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an-Approach to diarrhea-by dr. rkdhaugoda,ctgu- 2014

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  • 1. Approach to diarrhea/Dysentery cholera/AGE/food poisoning Girdiasis / amoebiasis/ viral diarrhorea / other causes Very common presenting problem
  • 2. epidemiology • Most common in developing country • High- morbidity and mortality-DIRTY URBAN AREAS • Public health concern and problem • Mostly danger in children with malnutrition/ AIDS/ patient with DM • EASY DIAGNOSIS- SYMPTOMATICALLY • TRETMENT MOSLY- EFFECTIVE- SYMPTOMATICALLY • EFFECTIVE EMPERICAL TREATMENT- MOSLY- ANTIBIOTICS/ ANTI-AMOEBIC/ ANTI- HELMENTHICS • NEEDS- PROPER-PREVENTIVE MEASURE-
  • 3. diarrhea • Normal output of stool 200 gm/ 24 hour • Diarrhea- passing of stool more than 200 gm /24 hour Various mechanisms of diarrhea  Osmotic-diarrhea  Malabsorption/maldigetion/too fatty food--celiac disease, pancreatic insufficiency,drugs( alcohol,neomycin,colchicine)  Inflammation- AGE/DYSENTERY  Secretory-FATTY ACID /BILE ACIDS/TOXINS/ ULCERATIVE COLITIS  Altered motility-IBS
  • 4. Osmotic diarrhea • Excess amount of poorly absorable substance like- magnesium sulphate ,lactulose, lactose ,magnesium hydroxide,polyethylene glycol. • These substances retaines more water- causes- osmotic diarrhea
  • 5. Definition of diarrhea • “Passage of loose ,liquid or watery stool 3 or more episode with history of recent change in consistency and character of stool.” • Acute diarrhea- lasts for few days to 1 week. AGE/ CHOLERA/ FOOD POISONING/ BACTERIAL AND AMOEBIC DYSENTARY • Chronic diarrhea:-generally lasts more than 3 weeks—common causes- AIDS, IBS, CHRONIC BACTERIAL INF. TB ABDOMEN, MALABSORPTION, CHROHN’S DISEASE, CA- COLON.CEOLIAC DISEASE • Diarrhea reflects increased water content of the stool, whether due to impaired water absorption and/or active water secretion by the bowel. • In severe infectious diarrhea, the number of stools may reach 20 or more per day, with defecation occurring every 20 or 30 minutes. In this situation, the total daily volume of stool may exceed two liters, with resultant volume depletion and hypokalemia. • Most patients with acute diarrhea have three to seven movements per day with total stool volume less than one liter per day.
  • 6. Definition of dysentery • Dysentery is an inflammatory disorder of the intestine, especially of the colon, that results in severe diarrhea containing blood and mucus in the feces with fever, abdominal pain,and rectal tenesmus (a feeling of incomplete defecation), caused by any kind ofinfection. • It is a type of gastroenteritis.
  • 7. dysentery Bacillary dysentery-diarrhea,loose, mucous bloody stool /fever, pain abdomen- stool--- plenty of pus cells and RBCs– Rx- antibiotis-COTRIMOXAZOLE/ cipro/oflo/ levofloxacin, Amoebic dysentery- E. histolytica- ( abdomen pain, loose,mucoid stool at late stage- blood mixed mucoid stool)- d/d- bacterial dysentery/ ulcerative colitis.- diagnosis- stool-re/me, treatment-metronidazole/ tinidazole/ ornidazole
  • 8. pathogenesis • Each specific pathogen has its own mechanism or pathogenesis, but in general the result is damage to the intestinal lining, leading to the local or systemic inflammatory immune response. This can cause elevated temperature, painful spasms of the intestinal muscles (cramping), swelling due to water leaking from capillaries of the intestine (edema), and further tissue damage by the body's immune cells and the chemicals, called cytokines, they release to fight the infection. The result can be impaired nutrient absorption, excessive water and mineral loss through the stools due to breakdown of the control mechanisms in the intestinal tissue that normally remove water from the stools, and in severe cases the entry of pathogenic organisms into the bloodstream. • Some microorganisms – for example, bacteria of the genus Shigella – secrete substances known as cytotoxins, which kill and damage intestinal tissue on contact. Viruses directly attack the intestinal cells, taking over their metabolic machinery to make copies of themselves, which leads to cell death.
