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ACUTEDIARRHOEALDISEASE

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AIMSOFTHELECTURE

o Definitions
o Riskfactors
o Pathogenesisandmechanisms
o Consequencesofwaterydiarrhea
o Site/durationofinfectivediarrhea
o Riskfactorsforpersistentdiarrhea
o PrinciplesofORT
o CompositionofORT
o Advantages/LimitationsofORT

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WHATISDIARRHEA?

Increaseinfrequency,fluidity&volumeoffeces,for
theageofthechild.

Inepidemiologicalstudies:

Thepassageofthreeormorelooseorwaterystoolsin
a24hourperiod,aloosestoolbeingonethatwould
taketheshapeofacontainer.
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MAGNITUDEOFTHEPROBLEM

Indevelopingcountries
1.3thousandmillionepisodes
4milliondeathseachyearinunderfives.
Economicburden:occupy1/3hospbeds
80%ofdiarrhealdeathsoccur<2yrsofage.
Isanimportantcauseofundernutrition.
Eatlessduringdiarrhea
Abilitytoabsorbnutrientsisreduced;
Nutrientrequirementsareincreased.

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DEFINITIONS
1.Acutewaterydiarrhea
Diarrheathatbeginsacutely,lastslessthan14days
(mostepisodeslastlessthansevendays),and
involvesthepassageoffrequentlooseorwatery
stoolswithoutvisibleblood.Vomitingandfevermay
bepresent.
2.Dysentery
Diarrheawithvisiblebloodinthefeces.Important
effectsofdysenteryincludeanorexia,weightloss,and
damagetointestinalmucosabytheinvasivebacteria.
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RISKFACTORSFORACUTEDIARRHEA

Failuretobreastfeedexclusivelyfor46months.

Failuretobreastfeeduntilatleastoneyearofage.

Usinginfantfeedingbottles.

Storingcookedfoodatroomtemperature.

Drinkingwatercontaminatedwithfecalbacteria.

Failingtodisposeoffinfantfeceshygienically.

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PREDISPOSINGHOSTFACTORS
Undernutrition.
Recentmeasles(Inpreviousfourweeks).
Immunodeficiency
Age:Firsttwoyearsoflife,maximumat611
monthsWhy?Weaningperiod
Declininglevelsofmaternalantibodies.
Lackofactiveimmunityintheinfant.
Infantstartstocrawl.
Seasonal:Rotavirusthroughouttheyear.
Bacterialinsummer&rainyseason.
Epidemics:Vibriocholera,Shigella.
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ENTEROPATHOGENS

Rotavirus
EnterotoxigenicEscherichia
coli
Shigella
Campylobacterjejuni
Vibriocholerae
Salmonella
Cryptosporidium

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PATHOGENESISOFVIRALDIARRHEAS
Replicatewithinthevillousepithelium,
causingpatchyepithelialcelldestruction
andvillousshortening.
Normallyabsorptivevillouscellsreplaced
byimmature,secretory,cryptlikecells.
Lossofdisaccharidaseenzymelactose
malabsorption
Recoveryoccurswhenthevilliregenerateandthe
villousepitheliummaturesE.g.:Rotavirus

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PATHOGENESISOFBACTERIALDIARRHOEAS
Mucosaladhesion:
Preventsorganismbeingsweptaway.
Fimbriaebindtomucosalreceptors.
Resultsinreducedabsorptivecapacity.
E.g.:Enteropathogenic/Enteroadherent
EColi.
Secretorytoxins:
Toxinsalterepithelialcellfunctionabsorptionofsodium
bythevilliisdecreased
increasedsecretionofchlorideinthecrypts.
Recoveryoccurswhenintoxicatedcellsarereplaced
byhealthycells.
E.g.:EnterotoxigenicE.coli,V.cholerae,Salmonella.
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PATHOGENESISOFBACTERIALDIARRHOEAS

Mucosalinvasion:

Directinvasion&destructionofmucosalcells.

Usuallyinthecolonanddistalileum.

Invasionmicroabscesses&superficialulcers.

