Diarrhea & Dehydration

Prof. Dr. M. Juffrie, SpAK, Ph.D

Quantum of Problem
Great public health problem in developing
countries
II killer disease
High Morbidity & Mortality.
70% deaths due to dehydration.
ORS brought revolution : Greatest invention
of
century.
5 Millions - 1.5 millions deaths/ annum
now.

Physiological Definition of Diarrhea

Loss of fluid and electrolytes via
stools is net result of imbalance
between secretory and absorptive
processes in small & large intestine.
Electrolytes have a critical role in the
regulation of water absorption and
secretion across the intestine.
Watery stools, more than 3 time a
day (24 hours) (WHO, 2007)
Walker Smith 2004

Normal Villi

What is not Diarrhea ?

Stools of an infant
Breast fed
Artificially fed
Exaggerated gastrocolic reflex
Irritable bowel syndrome (IBS)
Spurious / factitious diarrhea

Age specific incidence for diarrhoea episode per Child per

year from 2 reviews of prospective studies in developing
areas,1980 - 2000
Number of episodes/person/year

2-5 episodes/year
Kosek et al. Bulletin of the WHO 2003; 81:197-204.

Types of Diarrhea
(a) Depending upon duration.
Acute diarrhea
3 - 7 days
Prolonged or Indeterminate 8 - 14 days
Persistent diarrhea
> 14 days
(b) Depending upon characteristics of
stools.
Watery diarrhea --- Secretory & Osmotic
Bloody diarrhea
--- Blood & Mucus
(Dysentery)
(c) Severity of diarrhea
Diarrhea with severe malnutrition
Diarrhea with HIV infection
Diarrhea with the other immune deficient

Pathogenesis
Absorption disorder
Secretory disorder
Osmotic disorder

Overview of
GI Processes
Food
Enterocyte
cAMP

Cl -

Secretion

1.
2.
3.
4.

Digestion

Absorption

Active
Change H+
Change ClGlucose

Motility
Na+

Blood Vessels

1
Osmotic

Common Causes of Acute

Diarrhoea
Infection highly contagious
Viral gastroenteritis (stomach flu)
Usually cause
explosive, watery
diarrhoea
Typically last only
48-72hrs
Usually no blood and
pus in stool

Rotavirus

 Bacterial enterocolitis
Sign of inflammation blood or pus in
stool, fever

E. Coli bacteria
Contaminated food or
water
Usually affect small kids

 Bacterial enterocolitis
Sign of inflammation blood or pus in
stool, fever

Salmonella enteritidis
bact
In contaminated raw or
undercooked chicken and
eggs

 Bacterial enterocolitis
Sign of inflammation blood or pus in
stool, fever

Shigella
bacteria

Campylobacter
bacteria

 Parasites

Cryptosporidium

Giardia lamblia

in contaminated
water can survive
chlorination

in contaminated
water
Usually not associated
with inflammation

Common Causes of Acute

Diarrhoea cont.
Food Poisoning
Brief illness cause by toxins produced by
bacteria
Cause abdominal pain, vomitting
Cause SI secrete high amnt of water
diarrhoea
Some bacteria produce toxins in food
before intake or in intestine after food is
eaten
Symptoms usually appear within sev.
hours

 Food Poisoning

Staphylococcus aureus
Produces toxins in food before it is eaten
Usually food contaminated left
unrefrigerated overnight

 Food Poisoning

Clostridium perfringens
Multiplies in food
Produces toxins in SI after contaminated food is
eaten

Common Causes of Acute

Diarrhoea cont.
Travellers Diarrhoea
Drugs / medications

DIARE
Diare akut keluarnya BAB 1x/ lebih yg
berbentuk cair dlm 1 hari/ lebih & berlangsung < 14
hari (Cohen MB)
Diare episode keluarnya tinja cair sebanyak 3x/
lebih, atau lebih dari 1x keluarnya tinja cair yg
berlendir atau berdarah dalam 1 hari (Shahid NS)
Faktor2 yang mempengaruhi kejadian diare:
Lingkungan kebersihan lingkungan &
perorangan
Gizi pemberian makanan
Kependudukan insiden diare pd daerah kota yg
padat/ kumuh
lebih
Pendidikan pengetahuan ibu
Perilaku masyarakat kebiasaan2
Sosial ekonomi

