ACUTE DIARRHEAL

DISEASE
Dr. SAIMA BAIRAM
Community medicine department
2014
 ACUTE DIARRHEAL
DISEASES
 Diarrhea
the passage of loose liquid or watery stool, passed more than
three times a day
 Diarrheal disease
group of diseases in which the predominant symptom is
diarrhea
 Clinical types of diarrheal disease
1. Acute watery diarrhea :lasts for several hours to days main danger is
dehydration, wt loss if feeding not continued, mainly caused by V.cholerae
or E coli bacteria and rotavirus
2. Acute bloody diarrhea:(dysentery)- main danger to intestinal mucosa,
sepsis and malnutrition , dehydration, marked by visible blood in stool
caused by shigella
 ACUTE DIARRHEAL
DISEASES
3. Persistent diarrhea: last for 14 days or long main danger is malnutrition

and serious non-intestinal infection, dehydration: e.g persons with illness

like AIDS

4. Diarrhea with sever malnutrition; dangers are sever systemic infection

dehydration heart failure and vitamin and mineral deficiency

Q:- Name of diarrhea in Urdu?

 ACUTE DIARRHEAL
DISEASES
 Diarrhea kills 2,195 children every day—more than AIDS, malaria, and
measles combined
 Globally, there are nearly 1.7 billion cases of diarrhoeal disease every year
( 4.6 million children died each year of dehydration caused by diarrhea
before Diarrhoeal disease control programme by WHO in 1980)
 Diarrheal disease is the second leading cause of death in children under
five years old
 Each year, an estimated 2.5 billion cases of diarrhoea occur among
children under five years of age (More than half of these cases are in Africa
and South Asia)
 Each year diarrhoea kills around 760 000 children under five
 Diarrhoea is a leading cause of malnutrition in children under five years old
 EPIDEMIOLOGICAL DETERMINANTS

 Agent factors
VIRUSES BACTERIA OTHERS

Rota viruses Camplylobacter E.Histolytica

jejuni
Astroviruses Escherichia coli Giardia intestinalis

Adenoviruses Shigella Trichuriasis

Calcivirus Salmonela Cryptosporidium

Norwalk group Vibrio- cholerae Intestinal worms

viruses
enteroviruses Bacillus cereus
 EPIDEMIOLOGICAL DETERMINANTS
Pathogens frequently identified in children with acute
diarrhoea

PATHOGEN % OF CASES

Viruses rotavirus 15 -25%

Bacteria E.Coli 10 -20 %

Shigella 5 -15 %

Campylobacter jejuni 10 -15 %

V.Cholerae 5- 10%

Salmonalla 1-5 %

protozoans Cryptosporidium 5- 15%

 EPIDEMIOLOGICAL DETERMINANTS

 DIARRHOEA OF NON-DIGESTIVE ORIGIN ( esp. in young

children)
 ENT infection
 Respiratory infection
 Urinary infection
 Malaria
 Bacterial meningitis
 Simple teething
 Malnutrition –leads to Kwashiorkor, coeliac disease and pellagra=
associated with dirrhoea
 EPIDEMIOLOGICAL DETERMINANTS

 Viruses- Rotavirus
 Discovered in 1973
 Leading cause of sever dehydrating diarrhoea in
children < 5 yrs
 Incidence peak during winter season
 It is shed in very high concentration ( >10 12
particles / gram) for many days in stool and vomit of infected person
 Transmission occurs primarily by faecal-oral route , direct from person to person
and indirectly -formites
 EPIDEMIOLOGICAL DETERMINANTS

 Bacterial causes
 E coli
 Diarrhea is mediated by toxins
 Causes acute watery diarrhea
 Travelers' diarrhea
 Spreads mainly by contaminated food and water
 EPIDEMIOLOGICAL DETERMINANTS

 Reservoir of infection: man & animal

 Enterotoxigenic E. coli, Shiegella, V. Cholerae, Giardia lamblia and E.

