Acute diarrhoeal diseases

ACUTE DIARRHOEAL DISEASES: 

ACUTE DIARRHOEAL DISEASES DR.SUDHARSHINI

DIARRHOEA: 

DIARRHOEA DEFINITION The passage of loose , liquid or watery stools More than 3 times a day Important The recent change in the consistency and the character of the stool

Leading Causes of Mortality and Burden of Disease world, 2004: 

Leading Causes of Mortality and Burden of Disease world, 2004 % Ischaemic heart disease 12.2 Cerebrovascular disease 9.7 Lower respiratory infections 7.1 COPD 5.1 Diarrhoeal diseases 3.7 HIV/AIDS 3.5 Tuberculosis 2.5 Trachea, bronchus, lung cancers 2.3 Road traffic accidents 2.2 Prematurity, low birth weight 2.0 % Lower respiratory infections 6.2 Diarrhoeal diseases 4.8 Depression 4.3 Ischaemic heart disease 4.1 HIV/AIDS 3.8 Cerebrovascular disease 3.1 Prematurity, low birth weight 2.9 Birth asphyxia, birth trauma 2.7 Road traffic accidents 2.7 Neonatal infections and other 2.7 Mortality DALYs

Distribution of child deaths for selected causes by selected WHO region, 2004: 

Distribution of child deaths for selected causes by selected WHO region, 2004

Distribution of causes of death among children aged under five years and within the neonatal period, 2004: 

Distribution of causes of death among children aged under five years and within the neonatal period, 2004

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Chronic diarrhoea Generally lasts > 3 weeks Common causes: IBS, AIDS, bacterial outgrowth of small int., Colon cancer, Chron’s disease Acute diarrhoea lasts a few days or up to a week X IMPORTANT !!! distinguish between acute and chronic diarrhoea >>>different diagnostis tests, different treatments

Types of Diarrhea : 

Types of Diarrhea Acute watery diarrhea: (80% of cases) Dehydration Malnutrition Dysentery: (10% of cases) Anorexia/weight loss Damage to the mucosa Persistent diarrhea: (10% of cases) Dehydration Malnutrition

Mechanisms of Diarrhea: 

Mechanisms of Diarrhea Osmotic Secretory Exudative Motility disorders

Mechanisms of Diarrhea: 

Mechanisms of Diarrhea Osmotic Defect present: Digestive enzyme deficiencies Ingestion of unabsorbable solute Examples: Viral infection Lactase deficiency Sorbitol /magnesium sulfate Comments: Stop with fasting No stool WBCs

Mechanisms of Diarrhea: 

Mechanisms of Diarrhea Secretory : Defect: Increased secretion Decreased absorption Examples: Cholera Toxinogenic E.coli Comments: Persists during fasting No stool leukocytes

Mechanisms of Diarrhea: 

Mechanisms of Diarrhea Exudative Diarrhea: Defects : Inflammation Decreased colonic reabsorption Increased motility Examples: Bacterial enteritis Comments: Blood, mucus and WBCs in stool

Mechanisms of Diarrhea: 

Mechanisms of Diarrhea Increased motility: Defect: Decreased transit time Example : Irritable bowel syndrome

EPIDEMIOLOGICAL DETERMINANTS: 

EPIDEMIOLOGICAL DETERMINANTS AGENT FACTORS RESERVOIR OF INFECTION HOST FACTORS ENVIRONMENTAL FACTORS MODE OF TRANSMISSION

AGENT FACTORS: 

AGENT FACTORS In the developing countries - INFECTIOUS in origin VIRAL BACTERIAL OTHERS

VIRAL AGENTS: 

VIRAL AGENTS Rota virus Astro virus Adeno virus Calci virus Corona virus Norwalk virus Entero virus

BACTERIAL AGENTS: 

BACTERIAL AGENTS Escherichia coli Campylobacter jejuni (egg poultrty usually bloody diarrhoes ) Shigella { dysentriae,flexnerri,boydii,sonnei } Salmonella Vibrio cholera Vibrio parahemolyticus (raw sea food) Bacillus cereus yersinia

OTHER INFECTIOUS AGENTS: 