ETIOLOGI DIARE
1. Faktor infeksi
a. Infeksi enteral infeksi pada GIT (penyebab utama)
Bakteri : Vibrio cholerae, Salmonella spp, E. coli
dll
Virus : Rotavirus (40-60%), Coronavirus, Calcivirus
dll
Parasit: Cacing (Ascaris, Oxyuris,dll), Protozoa
(Entamoba histolica,Giardia Lambia, dll) Jamur
(Candida Albicans)
b. Infeksi parenteral infeksi di luar GIT (OMA, BP,
Ensefalitis,dll)
2. Faktor malabsorbsi : KH, Lemak, P
3. Faktor makanan : basi/ beracun, alergi
4. Faktor psikologis : takut dan cemas

PATOFISIOLOGI
VIRUS masuk enterosit (sel epitel usus halus) infeksi &
kerusakan fili usus halus
Enterosit rusak diganti oleh enterosit baru (kuboid/ sel
epitel gepeng yg blm matang) fungsi blm baik
Fili usus atropi tdk dpt mengabsorbsi makanan &
cairan dgn baik
Tek Koloid Osmotik motilitas DIARE

BAKTERI NON INFASIF (Vibrio cholerae, E. coli

patogen) masuk lambung duodenum berkembang

biak mengeluarkan enzim mucinase (mencairkan lap
lendir) bakteri masuk ke membran mengeluarkan
subunit A & B mengeluarkan (cAMP) merangsang
sekresi cairan usus, menghambat absobsi tampa
menimbulkan kerusakan sel epitel tersebut volume usus
dinding usus teregang DIARE

BAKTERI INFASIF (Salmonella spp, Shigella spp,

E. coli infasif, Champylobacter) prinsip perjalanan

hampir sama, tetapi bakteri ini dapat menginvasi sel
mukosa usus halus reaksi sistemik (demam, kram
perut) dan dapat sampai terdapat darah
Toksin Shigella masuk ke serabut saraf otak
kejang

BERDASARKAN PATOFISIOLOGI
Diare osmotik : diare akibat adanya bahan yang tidak dapat
diabsorbsi oleh lumen usus hiperosmoler hiperperistalsis
Diare sekretorik : terjadi akibat stimulasi primer dari enterotoksin
atau oleh neoplasma
Diare akibat gangguan motilitas usus : gangguan pada kontrol
otonomik

Treatment of Acute Diarrhea

Oral Rehydration Therapy

Dietary therapy
Zinc therapy
Antimicrobials
Education

Oral Rehydration Therapy (ORT)

Oral Rehydration Solution

(ORS)
WHO - ORS = Physiological
Basis
Other Fluids & Liquid Diets

Home Available Fluids

Recommended
Salt sugar solution
Lemon
water(Sikanjabi)
Rice water / Kanjee
Soups
Dal water
Lassi
Coconut water
Plain water

Not recommended
Simple sugar
solution
Glucose solution
Carbonated soft
drinks
Fruit juices-tinned
or fresh
Fluids for athletes
Gelatin desserts
Tea/Coffee

Composition of WHO High & Low Osmolality

ORS

----------------------------------------------------------------------------------------------------------------------------------Ingredients / L
High Osmolality Low Osmolality
Components /
Litre_________
Sodium Chloride
3.5
2.6
Na
90
75
Sodium Citrate
2.9
2.9
Citrate
10
10
or
Sodium Carbonate
2.5
2.5
H CO3
30
30
Potassium Chloride 1.5
1.5
K
20
20
Glucose
20
13.5
Glucose
111
75
Osmolality
311
245
------------------------------------------------------------------------------------------------------------------------------------

Limitations of WHO High Osm-ORS

Does not lower volume, frequency and
duration of
diarrhea
Induces vomiting due to taste, acceptability
poor
Enhances volume, purge rate & duration of
diarrhea due to high osmolality
More chances of dehydration
Dehydrating fluid
So more oftenly IV fluids required
Hypernatremia
Good to correct deficit fluids but not good

Need of Low Osm-ORS

Does lower volume, frequency &

duration
Equally effective in cholera, toxin
related & RV diarrhea : Deficit &
maintenance therapy
No need of IV fluids
Good for all ages infancy to adulthood
Asymptomatic hyponatremia.

