Diarrheoa

= Passage of unusually loose or watery stools usually at least three times in a 24 hour period

Diarrhea Duration Mechanism

1. Acute diarrhea ( < 14 days )
2. Persistent diarrhea ( ≥ 14 days )
1. Secretory diarrhea
 Occur due to active enzyme adenil cyclase, which would convert adenosine triphosphate (ATP) cyclic
adenosinemonophosphate (cAMP).
 Accumulation of intracellular cAMP causes active secretion of water, chloride ion, sodium, potassium, and
bicarbonate into the intestinal lumen.
 Adenil cyclase is activated by a toxin produced by microorganisms:
Vibrio cholerae, Enterotoxigenic Eschericia colli (ETEC), Shigella, Clostridium, Salmonella, and Campylobacter
2. Invasive diarrhea
The existence of the invasion of microorganisms into the intestinal mucosa  damage to the intestinal mucosa. Invasive
diarrhea caused by viruses, bacteria, or parasites.
- Dysenteriform bloody diarrhea is usually caused by the bacterium Shigella, Salmonella, and EIEC.
- Non Dysenteriform not bloody, usually caused by rotavirus
3. Osmotic diarrhea
 Caused by high osmotic pressure inside intestinal lumen  draw fluid from the intracellular into the intestinal lumen
 cause watery diarrhea.
 Osmotic diarrhea is most often caused by carbohydrate malabsorption.
 Lactose is fermented by the enzyme lactase would  absorbed in the small intestine.
 In case this disakaridase enzyme deficiency, the accumulation of lactose in the intestinal lumen will cause the high
osmotic pressure, causing diarrhea.

Etiology.
1. Acute infectious diarrhea: noninflammatory and inflammatory.
a. Enteropathogens elicit noninflammatory diarrhea through enterotoxin production by some bacteria, destruction of villus (surface) cells by
viruses, adherence by parasites, and adherence and/or translocation by bacteria.
b. Inflammatory diarrhea usually is caused by bacteria that invade the intestine directly or produce cytotoxins. Some enteropathogens possess
more than one virulence property.

2. Chronic or persistent diarrhea lasting 14 days or more may be due to

a. an infectious agent such as Giardia lamblia, Cryptosporidium parvum, and enteroaggregative or enteropathogenic Escherichia coli;
b. any enteropathogen that infects an immunocompromised host;
c. residual symptoms due to damage to the intestine by an enteropathogen after an acute infection.
d. Others

Other Causes of Diarrhea

1. FEEDING DIFFICULTY d. Mushrooms
2. ANATOMIC DEFECTS 6. NEOPLASMS
a. Malrotation a. Neuroblastomas
b. Intestinal duplications b. Ganglioneuromas
c. Hirschsprung disease c. Pheochromocytomas
d. Fecal impaction d. Carcinoid
e. Short bowel syndrome e. Zollinger-Ellison syndrome
f. Microvillus atrophy f. Vasoactive intestinal peptide syndrome
g. Strictures 7. MISCELLANEOUS
3. MALABSORPTION a. Nongastrointestinal infections
a. Disaccharidase deficiencies b. Milk allergy
b. Glucose-galactose malabsorption c. Crohn disease (regional enteritis)
c. Pancreatic insufficiency d. Familial dysautonomia
d. Cystic fibrosis e. Immune deficiency disease
e. Shwachman syndrome f. Protein-losing enteropathy
f. Reduced intraluminal bile salts g. Crohn disease (regional enteritis)
g. Cholestasis h. Familial dysautonomia
h. Hartnup disease i. Immune deficiency disease
i. Abetalipoproteinemia j. Protein-losing enteropathy
j. Celiac disease k. Ulcerative colitis
4. ENDOCRINOPATHIES l. Acrodermatitis enteropathica
a. Thyrotoxicosis m. Laxative abuse
b. Addison disease n. Motility disorders
c. Adrenogenital syndrome o. Pellagra
5. FOOD POISONING
a. Heavy metals
b. Scombroid
c. Ciguatera

BACTERIAL ENTEROPATHOGENS.

