APPROACH TO ACUTE DIARRHOEA
DR. PANKAJ KUMAR SINGHAL
ASSISTANT PROFESSOR
Department Of Pediatrics
GOVT. MEDICAL COLLEGE, KOTA
OBJECTIVES
INTRODUCTION/ DEFINITION
CAUSES
ETIOPATHOGENESIS
CLINICAL FEATURES AND COMPLICATIONS
DIAGNOSIS
EVALUATION OF DEHYDRATION
TREATMENT
PREVENTION
Introduction
Common cause of death in developing countries
Second most common cause of infantdeaths
worldwide.
DIARRHOEA
Diarrhoea defined as excessive loss of fluid and electrolyte
in stool.
For infants stool output >10 ml/kg/24 hr and >200g/24hr for
older children.
When there is an in frequency, volume or liquidity ( Recent
change in consistency) of the bowel movement relative to the
usual habit of each individual.
Nelson Textbook of Pediatrics, 20th ed
DEFINITIONS
• Acute diarrhea
Duration <2 wks, usually of infectious origin
• Prolonged diarrhea
Diarrhea of duration 14 days of presumed infectious etiology. It
may be an indicator for children with a high risk of progression to
Persistent diarrhea
• Chronic diarrhea
Diarrhea of more than 4 weeks duration.
• Dysentry
Bloody diarrhoea, visible blood and mucus present.
Nelson Textbook of Pediatrics, 20th ed
Persistent diarrhea
Persistent diarrhea (PD) is an episode of diarrhea of presumed
infectious etiology, which starts acutely but lasts for more than 14
days, and excludes chronic or recurrent diarrheal disorders such as
tropical sprue, gluten sensitive enteropathy or other hereditary
disorders [WHO] (INDIAN PEDIATRICS, JAN 2011)
passage of >=3 watery stools per day for >2 weeks in a child who
either fails to gain weight or loses weight.(ESPGHAN)
WHAT IS NOT A DIARRHOEA ?
1. Frequent formed stools
2.Pasty stools in breastfed child
3.Stools during or after feeding
4.PSEUDODIARRHOEA:Small volume of stool frequently
(IBS)
ETIO-PATHOGENESIS
CLINICAL FEATURES
BLOODY STOOLS – BACTERIAL ETIOLOGY
Hemolytic Uremic Syndrom
ABDOMINAL PAIN – Gastro Enteritis
PERITONEAL SIGNS - APPENDICITIS
DIAGNOSIS
ATLEAST 3 STOOLS PER 24H
ASSESSING DEHYDRATION
-H/O NORMAL FLUID INTAKE AND OUT PUT
- PHYSICAL EXAMINATION
- PERCENTAGE OF BODY WT LOSS
EVALUATING DEHYDRATION
GENERAL CONDITION-MENTAL STATUS*
THIRST*
EXTREMITIES
CAPILLARY REFILL TIME
SKIN TURGOR
BREATHING
HEART RATE
B.P
PULSE QUALITY
EYES*
TEARS*
MUCOUS MEMBRANES*
ANTERIOR FONTANELLE
URINARY OUTPUT
SIGNS NONE /MINIMAL SOME/ MILD SEVERE ( >9%
DEHYDRATION(<3 TO LOSS OF B.WT)
% MODERATE(3
LOSS OF BODY WT) -9% LOSS OF
B.WT)
CLINICAL DEHYDRATION SCORE
N o Dehydration: PLAN-A
Some Dehydration: PLAN-B
Severe Dehydration: PLAN-C
PLAN – A
Treat Diarrhea at Home.
4 Rules of Home Treatment:
GIVE EXTRA FLUID
CONTINUE FEEDING
WHEN TO RETURN [ADVICE TO MOTHER]
GIVE ORAL ZINC FOR 14 DAYS
Give extra fluid
TELL THE MOTHER:
Breastfeed frequently and for longer at each feed
If exclusively breastfeed give ORS for replacement of stool
losses
If not exclusively breastfed, give one or more of the
following:
ORS, food- based fluid (such as soup, rice water,
coconut water and yogurt drinks), or clean water.
TEACH THE MOTHER HOW TO MIX AND GIVE O.R.S
AMOUNT OF FLUID TO GIVE IN ADDITION TO THE
USUAL FLUID INTAKE:
Up to 2 years: 50 to 100 ml after each loose stool.
2 years or more: 100 to 200 ml after each loose stool.