  • 9. GENERAL APPROACH • CLINICAL AND EDIDEMIOLOGICAL HISTOTRY • CLINICAL ASSESSMENTS- assessment of dehydration- dry tongue, skin turgor, shrunken eye, amount of urine output, blood pressure measurement, capillary filling test. • Investigations– stool r/e, stool c/s, blood for- CBC, ELECTROLYTE, UREA CREATININE, MALARIA PARASITE. • MANAMENT- isolation- regardeless of cause of dirrhea, fluid and electrolyte replacement, antibiotics,anti-amoebic, anti-helmenthics, anti-emetics, anti-pyretics,anti-viral anti- fungal,anti-histamine, anti- motility agent,
  • 10. Acute diarrhea • Very common presenting problem-in clinical practice / in community. • One of the most important public health problem • The mod-of transmission- fecal-oral route. • Common causes are- bacterial toxins,infection, viral , protozoal infections and parasitic infestations. • Other causes may be non- infectious agents. • Principle of treatment=fli Clostridium perfringens Multiplies in food Produces toxins in SI after contaminated food is eaten ud and electrolyte replacement, rest, avoid contamination, antiboitics/ anti-diarrheal, anti-emetics, anti-spasmodics, anti-hiatamine.
  • 11. Causes • Infectious- most- common-bacterial/protozoal • Non-infectious- toxins/drugs • Psychological- anxiety • Self-Induced- laxatives
  • 12. Noninfectious diarrhea • Drugs- other drugs • Antibiotic associated diarrhea-kills normal flora • Food allergies • Gastrointestinal diseases such as inflammatory bowel disease • Other disease states such as thyrotoxicosis and the carcinoid syndrome. • Ischemic colitis – – acute lower abdominal pain preceding watery, then bloody diarrhea; – acute inflammatory changes in the sigmoid or left colon while sparing the rectum • Toxins – – organophosphate insecticides – amanita and other mushrooms; – arsenic
  • 13. Infectious-diarrhea • Food poisoning-staphylococcal, shigellosis , salmonellosis • Acute gastro-enteritis • Cholera • Travelers' diarrhea • Giardiasis • Amoebiasis • Viral diarrhea • Helminthiasis • Antibiotic associated diarrhea-
  • 14. RISK PERSONELS 1. Travelers - enterotoxigenic or enteroaggregative Escherichia coli, Campylobacter, Shigella, Giardia 2. Consumers of certain foods - – Salmonella, Campylobacter, or Shigella from chicken – enterohemorrhagic E. coli (O157:H7) from undercooked hamburger – Bacillus cereus from fried rice or other reheated food – Staphylococcus aureus or Salmonella from mayonnaise or creams – Salmonella from eggs – Listeria from uncooked foods or soft cheeses – Vibrio species, Salmonella, or acute hepatitis A from seafood, especially if raw.
