ACUTE DIARRHEAL DISEASE

kottayam medical college

Dr.Mohemed sanowfer

What is diarrhea?Diarrhea is the passage of loose watery stools

at least 3 times in a 24hr day

Recent change in the consistency of stools

CLINICAL TYPES Acute watery diarrhea

Acute bloody diarrhea (dysentery)

Persistent diarrhea (>14 days)

Diarrhea with severe malnutrition

WHAT CAUSES ACUTE DIARRHEA?VIRUS - ROTAVIRUS

BACTERIA - ENTEROTOXIGENIC E.coli

Shigella, Salmonella

Vibrio cholerae(5-10%)

EIEC,EHEC,LA-EC,DA-EC

C.JEJUNIOTHERS- E.histolytica, g.lamblia

50%

Pathophysiology Diarrhea water & water soluble substances

like electrolyte , metabolites, vitamins are lost

ECF

50% cases – Na remains normal [140 mEq/L]

45% - hyponatremia

5% - hypernatremia[ underestimated]

Na+

Na+

Na+

Na+

ECF

ICF

ECF

ICF

H2O

H2O

H2O

H2O

H2O

H2O

H2O

H2O

Na

NaNa

Na

ASSESSMENT OF CHILD WITH DIARRHEACLINICAL ASSESSMENT

HISTORY-Duration -watery/bloody -severity -associated symtoms -feeding

ASSESS IN EXAMINATION-1 Physical signs of dehydration -2 nutritional status of the child -3 pneumonia,otitis media

LABORATORY INVESTIGATIONS 1 STOOL MICROSCOPY 2 STOOL CULTURE 3SERUM ELECTROLITES,RFT 4TESTS FOR STOOL pH

ORAL REHYDRATION THERAPY ORT1 ORS Solution

2Solutions made from sugar & salt

3Food based solutions -rise water with salt -butter-milk with salt

4Other home made fluids- -1 plain water, lemon water, coconut water -2 thin rise kanji

Comparison b/w low osmolarity ORS&WHO-ORS

INGRADIENTS CONC(MMOL/L)

LOW OSMOLARITY WHO-ORS ORS [NEW]

SODIUM 75 90

POTASSIUM 20 20

CHLORIDE 65 80

CITRATE 10 10

GLUCOSE 75 111

ADVANTAGES OF LOW OSMOLARITY ORS

1 MORE EFFICIENT ABSORPTION OF SODIUM&WATER

2 REDUCED NEED OF IV FLUIDS

3 REDUCTION IN STOOL OUTPUT

4 LOWER VOMITING

5 NO SIGNIFICANT HYPONATREMIA

ASSESSMENT OF SEVERITY OF DEHYDRATIONLOOK AT

CONDITION

EYESTEARS

MOUTH&TONGUETHIRST

WELL ALERT

NORMALPRESENT

MOIST

DRINKS NORMALY,NOT THIRSTY

RESTLESS IRRITABLE,SUNKENABSENT

DRY

DRINKS EAGERLY

LETHARGIC/UNCONSCIOUS

VRY SUNKEN ABSENT

VERY DRYDRINKS POORLY ,NOT ABLE TO DRINK

FEEL SKIN PINCH GOES BACK QUICKLY

GOES BACK SLOWLY

GOES BACK VRY SLOWLY

DECIDE NO SIGNS OF DEHYDRATION

SOME DEHYDRATION

SEVERE DEHYDRATION

TREAT PLAN A PLAN B PLAN C

TREATMENT OF ACUTE DIARRHEATREATMENT OF DEHYDRATION

ZINC SUPPLIMENTATION

NUTRITIONAL MANAGEMENT

DRUG THERAPY

SYMPTOMATIC TREATMENT

TREATMENT PLAN APATIENT WITHOUT PHYSICAL SIGNS OF DEHYDRATION

Homely management with ORAL REHYDRATION THERAPY

AGE Amount of ORS other ORT fluids Amount of ORS to provide for give after each loose stools use at home

