Acute Diarrheal Diseases

Dr. Priyanka Sachdeva

 DEFINITION

 Diarrhoea is defined as passage of loose, liquid

or watery stools. These liquid stools are usually
passed more than three times a day

 However , it is the recent change in consistency

and character of stools rather than the number
of stools.
 CLINICAL TYPES

• Acute watery diarrhoea.

• Acute bloody diarrhoea.

• Persistent diarrhoea.

• Diarrhoea with severe malnutrition.

 CLINICAL TYPES OF DIARRHEA
• Acute watery diarrhea: which lasts several hours to days,
main danger is dehydration, weight loss also occurs if
feeding is not continued. Pathogens that usually cause
diarrhea include V cholerae, E coli, or rotavirus.

• Acute bloody diarrhea: which is also called dysentery.

Main danger is damage to intestinal mucosa, sepsis &
malnutrition, other complications include dehydration. It is
marked by visible blood in stools. Most common cause is
Shigella.
 CLINICAL TYPES OF DIARRHEA
Persistent diarrhea: Which last for 14 days or longer,
main danger is malnutrition & serious non-intestinal
infection, dehydration may also occur. Persons with
other illness, such as AIDS, are also more likely to
develop persistent diarrhea.

Diarrhea with severe malnutrition (Marasmus &

kwashiorkor)- Main dangers are severe systemic
infection, dehydration, heart failure, vitamins & minerals
deficiency.
 EPIDEMIOLOGICAL DETERMINANTS
Agent factors

In developing countries, diarrhoea is almost universally infectious in origin. A wide

range of organism can cause dairrhoea.

Viruses: such as Rotavirus, Astrovirus, Adenoviruses, Calciviruses

Coronaviruses, enteroviruses, Cytomegaloviruses.

Bacteria: Shigella, Salmonella, Vibrio cholerae, Bacillus cerus,

Staphylococcus aureus, Clostridium perfringes,
Enterotoxigenic E coli, Enterohemorrhgic E Coli,
Campylobacter jejuni, Entero invasive E coli,
Chlamydia, Neisseria gonorrhoeae.

Others: E histolytica, Giradia intestinalis,

Intestinal worms, Cyclospora.
 Pathogens frequently Identified in children with
Acute Diarrhea in Developing Countries
Pathogens % of cases

Viruses Rotavirus 15-25%

Bacteria Enterotoxigenic E coli 10-20%

Shigella 5-15%
Campylobacter jejuni 10-15%
Vibrio cholerae 5-10%
Salmonella(non-typhoid) 1-5%
Enteropathogenic E Coli 1-5%

Protozoans Cryptosporidium 5-15%

No Pathogen 20-30%
Found
 Reservoir of Infection
• Man is the principal reservoir & thus most transmissions
originates from human feces, like enteropathogenic E coli,
Shigella, Vibrio cholerae, Giradia lambia, E histolytica.

• For other enteropathogens, animals are important

reservoirs & transmission originates both from human &
animal feces- like campylobacter jejuni, Salmonella spp etc.
 Host factors

• Diarrhea is most common in children especially

those between 6 months to 2 years.
• Incidence is highest in age group 6-11 months.

• More common in person with malnutrition.

• Poverty, prematurity, reduced gastric acidity,

immunodeficiency, lack of personal or domestic
hygiene & incorrect feeding practices are all
contributing factors.
 Environmental Factors
• Distinct seasonal patterns of diarrhea occur in many geographical
areas.
• In temperate climates, bacterial diarrhea occurs more frequently
during the warm season, whereas viral diarrhea, particularly caused
by rotavirus peak during the winter.
• In tropical areas, rotavirus diarrhea occurs throughout the year,
increasing in frequency during the drier, cool months, whereas
bacterial diarrhea peaks during warmer, rainy season.
• Incidence of persistence diarrhea follows the same seasonal patterns
as that of acute watery diarrhea.
 Mode Of Transmission
• Most of the pathogenic organisms that cause diarrhea, are
transmitted primarily or exclusively by the “fecal-oral-
route”.

