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Acute Watery Diarrhea

Acute Watery Diarrhea


Dr. Kishore Chandki
Consulting Child Specialist CHL-Apollo Hospital, Indore, INDIA

Acute Watery Diarrhea

World Health Report 2005, U5MR estimates from UNICEF2004, State or the worlds children 2006

Acute Watery Diarrhea


National M.P.
Children with diarrhoea in the last 2 26.2% weeks who received ORS Children with diarrhoea in the last 2 58% weeks taken to a health facility Children with acute respiratory 64.2% infection or fever in the last 2 weeks taken to a health facility Children age 6-35 months who are anemic Children under 3 years who are underweight 79.2% 49.5% 28.6% 60.1% 68.7%

82.6% 60.3%

2005-2006, National Family Health Survey (NFHS-3)

Acute Watery Diarrhea

National Data

M.P. Data
2005-2006, National Family Health Survey (NFHS-3)

Acute Watery Diarrhea

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Survey By Registrar General of India

Acute Watery Diarrhea


Definition
Passage of three or more liquid or watery stools in a day recent change in consistency & character of stools is more important Duration < 7-14 days 7Volume In infants > 10 g/kg In children older than 3 > 200g/day

Acute Watery Diarrhea

Acute Watery Diarrhea


Passage of frequent formed stools Passage of pasty stools in a reast fed infant Passage of stools several times a day y neonates; during or immediately after feeding : Gastrocolic Reflex Passage of frequent, loose greenish-yellow greenishstools on 3rd & 4th day of life: transitional diarrhea

Acute Watery Diarrhea


WHO Classification of DD:
Acute Watery Diarrhea (AWD) cute ( WD) Acute Dysentery & Severe Dysentery Cholera Chronic Diarrhea Persistent Diarrhea

Acute Watery Diarrhea

Acute Gastroenteritis Infantile Diarrhea Toddlers Diarrhea Winter Diarrhea Travelers Diarrhea

Acute Watery Diarrhea


mL/kg/day Diet 100 Saliva 70 Gastric Juice 70 Pancreatic + Bile 45 Total 285

Stool output 5-10 5g/kg/day

Acute Watery Diarrhea


Loss of 1 litre fluid in diarrheal stools ECF } 1.6 litre 7%

ECF 14 litres

Loss of 0.8 litre fluid in diarrheal stools

50%

CHILD 7 Kg ADULT 70 Kg

Acute Watery Diarrhea

Acute Watery Diarrhea


Viruses
Infective

Bacteri a

Parasites

Parenteral

Acute Watery Diarrhea


IBD Anatomic & Mechanical Food Poisoning Malnutrition Toxins Neoplasms Immune deficiency

NonNon-infective
Psychogenic

Hepatic

Endocrinopathy Miscellaneous Food Intolerance Pancreatic Improper Feeding

Malabsoption

Acute Watery Diarrhea

Acute Watery Diarrhea


S E C R E O R Y

q Absorption

o Secretion

Examples Cholera ETEC

Features No fecal leucocytes Persists during fasting

Acute Watery Diarrhea


Mechanisms O S M O T I C

Trasport Defect

Maldigestion Solute

Examples
Lactase

Features
fecal leucocytes Stops with fasting, o breath H2
No

Deficiency Laxative Abuse

Acute Watery Diarrhea


Mechanisms
M U C O S A L I N V A S I O N

Examples
Salmonella Shigella

Features
leucocytes Blood/Mucus in stools
Fecal

Acute Watery Diarrhea


Mechanisms
o M O T I L I T Y

Examples
IBS Thyrotoxicosis

Features
Infection

may also contribute

Acute Watery Diarrhea


q Blood Volume

L O S S

Orthostatic Hypotension

q B.P., Cold extremities

Weak & thready Pulse

qHydrostatic pressure in renal glomeruli q CSF Pressure

q Urine filtration Depressed AF Sunken Eyes

q Urine flow

q Intraocular O Pressure

q Organ Perfusion

Dried oral mucosa, Absent tears, Lethargy, Unconsciousness Deep & Rapid breathing Abdominal distension, ileus, hypotonia

E Acidosis C F Hypokalemia

Acute Watery Diarrhea


Transmission:
Oral-fecal route
Infected food/water Direct person-to-person contact

