Acute infectious diarrhea

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an approach to evaluation and management of acute diarrhoea

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Acute infectious diarrhea

  1. 1. Acute infectious diarrhea Food poisoning & Acute gastroenteritis
  2. 2. Causes  Food-poisoning- preformed exotoxin  S.aureus, B,cereus, C.perfringens  Non-inflammatory- viral/enterotoxin- proximal small intestine  Viral- rotavirus, norwalk-like virus  Bacteria- ETEC, V.cholerae  Parasite- Giardia  Inflammatory- cytotoxin/invasive- distal small intestine or colon  Parasite- E.histolytica  Bacteria- Shigella, Salmonella, EHEC/EIEC, Campylobacter, Yersinia, V.parahemolyticus
  3. 3. Evaluation  History-  Duration- >2 weeks is chronic  Fever- suggests invasive disease  Stool- dysentery-inflammatory, rice water-Cholera  Abdominal pain- inflammatory>non-inflammatory  Tenesmus- proctitis- Shigellosis/Amoebiasis  Vomitting- s/o food poisoning  Prior antibiotic use- C.difficile-pseudomembranous colitis  Examination-  Fever, e/o dehydration- tachycardia, hypotension, weight loss  Stool examination-  For WBC- presence s/o inflammatory cause
  4. 4. Management  Dx-  Clinical & stool examination  Assess hydration status  Treatment-  No specific dietary restrictions or recommendations  Continue breast-feeding  ORS- nimbu-paani, rice water, commercial preparations  IV fluids- Ringer’s lactate- vomiting, ileus, altered sensorium  Antiemetics- metoclopramide, domperidone  Antibiotics- dysentery, pseudomembranous colitis, immunosuppressed  Antimotility agents- Loperamide, not in children  Prevention-  Sanitation & hygiene  Vaccine- rotavirus, typhoid, cholera
  5. 5. ORS constituents- per liter water NaCl- 3.5 gm NaHCO3- 2.5 gm KCl- 1.5 gm Glucose-20 gm
  6. 6. Food poisoning  Due to preformed enterotoxin  Abrupt onset  S.aureus-  1-6 hours, intense vomiting with diarrhea  C.perfringens-  6-12 hours, profuse diarrhea with cramps & nausea  B.cereus-  Reheated rice- 1-6 hours, severe vomiting with diarrhea  Meat/gravy- 6-12 hours, severe diarrhea with nausea/vomiting  Rx- supportive- antiemetics & ORS
  7. 7. Escherichia coli  Gram –ve bacillus  Normal commensal in human gut  Virulent types-  Enterotoxigenic- leading cause of watery diarrhea, most common cause of travellers’ diarrhea  Enteropathogenic- diarrhea with mucus  Enteroinvasive- profuse diarrhea with fever  Enterohemorrhagic- dysentery, can cause HUS  Enteroaggregative- watery diarrhea  Rx- supportive, fluoroquinolones shorten duration
  8. 8. Cholera  Caused by bacteria V.cholerae  Primarily affects small-intestine  People with O blood group more affected, carriers of cystic fibrosis are protected  Toxin leads to cAMP activation causing secretion of water, Na, K, Cl & HCO3  Causes profuse diarrhea (rice water), with abdominal pain, ± vomiting
  9. 9. Management  Dx-  Clinical  Stool enrichment/culture  Rx-  ORS, ± IV fluids  Antibiotics shorten duration- Doxycycline, cotrimoxazole  Prevention-  Whole cell inactivated oral vaccine  Sanitation  Proper sewage disposal  Water treatment/purification
  10. 10. Salmonella typhi  A gram –ve bacillus  Causes diarrhea with mild fever or TYPHOID- enteric fever  Stages- each lasting ~1 week  1- mild fever, relative bradycardia, malaise, leucopenia, blood culture +ve, Widal test -ve  2- high fever, Rose spots on trunk, delirium, bradycardia, diarrhea (occasionally constipation), HSmegaly, blood culture/Widal test +ve  3- high fever, delirium, complications- hemorrhage, perforation, peritonitis, cholecystitis, metastatic abscess  4- resolution/defervescence
  11. 11. Management  Dx-  Clues- relative bradycardia, coated tongue, lymphopenia, splenomegaly  Blood/marrow/stool culture  Widal test- Ab against O/H Ag- preferably 4-fold rising titres (high false +ve rate due to cross-reactivity with other Salmonella species & malaria)  Rx-  Antibiotics- 3rd /4th generation cephalosporin- oral/IV x 10 days  Supportive- rehydration  Surgery, as required for complication- hemorrhage, perforation  Prevention-  Sanitation & hygiene  Vaccine- live oral/injectable polysaccharide, booster every 5/2 years

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