• Fecal-oral-route may be water borne, food borne, or direct

transmission(via fingers, fomites, or dirt)
 ASSESSMENT
OF
HYDRATION STATUS
Look, Feel and Decide Chart for assessment of Dehydartion in diarrhoea
Condition Well, Alert *Restless, *Lethargic or
Irritable* unconscious;Floppy*
Look at Eyes Normal Sunken Very sunken
Tears +nt -nt -nt
Tongue Moist Dry Very Dry
Thirst Not thirsty *Thirsty, *Drinks poorly or
drinks eagerly* unable to drink*

Feel Skin Goes back *Goes back *Goes back very

pinch instantly slowly* slowly*

Decide No 2 or more signs 2 or more signs

dehydration including atleast including atleast one
one * marked * marked
(SOME (SEVERE
DEHYDRATION) DEHYDRATION)

Treat Treat. A Weigh the Weigh the

child,Treat.B child, Treat C
Skin Pinch
sunken eyes
 TREATMENT PLAN A
4 Rules of home treatment
1.Give extra fluid-
Breastfed frequently,

Give one or more : ORS solution, food based fluids such as soup,
rice water and clean water

Teach the mother how to mix and give ORS. Give the mother
packets of ORS to use at home.

Show the mother how much fluid to give (After each loose stool
and between them) in addition to the usual fluid intake:

Up to 2 years : 50-100 ml

2 years or more:100-200 ml
>10 years: as much as wanted
Tell the mother to:
Give frequent small sips from cup
In case of vomiting: Wait 10 min. then continue but
slowly,
Continue giving extra fluids until the diarrhea stops

2.Give Zinc Supplements:

Tell the mother how much zinc to give:
< 6 months (dose 10 mg/day): x 14 days
>6 months (dose 20 mg/day): x 14 days

3. Continue feeding

4. Tell the mother when to return

 TREATMENT PLAN B
• Determine amount of ORS over 4 hour period:
75 ml/kg body
• If the child wants more ORS then give more
• For infants < 6 months (not breastfed):
give 100-200 ml clean water also

Age < 4 4-12 12-24 24-60

(months)
Weight (kg) <6 6-<10 10-<12 12-19
Amount (ml) 200-400 400- 700- 900-
700 900 1400
Tell the mother to:
 Give frequent small sips from cup
 In case of vomiting: Wait 10 min. then continue but slowly,
 Continue giving extra fluids until the diarrhea stops

After 4 hours

 Reassess as per assessment chart and treat accordingly

(Plan A,B or C)

 If the mother leave before completing treatment:

• Show her how to prepare ORS solution at home
• and how to give ORS to finish 4 hr treatment
• Also give 2 packets ORS

 Explain the 4 rules of home treatment:

1.Give extra fluid 2.Give zinc supplements

3.Continue feeding 4.When to return
 TREATMENT PLAN C

If the child can drink, give ORS orally while the drip is set up.

Age First give Then give

30ml/kg in 70 ml/kg in
< 12 months 1 hour* 5 hour*
12 months - 5 years 30 min.* 2 ½ hours*

* Repeat once if radial pulse is still very weak or not detectable

•Reassess the child every 1-2 hours.

If hydration status is not improving give the IV drip more rapidly

•Also give ORS (5 ml/kg/hour) as soon as the child can drink.

•Reassess an infant after 6 hours and child after 3 hours:

Decide the treatment
 FOLLOW UP

• Follow up after 2 days in dysentery, after 5 days in

acute diarrhea.

• Return immediately if the child develops:

 Many watery stools,
 Repeated vomiting,
 Fever,
 Poor or unable to drink and eat/ breastfeed,
 Blood in stool
CONTROL OF DIARRHEAL DISEASES
• It is now obvious that many different organisms cause
diarrhea-some known & many unknown-cause. It is also
clear that they do not act in same way to cause diarrhea.

• But from epidemiological point of view, they are considered

together because of common symptom, diarrhea..

• It is now firmly established that regardless of causative

agent or the age of patient, sheet anchor of treatment is oral
rehydration therapy such as the one advocated by WHO/
UNICEF.

• Diarrheal Disease Control (DDC) Programme of WHO was

launched in 1980, advocated several intervention measures
to be implemented simultaneously.
Components of a Diarrheal Disease Control Programme
• Intervention measures recommended by WHO, may be
classified as below:
Short term:--
Appropriate clinical management.

