Diarrhea अतिसार-1.pdf

Medical & health

1. Diarrhea
अ?तस!र




स2स्त??तकत!र्ण- $स्त??तकत!र्ण - र*शन" वम!र्ण (ब0च-2019)
ड( सत्यर्ण $क!श च+धर# ($वक्त!) अन?म!2क - 4 2 2 1 9 11 1 00 49

2. ?न??क्त - ग?द/न बह?!वसरणम?तस!र0: (मध?क*ष)
ग?द! स/ अlधक म!! मE !व य?क्त मल क! ब!हर ?नकलन! अ?तस!र कहल!त! ह0
। वय!न?स!र ब!लकI मE ह*न/ पर इसक' स2ज्ञ! ब!ल!?तस!र ह*त" ह0।
भ/द-

म क!श्यप चरक स?.?त व!ग्भट
1 आम!?तस!र व!तज व!तज व!तज
2 पक्व!?तस!र ओपज्ञज ओपज्ञज ओपज्ञज
3 व!त!?तस!र कफज कफज कफज
4 ओपज्ञ!?तस!र स?#प!तज स?न्नप!तज सन्न"प!तज
5 श्ल/ष्म!?तस!र श*कज श*कज श*कज
6 रक्त!?तस!र भयज आमज भयज

3. स!म!न्य ?नद!न-
1.ग??,अ?त?स्नग्ध,अ?त?क्ष,अत्य?ष्ण,अ?त!वऔर अ?तश"तल !?यI क!
स/वन।
2.ओव?nध!शन,अध्यशन,अज"ण!र्णशन,अस!त्मय!शन।
3.स्न/हन,स्व/दन!?द क/ अ?तय*ग य! gमथ्य!य*ग स/ ।
4.ओवष!द,PQ,श*क स/।
5.ब!लकI मE अ?तस!र स्वत2 ?य!lध क/ ?प मE अथव! ?य!lधयI क/
लक्षण स्व?प gमलत! ह0। ज0स/-क्ष"रअलसक,क?gमर*ग,त!ल?क2टक,
म?ओज्ञक!भक्षण,दEत*भ्द/द जन्य अ?तस!र।ब!लह मE भ" अ?तस!र लक्षणI
क/ ?प मE gमलत! हG।
ज0स/-पत्तन!ह,न0गम/ष,ओपत?ह,र/वत" NR श?ष्कर/वत"।

4. सम्$!?प्त- श्ल/ष्मओपज्ञरस!?द ज* क!यर्ण!व हG वह अन्तर!?ग्न क* मन्द कर तथ!
व!य? nव!र! $/?रत ह*कर मल क/ स!थ अlधक म!! मE न"च/ क' ओर सरण कर
अ?तस!र न!मक घ*र ?य!lध क* उत्पन्न करत/ हG।

5. पत्वर्ण?प- ?दय $द/श,न!gभ,ग?द!,उदर तथ! क?oक्ष त*द,अ2गI मE gशlथलत!,अध*ग
व!य? क! अवर*ध,मन क' अ$व?ओज्ञ,आध्यम!न,भ*जन क! प?रप!क न ह*न!।

6. स!म!न्य लक्षण- द/हव0व?यर्णमर?तम?र्णखग्ल!?नर?न!त!।
व!तकमर्ण?नव?ओज्ञश्च/त्य?तस!र!व/दन!:।।(क!.सत्.25/14)

द/हव0व?यर्ण,अर?त,म?खग्ल!?न,अ?न!!,व!य?कमर्ण क' ?नव?ओज्ञ अ?तस!र क! स!म!न्य
लक्षण ह0।
व!त!?तस!र!- अ?ण2 फ/?नल2 ?क्षमल्पमल्प2 म?ह?्मह?र्ण,।
शक?द!म2 स?क्शब्द2 म!?त/न!?तस!यर्णत/ ।।( म!.?न. 3/6 )

व!?तक अ?तस!र मE अ?ण,झ!गय?क्त,?S एव2 आम मल थ*ड़" - थ*ड़" म!! मE
ब!र ब!र प"ड़! एव2 शब्द क/ स!थ ?नकलत! ह0।

7. ओपज्ञ!?तस!र लक्षण- ओपज्ञ!त्प"त2 न"लम!ल*?हत2 व!
त?ष्ण!मत्च्छ!र्णद!हप!क*पपन्नम्।( म!.?न. 3/7)

