Diarrhea- Excessive loss of fluid & electrolyte in the stool.
- Passage of 3 or more loose or watery stool in a 24 hour period.
- Loose stool- That would take the shape of a container.
- For practical purpose, the recent change in consistency & character of the stool & its water content.
Types of Diarrhea
- Acute watery diarrhea- lasts < 14 days.
- Dysentery- Diarrhea with visible blood & mucus.
- Persistent Diarrhea- Duration >14 days. Cause- infectious.
- Chronic diarrhea-Duration >14 days. Cause- noninfectious.
Causes
- Viruses (e.g., adenovirus, rotavirus, Norwalk virus)
- Escherichia coli, Clostridium difficile and Campylobacter, Salmonella, and Shigella are common bacterial causes
- Bacillus cereus, Clostridium perfringens, Staphylococcus aureus, Salmonella, and others cause food poisoning
- Entamoeba histolytica and Giardia, Cryptosporidium, and Cyclospora are parasitic or protozoal agents that cause diarrhea.
Causative agents
| Causative agent | Incubation period | Duration of illness |
| 1.Rotavirus | 1-4 days | 4-8 days |
| 2.Norovirus | 12-48 hrs | 12-60 hrs |
| 3.ETEC | 1-3 days | 3->7days |
| 4.EHEC | 1-8 days | 5-10 days |
| 5.Salmonella spp. | 1-3 days | 4-7 days |
| 6.Shigella spp. | 24-48 hrs | 4-7 days |
| 7.Bacillus cereus | 1-6 hrs | 24 hrs |
| 8.Clostridium perfringens | 8-16hrs | 24-48 hrs |
| 9.Staph aureus. | 1-6hrs | 24-48 hrs |
| 10.Vibrio cholera | 24-72 hrs | 3-7 days |
| 11.Entamoeba histolytica | 2-3d to 1-4 Wks | Several wks to mths |
| 12.Giardia lamblia | 1-2 Wks | Days to wks |
| 13.Cryptosporidium | 2-10days | Remitting/ relapsing |
Consequences/complication
- Dehydration
- Dyselectrolytemia
- Malnutrition
- Acute renal failure
- Septicemia & septic shock
- Hemolysis, renal failure & hemorrhage
- Hemolytic uremic syndrome
Assessment of hydration status
| Symptom | Minimal/ no dehydration (<3% wt loss) | Mild to moderate dehydration 3-9% wt loss) | Severe dehydration (>9% wt loss) |
| 1.Mental status | Well alert | Normal, fatigue or restless, irritable | Apathetic, lethargic, unconsciousness |
| 2.Thirst | Drinks normally | Thirsty, eager to drink | Drinks poorly, unable to drink |
| 3.Heart Rate | Normal | Normal to increased | Tachycardia, bradycardia. |
| 4.Quality of pulses | Normal | Normal to decreased | Weak, thready |
| 5.Breathing | Normal | Normal, fast | Deep |
| 6.Eyes | Normal | Slightly sunken | Deeply sunken |
| 7.Tears | Present | Decreased | Absent |
| 8.Mouth & tongue | Moist | Dry | Parched |
| 9.Skinfold | Instant recoil | Recoil in < 2sec | Recoil in >2 sec |
| 10.Capillary refill | Normal | Prolonged | Prolonged |
| 11.Extremities | Warm | Cool | Cold, mottled |
| 12.Urine output | Normal to decrease | Decreased | Minimal |
Assessment of hydration status (IMCI Protocol)
| Clinical signs General condition Eyes Thirst* Skin Pinch |
Well alert Normal Drinks normally Go back quickly |
Restless, irritable Sunken Drinks eagerly, thirsty Goes back slowly |
Lethargic, unconscious Sunken Drinks poorly Goes back very slowly |
| Decide | No signs of dehydration | If the patient has 2 or more signs, there is “some signs of dehydration” | If the patient has 2 or more signs, there is “severe dehydration” |
| Plan | Plan A | Plan B | Plan C |
* infant < 2mths of age, thirst is not assessed & decision regarding ‘some’ or ‘severe’ dehydration is made if 2 of the 3 signs are present
Guidelines for replacement of Fluid & Electrolytes
Plan A
- < 6 months- quarter glass or cup( 50ml)
- 7 months- 2 years- quarter to ½ glass or cup(50-100ml)
- 2-5 yrs ½ to 1 glass or cup(100-200ml)
- Older children- as much as the child can take.
Plan B
- Correction of dehydration- ORS @ 75ml/kg over a period of 4 hours.
- Reassess after 4 hours-if still dehydrated, repeat deficit therapy. If rehydrated, treat as “no dehydration” with Plan A
- If ORT is not successful, treat as “ severe dehydration” with intravenous fluids as in Plan C.