  • 15. RISK PERSONELS 3. Immunodeficient persons – primary immunodeficiency (e.g., IgA deficiency, common variable hypogammaglobulinemia, chronic granulomatous disease) – secondary immunodeficiency states (e.g., AIDS, senescence, pharmacologic suppression) 4. Daycare attendees and their family members 5. Institutionalized persons- HEALTH CARE PERSONS
  • 16. Infectious diarrhoea may be associated with systemic manifestations – Reiter's syndrome - arthritis, urethritis, and conjunctivitis may accompany or follow infections by Salmonella, Campylobacter, Shigella, and Yersinia. – Hemolytic-uremic syndrome - enterohemorrhagic E. coli (O157:H7) and Shigella
  • 17. Common bacteria causing diarrhea • E.coli • Compalobacter jejunu • Shigella (DYSENTERAI, SONNEI) • Salmonella • VIBRIO CHOLERA • VIBRIO-PARAHEMOLYTICUS(SEA FOODS) • BASILUS CEREUS • YARSINIS
  • 18. COMMON VIRUS CAUSING DIARRHEA • ROTA VIRUS • ASTRO VIRUS • ADENO VIRUS • CORONA VIRUS • ENTERO-VIRUS
  • 19. OTHER COMMON INFECTIOUS AGENTS OTHER THAN BACTERIA AND VIRUS • E.HYSTOLYTICA,GIARDIA LUMBRIA(protozoal) • TRIGHURIASIS ,ROUND WORM( helminthes) • FUNGAL- (CRYPTOSPORIDIUM , CANDIDA) • OTHER HELMINTHS- H. NANA
  • 20. Viral diarrhea • Causes Acute Diarrhoea: • Common Causes of Acute Diarrhoea Infection – highly contagious Viral gastroenteritis Rotavirus Usually cause explosive, watery diarrhoea Typically last only 48-72hrs Usually no blood and pus in stool
  • 21. Bacterial diarrhea cholera • Caused by vibrio-cholera- survives 2 weeks in fresh water and 8 weeks in salt water • Causes- Acute watery diarrhea • Clinical features-severe watery diarrhea(rice-water ) without colic ,with vomiting , intense dehydration with muscular cramps ,low out put urine and features of shock. • Epidemic in many part of worlds- India, Africa • Transmission-feco-oral-route- contaminated foods/waters • Diagnosis- hx of epidemic outbreak, stool test-dark field microscopy-shows –shooting star –motility of v. cholerae. • Other Ix- electrolyte, urea /creatinine, stool culture, blood CBC, • Should notify– epidemiology department • Management- • fluid and electrolyte REPLACEMENT, ASSESSMENT OF DEHYDRATION • ORS, IV FLUIDS ( RINGER LACTATE-BEST/ NORMAL SALINE)-5-6 LITER/24 HOUR-TOTAL 50 LITRES- OVER-5- 7 DAYS • TETRACYCLINE CAP , OXY TETRACYCLINE INJ. • CIPROFLOXACIN 1 GRAM, DOXYCYCLINE 3OO MG SINGLE DOSE- MAY HELP . • PREVENTION- strict- maintaining of personal hygiene and sanitation, cholera vaccine, health education, proper waste disposal , avoid contamination, clean drinking water.
  • 22. Food poisoning/ acute gastroenteritis • Acute -Gastro-enteritis- food poisoning, other infectious agents/toxins • Food Poisoning Brief illness cause by toxins produced by bacteria Cause abdominal pain, vomiting , secrete high amount of water – diarrhoea Some bacteria produce toxins in food before intake or in intestine after food is eaten Symptoms usually appear within several . Hours • Staphylococcus aureus- common cause Produces toxins in food before it is eaten Usually food contaminated left unrefrigerated overnight • Clostridium perfringens Multiplies in food Produces toxins in SI after contaminated food is eaten • c/f– profuse vomiting, Fever the diarrhea with discomfort in abdomen- bood cbc- leucocytosis • Tratment= antiemetics/ fliud and electrolytes/ iv fluids/ antboitic- ciprofloxacin or ofloxacin + metronidazole or tinidazole
  • 23. INVESTIGATIONS • Stool R/E, M/E • Stool culture • Serologic Ix- for certain toxins, virus, parasites • Blood CBC, electrolyte, urea, creatinine,RBS • IF STOOL-REPORT- NORMAL and diarrhea persistent • Sigmoidosopy, colonoscopy,usg, CT/MRI- TO SEE CD /UC, OR SURGICAL –DISODERS-DIVERCULITIS, SCHEMIC BOWEL DISEASE,PARTIAL OBSTRUCTION • HIV-SCREENING • TB-antibody, serum deaminase • If all are normal- IBS.
  • 24. INTEGRATED MANAGEMENT 1.Counseling about the nature of disease and course To patient and patient party- very important- part. 2. Proper assessment of dehydration and Isolation of the patient/ concern for epidemic outbreaks 3. Maintain – infection prevention- 4. Fluid replacement-judicial in children, with other comorbidities- heart disease BP. Children. 5. Combine antibiotics– cipro/oflo+ metronidazole/tinidazole + albendazole 6. Adjunctive –codiene/ ondacetrone, h2 blockers. Antispasmodics, anti-histamine- avomine,antimotility- (loperamide) . If necessary- anti-viral/ anti-fungal- agent