The lecture has been given on Oct. 28th, 2010 by Dr. Adnan.

1. Diarrhea
Dr. Adnan Hamawandi
Professor of Pediatrics

2. Dysentery
 Is defined as diarrhea with visible blood in
stools.
 The most important and frequent cause of
acute dysentery is Shigella. Other causes
include Campylobacter jujeni, Salmonella,
and enteroinvasive E. coli.
 Entameba histolytica causes dysentery in
older children but rarely in children under 5
years of age.

3. Dysentery
Dysentery is specially sever in :-
1. Malnourished infants and children.
2.Those who develop clinically evident
dehydration during their illness. 3. Those who
are not breast fed. 4. Children with measles
or had measles in the preceding month.
5. Those who present with convulsion or
develop coma.

4. Dysentery
Clinical features and diagnosis
The clinical diagnosis of dysentery is based
solely on the presence of visible blood in the
diarrheal stool. The stool will also contain pus
cells which are visible microscopically, and it
may contain large amounts of mucus, the
later features suggest infection with an
invasive microorganism, but alone are not
sufficient to diagnose dysentery.

5. Dysentery
Clinical features and diagnosis
 Patients frequently have fever, cramping
abdominal pain and tenesmus.
 The cause is identified by stool culture.
 Stool microscopy may help in differentiating
E.histolytica which can only be diagnosed
with certainty when trophozoites containing
RBCs are seen in fresh stools or in mucus
from rectal ulcers obtained during
colonoscopy.

6. Dysentery
Complications
 Intestinal perforation.
 Toxic megacolon.
 Rectal prolapse.
 Convulsions.
 Septicemia.
 Hemolytic uremic syndrome.
 Prolonged hyponatremia.

7. Dysentery
Management
 Children with dysentery should be presumed
to have Shigellosis and treated accordingly.
This is because Shigellae cause 60% of
dysentery cases seen at health facilities and
nearly all cases of sever life threatening
disease.
 1. Antimicrobial therapy:
Trimethoprim sulfamethoxazole is the usual
choice for five days.

8. Dysentery
Management
There should be substantial improvement
after 2 days i.e. reduced fever, less pain and
fecal blood, and fewer loose stools. If this
does not occur the antimicrobial should be
stopped and a different one used like
Naladixic acid, Cefixime, or Ceftriaxone
according to the local culture and sensitivity.
2. Fluid: Assess and correct any dehydration.
3. Feeding: Continue feeding.

9. Persistent diarrhea
 Is a diarrheal episode that last for 14 days or
longer. About 10% of acute diarrheal
episodes become persistent.
 Persistent diarrhea is largely a nutritional
disease, it occur more frequently in children
who are already malnourished and is itself an
important cause of malnutrition. It is
associated with increased mortality causing
about 30% of all diarrhea associated death.

10. Persistent diarrhea
There is no single microbial cause although
Shigella, Salmonella, Enteroinvasive E.coli
and Cryptosporidium play a greater role than
other agents. Irrespective of the cause,
persistent diarrhea is associated with
extensive changes in the bowel mucosa,
specially flattening of the villi and reduced
production of disaccharidase enzymes; these
cause reduced absorption of nutrients and

11. Persistent diarrhea
perpetuate the illness after the original
infectious cause has been eliminated.
 Risk factors:
1. Malnutrition.
2. Young age.
3. Recent introduction of animal milk(formula
4. Immunological impairment.
5. Recent diarrhea.

12. Persistent diarrhea
Management
 Fluid and electrolyte replacement.
 Nutritional therapy: the goals are
1. Reduce temporarily the amount of animal
milk or lactose in the diet. 2. Provide a
sufficient amount of energy, protein, vitamins
and minerals. 3. Avoid foods or drinks that
may aggravate diarrhea. 4. Ensure adequate
food intake during convalescence to correct
malnutrition.

13. Persistent diarrhea
Management
 Drug therapy:
Antimicrobials and antiprotozoal agents
should be given only when indicated and
according to culture and sensitivity. However,
blind use of these drugs is not effective and
should not be given as they may make the
illness worse. Likewise antidiarrheal drugs
has no proven value and should not be
given.

14. Extraintestinal causes of diarrhea
 Parenteral diarrhea( otitis media, UTI,..
 Congenital defects( malrotation, duplication..
 Malabsorption( cystic fibrosis, celiac disease
 Endocrinopathies( CAH, hyperthyroidism..
 Neoplasms( neuroblastoma,
 Inflammatory bowel diseases
 Miscellaneous(acrodermatitis enteropathica,
Hartnup disease..