ACUTE DIRRHOEAL DISEASES

DEFINITION
Watery Diarrhea: 3 or more liquid
or watery stools in 24 h
Dysentery: Presence of blood
and/or mucus in stools
Persistent Diarrhea: Diarrhea
lasting for 14 days or more
Global Problem
4.6 million children
less than 5 years of
age die of diarrheal
diseases.
Diarrhea accounts
for 19% of all deaths
among children
ages 0-4.
Eighty-five percent
of diarrheal deaths
occur in the first
 TYPES OF DIARRHEA
D ia rrh ea

W a tery d ia rrh ea D y sen tery P ersisten t d ia rrh ea

R o ta v iru s d ia rrh ea S h ig ello sis C a u ses a re m o stly u n k n o w n

E . c o li d ia rrh ea A m eb ia sis
C h o lera
COMMON CAUSES OF
DIARRHEA- BACTERIA
Vibrio cholera
Shigella
Escherichia coli
Salmonella
Campylobacter jejuni
Yersinia enterocolitica
Staphylococcus
Vibrio parahemolyticus
Clostridium difficile
COMMON CAUSES OF
DIARRHEA- VIRUS
Rotavirus
Adenoviruses
Caliciviruses
Astroviruses
Norwalk agents and Norwalk-like
viruses
COMMON CAUSES OF
DIARRHEA- PARASITE
Entameba histolytica
Giardia lamblia
Cryptosporidium
Isospora
COMMON CAUSES OF
DIARRHEA-OTHERS
Metabolic disease
Hyperthyroidism

Diabetes mellitus

Pancreatic insufficiency

Food allergy
Lactose intolerance

Antibiotics
Irritable bowel syndrome
 TRANSMISSION
Most of the diarrheal agents are
transmitted by the fecal-oral route
Some viruses (such as rotavirus)
can be transmitted through air
Nosocommial transmission is
possible
Shigella (the bacteria causing
dysentery) is mainly transmitted
person-to-person
 SEASONALITY
Disease Common season
Cholera Winter
Rotavirus diarrhea Winter
Shigellosis Dry summer
 PERSON-AT-RISK
Cholera: 2 years and above,
uncommon in very young infants
Shigellosis: more common in
young children aged below 5 years
Rotavirus diarrhea: more common
in young infants and children aged
1-2 years
E. coli diarrhea: can occur at any
age
Amebiasis: more common among
 TYPES OF SHIGELLA
The major serotypes of Shigella
that cause diarrhea are:
Dysenteriae type 1 or Shigella
shiga
Shigella flexneri
Shigella sonnei
Shigella boydii
 TYPES OF E. COLI
Six major types of Escherichia coli
cause diarrhea:
Enterotoxigenic E. coli (ETEC)
Enteroinvasive E. coli (EIEC)
Enteropathogenic E. coli (EPEC)
Enterohemorrhagic E. coli (E. coli
O157:H7)
Enteroaggregative E. coli (EAggEC)
Diffuse adherent E. coli (DAEC)
 CLINICAL FEATURE:
CHOLERA
Rice-watery stool
Marked dehydration
Projectile vomiting
No fever or abdominal pain
Muscle cramps
Hypovolemic shock
Scanty urine
 CLINICAL FEATURE:
E. COLI DIARRHEA
Watery stools
Vomiting is common
Dehydration moderate to severe
Fever often of moderate grade
Mild abdominal pain
 CLINICAL FEATURE:
ROTAVIRUS DIARRHEA
Insidious onset
Prodromal symptoms, including
fever, cough, and vomiting
precede diarrhea
Stools are watery or semi-liquid;
the color is greenish or yellowish
typically looks like yoghurt mixed
in water
Mild to moderate dehydration
Fever moderate grade
 CLINICAL FEATURE:
SHIGELLOSIS
Frequent passage of scanty
amount of stools, mostly mixed
with blood and mucus
Moderate to high grade fever
Severe abdominal cramps
Tenesmus pain around anus
during defecation
Usually no dehydration
 CLINICAL FEATURE:
AMEBIASIS
Offensive and bulky stools
containing mostly mucus and
sometimes blood
Lower abdominal cramp
Mild grade fever
No dehydration
LABORATORY DIAGNOSIS
Stool microscopy
Dark field microscopy of stool for
cholera
Stool cultures
ELISA for rotavirus
Immunoassays, bioassays or DNA
probe tests to identify E. coli
strains
 ASSESSMENT OF
DEHYDRATION
Dehydration
Mild Moderate Severe
Appearance irritable, irritable, lethargy,
thirsty very coma, or
thirsty unconscious
Anterior normal depressed markedly
Fontanelle depressed
Eyes normal sunken sunken
 ASSESSMENT OF
DEHYDRATION (contd.)
Dehydration
Mild Moderate Severe
Tongue normal dry very dry,
furred
Skin normal slow very slow
retraction retraction
Breathing normal rapid very rapid
 ASSESSMENT OF
DEHYDRATION (contd.)