Toxinscausetissuedamageandpossiblyalso
mucosal secretionofwaterandelectrolytes.

E.g.:Shigella,enteroinvasiveE.coli
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PATHOGENESISOFPROTOZOALDIARRHOEAS

Productionofmicroabscesses:
Mucosaladhesion:
G.lambliaandCryptosporidiumadheretothesmall
Occurs only when the infecting strain ofthe
bowelepitheliumcausingshorteningofthevilli
Entamoeba histolytica is virulent. In 90%of
human infections, the strains are not virulent;in
which case there is no mucosal invasion andno
symptoms,althoughamoebiccystsarepresentin
thefeces.
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FLUIDBALANCEINTHEGUT

Absorption&secretionofwater&
electrolytesoccurthroughoutintestine.
Theyaresimultaneouslyabsorbedby
thevilli&secretedbythecryptsofthe
mucosa.
Intestinallumenblood.
Water

Electrolytes
Normally fluid absorption > > fluid secretion

Changeinthistwodirectionalflow morefluid
enterslargeintestine.Ifthisexceedscolonicabsorptive
capacity,diarrheaoccurs.
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MECHANISMSOFDIARHEA

oOsmoticdiarrhea

oSecretorydiarrhea

oInflammatorydiarrhea


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OSMOTICDIARRHEA

Smallbowelmucosaisaporousepithelium;waterand
saltsmoveacrossitrapidlytomaintainosmoticbalance
Diarrheaoccurswhenapoorlyabsorbed,osmotically
activesubstanceispresentinthegut.

Ifsubstanceisisotonic,thewaterandsolutewillsimply
passthroughthegutunabsorbed,causingdiarrhea.
E.g.;magnesiumsulfate,lactose.
Ifitisahypertonicsolution,waterwillmovefromtheECF
intothegutlumenuntilosmolalityisequalizedvolumeof
stool&dehydration.
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OSMOTICDIARHOEA
Features:
Stoolingstopsonfasting.

StoolpHacidic.

Reducingsubstancepositive.

E.g..Rotavirusdiarrhea.
Disaccharidemalabsorption.
Monosaccharidemalabsorption.
Lactuloseingestion.
Treatment:
Removeoffendingagentfromdiet.

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SECRETORYDIARHOEA

ACTIVESECRETION
Causedbytheabnormalsecretion(waterandsalt)
intothesmallbowel.
Occurswhen
Sodiumabsorptionbythevilliisimpaired.
Chloridesecretionincrypts
continues/increased.
Mediators..CyclicA.M.PofCholera
..CyclicG.M.PofE.T.E.C
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SECRETORYDIARHOEA

Features:
Stoolingcontinuesonfasting.
StoolpHalkaline.
ReducingsubstanceNegative.

Treatment:
Treatunderlyingcause.
Correctfluid&electrolytedeficits.
Limitedroleforantibiotics.

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CONSEQUENCESOFWATERYDIARRHOEA
1.Dehydration
..Isotonicdehydration:commonest
Netlossesofwater&sodiumarein
proportion.

..Hypernatremicdehydration
Netlossofwaterinexcessofsodium.
Severethirstoutofproportiontothedehydration.
..Hyponatremicdehydration

Replacementwithfluidsoflowsalt
concentration
Rare,usuallyiatrogenic
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CONSEQUENCESOFWATERYDIARRHOEA

2.Metabolicacidosis
Causes:Lossofbicarbonateinthestool.
Poorrenalbloodflow,productionoflacticacid.
Lowbicarb,arterialpH<7.10,deep/rapid
breathing.
3.Potassiumdepletion
Duetolargefecallosses(esp.ininfants)
Signs:Muscularweakness,Paralyticileus.

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RECAPOFIMPORTANTPOINTS

Diarrheaisanimportantcauseofmalnutritionanddeathin
childrenbelow2yrs.