OTHER INFECTIOUS AGENTS Entameoba histolytica Giardia intestinalis Trichuriasis Cryptosporidium candida Intestinal worms

Common Causes of Acute Diarrhoea: 

Common Causes of Acute Diarrhoea Infection – highly contagious Viral gastroenteritis (“stomach flu”) Rotavirus Usually cause explosive, watery diarrhoea Typically last only 48-72hrs Usually no blood and pus in stool

ROTAVIRUS: 

ROTAVIRUS Leading cause of SEVERE , DEHYDRATING DIARRHOEA IN CHILDREN < 5 YEARS . First Episode Developing countries – ¾ children – before 12 months Developed countries – 2 – 5 years

BACTERIAL : 

BACTERIAL ETEC (ENTEROTOXIGENIC E . COLI) Acute watery diarrhoea in adults & children Most common cause of the TRAVELLER’S DIARRHOEA Heat labile and heat stable toxins – cholera toxins

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Bacterial enterocolitis Sign of inflammation – blood or pus in stool, fever E.heamorrhagic Coli bacteria Contaminated food or water Usually affect small kids

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Bacterial enterocolitis Sign of inflammation – blood or pus in stool, fever Salmonella enteritidis bact In contaminated raw or undercooked chicken and eggs

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Bacterial enterocolitis Sign of inflammation – blood or pus in stool, fever Shigella o157 hh7bacteria Campylobacter bacteria

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Cryptosporidium in contaminated water – can survive chlorination Parasites Giardia lamblia in contaminated water Usually not associated with inflammation

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Common Causes of Acute Diarrhoea – cont. Food Poisoning Brief illness cause by toxins produced by bacteria Cause abdominal pain, vomiting SI secrete high amount of water – diarrhoea Some bacteria produce toxins in food before intake or in intestine after food is eaten Symptoms usually appear within sev . hours

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Food Poisoning Staphylococcus aureus Produces toxins in food before it is eaten Usually food contaminated left unrefrigerated overnight

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Food Poisoning Clostridium perfringens Multiplies in food Produces toxins in SI after contaminated food is eaten

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Common Causes of Acute Diarrhoea – cont. Traveller’s Diarrhoea Drugs / medications

PARENTRAL INFECTIONS: 

PARENTRAL INFECTIONS Non digestive origin ENT INFECTIONS RESPIRATORY INFECTIONS URINARY TRACT INFECTIONS MALARIA MENINGITIS TEETHING

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MALNUTRITION INBORN ERRORS OF METABOLISM - Health gap – developed countries- enzyme deficiency, severe infection

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who definition of aids for children an episode of diarrhoea more than 30 days of duration

RESERVOIRS OF INFECTION: 

RESERVOIRS OF INFECTION MAN ANIMAL ETEC C. JEJUNI SHIGELLA SALMONELLA E.COLI CHOLERA PARASITES

HOST FACTORS: 

HOST FACTORS DIARRHOEA- 6 MONTHS- 2 YEARS Highest incidence – 6 – 11 months REASONS Decreased maternal Ab Lack of the acquired immunity Contaminated food Crawling initiation

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Malnutrition – vicious circle Poverty Prematurity Reduced gastric acidity Immunodeficiency Lack of personal & domestic hygiene Secretory ig a def

ENVIRONMENTAL FACTORS: 

ENVIRONMENTAL FACTORS Distinct seasonal variations TEMPERATE REGIONS Bacterial – warm season Viral - winter TROPICAL REGIONS Bacterial – warmer , rainy Viral - dry , cold

MODE OF TRANSMISSION: 

MODE OF TRANSMISSION Faecal – oral route Water – borne Food – borne OTHERS Direct – fomites , fingers, dirt – mainly for tye children.