Inflammatory diarrhea
Aeromonas
Campylobacter jejuni
Clostridium difficile
enteroinvasive E. coli
Shiga toxin–producing E. coli (E. coli O157:H7)
Plesiomonas shigelloides
Salmonella
Shigella VIRAL ENTEROPATHOGENS.
Vibrio parahaemolyticus
Yersinia enterocolitica. Main causes
Rotavirus
enteric adenovirus
astrovirus
Norwalk agent–like virus
calicivirus.
Noninflammatory diarrhea
enteropathogenic E. coli Immunocompromised
enterotoxigenic E. coli Cytomegalovirus
Vibrio cholera Herpes simplex Virus.

PARASITIC ENTEROPATHOGENS.
G. lamblia
Entamoeba histolytica
Strongyloides stercoralis
Balantidium coli
Cryptosporidium parvum
Cyclospora cayetanensis
Isospora belli
Enterocytozoon bieneusi
Encephalitozoon intestinalis
Balantidium coli, Trichuris trichiura, and E. histolytica can produce bloody diarrhea in humans.

DIAGNOSIS

HT
•Stool characteristics consistency, color, volume, frequency
• Presence of associated enteric symptoms nausea/vomiting, fever, abdominal pain
• Use of child daycare common: rotavirus, astrovirus, calicivirus; Campylobacter,
Shigella, Giardia, and Cryptosporidium sp
• Food ingestion history raw/contaminated foods, food poisoning
• Water exposure swimming pools, marine environmeny
• Camping history possible exposure to contaminated water sources
• Travel history common pathogens affect specific regions; also consider
rotavirus and Shigella, Salmonella, and Campylobacter spp
• Animal exposure young dogs/cats: Campylobacter spp; turtles: Salmonella spp
• Predisposing conditions hospitalization, antibiotic use, immunocompromised state

PE
Signs and symptoms of diarrhea may include the following:
• Dehydration:
Lethargy
depressed consciousness
sunken anterior fontanel
dry mucous membranes
sunken eyes
lack of tears
poor skin turgor
delayed capillary refill >2’’

• Failure to thrive and malnutrition:

Reduced muscle/fat mass or peripheral edema
• Abdominal pain/cramping
• Borborygmi
• Perianal erythema

nausea and vomiting within 6hr

paresthesia within 6hr;
neurologic and gastrointestinal tract symptoms within 2hr;
abdominal cramps and watery diarrhea within 16–48hr; fever, abdominal
cramps, and diarrhea within 8–72hr; abdominal cramps and bloody diarrhea
without fever within 72-120hr;
neurologic signs and symptoms within 6–24hr;
nausea, vomiting, and paralysis within 18–48hr

LE
Stools examined for ova and parasites if they
(1) have a history of recent travel to an endemic area,
stool cultures are negative for other enteropathogens, and diarrhea ≥ 1 wk;
(2) are part of an outbreak of diarrhea
(3) are immunocompromised.
enteropathogens.
Complications
Hypernatraemic dehydration (sodium >150 mmol/L)
• Results from severe water and sodium depletion with greater loss of water. This can lead
to severe neurological sequelae if rehydration is not carried out appropriately.
• Oral rehydration therapy is preferred to i.v. rehydration. If the patient is in shock, give a
bolus of normal saline 20 mL/kg i.v., repeat until organ perfusion is restored.
• Following this, ‘slow ORT’ aiming to complete rehydration over 12 h is required, followed
by maintenance fl uids.
• Serum electrolytes should be monitored on a 4 hourly basis. As a guideline, serum sodium
should not fall by >0.5 mmol/L per hour.
• Consultation with an intensive care unit is recommended for these patients.
Hyponatraemic dehydration (serum sodium <130 mmol/L)
• Can cause seizures and coma, and requires consultation with an intensive care unit.
• Be aware of iatrogenic hyponatraemia due to fluid (hypotonic) overload.

Management
Supportive, because the majority of these illnesses are self-limited.
Exceptions are botulism, paralytic shellfish poisoning, and long-acting mushroom poisoning, all of which may be fatal in
previously healthy persons.

The main objectives in the approach to a child with acute diarrhea are to
(1) assess the degree of dehydration and provide fluid and electrolyte replacement,
(2)prevent spread of the enteropathogen,
(3) in select episodes determine the etiologic agent and provide specific therapy if indicated