Commenest cause ammong poor countries with low hygiene droughts, war

1. DIARRHEAL DISEASE
- Defined as the passage of three or more loose or liquid
stools per day
- The disease caused by multiple viral, bacterial,
and parasitic organisms.
Global burden
-affect people of all ages throughout the world.
-Children, however, are the most vulnerable;
- second leading causes of death worldwide < 5 years
-accounting 1.5 million deaths per year.
- More than 80% of these deaths occur in Africa and
Southeast Asia.

2. In Ethiopia
- It is the first among top 10 leading cause of morbidity
under 5 years
-It is the third among top 10 causes of hospital admission
under 5 years
ETIOLOGY
Viral
-Rotavirus
-Astrovirus
-Norovirus and other calicviruses
-Adenovirus (types 40 and 41)
-Picornavirus
-Norwalk virus

3. Bacterial
-Campylobacter species (particularly jejuni)
-Clostridium difficle
-Escherichia coli
-Salmonella species (e.g., typhi)
-Shigella species
-Mycobacteria avium complex
-Vibrio cholera
-Yersinia enterocolitica
-Aeromonas species
Parasite
-Giardia
-Cryptosporidium spp.
-Amoeba

4. Other Causes of diarrhea
-Anatomic defects
-malrotation
-short bowel syndrome
-Malabsorbtion
-Endocrinopathies
-Thyrotoxicosis
-Food poisoning
-Heavy metals
-mushrooms
-Neoplasms
-neuroblastoma
-Others- milk allergy

5. PATHOGENESIS
-disruption of reabsorbtion in the intestine is caused by
virus,bacteria,parasite
-once ingested, viral particles enter  enterocytes of the
small intestinal villi  induce villus shortening and cell
destruction  which cause inflammationimpairs
absorption of nutrients  this potentiates the diarrhea.
-Villus cells are temporarily replaced with immature
crypt-like cells that cause the intestine to secrete water
and electrolytes
- Recovery occurs when the villi regenerate
and the villus epithelium matures

6. Bacteria
- utilize three mechanisms to induce illness
- adhesion,
-toxin production
- mucosal invasion
-The bacteria adhere to the intestinal mucosa 
multiply interfere with absorption cause fluid secretion
lead to increased diarrhea
-Bacterias secrete enterotoxins that alter small intestine
function stimulate secretion cause watery diarrhea.
-The toxins can block sodium absorption, which also
increases water and electrolyte losses.

7. -Toxins trigger inflammation that also increases diarrhea.
- Cytotoxins  cause cell death of the distal small intestine
or colon and lead to bloody mucous stools.
- Invasive bacteria cause ulceration or abscess
formation  causes white blood cells and visible blood
in the stool.
PATHOPHYSIOLOGY
Osmotic diarrhea
-caused by the presence of non absorbable solutes in the
GI tract. E.g - Lactose intolerance caused by lactase enzyme
deficiency
-ingesting large amount of sugar containing
fluids
-ingesting magnesium salts,lactulose
resulting in osmotic load

8. Secretory diarrhea
activation of intracellular mediators inhibit NaCl
absorbtion. E.g -E.coli
-is characterized by extremely watery stools
-stool analysis reavels high sodium chloride content
DDX
OSMOTIC SECRETORY
volume of stool <200ml/24hr >200ml/24hr
response to fasting diarrhea stops diarrhea continues
stool Na+ <70mq/L >70mq/L
reducing substances posetive negative
stool PH < 5 >6

9. CLASSIFICATION
- Acute watery diarrhea
-with no DHN
-with some DHN
-with severe DHN
- Persistent diarrhea
- Dysentery

10. -During diarrhoea there is an increased loss of water
and electrolytes (sodium, potassium, bicarbonate)
in the liquid stool.
-Dehydration occurs when these losses are not
adequately replaced and a deficit of water and
electrolytes develops. The degree of dehydration is
graded according to symptoms and signs that reflect
the amount of fluid lost.

