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ACUTE DIARRHEA |
Sanjay Prabhu
1. What is Diarrhoea?
It is the passage of liquid or watery stools more than 3 times a day. A recent change in character of stool is more important.
2. What is dysentery?
Gross blood in the stool is the hallmark of dysentery and may be accompanied by abdominal cramps and fever.
3. What is not diarrhoea?
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Passage of frequently formed stools. |
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Passage of pasty stools in breast fed infants. |
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Passage of stool during or immediately after feeding due to gastrocolic reflex. |
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Passage of frequent loose greenish yellow stools on the 3rd and 4th day of life called as transitional stools. |
4. What are the consequences of diarrhoea?
Dehydration and Malnutrition leading to Death.
5. Why does diarrhoea cause malnutrition?
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Impaired intestinal absorption causes loss of nutrients in diarrhoea. |
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Increased catabolism(waste of energy) due to infection. |
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A child with diarrhoea is often not hungry. |
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Mothers withhold food during diarrhoea. |
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Doctors do not emphasize proper feeding during diarrhoea. |
6. What are the common causes of diarrhoea?
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Rotavirus is the commonest cause of dehydrating diarrhoea in children. |
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Cholera is seen in epidemics. |
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Shigella is the most common cause of dysentery. |
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Giardia and Amoebiasis are uncommon causes of acute diarrhoea. |
7. How do you assess a child with diarrhoea?
| History |
: Stool frequency, quantity and type of stool |
| : Blood in the stool |
| : Fever |
| : Decreased passage of urine |
| : Vomiting - pronounced in rotaviral diarrhoea |
| : Abdominal distension |
| : Altered Sensorium |
| : Feeding history |
Examination:
Condition |
Well, alert |
Restless, irritable |
Lethargic, drowsy, floppy |
Eyes |
Normal |
Sunken |
Very sunken and dry |
Tears |
Present |
Absent |
Absent |
Tongue |
Moist |
Dry |
Very dry |
Thirst |
Drinks normally |
Thirsty, drinks eagerly |
Unable to drink |
Skin pinch |
Normal |
Delayed |
Very delayed |
Status |
No dehydration |
Some dehydration |
Severe dehydration |
8. What investigations are helpful?
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Stool routine is not of much value as more than 10 leukocytes per HPF are also seen in rotaviral diarrhoea. There is no role of stool pH and reducing substances in acute diarrhoea as the lactose intolerance in this condition is self-limiting.
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Trophozoites of giardia and E Histolytica may be sometimes demonstrated rarely. |
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Stool culture usually grows E coli which may be a commensal. |
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Serum electrolytes may be needed in very dehydrated patients. |
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9. What is ORAL REHYDRATION THERAPY (ORT)?
It is the cornerstone of management of diarrhoea. The term ORT includes
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ORS solution- Lancet calls it the most important medical achievement of the last century. |
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Home made salt sugar solution. |
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Food based solutions. |
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Culturally acceptable fluids in presence of continued feeding. |
10. Why use WHO ORS?
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Osmolarity is less than or equal to 300 mosm. |
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Glucose concentration is of 20 gms to achieve optimum sodium and water absorption. |
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Sufficient sodium concentration 90 meq/ litglucose to sodium molar ratio of 1:1 |
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Potassium concentration of 20 meq/lit |
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Citrate concentration of 10 mmol or bicarbonate conc of 30 mmol/lit |
11. How do you give fluid therapy in diarrhoea?
PLAN A - TO PREVENT DEHYDRATION
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Provide normal daily fluid requirements. |
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Breast milk or full strngth animal or formula milk. |
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Semisolid food if eaten by child. |
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Replace ongoing losses. |
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Home available fluids- plain water,lemon water,curd water,coconut water,rice kanji, dal without salt. These fluids along with food provide ORT. |
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Avoid aerated drinks, tea or plain glucose water without salt as it may cause osmotic diarrhoea. |
Salt Sugar Solution
A finger pinch of salt plus 1 teaspoon of sugar in a glass of water.
WHO ORS
How much to give?
Less than 24 mths of age:- 50-100 ml per loose stool
2-10 years of age:- 100-200 ml per loose stool
More than 10 years of age:- as much as required
How to give?
One teaspoon every 1-2 mins for child less than 2 years and frequent sips from cup
for older children. If the child vomits, wait for 10 mins and give slowly.
What are the DANGER SIGNS?
Many water stools
Repeated vomiting
Marked thirst
Eating or drinking poorly
Fever - high grade
Blood in the stool
Drowsy child
Marked oliguria
PLAN B- REHYDRATION THERAPY IN A CHILD WITH SOME DEHYDRATION
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75 ml per kg body weight ORS in 1st 4 hrs and then reasess. |
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In children less than 6 months, give 100-200 ml water if not breast-fed. |
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ORS is effective in 95% cases. |
When is it not effective?
High rate
of purging > 15 ml /kg /hr
Persistent
vomiting>3/hr
Incorrect
administration or preparation of ORS
Abdominal
distension and ileus
Altered
sensorium
PLAN C - SEVERELY DEHYDRATED CHILDREN
Ringer lactate or Normal saline given Intravenously 100 ml /kg
| 1st
30 ml /kg |
over 1 hr in child <12 months |
| over 30 mins in child > 12 months |
| 2nd 70 ml/ kg |
over
5 hrs in child <12mths |
| over
2 ½ hrs in child>12mths |
12. What are the indication for antibiotics?
Malnourished or premature infants
Gross blood in stool
Associated non GI infections e.g. pneumonia
13. What is the choice of antibiotics?
Ampicillin+Gentamicin in malnourished and prematures.
| Shigella |
- trimethoprim+sulfa |
| - nalidixic acid |
| -cefatriaxone |
| -ciprofloxacin |
| Cholera |
-trimethoprim+sulfa |
| -chloramphenicol |
| -tetracycline |
14 .What should not be used in treatment of acute diarrhoea?
Adsorbents-kaolin, pectin
Motility suppressants-opiates
Steroids
Diphenoxylates+atropine
Combination antibiotics- nalidixic acid+ metronidazole
Lactobacillus
15. What is the dietary management in diarrhoea?
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Children should continue to be fed during acute diarrhoea because feeding is physiologically sound and prevents or minimises the deterioration of nutritonal status. |
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In acute diarrhoea breast-feeding should be continued with ORS uninterrupted even during dehydration. |
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ptimally energy dense foods with the least bulk are recommended for routine feeding and those available in the household should be offered during diarrhoea in small quantities but frequently. |
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Staple foods that do not provide optimal calories per unit weight should be enriched with fats,oil or sugar e.g khichri with oil, rice with milk or curd and sugar,mashed potatoes with oil and lentil. |
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Foods with high fibre content e.g coarse fruits and vegetables to be avoided. |
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In non-breast fed infants, cow or buffalo milk can be given undiluted after correction of dehydration together with semisolid foods. Milk should not be diluted with water. Alternatively milk cereal mixtures can be used. |
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Outine lactose free feeding is not required in acute diarrhoea even when reducing substances are detected in the stools. Lactose malabsorption meriting dietary modification is very uncommon in acute diarrhoea. |
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During recovery, an intake of at least 125% of normal should be attempted with energy dense foods till nutritional status is normal as measured for age. |
Further Reading:
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