Diarrhea

Diarrhea

According to world health organization Diarrhea is defined as passage of 3 or loose stool per day or passing more stools than normal for the age.

Classification of Diarrhea

1. On the basis of duration

2 types;

Acute diarrhea

Chronic diarrhea

2. On the basis of clinical presentation

2 types;

Acute watery diarrhea

Acute bloody diarrhea

3. On the basis of physiology

5 types;

1. Secretory diarrhea

2. Osmotic diarrhea

3. Exudative diarrhea

4. Motility related

5. Inflammatory diarrhea 

1. Secretory diarrhea

Increase secretion or inhibition of absorption in intestine.

For example; diarrhea caused by cholera toxin.

2. Osmotic diarrhea

When too much water drawn into bowel.

If child drinks excessive sugar or salt solution, water is drawn from body into bowel, causes osmotic diarrhea.

3. Exudative diarrhea

Presence of blood or pus in stool. Exudative diarrhea occur due to inflammatory bowel disease such as; crohn's disease or ulcerative colitis, food poisoning, infection with E. Coli.

4. Motility related diarrhea

Caused by hypermotility; rapid movement of food through intestine. 

If peristalsis quickly occur through gastrointestinal tract, very less time for absorption of nutrients and water. Mainly occurs in hyperthyroidism, diabetes patients.

5. Inflammatory diarrhea 

Occurs when damage to mucosal lining or brush border enzyme; decrease ability to absorb. 

Caused by bacterial, viral, parasitic or autoimmune disorder; inflammatory bowel diseases.

Etiology

1. Infection

a. Bacteria

E. Coli, Shigella, Salmonella, Staphylococcus 

b. Virus

Influenza virus, Enterovirus, Rotavirus

c. Parasites

Cryptospodiasis, Giardia lambia, Entamoeba histolytica, Amoeba

d. Fungi

Candida albicans

2. Drugs

Intake of antibiotics and iron supplements lead to diarrhea

3. Dietary cause

Food poisoning, food allergies, over eating, unhygienically prepared food 

4. Surgical condition

Intussusception, polyps, diverticulitis lead diarhoea 

5. Miscellaneous causes

Malabsorption Syndrome, celiac disease, ulcerative colitis, irritated bowel syndrome lead to diarhoea in children.

Predisposing factors

1. Age

More frequent in children under age of 2 year's.

2. Season

More common in summer and rainy season.

3. Socioeconomic status

Living in poor sanitary condition.

4. Dietary factor

Higher in artificial feeding children 

5. Teething

During teeth eruption, infant puts dirty hand or object into mouth causing infection or diarrhea.

 

Physiological Disturbance in Diarrhea

Water present in two fluid compartment;

1. Extracellular fluid

2. Intracellular fluid

1. Extracellular fluid includes circulating blood, Secretion and fluid in gastrointestinal tract. 

2. Intracellular fluid includes cytoplasm, nucleoplasm, and protoplasm.

Diarrheal losses from extracellular fluid,  large amount of water and water soluble nutritive substance such as; electrolytes, matabolities and vitamins.

Loss of water from extracellular compartment causes reduction or shrinkage in volume of extracellular compartment. 

Sodium is major osmotic component of extracellular fluid.  Serum sodium level reduced excessive sodium lost in stool.

Dur to hyponatremia, Osmolality of extracellular fluid compartment falls, causing movement of water from extracellular compartment to intracellular compartment, causes reduction in already reduced extracellular fluid.

Due to reduceed blood volume of extracellular compartment, rest weak and fall in blood pressure. 

Due to reduced blood volume; blood supply to kindney reduced and leads to decrease Glomerular filteration; decrease urine output.

Large amount of potassium loss in diarhoeal stool, serum potassium falls, if continuous for long time. Result in abdominal distension, paralytic ileus and hypotonia.

Bicarbonate also lost due to diarrhea, result acidemia occurs. Breathing become deep and rapid., Known as Kussmal breathing.

Clinical features

1. Mild diarrhoea

2-5 loose stools in 24 hours; stool may be green, containing mucus.

Tears present

Mouth and tongue wet.

Fontanelle(infants); normal

Skin when pinched, goes back quickly

Breathing normal.

Thirst; more than normal

Vomiting; none or small amount 

2. Moderate diarrhea

5- 10  loose stool in 24 hours, fever, irritability, anorexia, vomiting present.

Vomiting; none or Small amount

Thirst; more than normal

Urine; small amount and dark

Condition; baby unwell, sleepy or irritable

Tears; absent

Eyes; sunken

Mouth and tongue; dry

Breathing; faster than normal

Skin; pinch, go back slowly

Pulse; faster than normal

Fontanels (infants); sunken

3. Severe Diarrhea

More than than 10 loose sto within 24 hours.  Severe vomiting also present.

