Diarrhea case conference (BCH)

1. DIARRHEA
CASE CONFERENCE
GROUP 5
Resplandor, Monedero, Taan
Reporters

2. OBJECTIVES
At the end of the session, the students will be
able to:
● Describe the sequence of metabolic changes
occurring during diarrhea
● Evaluate nutritional status of patients
● Evaluate the adequacy of the diet before and
during diarrhea
● List the important things to consider in advising
the parents of pediatric patients with diarrhea

3. CASE #1
Age: 10 months old
Gender: Female
Weight: 8kg
Chief complaint: Diarrhea of 1 day duration (occurred 4x)
History of Present Illness:
- Breastfed since birth
- No accompanying vomiting
- Started eating congee with fish & vegetables @ 5mos.
- At onset of the diarrhea, the mother stopped breastfeeding & giving solid foods; instead
shifted to giving am with sugar
Physical examination:
- Child is alert with good skin turgor and adequate urine output

4. 1. Describe the sequence of the various metabolic
changes observed in diarrhea and correlate these
to the clinical manifestations observed in the
patient (e.g. gastrointestinal function and motility,
alteration in fluid volume, composition, acid-base
balance, etc.)

5. What is it?
● Increase in frequency of bowel evacuation and water content in stool
● More than 3 bowel movements per day
● Loose and watery stools
● Causes the body to lose electrolytes and water
Diarrhea

6. ● Osmotic Diarrhea
● Secretory Diarrhea
● Malabsorptive Diarrhea
Types of Diarrhea

7. - Gastrointestinal function and Motility
- Alteration in fluid volume
Metabolic changes in Diarrhea

8. ● Metabolic Acidosis
○ Increase in bicarbonate loss
● Hypokalemia
○ Can cause muscle weakness, muscle
cramps and and cardiac arrhythmias
Acid-Base Balance

9. 2. Evaluate the nutritional status and state of
hydration of the patient (use growth chart and
assessment of hydration table). Compute for the
ideal weight for age of the patient.

11. ● The Ideal Body weight for a 10 month old girl is 9.2 kg.
● According to Gomez Classification:
○ IBW = 8kg / 9.2 kg (100) = 86.9%
○ Interpretation: If the weight for age falls between 75-89%
then the patient would have First degree Malnutrition and
underweight.
Gomez Classification

12. 3. Determine the adequacy of the patient’s diet
before and during diarrhea; relate this to the cycle
of malnutrition and diarrhea.

13. - BREASTFEED AT BIRTH
- CONGEE WITH FISH AND VEGETABLES
BEFORE THE ONSET
OF DIARRHEA
*ADEQUATE

14. - STOPPED BREASTFEED AND SOLID
FOODS
- SHIFTED TO AM WITH SUGAR
DURING THE ONSET
OF DIARRHEA
*INADEQUATE

15. CYCLE OF DIARRHEA AND MALNUTRITION

16. 4. What advice should be given to the patient’s
mother regarding breastfeeding, use of home
fluids or oral rehydration solutions, and other
nutritional support for the patient; describe their
advantages

17. BREASTFEEDING
● One of the most effective ways to ensure
child health and survival. However, nearly 2
out of 3 infants are not exclusively
breastfed for the recommended 6 months
● Studies in some developing nations have
shown that those who receive exclusive
breastfeeding during their first 6 months of
life are better protected against
infection with diarrheal diseases.

18. BREAST MILK
Ideal Food for Infants
safe, clean and contains
antibodies which help protect
against many common childhood
illnesses
Contains COLOSTRUM
Provides all the energy and
nutrients

19. ● Proper Breastfeeding Positioning and Attachment.
ADVICE TO MOTHER ABOUT BREASTFEEDING
GOOD FEEDING POSITIONING
● Baby’s head and body are in straight
line
● Baby is facing the breast, with nose
towards the nipple.
● Mother is holding the baby’s body
close to her body and supporting the
baby’s whole body.