प0ओज्ञक अ?तस!र मE मल प"ल!, न"ल! य! क?छ रक्त वणर्ण क! आत! ह0 एव2 र*ग" क*
त?ष्ण! NR मत्च्छ!र्ण ह*त" ह0। सव!Mग मE द!ह एव2 ग?दप!क भ" ह*त! ह0।

8. श्ल/ष्म!?तस!र! लक्षण-

श?क्ल स!न्!2 श्ल/ष्मण! श्ल/ष्म!य?क्त2 ओवस्2 श"त2 ?ष्टर*म! मन?ष्य,।।( म!.?न. ⅜)

कफज अ?तस!र स/ प"औडत मन?ष्य क/ रIगट/ खड़/ ह* ज!त/ हG NR वह सफ/द,ग!ढ/
कफय?क्त द?गर्ण?न्ध तथ! श"तल मल क! प?रत्य!ग करत! ह0।

9. स?न्नप!तज अ?तस!र लक्षण-
वर!ह स्न/हम!2स!म्ब?स?श2 सवर्ण ?ओपण2।
क?च्छस!ध्यम् अ?तस!र2 ओवnय!द*षय*nभव2।।(म!.?न.⅜)

स?न्नप!तज अ?तस!र मE वर!ह क/ स्न/ह म!2स अम्ब? क/ स?श एव2 फ0लन/ व!ल!
मल क! ?नस्सरण ह*त! ह0।
त"नI द*षI क/ लक्षणI स/ य?क्त यह अ?तस!र क?च्छस!ध्य ह*त! ह0।

10. आग2त?क अ?तस!र:
आग2तत् nव!वत"स!र+ म!नस+ भयश*कज*।
तज्ञय*लर्णक्षण2 व!य*यर्णद?तस!रलक्षण2।।(च.lच.19/11)

म!नgसक द*षI स/ भयज NR श*कज य/ द* आगन्त?क अ?तस!र ह*त/ हG। इन
द*नI क!रणI स/ ह*न/ व!ल/ अ?तस!र र*ग मE व!त ज अ?तस!र क/ ज* लक्षण बत!ए
गए हG,व/ ह#/ लक्षण इनमE भ" प!ए ज!त/ हG।

11. lचiकत्स! gसnध!2त-
प"त2 प"त2 च य, स्तन्य2 सव!तम?तस!यर्णत/।
तस्य!प्य/ तत्पर2 पथ्य2 द#पन2 बलवणर्णक?त्।।( अ.स2.उ. 2/102)
स्तनप!य" gशश?ओ2 मE ब!र ब!र स्तन्य प"कर व!त य?क्त मल क! त्य!ग ह*न/ पर
स्व2 द#पन औषध" क! $य*ग करन! च!?हए।


न त? स2हण2 द/य2 पत्वर्णम!म!?तस!?रण/।
ओवबध्यम!न!, $!ग्द*ष! जनतन् बहत्न।।( च.lच.19/ 15)
आम!वस्थ! मE स2!ह# औषlधय!1 नह#2 द/न" च!?हए,अन्यथ! क*ष्ठ मE स2lचत द*ष
अत्यlधक व?nध ह*कर अन/क ?य!lधयI क* उत्पन्न करत/ हG।

12. त!द* ल!2घन2 क!यर्णम?तस!र/ष? द/?हन!म्।
तत, प!चनस2य?क्त* यव!ग्व!?दम* ?हत,।।( स?.उ. 40/25)

सवर्ण$थम ल2घन क/ ब!द द#पन प!चन एव2 यव!गत् क! म ?हतकर ह0।

व!य*रनन्तर2 ओपज्ञ2 ओपज्ञस्य!नन्तर2 कफम्।
जय/त्पत्वM य!ण!2 व भव/nय* बलवज्ञम,।।( अ.?.lच. 9/122)

अ?तस!र मE सवर्ण$थम व!त क', उसक/ ब!द ओपज्ञ क',उसक/ ब!द कफ क'
lचiकत्स! करन" च!?हए अथव! ज* द*ष अlधक बलव!न ह* उसक' lचiकत्स!
पहल/ करन" च!?हए।

13. य*ग-
(क!श्यप स2?हत! गgभर्णण" $करण मE वhणर्णत अ?तस!र क' lचiकत्स! )

