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DIARRHEA &

DEHYDRATION
DONE BY: MOHAMMED A. SYAM

Learning Objective

Definition of diarrhea
Classification of diarrhea
Mechanism of diarrhea
Approach
Management
Dehydration

GENERAL INFORMATION
Diarrhea is one of the leading causes of mortality (infectious).
One of the preventable causes of neonatal mortality.
Diagnosis depends on the history in the first place, then on
medical tests to detect the origin of the problem
There are many causes for diarrhea, these include:

Infective causes.

Non-infective causes.

Endocrine.

Factitious.

DIARRHEA

Common clinical problem.

Generally defined as:


an increase in bowel frequency, or a decrease in the consistency (form) of
stool.
Quantitatively Definition:
A stool output greater than 200g/d in children >2 years old.
A stool output greater than 10ml/kg/d in children <2 years old.

It can be classified as organic or functional, or depending on the period


acute (less than 2 weeks) chronic (more than 2 weeks), in addition, it can be
classified as (watery, dysentery, persistent).

DIARRHEA
Organic diarrhea
Stool weight of more than 250 mg/day.
Functional diarrhea
Is diarrhea in the absence of any abnormalities
regarding digestion and absorption of nutrients,
fluids and electrolytes , and without any structural
abnormalities.

Diarrhea Classification
Watery
Acute
<2weeks
Diarrhea
Chronic
>2weeks

Bloody
(Dysentery)
Chronic
without
infection
Persistent
with infection

Amebic
Entamoeba
histolytica
Bloody
Bacillary
Shigella,
Salmonella
Not always bloody

~3-20% of all acute


diarrhea
90% cases in <1 y old
children

Mechanisms of
Diarrhea

Osmotic

Secretory

Exudative

Motility disorders

Osmotic:
due to: presence of high concentration of non -absorbed
hypertonic Substances in intestine which will attract fluid
from the blood to Intestine
Digestive enzyme deficiencies
Ingestion of unabsorbable solute
Viral infection

stop with fasting

Secretory:

Defect:
Increased secretion
Decreased absorption

Examples:
Cholera
Toxinogenic E.coli

Comments:

Persists during fasting


Watery,
Large volume fecal output > 1 Ltr per day,

Exudative Diarrhea:

Defects:

Inflammation
Decreased colonic reabsorption
Increased motility

Examples:

Bacterial enteritis

Comments:

Blood, mucus and WBCs in stool

Increased motility:

Defect:

Decreased transit time

Example:

Irritable bowel syndrome

MECHANISMS OF
DIARRHEA

Acute Diarrhea

Less than 2 weeks

COMMON CAUSE OF DIARRHEA


1. Infectious:

Viral gastroenteritis (rotavirus, noravirus, adenovirus):


Highly contagious.
Explosive watery diarrhea.
Lasts for 48-72H.
Blood and puss are uncommon in stool.
Bacterial enterocolitis (E.coli, Salmonella, campylobacter, shigella)
Most of them cause direct damage to the epithelium (inflammation).
Fever is a common symptom.
Blood or pus may be present.
Parasites (cryptosporidium, giardia lambila):
Can be transmitted in contaminated water.
GIARDIA associated with foul smell, steatorrhea feces

2. Food poisoning (Staphylococcus aureus)

Brief illness caused by toxins produced by bacteria

abdominal pain, vomiting +/-fever

SI secrete high amount of water diarrhoea

Symptoms usually appear within sev. hours

3. Travellers Diarrhoea
4. Drugs / medications

Chronic Diarrhea

More than 2 weeks

Chronic Diarrhea

Persistent
diarrhea
Acute onset
Prolonged for >2wk
Mostly infection related
Young <1year old

chronic
diarrhea

Insidious onset
Duration wks to months
Any age group
Mostly not infection
related

Chronic Diarrhea Causes

Infection

Gastrointestinal infection is the most common cause of


chronic diarrhea

HIV

Infection

Giardia Lambia: (Giardiasis) associated with traveller

A parasite that attaches itself to the lining of the small intestines,


where it disturbsthe body's absorption of fats and carbohydrates.