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Complications of Diarrhoea Dehydration Excessive loss of fluids and minerals (electrolytes) from the body Common in infants and young children with viral gastroenteritis or bacterial infection Kidney failure, eg in infection by E.coli Electrolyte deficiency Irritation to anus due to frequent passage of watery stool containing irritating substances

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Dehydration Acute renal failure Venous Thrombosis - Cerebral, Renal HUS ( Heamolytic Uraemic Syndrome) Malabsorption Food Intolerance Intussusceptions Disseminated Intravascular Coagulation Persistent Diarrhea Dyselectrolytaemia Complications of Acute Diarrhoea

Features of Dehydration: 

Features of Dehydration Mild Moderate Severe Looking at the condition Well, alert Restless, Irritable Lethargic or unconscious; floppy Eyes Normal Sunken Very sunken & Dry Tears Present Absent Absent Mouth & Tongue Moist Dry Very dry Thirst Drinks normally, no Thirst Thirst, drinks eagerly Drinks poorly or not able to drink Feel Skin pinch Goes back Quickly Goes back slowly Goes back very slowly > 2 sec Decide – Hydration Status No signs of Dehydration Has two or more signs, there is Some Dehydration Has two or more signs, there is Severe Dehydration

Signs of Dehydration: 

Signs of Dehydration

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Measurement of BP in upright and supine post – demonstrate orthostatic hypotension, confirm dehydration Moderate – severe diarrhoea, blood electrolytes Examination of small amount of stool under microscope – if inflammation present, further test particularly for bacterial and parasitic infection Tests for Acute Diarrhoea

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Stool - Ova, Cysts, Trophozoites , Leucocytes Hanging drop for V. cholerae Culture practically not required Blood tests - CBC, Serum Electrolytes BUN and Creatinine Culture and sensitivity 3. Urine - R/M, Culture may be required Septic screen if required Serum electrolytes are not required in those to be hydrated by ORS, recommended in some dehydration with doughy feeling of skin and where findings are inconsistent with straight forward diarrhea. Investigation in a child with acute severe diarrhoea

Management: 

Management Prevention of Dehydration Treatment of Dehydration Nutritional support Ancillary therapy

Acute Diarrhoea without Dehydration ( Plan - A ): 

Acute Diarrhoea without Dehydration ( Plan - A ) Asses Risk of Dehydration High Risk Low Risk Age < 6 months Age ≥ 6 months Vomiting > 4 times/day Vomiting ≤ 4 times/day Liquid motions > 8 times/day Stool ≤ 8times/day Continue usual fluids Encourage to take more Discharge Contd..

High Risk Admit for Observation (Plan - A Contd…): 

High Risk Admit for Observation (Plan - A Contd …) Maintenance fluid On going loss - ORS 10 ml/kg/each stool/vomiting Reassess every 4 hours Good hydration Dehydration ensues Stable on ORS treat as Some Dehydration Discharge with ORS Packets and advise

ACUTE DIARRHOEA WITH SOME DEHYDRATION (Plan - B): 

ACUTE DIARRHOEA WITH SOME DEHYDRATION (Plan - B) ADMIT Uncertainity over diagnosis ORS 30 to 80 ml./kg. Doughy skin in 4 hours Reasses after 4 hours Check Blood for urea, creatinine & electrolytes Dehydration No Dehydration Persists (Treat as Plan - A) Na+ Consider NGT <150mEq/ Ltr . >150mEq/ Ltr . For rehydration with ORS ADMIT Rehydrate Dehydration Continues No Dehydration over 12 hours with (Treat as Plan - A) Deficit and maintenance fluid with ORS. Review every 2 hours Contd…… Contd……

PLAN - B Contd..: 

PLAN - B Contd.. Dehydration Continues Review every 2 hours Commence IV. Fluid Dehydration continues Calculate for Dehydration NGT/IV Fluids. Maintenance, Ongoing losses Invest - Urea creatinine No Dehydration And electrolytes (Treat as Plan - A) No signs of dehydration (Treat as Plan - A) Maintenance fluid - 100 ml/kg ORS for 1 st 10 kg. then 50 ml./kg. for next 10 kg.