20. ADVICE TO MOTHER ABOUT BREASTFEEDING
SIGN OF GOOD ATTACHMENT
● More areola is visible above the baby’s mouth than below
● Mouth is wide open with the lower lip turned outward
● Baby’s chin is touching the breast
● Baby’s sucking is slow and deep

21. ● Give more frequent, longer breastfeeds, day and night.
● If taking other milk, replace with increased breastfeeding
● Advise the mother on the benefits of Breastfeeding to her.
○ Associated with a natural method of birth control
○ Reduces risks of breast and ovarian cancer, type II diabetes, and
postpartum depression
● Advise the mother on the benefits of Breastfeeding to her baby.
○ Decreases the risks of being overweight or obesity
○ Decreases the development of type II diabetes
ADVICE TO MOTHER ABOUT BREASTFEEDING

22. ● Oral Rehydration Solution:
○ is a special combination of dry salts that is mixed with safe water.
It can help replace the fluids lost due to diarrhea.
● Where can it be obtained?
○ ORS packets are available from health centres and pharmacies
○ It can also be home made:
■ 6 level teaspoons of sugar and 1/2 level teaspoon of salt
dissolved in 1 liter of safe and clean water.
● A child under the age of 2 years needs at least 1/4 to 1/2 of a large
cup (250 mL) of the ORS drink after each watery stool.
USE OF HOME FLUIDS OR ORAL REHYDRATION SOLUTIONS

23. ● COMPLEMENTARY FOOD: Must be timely introduced at 6 months of
age
○ Feed 3 times a day if breastfed; feed 5 times a day if not breastfed
○ Introduced one at a time for a week
■ Start with lugaw, mashed vegetables or beans, steamed
tokwa, flaked fish giving one to two teaspoons a day.
NUTRITIONAL SUPPORT FOR THE PATIENT

24. 5. What biochemical significance if any, can be given
to the use of “am” with sugar in diarrheic patients?

25. ● suspension of starch obtained by draining boiled rice or by
boiling rice until it completely dissolves into the water
● recognized as a good preventive measure against diarrheal
diseases based on the same scientific principle, where
absorption of salt and water in the intestines is linked to
absorption of glucose
RICE WATER or “AM”

26. BIOCHEMICAL ASPECT OF RICE WATER or “AM”

27. BIOCHEMICAL ASPECT OF RICE WATER or “AM”
SGLT1

28. CASE #2
Name: Benjie
Age: 3 years old
Gender: Male
Weight: 11 kg
Chief complaint: Diarrhea & Vomiting of 3 days duration
History of Present Illness:
- Diarrhea occurred 6x a day and vomiting 3x a day. Past history revealed that the patient was
breastfed for 2 months then shifted to Bonna, 1:2 dilution. Solid food was started at 4 months old.
The patient is presently being given “lugaw” since the onset of diarrhea.
Physical Examination:
- Patient was irritable
- Temperature: 37 ͒C,
- Heart rate: 100 beats/min
- Respiratory rate: 20 cycles/min
- (+) sunken eyeballs
- Mouth and tongue were dry
- Poor skin turgor
- Decreased urine output
- Abdomen was slightly distended with hypoactive
bowel sounds
Laboratory:
- Serum electrolytes showed normal sodium and
decreased potassium levels.

29. 1. Assess the nutritional status, electrolyte status,
and state of hydration of the patient.

30. ● The Ideal body weight of a 3-year-old boy is 14 kg but the child is 10 kg
only.
○ For 1-5 y/o: Age in Years X 2 + 8
○ Assessment: Underweight
● Gomez Classification
○ (11/14) x 100%= 78.6%
○ Assessment: First degree Malnutrition
● His distended abdomen and hypoactive stomach lend visible evidence
of poor nutrition.
NUTRITIONAL STATUS

31. ● Assessment: Hypokalemic due to diarrhea.
ELECTROLYTE STATUS

32. ● Assessment: Some Dehydration
STATE OF HYDRATION

33. 2. Discuss the sequence of events in diarrhea that
will lead to alterations in volume, electrolyte,
osmolality, and acid-base balance as shown in this
case.

35. ● Due to excessive gastrointestinal fluid losses.
● The body tries to maintain the fluid loss by decreasing the
urine output with low fractional sodium excretion as
manifested by patient.
VOLUME & OSMOLALITY: Isotonic dehydration

36. ● Large fecal losses → Potassium depletion
● Vomiting also contributes to potassium depletion
ELECTROLYTE: Hypokalemia

37. ● Diarrhea → direct loss of Bicarbonates → Metabolic
Acidosis
ACID- BASE BALANCE: Metabolic Acidosis

38. 3. What instructions will you give regarding fluid
replacement?

