MBBS Lecture

5. WELCOME ALL

6. 6

7. Dr Mohammad Nurul Huq

8. 8
ARI
54%
Diarrhoea
85%
Malaria
79%
Measles
89%
Percentage of deaths occurring among:
Global Burden of Diseases Borne by U-5 Children Year 2000

9. 9
Diarrhea Key Facts
 Globally: 1.7 billion cases/y. 2 attacks/child/y
 2nd largest U-5 killer (0.52mn/y: 2018)
 Was No.1 (5mn)
 Most deaths from dehydration
 Preventable/treatable: safe food & sanitation
 Bangladesh: 15,000 deaths (2.19% of total deaths)/y
 A leading c/of malnutrition in U-5

10. 10
Diarrhea Death is Falling
 Successful ORT
 Breastfeeding, no bottle, no formula
 Safe water & food, hand washing
 Health education, improved sanitation
 Immunization
 HPVAC, Zn
 Fall in malnutrition
 Awareness
HPVAC: high potency Vitamin A capsule. Zn: zinc

11. 11
50 Years of ORS (1968)
 Absorption of salt plus water is enhanced with glucose,
amino a.  discovery of ORS & later rice ORS
WHO:
“ORT is the most rewarding scientific
achievement of 20th century”

12. 12
Definition of Diarrhea
Passage of 3 loose stools/24h. Loose stool: one that
takes up the shape of the container
Exception!!
 EBF babies pass many loose/unformed motions/d
 They do not develop dehydration & thrive well!
 We call these BM stools!
With its other unique qualities BM
also has ORS like action

13. 13
Breast milk stools

14. 14
Diarrhea Harms ..
Dehydration
 Dyselectrolytemias
 Malnutrition
 VADX
 Anemia
 More infx
 Growth failure
VADX: Vitamin A deficiency & xerophthalmia. Infx.: infection

15. 15
Diarrhea Causes Malnutrition
 Food intake  by 1/3 (appetite poor, NVD)
 Malabsorption
 Faulty feeds, food fads
 Starvation therapy (‘rest to bowel’)
 VADX  Infx
 More nutrients to cope with diarrhea
Malnutrition makes D. worse. Mn.  longer, severer D.
The cycle can be broken by good nutrition
Stress on feeding in D.!
D: diarrhea

16. 16
Diarrhea Kills ..
Shock, ARF
 Dyselectrolytemia (hypokalemia)
 Severe malnutrition
 Associated inf. (pneumonia)
 HUS (E coli)
 GBS (C jejunae)
How dehydration kills
 Hypovolemia
For each 1% dehydration body function falls by 5%
20% dehydration is lethal

17. 17
Predisposing Factors for D.
 Not breast feeding, formula feeds, feeding bottle
 Not washing hands
 Unsafe foods, drinks, waste disposal
 No immunization, malnutrition
 Measles
 VADX
 Zn deficiency
 Immunodeficiency

18. 18
Complications
Dehydration
 Shock, ARF, acidosis
 Hypokalemia
 Hyponatremia
 Hypochloremia
 Hypocalcemia (more in chronic D)
 Hypoglycemia, fit
 Hypothermia
 Food intolerance
 GBS, HUS, anemia
 Malnutrition
 VADX
 Shigella encephalopathy

19. 19
HUS: Schistocytes (broken RBCs)
Often seen in hemolytic a. & is
frequently a consequence of artificial
heart valves & HUS, thrombotic
thrombocytopenic purpura

20. 20
Types of Ac. Diarrhea
3 clinical types
 Ac. watery D (AWD) 75% lasts several hours to days
 Ac. invasive D (AID) 15% or ac. bloody D (dysentery)
 Persistent D (PD) 10% lasts 14d or more

21. 21
Ac. Watery Diarrhea
 Commonest
 Large motions: rapid dehydration
 45% of diarrheal deaths
 No invasion
 Duration ~7 days
 Classical: rotavirus, cholera

22. 22
Cl. Features of AWD
 Usually starts as a viral syndrome*
 Loose/watery stools
 NV
 + Fever
 +/- Abdominal pain
*Viral syndrome: cold, cough, flushing, red eyes, malaise, bodyache, etc.

