| ID | 376 |
|---|---|
| Name | ACUTE DIARRHOEA |
| Cause | Causes of acute diarrhoea: A. Host factors. B. Environmental factors. C. Etiological factors. Host factors: 1. Age- 90% diarrhoea under 2 yrs. 2. Protein- energy malnutrition (PEM). 3. Vita-A status- 3 times more in vita- A deficiency. 4. Bottle feeding- frequency of diarrhoea is more. Environmental factors: 1. Lack of safe water. 2. Overcrowding. 3. Unhygeinic disposal of nightsoil. Etiological factors: 1. Enteral causes- a. Viruses, Rota virus is responsible for upto 50% of diarrhoea in children, aging 6-24 months. Other viruses are : norwalk agent, astrovirus, calicivirus, coxsakie, adenovirus, echovirus, picorna virus. b. Bacteria, enteropathogenic E coli (EPEC) are associated with epidemics of diarrhoea in newborn nurseries. Enterotoxigenic E coli (ETEC). Enteroinvasive E coli (EIEC), vibrio cholere, shigella, non-typhoid salmonella, campylobacter jejuni, yersinia enterocolitica, clostridium difficile are also responsible for diarrhoea. c. Parasities, giardia lamblia, entamoeba histoly-tica, trichuris trichuira, strongyloides sterco-ralis. Diarrhoea is not an usual feature in infestation with ankylostoma duodenalis, ascaris Lumbricoides, tenia or hymenolepsis. d. Fungi, Candida albicans. 2. Parenteral causes- Pneumonia, pyelonephritis, meningitis, septice-mia etc may be associated with diarrhoea. Otitis media, tonsilitis, malabsorption syndrome may be associated with diarrhoea. 3. Dietary & others-food allergy, cow’s milk allergy, dietary indiscretion, drugs (ampicillin etc), soya protein, lactose intolerance. |
| Signs Symptoms | Signs and symptoms associated with diarrhea may include: Frequent loose, watery stools. Abdominal cramps. Abdominal pain. Fever. Bleeding. Lightheadedness or dizziness from dehydration. |
| Diagnosis | Acute diarrhea is defined as three or more loose or watery stools per day. Diarrhea can be caused by infections or other factors. Sometimes, the cause of diarrhea is not known. Diarrhea caused by an infection usually begins 12 hours to four days after exposure and resolves within three to seven days |
| Investigations | Investigations: 1. Blood- routine count. 2. Stool- routine test, reducing subs. & c/s. 3. Urine- routine test. 4. Special tests- blood urea, s.. creatininine s. electrolytes & TCO if needed. |
| Management | Management:17 A. Fluid therapy: 1 . Correction of existing water and electrolyte deficit as indicated by the presence of signs of dehydration (rehydration therapy). Table-2) 2. Replacement of abnormal ongoing losses of water and electrolytes due to continous diarrhoea or vomiting to pevent recurrence of dehydration (maintenance therapy). (Table-3) B. Provision of normal daily fluid requirement and maintenance of nutrition. C. Treatment of complications. D. Preventive measure for diarrhoea 1 . Rehydration therapy Table-2 : Guidelines for rehydration therapy (as suggested by WHO). Degree of Age group Type of Volume of Duration of dehydration fluid fluid (per kg administration (Table 1) body weight) Mild All ORS Solution 50 ml/kg Within 4 hours Moderate All ORS Solution 100 ml/kg Within 4 hours Cholera saline1 30 ml/kg IV Within 1 hour followed by Severe Infants Cholera Saline 40 ml/kg IV Within next 2 hours followed by ORS Solution 40 mL/kg Within next 3 hours Older Cholera saline 110 ml/kg IV Within 4 hours; Children initially as fast as & adults possible, until radial pulse is palpable. 2. Maintenance therapy Table-3 : Guidelines for maintenance therapy Nature of diarrhoea Type of fluid Administration Amount of fluid Mild diarrhoea : (not more ORS By mouth : 100 ml/kg body than one stool every 2 hours at home weight per day or longer, or les than 5 ml until diarrhoea stops* stool per kg per hour). Severe diarrhoea: (more than ORS By mouth: Replace stool losses one stoolevery 2 hours, at treatment volume if not or more than 5 ml of stool facility mesurabe, give 10-15 ml/kg per kg per hour) centre body wt per hour. Severe diarrhoea with recurrence Treat as for severe dehyration of sings of dehyration. described in Table 2. *As an alternative, mothers can be advised to give 10 ml/kg body weight for each diarrhoea stool in case of infants. In older children and