Acute management of acute watery diarrhea

This presentation explains acute diarrhoea, the pathophysiology, types, complications and management

1. ACUTE DIARRHEAL DISEASE IN ADULTS BY DR NWAEBOH UZOMA .C. [TEAM F] FMC ASABA

2. OUTLINE: INTRODUCTION EPIDEMIOLOGY ETIOLOGY RISK FACTORS PATHOPHYSIOLOGY SIGNS AND SYMPTOMS INVESTIGATIONS COMPLICATIONS ALTERNATIVE DIFFERENTIALS MANAGEMENT PROGNOSIS/PREVENTION

3. INTRODUCTION: Diarrhea simply means a change in the consistency of stool to being abnormally loose or fluid and increase in the frequency of stools more than is normal for the individual Diarrhea is defined as passage of abnormally liquid or unformed stools at an increased frequency. Diarrhea can also be defined as at least 200grams of dry weight of stool per day. Two common causes associated with stools <200g/day: Pseudo diarrhea Fecal incontinence

4. DEFINITION OF ACUTE DIARRHEA: Acute diarrhea can be defined as the abrupt onset of 3 or more loose stools per day no longer than 14 days . CLASSIFICATION: Diarrhea can be classified as: Acute if less than 2 weeks duration Persistent if 2-4 weeks duration and Chronic if more than 4 weeks duration

5. In osmotic diarrhea, there is ingestion of osmotically active substance like lactose in lactase deficiency It also occurs by ingestion of non-absorbable solutes like lactulose or in laxative abuse.

6. EPIDEMIOLOGY: Worldwide,>1 billion individuals suffer one or more episodes of acute diarrhea each year. Among the 100 million persons affected annually by acute diarrhea in the United States, nearly half must restrict activities. 10% consult physicians, 250,000 require hospitalization and 5000 die[primarily the elderly] The annual economic burden to society may exceed $20 billion. Acute infectious diarrhea remains one of the most causes of mortality in developing countries, particularly among children, accounting for 2-3 million deaths per year Acute diarrhea occurs frequently in children between the ages of 6 months and 3 years Diarrhea in infants below 6 months is usually associated with early introduction of infant formula feeds, which are readily contaminated.

7. In a study carried out among adults in urban Zambia in Lusaka town to determine the prevalence of persistent diarrhea in adults. 460 households were assessed representing a sample of 1440 adults. 94 adults were reported as having had diarrhea in the 2 weeks prior to the survey, implying an attack rate of1.74 per adult per year. Of these cases, 6 had diarrhea of between 2 to 4 weeks duration and 10 had diarrhea of over 4 weeks duration

8. In a study conducted to determine the etiology of acute diarrhea in adults in southwest Nigeria, Ile-Ife Osun State. Stool specimen from 113 adult outpatients with diarrhea and 63 controls were examined for bacterial and parasitic enteric pathogens. Enterohemorrhagic E coli [EHEC][P<0.02], enteroaggregative E. coli [EAEC][P<0.02], and Entamoeba histolytica [p<0.0002] were significantly associated with diarrhea. Salmonella, Shigella , nontoxigenic Vibrio cholerae , other categories of diarrheagenic E. coli as well as a variety of helminths were recovered more frequently from the stools of patients than from stools of controls, but did not show a significant association with disease Multiple pathogens were recovered from 36.3% specimens Bloody diarrhea was commonly associated with E. histolytica and diarrheagenic E.coli infections

9. AETIOLOGY: ENTEROTOXIC, NON INFLAMMATORY OR NON INVASIVE CAUSES: Enterotoxic E.Coli [ETEC] – causes traveler’s diarrhea Clostridium Difficile – recent hospitalization and antibiotic. Vibrio Cholerae –Water contaminated with faeces [Rice water stool] Staphylococcus Aureus – Contaminated foods: left over food,salads,dairy products. [It is vomiting predominant] Bacillus Cereus – Uncooked or reheated rice like Chinese rice,fried rice. Viruses – Norovirus,Rotavirus , CMV Protozoa- Giadia Lambia [ fresh water,unfiltered water during trip camping]

10. INVASIVE OR INFLAMMATORY CAUSES: Salmonella- From uncooked or undercooked poultry, eggs Shigella – From contaminated food, water and vegetables, poultry. Causes HUS Enterohaemorrhagic E. Coli [0157.H7] - Undercooked or uncooked meat, Hamburgers. Causes HUS also as it contains shiga toxins Campylobacter Jejuni –From uncooked or undercooked poultry. It is very infectious and a common cause. Entamoeba Histolytica – It is a protozoa seen in immunocompromised patients, homosexuals and contaminated water.

11. RISK FACTORS Age: Children and elderly people are at a higher risk Poor hygiene Daycare attendee and their family members Hospitalized persons[recent antibiotics intake eg clindamycin,amoxicillin ] Travelers: Africa, Central America,Asia Homosexuals Immuno -compromised persons

12. PHYSIOLOGY OF NORMAL BOWEL: Fluid enters the GI tract from ingestion of liquids and GI secretions. About 80% of total fluid is absorbed by small bowel, while 10% is absorbed by the large bowel. Net fluid and electrolyte exchanges vary along the villus Net absorption of fluid and electrolytes occurs at the tip of the villus, while net secretion of fluid and electrolytes takes place at the crypt. Water flows across the epithelium by osmosis, driven by Na+ and Cl - in particular. In a healthy bowel, absorption dominates over secretion Diarrhea occurs when the bowel shows increased secretion and / or decreased absorption of fluid.