Long term:
• Better MCH care practices.
• Preventive strategies.
• Preventing diarrheal epidemics
 Appropriate Clinical Management
Oral Rehydration Therapy:
• With the introduction of oral rehydration by WHO it is
now firmly established that oral rehydration treatment
can be safely & successfully used in treating acute
diarrhea due to all etiologies, in all age groups, in all
countries.
• Aim of oral rehydration is to reduce dehydration &
mortality.
• It has been observed that 90-95% cases of cholera &
acute diarrhea can be treated with oral rehydration alone.
• Oral fluid therapy is based on the fact that glucose given
orally enhance the intestinal absorption of salt & water
& is capable of correcting the electrolyte & water deficit.
• At first the composition of ORS recommended by WHO
was sodium bicarbonate based.
• Inclusion of trisodium citrate in place of sodium
bicarbonate, made the product more stable & it resulted
in less stool output, probably because of direct effect of
trisodium citrate in increasing intestinal absorption of
sodium & water.
 Recommended Formulations
• Because of the improved effectiveness of reduced
osmolarity ORS solution, WHO & UNICEF are
recommending that countries manufacture & use the
following formulations in place of previous recommended
ORS solution.

• Since 2004, new ORS formulation is the only one procured

by UNICEF.

• India was the first country in the world to launch this ORS
formulation since 2004.
 Composition of Reduced Osmolarity ORS
Reduced Osmolarity ORS Grams/litre
Sodium chloride 2.6
Glucose ,anhydrous 13.5
Potassium chloride 1.5
Trisodium citrate-dihydrate 2.9
Total weight 20.5
Reduced osmolarity ORS Mmol/litre
Sodium 75
Chloride 65
Glucose anhydrous 75
Potassium 20
Citrate 10
Total Osmolarity 245
 Guidelines for Assessing Dehydration &
Oral Rehydration
Dehydration
Mild Severe
Patient’s Appearance Thirst- alert, restless Drowsy, limp, cold, sweaty, may be
comatosed
Radial Pulse Normal rate & Rapid, feeble, sometimes impalpable
volume
Blood Pressure Normal Less than 80 mm of Hg, may be
unrecordable
Skin Elasticity Pinch retracts Pinch retracts very slowly
immediately (more than two seconds)
Tongue Moist Very dry
Ant. Fontanelle Normal Very sunken
Urine Flow Normal Little or none
% body Weight Loss 4-5% 10% or more
Estimated Fluid Deficit 40-50 ml/kg 100-110ml/kg
 Guidelines for Oral Rehydration Therapy
(for all ages) During First 4 Hours
Age(. ) Under 4 4-11 1-2 2-4 5-14 15 years
months months years years years or over

Weight in Under 5 5-7.9 8-10.9 11- 16- 30 or

(Kg) 15.9 29.9 over

ORS 200-400 400- 600-800 800- 1200- 2200-

solution 600 1200 2200 4000
(ml)