Dehydration
Mild Moderate Severe
Pulse normal rapid and feeble or
low imperceptible
volume
Urine normal dark scanty
Weight < 5% 6 - 9% 10% or more
loss
 TREATMENT
Rehydration replace the loss of
fluid and electrolytes
Antibiotics according to the type
of pathogens
Start food as soon as possible
COMPOSITION OF ORS

Ingredient Amount (g/liter)

Sodium chloride 3.5
Trisodium citrate or 2.9 or
Sodium bicarbonate 2.5
Potassium chloride 1.5
Glucose 20.0
AMOUNT OF SALT LOSS
DURING DIARRHEA
Diarrhea Salt (mmol/L)
Na K Cl HCO3
Cholera 88 30 86 32
(child)
Cholera 135 15 100 45
(adult)
E. coli 53 37 24 18
Rota 37 38 22 6
virus
ANTIMICROBIAL AGENTS
Type of diarrhea Antimicrobial agent
Cholera Tetracycline,
Doxycycline,
Ciprofloxacine
Shigellosis Pivmecillinam
(Selexid), Nalidixic
acid, Ciprofloxacin,
Ceftriaxone
Amebiasis Metronidazole
 COMPLICATIONS:
WATERY DIARRHEA
Dehydration
Electrolyte imbalances
Tetany
Convulsions
Hypoglycemia
Renal failure
 COMPLICATIONS:
DYSENTERY
Electrolyte imbalances
Convulsions
Hemolytic uremic syndrome (HUS)
Leukemoid reaction
Toxic megacolon
Protein losing enteropathy
Arthritis
Perforation
 VACCINES
An oral cholera vaccine is
available, which gives immunity to
50-60% of those who take the
vaccine, and this immunity lasts
only a few months.
No vaccines are available against
shigellosis
A vaccine against rotavirus
diarrhea has been withdrawn
 PREVENTION
Safe drinking water and food
Boil it, cook it, peel it, or forget it.
"
Hand washing
Proper sanitation
 Etiological Agents
Bacterial, Viral, and Protozoans
Parasitic Agents Giardia
Rotavirus

Rotavirus

Giardia
Enterotoxigenic E.
Coli
E.Coli
Shigellae
Salmonellae Entamoeba
Vibrio Cholerae World Health Organization. 1997.
Campylobacter jejuni http://www.who.int/chd/pub/imci/fs_180.html
 Transmission
Diarrheal agents are mostly spread
via the fecal-oral route.

physical contact with infected feces

eating or drinking contaminated food
or water
person to person relay

World Health Organization. 1998. The Epidemiology and Etiology of Diarrhea. http://www.who.int/chd/pub/cdd/meded/1med.htm
Pathophysiology
Intestinal wall becomes damaged
Impaired absorption
Body expels large amounts of
fluids
Shock, blood pressure drops,
kidneys shut down
Death
Socioeconomic factors

Poverty
Overcrowding
Poor sanitation
Contamination of
water
Inadequate food
hygiene

UNICEF. 1998. The State of the Worlds Children, 1998. Oxford and New York: Oxford University Press.
 Risk Factors

Household crowding
Low maternal education
Low birth weight

aeson, M., & Merson, M. 1990. Global progress in the control of diarrheal diseases. Pediatric Infectious Diseases Journal, 9: 345-35
 Behavioral Factors
Failure to breast- Storing food at
feed exclusively room temperature
for the first 4-6 Contaminated
months of life drinking water
Failure to
continue breast-
Failure to wash
feeding until one hands
year of age Failure to dispose
Using infant of feces
bottles hygienically
aeson, M., & Merson, M. 1990. Global progress in the control of diarrheal diseases. Pediatric Infectious Diseases Journal, 9: 345-3
Host Factors

Immunosuppression
Measles
Malnutrition
Malnutrition and Diarrhea

The Vicious Cycle

(Please see handout.)
Clinical Signs and
Symptoms

Figure 15.1, Lankinen et.

al
Table 15.3, Lankinen et. al.
Prevention Strategies
Breast Feeding
Improved
weaning practices
Proper use of
water
Hand washing
Disposing feces
properly
Effectiveness of
measles
3 main types of diarrhea
Type of % of cases of % of deaths % of deaths
diarrhea diarrhea due to diarrhea preventable by
standard case
management
Acute 80 50 100
Watery
Dysentery 10 15 80
Persistent 10 35 80

Total 100 100 90

World Health Organization. 1997. WHO Fact Sheet: Reducing Mortality from Major Childhood Killer Diseases. Fact Sheet
Number 180. http://www.who.int/chd/pub/imci/fs_180.html
Case Management

