Download MBBS Acute Diarrheal Disease Lecture PPT

Diarrhoea is defined as recent change in consistency
and frequency of stools i.e, liquid or watery stools that
occur more than 3 times a day.
In a vast majority of cases these acute episodes
subside within 7 days.

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Persistent diarrhoea: Acute diarrhoea persisting for
more than 2 weeks ( 5 to 15% cases )mostly due to
infections.
Chronic diarrhoea: Insidious onset diarrhoea of more
than two weeks duration in children mostly due to non

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-infectious conditions causing malabsoption (IBD)

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If there is associated blood in stools it is termed as dysentery.
Diarrhoea accounts for over 20% of all deaths in underfive
children.
Globally it affects 3 to 5 billion cases and causes about 2

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million deaths a year.
Consequences of diarrhoea in children: malnutrition
,dehydration, electrolyte imbalance, acid base imbalance

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ETIOLOGY
Most common: Intestinal infections( bacterial, viral or parasitic)

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Other causes:
? Certain drugs(antibiotics,NSAIDs,PPIs,cytotoxic drugs)
? food allergy
? systemic infections( urinary tract infection and otitis media)
? surgical conditions( appendicitis or Hirschsprung disease).

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Rotavirus remains the leading cause of severe gastroenteritis
worldwide.
In India- rotavirus and enterotoxigenic E.coli

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Bacterial: E.coli, Shigella, Vibrio cholerae,
Salmonella, Campylobacter, Bacillus cereus,

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Clostridium difficile, S.aureus.
Viral: Rotavirus, Norovirus, enteric adenovirus,
coronavirus
Parasitic: Giardia lamblia, Cryptosporidium parvum,
Entamoeba, Isospora

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RISK FACTORS
Poor sanitation and personal hygiene
Non availability of safe drinking water
Unsafe food preparation practices
Low rates of breastfeeding

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Low immunization
Young children (less than 2 years)
Malnutrition
Hypo or achlorhydria
selective IgA deficiency

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HIV infection, immunodeficiency
Chronic use of antibiotics (clostridium difficle)
Travel

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PATHOGENESIS
60% of a child's body weight is water -ECF and ICF

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compartments
Diarrheal losses comes from ECF which has relatively high
sodium and low potassium
In 50% cases concentration of sodium in plasma remains
normal

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In 40 to 45% cases excessive sodium is lost in stools -
hyponatremia and fall in ECF osmolality- movement of
water from ECF to ICF compartment - Further shrinkage
of ECF volume.
In both hyponatremic and isonatremic dehydration, skin

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turgor or elasticity is lost.

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In 5% cases, especially when child is given fluids with extra
salt ,serum sodium increases - ECF osmolality increases -
water moves from ICF to ECF -skin appears soggy duffy or
leathery.

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Therefore a severe case of hypernatremic dehydration is
likely to be underestimated.
As ECF compartment is depleted ,blood volume decreases-
weak thready pulse, low BP and cold extremities.
Low hydrostatic pressure in Renal glomeruli- filtration of

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urine decreases
Since intestinal secretions are alkaline, considerable
bicarbonate is lost in diarrhoeal stools -acidosis-
kussmaul's breathing .

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CLINICAL FEATURES

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? Thirsty
? Irritable
? Decreased skin turgor
? Fontanelle ( if open ) ? is depressed
? Eyes appear sunken

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? Tongue and inner side of cheeks appear dry
? Decreased urine output
? Urine passed at longer intervals
? Weak and Thready pulses
? Low blood pressure

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? Cold extremities
?Due to hypokalemia-Abdominal distension,paralytic
ileus,muscle hypotonia,ST depression,Flat T wave
? Kussmauls breathing

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Decreased skin turgor

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Depressed fontanelle

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Assessment of child with
acute diarrhea

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Goals of assessment
1. Determine the type of diarrhea ie.,acute

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watery diarrhea , dysentery or persistent
diarrhea
2. Look for dehydration and other
complications
3. Assess for malnutrition

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4. Rule out nondiarrheal illness
5. Assess feeding ( both preillness and
during illness )

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History
Should include information on

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1. Onset of diarrhea, duration and number of
stools per day
2. Blood in stool
3. Number of episodes of vomiting
4. Presence of fever, cough , and other significant

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symptoms
5. Type and amount of fluids and food taken
during the illness and the pre illness feeding
practices
6. Drugs and local remedies

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7. Immunization history

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Examination
Assessment of degree of dehydration
Features of malnutrition
Systemic infection

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Fungal infection

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Features
No dehydration
Some dehydration
Severe dehydration

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Sensorium
Alert
Irritable
Lethargic/
unconscious

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Thirst
Not thirsty; drinks
Thirsty; drinks
Drinks poorly or not
normally

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eagerly
able to drink
Skin turgor
Goes back quickly
Goes back slowly

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Goes back very slowly
Eyes
Normal ; tears
Sunken ; tears absent Very sunken ; tears
absent

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Oral mucosa
Moist
Dried
Very dry
Definition

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No signs of
If 2 or more of the
If 2 or more of the
dehydration
above signs including above Signs including

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atleast one key sign
atleast one key sign
are present
Heart rate
Normal

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Normal; maybe
Tachycardia;
increased
bradycardia in most
severe cases

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Pulse and extremities Normal,warm
Normal- decreased
Weak thready or
volume,cold
impalpable,cold

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Severity of dehydration
No dehydration - < 50 ml/kg
Some dehydration ? 50 ? 100 ml / kg
Severe dehydration > 100 ml/ kg

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1.Look for features of malnutrition-

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Anthropometry
Examination for wasting
Edema
Signs of vitamin deficiency
2.Systemic infection (cough,high grade

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fever,fast breathing etc.)
3.Fungal infection- Oral thrush,perianal
satellite lesions

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Laboratory investigations
Stool microscopy(cholera, giardiasis)

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Stool culture
Hemogram
Blood gas estimation
Serum electrolytes
Renal function tests

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