GIT

1. DIARRHOEA.
MAJ J GOMA

2. Introduction
Defined as a change in consistency and frequency of stool
• i.e. waterly stool that occurs > 3 times in a day
It is termed dysentery if associated with blood
 acute diarrhea last for 2 weeks or less
Persistent diarrhea last > 2 weeks

3. Global annual burden of diarrhea is~ 3 – 5 billion
Causes ~ 2 million deaths a year
20 % of deaths in < 5 children is due to diarrhea
Two most important consequences of diarrhea:
• Malnutrition
• Dehydration

4. Malnutrition and diarrhoea form a vicious cycle
malnutrition increases the risk and severity of diarrhea
Impaired absorption, loss of nutrients, Impaired absorption, loss of nutrients,
increased catabolism and improper feeding in diarrhea aggravate the severity
of malnutrition.
Significant dehydration with abnormal electrolyte and acid-base
status occurs in 2-5% of all cases of diarrhea, which may be fatal.

5. Etiology of diarrhea
1.Bacterial
A. Escherichia coli:
• Enterotoxigenic
• Enteropathogenic
• enteroinvasive*,
• enterohemorrhagic*
• enteroaggregative types

6. • Shigella*:
• S. sonnei,
• S. f!exneri
• S. boydii
• S. dysenteriae

7. • Vibrio cholerae serogroups 01 and 0139
• Salmonella*:
• Chiefly S. typhi
• S. paratyphi A, B or C
• Campylobacter species

8. 2. Viral:
• Rota virus leading cause of diarrhea
• Human caliciviruses: Norovirus spp.; Sapovirus spp.
• Enteric adenoviruses serotypes 40 and 41
• Astrovirus
• Norwalk agent-like virus
• Hepatitis A
• Stroviruses
• coronaviruses
• cytomegalovirus

9. 3.Parasitic
• Giardia lamblia
• Cryptosporidium parvum
• Entamoeba histolytica*
• Cyclospora cayetanensis
• lsospora belli
• Others: Balantidium coli, Blastocystis ho,ninis, Encephalitozoon
• intestinalis, Trichuris trichiura

10. Risk factors
• Poor sanitation and personal hygiene
• Non availability of safe drinking water
• Unsafe food preparation practices
• Low rates of breastfeeding and immunization
• Young children < 2 years
• Malnutrition
• Attendance to child care centers
• Poor maternal education
• Immune deficient individuals

11. Mechanisms of acute diarrhoea
• Osmotic
eg Lactose intolerance
• Secretory
eg Cholera
• Mucosal inflammation
eg Invasive bacteria
• Motility disturbance
eg irritable bowel syndrome
• Mixed secretory-osmotic
eg Rotavirus

12. Mechanism of infective diarrhoea
• Non- inflammatory :
• enterotoxin production
• Villus destruction
• Adherence to surface
• Inflammatory:
• Direct invasion
• cytotoxins

13. • Risk factors for prolonged and recurrent episodes of diarrhea
include:
• presence of hypo- or achlorhydria ( due to Helicobacter pylori
infection or therapy with proton pump inhibitors)
• selective IgA deficiency
• infection with human immunodeficiency virus (HIV)
• Alteration of normal intestinal microflora by antibiotics can
predispose to C. difficile infection.

14. Assessment of acute diarrhea disease
Goals of assessment:
i. determine the type of diarrhea, i.e. acute watery diarrhea, dysentery
or persistent diarrhea
ii. look for dehydration and other complications
iii. assess for malnutrition
iv. rule out non diarrheal illness especially systemic infection
v. assess feeding, both pre illness and during illness.

15. History - should include information on:
i. onset of diarrhea; duration and number of stools per day
ii. blood in stools
iii. number of episodes of vomiting;
iv. presence of fever, cough, or other significant symptoms (e.g.
convulsions, recent measles)
v. type and amount of fluids (including breast milk) and food taken
during the illness and pre illness feeding practices
vi. drugs or other local remedies taken (including opioids or anti
motility drugs like loperamide that may cause abdominal distention);
and
vii. immunization history.

16. • Physical examiniation: Assess hydration status and look for other clinical
features
parameter No dehydration Some dehydration Severe dehydration
Consciousness Well alert Restless, alert Lethargic/unconsciousness
Eyes Normal Sunken Very sunken & dry
Tears Present Absent Absent
Mouth and tongue Moist Dry Very dry
Skin pinch/turgor Goes back quickly Goes back slowly Goes back very slowly
Thirst Drinks normally, no thirst Thirst, drinks eagerly 'Drinks poorly' or is not able to
drink
Decision The patient has no signs of
dehydration
If the patient has two or
more signs, there is some
dehydration
If the patient has two or more
signs, there is severe
dehydration with one of the
signs being altered
consciousness commonly
Treatment Use Plan A Use Plan B Use Plan C urgently