histolytica – man is principle reservoir and transmission originate from

humans

 Campylobacter jejuni, Salmonella- animals are important reservoir

and transmission originate from both animal and human feces

 Viral agent of diarrhea- role of animal reservoir is uncertain

 EPIDEMIOLOGICAL DETERMINANTS

 HOST FACTORS
 AGE
 Children age 6 months to 2 years (esp. 6 -11 months when
weaning starts
 Children <6 months age who are on artificial feeding
 Reason-- declining levels of maternally acquired antibodies, lack of active immunity
in infants, introduction of contaminated food and direct contact with human or animal
feces when infant starts to crawl
 Person with Malnutrition – vicious cycle( malnutrition –infection-
diarrhoea- malnutrition)
 Contributory factors-- poverty, prematurity, reduced gastric acidity,
immunodeficiency, lack of personal and domestic hygiene and
incorrect feeding practices
 EPIDEMIOLOGICAL DETERMINANTS

 Environmental factors
 Bacterial diarrheal:- warm climate
 Viral diarrheal :- cold climate (winters), in tropical area rotavirus
infection occur through out the year
 Complex emergencies and natural disasters:-
 Displacement of population into temporary, overcrowded shelters is often
associated with polluted water sources, inadequate sanitation poor hygiene
practices, contaminated food and malnutrition
 Mode of Transmission

 Faecal-oral route transmitted may be by:-

 Water-borne
 Food- borne
 Direct ( fingers, fomites or dirt )
 Control of Diarrheal Diseases

 DIARRHOEAL DISEASES CONTROL PROGRAMME BY WHO IN 1980

COMPONENTS OF DIARRHOEAL DISEASE CONTROL PROGRAM
 SHORT –TERM
a. Appropriate clinical management
 Oral rehydration therapy
 Intravenous rehydration
 Maintenance therapy
 Appropriate feeding
 Chemotherapy
 Zinc supplementation
 LONG –TERM
a. Better MCH services( maternal nutrition, child nutrition)
b. Preventive strategies( sanitation, health education, immunization)
c. Preventing diarrheal epidemics
 Control of Diarrhoeal Diseases

 SHORT –TERM
a. APPROPRIATE CLINICAL MANAGEMENT
 ORAL REHYDRATION THERAPY
 Aim: To prevent dehydration and reduce mortality
 ORS: oral rehydration salt
 Two types:
 ORS citrate
 Composition: (in 1 litre of potable or pre- boiled water)
 Sodium chloride 3.5 gms
 Potassium chloride 1.5 gms
 Tri-sodium citrate dihydrate 2.9 gms
 Glucose anhydrous 20 gms
 ORS: Oral Rehydration Salt

 ORS Bicarbonate: (in 1 litre of potable or pre- boiled

water)
 Sodium bicarbonate 2.5 gms
 Sodium chloride 3.5 gms
 Potassium chloride 1.5 gms
 Glucose(Dextrose) 20 gms
 ORS Citrate is better one because:-
 Tri-sodium citrate has made product more stable
 Less stool because of direct effect of tri-sodium citrate in increasing
intestinal absorption of sodium and water
 Guidelines for assessing dehydration and
oral rehydration

Dehydration:
 75% of the body's weight is made up of water

 Dehydration is an abnormal condition in which the body's cells are

deprived of an adequate amount of water

 Dehydration negatively affects important bodily functions, including

toxin elimination, delivery of nutrients and oxygen to the cells of the
body, energy production, and joint lubrication. Severe dehydration
affects every body system and can also impact the proper balance
of vital electrolytes.
 Causes of dehydration

 Diarrhoea:
 Vomiting:
 Sweat:
• The body can lose significant amounts of water in the form of sweat when it
tries to cool itself.
• Whether the body temperature is increased because of working or
exercising in a hot environment or because a fever is present due to an
infection; the body uses water in the form of sweat to cool itself.
• Depending upon weather conditions, a brisk walk may generate up to 16
ounces of sweat (a pound of water) an hour to allow body cooling, and that
water needs to be replaced by the thirst mechanism signalling the person to
drink fluids
 Causes dehydration
 Diabetes:
• In people with diabetes, elevated blood sugar levels cause
sugar to spill into the urine and water then follows, which
may cause significant dehydration., (polyuria)
 Burns:
• The skin acts as a protective barrier for the body and is also
responsible for regulating fluid loss.
• Burn victims become dehydrated because the damaged
skin cannot prevent fluid from seeping out of the body.
 Causes dehydration
 Inability to drink fluids:
• The inability to drink adequately is the other potential cause of
dehydration.
• Whether it is the lack of availability of water, intense nausea with or
without vomiting, or the lack of strength to drink, this, coupled with
routine or extraordinary water losses can compound the degree of
dehydration
 Signs and Symptoms of
Dehydration
• The body's initial responses to dehydration are thirst to increase
water intake, and decreased urine output to try to conserve water
loss. The urine will become concentrated and more yellow in colour.