adults, thirst is an adequate guide for fluid needs; they can be told to drink as much as they want to satisfy their thirst. B. Provision of normal daily fluid requirement & maintenance of nutrition The breast-fed infants should be allowed breast feeding as the infant desires; non-breast fed infants should be allowed to have milk and other foods that is normally consumed by him. Milk may be diluted with an equal volume of water until diarrhoea stops, especially for infants. There is no physiological basis for resting the bowel during or following acute diarrhoea. In fact, fasting has been shown to reduce further the ability of the small intestine to absorb a variety of nutrients. Even during acute diarrhoea, 60% of the normal absorption of nutrients occur. This is particularly true for fat and oils which can provide a large amount of energy. Greater weight gain has been documented in infants given a liberal dietary intake during diarrhoea when compared with others on a more restricted intake. It has also been demonstrated that the presence of foodstuff in the intestinal lumen increases production- of digestive enzymes and proliferation of intestinal mucosal cells. The resumption of breast-feeding and other milk feeds is essential for meeting normal daily fluid requirement and for the maintenance of adequate nutrition (daily fluid requirement is described earlier in this chapter; energy requirement can be calculated as 110 kcal/kg/day). When disaccharidase deficiency occurs (can be tested clinically by heating 5ml of Benedict’s solution in a test tube applied into it 8 drops of watery stool- development of brick-red colouration indicates severe reduction), the patients may be kept on low lactose formula, temporarily, for 3 to 7 days. In infants 4-6 months of age or older who have not previously been given semisolid food, this is a good time to start feeding with such food. In these infants, and in some of those who have lost their appetite during diarrhoea, a considerable efforts may be necessary to get them to eat. In such cases frequent small meals should be given. Foods which are rich in potassium (e.g fruit juices, bananas, coconut milk) are useful in view of the losses of body potassium during diarrhoea. C. Treatment of cause: Most cases of diarrhoea are self-limiting. Antibiotics have little role in altering the course of the illness; it is commonly used in infection with invasive organisms. In discriminate use of antibiotics may lead to- - emergence of resistant strains, - eliminate the indigenous bacteria and deprive the body of their protective role, - promote development of carrier state. Most cases of watery diarrhoea occuring due to rotavirus & ETEC do not need antibiotic therapy. Pectin and kaolin prevent absorption of nutrients from gut, and now is not used for treatment of acute diarrhoea. Diphenoxylate hydrochloride with atropine reduces motility of the gut (increased motility of the gut is an important defence mechanism to prevent establishment of ETEC, Shigella etc in the intestine); decreased motility of the gut leads to stasis of the bacteria which then proliferate in the gut. This is why Diphenoxylate hydrochloride plus Atropine is not advocated now-a-days in the treatment of diarrhoea. The same disadvantage also lies with loperamide. Table-4 : Antimicrobials commonly used in the treatment of specific causes of acute diarrhoea. Cause Drug (s) of choice Dose & duration of treatment Cholera Tretracycline, or Tretracycline orally 50mg/kg/day, q.i.d Doxycycline, or doses x 3 days; or doxycycline orally 5mg/ Erythromycin, or kg/day in single Co-trimoxazole, or dose. (Use of tetracycline in children < 9 years is not recommended). Furazolidone Co-trimoxazole: IMP 8-10mg/kg/day & SMX 40mg/kg/day orally b.i.d doses x 7 days. Erythromycin 40mg/kg/day, q.i.d doses x 3 days. Furazolidone 5-8mg/kg/day, q.i.d x3 days. Shigellosis Ceftriaxone i.m or i.v 50-100mg/kg/day Ciprofloxacin orally 20-30mg/kg/day, b.i.d x 7-10 days. Ampicillin lOOmg/kg/day q.i.d doses x 5 days. Co-trimoxazole: IMP lOmg/kg/day & SMX 50mg/kg/day b.i.d x 7 days. Nalidixic Acid 55mg/kg/day, q.i.d doses x 5-7 days. Pivmecillinam 40-50mg/kg/day, q.i.d doses x 7 days. E. coli Co-trimoxazole, or See