It is transmitted through contaminated water

It can be asymptomatic in many cases

Severe watery stools that contains fat (floats, shiny and smells
very bad)

Weight loss, and abdominal pain

Common in daycare nurseries and related to abroad travel


(outbreak)

Malabsorption
1. Lactose Intolerance

Acquired lactose intolerance is common in infants and young children

Following acute gastroenteritis

Symptoms may include abdominal pain, bloating, diarrhea, gas, and nausea. These
typically start between half and two hours after drinking milk

The superficial mucosal cells which contain lactase are stripped-of

Lactose is accumulated in the bowel with high levels prolonged diarrhea

Watery stools with low pH----------acidic diarrhea

congenital lactose intolerance is rare

Diagnosis may be confirmed if symptoms resolve following eliminating lactose


from the diet. Other supporting tests include a hydrogen breath test and a

Malabsorption
2. Coeliac Disease

A mucosal defect with permanent inability to tolerate gluten (wheat & rye)

Most present before age of 2 years with failure to thrive, irritability, anorexia,
vomiting and diarrhea.

Signs include wasted muscles, abdominal distention and pallor due to iron
deficiency anemia

The stools are pale, fatty and foul smelling.

Coeliac antibodies levels are raised (TG & endomysial)+in villus atrophy

Subtotal villous atrophy is found in jejunal biopsy (diagnosis).

Malabsorption
3. Cystic Fibrosis

It has a genetic origin (CFTR single gene mutation) that makes


the body produce abnormally thick and sticky mucus which builds
up in the lungs and in the pancreas.

Pancreatic insufficiency will lead to fat and protein maldigestion

It starts in infancy with failure to thrive and respiratory infections

Pale fatty stools that float with foul smelling and mucus.
(steatorrhea)

Inflammation
Inflammatory

Bowel Disease (IBD)

1) Crhons disease
2) Ulcerative Colitis

In late childhood and adolescence

Unpredictable exacerbations and remissions

Raised inflammatory markers (ESR & CRP)

Cows Milk Protein Intolerance

Allergic-like in nature and it is a rare condition

often bloody diarrhea (may be watery)

less common in breast-fed babies


*Urticarial
*Bronchospasm
*Eczema

symptoms should subside within one week of withdrawal

In most cases the intolerance resolves in 1-2 years

Endocrine
1.

Hyperthyroidism

2.

Adrenal insufficiency

3.

Hypoparathyrodism

4.

Diabetes Mellitus

Non- Pathological (Toddler


Diarrhea):

Chronic non-specific diarrhea of infancy

It afects children from 6 months to 5 years old of


age.

Functional diarrhea in nature

No malabsorption, weight loss or organic pathology

A thriving toddler with normal growth and weight


gain

Active child with normal appetite

Cont

Caused mainly by excessive intake of sweetened liquids


(fruit juice),That will overwhelm the disaccharide absorptive
capacity of intestine .

Rapid gastro-colic reflex fast gut transit time


(dysmotility)

Frequent watery or loose stools containing undigested food

A period will pass with normal bowel habits

Afected children will have 3-10 loose stools per day.

They happen when the child is awake and sometimes


immediately after eating.

No nocturnal diarrhea

No blood in stools

No signs of inflammation or infection

The diagnosis is only made if the toddler is thriving

Reassurance is required (90% self limiting)

Eliminating excessive fruit juice

Eliminating dietary sorbitol

Reducing fluid intake if excessively

Increase fat intake

Increase fibers in the diet

(non-absorpable sugar in apples, pears)

(fat can slow down a child's digestion allowing more time


for absorption of nutrients).

Complications of Diarrhea

Dehydration

Electrolyte deficiency

Malnutrition

Paralytic ileus

Irritation to anus due to frequent passage of watery stool containing irritating substances

Degree of Dehydration

Isotonic Dehydration

When proportionally the same amount of water and


sodium is lost from the body, the sodium concentration
of the extracellular fluid and hence its tonicity will not
change this is isotonic dehydration. Statistically, in
most cases (~ 80%) dehydration is isotonic2.

