DIARRHOEA

Diarrhoea is the passage of 3 or more loose (a loose stool being one that would take the shape of the
container)or liquid stools per day (in a 24-hour period), or more frequently than is normal for the
individual. (WHO). Gastroenterologists define it as more than 200g of stool per day (Davidson’s)

It is the 2nd leading cause of death of children under five years of age (16%) – first being Pneumonia
(17%)

CAUSES OF DIARRHOEA

MICROBIAL: Bacterial: B. Cereus, Staph aureus, clostridium spp.,

Enterohhgic/enteroinvasive/enterotoxigenic E.coli, salmonella, shigella, vibrio cholera (01 and 0139
BENGAL), vibrio parahemolyticus, yersinia enterocolitica

Viruses: rotavirus, norovirus (Norwalk virus), astrovirus, calicivirus, CMV (esp. in AIDs pt), HSV

Parasites: cryptosporidium parvum (in AIDs), e. histolytica, giardia lamblia,

NON-MICROBIAL: feeding difficulty, anatomic defects (eg-malrotations, short bowel syndrome,

hirschprungs), malabsorption (disaccharidase deficiency, pancreatic insufficiency, cystic fibrosis, CLD,
cholestasis, hartnup’s disease, celiac disease, tropical sprue), endocrinopathies (thyrotoxicosis, addison’s
adrenogenital syndrome), food poisoning (heavy metals, scombroid, ciguatera, mushrooms), neoplasms
(neuroblastoma, pheochromocytoma, carcinoid, Zollinger-Ellison, VIP-secreting tumor-pancreatic
cholera), misc. (non-GI infections, milk allergy, crohn’s, familial dysautonomia, protein-losing
enteropathy, immune deficiency, acrodermatitis enteropathica-zinc deficiency, laxative abuse, pellagra

Infants are at particular risk of dehydration because of their:

 greater surface area to weight ratio, leading to greater insensible water losses (300 ml/m2
per day, equivalent in infants to 15-17 ml/kg per day)
 inability to gain access to fluids when thirsty
 higher basal fluid requirements (100-120 ml/kg per day, i.e. 10-12% of body weight)
 immature renal tubular reabsorption processes.

TYPES OF DIARRHOEA

1. Acute watery diarrhoea includes cholera, E.coli, Rotavirus

2. Bloody diarrhoea, often referred to as dysentery,
is marked by visible blood in the stools. It is
associated with intestinal damage. MCC = Shigella. Others, c.jejuni, e.histolytica, enterhhgic e.coli etc

3. Persistent diarrhoea is an episode of diarrhoea,

with or without blood, that lasts at least 14 days.
Undernourished children and those with other
illnesses, such as AIDS, are more likely to develop
persistent diarrhoea.
Causes of persistent diarrhoea in HIV-positive children
include HIV-related malabsorption, gut manifestation of
tuberculosis, gut infections and infestations of pathogens
such as Cryptosporidium parvum, Cyclospora cayetanensis,
Isospora belli, Microsporidia and cytomegalovirus. (who)

Other causes of chronic/persistent diarrhea:

CAUSES OF CHRONIC DIARRHOEA IN THE TROPICS

 Giardia intestinalis
 Strongyloidiasis
 Hypolactasia (primary and secondary)
 Enteropathic E. coli
 Tropical sprue
 Chronic calcific pancreatitis
 HIV enteropathy
 Intestinal flukes
 Chronic intestinal schistosomiasis

22.18 CHRONIC OR RELAPSING DIARRHOEA

  Colonic Malabsorption Small bowel
Clinical Blood and mucus in Steatorrhoea Large-volume, watery stool
features stool
  Cramping lower Undigested food in the Abdominal bloating
abdominal pain stool
    Weight loss and nutritional Cramping mid-abdominal
disturbances pain
Some causes Inflammatory bowel Pancreatic VIPoma
disease
  Neoplasia   Chronic pancreatitis Drug-induced
  Ischaemia   Cancer of pancreas   NSAIDs
  Irritable bowel   Cystic fibrosis   Aminosalicylates
syndrome (MCC)
    Enteropathy   Selective serotonin re-
uptake inhibitors (SSRIs)
      Coeliac disease  
      Tropical sprue  
      Lymphoma  
      Lymphangiectasia  
Investigation Colonoscopy with Ultrasound, CT and MRCP Stool volume
s biopsies
    Small bowel biopsy Gut hormone profile
    Barium follow-through Barium follow-through
 Box 13.3 Conditions which can mimic gastroenteritis