• Patient’s age should only be used if weight is not known. The

approximate amount of ORS in ml may also be calculated by
multiplying the patient’s weight (expressed in kg by) 75
 Guidelines for Oral Rehydration
• Actual amount given will depend upon the patient’s desire to
drink & by surveillance of signs of dehydration, keeping in mind
greater amount should be given to heavier patients, those with
greater signs of dehydration & those with still having watery
diarrhea.
• General rule is that patient should be given as much ORS
solution as they want, and that signs of dehydration should be
checked until they subside.
• Older children & adults should be given as much water as they
want, in addition to ORS solution.
• Mothers should be taught how to administer ORS solution to
their children following which mother feeds the solution to her
child.
• It is best if demonstration is given by health worker under their
supervision respecting the following rules:
 Guidelines for Oral Rehydration
• For children under age 2 years, give a teaspoon every 1-2 minutes, and
offer frequent sips out of a cup for older children. Adults may drink as much
they like.
• Try to give estimated required amount within 4 hours.
• As a general rule after each loose stool, give under 2 months children 50-
100ml, children aged 2-12 months give 100-200 ml, & older children &
adults as much fluid as they want.
• If child vomits, wait for 10 minutes, then try again, giving the solution slowly
1 tsf every 2-3 minutes.
• If the child wants to drink more ORS solution than the estimated amount,
and does not vomit, there is no harm in feeding more.
• If the child refuse to drink the required amount & signs of dehydration
disappeared, rehydration is completed.
• Treatment plan for non-dehydrated diarrheic children is resumed.
• If the child is breast fed, it should be persued during treatment with ORS
solution.
 Guidelines for Oral Rehydration
• Introduction of rehydration fluid has not only reduced the cost of
treatment, but also made possible, treatment of patients in their
homes by health workers or their relatives.
• Ingredients required for ORS solution are inexpensive & redially
available, solution can be prepared with ordinary drinking water &
need no sterilization.
• Packets of ORS mixture are now freely available in all PHC, sub
centers & chemist shops.
• Contents of the packet are to be dissolved in one liter of drinking
water.
• Solution should be made fresh daily & USED WITHIN 24 HOURS.
• It should not be boiled or otherwise sterilized.
• If the WHO mixture is not available, a simple mixture of table salt
(one level teaspoon)and sugar (6-level teaspoon), dissolved in
one litre of drinking water may be safely used until proper mixture
is obtained
 Guidelines for Oral Rehydration
• Infant’s usual diet of cereals, vegetables & other foods should be
continued during diarrhea, and increased afterwards.
• Food s should never be withheld & child’s usual food should never
be diluted.
• Aim is to give as much nutrient rich food as the child will accept.
• Most of the children with watery diarrhea regain their appetite after
dehydration is corrected, whereas those with bloody diarrhea often
eat poorly until the illness resolves .
• These children should be encouraged to resume normal feeding as
soon as possible.
 Intravenous Rehydration
• Intravenous infusion is usually required only for the rehydration
of severely dehydrated patients who are in shock or unable to
drink. Such patients are best transferred to a nearest hospital or
treatment center.
• Solutions recommended by WHO for I/V infusion are: Ringer’s
lactate solution(also called Hartmann’s solution for injection). It
is the best commercially available solution. It supplies adequate
concentration of sodium & potassium & lactate yields
bicarbonate for correction of acidosis. It can be used to correct
dehydration due to acute diarrheas of all causes.
• Diarrhea treatment solution: Also recommended by WHO an
ideal solution for I/V infusion. It contains in one liter, sodium
chloride 4gm, sodium acetate 6.5gm, potassium chloride 1gm &
glucose 10gm.
• If nothing else is available, normal saline can be given because
it is often redially available
 Intravenous Rehydration
• Initial rehydration should be fast until an easily palpable pulse
is present. Reassess the patient every 1-2 hours. If
dehydration is not improving, give the I/V drip more rapidly.
After infusing 1-2 liters of fluids, rehydration should be carried
out at relatively slow rate until pulse & blood pressure return to
normal. When the patient can drink the oral fluids give ORS
about 5ml/kg/hour.
• Treatment plan for rehydration therapy:

Age First give Then give

30ml/kg in 70ml/kgin

Infants 1 hour 5 hours

(under 12 months)
Older 30 minutes Two & half hours
 Maintenance Therapy
• After the initial fluid & electrolyte deficit is corrected(signs of
dehydration gone), oral fluids should be used for maintenance
therapy.
• In adults & older children thirst is an adequate guide for fluid
needs, they can be told to drink as much they can to satisfy
their thirst

Amount of Diarrhea Amount of oral fluid

Mild diarrhea(not more than one stool every 100ml/kg body weight per day until diarrhea
two hours or longer, or less than 5 ml stool stops
per kg per hour