Risk Factors:
Age < 2 years Malnutrition/Immune deficiency Intercurrent infections e.g. measles Low socioeconomic status, environmental sanitation & personal hygiene

Acute Watery Diarrhea


Clinical Assessment: Onset, frequency, quantity, and character Recent oral intake Urine output Associated symptoms

Acute Watery Diarrhea


Clinical Assessment: Accurate weight Mental Status Vitals, CRT Breathing Eyes & Tears Mucous membranes Extremities Skin pinch

Acute Watery Diarrhea

Acute Watery Diarrhea


Clue to Diagnosis:
Viral: Watery, severe vomiting, low grade fever, usually with URI Rotavirus : <2 yrs, Vomiting early, mild fever, large volume watery stools just like urine ETEC / Cholera : Vomiting, no fever, Secretory diarrhea Rice watery stools, fishy odor Shock Very sick/Immunocompromised child: Staphylococcus, Cl. Difficle, Candida albicans Giardia: Watery with/without cramps, not thriving well

Acute Watery Diarrhea


Site of Pathology
Small Intestine (Enteritis)

Character of Stools
Large volume, watery. No pus/blood (Naked eye / microscopy) Frequent, small volume. Pus &/ blood present. Initially large volume watery stools changing to small volume stools. (Macro- or (MacroMicroMicro-scopic pus/blood present)

Likely Organism
Viruses, V. Cholerae, E. Coli (EPEC, ETEC, EAEC), toxins, cryptosporidium Shigella, E. histolytica, E. Coli (EHEC, EIEC), Cl. Difficile Salmonella, Shegella sonnei, Campylobacter

Large Intestine (Colitis) Small & Large Intestine (Enterocolitis)

Acute Watery Diarrhea


Complications:
oDehydration, Renal Failure oMalnutrition oSecondary lactose intolerance oPostinfective intestinal malabsorption (Tropical Sprue) o Postinfective irritable bowel syndrome oErythema nodosum (Salmonella, Campylobacter, Yersinia enterolytica

Acute Watery Diarrhea


Complications:
oSepticemia (Salmonella, Yersinia, Campylobacter) oToxic colonic dilatation (Salmonella, Shigella, C. difficile, Campylobacter) oHUS (EHEC 0157:H7; Shigella dysenteriae) oReactive Arthritis (Salmonella, Shigella, Campylobacter esp. in HLA-B27 positive) 2nd or HLA3rd week of illness oDVT, Cerebral venous thrombosis (with severe dehydration) oDyselectrolytemia, convulsions

Acute Watery Diarrhea


Assessment of Dehydration
No 3-5% S Mild O Moderate 6-10%
M E Wt. Loss <3% Features

Increased thirst, irritability q Skin turgor, depressed fontanelle, dry mucous membranes, sunken eyes Drowsy, apathetic, refusal to feed/drink, anuria, acidosis, shock

Severe
WHO 1995; ESP GHA N 2001

>10%
CDC; 1992, AAP 1996

Acute Watery Diarrhea

Acute Watery Diarrhea

Acute Watery Diarrhea


Signs unreliable in Malnourished:
Mental status Mouth, tongue, tears Skin pinch

Signs useful:
Thirst Pulses Urine output

Acute Watery Diarrhea


Isotonic
(Na+ 130-150) 13070-80% 70-

Hypertonic
(Na+ >150) 5-10%

Hypotonic
(Na+ <130) 15-20% 15-

Skin Temp Turgor Feel Mucous membrane Eyes A. F. Sensorium Pulse B. P.