1. कल्य!णक अवल/ह-
ओपप्पल#,ध!तक',ल*",म!2ओवष्ठ!,पnमक/सर,पnम,म*चरस,श्य*न!क,न!गक/सर क/
चत्णर्ण क* घ?त,मत्स्य??डक! एव2 क्ष+! gमl.त कर अवल/ह बन!कर द/न/ स/ सभ"
$क!र क/ अ?तस!रI क! न!श ह*त! ह0।
2.रक्त अ?तस!र क' lचiकत्स!
●ब!ण मत्ल क्व!थ मE प?ष क! ब"ज शकर्णर! एव2 मध? gमl.त कर स/वन कर!ए2।
●कमल,म2?जष्ठ!,य?ष्टमध?,चन्दन,कमलक/सर क/ चत्णर्ण क* मध? मE gमl.तकर
द?ग्ध क/ स!थ स/वन कर!ए2।

14. चरक स2?हत! मE वhणर्णत य*ग-
●अ?तओवष!?द चत्णर्ण-ओपज्ञज अ?तस!र मE द/य
●रस!न्जन!?द चत्णर्ण-कफज अ?तस!र मE द/य
●कओपत्थ!?द चत्णर्ण-कफज अ?तस!र मE द/य
●न"ल*त्पल!?द य*ग- रक्तअ?तस!र मE द/य
●द!?यर्ण?द घ?त-सभ"अ?तस!र मE द/य


ओवऔड2ग?द चत्णर्ण (य*.R.) -व!य ओवड2ग,अजम*द!,ओपप्पल# चत्णर्ण समभ!ग मE
ल/कर मध? क/ स!थ ल/हन/ कर!कर स?ख*ष्ण जल क! प!न कर!यE। यह
gशश? क/ आम?तस!र! क* नष्ट करत! हG।

15. ब!लचत?भर्ण! चत्णर्ण- न!गरम*थ!,ओपप्पल#,अ?तओवष!,ककर्णट.?2ग",
क! समभ!ग चत्णर्ण करक/ मध? gमl.तकर ल/हन कर!न/ स/ ज्वर,
अ?तस!र,क!स,श्व!स,वमन क! न!श ह*त! हG।

16. Diarrhea
● Introduction
● Types
● Etiology
● Pathogenesis
● Clinical manifestation of Acute diarrhea
● Assessment of Diarrheal dehydration (WHO)
● Treatment

17. Introduction-

.Diarrhea is defined as a change in consistency and frequency
of stools, i.e. liquid or watery stools, that occur >3 times a
day.However Consistency of stool is more important than
frequency.

Or an increase in daily stool weight more than 10gm/kg/
day for children upto 3 years of age and more than 200gm in
older children,along with abnormal increase in stool
frequency & consistency.

18. TYPES
Acute
watery
diarrhea
Acute
bloody
Diarrhea
Persistent
Diarrhea
Chronic
Diarrhea

19. Types-
Acute watery Diarrhea: It is the passage of liquid or watery
stool more than three times a day. Resolves within a week.

DANGER SIGNS-Dehydration,weight loss.

Acute Bloody Diarrhea: Similar to acute watery diarrhea but
associated with large amount of blood.

DANGER SIGNS-Sepsis,Malnutrition,Intestinal damage,
dehydration

20. Persistent Diarrhea:An episode of diarrhea with acute onset,
prolong duration of 14 days or longer and presumed to have an
infectious etiology.
DANGER SIGNS- Malnutrition,severe non intestinal
infection, dehydration.

    Chronic Diarrhea: Diarrhea that has an Insidious onset
prolong duration of more than two weeks with an obvious
malabsorptive disorder like Kwashioskar & Marasmus disease.
DANGER SIGNS- Severe systemic infection,
dehydration,Vitamins and minerals deficiency,heart faliure.

21. Etiology:
Rotavirus &E coli are the main cause of diarrhea among children.
Cholera-5% _ 10% Cases of diarrhea.
A.Enteric infection:
Bacteria: Ecoli,Salmonella,Staphylococcus etc.
Viruses : Rotavirus,norwalk,influenzae virus
Parasites: Enteric histolytica,Giardia lambia,malaria
Fungi :Candida albicans
Parentral :URTI,tonsilitis,Pneumonia, UTI
B.Dietetic:Overfeeding,starvation,allergy,food poisoning
C.Drugs:Antibiotic
D.Non-specific

22. Pathogenesis :
The Pathogenic organism produce diarrhea by one or more
followings mechanism:
1. Adhesion to intestinal mucosal wall
2. Elaboration of exotoxin (secretory diarrhea)
3. Mucosal invasion (exudative diarrhea)

23. Physiological changes in Diarrhea:
1.Feeble pulse,cold extremities,Irritable or lethargy.
2.Gastrointestinal manifestation like-
loose watery stool,anorexia,vomiting,abdominal
discomfort.
3.Fluids and Electrolyte balance disturbance:
a. Hyponatremic dehydration
b. Hypernatremic dehydration
c. Hypookalemia

24. ●60% of body fluid divided into 2 compartment ie. ECF (Extracellular fluid) and
ICF ( Intracellular fluid)
●Extracellular compartment has blood vessels,intestinal fluids & secretions.
●Diarrheal losses come from ECF, which is relatively rich in sodium and has low
potassium.
●During each diarrheal episode large amount of water & water soluble
nutrients such as electrolytes,metabolites and vitamins & minerals are lost
from the body.
●Excessive loss of water cause reduction or shrinkage in the Volume of
extracellular compartment.

