2. Diarrhea - Change in consistency and frequency of stools,
i.e. liquid or watery stools, > 3 times a day.
episode > 14 days - persistent diarrhea.
Dysentry- If there is associated blood in stools.
Most imp consequences - malnutrition and dehydration.
3. Etiology-
Rotavirus is the leading cause of severe, dehydrating gastroenteritis worldwide.
• In India- rotavirus ( mc age -infant and toddler) + E. Coli( enterotoxigenic) around
50% cases
• Cholera -5-10% cases ,shigella and salmonella 3- 7% cases
• EHEC and EIEC- causes dysentery,
• candida albicans - in patient with malnutrition, immunocompromised, after
prolonged antibiotic treatment.
• Clostridium difficile -in pt who have received broad spectrum antibiotics.
4. Causes of acute diarrhea:
Bacterial
Escherichia coli: Enterotoxigenic, enteropathogenic, enteroinvasive*,
enterohemorrhagic* and enteroaggregative types
Shigellala*: S. sonnei, S. flexneri, S. boydii and S. dysenterie
Vibrio cholerae serogroups 01 and 0139
Salmonella*: Chiefly S. typhi and S. paratyphi A, B or C
Campylobacter species*
Viral
Rotavirus
Human caliciviruses: Norovirus spp.; Sapovirus spp. Enteric
adenoviruses serotypes 40 and 4~
Others: Astroviruses, coronaviruses, cytomegalo virus,
Picornavirus
Parasitic
Giardia lamblia Cryptosporidium
parvum Entamoeba histolytica *
Cyclospora cayetanensis lsospora
belIi
5. Risk factor:
• Poor sanitation.
• Poor personal hygeine.
• Non availability of safe drinking water
• Unsafe food preparation practices.
• Low rates of breast feeding and
immunization
• hypo or achlorhydria and immunodeficiency
6. Pathogenesis
• Diarrheal losses come from ECF.
• ECF is relatively, rich in sodium and has low potassium.
• resulting in shrinkage of ECF volume.
• ECF - circulating blood, intestinal fluid and secreations.
3 Types:-
• Isonatremic dehydration(50%)
• Hyponatremic dehydration (40 to 45%)
• Hypernatremic dehydration
7. Clinical feature:
• Sunken eye
• Dry tongue
• Depressed frontanelle ( if open).
• Weak thready pulse, low blood pressure,
• cold extremities.
• Reduced urine output
• Abdominal distension, paralytic ileus, and
muscle hypotonia if depleted potassium stores.
• ECG shows ST depression and flat T wave.
10. Assessment of child with acute diarrhea
• Goals of assessment
• History
• Examination
• Lab investigation
Goals of assessment
• Determine the type of diarrhea, dysentry or persistent diarrhea.
• Look for dehydration and other complications
• Assess for malnutrition
• Rule out non diarrheal illness - systemic infections
• Assess feeding - preillness and during illness.
11. History:
• Onset of diarrhea - duration and number of stool per day.
• Blood in stools.
• No. Of episodes of vomiting.
• Presence of fever cough, convulsion, recent measles.
• Type and amount of fluids and food taken during illness and pre illness feeding
practices.
• H/O drugs like opioids and antimotility drug loperamide taken.
• Immunization history.
12. Principles of management
1. Rehydration and maintaining hydration.
2. Ensure feeding
3. Oral supplemental of zinc.
4. Early recognition of danger signs and treatment of complications.
5. Cornerstone of management is use of oral rehydration solution.
ORS
Physiological basis
• In diarrohea glucose dependant sodium pumps remain intact.
• So glucose dependant sodium and water absorption is the principle behind
replacing glucose and sodium in 1:1 molar ratio in ors.
• Glucose concentration should not exceeds 111 mmol / litre
14. Treatment:
Treatment planA- may be treated at home.
• Give feeding counselling
• explain danger sign to mother / caregiver.
• Treatment plan B
1. provision of normal daily fluid requirement –up to 10 kg = 100ml/ kg,10- 20 kg=50
ml/ kg & >20 kg= 20 ml/ kg.