Continue feeding
Continue usual feeding, which the child was
taking before becoming sick 3-4 times
(6 times)
Upto 6 months of age:
Exclusive Breast feeding
6 months to 12 months of age:
add Complementary Feeding
12months and above:
Family Food
When to Return
[Advice to
mother]
Advise mother to return immediately if
the child has any of these signs:
Not able to drink or breastfeed or drinks poorly
Becomes sicker
Develops fever
Blood in stool
[IF IT WAS NOT THERE EARLIER]
PLAN – B
Plan-B is carried out at ORT Corner in
OPD/ clinic/PHC
Treat ‘some’ dehydration with ORS
(50-100 ml/kg)
Give 75 ml/kg of ORS in first 4 hours
If the child wants m o r e, give more ORS
After 4 hours: Re-assess and classify
degree of dehydration
Signs of sever dehydration
Child not improving after 4 hours
Refer
to higher center –give ORS on way/keep
warm/BF
When child comes back follow up as other
children
PLAN – C
Start I.V. Fluid immediately
Give 100 ml/ kg of Ringer’s Lactate
Age First give Then give
30ml/ kg 70 ml/ kg
in in
Under 12 1 hour 5 hours
months
12 months and ½ hour 2½ hour
older
Fluid therapy in severe dehydration
Use intravenous or intraosseus route
Ringers Lactate with 5% dextrose or ½ normal saline with 5% dextrose at
15 ml/kg/hour for the first hour
* do not use 5% dextrose alone
Continue monitoring every 5-10 min.
Assess after 1 hour
If no improvement or worsening If improvement(pulse slows/faster
capillary refill /increase in blood
pressure)
Consider septic shock Consider severe dehydration with
shock
Repeat Ringers Lactate 15 ml/kg
Switch
over 1 hto ORS 5-10ml/kg/hr orally or by
nasogastric tube for up to 10 hrs
What Is ORS
HOW TO PREPARE ORS
Safe & effective
Can alone successfully rehydrate 95-97% patients
with diarrhea,
Reduces hospital case fatality rates by 40 - 50%
Cost saving
Reduces hospital admission rates by 50% and
cost of treatment by 90%
Composition of standard and low
osmolarity ORS solutions
STANDARD ORS SOLUTION LOW
OSMOLARITY ORS
( MEQ
GLUCOSE 111OR 75
SODIUM 90 75
MMOL/ L)
CHLORIDE 80 65
POTASSIUM 20 20
CITRATE 10 10
OSMOLARITY 311 245
LOW OSMOLARITY ORS IS BEST
LAB.EVALUATION AND IMAGING
STOOL CULTURE- salmonella
shigella
yersinia
campylobacter
pathogenic
E.coli-
serotyping
RAPID STOOL TEST: for
Biochemical tests:
inflammatory BUN
markers
Ser.bicarbonate
Hematological tests: white <17
mEq/L GRBS
blood cell band count
>100/mm
USG 3.
C-reactive protein cut
point of >12
milligrams/dl
TREATMENT
ANTIEMETIC-Ondansetron 0.5mg/kg/dose
ORS
Zinc for 14 days ( 10mg per day for age < 6month, 20 mg per day for
age > 6 month)
NO ANTIMOTILITY MEDICATION : Diarrhea may function as an evolved
expulsion defense mechanism
Can cause HUS in EHEC infection.
PROBIOTICS - Lactobacillus GG and
Saccharomyces boulardii
ANTIBIOTICS FOR A/C GE
Anti microbial drugs: regularly useful
a) Cholera:
Tetracyclin: reduce stool volume to nearly half.
co-trimoxazole
For multidrug resistancecholera :
norfloxacin/ciprofloxacin
b) Campylobacter jejuni:
Norfloxacin and other fluoquinolones
c)Clostridium difficile:
metronidazole,/vancomyci
n
d) Amoebiasis: metronidazole
e) Giardiasis:
metronidazole/diloxanidef
uroate
PROBIOTICS
• DEFINITION- Live micro-organisms that, when administered in
adequate amounts, confer a health benefit on the host
MECHANISM OF ACTION
Take-home messages
• Monsoon diarrhoeas may be bacterial in origin,
but winter diarrhoeas are almost always viral.
• Most children with watery diarrhoea do not need
metronidazole.
• Most children with typical diarrhoea do not need
any investigations.
• ORS & Zinc is the mainstay of therapy.
• IV therapy is only recommended for kids with
uncontrolled vomiting, very frequent diarrhoea,
grade II dehydration or more and those with
altered sensorium or any other complications.
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PREVENTION
“Good nutrition and hygiene can prevent
most diarrhoea”.