Role of Diet in Acute Diarrhea

Dietary therapy
Key role in treatment of diarrhea
Gained great importance in recent
years.
Early refeeding during or after
rehydration mandatory
Delayed feeding even by one day-slow
recovery
Fasting deterimental for outcome

Advantages of Dietary Therapy

Maintains nutrition, helps in
absorption
Faster recovery
Take care of infection and avoids
malnutrition
Prevents prolongation of diarrhea
Corrects malnutrition in malnourished children.
Extra diet in convalescence / on
recovery

What are the Diets to be Continued or Given ?

Age appropriate diets

Breast feeding : Aseptic paint.
Artificially fed milk
Whatever child taking earlier
Rice, khichri, pulses/ curd/yogurt
Small frequent aliquots Spoon & Katori

Foods to be Avoided

Fat rich
Fruits and fruit juices
Junk foods
Spicy foods
Carbonated fluids
Sugar & glucose rich foods

Diarrhea

Continue breast
feeding

Mucosal injury
(Malabsorption)

ORS
PD

Cereal supplements

TREAT THE DIARRHEA WITH REGULAR DIET

Malnutrition
(Marasmus)

Role of Zinc in Acute Diarrhea

Acute as well as persistent diarrhea
Tremendous loss in stools.
Absorption of Zinc intact

Deficiency during diarrhea results into

lowering of
Cell division & maturation.
Tissue growth & repair.
Maturation of enterocytes.
Brush border enzymes.
Water & electrolyte absorption.
Immune functions.

Zinc Supplementation in AD
Responsible for > 200 enzymes in body.
Improves the immune function & absorption.
Supplementation in AD and PD helpful in 20-30%
reduction in diarrhea.
42% lower rate of treatment failure or death.
Dosages
o Infants 10mg daily x 2 weeks.
o Older children 20mg daily x 2 weeks.
o Persistent diarrhea x 4 weeks

Acta Pediatr 2001

Am J Clin Nutr 2000
ASCODD 2001

Antimicrobial Therapy in AD
No proof that antibiotics effective
in
reducing the duration of diarrhea
Cochrane review of 12 trials no
advantage rather adverse effects
more in
acute watery diarrhea.

Why Antibiotics are not Required in AD?

Lack of knowledge of sensitivity of drug
against causative agent
Risk
bacteria

of

development

of

Risk of adverse reactions (AAD)

Cost of treatment

resistant

Indications for Antimicrobials

---------------------------------------------------------------------------------------------------Micro - organisms
Drugs
-------------------------------------------------------------------------------------------------- Bacteria
- Shigella
Nalidixic acid, Norfloxaclin
Ciprofloxacin
Ofloxacin, Cefotaxime, Ceftriaxone
- Salmonella typhi
Ciprofloxacin, Ofloxacin
- Vibrio cholera
Cotrimoxazole,
Tetracycline,Ciprofloxacin,
- Compylobacter jejuni
Nalidixic acid, Norfloxacin,
Furazolidine
- EPEC (PD)
Furazolidine, Norfloxacin,
Cotrimoxazole
Protozoa
- Giardia lamblia
} Mitronidazole,
- Entameba histolytica
} Tinidazole, Nitazoxanide,
Furazolidine

Other Special Indications of Antibiotics.

Severity of symptoms
factors

Host related risk

* Severely sick child

* Neonatal age
* Septicemia
* Malnutrition
* Neurological involvement * HIV Infection
* Septic shock State
* Other immune
deficiency
* Invasive diarrhea
Socio- environmental
indications
* Cholera
* Nosocomial infection
* At risk contacts.

Probiotics
Duration of acute diarrhea decreases by
one day in meta-analysis
Saccharomyces boulardii : Strong
benefit in AAD
Shown in meta-analysis of seven studies

Aliment Pharmacol Ther 2002

Diet in Indeterminate Diarrhea

(8-14 days)
Breast feeds continue
Diet A : Low lactose diet
Diet B : Lactose free diet, if no
response to Diet A.
Diet C : Monosaccharide based diet if
no response to Diet B.

