ACUTE DIARRHEA

AMBREEN AYUB
ROLL # 06
Definition:
Passage of three or more stools in a day, of consistency softer
than usual for the child, or one watery stool is defined as
diarrhea

Termed as ‘acute’ when diarrhea lasts less than 2 weeks (14

days)
Incidence and Epidemiology
 3-4 episodes of diarrhea per child per year
 Maximum incidence in 1st year of life
 Accounts for 40-50 % of hospital admissions in summer and rainy season
 Causes 16% of all child deaths in Pakistan

Acute diarrhea – one of the leading causes of morbidity and mortality in

children
Major mechanism of transmission is feco-oral route
Etiology
 Caused by a wide variety of enteropathogens
-Bacteria: E. coli, salmonella, shigella, vibrio cholerae
-Viruses: Rota Virus, Enteric adenovirus
-Parasites: Entamoeba histolytica, Giardia lamblia
Fungi: Candida albicans

Other causes of acute diarrhea include:

1. Infections like otitis media, UTI, pneumonia
2. 2. Food allergies, overfeeding, antibiotics
Pathogenesis:
1. Enterotoxigenic (E.coli)
 Diarrhea results from action of toxins released by the bacteria on
intestinal mucosa
 Released toxins  bind to epithelial surface of enterocytes  activate
adenylyl cyclase system  cause massive secretion of sodium and
chloride in gut lumen
 Toxins increase secretory activity of gut too
 Regeneration of affected cells in 2-5 days enables recovery
2. Entero-invasion (shigella and salmonella)
-Invasion of enterocytes  necrosis and ulcer formation  diarrhea with
blood and mucus in stool
-Presents as fever, abdominal cramps and tenesmus

3. Disaccharidase deficiency (Rota virus)

Invades intestinal cells, altering their function
Causes shedding of mucosal cells with loss of disaccharides
Osmotic diarrhea ensues due to failure of digestion of lactose and other
disaccharides
Signs and symptoms
Evaluation
History:
Presenting complaints – loose motion, vomiting, fever etc.
Loose motion (duration, frequency, grade, blood/mucus, color and contents
of stool)
Vomiting (duration, frequency, association with food, color, content, blood,
nature)
Any associated illness (cough, rash in measles, UTI complaints)
Urine passing, color and quantity
Feeding history
Treatment given (very important)
Examination
General appearance (drowsy, irritable)
GPE (vitals and weight)
Mucous membranes (dry, parched)
Skin turgor (normal/going back on pinch)
Eyes (sunken, dry)
Anterior fontanelle (open/closed, depressed, bulging)
Abdomen (distension, any palpable mass, bowel sounds)
CNS and respiratory examinations
Stool grading:
 Helps in assessing the stool water loss
 Also helpful in assessing prognosis i.e. worsening and improvement of
diarrhea can be known
Classification of dehydration
 Mild: When weight loss is less than 5 % (Infant is irritable and restless,
marked thirst, slightly depressed fontanel)
 Moderate: when weight loss is between 5-10 % (More marked irritability,
sunken eyes and fontanel, skin pinch abnormal)
 Severe: When weight loss is more than 10 % (critical condition due to
oligemia and peripheral circulatory failure. Cold skin, cyanosed
extremities, deeply sunken fontanel and ceased urine output)
Investigations:
1. Blood counts
2. Stool examination for
pH and reducing substances
giardia cysts and entameoba
bioassay for E.coli
culture and sensitivity
3. Serum electrolytes (Na and K) and bicarbonates
4. Urine examination and culture (for parenteral diarrhea)
5. Blood culture (Salmonella and Shigella)
6. X-ray chest (pneumonia)
Management
 Before starting therapy, degree and type of dehydration is assessed
Does the child have diarrhea:
If YES,
1. For how long?
2. Is there blood in the stool?
LOOK and FEEL:
General condition: lethargic or unconscious? Restless and irritable?
Look for sunken eyes
Offer the child fluid: Unable to drink? Drinking eagerly/thirsty?
Pinch abdomen skin; does it go back very slowly (longer than 2 seconds) or slowly?
Classification of dehydration
Treatment plan A (for no dehydration)
 Treat Diarrhea at home:
Mother counselled on 3 rules
1. Give extra fluid (as much as child takes)
 Breastfeed frequently and for longer at each feed
 Exclusive breastfed, give ORS or clean water in addition
 If weaning has started; give ORS solution and food based fluids like soup, yogurt etc
 Teach mother how to mix and give ORS. Give 2 packets to use at home
 Tell mother how much fluid to give additionally


