Briefly explanation on how diarrhea happens and its management

1. DIARRHEA
 BY
 KELVIN BESA MUTEMA

2. Physiology
 8 to 9lts of fluid enters the small bowel in 24hrs
period
 1 to 2lts is absorbed in the small bowel and then
enters the colon
 Almost all of this fluid is absorbed as it travels
through the colon, leaving less then 200g/day of
stool
 Disruption of the absorption of ions, solutes, water
or increased secretion of electrolytes results in
water accumulation in the intestine and diarrhea.

5.  Diarrhea
: Increased frequency of stools (>3/day) with increased
stool weight(>200gm/day)
 Acute Diarrhea:
Diarrhea lasting less then two weeks.
 Chronic Diarrhea
Diarrhea lasting more then two weeks.
 Pseudo diarrhea:
Increased frequency with liqudity weight
<200gm/day( proctitis or IBS)
 Fecal Incontinence
 involuntary discharge of fecal content(anorectal
problems)
Definations

6. Disease Burden
 Diarrhea disease is the second leading cause of
death in children under five years old. It is both
preventable and treatable.
 Each year diarrhea kills around 760 000 children
under five.
 Globally, there are nearly 1.7 billion cases of
diarrheal disease every year.
 Diarrhea is a leading cause of malnutrition in
children under five years old.

7. Monthly Diarrhea cases for HAHC
0
50
100
150
200
250
300
350
Below 5yrs
Above 5yrs

8. ETIOLOGY
INFECTIONS
DRUGS
DIETARY CAUSES
SURGICAL CONDITIONS
OTHER CAUSES

9. Etiology
 Infectous
 Viral
 Rota virus,
 Nora virus
 Bacteria
 E .Coli
 Vibro cholera,
 Shigella
 Salmonella

10. Parasites
 Amoeba
Giardia
Other infections ;
HIV
Hepatitis A
Malaria
melease
Fungi
Candida albicans

11. Non infectious
Endocrine Disease
DM
Hyperthyroidism
Hypoparathyroidism
Other causes
Too much alcohol
L intolerance
Spicy food
Stress
 Medicine

12. MEDICATIONS COMMONLY ASSOCIATED
WITH DIARRHEA
 Osmotic:
◦ Magnesium containing anti acids and laxatives
◦ Mannitol
 Secretory:
◦ Amoxil
◦ Quinine
◦ Misoprostol
 Motility
◦ Erythromycin
◦ Metoclopramide

13. TRANSMISSION
Person-to-person through fecal-oral route
Food or water contaminated
Nosocomial transmission is possible
Air borne like Rota virus

14. TYPES OF DIARRHEA
DIARRHEA
WATERY
DIARRHEA
ROTA VIRUS
E.COLI
CHOLERA
STAPHY AUREUS
BLOODY
DIARRHEA
SHIGELLOSIS
AMEBIASIS
SALMONELLA
PERSISTANT
DIARRHEA
UNKNOWN
CAUSE

15. Acute Watery Diarrhea
 Constitutes 80% of cases of diarrhea
 Begins acutely, lasts less than 14 days (most
episodes last less than 7 days),
 Involves passage of frequent loose or watery stools
without visible blood.
 Vomiting may occur, Fever may be present
 Mainly causes:
◦ Dehydration that can be fatal
◦ Contributes to malnutrition

16. Dysentery (Bloody Diarrhea)
 Constitutes 10% of cases of diarrhea
 Diarrhea with visible red blood in the stools
 Main causes
◦ Anorexia
◦ Rapid weight loss
◦ Damage to the intestinal mucosa

17. Persistent Diarrhea
 Constitutes 10% of cases of diarrhea
 Diarrhea that begins acutely as watery diarrhea or
as dysentery and lasts for 14 days or more.
 Should not be confused with chronic diarrhea
which is recurrent or long-lasting diarrhea due to
noninfectious causes.

18. Small vs large intestinal diarrhea
FEATURES SMALL BOWEL
DIARRHEA
LARGE BOWEL
DIARRHEA
Volume Large Small
Color Light Dark
Smell Very foul Foul
Nature Watery/Greasy Mucoid
Blood in stool Rare Common
Pus in stool Rare Common
Abdominal pain Mid abdomen(colic) Lower
abdomen(continues)
Urgency Absent present
Pathogens V.Cholera , E.Coli ,
viral ,giardia
TB
Shigella E .Histolytica
Rectal colitis

19. Predisposing factors
Teethin
g
Age
Season
Socio
Economi
c
status
Dietary
factors

20. High risk factors and Groups
 Contaminated water and food
 Poor hygiene
 Immune deficient individuals
 Lack of breastfeeding
 Malnutrition
 Poor sanitation
 Nutritional deficiency