13. PATHOPHYSIOLOGY [In Non Invasive Acute Diarrhea]: Non invasive bacteria like V. cholera and Enterotoxigenic E.coli produce toxins which induce secretory diarrhea Bacterial pathogens after ingestion proliferate and elaborate enterotoxins in the intestinal lumen. These enterotoxins stimulate receptors at the intestinal mucosal surface and produce cyclic adenosine monophospate [C-AMP] via adenyl cyclase C-AMP increases the activities of CFTR which increases chloride secretion at the intestinal lumen. Ca2+ does this via calcium activated channel activation.

14. It also inhibit the reabsorption of sodium from the intestinal lumen into the cell via inhibition of NaHE3 This causes inhibition of influx of NaCl and water into the villous cells and secretion of NaCL and water by the crypt cells into the intestinal lumen These two changes lead to secretion of large amount of water and electrolytes in the intestinal lumen.

15. PATHOPHYSIOLOGY [IN Invasive Acute Diarrhea] Invasive bacteria like S higella , E nteroinvasive E .coli, Salmonella, Campybacter invade mucosal intestinal cells. In the cells, they stimulate release of pro-inflammatory cytokines like TNF, IL6, IL 8. These pro-inflammatory cytokines produce ulceration and destruction of intestinal mucosal epithelium with bloody exudates. They also cause intracellular calcium ion signalling . The calcium ion enhances the activities of Ca2+ Activated Channels which increases chloride secretion at the intestinal lumen. Calcium ion also inhibits sodium absorption into the intestinal cell by inhibiting the NaHE3 activities.

16. SIGNS AND SYMPTOMS This depends on etiology and level of dehydration, however, the following may be seen: Generalized body weakness Dehydration Fever Abdominal pain and cramps

17. Tenesmus Blood and / or mucus in stool Bloating Nausea and vomiting

18. COMPLICATIONS Dehydration Acute kidney injury Hypovolemic shock Metabolic acidosis Anemia Sepsis Chronic diarrhea

19. DIFFERENTIAL DIAGNOSIS Appendicitis Diverticulitis Mesenteric ischaemia Giardiasis Shigella infection Lactose intolerance Irritable bowel disease Ulcerative colitis

20. MANAGEMENT Most diarrheal diseases are of viral etiology and are self limiting. Oral fluid therapy may be instituted: water, ORS In non infectious diarrheal disease, antidiarrhea agents like loperamide , bismuth subsalicylate can be given. If there is presence of red flags, evaluate patient properly and treat accondingly .

21. ALGORITHM FOR MANAGEMENT OF ACUTE DIARRHEA Evaluate patient for severe fluid loss Estimate quantity of fluid loss via stool and vomitus Assess for buccal mucosa, skin turgor for dehydration, pulse rate and volume, blood pressure, urine output Dizziness, fainting spell present Severe dehydration present Pulse rate .100 b/min Moderate /small volume pulse

22. Postural dizziness / hypotension Hypotention [BP< 90/50MMHg] Reduced urine output <60ml/hour Other features of hypovolemic shock If yes, replace lost fluid and electrolyte intravenous fluid: Use colloids e.g Dextran etc or crystalloids eg normal saline Avoid use of potassium containing fluid if oliguria or anuria is present

23. If No: Replace lost fluid and electrolyte orally with ORS if no vomiting If vomiting is present, give intravenous fluids

24. 2 Monitor parameters earlier assessed closely while fluid and electrolytes are being corrected till they return to normal 3 If unconscious, institute other relevant resuscitative measures 4 Meanwhile obtain other relevant clinical history and examination 5 Collect blood samples for electrolyte, urea and creatinin Collect fresh stool samples for microbiology studies

25. Use antibiotics only if the following are present: Cholera is likely diagnosis Fever Colicky abdominal pain Mucoid stool Blood in stool Tenesmus Use of heart valve prothesis or other forms of prosthesis

26. Avoid use of anti-emetic drug If vomiting is present, place patient on nil per oral, give antibiotics parenterally if indicated Resume oral feeding and drugs when symptoms improve Avoid use of anti-diarrheal drugs except in cases of non – infectious diarrhea

27. PROGNOSIS Prognosis of severe acute diarrhea is bad in : Children T he elderly I mmuno -compromised patients.

28. PREVENTION Good hygiene: proper hand washing with soap and good water after going to toilet, before eating etc Proper storing of food Eating of healthy food Drinking good water Avoid travelling to diarrhea endemic areas Avoid antibiotics abuse

29. THANK YOU

30. REFERENCES: Harrison Principle of Internal Medicine, 18 th edition, Longo,Fauci , Kasper, Hauser, Jameson, Loscalzo Paediatrics And Child Health in The Tropical Region-3 rd Edition, Azubuike and Nkanginieme Wikipaedia , Slideshare JJ Medf ED MedNerd-Dr Waqas Fazal Journals of Clinical Microbiology P Kelly et al. Acta Trop