25. Hyponatremic dehydration: ( most common)
Excessive Sodium loss during diarrhea



Relative decline of Na+ level in ECF



osmolarity of ECF fall causing movement of water from ECF to ICF




further shrinkage in already reduced ECFcompartment Volume

In hyponatremic dehydration Skin appears wrinkled like old man,On pinching it takes few
seconds to return to normal position.

26. Hypernatremic dehydration:
In about 5% Of diarrheal Cases ( if child has taken fluid with more amount of
salt,Na+ level may be elevated in ECF Compartment. (>150meq/I).
Then osmotic pressure in ECF is relatively higher than ICF.



fluid moves from ICF to ECF and partially mask the loss of Skin turgor.



Skin appears soggy, doughy and lethargy

Fluids move from ICF to ECF Compartment in hypernatremic dehydration thus
partially compensating the fluid depletion of ECF compartment.

27. Hypokalemia:
low level of K+ in case of severe malnutrition.



Diarrheal stooI contains large amount of k+ if diarrhea Persist for few days.



fall in serum k+ level develops hypokalaemia
clinical features of hypokalemia:
●Abdominal distension
●Hypotonia of abdominal muscle
●Paralytic ileus.
●ECG Shows depression of ST segment and flat T Wave.

28. Clinical manifestation of Acute diarrhea



Features Viral Bacterial: invasiveBacterial:
non-invasive
Stool
characteristics
Watery
Watery/ Semi-solid
(mucus but
no blood)
Frequent, Semisolid,
small in amount with
mucus and blood

Vomiting
Severe slight Moderate
Pyrexia
Slight Nil Moderate/high
URTI
Present Nil Nil
Seizure
Nil Nil occasionally
Toxemia
Nil Nil Slight
Stool microscopy
Moderate pus cells

NAD Moderate pus & red cells

29. Assessment of Diarrheal dehydration (as per WHO)
Parameters No Dehydration Some dehydration Severe dehydration
Condition Well alert Restless,irritable Lethargic, Unconscious
Eyes Normal Sunken Sunken
Tears Present Absent Absent
Mouth and tongue Moist Dry very dry
Thirst Normal Thirsty unable to drink
Skin turgidity Skin pinch goes back
quickly
Skin pinch goes back
slowly
Skin pinch goes back
very slowly
Treatment plan PLAN “A “ Weigh the Patient and
use PLAN"B“
Weigh the Patient and
use PLAN "C” Urgently

30. Treatment
Principles of management of acute diarrhea:
1.REHYDRATION THERAPY
2.ANTI-MICROBIAL THERAPY
3.SYMPTOMATIC TREATMENT
4.MAINTAIN ANCE OF HYDRATION AND NUTRITION
5.MANAGEMENT OF COMPLICATION
6.ORAL SUPPLEMENTATION OF Zinc ,PRE & PRO- BIOTICS
etc.

31. REHYDRATION THERAPY :
Oral rehydration therapy (ORT) is ideal for mild dehydration and a majority of
children with moderate dehydration.
Each motion must be followed by replacement with equal amount of ORS . Breast
feeding must not be discontinued.It Potentiates the usefulness of ORT.

Oral rehydration means drinking solution of clean water , sugar and mineral salt to
replace the water and salt from the body during diarrhea especially when
accompanied by vomiting ,gastroenteritis.

32. Standard formulation :
The Standard formulation recommended by WHO until recently has an
OSmolarity of 311 mmol/l
Low Osmolarity ORS:
1.WHO has done Well to introduce a lower Osmolarity ORS to cut down the risk of
hypernateremia, which earlier restricted its wide usage in neonates.

2.This formulation provides a total osmolarity of 245mmol/L compared to
Standard WHO formulation with 311 mmol/L.

