The document describes a clinical scenario of a 48-day-old infant with severe diarrhea and dehydration, detailing symptoms, examination findings, differential diagnoses, risk factors, pathogenesis, and mechanisms of diarrhea. It outlines treatment strategies, including fluid and electrolyte management, nutritional care, and specific interventions for various scenarios like severe dehydration or invasive diarrhea. It emphasizes the importance of preventive measures such as exclusive breastfeeding, improved sanitation, and proper feeding practices to reduce the incidence of diarrhea.

1. DIARRHOEA WITH
DEHYDRATION

2. CLINICAL SCENARIO
• A 48 days old infant with c/o
• loose stools for 4 days
• vomiting since 2 days
• associated with abdominal distension, fever, poor feeding and
irritability and decreased urine output of 1 day duration.
• Loose stools were watery, 8-10 episodes, yellowish in colour, and
there is no blood in stools.
• Vomitings – non bilious, non projectile, 3-4 episodes/day ,
contains food particles.

3. • Vitals :
• Temp : 102 F
• RR : 50/min
• HR : 180/min
• BP : 70/50 mm Hg

4. EXAMINATION FINDINGS
• CRT -4 sec periphery, central 2 sec
• Lethargic
• Acidotic breathing
• AF Depressed
• Sunken eyes present
• Skin pinch (>3 sec)
• Oral mucosa –dry
• Skin : mottling present

5. SYSTEMIC EXAMINATION
• CNS- conscious, lethargic. No focal deficit
noted.
• P/A : Soft, mild distension, liver just palpable,
• CVS : S1 and s2 are heard . No murmurs
• RS : B/L air entry present . No added sounds

6. Differential diagnosis :
• Acute gastroenteritis with severe dehydration
• Sepsis

7. • Definition:
• Passage of loose /watery stools atleast 3 times in a 24 hr period.
• Types of Diarrhoea
1. Acute watery diarrhoea,
2. Invasive bloody diarrhoea
3. Persistent diarrhoea
4. Chronic diarrhoea.

8. RISK FACTORS FOR ACUTE
DIARRHOEA
• Failure to breast feed exclusively for 4-6 months.
• Failure to breast feed until atleast 1 yr of age.
• Using infant feeding bottles .
• Failure to dispose off infant feces hygenically.
• Drinking contaminated water.

9. PREDISPOSING FACTORS
• Under nutrition
• Recent measles (in previous 4 weeks )
• Immunodeficiency
• 1st 2 years of life

11. ASSOCIATED CONDITIONS
• Systemic infections associated with diarrhea include influenza,
measles, dengue fever, human immunodeficiency virus
infection, and malaria.
• Serious bacterial infections associated with diarrhea include
pneumonia, urinary tract infection, meningitis, and sepsis.
• Surgical emergencies such as intussusception or appendicitis
also may present with diarrhea.

12. PATHOGENESIS
• Viral diarrhoeas :
• Replicate within the villous epithelium causing patchy epithelial
cell destruction and villous shortening.
• Loss of disaccharidase enzyme - lactose malabsorption

14. • Bacterial diarrhoeas :
• Mucosal adhesion : results in reduced absorptive capacity . Eg :
EPEC, EAEC
• Secretion of toxins : alter epithelial cell function. Absorption of
sodium is decreased and secretion of chloride is increased. Eg :
ETEC,V. Cholerae, Salmonella
• Mucosal invasion : Destruction of mucosal cells in colon and distal
ileum with formation of invasion micro abscesses and superficial
ulcers and mucous secretion of water and electrolytes . Eg : EIEC,
Shigella.

16. • Protozoal Diarrhoeas :
• Production of micro abscesses

17. MECHANISMS OF DIARRHOEA
• Osmotic Diarrhoea :
• Diarrhoea occurs when a poorly absorbed substance osmotically
active substance is present in the gut.
• Substance is isotonic / hypertonic
• Stooling stops on fasting
• Stool ph acidic
• Reducing substances positive
• Eg: rotavirus diarrhoea, disaccharide malabsorption .

18. • Secretory diarrhoea :
• Abnormal secretion of water and salt into the small bowel.
• Due to impaired absorption of sodium absorption by the villi and
increased secretion of chloride in crypts.
• Eg: mediators like Cyclic AMP of cholera, Cyclic GMP of ETEC
• Stooling continues even on fasting , stool ph alkaline , reducing
substances are negative.

