Acute Diarrhoeal Diseases

Diarrhoea

• Passage of loose, liquid or

watery stools.
• Liquid stools >3 times/day

• Recent change in Consistency

and character of stool - More
important than no. of stools.
Clinical type of Diarrhoeal Diseases

1. Acute watery diarrhoea-

– Few hours to days
– Dangers-
• dehydration &
• weight loss
– Pathogens-
• V. cholerae
• E.coli
• rotavirus
Clinical type of Diarrhoeal Diseases
2. Acute bloody diarrhoea-
• Also called dysentery
• Dangers-
• Damage to intestinal mucosa
• Sepsis
• Malnutrition
• Dehydration
• Visible blood in stools
• Pathogen-
• Shigella
Clinical type of Diarrhoeal Diseases

3. Persistent diarrhoea-
– Last 14 days or longer
– Dangers-
• Malnutrition
• Dehydration
– Disease-
• AIDS
Clinical type of Diarrhoeal Diseases

4. Diarrhoea with severe malnutrition-

• Marasmus or Kwashiorkor
– Dangers-
• Severe systemic infection
• Dehydration
• Heart failure
• Vitamin & Mineral deficiency
 Problem Statement-World

• Diarrhoea causes 11 % of child death worldwide.

• In children under five years of age- Median of 3

episodes of diarrhea per child year.
 Problem Statement-India
• Diarrhoea causes 8 % of U5 deaths.
• Diarrhoea is a leading cause of death during
emergencies & natural disasters b/o-
– Displacement of population in temporary,
overcrowded shelters.
• Polluted water source
• Inadequate sanitation
• Poor hygiene practices
• Contaminated food
• Malnutrition
 Types-Causes
1. Infectious:
– Digestive origin
– Non- digestive origin- ENT infections, Resp and urinary
infections, malaria
2. Noninfectious - abnormal mucosa
– Inflammatory Bowel disease
– Celiac disease, microscopic colitis, eosinophilic and allergic
gastroenteritis, radiation enteritis
3. Inborn error of metabolism- congenital enzyme
deficiencies
 Infectious diarrhea
• Mostly feco-oral route-

• Bacterial
• Viral
• Parasitic
 Bacterial
• Watery
– Enterotoxigenic-
• Vibrio cholera
• Enterotoxigenic E.coli
– Food borne toxins-
• Bacillus cereus
• Clostridium perfringens
 Bacterial
• Bloody
– Invasive
• Campylobacter jejuni
– Destructive
• Shigella
• Enteropathogenic E.coli
• Clostridium difficile
 Viral
• Rotavirus
– Children less than 2 years
– Most common cause of diarrhea in children all over the
world
• Norwalk
– Older children and adults
• These viruses injure the small intestinal mucosa
• Watery diarrhea
• CMV
– Immuno-compromised
 Parasitic
• Protozoa
– Giardia lamblia
– Entamoeba histolytica
– Cryptosporidium
• Helminths
– Ascaris lumbricoides
– Ancylostoma
– Strongyloides stercoralis
– Trichinella spiralis
– Capillaria philippensis
 In Immuno-compromised Hosts
• Besides the common pathogens,
– Giardia
– Legionella
– Candida albicans
– Cryptosporidium species
– Mycobacterium avium-intralcellulare
– CMV
 Reservoir of Infection
• Human-
– ETEC
– Shigella
– V. Cholerae
– Giardia lamblia
– E.histolitica
• Animals
– Campylobactor jejuni
– Salmonella
– Y. enterocolitica
 Host factors
• Most common age group- 6 m to 2 yrs
• Highest in 6-11 months at weaning b/o-
– Decline level of acquired maternal antibodies
– Lack of active immunity in infants
– Introduction of contaminated foods
– Direct contact with human & animal faeces due
to start crawling
– Infants feeds on Cow milk or infant feeding
formulas
 Host factors
• Malnutrition-Infection-Diarrhoea
• Poverty
• Prematurity
• Immunodeficiency
• Lack of personal & domestic hygiene
• Incorrect feeding practices
 Environmental factors
• In general-
– Virus-Winter season
– Bacteria-warm season
• In India-
– Rotavirus-through the year, increases in
frequency in drier, cool months
– Bacterial- Warm & rainy season
 Mode of Transmission

• Faecal-oral route-
– Water borne
– Food borne
– Direct transmission
• Finger
• Fomites
• Dirt
Control of Diarrhoeal Diseases

