presented by dr. mujahid chandio

1. Dr. Mujahid Ali Chandio
Assistant professor
Medical unit 1
MBBS, FCPS

2.  Increase in frequency, size or loosening of bowel
movements.
 Differentiate from fecal incontinence or functional
bowel disease- normal stool weight
 With diet- less than 200g/day

3. Pathophysiology
 Increased active anion secretion
 Decreased absorption of water and electrolytes

4. Types
 Noninfectious
 abnormal mucosa
 Inflammatory Bowel disease
 Celiac disease
 microscopic colitis
 eosinophilic and allergic gastroenteritis
 radiation enteritis
Normal mucosa
 Osmotic diarrhea
 Mal-absorption
 Rapid intestinal transit- IBS

5. Infectious diarrhea
 Mostly feco-oral route
 Bacterial
 Viral
 Parasitic

6. Bacterial
 Watery
 Enterotoxigenic-
 Vibrio cholera
 Enterotoxigenic E.coli
 Food borne toxins-
 Bacillus cereus
 Clostridium perfringens
 Mycobacterium avium-intracellular complex

7. Bacterial
 Bloody
 Invasive
 Campylobacter jejuni
 Shigella
 Enteropathogenic E.coli
 Clostridium difficile

8. Viral
 Rotavirus
 Children less than 2 years
 Most common cause of diarrhea in children all over the
world
 Norwalk
 Older children and adults
 These viruses injure the small intestinal mucosa
 Watery diarrhea
 CMV
 Immunocompromised

9. Parasitic
 Protozoa
 Giardia lamblia
 Entamoeba histolytica
 Cryptosporidium
 Helminths
 Ascaris lumbricoides
 Ancylostoma
 Strongyloides stercoralis
 Trichinella spiralis
 Capillaria philippensis

10. Opportunistic pathogens
 Clostridium difficile
 Nosocomial pathogens in healthcare and long term care
facility
 Poor handwashing
 Clindamycin, cephalosporins, ampicillin
 Exotoxin mediated

11. In immunocomromised Hosts
 Besides the common pathogens,
 Giardia
 Legionella
 Candida albicans
 Cryptosporidium species
 Mycobacterium avium-intralcellulare
 CMV

12. Others
 Tropical sprue
 In those who live or travel to the tropics
 Overgrowth of predominantly coliform bacteria in the
small intestine
 Whipple’s Disease
 Infection by Tropheryma whippelii
 HLA B27

13. History
 Is it truly diarrhea?
 Duration-
 acute <3 weeks
 Chronic >4 weeks
 Texture
 Frequency
 Blood?

14. History
 Fever
 Vomiting
 Abdominal pain
 Fainting or dizzyness
 Travel
 Drug use
 Diet
Weight loss

15. History
 Alcohol
 Abdominal operations
 Chemotherapy
 Radiation
 Immune status
 Comorbidities

16. Physical
 Vital signs
 Orthostatic signs
 Hyperventilation- acidosis
 Volume status
 Skin tenting
 Dry mucous membranes
 Resting tachycardia
 Hypotension
 Sunken eyeballs
 Scaphoid abdomen

17. Physical
 Abdominal and rectal exam.
 Distension
 Bowel sounds
 Tenderness
 Masses

18. Physical
 Chronic diarrhea
 Malnutrition
 Weight loss
 Muscle wasting
 Tetany
 Oral and skin lesions
 Peripheral neuropathy
 Ataxia
 Edema

19. Labs
 Stool tests for inflammation
 Pus cells- specific but low sensitivity( about 50%)
 Lactoferrin
 Released from leucocytes during an inflammatory reaction
 Sensitivity is 90% but less specific

20. Labs
 Stool culture
 Positive in only 40 to 60%
 Stool for ova and parasites
 Stool for Clostridium difficile toxin
 Stool Sudan test for fat
 Stool Electrolytes-differentiates secretory diarrhea
from osmotic diarrhea
 Stool pH-<7 indicates carbohydrate malabsorption