18. Investigations
oNot needed routinely in acute diarrhoea
oStool microscopy is not helpful in management except in selected
situations, such as cholera and giardiasis
oStool culture is of little value in routine management of acute
diarrhea
oIt is useful in cases such as Shigella dysentery

19. oHemogram, serum electrolytes and renal function tests are not
indicated routinely but they are performed only if the child has
associated findings which suggests acid-base imbalance, electrolyte
imbalance, sepsis or renal failure such as:
• Pallor
• labored breathing
• altered sensorium
• Seizures
• paralytic ileus or oliguria

20. Principles of Management
• Management of acute diarrhea has four major components:
• (i) rehydration and maintaining hydration
• (ii) ensuring adequate feeding
• (iii) oral supplementation of zinc
• (iv) early recognition of danger signs and treatment of
complications

21. Treatment Plan A: for no dehydration
oSuch children may be treated at home after explanation of feeding
and the danger signs to the mother/ caregiver
oThe mother may be given WHO ORS for use at home as per Table
below
Age Amount of ORS to give after
each loose stool
Amount of ORS to be provided
at home
<24 months 50-100 ml 500ml/day
2-10 years 100-200 ml 1000ml/day
>10 years Ad lib 2000ml/day

22. oExplain use of ORS, i.e. the amount to be given, how to mix
o Give a teaspoonful every 1-2 min for a child under 2 years
oGive frequent sips from a cup for an older child
o if the child vomits, wait for 10 min
• Then give the solution more slowly (for example, a spoonful every
2-3 min)
• If diarrhea continues after the ORS packets are used up, tell the
mother to give other fluids suitable for diarrhoea or return for
more ORS

23. oDanger signs requiring medical attention or immediate return to
the health facility are:
ocontinuing diarrhea beyond 3 days
oincreased volume/ frequency of stools
orepeated vomiting
oIncreasing thirst
orefusal to feed
oFever
oblood in stools

24. Plan B treatment : Some dehydration
oAll cases with obvious signs of dehydration need to be
treated in a health facility
oDeficit replacement or rehydration therapy is calculated as
75 ml/kg of ORS
oto be given over 4 hours
oIf ORS cannot be taken orally then nasogastric tube can be
used

25. Treatment Plan C: Children with "Severe
Dehydration"
oIntravenous fluids should be started immediately using
• ½ strength Darrow's in 10% dextrose
• Ringer lactate with 5% dextrose.
o plain Ringer solution may be used as an alternative, but 5% or 10%
dextrose alone is not effective
oA total of 100 ml/kg of fluid is given
• over 6 hr in children <12 months
• over 3 hr in children >12 months as shown below.

26. Management of intravenous hydration should
be done as follows:
Age 30 ml/kg 70 ml/kg
<12 months 1 hour 5 hours
>12months 30 min 2 ½ hours

27. oIf IV fluids cannot be given (for reasons of access, logistic
availability or during transport)
oORS is given at 20 ml/kg/hour for 6 hours (total
120 ml/kg) nasogastric feeding tube
oThe child should be reassessed every 1-2 hours
oif there is repeated vomiting or abdominal distension, the
oral or nasogastric fluids are given more slowly
oIf there is no improvement in hydration after 3 hours, IV
fluids should be started as early as possible
oThe child should be reassessed every 15-30 min for
pulses and hydration status after the bolus of 100 ml/kg
of IV fluids

28. Drug Therapy in therapy
oMost episodes of diarrhea are self-limiting and do no
require any drug therapy except in a few situations such as:
• Bacillary dysentery
• Cholera
• Amebiasis
• Giardiasis
oEscherichia coli are normal gut flora and their growth on
stool culture is not an indication for antibiotics

29. oAcute diarrhea may be the manifestation of systemic infection
oMalnourished infants, prematurely born and young infants are at a
high risk systemic infection/sepsis
oSuch patients should be screened and given adequate days of age
appropriate systemic antibiotics for sepsis
oPresence of the following signs are suggestive of sepsis in infants:
o poor sucking
oabdominal distension
ofever or hypothermia
o fast breathing
osignificant lethargy or inactivity in well-nourished, well
hydrated infants points towards sepsis

30. oAntimotility agents such as loperamide or imodium reduce peristalsis or gut
motility
oReduction of gut motility allows more time for the harmful bacteria to
multiply
oThese drugs may cause
odistension of abdomen
oparalytic ileus
obacterial overgrowth and sepsis
oThey should not be used in children with acute diarrhea as they can be
dangerous and fatal especially in infants

31. oAn occasional vomit in a child with acute diarrhea does not
need an antiemetic
oSevere or recurrent vomiting which interferes with ORS
intake may require ondansetron (0.1-0.2 mg/kg/dose)
oChildren with refractory vomiting despite administration of
ondansetron may require intravenous fluids

32. oZinc deficiency widespread among children in developing countries
oIntestinal zinc losses during diarrhea aggravate pre-existing zinc
deficiency
oZinc supplementation is now part of the standard care along with
ORS in children with acute diarrhea
oZinc is helpful in decreasing:
severity of diarrhoea
duration of diarrhea
also risk of persistent diarrhea
oZinc dose:
10mg of elemental zinc per day ( infants < 6 months) for 14
days
20 mg of elemental zinc per day for children >6 months for 14
days