Dietary Algorithm for Treatment Of PD

Success

Discharge

Appropriate
diet 7-14 days

Stabilize

Start Diet A

Treatment failure (Screen for infections)

Start Diet B

Success
Failure (Screen for infection)

Discharge
Diet C

Diet A after 10 days

Success
Failure

After 7-14 days

normal diet

Gradually
Parenteral
Diet B then
nutrition
Diet A & normal
Bull WHO 1996

Traditional Practices to be Avoided

Antimotility & antispasmodic drugs

Stool binding agents
Enzyme preparations & steroids
Antimicrobial agents in combination
Bottle feeding
IV fluids to every case
Starvation-Nothing like bowel rest
These will hamper natural clearance,
lower immunity, promote growth of
unusual organisms & PEM

Practices to be Adopted
Breast feeding: Aseptic paint for

GIT
Cereal supplementation
Spoon & katori/ directly from pot
Judicious use of antimicrobials
Proper hygiene & sanitation
Rotavirus vaccine

When to refer to higher center

Duration of diarrhea more than 7
days
Fast deteriorating condition
No response to usual therapy
Associated complications
Severely malnourished child
HIV positive

 to conclude
Low Osm-ORS.. quite
effective
Zinc therapy ..important
component
Treat diarrhea with regular
diet
Limited use of antibiotics :

DEHYDRATION

OBJECTIVES
At the end of this lecture you will
able to know the followings:
*What is dehydration?
*What are the causes of dehydration?
*The clinical manifestaions of
dehydration.
*The investigations required.
*Management of dehydration.

DEHYDRATION
Fluid and electrolytes requirements
Water: : Constitutes about 70% of infant's body
weight as compared to 60% in adults.

Most of the water is found within the

cells of the body (intracellular space).
The rest is found in the extracellular
space, which consists of the blood vessels
(intravascular space) and the spaces
between cells (interstitial space).
Total body water = intracellular space +
intravascular space + interstitial space

Average daily requirement of water (ml/kg):

-First year: 130 150.
-2 to 4 years: 100 130.
-4 to 10 years: 70 100.
-10 to 18 years: 50- 70.

Dietary Reference Intakes (DRI) of electrolytes:

Sodium (mg/day): 120 in the 1st 6months,
200 in the age 7-12 months,
225 in the age 1-3 years, and 300 from 48 years of age.

Potassium (mg/day): 500 in the 1st 6 months,

700 from7-12 months,
1000 from1-3 years, and 1400 from
4-8 years of age.

What is dehydration?
Dehydration occurs when the amount of water leaving
the body is greater than the amount being taken in.
We lose water routinely when:
We breathe and humidified air leaves the body;
We sweat to cool the body; and,
We urinate or have a bowel movement to get rid the body
waste products.

Hyponatremia ;
Is a condition in which the body's stores of sodium are
too low, and this condition can result from drinking extreme
amounts of water.
Hyponatremia can lead to confusion, lethargy, agitation,
seizures, and in extreme cases, even death.
Early symptoms are nonspecific may include
disorientation, nausea, or muscle cramps. The symptoms
of hyponatremia may also mimic those of dehydration, so
athletes experiencing these symptoms drinking more water
that result in further worsening the condition.

CONSERVATION OF BODY WATER

In a normal day, a person has to drink a significant amount
of water to replace the routine losses.
If intravascular water is lost, the body can compensate by
shifting water from cells into the blood vessels, but
this is a very short-term solution. Signs and symptoms of
dehydration will occur quickly if the water is not replenished.
The thirst mechanism signals the body to drink water
when the body is dry. As well, hormones like anti-diuretic
hormone (ADH) work within the kidney to limit the amount
of water lost in the urine.

The electrolytes in our body include sodium, potassium,

chloride, calcium and phosphate, but sodium is the
substance of most concern when replacing fluids lost
through exercising.

Hypernatremic dehydration
Dehydration,characterized by increased concentrations of
sodium and chloride in the extracellular fluid, it results from
diarrhea in infants.
The occurance of the hypernatremia and hyperchloremia lies
in the relatively greater expenditure of water than electrolyte
via skin, lungs, stool and urine. The water deficit in these
infants is primarily intracellular.
The majority of infants with this type of dehydration show
varying degrees of depression of central nervous system
varying from lethargy to coma. Convulsions are frequently
observed.
Dilute solutions of electrolyte are indicated in rehydration.
Rapid adjustment, however, appears to accentuate the CNS
disturbance. Rehydration is best carried out slowly over a 2to 3-day period.

What causes dehydration?

Diarrhea: is the most common reason for loss of excess water.