Hypertonic (Hypernatremic) Dehydration

When proportionally more water than sodium is lost from the body, the extracellular
fluid has increased concentration of sodium and becomes hypertonic regarding the
intracellular fluid and therefore attracts water from the cells. This results in the cell
shrinkage, which may cause brain shrinkage, Itisaparticularlydangerous

formofdehydration,
mayleadtojittery
movements, increased
muscletone, withhyperreflexia,altered consciousness, seizures and
multiple, small cerebral haemorrhages. Transienthyperglycaemia
occursinsomepatientswithhypernatraemic dehydration; it is
selfcorrecting anddoesnotrequireinsulin

Hypotonic (Hyponatremic) Dehydration

When proportionally more sodium than water is lost, the


sodium concentration of the extracellular fluids falls, which
therefore becomes hypotonic in comparison to intracellular fluid,
so water moves from the extracellular fluid into the cells. This
causes cell swelling, possibly resulting in the brain swelling
(cerebral edema)

Types of dehydration

The following children are at increased risk of dehydration:

Infants,< 6monthsofageorthosebornwithlowbirthweight.
Iftheyhavepassed 6diarrhoealstoolsintheprevious24h
Iftheyhavevomitedthreeormoretimesintheprevious24h
Iftheyhavebeenunabletotolerate(ornotbeenofered)extra
fluids
Iftheyhavemalnutrition.

Infantsareatparticularriskof
dehydrationbecause:

Theyhaveagreatersurfaceareatoweightratio
thanolder children,

They have higher basal fluidrequirements

Immaturerenaltubularreabsorption.

Theyareunabletoobtainfluidsforthemselves
whenthirsty

APPROACH
Detailed history.
Is
it
actually
diarrhea?

Stool volume.
Frequency.
Consistency.
Travel history.
Smell
Color
Family history
Type of food

Physical examination.

Assessment of dehydration.
Weight loss.
Extra-intestinal symptoms.
Abdominal examination.
Rectal examination.

Investigations:

Initially, electrolytes, blood urea nitrogen, creatinine, and urinalysis, indication of


hydration.

Stool specimens should be examined for mucus, blood, and leukocytes, if + think
about colitis in response to bacteria that difusely invade the colonic mucosa, such
as Shigella, Salmonella, C. jejuni,and invasive E. coli.
Stool cultures are recommended for patients with fever, profuse diarrhea, and
dehydration
If the stool test result is negative for blood and leukocytes, and there is no history
to suggest contaminated food ingestion, a viral etiology is most likely.
fecal immunoassays are the diagnostic tests of choice for Girdia

TREATMENT
Most infectious causes of diarrhea in children are self-limited.
Management of viral and most bacterial causes of diarrhea is primarily supportive and
consists of:
correcting dehydration and ongoing fluid and electrolyte deficits and
managing secondary complications resulting from mucosal injury.

Hyponatremia is common; hypernatremia is less common.

Traditionally therapy for 24 hours with oral rehydration solutions alone is


effective for viral diarrhea.
Therapy for severe fluid and electrolyte losses involves IV hydration.
Less severe degrees of dehydration (<10%) in the absence of excessive
vomiting or shock may be managed with oral rehydration solutions
containing glucose and electrolytes.
Ondansetron may be administered to reduce emesis when persistent.

Antibiotic therapy is necessary only for patients with:


S. typhi (typhoid fever) and
sepsis or bacteremia with signs of systemic toxicity,
infants younger than 3 months with nontyphoidal salmonella.

Antibiotic treatment of Shigella produces a bacteriologic cure in


80% of patients after 48 hours.
Recommended treatment for children is an oral third-generation
cephalosporin or a fluoroquinolone

Treatment of C. difficile (pseudomembranous colitis) includes


discontinuation of the antibiotic
if diarrhea is severe, oral metronidazole or vancomycin.

E. histolytica dysentery is treated with


metronidazole followed by a luminal agent, such as iodoquinol.

The treatment of G. lambliais with albendazole, metronidazole, furazolidone, or


quinacrine.
Nitazoxanide can be used in children younger than 12 months of age for the
treatment of Cryptosporidium

Oral Rehydration Solution (ORS):

Efective in all types & all degrees of dehydration.


Can prevent dehydration if given early in the disease.
Cheap, easy to administer; can be given by mother at home.

No chance of OVERHYDRATION or electrolyte overdose.

ORS contents:Sodium Chloride


Tri-Sodium Citrate (bicarbonate)
Potassium Chloride
Glucose

RESOURCES
Literature:
Tom Lissauer, Graham Clayden, Illustrated textbook of
pediatrics, 4th edition,(Mosby Elsevier, 2012).
Robert M. Kliegman, Bonita F. Stanton, nelson textbook of
pediatrics, 19th edition, (Elsevier Saunders, 2011).
Parveen Kumar, Michael Clark, Kumar and Clark's clinical
medicine, 8th edition, (saunders Elsevier, 2012).

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