above. (ETEC,EIEC, Ciprofloxacin EPEC). Acute Metronidazole, or Metronidazole 30mg/kg/day x 5-10 days intestial Tinidazole followed Tinidazole 60mg/kg/day x 3 days, amoebiasis by iodoquinol, or paromomycin Acute Furazolidone, or Metronidazole 20mg/kg/day x 5 days giardiasis Metronidazole, or Quinacrine 5-7mg/kg/day in divided doses x (Giardia Albendazole, or 5 days. lamblia) Nitazoxanide Nitazoxanide: Children of 12-47 months, Quinacrine l00mg 12 hourly & 4-1 1 years, 200mg 12 hourly for 3 days Clostridium Metronidazole See avobe difficile (1st line) followed by iodoquinol, or paromomycin Vancomycin (2nd line) Cryptospori- Nitazoxanide Child: 12-47 months 100mg every 12 hours x dium parvum 3 days 4-11 years- 200mg every 12 hours x 3 days (The drug should be taken with food). Recently trials are being conducted using drugs which inhibit prostaglandins, such as aspirin. D. Treatment of complications: Anuria: 1. If anuria is less than 24 hours, replace the existing fluid loss by cholera saline. 2. If anuria is more than 24 hours, correct the fluid loss with 5% dextrose in normal saline. If the child passes urine, then cholera saline is to be started. 3. If the child does not pass urine after rehydration, management should be given as described in chapter seven under management of Acute Renal Failure. Correction of acidosis: Acidosis should be measured by estimation of bicarbonate in blood. The acidosis is corrected then with sodium bicarbonate solution according to the formula-0.35 x weight in kg x base deficit (mEq/l)= amount of bicarbonate in mEq. In urgent situations where acidosis is evident clinically, sodium bicarbonate can safely be given in a dose of 3ml/kg/dose; half of the amount diluting with equal volume of i.v fluid can be given slow i.v, the remaining half can be put into the infusion bag to be infused within 6-8 hours (1ml of 8.4% NaHCOs solution = 1 mEq of NaHCOs). Paralytic ileus (hypokalemic): 1. Existing fluid loss should be corrected with cholera saline. A more rapid correction can be achieved by addingt potassium chloride 10-20 mmol/1 to the infusion fluid. 2. Continuing loss to be added to existing loss & corrected by cholera saline. 3. Nutrition to be maintained with 10% glucose saline i.v with nothing by mouth until bowel sound appears. 4. Large amounts of potassium,usually upto 3mEq /kg/24 hours may have to be given orally. 5. Serum K+ level should be estimated or ECG monitoring should be done. Hyponatremia: It should be corrected by finding out the total amount of sodium (in mEq) required from the following formula : Cd - Ca x 0.6 x body weight in kg. Here, Cd and Ca represent respectively the serum sodium concen-tration desired and the one actually present, expressed as mEq/1. Then it can be corrected either by 3% NaCl solution, isotonic saline or common salt (1 gm =17 mEq). Hypernatremic dehydration: The incidence of seizure may be reduced by correcting hypernatremia slowly over a period of days, therapy is adjusted to return serum sodium level towards northal by not more than 10 mEq/1/24 hours. It should be corrected by 5% dextrose in 1/2 to l/4th physiological saline. A suitable regimen is to administer 60-75ml/kg/24 hour of a 5% dextrose solution containing 25mEq/L of sodium as a combination of the bicarbonate and chloride. If seizures occur, they may often be controlled by 3-5ml/kg of a 3% NaCl solution i.v. Or by hypertonic mannitol, Anticonvulsants may also be added. Hypocalcemia is also seen occasionally during treatment of hypernatremic dehydration, and may require i.v. calcium. Amount of maintenance fluid and sodium should be reduced by about 5% during this Phase of therapy, since these patients have high level of ADH, resulting in low volume urine. Peripheral circulatory failure: Blood vlume should be restored by Plasma, whole blood, dextran or 5% dextrose in normal saline. Convulsion: It may occur following thrombosis of cerebral vessels due to hemoconcentration, rapid correc-tion of hypernatremia, severe hyponatremia, hypocalcemia, hypomagnesemia or post-acidotic tetany. Treatment should be aimed at correction of the cause. |
