ACUTE DIARRHEA IN CHILDREN AND ADULTS.pptx

ACUTE DIARRHEA ETIOLOGY,CLINICAL FEATURES AND MANAGEMENT OF DIARRHEA

1. ACUTE DIARRHEA IN CHILDREN & ADULTS Dr.G.VENKATA RAMANA MBBS DNB FAMILY MEDICINE

2. DIARRHEA Definition : P assage of abnormally liquid or unformed stools at an increased frequency (>3 times a day) Acute diarrhea: < 2 weeks in duration Persistent diarrhea: 2-4 weeks in duration Chronic diarrhea: >4 weeks in duration Dysentery or Invasive diarrhea: D iarrhea with visible blood, in contrast to watery diarrhea Dysentery is commonly associated with fever and abdominal pain

3. ETIOLOGY More than 90% of cases of acute diarrhea are caused by infectious agents T hese cases are often accompanied by vomiting, fever, and abdominal pain The remaining 10% or so are caused by medications, toxic ingestions, ischemia, food indiscretions, and other conditions

4. ETIOLOGY V iruses Rotavirus Adenoviruses Norovirus Astrovirus Hepatitis A B acteria Salmonella Shigella Escherichia coli ( Enterotoxigenic   , Enteroaggregative , Enteroinvasive   , Enterohemorrhagic ) Vibrio cholerae O1 or O139 Clostridioides difficile , Campylobacter Yersinia , Listeria , Plesiomonas, Aeromonas species

5. ETIOLOGY Parasites Giardia lamblia Entamoeba histolytica Cyclospora Isospora Cryptosporidium Strongyloides Opportunistic Microsporidia Mycobacterium avium intracellulare Cytomegalovirus Herpes simplex virus

6. ETIOLOGY Drugs Laxatives Sorbitol Antacids Colchicine Quinidine Diuretics Digitalis Propranolol Theophylline Alcohol Antibiotics Heavy metals

7. ETIOLOGY Other causes Occlusive or nonocclusive ischemic colitis Colonic diverticulitis and graft-versus-host disease Ingestion of toxins including organophosphate insecticides, amanita and other mushrooms , arsenic, and preformed toxins in seafood such as ciguatera (from algae that the fish eat) and scombroid (an excess of histamine due to inadequate refrigeration) Acute anaphylaxis to food ingestion S ystemic infections (e.g. urinary tract infection and otitis media) S urgical conditions (e.g. appendicitis or Hirschsprung disease ) can also present as acute onset diarrhea

8. Acute watery diarrhea   causes E nterotoxigenic   E.coli   V.cholerae   Norovirus Campylobacter species N ontyphoidal Salmonellae Aeromonas  species Enteroaggregative  E. coli  Acute bloody diarrhea   causes Shigella  species Campylobacter jejuni E nteroinvasive and enterohemorrhagic  E. coli N ontyphoidal  Salmonella species Entamoeba histolytica Schistosoma mansoni

9. RISK FACTORS P oor sanitation and personal hygiene N onavailability of safe drinking water Unsafe food preparation practices Low rates of breastfeeding and immunization Risk factors for prolonged and recurrent episodes of diarrhea P res en c e of hypo or achlorhydria (due to Helico bac t e r pylori infection or therapy with proton pump inhibitors) S elective IgA deficiency Infection with human immunodefic ie nc y v irus (HIV ) and other chronic conditions

10. CLINICAL FEATURES Typical findings   Watery diarrhea is characteristically nonbloody , whereas dysentery is defined as diarrhea with visible blood A "rice-water" appearance of stool flecked with mucous is suggestive of cholera Furthermore, diarrhea caused by  V. cholerae  may present very suddenly with vomiting and abdominal cramping but not frank pain or tenesmus Fever is uncommon in cholera In contrast, shigellosis is typically characterized by the frequent passage of small liquid stools that contain visible blood, with or without mucous Abdominal cramps and tenesmus are common, along with fever and anorexia However, within these two categories of diarrhea, the specific infectious causes cannot be determined based on signs or symptoms

