Diarrheal diseases are a major public health concern worldwide, especially among children under 5 years old. Diarrhea is defined as having 3 or more loose stools per day and can be caused by bacterial, viral, parasitic, or fungal infections. The main risk factors are poor hygiene, inadequate food safety, and low socioeconomic status. Diarrhea is classified based on duration and etiology. The main signs and symptoms include loose stools and dehydration. Treatment focuses on oral rehydration and management of dehydration severity from no dehydration managed at home to severe dehydration treated intravenously in a hospital. Prevention emphasizes handwashing, food safety, breastfeeding, and vaccination.

1. Diarrheal Diseases &
Dehydration
Presented by : Ngunyi Yannick L.
MD, Faculty of Health Sciences
University of Buea, Cameroon

2. Plan
• Definition
• Epidemiology
• Risk factors
• Types of diarrhea
• Etiology
• Signs/Symptoms
• Workup
• Complications
• Prevention
• Management
• Dehydration

3. WHAT IS DIARRHEA?
• Diarrhea is defined by the World Health Organization as having 3 or
more loose or liquid stools per day, or as having more stools than is
normal for that person.
• Increase in daily stool weight above 200gm
• Diarrhea is usually a symptom of an infection in the intestinal tract,
which can be caused by a variety of bacterial, viral, fungi and parasitic
organisms.

4. Epidemiology
• People of all ages can get diarrhea, but it is more common in
children below five years of age.
• Diarrhea is a Public Health Concern, & its the second leading
cause of mortality and morbidity in the world after pneumonia
among children under five globally.
• Globally, there are about two billion cases of diarrheal disease
every year.

5. Epidemiology
• Today only 39 per cent of children with diarrhea in developing
countries receive the recommended treatment, and limited trend
data suggest that there has been little progress since 2000
• Nearly one in five child deaths (about 1.5 million each year) is
due to diarrhea.
• 3rd main cause of death in Cameroon after HIV and Lower Respiratory
Infections.

6. Risk factors
• prematurity
• immunodeficiency conditions
• lack of personal hygiene
• inadequate food hygiene
• Poor infant feeding practices
• illiteracy
• poor socio-economic status

7. Types of Diarrhea
Based on duration
1. Acute diarrhea :
Acute watery or bloody diarrhea (dysentery)
lasting less than 14 days
2. Persistent/chronic diarrhea.
>14 days

8. Based on etiology
1. Osmotic diarrhea
 Too much water is drawn into the bowels.
 This can be the result of maldigestion in which the nutrients are left in
the lumen to pull in water (e.g., pancreatic disease)
 Caused by osmotic laxatives (which work to alleviate constipation by
drawing water into the bowels)

9. Based on etiology
2) Motility-related diarrhea
 Due to rapid movement of food through the intestines
 If the food moves too quickly through the GIT, there is not enough
time for sufficient nutrients and water to be absorbed.
 Due to over stimulation of the parasympathetic system
3) Secretory diarrhea
 increase in the active secretion, or there is an inhibition of absorption.
 The most common cause is a cholera toxin that stimulates the secretion
of anions, mostly chloride ions.

10. Based on etiology
4) Inflammatory diarrhea
 Occurs when there is damage to the mucosal lining, which
leads to a passive loss of protein-rich fluids, and a decreased
ability to absorb these lost fluids.
 caused by bacterial infections, viral infections, fungal
infections, parasitic infestations, or autoimmune conditions

11. Etiology / Causes
A. Infectious causes
Viral Infections
• Rota virus (40% of cases in children <5ys )
• Norovirus (Adults)
• Adenovirus types 40 and 41
• Astroviruses
Parasitic Infections
• Giardia lamblia
• Entamoeba histolytica
Bacterial Infections
• Escherichia coli
• Salmonellae
• Shigella
• Campylobacter
• Vibrio cholera
• Clostridium difficile
Fungi
• Candida albicans

12. Etiology / Causes
B) Non infectious causes
Malabsorption
Cystic fibrosis,
Coeliac disease
Food Intolerance or Allergy
Lactose Intolerance,
Cow's milk Protein Allergy
Drug induced- Antibiotics
Surgical Conditions
Appendicitis
Intussusception
Partial bowel obstruction
Other rare conditions
Haemolytic-uraemic syndrome
Pseudomembranous colitis
Toddler diarrhoea

13. Signs & symptoms of Diarrheal diseases
• Mostly signs and symptoms of dehydration such as
Weight loss, poor skin turgor, dry mucus membranes, dry lips, pallor,
sunken eyes, depressed fontanelles
• Abdominal pain
• Fever
• Frequent loose stools with/without Blood or mucus
• Vomiting, headache
• Behavioral changes like irritability, restlessness, weakness,
lethargy, sleepiness, delirium, stupor and flaccidity
• Rice water stools in case of cholera

14. Signs & symptoms
• Convulsions and loss of consciousness may also be
present in some children with diarrheal diseases, due to
loss of electrolytes.
• Hypotension, tachycardia, tachypnea, cold clammy
extremities
• Decreased or absent urinary output

15. Workup / Investigations
a. Stool cultures for bacterial and viral pathogens,
b. Full Blood Count
c. Stool analysis: direct inspection for ova and parasites
d. immunoassays for certain bacterial toxins (C. difficile)
e. Serum electrolytes
f. Kidney function test (urea + creatinine)
g. Other tests to rule out specific etiologies e.g. Widal for
salmonella infection

