You are on page 1of 29

DIARRHEA

by
Harold Rugnao
ESSENTIAL CONCEPTS OF DIARRHEA
DIARRHEA
passage of unusually loose or watery stools, at
least 3x in a 24 hr period
CLINICAL TYPES OF DIARRHEA
Acute watery diarrhea
Acute bloody diarrhea
Persistent diarrhea
Diarrhea with severe malnutrition
ESSENTIAL CONCEPTS OF DIARRHEA
Dehydration
Deficit of water and electrolyte
Malnutrition
Zinc Deficiency
Use of antimicrobials and anti-diarrheal drugs
Important Microbial Causes of Acute
Diarrhea in Infants and Children
Rotavirus Campylobacter jejuni
Escherichia Coli Vibrio cholerae 01
Enterotoxigenic
and 0139
Localized adherent
Salmonella
Diffuse Adherent
Giardia duodenalis
Enteroinvasive
Enterohemorrhagic
Entamoeba
histolytica
Shigella
Cryptosporidium
ASSESSMENT OF CHILD WITH
DIARRHEA
1. History
2. Physical Exam
3. Determine Degree of Dehydration and
select treatment plan
4. Diagnose other important problems
ASSESSMENT OF DIARRHEA PATIENTS
FOR DEHYDRATION
A B C
LOOK AT: CONDITION Well, alert Restless, irritable Lethargic or
unconscious
EYES Normal Sunken Sunken
THIRST Drinks Drinks eagerly, Drinks Poorly or not
normally, not thirsty able to drink
thirsty
FEEL: SKIN PINCH Goes back goes back slowly goes back very slowly
quickly
DECIDE NO SIGNS SOME SIGNS OF SEVERE SIGNS OF
OF DEHYDRATION DEHYDRATION
DEHYDRA-
TION
TREAT Use Weigh the patient, Weigh the patient, use
treatment use Treatment Treatment Plan C
plan A Plan B URGENTLY
ESTIMATED FLUID
DEFICIT
Assessment Fluid deficit as Fluid deficit in
%of body wt ml/kg body wt
No signs of <5% < 50ml/kg
dehydration
Some dehydration 5 – 10 % 50 – 100 ml/kg

Severe >10% >100 ml/kg


dehydration
Management of Acute Diarrhea
(without blood)
Objectives:
Prevent dehydration, if there are no signs of
dehydration
Treat dehydration, when it is present
Prevent nutritional damage
Reduce the duration and severity of diarrhea
and the occurrence of future episodes
Plan A – Treat Diarrhea at Home
1. GIVE EXTRA FLUID
 TELL THE MOTHER
 Breastfeed frequently and for longer at each feed
 If the child is exclusively breastfed, give ORS or
clean water in addition to breastmilk
 If the child is not exclusively breastfed give one or
more of the following: ORS, food base fluids, or
clean water
 TEACH THE MOTHER HOW TO MIX ORS
 Home made solution: 3g/l of table salt (one level
tspful) and 18g/l of common sugar
SHOW THE MOTHER HOW MUCH FLUID TO GIVE IN
ADDITION TO THE USUAL FLUID INTAKE
 Up to 2 years 50 to 100ml after each loose
stool
 2 years or more 100 to 200 ml after each loose
stool
 Oldre children as much fluid as they want

Tell the mother to


 give frequent small sips from a cup
 If the child vomits, wait 10 mins. Then continue, but
more slowly
 Continue giving extra fluid until the diarrhea stops
1. GIVE SUPPLEMENTAL ZINC
- 10 – 20mg to the child everyday for 10 – 14
days

2. CONTINUE FEEDING
- To prevent malnutrition

3. TAKE THE CHILD TO A HEALTH WORKER


IF THERE ARE SIGNS OF DEHYDRATION
OR OTHER PROBLEMS
- Starts to pass many watery stools
- Repeated vomiting
- Becomes very thirsty
- Eating or drinking poorly
- Develops fever
- Blood in the stool
- Child does not get better in 3 days
Plan B – Treat Some Dehydration with
ORS
Give in clinic recommended amount of ORS
over 4-hour period
DETERMINE AMOUNT OF ORS TO GIVE
DURING FIRST 4 HOURS
*AGE Up to 4 mos 4 mos up to 12 mos to 2 2 yrs to 5
12 mos yrs yrs
WT < 6 kg 6 – < 10 kg 10 – <12 kg 12 – 19 kg
In ml 200 – 400 400 – 700 700 – 900 900 – 1400
*Use the child’s age only when you do not know the weight. The
approximate amount of ORS required (in ml) can also be calculated by
multiplying the child’s weight (in kg) times 75
AMOUNT OF ORS TO GIVE DURING FIRST 4
HOURS

*AGE Up to 4 4 mos up 12 mos 2 yrs to 4 5 – 14 15 yrs or


mos to 11 to 23 yrs yrs older
mos mos

WT < 5 kg 5 – 7.9 8 – 10.9 11 – 15.9 16 – 29.9 30 kg or


kg kg kg kg more

In ml 200 – 400 – 700 – 900 – 1200 – 2200 –


400 700 900 1400 2200 4000
*Use the child’s age only when you do not know the
weight. The approximate amount of ORS required (in
ml) can also be calculated by multiplying the child’s
weight (in kg) times 75

 for infants under 6 mos who are not breatfed, if using


the old WHO ORS solution containing 90mmol/L of
sodium also give 100-200ml clean water during this
period. However if using the new reduced (low)
osmolarity ORS solution contining 75mmol/L of
sodium, this is not necessary

