Diarrhea

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Diarrhea

• Dr.K.S.Sunil
• MBBS, MD, PGDGM

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• Increase in frequency, size or loosening of bowel
  movements.
• Differentiate from fecal incontinence or
  functional bowel disease- normal stool weight
• With western diet- less than 200g/day

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Pathophysiology

• Increased active anion secretion
• Decreased absorption of water and electrolytes

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Types

• Transmissible agents
• Noninfectious - abnormal mucosa
• Inflammatory Bowel disease
• Celiac disease, microscopic colitis, eosinophilic
  and allergic gastroenteritis, radiation enteritis
• Noninfectious - normal mucosa
• Osmotic diarrhea
• Mal-absorption
• Rapid intestinal transit- IBS

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Infectious diarrhea

• Mostly feco-oral route
• Bacterial
• Viral
• Parasitic

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Bacterial

• Watery
• Enterotoxigenic-
• Vibrio cholera
• Enterotoxigenic E.coli
• Food borne toxins-
• Bacillus cereus
• Clostridium perfringens
• Mycobacterium avium-intracellular complex

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Bacterial

• Bloody
• Invasive
• Campylobacter jejuni
• Destructive
• Shigella
• Enteropathogenic E.coli
• Clostridium difficile

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Viral

• Rotavirus
• Children less than 2 years
• Most common cause of diarrhea in children all
  over the world
• Norwalk
• Older children and adults
• These viruses injure the small intestinal mucosa
• Watery diarrhea
• CMV
• Immunocompromised

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Parasitic

• Protozoa
• Giardia lamblia
• Entamoeba histolytica
• Cryptosporidium
• Helminths
• Ascaris lumbricoides
• Ancylostoma
• Strongyloides stercoralis
• Trichinella spiralis
• Capillaria philippensis

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Opportunistic pathogens

• Clostridium difficile
• Nosocomial pathogens in healthcare and long term
  care facility
• Poor handwashing
• Clindamycin, cephalosporins, ampicillin
• Exotoxin mediated

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In immunocomromised Hosts

• Besides the common pathogens,
• Giardia
• Legionella
• Candida albicans
• Cryptosporidium species
• Mycobacterium avium-intralcellulare
• CMV

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Others

• Tropical sprue
• In those who live or travel to the tropics
• Overgrowth of predominantly coliform bacteria in
  the small intestine
• Whipples Disease
• Infection by Tropheryma whippelii
• HLA B27

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History

• Is it truly diarrhea?
• Duration-
• acute lt3 weeks
• Chronic gt4 weeks
• Texture
• Frequency
• Blood?

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History

• Fever
• Vomiting
• Abdominal pain
• Fainting or dizzyness
• Travel
• Drug use
• Diet
• Weight loss

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History

• Alcohol
• Abdominal operations
• Chemotherapy
• Radiation
• Immune status
• Comorbidities

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Physical

• Vital signs
• Orthostatic signs
• Hyperventilation- acidosis
• Volume status
• Skin tenting
• Dry mucous membranes
• Resting tachycardia
• Hypotension
• Sunken eyeballs
• Scaphoid abdomen

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Physical

• Abdominal and rectal exam.
• Distension
• Bowel sounds
• Tenderness
• Masses
• Stool swab- culture

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Physical

• Chronic diarrhea
• Malnutrition
• Weight loss
• Muscle wasting
• Tetany
• Oral and skin lesions
• Peripheral neuropathy
• Ataxia
• Edema

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Labs

• Stool tests for inflammation
• Pus cells- specific but low sensitivity( about
  50)
• Lactoferrin
• Released from leucocytes during an inflammatory
  reaction
• Sensitivity is 90 but less specific

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Labs

• Stool culture
• Positive in only 40 to 60
• Stool for ova and parasites
• Stool for Clostridium difficile toxin
• Stool Sudan test for fat
• Stool Electrolytes-differentiates secretory
  diarrhea from osmotic diarrhea
• Stool pH-lt7 indicates carbohydrate malabsorption

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Other investigations

• Flexible sigmoidoscopy
• Pseudomembranes
• Inflammation
• Melanosis coli
• Blood Hormone levels
• Serum gastrin, VIP, somatostatin, cortisol,
  neurokinins, calcitonin
• Carcinoid- serotonin, urine 5-hydroxyindoleacetic
  acid

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Management

• Fluid therapy
• Persons with moderate to severe diarrhea lose
  large amounts of Na, CL, K, HCO3 H20
• Pre renal azotemia, hypokalemia, metabolic
  acidosis
• ORS
• IV Fluids

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ORS-principle

• Saline solution (water plus Na) by mouth - no
  beneficial effect
• Na absorption is impaired in the diarrhoeal
  state
• if the Na is not absorbed water cannot be
  absorbed.
• Excess Na in the lumen of the intestine causes
  increased secretion of water and the diarrhoea
  worsens.

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ORS

• Glucose - absorbed through the intestinal wall -
  unaffected by the diarrhoeal disease state -
  sodium is carried in conjunction through by a
  co-transport coupling mechanism. This occurs in a
  11 ratio, one molecule of glucose
  co-transporting one sodium ion (Na).

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• Starch
• metabolized in the intestine to glucose and
  therefore it has the same properties of enhancing
  sodium absorption
• less osmotic effect in the lumen of the
  intestine.

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• Citrate, a base precursor, corrects acidosis and
  enhances the absorption of water and electrolytes

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ORS-History

• First developed in the early 1950s and was
  formulated to mirror ions lost in stool.
• In the early 1960s the mechanism by which ORT
  works, the coupled transport of sodium and
  glucose, was discovered.6
• In 1971, the efficacy of ORT demonstrated during
  an epidemic of cholera in a refugee camp in
  Bangladesh.
• ORT reduced the death rate from more than 50 to
  only 5.7 By the early 1970s a consensus was
  reached about the effectiveness of ORT.

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ORS

• Lancet- "potentially the most important medical
  advance this century"
• World Health Organization estimates that 90 of
  diarrheal deaths worldwide could be prevented
  with appropriate treatment with ORS

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ORS

• Start early
• Rice based ones ( Glucose polymers) increase
  intestinal fluid absorption
• In adults use urine output for monitoring

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ORS

• Sodium Chloride 3.5 grams
• Sodium Bicarbonate 2.5 grams
• Potassium Chloride 1.5 grams
• Glucose 20 grams

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ORS
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ORS- caution

• A number of studies have addressed the concern
  that ORT can lead to hypernatremia in neonates
  and infants.
• These studies show that administration of breast
  milk or plain water after rehydration prevents
  this problem.1

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IV Fluids

• Must contain Potassium and a base
• Ringers lactate

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Chronic Diarrheas

• Zn and Magnesium replacement

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Antibiotics

• Invasive bacterial Enteritis- esp.Shigellae
• Quinilone orally twice daily for 3 days
• Cholera
• Traveler's diarrhea
• Prophylactic- not recommended
• A single dose of oral Quinilone at onset
• Clostridium difficile
• Metronidazole
• Oral Vancomycin

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Antimotility agents

• Should be avoided
• Concern for promoting bacterial invasion or
  prolonging the infection

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Food

• Do not withhold
• Withholding food, even for one or two days,
  greatly exacerbates the malnutrition
• Coupled with anorexia, caused partly by chronic
  potassium depletion, causes a vicious circle
• It is this diarrhoea/malnutrition cycle rather
  than acute dehydration that causes almost half of
  the five million deaths a year in under five year
  old children that are associated with diarrhoeal
  disease.

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Good nutrition and hygiene can prevent most
diarrhea.

• Thank You!