23. 23
Causes of AWD
 Rotavirus
 ETEC
 EPEC
 V. cholerae
No pathogen detectable in 5%
 Giardia
 Nontyph. salmonella
 Cryptosporidium
 A. hydrophila

24. 24
Rota Virus
 33% of all D.
 60% of all D. <2yoa
 6,000 to 15,000 U-5 deaths in Bangladesh
 Starts as URT catarrh
 Yellowish/greenish watery stools with flakes of feces
 Rapid dehydration
 Vaccine preventable: v. effective
URT: Upper Resp. Tract

25. 25

26. Cholera
is an extremely pathogenic d.; can cause severe AWD (40
motions/d). IP: 12h-5d. Affects both children &
adults & can kill within hours
 Inoculum: 108 (100,000,000) organisms
 C/by food or water contaminated with V. cholerae. It is a
global threat to PH & an indicator of poor social dev.
 1.3-4.0 million cases/y, & 21k-143k deaths worldwide
 Most inf. have no or mild SS
 Safe water & sanitation is critical to control
 Strategy to reduce cholera deaths by 90% was launched
in 2017. Oral cholera vax., surveillance, water,
sanitation & hygiene, social mobilization are
needed for this 26

27.  It is present in faeces for 1-10d
 Many serogroups, but O1 (common) & O139 cause
outbreaks; no difference in severity
 Rx.: mostly ORT. Some: IVF & ABT (less severity &
duration)
 With early & proper Rx, the CFR is <1%
 Zinc is an imp adjunctive for U-5 (reduces duration & may
prevent future episodes of other AWD)
Case fatality rate (CFR)
27

28. 28
V cholerae

29. 29

30. Giardiasis
is an inf. in small gut, c/by G lamblia: found in animal &
human feces; spreads P2P, by contaminated food. Pet
dogs & cats frequently have it
 Acquired most commonly by water contaminated by
animal feces, diapers, & agricultural runoff
 Cooked food is safe
 Found all over the world; more common in overcrowding
with poor sanitation; can thrive in soil for long period
May asymptomatic. IP: 1-2w. Common SS:
 Fatigue, ANVD (greasy stools), AP
 Bloating, wt. loss, excessive gas, headache
30

31. 31

32. Dx
 Stool ME. Multiple samples may be needed
 Endoscopy
Rx
 Mostly self-limiting
 Metronidazole for 5-7d, Tinidazole single dose
 Nitazoxanide for 3d
 Paromomycin in pregnancy
Complications
 Wt loss, dehydration, lactose intolerance, malnutrition
Washing hands, not swallowing water on swimming,
avoiding drinking untreated surface water, uncooked
local produce can prevent
Usually last 6-8w, but lactose intolerance can persist 32

33. 33
Remember AWD..
Commonest
 Rapid severe dehydration
 Rx only by ORT
 No ABT (antibiotic therapy)*
 Self- limiting
Wrong Rx may lead to Persistent D.
 Increased fluid & continued feeding is v. imp.
*ABT recommended in cholera

34. 34
Ac. Inv. D. (Dysentery)
Features
 Invasion:
 Inflammation:
 System upset:
 Characteristic stools:
Dysentery: loose s. mixed with mucus & blood; AP & tenesmus (urge
to purge with little output: irritation of internal anal sphincter)

35. 35
 Invasion : inflammation, spread
 Inflammation : congestion, edema, mucus,
ulcer, bleed, AP, tenesmus,
distension
 Sys. Upset : HGF, NV, HA, toxic,
prostration
 Stools : Dysenteric: frequent (>6/d),
plenty pus cells, RBC,
macrophages,
epithelial cells, bacilli

36. 36
Colitis in Ac. Inv. Diarrhea

37. 37
Rectal prolapse

38. CT of Amebic L. Abscess (F, RUQ Pain & Pleuritic Pain)

39. 39
C/of Ac. Invasive Diarrhea
 Shigella (60%)
 Salmonella (some strains)
 EIEC, other E coli
 Campylobacter
 Helicobacter
 E. histolytica