• Components of Diarrhoeal disease control

programme (1980 by WHO)-
1. Short term-
1. Appropriate clinical management
2. Long term-
1. Better MCH practices
2. Preventive strategies
3. Preventing diarrhoeal epidemics
 Management
• Fluid therapy
• Persons with moderate to severe diarrhea lose large
amounts of Na, Cl, K, HCO3 & H20
• Pre renal azotemia, hypokalemia, metabolic acidosis
– ORS
– IV Fluids
 Oral Rehydration Therapy
• Na+ absorption is impaired in the diarrhoeal state
• If the Na+ is not absorbed water cannot be absorbed.
• Excess Na+ in the lumen of the intestine causes
increased secretion of water and the diarrhoea worsens
• Aim of ORT: To prevent dehydration and reduce
mortality
– .
 ORS
Glucose –correct the electrolyte and water deficits
•Absorbed through the intestinal wall and is
unaffected by the diarrhoeal disease state
•Sodium is carried in conjunction through by a co-
transport coupling mechanism.
•This occurs in a 1:1 ratio, one molecule of glucose
co-transporting one sodium ion (Na+).
Citrate: Corrects acidosis and enhances the
absorption of water and electrolytes
 Composition of Reduced
Osmolarity ORS- (Jan.2004)
Reduced Osmolairty ORS Grams/ litre

Sodium Chloride 2.6 grams

Tri-sodium citrate 2.9 grams
Potassium Chloride 1.5 grams
Glucose 13.5 grams
Total weight 20.5 grams
 Composition of Reduced
Osmolarity ORS
Reduced Osmolairty ORS mmol/ litre
Sodium 75
Chloride 65
Glucose, Anhydrous 75
Potassium 20
Citrate 10
Total Osmolarity 245
Assessment of Dehydration
Dehydration
D
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y
d
r
a
t
I
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n
Sunken abdomen, dehydration
 Guidelines for Oral Rehydration Therapy
(for all ages) during first four hours
• If the child’s weight is known, ORS required in first 4
hours = 75 ml/ kg
• IF weight unknown, then determine on the basis of age

Age Under 4 4-11 1-2 2-4 5-14 15 years

months months years years years or over
Weight Under 5 5-7.9 8-10.9 11-15.6 16-29.9 30 or
(Kg) above
ORS 200-400 400-600 600-800 800- 1200- 2200-
solution 1200 2200 4400
(ml)
 Guidelines for Oral Rehydration
Therapy
• Children <2 years: Give a teaspoon every 1- 2
minutes,
• Older children: Offer frequent sips out of a cup.
• Adults may drink as much as they like.
• Try to give the estimated required amount within a
4-hour period.
 Guidelines for Oral Rehydration
Therapy
• As a general guide, after each loose stool, give –
• Children <2 years: 50-100 ml (a quarter to half a
large cup) of fluid;
• Children 2-10 years : 100-200 ml (a half to one
large cup);
• Older children and adults : As much fluid as they
want.
 Guidelines for Oral Rehydration
Therapy
• If the child vomits, wait for 10 minutes, then try
again, giving the solution slowly - a spoonful
every 2 to 3 minutes.
• If the child wants to drink more ORS solution than
the estimated amount, and does not vomit, there
can be no harm in feeding him/her more.
 Guidelines for Oral Rehydration
Therapy
• If the child refuses to drink the required amount
and signs of dehydration have disappeared,
rehydration is completed.
• The treatment plan for non-dehydrated diarrhoeic
children is then resumed.
• If the child is breast-fed, nursing should be
pursued during treatment with ORS solution.
 Home treatment of dehydration
• Simple mixture consisting of table salt (one level
teaspoon) and sugar (6 level teaspoon) dissolved in
one litre of drinking water
• Rice water; unsalted soup, yoghurt drinks, green
coconut water
• Avoided: Tea, Coffee (purgative)
• Sweetened with sugar: Osmotic Diarrhoea &
Hypernatremia: eg. Commercial carbonated
beverages, commercial fruit juices
 IV Fluids

• Only for the initial rehydration of severly dehydrated

patients
• Ringer’s lactate:
– Supplies adequate concentrations of sodium and potassium
– Lactate yields bicarbonate for correction of the acidosis.
• Diarrhoea Treatment Solution (DTS):
– Ideal Polyelectrolyte solution for intravenous infusion.
– It contains in one litre, sodium chloride 4 g, sodium acetate
6.5 g, potassium chloride 1 g and glucose 10 g.
 Treatment plan for Rehydration Therapy