Oral Rehydration Therapy

Nutritional Management
Drug Therapy
Oral Rehydration Therapy

(video)
Nutritional Management
Appropriate feeding during
diarrhea is encouraged
Decrease in stool output
Shortened duration of illness

Significant weight gain

Improved nutritional status

Duggan, C., & Nurko, S. Feeding the gut: Scientific basis for continued enteral nutrition during acute diarrhea.
Journal of Pediatrics, 131(6): 801-808.
Nutritional Management
Recommendations for nutritional
therapy depend on the age and
diet of the child.
Breast-fed infants
Bottle-fed infants

Weaned Children
Nutritional Management

Breast-fed infants
Continue nursing on demand
ORS

http://www.rehydrate.org/html/dia020.html
Nutritional Management

Bottle-fed infants
Formula
Mixed diet

ORS

Duggan, C., & Nurko, S. Feeding the gut: Scientific basis for continued enteral nutrition during acute diarrhea.
Journal of Pediatrics, 131(6): 801-808.
http://www.rehydrate.org/html/dia020.html
 Nutritional Management
Weaned Children
Continuation of regular diet
Easily digested diet

Complex carbohydrates (rice,

potatoes, bread)
Lean meats (e.g. chicken)

Yogurts, fruits, and vegetables

Duggan, C., & Nurko, S. Feeding the gut: Scientific basis for continued enteral nutrition during acute diarrhea. Journal
of Pediatrics, 131(6): 801-808.
Nutritional Management

Micronutrient supplementation
Zinc
Vitamin A

Folic Acid

Duggan, C., & Nurko, S. Feeding the gut: Scientific basis for continued enteral nutrition during acute diarrhea. Journal
of Pediatrics, 131(6): 801-808.
 Drug Therapy

Avoid
Adverse reactions
Antibiotic resistance

Unnecessary costs

laeson, M., & Merson, M. 1990. Global progress in the control of diarrheal diseases. Pediatric Infectious Disease Journal, 9: 345-35
Cost Effectiveness
ORT is less than one-tenth as expensive
as intravenous fluid and it is as
effective.
One packet of ORS costs about 8 cents.
An estimated 1 billion dollars per year
could be saved worldwide by
appropriate treatment of diarrhea and
elimination of drug therapy for diarrhea.

USAID. 1999. Http://www.info.usaid.gov/pop_health/cs/csddc.htm

New Developments

Super-ORS
Rotavirus vaccine
Controversies

Underuse of ORT and overuse of

drugs
Boil the water
nt scheme used for children with bloo
Thank you
 Super ORS
fortified ORS with the amino acid glycine decreases stool volume
by 49-70% and duration of diarrhea 28-30%, other studies
indicate that it induces excess sodium concentrations in the blood
ORS fortified with the amino acid L-alanine reduced the severity of
symptoms and the need for fluid in patients afflicted with cholera
and enterotoxigenic Escherichia coli. Further studies reveal that
rice powder based ORS (50-80 g/l) reduces stool volume 24-49%
and duration of duration 30%.
The advantage of using rice is that when it hydrolyzes glucose,
amino acids, and oligopeptides emerge. Each 1 of these chemicals
facilitate sodium absorption through separate pathways.
Disadvantages include the fuel must be used to cook the rice, rice
based ORS ferments within 8-24 hours making it useless, and the
rice or pop rice needs to be ground.
 TYPES OF VIBRIO
CHOLERA
Two major biotypes of Vibrio
cholera that cause diarrhea are:
Classical
ElTor
Two common serotypes of Vibrio
cholera that cause diarrhea are:
Inaba
Ogawa
 Vibrio cholerae O139
Vibrio cholerae in O-group 139 was first
isolated in 1992 and by 1993 had been
found throughout the Indian
subcontinent. This epidemic expansion
probably resulted from a single source
after a lateral gene transfer (LGT) event
that changed the serotype of an
epidemic V. cholerae O1 El Tor strain to
O139.
More information:
http://www.cdc.gov/ncidod/EID/vol9no7
/02-0760.htm
 Vibrio vulnificus
The organism Vibrio vulnificus causes wound infections,
gastroenteritis or a serious syndrome known as
"primary septicema."
V. vulnificus infections are either transmitted to humans
through open wounds in contact with seawater or
through consumption of certain improperly cooked or
raw shellfish.
This bacterium has been isolated from water, sediment,
plankton and shellfish (oysters, clams and crabs)
located in the Gulf of Mexico, the Atlantic Coast as far
north as Cape Cod and the entire U.S. West Coast.
Cases of illness have also been associated with brackish
lakes in New Mexico and Oklahoma.
For more information:
http://hgic.clemson.edu/factsheets/HGIC3663.htm