This document discusses acute diarrhea in children. It defines diarrhea and lists its leading causes as enterotoxigenic E. coli, enteroinvasive bacteria like Shigella and Salmonella, rotavirus, Vibrio cholerae, and Giardia lamblia. It describes the mechanisms by which these pathogens cause diarrhea and outlines their clinical presentations. The document also covers factors that increase susceptibility to diarrhea, effects of dehydration, evaluation of patients, management of rehydration, and treatment for specific causes.

1. Acute Diarrhea
By: Dr. Noshirwan P. Gazder

2. Defenition
• Passage of three or more stools in a day, of consistency softer than
usual for the child, or one watery stool is defined as “Diarrhea”.

3. • Diarrhea is one of the leading causes of morbidity and mortality in
children.
• There are 3-4 episodes of diarrhea per child per year.
• Maximum incidence is in the 1st year of life.
• Major transmission is fecal/oral or by ingestion of contaminated food
or water.

4. Factors Increasing Susceptibility To Diarrhea
• Exposure to unsanitary conditions.
• Ingestion of contaminated food or water.
• Lack of breastfeeding.
• Malnutrition.
• Measles.
• Level of Maternal Education.

5. Common Causes of Acute Diarrhea

6. Enterotoxigenic E. Coli
• Diarrhea results from action of toxins released by the bacteria on
intestinal mucosa.
• Toxins are heat labile (LT) and heat stable (ST).
• The LT toxins bind to the epithelial surface of enterocytes, causing
accumulation of cyclic AMP causing massive secretion of sodium and
chloride in the gut lumen.
• The ST toxin activates guanylate cyclase, which increases secretory
activity of the gut.

8. Entero-Inasive (Shigella & Salmonella)
• These cause invasion of enterocytes and results in necrosis and ulcer
formation leading to diarrhea with blood and mucus in the stool.
• It presents as fever, abdominal cramps and tenesmus and small
volume of bloody mucoid stools with many pus cells.

9. Rota Virus
• It invades intestinal cells and alters their functioning and
reproduction.
• The exact mechanism in Rota virus is not known. But towards the end
of the illness it causes shedding of mucosal cells with loss of
disaccharides.
• It manifests as osmotic diarrhea due to failure of digestion of lactose
and other disacharrides.
• Recovery occurs when the mucosal surface regenerates.

10. Vibrio Cholerae
• They adhere to and multiply on the mucosa of small intestine and
produce heat labile enterotoxin, which attaches to a receptor (GM1
ganglioside) on gut epithelium.
• It activates adenylate cyclase to produce increased amount of cyclic
AMP, which causes decreased absorption of sodium and chloride
resulting in water and electrolyte loss.

11. Giardia Lamlia
• Pear shaped, flagellated trophozoite with ventral sucking discs.
• Spread via the oro-fecal route.
• Humans ingest cysts which form trophozoites in the duodenum.
• Trophozoites attach to the duodenal wall but do not invade and
interferes with absorption of fat and protein.

13. Effects of Diarrhea
1. Loss of Water:
• Loss of skin turgor.
• Weak or absent pulse.
• Sunken eyes.
• Sunken fontanelles.
• Dry Mucous membranes.
• Anuria.
2. Loss of Nutrients:
• Hypoglycemia, convulsions or
coma.
• Weight loss or marasmus.

15. 3. Loss of bicarbonate:
• Vomitting and retching.
• Deep and sighing respiration.
• Irritability (Increased O2 demand
of brain)
4. Loss of Potassium:
• Abdominal distention.
• Paralytic ileus.
• Sustained Shock.

16. Clinical Features
• Onset is sudden with diarrhea and vomitting.
• Stools are large in volume, watery in consistency.
• Dehydration develops rapidly due to loss of body water and
electrolytes in stools and vomitting.
• Acute diarrhea is usually a self-limited disease. Vomitting and fever
usually resolve quickly but diarrhea persists for 3-4 days then
gradually diminishes over another 4-5 days.

17. Grading of Stools
Grade
Grade 1 Normal formed stools.
Grade 2 Soft stools.
Grade 3 Liquid stools taking shape of the container.
Grade 4 Watery stools with flakes, appearing opaque in glass container.
Grade 5 Watery stools with few flakes, appearing translucent in color.

18. Complications
• Dehydation and Shock.
• Metabolic acidosis.
• Convulsions or Coma.
• Malnutrition. (long standing diarrhea)
• Acute Renal shutdown.
• Super-added infections.
• Death.

19. Evaluation of the Patient
-History:
• Loose motions.(duration, frequency, grade, color of stool, blood in stool)
• If the child has vomitting.(duration, frequency, relation with food, quantity,
color of vomitus, blood in vomitus)
• If the child has a fever.( duration, low or high grade)
• Abdominal pain or distention.
• Any history of seizures.
• Urine passed or not within 6 hours, and in how much quantity.
• Any associated symptoms such as cough, rash or urinary complains.
• BIND.

20. Examination
• General behaviour ( drowsy, irritable)
• Anthroprometry and General physical examination.
• Mucous membranes (normal, dry or parched)
• Skin turgor (normal, goes back slowly, goes back very slowly)
• Eyes (Shiny with tears, not sunken, sunken)
• Anterior fontanelle ( open, closed, depressed)
• Abdomen (normal, distended, any mass palpable,bowel sounds)
• CNS and respiratory system examination to find any associated
abnormality.

21. Investigations
• CBC.
• Stool examination for pH, Giardia cysts or entamoeba, Bioassay for
E.coli, Culture and Sensitivity.
• Serum electrolytes.
• Blood culture. (salmonellosis or shigellosis)
• X-ray chest. (pneumonia)

22. Management
• Before starting therapy, we assess degree and type of dehydration.
• If the child has diarrhea we Ask, For how long and if there is blood in
the stool
• We will then Look at the child's general condition. Is the child:
Lethargic or unconscious or restless and irritable
• Look for sunken eyes.
• Offer the child fluid, Is the child not able to drink or drinking poorly or
is the child drinking eagerly.
• Pinch the skin of the abdomen, does it go back slowly or very slowly
(longer than 2 seconds).

27. Treatment of Choice
• Cholera: Tetracycline 50mg/kg/day PO for 2 days.
Furazolidine 5mg/kg/day PO for 3 days.
• Shigella: Ampicllin 100mg/kg/day for 5 days.
Nalidixic acid 55mg/kg/day for 5 days.
• Giardiasis: Metronidazole 15mg/kg/day for 5 days.
• Amebiasis: Metronidazole 30mg/kg/day for 5 days.

28. Thank You