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  1. 1. DIARRHEAIntroductionDiarrhea is an increase in the frequency of bowel movements or a decreasein the form of stool (greater looseness of stool). Although changes in frequency ofbowel movements and looseness of stools can vary independently of each other,changes often occur in both.Diarrhea needs to be distinguished from four other conditions. Although theseconditions may accompany diarrhea, they often have different causes and differenttreatments than diarrhea. These other conditions are:1. Incontinence of stool, which is the inability to control (delay) bowelmovements until an appropriate time, for example, until one can get to thetoilet2. Rectal urgency, which is a sudden urge to have a bowel movement that is sostrong that if a toilet is not immediately available there will be incontinence3. Incomplete evacuation, which is a sensation that another bowel movement isnecessary soon after a bowel movement, yet there is difficulty passing furtherstool the second time4. Bowel movements immediately after eating a mealMost kids battle diarrhea from time to time, but the good news is that itsoften caused by infections that dont last long and usually are more disruptive thandangerous. Still, its important to know what to do to relieve and even preventdiarrhea.Definition:To most individuals, diarrhea means an increased frequency or decreasedconsistency of bowel movements; however, the medical definition is more exactthan this. In many developed countries, the average number of bowel movements
  2. 2. is three per day. However, researchers have found that diarrhea best correlates withan increase in stool weight; stool weights above 10oz (300 gs) per day generallyindicates diarrhea. This is mainly due to excess water, which normally makes up60-85% of fecal matter. In this way, true diarrhea is distinguished from diseasesthat cause only an increase in the number of bowel movements (hyperdefecation)or incontinence (involuntary loss of bowel contents).Diarrhea is also classified by physicians into acute, which lasts one or two weeks,and chronic, which continues for longer than 2 or 3 weeks. Viral and bacterialinfections are the most common causes of acute diarrhea.Causes of DiarrheaDiarrhea — frequent runny or watery bowel movements (poop) — is usuallybrought on by gastrointestinal (GI) infections caused by viruses, bacteria, orparasites.The specific germs that cause diarrhea can vary among geographic regionsdepending on their level of sanitation, economic development, and hygiene. Forexample, developing countries with poor sanitation or where human waste is usedas fertilizer often have outbreaks of diarrhea when intestinal bacteria or parasitescontaminate crops or drinking water.In developed countries, including the United States, diarrhea outbreaks aremore often linked to contaminated water supplies, person-to-person contact inplaces such as child-care centers, or "food poisoning" (when people get sick fromimproperly processed or preserved foods contaminated with bacteria).In general, infections that cause diarrhea are highly contagious. Most casescan be spread to others for as long as someone has diarrhea, and some infectionscan be contagious even longer.
  3. 3. Diarrheal infections can be spread through:dirty handscontaminated food or watersome petsdirect contact with fecal matter (i.e., from dirty diapers or the toilet)Anything that the infectious germs come in contact with can becomecontaminated. This includes toys, changing tables, surfaces in restrooms, even thehands of someone preparing food. Kids can become infected by touching acontaminated surface, such as a toilet or toy, and then putting their fingers in theirmouths.VirusesA common cause of diarrhea is viral gastroenteritis (often called the"stomach flu," it also can cause nausea and vomiting). Many different viruses cancause viral gastroenteritis, which can pass through a household, school, or day-carecenter quickly because its highly infectious. Although the symptoms usually lastjust a few days, affected kids (especially infants) who are unable to get adequatefluid intake can become dehydrated.Rotavirus infection is a frequent cause of viral gastroenteritis in kids.Rotavirus usually causes explosive, watery diarrhea, although not all will showsymptoms. Rotavirus has commonly caused outbreaks of diarrhea during thewinter and early spring months, especially in child-care centers and childrenshospitals, however, a vaccine now recommended for infants has been found toprevent approximately 75% of cases of rotavirus infection and 98% of the severecases that require hospitalization.Another group of viruses that can cause diarrhea in children, especiallyduring the summer months, are enteroviruses, particularly coxsackievirus.
