Diarrhea

Diarrhea Definition: Stool that contains more water than normal

Leading cause of death in developing Countries. 3.2 million deaths/Year in those <5y of age, with average 3.3 episodes of Diarrhea/year, may reach to 9/year. In some areas, death mostly occurs in the 1st 2 years of life (80%), the main causes are: dehydration, malnutrition & serious infection. Diarrhea represents an economic burden on the developing countries which includes bed-occupancy (about 1/3 of hospital beds in some countries occupied by patients with Diarrhea), also I.V. fluid (expensive), Rx. & ineffective drugs

Types of Diarrhea: - Acute watery: <14 days, some times associated with vomiting. - Dysentery: diarrhea + visible blood in the faces associated with rapid weight loss due to anorexia. - Persistent Diarrhea: >14days,episodes of watery Diarrhea or dysentery associated with dehydration & malnutrition. - Chronic Diarrhea: is not due to infection but chronic diseases (crohn`s, coeliac,..) so it is not included here.

Epidemiology: Transmission is promoted by specific behaviors: 1 Failing to breast–feed exclusively for the 1st 4-6 months of life. 2. Using infant feeding bottles. 3. Storing cooked food at room temperature. 4. Using drinking water contaminated with fecal bacteria. 5. Failing to wash hands after defecation, disposing of feces, or before handling food.

Etiology:- According to prevalence: Rota Virus ETEC enterotoxigenic E-coli. Shigella. Campylobacter jejuni. E.histolytica. V.cholerae Cryptosporidi Salmonella

Causes of Malnutrition in diarrhea 1. Reduced food intake due to:- - Anorexia (especially in dysentery) - Vomiting: with a low discourage attempts at feeding. - Withholding of food :based on traditional believes about Rx. Of D.(Rest the bowel). - Giving food with reduced nutrient value: gruel, soup in the believe that a diluted food is easier to digest.

2. Decreased absorption of nutrients: - Damage to the absorptive (villous) epithelial cells. - Disaccharide’s deficiency owing to impaired production of enzyme by the damage villous (may lead to mal-absorption of disaccharide sugar especially lactose) - Reduced internal concentration of bile acids that affects the fat absorption. - Rapid transit of food through the GIT, leaving an insufficient time for digestion and absorption

3. Increased nutrition requirements due to: - Metabolic demands with fever - Damaged appetite -The need to replace serum protein lost through the damaged mucosa as in dysentery.

Prevention of Diarrhea: Giving only breast milk for the first 4-6 months of life (Exclusive BF). Avoiding the use of infant feeding bottles. Improving practices related to the preparation & storage of weaning food to decrease contamination Using clean water for drinking. Washing hands (after defecation/disposing feces & before eating or preparing food. Safe disposing of feces including those of infants (its risky, contaminated & not sterile as misbelieved).

Measures that strengthen the defense : Continue to breastfeed for at least 2 years of life. 2. Improving nutritional status by improving nutritive value & increase amount of weaning food. 3. Immunization against measles.

Control of Diarrheal Diseases CDD

I- Assessment General condition Eye Mouth Thirst Tears Pinched Skin Well, alert Irritable,* restless Lethargic,* unconscious Eye Normal Sunken Very sunken Mouth Moist Dry Very dry Thirst Not thirsty Drinks * Eagerly Can not * drink Tears Present Absent Pinched Skin Goes back quickly Goes back* slowly Very slowly *

Rx.1:-Assess: Condition: Well ,alert Irritable,* restless Lethargic or * unconscious Eyes: Normal Sunken Very sunken Tears: Present Absent Mouth Moist Dry Very dry Thirst: Not thirsty Drink eagerly * Unable todrink* Pinched skin Goes back quickly Goes bacslowly* Very slowly*   A B c No dehydration some dehyd. Severe dehyd. At home PHC (ORS) Hospital (I.V.) if<2y. Keep on BF if>2y.give much fluid preferably salty Increase food intake (Not roughage, not diluted, not sweat)add 1spoon oil 100-200ml ORS or fluid after each loose motion according to age teach the mother how to prepare& administer consult after 3 days if: -doesn’t get better -vomiting -increase diarrhea -fever -blood with stool Wt. * 70 in the 1st 4 hr. then assess & behave accordingly Wt.* 100 1/3 during1/2hr. 2/3 during 2hrs. +ORS then assess

Why CDD? If there is fever think of malaria if the area is endemic If there is fever & blood think of shigellosis If the stools are watery look for cholera in the area If there is blood with stool dysentery) & Rx. shigellosis failed then think of parasite (Amoebiasis) If diarrhea lasted > 14 days think of Giardiasis Never give antibiotics apart from these conditions Never give anti-diarrhea,anti-spasmodic,or anti-emetic Why CDD? To decrease morbidity & mortality in an easy, rapid way with less facilities & with the participation of all health workers at different levels & also the family.