| Introduction | Passing of liquid or watery or soft bloody stools usually more than 3 times a day is defined as acute diarrhoea. The diarrhoea is always associated with some alteration of the usual habit of child. Mother’s definition of diarrhoea should be considered in case of breast-fed infants. Passing of frequent but formed stool usually not considered as diarrhoea. Breastfed babies often pass frequent loose pasty stools, which is not a diarrhoea. This is due to the osmotic effect of the lactose & may be considered as relative lactose intolerance & this is of no clinical significance. Most of the acute diarrhoeas not last more than 7 days. |
| History | |
| Etiology | The most common causes of acute and persistent diarrhea are infections, travelers' diarrhea, and side effects of medicines. Viral infections. Many viruses cause diarrhea, including norovirus link and rotavirus link. Viral gastroenteritis is a common cause of acute diarrhea. |
| Clinical Features | Clinical features : Assessment of dehydration: Excessive loss of body water and electrolytes with stools and vomitus will cause dehydration . Degree of dehydration may be mild (when % weight loss is 4-5%), moderate (when % weight loss is 6-9%), and severe (when % weight loss is 10% or more). Assessment of dehydration is important for management of diarrhoea, and is given below: |
| Preventions | E. Prevention For prevention of cholera, cholera vaccine is given i.m. the efficacy of which is questionable. Recently ICDDR.B has evolved an oral vaccine claimed to be more effec-live, given for 3 doses at 1 month interval. Each dose consits of 5.0mg of purified B-subunit & 2x 1011 killed V. cholere cells. Education about washing the hands can reduce the secondary attack rates of diarrhoea within families by 85%. Improved hygiene including proper disposition of excreta also has the added benefits of reducing diarrhoea caused by gut parasites. Safe water drinking is also of utmost importance. |
| Treatment | ELDERLY In most cases, diarrhea can be treated at home with plenty of liquids to replace lost fluids and electrolytes. The BRAT diet — bananas, rice, apple sauce, and toast — can also help ease symptoms. Potatoes, peanut butter, and skinless chicken or turkey are also other good food choices IN PREGNANCY Drinking plenty of fluids, eating bland food, and adding probiotics to your diet may help settle your stomach and prevent dehydration. If your diarrhea lasts more than 2 to 3 days, or if it's severe, reach out to your doctor. Ongoing or severe diarrhea can lead to dehydration which may cause pregnancy complications INFANTS Most children with acute diarrhea should be treated with Oral Rehydration Solution (ORS), a mixture of water, salts, and glucose, in both the replacement and maintenance phase. For children with severe dehydration, the replacement phase should begin with intravenous fluids (IVF) BLOODY DIARRHOEA Drink lots of water and other fluids. You may be able to treat diarrhea at home using over-the-counter medications, such as loperamide (Imodium A-D), but ask your doctor first. In some cases, your doctor may advise against taking standard anti-diarrheal medications because they are not effective against E. coli |
| Complications | The possible complications of an acute diarrheal illness include dehydration, metabolic acidosis, impaired consciousness, convulsions, circulatory shock, and prerenal azotemia |
| Prognosis | Acute-onset diarrhea is usually self-limited; however, an acute infection can have a protracted course. Management is generally supportive: In most cases, the best option for treatment of acute-onset diarrhea is the early use of oral rehydration therapy (ORT) |
| Types | Types of acute |
| Classification | Classification according to biochemical types of dehydration: 1. Hypotonic or hyponatremic dehydration 20-30% 2. Isotonic dehydration - 60% 3. Hypertonic or hypernatremic dehydration- 10% (commonly due to excessive intake of ORS) |
| Observation | |
| Pathology | Specific pathogenic mechanisms for acute infectious diarrhea include tissue invasion, enterotoxin production, and adhesion of infectious agents to epithelial cells. Antidiarrheal agents remove secretagogues from the intestinal tract, stimulate fluid absorption, and inhibit electrolyte movement. |
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