DIARRHEA

DR. BILAL RAFIQUE MALIK

Assistant Professor Of Medicine
South Medical Ward
KEMU/Mayo Hospital, Lahore.
 Definition And Classification
• Diarrhea is defined as the passage of loose or watery
stools, typically at least three times in a 24-hour period.
However, the recent change in consistency and
character of stool is more important than the number of
stools passed per day.
• Invasive Diarrhea: Diarrhea with blood in stool, also
known as dysentery.
• Classification:
Acute diarrhea: duration ≤ 14 days
 Persistent diarrhea: duration ≥ 14 days but ≤ 30 days.
Chronic diarrhea: duration ≥ 30 days.
 Epidemiology
• Epidemiology of diarrhea varies in developed
versus developing countries
• In the U.S., diarrheal illnesses are not usually
reported to the CDC unless associated with an
outbreak or an unusual organism
• Worldwide, chronic diarrhea affects about 5%
of the adult population and 3% - 20% of
children
 Physiology
• Approximately 9 L of fluid enters the proximal small
intestine
– 2 L of this fluid are from the diet and the rest consists of
intestinal secretions.
• Because of meal content, duodenal chyme is
usually hypertonic.
• When the chyme reaches the ileum, the osmolarity
adjusts to that of the plasma with most dietary fat,
carbohydrate, and protein being absorbed.
 Physiology
• The volume of ileal chyme decreased to about 1 L
per day when entering the colon
• Colonic absorption further decreases the volume
to 100ml a day
• If small intestine water capacity is exceeded,
chyme overloads the colon resulting in diarrhea
• Colon absorptive capacity is about 5 L per day
• Colonic fluid transport is critical to water and
electrolyte balance
 Etiology
• Most cases of acute diarrhea are caused by
infections with viruses, bacteria, or protozoa
and are usually self-limiting
• Evaluation of noninfectious cause is considered
if diarrhea persists and if no infectious
organism can be identified or if the patient falls
into a high-risk category for metabolic
complications with persistent or chronic
diarrhea
 Causes of Acute Diarrhea
• Most causes of acute diarrhea is infectious in
etiology.
• The causes can be divided into inflammatory
and non inflammatory depending upon the
degree of inflammation of bowel.
Causes of acute diarrhea
Causes of Chronic Diarrhea
Causes of chronic diarrhea
 Complications of acute diarrhea
• Severe volume depletion and electrolyte
imbalance is the most important complication.
• Acute Kidney injury secondary to dehydration.
• Bacteremia and septicemia
• Hemolytic uraemic syndrome
• Guillain Barre syndrome
• Reactive arthritis
 Differential diagnosis
• Most cases of acute diarrhea in adult is caused
by local infection of the gut. However,
systemic infections like influenza, acute HIV
infection, dengue fever, malaria, COVID-19 can
also cause diarrhea.
• Non-infectious cause should be considered in
patient in recurrent or chronic diarrhea.
 Clinical assessment of patient with acute
diarrhea
• Careful history and physical examination to
identify the type of diarrhea and degree of
hypovolemia.
Severity of Hypovolemia
 Laboratory
• Not routinely required.
• Microscopic evaluation of stool and stool
culture.
• Renal function test, serum electrolytes, Blood
glucose monitoring may be required in severe
cases not responding to initial fluid therapy.
 Treatment
• Adequate fluid and electrolyte replacement
and maintenance are essential to the
management of diarrheal illness.
• Antimicrobials are not routinely warranted,
but they do play a role in the treatment of
bloody diarrhea and during diarrheal
outbreaks.
Fluid management
 Treatment
• Antibiotic therapy
Not routinely indicated.
Should be considered if cholera is suspected or in
patient with bloody diarrhea (dysentery).

• Diet: small meals to b provided frequently,

soon after the patient is able to tolerate.
 Prevention
• Measures are directed to prevent the spread of
organisms from person to person and within the
community. These includes:
Hand washing with soap
Ensuring the availability of safe drinking water
Appropriate disposal of human waste
Breastfeeding of infants and young children
Safe handling and processing of food
Control of flies
Vaccination for cholera (killed whole-cell oral vaccine)
Evaluation Of Patient With Chronic Diarrhea

• Detailed history, physical examination, laboratory investigations.

• Alarming features in patient with chronic diarrhea:
– Age of onset after age 50 years
– Rectal bleeding or melena
– Nocturnal pain or diarrhea
– Progressive abdominal pain
– Unexplained weight loss, fever, or other systemic symptoms
– Laboratory abnormalities (iron deficiency anemia, elevated C-reactive
protein or fecal calprotectin)
– Family history of inflammatory bowel disease (IBD) or colorectal cancer
• Thank You