21. CONSUMER OF CERTAIN FOOD
PATHOGENS FOOD INCUBATION
SALMONELLA CHICKEN/EGGS,SEA
FOOD/MAYONNAISE/
CREAM
12hrs to 11days
BACILLUS CEREUS FRIED RICE
/REHEATED FOOD
1hr to 8hrs
STAPHY AUREUS MAYONNAISE/CREA
M
1 to 8hrs
LISTERIA UNCOOKED FOOD 1week to 2weeks

22. Brief Pathophysiology
 Adequate fluid balance in humans depends on
the secretion and reabsorption of fluid and
electrolytes in the intestinal tract; diarrhea
occurs when intestinal fluid output overwhelms
the absorptive capacity of the gastrointestinal
tract. The 2 primary mechanisms responsible
for acute Diarrhea are (1) damage to the villous
brush border of the intestine, causing
malabsorption of intestinal contents and
leading to an osmotic diarrhea, and (2) the
release of toxins that bind to specific
enterocyte receptors and cause the release of
chloride ions into the intestinal lumen, leading
to secretory diarrhea.

23. PATHOPHYSIOLOGY MECHANISM
Osmotic
diarrhea
When an ingested solute is not absorbed properly , the higher
concentration gradient within the lumen acts to draw water
into
intestinal lumen and greatly increases the water content of the
stool.eg lactose intolerance.
Secretory
diarrhea
 The intestine actively secret water into the intestine because of the
activation of intracellular mediators(cyclic AMP , cyclic GMP ,
intracellular Ca++)which stimulate active Cl- secretion and inhibit the
neutral coupled Na CL absorption. cholera E.coli , Staphy aureus
and Shigella .

24. Inflammatory Intestinal
Diarrhea
 inflammation leads to blood , mucus and
protein exudate
accompanied by fluid and electrolyte.eg
infection , IBD or celiac disease.
Motility
disorder
 Both an increase and decrease in gut
motility can be a cause of diarrhea.

25. SEASONALITY
Disease Common season
Cholera Winter
Rotavirus diarrhea Winter
Shigellosis Dry summer

26. CLINICAL FEATURE: CHOLERA
 Rice-watery stool
 Marked dehydration
 Projectile vomiting
 No fever or abdominal pain
 Muscle cramps
 Hypovolemic shock
 Scanty urine

27. CLINICAL FEATURE:
E. COLI DIARRHEA
 Watery stools
 Vomiting is common
 Dehydration moderate to severe
 Fever– often of moderate grade
 Mild abdominal pain

28. CLINICAL FEATURE:
ROTAVIRUS DIARRHEA
 Sudden onset
 Prodromal symptoms, including fever, cough, and
vomiting precede diarrhea
 Stools are watery or semi-liquid; the color is
greenish or yellowish– typically looks like yoghurt
mixed in water
 Mild to moderate dehydration
 Fever– moderate grade

29. CLINICAL FEATURE:
SHIGELLOSIS
 Frequent passage of scanty amount of stools,
mostly mixed with blood and mucus
 Moderate to high grade fever
 Severe abdominal cramps
 Tenesmus– pain around anus during defecation
 Usually no dehydration

30. CLINICAL FEATURE:
AMEBIASIS
 Offensive and bulky stools containing
mostly mucus and sometimes blood
 Lower abdominal cramp
 Mild grade fever
 No dehydration

31. LEVEL OF DEHYDRATION
MILD MODERATE SEVERE
Infants and young
childred
Thirsty , alert,
restless
Thirsty ,
restless,
irritable
Drowsy , cold ,
sweaty ,
comatose
Older childred Thirsty, alert Thirsty ,alert LOC , cold
,sweaty.
Tachycardia Absent Present Present
Palpable pulse Present Present (weak) Decreased
Blood pressure Normal Hypotension Hypotension
Skin turgor Normal Goes back slow Goes back very
slowly
Tongue Normal wet Dry Very dry
Fontanelle Normal Slightly
depressed
Depressed
Tears Present Present or
absent
Absent
Breathing Normal Rapid Very rapid
Urine output Normal Dark color Anuria
Weight loss <5% 6-9% >10%

33. LABORATORY DIAGNOSIS
 Stool microscopy
 Dark field microscopy of stool for cholera
 Stool cultures
 ELISA for rotavirus
 Immunoassays, bioassays or DNA probe tests to
identify E. coli strains

34. MANAGEMENT
REPLACEMENTS OF FLUIDS
ADMINISTRATION OF
PRESCRIDED DRUGS
MAINTENANCE OF
NUTRITIONAL STATUS
PREVENTION OF DIARRHEA
HEALTH EDUCATION

35. TREATMENT PLAN A GUIDELINES
Home therapy to prevent dehydration and
malnutrition
◦ Rule 1:
Give the child more fluids than usual, to prevent
dehydration 10mls/kg
◦ Rule 2:
Give supplemental zinc (10 - 20 mg) to the child,
every day for 10 to 14 days
◦ Rule 3:

36. TREATMENT PLAN A
AGE ORS(PER EVERY STOOL)
<24 MONTHS 50 TO 100mls
2yrs to10yrs 100 to 200mls
>10years As the child can tolerate

37. PLAN B GUIDELINES
Oral rehydration therapy for children with some
dehydration
◦ Give ORS 75mls/kg for 4hours
◦ Monitoring the progress of oral rehydration therapy
◦ Meeting normal fluid needs
◦ If oral rehydration therapy must be interrupted
◦ When oral rehydration fails
◦ Giving Zinc
◦ Giving food

38. PLAN B
AGE WEIGHT(KG) ORS
< 4Months <5kg 200 to 400mls
4 to 12Months 5 to 8kg 400 to 600mls
1 to 2years 8 to 11kg 600 to 800mls
2 to 4years 11 to 16kg 800 to 1200mls
5 to 14year 16 to 30kg 1200 to 2200mls
>15years >30kg 2200mls

39. Treatment Plan C:
 For patients with severe dehydration
◦ Guidelines for intravenous rehydration
◦ Monitoring the progress of intravenous
rehydration
◦ What to do if intravenous therapy is not available
◦ Electrolyte disturbances

40. PLAN C
AGE 1ST GIVE THEN GIVE
<12Months 30mls/kg in 1hrs 70ml/kg in 5hrs
12month to 5yrs 30ml/kg in 30minutes 70ml/kg 2hrs 30minutes

41. COMPOSITION OF ORS
Ingredient Amount (g/liter)
Sodium chloride 3.5
Trisodium citrate or
Sodium bicarbonate
2.9 or
2.5
Potassium chloride 1.5
Glucose 20.0

42. AMOUNT OF SALT LOSS DURING DIARRHEA
Salt (mmol/L)
Diarrhea
Na K Cl HCO3
Cholera
(child)
88 30 86 32
Cholera
(adult)
135 15 100 45
E. coli 53 37 24 18
Rota
virus
37 38 22 6

43. ADMINISTRATION OF PRESCRIDED
DRUGS
 ANTIEMETIC
 ANTIDIARRHEA
 DECREASES INTESTINAL
MOTILITY
 ANTIBOTIC
 MICRONUTIENTS

44. BEFORE AND DURING HOSPITALISATION

45. Zinc mechanism

46. PRESCRIDED DRUGS
Condition Drugs of choice Other drugs Benefits
Cholera Tetracycline,
Doxycycline.
Ciprofloxacin
Erythromycin
Relieves
symptoms
Shorten illness
Decrease
transmission
Shigellosis Nalidixic acid
Ciprofloxacin
Ceftriaxone
Amoebiasis Metronidazole Tinidazole
Traveler s
diarrhea
Ciprofloxacin Co trimoxazole
Clostridium d Metronidazole
Tx of confirmed
Salmonella,
Shigella ,
campylobacter.
Ciprofloxacin
Azithromycin
Erythromycin
Co trmoxazole

47. COMPLICATIONS:
WATERY DIARRHEA
 Dehydration
 Electrolyte imbalances
 Tetany
 Convulsions
 Hypoglycemia
 Renal failure

48. COMPLICATIONS:
BLOODY DIARRHEA
 Electrolyte imbalances
 Convulsions
 Hemolytic uremic syndrome (HUS)
 Leukemoid reaction
 Toxic megacolon
 Protein losing enteropathy
 Arthritis
 Perforation

49. PREVENTION
 Safe drinking water and food
 “Boil it, cook it, peel it, or forget it. "
 Hand washing
 Proper sanitation
 Vaccination
 ROTA VACCINE At 6weeks and 10weeks
 Cholera vaccine(50 to 60% protection and few
month immunity)

50. 9 /09/ 2022
THANK YOU

51.  Case
F/A
Vitals Temp:36.5
BP:84/54
Pulse 125b/m
C/O Diarrhea 3/52 Heart palpitations 2/52
Vomiting 3/52 Dizziness 2/52
Chest pain 3/52 Weakness 2/52
Cough 3/52 Abdominal fullness7/7
C/A Gradual onset of the above complaints which with passing of
waterly loose stool four times in a day for three weeks now with
history of coughing out sputum with blood for 5days now.
OBS/GYN HX LMP 29/08/22 G4 P3
DHX Recently initiated on ART 4/12 ago PMHX
RVD
FMH NIL SHX Alcohol and Smoking she stopped 4/12
ago

52.  P/E GC Stable J /P++/C Afebrile /weight loss
ABD skin pinch slowly/tenders on touch/no mass felt
RS chest clear no crep or wheezing
CVS normal s1s2 normal/ tachycardia
CN conscious/orientated/no neck stiffness
MS n/a
HEENT n/a
SKIN n/a
MSE normal
QUESTION 1 What is the DX /DD/MGT