Acuteuncomplicatedwaterydiarrheasettlesin714days

NormallyH2Oabsorbedbyvilli>>secretedbycryptcells

SecretorydiarrheaoccurswhenNa+absorptionbythevilliis
impaired,whileClsecretionincryptscontinues

Osmoticdiarrheaoccurswhenapoorlyabsorbed,osmotically
activesubstanceispresentinthegut

Dehydration,acidosisandhypokalemiaarecomplications
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MECHANISMSOFDIARRHEA

3.Inflammatorydiarrhea
A.InfectiveShigellosis,Amoebiasis.
B.NoninfectiveUlcerativecolitis.

Howtodiagnose?

A.Fever.
B.Bloodinstool.Increasedfecalleucocytes.
C.Abdominalpain,cramps,tenesmus.

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MANAGEMENTOFDYSENTERY

Antibiotics:Dependsonlocalsensitivitypattern
..Nalidixicacid,Norflox,Cefixime
Givenfor5days.
Fluids:
Oralreplacementenough,unlessvomitingpresent.
Feeding:
Continuebreastfeeding
Giveenergy&nutrientrichfoodssixtimesaday.
Oneextramealadayfortwoweeksfollowup.
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MOREONINFECTIVEDIARRHEA
SITE DURATIO
N
1. CholeraSmallBowel3to6days
2. ShigellaLargeBowel7to14days
3. RotaVirusSmallBowel5to7days
4. ETECSmallBowel5to10days
5. EIECLargeBowel??
6. SalmonellaSmall&Large37days
7. GiardiaSmallBowelChronicity
8. AmoebiasisLargeBowelChronicity

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TERMINOLOGIESINDIARRHEA

PersistentDiarrhea
Anepisodeofdiarrhealofpresumedinfectious
etiologythatbeginsacutelyandlastsformorethan
14days.

Chronicdiarrhea
Diarrheathatisrecurrent/lastingmorethan14days,
isduetononinfectiouscause&associated
withmalabsorption.E.g.Celiacdisease

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PERSISTENTDIARRHEA

RISKFACTORS

Infantsbelow6months
Malnourishedinfants
Multipleantibiotics
Multiplephysicians
Notbreastfed
Repeateddiarrhea
EnteropathogenicE.coliinfection

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ORALREHYDRATIONTHERAPY

Whatisit?
Administrationoffluid&electrolytesorallyto
treatorpreventdehydration.
Why?
Correctionofwater&electrolytedeficitis
possibleorally
Reducemortality
Cheap,easyandscientific

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STORYOFORALREHYDRATIONTHERAPY

Developedinthelate1960s
LifesaverincholeraepidemicineastIndiain70s
Inthelast40yrs,hassavedmorelivesthanany
othermedicalinvention.
In1980:5milliondeaths<5yrsfromdiarrhea
In2000:Only1.8milliondeaths!!!

Theproblemtoday:lowORSusagebyhealth
workers

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SCIENTIFICBASISOFORT

AbsorptionofH2O/Na/K/HCO3nearnormalin
diarrhea

Glucosecoupledsodiumabsorptionpromoteswater
absorptionacrossintestinalmucosa

Maximalabsorption,whenNatoglucoseratiois1.0

Potassiumabsorptionoccursbypassivediffusion

Water/electrolytelossesindiarrheacanbe
effectivelycorrectedbyORT 29
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COMPOSITIONOFCURRENTORS

CONTENTSGm OSMOLARITY
KCl1.5 Na75
Glucose13.5 Cl65
NaCl2.6 Glucose75
Trisodiumcitrate2.9 K20
Citrate10

TOTAL20.5 TOTAL245

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DIARRHEAMANAGEMENTINIMNCI

Assessmentofdehydration

MixingofORSanddetailsofadministration

Treatmentofdiarrheaathome(PlanA)

Treatingsomedehydrationinclinic(PlanB)

Treatingseveredehydrationinanemergency(PlanC)

Managementofdysentery

Dietinacutediarrhea
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RICEBASEDORS
Ricepowderwhendigestedreleasestwicetheamountof
glucosethaninORS.Thisisenoughtosupporttheabsorption
ofwater&electrolytesinORS
Proteininriceaddstothiseffectbyrelease&absorptionof
aminoacids.
OsmoticactivityofriceORS(220mOsm/l)islowerthanthat
ofbloodorothertissues(290mOsm/l).
Caloriesinricemayhelppreventmalnutrition
Trialsshowlowerrateofstoolvolumeincholera.
Morestudiesneededinnoncholeradiarrhea.
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ADVANTAGESOFORT