Worldwide, more than four million children die each year
because of dehydration from diarrhea. -Vomiting: can also be
a cause of fluid loss .
Sweat: The body can lose significant amounts of water when it
tries to cool itself by sweating whatever the cause of hotness of
the body such as intense exercising in a hot environment, or
presence of fever .
Diabetes: In people with diabetes, elevated blood sugar levels
cause sugar to spill into the urine and water then follows. For this
reason, frequent urination and excessive thirst are among the
symptoms of diabetes.
Chronic renal failure: dehydration occurs due to polyuria.
Burns: dehydration occur because water moves into the
damaged skin. Other inflammatory diseases of the skin are also
associated with fluid loss.
Inability to drink fluids: The inability to drink adequately is
the other potential cause of dehydration.

Clinical picture:
Examination.

- Body weight.
- Temperature.Signs of dehydration.
- Systemic
examination.
General manifestations:
- Dry skin and mucous membrane.
- Decrease all body secretions (urine,
sweats, tears, saliva)
- Depressed fontanel, sunken eyes,
thirst, irritability, lately hypotension,
acidosis and coma.

DEGREES OF DEHYDRATION:
Degree of
dehydration

Plan A:
No
dehydratio
n

Plan B:
Some
dehydratio
n

Plan C:
Severe
dehydratio
n

General condition

Calm, alert

Restless
irritable

Lethargic,
unconscious

Eye manifestation

Normal

Sunken

Sunken

Ability to drink

Normal

Thirsty,
eager to
drink

Poor

Skin pinch

Goes back
quickly

Slowly

Very slowly

IMCI MANAGEMENT: Integrated

management of childhood
illness ( WHO)
* Plan A: Give fluid and food to treat diarrhea at home
If child is 2 years or older and there is Cholera in your area,
give antibiotic for cholera.
Advise mother when to return immediately
Follow-up in 5 days if not improving.
* Plan B: Give fluid and food for some dehydration.
If child has also a severe classification:
Refer URGENTLY to hospital with mother giving
frequent sips of ORS on the way
Advise the mother to continue breast-feeding
If child is 2 years or older and there is Cholera in your area,
give antibiotic for cholera.
Advise mother when to return immediately
Follow-up in 5 days if not improving.

IMCI MANAGEMENT: Integrated

management of childhood illness (
WHO)
* Plan C: - Give fluids for severe dehydration or If
child has also another severe classification:
Refer URGENTLY to hospital with mother giving
frequent sips of ORS on the way
Advise the mother to continue breast-feeding
If child is 2 years or older and there is Cholera
in your area, give antibiotic for cholera.
100 cc/kg/bw: 30 cc/kg in first hour, 70 cc/kg
in second 21/2 hour for child > 1 year; and in
first 1 hour and 5 hours further for child < 1
year (WHO 2007)

MANAGEMENT OF DEHYDRATION
-Replace Phase 1: Acute Resuscitation :
Give Lactated Ringer OR Normal Saline at 10-20 ml/kg IV
over 30-60 minutes.
May repeat bolus until circulation stable
-Calculate 24 hour maintenance requirements
Formula:
First 10 kg: (100 cc/kg/24 hours)
Second 10 kg: (50 cc/kg/24 hours)
Remainder: (20 cc/kg/24 hours)
Example: 35 Kilogram Child
Daily: 1000 cc + 500 cc + 300 cc = 1800 cc/day
-Calculate Deficit:
Mild Dehydration: (40 ml/kg)
Moderate Dehydration: (80 ml/kg)
Severe Dehydration: (120 ml/kg)

MANAGEMENT
Continue ---------Calculate remaining deficit:
Substract fluid resuscitation given in Phase 1
-Calculate Replacement over 24 hours:
First 8 hours: 50% Deficit + Maintenance
Next 16 hours: 50% Deficit + Maintenance
Determine Serum Sodium Concentration
Hypertonic Dehydration (Serum Sodium > 150)
Isotonic Dehydration
Hypotonic Dehydration (Serum Sodium < 130)
Add Potassium to Intravenous Fluids after patient voids urine
Potassium source
Potassium Chloride
Potassium Acetate for Metabolic Acidosis
Potassium dosing
Weight <10 kilograms: 10 meq KCl /liter glucose
Weight >10 Kilograms: 20 meq KCl /liter glucose