19. • Inflammatory Diarrhoea :
• Infective or non infective
• Fever , blood in stools, abdominal cramps,
tenesmus and increased fetal leucocytes .

20. CLINICAL ASSESSMENT
• Classification of type of diarrhoeal illness
• History
• Presence of fever, cough, or other important problems (e.g.
convulsions, recent measles);
• Pre-illness feeding practices;
• Type and amount of fluids (including breastmilk) and food taken
during the illness;
• Drugs or other remedies taken;
• Immunization history

23. • Degree of dehydration should be assessed based on
physical signs and symptoms
• WHO GUIDELINES

25. • Nutritional status :
• Recurrent diarrhea in childhood is associated with malnutrition,
which contributes to delays or irreversible deficits in physical
and cognitive development.
• Children with acute diarrhoea and malnutrition are at increased
risk for developing fluid overload and heart failure during
rehydration
• The risk of serious bacterial infection is also high.
• As a result, such children require an individualized approach to
rehydration, nutritional care, and antibiotics

26. • Physical examination :
• Temperature : Fever/ hypothermia
• Respiratory tract : Tachypnoea, cough or difficulty breathing.
Assessed for pneumonia following initial rehydration.
• Abdomen : abdominal pain out of proportion to typical GE – surgical
emergencies (intussusception, appendicitis).
• CNS : irritability, lethargic and coma,
encephalopathy/seizure(shigella)
• If child with diarrhoea has seizures r/o hypoglycemia,
hyponatremia, hypernatremia, meningitis, febrile seizures,

27. DIAGNOSTIC STUDIES
• Child presented with seizures/ altered consciousness- glucose and
electrolytes assessment
• Suspected pneumonia , sepsis, meningitis , UTI or HIV infection –
relevant investigations
• Acute abdominal findings on physical examination – imaging
studies
• Stool microscopy :
• Cholera
• Acute bloody diarrhoea (E. histolytica )
• Invasive bloody diarrhoea not responding to empiric antibiotic therapy .

28. TREATMENT
• Correct fluid and electrolyte losses
• Fluid management – 2 phases :
1.Replacement : Replenish deficits in water and electrolytes lost.
Continued until all signs and symptoms of volume depletion are absent
and patient has urinated
2.Maintenance : counters ongoing losses of water and electrolytes.
Continued until all symptoms resolve.
• ORS in both replacement and maintenance phase .
• Severe dehydration – replacement with intravenous fluids .

30. NO SIGNS OF DEHYDRATION (<5%):
• Only maintenance therapy- ORS to counter ongoing losses.
• No hospital admission, only brief period of observation to verify that
the child is tolerating oral fluids.
• <2 yrs :50-100ml of ORS/each episode of loose stool
• >2 yrs : 100-200ml of ORS/ each episode of loose stool.
• Older children and adults : as much as they want .
• Supplemental fluids along with ongoing feeding are enough if stool
amount is modest.

32. VITAMINS AND MINERALS
• Zinc supplementation
• It reduces the frequency, duration and recurrence of diarrhoea .
• In less than 6m : 10mg/day, >6m : 20mg/day.

33. NUTRITION
• Encourage sufficient feeding both during and after diarrhoeal
illness.
• Infants :Breast feeds / undiluted formula feeds in addition to ORS.
• Children : solid foods rich in energy content and micronutrients at
frequent intervals

34. DANGER SIGNS
• Starts to pass many watery stools
• Has repeated vomiting
• Becomes very thirsty
• Is eating or drinking poorly
• Develops a fever
• Has blood in the stool
• The child does not get better in three days

35. SOME DEHYDRATION (5-10%)
• Require replacement therapy with ORS in supervised setting .
• Total fluid deficit to be given with 1st 3-4 hrs of presentation.
• If ongoing stool losses are profound these losses are added to the initial
amount of fluids given over 1st 4 hrs
• Observed fluid replacement and frequent reassessment of hydration
status is essential.
• Replacement should be continued until all signs of dehydration are
resolved and patient urinates.