21. Other investigations
 Flexible sigmoidoscopy
 Pseudomembranes
 Inflammation
 Melanosis coli
 Blood Hormone levels
 Serum gastrin, VIP, somatostatin, cortisol, neurokinins,
calcitonin
 Carcinoid- serotonin, urine 5-hydroxyindoleacetic acid

22. Management
 Fluid therapy
 Persons with moderate to severe diarrhea lose large amounts
of Na, CL, K, HCO3 & H20
 Pre renal azotemia, hypokalemia, metabolic acidosis
 ORS
 IV Fluids

23. ORS-principle
 Saline solution (water plus Na+) by mouth - no
beneficial effect
 Na+ absorption is impaired in the diarrhoeal state
 if the Na+ is not absorbed water cannot be absorbed.
 Excess Na+ in the lumen of the intestine causes
increased secretion of water and the diarrhoea worsens.

24. ORS
 Glucose - absorbed through the intestinal wall -
unaffected by the diarrhoeal disease state - sodium
is carried in conjunction through by a co-transport
coupling mechanism. This occurs in a 1:1 ratio, one
molecule of glucose co-transporting one sodium
ion (Na+).

25.  Starch –
 metabolized in the intestine to glucose and therefore it
has the same properties of enhancing sodium
absorption
 less osmotic effect in the lumen of the intestine.

26.  Citrate, a base precursor, corrects acidosis and
enhances the absorption of water and electrolytes

27. ORS-History
 First developed in the early 1950’s and was
formulated to mirror ions lost in stool.
 In the early 1960’s the mechanism by which ORT
works, the coupled transport of sodium and
glucose, was discovered.6
 In 1971, the efficacy of ORT demonstrated during
an epidemic of cholera in a refugee camp in
Bangladesh.
 ORT reduced the death rate from more than 50% to only
5%.7 By the early 1970’s a consensus was reached about
the effectiveness of ORT.

28. ORS
 Lancet- "potentially the most important medical
advance this century"
 World Health Organization estimates that 90% of
diarrheal deaths worldwide could be prevented with
appropriate treatment with ORS

29. ORS
 Start early
 Rice based ones ( Glucose polymers) increase
intestinal fluid absorption
 In adults – use urine output for monitoring

30. ORS
 Sodium Chloride 3.5 grams
 Sodium Bicarbonate 2.5 grams
 Potassium Chloride 1.5 grams
 Glucose 20 grams

31. ORS
Solution Na
Mmols
/L
K Cl Carb. Osmolality
WHO 90 20 80 111 310
Rice
Based
90 20 60 111 260

32. ORS- caution
 A number of studies have addressed the concern that
ORT can lead to hypernatremia in neonates and
infants.
 These studies show that administration of breast milk
or plain water after rehydration prevents this problem.1

33. IV Fluids
 Must contain Potassium and a base
 Ringer’s lactate

34. Chronic Diarrheas
 Zn and Magnesium replacement

35. Antibiotics
 Invasive bacterial Enteritis- esp.Shigellae
 Quinilone orally twice daily for 3 days
 Cholera
 Traveler's diarrhea
 Prophylactic- not recommended
 A single dose of oral Quinilone at onset
 Clostridium difficile
 Metronidazole
 Oral Vancomycin

36. Antimotility agents
 Should be avoided
 Concern for promoting bacterial invasion or
prolonging the infection

37. Food
 Do not withhold
 Withholding food, even for one or two days, greatly
exacerbates the malnutrition
 Coupled with anorexia, caused partly by chronic
potassium depletion, causes a vicious circle
 It is this diarrhoea/malnutrition cycle rather than acute
dehydration that causes almost half of the five million
deaths a year in under five year old children that are
associated with diarrhoeal disease.

38. Good nutrition and hygiene can
prevent most diarrhea.
Thank You!