Systemic Septicaemia, meningitis

infection
Local infections Respiratory tract infection, otitis media, hepatitis A, urinary tract infection
Surgical Pyloric stenosis, intussusception, acute appendicitis, necrotising enterocolitis,
disorders Hirschsprung's disease
Metabolic Diabetic ketoacidosis
disorder
Renal disorder Haemolytic uraemic syndrome
Other Coeliac disease, cow's milk protein intolerance, adrenal insufficiency

Key actions to reduce burden of childhood diarrhea

WHO 7-POINT PLAN FOR COMPREHENSIVE DIARRHOEA CONTROL

Primary Prevention: (to prevent onset)
 Rotavirus and measles vaccination
 Handwashing with soap
 Supply of safe drinking water
 Community-wide sanitation
Secondary Prevention: (to prevent severity)
 Fluid rehydration
 Promote EARLY AND EXCLUSIVE breastfeeding, Vitamin A supplementation
 Zinc
Treatment:

 ORT (low osmolarity ORS)

 Zinc
 Continued feeding (including breastfeeding)
 Antibiotics, if need be
 Treat underlying cause, if any.

ASSESSMENT OF DEHYDRATION

HISTORY: (emphasis put on 6 areas)

 Age, and Residence/travel history (any local outbreaks in the area?)

 Passage of stool (loose/watery/bulky/frothy, frequency, duration, has it happened before?, any
blood, pain,mass, tenesmus, parasites etc )
  Any other associated symptoms (eg- vomiting, lethargy, eating/drinking poorly, convulsions,
fever, oliguria etc)
 Family history : Are other family members affected? (suggest infectious case)/FH of
malabsorption (eg – cystic fibrosis, celiac disease?)
 Nutritional history – ask about food and feeding habits (diarrhea most with milk/diary products
– lactose intolerance, poor food quality/quantity – malnutritionetc)
 Drug history – H/O of antibiotic us (eg ampicillin, clindamycin, 3rdgen ceph. Etc that cause
pseudomembranous colitis)

Table 13-1. Clinical assessment of dehydration

  Moderate Severe dehydration

dehydration
Body weight loss 5-10% >10%
General appearance Thirsty, drowsy
Drowsy, limp, cold, sweaty,
cyanotic extremities
Respiration* Deep, may be rapid Deep and rapid
Eyes (ask mother whether eyes are normal Sunken Grossly sunken
or more sunken than usual)
Tears Reduced/absent Absent
Mucous membranes Dry Very dry
Capillary refill time* Prolonged (> 2 Prolonged (>2 seconds)
seconds)
Tissue turgor*(less useful in PEM/obese Retracts slowly Retracts very slowly
children)
Blood pressure Normal or low Low
Radial pulse Rapid and weak Rapid, thready, may be
impalpable
Anterior fontanelle Sunken Very sunken
Urine output Reduced Marked oliguria

*Most helpful and reliable signs.

In case of NO DEHYDRATION, body wt loss 1-4%, with a well/alert appearance, drinks
normally, and all other features being normal.
ALL the above and treatment below apply for hyponatremic and isonatremic types of
dehydration. Hypernatremic types (mainly due to insensible water loss from high fever/dry,hot
environment, or prfuse low-Na diarrhea) are difficult to diagnose due to paucity of S/S and is a
particularly dangerous form of dehydration as water is drawn out of the brain and cerebral shrinkage
within a rigid skull may lead to multiple, small cerebral haemorrhages and convulsions. Transient
hyperglycaemia occurs in some patients with hypernatraemic dehydration; it is self-correcting and does
not require insulin. It is even more difficult to manage: Once circulation has been restored, a too rapid
reduction in plasma sodium concentration and osmolality will lead to a shift of water into cerebral cells,
resulting in cerebral oedema and possible convulsions. The reduction in plasma sodium should therefore
be slow, over 48 hours, in order not to exceed a reduction in plasma sodium of 10 mmol/L per 24 hours.