40. Shigellosis
c/by Shigella. Very contagious: only 10 bacteria
SS: D, F, cramps, tenesmus 1-2d post-exposure. Duration 5-
7d. (4 or more weeks). Commonly young children
 May be asymptomatic, but spreads
 2% with S flexneri will have post-inf. arthritis, eye
irritation, & dysuria for months or years, & can be chr.
It usually does not occur with other types
Rx
 Most recover without Rx.
 ORT. Ciprofloxacin for adults, & azithromycin for children
There may be AB Resistance
40

41. 41
Intracellular Shigella

42. 42
EM: Salmonella

43. 43E coli, flagella
E coli Diarrhea (Including HUS).
EM of E coli O157:H7 showing
flagella

44. Amebiasis
is an gut inf. typically by contaminated food; c/by E
histolytica: a protozoon
 Often lives in large gut without SS. Causes dysentery
with F., rarely spreads into liver, lungs, brain
 Typically occurs in areas of poor sanitation
CF in children
 Mostly minimal/no symptoms. Gradual AP, loose/watery
motions, cramps, AN. Sometimes F & dysentery
 IP: days-weeks; may be months
44

45. Dx
 Stool ME (3 samples), blood tests
Rx
 Metronidazole (DoC) for 5d, tinidazole
 Paromomycin & diloxanide furoate: used along with
metronidazole when GI symptoms are present.
Asymptomatic stool carriage can be cleared by
these alone
Prevention
 Cooked food, hand washing, safe water
45

46. 46

47. 47E. histolytica Trophozoite in Stool Showing Ingested RBCs

48. 48

49. 49
Remember AID may cause:
 Complications: HUS (E. coli), GBS (Campylobacter)
 Malnutrition
 Anemia
 Persistent diarrhea
 Death

50. 50
Persistent Diarrhea
30-50% of diarrheal deaths!
Almost unknown in E B F B
 Starts as AWD/AID; but predisposing
factors prolong it > 14d
 Child is malnourished, develops VADX
 Often with serious non-GIT infx.
EBFB: exclusively breastfed babies

51. 51
Predisposing Factors for PD
 Not breastfeeding
 Bottle feeding
 Unjustified ABT
 Malnutrition
 VADX
 Immunodeficiency
 Starvation therapy
 Food intolerance
Preventing these can avert PD

52. 52
Effects of PD
A serious condition!
 Dehydration
 Rapid wt. loss, malnutrition
 Malabsorption: nutrient deficiencies, VADX

53. 53
Causes of PD
No single microbial cause
Some may play a role:
 Cryptosporidium
 Enteroaggregative E. coli
 Shigella

54. 54
Chronic vs. PD
Don’t confuse chr. D with PD
Chr. diarrhea is:
 insidious
 long lasting/recurrent
 usually non-infx. causes (eg thyrotoxicosis)

55. 55
 History. Volume of urine (never forget). Looking at
the stool
 Physical Exam
S/of dehydration & malnutrition
Assessing Diarrhea

56. 56
History
 Duration & onset
 Stool: times, vol., form,
color, blood +/-mucus
 AP, fever
 Distension
 Tenesmus
 NV, appetite, activity
 Urine vol.

57. 57
IMCI
Management of
Diarrhoea

58. 58
History taking
1. General Danger Signs
2. Main Symptoms
a. Cough
b. Diarrhea 
c. Fever
d. Ear Problems
3. Nutritional Status
4. Immunization Status
5. Other Problems IMCI record form

59. 59
DANGER
SIGNS
CONVULSIONS
INABILITY TO DRINK
OR BREASTFEED
VOMITING
LETHARGY
UNCONSCIOUSNESS

60. 60
4 Signs to classify:
 General condition
 Sunken eyes
 Thirst
 Skin pinch
Assessing Dehydration

61. 61
Child’s general condition
 Lethargic or unconscious (also a GDS)
 or Restless (a child who cannot be consoled)
 or Well & alert

62. 62Consoled

63. 63
Sunken eyes:
– Dehydration
– Visible wasting
– Old age
 Though less reliable it is still useful