3. It is supposed to lower stool output,shorten diarrheal duration and reduce
vomiting.It maybe given at all ages.

33. Composition of WHO recommended ORS
constituent g/L Ions Mmol/l
Sodium chloride 2.6 Sodium 75
Anhyd. Glucose13.5 chloride 65
Potassium
Chloride
1.5 Glucose 75
Trisodium
citrate,di hydrate
2.9 Potassium 20
Citrate 10
Total Osmolarity 245mmol/l

34. Treatment plan"A” for No dehydration:
Such children can be treated at home by advising ORS and explanation of
adequate feeding and the danger signs to the mother.
Danger signs :continuing diarrhea for more than 3 days,increased volume and
frequency of stools, repeated vomiting,increased thirst, refusal to feed,or blood in
stool.

Age
ORS or other rehydration fluid
after each loose stool.
<2 yrs
50-100ml
2-10 yrs
100-200 ml
>10 yrs
according to thirst

35. Treatment Plan"B” for some dehydration -
1.All cases with obvious signs of dehydration need to be treated in a health center or
hospital.
Fluid therapy for dehydration has 3 components:
1. REHYDRATION therapy/DEFICIT REPLACEMENT

It is the correction of existing water and electrolyte deficit.
Give 75ml/kg of ORS in 1st four hours
If the child Continue to have some dehydration after 1st 4 hours of rehydration therapy then
repeat another four hour treatment of ORS solution and start to give milk or breast feed
frequently followed by semi solid food.
2. REPLACEMENT of ONGOING FLUID LOSSES

This begins when sign of dehydration disappears.
ORS should be administered in volume equal to diarrheal fluid loses. Approximate 10-20ml
for each watery stool and 3-5ml for each vomiting,
3. NORMAL DAILY FLUID REQUIREMENT
Upto 2 yrs → 500 ml/day ; 2 to 10 years → 1000ml/day ; > 10 years 2000ml/day

36. General fluid calculation in dehydration:
fluid in dehydration has 3 components :
1.DEFICIT FLUID
quantity of deficit fluid depends on degree of dehydration.







2.On going fluid loss:
for each watery stool→ 10-20ml
for each vomiting →3-5ml
Degree of Dehydration Acute weight loss Assesment of fluid loss
mild dehydration upto 5% 50ml/kg
Moderate dehydration 5 % to 10% 100ml/kg
Severe Dehydration >10% 150ml/kg

37. 3. MAINTAINANCE FLUID
Amount of maintainance fluid depends on weight of the child
Weight of chid fluid required
upto 10 kg → 100 ml /kg/day
10 - 20 kg → 1000 +50ml/kg/day
> 20 kg → 1500 +20 ml/ kg / day

Total fluid = deficit fluid + ongoing fluid + Maintanance fluid
= 50×10 + 2 x 10 + 100 X 10 [ for 10 kg Weight ]
= 1520 ml/day



20 ml is given in first hour → if urine is not passed → Again 20ml/kg fluid given
followed furasamide 1mg /kg if Urinary
bladder gets empty
i if urine passes

Rest fluid given in 7hour
Half of the total fluid given in first 8
hours
Rest half given in 16 hours

38. Treatment Plan "C” for severe dehydration
1.Parentral route is assessed to administer intravenous fluids.
2.Ringer lactatewith 5% dextrose,normal saline of ringer lactate is
administered.
3.If Parenteal route cannot be assessed and intravenous fluids cannot be
given,nasogastric feeding should be administered at 20 ml/kg/hours for 6
hours (total 120 ml/kg).







If the child is improving but still showing some signs of dehydration then
discontinue IV fluid & start treatment plan B.
Observe the child atleast for 6 hours before discharging.
Age 30ml/kg 70ml/kg Total (100
ml/kg)
less then 12months 1hour 5 hour over 6 hours
More that 12 months 30min 2.5 hr over3 hours

39. Antimicrobial therapy :
1.Ampicillin- 100mg/ kg/ day
2. Cotrimoxazole- 4-12mg/kg/day
3. Furazolidine- 8mg/kg/day,
4. Metronidazole
5. NorfIoxacin- 4-12mg/kg/day
Symptomatic treatment :
Ondansetron 0.1-0.2mg/kg /dose in severe of reccurrent
vomiting.

40. Dietary management of acute diarrhea:
1.Breastfeeding to be continued In exclusively breastfed infants.
2. Fibre rich food to be avoided for eg. coarse fruit and vegetables.
3. undiluted cow or buffalo milk can be given in non-breastfed infants,along with
semisolid food like dalia.

Zinc Supplementation:
● It reduces severity duration of diarrhea and also the risk of Persistent
diarrhea.
●10 mg of elemental Zinc /day for children < 6 month
●20mg of elemental Zinc /day for children > 6 months for 14 days

41. THANK YOU ??????