INVESTIGATIONS:

Hematological: CBC and PBF, U&E, giemsa stain for plasmodium spp., levels of heavy metal
(thallium, cadmium, arsenic, lead etc)
Imaging: USG of abdomen, X-ray of abdomen (r/o intusussception, necrotizing entercolitis, esp
in neonates), ct/mri, Barium studies, proctosigmoidoscopy to detect polyps, ulcers, melanosis
coli from laxative abuse etc. (sometimes chest x-ray, blood&urine cultures also req to rule out
other systemic causes)
Biopsy and histopathology: to dx celiac disease, IBD,
Test stool for: leucocytes, blood (dx invasive diarrhea), ova/parasites in saline wet mount, fat
content (steatorrhea), toxin assay (eg - clostridium difficile toxin), culture for Salmonella,
Shigella, (rule out Enterohhgic e.coli where antibiotics can cause HUS), stool osmotic gap (300
mOsm/kg – 2 x (stool Na + stool K+) = if >100 mOsm/kg >> lactose intolerance)

(In adults with chronic/relapsing diarrhoea, RBS, Thyroid function tests, 5-HIAA excretion in
urine, RFT etc should also be given)

TREATMENT:

NO DEHYDRATION – TREATMENT PLAN A

 Give the CHILD MORE FLUIDS (cereal gruel or ORS) than usual to prevent
dehydration (after each loose stool, give 50-100 ml ORS for <2yrs. and 100-200 ml ORS
 for >2 yrs)
 Give the child plenty of food to prevent undernutrition (breastfeed frequently and wean
with khichuri, mashed banana, fresh fruit juice etc)
 Bring the child back for re-assessment if he/she does not get well in 3 days or develops,
many watery stools, blood in stool, vomiting frequently, poor drinking, marked thirst,
fever.

SOME DEHYDRATION – TREATMENT PLAN B

 A 6-hour trial of oral rehydration can be instituted, aiming to give 100 ml/kg over this period
(orally or by nasogastric tube). If there is no improvement in the child's symptoms and state of
hydration, intravenous rehydration should be given.
 OR 75 ml/kg of ORS can be instituted over 4 hours
 Encourage mother to continue breastfeeding/weaning as appropriate
 REASSESS the child in 4 hours, if he/she continues to deteriorate, shift to plan c, if same, repeat
plan B, if improves, go to plan A
 In both plan A and B, give child 1 tbsp/1-2 min for <2 yrs and frequent sips from a cup for an
older child. If chilkd vomits, wait 10 min, then give at a more slower rate 1 tbsp/2-3 min. If
eyelids become puffy, stop ORS and given plain water or breast milk.

SEVERE DEHYDRATION – TREATMENT PLAN C

Immediate IV rehydration
Ringer’s lactate (best) can be used (100 ml/kg in divided doses according to age)

Fluid req can be given according to age and body wt, as in if <1 yr, first 30 ml/kg to given
in 1 hour and the rest 70 ml/kg in 5 hours. For >1 year, first 30 ml/kg in ½ hour and next 70
ml/kg in 2 ½ hours.

Fluid requirements can also be given according to calculation as fluid deficit (in ml) =
%dehydration x weight in kg x 10 (so in severe dehydration – (10x10) 20 ml/kg 0.9% NS
given within ½ hour to treat shock in PHASE 1 and if pt. improves, plasma Na is measures.
If normal or low, pt is rehydrated in PHASE 2 with 0.45% saline/2.5% dextrose in 24
hours but if hypernatremic, it is done in 48 hours.) – close monitoring of fluid balance,
serum electrolytes, clinical condition, weight, plasma creatinine required. ------ IN
MAINTENANCE phase, to supplement continuing losses (from fever, vomiting and
diarrhea, hyperventilation, pooling of fluid in gut, capillary leak) is according to wt, fluid
req.: first 10 kg = 100 ml/kg/24hours, 2nd 10 kg = 50 ml/kg/24 hours, subsequent kg = 20
ml/kg/24 hours

Reassess pt by radial pulse every 1-2 hours, if pulse still low, increase IV drip rate. As soon
as pt take orally, give ORS (abt 5ml/kg) every 3-4hrs in infant and 1-2 hrs in older child.
After 6 hours in infants and 3 hrs in older children, we ned to reevluate the pt by clinical
signs and assign again in its respective plan A.B.C

IF IV not immediately available, give 20 ml/kg/hr ORS by NG tube or orally.