Age First give 30 Then give 70

ml/kg in mi/kg in
Infant (Under 12 1 hour 5 hours
months)
Older 30 minutes 2 hour & 30
minutes
• Initial Rehydration should be fast
• Examine at intervals during rehydration
• If eyelids become puffy, IV fluid should be stopped
 Maintenance Therapy
Amount of Diarrhoea
Mild diarrhoea
•not more than one stool every 2
hours or longer, or
•less than 5 ml stool per kg per
hour)
Severe diarrhoea
•more than one stool every 2
hours, or
•more than 5 ml of stool per kg
per hour)
Amount of Oral Fluid
• 100 ml/ kg body
weight per day until
diarrhoea stops
• Replace stool losses
volume For volume;
• If not measurable give
10-15 ml/kg body
weight per hour
 Appropriate Feeding
• Normal food Intake
• Do not withhold food, even for one or two days, greatly
exacerbates the malnutrition
• Newborn infants with diarrhoea who show little or no
signs of dehydration can be treated by breast-feeding
alone.
• Those with moderate or severe dehydration should receive
oral rehydration solution.
• Breast-feeding is continued along with oral rehydration
solution given after each liquid stool.
 Chemotherapy
Antibiotics
•Diarrhoea due to cholera:
– Drug of choice is doxicycline, tetracycline,
TMP-SMX and erythromycin.
•Diarrhoea due to shigella:
– Drug of choice is ciprofloxacin
 Antimotility agents
• Should be avoided
• Concern for promoting bacterial invasion or
prolonging the infection
 Zinc Supplementation
• Reduces the episode's duration and severity
• Infants under 6 months of age: 10 mg/ day
for 10-14 days
• Children older than 6 months: 20 mg/ day
for 10-14 days
 Better MCH care practices
• Maternal nutrition-
– Reduce low birth weight of baby
– Improve quality of breast milk
• Child nutrition-
– Promotion of breast feeding
– Appropriate weaning practices
– Complementary feeding
– Vit. A supplementation
 Preventive Strategies
• Sanitation-
– Improve water supply
– Improve excreta disposal
– Improve domestic & food hygiene
– Improve personal hygiene
• Hand washing
• Health Education-
– Breast feeding
– Improved weaning
– Clean drinking water
– Use of latrine
– Proper disposal of toddlers stool
 Preventive Strategies
• Immunization-
– Measles
– Rotavirus vaccine
Rotavirus vaccine – Two live oral vaccines
Rotarix (GSK Bio) Rota Teq (Merck)
Origin Human monovalent Bovine pentavalent
Vaccine 2 doses- oral 3 doses- oral
Dose
Schedule With Penta-1 and Penta- 2 With Penta-1, Penta- 2
and Penta- 3
Age First dose not later than 12 First dose, 6- 12 weeks
restrictions weeks Last dose before 32
Second dose not later than weeks
24 weeks
Presentation Lypophilized, reconstituted Liquid
or liquid
Side effects Intussusception Intussusception
 Prevention of diarrhoeal
epidemics-Primary Health Care
• The Integrated Global Action Plan for the
Prevention and Control of Pneumonia and
Diarrhoea:
– Reduce mortality from diarrhoea in U5 children <1 per
1000 live births;
– Reduce the incidence of severe diarrhoea by 75% in U
5 children compared to 2010 levels;
– Reduce by 40% the global number of U 5 children who
are stunted compared to 2010 levels.
Diarrhoeal Diseases Control Programme
• Started in 1978-
– Reducing mortality & morbidities due to diarrhoea
• 1985-86- National Oral rehydration therapy
programme-
– Case management of diarrhoea
– Improve maternal knowledge for home based
fluid,ORS and continued feeding
• 1992-93-CSSM
• 1997- RCH
• 2005- NRHM under IMNCI
Monitorable treatment and Diarrhoea
Prevention Indicators
A. Diarrhoea Prevention Indicators
1. Percentage of population using :
– Improved drinking water sources
– Improved sanitation facilities
2.Percentage of one year old immunized against
measles
3.Vitamin A supplementation coverage rate (per
cent full coverage) 6 to 59 months
Monitorable treatment and Diarrhoea
Prevention Indicators
4. Percentage of children who are
– under-weight
– stunted
– exclusively breast-fed
– breast-fed with -complementary food (6 to 9
months age)
– still breast-feeding
Monitorable treatment and Diarrhoea
Prevention Indicators
B. Diarrhoea Treatment Indicators
• Percentage of children under five years with
diarrhoea receiving:
1. ORT with continuous feeding
2. ORS packet
3. Recommended home made fluids
4. Increased fluids
5. Continued feeding
Monitorable treatment and Diarrhoea
Prevention Indicators
C. Use of oral rehydration therapy
• Percentage of children U5 with diarrhoea
receiving oral rehydration therapy
1. Gender –
2. Residence-
3. Wealth index quintiles- Poorest, second,
middle, fourth, richest
Thanks for attention!