• As the level of water loss increases, more symptoms can become

apparent
 signs and symptoms of dehydration

 The following are signs and symptoms of dehydration.

 Dry mouth
 The eyes stop making tears
 Sweating may stop
 Muscle cramps
 Nausea and vomiting
 Heart palpitations
 Light-headedness (especially when standing)
 Weakness
 Decreased urine output
 With severe dehydration, confusion and weakness will occur as the brain
and other body organs receive less blood. Finally, coma, organ failure,
and death eventually will occur if the dehydration remains untreated
 Assessment of dehydration
Mild Severe
Patients appearance Thirsty, alert, restless Drowsy, limp, cold,
sweaty, may be
comatose
Radical pulse Normal rate and Rapid, feeble,
volume sometime impalpable
Blood Pressure Normal < 80 mmHg, OR
recordable
Skin elasticity Pinch retracts Pinch retracts very
immediately slowly(more than 2
seconds)
Tongue Moist Very dry
Ant. Fontanelle Normal Very sunken
Urine flow Normal Little OR None
% of body loss 4-5% 10% or more
Estimated fluid deficit 40-50ml 100-110 ml/kg
 Guidelines for oral
rehydration
 Guidelines for oral rehydration therapy (for all ages) during the first
four hours
 (*) The age of patients should only be used if wt is not known. The
approximate amount of ORS required in ml is also calculated by
multiplying the pts wt (expressed in kg) by 75

Age (*) Under 4-11 1-2 2-4 5-14 15 or

4 month yrs yrs yrs over
s
Weight(k Under 5-7.9 8-10.9 11- 16- 30 or over
g) 5 15.9 29.9
ORS 200- 400- 600- 800- 1200- 2200-
solution 400 600 800 1200 2200 4000
ml)
 Guidelines for oral
rehydration
 Initial treatment with ORS over a period of 4 hrs
 Amount of ORS in ml is calculated by multiplying child's
wt in kg by 75
 ORS is given slowly during this time by spoonfuls or sips
 Breast feeding should be continued
 After 4 hrs child is re-assessed and re- classified for
dehydration
 ORS prepared at home:( indigenous ORS)

 Advice mother or care taker to wash hands with soap

and water
 4 Glasses of pre-boiled cooled water (1 liter)
 8 Tea spoon full/4 Table spoon full of sugar/ 1 fist (20
gms)
 1 or 2 Teaspoon full/1 Table spoon full of common salt/ 1
pinch (5gms)
 Few drops of lemon juice if easily available
 Mix well and use within 24 hrs
 Fluids to be avoided during
diarrhea
 Few fluids are potentially dangerous and should be avoided during
diarrhea
 Drinks sweetened with sugar(cause osmotic diarrhea and hyper-
natraemia)
 Commercial carbonated beverages
 Commercial fruit juices
 Sweetened tea
 Coffee (stimulant or purgative effect)
 Intravenous Rehydration

 Required in sever dehydration , patient in shock and those unable

to drink
 Solutions recommended by WHO are:
 Ringers lactate solution: adequate concentration sodium
and potassium and lactate yields bicarbonate for correction
of acidosis
 Diarrhoea treatment solution(DTS):it contains in 1 litre
sodium chloride(4g) sodium acetate(6.5g) potassium
chloride(1g) glucose (10g)
 Normal saline: if nothing else available, poorest solution, it
will not correct acidosis and does not replace potassium
 Treatment Plan For Rehydration
Therapy

 Give IV fluids immediately. If the child can drink,

give ORS by mouth while the drip is set up.
 Give 100ml/kg Ringers Lactate solution(if not
available normal saline) divided as follows:
AGE First give 30 Then give
ml/kg 70ml/kg

Infants( under 12 1 hour 5 hour

months

Children(12 months 30 minutes 2 ½ hours

up to 5 years)
 Treatment Plan For Rehydration Therapy

 Reassess the patient every 1-2 hours

 After infusion 1-2 liters of fluid, rehydration should be
carried out at a somewhat slower rate until pulse and bd pr
return to normal
 When patient can drink the oral fluids gives ORS about
5ml/kg/hour
 SHORT –TERM
Appropriate clinical management

 Maintenance Therapy
 Appropriate Feeding
 Chemotherapy
 Zinc supplementation