Diarrheal diseases are common in children, especially in developing countries. There are three main types: acute, persistent, and dysentery. Acute diarrhea lasts less than 14 days while persistent lasts 14 days or longer. Dysentery involves bloody stools. Risk factors include suboptimal breastfeeding, contaminated water/food, and malnutrition. Treatment involves oral rehydration for mild cases and IV fluids for severe dehydration. Antibiotics are given for dysentery. Feeding should continue and mothers advised on follow up care.

1. DIGESTIVE DISORDERS
Chapter-2

2. Diarrheal diseases
• Diarrhea is one of the most common diseases
of children, especially of those living in
developing countries.
• It is defined as passage of three or more loose
or watery stools per 24 hours; or
• It is an increase in stool frequency or liquidity
that is considered abnormal by the mother.

3. Types
There are three clinical types of diarrhea
• Acute diarrhea- A diarrheal episode that
begins acutely and lasts for less than 14 days
with passage of watery stools without blood.
• Persistent diarrhea- This is a diarrheal
episode that starts acutely and lasts for 14 days
or longer
• Dysentery- diarrhea with visible blood in it.

4. Epidemiology
• An estimated 500 million children in the developing
world suffer from diarrhea three or four times a year
• Diarrheal disease cause about 30% of infant deaths in
developing countries and contribute a lot to the high
prevalence of malnutrition in such countries.

5. • Acute watery diarrheal episodes are the
commonest accounting for 80-82% of the
cases.
• Children of 6-11 months of age are the most
commonly affected
• This coincides with onset of initiation of
complementary feeding.
Epidemiology cont…

6. Risk factors for diarrhea
1. Behavioral risk factors
Sub-optimal breast-feeding practice-
• Early initiation of complementary feeding increases
the incidence of diarrheal diseases, hence increasing
child mortality and morbidity.
Using feeding bottles
• Feeding bottles are difficult to clean, easily
contaminated, and are fertile media for microbial
growth.

7. Behavioral risk factors cont…
Eating uncooked food
• If the food item is improperly handled, and given to
the child unheated.
Drinking contaminated water
• contaminated water is the main source of pathogens
causing diarrheal diseases.
Not washing dirty hands
Not disposing of feces safely

8. 2. Host factors affect incidence or severity of diarrhea
 Malnutrition- malnourished children have frequent
episodes of diarrhea and each episode is more severe
and long lasting.
 Measles- recent measles attack predisposes to
diarrhea.
 Immunosuppression- like HIV/ AIDS, DM patients
have more frequent and more severe diarrhea and the
offending organisms could be opportunistic
organisms.

9. Etiologic agents
• The commonest cause of acute watery
diarrhea is rota virus and
– others are Escherichia coli, vibrio cholerae, giardia
lamblia, etc.
• The commonest cause of dysentry is shigella
and
– others are campylobacter jejuni, entero invasive
E.coli, entamoeba histolytica, etc.
• The transmission is usually through the fecal-
oral route-by ingestion of fecally contaminated
water or food.

10. Pathophysiology of Diarrhea
• Microbial agents cause diarrhea by any one of
the following mechanisms:
– Villous damage and epithelial cell destruction e.g.,
rota virus
– Mucosal adhesion e.g., giardia lamblia
– Mucosal invasion e.g., shigella, entamoeba
histolytica
– Release of toxins e.g., vibrio cholerae

11. Complications of diarrhea
The commonest complications that are expected in
patients with acute watery diarrhea are:
• Dehydration and hypovolemic shock
• Electrolyte imbalance such as;
 hypokalemia due to loss of K+ in diarrheic stools,
 hyponatremia due to loss of Na+ in diarrheic stools
• Base deficit acidosis; due to loss of bicarbonate in
diarrheic stools:
• Malnutrition; due to reduced intake and absorption,
and increased requirement associated with diarrhea

12. Dehydration
• Dehydration is the main cause of death from
acute diarrhea.
• It is associated with loss of body fluid and
electrolytes mainly sodium through the diarrheal
stools

13. Assessment and classification of dehydration
• Based on the degree of dehydration
1. Severe Dehydration: two of the following signs:
• Lethargy or unconsciousness
• Sunken eyes
• Not able to drink or drinking poorly
• Skin pinch goes back very slowly (takes >2 sec)

15. Assessment and classification of dehydration
2. Some Dehydration: Two of the following signs:
• Restless, Irritable
• Sunken eyes
• Drinks eagerly & thirsty
• Skin pinch goes back slowly (takes <2 sec)
3. No dehydration
• No enough signs to classify as some or Severe
dehydration

16. Clinical manifestation
1. Acute watery
• This is defined as a diarrheal episode that begins
acutely and lasts for less than 14 days with passage
of frequent loose or watery stools without blood.
• It is commonly accompanied by dehydration.
• Vomiting and fever may be the manifestation.
• The common etiologies are Rotavirus, E. Coli
(entero toxigenic), and V. Cholerae.

