1. Diarrhea

2. Diarrhoea What is Diarrhoea? Diarrhoea is a symptom characterized by an abnormal increase in stool frequency (more than 3 times daily) or liquidity (> 80% water); Diarrhoea is a symptom characterized by an abnormal increase in stool frequency (more than 3 times daily) or liquidity (> 80% water); The normal frequency of bowel movements varies with each individual The normal frequency of bowel movements varies with each individual

3. Diarrhoea DEFINITIONS – IDSA & WGO “Diarrhea” is an alteration in a normal bowel movement characterized by an increase in the water content, volume, or frequency of stools. In adults, a decrease in consistency (i.e., soft or liquid) and an increase in frequency of bowel movements to >3 stools per day (24 hrs) have often been used as a definition for epidemiological investigations. Diarrhea is defined as daily stools with a mass greater than 15 g/kg for children younger than 2 years and greater than 200 g for children aged 2 years and older. “Infectious diarrhea” is diarrhea due to an infectious etiology, often accompanied by symptoms of nausea, vomiting, or abdominal cramps. Dysentery describes an infectious diarrhea with visible blood and mucus in the stool. “Acute diarrhea” is an episode of diarrhea of <14 days in duration. “Persistent diarrhea” is diarrhea of 14 or more days in duration. Some experts refer to diarrhea that lasts 30 days or more as “chronic.” 3

4. Diarrhoea

5. Causes: bacterial or viral infection through ingestion of contaminated food or drink; bacterial or viral infection through ingestion of contaminated food or drink; 1. E.Coli, S.aureus  toxins  mucosal cells  hypersecretion of fluid  watery diarrhoea with little or no fever or other symptoms;

6. Diarrhoea Causes: 2.Invasive E. coli, salmonella and shigella: directly invade mucosal epithelial cells and cause an inflammatory reaction  less fluid diarrhoea accompanied by nausea, vomiting, cramps and sometimes low-grade fever

7. Diarrhoea Causes: 3.Viral infections, which often affect babies and young children, also produce watery diarrhoea 4.Non-infective causes: stress, alcohol, and hot spicy food 5.Drugs: antibiotics “all but varying degrees”. Depends on extent that drug disrupts normal intestinal microflora. Other: laxatives, misoprostol. Olsalazine, anticancer, antihypertensive agents, parasympathomimitic drugs, digoxin, quinidine, magnesium hydroxide. 6.Chronic diarrhea. Lasts more than 4 weeks. Protozoal infections, food, IBS, hyperthyroidism.

8. Diarrhoea Infectious diarrhea Infectious diarrhea is further classified into non-inflammatory and inflammatory diarrhea. 8 Non-inflammatory diarrheasInflammatory diarrheas Generally a less severe illnessGenerally a more severe illness Patients present with nonbloody, watery stools; patients are afebrile and without significant abdominal pain. Patients present with bloody diarrhea, severe abdominal pain, and fever. Examination of stool specimens does not reveal the presence of fecal white blood cells (WBC) or occult blood. Examination of stool specimens reveals the presence of large numbers of fecal leukocytes. Typically caused by rotaviruses, noroviruses, Staphylococcus aureus, Bacillus cereus, Clostridium perfringens, Cryptosporidium parvum, and Giardia lamblia. Caused by invasive pathogens including Campylobacter jejuni, Shigella species, Salmonella species, Clostridium difficile, Shiga toxin-producing Escherichia coli (STEC), and Entamoeba histolytica. Most patients require only supportive therapies Selected persons may benefit from antimicrobial therapy directed at the causative pathogen.