There is no place for medications for the vomiting or diarrhoea of gastroenteritis as they:

 are ineffective
 may prolong the excretion of bacteria in stools
 can be associated with side-effects
 add unnecessarily to cost
 focus attention away from oral rehydration.

Antibiotics are indicated only for specific bacterial or protozoal infections (e.g. cholera,
shigellosis, giardiasis).
ROLE OF ZINC IN DIARRHOEA

<6mo = 10 mg/d for 10 days

>6mo – 5y = 20 mg/d for 10 days (oral dispersible tablets)
Zinc:
 Reduce the duration and severity of both acute and persistent diarrhea
  . It boosts up the immune system
 Helps in healing the intestinal lining
 Improves absorption of fluids and ORS
 Prevent recurrence of diarrhea for the next 3-4 months

COMPOSITION OF REDUCED OSMOLARITY ORS

Reduced osmolarity ORS (grams/litre)
 Sodium chloride - 2.6
 Glucose, anhydrous - 13.5
 Potassium chloride - 1.5
 Trisodium citrate,Dehydrate - 2.9
Total weight - 20.5
Reduced osmolarity ORS (mmol/litre)
 Sodium 75
 Chloride 65
 Glucose, anhydrous 75
 Potassium 20
 Citrate 10
Total osmolarity 245
 

Composition of the Cholera Saline is as follows:

a) Na+ 3.0 gm/l = 133 mmol/l
b) K+ 0.5 gm/l = 13 mmol/l
c) Cl- 3.5 gm/l = 98 mmol/l
d) Acetate 2.8 gm/l = 48 mmol/l
e) Acetate is converted in to bicarbonate, which is required for cor-
rection of acidosis. In some solution, lactate is used instead of
acetate.
* Ringer's Lactate Solution contains low Potassium 4 mmo0l/l

One litre of lactated Ringer's solution (Hartmann’s soln.) contains:

 sodium ion = 130 mmol/L

 chloride ion = 109 mmol/L
 lactate = 28 mmol/L
 potassium ion = 4 mmol/L
 calcium ion = 1.5 mmol/L

Other Stuff:

FROM DAVIDSON 20th edition

13.16 SEVERITY MARKERS IN ACUTE GASTROENTERITIS

Chronic conditions
 Age > 65
  Diabetes mellitus
 Rheumatoid or other autoimmune disease
 Chronic renal disease
 Valvular heart disease (especially with valve replacements)
 Acquired or secondary immunodeficiency
 Any internal prostheses

Current drug therapy

 Diuretic therapy
 Angiotensin-converting enzyme (ACE) inhibitor therapy
 Corticosteroid therapy
 Cytotoxic therapy
 Proton pump or H2-receptor blockers

Current illness
 Number of stools per 24 hours
 Presence of blood per rectum
 Abdominal pain
 Associated systemic toxicity

13.14 CAUSES OF BLOODY DIARRHOEA

Infectious

 Campylobacter spp. (p. 326)

 Shigella dysentery (p. 330)
 Non-typhoidal salmonellae (p. 328)
 Enterohaemorrhagic E. coli (EHEC, p. 328)
 Entero-invasive E. coli (EIEC, p. 328)
 Clostridium difficile (p. 329)
 Vibro parahaemolyticus (p. 330)
 Entamoeba histolytica (amoebic dysentery, p. 358)

Non-infectious

 Diverticular disease (p. 929)

 Rectal or colonic malignancy (p. 923)
 Inflammatory bowel disease (p. 910)
 Bleeding haemorrhoids (p. 933)
 Anal fissure (p. 933)
 Ischaemic colitis (p. 923)
 Intussusception

13.13 CAUSES OF ACUTE DIARRHOEA

Infectious

Toxin-mediated

 Bacillus cereus (p. 326)

 Staphylococcal enterotoxin (p. 325)
 Clostridial spp. enterotoxin (p. 326)
 Scombrotoxic (p. 331)