 Tell mother to give frequent, small sips from cup. Continue extra fluid until diarrhea stops
 Treatment A (contd)
2. Continue feeding:
 Continue breastfeed frequently
 If not on breast feed, give cow’s/formulae milk half diluted for 2 days
 Give food (if child has started weaning) 4-6 times/day (pulses, vegetables, meat etc)
 Give mashed banana to provide potassium

3. Advise mother to follow up after 5 days

4. Advise mother to return immediately if child is:

 Not able to drink/breastfeed
 Becomes sicker/develops a fever
 Blood in stool
Treatment plan B (for some dehydration)
 Treat with ORS; Amount of ORS to give during the first 4 hours
 Treatment plan B (contd)
Give frequent, small sips from cup
If child vomits, wait for 10 minutes. Then continue ORS, but more slowly

AFTER 4 HOURS:
Re-assess the child and classify for dehydration
Select appropriate plan to continue
If mother wants to leave clinic before completing treatment, guide fully about ORS and 3 rules of home
treatment
 Give extra fluid
 Continue feeding
 When to return
Treatment Plan C
 1. Can you give IV fluid immediately?
If yes, start it immediately  100 ml/kg Ringer’s lactate solution divided as follows:

Reassess child every1-2 hours, give IV drip more rapidly if hydration status not improving
Give ORS as soon as child can drink
IF you can not give IV FLUIDS THEN;
Check if there is IV treatment nearby and refer urgently to the hospital

IF no treatment available nearby then;

Hospital Management of severe
dehydration
 Basic principle is to match output with input of water and electrolytes. Given fluids correct the following
1. Deficit therapy:
Correct water and electrolyte deficit; Ringer’s solution or normal saline is given 100 ml/kg as follows:
Infants (under 12 months of age) – First give 30 ml/kg in 1 hour, then 70 ml/kg over next 5 hours
Children (up to 5 years age) - First give 30 ml/kg in 30 minutes, then 70 ml/kg over next 2 hours

2. Concurrent losses: Replacement of ongoing losses due to diarrhea and vomiting

5 % dextrose is given 100 ml/kg/day
3. Electrolyte replacement
Potassium replacement started usually in 6-8 hours when urinary flow is established
In 24 hours, maximum 40 mEq/l of potassium given
Bicarbonate given in severe metabolic acidosis. Given sodium bicarbonate 2 mEq/kg slow
and diluted IV, repeat after 2 hours if required

4. Dietary management:
Feeding should be continued to prevent body catabolism and weight loss
Breastfed infants allowed feed as often as the infant desires
Bottle-fed infants: ratio of ORS to other fluids 2:1
5. Antibiotic therapy
Complications
Most complications are due to delayed diagnosis and therapy.
Include:
1. Dehydration and shock
2. Metabolic acidosis
3. Paralytic ileus (hypokalemia)
4. Convulsions and coma ( hypernatremia)
5. Death

Diarrhea can be prevented by;

 Prolonged breastfeeding
 Handwashing, clean food and water supply, and proper sewage treatment
 Using boiled water/milk in endemic areas
Improved case management of diarrhea

 Prompt identification and appropriate therapy of diarrhea significantly reduces duration nd

complications of diarrhea

 WHO/UNICEF recommendations to use ORS, Zinc supplementation, and appropriate use of

antibiotics have played major role in reducing diarrhea deaths among children
CBL
A 5 year old girl is brought to paeds opd with complaints of fever and loose stools
1. What questions will you ask in history?
2. What physical examination would you perform?
3. How will you investigate the child?
4. How will you manage?
5. How can you prevent the disease?