11. (A) Green watery stool Green colored stool, often seen in rotavirus gastroenteritis (B) Rice water stool White colored stool characteristic of severe cholera

12. CLINICAL ASSESSMENT C areful history and physical examination in order to assess the type of diarrhea and the severity of hypovolemia Based on the appearance of the stool, diarrhea can be classified as watery or bloody The physical examination should focus on characterizing the degree of volume depletion Early hypovolemia Signs and symptoms may be absent WHO terms this 'no dehydration' Moderate hypovolemia Thirst , restless or irritable behavior, decreased skin turgor, sunken eyes, WHO terms this 'some dehydration' Severe hypovolemia Diminished consciousness, lack of urine output, cool moist extremities, rapid and feeble pulse, low or undetectable blood pressure, peripheral cyanosis, WHO terms this 'severe dehydration'

13. Assessment of severity of volume depletion Examination Mild hypovolemia Moderate hypovolemia Severe hypovolemia Look at: Mental status Alert Restless, irritable Lethargic or unconscious Eyes Normal Sunken Very sunken and dry Tears Present Absent Absent Mouth/tongue Moist, slightly dry Dry Very dry Thirst Increased thirst Thirsty, drinks eagerly Drinks poorly or not able to drink Feel: Skin pinch Goes back rapidly Goes back slowly Goes back very slowly (tenting) Pulse Normal Rapid, weak Very fast, weak or nonpalpable Extent of volume loss   <5% of body weight From 5 to 10% of body weight >10% of body weight Estimated fluid deficit   <50 mL/kg 50-100 mL/kg >100 mL/kg

14. Assessment of severity of volume depletion

15. Laboratory studies Routine microscopy of fresh stool : Identify the presence of numerous fecal leukocytes with any number of red blood cells, suggesting an invasive bacterial infection Microscopic evidence of  Entamoeba trophozoites   containing high counts of red blood cells  Amoebic dysentery Notably, finding cysts or trophozoites without red blood cells in a bloody stool does not indicate that  Entamoeba  is the cause of illness, since asymptomatic infection is frequent among healthy persons in resource-limited countries Cholera can be diagnosed using dark-field microscopy, in which motile Vibrios appear as "shooting stars Stool culture Serum electrolyte and glucose testing Blood urea and serum creatinine HIV testing

16. Trophozoites of  E. histolytica   with ingested erythrocytes stained with trichrome

17. Hanging drop for bacterial motility Positive / Darting motility of Vibrio cholerae

18. Consequences of diarrhea in children Malnutrition D ehydration Malnutrition and diarrhea form a vicious cycle , since malnutrition increases the risk and severity of diarrhea Impaired absorption, loss of nutrients, increased catabolism and improper feeding in diarrhea aggravate the severity of malnutrition

19. Complications of acute diarrheal diseases in adults   The sequelae of severe volume depletion are the most important systemic complications of acute diarrheal disease in adults Hypovolemia and accompanying electrolyte imbalances S ystemic complications Bacteremia: Shigella species, Nontyphoidal Salmonella enterica , Campylobacter fetus Hemolytic-uremic syndrome: Shigella species, Shiga toxin-producing Escherichia coli Guillain-Barré syndrome :Campylobacter jejuni Reactive arthritis : Campylobacter species, Salmonella species, Shigella flexneri Serious complications may occur with  Shigella  infection, including sepsis, seizures, rectal prolapse, toxic megacolon , and the hemolytic-uremic syndrome Among individuals with HIV infection in resource-limited settings, bacteremia with non- typhoidal  Salmonella enterica  is a particular concern

20. Management of acute diarrhea has four major components: ( i) Rehydration and maintaining hydration (ii) Ensuring adequate feeding (iii) Oral supplementation of zinc in children ( iv) Early recognition of danger signs and treatment of complications The cornerstone of acute diarrhea management is rehydration by using oral rehydration solutions

