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poisoning/traveller diarrhea/water
and electrolyte imbalance.
By
Dr Williams E.A
Introductions
Definitions
• An increase in frequency, volume and often
urgency of the passage of stool and decrease in
stool consistency.
medications)
to V. cholerae)
Aetio-pathogenesis
Pathophysiology of Diarrhea
– Rotavirus
– Norwalk virus
– Norovirus
Parasite/Protozoa
• Entameba histolytica
• Giardia lamblia
• Cryptosporidium
• Isospora
• Cyclospora cayetanensis
OTHERS
• Metabolic disease
Hyperthyroidism
Diabetes mellitus
Pancreatic insufficiency
• Food related
Carbohydrate intolerance (lactose)
Allergy
Additives
sorbitol
• Medications : Antibiotics, laxative, antacid, NSAID,
nutritional supplement, colchicine.
• Irritable bowel syndrome
• Inflammatory bowel disease
• Celiac disease
Major causes of acute diarrhea
• Viral infection
• Bacteria infection
• Parasitic infection
• Medication
• Food poisoning/related
• Abrupt onset of chronic diarrhea
Major causes of chronic diarrhea
• Food intolerance
• Diverticulitis
• Malabsorption syndrome
• Immunosuppression
Clinical findings
Symptoms and signs
- travel hx
immunosuppression.
- fever
- hypotension
- orthostasis
- tachycardia
• Stool evaluations:
- fecal leukocytes
calprotectin
are:
• Treatment of dehydration (replace fluid loss).
• Antidiarrheal medications
• Intravenous hydration
Dehydration
Mild Moderate Severe
Appearance irritable, irritable, lethargy,
thirsty very coma, or
thirsty unconscious
Anterior normal depressed markedly
Fontanelle depressed
Eyes normal sunken sunken
ASSESSMENT OF DEHYDRATION (contd.)
Dehydration
Mild Moderate Severe
Tongue normal dry very dry,
furred
Skin normal slow very slow
retraction retraction
Breathing normal rapid very rapid
ASSESSMENT OF DEHYDRATION (contd.)
WHO recommended ORT formula per liter of
water.
• Massive diarrhea
- hartman solution
- normal saline (.9% saline)
- 5% dextrose solution dissolved in water.
- ringer’s lactate solution.
Composition IV fusions
Fluid Na Cl K Lactate Ca Glucose Osmol
mmol/l mmol/l mmol/l mmol/l mmol/l g/l mOsm/l
Normal 135 - 145 100 - 110 3.5 – 5.0 0.5 – 2.2 2.2 – 2.6 100 - 275 - 300
plasma 140
5% D/w 0 0 0 0 0 50 278
Antidiarrheal medications
• Fever
• Dysentery
• Toxic megacolon
• Colonic distention
• Fever
• Shock
• Extremes of age
• Dysentery
• Immunosuppression
• Traveler’s diarrhea
• In Practice: Watery
Fatty
Bloody
Osmotic Diarrhea
Low pH
Stool Analysis
Carbohydrate
FOG>125 malabsorption
Dietary review
High Mg output
Breath H2 test
Inadvertent ingestion
(lactose)
Laxative abuse
Lactase assay
Secretory Diarrhea
Fatty Watery
Bloody IBS
Chronic
IBD Neuroendocrine
pancreatitis
Infection Infection
EPI
Radiation IBD
Celiac SIBO
Ischemia
SIBO Microscopic
Cancer
Cirrhosis Celiac
Cholestasis DM
Non-osmotic laxative
Bile Salt Depletion
Short Gut
Villous adenoma
Alcohol (sugar)
SECRETORY DIARRHEA
4. Cholestyramine
1. Exclude 2. Exclude
3. Selective testing trial for
Infection Structural disease
bile acid diarrhea
Other pathogens
"Standard" Sigmoidoscopy or
colonoscopy/biopsy Urine
Ova & parasites
Coccidia 5-HIAA
Microsporidia Histamine
Giardia antigen
CT scan of abdomen
Other tests
TSH
ACTH stimulation
Serum protein
Small bowel bx electrophoresis
Immunoglobulins
and
aspirate for quantitative
culture
Fecal osmolar gradient (FOG)
• If <50 secretory
2. post-vagotomy
3. sympathectomy
5. hyperthyroidism
Steatorrhea
deactivation by HCL
1. Exclude
Structural Disease
2. Exclude
pancreatic exocrine
insufficiency
Stool chymotrypsin
Bentiromide test Secretin test
activity
Length of Ileal resection determines if fatty or
watery
1. < 100cm resected : compensated with reduced BS
returned to Liver. Unabsorbed BS pull water through
colon wall into lumen get watery diarrhea. OK to use
cholestyramine.
Exclude Exclude
Structural Disease Infection
Bacterial pathogens
Small bowel "Standard"
Radiographs Aeromonas
Plesiomonas Tuberculosis
CT scan of abdomen
ElTor
Ogawa
Vibrio cholerae O139
• Rice-watery stool
• Marked dehydration
• Projectile vomiting
• Muscle cramps
• Hypovolemic shock
• Scanty urine
SHIGELLA
Shigella flexneri
Shigella sonnei
Shigella boydii
CLINICAL FEATURE:
SHIGELLOSIS
• Usually no dehydration
Nontyphoidal salmonellosis
- hypoacidity
- recent use of antibiotics
- extremes of age
- immunosuppression.
• Salmonella adhere to and invade the intestinal
epithelium, and are ingested by macrophages in which
virulent form can survive and disseminate to distant
site.
• Incubation period of 12 to 72hours
• Watery stools
• Vomiting is common
• Insidious onset
• No dehydration
Bacillius cereus
- Diarrhea
- Flatulence
- Abd cramps
- Epigastric pain
- Weight loss
• Stool sample should be atleast 3 times.
• Rx: metronidazole
Traveler’s diarrhea
- poor sanitation.
- immunosuppression.
stomach surgery).
- ETEC
- EAEC
- campylobacter
- salmonella
- shigella
- invasive E. coli
• Dehydration
• Electrolyte imbalances
• Tetany
• Convulsions
• Hypoglycemia
• Renal failure
COMPLICATIONS: DYSENTERY
• Electrolyte imbalances
• Convulsions
• Leukemoid reaction
• Toxic megacolon
• Arthritis
• Perforation
VACCINES
• Hand washing
• Food safety
COMMUNITY STRATEGIES TO REDUCE DIARRHEA
• Measles vaccination
Vitamin –A prophylaxis
Improved Nutrition
Immunization
- Measles immunization
ROTA VIRUS VACCINE
Two live oral attenuated rotavirus vaccines were licensed
(Rota Teq)
They Provide 75-80% protection against rotavirus diarrhoea