64. 64
Signs of Dehydration

65. 65
Thirst: 3 stages
 Not able to drink or drinks poorly
weak, drinks with help, swallows only if fluid is
put in mouth
 Drinking eagerly, thirsty
wants to drink more
 Drinks normally

66. 66
Drinks eagerly

67. 67
Skin Pinch
 Middle of umbilicus & flank
 Pinch all layers with thumb + index in long axis for
1 sec & release suddenly:
– goes back very slowly (>2 sec)
– slowly
– or immediately

68. 68

69. 69

70. 70
Exception!
 Marasmic & elderly: pinch goes back slowly
 Obesity/edema: goes back immediately though
dehydrated!
Though less reliable it is useful

71. 71

72. 72
Any 2 signs:
• Lethargic or unconscious
• Sunken eyes
• Unable to drink/drink poorly
• Skin pinch returns v. slowly
Severe
dehydration
(Rx plan A)
Any 2 signs:
• Restless, irritable
• Sunken eyes
• Drinks eagerly, thirsty
• Skin pinch returns slowly
Some
dehydration
(Rx plan B)
Not enough signs to classify as
above
No
dehydration
(Rx plan C)

73. 73
No
dehydration
Plan A
Some
dehydration
Plan B
Severe
dehydration
Plan C
Look:
Gen.
Con.
Eyes
Thirst
Well, alert
Not sunken
Drinks well
Restless, irritable
Sunken
Thirsty, drinks
eagerly
Lethargic/coma
Sunken
Drinks poorly or
not able to
Feel:
Skin
pinch
Goes back
quickly
Goes back
slowly
Very slowly
Classifying Dehydration

74. 74
Principles of Rx
Only rehydration in most cases
 Correct existing deficit
 Replace further loss
 IVF in severe dehydration
 Feeding, specially BM continued
 Antimicrobials if warranted

75. 75
 Severe ....: immediate replacement with IVF, NGT
or ORT (Plan C)
 Some ......: ORTC/at home (Plan B)
 No .....: at home (Plan A)
Rehydration Plan

76. 76
Rx Plan
A
 Rx at home
 Teach
 IF/CF *
B
ORS in 4h: 70 ml/kg
<4 mo 200- 400ml
4-12 mo 400- 600ml
1-2y 600- 800ml
2-4y 800-1200ml
5-14y 1200-2200ml
Reassess after 4 h: select
plan A, B, or C
C
Start IVF @ 100ml/kg
50% in first 2h
50% next 3-4h
Replace further loss;
ORT if can drink
Assess pulse, BP, UOP
frequently & review Rx
plan
* IF/CF: increased fluid & continued feeding

77. 77
Some dehydration

78. 78
Feeding in Diarrhea
 Growth slows during diarrhea but children catch up later
 Give an extra meal for 2w
 Continue BM+ORT, family foods
 Severe malnutrition: feed during ORT, rehydrate slowly

79. 79
Any dehydration Severe PD
No dehydration Persistent diarrhea
Classification of PD

80. 80
 Severe PD: hospitalise
 Feeding is most important:
– tempo.  animal milk
– energy, protein, vitamins, minerals
– avoid aggravating foods
– enough food during convalescence
 No routine ABT
Treatment of PD

81. 81
Remember! PD means
 Malabsorption
 Weight loss, malnutrition, VADX
 Hidden infx
 Death!

82. 82
Dysentery Syndrome
Basically Invasive Diarrhoea
 Bloody mucoid stools, F, cramps, tenesmus. High MM
 Stool CS is rarely possible
 More severe in malnourished, not breast-fed, or bottle
fed babies.  frequent & severe in measles
  likely to become PD
MM: morbidity & mortality

83. 83
Classification of Dysentery (IMCI)
 Classify dysentery if blood is in stool
 15% diarrheas in U-5y are dysentery
 15% of diarrheal deaths
Blood in the stool Dysentery

84. Other Causes of Bloody Stools
 Rectal polyp
 Anal fissure
 Meckel diverticulum
 Diverticulosis/diverticulitis
 Cow’s milk protein intolerance
 AV malformation
 Hemorrhagic disease
84