17. 2. Bloody diarrhea
• This is diarrhea with visible blood either
macroscopically or microscopically.
• Most episodes are due to Shigella.
• Others like salmonella, entero invasive E
Coli, and E. Hystolytica are also incriminated.
Clinical manifestation cont…

18. 3. Persistent diarrhea
• It begins acutely, but it is unusually prolonged
duration, at least 14 days.
• It may begin as either watery diarrhea or as
dysentery.
Clinical manifestation cont…

19. Principles of Management of acute diarrhea
A. Antibacterial or anti parasitic therapy
• Anti microbial agents should not be used routinely
Dysentery- this should be treated with antimicrobials
effective for shigella.
• Oral antibiotics for 5 days should be given.
• The first line drugs are cotrimoxazole.
• If these are not effective, use the second line drugs
like nalidixic acid or ciprofloxacin.

20. Principles of Management of acute diarrhea cont…
If cholera is suspected;
• Cotrimoxazole or erythromycin are the first
line drug in younger children.
• Tetracycline is the drug of choice for children
older than 8 years.
If trophozoites or cyst of giardia or E.
histolytica are seen in stool microscopy;
• Anti-protozoal (Metronidazole or Tinidazole)
are considered.

21. B. Rehydration therapy
Level of dehydration Treatment
Severe dehydration Plan-C (rehydrate urgently
with IV fluids)
Some dehydration Plan B (rehydrate at the health
center with ORS)
No dehydration Plan-A (treat at home to
prevent dehydration)
Principles of Management of acute diarrhea cont…

22. Treatment plan A for No Dehydration
GIVE EXTRA FLUID (as much as the child will
take)
• Tell the mother to breastfeed frequently and for
longer at each feed.
• If the child is exclusively breastfed,;
– give ORS or clean water in addition to breast milk.
• If the child is not 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.

23. • ORS amount guide for use
Less than 2 years = 50-100ml after each loose
stool
2-10 years = 100-200ml after each loose stool
More than 10 years = as much as wanted.
Treatment plan A cont…

24. • Advice the mother:
– how to prepare ORS solution (one packet in one liter of
pure water), and
– To give the fluids with teaspoon, not bottle.
• If vomiting occurs, the mother should stop giving the
fluid for about 10 minutes and start again, but give it
more slowly.
• Finally it is good to advise mothers to take the child to
health worker:
– if the child doesn’t get better in 3 days or develops many
watery stools, repeated vomiting, poorly eating, fever, or
blood in the stool.
Treatment plan A cont…

25. Treatment plan B in some dehydration
I. ORS
• When there is some dehydration, the deficit of water is
between 50 and 100 ml for each Kg of body weight.
– The ORS needed for rehydration can be estimated, using
75ml/Kg as the approximate deficit to be given over four
hours.
– If puffy eyelids (sign of over-hydration), stop ORS and give
water or breast milk and treat as plan A.

26. II. Intravenous therapy
• This is the last option:
– When oral treatment is not feasible (in case of
severe vomiting, severe diarrhea)
– Loss of greater than 15ml/Kg of body water per hour
– Glucose malabsorption.
• The dose is 70ml/Kg over 3-4 hours.
Treatment plan B cont…

27. • At the end of either IV or oral therapy, it is
recommended to reassess the child after four
hours of initiation of therapy.
– If still, patient has some dehydration, repeat the
same volume.
– If no dehydration, treat as plan A.
– If severe, treat as plan C.
Treatment plan B cont…

28. Treatment Plan C for Sever Dehydration
Intravenous therapy
• The most preferred Intra venous fluid is
Ringer’s Lactate.
• The initial 30ml/Kg is designed to expand
ECF volume rapidly and improves
circulatory and renal function.
• Subsequent therapy (70ml/Kg) is aimed at
replacing deficits while providing for
maintenance water.

29. IV Ringer’s lactate
Age 30ml/kg 70ml/kg
<12months Over 1 hour 5 hours
>12 months Over 30 minutes 2.5 hours

30. • Re-asses every 15-30 minutes until you get full
radial pulse.
If radial pulse is still undetectable, repeat the same
dose (30ml/Kg) once more.
Give ORS (5ml/kg/hr) as soon as child is able to
drink.
Re-asses child after 3 or 6 hours depending on the
age.
Then treat accordingly as plan A, B, or C.
Treatment Plan C cont….

31. Oral therapy or Nasogastric tube therapy
• This is done if IV therapy is not possible.
• The oral replacement is used if the child is able to
drink, if not the nasogastric replacement is used.
– ORS is given at a rate of 20 ml/kg/hr (the maximum
rate of infusion) over 6 hours.

32. Oral therapy or Nasogastric tube therapy cont…
• Reasses after one to two hours.
• If no improvement in 3 hours, treat with
intravenous fluids.
• This approach is not as satisfactory as IV infusion
because the fluid cannot be given as rapidly and
additional time is required for it to be absorbed
from the intestine.
• The oral replacement cannot be used for patients
who are very lethargic or unconscious.

33. C. Feeding of the child
• Breastfeeding should be frequent than usual and
should continue without interruption.
• Formula or cow’s milk should be given as usually
prepared.
• Those who are on complementary diet should continue
the feeding both during and after the diarrhea.
• During diarrhea, give as much food as the child
wanted.
– Small, frequent feedings are tolerated better than large
feedings given less frequently.

34. D. Follow up
• Advise the mother to return immediately to the
clinic:
– if the child become more sick, or unable to drink,
or breastfeed, or drinks poorly, or develops fever,
or shows blood in stool.
• If the child shows none of these signs but is
still not improving, advice the mother to return
for follow up at 5 days.

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