21. Physiological basis for oral rehydration therapy In most cases of acute diarrhea, sodium and chloride are actively secreted from the gut mucosa due to pathogen-induced dysfunction of several actively functioning absorption pumps However , glucose dependent sodium pump remains intact and functional transporting one molecule of glucose and dragging along a molecule of sodium and one of water across intestinal mucosa resulting in repletion of sodium and water losses The glucose dependent sodium and water absorption is the principal behind replacing glucose and sodium in 1:1 molar ration in the WHO oral rehydration solution ( ORS )

22. An important consideration in making ORT is that the osmolarity of the replacement fluid should not exceed that of blood (290 mmol /L) Keeping the intestinal lumen at lower osmolarity as compared to blood allows for greater absorption of fluids into the bloodstream across concentration gradient, which also results in electrolyte absorption (by solvent drag) Since the concentration of glucose increases osmolarity , it is suggested that glucose concentration shou ld not exceed 111 mmol /L Meta- analyses have shown that use of low osmolarity ORS causes reduction of stool output, decrease in vomiting and decrease in the use of unscheduled intravenous fluids without increasing the risk of hyponatremia For this reason, the recommendation for use of standard WHO ORS (having osmolarity of 311 mmol /L) was changed to low osmolarity WHO ORS (having osmolarity of 245 mmol /L)

23. Composition ( mEq /L) of common solutions used for rehydration Route Solution Na+ K+ Cl – HCO3– Citrate Ca ++ Glucose/ carbohydrate Intra venous Normal saline 154 – 154 – – – – Ringer's Lactate 130 4 111 28 – 3 – Ringer's Lactate + 5 percent dextrose 130 4 109 28 – 3 278 Cholera saline ("Dhaka solution") 133 13 98 48 – – 140 Oral Standard ORS 90 20 80 – 10 – 111 Hypo-osmolar ORS 75 20 65 – 10 – 75 ReSoMal * (Reduced Osmolarity ORS for Malnourished Children) 45 40 76 – 7 – 125

24. Approach to fluid management in adult with hypovolemia

25. Recommendations on dietary management of acute diarrhea in children i. In exclusively breastfed infants, breastfeeding should continue as it helps in better weight gain and decreases the risk of persistent diarrhea. ii. Optimally energy dense foods with the least bulk, recommended for routine feeding in the household, should be offered in small quantities but frequently (every 2-3 hours). iii. Staple foods do not provide optimal calories per unit weight and these should be enriched with fat or oil and sugar, e.g. khichri with oil, rice with milk or curd and sugar, mashed banana with milk or curd, mashed potatoes with oil and lentil. iv. Foods with high fiber content , e . g. coarse fruits and vegetables should be avoided. v. In nonbreastfed infants , cow or buffalo milk can be given undiluted after correction of dehydration together with semisolid foods Milk should not be diluted with water during any phase of acute diarrhea Alternatively, milk cereal mixtures , e . g. dalia , sago or milk-rice mixture, are preferable vi. Routine lactose-free feeding, e.g. soy formula is not required during acute diarrhea even when reducing substances are detected in the stools vii.During recovery, an intake of at least 125% of recommended dietary allowances should be attempted with nutrient dense foods; this should continue until the child reaches pre-illness weight and ideally until the child achieves a normal nutritional status

26. Dietary recommendations in adults Small meals can be provided frequently, as soon as the patient is able to tolerate Foods with high fat content should be avoided until the gut function returns to normal after a severe bout of diarrhea Dairy products (except yogurt) may be difficult to digest in the presence of diarrheal disease This is due to secondary lactose malabsorption , which is common following infectious enteritis and may last for several weeks to months Thus , temporary avoidance of lactose-containing foods is reasonable

27. Zinc Supplementation in children It is helpful in decreasing severity and duration of diarrhea and also risk of persistent diarrhea Z inc is recommended to be supplemented as sulfate, acetate or gluconate formulation , D ose of 20 mg of elemental zinc per day for children > 6 months for a period of 14 days Dose of 10 mg of elemental zinc per day for children < 6 months for a period of 14 days