9. Diarrhoea

10. Consequences Normal faeces contain 60-85 % water Normal faeces contain 60-85 % water Water loss during defecation= 70-200 mL/day Water loss during defecation= 70-200 mL/day In diarrhoea: water loss 4X normal  K and Na loss  fall in plasma pH (acidosis)  serious metabolic consequences In diarrhoea: water loss 4X normal  K and Na loss  fall in plasma pH (acidosis)  serious metabolic consequences Fluid & electrolyte losses are increased if vomiting also occurs

11. Diarrhoea Consequences In babies/children: hazardous as high proportion of total body weight is lost and dehydration can occur very rapidly In babies/children: hazardous as high proportion of total body weight is lost and dehydration can occur very rapidly Elderly are also particularly sensitive to the effects of fluid and electrolytes loss, especially if on diuretics Elderly are also particularly sensitive to the effects of fluid and electrolytes loss, especially if on diuretics Reduction in blood volume  + RAS  + aldosterone  (1) loss of K (hypokalemia) Reduction in blood volume  + RAS  + aldosterone  (1) loss of K (hypokalemia) (2) Excessive fluid loss  reduction of renal artery flow  renal failure

12. Diarrhoea Patient Evaluation: All of the following must be considered before selecting the most appropriate management.  Age  Onset and duration or diarrhea  Description of stool  Other symptoms  Medications  Recent travel  Medical history. 12

13. Diarrhoea When to refer to a physician  Very young or very old.  Blood/mucus in stool.  High fever (greater than 38.5 ˚C).  Dehydration or weight loss greater than 5 % of total body weight. Signs of dehydration: dry mouth, sunken eyes, crying without tears, dry skin that is less elastic than normal skin (decreased skin turgor with tenting).  Severe vomiting..  Duration: (see following slide) 13

14. Diarrhoea

15. When to Refer? (Duration) If diarrhoea lasts more than: 72 hours : adults and older children 72 hours : adults and older children 48 hours : children < 3 years old & elderly 48 hours : children < 3 years old & elderly 24 hours in children < 1 year old 24 hours in children < 1 year old Refer Immediately in infants under 3 months old Refer Immediately in infants under 3 months old

16. Diarrhoea 16

17. Diarrhoea Treatment of children based on the degree of dehydration 17

18. Diarrhoea

19. Treatment Oral rehydration therapy (ORT) Oral rehydration therapy (ORT) Opioids Opioids Adsorpants Adsorpants Dietary management Dietary management In UK: belladonna extract In UK: belladonna extract

20. Diarrhoea Oral rehydration therapy (ORT) First line treatment of acute diarrhoea First line treatment of acute diarrhoea the very young & elderly (particularly important) the very young & elderly (particularly important) ORT not intended to relieve symptoms ORT not intended to relieve symptoms Use of antidiarrheals (antimotility drugs or adorbants) is regarded unnecessary and sometimes undesirable Use of antidiarrheals (antimotility drugs or adorbants) is regarded unnecessary and sometimes undesirable Use of antidiarrheals (for comfort/convenience) is used as adjunct to ORT Use of antidiarrheals (for comfort/convenience) is used as adjunct to ORT

21. Diarrhoea Oral rehydration therapy (ORT) Mode of action: replace water and electrolytes lost through diarrhoea and vomiting; replace water and electrolytes lost through diarrhoea and vomiting; K & Na: replace ions K & Na: replace ions citrate and/or bicarbonate: correct acidosis citrate and/or bicarbonate: correct acidosis glucose: carrier for Na ions and hence water across the mucosa of the small intestine glucose: carrier for Na ions and hence water across the mucosa of the small intestine

22. Diarrhoea Oral rehydration therapy (ORT) ORT is not intended to stop diarrhoea, but acute diarrhoea is self-limiting and normally ceases within 24-48 hours; ORT is not intended to stop diarrhoea, but acute diarrhoea is self-limiting and normally ceases within 24-48 hours; ORT can be recommended for patients of any age, even when referral to a doctor is considered necessary ORT can be recommended for patients of any age, even when referral to a doctor is considered necessary

