DIARRHOEA.pptx including types and duration

DIARRHOEAAND
DEHYDRATION
MANAGMENT

PRESENTATION
OUTLINE
0 Introduction
0 Definition
0 Aetiology
0 Classification
0 Pathophysiology
0 Clinical manifestation
0 Complications
0 Management
0 Hypernatremic(hypertonic) Dehydration
0 References

Introduction
Commonest cause of death among children in developing
countries.

Much of which is acute diarrhoea and most commonly
due to infections [90%].

It is the leading cause of malnutrition in children under
five year old.
[WHO].

Definition
 Diarrhoea is defined as the passage of
three or more times of loose or liquid
stool per day.
NOTE: Frequent passing of formed stool is not diarrhea,
[WHO]

Aetiology
Causes of acute diarrhoeal
diseases can be classified as
infectious and non infectious
causes.

Infectious causes of diarrhoea:
Infectious causes can be further classified as
 Viral [70%]
0 Rotavirus(40%)
0 Norwalk virus
0 Enteric adenovirus
0 Others: astroviruses, enteroviruses
 Bacterial [10-20%]
0 E. Coli(a number of strains)
0 Campylobacter jejuni
0 Salmonella sp
0 Shigella spp
0 Salmonella typhi
0 Vibrio cholera

Parasitic [< 10%]
0 Entamoeba histolytica
0 Giardia lamblia
0 Cryptosporidium parvum
0 Isospora belli
0 Cyclospora cayetanensis
0 Microsporidia
(Enterocytozoon bieneusi, Encephalitozoon intestinalis)

DIARRHOEA.pptx including types and duration

NON INFECTIOUS CAUSES OF
DIARRHOEA
Drugs:Antibiotics,anti-
hyyertensives,Cancer drugs,and ant-acid
containg magnesium
Intestinal diseases: Inflammatory bowel
and coeliac disease
Food allergy : Cow’s Milk, soya

CLASSIFICATION OF
DIARRHOEA
There various ways of classifying diarrhoea:
 Duration[WHO]
0 Acute-< 14 days
0 Persistent-14 days or longer
 Nature: Watery or bloody
 Pathophysiology of diarrhoea
 Based on aetiology: Infectious and non infectious

PATHOPHYSIOLOGY
The following are the mechanisms by which diarrhoea develop:
1.Secretory mechanism
 Enterotoxins[V.cholera,E.coli]
 Hormones [vasoactive intestinal peptide in the vermer-
morrison syndrome]
 Some laxative [docusate sodium]
2.Osmotic mechanism [The act as a semi-pearmeable membrane
and fluid enter the bowel if there is large quantities of non
absorbed hypertonic Substances in the lumen]
 Magnesium containing antaacid
 Malabsroption
 Absorptive defects

3.Inflammatory diarrhoea[mucosal destruction]
Diarrhoea occurs due to mucosal demage resulting in fluid and
blood loss.
Dysentery due to shigella
Inflammatory conditions[ulcerative colitis and crohns disease]

Secretory diarrhoea
0 Large volumes of water are normally secreted into the
small intestinal lumen, but a large majority of this
water is efficienty absorbed before reaching the large
intestine.
0 Diarrhea occurs when secretion of water into the
intestinal lumen exceeds absorption.
0 Vibrio cholerae, produces cholera toxin, which strongly
activates adenylyl cyclase, causing a prolonged increase
in intracellular concentration of cyclic AMP within
crypt enterocytes. This change results in prolonged
opening of the chloride channels that are instrumental
in secretion of water from the crypts

0 , allowing uncontrolled secretion of water.
0 Exposure to toxins from several other types of
bacteria (e.g. E. coli heat-labile toxin) induce the
same series of steps and massive secretory diarrhea
that is often lethal unless the person or animal is
aggressively treated to maintain hydration.

Clinical features
The clinical features of diarrhoea may vary from patient to
patient based among others reasons;
 Duration
 Aetiology
Some of the common clinical features include
 Watery or loose stool+/-blood
 Abdominal cramps
 Tenesmus- where there is a feeling of constantly needing to
pass stools, despite an empty colon.

 Urgency-the strong desire to evacuate stool
 Abdominal pain
 May be associated with vomiting and fever
 Dehydration: Signs of dehydration include
Dry mucous membranes
Rapid t pulse,↓BP,capillary refil time > 2sec
No wet diapers for 3 hours or more
Sunken eyes or anterrior fontanelle
↓or ↑ temperature
irritability
Reuduced skin turgor

RISK FACTOR OF
DEHYDRATION
children younger than 1 year, particularly those
younger than 6 months
infants who were of low birthweight
children who have passed more than five diarrhoeal
stools in the previous 24 hours
children who have vomited more than twice in the
previous 24 hours
infants who have stopped breastfeeding during the
illness
children with signs of malnutrition.