ACUTE DIARRHOEA WITH SEVERE DEHYDRATION (Plan - C) : 

ACUTE DIARRHOEA WITH SEVERE DEHYDRATION (Plan - C) Rapid bolus of Ringer lactate/Normal saline, 20 ml./kg. Circulation Circulation Restored not restored Serum Na+ Further bolus of NS max. 40 ml./kg. > 150 mEq /L < 150 mEq /L (Treat as (Treat as Improved Not Improved Plan - B) Plan - B) ADMIT to Intensive care unit Consider Ventilation With Circulatory Compromise Admit Investigate Continue assessment and treat according to grade of hydration

Components of Fluid Required: 

Components of Fluid Required Deficit Fluid: Some dehydration (3-8%) – 30-80 ml/ kg. Serve dehydration (> 9%) – 100 ml/ kg. Maintenance Fluid : 100ml/kg/24 hours for first 10 kg body weight. 50ml/kg/24 hours for next 10kg body weight. 20ml/kg/24 hours thereafter. Ongoing Loss : Measured as the actual stool volume/weight. Reassessing the grade of dehydration after 4 to 8 hours. With each stool roughly 10ml/kg. is lost.

Composition of Fluids for Intravenous & Oral Rehydration: 

Composition of Fluids for Intravenous & Oral Rehydration Oral Osmolarity mOsm/L Glucose mmol/L Sodium mmol/L Chloride mmol/L Potassium mmol/L Base (Citrate) mmol/L WHO ORS 311 111 90 80 20 10 WHO Low Osmolar ORS 245 75 75 65 20 10 IAP Recomnd. ORS 224 84 60 50 20 10 INTRA VENOUS FLUID Ringer’s lactate 280 130 110 04 25 (Bicarb) Normal Saline 308 154 154

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IV deficit should be given over 6 to 8 hours. Maintenance & Ongoing loss over 16 hours for the day. OR After 1 st hour infusion rest fluid and electrolytes for the day should be calculated and divided in 23 hours. Reassessment to continue every 4 to 8 hours. Time of Replacement

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Breast Fed : Continue Breast feeding throughout rehydration and Maintenance phases. Formula fed : Restart feed at full strength as soon as rehydration is complete (ideally after 4 hours) Weaned Children : Child’s normal fluids and solids following rehydration. Avoid fatty foods or foods high in simple sugar. Management of feeding during Acute Diarrhoea

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Self limiting infection Unnecessary in most cases Indicated in Infants under 6 months of age. Immunocompromised infants. Clinical suspicion of bacteremia. Indication of Chemotherapy / Antibiotics

Chemotherapy For Bacterial & Protozoal Diarrhoea: 

Chemotherapy For Bacterial & Protozoal Diarrhoea Etiologic agent Chemotherapy Shigella Nalidixic acid, Cotrimoxazole , Ampicillin Enteroinvasive E:coli Nalidixic acid, Cotrimoxazole , Ampicillin , Inj Gentamicin (in case of septicemia) Salmonella Ampicillin , Chloramphenicol Campylobacter jejuni Erythromycin, Furazolidin , Chloramphenicol , Gentamicin Vibrio cholerae Furazolidin , Cotrimoxazole , Tetracycline, Erythromycin, Ent . histolytica Metronidazole , Tinidazole , Secnidazole , Paromomycin Giardia Metronidazole , Tinidazole , Secnidazole , Ornidazole , Furazolidine

Zinc in the Treatment of Acute Diarrhea: 

Zinc in the Treatment of Acute Diarrhea As adjunct to oral rehydration & offers modest benefit. 20mg of elemental Zn during the period of Diarrhea and 7 days following it. Not recommended below 3 months. Zn Sulphate / Gluconate /Acetate can be used Probiotics in the Treatment of Diarrhea Probiotics are non pathogenic micro-organisms. Beneficial effect in Rotavirus Diarrhea. It reduces the duration of Diarrhea in most cases Antidiarrhoeals Contraindicated in Infants & Children

Prognosis : 

Prognosis Mortality is high in newborns & Infants. Malnutrition carries poor prognosis. Systemic diarrhea/diarrhea with resistant invasive pathogens increase risk of fatality. Serve dehydration with shock and dyselectrolytemia have adverse effect on outcome. Prompt and adequate therapy helps in better outcome.

Prevention : 

Prevention Improvement of Nutritional status. Safe drinking Water Supply in community. Exclusive Breast feeding till 6 Months. Easy availability of ORS sachets. Hand washing before handling food. Vaccines : Rotavirus vaccine ETEC Vaccine Cholera Vaccine Typhoid Vaccine Shigella Vaccine – To be available.

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Thank You for Being Patient Till the End