11. -Acute watery diarrhoea —More than 3 stools per day
—No blood in stools
-Dysentery —Blood in stool (seen or reported)
-Persistent diarrhoea —Diarrhoea lasting 14 days or longer
Signs or symptoms
1. Severe DHN
- lethargy/unconsciousness
- sunken eyes
- unable to drink or drinks poorly
-skin pinch goes back very slowly ( ≥2 seconds )

12. Some dehydration
- restlessness, irritability
- sunken eyes
-drinks eagerly, thirsty
-skin pinch goes back slowly
-dry tongue
TWO OR MORE of the following the above signs indicate
DHN
-No dehydration
-No enough sign of DHN

13. Chronic Diarrhea
-It is diarrhea lasting more than two weeks
Etiology
Infancy
-postgasterointeritis malabsorbtion
-cow protein intolerance
Childhood
-Gardiasis
-Cystic fibrosis
- postgasterointeritis malabsorbtion syndrome

14. Adolescence
-Irritable bowel syndrome
-Inflammatory bowel disease
- Gardiasis
-Lactose intolerance
DIAGNOSIS- S/E,STOOL CULTURE,SEROLOGY
TREATMENT
Severe DHN - Treatment Plan C
First give Then give
Age 30ml/kg in 70ml/kg in
Infants 1 hr 5 hrs
under 12 month
children
12 month-5 years 30 minutes 2 ½ hrs

15. -Reassess the child every 15–30 minutes.
-If hydration status is not improving, give the IV drip more
rapidly.
- Also give ORS (about 5 ml/kg/hour) as soon as
the child can drink: usually after 3–4 hours (infants)
or 1–2 hours (children).
-Reassess an infant after 6 hours and a child after
3 hours. Classify dehydration. Then choose the appropriate
plan (A, B, or C) to continue treatment.

16. Some DHN – Treatment plan B
Use the child’s age only when you do not know the weight. The
approximate amount of ORS required (in ml) can also be calculated
by multiplying the child’s weight (In kg) by 75.
- If the child wants more ORS than shown, give more
AGE Up to 4 months up to 12 12 months up to 2 years up to
4 months months 2 years up to 5 years
WT < 6KG 6-10 KG 10-12 KG 12-19 KG
IN ML 200-400 400-700 700-900 900-1400
Determine amount of ORS to give during first 4 hours.

17. After 4 hours:
— Reassess the child and classify the child for dehydration.
— Select the appropriate plan to continue treatment.
— Begin feeding the child in clinic.
1 - give extra fluid
2- give zinc supplements for 10–14 days
3- continue feeding
4- return if the child develops any of the following signs:
— drinking poorly or unable to drink or breastfeed
— becomes more sick
— develops a fever
— has blood in the stool.

18. Give zinc supplements
-Up to 6 months 1/2 tablet (10 mg) per day
-6 months and more 1 tablet (20 mg) per day
for 10–14 days
-Continuation of nutritious feeding is an important
element in the management of diarrhea.
No DHN -Treatment Plan A
-Treat the child as an outpatient.
-Counsel the mother on the 4 rules of home treatment:
— give extra fluid
— give zinc supplements

19. — continue feeding
— give advice on when to return.
Give extra fluid, as follows:
— If the child is being breastfed, advise the mother to
breastfeed frequently and for longer at each feed. If the
child is exclusively breastfed give one or more of the
following: ORS solution, food-based fluids (such as soup,
rice water, and yoghurt drinks), or clean water.
Give ORS at home
-Up to 2 years 50 to 100 ml after each loose stool
-2 years or more 100 to 200 ml after each loose stool
-GIVE ZINC SUPPLEMENTS

20. ANTIMICROBIAL THERAPY
-E.Coli TMP/SMZ
-Salmonella ceftriaxone,cefotaxime
-Shigella ceftiaxone
-Vibro cholerae Doxocycline or TTC
UNICEF and WHO recommend a seven point plan to
improve diarrheal disease control, focusing on
-Fluid replacement to prevent dehydration
-Zinc treatment
-Rotavirus and measles vaccinations
- Promotion of early and exclusive breastfeeding and
vitamin A supplementation

21. -Promotion of hand washing with soap
-Improved water supply quantity and quality,
including treatment and safe storage of household
water
-Community-wide sanitation promotion.

22. THANK YOU