39. ● Most infectious diarrhea is self-limiting, medical care is primarily
supportive. Oral rehydration (OR) is the mainstay of treatment for all
Children affected by diarrhea; never neglect OR,even in the absence of
overt dehydration, because maintaining hydration is necessary.
Consider intravenous rehydration only in the unlikely event that OR is
unsuccessful
● OR therapy is the cornerstone of treatment, especially for small-bowel
infections that produce a large volume of watery stool output.

40. ● A 5-cc or 10-cc syringe without a needle is a very useful tool.
● OR is now universally recommended to be completed in an expedite way,
within 4 hours.
○ At completion of hydration, resumption of feeding is recommended
strongly. In fact, many studies convincingly demonstrate that early
refeeding hastens recovery.

41. 4. Explain the role of glucose in oral rehydration
solutions.

42. ● Due to large amounts of sodium secreted into the intestinal lumen so quickly
very little sodium is reabsorbed, which can lead severe hyponatremia
● Sodium absorption via the intestine occurs in two stages.
● The first is at the outermost cells (intestinal epithelial cells) at the surface of
the intestinal lumen. Sodium passes into these outermost cells by cotransport
facilitated diffusion (symport diffusion) via the SGLT1 protein. From there,
sodium is pumped out of the cells (basal side) and into the extracellular space
by active transport via the sodium potassium pump.
ROLE OF GLUCOSE IN ORS

44. 5. What recommendations will you give regarding
the nutritional management of the patient?

45. ● To maintain electrolyte levels: Broth & Soup which contain Na+ Fruit
Juices, Soft Fruits & Vegetables which contain K+
● BRAT diet:
B – Bananas
R – Rice
A – Applesauce
T – Toast
● Avoid because they tend to aggregate diarrhea:
1) Milk products
2) Greasy foods
3) High fiber
4) Very sweet food

46. Case 1:
● Diarrhea is increase in frequency of bowel evacuation and water content in stool
● Assessment: First degree Malnutrition and underweight.
● Breastfeeding and solid foods SHOULD be given
● Breastfeeding is one of the most effective ways to ensure child health and survival.
● ORS is a special combination of dry salts that is mixed with safe water. It can help replace the fluids lost
due to diarrhea.
● Rice Water or “am” Biochemical Aspect: Addition of sugar → decrease osmotic pressure → increases the
salt and water absorption → decrease the stool volume.
Case 2:
● Assessment: First degree Malnutrition & Underweight; Hypokalemic & with Some Dehydration
● Alteration due to Diarrhea: Isotonic Dehydration (Volume & Osmolality), Hypokalemia (Electrolytes) and
Metabolic Acidosis (Acid- Base Balance)
● OR therapy is the cornerstone of treatment, especially for small-bowel infections that produce a large
volume of watery stool output.
● Nutritional Management: BRAT diet and Soft Fruit and Vegetables with high K+ content.
SUMMARY

47. ● Murray, R. K. (2003). Harper's illustrated biochemistry. New York: McGraw-Hill.
● D.M. Vasudevan, Sreekumari S., Kannan Vaidyanathan. (2011). Textbook of biochemistry for medical
students (ed.6). New Delhi: Jaypee Bros. Medical Publishers,
● Integrated Management of Childhood Illnesses (2016) by WHO and UNICEF
● WHO. https://www.who.int/health-topics/breastfeeding#tab=tab_1
● ORS. https://rehydrate.org/solutions/homemade.html
● Loo, D. D., Zeuthen, T., Chandy, G., & Wright, E. M. (1996). Cotransport of water by the Na+/glucose
cotransporter. Proceedings of the National Academy of Sciences of the United States of America,
93(23), 13367–13370. https://doi.org/10.1073/pnas.93.23.13367
● Islam MS, Nishiyama A, Sakaguchi E. Rice gruel and rice starch reduce sorbitol-induced diarrhoea in
cecectomized rats. Digestion. 2005;72(1):13-21. doi: 10.1159/000087398. Epub 2005 Aug 10. PMID:
16103671.
● https://rehydrate.org/diarrhoea/tmsdd/2med.htm
● https://www.lecturio.com/magazine/dehydration
● https://media.lanecc.edu/users/powellt/FN225OER/Carbohydrates/FN225Carbohydrates4.html
REFERENCES:

48. Thank You
for
Listening!