28. Antibiotics are not recommended for routine treatment of acute diarrhea in children In acute diarrhea, antimicrobials are indicated in bacillary dysentery, cholera, amebiasis and giardiasis Acute diarrhea may be the manifestation of systemic infection and malnourished, prematurely born and young infants are at a high risk Thus such babies should be screened and given adequate days of age appropriate systemic antibiotics for sepsis Presence of (i ) poor sucking; (ii) abdominal distension; (iii) fever or hypothermia ; (iv) fast breathing; and (v) significant lethargy or inactivity in well-nourished, well-hydrated infants points towards sepsis

29. Antimicrobial therapy is not typically indicated for the treatment of acute watery diarrhea in adults in resource-limited settings, as most cases resolve spontaneously Start empiric antibiotic therapy in the following circumstances in adults Severe illness (fever ≥38.5°C [101.3°F], hypovolemia , ≥6 unformed stools per 24 hours, severe abdominal pain) Features of inflammatory diarrhea (bloody diarrhea, small volume mucous stools, fever) High-risk host features (age ≥70 years, cardiac disease, immunocompromising condition, inflammatory bowel disease, pregnancy) In these circumstances, the benefits of antibiotic therapy likely outweigh the low risk of potential complications from treating STEC

30. Dysentery   In contrast to the treatment of watery diarrhea, adults with bloody diarrhea should be treated promptly with an antimicrobial that is effective against  Shigella   Patients who do not respond after 48 hours or deteriorate within 24 to 48 hours can be switched to a different antimicrobial agent If there is still no response, treatment for amebic dysentery due to  E. histolytica  can be given Although initial empiric treatment for amebic dysentery is not routinely warranted, it should be given at any point if trophozoites are visualized on stool microscopy Treatment for amebic dysentery usually entails  metronidazole  (500 to 750 mg orally three times daily for 7 to 10 days) followed by an intraluminal agent Ciprofloxacin  or  azithromycin  are reasonable first-line antibiotics for shigella,although clinicians should be aware that failure due to resistance is possible and second-line drugs may be required

31. Antimotility agents in children S ynthetic analogues of opiates ( diphenoxylate hydrochloride or lomotil and loperamide or imodium ) reduce peristalsis or gut motility and should not be used in children with acute diarrhea Reduction of gut motility allows more time for the harmful bacteria to multiply These drugs may cause distension of abdomen, paralytic ileus, bacterial overgrowth and sepsis and can be dangerous, even fatal, in infants

32. Antimotility agents in adults For patients who want symptomatic therapy, the antimotility agent  loperamide  (Imodium) can be used cautiously in patients in whom fever is absent or low grade and the stools are not bloody The dose of loperamide is two tablets (4 mg) initially, then 2 mg after each unformed stool for ≤2 days, with a maximum of 16 mg/day A void antimotility agents in patients with clinical features suggestive of dysentery (fever, bloody or mucoid stools) unless antibiotics are also given because of concerns that antimotility agents can prolong disease in such infections or lead to more severe illness

33. Antisecretory agents Racecadotril inhibits intestinal enkephalinase Reduces the stool output and duration of diarrhea Dose:100mg TDS Probiotics Lactobacillus rhamnosus (formerly Lactobacillus casei strain GG) , L.sporogenes,L.plantarum ,several strains of bifido -bacteria, Enterococcus faecium SF68,and the yeast Saccharomyces boulardii have some efficacy in reducing the duration of acute diarrhea

34. PREVENTION Hand washing with soap Ensuring the availability of safe drinking water Appropriate disposal of human waste Breastfeeding of infants and young children Safe handling and processing of food Control of flies Vaccination Cholera vaccine ( live attenuated,oral ) Rota virus vaccine (live attenuated,oral ) Candidate vaccines for shigellosis are undergoing testing