  4. 4. Bacteria and ParasitesMany different types of bacteria and parasites can cause GI and diarrhea. Here area few that you may have heard about:E. coli bacteria: Most E. coli infections are spread through contaminatedfood or water, such as undercooked hamburgers or unwashed fruit that cameinto contact with animal manure.E. coli infections, which usually affect kidsduring their first few years of life, also can be spread via contaminatedswimming water and petting zoos.Salmonella enteritidis bacteria: In the United States, these bacteria (foundin contaminated raw or undercooked chicken and eggs) are a major cause offood poisoning, especially during summer.Campylobacter bacteria: Infants and young adults are most commonlyaffected by these infections, especially during the summer. The bacteria areoften found in raw and undercooked chicken.Shigella bacteria: Shigella infection (called shigellosis) spreads easily infamilies, hospitals, and child-care centers. Kids 2 to 4 years old are the mostlikely to be infected.Giardia parasite: Infection with Giardia (called giardiasis) is easily spreadthrough child-care settings and contaminated water supplies, especiallywater parks and pools (the bacteria are resistant to chlorine treatment),childrens "touch tanks" in aquariums and museums, and contaminatedstreams or lakes.Cryptosporidium parasite: Found especially in drinking and recreationalwater, this parasite often is the culprit behind diarrhea epidemics in child-care centers and other public places. Cryptosporidiosis often causes waterydiarrhea that can last for 2 weeks or more.
  5. 5. Diarrheal infections are a normal part of childhood for many kids, but diarrheacan be a symptom of a number of non-infectious diseases and conditions,especially when it lasts several weeks or longer. It can indicate foodallergies, lactose intolerance, or diseases of the gastrointestinal tract, such as celiacdisease and inflammatory bowel disease.Signs and SymptomsSymptoms typically start with crampy abdominal pain followed by diarrhea thatusually lasts no more than a few days. Infections with many of the viruses,bacteria, and parasites that cause diarrhea also can bring on other symptoms, suchas:feverloss of appetitenauseavomitingweight lossdehydrationIn cases of viral gastroenteritis, kids often develop fever and vomiting first,followed by diarrhea.TreatmentTreatment is ideally directed toward correcting the cause; however, the firstaim should be to prevent or treat dehydration and nutritional deficiencies. The typeof fluid and nutrient replacement will depend on whether oral feedings can betaken and the severity of fluid losses. Oral rehydration solution (ORS) orintravenous fluids are the choices; ORS is preferred if possible.
  6. 6. A physician should be notified if the patient is dehydrated, and if oral replacementis suggested then commercial (Pedialyte and others) or homemade preparations canbe used. The World Health Organization (WHO) has provided this easy recipe forhome preparation, which can be taken in small frequent sips:Table salt—3/4 tspBaking powder—1 tspOrange juice—1 cWater—1 qt (1l)When feasible, food intake should be continued even in those with acutediarrhea. A physician should be consulted as to what type and how much food ispermitted.Anti-motility agents (loperamide, diphenoxylate) are useful for those withchronic symptoms; their use is limited or even contraindicated in most individualswith acute diarrhea, especially in those with high fever or bloody bowelmovements. They should not be taken without the advice of a physician.Other treatments are available, depending on the cause of symptoms. Forexample, the bulk agent psyllium helps some patients by absorbing excess fluidand solidifying stools; cholestyramine, which binds bile acids, is effective intreating bile salt induced diarrhea. Low fat diets or more easily digestible fat isuseful in some patients. New antidiarrheal drugs that decrease excessive secretionof fluid by the intestinal tract is another approach for some diseases. Avoidance ofmedications or other products that are known to cause diarrhea (such as lactose) iscurative in some, but should be discussed with a physician.PreventionAlthough its almost impossible to prevent kids from ever getting infections thatcause diarrhea, here are some things to help lessen the likelihood:
  7. 7. Make sure kids wash their hands well and often, especially after using thetoilet and before eating. Hand washing is the most effective way to preventdiarrheal infections that are passed from person to person. Dirty hands carryinfectious germs into the body when kids bite their nails, suck their thumbs,eat with their fingers, or put any part of their hands into their mouths.Keep bathroom surfaces clean to help prevent the spread of infectiousgerms.Wash fruits and vegetables thoroughly before eating, since food and wateralso can carry infectious germs.Wash kitchen counters and cooking utensils thoroughly after theyve been incontact with raw meat, especially poultry.Refrigerate meats as soon as possible after bringing them home from thesupermarket, and cook them until theyre no longer pink. After meals,refrigerate all leftovers as soon as possible.Never drink from streams, springs, or lakes unless local health authoritieshave certified that the water is safe for drinking. In some developingcountries, it may be safer to drink only bottled water and other drinks ratherthan water from a tap. Also, exercise caution when buying prepared foodsfrom street vendors, especially if no local health agency oversees theiroperations.Dont wash pet cages or bowls in the same sink that you use to preparefamily meals.Keep pets feeding areas (especially those of reptiles) separate from familyeating areas.When to Call the DoctorCall your doctor if your child has diarrhea and is younger than 6 months old or has:
  8. 8. a severe or prolonged episode of diarrheafever of 102°F or higherrepeated vomiting, or refusal to drink fluidssevere abdominal paindiarrhea that contains blood or mucusCall the doctor immediately if your child seems to be dehydrated. Signs ofdehydration include:dry or sticky mouthfew or no tears when cryingeyes that look sunken into the headsoft spot (fontanelle) on top of the head that looks sunkenlack of urine or wet diapers for 6 to 8 hours in an infant (or only a very smallamount of dark yellow urine)lack of urine for 12 hours in an older child (or only a very small amount ofdark yellow urine)dry, cool skinlethargy or irritabilityfatigue or dizziness in an older childCaring for Your ChildMild diarrhea is usually no cause for concern as long as your child is actingnormally and drinking and eating enough. Mild diarrhea usually passes within afew days and kids recover completely with care at home, rest, and plenty of fluids.A child with mild diarrhea who isnt dehydrated or vomiting can continue eatingand drinking the usual foods and fluids, including breast milk or formula forinfants and milk for kids over 1 year old. In fact, continuing a regular diet may
  9. 9. even reduce the duration of the diarrhea episode, while also offering propernutrition. Of course, you may want to give a child smaller portions of food until thediarrhea ends.Antibiotics or antiviral medications are not prescribed for cases of diarrheacaused by bacteria and viruses because most kids recover on their own. Butantibiotics are sometimes given to very young children or those with weak immunesystems to prevent a bacterial infection (such as salmonellosis) from spreadingthrough the body.If the illness is caused by a parasite, it can be treated with antiparasiticmedicines to cure or shorten the course of the illness. The doctor may order a stooltest, in which a stool sample will be examined in the laboratory to see whichspecific germ is causing the diarrhea (bacteria, virus, or parasite).Although you may be tempted to give your child an over-the-counter anti-diarrheamedication, dont do so unless your doctor gives the OK.The primary concern when treating a diarrhea is the replacement of fluids andelectrolytes (salts and minerals) lost from the body from diarrhea, vomiting, andfever. Depending on the amount of fluid loss and the severity of vomiting anddiarrhea, your doctor will probably instruct you to:Continue your childs regular diet and give more liquids to replace those lostwhile the diarrhea continues if there are no signs of dehydration.Offer additional breastmilk or formula to infants.Use an oral rehydration solution (ORS) to replace lost fluids in non-dehydrated children.Many of the "clear liquids" used by parents or recommended by doctors in thepast are no longer considered appropriate for kids with diarrhea. Dont offer: plainwater, soda, ginger ale, tea, fruit juice, gelatin desserts, chicken broth, or sportsdrinks. These dont have the right mix of sugar and salts and can even make
  10. 10. diarrhea worse. Infants and small children should never be rehydrated with wateralone because it doesnt contain adequate amounts of sodium, potassium, and otherimportant minerals and nutrients.Doctors often recommend that kids who show signs of mild dehydration begiven oral rehydration solutions to replace body fluids quickly. These are availablein most grocery stores and pharmacies without a prescription. Brand-namesolutions often end in "lyte." Your doctor will tell you what kind to give, howmuch, and for how long. Never try to make your own ORS at home unless yourdoctor says its OK and gives you a precise recipe.In some cases, kids with severe diarrhea may need to receive IV fluids at thehospital for a few hours to help combat dehydration.The best way to manage your childs diarrhea depends on how severe it is, whatgerm caused it, and your childs age, weight, and symptoms. So be sure to ask yourdoctor for recommendations about treatment.
