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

Consider septic shock
capillary refill /increase in blood
pressure)
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.

41
 PREVENTION

“Good nutrition and hygiene can prevent

most diarrhoea”.