Cold Poor Dry Dry Sunken & soft Depressed Drowsy Rapid Low

Cold/Hot Fair Doughy Parched Sunken Levelled/D Irritable Mod. rapid Mod. Low

Cold Very Poor Clammy Slightly moist Sunken & soft Depressed Comatose Rapid Very Low

Acute Watery Diarrhea

ICF ECF
Fluid moves from ECF to ICF comprtment In hyponatremic dehydation accentuating fluid depletion in ECF

ICF ECF
Fluid moves from ICF to ECF compartment in hypernatremic (hypertonic) dehydration, thus partially compensating for fluid depletion of ECF compartment

Acute Watery Diarrhea

Acute Watery Diarrhea


Investigations:
Stool Routine, pH; Reducing Substances No role in acute diarrhea Stool Culture Not indicated, not useful, misleading Hemogram, Urine If systemic infection suspected Blood urea, ABG, Electrolytes Severe persistent dehydration

Acute Watery Diarrhea


Investigations:
Gross / Naked eye examination of stool: Most Important: Semisolid / Watery, Amount Color : White, yellow, greenish yellow, blood stained Smell Presence of blood / mucus

Acute Watery Diarrhea


Interpretation of Lab Data:
Fecal leucocytes: >10/hpf is significant, false positive with viral Hanging drop preparation: Motile organism pH & reducing sugar: (liquid part of stool) pH < 5.5 1+/0.5% sugar ppt. Borderline significance 2+/1.0% Clinically significant False positive in breast fed; even without diarrhea Stool Culture: Utility in Shigella, V. cholerae E. coli: Commensal/Causative

Acute Watery Diarrhea

Acute Watery Diarrhea


Indications of i. v. Line:
Severe Dehydration with or without signs of shock Fatigue, stupor or coma (unable to drink) Children with persistent vomiting &/or abdominal distension Prolonged oliguria or anuria Any other serious complication that prevents successful oral therapy Septicemia or other systemic infection

Acute Watery Diarrhea


Indications of Hospitalization:
Age < 6 months Severe Dehydration Severe Malnutrition Systemic Infection Severe lactose malabsorption

Acute Watery Diarrhea


Severe Dehydration

Acute Watery Diarrhea


Severe Dehydration:
First give 30 Then give 70 ml/kg in ml/kg in 1 hour* 5 hours 30 minutes* 2 hours

Up to 12 months 12 months & Older

*Repeat once if radial pulse is still very weak or not detectable

Fluid of choice: Ringer lactate with 5% dextrose Ringer lactate Normal Saline

Acute Watery Diarrhea


G I Still Severe dehydration V E N F L U I D
Improving but some dehydration Repeat IV fluids

Discontinue IV treatment

Shift to Plan B

No dehydration

Discontinue IV treatment

Shift to Plan A

Acute Watery Diarrhea


Circulatory Collapse in Malnourished:
First give 15 Then ORS 15 ml/kg in ml/kg/hr Any Age 1 hour* Up to 10 hrs

*Repeat if necessary

Fluid of choice: Half strength Darrows solution with 5% dextrose Ringer lactate with 5% dextrose 0.45% (half normal) saline with 5% dextrose

Acute Watery Diarrhea


Hypernatremic Dehydration:
First give 30 ml/kg in Any Age 30 min* Then 1.251.251.5 times maintenance Over 24-84 24hrs

*Repeat if necessary Fluid of choice: D5 NS or D5 NS (both with 20 mEq/Kg K+ unless contraindicated)


Water deficit = Body weight v 0.6 (1-145 / [Current sodium])

Acute Watery Diarrhea


Fluid overload:
oRapid weight gain with decreasing Na+ oPeripheral edema, puffy eye lids

Inadequate Fluids:
oVery rapid weight loss with increasing Na+ or o Persistent tachycardia

Acute Watery Diarrhea


Components of Parenteral Fluids Na+
(mEq/L)

Cl(mEq/L)

K+
(mEq/L)

Lactate Osmolarity
(mEq/L) (mOsm/L)

NS 0.5 NS 0.2 NS L.R. Darrows

154 77 30 130 61

154 77 30 109 52

4 17

28 27

308 154 60 271 157

Acute Watery Diarrhea


No Dehydration Some Dehydration Severe Dehydration Objective Prevention of Correction of Correction dehydration mild to of severe & moderate dehydration malnutrition. dehydration & by ORT Dyselectroly ORS optional temia by IVF Where Home ORT Corner Intensive Care By whom Mother or Care taker Under supervision in a health facility Doctor & Staff

Acute Watery Diarrhea


Prevention:
Breast-feeding, avoid bottle BreastImproved weaning practices Personal hygiene Safe disposal of the stools of young children Measles immunization Vitamin A, Zinc supplementation Continued feeding the child during diarrhea Vaccines