16. Complications of Diarrheal diseases
• Dehydration:
Main complication of diarrheal diseases
Leading cause of mortality in diarrheal diseases
Causes end organ failure
• Electrolyte imbalance:
From excessive loss of electrolytes
can lead to seizures and muscle spasms

17. Prevention
• Keep your hands clean
• Wash fruits and vegetables
• Refrigerate and cover food
• Eat well-cooked foods
• Rotavirus Vaccination (Rotarex at 6th & 10th week)
• Promotion of early and exclusive breastfeeding and vitamin A
supplementation
• Community-wide sanitation promotion

18. Management
 Mainly fluid replacement (with ORS or IV crystalloids) to prevent or
correct dehydration & correction electrolyte imbalance
Reassess hydration state and hydrate accordingly with respect to
severity of dehydration
no dehydration- WHO plan A
some dehydration- WHO plan B
severe dehydration- WHO plan C
 Zinc supplement
 Antibiotherapy for bacterial causes
 Antidiarrheal agents (loperamide, racicadotril(1-1-1))

19. Dehydration
Dehydration is a deficit of total body water, with or without
electrolytic and acid-base disturbances.
 It occurs when free water loss exceeds free water intake
 Main complication in patients with diarrheal diseases and
leading cause of mortality in these patients.

20. Classification Of Dehydration
1) Severe Dehydration
Two or more of the following signs:
• lethargy or unconsciousness
• sunken eyes
• unable to drink or drinks poorly
• skin pinch goes back very slowly (>2 s)
• Manage with WHO plan C

21. Classification Of Dehydration
2) Some Dehydration
Two or more of the following signs:
• restlessness,
• irritability
• sunken eyes
• drinks eagerly, thirsty
• skin pinch goes back slowly
• Manage with WHO plan B
3) No Dehydration
• Not enough signs to classify as
some or severe dehydration
• Manage with WHO plan A

22. WHO Management of Dehydration
PLAN A (NO DEHYDRATION – TREAT AT HOME)
Teach mother or family member how to give Oral rehydration solution (ORS)
at home.
FOR EACH LOOSE STOOL UNTIL DIARRHOEA RESOLVES;
• Children < 2yrs give 50-100mls of ORS
• Children 2-10yrs give 100-200mls of ORS
• Children > 10yrs or older and adults should take as much as they want (AD
LIBIDUM).
• If child vomits, wait 10mins and then continue slowly 5mls every 2-3mins.

23. Management of Dehydration
• Give Zinc supplements.
children <= 6months  ½ tab/day x 14days
children > 6months  1 tab/day x 14days
• Continue breast feeding without interruption
• For children < 6 months on formula or cow’s milk, give half strength
for 2days. After 2 days give usual formula or cow’s milk
• For older children give usual cow’s milk
• Children > 6 months give soft or semi solid weaning foods. Give as
much food as they want but every 3-4hrs (6x/day), small frequent
feeds are better tolerated.

24. Management of Dehydration
PLAN B (SOME DEHYDRATION – ADMIT PATIENT)
• Give ORS, 75mls/kg in 4-6hrs
• If patient asks for more ORS, give pure water 100-200mls in the first
4hours.
• If child vomits, wait 10mins and then continue slowly 5mls every 2-
3mins.
• Continue feeding as in Plan A

25. Management of Dehydration
• PLAN C (SEVERE DEHYDRATION – ADMIT PATIENT)
• Patients with severe dehydration can die from hypovolemic shock, so treat
as hypovolemic shock. Treatment of choice is intravenous rehydration with
crystalloids.
• REQUIRED FLUIDS: Ringer’s lactate, Normal saline, Half- strength DARROW’S
solution with 2.5% or 5% dextrose, or Half normal saline in 5% dextrose.
• INFANTS: 30mls/kg first hr 70mls/kg for the next 5hrs = 100mls/kg in 6hrs
• OLDER CHILDREN AND ADULTS: 30mls/kg within 30mins 70mls/kg over
2.5hrs = 100mls/kg in 3hrs.

26. Management of Dehydration
• NB; if after the first 30mins the radial pulse is still weak and rapid,
repeat a second infusion of 30mls/kg.
• If IV therapy is not possible  NG replacement – maximum
20mls/kg/hr. If there is increasing abdominal distension and frequent
vomiting  Give slowly
ORAL REPLACEMENT
• Children <2yrs give, ORS by spoon 5mls/min. In older children from a
cup, as soon as the patient is able to drink. Avoid NG and oral
replacement in case of paralytic ileus.

27. Management of Dehydration
TRANSITION TO PLANS B AND A
• Usually rehydration period for plan C is 3-6hrs. Reassess the patient’s
hydration status and either continue plan C or change to plans B or A.
• Patients with severe dehydration should be hospitalized until diarrhea
stops.

28. References
1. World Health Organization (WHO)
2. "Diarrhea in non travelers: risk and etiology“
3. "Astrovirus gastroenteritis". The Pediatric Infectious Disease Journal 21
4. Williams, George; Nesse, Randolph M. (1996). Why we get sick: the new
science of Darwinian medicine. New York: Vintage Books. pp. 36–3
5. Wikipedia.com

29. THANK YOU FOR YOUR
KIND ATTENTION