Lowcost

EliminatesneedforIVlineplacement

Treatmentcanbedone/continuedathome

Safeandfewsideeffects

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LIMITATIONSOFORTUSE

Difficultwhenmentalstatusisaltered

(aspiration)

Difficultwhenthereisparalyticileus

Severedehydration

Highfailurerateifstooloutputremainsexcessive

Difficultinsevere/persistentvomiting,whenORS
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ASSESSMENTOFACHILDWITHDIARRHOEA

HISTORY PHYSICALEXAM.
AcutewateryD SignsofDehydration
Dysentery NutritionalStatusof
PersistentD. child
Watery,large,frequent Pneumonia,
Vomiting68hrs OtitisMedia
Urine
Otherinfections
Natureoffluids
Feedingbeforeillness

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ASSESSMENTOFACHILDWITH
DIARRHOEA

NODEHYDRATION
LOOKAT
Condition WellAlert
Eyes Normal
Tears Present
Mouth&Tongue Moist
Thirst DrinksNormallyNotThirsty
FEEL
SkinPinch Goesbackquickly

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ASSESSMENTOFACHILDWITHDIARRHOEA(CONT)
SOMEDEHYDRATION

Lookat Twooffollowingsigns
Condition Restless,Irritable
Eyes Sunken
Tears Absent
Mouth&Tongue Dry
Thirst Thirsty,Drinkseagerly
Feel
SkinPinch Goesbackslowly
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ASSESSMENTOFACHILDWITHDIARRHOEA
(CONT)SEVEREDEHYDRATION

LOOKAT
Condition Lethargicorunconscious,floppy
Eyes Verysunken&dry
Tears Absent
Mouth&Tongue Verydry
Thirst Drinkspoorlyornotabletodrink
FEEL
SkinPinch Goesbackveryslowly

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MANAGEMENT

NoDehydration PLANA

SomeDehydration PLANB

SevereDehydration PLANC

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ORSFORPREVENTIONOFDEHYDRATION
(PLANA)

Amt.ofORSafter AmtofORSto
Age eachloosestool provideforuseat
home

<24months 50100ml 500ml/day

1000ml/day
210years 100200ml

10years/more Asmuchaswanted 2000ml/day

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TREATMENTPLANB
(FORSOMEDEHYDRATION)

RehydrationTherapy75ml/KgORSin1st4hours

MaintenanceTherapy

ProvisionofNormaldailyfluidrequirements

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TREATMENTPLANC
SEVEREDEHYDRATION:IVFLUIDTHERAPY
RINGERLACTATE/N.SALINE

Age First30ml/kg Then70ml/kg

<12months 1hour 5hours

Olderchildren 30minutes 21/2hours

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NUTRITIONALMANAGEMENTOFACUTE
DIARRHOEA

DiarrheaWorsensNutritionalstatus

a)Decreasedfoodintake

Anorexia/

Maternalfoodwithholding

b)Intestinalmalabsorption

Macronutrients&Somemicronutrients

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RECOMMENDATIONS

ContinueFeeding

ContinueBreastFeedingevenduring

rehydration

Animalmilkneednotbediluted

Enrichstaplefoodsfats&oil/sugar

Highfibercontentfoodsavoided

Routinelactosefreefeedsnotneeded

Duringrecovery125%intake

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RECAP
Persistentdiarrhealasts>14days.Infants<6
months,malnourishedandnotbreastfedareathigh
risk.
Highfever,bloodinstool&abdominalcramps
suggestdysentery
ORTislifesavingindiarrhealdehydration.
PrincipleofORTisthatglucosecoupledsodium
transportpromoteswaterabsorptionacross
intestinalmucosa
TotalosmolarityofcurrentORSisonly245mOsm/L
AdvantagesofORTaremorethanthelimitations.
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THANKYOU

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