33. Rotavirus
Incubations period: 1–3 days
Clincal features: vomiting, watery diarrhea, low-grade
fever. Temporary lactose intolerance may occur.
Infants and children, elderly, and immunocompromised
are especially vulnerable.
Duration of illness: 4–8 days
Risk: Fecally contaminated foods. Ready-to-eat foods
touched by infected food workers (salads, fruits).
Otherwise universal infections regardless of risk
Diagnosis: Identification of virus in stool via immunoassay
Treatment: Supportive care. Severe diarrhea may require
fluid and electrolyte replacement.

34. Bacterial dysentery
Desentery is diarrhoea associated with passage of blood in stool.
Bacterial causes is mainly invasive bacteria resulting in inflammatory
diarrhoea.
Main bacterial causes include; Shigella, campylobacter, salmonella,
and ETEC E.coli
Indication for antibiotics use
Treament: Nalidixic acid and ciprofloxacin

35. Amoebic desentery
Main cause are entamoeba hystolytica and giadia lambriae.
Entamoeba histolytica;
incubation period is 2–3 days (1–4 wk),
presents with Diarrhea (often bloody), frequent bowel movements, lower abdominal
pain.
Duration of illness may be protracted (several weeks to several months).
Associated risk foods is any uncooked food or food contaminated by an ill food handler
after cooking, drinking water.
Diagnosis is through examination of stool for cysts and parasites—may need at least 3
samples.
Serology for long-term infections.
Treatment : Metronidazole and a luminal agent (iodoquinol or paromomycin) are drugs
of choice

36. Giardia lamblia
Incubation period is 1–2 wk
Presents with diarrhea (may be bloody), stomach cramps, gas, weight loss
Duration of illness may be days to weeks
Associated risk food is any uncooked food or food contaminated by an ill
food handler after cooking; drinking water.
Diagnosis is by examination of stool for ova and parasites—may need at
least 3 samples.
Treament: Metronidazole

37. Persistent Diarrhoea
Persistent diarrhea is an episode of diarrhea which starts acutely but
lasts for more than 14 days
It should not be confused with chronic diarrhea which has a prolonged
duration but an insidious onset and includes conditions causing
malabsorption

38. Etiopathogenesis
Persistent diarrhea starts as acute diarrhea
Presumably from infectious cause but that is not
always the case
Prolongation of diarrhea is not entirely due to
infection

39. • Various factors that are implicated in pathogenesis include:
oThe predominant problem is the worsening nutritional status
o This impairs the reparative process in the gut which worsens nutrient
absorption and initiates a vicious cycle that can only be broken by proper
nutrition
o Persistent diarrhea is more common in malnourished children
o One of the major obstacles to nutritional recovery is secondary lactose
intolerance and impaired digestion of other complex carbohydrates due to
decrease in brush border disaccharidases.

40. Pathogenic E. coli, especially the enteroaggregative and
enteroadherent types result in malabsorption by causing persistent
infection.
Associated infections of the urinary tract or another focus of infection
(more commonly in malnourished children) contribute to failure to
thrive and mortality.

41. Prolongation of an acute diarrhea may rarely be a manifestation of
cow milk protein allergy
oincreased gut permeability in diarrhea predisposes to
sensitization to oral food antigens.

42. The use of antibiotics in acute diarrhea suppresses normal gut flora
oThis may result in bacterial overgrowth with pathogenic
bacteria and/or overgrowth of fungi
oLeads to persistent diarrhea and malabsorption
Cryptosporidium infection is frequently implicated in persistent
diarrhea
oeven in immunocompetent children

43. Clinical Features
Majority of patients pass several loose stools daily but remain
well hydrated
Dehydration develops only in some patients due to:
o high stool output
owhen oral intake is reduced due to associated systemic
infections
The major consequences of persistent diarrhea are:
ogrowth faltering
oworsening malnutrition
odeath due to diarrheal or non diarrheal illness

44. The presence of secondary lactose intolerance should be considered:
when the stools are explosive (i.e. mixed with gas and passed
with noise)
presence of perianal excoriation

45. Management of persistent diarrhoea
The principles of management of persistent diarrhoea include the
following:
• (i) Correction of:
• Dehydration
• Electrolytes
• hypoglycemia
• (ii) evaluation for infections using appropriate investigations
(Hemogram, blood culture and urine culture) and their
management
• (iii) Nutritional therapy

46. Two-thirds of patients with persistent diarrhea can be treated on
outpatient basis
Patients in need of hospital admission are those with:
age less than 4 months and not breastfed
presence of dehydration
severe malnutrition (weight for height <3 SD, mid-upper arm
circumference <11.5 cm for children at 6-60 months of age, or
bilateral pedal edema)
 presence or suspicion of systemic infection.

47. THE
END