Severe diarrhea(more than one stool every Replace stool loses volumes for volume, if
two hours, or more than 5 ml of stool per kg not measurable give 10-15 ml/kg body
per hour) weight per hour.
 Appropriate Feeding
• Medical profession has reeled for centuries under the mistaken
assumption that it is important to rest the gut during diarrhea.
• Current view is that during diarrhea, normal food intake should
be promoted as soon as the child whatsoever the age, is able
to eat.
• This is specially relevant to exclusively breast fed patients.
• New born infants with little or no signs of dehydration can be
treated by breast feeding alone. Those with moderate or severe
dehydration should receive ORS solution.
• Breast feeding is continued with ORS solution after each liquid
stool.
• Breast milk not only helps the infant to recover from an attack of
diarrhea both in terms of nutrients it supplies & its rehydrating
effect, but it helps to prevent further infection because it has
protective properties.
 Chemotherapy
• Unnecessary prescription of antibiotics & other drugs will do
more harm than good in the treatment of diarrhea.
• Antibiotics should be considered where the cause of diarrhea
has been clearly identified as shigella, typhoid or cholera.
• For diarrhea due to cholera, drug of choice is Doxycycline,
tetracycline and erythromycin.
• For diarrhea due to shigella, drug of choice is ciprofloxacin.
Drugs that should not be used in diarrhea are:
Neomycin: damage intestinal mucosa.
Purgatives: worsen diarrhea & dehydration.
Tincture of opium or atropine-dangerous for children because
of decreased intestinal transit time
Steroids: useless.
Oxygen useless.
Charcoal, pectin, bismuth(no value)
 Zinc Supplementation
• When a zinc supplement is given during an episode of
acute diarrhea, it reduces the episode’s duration & severity
the incidence of diarrhea .
• In addition zinc supplement given for 10-14 days lower the
incidence of diarrhea in following 2-3 months.
• WHO/UNICEF therefore recommended a daily 10mg of zinc
for infants under 6 months of age, and 20mg for children
older than 6 months for 10-14 days.
 Better MCH Care
• Maternal Nutrition: Improving maternal nutrition will reduce the problem of
low birth weight & improve the quality of breast milk.
• Child nutrition:
• Promotion of breast feeding: Any measures to promote breast feeding
are likely to reduce diarrheal diseases. Breast fed child is at low risk of
severe diarrhea & death than the bottle fed child. It should be continued
as long as possible.
• Appropriate complementary feeding practices: Poor complementary
feeding practices are a major cause of diarrhea. Child should not be
weaned (not less than 6 months) using nutritious locally available foods &
should be hygienically prepared.
• Supplementary feeding: It is necessary to improve the nutritional status of
children aged 6-59 months.
• Vitamin A supplementation: It is a critical preventive measure, mortality
reduction ranges from 19-54%.
• This reduction is associated with decline in deaths due to diarrheal
diseases & measles. It also reduce the duration, severity & complications
associated with diarrhea.
 Preventive Strategies
• Sanitation: Measures to reduce transmission emphasize the
traditional improved water supply, improved excreta disposal, &
improved domestic & food hygiene.
• Simple hygienic measures like hand washing with soap before
preparing the food, before eating , before feeding a child, after
defecation & after disposing the stool of the child should be
promoted.
• Latrine should be cleaned by regular washing .
• If there is no latrine, members should defecate at some
distance from house, paths or areas where children play & at
least 10 meters away from water supply source.
• Children should not be permitted to defecate indiscriminately.
 Health Education & Immunization
• Environmental measures requires educational support, to
ensure their proper use & maintenance of such facilities.
• An important function of the health worker is to prevent
diarrhea by convincing the family members to adopt &
maintain certain preventive practices like breast feeding,
improved complementary feeding, clean drinking water, use
of plenty of water for hygiene, use of latrine, proper disposal
of stools of children.
• Immunization: Immunization against measles is a potential
intervention for diarrhea control. When administered at
recommended age, measles vaccine can prevent up to 25%
of diarrheal deaths in children under 5 years of age.
 Rotavirus Vaccine
• Two live attenuated rotavirus vaccines were licensed in 2006,
monovalant human rotavirus vaccine(RotrixTM) & pentavalent
bovine-human vaccine(Rota-Teq TM).
• Both vaccines have demonstrated very good safety & efficacy
profile in large clinical trials.
• RotrixTM is administered orally as two dose schedule to infants,
first dose is given at the age of 6 weeks & should not be given
later than the age of 12 weeks. Second dose is given 4 weeks
after the first dose, but not later than 24 weeks.
• Rota-TeqTM, recommended doses schedule 3 oral doses at
ages of 2,4 & 6 months or 6,10 and 14 weeks. Vaccination
should not be initiated after 12 weeks & should be completed
before the age of 32 weeks.
Thank You