Vomiting; very frequent

Thirst; unable to drink

Urine; no urine for 6 hours

Condition; very sleepy, unconscious, having fits

Tears; absent

Eyes; very sunken

Mouth and tongue; very dry

Breathing; very fast and deep

Skin; pinched, goes back very slowly

Pulse; very fast, weak

Fontanels (infants); very sunken 

Classification of dehydration

On the basis of osmolality dehydration classified into 3 category;

1. Isotonic dehydration

2. Hypotonic dehydration

3. Hypertonic dehydration

1. Isotonic dehydration

Condition when electrolyte and water deficits are present in equal amount.

Plasma sodium remains between normal, between 130 to 150 mEq/L.

Characterized by hypovolemic shock.

2. Hypotonic dehydration

Condition occurs when electrolyte deficit exceeds water deficit.

In hypotonic dehydration water moves extracellular compartment to intra cellular space.

Intracellular fluid (ICF) is more concentrated then extra cellular fluid (ECF).

Serum sodium level falls below 130mEq/L.

In hypotonic dehydration, shock is frequent.

3. Hypertonic dehydration

Condition when water loss exceeds the electrolyte loss caused by larger loss of water or larger intake of electrolytes.

In hypertonic dehydration, fluid shift from intracellular compartment to extracellular compartment.

Plasma sodium level rises, greater than 150 mEq/L.

Hypertonic dehydration, occur in children who received high protein nasogastric tube feeding.

Shock is less, neurologic disturbance may present; 

Alteration in consciousness, lethargy, increased muscle tone with hyper-reflexia and hyper- irritability to stimuli, alteration in pulse, thirst, tachycardia.

Diagnostic Evaluation

1. Collect History;

Number of tool passes and description 

Body weight prior to illness

Presence of abdominal pain, cramps, tenesmus, fever

Fluid intake

Frequency of Urination

2. Physical examination; assess degree of dehydration

3. Stool examination

Presence of Ova or cyst of parasites, presence of blood, mucous, leucocytes, glucose.

4. Stool culture

Identification of microorganisms

5. Blood tests

1. Hematocrit

Elevated hematocrit, if infant is dehydrated.

2. Blood urea nitrogen (BUN); elevated, renal circulation impaired due to dehydration.

3. Serum sodium, bicarbonate, potassium, chloride level reduced

Management

1. Replacement of fluids

Assessment of fluid and electrolyte imbalance.

Oral rehydration therapy replace the fluid and electrolyte lost from body during Diarrhea. o

Prepared ORS can stored 24 hours.

Oral rehydration therapy (ORS)

Homemade solutions; used for rehydration are salted rice water, salted pulses (daal) water, salted yogurt drinks (lassi, chachh).

At home, ORS can prepare by mixing three finger pinch salt (3grams), and two tablespoon sugar (18 grams) in 1 litre water, given to child after every loose stools.

Readymade ORS packets recommended by WHO and UNICEF.

Treatment

1. Treatment plan A

For mild dehydration

Home made prepared ORS can given.

Increase amount of home based fluids; rice water, salted lassi, lemon water, coconut water, soups, fruit juice, daal water given to child.

2. Treatment plan B

For signs for moderate dehydration.

1. Rehydration therapy

Correct fluid and electrolyte balance.

2. Maintenance therapy

After sign of dehydration disappear, start maintenance therapy.

Replacement losses due to continuing Diarrhea.

3. Normal daily fluid requirements

Take plenty of fluid daily.

3. Treatment plan C

For children with severe dehydration

1. Start intravenous fluids immediately

2. Give ORS to drink

3. Ringer lactate solution; IV fluids given

If ringer lactate not available, normal saline (0.9%) used.

2. Administration of prescribed drugs

Anti- Diarrheal drugs administerd.

3. Maintenance of nutritional status

Brestfeeding continued along with ORS.

In non Brest fed infants; semi solid foods, khichdi, soft cooked rice with milk or curd with sugar, mashed banana, mashed potatoes.

Avoid spicy food and high fibre content foods, may irritate bowel mucosa.

Zinc suppliment given to children suffering from Diarrhea.

4. Prevention of Diarrhea

Avoid bottle feeding.

Given freshly coocked food

Clean water, and utensils

Hygienic prepared food

Food kept covered, protect from dustand flies

Not finger put in mouth

Was fruits and vegetables before consuming 

5. Educating parents

Children wash their hand before eating food.

Children wash their hand after going to toilet.

Provide Immunity boosting nurtritious food.

Prevent from infection