Infective food poisoning

 Rotavirus gastroenteritis (p. 311)

 Campylobacter (p. 326)
 Salmonella (p. 328)
 Verocytotoxigenic E. coli (p. 328)
 Other E. coli, e.g. travellers' diarrhoea (p. 328)
 Shigella (p. 330)
 Clostridium difficile (p. 329)
 Norovirus (p. 311)
 Cholera (p. 330)

Protozoal

 Giardiasis (p. 359)

 Amoebic dysentery (p. 358)
 Cryptosporidium (pp. 360 and 387)
 Isosporiasis (p. 388)
 Microsporidiosis (p. 388)

Systemic illness

 Sepsis (+ sepsis syndrome, p. 317)

 Meningococcal sepsis (p. 189)
 Pneumonia (especially 'atypical disease', p. 687)
 Malaria (p. 342)
Non-infectious

Gastrointestinal

 Acute diverticulitis (p. 929)

 Inflammatory bowel disease  Ulcerative colitis (p. 910)  Crohn's disease (p.
910)
 Bowel malignancy (p. 923)
 Pelvic inflammatory disease (p. 410)
 Overflow from constipation (p. 930)

Metabolic upset

 Ketosis (e.g. diabetic decompensation)

 Vasoactive intestinal peptide release (p. 858)
 Carcinoid syndrome (p. 903)
 Uraemia (p. 485)

Drugs and toxins

 NSAIDs
 Cytotoxic agents
 Antibiotics
 Ciguatera fish poisoning (p. 331)
 Dinoflagellates (p. 331)
 Plant toxins (p. 331)
 Heavy metals (p. 331)

FROM DAVIDSON 21st edition:

Causes of infectious gastroenteritis:

 Preformed toxins in food <6h incubation: b. cereus, staph. Aureus, clostridium spp. Enterotoxin
 Bacterial 12-72 hours incubation: v. cholera, e.coli (ehhgic*,etox,enteroinvasive), salmonella*,
shigella*, campylobacter*, c. diff*
 Virus, short incubation: rotavirus, norovirus
 Protozoal, long incubation: g. lamblia, cryptosporidium, microporidiosis, amoebic dysentery*,
isosporiasis

*associated with bloody diarrhea

DDx of acute diarrhea and vomiting

Infectious causes:

 Gastroenteritis
 C. difficile
 Acute diverticulitis
 Sepsis
 PID
 Meningococcemia
 Pneumonia (esp.’ atypical disease’)
 Malaria

Non-Infectious

Gastrointestinal:

 IBD
 Bowel malignancy
 Overflow from constipation

Metabolic:

 DKA (even in Diabetic autonomic neuropathy)

 Thyrotoxicosis
 Uremia
 Neuroendocrine tumors releasing VIP or 5-HT

Drugs and toxins:

 NSAIDs
 Cytotoxic agents
 Antibiotics
 PPIs
 Dinoflagellates
 Plant toxins
 Heavy metals
 Ciguatera fish poisoning
 Scombrotxic fish poisoning

MOST COMMON CAUSES OF TRAVELLER’S DIARRHOEA

ETEC, SHIGELLA, C.JEJUNI, SALMONELLA, PLEISOMONAS SHIGELLOIDES, NON-CHOLERA, VIBRIO,

AEROMONAS spp.
**Diarrhoea may also be a symptom of systemic upset in addition to being a specific indicator of
gastroenteritic infection or disease. Stress, whether psychological or physical, will produce loose stools
in susceptible individuals without overt gastrointestinal disease. Sepsis from a non-gastrointestinal site
frequently results in diarrhoea; for example, up to 30% of patients with lobar pneumonia have diarrhoea
as a presenting symptom. (so chest x-ray is req in diarrhea)

**Infectious diarrhea in old age: usually due to C. diff. infection

** Antibiotics:

 V. cholera: Doxycycline or tetracycline

 Shigella: ampicillin/cipro/ceftriaxone
 E.coli (all strains, except ehec): TMP/SMZ
 Salmonella: ceftriaxone
 C. jejuni: macrolides
 C. diff: oral metronidazole or oral vancomycin
 Giardia & E.histolytica : metronidazole (followed by iodoquinol in EH)