Plan C
| Infant (<1 year) | Older child (>1 year) | |
| Volume of Ringers lactate | 30ml/kg body wt within first 1 hour followed by 70 ml/kg body wt over next 5 hours | 30ml/kg body wt within ½ hour followed by 70ml/kg body wt over the next 2.5 hours |
Monitoring – Access for improvement every 1-2 hours
If not improving, give iv infusion more rapidly
Encourage oral feeding by giving ORS @ 5ml/kg/hr along with iv fluid as soon as the child is able to drink.
Reassess hydration status- After 6 hrs/3 hrs assess hydration status & choose an appropriate plan(A, B or C)
Clinical evaluation of dehydration
- Mild dehydration (<5% in infant,<3% in an older child or adult)- normal or increased pulse, decreased urine output, thirsty, normal physical finding
- Moderate dehydration (5-10% in an infant, 3-6% in older child or adult)- tachycardia, little or no urine output, irritable/lethargic, sunken eyes & fontanelle, decreased tears, dry mucus membranes, mild delay in elasticity (skin turgor), delayed capillary refill (>1.5 sec) cool & pale
Clinical evaluation of dehydration
- Severe dehydration (>10% in an infant; >6% in older child or adult)- rapid & weak or absent peripheral pulses, decreased blood pressure, no urine output, very sunken eyes & fontanelle, no tears, parched mucus membrane, delayed elasticity (poor skin turgor), very delayed CRT (>3 sec), cold & mottled, limp, depressed consciousness
Fluid management of dehydration
- Restore intravascular volume- 20ml/kg NS over 20 min. Repeat as needed.
- Calculate 24 hrs fluid needs- maintenance + deficit volume
- Subtract isotonic fluid already
administered from 24 hrs fluid needs
Fluid management of dehydration
- Administer remaining volume over 24 hrs using ½ NS + 5% Dextrose & 20meq/l KCl
- Replace ongoing loss as they occur
- In a child with a known or probable metabolic alkalosis (child with isolated vomiting), RL should not be used as lactate will worsen the alkalosis.
- Because dehydration can be associated with acute renal failure & hyperkalemia, potassium is
withheld from IV fluid until the patient has voided.
Summary of treatment
| Degree of dehydration | Rehydration therapy | Replacement of losses | Nutrition |
| Minimal or no dehydration | Not applicable | <10 kg: 60-120 ml >10 kg:120-240 ml ORS for each diarrheal episode/vomiting | Breast feeding + age appropriate normal diet with adequate calorie intake |
| Mild to moderate dehydration | ORS, 50-100 ml/kg body wt over 3-4 hrs | Same | Same |
| Severe dehydration | RL or NS in 20ml/kg body wt IV until perfusion & mental status improve, then 100ml/kg body wt ORS over 4 hr, or ½ NS & 5% D IV at 2* maintenance dose | Same, if unable to drink, administer through NG tube or administer 5% Dextrose with1/2 NS with 20 meq/l KCL IV | Same |
Oral rehydration salts (ORS) solutions
- Preservation of the facilitated glucose-sodium cotransport system in the small-bowel mucosa is the rationale of oral rehydration therapy.
- Greater net absorption of an isotonic salt solution with glucose than of one without it.
- Potassium replacement during acute diarrhea prevents below-normal serum concentrations of potassium
- Bicarbonate and citrate are equally effective in correcting the metabolic acidosis caused by diarrhea and dehydration
Oral Rehydration Salt
| ORS | Gm/liters | ORS | Mmol/liters |
| Sodium chloride | 2.6 | Sodium | 75 |
| Glucose, anhydrous | 13.5 | Chloride | 65 |
| Potassium chloride | 1.5 | Glucose, anhydrous | 75 |
| Trisodium citrate dihydrate | 2.9 | Potassium | 20 |
| Citrate | 10 | ||
| Total osmolarity | 245 |
Advantages of this new reduced osmolarity ORS solution
- It reduces stool output or stool volume by about 25% when compared to the original WHO-UNICEF ORS solution
- It reduces vomiting by almost 30%
- It reduces the need for unscheduled IV therapy by more than 30%.
- According to the MOHP and 2001 NDHS, nearly all mothers of children under 5 years old in Nepal know about ORS packets (97.8 percent); however, only 32 percent of mothers administered ORS during a recent bout of diarrhea
Fluids to avoid
- Fluids causing hypernatremia -most soft drinks
-sweetened fruit drinks
-sweetened tea - Fluids with stimulant, diuretic or purgative effect -coffee
-some medicinal teas
Clinical approach to diagnosis
- Access in the examination- physical signs of dehydration, nutritional status of a child, presence of other infections & signs of shock.
- Rotavirus diarrhea- vomiting is early feature & diarrhea is more severe.
- Large & watery stool in secretory diarrhea- ETEC or Vibrio cholerae (rice watery)
- Fever, abdominal cramps & tenesmus with the passing of blood & mucus in dysentery (colitis)
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