Classification of levels of dehydration
[modified from WHO and IMCI]
No
dehydration
Some dehydration Severe
dehydration
Shock
•Alert with
normal eyes
• Not thirsty
• Normal skin
pinch
2 or more signs:
• Restless and
irritable
• Thirsty and drinks
eagerly
• Skin pinch returns
slowly
• Fontanelle is
sunken
2 or more signs:
• Lethargic or
sleepy
• Deeply sunken
eyes and
fontanelle
• very slow skin
pinch
Signs of:
• depressed level of
consciousness or
weakness
• weak or absent
peripheral pulses
• a prolonged
capillary refill time
of > 3 seconds
• tachycardia of > 120
bpm

Investigations
Laboratory
 Stool mcs
 Immunoassay e.g ELISA
 Blood culture
 PCR
 Modifield ZN Microscopy-Paratic infections
 U&E,Creatinine
Radiological
 Barium enema or meal

Management
PRINCIPLES OF MANAGEMENT
 Fluids
 Zinc supplements
 Continued feeding[Avoid juice and carbonated drinks]
FLUID MANAGEMENT
 Assess hydration and vitals
 If in shock manage shock
 Depending on the level of dehydration, give fluids as outlined
below

0 PLAN C : Children with severe dehydration
0 should be given rapid IV rehydration followed by oral
rehydration therapy. (100 ml/kg)
Repeat once if the pulses are weak or not detectable
Reassess patient every 1-2 hours. If hydration is not improving, give IV
drip more rapidly.
After completion of IV fluids, reassess the patient and choose the appropritte
treatment plan [A,B,C]
If IV therapy is not available ,then ORS by NG tube or orally at 20ml/kg/ for
6hours[total of 120ml/kg] should be given.
If the abdomen becomes distended or the child vomits repeatedly, the
ORS should be give more slowly.
Age First give 30ml/kg in Then give 70ml/kg in
<12 months old 1 hour 5 hours
≥12 months old 30minutes 2 ½ hours

PLAN B:SOME DEHYDRATION
75ml of ORS × patient’s weight(kg) to be given in 4
hours
After 4 hours, reassess the child and decide what
treatment to be given next as per level of dehydration.
Children who continues to have some dehydration
even after 4 hours should receive ORS by NG tube or
½ strength darrows intravenously(75ml/kg in 4hours)
If abdominal distension occurs, oral rehydration
should be withheld and only IV rehydration should
be given.

PLAN A:No dehydration: Amounts of ORS to be given
per loose dependent on specific age listed below.
ZINC SUPPLEMNTS
Give zinc supplements(10-20mg/kg for 10-14 days)
CONTINUED FEEDING
Give appropriate feeds. Avoid juices and carbonates
drinks
Age(years) < 2 2-5 Older
children
ORS(ml) 50-100 100-200 As much as
they want

HYPERNATREMIC DEHYDRATION
0 When proportionally more water than sodium is lost from the
body, the extracellular fluid has increased concentration of
sodium and becomes hypertonic regarding the
intracellular fluid and therefore attracts water from the cells.
This results in the cell shrinkage, which may cause brain
shrinkage.
THOSE THAT ARE AT RISK OF HAVING (HD)
Diarrhea in children, especially young infants (in 20% of
pediatric diarrhea)
Water deprivation
Excessive sweating Hyperventilation (prolonged fever, anxiety)
Diabetes insipidus (both central and nephrogenic)
Endstage renal failure
Drinking sea water in attempt to treat dehydration
Accidental infusion of hypertonic solutions

Complications
The major complications: dehydration and hypovolemic
shock.
Electrolyte imbalance :Hyponatremia is common;
hypernatremia is less common.
Metabolic acidosis: results from losses of bicarbonate in stool.
 Lactic acidosis: results from shock
Hyperphosphatemia : retention of phosphate due to transient
prerenal-renal insufficiency[severe dehydration]
Seizures: may occur with high fever, especially with Shigella.
Intestinal abscesses: - with Shigella
.

Intestinal perforation-Salmonella infections, especially typhoid
fever, leading to
Esophageal tears : Severe vomiting associated with gastroenteritis.
Deaths: resulting from diarrhea reflect the principal problem of
disruption of fluid and electrolyte homeostasis, which leads to
dehydration, electrolyte imbalance, vascular instability, and shock

References
1. WHO website.
2. General Paediatric Protocols ,Arthur Davison
Children’s Hospital.1st
Edition
3. Gary D H,Stephen J M.Pathophysiology of Diseases,an
introduction to clinical medicine.7th
edition.McGraw
Hill Education

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