23. Diarrhoea An oral rehydration product (Dioralyte Relief [Sanofi-Aventis]) containing powdered rice starch in place of glucose is claimed to achieve even greater rehydration than glucose over time, and the rice starch is claimed to help produce firmer stools, leading to faster recovery compared with glucose. A Cochrane Review found that polymer (including rice)-based ORS showed some advantages compared with glucose-based ORS for treating diarrhea of any cause. 23

24. Diarrhoea

25. Dose & Administration of ORS the content of 1 sachet or 2 effervescent tablets should be dissolved in 200-250 ml of water (freshly bolied and cooled in case of infants) the content of 1 sachet or 2 effervescent tablets should be dissolved in 200-250 ml of water (freshly bolied and cooled in case of infants) discard unused solution 1 hr after reconstitution or no longer than 24 hrs (if refrigerated) discard unused solution 1 hr after reconstitution or no longer than 24 hrs (if refrigerated) Dose, adults: 200-400 ml after every loose motion, or 2-4 L over 4-6 hrs Dose, adults: 200-400 ml after every loose motion, or 2-4 L over 4-6 hrs

26. Diarrhoea Dose & Administration of ORS Patients may prefer to sip 1-2 tsp every few minutes rather than drink large quantities less frequently Patients may prefer to sip 1-2 tsp every few minutes rather than drink large quantities less frequently children > 2 yrs: cupful (200ml) after every loose stool children > 2 yrs: cupful (200ml) after every loose stool children < 2 yrs: ¼- ½ cupful children < 2 yrs: ¼- ½ cupful Infants: 1-1.5 normal feed volume Infants: 1-1.5 normal feed volume Both breast and bottle-fed babies should continue to be fed normally (without dilution) Both breast and bottle-fed babies should continue to be fed normally (without dilution)

27. Diarrhoea Contraindications & cautions No contraindications to ORS unless the patient is vomiting frequently  IV fluid and electrolyte replacement; No contraindications to ORS unless the patient is vomiting frequently  IV fluid and electrolyte replacement; fluid overload from excessive administration of ORS is highly unlikely unless continued for babies and young children > 48 hrs (recognised by puffy eyelids)  rapidly withhold ORS and other liquids fluid overload from excessive administration of ORS is highly unlikely unless continued for babies and young children > 48 hrs (recognised by puffy eyelids)  rapidly withhold ORS and other liquids

28. Diarrhoea Dietary Management Traditionally: withdrawal of feedings, initiation of clear liquids, with a slow reintroduction of feedings in 24 hrs Traditionally: withdrawal of feedings, initiation of clear liquids, with a slow reintroduction of feedings in 24 hrs However, oral intake does not worsen diarrhoea, clinically significant nutrient malabsorption is uncommon (80-95% CHO, 70% of fat and 75% of the nitrogen from protein) in acute diarrhoea and bowel rest is generally not necessary However, oral intake does not worsen diarrhoea, clinically significant nutrient malabsorption is uncommon (80-95% CHO, 70% of fat and 75% of the nitrogen from protein) in acute diarrhoea and bowel rest is generally not necessary

29. Diarrhoea What foods are best for refeeding? Diet should include: complex carbohydrate-rich foods (e.g. white boiled rice, potatoes, white bread) complex carbohydrate-rich foods (e.g. white boiled rice, potatoes, white bread) Yogurt (why?) Yogurt (why?) lean meats (e.g. steamed chicken) lean meats (e.g. steamed chicken) Some fruits and vegetables (e.g. blueberries, bananas) Some fruits and vegetables (e.g. blueberries, bananas)

30. Diarrhoea What foods are best for refeeding? most infants and children with diarheoa can tolerate full-strength breast milk and cow’s milk; most infants and children with diarheoa can tolerate full-strength breast milk and cow’s milk; The familiar BRAT (bananas, rice, apple sauce and toast) is frequently prescribed-  insufficient calories, protein and fat especially in strict or prolonged use and is not recommended by AAP The familiar BRAT (bananas, rice, apple sauce and toast) is frequently prescribed-  insufficient calories, protein and fat especially in strict or prolonged use and is not recommended by AAP