diarrhoea
Oral rehydration therapy (ORT)
Mode of action:
replace water and electrolytes lost
through diarrhoea and vomiting;
K & Na: replace ions
citrate and/or bicarbonate: correct
acidosis
glucose: carrier for Na ions and hence
water across the mucosa of the small
intestine
Diarrhoea
Oral rehydration therapy (ORT)
ORT is not intended to stop diarrhoea, but
acute diarrhoea is self-limiting and
normally ceases within 24-48 hours;
ORT can be recommended for patients of
any age, even when referral to a doctor is
considered necessary
Diarrhoea
An oral rehydration product (Dioralyte Relief
[Sanofi-Aventis]) containing powdered rice
starch in place of glucose is claimed to achieve
even greater rehydration than glucose over
time, and the rice starch is claimed to help
produce firmer stools, leading to faster recovery
compared with glucose.
A Cochrane Review found that polymer
(including rice)-based ORS showed some
advantages compared with glucose-based
ORS for treating diarrhea of any cause.
Diarrhoea
23
Diarrhoea
Dose & Administration of ORS
the content of 1 sachet or 2 effervescent
tablets should be dissolved in 200-250 ml
of water (freshly bolied and cooled in case
of infants)
discard unused solution 1 hr after
reconstitution or no longer than 24 hrs (if
refrigerated)
Dose, adults: 200-400 ml after every
loose motion, or 2-4 L over 4-6 hrs
Diarrhoea
Dose & Administration of ORS
Patients may prefer to sip 1-2 tsp every few
minutes rather than drink large quantities less
frequently
children > 2 yrs: cupful (200ml) after every
loose stool
children < 2 yrs: ¼- ½ cupful
Infants: 1-1.5 normal feed volume
Both breast and bottle-fed babies should
continue to be fed normally (without dilution)
Diarrhoea
Contraindications & cautions
No contraindications to ORS unless
the patient is vomiting frequently  IV
fluid and electrolyte replacement;
fluid overload from excessive
administration of ORS is highly unlikely
unless continued for babies and young
children > 48 hrs (recognised by puffy
eyelids)  rapidly withhold ORS and
other liquids
Diarrhoea
Dietary Management
Traditionally: withdrawal of feedings,
initiation of clear liquids, with a slow
reintroduction of feedings in 24 hrs
However, oral intake does not worsen
diarrhoea, clinically significant nutrient
malabsorption is uncommon (80-95% CHO, 70%
of fat and 75% of the nitrogen from protein) in acute
diarrhoea and bowel rest is generally not
necessary
Diarrhoea
What foods are best for
refeeding?
Diet should include:
complex carbohydrate-rich foods (e.g.
white boiled rice, potatoes, white bread)
Yogurt (why?)
lean meats (e.g. steamed chicken)
Some fruits and vegetables (e.g.
blueberries, bananas)
Diarrhoea
What foods are best for
refeeding?
most infants and children with diarheoa
can tolerate full-strength breast milk and
cow’s milk;
The familiar BRAT (bananas, rice, apple
sauce and toast) is frequently prescribed insufficient calories, protein and fat
especially in strict or prolonged use and is
not recommended by AAP
Diarrhoea