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Title: Diarrhoea

Name of the Lecturer: Dr.Winsely

Date: 15-04-2010

Lecture Series: Child Health

reserved to author and Christian Medical


College, Vellore

Diarrhoea

What is diarrhoea?

Three or more liquid stools a day


 A change in consistency and number of
stools, as perceived by the mother
 More than 10 gm/kg/day


Burden of diarrhoea
Global Deaths


Terrorism in 2005

2000

The Washington Post

Natural disasters in 2005 91,900


United nations development programme 2006 annual report

Diarrhoea in 2005

2,200,000

WHO 2005 State of World Health Report

Types of diarrhoea

Acute watery diarrhoea(<7


diarrhoea(<7 days)
 Acute bloody diarrhoea
 Intermediate diarrhoea(8
diarrhoea(8-14 days)
 Persistent diarrhoea(>14
diarrhoea(>14 days)
 Chronic diarrhoea(>14
diarrhoea(>14 days)


Pathogenesis of Diarrhoea





Secretory Diarrhoea
Osmotic Diarrhoea
Inflammatory Diarrhoea
Motility Diarrhoea

Toxin induced
Lactose intolerance
Shigella, EHEC
Hirschprung disease
Anorectal malformation

Secretory and Osmotic Diarrheas are more


common.

Mechanism of Secretory Diarrhea


Neurotransmitters
Hormones
Bacterial Enterotoxins
Cathartics

Stimulate receptors on the enterochromaffin cells


stimulate
Cyclic AMP Cyclic GMP
Ca ions
stimulate
Cl-, H2O and CHO3
Secretion by the enterocytes

Osmotic Diarrhea
IN THE SMALL INTESTINE
Ingestion of non-absorbable solutes
Fluid entry into the small bowel
Intraluminal solutions become iso-osmotic with the plasma
Intraluminal Na+ concentration drop below 80 m osmol

Steep lumen to plasma gradient

Osmotic Diarrhea
IN THE COLON
Carbohydrate

Non metabolizable substrates

Metabolized by Bacteria
Na+ and H2O
Short Chain fatty acids

may be absorbed by colon

(Organic anions)

Quadrupling the Osmolality

A linear relation between


ingested osmotic load &
stool water output

Osmotic Diarrhea
Short-Chain Fatty Acids
(Organic Anions)
Promote more fluid in the colon
Obligate retention of inorganic cations
Further increasing the osmotic load

More fluid in the colon

Osmotic Diarrhea


If the capacity of bacterial flora is


exceeded;
Unabsorbable carbohydrates
Organic anions
Inorganic cations
Fluids

Retained in the Colon

Secretory vs Osmotic








Dehydration
Dyselectrolytaemia
Large Volume Stool
Stool Sodium > 70
70mEq/L
mEq/L
Stool often Alkaline
No effect with
Discontinuation of feeding
Osmolality equals to ionic
constituents









Stools Small or large


volume, watery or loose
Stool sodium < 50 mEq/L
Stool Reaction Acidic (pH
< 5 .5 )
Discontinuation of feed
results in improvement.
Stool Osmolality Less than
the ionic Constituents
Perianal excoriation
Abdominal distention before
passing stool.

Viruses associated with gastroenteritis


rotaviruses
caliciviruses
Noroviruses
Sapoviruses
astroviruses
rotaviruses
adenoviruses 40, 41
Sapporo-like viruses

Norwalk-like viruses

Bacteria causing diarrhoea


Campylobacter, Shigella,
Salmonella, E. coli,
Vibrio cholerae, Aeromonas,
Yersinia


Parasites causing diarrhoea


Giardia,
 Cryptosporidium
 E. histolytica
 Strongyloides


CausesCauses- the top eight


Rotavirus 43.3%
Norovirus 15.8%
Enteropathogenic E. coli 15.8%
Cryptosporidium 15.2%
Adenovirus 6.4%
Enterotoxigenic E. coli 6.3%
Campylobacter 5.7%
Enterohamorrhagic E. coli 4.4%

Rotavirus
Norovirus
EPEC
Cryptosporidium
ETEC
Adenovirus
Campylobacter
Astrovirus
Vibrio
Shigella
Others
Unknown

Signs of Dehydration

Plan B
Oral rehydration with ORS
75
75ml/kg
ml/kg over 4 hrs
 Zinc
 Continue feeding
 Reassess


ORS
cyclic nucleotides induce fluid secretion

without affecting glucoseglucose-stimulated Na


absorption; and glucose enhances Na and
fluid absorption without modifying fluid
secretion
Glucose electrolyte solution with addition of
base

Reduced Osmolarity ORS


Reduced osmolarity ORS

grams/litre

Sodium chloride

2.6

Anhydrous Glucose

13.5

Potassium chloride

1.5

Trisodium citrate, dihydrate

2.9

Reduced osmolarity ORS

mmol/litre

Sodium

75

Anhydrous Glucose

75

Chloride

65

Potassium

20

Citrate

10

Total Osmolarity

245

Improved GI physiology in low


osmolarity ORS

Low OSm.
ORS

290
mmol/L
Blood

210
210--260
mmol/L
Small bowel

Increase in
Gastric emptying
Prevents vomiting

Net flow of water into Blood

Decrease in Stool Output

Advantage - Reduced
Osmolarity ORS







Reduces stool volume by 20%


Reduces vomiting by 30%
Reduces need for supplemental IV fluids by 33%
Decreased treatment failure to <3% from 5%
Reduced risk of hypernatremia

Plan C

WHO/UNICEF Joint statement on clinical


management of acute diarrhoea
Recommendations:
20 mg* per day of zinc supplementation for
1010-14 days starting as early as possible after
onset of diarrhoea

* 10 mg per day for infants <6 mo (more


evidence required)
Administration: Once or twice daily

What is dysentry?
Bloody diarrhea -

diarrheal episode with


visible red blood

Does not include:


a)
Blood streaks on surface of formed stool
b)
Blood detected only by microscopic
examination or biochemical tests.
c)
Digested blood (malena)
Syndrome of bloody diarrhea with fever,
abdominal cramps, rectal pain & mucoid stools

What antibiotic?


Dysentry (Shigella, E.Coli)

Co-trimoxazole
CoAmpicillin
Quinolone
Cephalosporin eg.Cefixime

Cholera
Doxycycline

Cryptosporidium
Nitazoxanide

Amoebiasis
Metronidazole

Other drugs in diarrhoea


Probiotics
 AntiAnti-secretory agents eg.Racecodotril


AntiAnti-motility agents eg.Loperamide


No Role in acute diarrhoea

Complications of Acute Diarrhoea












Dehydration
Acute renal failure
Venous Thrombosis - Cerebral, Renal
HUS ( Haemolytic Uraemic Syndrome)
Malabsorption (secondary lactose intolerence)
Intussusception
Disseminated Intravascular Coagulation
Persistent Diarrhoea
Dyselectrolytaemia

Copyright of this educational material rests with the


author and Christian Medical College, Vellore.
Duplication, revision and redistribution are not
permitted. For any further clarification please contact
the concerned author

reserved to author and Christian Medical College, Vellore

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