2. Rehydration to correct the existing water or electrolyte deficits: calculated as 75 ml/ kg
of ORS to be given over 4 hours.
3. Maintenance to replace ongoing losses to prevent recurrence of dehydration - this phas
should begin when signs of dehydration disappear. ORS should be administered in
volumes equal to diarrheal losses maximum of 10 ml / kg stool.
15. Oral rehydration therapy to prevent dehydration (Plan A)
Age Amount of ORS or other culturally
appropriate ORT fluids to give after each
loose stool
Amount of ORS to
provide for use at
home
<24mo 50-100 ml 500 ml/day
2-10 yr 100-200 ml 1000 ml/day
>10 yr Ad lib 2000 ml/day
Guidelines for treating patients with some dehydration (Plan B)
Age <4 mo 4-11 mo 12-23 mo 2-4 yr 5-14 yr >15 yr
Weight < 5 kg 5-8 kg 8-11 kg 11-16 kg 16-20 kg >30 kg
ORS, ml 200-400 400-600 600-800 800-1200 1200-
2200
>2200
Number of
glasses
1-2 2-3 3-4 4-6 6-11 12-20
16. Treatment plan C
Children with severe dehydration -Iv fluid started immediately with ringer
lactate with 5% dextrose.
Normal saline or plain RL can be used. If
• Persistence of severe dehydration: iv infusion is repeated.
• Hydration is improved but some dehydration is present: iv fluids are
discontinued, ORS is administeredover 4 hr acc to plan B
17.
18. Zinc supplementation:_
• Decrease sseverity and duration of diarrhea
• 20 mg of elemental zinc / day for children > 6 month for 14
days.
Prevention of Diarrhea and Malnutrition
Proper Nutrition
Adequate Sanitation
Vaccination
19. Symptomatic treatment
Severe and recurrent vomiting- oral ondansetron 0.15 mg/ kg/ dose.
If sign of potassium depletion- potassium chloride ( 30-40)
meq/ L should be administered iv.
Drug therapy
1. Antimicrobial indicated in bacillary dysentery, cholera,
amebiasis, giardiasis.
2. Antisecretary agent- Racecadotril inhibiting intestinal
enkephalins.
3. Probiotics- lactobacillus rhamnose's GG >10 10 cfu/ day or
saccharomyces boulardii 250- 750 mg / day for 5- 7 day.
20. • Dysentery-- grossly visible blood in stool.
• Bacillary dysentery> amoebic dysentery
• Shigella flexneri- mc organism in developing countries.
• . Shigella dysenteries - epidemics of dysentery.
• Treatment - administration of ORS, continuation of oral diet, zinc
supplementation, appropriate antibiotic.
• First line antibiotic for shigellosis-ciprofloxacin ( 15 mg/ kg/day) bd for 3
days.
• IV ceftriaxone ( 50- 100 mg / kg / day for 3-5 dayday in sick child. Oral
azithromycin can be used.
• For amoebic dysentery tinidazole or metronidazole is drug of choice.
21. Persistent diarrhea
Last >14 days
Etiopathogenesis
1. Worsening nutritional status- persistent diarrhea more common in
malnourished children.
2. E.coli usually enteroaggregative and enteroadherent type. Cow milk
protein allergy
3. Bacterial overgrowth because of use of antibiotic in acute
diarrhea.
4. Cryptosporidium inf.
Complication-growth flattering, worsening malnutrition, lactose
intolerance. Management-principles of mgt
1. Correction of dehydration, electrolyte, hypoglycemia.
2. Lab investigation.
3. Nutritional therapy.
22. • Supplemental vitamin and minerals- twice the RDAfor 2-4 week.
• VitAdeficiency at 2 lakh iu for children > 12 month,1 lakh iu for children 6-12
month of age.
• Zinc (10-20) mg/ day for at least 2 week between 6 month to 3 year of age.
• Magnesium is given 0.2 ml/ kg/ dose of 50 % mgso4 bd for 2-3 day.
• Potassium at 5-6meq/kg/day orally or iv infusion during initial stabilization
phase.
• Role of antibiotic
Cephalosporine and aminoglycoside can be started empirically And
changed after culture report.