For infants under 6 mos who are not breastfed, also


give 100 – 200 ml of clean water during this period

If the child wants more ORS than shown, give more

Note: during initial stages of therapy, while still


dehydrated adults can consume upto 750ml/hr if
SHOW THE MOTHER HOW TO GIVE ORS
SOLUTION

AFTER 4 HOURS
Reassess the child and classify the child for
dehydration
Select the appropriate plan
Begin feeding the child

MEET NORMAL FLUID NEEDS


 IF THE MOTHER MUST LEAVE BEFORE
COMPLETING TREATMENT
 Show her how to prepare ORS
 Show her how much ORS to give to finish the
4-hour treatment at home
 Give her enough ORS packets to complete
hydration
 Explain the 3 rules of HOME TREATMENT
1. Give extra fluid
2. Continue feeding
3. When to return
WHEN ORAL REHYDRATION FAILS
Continuing rapid stool loss (>15–20 ml/kg/hr)
Insufficient intake of ORS owing to fatigue or
lethargy
Frequent, severe vomiting

GIVING ZINC

GIVING FOOD
Treatment Plan C – for patients with
severe dehydration
1. GUIDELINES FOR INTRAVENOUS
REHYDRATION
 Give 100ml/kg Ringer’s Lactate Solutiona
divided as follows:
Age First give 30ml/kg in: Then give 70ml/kg in:
Infants (under 1 hourb 5 hours
12 months)
Older 30 minutesb 2 ½ hours
• Reassess the patient every 1 – 2 hrs. If hydration is not improving, give the IV drip
more rapidly
•After 6 hrs (infants) or 3 hrs (older patients), evaluate patient using the assessment
chart. Then choose the appropriate Treatment Plan
a
if Ringers Lactate Solution is not available, nomal saline may be used
b
Repeat once if radial pulse is still very weak or not detectable
2. MONITOR THE PROGRESS OF INTRAVENOUS
REHYDRATION
3. ELECTROLYTE DISTURBANCES
 Hypernatremia
 Serum Na > 150mmol/L
 Can cause convulsions

 Hyponatremia
 Serum Na < 130mmol/L
 Lethargy, less often, seizures
 Hypokalemia
 Serum K+ <3 mmol/L
 Muscle weakness, paralytic ileus, impaired
kidney function and cardiac arrhythmia
Management of
Suspected Cholera
Cholera differs from acute diarrhea of other
causes in 3 ways:
It occurs in large epidemics that involve both
children and adults
Voluminous watery diarrhea may occur, leading
rapidly to sever dehydration with hypovolemic
shock
For cases with sever dehydration appropriate
antibiotics may shorten the duration of the
illness
Antimicrobial Therapy
Management of Acute Bloody
Diarrhea (Dysentery)
 Shigella is the most common cause of bloody
diarrhea
 Ciprofloxacin for 3 days
Out Patient Management of Bloody
Diarrhea
CHILD WITH LOOSE STOOLS
WITH BLOOD

REFER TO
SEVERELY MALNOURISHED?
HOSPITAL
Yes
No

GIVE ANTIMICROBIAL FOR


SHIGELLA

COMPLETE 3
BETTER IN 2 DAYS? DAYS
Yes TREATMENT
No
INITIALLY DEHYDRATED REFER TO
AGE< 1Y/O OR MEASLES HOSPITAL
Yes
IN PAST 6 WEEKS

CHANGE TO SECOND
ANTIMICROBIAL FOR
SHIGELLA b

COMPLETE 3
BETTER IN 2 DAYS? DAYS
Yes TREATMENT
No

REFER TO HOSPITAL OR
TREAT FOR AMOEBIASIS
Management of
Persistent Diarrhea
 Persistent Diarrhea
Diarrhea, with or without blood, that begins acutely
and lasts at leat 14 days.
Usually associated with weight loss, and often, with
serious non-intestinal infections

Objective of treatment is to restore weight


gain and normal intestinal function by:
Appropriate fluids to prevent or treat dehydration
A nutritious diet that does not cause diarrhea to
worsen
Supplementaryvitamins and minerals
Treat in the Hospital:
Children with serious systemic infection
Children with signs of dehydration
Infants below 4 months of age

Prevent or treat dehydration


Identify and treat specific infections
Give a nutritious diet
Give supplementary multivitamins and
minerals
Monitor response to treatment
Management of Diarrhea with Severe
Malnutrition
Assess for Dehydration
Manage Dehydration
Feeding
Use of antimicrobials
Other Problems Associated with
Diarrhea
Fever
Convulsions
Vitamin A deficiency
Prevention of Diarrhea
Breastfeeding
Improved feeding practices
Use of safe water
Handwashing
Food safety
Use of latrines and safe disposal of stools
Measles immunization