37. SOME
DEHYDRATION
TOTAL FLUID
DEFICIT ( IN 4 HRS)
ASSESS
SOME
DEHYDRATION
REPEAT PLAN B
Offer foods and
fluids.
Reassess
frequently
NO
DEHYDRATION
(REHYDRATION
COMPLETE)
PLAN A
SEVERE
DEHYDRATION
PLAN C

38. ORAL REHYDRATION THERAPY FAILS
• The usual causes for these “failures” are:
• continuing rapid stool loss (more than 15-20 ml/kg/hour), as occurs
in some children with cholera;
• insufficient intake of ORS solution owing to fatigue or lethargy;
• frequent, severe vomiting.
• Such children should be given ORS solution by nasogastric (NG) tube
or Ringer's Lactate Solution intravenously (IV) (75 ml/kg in four hours),
usually in hospital.
• After confirming that the signs of dehydration have improved, it is
usually possible to resume ORT successfully

39. SEVERE DEHYDRATION
• The goal of rehydration with intravenous fluids is to stabilize the
circulation immediately.
• Isotonic crystalloid fluids such as Ringers’ Lactate solution or
normal saline be used.
Age 30ml/kg 70ml/kg
<12 months 1hr 5 hrs
>12 months 30mts 2.5 hrs

40. • ORS should be initiated in addition to intravenous fluids as soon as
the patient can drink.
• If child has seizures and hypoglycemia is suspected then a rapid
bolus of iv dextrose should be given followed by addition of 5 %
glucose to intravenous fluids .
• If iv access not established or no availablity of iv fluids then
administer fluids via NG tube or intraosseous access.

42. CHOLERA
• Dehydration : same guidelines .
• Some dehydration : give ORS , but in cases of profound vomiting
or continued stool losses give ORS along with intravenous fluids
• Patients with severe volume depletion or hypovolemic shock —
Intravenous fluids should be urgently administered to rapidly
restore circulation

43. • After being rehydrated, patients should be reassessed for signs of
dehydration at least every 1-2 hours, and more
often if there is profuse ongoing diarrhoea.
• If signs of dehydration reappear, ORS solution should be given
more rapidly. If patients become tired, vomit frequently or develop
abdominal distension, ORS solution should be stopped and
rehydration should be given IV with Ringer's Lactate Solution (50
ml/kg in three hours), with added potassium chloride.

45. INVASIVE DIARRHOEA

46. • Correction of fluid and electrolyte losses
• Appropriate nutritional care
• Treatment of underlying cause of illness
• Entamoeba histolytica :
• Metronidazole (35 to 50 mg/kg per day in three divided doses
for 7 to 10 days in children to a maximum of 750 mg PO three
times daily) is a standard treatment regimen with a cure rate of
approximately 90 percent

48. REHYDRATION IN MALNOURISHED CHILDREN
• Clinical signs of dehydration are masked.
• Signs that remain useful for assessing hydration status include:
• eagerness to drink (a sign of some dehydration),
• lethargy, cool and moist extremities, weak or absent radial
pulse, and reduced or absent urine flow (signs of severe
dehydration).
• Difficult to distinguish severe dehydration from septic shock.

52. DEHYDRATION IN NEPHROTIC SYNDROME
• First episodes or relapses of NS can be concurrent with acute
gastroenteritis(AGE) infections
• This condition can cause further deterioration of the hypovolemic
state, as intravascular water is lost through both AGE-related
vomiting/diarrhea and NS related fluid shifting into the interstitium
• A careful detection of all the signs of dehydration is fundamental,
and a proper and timely treatment could reduce the risk of a
possible evolution to AKI

53. • Assessment of fluid status in child with diarrhoea and AGE :
• Clinical :
low BP , high refill time Abnormal skin turgor
sunken eyes, weight
pallor, cold hands and feet,
drowsiness
• Laboratory :
• Urine sodium : <20 meq/l
• FeNa 0.2%
• Urinary K+/K+ + Na+ (ratio greater than 60%)

54. Acute GE + NS
Edema + hypovolemia
1 or 2 boluses of isotonic saline
(10-20ml/kg infused over 20-30
mts
i.v. 20% albumin infusion
(1.25–5 mL/kg in 3–4 h)
furosemide (1 mg/kg, during
the second half or at the end
of the albumin infusion)
i.v. 4.5% albumin solution
(10–20 mL/kg in 3–4 h) potentially
followed by furosemide

55. • Other problems with diarhoea
• Fever
• Convulsions
• Vitamin A deficiency.
• Usage of drugs :
• Antimicrobials
• Antidiarrhoeal drugs
• Antiemetics

56. PREVENTION
• Exclusive breastfeeding
• Improved feeding practices
• The consumption of safe food and water.
• Handwashing
• The use of latrines
• Immunizations