  11. 11. ORAL REHYDRATION SOLUTIONSTravellers’ diarrhea is a common illness in travellers. Oral rehydrationsolutions (ORSs) are used to treat dehydration caused by diarrhea.An ORS contains three things:1. Clean water2. Electrolytes (also called ―salts‖), which are chemicals that your body needsto function properly3. Carbohydrates, usually in the form of sugarUnlike other fluids, the ratio of the ingredients in an ORS matches what thebody needs during a diarrheal illness.An ORS can be made by mixing packets of oral rehydration salts with water orby following the recipe proved below. Packets of oral rehydration salts areavailable at most pharmacies.ORAL REHYDRATION SOLUTION BE USESIt is essential to drink extra fluids as soon as diarrhea starts.For most healthy adults with uncomplicated travellers’ diarrhea, hydrationcan be maintained without ORS by drinking diluted juices or sports drinks,purified water, or clear soups. Although it may not be necessary, healthyadults with mild diarrhea can also use ORS if they prefer.Dehydration from diarrhea is more of a concern in children, those withunderlying medical conditions, and the elderly.
  12. 12. Fluids should be consumed at a rate to satisfy thirst and maintain pale-coloured urine. The World Health Organization recommends drinking thefollowing amounts of ORS during a diarrheal illness:Age AmountChildren under 2 years 50–100 mL (¼ to ½ cup) after each loose stool, upto approximately 0.5L (2 cups) a day.Children 2 to 9 years 100–200 mL (½ to 1 cup) after each loose stoolmovement, up to approximately 1L (4¼ cups) aday.Persons 10 years or older As much as wanted, up to approximately 2L (8½cups) litres a day.Infants should continue to receive breast milk or their usual formula inaddition to ORS. Children who are no longer nursing and adults shouldcontinue to eat solid food in addition to ORS.Avoid alcohol; caffeinated drinks like cola, tea, and coffee; or sugarybeverages like pop and sweetened fruit juices during diarrheal illness.Alcohol and caffeine can worsen dehydration and sugary drinks can worsendiarrhea.Seek medical attention if the travellers’ diarrhea is bloody; is accompaniedby a high fever, jaundice (yellow skin), or persistent vomiting; or ifdehydration does not improve despite the use of ORS.PREPARING ORAL REHYDRATION SOLUTIONSCOMMERCIALLY AVAILABLE ORAL REHYDRATION SALTS:
  13. 13. Mixing commercially available oral rehydration salts with water producesan oral rehydration solution.Packets of oral rehydration salts are available in pharmacies in mostcountries, although it is recommended you purchase them before leavingCanada and include them in your travel health kit.Instructions for preparing the oral rehydration solution and dosage should befollowed carefully. Use boiled or treated water to prepare the oralrehydration solution.Homemade oral rehydration solution:If packets of oral rehydration salts are not available, travellers are advised tofollow the World Health Organization’s ORS recipe:Ingredients AmountPurified waterSaltSugar1 L (4¼ cups)2.5 mL (½ teaspoon)30 mL (6 teaspoons)Oral rehydration solutions should be consumed or discarded within 12 hoursif held at room temperature or 24 hours if kept refrigerated.