<24 m 50-100 ml 500mL/day

2-10 yr 100-200ml 1000mL/day

>10yr as much as wants 2000mL/DAY

Mother should be educated to increase the amount of culturally appropriate home available fluids

Describe and show the amount to be given after each stool using a local measure

Show mother how to mix ORS and how to give.Give a teaspoon full every 1 – 2 min under 2yrsIf the child vomits wait for 10min then give

slowly 2-3 min intervalIf diarrhea continues after ORS packets are used

up give other fluids or return for more ORS

TREATMENT PLAN BPATIENT WITH PHYSICAL SIGNS OF DEHYDRATION

Rehydration therapyCorrection of existing water and elecrolyte deficit

as indicated by presence of signs of dehydration

Maintenance therapyReplacement of ongoing loses due to continuing

diarrhea to prevent the recurrence of dehydration

Provision of normal daily fluid requirements

Rehydration therapy75ml/kg of ORS in the first 4 hr

Maintenance therapyORS should be administered in volume equal to

diarrhea losses [10-20 ml/kg] for each liquid stool

Offer plain water in between

Encourage breast feeding

If the child continues to have some dehydration after 4hrs repeat another 4hrs treatment with ORS solution [ as in rehydration therapy]

How effective is ORT 95 -97%

When ORT ineffectiveHigh stool purge more than 5ml/kg/hr

Persistent vomiting - >3/hr

Abdominal distention and ileus

Glucose malabsorption

TREATMENT PLAN CCHILDREN WITH SEVERE DEHYDRATIONI V fluids immediatelyRL solution

[ ideal – RL + 5% dextrose]0.9% NS

IV not accessible – ORS using naso-gastric tube @ 20ml/kg/hr [total 120ml/kg]

Reassess every 1-2hr

Repeated vomiting & abdominal distention – IV slowly

MonitoringEvery 15-30min reassessNot improving – IV rapidlyAfter full IV fluids – REASSESSIf signs of dehydration still present repeat iv

fluids as outlined earlierImproving but some dehydration discontinue

iv and give ORS for 4hrs [plan B]Observe the child at least 6hrs before

discharge to confirm that mother is able to maintain child’s hydration by ORS solution

Zinc in diarrhea

Zinc plays a critical role in metalloenzymes polyribosomes, cell membranes, cellular functions.

<6month – 10mg/day>6month – 20mg/dayAdv –

16% faster recovery31% reduction in stool output

10-14 days

Dietary recommendations for management of diarrheaContinue feeding Breast feeding – continuedOptimally energy dense foods with least bulk [small

quantities but frequently]Staple foods enriched with fats and oilsAvoid foods with high fiber contentIn non breast fed infants – cow milk given undiluted During recovery a intake of atleast 125% of normal

RDA should be attempted with nutrient dense foods

Drug Therapy

Antibiotics & chemotherapeutic agents [dysentery & cholera]

Malnourished/ prematurely born with diarrheaWell nourished child diarrhea

Poor sucking Abdominal distentionFever/ hypothermiaFast breathingSignificant lethargy

Binding agents

Formulations based on pectin, kaolin, bismuth salt

Anti motility agents – diphenoxylate hydrochloride [lomotil], loperamide

Anti secretory agents – racecadotril [ acetorphan]Inhibit intestinal enkephalinase

Probiotics – Lactobacillus rhamnosus, L. plantarum, several strains of bifidobacteria

Symptomatic treatmentVomiting

Severe- metoclopromide 0.1 – 0.2 mg/kgPhenothiazine 0.5mg/kg

• Abdominal distention•Bowel sounds present – no treatment

Absent/ Gross distentionKCl iv 30-40mEq/LIntermittent nasogastric suction

PreventionHealth education

Exclusive breast feeding

Supplementary feeding

Sanitation & hygiene

Clean hand, Clean container & Clean environment

Thank You