85. 85
3 Types of Dehydration
Serum Na
 Isotonic 130-150 mmol/l
 Hypertonic >160 mmol/l
(hypernatremic)
 Hypotonic <130 mmol/l
(hyponatremic)

86. 86
Isotonic: commonest
 Fluid lost in DV is isotonic
 Plasma osmolality 275-295mOsmol/l
 Serum Na is 130-150 mmol/ l
The patient
Proportionately dehydrated

87. 87
Hypertonic
 Caused by rehydration by hypertonic fluid
 Serum Na is >160 mmol/l
 Osmolality is >295 mOsmol/l
The patient is
 severely dry, thirsty, irritable, bounding pulse
 fits at Na >165mmol/l

88. 88
Hypotonic
 caused by rehydrated with hypotonic fluid
 Serum Na <130 mmol/l
 Osmolality <275 mOsmol/l
The patient is
 Lethargic, feeble pulse
 Postural hypotension
 May have fits: Na 120 mmol/l

89. 89
OLD ORS

90. New ORS (WHO):
 All ingredients except K + & alkali
are reduced: 27.9  20.5 g
 It is hypo-osmolar: 311  245mmol/L

91. New Old
NaCl 2.6 g/l 3.5 g/l
Glucose 13.5 20
KCl 1.5 1.5
Trisodium citrate 2.9 2.9
Total 20.5g 27.9g
Osmolarity mmol/L mmol/L
Na 75 90
Cl 65 80
Glucose 75 111
K 20 20
Base 10 10
Total 245 311
Old & New ORS (1L)

92. 92
Old vs. New ORS
Old
 Hypertonic
 More vomiting
 More stools
 IVF
New
 Hypotonic
 -20%
 -30%
 -33%

93. 93
Rice based ORS
 Water 500ml
 Rice powder 30-40 g
 NaCl 2.5 g
Boil for 5-7 min
Rice ORS is equally effective
Don’t consider it as food!

94. 94
Home Made SSS (salt sugar solution)
 Water 500 ml
 Table salt 3 finger pinch
 Sugar/molasses 4 finger grip
3 finger pinch
4 finger grip

95. 95
Use of ORS
 Only for diarrhea or V+D
 Not for vomiting alone
 Never as soft drink nor tonic or water
 Do not use in excess
Rice ORS is not a food!

96. 96
ORS may be Ineffective
 Severe dehydration, vomiting
 Lethargic, unconscious
 Rapid loss of water
 Sugar malabsorption (large stools, reducing substance)

97. 97

98. 98
 WHO: increased fluids (ORS or home-made SSS plus
continued feeding (IF/CF)
 It is the key program to control diarrhea dehydration
Sugar-salt soln. (SSS)
Oral Rehydration Therapy (ORT)?

99. 99
ORT Corner
 OPD room for ORT
 Trained person, ORS & tools
 For ‘No- & Some- dehydration’
 4 - hr stay  reassessed
 Mostly return home
 Some may need admission
 Training & counseling mothers

100. 100

101. 101
Antimicrobials in Diarrheas
 Not used routinely, mostly NONE
 Kills commensals
 Secondary/superinfection
 Expensive, toxic, allergic

102. 102
Indications of ABT
 Shigellosis
 Inv. salmonellosis
 Cholera
 Giardiasis
 E. histolytica
 C. jejuni
 Y. enterocolitica

103. 103
Do not use:
 Loperamide, diphenoxylate: not effective: SoB &
severe distension
 Antispasmodics: inhibit peristalsis
 Kaolin, pectin, charcoal, attapulgite:  consistency, but
no  fluid loss. They can  action of other drugs

104. 104
ZINC IN DIARRHEA (ICCDR’B)
 Significant role in the MDG #4
 Globally, 400,000 lives could be saved:
  severity, duration, recurrence, admission
 positive impact on pneumonia
 Entire U-5 of Bangladesh is targeted:
 It could save 75,000 lives/y

105. 105
Why Zinc Rx. In Bangladesh?
 It is rich in protein foods: poor have  Zn
 Soil is poor in Zn
 U-5 are the most vulnerable
 Evidence of benefit exists
 Essential for growth, immunity
 Supplement till ideal foods for all attained

106. 106
Prevention of Diarrhea
 EBF, no bottle nor formula
 Hand washing
 Safe food, water
 Safe eating
 Disposal of excreta
 Immunization
 HPVAC
 Safe complementary feeds
 No overcrowding
All are virtually low-cost interventions

107. 107

108. 108
Vaccines for Diarrhea
 Cholera (Dukoral)
 Rota virus
 ETEC (Dukoral)
 Typhoid
 Measles

109. 109
MESSAGE
 ORT  diarrheal MR by 70%
 No ABT in most diarrheas
 Feeding is v. important
 Prevention is low-cost
 Zn has a role
 Vitamin A in prolonged diarrhea

110. HUS
destroys RBCs. It is the commonest c/of ARF in children.
Although it can cause serious complications, most
children recover
 Healthy RBC are smooth & round. In HUS, toxins destroy
RBC & render them misshapen (schistocyte): may
clog the tiny BV in the kidneys
110

111. 111
Healthy RBCs (left) are smooth & round. In HUS, toxins
destroy them (right). These misshapen cells may clog the

112. Causes of HUS
 E. coli toxins destroy RBCs
 It is found in contaminated meat, dairies, & juice.
Swimming pools or lakes can be contaminated
 Most E coli AGE recover fully & do not develop HUS
112

113. CF of HUS
 The child is pale, tired, irritable. May have small bruises,
epistaxis, haematuria. SS may not develop till a week
 ARF (>50%). Damaged RBCs, acid hematin clog the tiny BV
in the kidneys. CF of AGN may appear. UOP falls. HTN
 Anuria for 12h should attend ED
Diagnosis
 H/o & PE. Dx is confirmed by PBF study to see if the RBC
are misshapen
CF: cl. features. ED: emergency dept.
113

114. Rx
 Maintaining FEB to ease SS & prevent further problems
 BT may be needed
 In severe cases: dialysis
 Some children may develop CKD
 Limiting protein in diet & treating HTN with ACEI helps
delay/prevent the onset of CKD
 Most children recover completely
114

115. Prevention
 Food hygiene especially for meats; avoiding unclean
swimming areas are the best ways
Points to Ponder
 HUS is the commonest c/of short-term-ARF in children.
Most children recover
 Most cases of HUS follow an AGE by E. coli
 Maintaining FEB eases SS & prevents further problems
 A child may need BT
 Only the most severe cases require dialysis
115

116. 116
MCQ
 Diarrhea is the biggest child killer
 Ac. ID causes more dehydration than AWD
 Shigella is the commonest c/of Ac. ID
 Diarrhea can cause ARF
 Glucose in ORS is meant for providing nutrition
 C jejuni can cause GBS

117. 117
MCQ
 Most diarrheas do not need ABT
 Cholera is an example of ac. invasive D
 In EBF babies diarrhea is virtually nil
 Persistent D is synonymous with chr. D
 Giardia causes ac. invasive D
 Breast milk stools can cause dehydration

118. 118
MCQ
 Persistent D with mild dehydration is severe PD
 Zinc Rx reduces diarrheal mortality
 Breast milk is discontinued if there is lactose intolerance
 Vitamin A is supplemented in prolonged diarrhea
 Diarrhea prevention interventions are expensive

119. 119
OSPE
 A 3 mo old formula fed child had mild runny nose &
cough for 1 d. It was f/by passage of frequent loose
watery motions containing flakes of feces.
– What is the most probable Dx?
 He was lethargic & could not drink. He had sunken eyes
& skin pinch went back v. slowly
– Classify his dehydration according to IMCI
– How do you treat this child?

120. 120
 A 2y old child had ac. HGF with V & AP immediately f/by
frequent loose mucoid & bloody stools. He had
tenesmus.
– What is the most probable Dx?
– How can you confirm it?
 He was restless with sunken eyes but drank eagerly; skin
pinch went back slowly.
– Classify his dehydration according to IMCI
– How do treat it?
– What ABT do you suggest?
OSPE

123. 123
Next Lec.
Infant Feeding

124. 124
THANK YOU